Many orthopedic surgeries, like interventional surgeries, must be performed under X-rays.
C-arm X-ray fluoroscopy locates the position of the L2 vertebral body and bilateral vertebral pedicles. The assistant begins disinfection and lays out sterile surgical drapes.
There was no problem with the positioning. Before the operation, Professor Tian explained the entire operation process to his assistant.
On the stage, Professor Tian used 1% lidocaine for local anesthesia and made an incision of about 0.5CM at the patient's second lumbar vertebra marking point.
Under the guidance of fluoroscopy, puncture is performed on both sides, and a cored puncture needle is inserted at the outer upper edge of the bilateral vertebral pedicles of L2 at an angle of about 10°.
The operation is skillful, and this kind of difficult surgery is almost not difficult for a surgeon of Professor Tian's level.
After the needle tip enters the vertebral pedicle under C-arm X-ray fluoroscopy, pull out the needle core and put in the guide pin. Insert the guide pin into the front 1/3 of the vertebral body, remove the puncture needle, and insert the working cannula.
After the hand drill reaches 1/2 of the vertebral body, pull out the hand drill and guide pin, and insert the expansion balloon through the working cannula. The fluoroscopy shows that the expansion balloon is in good position. After gradually opening it with the expansion balloon, the C-arm X-ray fluoroscopy showed that the height of the vertebral body returned to close to normal height.
Professor Tian took out the balloon, and his assistant had already prepared the bone cement.
After 1 minute and 30 seconds, the bone cement was slowly injected through the working cannula under C-arm fluoroscopy.
The operation was about to end at this point. Professor Tian was injecting bone cement while looking at the image of the bone cement intently.
"The operation here must be meticulous and careful." Professor Tian explained to his assistant while applying bone cement.
"What is the biggest complication of bone cement injection?" Professor Tian asked.
"Bone cement leakage," the assistant replied.
Professor Tian belongs to the more academic type, not too arrogant, like a southerner.
Professor Tian would ask a lot of questions to the doctors who came to him for further training during every operation.
As a training doctor, I was not used to it at first, but I couldn't be left speechless by Professor Tian asking some simple questions on the operating table.
Although it is hard work to prepare, endorse, and train to be a doctor, your level improves very quickly.
"Not sure." Professor Tian explained while slowly injecting bone cement: "The most serious complication is pulmonary embolism. Bone cement leakage is very common, because patients have osteoporosis, so 73% of patients had no reaction after leakage.”
Professor Tian did not continue to explain, because the patient was under local anesthesia. If the explanation was too serious and caused the patient to be nervous and cause a myocardial infarction, then he would be looking for trouble for himself.
"Just be careful not to touch the communicating artery and vein with the tip of the injection needle." Professor Tian injected 2 ml of bone cement. "Generally, this is a very low-risk operation. What do you want next? Do it yourself, and I will be your assistant on the side."
When the patient heard what Professor Tian said, he was glad that he seemed to be lucky, so he rushed Professor Tian to do it himself.
When about 2.5 mL of bone cement was injected, Professor Tian was startled.
Under fluoroscopy, a strip-shaped "bone cement X-ray contrast agent" shadow extending upward appeared on the right side of the front edge of the vertebral body. The image is like a small insect, constantly climbing.
Uh... Professor Tian was speechless. If he said it leaked, it would leak. Have you ever opened your mouth
It's okay, it's okay, Professor Tian comforted himself in his heart.
Literature reports that the incidence of bone cement venous leakage accounts for approximately 24% of bone cement leakage, and the incidence of pulmonary embolism due to venous leakage is 4.6% to 6.8%. Most of them are small amounts of pulmonary embolism with no obvious clinical symptoms.
Only 0.4% to 0.9% of patients with pulmonary embolism will develop clinical symptoms.
This probability is so small that there is almost no need to worry.
During clinical operations, Professor Tian also encountered situations where bone cementing was complicated by pulmonary embolism.
Most patients recover after lying down for a while, and there are no special complications. There is not much treatment after the operation and it does not affect anything.
He comforted and encouraged himself in his heart - it will be okay, it will be okay.
Through continuous C-arm dynamic fluoroscopy, it was observed that the location of the contrast agent shadow continued to change, passing through the right atrium, right ventricle, and finally staying in the right lung.
Professor Tian had stopped operating. He watched helplessly as the bone cement entered the right lung, and his hands were numb.
What a deal! Why did I encounter pulmonary embolism? Professor Tian, who has always had a mild temper, cursed in his heart, and now he can only pray that the patient will have no clinical symptoms.
No one can avoid complications during surgery.
No matter how careful you are, no matter how thorough the preoperative preparation is, it cannot be avoided.
The only thing that didn't cause any trouble was that less surgery was done! This is a consensus among the medical community. As long as a certain number of surgeries are performed, various complications will definitely arise.
For example... today's pulmonary embolism.
"Are you feeling uncomfortable?" Professor Tian asked softly when he saw that the bone cement had reached the right lung.
"No." The patient replied, "Everything is fine. Professor Tian, you did a great job. I didn't feel any pain at all."
Professor Tian sighed inwardly, did he do well
The surgery should have been good, but when complications occurred, how could I have the audacity to say that I had done a good job
The patient's images showed that bone cement entered the right lung, but there were no clinical symptoms of pulmonary embolism.
Professor Tian thought that the bone cement overflowed from the vertebral body, entered the paravertebral veins, and then migrated to the lungs, causing multiple embolisms in the pulmonary arterioles.
Stop the operation. If you go ahead and do it, everything will turn into nothing.
He immediately stopped the bone cement injection and sutured the incision.
After finishing the procedure, Professor Tian helped the patient lie down with his own hands, for fear that the assistant would make a mistake and cause the patient to have aggravated fractures or other accidents.
There are enough accidents. If you can, try as few as possible.
The patient was changed from prone to supine, oxygen inhalation and ECG monitoring were performed, and venous access was opened.
For patients with asymptomatic bone cement pulmonary embolism, there is no recognized treatment plan at home and abroad. Currently, there is a tendency not to use prophylactic anticoagulants, but only to closely follow up to observe changes in the condition.
Although the operation failed, as long as the patient is fine, there can be no major problems. Professor Tian felt a little uneasy and carefully observed the patient's condition.
While closely observing his condition, he urgently requested respiratory medicine, cardiothoracic surgery and other related departments to enter the operating room for consultation.
After 1 hour of observation, the patient showed no symptoms of discomfort. The Department of Respiratory Medicine and Cardiothoracic Surgery do not recommend excessive treatment. They should observe changes in the condition and make further decisions if there are any changes.
After the patient developed pulmonary embolism during the operation, the patient never showed symptoms of intrapulmonary gas exchange disorders such as dyspnea, tachypnea, or increased respiratory rate.
Professor Tian feels that he is quite lucky, at least the patient is fine.
It's just that the operation failed. When I go back, I have to do a lot of explaining work with the patient's family to try to win their understanding, so as not to cause any doctor-patient disputes.