RU2393756C1 - Method of selecting tactics of treating patients with degenerative affection of spine - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely to vertebrology. In course of selection of tactics of treating patients with degenerative affection of spine performed are radiologic, computer-tomographic (CT) and electroneuromyographic (ENMG) examinations. Attention is focused on indices of: height between vertebra bodies at the level of affected vertebral-motor segment, narrowing of spinal canal, deformation of dural sac and roots, state of spinal marrow motoneurons activity. After that spine traction under ENMG control is performed. Value of spine traction force is selected and left at the level at which constancy of values of spine marrow motoneurons activity is achieved. CT control is carried out at earlier selected value of traction force of: dynamics of change of spine canal lumen, deformation of dural sac and roots at the level of affected vertebral-motor segment, restoration of height between vertebrae bodies at the level of affected vertebral-motor segment. Obtained values are compared with values of initial indices. Degree of their changes is evaluated. Depending on them tactics of treatment is selected. In case of unchanging state and constancy of index values surgical treatment with spinal canal revision is prescribed. In case when observed is essential positive dynamics in change of index values in deformation of dural sac and roots, restoration of height between vertebrae bodies at the level of affected vertebral-motor segment and depending on decrease of narrowing of spinal canal lumen to a half of initial value, interspinal dynamic fixation of affected spine segment is prescribed. In case when narrowing of spinal canal lumen reduces per a half and more of initial value, puncture decompression of affected disc by hydroplasty method is prescribed. In case of virtually complete restoration of indices in process of said examination and control, puncture decompression of affected disc by electromagnetic exposure in traction mode is prescribed.

EFFECT: method ensures realisation of rational selection of adequate treatment taking into account state of neuromuscular apparatus and character of changes under impact of traction of spinal canal lumen.

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Description

The invention relates to medicine, namely to vertebrology, and can be used in orthopedics, neurosurgery and traumatology to select the optimal tactics for assisting patients with degenerative lesions of the spine.

The well-known "Method for the diagnosis of the functional state of the spine" [RU patent for the invention No. 2156107]. The value of electrical conductivity is measured at 24 biologically active points (BAP) of 12 classical meridians located on the meridian of the bladder in the region of the skin zones of Abrams at the level of the vertebral-motor segment (PDS). The values are plotted on the axis of the polar diagram. Build a regulatory profile (NP). When all 24 values are located within the boundaries of the NP, the functional state of the spine is diagnosed as normal. When 1-12 values go beyond the upper border of the NP, a functional disorder of the spine is diagnosed at the level of the corresponding segments according to the algorithmic type with a reflex muscular-tonic component. When 1-12 values go beyond the lower border of the NP, there is a violation of the autonomic-vascular type with a reflex ischemic component. When more than 12 out of 24 values go beyond the upper boundary of the NP, there is a violation of the type of reflex muscle hypertonicity. If more than 12 out of 24 values go beyond the lower boundary of the NP, there is a violation of the type of reflex muscular hypotension, and when the values go beyond both the upper and lower boundaries of the NP, the character of violations of the functional state of the spine is diagnosed by the predominance of the direction of their exit, for which the equilibrium coefficient is calculated .

This method allows for differential diagnosis, depending on which users make the choice of medical care.

However, this method is very specific and is intended for a narrow circle of neurologists with knowledge and skills of neuroacupuncture. Depending on the degree of thoroughness and compliance with the specifics of constructing diagrams for 24 biologically active points, as well as other special techniques, the accuracy of dividing patients into groups and all subsequent steps in choosing adequate medical care may be impaired.

Also known is the “Method for electroneuromyographic diagnosis of spinal cord root lesions” [RU patent No. 2299010 for pain syndromes of spinal osteochondrosis, including the study of the speed of an impulse along the proximal motor fibers of the sciatic nerve with indirect muscle stimulation in supramaximal mode. Conductivity is studied in the distal and proximal sections of the nerve and with an average F-wave amplitude of 450.0 to 500.0 μV and an M-response amplitude of 3.5 to 6 mV, asymmetry between the sides of less than 1 mV and a pulse conduction speed of 40 to 60 m / s fix the stage of proximal asymmetry. With an average F-wave amplitude of 350 to 450 μV and total dispersion of 10 to 15 m / s, an M-response amplitude of 3.5 to 6 mV, asymmetries between the sides of less than 1 mV and a pulse velocity of 40 to 60 m / with fix the stage of radiculopathy. With an average F-wave amplitude of 150 to 350 μV and total dispersion of 15 to 20 m / s, an M-response amplitude of 1.5 to 3.5 mV, asymmetries between the sides of more than 1 mV and a pulse conduction speed of 40 to 60 m / s fix the stage of radiculopathy - axonopathy. With an average amplitude of F-waves from 500 to 1000 μV, with an amplitude of the M-response from 1.5 to 3.5 mV, with an asymmetry between the sides of more than 1 mV and a pulse velocity of 40 to 60 m / s, the stage of myelopathy - radiculopathy is fixed - axonopathies.

However, despite the fact that the method quite clearly classifies the functional lesions of the roots of the spinal cord and divides the patients into three groups depending on the existing pathologies, the prescription of treatment for each of these groups in this method is not clearly prescribed. This method implies standard treatment for each of the three identified groups, without making a choice of recommendations and treatment of pathologies, even for conservative or surgical approaches.

Also known is the "Method of planning surgical correction of scoliotic deformity" [RU patent for the invention No. 2309692], which includes spinal radiography. Then, the apical and terminal vertebrae, the localization and the length of the arcs of curvature and anti-curvature are determined by spondylograms. Measure the magnitude of scoliotic deformation, the angle of deformation according to Cobb, the rotation of the apical vertebra. Rieser bone maturity and completeness of spinal growth are assessed. The mobility of the deformed spine and the length of the fusion are calculated. The possibility of dorsal, ventral, or bilateral correction is determined by the extent and location of the scoliotic arch, the angle of deformation according to Cobb, mobility and completeness of spinal growth. Make a choice of the type and degree of correction. The indices of rotation of the vertebra from the apical to the terminal arches of curvature are calculated. The nomenclature of the calculated parameters of the vertebrae of the scoliotic arch is determined. Carry out a choice of metal frame size. At the same time, the condition of the terminal apophyses of the vertebrae in the thoracic region is assessed by spondylograms in the lateral projection, and in the lumbar region - by the spondylograms in the direct projection.

However, not taking into account the functional state of the conduction function of the spinal cord and its roots, as well as the condition of the spinal canal for the choice of treatment tactics for even one class of degenerative diseases of the spine accompanied by deformations of the spinal canal, it is currently difficult to choose a medical purpose that meets international standards.

Also known is the "Method for determining the surgical treatment strategy for compression of the spinal cord at the cervical level in degenerative stenosis" [patent RU invention No. 2317119], including the study of somatosensory evoked potentials. Transcranial magnetic stimulation is carried out in the projection of the motor cortex and in the root area at the cervical level. Evoked motor responses are recorded and the time of central motor conduction (VTsMP) is determined. The parameters of short-latent somatosensory evoked potentials are recorded and determined at once, and with an increase in VCMP and indicators of somatosensory potentials within the normal range, a discectomy or corporectomy is performed by the anterior cervical approach, if the VCMP is normal, and the parameters of the somatosensory evoked potentials are changed, laminoplasty is performed.

However, this invention is useful in choosing a surgical treatment strategy for a fairly narrow class of diseases, limited only by deinfo stenosis at the level of the cervical spine.

Also known is the "Method for identifying a variety of forms of lumbar osteochondrosis, including the evaluation of neuroimaging data" [RU patent for invention No. 2313283]. Additionally, the data of CT, CT of the lumbar spine and MRI, CT, CT of the brain are assessed when a combination of protrusion or prolapse of several adjacent lumbar intervertebral discs with leukoaraiosis, foci of demyelination, and hypotrophy of the brain substance is determined, and the radiculoencephalopathic form is determined. If protrusion or prolapse is detected only in several adjacent lumbar intervertebral discs without signs of brain damage, the radiculopathic form is determined.

This method identifies various forms of the disease that require a different approach, therapeutic measures and indications for surgical treatment. However, this method does not determine surgical tactics and the choice of type and scope of operations.

Also known is the publication “Optimization of the tactics of surgical treatment of patients with lumbar osteochondrosis” [abstract of the dissertation for the degree of candidate of medical science Ostrovsky V.V. Saratov, 2006, p.6]. In this paper, the selection criteria for repeated surgery in patients with relapse of pain after unsuccessful conservative therapy and unsuccessful operations on the lumbar spine are determined. The methodology of a combined method of treating patients with relapse of chronic discogenic pain syndrome caused by hernias of the intervertebral discs is substantiated.

However, this publication does not cover all types of degenerative pathologies of the spine and is not intended for this. Optimization of surgical treatment tactics is limited by the fact that it tends to use the complex effect of direct electrostimulation and neuroprotective drugs administered through the catheter to the affected spinal roots.

The closest analogue to the claimed solution is a method for determining surgical tactics and the choice of surgical intervention, described in the review "Surgical interventions for stenosis of the lumbar spine" clinic of spinal pathology of the Institute of Neurosurgery. Academician A.P. Romodanov / Kiev, Ukraine (information on the analogue is attached in the application materials). Material taken http://www.spine.kiev.ua/en/specialist_b08. html

A classification of stenosis is given and, depending on it, taking into account the type and subspecies of pathologies, as well as other features, the treatment tactics are selected. When choosing treatment tactics, an algorithm is formulated. Planning the type and extent of the operation is based on an assessment of the neurological syndrome and its compliance with radiological and tomographic data. Sections are presented: diagnostics, surgical tactics and choice of surgical intervention. Dan also has a section - surgical technique. The review was made soundly, interesting material was collected, and it was comprehensively presented.

“Depending on the type of stenosis, decompression of the spinal or radicular canals is used. An expanded decompression laminectomy at the level of two to three segments is performed for polysegmental stenosis of the lumbar spinal canal. A particularly good clinical effect with a minimal risk of instability is achieved in the elderly, with a rigid spine (due to severe osteophytosis). Monosegmental stenosis requires a laminectomy and a facetectomy at the level of the affected segment. Patients with unilateral neurological manifestations can undergo sparing decompression with mandatory resection of the medial part of the arched joints and the removal of additional soft tissue compressing components (protrusions and hernias of the intervertebral discs, hypertrophic yellow ligament, ossified posterior longitudinal ligament, etc.). Lateral stenosis and the radicular syndromes caused by them are eliminated by facetectomy, foraminotomy.

Thus, the following interventions are currently used in the surgical treatment of stenosis of the lumbar spine:

“Targeted” posterior decompression of lateral recessus - inter-laminectomy, medial facetectomy;

“Aimed” anterior and posterior decompression of the lateral recessus - interlaminectomy, medial facetectomy, discectomy, osteophytectomy;

decompression laminectomy;

decompression laminectomy and medial facetectomy;

fixation of the spine with the use of mobile and fixed prostheses of the intervertebral discs, cages, transpedicular systems.

Surgical tactics and choice of surgical intervention.

With lateral stenosis, mainly caused by hypertrophic arthrosis of the intervertebral joint, “targeted” posterior decompression of lateral recessus (interlaminectomy, medial facetectomy) is indicated. Such operations were performed by us in 21% of patients with stenosis.

In case of combined stenosis, an “aimed” anterior and posterior decompression of lateral recessus (interlaminectomy, medial facetectomy, discectomy, osteophytectomy) was performed, which was performed by us in 42% of patients. These were mainly stenoses developing as a result of hypertrophic arthrosis of the intervertebral joint (in combination with ossified hernias and osteophytes, ossification of the posterior longitudinal ligament).

Patients with central stenosis of the spinal canal at several levels in the presence of moderate to severe progressive radiculopathy are shown decompression laminectomy [F.M. Phillips et al., 2002]. Such an operation is used in 20% of cases. These are mainly stenoses with ossification of the posterior longitudinal ligament centrally at many levels.

Patients with central stenosis of the spinal canal at several levels in combination with stenosis of lateral recesses are shown decompression laminectomy in combination with medial facetectomy. This operation is used in 11% of cases. These are mainly stenoses with ossification of the posterior longitudinal ligament centrally at many levels in combination with multilevel hypertrophic arthrosis of the intervertebral joints, where it is impossible to perform interlaminectomy and medial facetectomy of all affected joints because of their large number.

Decompression of the dural sac and roots in combination with fixation of the vertebrae is indicated for patients with lumbar stenosis and instability. Stabilizing interventions for spinal stenosis are much more common. Such operations are indicated: with a combination of stenosis and degenerative scoliosis of the lumbar region of adults, with a combination of stenosis and spondylolisthesis, with radiologically documented instability of the lumbar spine, pain and neurological manifestations, with previously operated spine syndrome and iatrogenic instability, with lumbalgia arising from movements [ PWDetwiler et al., 1997; M.W. Fox, B.M. Onofrio, 1997]. ”

However, the closest analogue does not provide for the selection of treatment tactics for patients with degenerative diseases of the spine at an early stage of spinal stenosis with herniated discs and their sequestration.

The task of the invention is to divide the degenerative diseases of the spine into groups of patients, taking into account the state of the neuromuscular apparatus and the nature of changes in the lumen of the spinal canal under the influence of traction, and depending on this, the implementation of a rational choice of adequate treatment.

The essence of the proposed method for the selection of treatment tactics for patients with degenerative lesions of the spine is characterized by the fact that they carry out x-ray, computed tomography (CT) and electroneuromyographic (ENMG) studies with fixation of attention on indicators: height between vertebral bodies at the level of the affected vertebral-motor segment, narrowing of the lumen spinal canal, deformation of the dural sac and roots, activity status of spinal cord motor neurons, then slowly and carefully carry out the stretching of of the spine under the control of ENMG, the magnitude of the spinal traction force is selected and left at a level at which the values of the activity values of the spinal cord motor neurons are constant, CT control is carried out with the traction strength selected before: dynamics of changes in the lumen of the spinal canal, deformation of the dural sac and roots at the level of the affected vertebral-motor segment, restoration of height between the vertebral bodies at the level of the affected vertebral-motor segment; compare the obtained values with the values of the initial indicators, evaluate the degree of their changes, depending on them choose treatment tactics:

- with a constant picture and constancy of the values of the indicators, surgical treatment with revision of the spinal canal is prescribed;

- with significant positive dynamics in changing values of indicators in reducing deformation of the dural sac and roots, restoration of height between vertebral bodies at the level of the affected vertebral-motor segment and depending on the reduction of narrowing of the lumen of the spinal canal

- up to half of the initial value - appoint interspinous dynamic fixation of the affected segment of the spine;

- half and more than the initial value - puncture decompression of the affected disk by hydroplastic is prescribed;

- with almost complete restoration of indicators in the process of the aforementioned research and control, puncture decompression of the affected disk by electromagnetic exposure in the traction mode is prescribed.

The technical result of the claimed invention. The method is carried out using technical means, devices and is impossible without the most modern methods: X-ray, computed tomography and electroneuromyographic studies. The criterion for significant action in the method is to achieve a certain level of activity of the spinal cord motor neurons, the dynamics of changes in height between the vertebral bodies at the level of the affected vertebral-motor segment, the lumen of the spinal canal and their delay at this level in the form of constant values. The method is simple, does not require additional equipment, except for the mandatory above for all neurotraumatological centers, however, it frees personnel from incorrect actions. When performing this study, patients with a high risk of complications are prescribed surgical treatment in accordance with the complexity of the developed disease. Otherwise, a minimally invasive intervention is prescribed. Thus, the method allows you to reasonably prescribe adequate treatment, saving time and avoiding overestimating the complexity of the operation in cases of pathology with the least risk of surgery. It is recommended for use in any neurotraumatological centers, as well as in standard medical facilities, provided that the necessary modern equipment is available - X-ray, CT, ENMG and appropriate staff qualifications.

The method is as follows.

At the initial examination, the patient is assessed for clinical, neurological and somatic status, a standard set of laboratory tests is performed, X-rays, CT and ENMG studies are performed. Among all the data obtained, special attention is recorded, including on indicators: the height between the vertebral bodies at the level of the affected vertebral-motor segment, narrowing of the lumen of the spinal canal, deformation of the dural sac and roots, and the state of activity of the spinal cord motor neurons. The latter, the activity of spinal cord motor neurons, is monitored using an electroneuromyograph in a monitoring mode. The activity of motor neurons is evaluated by the following main parameters of the ENMG: the amplitude of the M-response, the speed of the pulse (SPI), the latent period (PL) of the F-wave. When confirming a degenerative lesion of the spine and detecting changes in the values of the parameters of the studies performed, the patient further diagnostic study is carried out using spinal traction. This set of studies is carried out for the patient in the mode of spinal traction, which can be done in different ways, both with the help of traction devices on the table of a computer tomograph in the position of the patient lying on his stomach, and with the help of a distracting corset, used, for example, to correct spinal deformities. Traction is carried out with extreme delicacy under the control of ENMG in order to avoid tractional even minor damage to neural structures. The spinal traction force is selected and set depending on the level of motor neuron activity values, namely, when the values of motor neuron activity are constant, the spinal traction force is fixed and considered to be working. All further research and manipulations during the study are carried out at this value of the traction force, without removing this load. Then carry out CT control. A comparative analysis of the newly obtained data with the initial ones is carried out and the dynamics is evaluated: changes in the lumen of the spinal canal, deformation of the dural sac and roots at the level of the affected vertebral-motor segment, restoration of height between the vertebral bodies at the level of the affected vertebral-motor segment, and, depending on the results of the comparative analysis, choose treatment tactics.

In different patients with various manifestations of degenerative lesions of the spine, the list of recommended appointments is usually limited by the authors in the following format.

With a constant picture and a constant value of the indicators, surgical treatment with an audit of the spinal canal is prescribed.

With almost complete restoration of indicators in the process of the aforementioned research and control, puncture decompression of the affected disk is prescribed by one of the methods of electromagnetic exposure in the traction mode. The most common of these are cold plasma and laser decompression. Radio frequency decompression of the intervertebral disc may also be used.

In those cases when there is a significant positive dynamics in changing the values of the indicators, which consists in simultaneously reducing deformation of the dural sac and roots, as well as in restoring the height between the vertebral bodies at the level of the affected vertebral-motor segment, resorting to minimally invasive surgery, and the choice of appointment is significant the degree depends on the size of the narrowing of the lumen of the spinal canal. So, if the value is less than half the initial value, an interspinous dynamic fixation of the affected segment of the spine is prescribed. If this value is greater than or equal to half of the initial value, puncture decompression of the affected disk is prescribed by the hydroplastic method in the patient's position in the traction mode.

The inventive method is illustrated using examples.

Example 1. Patient M., 46 years old. The diagnosis at admission is osteochondrosis of the lumbar vertebra with vertebral radicular compression pain syndrome. Surgical treatment recommended. Using the above-described examination technology with the inclusion of clinical and neurological examination of the patient and laboratory tests, the data were verified using hardware studies on the day of admission: X-ray, CT, ENMG studies, first without spinal traction, and then with traction. The dynamics was noted in the indicators: before extension, the initial height between the vertebral bodies was 3.2 mm, the narrowing of the spinal canal due to the bulging of the disc by 6.5 mm, with the following indicators of the activity of spinal cord motor neurons - the amplitude of the M-response of the short extensor of the fingers of the right foot was 4 , 8 mV, SPI - 44 mm / s, LP of the F-wave 44 mm / s, the severity of the block of F-waves - 72%. On the left, the indicators are within the age norm. In the muscles innervated by the LV with the root on the right, spontaneous activity was absent.

Under the action of traction, an increase in the level of segmental activity of motoneurons by 50% was noted (Block F waves decreased to 40%), the height between the vertebral bodies was increased from 3.0 mm to 5.0 mm, and the narrowing of the lumen of the spinal canal from 6.5 mm to 4 , 0 mm.

In a comparative analysis of the results of the study, it was noted that there is significant positive dynamics in changing the values of the indicators in the form of a decrease in the deformation of the dural sac and roots, in restoring the height between the vertebral bodies at the level of the affected vertebral-motor segment, and in reducing the narrowing of the lumen of the spinal canal to half from the initial values. The patient was prescribed minimally invasive surgical treatment - interspinous dynamic fixation of the affected segment. In accordance with the chosen treatment tactics, the patient was hospitalized in a hospital where, after standard preoperative preparation, the above operation was performed.

Example 2. In exact accordance with the above claimed method, a survey was conducted of a patient Yu., 36 years old, who was sent to determine treatment tactics with a diagnosis of ostechondrosis of the lumbar spine, prolonged lumbar ischialgia on the left. The patient, as in the previous case, was examined according to the technology described above. The following results were obtained: initially, before stretching, the height between the vertebral bodies was 3.5 mm, the narrowing of the spinal canal due to the bulge of the disc by 6.5 mm, with the following indicators of the activity of spinal cord motor neurons - the amplitude of the M-response of the short extensor of the fingers of the right foot was 4, 2 mV (8.3 Mv on the left), SPI - 40 mm / s (48.4 ms on the left), F-wave PL 46 mm / s (43 m / s on the left), F-wave block severity - 80% (left 35%).

Under the action of LP stretching, the F-wave amounted to 45 m / s, the blocking of F-waves decreased to 20%. The height between the vertebral bodies increased from 3.5 mm to 5.0 mm, reducing the narrowing of the lumen of the spinal canal from 6.0 mm to 2.0 mm.

A thorough comparative analysis of the data obtained as a result of a study on the proposed technology was carried out. All signs of the disease fit into the variant of the claimed invention "almost complete restoration of indicators in the process of the claimed research." In this regard, the patient was prescribed decompression of the affected disk by cold plasma nucleoplasty in the traction mode. On the same day in the patient's hospital this operation was performed. Two hours after the operation, the patient was discharged from the hospital in good condition.

Example 3. Patient S., 52 years old. He was sent to a hospital with a diagnosis of osteochondrosis of the lumbar spine, median hernia of the LV-SI segment of the disc, with a pronounced narrowing of the lumen of the spinal canal, myeloradiculopathy from the level of the SI segment. When conducting a survey on the proposed technology at the time of traction, a negative dynamics was noted in the change in the activity values of the spinal cord motor neurons. In this connection, the traction was stopped, the study was terminated. The patient is classified according to the classification of the proposed method of choosing tactics to a group with an unchanged picture and the constancy of the values of the indicators. The patient is prescribed open access surgical treatment. The patient was hospitalized in a hospital, where this type of surgical treatment was performed in a planned manner.

Claims (1)

A method for choosing treatment tactics for patients with degenerative spinal injury, characterized by the fact that they carry out X-ray, computed tomography (CT) and electroneuromyographic (ENMG) studies with focus on indicators: height between vertebral bodies at the level of the affected vertebral-motor segment, narrowing of the lumen of the vertebral channel, deformation of the dural sac and roots, activity status of the motor neurons of the spinal cord, then slowly and carefully carry out the extension of the spine under cont by the role of ENMG, the magnitude of the spinal traction force is selected and left at the level at which the values of the activity values of the spinal cord motor neurons are constant, CT monitoring is carried out at the traction strength chosen before: dynamics of the change in the lumen of the spinal canal, deformation of the dural sac and roots at the level the affected vertebral-motor segment, restoration of height between the vertebral bodies at the level of the affected vertebral-motor segment; compare the obtained values with the values of the initial indicators, evaluate the degree of their changes, depending on them choose treatment tactics:
with a constant picture and constancy of the values of the indicators, surgical treatment with revision of the spinal canal is prescribed;
with significant positive dynamics in changing values of indicators in reducing deformity of the dural sac and roots, restoration of height between vertebral bodies at the level of the affected vertebral-motor segment and depending on the reduction of narrowing of the lumen of the spinal canal: interstitial dynamic fixation of the affected segment of the spine is prescribed up to half of the initial value ; half or more of the original value
prescribe puncture decompression of the affected disk by hydroplasty;
with almost complete restoration of indicators in the process of the aforementioned research and control, puncture decompression of the affected disk by electromagnetic exposure in the traction mode is prescribed.