Anterior cervical discectomy and interbody fusion

Cervical spondylosis surgery can be divided into anterior cervical approach, lateral anterior decompression and posterior laminectomy, semi-laminar resection and laminectomy. Treatment of diseases: cervical spondylosis of cervical spondylotic myelopathy Indication Anterior cervical discectomy and interbody fusion are applicable to: 1. Single-segment cervical spondylosis or radiculopathy with cervical spondylosis, non-surgical treatment can not be alleviated, and the symptoms and signs gradually worsened. 2. Cervical spondylotic myelopathy, which is aggravated in the short term, should be operated as soon as possible. 3. Sudden cervical spondylosis or induced by trauma, resulting in quadriplegia. 4. Cervical disc herniation is severe or progressive, and non-surgical treatment can not be relieved. Contraindications 1. The general condition is poor, or combined with important organ diseases, can not bear the surgical trauma. 2. Combined with other diseases such as ossification of the posterior longitudinal ligament of the cervical spine. 3. The diagnosis is not clear. Although there are symptoms similar to cervical spondylosis, there are doubts about imaging examination and nervous system examination. 4. Older patients, who lose normal self-care ability, can not cooperate with preoperative preparation and postoperative treatment is not suitable for surgery. 5. Cervical spondylosis has a long course of disease, combined with quadriplegia, muscle atrophy, and joint stiffness, indicating severe spinal cord injury. Even if decompression, spinal cord function is difficult to recover. Preoperative preparation 1. Move the trachea and esophagus training Especially for intraoperative anesthesia with cervical plexus block, the trachea and esophagus must be trained before surgery. The anterior cervical approach is to reach the front of the vertebral body through the gap between the visceral sheath and the vascular nerve sheath. Therefore, the visceral sheath should be pulled to the opposite side during the operation to reveal the front or side of the vertebral body. If the preoperative traction is not satisfactory, the operation may be suspended due to the inability to pull the trachea. If it is barely carried out, it may damage the trachea or esophagus, and even cause postoperative laryngeal spasm and edema. The training method is that the patient or another person uses the 2 to 4 fingers to insert the visceral sheath and the vascular sheath gap on the side of the incision outside the skin, and continuously moves to the opposite side. At the beginning, it lasts for 10 to 20 minutes, and then gradually increases to 30 to 40 minutes. The trachea must be pulled through the midline and trained for 3 to 5 days. This kind of pulling is easy to stimulate the trachea to cause symptoms such as reflex dry cough, and it is necessary to repeatedly explain the importance to the patient. 2. Bed urination, defecation training There will be several days of bed rest after surgery. In order to reduce the urinary tract infection caused by postoperative urination, defecation, and catheterization, urination and defecation exercises must be performed before bed. Surgical procedure Incision For the reduction during the operation, the right anterior oblique incision is used in the anterior cervical approach. The incision has a wide field of view and the incision is loose, which facilitates intraoperative traction. For patients who underwent anterior decompression alone, the right transverse incision of the anterior cervical approach may be used. The incision has a small scar and a good postoperative appearance. The length of the slit is generally 3 to 5 cm. 2. Exposure of the vertebral body and the front of the disc Cut the skin and subcutaneous tissue, cut the platysma muscle, and perform blunt and sharp separation on the deep side of the platysma muscle after hemostasis, 2~3cm above and below, and expand the longitudinal exposure range. The medial edge of the sternocleidomastoid muscle and the visceral sheath are loose, which is an ideal surgical approach. Accurately determine the carotid sheath and the visceral sheath of the neck, and the fascia between the medial aspect of the sternocleidomastoid and the visceral sheath of the sternocleidosis is lifted and cut open, and the lesion is expanded upward and downward along the gap. The department is a loose connective tissue that is easy to separate. The scapular lingual muscle can be seen on the outside of the cervical visceral sheath and can be directly exposed from the inside or from the outside. During the operation, the fingers were blunt loosened along the separated gaps, and then gently separated deep into the vertebral body and the front of the disc. When the superior thyroid artery is exposed, the superior laryngeal nerve is seen above it. If not seen, there is no need to probe and dissociate to avoid damage. After the cervical visceral sheath and carotid sheath are separated, the trachea and esophagus are pulled to the midline by a hook, and the carotid sheath is pulled to the right side to reach the vertebral body and the intervertebral disc space. Use the long scorpion to lift the anterior fascia and then cut it layer by layer, then longitudinally separate the fascia, and gradually enlarge the exposed vertebral body and intervertebral space, usually 1 or 2 intervertebral discs. Separation of the two sides should not exceed 2 to 3 mm of the medial edge of the long neck muscle. If the lateral separation is too large, it may damage the vertebral artery and sympathetic plexus that pass through the transverse process. 10.3 3. Positioning Fresh cervical spine trauma with vertebral fracture or anterior longitudinal ligament injury, can be positioned by visual observation. For old fractures or simple intervertebral disc injuries, it is sometimes difficult to distinguish under direct vision. The most reliable method is to remove the tip of the injection needle to retain the length of 1.5cm, insert the intervertebral disc, and take the lateral cervical X-ray film according to the X-ray film or C. The arm machine is positioned in perspective. 4. Open the vertebral body, reset For intraoperative reduction, there must be a cervical anterior vertebral body expander. Screw the spreader screw into the center of the upper and lower vertebral bodies of the dislocation segment, insert the spreader on the open screw, and open the upper and lower ends. For fresh cervical spine fracture and dislocation, those who have undergone posterior surgery reduction, open the vertebral body is beneficial to restore the height of the injured intervertebral space, reduce the compression of the spinal cord, and facilitate the operation during discectomy. For those who have not been reset, the vertebral body can generally achieve the reduction of the anterior approach, and even for the old fractures and dislocations, some can also achieve the reset. For those who cannot be reset, anterior decompression can be performed. 5. Remove the intervertebral disc The anterior longitudinal ligament was incised in an I or Z shape and peeled off to the sides to reveal the outer layer of the annulus of the intervertebral disc. Cut the fiber ring with a long-handled knife, the depth is 2 ~ 4mm, and the upper and lower blunt peeling apart. The nucleus pulposus extends through the annulus fibrosus into the intervertebral space, from shallow to deep, and the nucleus pulposus is removed from one side to the other. The force should be slow and the jaws should not be too big. If the intervertebral space is narrow, the nucleus pulposus clamp is not easy to extend, and the intervertebral space can be appropriately expanded by the vertebral body expander, or the patient can be pulled by the underarm staff. It is necessary to strictly control the depth of the nucleus pulposus into the intervertebral space, and the depth of the nucleus pulposus into the intervertebral space is generally controlled at 20 to 22 mm. If it is too shallow, it will not be able to grasp the prominent nucleus pulposus. In order to prevent the nucleus pulposus from extending too deep and causing spinal cord injury, a holster can be placed on the tip end of the nucleus pulposus as a depth marker. When approaching the posterior edge of the vertebral body, use a curette to scrape the residual disc tissue and cartilage plate. The nerve stripper was used for exploration, and the posterior edge of the vertebral body and the epidural space were unobstructed, and there was no residual pressure. At this time, the decompression was thorough. 6. Take bone and bone graft Cut a small piece of bone graft with a bone chisel at the left side of the sac, and trim the rules. The endplate cartilage above and below the intervertebral space is scraped off until there is bleeding. The cancellous bone surface of the bone graft is directed upwards and downwards, and the vertebral body is used to hit the intervertebral space. The end of the bone graft is 1-2 mm lower than the anterior edge of the vertebral body, and the bottom of the bone graft is kept 4 to 5 mm from the anterior wall of the spinal canal. gap. Loosen the vertebral body expander to make the bone graft tightly inserted. 7. Fixed For those who have not been retrogradely fixed, they must be supplemented with anterior cervical plate fixation. The vertebral body of the dislocation is fixed with a short plate to obtain an immediate stabilization effect on the anterior column of the cervical spine. Otherwise, the dislocation destroys the stability of the posterior column, and the anterior decompression destroys the stability of the anterior column. The stability of the three-column of the cervical vertebra is destroyed, and the bone graft is difficult to achieve bone healing. For those who have stabilized the posterior column, it is best to use the cervical anterior plate when conditions permit. 8. Suture incision The wound was repeatedly washed with ice physiological saline, the anterior cervical fascia was sutured, and a half-tube drainage strip was placed, and the incision was closed by layer-by-layer suture. complication Spinal cord and nerve root injury Spinal cord and nerve root injury are serious complications that can cause paralysis and even death. 2. Vertebral artery injury Vertebral artery injury is a serious complication, and if it is not effective, it can be fatal. 3. Esophageal and tracheal injuries Esophageal and tracheal injuries are caused by excessive traction, which can also cause accidental injuries during deep operation. Such complications are rare, but they can cause mediastinal infections, and the mortality rate is quite high, so it must be sufficiently vigilant. 4. Postoperative local hematoma formation Postoperative local hematoma formation is a serious complication. It usually occurs within 12 hours after surgery. Severe cases can cause asphyxia and must be observed closely after surgery. 5. Superior laryngeal nerve and recurrent laryngeal nerve injury Ligation and cutting of the upper thyroid gland may cause ipsilateral superior laryngeal nerve injury. When the trachea and esophagus are retracted, the contralateral superior laryngeal nerve may be pulled. After drinking water and cough, the latter usually takes several days. Can recover. Treatment of the lower thyroid vessels may damage the recurrent laryngeal nerve. One side of the recurrent laryngeal nerve injury may cause hoarseness and suffocation, and is mostly temporary. It usually recovers within 1 to 3 months after injury. 6. Cerebrospinal fluid leakage Cerebrospinal fluid leakage caused by dura mater, promotes the occurrence of infection and spreads easily to the central nervous system, hinders the healing of the incision and even causes the incision to split, and can also cause a decrease in intracranial pressure and loss of body fluid. The key to prevent cerebrospinal fluid leakage is the application of microsurgery technique during surgery to avoid unnecessary dura mater damage; if the dura mater needs to be opened, the cerebrospinal fluid can be drained for 3 to 4 days after operation, and the dura mater is as small as a pinhole. Treatment often heals itself, and larger defects often require repair with fascia or fibrin glue. 7. Bone grafts fall off Bone graft loss is a serious complication. The trimmed bone graft should be 2mm longer than the bone window, and the cervical vertebra should be opened when embedded, so that the intervertebral space is slightly enlarged. After the bone is embedded, the cervical vertebra is moved to see if the bone graft is loose. If it is loose, it will be embedded or trimmed before being tightly fitted. 8. Bone graft does not heal Non-healing of bone grafts rarely occurs. This procedure can be minimized as long as the endplate, bone graft and effective internal fixation are properly treated during the operation and effective braking is performed after surgery. 9. Infection The infection rate of anterior cervical incision is not high, but the infection of the incision can spread to the spinal canal, spinal cord, etc., leading to serious consequences, so it is necessary to pay attention to prevention. Closely repair the dura mater and suture incision to prevent cerebrospinal fluid leakage and incision splitting, and eliminate residual cavity is the key to prevent postoperative infection.

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