卷 16, 编号 2 (2010)

Monolateral spinal anaesthesia as a component of general anaesthesia was compared to the spinal anaesthesia as a component of general anaesthesia for the unilateral low extremity orthopedic surgery in children. Analgesic effect of two methodics was analysed in 120 children (age 1-18 years old, ASA 1-2). Monolateral spinal anesthesia provides the same level of analgesia thus decreasing zone of desympathysation and providing more hemodynamic stability and decreasing loss of heat. Monolateral spinal anesthesia is not complicated with urinary retention in contrast to classic spinal anaesthesia. Monolateral spinal anesthesia is an effective alternative to a classical spinal anesthesia for the unilateral low extremity orthopedic surgery in children.

The role of interposition of soft tissues into tibiofibular syndesmosis is analyzed as a cause of unsatisfactory outcomes in the ankle joint pronation fracture treatment. The study is based on clinical (452 patients) and experimental material (36 experiments) including unfixed anatomic objects. The elevator for minimal invasive operative elimination of interposition of stumps of distal tibiofibular syndesmosis anterior and posterior ligaments is developed and tested.

The cicatrical deformities of the foot and secondary changes in tendons, muscles and in osteoarticular system with respect to the age and scar location were discussed. It was pointed to a high risk of early development of foot deformities, especially in young children up to five years of age. This indicates the need for regular medical check-up. Clinical experience shows that the hypertrophic scars that extend from the lateral surfaces of the foot to the ankle region create preconditions for development of multiplanar foot deformities, especially in the period of intensive growth of the skeleton. Possible complications in the treatment of multiplanar foot deformities in the presence of scar lesions of surrounding tissues associated with an increased risk of trophic disorders and the development of the inflammatory process are considered. Recommendations on stages of surgical treatment are given.

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The article is dedicated to the vital problem of the consequences caused by negligent surgical treatment of those who suffered spinal and vertebral trauma. The authors carried out a cooperative survey of the results of the previous treatments of patients with traumas with and without complications and they came up with the algorythm of surgical methods, based on the data analysis. Vast database of 614 clinical case treatments with post-operative observations of 1 to 10 years long have been used. The work is aimed at raising the standarts of surgical treatments and improvement of neurological & anatomo-functional results.

The aim of the work is the optimizing the organization of medical care to victims of accidents on federal roads M5 and M7. The priority direction in improving outcomes of treatment in patients with polytrauma is an organization of all the processes of diagnostics, resuscitation and surgical treatment based on the timeliness and appropriateness. A special feature of motor accidents in Russia is a long period of patients isolation affected due to geographical features, that in combination with low temperatures increases the proportion of irreversible losses. In UGKB № 21 for the last 5 years 1315 patients with polytrauma were treated. A retrospective study of clinical data showed that among them persons with injuries of the locomotor system amounted to 1,196 (91%), abdomen - 79 (6%), chest - 197 (15%), central and peripheral nervous system - ИЗО (86%). The victims with vertebral-spinal injury amounted to 96 (8%). Surgical treatment was performed after normalization of the patient general condition from 2 to 5 phases of medical care, poor results were obtained in 4 (1%) cases. The most effective form of medical care organization for vertebral-spinal cord injury is a two-stage system.

A study of the efficacy of medical rehabilitation of 170 patients with spinal-cord injury through the application of modern rehabilitation and surgical technologies was conducted. Patients of I (control) group received standard set of conservative treatment and rehabilitation. Patients of II (main) group the rehabilitation was supplemented with therapeutic exercises with the use of loop complex «Hope» and the rate of adaptation to the stress of hypoxia in the late period of injury. Patient of III (control) group surgical treatment and the conventional range of rehabilitation were performed. Patients of IV (main) group the rehabilitation was completed with early activation using espandernogo complex «Hope» and the rate of adaptation to the stress of hypoxia in the late period of injury. It is proved that the developed complex rehabilitation of patients with spinal-cord injury using an early stable functional osteosynthesis with the minimum extent necessary, the use of complex «Hope» can improve the functional results at the expense of early motor activation, preventing the formation of contractures and muscle atrophy. The use of adaptation to the stress of hypoxia in the late period of vertebro-spinal cord injury improves overall health, reduces the severity of autonomic reactions, emotional stress, can cut pain syndromes.

The possibilities of epidural electrical stimulation in the complex treatment of patients with spinal injury in the acute and late periods of traumatic disease of the spinal cord. The authors presented the analysis of treatment results of 356 patients with a spinal-cord injury at age 16 to 71 years, including 293 patients in the acute and early periods of trauma, and 63 - in the late period. Injuries of the cervical spine were observed in 145 (40,7%) men, thoracic - in 59 (16,6%), thoracolumbar - in 89 (25,0%), lumbar - in 63 (17,7%). As the result of the conducted electropulse influence on the spinal cord in the acute period of the trauma we succeeded in achieving positive outcomes in 80,9% of patients, and that is 11,7% better, than in the comparison group. That allowed us to restore lost functions of the spinal cord more completely in more than the half of the patients with consequences of vertebral cerebro-spinal trauma.

By means of mathematical modeling studying influence of angular deformation of a body on development of a spinal stenosis was performed. It is proved, that the increase in a corner of deformation promotes development of narrowing of the channel. The given law on an example of treatment of 10 patients with chronic damages of a backbone and a spinal cord is studied. At all patients the progression of deformation that has demanded surgical treatment was observed. The lead treatment has reduced a painful syndrome, has improved social adaptation, but has not affected a level of neurologic deficiency.

Experimental biomechanical study was performed in 60 spine specimens. Anterior wedge osteotomy and fixation of a specimen in a kyphotic position modeled kyphotic deformity. Deformity correction with various instrumentation systems was firstly performed by maximal extension of segments adjacent to kyphosis-producing block, and carried on after crossing of intervertebral anatomical structures. The study resulted in defining rational approach to surgical correction of posttraumatic deformities in the thoracic and lumbar spine. Minor kyphotic deformities are effectively corrected by instrumentation without mobilization of the spine. Large unfixed kyphosis sometimes requires anterior mobilization. Cases with rigid posttraumatic kyphotic deformity should be operated on with combined mobilization of the spine.

The effectiveness of vertebroplasty in treatment of 84 patients with osteoporosis and pathological fractures of the vertebrae was evaluated. 68 patients of the first group were underwent a comprehensive conservative treatment, percutaneous vertebroplasty was performed additionally in 16 patients in second group. The study found that in the second group treatment results were slightly better: the investigated parameters showed a significant dynamics, ie, vertebroplasty improved the results of treatment of osteoporotic patients with pathological fractures of the vertebrae.

85 patients with osteoporotic vertebral fractures of lower thoracic and lumbar spine were operated. Surgical options including posterior reconstruction, anterior reconstruction and combined anterior and posterior surgery, vertebroplasty. In the postoperative period the great attention was given to rehabilitation and correction lowered BMD depending on osteoporosis type. The long-term outcomes were followed in 69%. Good results were achieved in 76% of cases, satisfactory - in 20%, unsatisfactory results - in 4%. The differential approach to surgical treatment osteoporotic spinal fractures in the thoraco-lumbar spine allows to restore in short terms stability of spine and return activity to patients.

In article results of treatment of 20 patients more senior 60 years with osteoporotic fractures of thoracolumbar spine. To all patients has been executed percutaneous kyphoplasty. In process kyphoplasty restoration of ventral departments of the broken vertebra on 15+6.2 % is reached. Correction of a local kyphosis angle is reached in limits 5-10e (7,3+2,5e). Recourse of a painful syndrome with 7,1+1,9 to 2,1+1,7 on a visual analogue scale is noted. In the remote period it is noted increases in a painful syndrome, increase of a local kyphosis angle and deformations of a body of a vertebra. Thus, percutaneous kyphoplasty, being a minimally invasive astabilisation technique, allows to restore strengthening characteristics of bodies of vertebras, to increase height ventral departments of bodies, correction of the biomechanical infringements resulting fracture thereby is reached.

Surgical treatment of 177 patients with monolocal fractures of thoracic and lumbar vertebral bodies was performed using transpedicular fixation (n=17), transpedicular fixation and osteoplasty (n=101), vertebroplasty (n=48) or kyphoplasty (n=ll). Restoration of support ability of the fractured osteoporotic vertebrae within ventral column by means of plasty particularly in combination with internal fixation allows achievement of better clinical outcomes, improvement of the quality of life in patients in the early and late periods after surgery.

At RSPC of traumatology and orthopaedic surgery and Institute of powders metallurgic porous implants are working out which allow complitely replace alio- and autotranplants and improve the surgical technology of interbody spondylodesis. Porous implants, made from mechanic durabilities, are bioinert or biocompatible materials, provide durabilities prime spondylodesis. It doesn't need an additional fixation, realize a possibility to grow a bone matter in powder structure of implants.

There is our experience of thoracoscopic surgery treatment of primary and metastatic spine tumors and paraspinal neurogenic tumors including "dumbbell". Thoracoscopic approach impressively decreases of complication rate in comparison with open surgery and considerably increase quality of life. Activization time for the patient with thoracoscopic surgery was 5,36+3,34 (for neurogenic paravertebral tumors 3,40+2,31). Comparison endoscopic and microsurgical methods demonstrate advantages of endoscopic technologies. Further development of neuroendoscopy in spinal surgery makes possible to increase effectiveness of treatment of various spine pathology. We conclude that neuroendoscopy is new and effective method of treatment not only degenerative diseases but is really effective technology of tumor resection both extra and intramedullar.

The results of treatment of 72 patients with pathological fracture of vertebra bodies against eosinophilic granuloma a spine are analysed. Orthopedic corset technologies are used in treatment of 42 patients, surgical treatment was applied. Orthopedic corset may be used in patients with eosinophilic granuloma of backbone. This method of treatment was used in a case of the absence of spine secondary deformations and neurologic semiology. Orthopedic corset treatment is associated with long immobilization on the average within 1,5-2 years and never leads to a complete recovery of the damaged spine. Surgical treatment consists in use only at loss of height of a body to 30-40%, when destruction of spine more severe it is necessary to use operative treatment in two stages. Absolute indications to surgical treatment are the neurologic deficit and secondary deformations of a spine. Surgical treatment allows to reduce terms of treatment till 3-4 months and quickly to return the patient to an active life.

The experience of surgical treatment of 19 patients with tumors of the upper-thoracic spine is analyzed. All the patients had undergone decompressive-stabilizing surgical procedures. Surgical approach, form of decompression and fixation were determined depending on the signs of compression of the spinal cord and neural structures, etiology and degree of the vertebral body destruction. Good and satisfactory short- and long-term results were achieved in all the patients. The case of surgical treatment of female patient with giant neurofibromas of Th2 vertebrae is also reported.

27 patients aged 2,5-61 years with skull base and C1-C2 vertebral body tumours and nontumorous pathology in the craniocervical junction underwent surgery. All patients revealed craniovertebral instability. To perform OSD we used autobone and metallic wire in 1 case, "Ventrofix" - 2; "CCD" - 9, "Vertex" - 15. In 26 cases OSD was followed by transoral tumor removal; in 1 - removal of the skull base chordoma spreading into C1-C2 segments was followed by OSD. In our practice we used original patent instruments, devices and surgical techniques. After the tumor has been removed, the skull defect hermetic closure and plasty were performed using the original patent technique for preventing postoperative CSF leakage as well as different glue compositions. This technique proved to shorten hospitalization period and reduce treatment costs as well as launch an early rehabilitation programme - on the 3d-4th day after operation. Use of new technologies in surgical treatment of skull base tumors invading upper cervical spinal segments accompanied by craniovertebral instability allowed to improve surgical outcome and start up early rehabilitation.