What Is a Posterior Bulging Disc?

Spine kyphosis is due to muscle ligament relaxation, osteomalacia, skeletal deformity caused by gravity due to standing for a long time.

Kyphosis

Scoliosis Abstract

Spine kyphosis is due to muscle ligament relaxation, osteomalacia, skeletal deformity caused by gravity due to standing for a long time.

Scoliosis is a common spinal deformity. Normal human thoracic kyphosis is less than 50 °. The apex of kyphosis is at T6 ~ 8, which forms a balanced physiological arc with lumbar lordosis. At this time, the sagittal gravity vertical line passes through C1T1T12 and S1 to maintain the optimal physiological curve and body. Balance to ensure that the human body can look forward normally. Congenital spinal deformity, spinal trauma, tuberculosis and other diseases can lead to an increase in the angle of kyphosis. When the kyphosis is greater than 60 °, the deformity will continue to aggravate and cause back pain, and even paraplegia will occur. Generally, corrective treatment is required [1, 2]. The classification and surgical treatment of kyphosis and the existing problems are summarized in the following in conjunction with the author's practice.

Scoliosis classification

1.1 Non-stationary deformities such as postural kyphosis, kyphosis caused by weak muscle strength or compensatory chest kyphosis with increased lumbar lordosis.

1.2 Fixed deformities such as Hume's disease, ankylosing spondylitis (most common), kyphosis caused by senile osteoporosis, deformities caused by congenital posterior hemivertebra, tuberculosis or trauma.

2 Surgical treatment of kyphosis

2.1 The purpose of surgery to restore the forward curve and the physiological curve of the sagittal plane of the spine.

2.2 Some factors related to surgical design [3, 4] a) Ankylosing hip joints should be replaced with joint replacement first. b) Multiplanar osteotomy is best for severe kyphotic deformity, generally 60 ° ± deformation, only one plane is sufficient. c) When the neck is stiff, the correction should not be excessive. The correction angle should be designed according to the angle between the eyebrow jaw line and the body's gravity line. The angle between the eyebrow jaw line and the mandible line and the body's gravity line. Generally 20 ° is appropriate, so that you can see the desk and 10 feet under your feet after surgery. d) The osteotomy should be selected at the anterior longitudinal ligament without ossification. If it is ossified, it should be loosened anteriorly or the posterior wedge osteotomy or transpedicular approach can be used. e) The width of the osteotomy is wedge-shaped 521 (2 cm at the posterior margin of the vertebral body at 5 cm between the spinous processes and 1 cm).

2.3 Surgical methods and operations

2.3.1 Some methods suitable for ankylosing spondylitis [5-14]

2.3.1.1 SmithPeterson method

[5] Created in 1945, V-shaped osteotomy at the back of the spine strong posterior extension (the operator on the table presses the back and the assistant on the table raises the shoulder) closes the osteotomy line internal fixation. During the operation, pay attention to the thinness of the inner plate of the V-shaped laminae to prevent the inner plate from compressing the spinal cord during closure. Disadvantages: People with calcification of the anterior longitudinal ligament cannot use this method; elderly people with arteriosclerosis should not tear the abdominal artery.

Internal fixation method: Early use of spinous process steel plate method, Harrington pressure stick method (not easy to operate) began in the 1980s. In recent years, C-D, CDH, TSRH method and so on have been used, but the price is expensive, it is difficult to hook, and the transverse process Easy to break. In severe ossification, the pedicle positioning structure disappears, often causing surgical difficulties. In the past 3 years, the correction with PRSS method is not only cheap, but also firmly fixed and easy to operate, and can prevent paraplegia caused by excessive posterior correction. For short-segment correction, we have tried Dick fixation. The short-term effect is good, but after a long-term follow-up, recurrence deformities appear at the upper and lower ends of the osteotomy, so the upper fixation must still reach the level of the third vertebra above the thoracic kyphosis. However, if the kyphosis is mainly in the lumbar spine, and the lumbar deformity is corrected, the thoracic kyphosis is close to normal, and it can also be used for short lumbar spine fixation.

2.3.1.2 After the osteotomy of the lamina and the pedicle of the Thomasson method in Hong Kong and the Thomason method in Japan, the cancellous bone in the vertebra was emptied through the pedicle, and the posterior vertebral body correction method was compressed. We improved and simplified this surgical method. Using a self-designed "Kyowa ring drill" with different angles [15], after the lamina osteotomy, a ring drill was inserted into the vertebral body through the pedicle, and the cancellous bone was removed by drilling to leave only the cortex of the vertebral body as an egg. Shell-shaped, and then pressurize the back to flatten the back of the vertebral body into a trapezoid with the bottom edge in front, and then fix it internally to achieve the purpose of orthopedics. This method is also suitable for those who have anterior longitudinal ligament ossification, and can avoid anterior loosening.

2.3.1.3 Vertebral osteotomy method Wedge vertebral wedge osteotomy was performed through the intervertebral space, and posterior compression correction was performed with a compression device. The disadvantage of this method is that there is slightly more bleeding. Care should be taken when osteotomy to avoid damage to the spinal cord and nerve roots.

2.3.2 Surgical treatment of Scheuermann's disease [16, 17]

In this case, more than 3 vertebral bodies (including the parietal vertebra) had an anterior wedge-shaped deformation greater than 5 °. Indications for surgery: Non-rigid deformity in children who have failed conservative treatment (Risser <3+) (those who can straighten a lot after a sleep); adults with kyphosis greater than 70 °, and those with back pain can undergo surgical correction.

2.3.2.1 Non-stiff people can use the Mor method for multi-segment facet joint bone graft fusion, and then perform posterior compression fixation. It should be fixed from T3 to L3-4, and the distal end must be at least the first vertebra of the lumbar lordosis. In order to prevent secondary kyphosis deformities above and below the operation.

2.3.2.2 The general method of stiff people is the same as that of ankylosing spondylitis. Because the deformity is mainly in the thoracic spine, because the ribs fix the thoracic spine, only the posterior osteotomy is used, and often the correction is unsatisfactory. Anterior loosening is required first. Resection of the small head of ribs in the area, loosen to the posterior edge of the vertebral body, otherwise it is not easy to work. It can be used as anterior support bone graft after loosening. Then turn over for posterior orthopedic fixation (or 3 weeks after surgery).

2.3.3 Congenital kyphosis [3, 4, 10, 11]

Its occurrence is mainly due to congenital anterior vertebral segmentation disorder (anterior vertebrae) and anterior vertebral developmental disorders to form wedge-shaped vertebrae (type I) or posterior hemivertebrae (type ), the latter treatment of braces has no effect as soon as possible. 95% of patients will rapidly develop and aggravate at the age of 8 to 15 years. Those with posterior hemivertebral body should be operated as soon as possible, because paraplegia is prone to occur. There are also hybrid types.

2.3.3.1 Simple posterior bone graft fusion is only suitable for those who are 5 years old and with a kyphosis less than 50 °. The fusion includes a deformed normal vertebra and a normal vertebra. After the rear is firmly fused, it is compensated by inhibiting the development of the normal posterior vertebra. Malformed kyphosis growth.

2.3.3.2 Anterior and posterior approach surgery is older than 5 years old, deformity above 60 °, anterior approach should be performed before anterior and posterior approaches, hemivertebral body resection is performed at the same time as anterior approach release of 1 to 2 segments above and below, and then At the hemivertebral resection, insert a Kirschner wire back to the small joint that is connected to the hemivertebra at the back to indicate the posterior spinous process laminectomy. The patient is more skilled and can perform surgery at the same time. Anterior and posterior surgery [3], that is, after the anterior hemivertebra is removed, the gauze fills the wound to temporarily close the incision, the patient's position is turned to the prone position, and then it enters the posterior spinous process lamina connected to the hemivertebra from the posterior approach. That is, the pedicle is removed, and then a posterior compression device is used for pressure fixation, and the posterior incision is sutured. The patient's position is then turned to the lateral position for anterior support bone grafting and fixation. It is generally safer to perform posterior surgery after 3 weeks. In patients with paraplegia, anterior surgery should be performed to completely decompress and remove the anterior compression of the spinal cord [17].

2.3.4 Treatment of senile kyphosis [3,4]

Surgical indications are: those with neurological symptoms, back pain or progressive kyphosis. The purpose of the surgery is to relieve back pain and fix the spine on a suitable physiological curvature to prevent the deformity from becoming worse. Surgical methods include anterior and posterior approaches, and anterior approaches are performed only when there are neurological symptoms. The special requirements for surgery are: due to severe osteoporosis of the patient, the lesion itself is not easy to control, and the fixation range during the operation must extend beyond the upper and lower posterior vertebrae. Internal fixation devices (two sticks) must be used on both sides of the vertebra, and the hooks must be large. In some cases, multiple rows of hooks are used to disperse the fixation stress and prevent lamina fractures at the fixation. In recent years, it has been suggested that pedicle screws are used for fixation, but osteoporosis can be easily loosened with pedicle screws. We use the PRSS method of the China Universal Device to obtain satisfactory results. It does not need to cut bones during placement, does not damage the rigidity of the lamina, nails are not easy to be fixed on the lamina, and the operation is easy to operate. Compared with European and American methods, it can reduce the operation time by more than an hour and reduce the surgical risk of the elderly.

2.3.5 Management of traumatic kyphosis [14,15]

In this disease, the surgical feature is mainly to relieve the anterior spinal compression caused by traumatic kyphosis, and correction of kyphosis is a secondary purpose of surgery.

2.3.5.1 Anterior decompression and support bone grafting method First, the fractured vertebral body is compressed to decompress the anterior spinal cord. In the past, many authors have stated that slotting into the back of the vertebral body near the spinal cord or scraping or using a small electric drill to remove the bone protruding into the spinal canal from the back of the vertebral body. We found that this operation is laborious, and the exposure is not good, and it is preferred to expose more widely. The upper and lower intervertebral disc tissue of the fractured vertebral body is first removed until it is completely loose, and then the fractured vertebral body is removed one by one from the front to the back. Curette, abrasive drill and pituitary bite forceps are used to remove the posterior cortical bone, then support the bone graft, re-implant the removed bone fragments, and fix them with anterior methods, such as Z-Plate steel plate and Kenada steel plate.

2.3.5.2 Posterior ring drill decompression and internal fixation orthopedic fixation method After spinal process lamina osteotomy through posterior approach, use Concord ring drill to drill into the vertebral body through the two pedicles of the fractured vertebral body and hollow out the vertebral body. For the posterior vertebral cancellous bone, scrape the cortex of the bone mass inside the spinal canal, and then use a special punch to strike forward to collapse the thinned cortex into the vertebral hollow, and decompress the spinal cord. Orthopedic fixation with PRSS and Chinese PRFS.

2.3.6 Tuberculous kyphosis [14, 18-19]

Combining drug treatment, lesion removal, and internal fixation can avoid the long-term bedriding ills of spinal tuberculosis patients in the past, and can also correct kyphosis at the same time.

Anterior lesion removal-bone grafting and internal fixation (Armstrong steel plate, Chinese ADS type I, type II and Z-Plate plate, etc.). The conditions of anterior bone grafting and internal fixation are that there is not much pus in the front, the lesion is completely cleared, no tuberculous granulation tissue, caseinous tissue and dead bone are visible to the naked eye, and the hardened bone is removed as far as possible until the bleeding point appears on the bone wound. Wash the wound, implant the hip bone block, take 2 ~ 3 gelatin sponges and apply 1 g streptomycin to fill the gap, and then fix it internally. If the anterior pathological lesions are more extensive, the infection is heavier, and the soft tissues are not healthy. It is best to use posterior bone graft fixation for posterior orthopedic fixation and orthopedic fixation with PRSS, TSRH, etc.

3Some problems and treatment in surgical treatment of kyphosis [18 20]

a) Nervous system damage and paraplegia. Spinal osteotomy, spinal canal decompression, compression, fixation, etc. are performed on the spinal cord and nerve edges, requiring higher surgical techniques, and the operation should be gentle. In addition, the following points should be noted. (A) T3 ~ 8 thoracic spinal canal is narrow. This feature should be understood when decompression in the front to prevent damage to the blood supply in front of the spinal cord. Decompression or discectomy cannot be performed from the back of the spinal cord. The thoracic spinal cord must not be concerned. Unfortunately, such paraplegia still occurs from time to time. (B) After ankylosing spondylitis kyphosis is a V-shaped osteotomy, the inner plate of the V-shaped bone should be removed and thinned before compression correction to prevent compression of the spinal cord. A flat V-shaped osteotomy should not be too large, otherwise a vertebral body at the osteotomy site may slip forward and compress the spinal cord to paralysis. When using PRSS for correction, pre-bent metal rods can be placed first and then pressure correction can be used to prevent the vertebral body from sliding forward at the osteotomy, thus avoiding this danger. (C) In patients with a wide range of osteotomy or decompression, spinal cord compression may occur after edema, and edema generally reaches a peak at 72 hours after operation. The author claims that 10 mg of dexamethasone is intraoperatively instilled in a small pot, and dexamethasone 10 mg in a small pot is continued to be infused 3 times a day after surgery (that is, instilled at 9 am, 3 pm and 9 pm) The drug was discontinued after 3 consecutive days.

b) Recurrence of malformations. (A) The short segment is fixed. (B) The long segment is fixed, but the upper segment does not exceed at least 3 vertebral segments above the parietal vertebra. Both of these methods are due to the correction of the kyphotic deformity above the body weight line still in front of the central axis of the body. (C) Loose or broken internal fixation. Often due to insufficient external fixation time, the bone graft at the osteotomy site does not heal. These cases require re-operation osteotomy and strong internal fixation, such as PRSS or TSRH.

c) Patients with cervical hyperextension. The thoracolumbar kyphosis was overcorrected so that the patient could not see the feet and things on the table, and was forced to perform a more dangerous cervical osteotomy.

d) There is still kyphosis at the waist, and its appearance is unattractive, which is caused by the inability to rebuild the lordosis or insufficient osteotomy after the osteotomy by using a flexible fixation (such as Harrington pressure stick).

e) The tuberculosis lesions are not completely removed. Forcible deformities are caused by placing an internal object in front of the tuberculosis, which causes recurrence of tuberculosis, sinus formation, and loosening of internal plants.

f) The old spinous process plate is still used for osteotomy, which cannot effectively fix the osteotomy, causing some cases of local pain and deformity to recur when getting up.

The correction of kyphosis is a more complicated surgical problem. Before the operation, the nature and deformity of the lesion should be comprehensively and thoroughly understood before a reasonable surgical plan can be formulated and ideal treatment results obtained.