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21 + 22-JANUARY-2008 KHALED EED FALEH AL-INEZI 30 YEARS
PARAPLEGIA BELOW TH12 AFTER RTA 10 YEARS AGO. PART - TWO
The next day:
The patient was sent back to
the operating room and in the prone position,
skeletonization of D8 down to the middle of the
sacrum was performed, including exposure of the
lateral transverse processii.
Using Inomed ISIS
intraoperative monitoring, the running roots of
Th 9-10-11and 12 and L4-5 and S1 were exposed
and isolated by umbilical tape. It was clear
that both Th 10 are not functioning and only
tiny twigs can be found, which are useless for
grafting and pinpoint tear of the right pleura
was accidentally noticed during exploration for
abnormal variation of these neural structures.
Due to this fact the Th 10 branches were omitted
as candidates for bridging. The pinpoint tear
was covered by muscle and the anesthesia team
was warned upon.
The Acromed construct was
removed and it seems that the D12 down to L2
were bony fused from posterior.
Drilling of the sacrum at the
trajectory of S1 was performed to expose the S1
roots at their postganglionic part was achieved
in both sides.
Inspection of the running
roots at the injury level revealed, that the
L1,2 and 3 were damaged anatomically and there
was no possibility to find and isolate them.
Using the saphenous graft,
anastamosis between Th9 and S1 was performed,
connecting the proximal part of
postganglionic Th9 and the distal end of the
postganglionic S1 from the left.
The other saphenous graft was
used to anastamose the right S1 and right L5,
taking into consideration the wide diameter of
one the branches of the saphenous graft, which
was sufficient to fill the diameter of the right
S1 root.
Using the sural nerves,
anastamosis between Th11 and both L5 was
undertaken and Th12 to L4 both sides using the
same technique as for the fist mentioned bridge.
The grafts were lax and they
were allocated, so as to be away from the bone,
near the muscle in the hope to have acceptable
blood supply.
Routine closure of the wound
with ready-vac drain with negative pressure
under the skin.
Smooth postoperative
recovery. The patient sent to the ICU. The
second operation took around 20 hours.
Serial check chest X-rays
were performed 3 times in the ICU to follow the
progression of pneumo or heamothorax, which was
negative.
Comments
This kind of surgery, still
in infancy and needs more perfection and more
proper decision-making policies. S2 and below
are less important to direct anastomoses to
them.
The harvested posterior
femoral nerves were not used in this case, which
means, that the operation must be staged in
other way.
In the next case, it is
better to explore the spine first, to see
exactly what nerves are useful and what nerves
remained with the patient in acceptable
anatomical shape. Using intraoperative
monitoring is a must and this surgery must be
guided with it, otherwise, putting anastamosis
between two functionally invalid structures is
only a waist of time and effort.
In this case the operation
must be divided into 3 stages: stage 1-
exploring the above and below the injury level
and studying all the involved roots functionally
and morphologically. The second stage, must be
the harvest of the needed grafts and their
required length and diameter and their number.
The third stage is the bridging of the
acceptable functionally and morphologically
dorsal donors with the acceptable anatomically
lumbo-sacral recipients.
The timing of surgery is
important. This patient was reluctant for long
time - 10 years after insult. This kind of
surgery must be performed 8-12 months after the
insult.
By planning this surgery in
successive three days, the surgeon will be able
to have the best choices and the more precise
actions.
This case brought another
task, which needs to be resolved. The damaged
L1-2-3 roots, must be approached by another
means: The extraperitoneal approach to the major
nerves arising from them, to be identified and
through tunneling to bring the grafts to the
back to follow the other anastomotic connections
with the dorsal donors. This must be resolved in
the next case.
The patient underwent
debridement of the right infragluteal area
28-September-2008 at the incision of the
harvested right sensory femoral nerve. The
conclusion for future operations is that not to
use the sensory femoral nerves, since they are
short in length and the area is susceptible to
bed sore formation.
