instrumented bone graft fusion

Device fixation and bone graft fusion for the treatment of scoliosis, after decades of continuous development, the formation of a variety of surgical procedures. Although these surgical methods vary, the purpose is to promote bone fusion. Therefore, all soft tissue debris on the bone tissue must be carefully cleaned, the cortex completely removed, the small joints destroyed, and a large number of autogenous iliac bone grafts are made. Treatment of diseases: congenital scoliosis scoliosis Indication 1. Etiology: idiopathic scoliosis, puberty development is faster, Cobb angle greater than 40 ° should be treated surgically. Congenital scoliosis, especially stiff, or neuromuscular scoliosis caused by spinal column collapse, should be an early operation. The longer the course of the disease, the more difficult it is to develop and the more difficult it is to correct. 2. Age: General orthopedic fixation surgery is performed after 12 years of age. For congenital scoliosis, local fusion should be performed to prevent local fusion of scoliosis. 3. Degree of scoliosis: At present, it is generally prescribed for surgery at a Cobb angle of 40° or more. Non-surgical treatment is performed below 40°. 4. Scoliosis: Heavier rotation of the thoracic scoliosis, accompanied by obvious thoracic deformity or kyphosis (hump angle) deformity, surgery ahead of lumbar scoliosis to prevent aggravation of respiratory function. 5. Scoliosis and early paraplegia should be performed early, decompression to remove paraplegia factors, to correct and prevent further aggravation of deformity. 6. For older adults with scoliosis, due to lumbar back pain caused by hyperplasia of the deformity site, or instability of the spine, fixed fusion surgery may also be considered. Contraindications Patients who do not meet the above age range or who have a lighter scoliosis. Preoperative preparation Preoperatively given a slow long-term traction, it can avoid a sudden correction of the stretch, and it is of great significance to prevent spinal nerve complications and increase the rate of surgical correction. Gradually increase the amount of traction before surgery to understand whether the patient has numbness, pain, muscle tension, muscle strength and reflex. After achieving a satisfactory degree of correction, the device was fixed with bone grafting. Myelography should be performed before surgery to rule out abnormalities in the spinal canal. Decompression, broken sticks and other complications. Surgical procedure 1. Harrington surgery Harrington first reported in 1962 to support or correct the scoliosis with metal internal fixation. The device is mainly composed of two parts, one is a stick and the other is a hook. Place the rod on the concave side of the side bend and place the pressure rod on the convex side. The proximal section of the spreader is ratcheted so that it can only be opened in the hook and not allowed to return. Its tail end is square to prevent it from rotating after inserting the hook. The pressure rod is thin and flexible; it is threaded throughout. The upper hook of the opening rod is a round hole, and the tail end hook is a square hole. The Rochester type of the pressure bar has a groove on the back of the hook, which makes it easy to put the pressure rod and the gasket. The upper hook of the open rod is generally placed between the small joints of the thoracic vertebrae, and the lower hook is placed on the upper edge of the lumbar vertebrae. The pressure rod is hooked on the transverse joint of the rib, and the lower hook is placed on the lower edge of the lumbar vertebra. Harrington instruments have better longitudinal support properties, less effect on Cobb angles greater than 50°, ie small angles, poor corrective force, and too large angles can be used with 2 spreaders or combined with pressurized bars. Harrington surgical procedures are currently internationally standardized. The patient was placed on a Hall-Relton surgical stent after general anesthesia. The skin is sterilized, covered with a sterile film, and the skin is injected under the skin before the skin is cut into a 1:400,000 adrenaline solution to reduce bleeding. A straight incision is made in the superior spinous process and the next spinous process in the fusion segment. The soft tissue of the spinous processes and the laminae on both sides was removed under the subperiosteum until the lateral joints of the two sides or the transverse joints of the ribs were exposed. Use the automatic spreader to open the muscles on both sides. Find a small joint on the upper end of the vertebra on the concave side of the lateral curve, cut it, and place the upper hook. A lower hook is placed on the lower edge of the lower vertebra of the lower end vertebra. Place a hook on each of the upper and lower hooks. Place the spine external fixation spreader between the upper and lower hooks. Rotate the spreader screw, open the side bend from the concave side, and select the appropriate length of the spreader rod to penetrate the upper and lower hook holes. Remove the outer spreader, and use the hook to make the upper hook open the 1~2 ratchet on the ratchet step of the upper part of the spreader rod to maximize the correction. Then perform an intraoperative wake-up test or evoked potential monitoring. It is proved that there is no over-correction, and then the segmental spinous processes, lamina and facet joints are to be used as the bone grafting bed. Then the humerus bone was taken or combined with the application of allogeneic bone grafting. Before closing the wound, place 1 or 2 negative pressure drainage tubes to reduce hematoma and prevent infection. If the Harrington spreader is used in conjunction with a pressurized rod, the pressure bar should be placed first. At present, Harrington expands the instrument orthopedics, and is often combined with Luque segmental laminar wire fixation to reduce complications such as decoupling and broken sticks after Harrington surgery alone. 2. Luque surgery was first reported by Mexican Luque in 1976. He placed two "L" shaped metal rods on the sides of the side bends. Insert the short arm of a metal rod into the lateral curve, the upper spine on the upper vertebra, and the short arm of the other "L" shaped metal rod into the lateral spine. In this way, the two rods are formed in a rectangular shape, and the metal rod is controlled to slide up or down, and all the interspinous ligaments and the ligamentum flavum which need to be fixed are cut off, and the interlaminar holes are opened. A wire is inserted through each interlaminar hole and passed through the intervertebral foramen through the lamina. Tighten the wire passing under each segment of the lamina to the metal rod on each side so that the lamina and the metal rod are completely fixed together. Luque procedure: position, incision, and exposure with Harrington surgery, after the exposure is complete: 1) Opening the window between the lamina: After removing the interspinous ligament or partial spinous process, the ligamentum flavum is exposed. First, a small hole is bitten by a rongeur, and the epidural space is separated by extending into the nerve stripper. Then use a small beveled Kerrison laminar rongeur to extend into the epidural space, gently press down the epidural fat, and lift the yellow ligament. A 0.5 cm diameter window is opened in the lamina gap for the wire to pass. 2) Under the lamina, wear a steel wire: cut a soft, non-elastic 0.8-1.0mm diameter steel wire to a length of about 50cm, and fold it into double strands, leaving a round hole at the top. The double-strand steel wire top section is curved into an arc shape with a diameter of the window between the two laminas. The top end of the curved wire is inserted into the opening between the next lamina, and passes through the epidural space, and is placed under the lamina, and is opened through the opening of the upper intervertebral foramen. Hook the small hole at the top of the wire with a small hook so that the wire is pressed against the lamina. The top end of the double-stranded steel wire is cut off to form a single strand, and the left and right sides are separated for fixing the "L" shaped rod. 3) Fix the "L"-shaped rod: Generally, an "L"-shaped rod is placed on the concave side to wind a wire around the metal rod, and then the steel wire is cross-tightened. Ligation from top to bottom. During the tightening of the wire, the assistant can gently press the convex side to facilitate orthopedics. Another "L" shaped rod was placed on the convex side, and in the same way, the steel wire under each lamina was ligated one by one from top to bottom. Make two "L" shaped rods, using the scoliosis of the apical vertebra as a fulcrum, and correct the scoliosis like a "splint". Bone grafting and fusion are equivalent to Harrington surgery. Luque surgery is securely fixed and the incidence of pseudoarthrosis is low, but each wire passes through the epidural space, increasing the chance of spinal cord injury. 3.Harri-Luque spinous process basal bone buckle wire fixation method Authorized by Harrington and Luque in 1985, but not under the laminar wire, but in the thickest part of the vertebrae, the spinous process base with the punch parallel plate Drill two parallel 1.5mm diameter holes, and pass the two ends of the wire with the bone buckle through the two holes from one side to the opposite side (the bone buckle is prepared in advance), and the side is Harrington with the passing wire. Stick or Luque sticks are fixed. In this way, the wire is passed through the bone buckle to the spinous process by the Wisconsin method as a transverse pulling force, and becomes a pressure on the opposite direction of the spinous process, thereby greatly enhancing the fixing ability of the steel wire. The authors have confirmed by biomechanical measurement and more than 100 clinical and practical comparisons that the correction rate and fixation force of the direction to the lateral convex are not weaker than the Luque method. However, the complexity of the Luque lamina under the wire is reduced, and the chance of directly damaging the spinal nerve is avoided or reduced. 4. Dwyer Surgery: In 1969, Dwyer of Australia used a surgical procedure to correct scoliosis from the front of the vertebral body. The operation is mainly suitable for the scoliosis of the L1 or less, especially for the case of severe absence or deformity of the lamina, and the case where the hook cannot be hooked is more suitable. Surgery is generally performed from the convex side of the chest and abdomen combined incision, the 10th rib is removed into the thoracic cavity, and the anterior and posterior aspect of the spine are exposed outside the peritoneum. Ligation of blood vessels that traverse the vertebral body. Longitudinal incision of the anterior longitudinal ligament and periosteum, and periosteal dissection on both sides, revealing the vertebral body. Each intervertebral disc in the range of the lateral convexity is removed, and a screw with a hole is screwed into each vertebral body, and the steel cable passes through the hole, and the steel cable is tightened to bring the vertebral body closer. The intervertebral space after the convex side resection disappears, and the spine is straightened. The flattening screw prevents the cable from retracting and corrects the side bend. The method is orthopedic but satisfactory. 5. Zielke Surgery: The Zielke device is actually a modified Dwyer device, and its approach is also the anterior approach. The biggest advantage of this method is that it has a large degree of correction and can be rotated; there are few fixed segments, only the pressure on the deformed segments, and no expansion, so there is less chance of injury to the nerve. 6. CD surgery: France Cotrel and Dubousset reported their new scoliosis orthopedic fixation devices in 1984. It is mainly suitable for juvenile idiopathic scoliosis and is one of the most effective fixation devices in the posterior spinal orthopedic surgery. However, the method is complicated and there are many complications. 7. Although the CD system has outstanding achievements in scoliosis, it still has design flaws. In order to make up for these shortcomings, scholars have developed improved systems such as Isola, Moss Miami, TSRH and CDH, which have become the domestic The most widely used internal fixation for the treatment of scoliosis. complication Low back pain is rare after thoracic scoliosis fusion, and lumbar pain is relatively common after lumbar fusion. The cause of low back pain after fusion is unknown, but the study found that the following conditions are related to this: 1 If postoperative torso decompensation occurs in the coronal or sagittal plane, then patients often have low back pain after surgery. Therefore, it is necessary to achieve balance on the center line of the humerus during fusion to avoid the occurrence of dislocation in the coronal or sagittal plane. Reimbursement. 2 postoperative low back pain is related to the disappearance of lumbar lordosis, so it is necessary to restore the physiological curvature of the sagittal plane of the spine. 3 postoperative low back pain is related to the extent of the lower fusion vertebra. If the fusion level exceeds the waist 3, the incidence of low back pain is increased, so selective fusion should be used whenever possible.