RU2254814C2 - Method for surgical treatment of neurological complications in patients with osteochondrosis - Google Patents

Abstract

FIELD: medicine, neurosurgery.

SUBSTANCE: the present innovation deals with surgical treatment of neurological complications in patients with degenerative-dystrophic vertebral lesion and partial disorder of conductor-segmental spinal functions. One should surgically remove spinal compression due to resecting anterior departments of affected osseous-cartilaginous structures of vertebral-motor segment. One should apply electrodes: one pair - intraoperationally epidurally upon dura mater above anterior spinal departments being above the level of its lesion; then another pair of electrodes - by puncturing into area of posterior departments being below the level of its lesion to conduct electrostimulation. Moreover, therapy should be supplemented with phonophoresis with neuroprotector preparations. Electrostimulation of posterior spinal departments starts on the 2^nd d, and that of anterior departments - on the 3d or 4^th d after operation. Parameters of curative electrostimulation should be matches for every patient individually with the help of electroneuromyography. The innovation enables to decrease postoperative complications.

EFFECT: higher efficiency of therapy.

2 cl,1 ex

Description

The invention relates to medicine, in particular to neurosurgery, and can be used for the surgical treatment of neurological complications in patients with degenerative-dystrophic lesions of the spine and a partial violation of the conductor-segmental functions of the spinal cord.

A known method for the treatment of spondylogenic myeloradiculioischemia by electrostimulation of the spinal cord [G.P. Blagorazumova // Sat. scientific works “Modern aspects of electrical stimulation and new technologies in neurosurgery and neurology” - Saratov, 1998.- S.60-61] with nichrome electrodes inserted puncture into the epidural and subdural spaces, while the electrical stimulation of the spinal cord is carried out with a frequency of 0.2-0 , 5 Hz and a pulse duration of 0.5-5.0 ms.

The disadvantages of the method are:

insufficient effectiveness of electrical stimulation of the anterior spinal cord, since stimulation is directed only to its posterior portions;

the absence of a targeted effect on the supraspinal and spinal centers of the nervous system;

the installation of electrodes by puncture (through the needle) into the subdural space (between the dura mater and the arachnoid) can cause a number of undesirable complications, in particular the occurrence of cerebrospinal fluid (cerebrospinal fluid outflow) and the development of meningitis.

The closest in purpose and combination of essential features is a method of treating patients with the consequences of spinal cord injury (a.s. SU No. 1512625, A 61 N 1/36, July 21, 1987, published in B.I. No. 37 for 1989 ., from 07.10.89), including laminectomy, resection of bone fragments compressing the spinal cord from the back (posterior decompression), intraoperative introduction into the subdural space into the posterior-lateral parts of the spinal cord along the lateral surfaces of its lumbar thickening below the level of damage to its electrode plates diameter 0.2-0.3 m and the length corresponding to the size of the segments of the spinal cord innervating the lower extremities, and the conduct of electrical stimulation starting after removal of the sutures on day 9-12, with bell-shaped pulses of 1-5 ms duration, a filling frequency of 4-10 kHz, a repetition rate of 8-12 Hz and voltage 13-20 V.

The disadvantages of the method are:

insufficient effectiveness of electrical stimulation of the anterior spinal cord, since stimulation is directed only to its posterior portions;

the placement of large-sized electrode plates in the subdural space causes a reactive scar adhesion process that reduces the therapeutic effect of electrical stimulation;

the absence of a targeted effect on the supraspinal centers of the central nervous system and its peripheral departments.

The tasks solved by the invention:

- acceleration of recovery of conductor-segmental functions of the spinal cord;

- the establishment of impaired interaction between supraspinal centers of the central nervous system with its peripheral departments;

- prevention of secondary damage to nerve cells of the spinal cord (inhibition of apoptosis).

In the proposed method for the surgical treatment of neurological complications of patients with osteochondrosis, surgical anterior decompression of the spinal cord is performed by resection of the anterior sections of the affected bone-cartilage structures of the spinal motor segment, electrodes are installed: one pair is intraoperatively epidural to the dura mater above the anterior spinal cord above its level lesions, and then another pair of electrodes - puncture into the region of the posterior regions below the level of its lesion, and conduct electro stimulation of the anterior spinal cord and posterior spinal cord. Treatment is supplemented by phonophoresis with neuroprotective drugs on the stimulated spine. Electrical stimulation of the posterior spinal cord begins on the second, and the anterior on the third or fourth day after surgery. The parameters of therapeutic electrical stimulation are selected individually using electroneuromyography.

The proposed method of treatment differs from the prototype:

- the nature of the decompression;

- method of installation of electrodes;

- simultaneous conduct of electrical effects;

- the time of the start of electrical stimulation;

- additional course of phonophoresis with neuroprotectors.

The proposed method of treatment allows you to go to a new level and quality of treatment for patients due to the simultaneous electro-stimulating effect on the posterior and anterior spinal cord, which allows you to restore the conductivity of the anterior and posterior conduction pathways and restore broken interneuronal connections.

The initial electrical stimulation effect on the posterior spinal cord allows you to activate the supraspinal centers of the central nervous system and to strengthen the control feedback signal from them to the front motor sections of the spinal cord, thereby restoring the disturbed interaction between the higher centers of the central nervous system and the peripheral parts of the nervous system.

The signal from organs and tissues to the damaged area of the spinal cord is amplified by electrical stimulation of the posterior sections and is sent to the higher sections of the central nervous system.

Electrical stimulation of the anterior spinal cord, in turn, makes it possible to enhance the conductivity weakened in the affected area along the efferent pathways and eliminate the mismatch between the stem structures, the reticular formation and the underlying parts of the spinal cord, which leads to the restoration of the innervation of internal organs and tissues from the segments located below level of damage to the spinal cord.

This closes the feedback system, which simulates the natural neurophysiological process in the affected spinal cord and restores the integrative functions of the central nervous system: the relationship between the higher centers of the central nervous system and peripheral parts.

Prolonged compression of the spinal cord during degenerative-dystrophic lesions of the spine leads to impaired cerebrospinal circulation and triggers autoimmune processes and apoptosis mechanisms of the nerve tissue of the spinal cord, which gradually captures new intact neuronal structures of the brain. Electrostimulation circular action from the rear to the front of the spinal cord leads to increased synoptic transmission, improved permeability of cell membranes and normalization of metabolism, enhanced by the action of neuroprotective agents during a phonophoresis session. As a result, inhibition of pathogenetic mechanisms triggering apoptosis occurs.

Thus, for the implementation of this method, not only simultaneity is important, but also the sequence of electrical stimulation from the posterior to the anterior spinal cord, which leads to an optimal therapeutic effect.

The method is as follows.

Under endotracheal anesthesia in the position of the patient on the back, access to the anterior sections of the cervical vertebrae is performed. Resection of the affected bone-cartilaginous structures of the vertebral-motor segment in front is performed according to the standard method and anterior decompression of the spinal cord is performed.

When conducting anterior corporodesis, before strengthening the bone graft between the bodies, the ends of the electrodes freed up for 1.0-1.5 cm from isolation are inserted into the epidural space and placed on the dura mater on the region of the anterior spinal cord above the site of its lesion. The electrodes are pressed against the dura mater with a hemostatic sponge.

After that, the electrodes are diverted to one side and the anterior corporodesis is performed, for which a bone autograft is installed by wedging in the groove between the bodies above and below the lying vertebrae so that the electrodes are free, i.e. did not appear to be trapped by a bone graft. The electrodes are brought out through additional punctures of the skin and fixed to it with sutures. The wound was sutured in layers tightly.

The patient is turned on his side. A roller is placed under the head so that the line of the spine is strictly horizontal.

After palpation of the orientation, the place of introduction of the electrodes is determined by the puncture way, focusing on the level of performed resection of the bone-cartilaginous structures in front, they retreat one vertebra down from it, then the epidural space is punctured with a special needle of the Tougli type through the interspinous bundle.

The needle connected to the water manometer is guided between the spinous processes of the vertebrae strictly along the midline until it touches the yellow ligament. The sensation of a slight “dip” and at the same time a decrease in the liquid column in the pressure gauge indicates that the end of the needle is in the epidural space. Further advancement of the end of the needle is stopped. By slightly pulling the plunger of the syringe, one can see that there is no cerebrospinal fluid. After that, an electrode is installed through the lumen of the needle. The needle is removed, and the electrode remains in the epidural space above the posterior spinal cord. In a similar manner, a second electrode is installed. The outer ends of the electrodes are sutured to the skin with a nodal suture.

After the electroneurographic examination and individual selection of the pulse current parameters, electrical stimulation by the apparatus of the "Eliman" type begins in the posterior spinal cord on the second, and the anterior - on the third or fourth day after the operation. Electrical stimulation sessions are carried out three times a day for 30 minutes. The course of treatment is three to four weeks.

During treatment, the position of the electrodes and the graft is monitored by x-ray. Correction of the parameters of the pulsed current and evaluation of the effectiveness of therapeutic electrical stimulation of the spinal cord is carried out using electroneuromyographic monitoring at least once a week.

On the fourth or fifth day after the operation, a phonophoresis course is performed with neuroprotectors (for example, with solomedrol).

Example. Patient T., 48 years old, was admitted to the Neurosurgery Clinic of SarNIIITO on May 23, 2003 with a diagnosis of osteochondrosis of the cervical spine with severe degenerative-dystrophic changes at the level of C3-C4 of the spinal motion segment, with a vertebro-medullary conflict at the level of C3-C4, with the development of mild spastic tetraparesis and dysfunction of the pelvic organs against the background of severe stenosis of the spinal canal.

During the fall, March 15, 2003, hit the back of the head with a sharp throwing of the head back. After that, the patient began to grow weak in the arms and legs, began to walk poorly, appeared stiffness in the muscles of the legs and impaired function of the pelvic organs.

The patient was hospitalized in the Clinic of Neurosurgery SARNIITO for examination and determination of treatment tactics.

A full range of examinations was carried out (review and functional radiographs of the cervical spine, positive myelography with omnipak, electroneuromyography, NMR imaging of the cervical spinal cord) and clinical analysis of the patient.

It was decided to carry out surgical treatment: decompression of the spinal cord in front with resection of the affected bone-cartilage structures of the spinal-motor segment of the cervical spine, the installation of electrodes on the front and rear structures of the spinal cord. Surgery was performed in accordance with the method described in the invention.

On the second day after the operation and conducting an electroneuromyographic examination, the patient began electrical stimulation of the posterior spinal cord with the Eliman-206 apparatus with pulse current parameters: amplitude 3V, frequency 65Hz, duration 0.2 ms. Electrical stimulation was carried out 3 times a day for 30 minutes. On the third or fourth day, stimulation of the anterior spinal cord was connected with pulse current parameters: amplitude 9V, frequency 60Hz, duration 0.2 ms.

On the third day after the operation, phonophoresis of the cervical spine with solomedrol was started: every other day in the amount of 7 procedures.

The total course of treatment was 28 days.

During treatment, the position of the electrodes and the graft was monitored by x-ray. The correction of the parameters of the pulsed current and the evaluation of the effectiveness of therapeutic electrical stimulation of the spinal cord was carried out using electroneuromyographic monitoring once a week.

A positive clinical effect in this patient was expressed in the disappearance of muscle spasticity, normalization of the bladder, increased movement in the right hand. The patient began to walk without assistance. The achieved treatment result was confirmed by the improvement of the electroneuromyographic parameters: the signs of demyelination of the nerve trunks disappeared (the speed of excitation propagation increased from 32.4 m / s to 48.2 m / s). An improvement in the functioning of the neuromuscular apparatus was indicated by an increase in the amplitudes of the evoked responses of nerves (from 2.4 μV to 8.2 μV) and tenar muscles (from 2.8 mV to 3.9 mV).

Medical and social effectiveness of the method is:

in the restoration of lost motor and sensory disorders;

in normalizing the functioning of the functions of the pelvic organs due to improved coordination of the work of the spinal centers;

in the disposal of patients from spastic-pain syndrome;

in the rapid social and labor adaptation of patients with neurological manifestations of cervical osteochondrosis.

Claims (3)

1. A method of surgical treatment of neurological complications in patients with osteochondrosis, including resection of the affected bone-cartilage structures of the spinal motor segment, the introduction of electrodes and electrical stimulation, characterized in that they conduct anterior decompression of the spinal cord, intraoperatively install one pair of electrodes in the epidural space on the dura mater the membrane above the anterior spinal cord is higher than the level of its damage, and the other pair of electrodes is punctured into the region of the posterior regions pinnogo cord below the level of destruction and carry out electrical stimulation. 2. The method according to p. 1, characterized in that it further conduct phonophoresis of the cervical spine with neuroprotective drugs. 3. The method according to claim 1, characterized in that the electrical stimulation of the posterior spinal cord begins on the second, and the anterior divisions on the third or fourth day after surgery.