How to Apply Intraoperative Ultrasound when Spinal Trauma Surgery Is Performed in the Lateral Decubitus Position?

Abstract

Objective: At present, intraoperative ultrasound was widely used in spinal surgery. But there have been no reports on the use of intraoperative ultrasound in lateral decubitus position spinal surgery. The authors' research objective was to describe the applications of intraoperative ultrasound in spinal trauma surgery when performed in the lateral decubitus position.

Methods: Six patients with polytrauma who underwent surgery for spinal trauma between June 2020 and March 2022 and could not be operated on using a posterior approach in the prone position. All six patients underwent surgery in the lateral decubitus position. During surgery, a capsular bag had been designed and surgical field can be filled with normal saline for acoustic coupling, and then ultrasound was used to observe and guide decompression, and assess injuries of the neural elements such as the spinal cord. The data of preoperative and postoperative (12 months) American Spinal Injury Association impairment scale (AIS), follow-up time, operation time, blood loss, ultrasound signal change of spinal cord, ultrasound guide decompression, internal fixation (12 months), and fracture healing(12 months) were collected.

Results: The study included four males and two females whose ages ranged from 19 to 56 years old (41.5 ± 13.06 years old). Follow-up times ranged from 12 to 20 months (14.33 ± 2.75 months). The operation times ranged from 195 to 248 mins (222.16 ± 16.86 mins). The estimated volume of blood loss ranged from 280 to 450 mL (383.33 ± 55.58 mL). The six cases' AIS (preoperative vs. postoperative) were A versus A, C versus D, A versus B, B versus B, B versus C, and B versus C. Intraoperative ultrasound was performed successfully in all patients using our designed method. Intraoperative ultrasound observation revealed varying degrees of changes in spinal cord echo in all patients. Intraoperative ultrasound provided excellent assistance in spinal cord decompression during surgery. The surgery was completed successfully with no surgery-related complications till the last follow-up. At the time of last follow-up (median time of 12 months) satisfactory fracture reduction and good internal fixation was confirmed on postoperative computed tomography scans and radiographs.

Conclusions: The authors represented the technology of intraoperative ultrasound in spinal trauma surgery when performed in the lateral decubitus position. This technology solves how to apply intraoperative ultrasound in lateral decubitus position.

Keywords: Decompression; Intraoperative Ultrasound; Lateral Decubitus Position; Posterior Approach; Spinal Trauma; Surgery.

FIGURE 1

The manufacturing method of the bag containing normal saline for placing ultrasonic probe: another new antimicrobial incise drape was applied to cover the surgical area and adhered to the previously attached drape, with its upper edge ~3 cm higher than the incision, and a capsular bag (A, B) with an upward opening was made. The surgical area with no drape pasted was covered with sterile gauze to prevent the probe from adhering to it (C). The capsular bag and surgical field were filled with normal saline for acoustic coupling (D). A sterile 10‐MHz ultrasound probe was placed through the reserved window, and by scanning along the longitudinal axis and vertical to the body, sagittal and cross‐sectional images of the dural sac and neural elements were obtained (E).

FIGURE 2

Case 1: The patient had pelvic fracture, enterostomy, and T‐tube drainage, and partial necrosis and dehiscence of the abdominal incision (A). Computed tomography (CT) and magnetic resonance imaging (MRI) showed comminuted fracture of T12 vertebral body and signal changes of spinal cord (B, C). The intraoperative ultrasound observation in lateral decubitus position showed that the spinal cord swelling and thickening were obvious (D), the injured spinal cord echo was heterogeneous (E), with slightly hyperechoic (D red arrow), isoechoic (D yellow arrow), and hypoechoic areas (D blue arrow). Postoperative CT showed satisfactory spinal canal decompression and reduction of fracture and good internal fixation position (F).

FIGURE 3

Case 2: Three‐dimensional computed tomography (CT) of pelvis showed unstable pelvic fractures (A). Spine CT and magnetic resonance imaging showed L2 burst fracture, and the fracture fragment encroach spinal canal compressing dural sac and cauda equina (B, C). In the lateral decubitus position, intraoperative ultrasound showed that cauda equina nerve herniated from the dural sac (D red arrow), the echo of conus medullaris and cauda equina was homogeneous. A subsequent ultrasound examination showed complete decompression of the spinal canal (E). Postoperative follow‐up radiographs showed satisfactory reduction of the fracture and a good internal fixation position (F).

FIGURE 4

Case 3: Computed tomography (CT) and magnetic resonance imaging showed T3/4 fracture and dislocation, T9 compression fracture, and obvious spinal canal encroachment (A–C). The surgeon used intraoperative ultrasound in lateral decubitus position and observed swelling and thickening of the spinal cord at the fracture site, and found displaced bone segments compressing the spinal cord (D red arrow). After further decompression, it was observed that the spinal cord decompression was completed (E), and a large hypoechoic area (E, blue arrow) in the spinal cord was found. Postoperative CT showed satisfactory canal decompression and fracture reduction and good internal fixation position (F).