Anterior decompression of cervical spinal cord injury with Cloward method

In 1961, Cloward applied the anterior cervical decompression method advocated in 11 patients with cervical spine fracture and fracture dislocation, and achieved good results. Raynor (1968), Norrell (1970), Nakano (1971), and Duan Guosheng (1984) reported the use of this method of surgery. It is believed that the removal of the vertebral compression fractures in the cervical spinal canal and the removal of the intervertebral disc tissue can improve the neurological function. Treatment of diseases: cervical spine fracture and dislocation Indication Cloward method for anterior decompression of cervical spinal cord injury is applicable to: 1. Cervical vertebrae fracture or fracture dislocation, spinal cord insufficiency injury, incomplete recovery of function after transcranial traction, there are still compression objects such as upper anterior horn of the vertebral body, ruptured intervertebral disc tissue and vertebral body fracture piece in front of the spinal cord. 2. The lower cervical vertebra (6~7) fracture or fracture dislocation, the complete damage of the spinal cord function is below the damaged plane. The operation can relieve the compression of 1~2 cervical nerve roots, which can improve the function of the fingers, but the lower limbs More difficult to recover. Contraindications 1. Cervical fractures and dislocations are severe, more than 1/3 of the anteroposterior diameter of the vertebral body, which is characterized by complete damage of spinal cord function. 2. Difficulty breathing or tracheotomy. Preoperative preparation 1. Preparation of skin and instruments for bone removal on one side of the tibia. 2. Prepare the X-ray cervical lateral radiograph to determine the fracture site. Surgical procedure Neck incision In the plane of the fractured vertebral body, from the anterior cervical line to the left or right sternocleidomastoid anterior border, the left or right transverse incision is 6-8 cm long, and the recurrent laryngeal nerve can be less pulled when the left incision is made. . The incisions are peeled up and down along the subcutaneous tissue, respectively. 2. Reveal the front of the vertebral body The platysma and deep fascia were cut along the anterior border of the sternocleidomastoid, and the sternocleidomastoid and carotid sheath were pulled to the outside; the thyroid, trachea and esophagus were pulled to the medial side. Often thyroid venous obstruction is revealed and can be sheared after electrocoagulation or ligation. The loose connective tissue is peeled off to the deep part, and the finger can touch the front of the cervical vertebra in the middle line, revealing 3 to 4 vertebral bodies. At this point, the automatic retractor can be replaced, taking care not to damage the esophagus. In the 3~4 plane of the neck, the superior thyroid artery and the superior laryngeal nerve can be encountered, and the upper thyroid artery should be cut off when the 2~3 intervertebral space of the neck is exposed. In the 7-plane of the neck, the inferior thyroid artery and the recurrent laryngeal nerve can be encountered. Carefully pull it down and do not damage the recurrent laryngeal nerve. 3. Fracture vertebral body positioning Cervical vertebrae fractures are compressed by the spinal cord. The compression mainly comes from the posterior superior angle of the compressed vertebral body and the intervertebral disc tissue protruding from the vertebral space above the fractured vertebral body. It can also come from the posterior part of the dislocated vertebral body and the fracture piece protruding into the spinal canal. Therefore, it is often necessary to determine The intervertebral space between the fractured vertebral body and its superior vertebral body. Generally, after the front of the vertebral body is exposed, two syringe needles are applied, respectively, and the depth of the intervertebral space and the adjacent intervertebral space are respectively penetrated to a depth of 1.5 cm. If the depth is too deep, there is a risk of stabbing the cervical spinal cord. The X-ray cervical lateral radiograph is taken next to the operating table, and after the wet film is washed out, the fractured vertebral body and the upper intervertebral space can be determined. 4. Intervertebral space drilling Centering on the upper intervertebral space of the fractured vertebral body, the anterior longitudinal ligament in front of the two cervical vertebrae is valvularly cut and turned to one side. Before the cervical spine is drilled, the adjacent vertebral body part of the intervertebral space is scheduled to be drilled into a metal retaining ring with 4 studs, and then a vertical hollow cylinder is connected to ensure that the drill bit is not drilled. Slip off or tilt. The Cloward-type adjustable depth round drill is placed in the hollow cylinder and the retaining ring, and the vertebral body is drilled in the front direction. Generally, the anteroposterior diameter of the cervical 3 to 7 vertebral body is 16 to 23 mm. Therefore, after drilling 15mm, the round drill should be withdrawn every 1mm, and the bottom of the drill hole should be inspected at the end of the stripper or the suction head. If the thin cortical bone behind the vertebral body is found to be vibrating or exposed. The posterior longitudinal ligament, that is, the drill should be terminated to avoid deep damage to the dura mater and spinal cord tissue. 5. Excision of the compression object A curette or a special Kerrison forceps is used to remove the posterior horn of the compressed vertebral body that protrudes into the spinal canal, the fracture piece and the ruptured intervertebral disc tissue, and the damaged posterior longitudinal ligament can also be removed to reveal the dura mater. If operated under a surgical microscope, it is easier to see the pressure that has entered the spinal canal and achieve complete decompression. The posterior longitudinal ligament hemorrhage and vertebral osteomyelitis were stopped by bipolar electrocoagulation and bone wax respectively. The excess bone wax should be removed after vertebral hemostasis, so as not to affect the bone healing of the implanted humeral column. 6. Take the humeral fusion Cloward is used to take the bone ring drill. The front end is serrated. The inner diameter is 1mm larger than the diameter of the round diamond. It is drilled from the outside to the inside slightly under the ridge to form a cylindrical bone. The length should be smaller than the anteroposterior diameter of the plane vertebral body. 3mm. If the bone bank bone is applied, it should be trimmed to the same size as the humerus bone column. The patient's head is pulled by the anesthesiologist. The surgeon uses a bone hammer to drive the humerus column into the vertebral hole. The front of the bone column is 1 mm below the front of the vertebral body. The bone column cannot be pushed too deep to prevent the bone column from protruding into the spinal canal. Internal compression of the spinal cord. 7. Suture incision The anterior longitudinal ligament flap should be sutured as much as possible to prevent the bone column from coming out. Before withdrawing the automatic retractor and closing the incision, the bipolar electrocoagulation is used to stop the bleeding, because once the neck hematoma occurs, it may cause difficulty in breathing and even suffocation. The drainage of the silicone tube should be deep in front of the vertebral body. The sternocleidomastoid and deep fascia are sutured, and the platysma, subcutaneous tissue and skin are sutured layer by layer. complication 1. Postoperative hematoma. The swelling of the operation should be closely observed within 1 to 2 days after the operation. If it is found that the breathing is difficult and the local hematoma is suspected, the wound should be opened quickly for treatment. 2. Postoperative neurological symptoms worsened. The cause should be analyzed. If there is bleeding or the sacral column is inserted into the deep compression spinal cord, surgery should be performed again. 3. The bone column is prolapsed. When affecting hypopharyngeal function, re-implantation should be taken out. 4. The sound is low and hoarse. Intraoperative injury caused by laryngeal and recurrent laryngeal nerve. The superior laryngeal nerve is accompanied by the vagus nerve and is accompanied by the superior thyroid artery. It enters the larynx to innervate the inferior pharyngeal muscle, the ring muscle and the larynx mucosa. After the injury, the sound is low and thick, and the throat has no sensation. The recurrent laryngeal nerve is adjacent to the thyroid gland. The artery moves upwards in the outer edge of the trachea and esophageal sulcus, and enters the larynx to control the movement of the vocal cords. The vocal cords on one side are paralyzed and hoarse. Therefore, the surgeon must be familiar with the vagus nerve and the two major branches of the walking and anatomical relationship, when separating and cutting the upper and lower thyroid artery must pay attention to protect the two nerves, such as due to the retractor tension and excessive hoarseness, should be hoarse Relax the retractor.

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