RU2489110C2 - Method of surgical treatment of muscular dystonia of lower extremities - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to neurosurgery. Selective rhizotomy of spinal cord roots of lumbar enlargement is performed. Additionally carried out is stimulation of terminal filament and if tonic contraction of shin muscles is detected, excision of terminal filament of spinal cord is carried out.

EFFECT: method makes it possible to increase operation effectiveness, which is reached due to detection and transection of radicels, which take part in formation of hyperactive arc of stretch-reflex.

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Description

The invention relates to medicine, namely to neurosurgery and can be used in the treatment of spasticity of the muscles of the lower extremities.

It is known that an increase in muscle tone or spasticity occurs due to many causes, such as stroke, craniocerebral and spinal injuries, cerebral palsy. In patients with muscular dystonia, neuroimaging of the spinal cord often reveals a low location of the cerebral cone - a fixed spinal cord. Clinically, a disease is usually manifested by muscle stiffness, which makes movement difficult; muscle cramps causing severe pain; involuntary crossings of the legs; bone-articular deformities.

Various methods are known for treating muscular dystonia of the lower extremities.

So, conservative methods of treatment include the use of medications - muscle relaxants, physiotherapeutic methods and physiotherapy exercises (Helme R.D. Motion disorders. Chapter 15. Section IV. 3.1.6. In the book: “Neurology” / Ed. M. Samuelsa. - M.: Practice, - 1997. - p. 492-503).

A significant drawback of the use of drugs is that they do not act selectively on the affected muscle, but on all muscles of the body, reducing their tone, which often leads to even greater impairment of motor functions.

Also known is a method of treating muscle dystonia by weakening muscle tone, including injecting type A botulinum toxins (dysport, botox, xeomin, lantox) into the affected muscles, which cause a decrease in pathological muscle tension and relieve pain (Dutikova EM, Lilin E. T. Botulinum toxin type A (dysport) in the treatment of cerebral palsy. M: Farmateka No. 7, - 2007. - p. 37-42).

The disadvantage of this treatment method is the short duration of the drug (3-4 months), after which the level of muscle spasm returns to the original (Baker R et al. Botulinum toxin treatment of spasticity in diplegic cerebral palsy: a randomized, double - blind, placebocontrolled , dose - ranging study. Developmental Medicine Child Neurology 2002; 44: 666-675).

The closest in technical essence to the proposed is a method of surgical treatment of muscular dystonia of the lower extremities by interrupting the arc of the stretch reflex and turning off its afferent link, i.e. by performing selective rhizotomy (Stepanchenko A.Yu. Selective posterior rhizotomy in the treatment of patients with spastic forms of cerebral palsy. Author. Diss. M., 1996, p.6-18).

In the implementation of the known method, one or two arches of the lumbar vertebrae (L _I - L _II ) are removed and the posterior roots of the spinal cord are selected, which are divided into fascicular groups consisting of radicelles at the epiconus level. If they contain afferent fibers involved in the formation of a hyperactive arc of the stretch reflex (tonic muscle contraction occurs in response to stimulation), then the roots giving such "pathological" answers cross. The peculiarity lies in the fact that they stimulate electromyography of conus medullaris nerve roots stimulatory electromyography and record the response to electrical stimulation, and in the absence of an answer, the structure under investigation is evaluated as a terminal thread.

The disadvantages of this method include the fact that the degree of functional improvement is 50-70%, and a relapse of spasticity occurs in 8-10% of cases (Penn RD Medical and surgical treatment spasticity. Neurosurg. Clin. North Am. 1 (3): 719 , 1990. - 27).

The objective of the proposed technical solution is to develop a method for the surgical treatment of muscular dystonia of the lower extremities.

The technical result of the proposed method is to increase the effectiveness of treatment, by identifying the radiocytes involved in the formation of the hyperactive arc of the stretch reflex, and their intersection.

The technical result is achieved by the fact that the method of surgical treatment of muscular dystonia of the lower extremities is carried out by performing selective rhizotomy of the roots of the spinal cord of the lumbar thickening.

Distinctive techniques of the proposed method are that they additionally stimulate the terminal filament and, if a tonic contraction of the calf muscles is detected, excise the terminal filament of the spinal cord.

A comparative analysis of the proposed method and the prototype showed that the claimed method differs from the known above methods. These differences allow us to conclude that the claimed technical solution meets the criteria of the invention of "novelty."

The patent research, as well as the analysis of scientific and medical information that reflects the current level of treatment for muscle spasticity, did not reveal technical solutions having distinctive techniques of the proposed method.

A distinctive technique of the proposed method is the additional stimulation of the terminal thread, which allows to identify a pathological reaction of the muscles of the lower extremities and the pelvic floor (stretch reflex) and is the basis for performing a rhizotomy of the roots of the spinal cord of the lumbar thickening and excision of the terminal thread of the spinal cord. Therefore, the claimed method allows to achieve the technical result seen by the applicant and the authors, namely, to increase the efficiency of surgical treatment of muscular dystonia of the lower extremities, by identifying and intersecting the pathological afferents that are part of the roots of the spinal cord and terminal thread, which are involved in the formation of the hyperactive arch of the strech - reflex. The above allows us to conclude that the proposed method meets the criterion of "inventive step".

The method comprising the claimed invention is intended for use in healthcare. This method can be used in surgery to treat muscular dystonia of the lower extremities. The possibility of its implementation is confirmed by the methods and means described in the application, therefore, the proposed solution meets the criteria of the invention "industrial applicability".

The essence of the proposed method is illustrated by figures 1 and 2. So, figure 1 shows the stage of the rhizotomy, where 1 is a portion of the roots (or radicel) of the pathological afferent, 2 is the root of the spinal cord of the lumbar thickening. Figure 2 is the step of crossing the terminal thread, where 3 is the crossed terminal thread.

The proposed method is as follows. Surgery is performed under general anesthesia. In the position of the patient lying on his stomach, an incision is made of the skin and aponeurosis in the projection of the spinous processes of ThX _II- L _II . The spinous processes and half-arches of the above vertebrae are skeletonized, after which a L ₁ lamectomy is performed. The dura mater is dissected linearly. The arachnoid membrane is removed, the posterior roots under which the rubber strip is brought in for their visualization are isolated. Under the control of electrical stimulation, dorsal selective rhizotomy is performed, i.e. the intersection of 70-80% radiocel (figure 1). A similar part of the operation is performed on the opposite side of the spinal cord. Then, an audit of the spinal space is carried out, sacred roots and terminal thread are identified. After its electrical stimulation and the identification of tonic contraction of the muscles of the legs perform excision of the terminal thread (figure 2). Control of hemostasis. A continuous seam of the dura mater is strengthened with a hemostatic sponge. Stitch in layers on the wound.

The essence of the proposed method for the surgical treatment of muscular dystonia is illustrated by a clinical example.

Patient Sh., 11 years old, was admitted on February 18, 2010 at the Institute of Hygiene and Genital Disorders.

Anamnesis: Sick from birth. Repeatedly underwent inpatient treatment in the neurological department of the ICDCH with a diagnosis of cerebral palsy (cerebral palsy), spastic diplegia (functional insufficiency of the third degree). Complications of the underlying disease: Equinus ankle deformity. Soha valga bilateralis.

CT scan of the brain: internal and external hydrocephalus at the age of 1 year. At the age of 2 years, febrile convulsions were observed once. In March 2003, he was undergoing treatment at the neurological department of the Research Institute of Pediatrics SB RAMS with a diagnosis of cerebral palsy. Last hospitalization in 2005, in the department of orthopedics, surgical treatment was performed - achilloplasty.

Against the background of treatment, positive dynamics were noted, legs began to relax and straighten better. But in 2006, hypertonicity of the muscles of the lower extremities began to increase. Botulinum toxin type A was twice injected (Distoprt 500 IU), after which there was a positive trend in the form of a decrease in spasticity, but after 6 months the muscle tone returned to its original state.

In December 2009, the child was examined by a neurosurgeon and surgical treatment of muscle spasticity of the lower extremities was recommended.

Survey conducted:

1. MRI of the lumbosacral spine and spinal cord (02/25/2010) - a congenital malformation of the spine: Spina bifida L _IV - S _I. Fixed spinal cord.

2. Interference electromyography (ENMG) of the leg muscles on both sides (12/23/2009): there is no spontaneous activity at rest. The interference pattern of maximum physical effort is a curve of sufficient amplitude and frequency, without pronounced signs of asymmetry, which corresponds to type III EMG (Yusevich Yu.S. Essays on clinical electroneuromyography / Yu.S. Yusevich. - M .: Medicine, 1972).

3. Somatosensory evoked potentials from the lower extremities (02.25.10) - In the study of somatosensory evoked potentials from the legs, a distinct peripheral (popliteal fossa), very low amplitude lumbo / sacral component on both sides was recorded; fuzzy cervical / stem on both sides and distinct cortical response components on both sides. There was a delay in the registration of the lumbo / sacral component of the response from two sides; a delay in conducting an impulse along afferent fibers of the sciatic nerves from two sides. Spinal time (L _III - C _V ) and central (C _V / trunk - cortex) impulse conduction times are normal on both sides.

Admission condition: General state of moderate severity, clear consciousness. Weight - 20.5 kg, Height - 147 cm. Well understands the addressed speech, performs some commands, answers questions correctly, emotional tone is reduced; score up to 7; finger counting operations.

Neurological status: The shape of the skull is normal. Cranial nerves: convergence reduced, strabismus inconstant converging on the right.

The motor sphere: active movements are limited in the flexors of the arms, extensors of the legs; with passive movements, muscle hypertonicity of the flexors of the hands, extensors of the legs, more on the left; the range of active movements in the joints is reduced (especially in the ankle joints, the back flexion of the feet from 2 sides is limited), tendon reflexes are high, left above, left foot clonus, live abdominal reflexes, pathological reflexes of Babinsky, Zhukovsky, Rossolimo, Jacobson-Lask with 2 sides. In an upright position, the support on the socks does not stand and walk independently. Meningo symptoms are negative. No pelvic abnormalities.

The operation according to the proposed method for the treatment of muscular dystonia of the lower extremities, including selective dorsal rhizotomy, excision of the terminal thread, was performed as planned.

In the postoperative period, the patient is prescribed antibacterial, vasoactive and symptomatic therapy.

In the early postoperative period, the patient noted a decrease in muscle tone of the lower extremities, an increase in the range of motion in the legs by 45 or more degrees.

To assess the dynamics of the process, a control examination was conducted after 3 months. According to neurophysiological research methods, an increase in the speed of conduction of an impulse along nerves was noted (n. Tibialis dexter et sinister, n. Ischiadicus dexter et sinister). With ENMG before surgery, the conduction velocity along the peroneal nerve on the right is 4.15 ms (with a norm of not more than 3.0 ms), the amplitude of the action potential of the short extensor of fingers is 4.3 mV (with a norm of at least 5.5 mV).

After surgical treatment, an improvement was noted in the form of an approach of speed indicators to the norm along the peroneal nerve on the right 3.57 ms (with a norm of not more than 3.0 ms), an increase in the amplitude of the action potential of a short extensor of fingers 5.0 mV (with a norm of at least 5.5 mV). Accordingly, during stimulation of the peroneal nerve on the left before the operation, a decrease in the amplitude of the indicators of the action of the short extensor of the fingers of the left foot was 2.2 mV (at a rate of at least 5.5 mV); the speed indicators of the impulse conduction along the left peroneal nerve at the level of the foot, lower leg, and knee corresponded to the norm. In the postoperative period, an increase in the amplitude of the action potential of the short extensor of the fingers of the left foot was 4.25 mV (at a rate of at least 5.5 mV).

Clinically marked improvement in gait, relief of voluntary movements, relief of pain in dystonic muscles, social activity.

According to the proposed method, three patients were treated. Good near and long-term results were obtained: muscle spasticity was eliminated, the range of movements in the extremities increased, muscle pains stopped, and the possibility of independent walking appeared. Significant regression of neurological symptoms was achieved in the form of a decrease in tone in the muscles of the lower extremities and, as a result, regression of myogenic contractions. Infectious complications were not observed.

Thus, the proposed method for the surgical treatment of muscular dystonia of the lower extremities in comparison with known technologies allows to increase the effectiveness of treatment due to more complete interruption of the arc of the stretch reflex, and also improves the quality of life of patients and their adaptation in the surrounding world.

The proposed method of treatment can be applied in practical health care, since it does not require exceptional funds for its implementation.

Claims (1)

A method for the surgical treatment of muscular dystonia of the lower extremities, comprising performing selective rhizotomy of the roots of the spinal cord of the lumbar thickening, characterized in that they additionally stimulate the terminal thread and, if a tonic contraction of the leg muscles is detected, excise the terminal thread of the spinal cord.

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