A.K. Dulaev, V.P. Orlov, K.A. Nadulich
(Medicomilitary Academy, Saint Petersburg)
A male patient S., born in 1943, was admitted to the Clinic of Military Traumatology and Orthopedics on September 16, 2002 with sequelae of severe trauma of the spine and spinal cord, sustained on December 30, 1990. A vicious position (angular kyphosis) of the anterior bone block at the level of L1-L2 vertebrae developed after laminectomy of L1-L3 vertebrae, posterior fixation of the spine with vertebral plates (January 9, 1991), removal of vertebral plates from posterior segments of the spine, resection of the body of L2 vertebra, anterior decompression of the spinal cord cone, anterior interbody spondylodesis of L1-L2 vertebrae (May 20, 1991). Besides, there were gross progressing kyphotic deformity of the lumbar spine (42o), stenosis of a vertebral canal, compression of the spinal cord cone at the level of L1-L2 vertebrae, flaccid paraparesis of lower extremities, dysfunction of pelvic organs of a peripheral type (retention). Trauma was a result of falling from the height (30.12.90). It was complicated by a wedge-like comminuted fracture of L1-L2 vertebrae, flaccid paraplegia of lower extremities, dysfunction of pelvic organs. Laminectomy of L1-L2 vertebrae and posterior fixation of the spine with a plate were peformed in Regional Military Clinical Hospital N 442. Four months later there was migration of vertebral plates, caused by cutting-through of spinous processes. They were removed on April 25, 1991. Then the patient underwent anterior decompression of the spinal cord and anterior corporodesis (20.05.91) with an autobone at the level of L1-L2 vertebrae. A postoperative period was characterized by regression of neurological symptoms. The patient began to walk. However, muscle strength in lower extremities did not restore completely; there was no restoration of a function of pelvic organs as well. During the last 1.5-2 years the patient complained of augmentation of muscle weakness in lower extremities and limitation of physical activity. Control rentgenographic examination was indicative of progression of kyphotic deformity of the spine at the level of trauma (from 34o up to 42o during 8 years). Subcompensated stenosis of a vertebral canal and increasing compression of the spinal cord cone at the level of L1 vertebra, caused by augmenting kyphotic deformity, could lead to progression of flaccid paresis of muscles of lower extremities. Thus, the patient was operated once again on October 16, 2002. It consisted in wedge-like resection of bodies of L1-L2 vertebrae, anterior decompression of the spinal cord cone, anterior mobilization of the spine, resection of arch-process articulations of L1-L2 and L2-L3 vertebrae, posterior internal correction and fixation of the spine with the Tenor transpedicular system at the level of Th12-L3 vertebrae, anterior spondylodesis with an autobone and use of a right-side extraperitoneal subcostal-pararectal approach. The operation resulted in elimination of kyphotic deformity of the lumbar spine and restoration of a sagittal balance of the trunk. Today the patient is subject to a course of restorative treatment.