RU2307619C2 - Method for treating spondylolisthesis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: it is necessary to fulfill the access to a pulpy nucleus of intervertebral disk located between adjacent vertebrae shifted against each other; then one should evaporate the part of pulpy nucleus substance at forming a cavity due to affecting it with laser radiation at efficient wave length in efficient energetic dosage. Additionally, one should carry out nondestructing laser impact upon articular lamellae being adjacent to the mentioned intervertebral disk by applying laser radiation at efficient wave length in efficient energetic dosage. The innovation provides stimulation of regenerative processes in the tissues of intervertebral disk and articular lamellae, the development of fibrous tissue and hyaline cartilage and reconstructs the shape and mechanical characteristics of vertebral column.

EFFECT: higher efficiency of therapy.

11 cl, 4 dwg, 2 ex

Description

The invention relates to medicine, namely to neurosurgery, and is intended for the treatment of spondylolisthesis, in particular for the treatment of spondylolisthesis using laser radiation on the tissue of the intervertebral disc.

Known methods of treating spondylolisthesis by open surgery with the installation of implants and grafts, for example by removing the intervertebral disc followed by fixing the vertebra with screws [patent RU 2186541, publ. 08/10/2002]. Such methods are highly traumatic, do not lead to complete recovery, require a long period for the rehabilitation of the patient in the postoperative period.

At the same time, a method is known for treating other diseases of the spine, in particular osteochondrosis, by percutaneous laser discectomy and decompression of the intervertebral discs, and in recent years many similar methods have been developed and used, the essence of which is to access the pulpous nucleus of the intervertebral disc and part of the substance of the pulpous nucleus is vaporized with the formation of a cavity by exposure to it by laser radiation, which is also known as laser vaporization of the intervertebral on disk [such as patents: US 5201729, publ. 04/13/1993; RU 2012388, publ. 05/15/1994; RU 2054956, publ. 02/27/1996; US 6562028, publ. 05/13/2003; RU 2212916, publ. 09/27/2003; RU 2268676, publ. January 27, 2006]. However, it is generally believed that spondylitis and spondylolisthesis are contraindications for using this effective method [see e.g. Makeeva T.I. Combined surgical treatment of herniated discs. In the collection of materials of the III Congress of Neurosurgeons of Russia: Surgery of diseases of the spine and spinal cord. - St. Petersburg, June 4-8, 2002 - P.265].

Meanwhile, there are known attempts to use laser vaporization for the treatment of displacements of the intervertebral discs [Dzyak L.A. et al. Surgical treatment of displacements of the lumbar intervertebral discs at several levels. In the collection of materials of the III Congress of Neurosurgeons of Russia: Surgery of diseases of the spine and spinal cord. - St. Petersburg, June 4-8, 2002 - P.246]. According to this method, the treatment of displacements of the lumbar intervertebral discs at several levels is carried out in stages, and at the first stage, endoscopic or interlaminar discectomy can be performed, and at the second, laser vaporization of displaced disks can be performed, or vice versa. However, the use of endoscopic or interlaminar discectomy at one stage leads to a relatively high tissue trauma when using this method as a whole. In addition, the small 2-day interval between the stages, during the first stage of laser vaporization, did not allow researchers to evaluate the effect of laser vaporization on the final result.

The technical task to be solved is the development of a minimally invasive method of surgical treatment of spondylolisthesis, which allows to reduce tissue injuries, reduce the recovery period, reduce treatment time and increase its effectiveness.

A method for the treatment of spondylolisthesis is proposed, which includes access to the pulpous nucleus of the intervertebral disc located between adjacent vertebrae displaced relative to each other, and the evaporation of part of the pulpous nucleus material with the formation of a cavity by exposure to it with laser radiation with an effective wavelength in an effective energy dose. What is new is that they additionally carry out a thermal non-destructive laser action on the locking plates adjacent to the intervertebral disc using laser radiation with an effective wavelength in an effective energy dose. Due to these laser influences, in particular, collagen tissue of the intervertebral disc is compressed, regenerative processes in the tissues of the intervertebral disc and closure plates are stimulated, in particular, fibrous tissue and hyaline cartilage develop in 20 days, which leads to a significant reduction in instability due to restoration of shape , mechanical characteristics of the system "adjacent vertebrae - locking plates - intervertebral disc", and ultimately leads to the restoration of normal standing of the system.

Laser exposure for the evaporation of part of the pulp nucleus substance can be carried out by laser radiation with a power of 2-4 W with a wavelength of 640-1200 nm with a total energy dose of laser exposure of 540-1500 J.

Laser exposure to evaporate part of the substance is best done periodically with the help of several successive actions, while in the interval from one exposure to another exposure the pulp core is irrigated with a solution of hydrogen peroxide, for example 3%.

Thermal non-destructive laser exposure can be carried out by laser radiation with a wavelength of 640-1200 nm. At the same time, the total energy dose of laser exposure to one end plate can be 4-32 J. The power of laser exposure can be 2-4 watts. In this case, it is better when the laser action on one end plate is carried out 2-4 times for 1-2 seconds each time.

Before exposure to laser radiation, an effective amount of a hypertonic solution can be introduced into the pulp nucleus, for example, using a 10% aqueous solution of sodium chloride, introduced in an amount of 0.5-2.0 ml.

The method can be carried out under control, for example using fluorographic x-ray control or computed tomography.

Access to the pulpous nucleus is best done using a hollow puncture needle through which the distal end of the fiber is inserted into the pulpous nucleus, the proximal end of which is optically connected to the laser source.

The invention is illustrated with reference to graphic materials. Figure 1 and figure 2 shows the functional spondylograms before and after treatment, respectively, according to the first example of a specific implementation, and figure 3 and figure 4 - functional spondylograms before and after treatment, respectively, according to the second example of a specific implementation.

The invention is illustrated by clinical examples.

Example 1. Patient I., 23 years old, athlete.

For 2 years, pain in the lumbar region was disturbing after a little physical exertion, working in a slope, could not stand upright for a long time, aching pain occurred at night. In recent months, the pain intensified, refused to play sports. Objectively: tension of the muscles of the back, straightened lumbar lordosis, limitation of tilts forward, backward and sideways. An X-ray of the lumbar spine in a lateral projection revealed a posterior displacement of L5 of the vertebra up to 3 mm, in functional images in the extension position the displacement increased to 6 mm (see figure 1). A CT study determined the protrusion of the L5-S1 disk.

The patient underwent a laser operation on the L5-S1 disk according to the well-known technique of multichannel laser decompression of the intervertebral disk (PPLDD), which is a variant of puncture non-endoscopic laser nucleotomy [patent RU 2268676, publ. January 27, 2006] for a number of specific features as described below.

The operation according to the PPLDD technique was performed under local anesthesia with intravenous potentiation. In an X-ray patient, they were placed on an X-ray table on the left side. Manipulations were performed under fluoroscopic control using an electron-optical converter (EOC). The L5-S1 disk was punctured with a conductor using the Erlacher method, designed to access the posterolateral and central parts of the disk, the puncture is performed between the arches, medial to the articular processes, departing from the midline by 1-1.5 cm. After perforation of the posterior parts of the fibrous ring, the conductor was advanced to the third quarters of the disk. A hollow puncture needle was inserted through the conductor approximately to the middle of the disk. Then the conductor was removed, leaving the straight needle in the same position. Then, a hypertonic solution (10% sodium chloride solution) in the amount of 1.0 ml was injected into the disk through a direct needle. After that, a fiber was inserted into the cavity of the direct needle to its distal end, the proximal end of which was optically connected to the Lazon-10-P laser unit (portable laser scalpel-coagulator TU 9444-001-07504407-99). Initially, laser irradiation was carried out through a straight needle. The exposure time (exposure) is 15 s, the radiation power with a wavelength of 970 nm is 3 W, which corresponds to an energy dose of 45 J. After this laser action, the optical fiber was removed, and the cavity formed in the disk in the form of a channel was irrigated through a straight needle with a 3% a solution of hydrogen peroxide in an amount of ~ 1.0 ml (possibly 0.5-5.0 ml). Then, the conductor was again inserted into the straight needle, after which the straight needle was removed, and a curved needle was inserted through the conductor approximately to the middle of the disk, and the conductor was removed. The curved needle was pulled back to the fibrous ring and again led forward into the pulp nucleus approximately the same distance, with the distal end of the curved needle extending somewhat to the side from the original direction. A new channel was formed from this position. The process of creating a new channel in the pulp nucleus consisted of two main stages - the actual formation of the channel and its expansion. At the first stage, a fiber was introduced into the curved needle, laser radiation with a power of about 3 W was turned on for 10 s, the fiber was pulled forward three quarters of the disk and pulled back, forming a new channel, and the laser radiation was turned off. At the second stage, the curved needle was rotated around its longitudinal axis and a new direction of the longitudinal movement of the fiber was used to expand the channel, and the manipulations with rotation at different angles were repeated several times. Thus, four adjacent channels were created. In between impacts, the pulp core was periodically irrigated with a 3% solution of hydrogen peroxide. The total dose of laser energy released in the laser activity zone was 720 J. After the cavity was formed in the form of adjacent channels in the pulpous core as a thermal channel, thermal non-destructive laser action (cauterization) was performed on the end plates by applying a fiber tip and a laser action with a length of 970 nm waves with a power of 3 W, 2 times for 1-2 seconds for each time with interruptions of 5-10 s.

After surgery, the patient was disturbed by back pain only during a long walk for a short time. On the control radiographs after 3 months, the displacement and instability of the L5 vertebra was not determined (see Fig. 2). Within 2 years after the operation, there is no pain in the lower back, leads an active lifestyle, returned to sports.

Example 2. Patient K., 32 years old, the driver.

For more than a year, pain in the lower back was worrying, especially when flexing and extending with irradiation to the left foot along the back surface to the toes of the foot. When walking, the pain intensified to lameness after 5-10 minutes. I could not stand for a long time because of pain in the lower back and leg, work in a slope, a sharp increase in pain was noted when unbending from a forward position. Lying only on the right side, when turning there was a shooting pain in the lower back and leg. Objectively: scoliosis to the left, tension of the paravertebral muscles, restriction of movements in the lumbar region is greater when tilting to the left and extension. Painful palpation in the area of the two lower lumbar spaces. A sharply positive symptom of Lasseg on the left, the Achilles reflex on the left is not caused. The radiographs showed signs of osteochondrosis, a decrease in the height of the two lower discs, scoliosis to the right, retrolisthesis of the L4 vertebra to 3 mm and L5 to 2 mm. On functional x-rays during extension, the displacement of the L4 vertebra increased to 7 mm, L5 to 4 mm (see figure 3). CT examination revealed a left-sided paramedian hernia of the L5-S1 disc up to 8 mm with compression of the dural sac and circular protrusion of the L4-L5 intervertebral disc.

A laser operation was performed on L4-L5 and L5-S1 discs simultaneously according to the PPLDD procedure, as described above in Example 1, except that L4-L5 and L5-S1 discs were punctured through the intervertebral foramen and between the arches and the herniated disc according to the scheme topographic and anatomical relationships at the level of L4-L5 and L5-S1 vertebrae, respectively [Korzh A.A., Talyshinsky PP, Khvisyuk N.I. Surgical access to the thoracic and lumbar vertebrae. M .: Medicine. 1968], the wavelength of the laser radiation was 650 nm, and the total dose of laser energy was approximately 1200 J per disk.

After the operation, the pain in the leg passed the next day, the pain in the lower back did not bother when walking and in a standing position, when turning in bed, could freely lie on the back, stomach, left side. The movements in the lower back were limited to the orthopedic corset. Given the long term of acute pain exacerbation in the postoperative period, he underwent a course of rehabilitation treatment in a neurological hospital for a month, which included non-steroidal anti-inflammatory drugs, B vitamins, blood flow improvers, and acupuncture. A month later, the patient went to work. Under loads noted slight discomfort in the left thigh. Received electrophoresis with placentol on the lumbar and physiotherapy exercises to strengthen the muscles of the back. At the control examination after 3 months, he did not show any complaints, he leads an active lifestyle. Movement in the lumbar in full, no scoliosis. Neurological symptoms without features. On the lateral and functional radiographs, displacement and instability of L4 and L5 vertebrae were not detected (see figure 4), with a CT study, left-sided protrusion of the L5-S1 disk is up to 3 mm. When viewed after 1 and 2 years, still no complaints. Neurological status unchanged.

Laser operations according to the PPLDD technique, in particular those described in the examples above, have been carried out since 2001 at the outpatient surgery department of the Primorsky Regional Diagnostic Center in Vladivostok for 150 patients with displacement and instability of the lumbar vertebrae of a degenerative nature in combination with compression of the dural sac and roots of the spinal cord caused by protrusion or prolapse of the intervertebral discs. Of these, 90 were men (60%) and 50 women (40%). The age of patients ranged from 17 to 70 years. Patients selected for laser surgery after examination mainly had unstable degenerative spondylolisthesis of the lower lumbar vertebrae of the first degree in combination with protrusion of the intervertebral disc and radicular syndrome. Most patients had a L5 vertebra shift - 86 people. (57.3%) in combination with a hernia of the intervertebral disc, the size of which did not exceed 8 mm. Vertebral L4 displacement was detected in 38 patients (25.3%), intervertebral disc deformity more often in the form of protrusion. In the direction of displacement, the majority of patients had retrospondylolisthesis, which is characteristic of stage I or discogenic instability - 122 (81.3%) patients, 28 had anterior spondylolisthesis (18.7%), of which 2 patients also had lateral vertebral displacement . It should be noted that in 9.3% (14) patients, a displacement of two vertebrae was revealed (9 cases - a staircase displacement, 5 cases - a combined displacement), and they underwent a laser effect on the intervertebral discs at two levels simultaneously. 10 patients (6.7%) had a displacement of the vertebrae of the II degree.

Laser surgery was performed on the day of admission in an X-ray operated room under the control of an image intensifier after general potentiation and local anesthesia. Used laser devices with a power of up to 10 W, generating laser radiation with a wavelength of 650 nm, 970 nm and 1064 nm. The next day, the patient was discharged home, and he could get up and walk, fixing the lumbar with a removable semi-rigid orthopedic corset. Sitting was allowed 10-14 days after surgery. Symptomatic treatment was carried out, a month later physiotherapy was connected - electrophoresis with placentol and physiotherapy exercises. Up to 3 months, patients wore an orthopedic corset during physical exertion, riding in transport, walking long distances. Inspection and x-ray control were carried out after three, six months and annually. In most cases (70.6%), on the operating table, or the day after the operation, there was a regression of neurological symptoms, pain, symptoms of tension of the nerve roots, restoration of strength in the muscles, reduction or disappearance of disorders of skin sensitivity. Almost all patients quickly had pain at rest. Syndrome of neurogenic intermittent claudication or claudication disappeared on the first day or turned into a soft, worn out form. The restoration of the statics and biomechanics of the spine took place more slowly, so some patients still had lower back pain for up to several weeks, but their intensity in all cases decreased. 14 patients (9.3%) the next day after laser surgery reported pain in the limbs when walking. He was given conservative treatment in the form of injections of non-steroidal anti-inflammatory drugs, decongestants, and epidural novocaine blockades. 26 patients (17.3%) in the postoperative period were additionally treated with medication in a neurological hospital, the pain syndrome was subsequently completely stopped.

After 3-6 months, 88% of the treated patients had no complaints, their neurological status was unremarkable, almost all returned to work. 13 people (8.7%) had lower back pain mainly after exercise, but there was no pain in the limbs. They were prescribed a second course of physiotherapy, physiotherapy exercises, massage, as the pain syndrome was caused by muscular-tonic manifestations, a violation of the statodynamics of the spine. In some cases, manual therapy was performed using myo-fascial release techniques and post-isometric muscle relaxation. In 5 patients (3.3%), a relapse of pain was observed over the past period, which was associated with a violation of a sparing physical regime. He underwent repeated laser surgery with a good result. A few months later, only 83 (55.3%) patients underwent an X-ray examination in dynamics, because the rest did not consider it necessary to come because of recovery. On lateral radiographs, vertebral displacement decreased, as a rule, by 2-4 mm, and in 25.3% of cases, the displaced vertebra returned to its physiological position. On functional radiographs, 96.4% of the examined showed stabilization of the vertebrae. Only in 3 (3.6%) cases did the instability of the vertebral-motor segment persist in combination with an intervertebral hernia of more than 8 mm before surgery and its size reduction during the control to 5-6 mm. In other cases, the control computed tomograms of hernias of the intervertebral disc were not detected, protrusions of up to 3-4 mm were preserved without signs of compression of the spinal roots and dural sac, the "vacuum phenomenon" almost always disappeared.

The above examples are used only to illustrate the possibility of carrying out the invention and do not limit the scope of legal protection presented in the claims, while a person skilled in the art is relatively easy to implement other ways of carrying out the invention.

Claims (12)

1. A method for the treatment of spondylolisthesis, including access to the pulpous nucleus of the intervertebral disc located between adjacent vertebrae displaced relative to each other, and the evaporation of part of the pulpous nucleus material with the formation of a cavity by exposure to it with laser radiation with an effective wavelength in an effective energy dose, characterized in that additionally carry out a thermal non-destructive laser action on the locking plates adjacent to the named intervertebral disc using Nuclear radiation with an effective wavelength in an effective energy dose. 2. The method according to claim 1, characterized in that the laser effect for the evaporation of part of the pulp core material is carried out by laser radiation with a power of 2-4 W with a wavelength of 640-1200 nm with a total energy dose of laser exposure of 540-1500 J. 3. The method according to claim 1, characterized in that the laser action for the evaporation of part of the substance is carried out periodically with the help of several successive actions, while in the interval from one action to another effect, the pulp core is irrigated with a solution of hydrogen peroxide. 4. The method according to claim 3, characterized in that the irrigation is carried out with a 3% solution of hydrogen peroxide. 5. The method according to claim 1, characterized in that the thermal non-destructive laser exposure is carried out by laser radiation with a wavelength of 640-1200 nm. 6. The method according to claim 5, characterized in that the total energy dose of laser irradiation on one end plate is 4-32 J. 7. The method according to claim 5, characterized in that the laser power is 2-4 watts. 8. The method according to claim 7, characterized in that the laser action on one contact plate is carried out 2-4 times for 1-2 s each time. 9. The method according to claim 1, characterized in that prior to exposure to laser radiation, an effective amount of a hypertonic solution is injected into the pulp nucleus. 10. The method according to claim 9, characterized in that as a hypertonic solution use a 10% aqueous solution of sodium chloride, introduced in an amount of 0.5-2.0 ml. 11. The method according to any one of claims 1 to 10, characterized in that the method is carried out under control using fluorographic x-ray control and / or computed tomography. 12. The method according to any one of claims 1 to 10, characterized in that the pulp core is accessed using a hollow puncture needle through which the distal end of the fiber is inserted into the pulp core, the proximal end of which is optically connected to the laser radiation source.

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