Discussion of postoperative complications of cervical spine (2): What are the complications of posterior cervical spine surgery?

Faced with complications of cervical spine surgery, doctors in Shaanxi dialect are “very chaotic”. Literary and artistic people said “eliminating people’s haggardness for Iraq”, understanding the probability of complications, countermeasures, possible causes of complications and future outcomes, and prevention. Yu Weiran. In this issue, we will discuss the complications of posterior cervical spine surgery. 1. What are the complications of posterior cervical surgery? How to prevent and reduce it?  An article published in the 2016 Asian Spine Journal entitled “Complications of Anterior and Posterior Cervical Spine Surgery” (complications of anterior and posterior cervical surgery) is also explained in detail Let’s take a look at the complications of the posterior cervical spine.  Complications of posterior cervical spine surgery  01 Spinal cord and nerve root injury   According to reports, the total incidence of neurological complications is 0.18%. If severe cervical kyphosis correction has been received, the incidence will increase (2.6%). When posterior correction surgery is used to treat cervical kyphosis, advanced neurological complications can be avoided by the following measures: intervertebral foramen stenosis and kyphosis deformity of each spinal cord segment not exceeding 9.7° should be performed preventive foraminal plasty to avoid Kyphosis correction is performed in C4-C5 segment, so the C5 nerve root paralysis is likely to occur when the maximum spinal cord retraction occurs in the segment. This problem is more common, but in most cases, it can heal itself. Similar to anterior surgery, spinal nerve monitor is a better auxiliary monitoring tool.  02 Screw fixation  The incidence of atlas vertebral screw misalignment is 0%-4%, and the axial spine is 0%-7%. C1-C2 transarticular screws or Magerl screws can also cause vertebral artery injury, nerve dysfunction, or bone defects (below). Vertebral artery injury is one of the most dangerous complications of screw fixation. The cause of this complication is usually caused by improper insertion of cervical pedicle screws. The incidence of iatrogenic vertebral artery injury was 1.3%, of which 4% occurred in Magerl screw internal fixation. Fortunately, the risk of neurological dysfunction is low (0.2%). If both vertebral arteries are damaged, the mortality rate will increase greatly. The lateral deviation of the screw often causes penetration of the transverse hole, resulting in vertebral artery injury. At present, we tend to use intraoperative CT and computer-aided navigation system technology to improve the screw direction and reduce spiral perforation.  Post-operative fixation of cervical necks C1-C2 with inter-articular screws    Figure A: Dislocation screws can be seen in the open position slices, where the right screw is excessively biased to the outside and the left screw is excessively biased to the inside.  Figure B: Axial CT scan of the atlas shows that the right screw penetrates the transverse hole and may damage the vertebral artery, and the left screw is inserted too far medially to penetrate the spinal canal. Fortunately, the patient did not develop hemiplegia, but these screws require revision surgery.   Inferior cervical lateral mass screw is a risk factor for nerve root injury (1.3%) and lateral mass fracture. X-ray fluoroscopy monitoring can prevent direct damage to the nerve root when inserting the side block screw. If the sagittal angle is less than 15° when inserted, it may cause stimulation of the nerve root by the protruding screw (below). The axial trajectory is 30° lateral to the midline, which may induce lateral mass fractures (1.6%) or screw cutting prolapse (1.3%). However, nerve damage is not common. Excessive placement of the screw medially can cause vertebral artery injury.   Postoperative (A) lateral computed tomography (CT) scan and (B) three-dimensional CT reconstruction showed that the lateral mass screw penetrated into the nerve root foramen (arrow). Because the patient is asymptomatic, keep these screws in place.  03 Posterior occipital neck fixation   Occipital neck fixation, the precise insertion of occipital screws is the key to preventing complications. When the screw is inserted to the upper side of the head, the transverse sinus will be damaged. According to records, screws loosened in 4.2%-7% of cases, and dural tears occurred in 0%-4.2% of cases during screw insertion. The scalp is thin in this area, and the protrusion of the implant can cause skin erosion. Dural tears can occur when occipital holes are drilled with fixed steel wires (25%-28%). A tearing of the dura mater can cause cerebrospinal fluid leakage, but insertion of a screw into the drill hole usually prevents cerebrospinal fluid leakage. Late complications of occipitocervical fusion include pseudo-articular joints (6%) and adjacent vertebral body degeneration (7%).  04, C5 paralysis   Yonenobu and others reported that the incidence of worsening C5 nerve root symptoms early after surgery was 3.

Step By Step Nine steps teach you how to treat lumbar spinal stenosis with minimally invasive decompression

In ancient times, there were nine lonely swords, which were extraordinary skills to recruit enemies. There are nine minimally invasive steps to accurately decompress lumbar stenosis. Professor Greger Lønne of the Department of Spine Surgery, Massachusetts General Hospital in the United States, after comparing the traditional open laminectomy and minimally invasive decompression (MIDminimallyinvasivedecompression) to treat lumbar spinal stenosis, proposed that MID surgery not only causes less damage to the posterior spinal structure, The patient has the advantages of fast recovery, short hospital stay, and rarely causes spinal instability. The indications, contraindications, surgical procedures, and precautions of MID surgery are recorded in detail for everyone to learn. The article was published in the December 2016 “JBJSEssentialSurgTech” magazine. Minimally invasive decompression of lumbar spinal stenosis is different from traditional open laminectomy. Minimally invasive decompression (MID) surgery can avoid important midline structures behind the spine (ie, spinous process, supraspinous and interspinous ligaments) Damage, and patients recover faster after surgery, causing less spinal instability and complications. This operation can be used for most patients with lumbar spinal stenosis, including patients with lateral recess stenosis and reoperation patients. However, for beginners to master MID technology, they must go through a difficult learning curve, especially for those with complicated scoliosis or obesity, and may need laminectomy treatment with better exposure. Now we will tell you about the indications, contraindications, operation process and precautions of MID surgery through a document. Indications 1. Neurogenic intermittent claudication, and cause pain and sensation in the back, hips and lower limbs 2. Walking, stretching the spine can cause symptoms, flexion can alleviate 3. Lumbar MRI shows at least one stage of stenosis Doctor-patient communication and patient compliance. Contraindications 1. Contraindications of anesthesia 2. Patients with lumbar instability should consider internal fixation surgery. Surgical steps Step 1: Preoperative preparation ——– According to the symptoms and MRI results, locate the decompression stage and location According to the MRI and X-ray results, accurate positioning, especially for patients with anatomical variation, fully inform the operation before surgery Risks, benefits, and alternatives. Mark the surgical area with a waterproof pen before surgery. Step 2: Prepare the operating room-ensure that the patient’s surgical site is accurate, and ensure that the surgical equipment is intact. Always choose general anesthesia, but epidural anesthesia or Spinal anesthesia can also be selected to give antimicrobial drugs 30 minutes before surgery to prevent patients from infection in the prone position or knee-elbow position to ensure that the spinal space is open to reduce abdominal compression (Figure 1) fixed hips on the fluoroscopic bed to ensure that the operation can be safely adjusted Bed direction C-arm is intact and ready for use. According to the surgeon’s preference, choose an operating microscope or a magnifying glass with a light source. Figure 1: Step 3: Scribing — Mark the decompression site of the stenosis stage under the C-arm. The device is used as a marker under the C-arm fluoroscopy in the lateral position (Figure 2, 3) mark the surgical site on the skin (Figure 4) Step 4: skin incision and channel position —— ensure that the channel position is correct and give local anesthesia before cutting the skin Can reduce pain. The skin incision is in the center of the channel position, and the length should be close to half of the expected channel diameter (for example, channel diameter 18mm, skin incision 9mm) (Figure 5). If two stages of decompression, the incision can be expanded to extend the dilator to the need for exposure The lower half of the lamina, determine the length of the channel (Figure 6). Gradually expand, and finally fix the retractor to the side of the operating bed (Figure 7, 8) lateral fluoroscopy, determine the location of the channel (Figure 9) in the microscope or with light source Under the magnifying glass, the anatomical identification of the decompression site lumbar spine, spinous process root, and articular surface. For more than three stages of decompression, contralateral incisions can be made at different stages. We often choose the middle incision and use a toothed retractor to retract (Figure 10) Step 5: Resection of the lower part of the lamina —— After entering the spinal canal, high-speed grinding drill and Kerrison rongeur should be used to apply pituitary rongeur and single Polar coagulation removes the soft tissue covering the lamina and key signs (Figure 11) If necessary, use bipolar electrocoagulation to stop bleeding and polish the lamina to expand the surgical space so that Kerriso can be used