RU2297193C2 - Method for treating degenerative vertebral diseases in elderly and senile patients - Google Patents

Abstract

FIELD: medicine, orthopedics.

SUBSTANCE: the present innovation deals with decompression-stabilizing interferences in case of degenerative diseases of vertebral lumbar department in elderly and senile patients. By not increasing the invasiveness of decompression operations and the risk of surgical interference it is necessary to carry out simultaneously decompression and fixation of a segment despite the presence of instability; fixation should be fulfilled with an X-shaped implant out of porous titanium nickelide; the implant should be applied through "a foramen" in interspinous space, the shape of which should correspond to that of an implant's edge surface, At first, the implant should be moved with its less transverse size up to the central narrow part, turn it for the angle of 90° till embracing the adjacent parts of spinous processes with the implant's lateral masses.

EFFECT: higher efficiency of therapy.

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Description

The invention relates to medicine, namely to orthopedics and neurosurgery, can be used for surgical decompression-stabilizing interventions for degenerative diseases of the lumbar spine in the elderly.

There is a method of surgical treatment of degenerative diseases of the spine with neurological symptoms, which consists in decompression of the spinal roots through microsurgical discectomy and partial medial facetectomy (Yasargil MG / Adv Neurosurg - 1977; 8: 422-7 /; Caspar W / Advances in Neurosurg. - 1977. .4. - P.74-77 /; Caspar W et al. / 8 ^th Annual Meeting of the Joint Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons. - Miami, Florida. - Fabroary 5- 9, 1992 /; Williams RW / Spine. - 1978.- N3 (2) .- P.175-182 /; Getty CJM et al. / J Bone Joint Surg (Br) - 1981; 63 B: 330-335 / ) These types of decompression interventions are performed for patients of all age groups and are palliative surgeries, which reduces the effectiveness of surgical intervention and does not relieve the patient of the risk of relapse of the pain syndrome. The reasons for the low effect of the primary decompression surgery may be segmental instability in the form of retrolisthesis, uneven disc height in the sagittal plane (like hyperextension), narrowing of the lumen of the spinal canal in the extension position due to protrusion of the posterior portions of the fibrous ring and deformation of the hypertrophic yellow ligament against the background of inclination processes of the vertebrae. The causes of relapse of the pain syndrome may be a recurrence of hernia and developing segmental instability. Therefore, the performance of only one decompression operation can reduce the effectiveness of surgical intervention and does not relieve the patient of the risk of relapse of the pain syndrome from the same level, which can cause repeated surgery, which is undesirable in elderly patients.

A known method of surgical treatment of degenerative diseases of the lumbar spine using decompression-stabilizing operations, consisting in decompression of the spinal roots by microdiscectomy and medial facetectomy, but with stabilization of the vertebral segment by implants introduced between the vertebral bodies, with the aim of forming a rigid (bone-metal bone) block RB / Spine: state of the art revives. Philadelphia: Hanley and Belfus - 1987; pp. 457-516 /; Bagby GW / Orthopedics 1988; 11: 931-4 /; Kuslich SD et al. / Spine 1998; 23: 1267 -79 /). The advantage of this operation is its radicalism, but this intervention is not always acceptable, since it is an invasive method and increases the risk of intraoperative and postoperative complications in elderly patients, especially against the background of the accompanying somatic pathology, and also increases the rehabilitation period necessary for the formation of bone metal interbody block.

Closest to the claimed one is a method of fixing the vertebral segment using an X-stop interspinous implant made of titanium consisting of a main body (including an oval spacer with a conical tissue expander) and a universal wing (Yerby S et al. / International Society of the lumbar Spine (2001), Edinbur /, Richards J et al. / International Meeting on Advanced Spine Techniques (2002), Montreux, Switzerland /; Swanson KE et al. / Spine, 28 (1) (2003), pp. 26-32 /). The disadvantage of this method is that the implant, introduced laterally into the interspinous space, requires additional assembly in the wound to prevent its migration, and the need for careful selection of the size (5 of them) creates technical difficulties. The method requires significant bilateral detachment of soft tissues from the spinous processes with their traction to the sides throughout the entire period of the operation, which leads to damage to the paravertebral tissues, increased postoperative pain, increases the recovery period, is the cause of a decrease in functional results in the postoperative period. The method is recommended by the authors only for the treatment of lumbar degenerative stenosis in patients in whom the symptoms of spinal stenosis are reduced in a sitting position, it is used without the decompressive stage of the operation, which limits its application.

The objective of the invention: to develop a method that improves the efficiency of decompression operations, without increasing their invasiveness and risk of surgery.

The solution of this problem will improve the results of treatment of conventional decompression surgery in elderly patients on the lumbar spine. When using the method, there is a positive therapeutic effect by keeping the operated lumbar segment of the spine in a light "flexion" position, with distraction of the posterior structures of the vertebral segment, unloading of the arched joints and posterior portions of the fibrous ring, reducing intradiscal pressure, limiting the extension of the vertebral segment, "straightening" deformed yellow ligament and an increase in the capacity of the spinal canal, a decrease in the symptoms of degenerative stenosis and facet syndrome and, reducing the pain impulses from the level of the lesion, the stabilization of the spinal segment in the sagittal plane, reducing the risk of recurrence of pain.

A positive economic effect is achieved by reducing the patient’s stay in bed, postoperative recovery, reducing the risk of intra- and postoperative complications, and reducing patients' disability. The method is simple, does not require the use of complex instruments, can be applied under local anesthesia. The social effect is achieved by improving the quality of life of patients.

The technical result is achieved by performing initial fixation of the operated segment with the help of a “simple” installation of the implant in the interspinous space after the decompressive stage of the operation, regardless of the presence of signs of segmental instability.

The method is as follows. After the decompression stage of the operation is performed, the thoracolumbar fascia is cut on the opposite side, parallel to the line of the spinous processes, from the side of the main stage of the operation, the distractor is inserted into the interspinous gap so that its branches are located at the base of the spinous processes on adjacent edges, then the gap is distarcated, then in special nippers are introduced into the wound in such a way that their branches are located on the lateral surfaces of the operated interspinous gap; CCW "in the interspinous ligament with the adjacent edges of the spinous processes, the size and shape of which correspond exactly to those of the lateral surface of the implant, then set the implant in the prepared" bed ". The implant through the formed "window" in the interspinous gap is carried out by a smaller cross-sectional diameter of the lateral masses. After the implant is located in the central, narrowest part between the spinous processes, it rotates 90 ° so that its lateral masses cover the adjacent parts of the spinous processes from the sides, thereby preventing the implant from displacing and providing the primary reliable fixation of the latter. After installing the implant in the correct position, the interspinous distractor is removed, and the implant is firmly jammed in its “bed”. The wound is sutured in layers.

The problem is solved due to the fact that they simultaneously decompress and fix the segment, regardless of the presence of instability; fixation is carried out with an X-shaped implant made of porous titanium nickelide, an implant is inserted through a “window” in the interspinous gap, the shape of which corresponds to the shape of the end surface of the implant, the implant is initially carried out with a smaller transverse dimension to the central narrow part; deploy 90 ° to cover the lateral masses of the implant adjacent parts of the spinous processes.

Clinical example: Patient K., 67 years old, was examined and treated at the NIITO Orthopedics Department from 08.13.04 to 08.27.04, IB No. 2159. During the examination, a clinical diagnosis was made - Osteochondrosis of the lumbar spine with a predominant lesion of L4-L5, L5-S1 intervertebral discs, left-sided hernia of the L5-S1 disc, instability of the L5-S1 segment, against the background of a transitional lumbosacral vertebra, compression radicular syndrome S1 on the left.

On August 17, 04, an operation was performed - L5-S1 interlaminectomy on the left, disc herniation, posterior mesenteric fixation with an implant made of porous nickelide titanium.

Under general anesthesia, a linear incision was made in the soft tissues along the line of the spinous processes of L5-S1. The intersternal gap L5-S1 is distinguished on the right and on the left. To the left of the spinous processes installed retractor. A typical L5-S1 interlaminectomy was performed on the left. Epidural fiber is absent. Ripple of the dura mater is not determined. The spine and dural sac are flattened on a dense elastic formation. Spine displaced medially. Subligamentary hernia was found, the posterior longitudinal ligament was dissected, the hernia was removed as several sequestered fragments. Spine and dural bag straightened, lie freely. The dural bag is pulsating. Produced a slight distraction of the interspinous gap L5-S1 segment with a distractor. On both sides of the interspinous gap L5-S1, branches of special nippers are inserted, a “window” is formed, the supraspinatus ligament is intact, an implant is inserted into the gap with a smaller cross-sectional diameter of the lateral masses. After the implant is located in the central narrow part between the spinous processes, it is rotated 90 ° to cover the lateral masses of the adjacent edges of the spinous processes, after elimination of distraction, the implant is firmly jammed in its bed. Liquor does not enter the wound. Hemostasis. Layered stitches on the wound. Aseptic dressing.

To evaluate the patient's treatment results, a visual analog 10-point pain assessment scale (VAS) and the Oswestry Index (ODI) in the preoperative and postoperative periods were used. The assessment of pain in the back and leg by YOUR in the preoperative period was 6 and 6 points, respectively, 6 months after surgery - 0 points in the back and legs. The Oswestry index in the preoperative period was 62% and 18% 6 months after surgery, the patient estimates the results of treatment in a six-month follow-up as excellent. When radiographic examination of the implant migration is not.

Claims (1)

A method for the treatment of degenerative diseases of the spine in elderly and senile people by interosteal fixation with an implant made of titanium of the vertebral segment, characterized in that after decompression, the operated segment is fixed regardless of the instability by an X-shaped implant made of porous titanium nickelide, an implant is inserted through a window into the interspinous the gap, the shape of which corresponds to the shape of the end surface of the implant, initially carry out the implant with a smaller transverse m to the central narrow part, deploy 90 ° to cover the lateral masses of the implant adjacent parts of the spinous processes.