RU2414182C1 - Method of surgical treatment of hernia of thoracic intervertebral disc - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to traumatology, orthopedics and neurosurgery. Posterolateral surgical access to vertebral canal is carried out by partial resection of pedicle of arch and articular processes of vertebra with preservation of their anatomic and functional integrity. Hernia ablation is carried out by resection of posterior part in intervertebral disc, partly bodies of adjacent vertebrae and edge of vertebral canal within the limits of middle supporting vertebral column, with further removal of hernia remnants from vertebral canal under endoscopic control.

EFFECT: method includes minimal volume of osteoligamental resection and does nor require stabilisation of operated part of spine due to preservation of main supporting structures of vertebra.

1 ex, 11 dwg

Description

The invention relates to medicine, namely to traumatology, orthopedics 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.

To date, the problem of choosing the best methods of surgical interventions on the thoracic spine with a hernia of the thoracic intervertebral disc is completely unresolved. At the same time, the surgeon has two tasks: neurosurgical - performing full decompression of the spinal cord and orthopedic - ensuring the maximum possible biomechanical stability of the operated vertebral segment by choosing the minimally invasive access.

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 due to extensive osteo-ligamentous resection.

Most methods of surgical treatment of hernias of the thoracic intervertebral discs currently used are quite traumatic, access to the disk space that they provide is not beneficial. 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 for the surgical treatment of hernias of the thoracic intervertebral discs (Aizawa T, Sato T, Sasaki H, Matsumoto F, Morozmni N. Results of surgical treatment for thoracic myelopathy: minimum 2-year follow-up study in 132 patients // J Neurosurg Spine. - 2007. - V.7. - P.13-20). This technique consists of a thoracotomy of the anterolateral transpleural operative access to the thoracic spine. To do this, the costal-transverse ligaments and joints, rib heads, legs of the vertebral arch are removed. Removal of a hernia of the intervertebral disc is performed by a special cylindrical cutter, while a significant part of the vertebral body is resected.

The disadvantage of this method is that it requires thoracotomy, opening the pleural cavity, which can lead to pulmonary complications: pneumothorax, atelectasis, pleural adhesions. To perform it, a resection of part of the bodies of adjacent vertebrae, legs of the vertebral arch, costal-transverse ligaments is required, which leads to instability of the vertebral segment and corporodesis performed by a bone graft or metal fixatives. After the operation, closed drainage of the pleural cavity is necessary.

Also known is a 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 Jjhh Batt S, Kurpad SN, Maiman DJ. Minimally invasive, extracavitary approach for thoracic disc herniation: technical report and preliminary results // Spine J. - 2006. - V.6 (2) .- P.157-163).

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 posterior operative access to the thoracic spine, resection of the arch, legs of the arch and intervertebral joint to remove the hernia (Arrests S.O. Endoscopic neurosurgery in the treatment of hernias of the intervertebral discs of the thoracic and lumbosacral spine. - Dis. Candidate of Medical Sciences. M, 2006. p. 82-84).

The disadvantage of this method is that the volume of the resection requires the removal of the arch, leg of the arch and intervertebral joint of the vertebra, leading to instability of the vertebral segment, requiring spinal fusion with metal clamps as the final stage of the operation. To remove a disc hernia, abduction and forced traction of the spinal cord is required to expose the disc space. Such manipulations in conditions of decompensation of blood circulation in a spinal cord squeezed by a hernia lead to postoperative neurological complications.

Given the above disadvantages of traditional surgical techniques, we have proposed a method for the surgical treatment of hernias of the thoracic intervertebral discs to perform the following tasks:

- the possibility of use in somatically severe patients with concomitant pathologies for which transthoracic access is contraindicated;

- lack of thoracotomy or manipulation of the chest and its contents;

- short duration of surgery and anesthesia;

- the minimum amount of osteoligamentous resection and blood loss;

- the absence of the need for direct manipulations on the neurovascular formations of the spinal cord at the thoracic level during its decompression;

- lack of orthopedic stabilization and reconstruction of the operated vertebral segment;

- the use of video endoscopic equipment to visualize hard-to-reach anatomical formations of the thoracic spinal canal.

The objectives are achieved in that in the method of surgical treatment of hernias of the thoracic intervertebral discs, the posterolateral surgical access to the spinal canal is carried out by partial resection of the arch leg and articular processes of the vertebra while maintaining their anatomical and functional integrity. Hernia is removed by resection of the posterior part of the intervertebral disc, partly the bodies of adjacent vertebrae and the edge of the spinal canal within the middle support column of the spine, followed by removal of the remains of the hernia from the spinal canal under endoscopic control.

The essence of the method is illustrated by drawings. In Fig.1 - the position of the patient on the abdomen and the direction of the skin incision, in Fig.2 - the thoracic vertebral segment and landmarks for performing posterolateral access to the spinal canal, Fig.3 - formation of the stroke in the upper part of the leg of the vertebral arch using an awl, figure 4 - the same in axial projection, figure 5 - the formation of the milling channel along the course formed by the awl of the stroke in the upper part of the leg of the vertebral arch, figure 6 - resection of the side wall of the spinal canal using a cutter, figure 7 - resection posterior third of the intervertebral disc and partially tel cm of vertebral hematomas to it with a bone spoon while preserving the anterior wall of the spinal canal; Fig. 8 is the same in axial projection; Fig. 9 is spinal cord decompression by mixing with the bone spoon the remnants of the anterior wall of the spinal canal and hernia into the resection zone of the posterior third of the vertebral body and intervertebral disc, in Fig.10 - the same in axial projection, in Fig.11 - revision of the spinal cord and hernia removal using an endoscope.

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 endotracheal anesthesia in the patient’s position on the abdomen.

A skin incision 1 is made along the midline 4-5 cm long in the area of the projection of the thoracic vertebrae 2 adjacent to the desired intervertebral disk 3. Next, a typical posterior surgical access to the thoracic vertebrae 2 is performed, during which transverse processes 4 and arches 5 of the thoracic vertebrae 2 are distinguished above and below the desired intervertebral disc 3 and intervertebral joint 6. The allocation is carried out on the one hand, respectively, lateralization of the hernia of the intervertebral disc 7.

After this, the formation of the course 8 is carried out in the upper part of the leg of the arch 9 adjacent to the lower edge of the intervertebral disc 3, with the help of an awl 10. The awl 10 is set at point 11, corresponding to the middle of the upper half of the leg of the arch 9, and immerses in circular movements to a depth of 3-4 cm, so as to reach the middle third of the body 12 of the thoracic vertebra 2.

Next, the formation of the milling channel 13 along the course formed by the awl 10 of the course 8. For this, a mill 14 with a diameter of 10-12 mm is used. During the passage of the cutter 14 along the formed path 8, the upper half of the leg of the arch 9 of the thoracic vertebra 2, the upper articular process 15, part of the lower articular process 16, and also the side wall of the spinal canal 17 are resected. The cutter 16 is immersed to the depth of the rear third of the vertebral body 12, respectively. Opening the lateral wall of the spinal canal 17 allows you to visualize the spinal cord 18 and to avoid trauma in the subsequent stages of the operation.

After the formation of the milling channel 13 in the upper part of the leg of the arch 9 and the posterior third of the vertebral body 12 with the opening of the lateral wall of the vertebral canal 17, a resection of the posterior third of the intervertebral disc 3 and partially of the bodies 12 of the vertebrae adjacent to it is performed. To do this, use a bone spoon 19. A bone spoon 19 forms a resection cavity 20 in the posterior third of the body 12 of the vertebra 2 and intervertebral disc 3 while maintaining the anterior wall of the spinal canal 17. The safety of the anterior wall of the vertebral canal 17 ensures the safety of resection of the posterior third of the body 12 of the vertebra 2 and intervertebral disk 3, while visual control of manipulations remains adequate due to visualization of the lateral surface of the spinal cord 18. After resection of the posterior third of the body 12 of the vertebra 2 and intervertebral disk 3 spin nd brain 18 remains compressed only herniated disc 7 is attached to the front wall 17 of the vertebral canal.

Next, direct decompression of the spinal cord 18 is carried out by mixing with a bone spoon 19 the remnants of the anterior wall of the spinal canal 17 with an adjacent hernia 7 from the spinal cord 18 into the formed cavity 20 in the posterior third of the body 12 of the vertebra 2 and intervertebral disc 3. Thus, during the entire operation no direct manipulations were performed on the spinal cord.

In conclusion, an audit of the spinal cord 18 is carried out using an endoscope 21 inserted into the resection cavity 20 of the posterior third of the body 12 of the vertebra 2 and intervertebral disc 3.

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. Due to the safety of two supporting structures: the anterior and posterior columns according to the classification of Denis F., 1983 and the anterolateral sections of the intervertebral disc, bone defect replacement is not required.

Hemostasis is performed. The wound is sutured in layers tightly. An aseptic dressing is applied to postoperative sutures.

Example

Patient D, 57 years old. Diagnosis: Osteochondrosis of the spine, lateralized right-sided hernia of the disc at the level of T8-T9 vertebrae with compression of the spinal cord. Thoracic myelopathy with lower paraparesis.

Complaints at admission: Pain in the thoracic spine, weakness in the limbs, more pronounced on the left, numbness in the legs.

Anamnesis of the disease: According to the patient, for several years he noted periodic pain in the lumbar spine with radiation to the lower extremities. A year ago, the patient received a minor spinal injury (jumped from a height), after which there was pain in the chest, lumbar spine, and growing weakness in the legs. He was treated at the place of residence. Computed tomography of the thoracic spine revealed a calcified lateralized right-sided hernia of the intervertebral disc at the T8-T9 level with severe compression of the spinal cord. Sent to a hospital for further examination and treatment.

Objective examination: The condition is relatively satisfactory, conscious, adequate, the skin clean, vesicular breathing, no rales. Heart sounds are rhythmic, no noise, R-76 per min, blood pressure 120/80 mm Hg The tongue is moist, the abdomen is soft, painless, the liver, spleen are not enlarged. The chair is regular, adequate diuresis.

Neurological examination: Pathological symptoms are revealed in the neurological status in the form of revitalization of tendon reflexes from the legs, D> S, hyposthesia from the T8 level of the segment, bilateral Babinsky.

The operation was carried out according to the proposed method: posterolateral surgical access to the anterolateral spinal canal of the thoracic spine at the level of T8-T9 and microsurgical removal of a hernia of the thoracic intervertebral disc using endoscopic technique.

Condition after surgery with pronounced positive dynamics. Discharged from the hospital on the 7th day. At the follow-up examination 1 month after the operation, there are no health complaints.

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 and damage to the paraspinal muscles, the absence of the need for thoracotomy, and the minimum amount of osteo-ligamentous resection of the vertebrae of their ligaments and joints. A more adequate decompression of the anterior spinal cord from posterolateral access is provided and the possibility of spinal cord injury is minimized, spinal instability is eliminated, the risk of damage to surrounding soft tissues, blood vessels, nerve structures, and shortening of the operation time is reduced.

Claims (1)

A method for surgical treatment of a hernia of the thoracic intervertebral disc, including posterior access to the thoracic vertebrae, removal of the hernia, characterized in that a channel is formed in the upper part of the leg of the vertebral arch and the adjacent intervertebral disc, the upper half of the leg of the arch, upper articular process, part of the lower the articular process, the lateral wall of the spinal canal, the posterior third of the intervertebral disc and partially the bodies of the vertebrae adjacent to it within the middle supporting column of the spine with preservation of the anterior th spinal canal wall, a front wall is displaced and hernia of the vertebral canal in the posterior third of the vertebral body resection zone and intervertebral disc hernia, followed by removal under endoscopic control.

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