RU2522916C1 - Method of treating diastematomyelia - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: arches and spinous processes are skeletonised at 1-1.5 cm from a median line at the level of the stylosteophyte. When exposing the posterior wall of the spinal canal, medial fragments of the arches and the spinous processes are sawn off en bloc. A junction of the stylosteophyte and the anterior surface of the spinal arch are transected. The fragments of the arches and spinous processes are lifted en bloc, and after the stylosteophyte is removed, this fragment is replaced and fixed after the anterior surface of the spinal arch is processed with a high-speed burr at the level of the stylosteophyte.

EFFECT: primary spinal stabilisation, prevented developing spinal deformity at the level of the intervention, reduced intraoperative injuries.

1 ex, 2 dwg

Description

The invention relates to medicine, namely to neurosurgery, and can be used in the treatment of diastematomyelia.

Closest to the claimed method is a method of treating diastematomyelia (Meacham W.F. Surgical treatment of diastematomyelia // J. Neurosurg. 1967. Vol 27. P.78-85), adopted as a prototype. A midline section provides access to the spinous processes and arches of the vertebrae one or two segments above and below the level of damage. Paravertebral muscles are separated and displaced laterally on both sides. The spinous process and the arc of the vertebra at the level of the location of the bone spine are resected, the dura mater divided by the bone spike is visualized. Laminectomy continues up and down throughout the splitting of the dura mater. The dura mater at the cleavage site is separated from the bone spine, after which the bone spike is resected with nippers to the base located on the front wall of the spinal canal. The dura mater is opened with a longitudinal incision above and below the level of cleavage, intradural fusion is removed, and if necessary, the remaining fragments of the bone spike base are resected. Suturing of the dura mater, layer-by-layer suturing of the surgical wound is performed.

The disadvantages of the method:

- destabilization of the spine, the development of spinal deformity, the syndrome of the operated spine due to a violation of the integrity of the structures of the back support complex at the level of intervention;

- an increased risk of developing liquorrhea in the early postoperative period, the risk of developing re-fixation of the spinal cord at the level of diastematomyelia in the late postoperative period due to a violation of the anatomical relationship of tissues in the area of intervention in violation of the integrity of the posterior wall of the spinal canal;

- high invasiveness of the intervention due to the wide mobilization of soft tissues with dissection of the elements of the ligamentous apparatus of the spinal column, wide skeletonization of bone structures.

The invention is aimed at creating a method for the treatment of diastematomyelia, providing primary stabilization of the spine, prevention of instability, spinal deformity, re-fixation of the spinal cord at the intervention level, and reducing the invasiveness of the operation.

The specified technical result in the implementation of the invention is achieved by the fact that in the known method of treating diastematomyelia, including laminectomy, separation of the bone spike from the dura mater, resection of the bone spike, elimination of intradural fusion, opening and restoration of the integrity of the dura mater, the feature is that when autopsy of the posterior wall of the spinal canal with a single block cut off fragments of the medial sections of the arches and spinous processes of the vertebrae, cross the junction of the thorn and the anterior surface of the vertebral arch, after which, with a single block, the fragments of the arches and spinous processes are lifted, and after removal of the bone spine, this fragment is fixed in place, having previously processed the front surface of the vertebral arch at the level of removal of the bone spike with a high-speed boron. This eliminates diastematomyelia, fixation of the spinal cord, while maintaining the integrity of the spinal canal, provides primary stabilization of the spine, and prevents re-fixation of the spinal cord at the level of diastematomyelia.

The method is as follows. After a cut of the skin and soft tissues, skeletonization of the arches and spinous processes at a distance of 1-1.5 cm from the midline, Liston's pliers and high-speed boron resect arcs at the same level above and below diastematomyelia, dissect the supraspinous, interspinous ligaments at the same level below diastematomyelia, Raise the caudal edge of the fragment of the arches and spinous processes by 1.5-2.0 cm, the bone spike along the front edge of the arc is cut with Liston's pliers and a scalpel, thus separating the bone spike from the fragment of the arches and spinous processes. The resected fragment of arches and spinous processes is raised 80-90 degrees up. Then the bone spike of diastematomyelia is removed with boron and nippers. Dissections are dissected, the dura mater is sutured in front and behind the spinal cord. In this way, the tightness of the dural sac is restored. Palpation revise the front surface of the vertebral arch at the level of elimination of diastematomyelia, and process it with high-speed boron. This eliminates the possible compression of the dural sac by the deformed structures of the posterior support complex while restoring the integrity of the spinal canal. A fragment of the arches and spinous processes is fixed to the spinous process of the underlying vertebra and paravertebral muscles with ligature sutures, and layer-by-layer suturing of the surgical wound is performed.

The inventive method is developed and passed clinical trials at the Russian National Scientific Research Institute named after prof. A.L. Polenova in the treatment of 2 patients with diastematomyelia. As a result of the application of this method, diastematomyelia and fixation of the spinal cord were eliminated, due to correction and restoration of the posterior wall of the spinal canal, the integrity of the spinal canal was preserved, possible instability of the spine, and repeated fixation of the spinal cord were prevented. In the postoperative period, no complications such as signs of instability, compression of nerve structures were noted.

We give an example extract from the medical history.

Patient P., 9 years old, IS No. 2802, was treated with a diagnosis of congenital malformation of the spine and spinal cord, diastematomy at the level of L2 vertebra, subdural lipoma at the level of L2-L3, fixed spinal cord syndrome. The operation was performed: laminectomy at the level of Th12-L3 vertebrae, elimination of diastematomyelia, fixation of the spinal cord, dura mater. Pronation. The cut in the lumbar region is median at the level of the spinous processes of the Th12-L3 vertebrae. Skeletal arches and spinous processes. The medial sections of the arches and spinous processes of L1-L3 are deformed, scarred, there is a sharp deepening of the furrow at the level of L1-L3 and right-sided scoliosis. The medial sections of the arches, the spinous processes and the posterior longitudinal ligament of the Th12-L3 vertebrae were raised in a single block, while a bone spike, 8-9 mm long, 2-3 mm wide, was dissected on the front surface of the L2 vertebral arch. Epidural fiber at the level of L1-L3 is absent, at the level of Th12 it is weakly expressed. At the L2 level, a bone-cartilage spike (dimensions: sagittal - 10-15 mm, transverse - 2-3 mm) the dural sac is divided into two parts, while the left half is slightly wider than the right. The hard shell was opened vertically closer to the median sagittal plane section. Removed subdural lipoma at the L2-L3 level. At the L1-L2 level of the spinal cord, a bone-cartilage spike 15-20 mm long divides the spinal cord into two cords. In this case, the left side is slightly wider than the right. Both cords are covered with a hard shell separating them from the bone spine. The bone spike is resected with nippers and a high-speed boron, has a dense surface structure and a cellular interior. The base of the spike on the back surface of the vertebral body L1 has an oval shape, 22 × 4 mm in size. Located 2-3 mm to the right of the midline (figure 1). After removal of the spike, the hard shell on the front wall of the dural sac was sutured with 5-0 interrupted sutures. The front surface of the spinal cord with multiple coarse scars is soldered to the TMT. The roots of the spinal cord have a horizontal course, thinned, ischemic, deformed in rough scars. Cords of the spinal cord at the level of diastematomyelia are thickened, have a dense texture, are covered with a thickened soft membrane, poor in the vascular network. Below the level of diastematomyelia, both cords connect at the level of the middle of the body L3. At this level, the spinal cord is flattened, pale. The lower edge of the spinal cord is located at the level of L5-S1 vertebrae. After myeloradiculolysis and elimination of fixation, the spinal cord spontaneously shifted vertically by 2-3 cm, the roots acquired a downward course. Hemostasis. Plastic TMT artificial shell. An audit was performed, processing by a high-speed boron of the front surface of the vertebral arch L2. Fragments of the arches and spinous processes are laid in place, fixed by interrupted sutures (Fig.2). Layered suture of the wound.

In the early postoperative period, signs of instability, compression of nerve structures were not observed. The patient is vertical on the fourteenth day after the operation, symptoms of re-fixation of the spinal cord were not observed.

Claims (1)

A method of treating diastematomyelia, including laminectomy, separation of the bone spike from the dura mater, resection of the bone spike, opening and restoring the integrity of the dura mater, characterized in that when opening the posterior wall of the spinal canal, fragments of the medial sections of the arches and spinous processes are cut with a single block, they cross the site connection of the bone spine and the anterior surface of the vertebral arch, after which, with a single block, the fragments of the arches and spinous processes are raised, and after removal of the bone spine fragment from fixed in place, pre-treating a high-speed bur front surface of the vertebral arch at the level of removal of bone spike.

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