lumbar spine fusion

Non-surgical treatments do not work for lumbar instability. Especially for patients with mild cauda equina or nerve root compression symptoms, due to the removal of the diseased intervertebral disc, it has a decompression effect, and the symptoms immediately improve. Treating diseases: spinal diseases, spinal deformity Indication The operation of the lumbar vertebrae is divided into posterior and anterior approaches. In the past, more posterior operations were performed, such as transverse bone graft fusion, small joint bone graft fusion, "H" shaped bone graft and bone grafting, and mechanical rods. Fixed surgery, etc., but from the perspective of anatomy and physiology, interbody fusion is the most appropriate. It can not only relieve the instability of the lumbar vertebrae, but also relieve the lateral instability and rotational instability caused by the instability of the flexion and extension. If the instability of the lumbar spine develops into a deformity and causes the cauda equina or nerve root to be compressed, stable surgery should be performed while releasing the compression. How to choose the operation at this time should be considered according to the patient's condition and the doctor's habits. Contraindications Patients with vertebral joints have lesions: for example, vertebral infection, vertebral endplate sclerosis and tumor. Others: refers to those who are old and weak, unable to withstand surgery and poor mental state, and difficult to cooperate after surgery. Preoperative preparation Preoperative x-ray films should be taken before surgery and further necessary auxiliary examinations should be performed according to the judgment to make correct preoperative diagnosis and positioning. Surgical procedure 1. Posterior fusion: The posterior fusion of the spine is mainly divided into two categories: one is the fixed spinous process, that is, the Albee method and the double plate fixed spinous process; the other is the fixed intervertebral facet joint and lamina, ie Hibbs method, improved Hibbs method, King facet screw fixation method, etc. There are more comprehensive applications for both. The fixation of the spine has now largely abandoned the double plate fixation of the spinous process, and replaced it with Steeffe steel, Luque rod, Harrington stick, pedicle screw and other techniques. 2, Hibbs post-spinal fusion: a median longitudinal incision, along the skin to cut deep fascia and supraspinous ligament. The small bone fragments were cut from the subepithelial strips, the lamina and the facet joints in turn, turned to the side, and partially overlap each other. The appropriate amount of autologous bone is implanted on the top to increase the amount of bone graft, promote fusion, and then suture the fascia. 3, "H" bone graft fusion: reveal the same as the front of the lamina. The soft tissue between the spinous processes of the spine to be fused is removed. If the three spines are merged, the middle spinous processes are preserved. The lamina is roughened by a small chisel. According to the fusion range, the length and width of the bone graft were measured first on the external humerus plate, and then the bone block was taken out with a bone knife. The bone pieces were bitten by a rongeur to make an "H" shaped bone groove. Lower the upper and lower spinous processes at the upper and lower ends of the operating table to separate them. Put into the trimmed bone graft, press the bone graft in the direction of the lamina, and lift the upper and lower ends of the operating table. Small bones are implanted on both sides of the bone graft and below to promote healing. 4, intertransverse fusion surgery: A. anesthesia, position and incision: general anesthesia or epidural anesthesia, prone position, in the lateral edge of the sacral spine muscle longitudinal incision, the lower end slightly curved and the posterior superior iliac spine meet. Cut the skin, subcutaneous tissue, and electrocautery to stop bleeding. B. Revealing the transverse process: Incision of the lumbar fascia at the outer edge of the sacral spine muscle, pushing the sacral spine muscle to the midline, and touching the transverse process in the deep part of the incision by hand. The muscles and ligaments attached thereto are peeled off under the periosteum along the dorsal side of the transverse process, and the dorsal side of the transverse process is exposed, and hemostasis is pressed by gauze. Then, the small facet joint was peeled off and revealed to the inside, and the cartilage surface of the articular process was removed with a bone knife to stop bleeding. C. Place the bone block: The muscle attached to the posterior superior iliac crest is exfoliated with a bone knife to reveal the posterior superior iliac spine. According to the length of the desired fusion, a bone block of the tibial cortex is drilled with a bone knife and a number of broken bone pieces are taken. The removed large bones are traversed across the lumbar vertebrae and atlas of the desired fusion. The upper end of the bone is placed on the transverse process and the lower end is placed on the rough surface of the humerus. Align the middle of the bone graft with a screw through the bone graft and a transverse process in the middle. Then put a lot of small broken bone pieces between and around the small joints, flatten them so that they touch each other without gaps. 5, anterior fusion: anterior fusion is also more common, including lumbar disc can also be removed from the anterior approach, and then anterior fusion. Here is a technique for interbody fusion between the anterior and posterior ventricles of the retroperitoneal vertebral body. a, position: supine position, the ankle is aligned with the waist bridge of the operating table. Raise the waist bridge to widen the lumbar intervertebral space for easy operation. Place an X-ray film under the waist before surgery to locate the intraoperative film. Flexion of both knees, under-knee bolster, relax abdominal muscles. b. Exposing the front of the vertebral ganglia: After successful epidural anesthesia or subarachnoid block, the left lower abdomen midline incision or left abdomen oblique incision. Starting from about 3 to 4 cm on the umbilicus to the top of the pubis, about 2 to 3 cm from the midline, the longitudinal incision is made next to the midline. Cut straight along the anterior rectus sheath. Find the inner edge of the rectus abdominis and pull it outward to reveal the posterior sheath of the rectus abdominis. At 4 to 6 cm from the midline, carefully cut the posterior rectus sheath. Be careful not to open or damage the deep peritoneum. Lift the posterior sheath of the rectus abdominis, separate the posterior sheath of the rectus abdominis from the blunt dissection of the peritoneum, and tilt the operating bed upwards as appropriate. Use the gauze-wrapped fingers to separate the peritoneal reflexes from the peritoneum and the lower abdominal cavity. The organ is pulled toward the center. Push the retroperitoneal fat and separate the peritoneum from the psoas muscle fascia. In the lower section of the incision, the common arteriovenous vein and the ureter across it can be revealed. The ureter should be pulled toward the midline along with the peritoneum. Carefully protect the blood vessels and ureters and continue to separate the midline to reveal the anterior and lateral anterior aspect of the lumbar spine. Abdominal aorta bifurcation is generally at the lumbar 4 to 5 intervertebral disc, and the lumbar 51 intervertebral disc is below the aortic bifurcation, which is located at the boundary between the physiological curvature of the lumbar spine and the physiological curvature of the posterior aspect of the atlas. Protruding forward, called the humerus, can be used as a positioning marker. If there is difficulty in positioning during surgery, X-ray film positioning can be taken on the operating table. If it is necessary to determine the presence or absence of a lesion in the intervertebral disc, a syringe can be used to inject intravenous saline to the central portion of the disc. If the volume exceeds 0.5 ml, the disc is diagnosed. Before cutting the soft tissue, you should do the puncture first; otherwise, if you accidentally damage the vein, there will be a lot of bleeding and it will be difficult to repair. The soft tissue is separated from the left side of the vertebral body, and the lateral anterior lumbar artery is searched for, and the ligation or suture is separated. Note that electrocautery can not be used because these blood vessels come directly from the abdominal aorta. If the electric ablation is damaged, such as damage to the abdominal aorta, it can cause fatal bleeding. The anterior longitudinal ligament was further dissected, and the subperiosteal dissection was carefully performed. The periosteum was pulled together with the abdominal aorta and the inferior vena cava to the right side, and the vertebral body and the intervertebral space were completely exposed. c. Vertebral osteotomy: The upper and lower vertebral bodies at the upper and lower cartilage attachments of the intervertebral disc are cut open with a bone knife, and the sides are also cut off. The implant was placed about 2.5 cm, and the partial disc was taken out together with the upper and lower cartilage plates and the thin layer of vertebral cancellous bone, and then the remaining intervertebral disc tissue was scraped off with a curette until the posterior longitudinal ligament was seen. Do not penetrate or damage the posterior longitudinal ligament. This procedure is usually performed between lumbar 5 and sputum 1 in degenerative lumbar instability. d. Implantation of the bone: an incision is made from the anterior superior iliac spine to the posterior iliac crest, and the iliac crest is exposed, and the subperiosteal dissection is performed on both sides. Then, a full-thickness humerus with a double-layered cortex is taken, so that the upper edge of the iliac wing is opposite to the anterior, and the two layers of the cortical are opposite to each other, and the height is slightly higher than the height of the intervertebral disc. The bone graft is tightly hammered into the intervertebral space. If the lumbar interbody fusion is performed, the front edge of the bone should be slightly lower than the plane of the anterior edge of the vertebral body after the hammer is tightened. If the surgery is performed at the waist 51 plane, the end of the operating table is lowered. First screw a screw in the middle of the front of the bone graft perpendicular to the bone surface. The length of the screw is transmitted through the bone graft and the waist 5 vertebral body. Insert the bone block into the gap and tighten the screw with a special screw. Shake the operating table to facilitate tightening the bone graft and round the excess part of the bone graft. The left incision has a good effect on the fusion of the waist 3~4 and the lumbar 4~5 gap, and it is also safe.