Special surgery saves young man after train accident
Surgery(11.08.2016) At the end of June 2016, an 18-year-old man was walking along the railroad tracks in the Freiburg city area at night when he was hit by a passing train. The first train driver to travel along the track the next morning discovered the seriously injured man. An ambulance was immediately alerted and took him to the emergency center at Freiburg University Hospital. There, the doctors diagnosed a number of injuries on the basis of a full-body CT scan: the liver, kidney and spleen were partially ruptured, ribs broken and the lungs bruised. A small tear in an inner facial bone had allowed air to enter the brain. A lumbar vertebra and a cervical vertebra were also broken.
Initially, the patient's low body temperature of 31 degrees Celsius was the biggest problem. "If it had been any colder at night, he probably wouldn't have survived," says PD Dr. Kilian Reising, Senior Consultant at the Clinic for Orthopaedics and Trauma Surgery. This also made it more difficult to treat the patient. This is because blood clotting no longer functions properly at such a low body temperature. Under these circumstances, an operation would have been life-threatening. For this reason, the doctors initially raised the body temperature slowly.
While it became clear over the following days that the internal injuries did not require surgery, the vertebral fractures absolutely had to be stabilized. The connecting element of the second cervical vertebra, on which the first vertebra rests, had broken off and shifted. If the displaced vertebra presses on the spinal cord, this can lead to paraplegia. In the event of such a fracture, several vertebrae and the head are usually screwed together from the back. "This provides the necessary stability, but the patient can never fully turn his head again. We didn't want to do that to the young man, so we looked for alternative solutions," explains trauma surgeon Dr. Reising.
Complex operations for a better quality of life
The doctors decided on a different approach. They opened the neck from the front at the level of the larynx, pushed the trachea and oesophagus to one side and the large neck vessels to the other. They then fixed the broken part of the vertebra with a screw about four centimetres long. However, a few days later it became apparent that the screw was not stabilizing the vertebra permanently. The doctors therefore looked for a new approach, still hoping to preserve the young patient's mobility.
Professor Dr. Dr. Rainer Schmelzeisen, Medical Director of the Department of Oral and Maxillofacial Surgery at the Freiburg University Medical Center, and Professor Dr. Norbert Südkamp, Director of the Department of Orthopaedics and Trauma Surgery at the Freiburg University Medical Center, suggested accessing the spine through the mouth behind the soft palate: a technique that is very rarely performed worldwide. The cervical spine and the fractured second cervical vertebra are located just below the base of the skull and immediately behind the back wall of the throat. It represents the most posterior area of the pharynx. "The advantage of this operation is that the anterior area of the cervical spine, and in particular the vertebrae immediately below the skull, can be seen directly. Anatomical stabilization is particularly easy via this approach," says Prof. Schmelzeisen.
The oral surgeon is one of the few people in the world who has performed such an operation twice in his life. The fact that the actual surgical site is very far away from the mouth opening caused difficulties. Many surgical instruments are not actually long enough for working "in depth". But with headlamps, a plate from wrist surgery, which was actually developed for stabilizing fractures of the radius, and a great deal of effort, the doctors took their chance.
Using a fine thread, the soft palate with the uvula was first moved forward and to the side to reveal the back wall of the throat. Prof. Schmelzeisen made an approximately six-centimetre-long incision through the mucous membrane and muscles of the pharynx to expose the connective tissue fascia layer in front of the spinal column. After he had also incised this, the bony surface of the vertebrae appeared. Through careful dissection, Prof. Schmelzeisen succeeded in avoiding injury to vital vessels such as the internal cerebral artery running laterally on both sides.
During the operation, a navigation device was used to determine the surgeon's position. The patient's computer tomography X-ray data is available during the operation. The tip of certain instruments can be identified during the operation using an infrared camera, allowing the surgeon to determine the exact position even when visibility is restricted. The surgical result can then be checked through an endoscope using fiber optics and is transmitted to a large screen in the operating theatre during the operation.
"The fractured vertebra was clearly visible. Once we had exposed it, the trauma surgeons were able to fix it," says Prof. Schmelzeisen. The T-shaped metal plate was attached to the vertebra with five screws. Finally, the posterior pharyngeal wall was sutured again. A good three weeks after the serious accident, the patient was able to leave the hospital with a very good health prognosis. "It is quite likely that the patient will make a full recovery," says Dr. Reising.
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