RU2311146C1 - Method for surgical treatment of hernia of thoracic intervertebral disk - Google Patents

Abstract

FIELD: medicine, traumatology, neurosurgery.

SUBSTANCE: the present innovation deals with anterior-lateral extrapleural access to anterior-lateral departments of vertebral canal of thoracic department of vertebral column. Resection of the bodies of adjacent vertebrae should be fulfilled for the depth of two thirds of the body's diameter. It is necessary to remove the hernia of thoracic intervertebral disk extrapleurally under endoscopic control that requires no stabilization of the operated department of vertebral column for reasons of keeping the main supporting vertebral structures.

EFFECT: higher efficiency of surgical therapy.

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Description

The invention relates to medicine, namely to traumatology and neurosurgery, and can be used for the surgical treatment of hernias of the thoracic intervertebral discs.

A hernia of the thoracic intervertebral disc is a rare pathology that causes severe neurological deficiency and is difficult to treat due to the peculiarities of the anatomical structure of the thoracic spine. Until now, the problem of choosing the optimal methods of surgical interventions on the thoracic spine with a hernia of the thoracic intervertebral disc is a completely unsolved problem. The main task of the surgeon is to perform full decompression of the spinal cord and ensure reliable stability of the spine, choosing the most secure access, without expanding the scope of intervention and possibly reducing the time limits for limiting physical activity and immobilization.

The main risk during operations for a hernia of the thoracic intervertebral disc: manipulations with the spinal cord and, therefore, its trauma; violation of the blood supply to the spinal cord due to damage to the radiculomedullary vessels; instability of the thoracic vertebral segment.

Most methods of surgical treatment of hernias of the thoracic intervertebral discs currently used are more traumatic, access to the disk space that they provide is not profitable. Due to the extensive resection of the vertebral bodies and ligaments, there is a high risk of damage to the radiculomedullary arteries, spinal cord and postoperative instability of the thoracic vertebral segment.

A known method of surgical treatment of hernias of the thoracic intervertebral discs, including anterior operative access to the thoracic spine to remove hernias of the thoracic intervertebral discs (Yumashev GS, Elizarov MN Treatment of ostechondrosis of the thoracic spine. Methodical recommendations. M., 1983. pg. 13-15).

This method includes access through the chest or abdominal cavity, an opening of the pleura or peritoneum is performed, removal of the disc and hernia of the thoracic vertebra is carried out by a special cylindrical cutter, with the help of which two semilunar grafts are cut from the bodies adjacent to the affected disc of the vertebrae. The resulting grafts are rotated 90 ° and a bone graft is inserted between them.

The disadvantage of this method is that it requires a large skin incision 20-25 cm long, opening the abdominal or pleural cavity, which can lead to pulmonary complications: pneumothorax, atelectasis, pleural fistulas or complications from the peritoneum: adhesions, peritonitis. The volume of the vertebral resection requires the removal of most of the vertebral body, leading to instability of the vertebral segment, requiring corporodesis as the final stage of the operation. After surgery, closed drainage of the pleural or abdominal cavity is required.

A known method of surgical treatment of hernias of the thoracic intervertebral discs, including posterolateral extrapleural operative access to the thoracic spine, removal of hernias of the thoracic intervertebral discs, arches and legs of the vertebral arch, articular processes, transverse processes, costal-transverse ligament (Lidar Z, Lifshutz Jj Bh, , Kurpad SN, Maiman DJ. Minimally invasive, extracavitary approach for thoracic disc herniation: technical report and preliminary results. Spine J. 2006 Mar-Apr; 6 (2): 157-63. Epub 2006 Feb 3).

The disadvantage of this method is the high morbidity, since access to the medial part of the disk space is difficult, and the removal of the disk and bone fragments is carried out behind the radiculomedullary neurovascular formations, increasing the risk of damage to them. This method does not visualize the ventral surface of the dural sac, requires the removal of the arch and the legs of the vertebral arch, articular processes, transverse processes, costal-transverse ligament, which leads to postoperative instability of the spine.

The closest is a method of surgical treatment of hernias of the thoracic intervertebral discs, including anterolateral transpleural operative access to the spinal canal of the thoracic spine, removal of the costal-transverse ligament and joint, rib head, legs of the vertebral arch, most of the vertebral body, removal of the hernia (Ohnishi K, Miyamoto K, Kanamori Y, Kodama H, Hosoe H, Shimizu K. Anterior decompression and fusion for multiple thoracic disc herniation. J Bone Joint Surg Br. 2005 Mar; 87 (3): 356-60).

The disadvantage of this method is that an autopsy of the pleural cavity is performed, which often leads to pulmonary complications. The volume of the resection of the vertebra requires the removal of most of the vertebral body, the legs of the vertebral arch, costal-transverse ligaments, leads to instability of the vertebral segment, requiring corporodesis with a bone graft or metal fixatives as the final stage of the operation. After surgery, closed drainage of the pleural cavity is required.

The objective of the present invention is to increase the therapeutic effect by reducing trauma, reducing damage to the paraspinal muscles, the absence of the need to open the pleura, the minimum volume of osteo-ligamentous resection of the ribs, vertebral bodies, their ligaments and joints. A more adequate decompression of the anterior spinal cord from the front access is provided and spinal cord injuries are reduced, spinal instability is eliminated, the risk of damage to surrounding soft tissues, blood vessels, nerve structures is reduced, and the operation time is shortened.

The problem is achieved in that in the method of surgical treatment of hernias of the thoracic intervertebral disc, including anterolateral surgical access to the spinal canal, removal of the rib head, herniation of the thoracic intervertebral disc, it is proposed that the anterolateral access be carried out extrapleurally. To resect the posterior part of the intervertebral disc, disc herniation, and the edge of the spinal canal within the middle support column of the spine, to a depth that captures 2/3 of the vertebral body diameter, followed by removal of the remains of the hernia in the spinal canal under endoscopic control.

The essence of the method is illustrated by drawings. Figure 1 - the position of the patient on the operating table, figure 2 - shows the direction of the anterolateral access and preparation of the pleura, figure 3 - the thoracic vertebral segment with a herniated disc compressing the spinal cord, figure 4 - resection of the rib head and costal -vertebral joint, in Fig.5 - the same in vertical projection, in Fig.6 - the formation of the channel in the disk and the posterolateral sections of the vertebrae adjacent to the disk, with the opening of the spinal canal and removal of the hernia, Fig.7 - revision of the formed channel and removal of hernia residues with an endoscope, on Fig - image of the supporting columns of the spine according to the concept of Denis with the middle column removed, shows the volume of the resection performed by the proposed method.

The method is as follows.

It is necessary to have microsurgical instruments, magnifying equipment (an operating microscope or a head magnifier), a rigid endoscope. Surgery is performed under general anesthesia. The patient is on his side. A roller is placed under the upper body. The head end of the operating table is lowered by 15 ° for lateral flexion of the body and expansion of the chest and intercostal spaces on the access side.

The surgeon is behind the patient. A skin incision 1 is made along the rib corresponding to the intervertebral disk on which the intervention is supposed to be, from the middle axillary line to the paravertebral line, 8-10 cm long. The skin, subcutaneous tissue, latissimus dorsi, are dissected in layers, after dissection of the fibers of the anterior dentate muscle, is dissected superficial sheet of the periosteum along the rib. The rib is allocated subperiosteally. A deep leaf of the periosteum is dissected and the edges of the wound are bred using a retractor. Parietal pleura 3 is dissected with a blunt method for extrapleural access, the anterolateral surface of the thoracic spine is exposed 4. The transverse process 5, rib 6, rib head 7 and rib-vertebral joint 8 are distinguished. A resection of the 9 heads of the rib 7 and the costal-vertebral joint 8 is performed with the preservation of the costal-transverse joint 10 and ligament 11. After this, the lateral intervertebral sections are well visualized. disk 12, from the edge of the spinal canal 13 to the anterior divisions of the vertebral bodies, and the bodies of adjacent vertebrae 14.

Then, with a milling cutter, within the middle supporting column of the spine, along the edge of the spinal canal 13, a resection 15 of the posterior part of the intervertebral disc 12 of the hernia of the disc 16 and partially of the bodies of the adjacent vertebrae 14 is made to a depth that captures 2/3 of the diameter of the thoracic vertebra. The resection hole 15 should be applied parallel to the anterolateral edge of the dural sac 17. The dural sac 17 is in the line of sight and the risk of spinal cord injury is minimal. As a result, a resection hole 15 is formed in the back of the affected intervertebral disk 12 and in the bodies of the vertebrae adjacent to it 14. The formed resection hole 15 allows you to complete the removal of 18 hernias of the disk 16 in the direction from the dural sac 17. Using the endoscope 19, the anterior epidural space is revised Removing 20 residual disc herniation.

In conclusion, an audit of the roots and intervertebral foramen is carried out. The fibrous ring of the anterolateral parts of the intervertebral disc remains unaffected. In view of the safety of two supporting structures: the anterior and posterior columns according to the classification of Denis F., 1983 (Fig. 8) and the anterolateral sections of the intervertebral disc, bone defect replacement is not required.

Hemostasis is performed. Rib retractors are removed. The wound is sutured in layers tightly: nodal sutures are applied to the intercostal muscles, subcutaneous tissue, and skin. An aseptic dressing is applied to postoperative sutures.

Example

Patient Sh., Born in 1950, was admitted to the clinic on November 21, 2003 with a diagnosis of Osteochondrosis of the thoracic spine mainly at the levels of Th5-Th6, Th6-Th7, Th7-Th8. Central disc herniation Th6-Th7. Lower paraparesis. Radicular pain on the left. Condition after interlaminar discectomy L4-L5, disc herniation on the left (from 08.28.2003). Upon receipt of a complaint of periodic pain in the lumbar spine, weakness in the legs especially on the left and in the left foot, a feeling of numbness from the lower edge of the sternum on the right and in the right foot, a tingling sensation in the left leg.

Sick since August 2003, when she began to notice pain in the thoracic and lumbar spine, then after 3-4 days the pain began to radiate in both legs, and after 2 days numbness in the left leg and weakness in the left foot joined. It was treated on an outpatient basis, but without effect. On August 28, 2003, an operation was performed at the hospital in the community: interlaminar discectomy L4-L5, removal of a hernia of the disc on the left. In the postoperative period, inflammatory changes were noted in the surgical wound, which healed by secondary intention. Neurological status showed no positive dynamics. Then it was treated on an outpatient and inpatient basis, but without effect and, despite the operation, the patient had lower spastic paraparesis.

When MRI of the thoracic and lumbar spine from 11/13/2003 - a picture of a hernia of the intervertebral disc Th5-6 with severe compression of the spinal cord. In the lumbar region, the pattern of detected changes corresponds most likely to inflammatory changes in the soft tissues.

The patient was hospitalized in a hospital for further examination and treatment.

Survey data at admission: general state of moderate severity. The skin of normal color, clean. Pulse 76 in 1 min, rhythmic. The vesicular breathing, no wheezing. The abdomen is soft, painless. Urination independent, frequent constipation.

In neurological status: in a clear mind, contact, adequate, oriented in place and in time. FMN - N. Strength and tone in the hands of S = D, saved. Tendon reflexes on the hands S = D, live. Tendon reflexes on the legs S> D, animated. Lower paraparesis is more pronounced in the left leg. Hypesthesia from T6 level in the right half of the trunk and the right lower limb. Paresthesia in the left leg. St. Lasega (+) on both sides, more on the left. S. Babinsky on the left.

The operation was performed on December 1, 2003 by the proposed method:

anterolateral extrapleural microsurgical approach to the intervertebral disc Th-6-Th-7, partial resection of the posterior parts of the bodies of Th-6 and Th-7 with a dissection of the spinal canal, microsurgical removal of a hernia of the disc using an endoscope. Due to the minimally invasiveness of the method, the need for corporodesis did not arise.

The postoperative course is smooth. Antibacterial, vascular, analgesic and vitamin therapy, exercise therapy, massage were carried out. Pain syndrome regressed to a large extent, and there is also a gradual increase in strength and range of motion in the left leg and a gradual restoration of sensitivity. The patient is gradually activated, independently gets up and walks (in the reclinator). It can serve itself. The postoperative wound healed by first intention, the sutures were removed on the 10th day.

In the control MRI of the thoracic spine from 12/05/2004, the condition after surgery is the removal of a hernia of the intervertebral disc Th6-Th7. Subarachnoid spaces and spinal cord are free.

The patient independently gets up and walks (in the reclinator). It can serve itself. To continue treatment, it is prescribed under the supervision of a neurologist and therapist for m / f. Condition at discharge is satisfactory.

The proposed method carried out successful surgical treatment of 5 patients.

The use of this method of surgical treatment of hernias of the thoracic intervertebral discs allows to increase the therapeutic effect of the operation by reducing trauma to the paraspinal muscles. The absence of the need to open the pleura, the minimum volume of osteo-ligamentous resection of the ribs, vertebral bodies of their ligaments and joints, providing more adequate decompression of the anterior spinal cord from the anterior approach and reducing trauma to the spinal cord, preventing postoperative instability of the spine and possible damage to surrounding soft tissues, blood vessels, nerve structures shortening the operation time.

The method is characterized by a minimum volume of osteoligmented resection and does not require stabilization of the operated spine due to the preservation of the main supporting structures of the vertebra.

Claims (1)

A method for surgical treatment of a hernia of the thoracic intervertebral disc, including anterolateral surgical access to the spinal canal, removal of the rib head, hernia, characterized in that the access is extrapleural, resection of the posterior part of the intervertebral disc within the middle supporting column of the spine, along the edge of the spinal canal, resection of adjacent vertebral bodies is performed to a depth of 2/3 of the thoracic vertebral body diameter, followed by removal of hernia residues in the spinal canal under endoscopic sky control.

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