Abstract
In accordance with almost 55 years of experience in pediatric spine surgery, it is easy for me to describe the evolution of surgical technique, as well as indications for surgical interventions that were initially performed without the use of any instrumentation (which now are still occasionally considered as useful) through the anterior and posterior approaches, and with postoperative immobilization with plaster braces. The first types of really effective instrumentations were created sequentially by Harrington and Luque, and in parallel with their development, the pedicle screws (Roy-Camille) were introduced into practice. We had to wait another 20 years before the segmental 3D strategy and CD instrumentation appeared, which remain the basis of modern spinal technologies to this day, regardless of the type of anchoring elements (hooks, screws, universal clamps or hybrid structures). For the present and the future, early interventions remain indicated for local pathological foci, which are usually the result of congenital anomalies with or without spinal cord compression. But for extended deformities, especially of thoracic localization, plaster and removable braces remain a good choice, regardless of the etiology and the presence or absence of pelvic tilt. When such methods did not give the desired result, a lot of efforts were made using various technologies to preserve the growth potentials of the spinal column without impairing respiratory function. At the same time, it was obvious that the incidence of complications was high, and the need for a final fusion was often stated. Hence the emergence of bipolar minimally invasive technologies with very promising results and significant number of patients who developed a spontaneous bone block, made the fusion surgery meaningless. As for older children and adolescents, the race to achieve maximum Cobb angle correction is becoming more controversial. It has been convincingly shown that it is much more important for the future, from the point of view of spinal function, to achieve 3D dynamic balance, which is determined by intervertebral discs located cranial and caudal to the area of surgical fusion.
Highlights
Мой почти 55-летний опыт в педиатрической вертебральной хирургии позволяет мне легко описать эволюцию хирургической техники, показания к оперативным вмешательствам из переднего и заднего доступов, выполнявшимся изначально без использования какого-либо инструментария, и послеоперационную иммобилизацию гипсовыми корсетами
In accordance with almost 55 years of experience in pediatric spine surgery, it is easy for me to describe the evolution of surgical technique, as well as indications for surgical interventions that were initially performed without the use of any instrumentation through the anterior and posterior approaches, and with postoperative immobilization with plaster braces
We had to wait another 20 years before the segmental 3D strategy and CD instrumentation appeared, which remain the basis of modern spinal technologies to this day, regardless of the type of anchoring elements
Summary
Протяженность костного блока позвоночных сегментов определяли в ходе предоперационного планирования, обычно с захватом обоих концевых позвонков, при этом в случаях перекоса таза следовало включить крестец в зону спондилодеза. Доступ к позвоночнику при кифосколиозе с вогнутой стороны деформации позволяет без особого труда расположить трансплантат-распорку (из большеберцовой или малоберцовой кости) даже по типу палисада при большом кифотическом компоненте, поскольку биомеханически трансплантат в этом случае располагается строго по линии нагружения позвоночника, прямо перед глазами хирурга. Когда необходима передняя декомпрессия дурального мешка и спинного мозга, техника переднего спондилодеза по типу распорок представляла собой надежный метод профилактики осложнений именно за счет присущей этому методу стабильности, в том числе и тогда, когда дорсальный спондилодез, хоть и без инструментария, тоже был необходим. При использовании технологий без инструментария послеоперационная иммобилизация для полноценного формирования костного блока играет ключевую роль и реализуется с помощью операционного корсета, отверстие в котором тщательно заделывается после заживления раны. Поэтому сейчас они применяются крайне редко, хотя в отдельных случаях позволяют разрешать особые клинические проблемы
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