1 case of convex malformation after spinal spinal cord of strong straight spinitis with cervical vertebrae overstretched

Strong straight spinabitis (AS) mainly affects the middle shaft bone and joints, often from the joints to the head side gradually progress, the late stage is often prone to chest and waist section after convex malformationSome AS patients often affect the strength of the entire spine, including cervical, thoracic, lumbar, seriously affecting the quality of life of patientsCervical malformations are mostly cervical vertebral post-convex malformations, such as jaw-thoracic malformations, while cervical overstretched malformations are relatively rare, and those without serious deformities require more no surgical interventionWe can encounter some very special cases in theclinical, the chest and waist section after the convex deformity is very large, but the increase of the jaw eyebrow (CBVA) is not large, even still in the normal rangeThe reason for this is that humans are erect animals, when there is a serious chest and waist later convex deformity, the need to stretch the hip or knee (joint splevening) to obtain relative flat-eye function, while very few people through the transition head-up, that is, cervical vertebrae overstretchto to obtain flat-sighted functionIn such patients, correcting the convex deformity of the chest and waist section will inevitably reduce the CBVA angle, or even become negativeAs the cervical spine has been strongly integrated, the chest lumbar correction after the cervical vertebrae overstretched deformities brought about by the new series of discomfort will be shownThis presents new difficulties in the orthopaedic design of the amputation, and the overall treatment has to be considered through the quertmal diastogram of the cervical spine to correct the overstretched deformityHowever, there are few reports of such cases in the current literature, and there is a lack ofconsensusOur hospital admitted 1 case of severe spinal spinitis cervical vertebrae overstretched deformities, reported belowclinicaldatathe patient's male, aged 36He was admitted to hospital in October 2017 due to "spinal deformities and back pain"Patients 20 years ago no obvious cause found mild convex deformity in the spine, after the symptoms gradually worsened, lower back pain aggravated, can not lie flatIn the hospitaldiagnosisfor strong straight spinabitis, patients take medicine home treatment, pain relief after discontinuation of drugs, during the recurrence of symptoms, back pain deformities further aggravated, a large number of activities after the emergence of shortness of breath, can not normally engage in laborAdmission: the patient stood in front of the bend, the spine after the convex deformity, the whole spine active, passive activity is limited, the limbs active, passive activity freeAuxiliary examination: Full spinal positive side X-ray measured, chest vertebrae rear convex (TK) 93.8 degrees, chest lumbar section protruding 30.8 degrees, lumbar spine after convex 10.3 degrees, sacropic offset (SVA) 259mm (Figure 1)Although the patient has severe spinal post-convex malformation and is associated with a negative facial imbalance, but because of its cervical pre-convex (CL) increase disfigured to 50.6 degrees, CBVA is only 21 degrees (Figure 2), although the cervical vertebrae can not move, but he can still look forward, vision can meet the needs of daily lifeHowever, due to the inability to lie flat and normally upright, the requirements for surgery to improve malformations and improve the quality of life are more strongsurgical design therefore communicate with patients and family members, the proposed first stage of the chest lumbar spine post-convex malformation orthopedic orthopaedic, the second phase of cervical vertebrae overstretched deformity orthopaedicOne of the phases uses the asymmetrical bone-cutting method of two-section VCD to partially correct the post-convex deformity of the thoracic lumbar spine, and at the same time correct the imbalance of the coronal surfaceOn October 16, 2017, intra-heeding techniques were performed in the orthopaedic and vertebral arch nail stick system at the back of the whole hemp desaline spineSix months later, the patient underwent surgery on April 25, 2018 for joint bone amputation of the front and rear cervical vertebrae, fixed in the rear vertebral arch nail rod system, and in-front titanium plate screw fixingcervical vertebral surgery technique (Figure 3): after the success of anesthesia, the patient takes the reclining position, under the body floor plastic mat, the item part and pillow under the pillow and fixed, the routine disinfection spread sterile towel, take the neck front left oblique incision, cut the skin in turn Subcutaneous tissue and cervical muscle, along the thoracic prostrusion and the interstitial between the inner band muscle inward separation, through the cervical artery inner end up in the pre-vertebral fascia, cut open the pre-vertebral fascia, revealed C6, C7 front of the vertebrae The perspective confirms the C6/7 vertebral gap, automatically pulls the surrounding tissue to both sides and head and tail directions, first in front of the C7 vertebrae wedge cut bone, ultrasonic bone knife to remove the loose bone in the vertebral body, until the cervical vertebral post-turret ligament Front, with fluid gelatin and gelatin sponge plug bone cut tank to stop the bleeding, with gauze to the bone-cut vertebrae and front esophagus isolation protection, fill and simple stitching bandage wound, sterile plastic film to protect the front incision, sterile dressingThen the head frame fixed the head, take the lower position, the neck is midcut, cut the skin, subcutaneous tissue and fascia electric cut open ligament, along the ligament to the deep part of the ichito, to the two sides of the bone membrane under the peeling attached to the muscles attached to the ratchet, vertebral plate, automatic opener to the sides of the cut to reveal the cervical rear structure, In C4, C5, C6 and T2, T3, T4 two sides of the vertebral arch root into the vertebral arch root screw, perspective see the vertebral arch screw position is good, with the bite of the bone pliers, vertebral plate bite pliers and ultrasonic bone knife to remove C6, C7, and part of the T1 vertebral plate and C7 joint strusion and vertebral arch rootFull display of C7, C8 nerve roots, detection and expansion of the neural root canal, in C5, T2 line vertebral plate submersion decompression, to ensure that the nerves are free of oppression To intercept the appropriate length of orthopaedic titanium rod, pre-bend ingest the right chest screw groove, screw into the nut, by lowering the head frame to close the front bone gap, reset the cervical spine, while slightly to the left, to correct the coronary position imbalance Observe the epidural during the reset process, until the epidural is stretched, you can stop the bending operation Tighten the nut hold The perspective saw the cervical malformation correction, the sadular surface and the coronal surface balance is good Lock the fixing nut and rinse it with ice salt water to ensure low temperature of the wild spinal cord In the intra-fixed position of the perspective see good, thoroughly rinse the incision to remove the patient's head frame, turn over the patient again to take the reclining position, the routine disinfection of sterile towels Once again through the neck cut in turn into the surgical area, the automatic opener to two cases and head and tail direction to open the surrounding tissue, to see the C7 vertebral bone face completely closed, into a walk ingest titanium plate fixed, in C6, C7, T1, T2 vertebrae each placed screw two In surgery see the inner fixed position is good, thoroughly rinse the incision, inventory device dressing is correct, check for inactive bleeding, layer by layer stitching the incision Sterile dressing is wrapped and fixed outside the neck the results of the operation went smoothly, during the operation bleeding about 1300 ml, the transmission of AB-type foreign red blood cells 6U, ordinary frozen plasma 5.6U There was no significant change in electrophysiological monitoring of the entire spinal cord during surgery, sEP and MEP The patient is awake after surgery, the condition is stable, the limbs feel and exercise function is normal After surgery, patients with 3d wear neck braces to move to the ground After the first operation, TK, TLK, lumbar front convex (LL) and SVA were reduced to 65.0 degrees, 17.3 degrees, -43.6 degrees, and 131.2mm (Figure 3) Because the cervical spine is fully fused, the postoperative CBVA is -21.7 degrees (Figure 4) 6 months after surgery follow-up, the X-ray and CT see cervical vertebrae have been fused (Figure 5) At this time, although the patient restored the sabutatofacial balance, but can not be looked flat, affecting the quality of life The CBVA in patients after the second operation was 2.9 degrees (Figure 6) There are many design methods discussed the bone-breaking strategy of severe spinal itis Overall preoperative design: Song et al and Zheng and others proposed a personalized bone-cutting method based on the lung gate method, according to the patient's pelvic parameters to calculate the bone cut angle, restore the sapathic position balance Reconstructing sadgenic balance and restoring patients' flatvision is the most important purpose of post-spinal convex malformation surgery For patients with strong cervical spines, postoperative vision must be considered in the surgical design In a very small number of patients with severe scoliosis, as the back convexness of the spine increases, the patient maintains a horizontal field of view through cervical overstretching When the orthopaedics of such patients are considered only for the asaneous balance of orthopaedics, the patient may be able to look up after surgery and unable to look flat and bow, thus affecting the quality of life Therefore, when correcting the back convex of the as spinal spine with a strong cervical spine, it is usually compromised in maintaining functional vision and correcting the sapathic balance, at the expense of the latter to ensure that the patient can look forward against the front after surgery, and to ensure the field of vision by reducing the angle of the amputation cervical vertebrae is difficult, and there is a greater risk of nerve vascular damage In previous reports, most of the cases were cervical hindcon or flexor malformations, usually using a simple back path in the C7 or T1 vertebrae for wedge-shaped back-arming to correct the back convex deformity of the neck or chest section In previous reports, it was usually the cheumine of the C7 or T1 vertebrae that was corrected by a simple back path in the C7 or T1 vertebrae to correct the back bump of the cervical chest segment In this case, because the patient's cervical front convex large, for overstretchmal, it is necessary to reduce the cervical vertebral frontal convex, so that the patient can restore flat vision The technique of cervical protrusion orthopaedic sortruation has been relatively mature, while the coverage of cervical vertebrae over-stretching bone is relatively small Search the relevant English literature database, a total of 4 patients reported, the author summarized it as follows Sengupta and others in the side lysing downstream cervical vertebrae after the joint bone-cutting to reduce the patient's cervical front altrues In this case, first by the cervical vertebrae after the cross-section to remove the C7 vertebral plate and reveal the C8 nerve root, and then in the same position, through the cervical vertebral left forward oblique incision revealed C7 vertebrae parallel wedge cut bone, and then to assist Harroche frame cervical vertebral flexion closed, and then with the cervical vertebral front nail plate fixed This cervical diastolegation amputee is open at the rear and closed in front In addition, there is a fracture of the back wall of the vertebrae during closure, which also has a certain risk of spinal cord injury Kose et al have reported three cases of cervical overstretched malformation caused by Becker-type muscular dystrophy They used the front-to-rear-front-entry, first by reclining the front-path surgery, opting for a wedge-shaped bone centered on the C7/T1 disc, removing the C7/T1 disc and the upper and lower vertebrae, and then reclining the back-path destruct surgery to remove C7, T1 ratchet, interrataligament, side block or vertebral arch screw fixed, under spinal cord monitoring, by the under-the-counter assistant will bend the head and neck, visible C7, T1 ratchet between the obvious open; This amputee also has the risk of spinal cord extension, because the rear vertebral plate has not been removed, it is not possible to directly monitor the state of the spinal cord during orthopaedics, and Kose's method is suitable for cases of no bone fusion in the rear structure, so it is not suitable for patients with severe spinal scoliosis cervical vertebrae If Kose's method is to be used to deal with cases of bone fusion behind the cervical vertebrae, the removal of the later bone structure and neurodecompression need to be added on this basis In the cases reported in this paper, due to the severe convex deformity of the patient's preoperative chest and waist section, and CBVA is basically normal, such as the two-section cut-off design proposed by Zheng, we choose to be in T12, L2 (near the rear convex vertices, and relatively safe) The two-section cut-off bone, in the case of not considering the jaw eyebrow angle needs the bone cut angle is: T12 , 50 degrees, L2 , 60 degrees, although the patient's sacropic balance is restored, but after surgery the patient will look up to the sky, lose the horizontal field of view If you consider the jaw eyebrow angle and reduce the correction rate, according to the best CBVA calculation bone angle, then its size should not exceed CBVA plus (PT-tPT) s 49 degrees, which, although the patient's horizontal field of vision is guaranteed, but the deficiency of correction caused by the operation is still seriously out of balance Therefore, it is very necessary to adopt the strategy of staging surgery: the first stage of the thoracic lumbar section to amputate the bone, restore the sacroonal balance; simple back road through C7 to loose bone wedge closed cut bone can complete the cervical vertebrae or cervical chest after convex malformation of orthopaedic, but for cervical vertebrae overstretched deformity, the need for confraction of the bone, if the simple use of the front road or the back road can not be completed Simple back-cut bone is difficult to shrink the front column, reduce the front convex, and can not protect the front of the spine soft tissue, such as the esophagus Through extension of the rear column increases the risk of nerve damage Although the simple front surgery can shrink the front column and the center column, but because the rear column has been integrated, which makes the reset process difficult to complete If the post-front or post-front-front-after-entry is used, the state of the spinal cord cannot be monitored when reset and closed in the front, increasing the risk of spinal cord injury Therefore, in this case, we do not document the post-front-before-front-front-back-entry, but rather use the front-back-front-front joint entry to perform cervical flexor orthopaedics The first step of the front surgery in the C7 vertebrae row wedge-shaped bone, and the cut bone face should be vertebrae arch root, in fact, the cut-off of the bone is more similar to the trapezoid, equivalent to the apex of the wedge is located in the middle point of the vertebral arch or spinal cord plane, at the same time, because the patient's cervical spine is fully integrated, even after the front column cut bone, the rear structure still maintains the stability of the cervical vertebrae, to ensure the safety of the position transformation process In addition, first of all, the front altruical bone amputation can be isolated from the esophagus and the vertebral vertebrae with gauze, reducing the risk of damage to the esophagus After the completion of the second step of back surgery, the square vertebral plate decompression, through the C7 vertebral arch root amputation and reset process The C7 vertebral arch root amputation on the one hand can continue the wedge cut in front, on the other hand, through the C7 amputation bone can make the abdominal and back side space of the spinal cord connected, to avoid vertebral fractures or remove other potentially damaged spinal cord bone In addition, the spinal cord is always in direct looking during the reset process, which can avoid the occurrence of nerve damage to a certain extent, and the later circuit operator can control the degree and progress of orthopaedics according to the spinal cord state The third step of the first road before the titanium plate screw fixing surgery can not only increase the stability of the cervical spine in patients with strong scoliosis, but also can verify the closure of the front bone cut, to observe whether there is esophagus damage operation points and precautions: (1) in the course of previous road operation attention to protect the esophagus, in order to avoid the orthosis process, the front of the vertebrae closed damage to the esophagus and other organs, can be in the C7 vertebral wedge cut bone with an endoscopy sponge filling, while the gauze temporarily isolated the esophagus; Plex hemorrhage risk, affect ingestive process; (3) after the operation of the rear decompression must be full, especially for C7, 8 nerve root loose, decompression; (4) reset process attention on the stage, under the table close cooperation, control head frame activity and the operation on the stage should not be too large; (5) after the road consectional orthopaedic orthopaedic process observed during the epidural stretch, can stop the bending operation , we think that the front-to-post-front joint entry, c7 flexor bone can successfully correct the cervical transverse malformation of patients with strong spinal scoliosis, the precise bone-cutting design before surgery, fine operation in surgery is essential to the success of surgery Of course, cases of cervical overstretched malformation are relatively rare, and the safety and effectiveness of this technique has yet to be further clinically verified