RU2294169C1 - Method for treating hernias of intervertebral disks of vertebral lumbar department surgically - Google Patents

Abstract

FIELD: medicine, neurosurgery.

SUBSTANCE: it is necessary to carry out interlaminar removal of disk's hernia; cut a fragment of subcutaneous-fatty fiber, infiltrate the fragment of subcutaneous-fatty fiber till saturation with suspension Depot-Medrol, wrap up a radicular funnel from all the sides and bare dorsolateral surface of dural sac with the fragment of subcutaneous-fatty fiber.

EFFECT: higher efficiency of therapy.

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Description

The invention relates to medicine, namely to neurosurgery, and can be used in the surgical treatment of patients with herniated discs of the lumbar spine.

Lumbosacral discogenic sciatica causing back pain accounts for 82% of all diseases of the peripheral nervous system and represents one of the most important socio-economic and medical problems. This pathology accounts for 85.4% of days of temporary disability for people of the most working age from 30 to 50 years. For example, in 1993, in a country like the Netherlands, the number of days of disability associated with spinal diseases amounted to 75.5 million. Often these diseases cause long-term disability and disability (Tulder MW et al. The cost-illness study of back pain in The Netherlands / Pain, 1995, Vol. 62, P.233-240). Direct costs for the treatment of back pain increase on average one and a half times every 6-7 years, and degenerative diseases of the spine and their neurological consequences are the leading cause of disability (Golubev G.Sh. et al. Treatment of pathology of the intervertebral disc and intervertebral joints from the perspective of evidence medicine / Actual issues of neurology and neurosurgery. - Collection of scientific works, Rostov-on-Don, 2005, pp. 154-155).

Due to the imperfection of the existing methods of surgical treatment of hernias of the intervertebral discs of the lumbar spine in the immediate and long-term postoperative periods, the percentage of relapses in back pain is high, which according to various authors make up from 5 to 38% of the number of patients operated on (Carragee EJ, Han MY, Suen PW, Kim D. Clinical outcomes after lumbar discectomy for sciatica: the effects of Fragment type and anular competence / Stanford, USA, J. Bone Joint Surg. Am., 2003, Jan., 85-A (1): P.102-108 ; Kayaoglu CR, Calikoglu C., Binler S. Re-operation after lumbar disc surgery: results in 85 cases / Erzurum, J. Int. Med. Res., 2003, Jul.-Aug., 31 (4): D. 318-323; Saruhashi Y., Mori K., Katsuura A., Takah ashi S., Matsusue Y., Hukuda S. Evaluation of standard nucleotomy for lumbar disc herniation using the Love method: results of follow-up studies after more than 10 years / Shiga, Japan, Eur. Spine J., 2004, Apr. 27, P.7). Moreover, as it was revealed during repeated operations, relapse of the pain syndrome in 36.4% of the operated patients was caused by the scar-adhesion process in the epidural space, compressing the nerve root and the radicular artery accompanying it, and in 28.2%, by the combination of the scar-adhesive process with a small recurrence of a herniated disc (Kayaoglu CR et al. Re - operation after lumbar disc surgery: results in 85 cases / Erzurum, J. Int. Med. Res., 2003, Jul.-Aug., 31 (4): P .318-323). Therefore, the prevention of the development of a scar-adhesion process in the epidural space, which leads to a decrease in the quality of life of patients with relapse of back pain after removal of herniated discs, increased disability, and often to repeated surgical intervention, remains an urgent and unsolved problem.

Conducted research on the medical-scientific and patent literature revealed various methods of surgical treatment of herniated discs of the lumbar spine.

Thus, the USSR Copyright Certificate No. 648207 (IPC A 61 B 17/00, 1979, BI No. 7) protected the "Method for the treatment of osteochondrosis of the spine", which provides for the removal of the spinous processes of adjacent vertebrae, removal of the affected disc by curettage with its bilateral microcorpodesis and posterior spondylodeosis fragments of the distant spinous processes.

The USSR author's certificate No. 657811 (IPC A 61 B 17/00, 1979, BI No. 15) describes the "Method for the neurosurgical treatment of discogenic lumbosacral radiculitis", which involves the expansion of the intercostal space of the spine, circular excision of the hernia and its removal together with the disk body.

USSR author's certificate No. 929071 (IPC A 61 B 17/00, 1982, BI No. 19) protected "A method for the treatment of injuries and diseases of the spine", which provides for resection of the intervertebral disc, interbody fusion with an autograft made from a resected arch in the form of a trefoil and embedded in the formed between the bodies of the vertebrae is a groove, and filling the free space of the groove with auto-chip.

The USSR author's certificate No. 1097285 (IPC A 61 B 17/00, 1984, BI No. 22) describes the "Method of surgical treatment of posterior-median and posterior lateral hernias of intervertebral discs", which provides for the formation of a vertical access channel, removal of lateral on the operative access side sections of the articular processes and lateral sections of the articular arches of the vertebrae, excision of the legs of the arches along the entire diameter and posterior surface of the vertebral bodies, exposure and excretion of the spinal roots and vessels, followed by the removal of hernias of the intervertebral disc on a posterior-lateral surface of the vertebral bodies.

The USSR copyright certificate No. 1297820 (IPC A 61 B 17/00, 1987, BI No. 11) protects the "Method for the surgical treatment of herniated discs" by posterior transligamenous access, enlargement of the intersternal gap with subsequent removal of the intervertebral disc with a hernial sac, and a portion of the fibrous ring excised on the side of the expansion of the intersternal gap, and hernia is removed after removal of the disc.

The USSR author's certificate No. 1426552 (IPC A 61 B 17/00, 1988, BI No. 36) describes the "Method for the treatment of diseases and injuries of the intervertebral discs", providing for their removal and placement between the vertebral bodies of the autodermal flap.

RF patent No. 2057486 (IPC A 61 B 17/00, 1996, BI No. 10) describes a "Method for the surgical treatment of hernias of the lumbar intervertebral discs", including hemiinterlaminar access to the spinal canal, excision of the yellow ligament, removal of the hernia of the disc, formation from the surface sheet thoracolumbar fascia of the flap, which, after removal of the disc hernia, is placed in place of the defect of the yellow ligament and fixed with sutures.

In the patent of the Russian Federation No. 2252713 (IPC A 61 B 17/00, 2005, BI No. 15), a method of surgical access and decompression of the spinal roots during the removal of hernias of the intervertebral lumbar discs in women, depending on the somatotype, is described, which includes soft tissue incision, a dissection of the long back muscles in the area of the intersternal gap, a resection of the yellow ligament and adjacent bone structures, and a resection of the cranial arch and the medial surface of the articular process is performed in volumes depending on the somatotype of the woman.

The disadvantages of the above methods of surgical treatment of hernias of the intervertebral discs are the complexity of their implementation, the trauma that violates the integrity of the vertebral segment due to the removal of the articular processes and the roots of the vertebral arches, the duration of postoperative treatment, as well as the insufficient treatment efficiency due to the possibility of scar development in the epidural space adhesive process, which is the cause of chronic pain in the postoperative period, leading to disability, reduce her quality of life of patients and often leads to the need for re-operation. The scar-adhesion process is formed around the radicular funnel and dural sac as a result of the conversion of wound detritus filling the epidural space after removal of the hernia of the disk into connective tissue, which coarsens over time, compresses the root along with its accompanying artery and leads to narrowing of the spinal canal, which lies in the basis of the formation of chronic pain syndrome. In repeated operations for the scar-adhesion process, coarse keloid scars are found around the root and dural sac, leading to their compression with all the ensuing consequences.

The closest in technical essence and adopted as a prototype is "A method for preventing the development of scar-adhesions in the epidural space after removal of herniated discs at the lumbar level" (RF patent No. 2243727, IPC A 61 B 17/00, 2005, BIPM No. 1 ), providing for the implementation of interlaminar hernia removal. In this case, after curettage of the disk cavity, a Tacho-Comb plate is placed on the defect of the posterior longitudinal ligament, and a fragment of subcutaneous fat on the feeding leg is brought onto the dorsal surface of the root and dural sac. However, this method is quite technically difficult to implement, since it is often difficult and complicated to form a complete vascular leg of an implantable fiber fragment with a wound depth of 7-10 cm or more, especially in men with developed muscle corset, despite the fact that the length of the surgical incision usually much less than the depth of the wound. The method is also not effective enough due to the possibility of development in the anterior epidural space of the scar-adhesive process. In the next few hours after the operation, the Tacho-Comb plate is impregnated with blood elements of the wound discharge and subsequently, as you know, the blood elements and collagen (a component of Tacho-Comb) are transformed into scar tissue, which subsequently causes chronic pain syndrome, which reduces the quality of life of patients and often leading to the need for reoperation.

The aim of the invention is to simplify the method of surgical treatment of patients with hernias of the intervertebral discs of the lumbar spine and increase the effectiveness of treatment by preventing the development of the scar-adhesion process in the epidural space.

This goal is achieved by the fact that after interlaminar removal of a hernia of the disc and cutting out a fragment from the subcutaneous fat of the patient’s operating wound, the cut out fragment of subcutaneous fat is first infiltrated until it is saturated with a Depot-Medrol suspension (from 40 to 80 mg depending on the size of the fiber fragment), and then they are wrapped around them with a radicular funnel on all sides, covering the dorsolateral surface of the dural sac, which is exposed after removal of the hernia. Muscles, aponeurosis and skin are sutured in layers. Apply an aseptic dressing.

Depot-Medrol (DEPO-MEDROL) is a synthetic glucocorticoid with pronounced immunosuppressive activity. Under the action of the drug, the number of immunoactive cells decreases, lysosome membranes stabilize, phagocytosis is suppressed, and the production of prostaglandins decreases. The use of the drug leads to the redistribution of body fat due to the effect of the drug on fat metabolism (Vidal. Medications in Russia / Handbook, 1998, p. B-189). In a free fat transplant, the preparation can be maintained for a time sufficient for revascularization of adipose tissue, i.e. for germination in the transplant of newly formed vessels, ensuring its blood supply. All this prevents the formation of scar-adhesions in the epidural space.

The method is as follows.

By means of an interlaminar approach, the sequestered fragment is removed that has fallen into the subglottic or epidural (in case of a posterior longitudinal ligament rupture) space of the degenerated pulpous nucleus. Removing the remnants of the pulpous nucleus from the intervertebral space is carried out using, for example, wire cutter-type nippers, with a working part width of 2-3 mm. In the surgical wound, thorough hemostasis is performed - stopping bleeding from the epidural veins and adjacent soft tissues. For example, they cut out with a pair of scissors a fragment from the subcutaneous fat of the patient with the size necessary in each case for wrapping them on all sides of the radicular funnel and the exposed dorsolateral surface of the dural sac. Using, for example, an insulin syringe and a thin needle, infiltration of 40-80 mg of Depo-Medrol suspension to saturation of the cut fiber is performed. Thus prepared a fragment of subcutaneous adipose tissue of the patient is wrapped around the radicular funnel, while the exposed dorsolateral surface of the dural sac is covered with the same fiber fragment. This technique performs anatomical restoration of the epidural fiber layer by using a fragment of autologous subcutaneous fat without any foreign materials. All these factors provide a warning of the development in the epidural space of the scar-adhesive process in the postoperative period. Muscles, aponeurosis and skin are sutured in layers. Apply an aseptic dressing.

The practical application of the proposed method is illustrated by an example from clinical practice.

Example.

Patient Zh., 47 years old, medical history No. 1216/161, was admitted to the neurosurgery clinic of Rostov State Medical University with a diagnosis of L4-L5 disc herniation on the left. The diagnosis of a herniated disc L4-L5 on the left was verified by magnetic resonance imaging (MRI).

Complaints of intense pain in the lumbar spine, radiating along the back of the thigh and lower leg, aggravated by movement, numbness of the plantar surface of the foot.

Back pain has been noted for 30 years, in recent years the intensity of pain has increased. The last exacerbation occurred after intense coughing and sneezing. Conservative treatment was without effect. The patient underwent MRI of the lumbosacral region, revealing a L4-L5 disc herniation on the left, stenotic spinal canal at this level, against the background of osteochondrosis and spondylarthrosis.

Objectively: restriction of active movements in the left leg due to sharp pain. Weakness of the back flexion of the left foot. Antalgic scoliosis to the right. Symptom Lassega 30 °, a positive symptom of Neri. Expressed are the muscles of the lumbar region, pain on palpation of the paravertebral point L5 on the left with radiation radiating along the back surface of the left leg.

The patient underwent surgery according to the claimed method. An interlaminar hernia of the L4-L5 disc on the left was performed. After removing the precipitated sequestered part of the pulpous nucleus with the help of wire cutter type cutters with a working part width of 2 mm, the residues of the pulpous nucleus were removed from the intervertebral space. A thorough hemostasis was carried out in the surgical wound. A fragment measuring 1.5 × 1.5 × 0.5 cm was cut out from the subcutaneous fat tissue of the patient’s wound surface with scissors. Using the insulin syringe and a thin needle, the selected fiber fragment was infiltrated until 40 mg of Depo-Medrol suspension was saturated. A fragment of the subcutaneous fat of the patient thus prepared was wrapped around the radicular funnel on all sides, while the dorsolateral surface of the dural sac was covered with the same fiber fragment. Sutures were applied to the muscles, aponeurosis and skin. An aseptic dressing was applied. After removing the stitches on the 9th day after the operation, the patient was discharged from the hospital in satisfactory condition.

After a long period of time, the patient underwent control MRI, which did not reveal data in favor of the formation of scar-adhesions in the epidural space. The patient's condition is satisfactory, the pain syndrome does not bother, sensitive disorders regressed, tension symptoms (Lasseg and Peri) are negative.

According to the proposed method, 34 people were operated on at the Neurosurgery Clinic of Rostov State Medical University for hernias of the intervertebral discs of the lumbar spine. All patients have a good state of health over a long observation period, there is no pain.

A retrospective analysis of case histories of 25 patients operated on for hernias of the intervertebral discs of the lumbar spine without the use of Depo-Medrol showed that relapse was observed in 6 patients (24%). On performed MRI, they had a scar-adhesion process (epidural fibrosis) in the epidural space, two of them were subjected to repeated operations.

Thus, in comparison with the prototype, the proposed method for the surgical treatment of hernias of the intervertebral discs of the lumbar spine is simpler to implement and more effective, since it allows to prevent the development of cicatricial adhesions in the epidural space, which is the cause of chronic pain in the postoperative period that reduces the quality of life patients, increasing disability and often leading to the need for reoperation.

Claims (1)

A method for the surgical treatment of hernias of the intervertebral disc of the lumbar spine, including interlaminar removal of a hernia of the disc and cutting out a fragment of subcutaneous fat, characterized in that after cutting out a fragment of subcutaneous fat, it is first infiltrated to saturate with a Depot-Medrol suspension, and then they are wrapped on all sides of the roots funnel and exposed dorsolateral surface of the dural sac.