RU2367366C1 - Prevention method of cicatrical adhesions in epidural cavity following lumbar discal hernia excision - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to neurosurgery. Intralaminar approach is followed with a herniation puncture through posterior longitudinal ligament with a needle with a light guide inserted through the lumen thereof. Discal hernia is removed with pulpal content by puncture involving the staged laser vaporisation with a needle moved from the herniation to the discal centre. Then a fragmented pedicle subcutaneous fat is delivered on a dorsal surface of posterior and dural sac.

EFFECT: method enables to improve efficiency in preventing the cicatrical adhesions due to preserved anatomic barrier between intervertebral discal cavity and epidural cavity, and reliable haemostasis.

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Description

The invention relates to medicine, namely to neurosurgery, to the section of surgery of the intervertebral disc of the lumbar spine.

Relapses of radicular pain after removal of hernias of the intervertebral discs of the lumbar spine according to different authors is from 6% to 15% (R. Davis 1994, R. Hoffab et.al., 1993, Labash A.T. 1992 ., Oleshkevich F.V. 2006) of the operated patients. Of these, 2/3 of patients have radicular pain due to scar-adhesions in the area of the operation.

There are various ways to prevent the development of scar-adhesions in the epidural space.

Careful hemostasis during surgery without the introduction of muscle flaps into the spinal canal (Samotokin B.N., Verkhovsky A.I. Postoperative relapses of neurological syndromes of lumbar osteochondrosis and their surgical treatment. // Questions of Neurosurgery, No. 6, Moscow, 1983, 30 -33 p.). It should be noted that careful hemostasis by the time the operation is completed does not exclude blood leakage into the epidural space in the early postoperative period.

Active drainage of the surgical wound (A. Lebedev, Long-term results of surgical treatment of hernias of the lumbar intervertebral discs and ways to improve them: Abstract of the dissertation of Candidate of Medical Sciences, St. Petersburg, 2002, 10 pp.). Drainage is placed on the skeletonized arches and spinous processes of the vertebrae and drains the blood accumulated on the dorsal part of the dural sac and root. On the ventral part of the root and dural sac, blood continues to accumulate, the decay products of which are the main factor of the adhesion process.

Introduction to the epidural space of solutions of steroidal anti-inflammatory drugs (Musikhin V.N. Clinic, diagnosis and treatment of discogenic lumbosacral epiduritis:

Dis., Cand. honey. sciences. - L., 1978 - 11 p.). Steroidal anti-inflammatory drugs are used to inhibit the migration of lymphocytes, macrophages and granulocytes into the epidural space. Glucocorticosteroids, by virtue of their pharmacokinetics, affect the developed cicatricial adhesions, but do not prevent its development.

Plastic surgery of the interlaminar gap using intermuscular fat (A. Lebedev, Long-term results of surgical treatment of herniated discs and ways to improve them: Abstract of thesis, Candidate of Medical Sciences, St. Petersburg, 2002, 10 pp.). Intramuscular fat as such does not exist (Sinelnikov R.D. Atlas of human anatomy, - M., 1963, T1). It is known that during repeated operations it is not easier to isolate neural structures against the background of implanted adipose tissue than in patients without implantation of fat fragments. In addition, cases of the development of equine tail compression syndrome after adipose tissue transplantation have been reported.

Nevertheless, the specific weight of the scar-adhesion process among the causes of relapse of the radicular pain syndrome remains high, up to 50% (Kholodov S.A. Microsurgical treatment of multilevel discogenic lesions of the lumbar spine. // Questions of Neurosurgery No. 3, Moscow 2001, p. 9).

Closest to the claimed method is a method for preventing the development of scar-adhesions in the epidural space after removal of hernias of the intervertebral discs at the lumbar level (RF patent No. 2243727, 2005), adopted as a prototype. Intralaminar hernia removal is performed. 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, the prototype is not effective enough, because:

- while maintaining the posterior longitudinal ligament, it is mechanically perforated over the hernial protrusion with the formation of a significant defect for insertion of the instrument into the cavity of the disk in order to remove the tissue of the pulpous nucleus, thereby destroying the natural anatomical barrier between various media - the cavity of the disk and the epidural space;

- mechanical removal of elements of the pulpous nucleus is associated with possible bleeding from the disk cavity and blood leakage into the epidural space with incomplete sealing of the disk cavity with a Tacho-comb plate and the formation of scar adhesions fibrosis;

- implantation into the epidural space of such a substance as the Tacho-comb plate carries a certain risk, since the further degradation of any foreign material is not fully understood.

The invention is aimed at creating a method for preventing the development of the scar-adhesions in the epidural space after removal of a hernia of the intervertebral disc at the lumbar level, which improves the efficiency of the method by maintaining the anatomical barrier between the disc cavity and the epidural space and reliable hemostasis.

The specified technical result in the implementation of the invention is achieved by the fact that in the known method of preventing the development of the scar-adhesions in the epidural space after removal of a hernia of the intervertebral disc at the lumbar level, including intralaminar access, removal of the hernia and summing of the subcutaneous fat fragment to the dorsal surface of the root and dural sac fiber on the feeding leg, the peculiarity is that they perform a puncture of hernial protrusion through the posterior longitudinal ligament with a needle and ny lumen through its fiber and removal of disc herniation of nucleus pulposus matter and produce puncture by a phased laser vaporization promoting herniation needle from the center of the disc.

Fragments of the damaged disk are removed puncture-free, without the formation of a defect in the posterior longitudinal ligament, and vaporization itself eliminates bleeding in the disk cavity due to thermal effects on the tissue. This ensures reliable protection of the ventral part of the dural sac and root from the development of the scar-adhesion process, since they continue to lie on the preserved natural anatomical formation - the posterior longitudinal ligament. Cicatricial factors are excluded: both blood leakage into the epidural space from the cavity of the removed disk with a possible displacement of the Tacho-Comb plate and depressurization of the disk cavity, and the contact of the root and the dural sac with the defect zone in the posterior longitudinal ligament or foreign material (Tacho-Comb). In addition, the remaining pulpous nucleus is densified, which essentially reduces the likelihood of recurrent hernial protrusions and postoperative pain. The method is as follows. Intralaminar access to a hernia of the intervertebral disc of the lumbar spine is made. After the medial displacement of the root and dural sac from the hernial protrusion, the disc herniation is punctured through the intact posterior longitudinal ligament with an 18g needle. Then, a quartz fiber with a diameter of 600 nm is introduced into the needle, transmitting the laser light energy in a pulsed mode. The source of laser energy is the ATKUS-15 diode laser. The needle is advanced from the hernial protrusion to the center of the disc. The total power of light energy is determined by the achievement of the effect of compaction of the substance of the disk and the "reduction" of the hernia of the disk. At the last impulses they “seal” the puncture site. The hernial protrusion of the posterior longitudinal ligament disappears. The spine and dural sac are returned to the anatomical lateral position on the posterior longitudinal ligament, where the hernial protrusion was located. Then a fragment of subcutaneous fat on the feeding leg is cut out and brought down to the dorsal surface of the root and dural sac. After that, an active drainage is placed over the arches over the arches and layered suturing of the surgical wound is performed.

We give an example - an extract from the medical history No. 34679. Patient S., 35 years old, was treated at the Alexander Hospital of St. Petersburg, at the neurosurgical department No. 3 from 07/02/07 to 07/14/07. Diagnosis: Osteochondrosis of the lumbosacral spine, herniated discs L4 / L5, L5 / S1 with persistent radicular pain syndrome L5, S1 on the left. Disc hernias were verified by magnetic resonance imaging of the lumbosacral spine. At the L5 / S1 level, sequestered disc herniation with a large epidural sequester was determined. In the interval L4 / L5, there was a hernia of the disc up to 6 mm, which compromises the spine. Conservative treatment for 3 months without effect.

07/03/07. the patient underwent surgery - transligamenous (interlaminar) removal of sequestered hernia of the L5 / S1 disk on the left - the epidural sequestra was removed, then through the existing defect in the posterior longitudinal ligament curettage of the L5 / S1 disk cavity was performed. According to the claimed method interlaminar access to the gap L4 / L5 on the left. Ligamentous hernia of the disc L4 / L5 was revealed. The posterior longitudinal ligament is intact. L5 root is displaced with a spatula, with hernial protrusion, medially. The puncture of the cavity of the disk L4 / L5 was performed through a hernial protrusion with a needle, along which a fiber was inserted into the disk. An open stepwise vaporization of a hernia of the L4 / L5 disk was performed with an ATKUS-15 diode laser. The needle moved from a hernial protrusion to the center of the disc. The power of light energy was 600 J. At the same time, there was a “reduction” of the hernia of the disk. At the last pulses with the extraction of the fiber, the puncture site was “sealed”. L5 spine returned to lateral position, laid on the posterior longitudinal ligament, where a herniated disc had swollen before. L5 spine lies freely, without any compression on it. A section of subcutaneous fat on a vascular pedicle is cut and laid on the dorsal surface of the root and dural sac. Active drainage was placed in the area of operation over the arches of the vertebrae. Layered suture of the wound.

5 months after the operation, the patient underwent control magnetic resonance imaging with contrast. Identified signs of a cicatricial process at the level of L5 / S1. There is no data for recurrence of herniated discs at the level of L4 / L5, L5 / S1. No data were obtained for the cicatricial adhesions at the L4 / L5 level. The patient is in satisfactory condition, the pain syndrome on the L5 root does not bother, there are no sensitive disorders, the symptoms of tension are negative, regression of the vertebral syndrome. Hypesthesia and episodic pains persist along the S1 root with a decrease in the Achilles reflex on the left.

The method provides removal of a herniated disc while preserving the posterior longitudinal ligament — a natural anatomical barrier between two media — the cavity of the disc and the epidural space; effective hemostasis (stopping bleeding from the cavity of a removed disk occurs due to thermal exposure); there is no defect in the posterior longitudinal ligament, after completion of the procedure, the site of puncture of the posterior longitudinal ligament and the fibrous capsule is sealed, thereby ensuring reliable sealing of the cavity of the removed disk and protecting the ventral part of the dural sac and root from the development of cicatricial changes. In addition, we achieve fibrotization (compaction) of the remaining substance of the intervertebral disc and possible undeleted fragments of the disc, which essentially reduces the likelihood of recurrent hernial protrusions and postoperative pain.

Claims (1)

A method for preventing the development of the cicatricial-adhesion process in the epidural space after removal of a hernia of the intervertebral disc at the lumbar level, including intralaminar access, removal of the hernia and summing up a fragment of subcutaneous fat on the dorsal surface of the root and dural sac, characterized in that the hernia is punctured protrusion through the posterior longitudinal ligament with a needle and a fiber is inserted through its lumen, and the hernia of the disk and the substance of the pulpous nucleus are removed by puncture put m phased laser vaporization, propelling the needle from the herniation to the center of the disc.