Anterior cervical decompression and fusion

Cervical spinal cord injury occurs quadriplegia, serious condition, respiratory complications often occur, and the mortality rate is high, so it is urgent to treat it. Cervical spinal cord injury has complete spinal cord injury, incomplete spinal cord injury, spinal cord semi-transverse injury, central spinal cord injury, anterior spinal cord injury, posterior spinal cord injury, and spinal cord injury without fracture and dislocation. Different types of cervical vertebrae have different indications for surgical treatment. For example, anterior spinal cord injury or central spinal cord injury caused by cervical burst fracture or cervical intervertebral disc injury, requiring cervical anterior decompression surgery, and central spinal cord injury or anterior spinal cord injury caused by cervical posterior extension injury , the need for posterior decompression surgery of the cervical spine. Treatment of diseases: cervical spine fracture and dislocation Indication Cervical anterior decompression fusion is applicable to: 1. Cervical burst burst fracture, the fracture block is displaced backwards to compress the spinal cord. 2. Cervical vertebrae injury with disc herniation compression of the spinal cord. This condition is more common in cervical posterior extension injury or compression injury, MRI can provide a clear diagnosis. 3. The old cervical spine fracture and dislocation has not been reset, or the posterior horn deformity has healed, and the spinal cord is incompletely compressed by the front. Contraindications The posterior structure of the cervical spine, such as the laminar spine fracture, is displaced, and the vertebral arch loses stability. In the acute phase, it is not suitable for anterior decompression, avoiding the simultaneous destruction of the stability of the anterior and posterior cervical spine. Preoperative preparation Fresh burst fractures should be performed under the traction of the skull. After the diagnosis is clear, the skull is given traction, which is beneficial to fracture reduction. It is not necessary to pull the cervical disc herniation and old dislocation. Surgical procedure 1. Incision revealed The neck 4-6 vertebral bodies were exposed. Generally, the right supraclavicular transverse incision is used, and the incision is made on the clavicle from 2 fingers to 3 cross fingers, from the outer edge of the sternocleidomast muscle to the midline. After cutting the skin and platysma, separate it up and down, and use the suture to pull the skin up and down and fix it on the surgical table at both ends of the incision. In the longitudinal separation between the sternocleidomastoid muscle, the carotid sheath and the midline tissue, the scapular lingual muscle can be displayed, and the scapulae muscle is sewed and cut at the middle sac, and cut to both sides, sometimes the ligature of the neck vein is cut. Separation into the deep part, the inferior thyroid artery is mostly in the plane of the neck 6 or the neck 7 vertebral body, the distal end is bifurcated, and the recurrent laryngeal nerve passes through the bifurcation. Therefore, when the lower thyroid artery is ligated, it should be performed in the arterial trunk, which requires double ligation. To prevent falling off. When dealing with a fracture of the neck 5, there is no need to find this artery. The midline of the thyroid gland is pulled to the opposite side to reveal the front of the cervical spine. 2. Positioning Cervical anterior decompression must be accurately positioned, although the neck 6 transverse process nodules are the largest, can be touched as a positioning standard, but usually the position is determined by intraoperative perspective or photo, C-arm X-ray machine is more convenient. Insert a needle into the cervical disc as a marker before seeing or photographing. After the anesthetic is injected under the anterior subfascial anterior fascia, the longitudinal incision is made, and the separation is not more than the length of the long neck muscle. The protrusion and the white intervertebral disc are clearly visible, and the fractured vertebral body can also show deformation and bleeding. If the fracture vertebral body is well defined, it may not be fluoroscopy or photo localization. For disc herniation or old fracture dislocation, it is necessary to locate. After the positioning is determined, the pressure is reduced. 3. Remove the prominent disc It is safer to use the ring saw method for decompression. The ring saw indicates that the drilled flat chiseled tail is driven into the intervertebral disc to be resected and the upper and lower vertebral body edges, so that the upper end is scored toward the head end, and the medium-diameter ring saw (outer diameter 1.3 mm) is placed, and the neck is confirmed on both sides. Between the long muscles, the other soft tissues are not embedded, and the circular saw is fixed in one hand with the direction of the center, not to the left or right. According to the front and rear direction of the intervertebral space, the saw is tilted toward the head or the tail, and the upper and lower vertebrae are included in the ring saw. The body is appropriate. When everything is right, twist the ring saw clockwise and gradually deepen it, and look at the length of the core. When the core is parallel to the upper end of the ring saw, it means that it has been drilled 1.5cm. When sawing the cortical bone at the posterior edge of the vertebral body, there is a feeling of sawing to the cortical bone. Look at whether the nick of the drill core rotates with the drill core. When the drill core rotates more than 180°-360° with the ring saw, it indicates that the intervertebral disc bone is completely free. At this point, you can pull out the positive and reverse spiral saws. If there is adhesion in the spinal canal, the patient often complains of neck pain or string numbness, you can use the positive and negative rotation 180 ° ~ 360 °, to tear open the adhesion, slowly pull the ring saw together with the core with the intervertebral disc plate Out. Check that the cylinder is intact. The cotton plate was inserted into the decompression hole to stop bleeding for a while, and under the direct light and the suction of the attractor, it was observed whether the intervertebral disc tissue or the fiber cord was pressed before the dura mater was removed. If there is residual pressure on the edge of the bottom of the hole, it can be bitten by a curved curette or a diagonal impact rongeur until the pre-dural is completely decompressed. 4. Bone fusion The bone was taken at the tibial tuberosity, and the bone was cut with a large bone (14 mm inner diameter). The circular bone column was about 2 cm long, and the base was removed with a bone knife. Insert the bone insert into the osteosynthesis saw, push out the bone graft, trim the broken end to make it smooth and 5 mm shorter than the anteroposterior diameter of the intervertebral space. Still in the bone extraction ring saw. Let the assistant under the arm control the mandible to the top of the head, make the decompression hole open, align the bone graft with the decompression hole, put it into the inlay, and let the bone graft enter the decompression hole and remove the ring saw. Observe whether the bone graft and the front edge of the vertebral body are in a plane. If it is still high, use the bone insert to level the bone graft. Do not push the bone graft deep into the decompression hole to prevent compression of the spinal cord. However, the bone graft can be slightly lower than the cortical bone of the anterior border of the vertebral body to prevent slipping out. 5. Burst fracture decompression The method of removing the bone from the burst fracture is to remove the upper and lower discs and then remove the bone. When the upper and lower intervertebral discs of the fractured vertebral body are removed by the ring saw method, the bone column on the side of the fractured vertebral body may be incomplete due to the fracture of the vertebral body. After the upper and lower intervertebral discs were removed, the intermediate fractured vertebral body was left, and the rongeur was used to bite it off until the displaced bone pieces were removed and completely decompressed. The left rectangular relief window, the bone grafting method will be described later. 6. Decompression of old cervical spine fracture and dislocation Old fractures and dislocations compress the spinal cord, often including dislocated intervertebral discs and their lower vertebral bodies. Therefore, the decompression range should include the upper and lower discs and the compression vertebral body. The decompression method is basically the same as above. However, because the trailing edges of the two vertebral bodies are not in the same plane, such as using the same ring saw to cut off the vertebral bodies of different planes, there is damage to the spinal cord. Therefore, the drill core should be inserted into the upper or lower edge of the intervertebral space, and the upper and lower vertebral bodies should be removed by a ring saw. 7. Rectangular window and bone graft fusion Measure the length and width of the rectangular window, and take the humeral bone graft a few millimeters according to its shape. The width can be slightly narrow and the thickness is 1.5~2.0cm. After removal, pruning, so that the ends of the cortical bone are slightly longer and make a small tip. The large decompression window is opened in the head, and the bone is implanted to insert the cortical tip into the cortical bone of the anterior border of the vertebral body. Underneath, it can prevent the escape. Before the bone grafting, the gelatin sponge was placed on the dura mater to stop bleeding. The lateral space of the bone graft can facilitate drainage. 8. Fixed In order to prevent bone graft compression, it can be fixed with cervical anterior plate, which is mostly titanium. MRI is still feasible after operation. 9. Close the wound The anterior fascia is very thin, generally does not need suture, the drainage rubber strip is placed in front of the vertebrae, and is taken out from the skin spurs under the incision and fixed by sutures to prevent the drainage strip from being sucked into the wound by the negative pressure of the neck. Suture the scapular scapula, platysma and skin. complication 1. The hoarseness or pharyngeal pain is caused by traction. If there is no recurrent laryngeal nerve injury, hoarseness can be recovered in a few days or weeks. 2. If the bone graft is too loose or the front width is narrow, it may be prolapsed. The prevention method is to take the length of the bone to be slightly larger, at least one end has a small apex protrusion, and the implant is inserted under the condition that the traction head enlarges the decompression hole, so that the cornea is inserted under the cortex of the anterior border to prevent the escape.