RU2358759C1 - Surgery-substitute in patients suffering from kimerly's and arnold-chairy anomalies - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: surgery-substitute approach in patients suffering from Kimerly's and Arnold-Chiary anomalies is ensured by inytoduction of botulotoxine type A into sternocleidomastoid and suboccipital muscles thus providing their prolonged relaxation.

EFFECT: prolonged clinical compensation of Kimerly's and Arnold-Chiary anomalies ensured by lower tone and power load on muscles and joints of craniovertebral junction bones.

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Description

The invention relates to medicine, namely to neuropathology, and can be used in the treatment of patients with Kimmerle and Arnold-Chiari anomaly.

Of the congenital anomalies of the craniovertebral transition, the most common in the population are the Kimmerli anomaly (Kimmerle) and the Arnold-Chiari anomaly (Chiari, Arnold-Chiari, Chiari).

These anomalies can be in two clinical conditions:

A. Compensation when neurological symptoms and syndromes of anomalies are absent completely or weakly expressed and do not impair the patient’s ability to work, and organic damage to the nervous system does not occur or is minimal;

B. The state of decompensation, when neurological symptoms or syndromes, abnormalities progress, disrupt the patient’s performance, can lead to organic damage to the nervous system up to vascular accidents (cerebral infarction) and death of the patient.

Surgical methods of treatment, head and neck immobilization, pharmacotherapy aimed at improving blood circulation and trophism in the affected parts of the nervous system and normalizing intracranial pressure are used to treat patients with decompensated anomalies of Kimerli and Arnold-Chiari. In a state of compensation, various methods of physical rehabilitation are used to combat paralysis, vestibular disorders and disorders of various types of sensitivity, vision, hearing, cortical disorders.

In neuropathology, “symptomatic” treatment of the posterior cervical sympathetic syndrome is used for abnormalities: ergotamine or bellaspon is prescribed, injections of vitamins B ₁ , B ₆ , B ₁₂ , pachinarpin (Skoromets A.A. Neuropathologist, St. Petersburg, Sotis Publishing House , 1999, p. 124); orthopedic treatment of Shants collar) (Morozov G.V., Romanenko V.A. Nervous and mental diseases, M., 1976, p.130), neurosurgical operation (Shutov A.A. Neurological rarity, Perm, 1992, p. 74 ) Disadvantages: lack of effectiveness, allergic reactions, drug intolerance, postoperative complications. And when using electrophoresis with novocaine on the cervical spine, allergic reactions to novocaine, intolerance to electrical procedures, increased blood pressure, complications in the form of burns, lack of effectiveness are manifested.

There is a method of treating Kimmerle's anomaly by physically affecting reflexogenic zones, characterized in that they act with microneedles on biologically active points of the body: 1K (yun-qiu-yuan), 16GV (feng fu), 7H (shen-men), 60V (kun -lun), 5N (tun-li), lobar points along the midline of the nail bed of the first finger of the hands and feet and pain points along the midline of the nail bed of 3 and 5 fingers of the brushes simultaneously for 30-60 minutes daily or every other day, a course of 4-10 procedures (RU 2203021, А61Н 39/08, publ. 04/27/2003).

The disadvantage of this method is the duration of treatment and lack of effectiveness.

The present invention is directed to solving the technical problem of stopping clinical decompensation and the long-term maintenance of clinical compensation for neurological symptoms and syndromes of Kimmerle and Arnold-Chiari anomalies.

The technical result achieved in this case is to increase the effectiveness of non-surgical treatment of patients with Kimmerle and Arnold-Chiari abnormalities.

The specified technical result is achieved by the fact that the method of non-surgical treatment of patients with anomalies of Kimerli and Arnold-Chiari consists in prolonged relaxation of the sternocleidomastoid muscles and the group of the suboccipital muscles by introducing Botulinum toxin type A into them.

These features are significant and interconnected with the formation of a stable set of essential features sufficient to obtain the desired technical result.

A method of non-surgical treatment of patients with anomalies of Kimerli and Arnold-Chiari was developed on the basis of an open relationship between the tonus-force imbalance of the muscles of the neck and decompensation of neurological symptoms and Kimerli and Arnold-Chiari syndromes.

Studies have found that a prolonged increase in the tone of the sternocleidomastoid muscle and the group of the suboccipital muscles (large posterior rectus of the head, small posterior rectus of the head, upper oblique head, lateral rectum of the head, belt head) leads to decompensation and an increase in neurological symptoms and syndromes of Kimmerli anomalies and Arnold Chiari. This is most likely due to an increase in the tonus-force load on the muscles, articulation of the bones of the craniovertebral transition and the appearance of antiphysiological movements in the joints of the bones of the craniovertebral transition. This relationship was proved by comparing the clinical examination data with the assessment of neurological and biomechanical status, electroneuromyography, cervical spine radiography with functional tests.

The inverse relationship has been similarly proved: after relaxation of the sternocleidomastoid and suboccipital muscles, the symptoms and syndromes of the anomalies of Kimmerli and Arnold-Chiari reduce completely or partially. The treatment method we developed is aimed at stopping clinical decompensation and maintaining the clinical compensation of neurological symptoms and syndromes of the above-mentioned abnormalities as monotherapy or as part of a comprehensive treatment.

The method consists in prolonged relaxation of the sternocleidomastoid muscles and the suboccipital muscle group by administering Botulinum toxin type A into them to reduce neurological symptoms and syndromes of the anomalies of Kimmerli and Arnold-Chiari. After the administration of the drug Botulinum toxin type A in accordance with the recommendations for its use, a steady decrease in the tone of the muscles injected with the drug is achieved. At the same time, a decrease in the severity of neurological symptoms and anomaly syndromes is achieved. The duration of the results is determined by the duration of the administered drug: 4-6 months or more.

Methodology of the procedure and patient preparation

The patient should be informed about the course of the procedure, about contraindications, possible complications and prognoses, in accordance with the Fundamentals of the legislation of the Russian Federation on the protection of public health. Contraindications to the introduction are identified in accordance with the recommendations of the manufacturer of the drug Botulinum toxin A.

The procedure requires 100-200 units of Botulinum toxin A (we used Botox from Allergan, USA) diluted with an isotonic solution at a concentration of 20 units of botulinum toxin A in 1 ml.

Sterile disposable syringes are used to administer insulin with a thin non-removable needle, 1 ml in volume. If it is necessary to use electroneuromyography to control the location of the needle in the muscle, a disposable sterile needle can be used for simultaneous needle electromyography and injection.

Preinjection treatment of the skin - in accordance with the general sanitary and hygienic requirements for injection technology.

The patient is laid on his back on a flat couch or on a couch with a lowering headrest.

The position for the introduction of the drug Botulinum toxin A into the muscles of the left half of the nape of the neck and neck: sternocleidomastoid, large posterior straight line of the head, small posterior straight line of the head, upper oblique head, lateral straight line of the head, and belt head. The head turns to the right, the chin is brought to the cricoid cartilage.

The position for the introduction of the drug Botulinum toxin A into the muscles of the right half of the nape and neck: sternocleidomastoid, large posterior straight line of the head, small posterior straight line of the head, upper oblique head, lateral straight line of the head, belt head. The head turns to the left, the chin leads to the cricoid cartilage.

The muscles to be injected are determined based on palpation data. The most tensed muscles are identified from those listed above, the palpation of the trigger points of which causes the patient one or more of the following sensations: pain, noise in the ear (ears), dizziness, double vision, or other visual disturbances, nausea, or paresthesia.

If it is necessary to control the location of the needle in the muscle (deep muscles, obesity), it can be carried out using an electroneuromyograph and a needle electrode with the function of an injection needle. We used the VOTOX 37mm / 27G needle from Allergan, USA and the Neurosoft electroneuromyograph from Russia.

The drug Botulinum toxin A is administered in accordance with the recommendations of the manufacturer of the drug, at a dose of 3-25 units per 1 muscle, depending on the size and severity of hypertonicity. Injections should be avoided near large vessels, nerves, autonomic nodes.

After performing the injection in accordance with the recommendations of the manufacturer of the drug Botulinum toxin A, it is recommended:

1) remain upright (do not lie) for 2 hours;

2) do not drink alcohol for 3 days;

3) do not perform thermal procedures in the field of injections or general thermal procedures for 3 days.

The expected effect of the performed procedure is in 3-7 days.

Clinical case descriptions for a patent

1. Patient A.

Initial inspection

Complaints: pain in the right half of the nape, shakiness, bouts of systemic dizziness, flies in front of the eyes, monotonous tinnitus.

From the anamnesis. Complaints of dizziness appeared for the first time in the last 2 months, provoked by twists and extension of the neck. The appearance of complaints is associated with a transferred sore throat. Vascular therapy (cavinton) - no effect. Brain MRI is the norm. X-ray of the cervical spine - an anomaly of Kimmerly. Diseases of the lungs, kidneys, tuberculosis, venous diseases, hepatitis denies. Allergy denied.

In somatic status. Normostenia. Normal skin color, clean. Sclera normal color. The language is clean. No swelling. The vesicular breathing is free, there are no rales. HELL 120/90 mm Hg, heart rate 80 per min, heart sounds are clear, the rhythm is correct. The area of the thyroid gland (palpation) is not changed. The abdomen is soft, painless. The liver and spleen are not enlarged by palpation and percussion; the lower edge of the liver is painless on palpation. There are no dysuric phenomena, Pasternatsky’s symptom is negative. Physiological administration controls.

In neurological status. Consciousness is clear. There are no meningeal signs. On the part of the FMN, there is a shallow horizontal nystagmus when averting the eyes to the left, to the right, otherwise, without features. There are no paresis of limbs. Deep reflexes are symmetrical. The abdominal reflexes are symmetrical. There are no pathological reflexes. In the Romberg position, it sways, when you turn your head to the right, the shakiness increases, to the left - it stops, with a maximum extension of the neck - a fall back. PNP without oversight, non-severe intentional tremor. Sensitivity is not impaired.

Pathobiomechanical status. Tension and pain points in the muscles of the neck and head (sternocleidomastoid, belt heads, vertical bundles of trapezius, lower oblique heads, mainly on the right). Soreness on palpation at the exit points of the occipital nerves, mainly on the right. Inflection in PDS C0-C1, C2-C3 is limited. The rotation to the right in PDS C1-C2 is limited.

Diagnosis: Bilateral Kimmerley complete anomaly. Syndrome of the vertebral-basilar arterial system, reflex-irritative type. Vestibulopathy. Transient visual disturbances. Occipital neuropathy.

Recommended by:

1. Avoid hitting the head and neck, forced physical exertion, straining, racks with emphasis on the head and neck;

2. In the event of a worsening condition (persistent headache, nausea, vomiting, speech disorders, visual disturbances, impaired coordination, weakness of one or more limbs), seek medical help immediately;

3. Botox therapy. The introduction of Botulinum toxin A. In the treatment room, a total of 100 units of Botox, diluted in 5 ml of isotonic sodium chloride solution, were introduced into the tense, painful bundles of the sternocleidomastoid, trapezius, belt muscles of the head, and the lower oblique muscles of the head.

Control examination 7 days after the introduction of Botulinum toxin A.

Complaints: neck muscle soreness.

The feeling of dizziness, tinnitus, visual disturbances, headache - decreased from the 4th day after the introduction of Botulinum toxin A and is not currently disturbing.

In neurological status. Consciousness is clear. There are no meningeal signs. From the FMN - without pathology. There are no paresis of limbs. Deep reflexes are symmetrical. The abdominal reflexes are symmetrical. There are no pathological reflexes. In the Romberg position is stable, including during turns and extension in the cervical spine. PNP without overshooting, non-rough intentional tremor is preserved. Sensitivity is not impaired.

Pathobiomechanical status. Tension in the muscles of the neck and head decreased, pain points are not detected. Functional restrictions remain: flexion in PDS S0-C1, rotation to the right in PDS C1-C2.

Diagnosis: Two-sided complete anomaly of Kimerli, in the stage of compensation.

Recommended by:

1. Avoid hitting the head and neck, forced physical exertion, straining, racks with emphasis on the head and neck;

2. In the event of a worsening condition (persistent headache, nausea, vomiting, speech impairment, visual disturbances, impaired coordination, weakness of one or more limbs), seek medical help immediately; Scheduled examination by a neurologist after 3 and 6 months.

2. Patient B.

Initial inspection

Complaints: shakiness, bouts of systemic dizziness, accompanied by impaired vision and double vision, pain in the parietal region when the head is tilted forward, a steady decrease in mood, insomnia.

From the anamnesis. Dizziness complaints first appeared 7-8 years ago. Short courses of vasoactive and nootropic therapy were carried out with short-term improvement. Surgery for a stomach ulcer in 1990, amputation of the uterus with appendages for bleeding in 2000. An MRI of the brain in 2006 revealed an Arnold-Chiari anomaly. Diseases of the lungs, kidneys, tuberculosis, venous diseases, hepatitis denies. Allergy to antibiotics (cannot specify) and household chemicals - rash, stomatitis. Hypercholesterolemia.

In somatic status. Low power. Normal skin color, clean. Sclera normal color. The language is clean. Hyperemia of the posterior pharyngeal wall (chronic pharyngitis). No swelling. The vesicular breathing is free, there are no rales. HELL 120/70 mm Hg, heart rate 80 min, heart sounds are clear, the rhythm is correct. The thyroid gland (palpation) is not changed. The abdomen is soft, painless. The liver and spleen are not enlarged by palpation and percussion, the lower edge of the liver is painless. There are no dysuric phenomena, Pasternatsky’s symptom is negative. Physiological administration controls.

In neurological status. Consciousness is clear. There are no meningeal signs. FMN - horizontal nystagmus when averted eyes to the left, to the right, otherwise - without features. There are no paresis. Deep reflexes are symmetrical. The abdominal reflexes are symmetrical. There are no pathological reflexes. In the Romberg position, falls when turning or tilting the head to the left, to the right. Rough intentional tremor. PNP without oversight, non-severe intentional tremor. Sensitivity is not impaired.

Pathobiomechanical status. Tension and pain points in the muscles of the neck and head (sternocleidomastoid, vertical bundles of trapezius, lower oblique heads, large posterior straight heads). Soreness on palpation at the exit points of the occipital nerves. Inflection in PDS C0-C1, C2-C3, C3-C4 is limited. Limited rotation in the PDS C1-C2, in both directions.

Diagnosis: Arnold-Chiari anomaly. Syndrome of the vertebral-basilar arterial system, reflex-irritative type. Vestibulopathy. Occipital neuropathy. Symptomatic astheno-depressive disorder.

Recommended by:

1. Gliatilin (Cerepro), 400 mg tablets, 1 tablet 3 times a day - 1 month, then 1 tablet 2 times a day - another 2 months;

2. Alprazolam, 1 mg tablets, 1-4 weeks, 1/4 tablets in the morning, 1/4 tablets in the afternoon, 1/2 tablet at bedtime; 5 week 1/4 tablet in the morning and evening; 6 weeks in 1/4 tablets at bedtime; further cancel;

3. Fluoxetine, capsules of 20 mg, 1 capsule in the morning - 6-12 months;

4. Diacarb, tablets of 250 mg, 1 tablet in the morning - 2 days to take, 5 days break - 2 months;

5. Asparkam, 6 tablets per day, on the same days as Diacarb;

6. Limit water intake 2–3 hours before bedtime, reduce salt intake;

7. Avoid hitting the head and neck, forced physical exertion, straining, racks with emphasis on the head and neck;

8. In the event of a worsening condition (persistent headache, nausea, vomiting, speech disorders, visual disturbances, impaired coordination, weakness of one or more limbs), immediate hospitalization in a neurosurgical hospital.

Scheduled examination by a neurologist after 2 months.

Complaints: shakiness, bouts of systemic dizziness, accompanied by visual impairment and double vision, pain in the parietal region when the head is tilted forward, persist.

In somatic status. Low power. Normal skin color, clean. Sclera normal color. The language is clean. Hyperemia of the posterior pharyngeal wall (chronic pharyngitis). No swelling. The vesicular breathing is free, there are no rales. HELL 120/60 mm Hg, heart rate 70 min, heart sounds are clear, the rhythm is correct. The thyroid gland (palpation) is not changed. The abdomen is soft, painless. The liver and spleen are not enlarged by palpation and percussion, the lower edge of the liver is painless. There are no dysuric phenomena, Pasternatsky’s symptom is negative. Physiological administration controls.

In neurological status. Consciousness is clear. There are no meningeal signs. FMN - horizontal nystagmus when averted eyes to the left, to the right, otherwise - without features. There are no paresis. Deep reflexes are symmetrical. The abdominal reflexes are symmetrical. There are no pathological reflexes. In the Romberg position, falls when turning or tilting the head to the left, to the right. Rough intentional tremor. PNP without overshot, no tremor. Sensitivity is not impaired.

Pathobiomechanical status. Tension and pain points in the muscles of the neck and head (sternocleidomastoid, vertical bundles of trapezius, lower oblique heads, large posterior straight heads). Soreness on palpation at the exit points of the occipital nerves. Inflection in PDS C0-C1, C2-C3, C3-C4 is limited. Limited rotation in the PDS C1-C2, in both directions.

Diagnosis: Arnold-Chiari anomaly. Syndrome of the vertebral-basilar arterial system, reflex-irritative type. Vestibulopathy. Occipital neuropathy. Symptomatic astheno-depressive disorder, remission.

Recommended by:

1. Gliatilin (Cerepro), 400 mg tablets, 1 tablet 2 times a day - 1 month; Fluoxetine, capsules of 20 mg, 1 capsule in the morning - up to 6-12 months, as agreed with the doctor;

2. Botox therapy. Introduction of Botulinum Toxin A. In the treatment room, a total of 100 units of Botox, diluted in 5 ml of isotonic sodium chloride solution, were introduced into tense, painful bundles of sternocleidomastoid, trapezoid, lower oblique muscles of the head, and large posterior rectus muscles of the head.

Control examination 7 days after the introduction of Botulinum toxin A.

Complaints: non-intense staggering when turning and tilting the head. Imbalances, double vision, headache - decreased from the 5th day after the introduction of Botulinum toxin A and currently do not bother. Neck movements do not cause discomfort.

In neurological status. Consciousness is clear. There are no meningeal signs. FMN - horizontal nystagmus when averted eyes to the left, right, and the rest - without features. There are no paresis. Deep reflexes are symmetrical. The abdominal reflexes are symmetrical. There are no pathological reflexes. In the Romberg position, a robust intentional tremor is stable. PNP without overshot, no tremor. Sensitivity is not impaired.

Pathobiomechanical status. Tension in the muscles of the neck and head decreased, pain points are not detected. Functional restrictions remain: rotation in both directions in PDS C1-C2 is limited.

Diagnosis: Arnold-Chiari anomaly, under compensation.

Recommended by:

1. Follow the recommendations from the previous consultation;

2. Scheduled examination by a neurologist after 3 and 6 months.

The present method is industrially applicable, tested and shown stable results in the reduction of neurological symptoms and syndromes of the abnormalities of Kimerli and Arnold-Chiari.

Claims (1)

A method of non-surgical treatment of patients with anomalies of Kimerli and Arnold-Chiari, which consists in prolonged relaxation of the sternocleidomastoid muscles and the group of the suboccipital muscles by the introduction of Botulinum toxin type A into them.