RU2380042C1 - Surgery technique for vertebral-basilar insufficiency syndrome - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention concerns medicine, namely neurosurgery. Occipital squama and great occipital foramen are resected. Posterior atlantooccipital membrane is incised with preserving posterior vertebral arch C1. External leaf of pachymeninx is dissected over cerebellum tonsils and medulla oblongata. The flaps of external leaf of pachymeninx are excised, and adhesions between pachymeninx and posterior vertebral arch C1 are dissected.

EFFECT: method allows normalising blood flow within craniovertebral junction.

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Description

The invention relates to medicine, namely to neurosurgery, and can be used to treat vertebro-basilar insufficiency syndrome in children and adults.

A well-known technique for decompression of the posterior cranial fossa according to Nuffziger-Town, which includes resection of the scales of the occipital bone and the edges of the large occipital foramen with or without dura mater (Surgery of the central nervous system. Edited by V.M. Ugryumov, part 1, Brain surgery, 1969), was repeatedly modified with the addition of resection of the posterior arch of the C1 vertebra, resection of the tonsils of the cerebellum, the addition of a shunt operation Torkildsen (Mirsadykov D.A., Yalfimov A.N., Voronov V.G., Tyutin L. A. Features of dia -diagnosis and treatment of Chiari malformation Arnold // Neurosurgery 2004. -.. №4 -. S.10-14).

The disadvantages of the technique are aimed only at increasing the volume of the posterior cranial fossa and improving cerebrospinal circulation without affecting the change in blood flow in the craniovertebral transition region.

The aim of the proposed method is to normalize the blood flow of the craniovertebral junction (CVP) region by decompressing the squeezed vertebral artery and the surrounding venous collectors of a scarred atlantooccipital membrane.

The technical result is achieved by excision of the posterior atlanto-occipital membrane and cicatricial fusion of the area of the CVP as follows.

Performing the operation according to the proposed scheme is possible both in the patient’s lying position and in the sitting position, however, the experience of operations shows that the sitting position is the most optimal from the point of view of the performance technique for the surgeon and the possibility of controlling hemostasis during the intervention.

In the patient’s position, sitting on the operating table using a three-point brace, a midline incision is made in the cervical-occipital region. After dissection of the skin, subcutaneous fat layer and aponeurosis, muscles are dissected and the scales of the occipital bone and the edge of the large occipital foramen are skeletonized. Resection of the scales of the occipital bone, posterior edge of the large occipital foramen, and excision of the posterior atlanto-occipital membrane without resection of the posterior arch of the C1 vertebra are performed. Next, cross-sectional dissection of the outer leaf of the thickened dura mater above the tonsils of the cerebellum and the medulla oblongata with dissection and excision of the resulting flaps of the outer leaf of the dura mater is made, and scar formation is made between the dura mater and the posterior arch C1 of the vertebra. Sutures are layered on the wound.

Confirmation of industrial applicability can serve as tabular data and medical histories (Tables 1, 2) below:

Table 1 The result of the treatment of a group of patients with vertebro-basilar insufficiency syndrome according to the proposed technique (n = 52). Indicator Before surgery After a week of surgery 3 months after surgery Headache 52 (100%) 7 7 Dizziness 22 (42%) 0 0 Nausea 32 (61.5%) 0 0 Vomiting 12 (23%) 0 0 Fluctuations in blood pressure 10 (19%) 2 2 Nosebleeds 6 (11.5%) 0 0 Fainting 10 (19%) 0 0 TCD and UZDG BCA (hemodynamically significant asymmetry of blood flow in the vertebral arteries, CA> 30%) 26 (50%) 0 0 Extension of the diameter of the internal jugular veins according to CT-AG 30 (57.6%) 0 0 Reduction of the diameter of the intracranial segment of the vertebral arteries by CT-AG 40 (76.9%) 2 2

table 2 The result of the treatment of a control group of patients with vertebro-basilar insufficiency syndrome (n = 52). Indicators Before treatment 1 month after therapy 3 months after therapy Headache 52 (100%) four 44 Dizziness 46 (88%) four 40 Nausea 46 (88%) four 36 Vomiting 10 (19%) one 6 Fluctuations in blood pressure 20 (38%) four 16 Nosebleeds 10 (19%) one four Fainting 8 (15%) 0 2 TCD and UZDG BCA (hemodynamically significant asymmetry of blood flow in the vertebral arteries, CA> 30%) 20 (38%) twenty twenty Extension of the diameter of the internal jugular veins according to CT-AG 52 (100%) four 44 Reduction of the diameter of the intracranial segment of the vertebral arteries by CT-AG 46 (88%) four 40

From tables 1, 2 it follows that the treatment according to standard methods gives only a temporary improvement in the patient's condition, the course has to be repeated several times during the year. Treatment according to the method proposed by us leads to the elimination of blood flow disorders for an unlimited period of time, dynamic observation of patients treated by our method for three years does not reveal relapse of the disease. The operation is carried out at the clinical base of GOU VPO "VGMA named after NN Burdenko Roszdrav "in the State Institution" VODKB No. 2 of the city of Voronezh "since 1999.

Clinical case: medical history No. 07P351

Patient B., 19 years old, was hospitalized in the DRL with complaints of headache, accompanied by nausea, fluctuations in blood pressure from 90/60 mm Hg up to 170/90 mmHg, fainting.

Sick from 3-4 years. At first, headaches were disturbed several times a week, stopped with medication. With age, the frequency and duration of seizures began to increase, fluctuations in blood pressure appeared, the girl could not get out of bed, often lost consciousness. She constantly received conservative treatment in the neurological department about a disorder of the autonomic nervous system, but the effect was short-lived, and over the past year - without effect.

The examination revealed: on the CT of the brain - prolapse of the cerebellar tonsils below the level of the large occipital foramen by 8 mm.

When conducting TCD and UZDG BCA, a decrease in the velocity of blood flow in the right vertebral artery with an asymmetry coefficient of 36%, an increase in the level of peripheral vascular resistance in the supralateral arteries.

When carrying out radiography of the spine - right-sided thoracolumbar scoliosis of 1 degree.

On CT angiography of the vessels of the head and neck revealed a narrowing of the intracranial segments of the vertebral arteries, a marked expansion of the vertebral plexus with the formation of collaterals.

The clinical diagnosis was established: vertebro-basilar insufficiency syndrome against the background of an anomaly in the development of the craniovertebral transition Arnold-Chiari - 1.

Operated on February 6, 2007: in the sitting position, the incision along the midline in the cervical-occipital region is about 10.0 cm, the scales of the occipital bone are skeletonized. A milling hole was applied, a bone window 3.0 × 3.0 cm was formed by the craniotome with removal of the edge of the large occipital foramen. Lack of pulsation of the dura mater (TMT), cicatricial fusion between the dura mater, occipital bone and posterior atlanto-occipital membrane was revealed. The membrane is thickened, dense. Scars and adhesions are separated, the posterior atlanto-occipital membrane is excised, taken for histological examination. A cross-shaped dissection of the outer leaf of the dura mater was performed with excision of the flaps formed, after which a good pulsation of the TMT appeared.

Hemostasis, stitches in layers to the wound.

A histological examination of the posterior atlanto-occipital membrane revealed fibrous tissue with areas of hemosiderosis, pulverized calcification and metachromasia.

In the postoperative period, pronounced positive dynamics in the form of relief of headache, normalization of blood pressure (110/70 mm Hg). Primary wound healing.

During CT CT angiography of the vessels of the head and neck 1 month after the operation, no pathology was detected, the blood flow was sufficient for TCD and UZDG BCA, the asymmetry coefficient in the vertebral arteries was 23% (hemodynamically insignificant).

1 year after the operation - no complaints, blood pressure 110/70 mm. Hg

On TKDG and UZDG BCA - the blood flow is sufficient, the asymmetry coefficient is 15%. CT angiography is the norm.

The inventive level of the technique consists in identifying the previously unknown effect of eliminating vertebro-basilar insufficiency during excision of the atlanto-occipital membrane.

The current level of technology does not contain information reflecting the role of pathological changes in the posterior atlanto-occipital membrane in the development of circulatory disorders in the vertebro-basilar basin. There is no indication of the relationship of cicatricial changes in the structure of the membrane with a violation of its elasticity. The relationship between changes in membrane elasticity and mechanical restriction of blood flow through the vertebral arteries and veins is not considered. The pathomorphological reasons for the development of vertebro-basilar insufficiency syndrome described in the literature relate only to degenerative changes in the bone-cartilaginous tissue in the cervical spine or muscle syndromes (A. Lutsik. Surgical treatment of vertebral artery syndrome. Osteochondrosis of the spine // Abstracts. - Novokuznetsk , 1973. - P.285-295 .; Radchenko V.A., Popsuyshapka K.A., Ivanisov A.N. Experience in the surgical treatment of stenosis of the vertebral artery canal with unvertebral arthrosis // Orthopedics, traumatology and prosthetics - 2004. - No. 1. - 86-89).

The association of cicatricial changes in the posterior atlanto-occipital membrane as the cause of the development of vertebro-basilar insufficiency syndrome in the sources of scientific medical literature available to us devoted to cerebrovascular disorders is not indicated (for example, Zhulev N.M., Kandyba D.V., Yakovlev N. .A. Cervical osteochondrosis. Vertebral artery syndrome. Vertebro-basilar insufficiency - St. Petersburg, 2002 - 575 s .; Vereshchagin N.V. Pathology of the vertebro-basilar system and cerebrovascular accident. - M .: Medicine, 1980. - 311 s. )

Vertebrogenic dizziness is also considered only as a result of degenerative changes that form at the level of the spine, but with the participation of soft tissues of the cervical spine: muscles, ligaments, joints of the spine. Vertebral artery syndrome causes a deterioration in blood circulation in the vertebral-basilar system, as well as irritation of nerve endings, sympathetic formations in the cervical spine. (A.I. Fedin. Dizziness in neurological practice // Materials of the scientific-practical conference. Dizziness: modern aspects of diagnosis and therapy, Moscow, 1999).

Thus, the proposed method of treatment can improve the pulsation of the vertebral arteries and restore the venous outflow from the plexus surrounding the vertebral arteries in the cranio-vertebral transition region. Our development contributes to the normalization of cerebral circulation by excision of the scar-modified posterior atlanto-occipital membrane and dissection of the external sheet of TMT soldered to it. The proposed method allows to exclude relapses of the disease characteristic of the conservative treatment of this pathology.

Claims (1)

A method of surgical treatment of vertebro-basilar insufficiency syndrome, including resection of the scales of the occipital bone and the posterior edge of the large occipital foramen, characterized in that the posterior atlanto-occipital membrane is excised with preservation of the posterior arch C1 of the vertebra, cross the outer leaf of the dura mater over the tonsils of the cerebellum and the brain, excise the flaps of the outer leaf of the dura mater and dissect the cicatricial fusion between the dura mater and the posterior arch C1 NCA.