Nineteenth Century Medical Guide

Chapter 208 205. New Furniture

When dealing with the ligamentum flavum, the most troublesome and fatal thing is to avoid the dural sac wrapped around the outside of the spinal cord. 【1】

This is not a difficult task for Carvey. He is just not familiar with the procedure of lumbar disc herniation surgery, and he still has a lot of experience in spinal trauma.But other people are different. They have no surgical experience, and they have basically never done surgery with such a small window.

During the cadaver practice, they often injure the dura mater by accident, so they all hope to get the opportunity to operate when the superficial ligamentum flavum is stripped during the formal operation.

Now Watman alone has the superficial ligamentum flavum peeled off, and the remaining deep ligaments cannot be handled by them.

"You don't want to try again?" Carvey looked at the stripped ligament in the plate and asked, "Below the ligament is the epidural space, which is still a little away from the dura mater."

"Farewell, practiced on the corpse five times, I broke it four times, and the nerves fell out." Massimov looked at the spatula dropped by Watman, and there was a shadow in his heart, and he was the first to fight Withdraw, "Whoever they want to do, do it, I won't do it anyway, let's talk about it when I become more proficient."

Waterman had already put on the posture of an assistant, and Olgi just smiled and shook his head: "I'll forget it too."

"What about you, Hills?" Kavi didn't forget his former superior, and asked with a rather relieved look, "Do you want to try?"

Hills was eager to try.

He has always been bold in handling the details of surgery, less timid than the two of them.Originally, dissecting a corpse was just to be familiar with the anatomical structure. If you really want to count the feel, a dead corpse is completely different from a living person. If you always look forward and backward, you will never be able to perform surgery well.

But that's only for ordinary patients. The person lying on the bed today is the Marshal of the Empire, and even he has to choose to back down.

"There are many patients with low back and leg pain, and there will be opportunities in the future." Hills shook his head, "The old Marshal's lower body depends entirely on this operation, so let's end it as soon as possible."

"Okay then, give me a blunt hook." Carvey slowly peeled off the proximal attachment point of the ligament with a very thin retractor, and separated it to the far end. "It's actually not very difficult, the main thing is to control the strength. Give me a 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】

Removal of the caudal lamina also requires scope, exposing at least the medial wall of the 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】

The surgery does not really open the window for dealing with the disc until this step.

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 herniated nature of the intervertebral disc.
This is something that must be clarified when every discectomy is performed, and it 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 do the bottom line. At least the surgeon has already known the approximate degree of intervertebral disc herniation before the operation, and the intraoperative exploration is only a fine-tuning of the operation method.

But now the conditions are limited, just like Fernan's abdominal surgery back then, I don't know what will happen until the last moment.Although discectomy was previously established, this is not fixed, and the surgical method will change with the intraoperative diagnosis.

Judging from the examination, Marshal Ludwig had a herniated intervertebral disc from lumbar 4 to sacral 1.

As for the type of protrusion, whether it is central, lateral, or distant lateral, or whether it is simply bulging, protruding, prolapsed, or free, Carvey has no way to judge, and everything is waiting for the operation 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, and the gap opened by the dural sac is pulled away by the dural retractor. Carvey saw a huge central lumbar disc herniation. 【5】

The range it occupies not only compresses the nerve root, 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 these years, and his lower body has been maintained on the verge of paralysis, which is simply torture.If it protrudes further, it may cause cauda equina syndrome. 【6】

The opening window was too small to fit the herniated disc, at least Karvey couldn't see its edge.Discectomy is only used for a small amount of herniation, especially for the compression of the foraminal nerve root, and such a large central herniation is obviously beyond the surgical indications.

Re-use of simple discectomy has very limited efficacy and a high risk of recurrence.

The old marshal is still in good health, but at this age, he can't stand the second operation. The bleeding and infection caused by ether and surgical trauma are quite fatal, and Carvey doesn't want it.

"A simple resection probably won't work." Carvey narrowed his eyes and recalled the way the orthopedic department dealt with the huge intervertebral disc.

The four of them stood by the operating table and looked at him eagerly. The intervertebral disc was removed, but they practiced and modified it several times. It should be able to deal with most situations. How can I change it?
It's not that Carvey didn't think about the ineffective discectomy. In addition to repeating the standard discectomy on the corpse with them, he also made other preparations.

Now the question is what surgery to change to?
Considering the physical condition of the old marshal, the simpler option is to perform extensive total laminectomy.The operation method is to cut off and open the entire posterior lamina of L4-S1 including the spinous process, and cover the paravertebral muscles to provide a backward relief area for the compressed spinal canal【7】

but.
Carvey immediately realized that such an operation would not work.

A wide total laminectomy, while effective, removes bony structures behind the spine, especially when the facet joints are involved, and is sure to cause postoperative spinal instability. 【8】

Mechanical instability of the spine interferes with daily life and is no better than a herniated disc.

Carvey took the periosteal stripper in his hand and gently drew two lines on the vertebral body.Is it only limited decompression?Keep the supraspinous ligament, interspinous ligament and spinous process, and only cut off the bilateral lamina? 【9】

Doing so can indeed preserve the bony structure behind the spine, and the spine will not become unstable
Carvey checked the old marshal's lumbar spine again, because the long-term intervertebral disc herniation caused irritation in the spinal canal, and 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 at the back of the spine, and keeping it will reversely stimulate the spinal cord in the center of the spinal canal.

It is inevitable to cut all the lamina, and it seems that we need to use that thing.

"Give me a rongeur, bone wax, and sandpaper." Carvey hesitated for a moment, then made a decision in his mind, and began to separate the paraspinal muscles on the left side, "I'm going to take all the spinous processes at the back of the spine." Cut it off, and then clean the disc completely."

"Cut it all off? Can the old marshal still straighten up?"

"It's enough to do a fixed repair." Carvey didn't say much, quickly peeled off the periosteum on the other side, took the rongeur from Hills, and used it directly on the spinous process, "The patient is 60 years old after all. It’s the age of [-], and we have to make a quick decision.”

The role of the rongeur is to cut off the useless lamina, the bone wax is used to stop the bleeding, and the sandpaper is used to smooth the sharp cut surface【10】.They were dazzled by the endless new gadgets, after all, there was absolutely no need to use these things to practice on corpses.

"This is."

"It's beeswax. I also mixed a little bit of paraffin wax and vegetable oil. It became a solid after it was sterilized and cooled." Carvey heated the wax block with the temperature of his palm, and then smeared it on the fracture of the venous sinus that is constantly leaking blood, "etc. After the bleeding is done, use a small piece of sandpaper and sand it down a little bit."

Previously, the range of laminectomy was limited, and the bleeding was not too much, so the bleeding could be stopped by pressing with gauze.

But now a large area of ​​resection is required, covering the lower edge of L4, the entire L5 and the upper edge of S1, and ordinary compression is not enough.There are a large number of venous sinuses in the bone, and the bleeding flow rate is not large after resection, but it is difficult to stop.It's not that the old marshal lost too much blood, but the main thing is that it will affect the vision of the operation area.

Originally, the anatomical structure was very thin and blurred, but if it was stained with blood and matched with an oil lamp, I'm afraid I couldn't see anything clearly.

Carvey’s next operation will be much faster than before. The new bone fusion operation is much more complicated than simply removing the intervertebral disc. If the operation is delayed for a long time, it will increase the difficulty of postoperative recovery: “Increase the length of the incision, directly remove the lumbar 5 Spinous processes and lamina were all cut off."

Perhaps it is the surgeon's intuition, even if there is no theoretical support in hand [11], others, including Watman, cannot understand the feasibility of this operation.

They are still helping Carvey, but they have no confidence in their mouths: "Will this not affect the stability of the old marshal's spine?"

"If you just do this, it will indeed be a little bit." Carvey used a bone chisel and a hammer to cut off the entire lumbar lamina, and then sealed the bleeding with bone wax. , the dural sac is inside."

Because the field of view has expanded a lot and the dural sac can be seen directly, the subsequent operation is much simpler than the previous small window operation.

Place the retractor at the starting point of the right nerve root, gently pull the dura mater to the left to expose the posterior part of the intervertebral disc, and then use forceps to remove the nucleus pulposus of the intervertebral disc that has broken the fibrous ring.At the same time of removal, it is necessary to go deep into the interior of the intervertebral disc, and use a spatula to remove as much soft tissue and cartilage as possible. 【12】

The same is true for the left nucleus pulposus.

"You have removed all the intervertebral discs used as buffers, what should you do next?" Watman looked at the fragments of cartilage tissue in his hand, puzzled. 【13】

"It's enough to fill the space with fillers." Carvey is very satisfied with the hollow intervertebral disc he repaired. "It's like dealing with old furniture that is no longer useful. You have to clean up the house first. Throw away what needs to be thrown away. Throw it away to make room for the new furniture."

"New furniture?"

"Um"

Carvey used a reamer to go deep into the intervertebral space, rotate it to expand, estimated a suitable distance [14], and started the next step: "Give me the scalpel, and we will find new furniture."

He asked Sears for a weapon, but his hands had already touched the old marshal's posterior superior iliac spine.Lift off the previously covered linen cloth, find the location, apply carbolic acid and alcohol for disinfection, and quickly make an incision.

The next step is to cut the fascia routinely, separate the periosteum, and expose the iliac cortex.

"What are you doing?"

Carvey put down the scalpel and replaced it with the bone chisel and hammer: "Build new furniture."【15】

[I will put the 3D demonstration of the specific operation in the easter egg chapter after the operation is over, because the characters haven't appeared yet, I can't play it for the time being]

It has been two and a half hours since the operation, and there is still no sign of it ending.

Those people in the living room have seen the world, and they are already prepared for the time required for Kavey's operation.In addition, they also need to discuss many war and military issues, and they 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?"

"Dr. Ed Nelson said." Jenny held the mirror in her hand and was still applying makeup on her face. "How about my face?"

"Only low-class women would wear makeup." Cecilia changed her previous cowardly attitude and said, "If you put powder on your face like this, you might as well ask that Dr. Ed Nelson to give you some blood. Believe me, a few small bugs are not painful or itchy, and can keep fair skin for several days."

Jenny didn't respond to these words: "Forget it, those bugs are disgusting."

Seeing that she was still so stubborn, Cecilia became more and more impatient: "We have been waiting outside the door for almost three hours."

"His surgery has always been like this, wasn't it also like this in the square before."

"Shouldn't the operation 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 a very high evaluation."

When Ed Nelson was mentioned, Cecilia became angry: "I can't believe what he said. The last time I promised to bring people to the nursing home, what happened? More than half of the people who came were our original customers, and finally asked us to come to the nursing home." Go find Ambassador Edward for publicity yourself."

"It's not that you want to find someone to act as a front."

"You don't look at the cost we spent. We have everything prepared, but the customer flow is not full on the day of the store opening. I can't even imagine how to make money afterwards?"

"Is everything ready?" Jenny has always had her own attitude towards this matter, "Anyway, I think there is something missing in the store."

"What?" Cecilia didn't understand what she meant, "We copied the model of the Canadian electrotherapy hospital, whether it's the equipment or the way of publicity. There are not many people there, but the business is much better than ours, and many people are willing to drive They enjoyed electrotherapy for hours, and some even stayed in the store and refused to leave.”

Jenny naturally knows, but she also knows the real gap between them: "Have you ever thought about the difference between that store in Canada and ours?"

".You mean there is a shortage of doctors in the store?"

"Yes, there are two doctors in the store in Canada. Although they are young, they are at least willing to endorse electrotherapy equipment. But here in Vienna, there are none, not a single one."

"That's why I think that Ed Nelson is annoying, and the [-]-[-] split is too greedy."

Jenny took out the cigarette case from her handbag, took out one and stuffed it gently into her mouth.Then he took out a match, lit himself on fire, and took two puffs: "The two young doctors in Canada also gave [-] to [-] points. He is a chief doctor, so it is no problem to get [-]% and [-]% of his reputation here."

After hearing this, Cecilia was heartbroken: "Do you mean to obey him?"

"No, I don't have much confidence in him anymore." Jenny shook her head and exhaled a few puffs of smoke. "It's really strange that a doctor can get so much money for just a few casual words and a pose for a photo."

"Yeah, the world is so unfair to women."

"But these are the rules of the game!" Jenny said, looking at a carriage slowly approaching the gate of the manor outside the window, "We can't break the rules directly, but we can break them slowly. Since doctors can earn so much money, we Why not become a doctor yourself."

(End of this chapter)