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Usmonov Isomiddin Khaydarovich, PhD., doctoral student of the republican specialized Scientific and Practical Medical Center of Phthisiology and Pulmonology, Tashkent, Chief Physician of the Bukhara Regional TB Dispensary, assistant of the Department of Phthisiology of the Bukhara Medical Institute E-mail: uisamiddin@bk.ru Nazirov Primkul Khodgamovich, doctor of medical sciences, professor, leading researcher of the Republican Specialized Scientific and Practical Medical Center of Phthisiology and Pulmonology, Tashkent, Chief doctor of the TB dispensary of the Republic of Karakalpakistan E-mail: nazirov.primkul@bk.ru
TECHNIQUE OF USE OF TITANIUM MESH CYLINDER OF EXEMPLARY CAGE TUBERCULAR SPONDYLITIS
Abstract: In this study, 180 patients with tubercular spondylitis (TS), who underwent RRT using titanium mesh cage, were studied. The age of patients was from 19 to 74 years old, an average of 42.4 years. Men - 93(51.7%), and women made up - 87 (48.3%). Ofthe 180 operated patients using titanium mesh cage, 13(73.9%) ofthe cage lumen was filled with auto bone, in 26 (14.4%) auto bone + hydroxyapatite with ossein compound + bicillin-5 3.000.000Un., In 15 (8.4%) without filling, and in 6 (3.3%) - hydroxyapatite with an ossein compound + bicillin-5 to 3.000.000U.
Keywords: tuberculosis spondylitis, surgical treatment, titanium cylinder shaped mesh cage.
Actuality: tuberculosis is today one of the most serious medical problems. The urgency of this problem is due to the prevalence of infectious lesions of the spine, which constitute from 2 to 8% of the number of all bone infections. At the same time, the incidence of spondylitis and discitis ranges from 0.5 to 5.9 cases per 100.000 people per year. Despite the modern level of development of medicine, observations of late diagnosis reach 75%, and mortality from spondylitis and discitis 5-12% [2].
The share of extra pulmonary tuberculosis localizations accounts for 4 to 17% of the total incidence of tuberculosis. The proportion of osteo-articular tuberculosis among extra pulmonary localizations ranges from 5 to 52% [5; 7; 12]. Spinal tuberculosis belongs to the category of severe disabling diseases. Many authors point out the peculiarities of the modern course of osteo-articular tuberculosis, which results in an increase of up to 44.7% among newly diagnosed patients with complicated forms of tuberculosis spondylitis (TS), and the frequency of post-mortem detection increased to 0.9% [4].
Compression of the spinal cord and its roots occurs in up to 90.7% of patients with TS, signs of neurological disorders -69% of cases, including spinal disorders - 44%. Despite the holding of a complex of therapeutic measures in 60% of cases, patients become disabled [1; 6; 8; 9; 10; 11].
Titanium block-grids have been used initially in pure reconstructive surgical orthopedics, and not only in spinal interventions for injuries [3; 18; 20] but also after removal of tumors [16; 21] and ankle arthrodesis [14; 15]. In recent years, data have appeared on the use of titanium block-grids in purulent spinal surgery, both in non-specific processes and in tuberculosis spondylitis [13; 17; 18; 19].
Material and methods of the study: in this study, 180 patients were studied with TS, who underwent RRT using titanium mesh cage. The age of patients was from 19 to 74 years old, an average of 42.4 years. Men - 93(51.7%), and women made up - 87(48.3%). All patients received preoperative preparation and anti-tuberculosis treatment in the period from 20 to 35 days. Spinal fusion with titanium mesh cage was performed on all parts of the spine.
Table 1. - Distribution of operations depending on the location of the vehicle
Spinal departments Number of patients %
1 2 3
Cervical region 6 3.3%
1 2 3
Cervicothoracic 3 1.7%
Thoracic 36 20.0%
Thoracolumbar 8 4.4%
Lumbar 109 60.6%
Lumbosacral 18 10.0%
Total: 180 100%
From (table 1), it can be seen that a large number of operations were performed in patients with TS localization in the lumbar - 109(60.6%), in the thoracic - 36(20.0%), and
less frequently in the cervico-thoracic - 3(1.7%) and cervical departments - 6(3.3%).
The severity of neurological disorders before the operation was as follows (table 2):
Table 2.- Assessment of the neurological status of patients with admission on a scale of N. L. Frankel et al. (1969) and supplemented by A. Yu. Mushkin et al. (1998)
Degree Clinical signs Number of patients
A Patients with anesthesia and plegia below lesion level 1(0.5%)
В Patients with incomplete sensitivity disturbances below the level of the lesion, no movement 9(5.0%)
С Patients with incomplete sensitivity disturbances have weak movements, but muscle strength is insufficient for walking 21(11.7%)
D Patients with incomplete sensitivity disturbances below the level of the lesion, there are movements, muscle strength is sufficient for walking with other help 56(31.1%)
E Patients without disturbing sensitivity and movement below the level of injury. There may be altered reflexes 54(30.0%)
R Presence of radicular syndrome 39(21.7%)
From (table 2), it can be seen that 48.3% of patients were admitted to the clinic with a general serious condition, deep spinal disorders, and in 21.7% of cases they had radicular syndrome and were disabled. The severity of pain syndrome according to the method of F. Denis was: 0 points - no; 1 point - 14(7.7%), 2 points - 27(15.0%), 3 points - 139(77.2%), 4 points - no.
Operations on the thoracic, thoracolumbar, lumbar and lumbosacral parts were performed by anterior-lateral access. The operations on the bodies of the thoracic spine were per-
Figure 1. Surgical access and the final form
formed through trans pleural - in 24(13.3%), extra pleural -in 12(6.7%) patients; thoraco-lumbar - torokodiafragmalny access - in 8(4.4%), lumbar and lumbosacral - by extra peritoneal accesses - in 127(70.6%) patients, with cervical and cervical-thoracic - by anterior left-sided access of Burkhardt -in 9(5.0%) patients. When performing operations in the thoracic, thoracolumbar, lumbar and lumbar-sacral parts of the spine, the position of the patient is on the side, and the cervical and cervico-thoracic - on the back.
operation of the cervical, cervico-thoracic spine
Figure 2. Surgical access and the final form of the operation of the thoracic spine
Figure 3. scheme of surgical access and the final form of the operation of the lumbar and lumbosacral spine
The results of surgical treatment depend on the radicalism and stability of the spinal fusion of the affected segment of the spinal column. The most radical and effective were operations in which specific changes were limited. With the defeat of 1-2 vertebral bodies, which were observed in 102(56.7%) patients, the bodies of the affected vertebrae were resected within the healthy bone, and with more common processes, with three lesions - in 69(38.3%) and four vertebrae - in 9(5.0%), extensive excision of a conglomerate of tissue from non-viable remnants of the vertebral bodies, necrotic discs, sequesters, caseous masses was required. Abscesses were removed from 109(60.6%) patients, they were located in the para-, pre-or epidural region in the zone of bone destruction. Due to the presence of spinal disorders in 88(48.9%) patients, the decompression of the spinal cord was performed. After removal of purulent-necrotic masses, fibrous tissues and radical resection of the bodies of the affected spine, spinal fusion is performed - restoration of the supporting ability of the spinal column using a cylinder of the shaped titanium mesh cage (Pyramesh) and conditions for restoring the functions of the spinal cord by decompression, elimination of pathological mobility, prevention of progression of the deformity. After removal of purulent-necrotic
masses and resection of the intervertebral discs and vertebral bodies on the border of healthy tissues, anatomical and functional reconstruction of the spinal column is performed. The size of the formed bed is measured with a caliper and trimmer, and a titanium mesh cage is cut. The cage lumen is filled with the above methods or without filling it is installed in the box and the put roller is removed. The implant-cage must stand firmly in the middle of the vertebral bodies so as not to squeeze the spinal cord and its roots. It is impractical to destroy the anterior wall of the spinal cord during resection, since its integrity ensures the stability of the cage and enhances consolidation.
In 8 (4.4%) patients after the implant was placed on top of the cage, additional reinforcement with its own rib was installed (Figure 4).
In 3 (1.7%) patients, two local radical-restoration operation were performed using titanium mesh cage, 2 of them in the lumbar, and 1 in the thoracic spine.
Results and discussion: the efficiency of operations was studied in the early (up to 30 days) and late postoperative period (from 6 months to 4.5 years).
Figure 4. Post-operative condition - combined spinal fusion VL1-2 of the lumbar spine with a titanium mesh cage + auto-bone + free auto graft (edge)
Figure 6. Bi local process in the lumbar spine
From (table 3) it can be seen that after the operation, neurological disorders persisted in the first month - in 160(88.9%), up to 1 year - in 35(19.4%), and more than 1 year — in 17(9.4%) patients, respectively. It should be noted that in the postoperative period up to 1 year and more neurological disorders on the scale of degrees B, C, D were not met, only in a single case, severe spi-
Table 3.- The effectiveness of modern cage in assessing the neurological
nal disorder in an advanced case of an incoming patient who did not follow the orthopedic regimen at home, as a result which fell and was hospitalized on a scale with a degree "A", a full plegia with dysfunction of the pelvic organs, therefore, it was operated on an emergency basis, but the spinal cord function was not restored, local and rootlets the pains disappeared.
operations with the use of titanium mesh status (on a scale of H. Frankel et al.)
Degree Neurological signs Before surgery Postoperative period
Before 1 month Before 1 year Over 1 year
А Patients with anesthesia and plegia below lesion level 1 0.5% 1 0.5% 10.5% 10.5%
В Patients with incomplete sensitivity disturbances below the level of the lesion, no movement 9 5.0% 1 0.5% - -
С Patients with incomplete sensitivity disturbances have weak movements, but muscle strength is insufficient for walking 2111.7% 14 7.8% - -
D Patients with incomplete sensitivity disturbances below the level of the lesion, there are movements, muscle strength is sufficient for walking with other help 5631.1% 4625.6% - -
E Patients without disturbing sensitivity and movement below the level of injury. There may be altered reflexes 5430.0% 3117.2% 168.9% 126.7%
R Presence of radicular syndrome 3921.7% 6737.2% 1810% 42.2%
Total: 180100% 16088.9% 3519.4% 179.4%
The results of modern operations using titanium mesh cage according to the criterion of the duration and severity of pain by the method of F. Denis (Table 4) are analyzed. Table 4 shows that pain after the operation for up to 1 month, which requires the use of painkillers, was mainly observed in the first week — in 117 (65%), after the
operation on the first night, all patients received narcotic analgesics in the form of injections. From 1 month to a year, there were slight intense pains 1 point - in 12(6.7%), and moderate 2 points - in 6(3.7%), no pain syndrome was observed for more than a year - in 176(97.8%) patients, respectively.
Table 4.- Evaluation of pain syndrome (according to the method of F Denis) before and after the operation with the use of titanium mesh cage
No. Duration of pain syndrome Points
0 1 2 3 4
1. Before surgery - 14 (7.7%) 27 (15.2%) 139 (77.2%) -
2. The first night after surgery - - - - 180 (100%)
3. After surgery up to 1 month - 63 (35.0%) 108 (60.0%) 9 (5.0%) -
4. After surgery up to 1 year 162 (90%) 12 (6.7%) 6 (3.3%) - -
5. After surgery for more than 1 year 176 (97.8%) 3 (1.6%) 1 (0.6%) - -
Total: 180 (100%)
For a comparative assessment between modern opera- currency spinal fusion in pain syndrome (Table 5) was contions, the effectiveness of traditional operation with auto bone sidered.
Table 5.- Evaluation of pain syndrome (according to the method of F Denis) before and after surgery with spondylodesis bone auto
No. Duration of pain syndrome Points
0 1 2 3 4
1. Before surgery - 7 (7.3%) 13 (13.5%) 76 (79.2%) -
2. The first night after surgery - - - - 96 (100%)
3. After surgery up to 1 month - 32 (33.3%) 36 (37.5%) 28 (29.2%) -
4. After surgery up to 1 year 43 (44.8%) 28 (29.2%) 16 (16.7%) 9 (9.4%) -
5. After surgery for more than 1 year 72 (75.0%) 14 (14.6%) 8 (8.3%) 2 (2.1%) -
Total: 96 (100%)
The use of new methods of surgical intervention in patients with TS significantly reduced the volume of operations, unnecessary injuries and the use of additional cuts. Intraoperative blood loss, the duration of operations and anesthesia are also reduced. The duration of operations was reduced from 1.5 to 2 hours, and when conducted by traditional methods, these operations last 2.5-3 hours.
Findings
1. The use of titanium reticulated cylinder of a cage has opened up additional possibilities in the surgical treatment of spinal tuberculosis: the possibility of using auto bone in the form of crumbs obtained from the zone of the operated segment, ensuring stable, strong spinal fusion.
2. When filling the lumen of the cage, especially the crumb of the auto bone + ossein-hydroxyapatite compound + bicillin-5, it helps to obtain early consolidation and long-
lasting antibacterial effect in the zone of the operated segment. In 73.9% of cases, the lumen of the cage was filled with auto bone, in 14.4% - auto bone + ossein-hydroxyapatite compounds + bitsilin-5 3.000000 Units., In 8.4% without filling, and in 3.3% with a mixture of ossein -hydroxyapatite compound with bicilin-5. In all cases, positive results were obtained, it has no contraindications, which allows them to be recommended for practice.
3. The orthopedic regime has a special role for obtaining positive results and the possibility of fusion of the bones of the operated segment. When using a titanium mesh cage, postoperative bed restraint is significantly reduced: with the TS of the cervical spine, to 15, the thoracic section, to 23, the lumbar and lumbosacral, to 31 days. The terms of walking on cruTShes are reduced on average to 2, and the corset from 3 to 6 months.
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