crazy scalpel

Wang Lei has always regarded Xie Ke's dissection skills as a miracle.

So even though he was shocked by his neat way of freeing his muscles, he didn't feel that there was anything wrong.But as a surgeon with a good reputation, he still didn't think it was right to choose wire fixation.

The so-called wire fixation system is to fix a single wire or cable to a structural bone graft or metal ring.

Generally, a bone plate cut from the rib or the curved iliac crest is selected, and steel wires are passed through the spinous process, sublaminar and facet joint holes, and then the lower half of the bone plate is tied to the spine.Then use suboccipital wire or occipital anchors to fix the upper half of the plate to the occipital bone.In this method, there are generally two long bone plates on the left and right sides of the midline.

Its disadvantage is that the longitudinal strength is limited. Since the long bone plate may move like a "piston" under the fixation of the steel wire, the movement of the neck will make the fixation weaker and weaker. External fixation is required.And even if external fixation is not required, it may become less and less reliable for load-bearing due to time.

Because of this, various occipital-cervical internal fixation systems have been developed in recent years, using screws and plates to better fix the spine.

Wang Lei obviously knew this too, so he couldn't figure out why Xie Ke chose a steel wire that almost no one used anymore.

Surgeons are, and must be, progressive.Because the development and improvement of various surgical methods and treatment methods are too fast.So that sometimes what you learned in school followed up with the equipment and instruments used in the hospital are completely different.It's only been a few years.

New things may not be completely right, but anything new is progress.Maybe after a few years it was found to be not good enough, or there is a better alternative.However, conservatism is absolutely not allowed.And no surgeon is willing to keep the old, unless he is not good enough to learn new things.The renewal of this line is sometimes more cruel than it.

However, Xie Ke's choice must be justified.

This truth, Wang Lei suddenly understood after seeing clearly the entire exposed spine segment of Zhongliang.

Whether it is a wire or a screw, the place where they drill holes cannot be separated from the occipital bone.Quantitative anatomy of the occipital bone is critical for occipitocervical fixation with intracranial wire and plate-screw systems.

Bone measurements around the occipital bone showed that the bone was thickest at the midline of the inion.In all specimens, the thickest bone was always at or near the midline.Likewise, the occipital bone becomes thicker from the foramen magnum to the inion.With the midline of the external occipital inion as the height, the shorter inferior nuchal line as the upper base, and the longer upper nuchal line as the lower base, the inverted trapezoidal area is the thickest part of the occipital bone. The bone here is about 8 mm.

However, what Wang Lei noticed was the lower part of the occipital bone and the middle part of the atlas.At the place where the superior articular process of the atlas crosses the groove of the vertebral artery to the upper part of the posterior arch of the atlas, there is a bony bridge on each side.One side is closed and one side is open.The bone bridge forms a bony ring over the vertebral artery through which the vertebral artery and the first cervical nerve pass.

rear bridge!

These two bony bridges are called the posterior bridge of the atlas, which is a variation of the bony structure.Its existence is not a good thing. Patients with posterior atlas bridge often have symptoms of vertebral artery and cervical nerves, such as vertigo, headache with neck discomfort, and numbness of limbs.Of course, there are people who are asymptomatic.

In the past, it was unknown because of the small number of specimens. Recently, more and more cases have reported that the incidence of this type of posterior bridge is as high as ten percent, and most of them are males.

Zhong Liangquan's rear bridge is different from most people's. One side is closed and the other is open.In other words, one side is a complete rear axle and the other side is an incomplete rear axle.

Zhu Ming obviously noticed the same thing as Wang Lei.They both frowned.

Before the operation, they all carefully read the CT, and they missed the diagnosis!

Regardless of whether the bone bridge affects the patient or not, although missed diagnosis is inevitable for a surgeon, there is a sense of frustration in the end.

Especially since Shayk had clearly been diagnosed.

Zhu Ming finally understood why Xie Ke insisted on using steel wires instead of screws which are popular nowadays.

The reason is simple, due to the existence of the rear axle, the angle and position of the nails become very difficult.

First of all, if it wasn't for Xie Ke's deliberate reminder, if they did the surgery themselves, it would be easy to put screws on it rashly.

Because this rear bridge can easily be mistaken for a wide lamina at first glance, and the lamina is the most suitable place for nail placement.Because the lamina is stronger than the facet joint in terms of resistance to tension and can provide safer stability, lamina fixation is generally preferred.

But if you do that, it will be a catastrophe.There is no doubt that there is a high probability of damaging the vertebral artery when the nail is placed in this way.

Thinking about it carefully, the rear bridge of Zhong Liangquan was quickly discovered by Zhu Ming and Wang Lei because of the asymmetry on both sides.If so, is it closed on both sides?That would be too easy to mistake for a lamina, especially if the physician hadn't considered the lesion at all.

And that's not all, Xie Ke took a thin rod made of gelatin sponge and drew an arc on the right side between c1 and c2, attracting the attention of Zhu Ming and Wang Lei.

After seeing it clearly, both Zhu Ming and Wang Lei were speechless.

Gosh!How did this bell beam grow? Wow, the atlas has a posterior bridge, and the vertebral artery runs so messy*, as if a thread hole was missed when knitting, and then pulled out again. .

The incidence of posterior bridge is not low, but the variation of vertebral artery course is not too common.

Vertebral artery variations are generally divided into three types.

In the first type, the vertebral artery runs under the atlas after leaving the transverse foramen of the axis, and directly enters the spinal canal without passing through the transverse foramen of the atlas.

In the second, the vertebral artery forms a window at the level of the atlas, one side runs normally, and the other side enters the spinal canal directly below the atlas and joins the other side above it.

In the third type, the course of the vertebral artery is normal, but the posterior inferior cerebellar artery originates from the vertebral artery between the atlantoaxial vertebrae and enters the spinal canal from the caudal side of the atlas.

The case of Zhong Liangquan belongs to the second type, and the incidence rate is generally considered to be less than one percent.

Vertebral artery variation is something that can't be seen on ordinary CT. Zhu Ming and Wang Lei didn't suspect anything, they just thought it was a temporary discovery.

But Xie Ke knew in his heart that he knew it long ago.

When Xie Ke virtualized his finger and cut into other people's body, although he would not be discovered and would not cause harm, he could still feel what kind of tissue he touched.Such as fat, muscle, fascia, blood vessels, bones, and even foreign bodies.

He didn't know why it was so unscientific, but after several experiments, he found that it was indeed true.

So when he secretly used this method to examine the structure around Zhong Liangquan's cervical spine, he had already made this discovery, but it couldn't be said in this way.

It's not that there are no tests that can detect this situation. For example, 3D-CT angiography can clearly see these variations.But this kind of 3D-CT is very advanced and expensive, and most people are unwilling to spend this money, and another city hospital does not have it for the time being, so if you want to do it, you have to go to the First Affiliated Hospital of Jiefang University.

Xie Ke mentioned something to Zhong Liangquan, but after seeing the price, Zhong Liangquan hesitated and asked him if not doing it would affect the operation.

Of course there is!Shayk wanted to tell him that.In order to avoid damage to the vertebral artery during surgery, it is very important to find out the anatomical variation around the atlantoaxial spine before surgery.Not to mention Wang Lei, a doctor like Zhu Ming who is quite experienced has missed the diagnosis!

On ordinary CT, the white image formed by this bone bridge and other bones is still relatively blurred, and can only be seen roughly.Except for freaks like Shayk, there are not many people who can correctly diagnose this disease.Many never even consider the possibility.

If it weren't for the fact that he was the one who performed Zhong Liang's surgery, Xie Ke would definitely try his best to persuade him to do 3D-CT, because this is really too clear, just like what you can see from anatomy. For the doctor who is going to perform the operation Confirming the anatomy of the patient is really helpful.

But since he did it himself, it would save a fortune.Xie Ke decided to tell Zhong Liangquan about this after the operation, so as to improve his understanding of this aspect and increase his initiative.

In addition, Xie Ke decided to tell Cai Tianqiao that the first hospital in the city should also be equipped with this kind of examination equipment.People like Cai Tianqiao who came back from abroad should also be more active.

Zhu Ming and Wang Lei were also deeply shocked by Zhong Liangquan's two mutations of the posterior bridge of the atlas and the random running of the vertebral artery.Ignoring these anatomical variations, which can lead to peripheral neurovascular injury and potentially serious complications, can be extremely dangerous.They were also terrified. After all, if Xie Ke hadn't given the hint and they were the chief surgeons, they might have made a big mistake now!

This situation is obviously not suitable for fixation with screw and plate, because it seems that no matter which angle the screw is placed from, it will inevitably damage the vertebral artery or paravertebral venous plexus.However, there are some important neurovascular tissues around the atlas lateral mass such as the spinal cord, C2 nerve root, and venous plexus around the greater occipital nerve, and it is almost impossible to avoid damage to these tissues if the paravertebral venous plexus bleeds.

Zhu Ming was fine, but Wang Lei was shocked!

He is so self righteous!

It's not that it's wrong to doubt Xie Ke, but that he relies too much on various new things brought about by the development of surgical science.Because he had never considered the variation of the vertebral artery in the matter of choosing a fixation object.

In his thinking, occipital-cervical fusion has almost been equated with screw placement. However, when he thinks about it carefully, the probability of variation in the course of the vertebral artery does not seem to be so small that it can be ignored, and the posterior bridge can be counted as a common variation!

Xie Ke saw his fear from his eyes, but in fact, screw insertion is not only a problem with mutations.It also has a potential problem with damage to the neurovascular tissue surrounding the ventral cervical spine.Placement of the c1 screw may irritate or injure the adjacent c2 nerve root, vertebral artery, and spinal cord.It's just that the probability of occurrence cannot be reported because of too little follow-up data.

But the hypoglossal nerve arises from the anterior condylar canal at the base of the skull and runs down between the internal carotid artery and the jugular vein.Cadaveric specimen studies also confirmed that the hypoglossal nerve was located 2–3 mm lateral to the midline dorsal to the internal carotid artery and anterior to the c-lateral mass.

If the screw can be placed translaminally, the risk may be relatively small, because it can avoid vertebral artery injury and allow direct vision of related structures, which correspondingly reduces the need for intraoperative navigation.But don't forget, Zhong Liangquan cut off the intervertebral disc between c1 and c2!He is obviously not suitable for this fixation method.

So not only because of the mutation, Xie Ke actually never thought of using screws from the very beginning!

The traditional steel wire fixing technology does have its flaws, however, Shayk has a way to make up for this flaw!

He will use an unprecedented method to fix Zhong Liangquan's atlanto-occipital joint!