Lumbar interfacial fixation

The use of interface fixation technology for the treatment of lower lumbar instability, this design is used to treat the instability of the lower lumbar spine, has more advantages than other surgical procedures, and is easy to grasp in operation. At present, both the stability of the early vertebral segments and the fusion of the vertebral segments of the vertebral joints have good curative effect, so it is worth promoting. Treatment of diseases: lower lumbar instability Indication Surgical indications: mainly used for patients with lower lumbar instability, the specific requirements are as follows: A. Age: Adults over 18 years of age are appropriate. B. Characteristics of clinical symptoms: If the patient has symptoms of waist and/or lower limbs when standing or walking, the symptoms disappear or are obviously relieved after lying down, which indicates that they have the basic conditions for performing vertebral section fusion. C. Whole body state: The patient is required to have good physical and mental state and can cooperate after surgery. Contraindications Surgical contraindications: The following conditions should not be selected: A. Vertebral spondylolisthesis: more than I° above the lumbar segment or lumbosacral segment of the spondylolisthesis without vertebral reduction. B. There are lesions in the vertebral joints: for example, vertebral infection, vertebral endplate sclerosis and tumor. C. Others: refers to those who are old and weak, unable to bear surgery and have poor mental status, and are difficult to cooperate after surgery. Preoperative preparation 1 Patient preparation: In addition to preoperative preparation for lumbar posterior or anterior surgery, detailed imaging measurements are performed on the applied vertebrae, and correct data is obtained to facilitate selection of the corresponding type of implant. AX line film: mainly for the posterior anterior position and lateral position. B. CT or MRI examination: measuring the anteroposterior diameter of the vertebral ganglia and observing the surrounding tissue state. 2 Select the appropriate size of the implant: A. Length: The anteroposterior diameter of the vertebral ganglia is less than 30mm, and the Cage of 20mm length is used; if the anteroposterior diameter of the vertebral ganglia is greater than 32mm, the Cage of 26mm is used; if the anteroposterior diameter of the vertebral ganglia is between 30~32mm, it can be used. Cage of 20mm-26mm length. Surgical procedure Posterior surgical procedure: 1 anesthesia: general anesthesia is appropriate, local anesthesia or epidural anesthesia can also be used, but the latter two are less effective in relaxing the waist muscles. 2 position: Take the prone position, use the bow frame as appropriate. 3 Incision: The median longitudinal incision in the posterior way, length 12 ~ 16cm. 4 revealing the diseased vertebrae: sequentially cut the layers, separate the bilateral sacral spine muscles, reveal the lamina and laminar space on both sides of the spinous process, and cut the ligamentum flavum after cutting the spine and interspinous ligament, that is, revealing the affected section Dural sac. 5Cage implantation technique (taking CHTF implant as an example): A. Inserting the saw core: firstly cut the posterior longitudinal ligament of the vertebral ganglion with a sharp knife, remove the contents with the nucleus pulposus, and then the third diameter of 9mm. The generation of the saw core is inserted into the intervertebral space with a depth of 15 mm. It is generally safer to insert from the lateral side, but it is necessary to avoid (or retract) the spinal nerve roots. B. Ring saw drilling: use the ring saw sleeve matched with the saw core to the outside of the saw core and drill into the deep. The depth can be grasped according to the scale on the saw core, generally 25 to 30 mm. C. Removal of intra-vertebral tissue: When the ring saw reaches 25 to 30 mm, it should be taken together with the tissue inside the vertebral joint, including the nucleus pulposus in the vertebral ganglia, the cartilage plate and the bone below it. Care should be taken to protect the dural sac and spinal nerve roots during surgery. To avoid injury to the nerve roots on both sides and the surrounding blood vessels, the corresponding type of C hook can be used. Or the pad is protected with a cotton sheet. After that, the residual tissue in the vertebra was removed with a nucleus pulposus and rinsed with iced saline. D. Using a tap to tap the internal thread of the vertebral joint: use the same type of internal thread mold - tap, and drill evenly into the depth along the direction of the ganglion ring saw, the depth is about 25 ~ 30mm. Then spin out, remove residue and rinse off. E. Screw into Cage: Use the Cage loader to implant the selected interfacial implant (filled in the cavity for the broken bone) into the intervertebral space in a clockwise direction. The front and rear position is preferably 3mm from the front edge of the vertebral body; the upper and lower positions should be symmetrical, so that the upper and lower sides of the implant are evenly embedded into the upper and lower vertebral cancellous bones, so that the new bone grows. Depending on the length of the vertebrae and the Cage specifications, one or two can be screwed in. After that, the area is rinsed clean, and the surgical field is left with 1 or 2 pieces of absorbent gelatin sponge. F. Sew and cut the layers in sequence: After the operation, the local area is free of foreign matter, and after rinsing again, the layers are sutured in sequence. Anterior surgical procedure: 1 anesthesia: more general anesthesia or epidural continuous anesthesia. 2 position: supine position, the waist of the operation side is slightly higher than 10 ° ~ 15 °. 3 Incision: According to the condition and the habit of the surgeon, one of the following incisions may be selected as appropriate. A. Front side median incision: mainly used for those with thinner body shape. After routine disinfection and draping, along the outer edge of the rectus abdominis sheath (to avoid the large blood vessels of the lower abdomen, more from the left side, but the right side of the lesion is still right to enter) to cut the skin, subcutaneous Tissue, and after suturing the surgical field with a therapeutic towel, the anterior sheath of the rectus abdominis is first longitudinally cut 0.5 to 1.0 cm inside the lateral edge of the rectus sheath, and then the rectus abdominis is pushed to the medial side to expose the rectus sheath. (The bottom is very thin, should be noted when separating), cut longitudinally to reach the extraperitoneal. B. The anterior median incision: that is, the incision is made along the midline, and the extraperitoneal space is exposed, which is less used than the former. C. Oblique incision: a conventional lower abdominal Mai's surgical incision, which is biased upward or downward depending on the site of the vertebral joint. Cut the skin and subcutaneous tissue, suture the incision with a treatment towel, cut the extra-orbital oblique muscle sheath and separate the muscle fibers, then use the straight vascular clamp head to pass through the intra-abdominal oblique muscle and the transverse abdominis in the middle of the surgical field, and The assistant alternately separates the muscles to the sides of the peritoneum (not too deep). When the finger can be extended, the surgeon holds the handle with one hand, and uses the fingers (index and middle finger) to separate the deep abdominal muscles and the deep muscles of the transverse abdominis to the patient's head. The surgeon and the assistant each hold a curved blood vessel. The forceps were clamped, cut, and ligated sutured symmetrically 1.5 cm from the rupture. This is repeated several times to reach the length of the incision. After that, use your fingers to push the peritoneum and internal organs to the right. The positioning of the lower lumbar vertebrae is generally more difficult, mainly based on the relatively clear anatomical features of the lumbosacral angle. In order to avoid mistakes, the camera should be positioned during the operation or under the perspective of the C-arm X-ray machine. 4 Protect or ligature adjacent vessels: Since the authors advocate lateral (generally left) access, there is no chance of injury to the sacral nerve that plays a leading role in sexual function. The lateral vascular branch is protected by a cotton swab; if the lumbar artery or venous branch (or its branches) interferes with the surgical procedure, the blood vessel should be freed with a long right angle clamp when fully exposed. Double ligation through the medium ligature. When the ligature is confirmed to be correct, cut it. After that, the large S-tube in front of the vertebral body was gently pulled to the opposite side with a large S-strap with a cotton pad. And fully reveal the lateral side of the vertebral body. Intraoperative venous plexus should be noted during surgery. When the distal end is compressed, it collapses due to emptiness in the venous plexus, and its appearance is the same as that of the general retroperitoneal tissue, so it is easy to tear or cut when it is separated (mistaken as the anterior longitudinal ligament, etc.) And cause major bleeding. Generally can be avoided, in case of occurrence, the use of absorbent gelatin sponge compression can achieve the purpose of stopping bleeding, and pay attention to supplement the corresponding blood volume. 5 removal of the nucleus pulposus: for patients with nucleus pulposus or early prolapse, the nucleus pulposus should be removed before placement of Cage (no nucleus pulposus lesions do not need this step). The specific operation is as follows: A. Incision of the anterior longitudinal ligament: the left side of the intervertebral space is the midpoint (corresponding to the middle of the vertebral body), and the anterior longitudinal ligament is cut into a "ten" shape with a long-handled knife. 2 cm x 2 cm and peeled off to reveal the fibers of the outer layer of the annulus. B. Cut the fiber ring: use a sharp knife to cut the fiber ring cartilage into a ten shape with a depth of about 5 to 7 mm. C. Remove the nucleus pulposus: operate under traction. The specific steps are as follows: first use the small-sized nucleus pulposus to press the predetermined depth (waist 5 ~ 1 and waist 4 ~ 5, generally 2.5 ~ 3.0 cm) along the intervertebral space to the deep side to insert the side to slow the contents outward Pull out, generally more than the nucleus pulposus tissue remaining in the intervertebral space; at the same time, the nucleus pulposus protruding into the spinal canal has been fragmented, should be repeated many times, and replace the middle and large nucleus pulposus, do It may be completely removed. The operation should gradually extend from the shallow part to the deep part. Since the intervertebral space has a flat central shape and a thin flat edge, when the nucleus pulposus reaches the posterior margin of the intervertebral space, there is a sense of resistance and it is difficult to pass through (in the case of non-use violence), so it is safer. For small residual fragments, or in patients with narrow intervertebral space, special thin nucleus pulposus can be used to remove it. However, care should be taken not to be too deep. Generally, a section of catheter with a comparable caliber is placed at the expected depth of the nucleus nucleus for easy observation. The residual nucleus pulposus was removed again after 5 min. This is the experience of the famous Japanese spine surgery expert Zhong Yesheng. At this time, the residual nucleus pulposus tissue can be taken out, and its volume is not small. The author also confirmed this phenomenon during the operation. This may be due to the removal of the large nucleus pulposus, the intervertebral space due to the pressure reduction, the fragments in the spinal canal or intervertebral space edge to the middle. D. Ice isotonic sodium chloride injection rinse local: After confirming the removal of the nucleus pulposus, the intervertebral space is repeatedly washed with ice isotonic sodium chloride injection at 5-10 °C to remove small fragments in the intervertebral space. E. Absorbent gelatin sponge placement: A small piece of absorbent gelatin sponge is divided into two pieces and inserted into the strip to the front of the posterior longitudinal ligament behind the intervertebral space. 6 interface internal fixator implantation technology: compared with posterior surgery is relatively simple, but should pay attention to the position and direction of the implant. The specific steps are as follows. A. Ring saw drilling: Take a ring saw with a diameter of 11, 13 or 15 mm on the outside (the former is a small one, the latter two are used for medium or large implants respectively), along the original incision, before The middle part of the vertebral ganglia is drilled under the longitudinal ligament, and the intervertebral space tissue and the upper and lower laminae and part of the cancellous bone are removed. Then, the taken-out tissue is observed, and the bone tissue is left for bone grafting. B. Unscrew the incision in the vertebra: use a thread mold (tap) equivalent to the size of the implant to drill evenly into the deep direction along the direction of the ring saw. The upper and lower ends of the vertebral ganglion are symmetrically twisted evenly, and when they reach a predetermined depth (25-30 mm), they are unscrewed and the surgical field is cleaned. C. Screw-in interface internal fixation device: Insert the corresponding type of Cage implant (with the broken bone in the cavity) onto the loader, and drill it clockwise to the deep part, so that it happens to be in the middle of the vertebral body. Pay attention to the symmetry of the up, down, left and right and front and back directions; or insert the oblique line. According to clinical experience, one Cage can be placed in each intervertebral space, or one can be placed on the left and right sides of the posterior surgical procedure. It can also be taken obliquely, depending on the condition and the doctor's habit. However, the operation requires the anterior vertebral body to be pulled to the left side, the anterior longitudinal ligament is cut, and the sphenoid bone is implanted from the front of the vertebral section. Its operation is the same as the posterior surgery. D. Stitching the incision of the anterior longitudinal ligament: after repeated rinsing with iced saline, the absorbent gelatin sponge is left in place, and the cut anterior longitudinal ligament is sutured with a thick thread.

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