The operation of spinal fracture and dislocation combined with paraplegia

The spinal cord is located in the spinal canal and is closely related to the spine. Therefore, fracture and dislocation of the spine, whether closed or open, is more likely to cause spinal cord injury. Generally speaking, spinal fractures without spinal cord injury rarely require surgical treatment; cervical spine fractures are commonly used for reduction and fixation of skull traction, and functional reduction of thoracic and lumbar fractures. In recent years, with the advancement of technology and the improvement of internal fixation equipment, the use of open reduction and internal fixation for the treatment of thoracic and lumbar fractures has an increasing trend. Spinal fracture and dislocation of spinal cord injury, often with reconstruction, decompression and internal fixation while exploring the spinal cord. The spinal cord parenchymal injury is currently not directly repairable. In recent years, people have tried omental metastasis to treat traumatic paraplegia. It is reported that the curative effect is still good. In general, the operation of spinal cord injury is often decompression. The purpose of the operation is to remove foreign bodies and relieve oppression. It should be implemented as soon as possible. Spinal cord decompression can be performed from the posterior (via laminectomy), lateral posterior (transforaminal resection), or anterior (transverse vertebral resection). In recent years, most scholars believe that spinal cord injury caused by spinal fracture and dislocation, bone fragments and other pressure-induced substances are mostly from the front of the spinal cord, laminectomy is difficult to relieve the spinal cord compression, but also because of the removal of the lamina, cut off the spine and spine The ligament affects the stability of the spine and is advocated for use or not. However, if the fracture of the attachment has broken bone pieces into the spinal canal, it is better to use laminectomy. It is more convenient to explore the spinal cord through this route. The anterior decompression is mostly used for spinal cord injury caused by thoracolumbar and thoracolumbar fracture and dislocation. Treatment of diseases: spinal fractures Indication 1. Open spinal cord or nerve root injury should be debridement as soon as possible. 2. Paraplegic patients, x-ray or ct scan showed fracture and dislocation of the vertebral body or its attachment, fractures or intervertebral discs into the spinal canal, and compression of the spinal cord. 3. Incomplete paraplegia patients, corpus callosum increased or stopped recovery, lumbar puncture prompted subarachnoid obstruction. 4. Patients with advanced paraplegia, lumbar puncture showed subarachnoid obstruction, ct showed fracture deformity healing oppressed spinal cord, or bone compression and other compression of the spinal cord. Contraindications The patient is too old and should be filled with poor general condition. Preoperative preparation 1. The fracture is caused by severe trauma. The patient has severe pain and blood loss. Analgesic and blood matching should be given before surgery. For patients with poor general condition or existing shock, anti-shock treatment such as infusion and blood transfusion should be given, and the operation should be performed after the condition is stable. 2. Preoperative fracture site should be taken with positive lateral x-ray film to determine the location, shape and displacement of the fracture, which is convenient for determining the surgical procedure and internal fixation. For those who need to take x-rays during surgery, they should inform the radiology department and the operating room in advance to prepare. 3. The surgeon should propose the special equipment to be used and check whether the preparation of the equipment is complete, so as to avoid temporary preparation and prolong the operation time. 4. Open fractures should be treated with antibiotics and tetanus antitoxins; or if the original open fractures were delayed for more than 2 weeks, antibiotics and repeated injections of tetanus antitoxin should be used. 5. After the reduction and reduction, the internal fixation or bone graft should be used. The antibiotic should be intravenously administered immediately after anesthesia, and once every 6 hours, share 4 times. 6. The fracture site should have sufficient range of cleaning and disinfection preparations. The surgeon should avoid contact with the suppurative wound on the same day, and strictly follow the hand washing procedure to prevent the wound infection. 7. Patients who need to delay surgery for the first time should be towed first, can be reset, temporarily fixed, and can overcome soft tissue contracture, reducing the difficulty of resetting during surgery. 8. Need to simultaneously bone fractures, such as delayed bone fractures, slow healing fractures, etc., should be prepared for the bone area after surgery. 9. When conditions permit, the injury site should be ct or magnetic resonance imaging. 10. After the injury is stable, it should be worn as a lumbar, Quix test, and sent cerebrospinal fluid examination. 11. Within 1 week after the injury, dexamethasone, mannitol and other intravenous drip should be given. 12. Take various measures to prevent complications of spinal cord injury such as hemorrhoids and urinary tract infections. 13. Cervical vertebrae fractures with cervical spinal cord injury should be used for skull traction before surgery. 14. Intraoperative internal fixation, should be prepared for wire, spinous plate, Hastelloy stick, luque rod, pedicle plate and other internal fixation equipment for alternative use. Surgical procedure (1) laminectomy, spinal exploration and fracture and dislocation reduction and internal fixation 1. Position: Cervical surgery, the patient is lying on the head, and the head is placed on the "head support" to continue the skull traction. Thoracic and lumbar spine surgery, the patient prone, the fracture site is placed on the "bridge" of the operating table, in order to shake the operating table during surgery, so that the spine is flexed or over-extended to assist in the reduction. 2. Incision, revealing lamina: Use the posterior side of the spine to reveal the pathway (see the posterior side of the spine). 3. Excision of the lamina (as an example of thoracic laminectomy): the spinous processes of the thoracic vertebrae overlap in a tile-like shape, and the spinous processes of the upper thoracic vertebrae cover the lamina of the next thoracic vertebra. Therefore, when the laminectomy is performed, the spinous process should be removed from the proximal end of the incision and the lamina should be bitten from the bottom. After the spinous process and lamina are exposed, the interspinous ligament of the fracture site is removed with a knife, and the spinous process is removed from the root of the spinous process with a spinous process scissors or a large rongeur, so that the confluence of the two sides of the lamina is thin and easy to remove. . Use the side angle double joint rongeur to insert from the lower edge of the lowermost vertebral plate to be removed. After biting a lamina in the shallow surface of the ligamentum flavum, cut the ligamentum flavum transversely and place it close to the deep side of the lamina. A nerve stripper that separates the gap between the epidural fat and the ligamentum flavum to prevent accidental injury to the dura during removal of the lamina. The rongeur is then placed in the gap and the lamina is removed one by one from bottom to top. The extent of laminectomy. The upper and lower ends include the diseased vertebrae and one of the upper and lower lamina; the two sides abut the inner edge of the articular process, so-called total laminectomy. Articular processes should be retained as much as possible to avoid instability of the spine. If the articular process must be removed due to the removal of the lesion, only one or two of the one side of the articular process can be removed, and the contralateral facet must remain intact. If the lesion is only on one side or on one side, it can also be used as a half. (Single) lateral laminectomy. Should be noted when removing the lamina: 1 any rongeur can not be inserted into the spinal canal too much, so as not to dampen the spinal cord; 2 the rongeur must be fully opened before the spinal canal can be inserted, and should not be inserted into the spinal canal and then opened; 3 When the lamina is removed, the surgeon should hold the rongeur grip in one hand and the end of the forceps with the other hand, and bite with the upward force to prevent the rongeur from sliding into the spinal canal and damaging the spinal cord. After laminectomy, bone oozing can be used to stop bleeding, and intraspinal venous hemorrhage can be stopped by a cotton tube. 4. Exploring the spinal canal and the spinal cord: Thoroughly stop the bleeding, rinse the incision, and protect the incision with a cotton strip to start the exploration. First explore the spinal canal, should pay attention to observe the integrity of epidural fat and dura mater, there are no broken bone fragments, hematoma, ruptured fibrous rings, ligaments or nucleus pulposus protruding into the spinal canal; if any, should be completely removed. After the cleansing, the spinal cord is probed. The epidural fat is first separated along the midline to reveal the dura mater. Check the dural color (normal hard film is white, shiny, such as dark red, suggesting contusion), with or without pulsation, and gently touch the dura mater with your fingers to check for localized bulges, lumps or sacs. When suspected spinal cord lesions or vertebral body posterior margin lesions, dural exploration should be performed. First, on the two sides of the midline of the dura mater, sew a needle pull line and clamp it with a mosquito clamp. Cut a small opening with a sharp edge between the two pull lines. Place the slotted probe to lift the dura mater and cut it along the slot with a sharp edged knife. Generally, cut 3 to 5 cm first, and then expand as needed. After the incision, pay attention to the color and quantity of cerebrospinal fluid, whether there is pulsation, whether there is hypertrophy of the dura mater, whether there is adhesion of the arachnoid, hemorrhage or cyst formation. After adsorbing cerebrospinal fluid, check whether the thickness of the spinal cord is consistent, with or without kyphosis or mass. If you need to explore the front of the spinal cord, you can cut 1 or 2 dentate ligaments, which are located between the nerve roots, and you can use the nerve stripper or nerve root hook to gently pull the spinal cord; or use a mosquito clamp to clamp the dentate ligament At the end of the spine, gently pull the spinal cord and flip it slightly to the opposite side to reveal the front of the spinal cord. Pay attention to the presence or absence of displaced bone fragments or vertebral bodies, or the nucleus pulposus, or the ruptured ligaments to compress the spinal cord. The pressure-induced substances found during the exploration should be removed at any time, but for the pressure-induced substances in front of the spinal cord, It is difficult to treat the lesions in the front of the spinal cord due to the posterior approach, which is easy to damage the spinal cord and should be cautious. If the spinal cord is not pulsating, a thin catheter should be inserted into the subarachnoid space, and the proximal and distal ends should be slowly entered for a distance, such as barrier-free, suggesting that the proximal and distal ends of the fracture are free of obstruction. If the spinal cord has localized bulging, the sputum is soft, and a fine needle can be used to puncture from the posterior median groove. If the cyst fluid or bloody fluid is withdrawn, the razor blade is used to cut from the posterior median groove to remove the cyst or hematoma. If the spinal cord has been ruptured, softened or liquefied, it should also be removed. 5. Reposition: The flexion fracture and dislocation can often be reversed under direct vision, and the method of spinal overstretching is reset. After the spinal cord exploration, an assistant at the head of the patient holds the two sides of the ankle and pulls upwards. The other assistant holds the patient's eyes and pulls downwards. At the same time, the two ends of the operating table are slowly raised, and the spine is overstretched. At this point in most patients, the posteriorly displaced spine is gradually reset. If necessary, the surgeon and assistant can each hold a lion's forceps, clamp the spinous process at the proximal and distal ends of the fracture, and reverse traction and reduction. If the stage and the stage are closely coordinated, it will be more conducive to resetting. For those who have a sudden insertion, the upper facet of the lower spine should be removed and then reset. 6. Internal fixation: Because the spinal cord injury is caused by instability of the spine, the surgery destroys the supraspinous and interspinous ligaments, which aggravates the instability of the spine. In addition, patients with paraplegia cannot be externally fixed, and early activities and rehabilitation are required to reduce complications. Therefore, after the reduction of the paraplegic spinal fracture, internal fixation is often used. Fixed method: (1) Spinous process wire fixation: After the reduction, 1 to 2 spinous processes are respectively fixed at the head end and the tail end of the lamina. The advantage of the spinous process wire fixation method is that the method is simple and safe, and the patient burden is small. The biggest shortcoming of this method is that the fixation is not strong, and because the spinous process is cancellous bone, it is difficult to withstand the stress of the spinal activity. It is generally used for the thoracic vertebrae with less activity and the less severe cervical vertebrae. (2) Spinous process plate fixation: First select the steel plate with the appropriate length and curvature to be placed on both sides of the spinous process. The general length is 2 degrees of spinous processes at the head end and the tail end of the fixed laminectomy. When fixed, use a spinous process drill to drill holes in the spinous process, then place the steel plate and fix it with bolts. The advantages and disadvantages of this method are basically similar to the fixation of the spinous process wire. (3) Harrington rod (Harrington rod) fixed: that is, fixed with a harrington device. It is generally used for unstable thoracolumbar fracture and dislocation, especially for patients with complicated paraplegia. In principle, the spine is straight and fractured, and the dislocation of the spine is used for posterior fixation; the flexion fracture of the spine is dislocated, and the compression rod is used for posterior fixation, but patients with paraplegia are often used to open the rod. The fixed range includes the injured spine and 2 to 3 spines above and below the injured vertebra. In addition to the fixed effect, the harrington rod also has a reduction effect, which can reduce the dislocation of the fracture, restore the inner diameter of the spinal canal, and create favorable conditions for the recovery of paraplegia. In addition, the harrington rod fixation is stronger than the spinous process plate, which can be turned over early for easy care and rehabilitation. The harrington rod can support or compress the lamina to create fixation and reduction. Therefore, the design should be based on the type and location of the spine fracture (front, middle, and rear). However, the harrington rod has a wide range of exposure, and there is a lot of bleeding. It is generally necessary to wait for the condition to stabilize after surgery. In addition, the rotation of the spine is prone to decoupling or breaking of the harrington rod, thus losing the fixation. Therefore, the harrington stick has many disadvantages, which may be the first choice for the treatment of spinal fractures. The instruments and surgical procedures of the Harrington rod device are seen in scoliosis surgery. (4) luque rod fixation: luque rod fixed anti-bending stress and anti-rotation stress are larger than harrington rod, and the fixation effect is stronger than harrington rod. It is most suitable for unstable thoracolumbar fracture and dislocation with large range of motion, and spinal cord or cauda equina Injury. Since the luque rod is fixed without the function of opening the spine, it should be fixed after the first reduction is satisfied. The fixed range of luque rods includes the injured spine and three spines above and below the injured vertebra. The fixing method has a double rod fixing and a dome fixing. Specific surgical procedures are seen in scoliosis surgery. The main disadvantage of luque rod fixation is that multiple wires passing through the subvertebral spinal canal can cause spinal cord and nerve damage. In the process of rehabilitation, the steel wire can be broken and lose the fixation effect. It should be fixed with thick steel wire at both ends. 7. Stitching the dura mater and the incision: After the exploration is completed, the gauze and the cotton strip with the thread are counted, and after the number is correct, the dura mater is sutured intermittently. If the dura mater is defective, the sacral fascia fascia graft can be removed for repair. After completely stopping bleeding, the wound is washed and sutured layer by layer. The epidural external hose is drained under negative pressure, and the rubber tube is taken out from the incision. (B) lateral posterior approach decompression Lateral posterior approach pedicleectomy for the treatment of thoracic and lumbar fractures with spinal cord injury is more direct and reasonable, and is generally used in the following situations: (1) The flexion-type compression fracture is incomplete or completely paraplegic, and the X-ray or ct examination shows that the vertebral body is obviously kyphosis or dislocation, resulting in stenosis of the anterior and posterior diameter of the spinal canal; (2) After posterior laminectomy and decompression, the sensory recovery, and the athletes recovered unsatisfactory; or the sensory and exercise recovered to a certain extent and no longer progressed, and the x-ray film or ct examination showed that the spinal cord was under pressure; (3) Incomplete paraplegia, after non-surgical treatment for 1 to 3 months, spinal cord function recovery was not satisfactory, and x-ray or ct examination showed compression in front of the spinal cord. 1. Position: commonly used lateral or lateral prone position. Usually the heavier side is on the upper side, or the compression is obvious, or the side with the facet fracture is on. 2. Incision and exposure: the midline incision of the thoracic and lumbar spine, peeling off one side of the lamina and articular process, and continuing to peel off the transverse process, the pedicle and the side of the vertebral body, in order to clearly reveal, the sacral spine muscle can be cut off. Peeling should be carried out close to the bone surface, taking care not to damage the lumbar nerves and large blood vessels. General bleeding can be blocked by dry gauze to stop bleeding. Under direct vision, use a rongeur to bite the transverse process, use the lumbar nerve as a guide to expose the pedicle and intervertebral foramen. After cutting the pedicle with a small straight or curved bone knife, use a laminar rongeur The pedicle is bitten and the side of the spinal cord is revealed. In the process of resection of the pedicle, care must be taken not to damage the nerve root or spinal cord. If it is necessary to enlarge the exposure, one side of the articular process, the lamina, and even the upper and lower pedicles can be removed. 3. Exploring and decompressing: gently pull the dura mater with a dura mater to separate the adhesion between the dura mater and the vertebral body, and find out the location and extent of the compression. The anterior side of the spinal cord has broken bone fragments and hematoma. The ruptured ligament, nucleus pulposus and granulation should be completely removed. Old fractures often have scars, callus, callus or posterior vertebral compression of the spinal cord. The scar can be removed, and the epiphysis at the posterior edge of the vertebral body can be removed with a curved small bone knife. For the kyphosis and posterior vertebral body, in order to avoid damage to the spinal cord due to vibration, or extrusion of the bone, or missing the hand, it is best to remove the epiphysis and the posterior cortical bone of the vertebral body without a small piece of bone knife. Instead, use a hand drill to drill a row of holes in one side of the epiphysis, and use a small spoon to scrape the cancellous bone under the epiphysis. When only a thin layer of cortical bone remains, use the vertebral collapser to The convex cortical bone is pressed into the void where the bone has been scraped. The lateral direction of the decompression should be more than the midline, preferably to the contralateral pedicle; after the longitudinal direction, the posterior vertebral body can be flush with the posterior border of the upper and lower vertebral bodies, and the spinal cord is no longer pressed. 4. Stitching: After decompression, completely stop bleeding with bone wax, etc., suture layer by layer. Conventional negative pressure drainage tube. If the vertebral body is severely compressed or has been treated with laminectomy, interbody fusion should be performed to promote vertebral fusion and increase the stability of the spine. complication The fixation or graft bone is broken, dislocated or cracked.

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