RU2122355C1 - Method of surgical management of arnold-chiari malformation in infants - Google Patents

Abstract

FIELD: medicine, neurosurgery and neuropathology. SUBSTANCE: method includes myeloradiculomeningolysis after herniotomy; separation of medullary cone, terminal filament and horse tail roots; section of terminal filament and shunting with the help of performance of terminal ventriculostomy. EFFECT: eliminated fixing of spinal cord, provision of correction of disturbances of liquorodynamics and prophylaxis of development of hydrocephalus and syringomyelia.

Description

 The invention relates to medicine, namely to neurosurgery and neuropathology.

 Arnold-Chiari malformation (MAC) is the most common congenital malformation of osteoneural development and is accompanied by significant mortality and persistent disability of patients. The main pathomorphological substrate of MAK is a chronic hernia of the cerebellum and brain stem in the cervical-occipital funnel with spinal hernia in the lumbosacral spine.

 A known method of treating MAK by performing reconstructive surgery on a craniovertebral junction, with restoration of the passage of cerebrospinal fluid (CSF) through the outlet of the fourth ventricle (Peter W., Carmel, MD Congenital Syringomyelia. In Batzdorf U. (ed): Syringomyelia: Current concepts in diagnosis and treatment. Baltimore, Williams & Wilkins, 1991, p. 140-150).

 There is also known a method of surgical treatment of MAK by hernia repair with simultaneous or subsequent ventriculoperitoneal shunting (WO Bell, T. Orbit, RAFroser. One-stage meningomyelocele closure and ventriculoperitoneal shunt placement. // Surg. Neurology. Vol. 27-N 3.-1987 .- pp. 233-237).

 The closest and accepted by us for the prototype is a method of treating MAK by herniation, lumboperitoneal shunting and myelotomy (Park TS, WS Cail, WC Broaddus, MGWalker. Lumboperitoneal shunt combined with myelotomy for treatment of syringohydromyelia.// J. Neurosurg. -1989. vol. 70 p. 721-727).

 The operation is performed as follows - after isolation of the hernia sac and meningoradiculolysis, the caudal part of the spinal cord is identified. In the most thinned part of the cyst, a 5 mm long myelotomy is performed. Caudal to the neural plate is the spinal end of the catheter, which is then carried out in the subcutaneous tunnel to the anterior abdominal wall. After performing a laparotomy, the other end of the catheter is lowered into the abdominal cavity, the wound is sutured in layers and hernioplasty is performed. However, this method has a number of significant drawbacks, which is primarily associated with the use of foreign materials for drainage of CSF.

 1. Infectious complications associated with the use of foreign material, as well as acute and chronic inflammatory processes of the abdominal cavity.

 2. Occlusion of the abdominal end of the catheter with an omentum and the formation of pseudocysts around the catheter.

 3. Adhesion of the edges of the myelotomy wound and obliteration of the opening between the cyst and subarachnoid space.

 4. Failure to fix the spinal cord.

 5. Further caudal displacement of the cerebellum and brain stem into the cervical-occipital funnel, due to lumboperitoneal drainage of the cerebrospinal fluid.

 The technical result of the proposed method is the elimination of fixation of the spinal cord and the prevention of internal hydrocephalus by performing hernia repair and correction of liquorodynamic disorders simultaneously.

 The technical result is achieved by isolating the hernial sac, performing meningomyeloradiculolysis and bypass surgery.

 What is new is that the medullary cone, the terminal thread and the cauda equina roots are additionally isolated, the terminal thread is crossed at the fixation site, and shunting is performed using terminal ventriculostomy.

 As a rule, a hernia of the hindbrain leads to occlusion of the outlet ventricles of the IV ventricle, the development of occlusal hydrocephalus and the formation of an intramedullary cavity along the entire length of the spinal cord and in its terminal filament, which, in addition, is deformed and fixed.

 Rough fixation of the terminal thread causes a violation of the ontogenetic development of the anatomical and topographic relationship of the spinal cord and spine. Due to fixation, the spinal cord is located almost throughout the spinal canal, never occupying its usual position (level of Th 12-LI vertebra). In addition, in the process of subsequent growth of the spinal cord, its fixation causes further caudal displacement of the cerebellum and brain stem into the cervical-occipital funnel, aggravating impaired drainage of the cerebrospinal fluid through the outlet of the IV ventricle and does not allow to restore normal anatomotopographic relationships between the spinal cord and spinal canal .

 Performing a terminal ventriculostomy promotes free drainage of CSC through the central channel of the spinal cord into the spinal subarachnoid space, preventing the development of occlusal hydrocephalus. Excision of the terminal thread eliminates fixation of the spinal cord and prevents further displacement of the hernia of the hindbrain into the cervical-occipital funnel.

 From the above it follows that the claimed technical solution, in comparison with the prototype, has the signs that they additionally secrete a medular cone, cross the terminal thread, and bypass surgery is performed by performing terminal ventriculostomy, which meets the criterion of "novelty."

 A new set of features ensures the achievement of a higher positive effect, which consists in eliminating the fixation of the spinal cord, correcting the disorders of cerebrospinal fluid dynamics and preventing the development of hydrocephalus and syringomyelia. Therefore, the solution has "industrial applicability".

 In the analysis of known methods, it was found that they lack information on the influence of the distinguishing features of the claimed method to achieve a technical result, therefore, the invention corresponds to the "inventive step".

 The proposed method for the treatment of MAC is as follows.

 Under endotracheal anesthesia in the patient’s position on the abdomen, a skin incision is made along the line of the spinous processes in the cranial direction from the hernia to identify the lumbar fascia. Then continue caudally until the opening of the hernial sac. After aspiration of the liquid, its contents are revised. Then the incision is continued around the circumference of the hernia with the separation of its membranous part from the "viable skin". Thus, the neural plate and the membranous part of the hernia are separated from the skin. Then perform a second incision to separate the membranous part of the hernial sac from the neural plate. Dull separation begins from the place of exposure of the lumbar fascia, continuing in the plane of the subcutaneous fat, between the thoracodorsal fascia and the dura mater. After adequate isolation of the membrane of the brain, it is cut off from the membranous part in the area of their connection, until the hard membrane is completely released from the connection with the dermis. The maximum preservation of the "viable" dura mater allows you to freely close its defect over the neural plate.

 Then, myeloradiculolysis is performed, the terminal thread is isolated, and after applying the clip at the place of its fixation, it is crossed to prevent bleeding from the artery of the terminal thread. The dura mater above the neural plate is sutured with a continuous suture, and the tightness is controlled by the Valsalva breakdown. Then, nodular screwing sutures are applied along the junction of the membranous part of the hernia, dermis and dura mater, which ensures the convergence of the skin edges of the wound. The skin wound is closed by applying separate vertical mattress sutures.

 The proposed method of treatment is confirmed by the following clinical example.

 B. S., 1 year 2 months. He was treated in the surgical department of the CSTO of Irkutsk from 09/22/92 to 11/11/92 for MAC, lumbosacral meningoradiculocele. From the source bol. N634.

 Sick from birth, in the maternity hospital a pediatrician was diagnosed with spinal hernia. Discharged 10 days after birth. He was under the constant supervision of a pediatrician at the place of residence. At the age of 9 months. started crawling on his stomach, then on his knees. At the age of 11 months began to stand with support. On admission he speaks 10 words, plays with toys.

 Objectively: the skull is dolichocephalic, head circumference 49 cm. In the neurological status, the low standing of the arches of the soft palate, the absence of a pharyngeal reflex, and hypotrophy of the sternocleidomus on the left attract attention. The motor sphere - tendon reflexes from the upper extremities are animated, live abdominal. Living knee, Achilles are not called. Hypotension in the muscles of the lower extremities, mainly in the distal parts. Hypermobility in the ankle joint. Decrease in pain and temperature sensitivity on the lower extremities by type of socks and in the perianogenital zone. Urinary and fecal incontinence.

 Locally: in the lumbosacral region, a hernial protrusion of a soft-elastic consistency, size 6.0 • 6.0 • 6.0 cm.

 With ultrasound of the brain through the middle cranial fossa (coronary section), there is a symmetrical expansion of the lateral and III ventricles of the brain, the expansion of the hole Monroe. During sagittal scanning, there is a lack of a large brain cistern, an unsharp deepening of the posterior cranial fossa. The caudal sections of the IV ventricle are located at the level of the edge of the large occipital foramen.

 Operation (08/10/92) - hernia repair, terminal ventriculostomy.

 Under endotracheal anesthesia, a linear skin incision 3 cm long along the line of the spinous processes L3-L4 in the cranial direction from the hernia with identification of the lumbar fascia. The incision was continued around the circumference of the hernial sac with the separation of the membranous part of the hernia from the “viable skin”. Through an additional circular incision, the dura mater is also separated from the membranous part of the hernia. The hernial sac is opened, cerebrospinal fluid is aspirated. Meningoradiculolysis with the release of a thickened terminal thread. The dura mater is sutured with a continuous suture. Leak test - Valsalva test. Hernioplasty by CheeK. (W.R. CheeK, J.P. Laurent, D.A. Cech Operative repair of Lumbosacral myelomeningocele. Technical note // J. Neurosurg. Vol 59., 1983, pp. 718-722). Stitches for subcutaneous tissue and skin. Aseptic dressing.

 Postoperative ultrasound of the brain and spinal cord revealed a decrease in the size of ventriculomegaly due to the lateral ventricles. III ventricle took on normal age sizes. The large occipital cistern is still not visualized. During sagittal scanning at the level of the arches of 5 lumbar and 1 sacral vertebrae, the terminal thread of the spinal cord is visualized in the spinal canal, in the lumen of which an echo-negative cavity with rounded walls is located.

 During dynamic observation, within 8 months, it was noted that the child develops in accordance with age, it became better to hold urine.

 Thus, the proposed method for the treatment of MAC in young children allows you to simultaneously fix the fixation of the spinal cord, treat disorders of cerebrospinal fluid dynamics, and prevent further progression of the disease.

Claims (1)

 A method for the surgical treatment of Arnold-Chiari malformation in young children, including the isolation of a hernial sac, performing meningomyeloradiculolysis, hernioplasty and bypass surgery, characterized in that the medullary cone, the terminal thread and the cauda equina are isolated, a clip is applied at the place of fixation of the terminal thread and they cross it, and bypass surgery is performed by performing terminal ventriculostomy.