What Is Posterior Cervical Surgery?

Posterior cervical disc herniation, also known as posterior cervical disc herniation, percutaneous posterior cervical disc herniation, and posterior approach to remove cervical disc herniation, mainly for the lateral type of shoulder and arm pain Patient with cervical disc herniation.

Posterior cervical discectomy

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Posterior cervical disc herniation, also known as posterior cervical disc herniation, percutaneous posterior cervical disc herniation, and posterior approach to remove cervical disc herniation, mainly for the lateral type of shoulder and arm pain Patient with cervical disc herniation.

Posterior cervical discectomy

Posterior cervical disc herniotomy; percutaneous posterior cervical disc herniation

Neurosurgery / Protrusion

80.5102

Disc herniation is a common clinical disease. Anatomically, there are no intervertebral discs between the vertebral bodies except cervical vertebrae and the sacrum. It consists of three structures: the nucleus pulposus, the annulus fibrosus, and the upper and lower cartilage plates. It is an important part of human spinal movement and resistance to longitudinal axis pressure. After 20 years of age, the water content of the intervertebral disc begins to decrease and the elasticity gradually decreases. Once the external force suddenly acts on the spine, it cannot evenly distribute the pressure, and the fibrous ring is partially or completely ruptured in the area with a large load, such as the posterior longitudinal ligament intact and the nucleus pulposus. Protrusion into the spinal canal is called herniated disc; sometimes the posterior longitudinal ligament is also torn, and the nucleus pulposus migrates to the epidural space, which is the prolapse of the nucleus pulposus (prolapse).

Intervertebral disc herniation can occur in any one of the intervertebral discs, but in the cervical, thoracic, and lumbar vertebrae, the disc herniation of the lower spine is more common. The incidence of intervertebral disc herniation was the largest in each spine, accounting for 85% of herniated discs, followed by cervical disc herniation, accounting for approximately 15%. Although there were 12 thoracic discs, there were very few disc herniations, Patterson (1978) statistics only accounted for 0.15 to 8%. The types of disc herniation are mostly divided into: lateral type; lateral central or ventral lateral type; central type.

In recent years, due to the development of neuroimaging, a far lateral protrusion of the lumbar intervertebral disc has been discovered, that is, the protruding part is on the anterolateral side of the articular surface. One of the reasons why the symptoms did not improve.

Lumbar disc herniation should be distinguished from lateral crypt stenosis syndrome in diagnosis. In addition to plain radiographs of the spine, CT cross-section, CT-myelography, and MRI are helpful in the diagnosis and differential diagnosis of the disease. In the clinical manifestations, the central type of protrusion showed quadriplegia and paraplegia in the cervical and thoracic spines, as well as sensory and sphincter dysfunction under the affected plane; in the lumbar spine, two legs and feet were numb, weak, and incontinent. Para-central type protrusions present in the cervical and thoracic vertebrae as hemilateral spinal cord injury syndrome; in the lumbar vertebrae, numbness in one side of the lower extremity, weakness of multiple nerve roots and cauda equina involvement. Lateral prominence is manifested as radiating shoulder and arm pain in the cervical spine, intercostal neuralgia in the thoracic spine, and sciatica in the lumbar spine.

Surgical treatment of this disease began in the 1940s, and surgical treatment was carried out in China in the early 1950s. The initial methods were mostly to open the window through the laminae of the ipsilateral diseased intervertebral space, or to remove the hemilateral lamina and ligamentum flavum, and then remove the marrow. nuclear. Cervical disc herniation is also a posterior approach. Laminae are opened with dental drills or rongeurs to remove the nucleus pulposus that compresses the nerve roots. Duan Guosheng et al. (1953) also reported the resection of cervical and lumbar disc herniation. This method of laminar drilling is still the ideal approach for lateral cervical disc herniation. Cloward (1958) first reported that a self-designed set of adjustable drilling depth circular drills and ring drills for bone removal were used to remove the central protruding disc tissue compressing the cervical spinal cord through the anterior cervical approach, which is safe and effective. At present, international applications are relatively common. Wang Baohua (1963) also reported anterior surgery. Thoracic disc herniation was originally performed as a laminectomy, and the anterior disc tissue was removed by the spinal cord. However, due to the narrow thoracic spinal canal, the spinal cord was stretched and compressed for a long time during operation. Some authors reported that the effect was not satisfactory. Crafoord (1958) and Hulme (1960) reported a transthoracic and transvertebral canal approach to resect a thoracic disc herniation that compresses the spinal cord, with good results. At present, the transthoracic approach is still used to remove the nucleus pulposus in front of the spinal cord. universal.

In recent years, with the development of imaging diagnostics, the clinical application of microsurgery and the development of new and applicable surgical instruments, the accuracy and surgical effect of disc herniation in various parts have significantly improved, and the surgical methods of distal and lateral lumbar disc herniation have significantly improved. , Also achieved good results. Currently, endoscopic resection of cervical, thoracic and lumbar disc herniation is increasing, but Dickman emphasizes that surgeons must be specially trained and work under the guidance of experienced experts.

Spurling et al. (1953) used a dental drill to drill holes between the lamina and the articular surface. Scoville called it key hole foramenotomy. Some authors also used hemi-lambular resection, including articular surface. Most or all resections. It is generally believed that total resection of one articular surface can affect the stability of the cervical spine. Many authors have used the anterior cervical approach to remove various types of cervical disc herniation, but anterior surgery is used for lateral patients with nerve compression. The operation seems to be too large. Therefore, many authors such as Raynor et al. (1985), Colias et al. (1987) and Aldrich et al. (1990) still advocate posterior approach, especially the application of microsurgical techniques. The operation is less traumatic, the hospital stay is short, and early recovery can be achieved after surgery.

Posterior cervical disc herniation is applicable to the lateral (or posterolateral) type of cervical disc herniation, which causes severe shoulder and arm pain, numbness and weakness in the affected limb, and is ineffective through conservative therapy.

1. The central type and lateral type (or ventral ventral) type of cervical disc herniation, the posterior approach is highly invasive.

2. Spinal cervical spondylosis, which is difficult to perform after surgery.

1. General preparation for the whole body According to the condition and examination, actively improve the overall condition of the patient, and give various necessary supplements and corrections.

2. For those with constipation, give laxative before operation, and give enema before operation. For patients with urination disorders, urethral catheterization should be performed before the operation, and the catheter should be left.

3. Those who need to be prone after surgery should perform prone training in advance so that the patient can adapt to this prone position.

4. Sedation was given the night before surgery, phenobarbital 0.1g.

5. Fasting for 6 to 8 hours before surgery.

6. Prepare the skin of the surgical field and clean and shave the day before the operation, and the range should be more than 15cm around the incision.

7. According to the needs of anesthesia, give medication before anesthesia.

8. Preoperative positioning The position of the spine where the laminectomy is to be removed should be determined before the operation. The easiest method is to locate according to the body surface landmarks. Due to the difference in body shape, there may be 1 or 2 spinous process errors in the positioning of the marks. In order to avoid errors, you can first locate the body according to the body surface mark, and then stick a lead on the body surface of the corresponding spinous process with adhesive tape.

Endotracheal intubation was performed under general anesthesia, and the lateral position was taken.

Surgical incision

The midline incision at the back of the neck is 6-8cm long, and the incision can be 4-5cm during microsurgery.

2. Intraoperative positioning

According to the surface anatomy of the spinous process of the seventh cervical spine, in the estimated lesion plane, an injection needle was inserted into the interspinous process ligament to a depth of 1 to 1.5 cm, and a lateral radiograph of the cervical spine was taken to determine the intervertebral space of the lesion.

3. Exposing the laminae and articular surfaces

Use a periosteal screwdriver to peel the paraspinal muscle from the spinous process and the lamina outward to the articular surface, revealing the upper and lower lamina of the diseased vertebral space. Use a unilateral automatic retractor to pull the paraspinal muscle to the outside. Soft tissue on the articular surface.

4.Keyhole-like window opening

A high-speed mini-drill is used to drill holes adjacent to the lamina and the articular surface. The medial part of the articular surface is excised no more than 1/2 of the full articular surface to form a bone window with a diameter of about 1 cm.

After the bone window is formed, the ligamentum flavum is removed, and the epidural fat should also be removed. Be careful not to damage the venous plexus. Once the venous plexus bleeds, the amount of bleeding is often very large. You can use bipolar electrocoagulation to stop bleeding, or you can use a tail line cotton sheet to stop bleeding. The lateral part of the dural sac and the nerve root cuff are exposed. The thick sensory root is in the superficial part, and the thin motor root is in the deep part. It is squeezed tightly by the protruding intervertebral disc tissue.

5. Nucleus pulposus

Generally, the nerve root is pulled upward, and the protruding part of the intervertebral disc can be cut. However, according to recent data, many patients see that the nucleus pulposus or its fragments have been prolapsed from the fibrous ring and the posterior longitudinal ligament. Removal by nucleus pulposus, and then check the adjacent epidural space for scattered nucleus pulposus fragments, and whether there is prominent nucleus pulposus in the intervertebral space breach. It is removed at the time of discovery, but deep resection into the intervertebral space is generally not recommended. Intervertebral disc tissue.

6. suture incision

Deep fascia, subcutaneous tissue and skin are sutured layer by layer.

1. Do not pull the dural sac excessively during the operation, and release the pressure plate for several minutes on time to prevent the cervical spinal cord from being pressed for too long and the neurological symptoms will be worsened after operation.

2. The nucleus pulposus tissue that has prolapsed from the fibrous annulus and posterior longitudinal ligament to the epidural space and the debris that travels far away should be looked for to avoid omissions and affect the postoperative efficacy.

1. Postoperative supine or lateral lying, preferably on a hard board. Keep your body straight and avoid twisting when turning over.

2. Postoperatively, we should closely observe whether the extremity dysfunction is aggravated, whether the sensory plane is rising or falling, if it is rising, it indicates that the spinal cord function is further damaged, and the cause should be actively found out and dealt with in time. Cervical spine operators should pay close attention to breathing.

3. Pay attention to whether there is cerebrospinal fluid outflow from wound drainage. If there is more cerebrospinal fluid outflow, consider removing the drainage in advance. Drainage is generally removed 24 to 48 hours after surgery.

4. People with paraplegia should be treated as paraplegia.

5. After high neck surgery, sometimes central high fever can occur, which should be treated in time.

6. Postoperative hard collar for 4-6 weeks.

1. Postoperative limb numbness and weakness caused by excessive traction of the nerve root during operation, mostly temporary.

2. Epidural hematoma The paraspinal muscles, vertebrae and epidural venous plexus are not completely hemostatic. Hematomas can form after surgery, which can lead to exacerbation of limb paralysis, which usually occurs within 72 hours after surgery. Hematomas can occur even when a drainage tube is placed. If this happens, you should actively check to remove the hematoma and stop bleeding completely.

3. Spinal edema is often caused by surgical operations that damage the spinal cord, and the clinical manifestations are similar to hematomas. Treatment is based on dehydration and hormones. In severe cases, such as dura mater has been sutured, surgery can be performed again to open the dura mater.

4. Cerebrospinal fluid leakage is mostly caused by inadequate suture of the dura mater and / or muscle layer. If there is drainage, it should be removed in advance. If the leakage is small, change the drug for observation. If the leakage cannot be stopped or the leakage is large, the leakage should be sutured in the operating room.

5. Incision infection and dehiscence are generally poor. Poor incision healing ability or cerebrospinal fluid leakage are prone to occur. Attention should be paid to aseptic operation. In addition to antibiotic treatment after surgery, the general situation should be actively improved, with special attention to protein and multivitamin supplementation. In special areas, such as between the shoulder blades, muscle layer sutures should be strengthened.