When dealing with the ligamentum flavum, the most troublesome and fatal thing is to avoid the dural sac wrapped outside the spinal cord. 【1】
This is not a difficult task in Kawei's hands. He is just not familiar with the process of lumbar disc herniation surgery, and he still has a lot of experience in spinal trauma. But others are different. They have no surgical experience and have basically never done surgery with such a small window.
During cadaver exercises, they often accidentally injure the dura mater, so they hope to get the opportunity to operate when peeling off the superficial ligamentum flavum during formal surgery.
Now that Waterman alone has the superficial ligamentum flavum dissection, the remaining deep ligaments are beyond their ability to handle.
"You don't want to try again?" Kawei looked at the stripped ligaments on the plate and asked, "Below the ligaments is the epidural space, which is still some distance away from the dural mater."
"Farewell, I practiced five times on the corpse, and I broke it four times, and the nerves fell out..." Massimov looked at the spatula Waterman dropped, and there was a shadow in his heart. The first one backed down and said, "Whoever wants to do it will do it. I won't do it anyway. I'll wait until I become more proficient."
Waterman had already assumed the position of his assistant, and Orji just smiled and shook his head: "I'll forget it."
"Where are you, Hills?" Kawei did not forget his former superior, and asked with a very relieved look, "Do you want to give it a try?"
Hills was eager to try.
He was always bold when dealing with the details of surgery, not as timid as the two of them. Originally, dissecting a corpse was just about getting familiar with the anatomical structure. In terms of feel, dead corpses are completely different from living people. If you always look forward and backward, you will never be able to perform the surgery well.
But that was only for ordinary patients. The person lying on the bed today was the Imperial Marshal. Even he had to choose to retreat.
"There are many patients with low back and leg pain, and there will be plenty of opportunities in the future." Hills shook his head, "The old marshal's entire lower body depends on this operation, so we'd better finish it as soon as possible."
"Okay, give me a blunt hook." Kawei used a very thin retractor to slowly peel off the proximal attachment point of the ligament and separate it distally. "In fact, it's not that difficult. The main thing is to control the strength. Give me the rongeur... As for the distal attachment point, there is no need to separate it. Just use the rongeur to remove it together with the lamina." [2]
There is also a range requirement for removing the caudal lamina, which must expose at least the medial wall of the vertebral pedicle: "In order to avoid damaging the nerve root, the tip of the rongeur used here should be kept parallel to the nerve root or dural sac to prevent damage. "【3】
It is not until this step that the surgery truly opens the window for dealing with the intervertebral disc.
The anatomical position of the intervertebral disc is deeper than the dural sac. Before proceeding with the operation, it is necessary to explore the space around the dural sac and carefully observe the nature of the herniation of the intervertebral disc.
This is something that must be clarified during every intervertebral disc resection, which directly determines the choice of the next surgical method. This is true even in modern times with advanced imaging examinations, which shows the importance of direct vision in judging the surgical situation.
But there is a premise, that is, there is imaging to back it up. At least the surgeon already knows the approximate extent of the disc herniation before the operation, and the intraoperative exploration is just to fine-tune the surgical method. ….
But now the conditions are limited, just like when Fernand had abdominal surgery, he didn’t know what the situation would be like until the last minute. Although discectomy was previously prescribed, this is not fixed and the surgical method will change depending on the intraoperative diagnosis.
Judging from the examination, Marshal Ludwig suffered from a herniated intervertebral disc from lumbar 4 to sacral 1.
As for the type of protrusion, whether it is central, lateral, or distant lateral, whether it is a simple bulge, protrusion, prolapse, or free, Kawei has no way to judge. Everything is waiting for the surgery to open the blind box. 【4】
Now, after more than half an hour of preparation for opening the window, the blind box has been opened. Using the dural retractor to pull away the gap created by the dural sac, Kawei saw a huge central lumbar disc herniation. 【5】
The area it occupies not only compresses the nerve roots, but also squeezes the entire spinal canal.
Just from this milky white protrusion, you can feel how uncomfortable the marshal's waist and legs have been over the years, and his lower body has remained paralyzed.
The edge is simply torture. If it protrudes further, cauda equina syndrome may occur. 【6】
The newly opened window was too small, and the field of view could not accommodate the herniated disc, at least Kawei couldn't see its edge. Discectomy is only used for a small amount of herniation, especially compression of the foraminal nerve roots. Such a large-scale central herniation is obviously beyond the indications for surgery.
Simple discectomy has very limited effect and is likely to recur.
The old marshal is still in good health, but at this age he cannot withstand a second surgery. The bleeding and infection caused by the ether and surgical trauma are quite fatal, and Kawei does not want it.
"Simple resection probably won't work." Kawei squinted his eyes and recalled how the orthopedics department dealt with the huge intervertebral disc.
The four of them stood by the operating table and looked at him eagerly. The procedure for disc removal was a procedure they had practiced and modified several times over and over again. It should be able to handle most situations. Why did they change it so easily?
It was not that Kawei had not thought about the situation where the discectomy would be ineffective. In addition to reviewing the standard discectomy on the cadaver with them, he also made other preparations.
The question now is what kind of surgery it should be?
Considering the old marshal's physical condition, the simpler option would be to undergo an extensive total laminectomy. The surgical method is to cut off the entire posterior lamina of lumbar 4-sacral 1, including the spinous process, and cover the paravertebral muscles to provide a backward relief area for the compressed spinal canal... 【7】
but......
Kavi immediately realized that such an operation would not work.
Although extensive total laminectomy is effective, it will remove the bony structure behind the spine, especially when the articular process is involved, which will definitely cause postoperative spine instability. 【8】
Mechanical instability of the spine can affect daily life and is no better than a herniated disc.
Kawei held the periosteal stripper in his hand and gently drew two lines on the vertebral body. Is it only a limited way to reduce stress? Keep the supraspinal ligament, interspinous ligament and spinous process, and only cut off the bilateral lamina? 【9】
This can indeed preserve the bony structure behind the lower spine, and the spine will not become unstable...
Kawei checked the old marshal's lumbar spine again. Due to the irritation in the spinal canal caused by long-term intervertebral disc herniation, a large number of hyperplastic osteophytes had formed around the periosteum. No matter how you look at it, there is no need to preserve the structure behind the ridge column. Retaining it will also reversely stimulate the crest in the center of the spinal canal. ….
Total laminectomy is inevitable, and it seems that that thing will be used.
"Give me rongeurs, bone wax and sandpaper." Kawei hesitated for a moment, made a decision in his mind, and began to separate the paravertebral muscles on the left side. "I want to remove the spinous process behind the vertebral column." Cut it all off, and then completely clean out the intervertebral disc."
"Cut it all off? Can the old marshal still straighten up?"
"Just do a fixed repair." Kawei didn't say much, and quickly peeled off the periosteum on the other side. He took the rongeur handed over by Hills and used it directly on the spinous process. "The patient is 60 after all. It’s too late, we have to fight quickly.”
The function of the rongeur is to cut off the useless lamina, the bone wax is used to stop bleeding, and the sandpaper is used to smooth the sharp cutting surface [10]. They were dazzled by the endless new gadgets. After all, there was no need to use these gadgets when practicing on corpses.
"This is......"
"It's beeswax. I also mixed a little paraffin and vegetable oil. After sterilization and cooling, it became this solid." Kawei heated the wax block with the temperature of his hand, and then applied it to the fracture of the venous sinus that was constantly leaking blood. "Wait a minute. After the bleeding is stopped, use a small piece of sandpaper to polish it a little..."
Previously, the scope of the laminectomy was limited, and the bleeding was not excessive. You could use gauze to apply pressure to stop the bleeding on your own.
But now a large area of resection is required, which extends to the lower edge of waist 4, the entire waist 5 and the upper edge of sacrum 1. Ordinary compression is completely insufficient. There are a large number of venous sinuses in the bones, and the bleeding rate after resection is not large, but it is difficult to stop. It's not that the old marshal is afraid of losing too much blood, but it's mainly that it will affect the vision of the surgical area.
The anatomy is very delicate
It's very moldy, and if it's stained with blood and matched with an oil lamp, I'm afraid I won't be able to see anything clearly.
Kawei's next operation was much faster than before. The new bone fusion surgery process is much more complicated than simply removing the intervertebral disc. Prolonged operation time will increase the difficulty of postoperative recovery: "Increase the length of the incision and directly cut the waist 5 The spinous processes and lamina of the patient were all cut off.”
Perhaps it was the surgeon's intuition. Even without theoretical support [11], others including Waterman could not understand the feasibility of this operation.
They were still helping Kawei, but they said without confidence: "Wouldn't this affect the stability of the old marshal's spine?"
"If you just do this, it will really hurt." Kawei used an osteotome and a hammer to cut off the entire lamina of waist 5, and then used bone wax to seal the bleeding. "Here's some salt water to wash away the blood stains. , inside is the thecal sac.”
Because the field of view has been greatly expanded and the dural sac can be viewed directly, the subsequent surgery is much simpler than the previous small window operation.
Use a retractor to place the right nerve root, gently pull the dura mater to the left to expose the back of the intervertebral disc, and then use forceps to remove the nucleus pulposus of the intervertebral disc that has broken the annulus fibrosus. While removing, you also need to go deep into the intervertebral disc and use a spatula to remove as much soft tissue and cartilage as possible. 【12】
The same goes for the nucleus pulposus on the left.
"You have removed all the intervertebral discs used for cushioning. What are you going to do next?" Waterman looked at the fragments of cartilage tissue at hand and was puzzled. 【13】
"Just fill the gap with filler." Kawei is very satisfied with the empty intervertebral disc shell he repaired. "It's like dealing with old furniture that is no longer useful. You have to clean up the house first and throw away the ones that should be thrown away. Throw away what needs to be thrown away and make room for new furniture where it belongs.”….
"New furniture?"
"Um......"
Kawei used a reamer to penetrate into the intervertebral space, rotated and spread it, estimated a suitable distance [14], and started the next step: "Give me the scalpel, and we will find new furniture now."
He asked Hills for the instrument, but his hands had already touched the old marshal's posterior superior iliac spine. He opened the linen that had been covered before, found the spot, applied disinfectant carbolic acid and alcohol, and quickly made an incision.
Next is the routine incision of the fascia, separation of the periosteum, and exposure of the iliac cortex.
"What are you doing?"
Kawei threw down the scalpel and replaced it with the osteotome and hammer: "Let's build new furniture." [15]
[I will put the specific 3D demonstration of the operation in the Easter egg chapter after the operation, but I can’t put it now because the characters haven’t appeared yet]
...
Two and a half hours have passed since the operation, and there is still no sign of it ending.
The people in the living room had seen the world, and were already prepared for the time required for Kawei's surgery. In addition, they also need to discuss many war and military issues, and have no concept of time.
But the two girls who had been waiting outside the manor were not so patient.
"Are you sure he came here for surgery?"
"What Dr. Ed Nelson said." Jenny held the mirror in her hand and was still applying makeup on her face. "Quickly see how my face is doing?"
"Only low-class women wear makeup." Cecilia changed her previous cowardly attitude and said, "It would be more economical for you to pile powder on your face like this and let that Dr. Ed Nelson give you some blood. Believe me, a few little bugs won’t hurt or itch, and can keep your fair skin for several days.”
Jenny had no reaction to this: "Forget it, those bugs are disgusting."
Seeing that she was still so stubborn, Cecilia became increasingly impatient: "We have been waiting outside the door for almost three hours."
"His operations have always been like this. Wasn't it also like this in the square before?"
"Shouldn't the surgery be completed as quickly as possible?"
"I don't understand either." Jenny shook her head, put away the mirror and powder, and said, "But I know that Dr. Ed Nelson gave him high marks."
Mention of Ednir
Sen, Cecilia got angry: "I can't believe what he said. Last time we agreed to bring people to the nursing home, but what happened? Most of the people who came were our old clients, and in the end we had to find Edward by ourselves. Ambassadors do publicity.”
"It's not because you want to find someone to show off."
"You don't even look at the money we spent. We prepared enough for everything, but the customer traffic was not full on the day we opened the store. I can't imagine how we will make money after that?"
"Everything is ready?" Jenny has always had her own attitude towards this matter, "I feel like there is something missing in the store anyway."
"What?" Cecilia didn't understand what she meant. "We copied the model of the Canadian Electrotherapy Hospital, both in terms of equipment and promotional methods. There were not many people there, but the business was much better than ours, and many people were willing to drive. I enjoyed electrotherapy for several hours, and some even stayed in the store and refused to leave."
Jenny naturally knew, but she also knew the real gap between them: "Have you ever thought about the difference between that store in Canada and us?"
"...You mean the store is short of a doctor?"
"Yes, there are two doctors in the store in Canada. Although they are young, they are at least willing to endorse electrotherapy equipment. But there are no doctors here in Vienna, not one."
"That's why I find Ed Nelson annoying. The 50-50 split is too greedy."
Jenny took out the cigarette case from her handbag, took out one and gently put it into her mouth. Then he took out a match, lit a fire for himself, and took two puffs: "The two young doctors in Canada also gave him a 40-60 score. He is a chief doctor, and his reputation here is no problem if he gets a 50-50 score."
Cecilia was heartbroken after hearing this: "Do you mean to comply with his wishes?"
"No, I don't have any confidence in him anymore." Jenny shook her head and exhaled a few puffs of smoke. "It's weird that a doctor can get so much money just by saying a few words and posing for a photo."
"Yes, this world is so unfair to women."
"But these are the rules of the game!" Jenny looked out the window at a carriage approaching the manor door and said, "We can't break the rules directly, but we can break them slowly. Since doctors can make so much money, we Why not become a doctor yourself.”.
Hao Xifeng reminds you: Remember to bookmark []w w w..com after reading it. I will update it next time so that you can continue reading. I look forward to the exciting continuation! You can also use the mobile version: wap..com, and you can read it anytime, anywhere....
