Posterior cervical open reduction and decompression fixation

Cervical spinal cord injury occurs quadriplegia, serious condition, respiratory complications often occur, and the mortality rate is high, so it is urgent to treat it. Cervical spinal cord injury has complete spinal cord injury, incomplete spinal cord injury, spinal cord semi-transverse injury, central spinal cord injury, anterior spinal cord injury, posterior spinal cord injury, and spinal cord injury without fracture and dislocation. Different types of cervical vertebrae have different indications for surgical treatment. For example, anterior spinal cord injury or central spinal cord injury caused by cervical burst fracture or cervical intervertebral disc injury, requiring cervical anterior decompression surgery, and central spinal cord injury or anterior spinal cord injury caused by cervical posterior extension injury , the need for posterior decompression surgery of the cervical spine. Curing disease: Indication Posterior cervical open reduction (decompression) fixation is applicable to: 1. Cervical fracture and dislocation, regardless of flexion compression or separation buckling, with or without articular process interlocking, can be combined with spinal cord injury. Although such damage can be restored by skull traction, but due to injury of the ligamentum flavum, ligamentum flavum, posterior longitudinal ligament, etc., the cervical spine often loses stability after healing, or the vertebral fracture healing loses the height of the front and causes cervical recurve. Caused by spinal cord damage, so you can choose open reduction and internal fixation to maintain cervical stability. 2. The indication for laminectomy and decompression is the compression of the spinal cord by laminar fracture. Another consideration for laminectomy is to explore and treat spinal cord injury. Once the cervical spine fracture and dislocation has been reduced, the spinal cord has been decompressed, but the spinal cord swelling and internal changes, there is still no decompression, such as local cold therapy or incision of dura mater decompression, the need for laminectomy. It should be limited to full and serious incomplete. 3. For the old cervical spine fracture and dislocation, because the anterior vertebral bone bridge connection can not be reset, but the vertebral arch has oppression to the spinal cord, the optic disc can also be removed for decompression. In such cases, the spinal cord is also compressed from the vertebral body in front of the spinal cord. Wherever the pressure is heavier, the decompression is performed. Contraindications For cases of fracture dislocation but severe comminuted vertebral body, the stability of the middle and anterior column has been lost, and the stability of the column after laminectomy is not suitable. Preoperative preparation In general cases, the skull is pulled before surgery. In addition to the joints, the majority of cases can be reset, which also decompresses the spinal cord. According to the general condition of the patient, the operation is scheduled early. However, it is estimated that the complete paraplegia within 6 hours after injury is not a spinal cord traverse, severe incomplete paraplegia, and those who intend to treat spinal cord injury early, do not have to wait. As long as the general condition allows, spinal cord injury can be treated surgically within a few hours. Surgical procedure 1. Incision revealed The midline incision of the item reveals the upper and lower lamina of the dislocation gap. 2. Dislocation reset For those who have no joints and joints, the head can be retracted and can be reset. There are joints and joints. Under the traction of the skull, a small periosteum screwdriver or a stripper is inserted into the facet joint to the front of the dislocation. Suddenly as a fulcrum, it is safe and slowly to subduct the articular process, so that it can return to the posterior superior articular process. At this time, the weight of the skull is reduced and the head is tilted back to reset. Because the cervical facet joint is short and flat, the front side is the side of the spinal dural. The insertion of the stripper does not damage the spinal cord, but it cannot slide to the midline. Therefore, it must be safe and there is no difficulty in resetting. 3. Laminectomy and decompression For the incomplete sputum, the spinal cord may not be explored. For the whole sputum and severe insufficiency within a few hours, the spinal cord injury can be treated. It is suitable for exploration and can remove the lamina of the dislocated vertebra. The central part of the spinal cord injury is the lamina of the dislocated vertebrae. Between the upper edge of the lower vertebral body, the lamina of the dislocated vertebra is removed, and the most severe part of the spinal cord injury is detected. In this case, the interspinous and ligamentum flavum has been broken, and the lamina can be directly removed from the lower edge of the lamina. For patients with laminar fractures and depression of the spinal cord, it is not possible to use a rongeur to insert a bite between the depressed fracture block and the dura mater, which will increase spinal cord injury. If the laminar fracture of one side of the vertebral plate is depressed, the lamina of the uninferior side should be removed first, the upper ligamentum ligament should be bitten, the ligamentum flavum of the lower edge of the inferior lamina should be cut, and the upper and lower ligaments should be clamped with two pliers. After lifting, use the stripper to insert under the sag fracture piece, and securely fracture the fracture block and then remove it. Pliers sandwiching the ligamentum flavum can also prevent the stripper from slipping off and the bone piece suddenly bounces back to damage the spinal cord. The decompression range should be to the inner edge of the articular process on both sides of the spinal dural, and the upper ligamentum flavum should be removed upwards. Downward, the dural can be exposed from 2 to 2.5 cm. Unless the spinal cord is swollen upward, there is usually no need to remove two The lamina, to observe whether the dura mater beats with the pulse beat, and there is no oppression above it. 4. Exploring and treating the spinal cord If there is no pulsation after the exposure of the dura mater, the tension of the touch is very large, indicating that the spinal cord is severely swollen. At this time, the dura mater should not be cut temporarily to prevent the swollen spinal cord from overflowing from the dura mater and aggravating the spinal cord injury. The treatment method is preceded by epidural cold therapy for 15 to 30 minutes, and the spinal cord swelling is slightly retracted, and then the dura mater is cut. If there is no obvious swelling of the spinal cord, the dura mater is directly cut, and one traction line is arranged on both sides of the midline of the dura mater. The small round needle 3-0 does not absorb the line, and the dura mater is sutured, and then the dura mater is cut in the middle of the two lines. However, the arachnoid membrane is preserved and the subarachnoid condition is observed. Acute wounds often have bleeding. If there is no bleeding, the arteries and veins on the back of the spinal cord can be seen. For example, the spinal cord has no obvious swelling, the color is white and pale yellow, the blood vessels on the back surface are clear, and the artery has beating. The amnion can be closed without cutting the arachnoid. If the spinal cord is obviously swollen, there is no cerebrospinal fluid or bleeding around, then the arachnoid is cut, and the bleeding is washed and sucked out. If there is bleeding in the spinal cord or a large local tension, the blood vessel can be avoided in the posterior sulcus, and the soft membrane can be cut with a sharp blade. It is best to cut the posterior midline of the spinal cord to the central part along the posterior median sulcus under the operating microscope. If a few drops of bloody fluid flow out, the central necrotic area is decompressed. Such a swollen diseased side should be treated with subdural cold therapy for 20 minutes, and the dura mater should be sutured continuously with a 3-0 line to continue the cold treatment. 5. Local cold therapy Cold treatment with ice physiological saline, the physiological saline bottle was placed in the refrigerator of the household refrigerator before the operation, the water temperature dropped to about 0 ° C, and was taken out when used. Use 2 silicone tubes or plastic tubes, cut 4 to 5 small holes in the side wall of the tube end, and place them on the epidural space. One is the inlet pipe and the other is the outlet pipe. One end of the inlet pipe is connected to the ice brine bottle, and the ice brine flows through the pipe to the epidural space and then flows out of the outlet pipe. During intraoperative cold therapy, the wound should be protected with a shawl. The spinal cord is covered with brain cotton to block the subarachnoid space. The iced saline can flow into the wound for 5 to 10 minutes without being discharged. After the spinal cord is swollen, the inflow and outflow pipes are kept, the incision is sutured, and the cold treatment is continued after the operation. The liquid flow rate of this cold therapy system is generally 5-7 ml/min, the water temperature at the inlet tube is about 0 °C, the epidural is 4 to 10 °C, and the outlet tube is 15 °C. 6. Fixed The simplest method of cervical spine fixation is wire fixation. Take the 18th wire, take the neck 5 (or neck 6) laminectomy as an example, the neck 4 spines are short and bifurcated, the wire bypasses the upper part, the kinks below do not slip, the lower neck 6 (or neck 7) spines The hair is long and downward, and the wire is wound around the lower edge of the base of the spinous process. The head is tilted back to the normal physiological lordosis curve of the cervical spine, and the wire is twisted. 7. Dislocation gap bone graft fusion In order to maintain stability, the dislocation gap should be bone graft fusion, the articular process should be scraped out of the rough surface, and the cut spinous process laminae can be cut into strips and planted on both sides. This method is simpler and easier, but the wire used should be thicker and softer to prevent breakage. The spinous process of the cervical spine is small, and the method of perforating and fixing the steel wire can break the fracture of the spinous process bone. It is now more secure with side block steel or shank screws. 8. Close the wound Layered sutured muscle layer, ligament fascia, subcutaneous and skin. Maintain the irrigation drainage system to secure the drainage tube to the skin (flush the drainage tube out of the skin next to the incision).

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