Zielke Anterior Derotation Spinopexy

Zielke's anterior derotation spinal fixation for the treatment of idiopathic scoliosis. Scoliosis is one of the most common spinal deformities. It means that one or several segments of the spine are bent laterally off the midline in the coronal plane, forming a curvature of the spine with a curvature of 10°. Diagnostic criteria, usually accompanied by an increase or decrease in the rotation of the spine and physiological lordosis and kyphosis in the sagittal plane. Scoliosis is a clinical diagnosis rather than an etiological diagnosis that can be caused by many diseases and can be divided into two broad categories depending on its cause. The first category is scoliosis, which is also known as idiopathic scoliosis. The initial onset age is mostly 10 to 13 years old. The diagnosis depends on medical history, symptoms, signs and necessary imaging studies. Current studies suggest that idiopathic scoliosis may be related to the following factors: 1 genetic factors; 2 hormone effects; 3 growth and development asymmetry; 4 connective tissue dysplasia; 5 neuro-equilibrium system dysfunction; 6 neuroendocrine system abnormalities; Others, such as older mother offspring and abnormal copper metabolism. The second category is scoliosis with known causes, including congenital scoliosis and neuromuscular scoliosis. Congenital scoliosis is a lateral curvature of the spine resulting from an imbalance in the longitudinal growth of the spine caused by vertebral malformations. The critical period of embryonic spine development is the fifth to sixth week of pregnancy, which is the time of the spine segmentation. Spinal deformity occurs in the first 6 weeks of pregnancy. The diagnosis of congenital scoliosis can only be made if an abnormality is observed on the radiograph of the spine. Neuromuscular scoliosis is a group of conditions characterized by loss of normal function in the brain, spinal cord, peripheral nerves, neuromuscular junctions, or muscles. It is generally believed that the loss of muscle strength or control of voluntary muscles, or loss of sensory function such as proprioception in young children with soft spine and rapid development is a factor in such lateral curvature. Most neuromuscular scoliosis is a longer "C" shape, involving the humerus, and common pelvic tilt, even small neuromuscular scoliosis continues to develop after skeletal maturity, many neuromuscular scoliosis Bending deformities require surgery. For idiopathic scoliosis, the degree of rotation of the vertebral body can be determined and measured by lateral displacement of the position of the spinous process or by displacement of the pedicle. According to the spinal range of the thoracic scoliosis and the functional structural state of the distal compensatory curve, King divided the thoracic scoliosis with structural scoliosis into the following types: 1King type I, the chest bend and the waist bend both exceeded the midline. "S" shape, the flexibility of the chest bend is greater than the waist bend; 2King II type, the chest bend and the waist bend are beyond the midline, showing an "S" shape, the Cobb angle and rotation of the chest bend are larger than the waist bend, and the waist bend is soft. More than the chest bend, the stable vertebra is often T12 or T11 or L1; 3King III type, the waist bend accompanied by the chest bend does not exceed the midline, and the waist bend is non-structural, generally no rotation in the standing position; 4King IV type, is a Long chest bend involving more spine, the vertebral vertebra usually enters the long thoracic curve at T10, L4, the appearance is abnormal, but L5 is still located in the center of the humerus; 5King V type, the upper and lower chest bends are structural, T1 upward chest The concave side of the bend is inclined, and T6 is often the boundary vertebra of the two bends. This classification system is mainly used to guide the selection of the level of fusion during orthopedic surgery. The pathological changes of scoliosis mainly show the lateral curvature of the spine. The first part of the curvature is called the primary side bend, and the opposite direction of the upper and lower bends is the compensatory side bend. In the intervertebral space within each bend, the concave side is significantly narrowed, and the convex side is widened, wherein the most convex portion, that is, the widest point of the convex side intervertebral space is the apex of the curvature. As the lesion progresses, spine rotation deformities are usually combined, and the development of the vertebral body, lamina, and pedicle is affected on the concave side. The soft tissue on both sides of the spine will also change, showing that the soft tissue on the concave side is contracted and thickened, while the convex side is elongated, thereby aggravating the vertebral deformity. Because the thoracic vertebra is a part of the thoracic spine, the thoracic and thoracolumbar scoliosis, the thoracic and ribs are also deformed accordingly, and the convex rib angle is increased to make the posterior chest wall a "razor back" deformity, and the concave side rib is horizontal. The side chest wall protrudes forward. Due to the above changes, the chest volume becomes smaller, and the internal organs are suppressed or displaced, so the cardiopulmonary function is affected to some extent, and the severe condition even causes the spinal cord to be compressed, causing spinal cord injury. An abnormality of the thoracic kyphosis of the spine over 50° is abnormal. If the anterior column of the spine is unable to withstand the pressure, causing the anterior column to contract, a kyphosis will occur. The posterior column of the spine is broken, and the inability to resist tension can also cause the posterior column to be relatively elongated. Abnormal kyphosis can be corrected by shortening the posterior column or extending the anterior column, or shortening the posterior column and extending the anterior column. Congenital kyphosis can be divided into three types, congenital vertebral body formation disorder (type I), congenital vertebral body segmentation disorder (type II) and mixed (type III). Treating diseases: scoliosis Indication Zielke's anterior derotation spine fixation is suitable for: 1. Idiopathic thoracolumbar scoliosis with posterior tibial deformity is the best indication. This method is better than the Dwyer method in fixing, and it can also correct vertebral body rotation and kyphosis. 2. The vertebral body attachment of thoracic scoliosis is poorly developed, the lamina is too thin, the articular process is too small, and it is not suitable for Harrington's rod correction or lumbar scoliosis with dural bulging. 3. Stiff thoracolumbar paralysis, requiring two-stage anterior and posterior fusion. 4. Those aged 12 to 18 years old. Contraindications 1. Involve scoliosis above T8. 2. Scoliosis with obvious pelvic tilt. 3. The patient's lung capacity and maximum respiration have been reduced by 40%. 4. Age less than 10 years old or osteoporosis. Preoperative preparation 1. Take the full-length positive X-ray of the spine and the full-spine full-shoulder slice to measure the degree of lateral curvature and vertebral rotation according to the X-ray film, and compare the suture position to measure the natural correction rate to understand the operation. Correct the maximum limit. For congenital malformations, especially those with suspected spinal cord longitudinal fissure should be performed first, and those with conditions can do CT scan or MRI. If it is confirmed that this disease is the first intraspinal bone septal resection. 2. Electrophysiological examination: those with conditions can perform electromyography or spinal cord evoked potential examination of paraspinal muscles and lower limbs. In order to understand whether there is spinal nerve damage, and as a control for intraoperative spinal cord monitoring. 3. Pulmonary function test: to understand the extent of lung function, such as the vital capacity of less than 60%, due to spinal surgery often reduce the original lung function by 15% to 20%, will lead to significant hypoxia. Therefore, lung function training must be performed before surgery, and the patient should perform deep exhalation training in the balloon. 4 to 5 times a day for 10 minutes each time, continuous 2 weeks will significantly improve lung capacity. 4. Blood biochemical examination: The normal value of blood CPK is 2130U/L. If it is obviously increased, especially in the anesthesia above 1000U/L, it is easy to develop malignant hyperthermia. Check blood potassium, sodium, chlorine and liver and kidney function, blood gas analysis Etc., can fully understand the basic situation of the whole body. 5. Skull pelvic ring traction: The most important step is the traction of the skull pelvic ring, which is towed in the traction frame during the day and in the semi-recumbent position on the slope bed at night. The time is as long as 9 to 12 weeks. By pulling, the soft tissue is relaxed, and the deformity is corrected to a considerable extent. 6. Bed and toilet training: After the hospital, the patient trains in the bed to urinate and urinate, which can prevent urinary retention and constipation due to unaccustomed operation, and can enable the patient to learn the correct axial turning method after surgery. 7. Application of antibiotics: intramuscular injection or intravenous administration of a sufficient amount of broad-spectrum antibiotics 24 hours before surgery can maintain the effective antibiotic concentration in the blood during surgery, and play a positive role in preventing postoperative infection. 8. Skin preparation: Because the patient's back is uneven, it is necessary to master the skin preparation method. Do not shave the skin. For those with folliculitis, 2.5% iodine is applied locally. In severe cases, it can be treated with reasonable treatment. All the folliculitis can be treated before it can be treated. 9. Preoperative positioning: After routine disinfection of the skin, the injection needle was inserted into the side of the spinous process in the center of the predetermined incision, and the vertebral body was confirmed by X-ray film, and then 0.5 ml of 1% methylene blue solution was injected. When the surgery is to be performed on the next day, the extent of the lamina can be accurately revealed. If the methylene blue solution has been absorbed during surgery (no injection of methylene blue solution into the periosteal tissue), it is best to further locate the intraoperative film. 10. Prepare blood for 800 to 1000ml. Surgical procedure Incision A combined chest and abdomen incision was made with the spine. An oblique incision is made on the surface of the rib to be resected and extends to the outer edge of the rectus abdominis. 2. Reveal the vertebral body and remove the intervertebral disc (1) Revealing the vertebral body: the 10th rib is removed according to the conventional method, and it is retained as the bone grafting material. The periosteum and the parietal pleura of the rib are longitudinally cut, and then the retractor is placed to retract the incision and then collapse. The lungs are retracted, the transverse angle is cut, and the aorta, inferior vena cava, kidney, and abdominal organs are pushed from the extraperitoneum to the opposite side. At this time, the vertebral body in the main convex range can be fully revealed, and the intercostal blood vessels and the traversing motion and the veins are firmly ligated. (2) Resection of the intervertebral disc: According to the patient's preoperative standing position X-ray film to determine the extent of the fixed vertebral body, the vertebral body is made of subperiosteal peeling, and then the intervertebral disc is wedge-shaped, the wedge-shaped base is on the convex side, but the concave side is retained. Fiber ring. The periosteum at the edge of the vertebral body was peeled off by 0.5 cm to prevent soft tissue from being embedded between the vertebral bodies. 3. Mounting screws and spinal orthosis The diameter of the vertebral body is measured and the length of the screw is determined to be passed through the contralateral cortical bone. The vertebral bodies in the fixed range are respectively fixed by screws. First use a drill bit to punch holes in the vertebral body, and the surface of the vertebral body is protected with a backing ring. Then screw in the hole in the vertebral body with a screw with a hole in the head. The vertebral bodies at the upper and lower ends of the scoliosis must be screwed with the side opening of the head, while the middle vertebral body is replaced with a screwdriver with a central opening in the head. The openings in the heads of these screws are specifically designed for the installation of threaded rods. When the screws are installed, insert a shapeable stainless steel threaded rod (ie Zielke rod) from the opening of each screw. Centering on the midpoint of the side bend, a C-ring is placed in each screw head to prevent the Zielke rod from sliding when the spine is orthopedic. Then use a rotating rod to perform derotation and pressurization until the spinal correction is satisfactory. The screw heads of the upper and lower vertebral bodies are fixed by two nuts. The screws of the middle vertebral body are fixed by only one nut to prevent the Zielke rod from sliding, and then the Zielke rod is gently turned to the front side of the convex side, and tightened again. Nuts. When the spine is rotated, the intervertebral space is embedded with the autogenous rib or tibia. The nut at both ends is tightened, and the deformity of the spine is further corrected. Then the threads at both ends of the compression rod are broken to prevent the nut at both ends from loosening. 4. Close the incision After completely stopping bleeding, flush the wound with saline and place a negative pressure drainage tube. The thoracic and lumbar vertebrae were covered with a parietal pleural and psoas muscles, respectively. Close the incision layer by layer. complication Zielke's anterior derotation spine fixation replaces Dwyer's steel cable with a strong, contoured threaded rod, so it can correct the kyphosis and correct rotation, thus avoiding the disadvantages of Dwyer surgery to aggravate kyphosis. . Other complications were associated with Dwyer spinal orthopedics.

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