RU2444295C2 - Method of estimating reserves of microcirculatory channel of horse tail roots - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to field of medicine, namely to neurosurgery and ultrasonic diagnostics. Intra-operation examination of blood flow of spinal roots in zone of disco-radicular conflict is carried out before and after decompression with further comparison of examined indices. Examination is performed by method of ultrasonic Dopplerography. In addition to compressed root and dural sac examined are adjacent sections of neighbour roots of horse tail. In case if after decompression observed is increase of indices of linear, volume and average rates of blood flow by not less than 30% in all examined anatomical formations, preservation of reserves of microcirculatory channel is diagnosed.

EFFECT: method makes it possible to increase reliability of estimation of degree of blood flow recovery in zone of disco-radicular conflict.

9 tbl, 2 dwg

Description

The invention relates to medicine, namely to methods for measuring blood flow, and is intended for the diagnosis of reserves of the microvasculature of the cauda equina roots during surgical removal of lumbar intervertebral disc herniation.

A known method for evaluating the microcirculation of a compressed root and dural sac during disc herniation in patients with lumbar intervertebral disc herniation before and after decompression by determining the microcirculation index (in perfusion unit) using laser Doppler flowmetry using two recording channels - red (sounding depth to 0.8 mm) and infrared (sounding depth up to 1.8 mm) (Mironov S.P., Vetrile S.T., Krupatkin A.I., Shvets V.V. Microhemocirculation of nerve roots and dura mater span of before and after discectomy of lumbar pain // Journal of Traumatology and Orthopedics Priorov -. 2006. - №3 -. S.57-60).

However, in this method, the blood flow of the entire transverse section of the spinal root is not recorded and the blood flow of the cauda equina roots adjacent to the disc-radicular conflict zone is not measured, since laser Doppler flowmetry is used, in which the study depth is from 0.8 to 1.8 mm, which aggregate reduces the reliability of the diagnosis of the degree of restoration of blood flow.

A known method for evaluating the reserves of microcirculation of the compressed root and dural sac during surgical removal of a disc herniation in patients with lumbar intervertebral disc herniation by determining volumetric capillary blood flow (ml / min * 100 g) using laser Doppler flowmetry (class 1 infrared laser) before and after decompression (Shevtsov V.I., Schurova E.N., Khudyaev A.T. Importance of intraoperative monitoring of the state of microcirculation of the dural sac and spinal root in the surgical treatment of patients with lower back intervertebral disc herniation // Neurosurgery - 2001. - No. 3. - P.26-30).

However, this method also does not record the blood flow of the entire transverse section of the compressed spinal root and does not measure the blood flow of the cauda equina roots adjacent to the disc-radicular conflict zone, since laser Doppler flowmetry is used for the study, in which the measurement depth is 1 mm and the volume of the tissue under study is no more than 1 cc mm In addition, the limited study area reduces the reliability of assessing the degree of restoration of blood flow in the zone of disco-radicular conflict.

The objective of the invention is to develop a method for assessing the reserves of the microcirculatory bed of the cauda equina roots, which provides an increase in the reliability of the diagnosis of the degree of restoration of blood flow in the zone of disco-radicular conflict.

The problem is solved in that in the method for assessing the reserves of the microcirculatory bed of the cauda equina in patients with lumbar intervertebral disc herniation, including intraoperative study of the blood flow of the spinal roots in the area of the discoradicular conflict before and after decompression, followed by comparison of the studied parameters, the study is performed by ultrasonic doppler , along with the compressed root and dural sac, the adjacent sections of the neighboring horseback roots are examined about the tail, and in cases where after decompression there is an increase in the linear, volumetric and average blood flow rates by at least 30% in all the studied anatomical formations, the preservation of the reserves of the microvasculature is diagnosed.

The implementation of the proposed method is illustrated by the description, the results of practical use and illustrative material, which shows:

Figure 1 - study area of the compressed spine (indicated by an arrow);

Figure 2 - study area of adjacent roots (indicated by arrow).

The method is as follows.

During surgical removal of the lumbar intervertebral disc herniation, after interlaminectomy, the microcirculatory blood flow of the dural sac and horse tail roots is compressed, measured (Figure 1) and adjacent to the cauda equina root disco-radicular conflict zone in the maximum compression zone (Figure 2).

Blood flow is assessed using a Minimax-Doppler-K ultrasound dopplerograph (Minimax, St. Petersburg) using an intraoperative 20 MHz probe (2 mm diameter of the working surface) in the microcirculation study mode. The depth of the location of the 20 MHz sensor is 5.0-8.0 mm, and the calculated value of the maximum volume of the investigated tissue is 7 mm ³ .

Blood flow indicators are measured by sequentially placing an intraoperative ultrasound sensor over a compressed root (1.5-2.0 mm) in the compression zone, then over the adjacent dural sac (1.5-2.0 mm) and the cauda equina roots lying under it, determining linear, volumetric and average blood flow velocity. Measurements are performed before and after decompression.

The obtained data are tabulated, analyzed and with an increase in the indicated blood flow parameters by 30% or more in all the studied anatomical formations - the compressed root, dural sac and adjacent cauda equina roots - the presence of microvasculature reserves is determined (Tables 1 and 2).

Table 1 Compressed root blood flow in patients with lumbar intervertebral disc herniation (group I), having pronounced dynamics after decompression measures (M ± m) Blood flow Stages of observation Before decompression (n = 17) After decompression (n = 17) The growth rate (%) V _{s (cm / sec)} 7.8 ± 0.4 15.0 ± 1.4 * 105.3 ± 20.0 (33 to 254) V _{s (ml / min)} 3.7 ± 0.2 7.3 ± 0.7 * 111.0 ± 10.0 (35 to 239) V _{m (cm / sec)} 3.7 ± 0.4 6.0 ± 0.6 * 80.8 ± 18.5 (43 to 169) PI 1.7 ± 0.2 2.3 ± 0.3 - Ri 0.80 ± 0.04 0.90 ± 0.04 - Note: * - the significance of differences between indicators from the initial level (p≤0.05). V _s - maximum systolic velocity (cm / sec), Q _s - volumetric velocity (ml / min), V _m - average speed (cm / sec), PI - ripple index (Gosling), RI - resistance index (Purselo).

table 2 Blood flow indices of the dural sac and adjacent roots in the area of disco-radicular conflict in patients with lumbar intervertebral disc herniation, with pronounced dynamics (group I) after decompression measures (M ± m) Blood flow Stages of observation Before decompression (n = 17) After decompression (n = 17) The growth rate (%) V _{s (cm / sec)} 9.1 ± 1.2 15.5 ± 1.4 * 108.6 ± 21.4 (32 to 242) Q _{s (ml / min)} 4.3 ± 0.6 7.3 ± 0.7 * 105.6 ± 25.1 (30 to 228) V _{m (cm / sec)} 4,5 ± 0,6 6.9 ± 1.0 * 73.3 ± 22.2 (30 to 167) PI 1.5 ± 0.1 1.9 ± 0.4 - Ri 0.80 ± 0.03 0.86 ± 0.02 - Note: * - the significance of differences between indicators from the initial level (p≤0.05).

The practical use of the method is illustrated by the following clinical observation. Patient A., 27 years old. Diagnosis: Lumbar osteochondrosis of the discs L _3-4 , L _4-5 , L ₅ -S ₁ , II-III period. Paramedian disc herniation L _3-4 on the left. Radicular syndrome L ₄ on the left.

Upon admission to the clinic of the Center, the patient complained of pain in the lumbar spine radiating along the lateral surface of the thigh, lower leg and to the first toe of the left foot. An. morbi: conservative treatment for 4 months without effect. According to computed tomography in the L _3-4 segment, a posterior, median, with lateralization to the left, sequestered hernia of the disc protruding into the spinal canal by 0.9 cm and descending caudally by 1.7 cm is determined.Compression of the root of the L ₄ and dural sac on the left.

The operation was performed - interlaminectomy L _3-4 on the left. Removal of a herniated disc L _3-4 on the left. During the operation, before and after removal of the hernia of the disk, blood flow was measured in the compressed root (L ₄ ), dural sac and adjacent horse tail roots (L ₅ , S ₁ , S ₂ ) (table 3).

Table 3 The results of intraoperative monitoring of the blood flow of the cauda equina roots of patient A., 27 years old. Blood flow Object of study Compressed spine L ₄ Dural bag and adjacent roots Before decompression After decompression Before decompression After decompression V _{s (cm / sec)} 7.5 17.3 7.8 17.1 Q _{s (ml / min)} 3.8 8.2 4.0 8.0 V _{m (cm / sec)} 4.0 5,6 4.2 6.2 PI 1.9 2.9 1.7 3,1 Ri 1,0 0.93 0.84 0.9

After decompression, the blood flow in the compressed and adjacent roots increased. In the compressed spine, linear, volume, and average speeds increased by 131%, 115%, and 40%, respectively, and in adjacent spines, by 119%, 100%, and 47%, respectively. This made it possible to diagnose the presence of a reserve of the microvasculature of both compressed and adjacent horse tail roots. The specified dynamics of blood flow allowed to refuse to conduct courses of complex symptomatic therapy. The patient was discharged with marked clinical improvement.

A comprehensive examination of the patient’s functional state in the immediate (13 days after surgery) and long-term (2 years 11 months after surgery) observation periods showed the presence of positive dynamics. The results of the study are presented in tables 4 and 5.

Table 4 The dynamics of the functional state of the compressed root of a patient A., 27 years old. Indicators Before treatment After treatment Coming period Remote period Thresholds of temperature pain. sensitivity in interested. Dermatome (city) Heat - 42.5 Heat is not Heat - 37.0 Pain - 45.0 Pain - 45.0 Pain - 42.0 MMS indicator muscle group (N * m) 53,2 - 110.0 Assessment of pain (VAS,%) 70 0 0 Note: the threshold of pain is normally 42.4 ± 1.2 ^˚ , the threshold of heat is 34.1 ± 0.6 ^˚

Table 5 The dynamics of the functional state of the adjacent cauda equina roots (L ₅ , S ₁ , S ₂ ) patient A., 27 years old. Indicators Before treatment After treatment Coming period Remote period Thresholds of temperature pain. sensitivity in interested. dermatomes (city) L ₅ L ₅ L ₅ Heat - 36.0 Heat - 38.0 Heat - 35.0 Pain - 45.0 Pain - 44.0 Pain - 43.0 S ₁ S ₁ S ₁ Heat - 36.0 Heat - 41.0 Heat - 33.0 Pain - 43.0 Pain - 45.0 Pain - 40.0 S ₂ S ₂ S ₂ Heat - 33.0 Heat - 35 Heat - 33.0 Pain - 42.0 Pain - 46.0 Pain - 40.0 MMS Shin Muscles (N * m) Tcc 14.6 - 40.8 Pss 54.6 - 93.8 Note: MMS - maximum moment of force, TSS - back flexors of the foot, PSS - plantar flexors of the foot.

In the long-term follow-up period, there was no pain syndrome; the thresholds of temperature-pain sensitivity were within normal limits. The muscle strength of the indicator group of the compressed root increased by 106.8%, of the adjacent horse tail roots (L ₅ and S ₁ ) - by 238% and 72%, respectively.

In general, in the group of patients with positive dynamics (17 patients) the blood flow in the region of the interested compressed root dermatome the threshold of pain sensitivity decreased (by 1-5 degrees) in 67% of patients in the immediate follow-up period after treatment and in 56% of patients in the long-term follow-up period (Tables 6 and 7). The study of the indicator group of muscles of the compressed root revealed that in 75% of cases, the maximum moment of force increased by 62%. In the area of dermatomes of adjacent roots (L ₅ , S ₁ , S ₂ or S ₁ , S ₂ ), temperature and pain sensitivity improved in the immediate follow-up period in 46.3% of patients, in the long-term period - in 83% of patients. The maximum moment of strength of the leg muscles (dorsal and plantar flexors of the foot) in the long-term follow-up period in most patients (80%) increased by 25-30%.

Table 6 Features of the dynamics of functional recovery of the compressed root of patients of groups I and II after removal of the lumbar intervertebral disc herniation (M ± m) Indicators Group I patients (n = 17) II group of patients (n = 11) Before treatment After treatment Before treatment After treatment Coming period Remote period Coming period Is remote
period The threshold of pain is concerned. dermatome (city) 46.8 ± 0.8 42.7 ± 1.9 * 42.0 ± 0.5 * 45.3 ± 0.8 45.0 ± 0.7 47.5 ± 0.3 MMS indicator muscle group (N * m) 62.8 ± 10.4 - 101.8 ± 6.2 * 57.7 ± 10.8 - 48.0 ± 18.1 Assessment of pain (VAS,%) 55.7 ± 8.1 14.2 ± 4.6 * 30.0 ± 9.8 * 51.7 ± 8.3 14.1 ± 5.8 * 46.3 ± 12.4 Δ% - 74.5% - 44.2% - 72.5% - 10.5% Note: * - the significance of differences between indicators from the initial level (p≤0.05). MMS is the maximum moment of force. Δ% - the magnitude of the change, expressed as a percentage. The threshold of pain is normally 42.4 ± 1.2.

Table 7 Features of the dynamics of the functional state of adjacent roots in patients of groups I and II after removal of the lumbar intervertebral disc herniation (M ± m) Indicators Group I patients (n = 17) II group of patients (n = 11) Before treatment After treatment Before treatment After treatment Coming period Remote period Coming period Remote period The proportion of patients with
I have a threshold for pain in dermatomas L ₅ , S ₁ , S ₂ (%) 82.6 ± 5.6 46.3 ± 3.1 83 ± 4.2 79.1 ± 4.2 43 ± 2.9 50 ± 3.8 MMS of the muscles of the leg (N * m) Tss 41.5 ± 3.3 - 52.0 ± 3.9 * 41.2 ± 10.1 - 34.8 ± 6.8 Pss 75.4 ± 10.3 - 100.4 ± 5.2 * 75.3 ± 14.4 - 74.2 ± 11.6 Assessment of pain (VAS,%) 57.7 ± 5.2 9.8 ± 3.3 * 24.2 ± 9.8 * 75.0 ± 10.1 22.5 ± 10.8 * 65.1 ± 10.0 Δ% - 83.0% - 58.0% - 70.0% - 13.0% Note: * - the significance of differences between indicators from the initial level (p≤0.05). MMS - maximum moment of force, TSS - back flexors of the foot, PSS - plantar flexors of the foot. Δ% - the magnitude of the change, expressed as a percentage.

In cases when, after decompression measures, there was no pronounced positive dynamics in the indicators of horse tail root blood flow (Tables 8 and 9) (group II, 11 patients), the absence of reserves of the microvasculature was determined and only a slight improvement in the functional state of the patients was observed.

Table 8 Compressed root blood flow in patients with lumbar intervertebral disc herniation (group II), not having dynamics after decompression measures (M ± m) Blood flow Stages of observation Before decompression (n = 11) After decompression (n = 11) V _{s (cm / sec)} 13.0 ± 1.5 13.1 ± 1.6 Q _{s (ml / min)} 6.2 ± 0.7 6.2 ± 0.8 V _{m (cm / sec)} 8.4 ± 0.9 7.8 ± 1.1 PI 1.6 ± 0.1 1.7 ± 0.1 Ri 0.85 ± 0.03 0.82 ± 0.02

Table 9 Blood flow indicators of the dural sac and adjacent roots in the zone of disco-radicular conflict in patients with lumbar intervertebral disc herniation that do not have dynamics (group II) after decompression measures (M ± m) Blood flow Stages of observation Before decompression (n = 11) After decompression (n = 11) V _{s (cm / sec)} 13.4 ± 2.2 12.9 ± 2.4 Q _{s (ml / min)} 6.3 ± 1.1 6.0 ± 1.1 V _{m (cm / sec)} 6.3 ± 1.7 6.5 ± 1.8 PI 2.0 ± 0.4 2.2 ± 0.5 Ri 0.80 ± 0.06 0.80 ± 0.07

In this group of patients, a decrease in pain sensitivity thresholds (by 2 degrees) in the compressed root spine dermatoma was recorded in the immediate follow-up period in only 33% of cases (Table 6), in the long-term follow-up period the pain sensitivity level returned to its initial state or worsened (increased pain thresholds 2 degrees). The function of the indicator muscle group either remained unchanged or decreased. A decrease in pain sensitivity thresholds in the area of adjacent dermatome dermatomes (Table 7) immediately after surgery was observed in 54.2%, and in the long-term follow-up period, in 50 ± 3.8%. The maximum moment of strength of the leg muscles (dorsal and plantar flexors of the foot) in the long-term follow-up did not significantly change with respect to the preoperative level. It should be noted that in this group the intensity of pain in the long-term follow-up was reduced by only 13% relative to preoperative values.

The data obtained as a result of the study on the presence of a reserve of the microvasculature served as the basis for determining the indications for the courses of symptomatic therapy and recommendations for subsequent treatment.

Using the proposed method in the clinic of FGU "RRC" WTO "them. Acad. GA Ilizarova of Rosmedtekhnologii ”showed that its use provides an increase in the reliability of the diagnosis of the degree of restoration of microcirculatory blood flow in the area of the disk-radicular conflict and can increase the reliability of the degree of prognosis of the improvement of the functional state of patients with lumbar intervertebral disc herniation after surgical treatment, take timely measures for additional symptomatic treatment in the absence of positive dynamics of blood flow.

Claims (1)

A method for assessing the reserves of the horse tail root microvasculature in patients with lumbar intervertebral disc herniation, including intraoperative study of the blood flow of the spinal roots in the area of discordicular conflict before and after decompression, followed by comparison of the studied parameters, characterized in that the study is performed by ultrasonic dopplerography, while the adjacent spine and dural sac are examined with the adjacent areas of adjacent horse tail roots and, in cases if after decompression there is an increase in linear, volumetric and average blood flow velocities by at least 30% in all the studied anatomical formations, the preservation of the reserves of the microvasculature is diagnosed.

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