When dealing with ligamentum flavin, the most troublesome and fatal thing is to avoid the dural sac wrapped around the lateral spinal cord. [1]

This is not a difficult task at Kawei. He is just not familiar with the process of lumbar disc herniation surgery and has a lot of experience in spinal trauma. But the others are different. They have no surgical experience and have basically never had surgery as small as a window.

During corpse exercises, they often accidentally traumatize the dura mater, so they all hope to get the operation opportunity when peeling off the shallow ligament of the calcareous.

Now Watman has exclusively stripped the shallow ligament of the yellow ligament, and the remaining deep ligaments are not something they can handle.

"Don't you want to try again?" Kawei asked, looking at the ligament stripped from the plate, "There is the epidural cavity below the ligament, which is still a little far from the dura."

"Farewell, I practiced on the corpse five times, I broke it four times, and my nerves fell out." Masimov looked at the spatula that Watman had dropped, and felt a shadow in his heart. He was the first to back down. "Whoever they want to do, I won't do it anyway, wait until he becomes more proficient."

Watman had already set off as an assistant, and Orgi just smiled and shook his head: "I'll forget it, too."

"Where are you, Hills?" Kawei did not forget his former superior, and looked quite relieved and asked, "Do you want to give it a try?"

Hills would love to try it.

He was always bold when dealing with the details of the surgery, not as timid as the two of them. Originally, dissecting the corpse was just simply familiar with the anatomical structure. If he really felt, the dead corpse was completely different from the living person. If he always looked at the foresight, he would never have good surgery.

But that was only for ordinary patients. The one who was lying in bed today was the Marshal of the Imperial Empire, and even he had to choose to retreat.

"There are many patients with lower back and leg pain, and there will be opportunities in the future." Hills shook his head, "The old marshal has relied on this surgery on his lower body, so it's better to end it as soon as possible."

"Okay, give me a blunt hook." Kawei used a very thin hook to slowly peel off the proximal attachment point of the ligament and separate it to the distal end. "In fact, it is not difficult. The main thing is to control the strength. As for the attachment point at the distal end, there is no need to separate it. Just use the bone-biting forceps and the laminar plate to remove it." [2]

There are also scope requirements for removing the caudal lamina, at least the medial wall of the pedicle must be exposed: "In order to avoid damage to the nerve root, the tip of the bone biting forceps used here should be kept parallel to the nerve root or the dural sac to prevent damage." [3]

The surgery did not really open the window for treating the intervertebral discs until this step.

The anatomical position of the intervertebral disc is deeper than that of the dural sac. Before continuing the operation, it is necessary to first explore the gap around the dural sac and carefully observe the herniated nature of the intervertebral disc.

This is something that must be clear when every discectomy is removed, which directly determines the choice of the next surgery method. Even if it is in modern times with advanced imaging examinations, it is the same, which shows the importance of direct vision on the surgical situation.

But there is a prerequisite, that is, imaging studies are used as a guarantee. At least before the operation, the surgeon has already known the approximate degree of disc herniation, and intraoperative exploration is just to fine-tune the surgical method.

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

From the examination, Marshal Ludwig had a herniated disc in waist 4-sacral 1.

As for the type of protruding, whether it is a central type, an lateral type, or a distant type, whether it is simply bulging, protruding, prolapsed or free from the outside, Kawei has no way to make a judgment, so everything is waiting for surgery to open a blind box. [4]

Now, after more than half an hour of opening the window, the blind box has been opened. The gap opened by the dura sac through the dura hook is pulled away, and Kawei saw a huge central lumbar disc herniation. [5]

The range 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 in recent years. The lower body has been on the edge of paralysis, which is simply torture. If it protrudes further outwards and becomes more severe, it may have a equine tail syndrome. [6]

The window just opened is too small, and the field of view cannot accommodate the herniated disc at all, at least Kawei cannot see its edge. Disc removal is only used for a small amount of herniation, especially for the compression of the nerve roots of the foramen nerves. Such a large-scale central antagonism obviously exceeds the surgical indications.

The effect of using a simple discectomy is very limited and is likely to recur.

The old marshal was still in good health, but at this age, he could not withstand secondary surgery, ether, bleeding and infection caused by surgical trauma, and infection were very fatal, and Kawei didn't want it.

"Simple resection probably won't work." Kawei squinted his eyes and recalled how the orthopedics treated the huge intervertebral disc.

The four of them stood by the operating table and looked at him with a gaze. However, they practiced and modified the discectomy several times repeatedly. They should be able to cope with most of the situations. How could they change it?

It was not that Kawei had thought that the discectomy was ineffective. In addition to reviewing the standard discectomy on the body with them, he also made other preparations.

Now the question is what surgery is changed to?

If you consider the physical condition of the old marshal, if you choose a simpler choice, you will do an extensive total laminectomy. The surgical method is to cut off the posterior lamina of the entire lumbar 4-sacral 1, including the spinous process, and cover the paravertebral muscles. It is enough to give the compressed spinal canal a backward relief area [7]

but.

Kawei immediately realized that such a surgery was not good.

Although extensive total laminectomy is effective, it will remove the bone structure behind the spine, especially when it involves joint processes, it will definitely cause postoperative spinal instability. [8]

Mechanical instability of the spine can affect daily life and is not much better than herniated discs.

Kavey took the periosteal stripper in his hand and gently drew two lines on the vertebrae. Could it be that he only had limited pressure reduction? He retained the supraspinal ligaments, interspinous ligaments and spinous processes, and only cut off the bilateral laminar? [9]

Doing so will indeed preserve the bone structure behind the spine, and the spine will not become unstable

Kawei checked the old Marshal's lumbar spine again. Because long-term herniation of the intervertebral disc caused stimulation in the spinal canal, a large number of hyperplastic osteophytes have formed around the periosteum. No matter how you look at it, the structure behind the spinal column is no longer necessary, and retaining it will reversely stimulate the spinal cord in the center of the spinal canal.

It is inevitable to have a complete lamina cut, and it seems that it is going to be used.

"Give me bone biting forceps, 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 half. "I want to cut off the spinous process behind the spine, and then completely remove the intervertebral disc."

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

"Just do fixing and repairing." Kawei didn't say much, quickly peeled off the periosteum on the other side, took the bone-biting forceps handed over by Hills, and directly used it on the spinous process. "After all, the patient is 60 years old, we have to fight quickly."

The function of bone biting forceps is to cut off useless laminar plates, bone wax is used to stop bleeding, and sandpaper is used to polish the sharp cut surfaces smoothly [10]. The endless new things are dazzled by them. After all, there is no need to use these things when practicing on corpses.

"This is."

"It's beeswax. I also mixed a little paraffin and vegetable oil. After disinfection and cooling, it became this solid." Kawei heated the wax block with the temperature of his palm, and then applied it to the fracture where the venous sinus kept bleeding out. "When the bleeding is completed, use a small piece of sandpaper and grind it a little."

Previously, the range of laminectomy was limited and there was not much bleeding. You can press gauze to stop the bleeding by yourself.

But now it is necessary to remove a large area, and the range affects the lower edge of the waist 4, the entire waist 5 and the upper edge of the sacral 1, and ordinary compression is not enough. There are a large number of sinuses in the bones, and the bleeding flow rate after the removal is not large, but it is difficult to stop it. It is not because of the fear that the old marshal will lose too much blood, but it will mainly affect the visual field of the surgical area.

Originally, the anatomy was very fine and vague, and if it was stained with blood, it would be impossible to see anything clearly with the oil lamp.

Kawei's next operation is much more rapid than before. The new bone fusion surgery process is much more complicated than simply resection of the intervertebral disc. The long-term operation time will increase the difficulty of postoperative recovery: "Increase the length of the incision and directly cut off the spinous process of the waist 5 and the laminar plate."

Perhaps it is the surgeon's intuition that even without theoretical support [11], others, including Watman, cannot understand the feasibility of this operation.

They were still helping Kawei, but they didn't have any confidence: "Will this affect the old marshal's spinal stability?"

"If you do this simply, it will be a bit." Kawei used a bone chisel and a hammer to cut off the entire laminar plate of waist 5, and then sealed the bleeding with bone wax. "Give some salt water and rinse off the blood stains, and the inside is the dural sac."

Because the field of vision has been expanded a lot and the dural sac can be directly viewed, the next surgery is much simpler than the previous small window operation.

Use a hook to place it at the starting point of the right nerve root, gently pull the dural to the left to reveal the back of the intervertebral disc, and then use forceps to remove the nucleus pulposus of the intervertebral disc that has broken the annulus. While removing it, you also need to go deep into the intervertebral disc and use a spatula as much as possible to remove all the soft tissue and cartilage inside. [12]

The same applies to the nucleus pulposus on the left.

"I've removed all the intervertebral discs used for buffering. What should I do next?" Watman looked at the cartilage tissue fragments at hand, feeling puzzled. [13]

"Just fill the gap with filler." Kawei was very satisfied with the empty shell of the intervertebral disc he had trimmed. "It's like dealing with old furniture that is useless. You have to clean up the house first, throw away what should be thrown, throw away what should be thrown, and free up the new furniture to have their own place."

“New furniture?”

"Um"

Kawei used a reamer to penetrate deep into the intervertebral space, rotated and spread it open, estimated a suitable distance [14], and started the next step: "Give me a scalpel, let's find new furniture now."

He asked Hills for the equipment, but his hands had already touched the old marshal's posterior superior iliac spine. He lifted the linen he had covered, found the location, applied the disinfection carbolic acid and alcohol, and made a quick incision.

Next is the routine incision of the fascia, separation of the periosteum, revealing the iliac cortex.

"What are you doing?"

Kawei dropped the scalpel and replaced it with the bone chisel and hammer he had just said: "Create a new furniture." [15]

[I will put the specific 3D demonstration of the operation in the easter egg seal after the operation. Now, because the character has not appeared yet, it is not possible to put it for the time being]

Two and a half hours have passed since the operation and there is no sign of ending yet.

Those people in the living room have also seen the world and have prepared for the time required for Kavey's surgery. In addition, they still need to discuss many issues in war and military aspects, so they have no idea about time.

But the two girls who had been waiting outside the manor were not so patient.

"Are you sure he's here for surgery?"

"Dr. Ed Nelson said." Jenny was holding the mirror in her hand and was still putting on her face. "Look at how my face is?"

"Only women who are not good at putting on makeup," Cecilia said, "It would be more affordable to let Dr. Ed Nelson put some blood on you if you piled powder on your face. Trust me, a few little bugs don't hurt or itchy, and can keep your fair skin for several days."

Jenny didn't respond to this: "Forget it, those bugs are so 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."

"He has always been doing this, and wasn't it the case in the square before?"

"The sooner the surgery, the better?"

"I don't understand either." Jenny shook her head, put away the mirror and the powder, and said, "But I know that Dr. Ed Nelson gave him a high evaluation."

When Cecilia mentioned Ednelson, she was angry: "He couldn't believe what he said. Last time she agreed to bring people to the nursing home, what was the result? Most of the people who came were our original old customers, and in the end we had to go to Ambassador Edward for publicity."

"You just want to find someone to serve as a storefront."

"You don't look at the cost we spent. You have prepared everything. As a result, the traffic of customers was not full on the day of opening the store. After that, I couldn't imagine how to make money?"

"All it's ready?" Jenny has always had her own attitude towards this matter. "I think there are still fewer things in the store anyway."

"What?" Cecilia didn't understand what she meant, "We copied the Canadian electrotherapy model, whether it was instruments or publicity methods. There were not many people there, but the business was much better than us. Many people were willing to drive for hours to enjoy electrotherapy, and even stayed in the store and refused to leave."

Jenny knew it naturally, but she also knew the real difference between them: "Have you ever thought about how different that Canadian store is from us?"

".You mean the store is missing a doctor?"

"Yes, there are two doctors in the Canadian store. Although they are young, they are willing to endorse electrotherapy instruments. But there is no place in Vienna, not one."

"That's why I think that Ed Nelson hates it. It's too greedy to split the 50% off."

Jenny took out the cigarette box from her handbag, took out a piece of it and stuffed it into her mouth. Then she took out a match, lit a fire for herself, and took a few puffs: "The two young doctors in Canada also gave a 46% chunk of the chunk of the chunk of the chunk of his fame here, and he is a chief doctor, and it's no problem to get a half point in his fame here."

Cecilia felt very distressed after hearing this: "You mean to follow his words?"

"No, I don't have much confidence in him anymore." Jenny shook her head and spit out a few sips of smoke. "It's strange that a doctor can get so much money by posing for a photo."

"Yes, this world is too unfair to women."

"But this is the rule of the game!" Jenny looked at a carriage that was slowly coming from the door of the manor outside the window and said, "We can't break the rules directly, but we can break it slowly. Since doctors can make so much money, why don't we become doctors by ourselves."
Chapter completed!