RU2531927C2 - Method for spinal canal repair accompanying lumbosacral stenosis - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to neurosurgery in bilateral compression lumbosacral stenosis, including multisegmental one. The method involves skeletonising an interspinous space in a projection of the maximum constrictive process. A separated spinous process of the vertebra is conditionally divided into three parts - distal, middle and proximal. An apex of the spinous process of the vertebra is dissected away counter-laterally in a horizontal plane at the boundary between the distal and middle parts. The muscles attached to a base of the spinous process of the vertebra are skeletonised from the opposite side. Central and lateral regions of the spinal canal are extended with preserving the facet joints from both sides. A hypertrophied portion of the yellow ligament is layered and incised from the stenosis to the dural sac with preserving supraspinous and interspinous ligaments. A posterior wall of the spinal canal is repaired. The pre-dissected apex of the spinous process of the vertebra is fixed to the muscular-ligamentous apparatus from the homolateral (operated) side.

EFFECT: method preserves natural biomechanics of the operated lumbosacral stenoses by avoiding coarse injuries of the musculoligamentous posterior support structures of the vertebra, and prevents recurrent stenosis.

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Description

The present invention relates to medicine, namely to neurosurgery, and can be used in the surgical treatment of bilateral stenotic degenerative compression lesions of the lumbosacral spine.

The mechanical causes of radicular syndrome are narrowing of the spinal canal and intervertebral foramen due to both static (disc herniation, ligament hypertrophy, narrow canal, osteophytes, thickening of the capsules of the intervertebral joints), and dynamic stenosis (due to instability), or a combination of them [1, 2 ].

A known method of osteoplastic laminotomy in a single unit [3], including a longitudinal section along the midline over the spinous processes of the skin, thoracolumbar fascia, supraspinatus ligament. Sequential layer-by-layer skeletonization of the spinous processes and plates of the vertebral arches, the formation of a single bone-ligamentous block, for which, in the region of the upper edge of the most cranial and lower edges of the caudal vertebral arches, a yellow ligament is cut from both sides. Then, along the entire length of the incision, platelets of vertebral arch are successively dissected bilaterally, and by pulling the laminotomy bone-ligamentous block, held by the supraspinatus, interspinous and yellow ligaments, pulling over the superior spinous process, these ligaments intersect at the level of the cranial border. The resulting non-free bone-ligamentous laminotomized single block, which remained fixed in the wound at its caudal end due to the supraspinatus and interspinous ligaments, is bent down and to the side, opening the surgical field. Then, the back wall of the spinal canal is restored by laying the laminated tomo-ligamentous block in place and fixed, starting from the caudal end of the wound, with 8-shaped sutures with silk threads sequentially on each side of the layer-by-layer wound closure.

The disadvantages of this method are: the lack of adequate expansion of the spinal canal and the associated complexity of intracanal manipulations, the impossibility of action on the intervertebral disc, as well as a predisposition to the development of long-term spinal instability.

Closest to the proposed one is a method for reconstructing the spinal canal for approaching the spinal cord, representing a osteoplastic laminectomy in single blocks [4], which includes dissecting the posterior wall of the spinal canal with longitudinal parallel sections along the articular processes while maintaining their integrity. In this case, the arches are dissected in an oblique-frontal plane near the articular processes, the posterior wall of the vertebral canal is cut from below or above with the formation of mobile P-, H-, or C-shaped flaps on the legs, consisting of vertebral arches, spinous processes and ligaments (in t .h. yellow - on both sides), with their leading up, down or to the side. After performing intracanal manipulations on the spinal cord, P-, H-, or C-shaped flaps on the legs are put in place, and the vertebral arches are fixed with transosseous sutures or bone nails, and the ligaments are fixed with nodal sutures. The postoperative wound is sutured without osteoplastic fixation of the spine.

However, the known method for the reconstruction of the spinal canal in the surgical treatment of stenotic lesions of the spine has significant drawbacks, namely: limiting the visualization zone of the nerve structures and intervertebral discs due to the insufficient volume of decompression of the spinal canal, and (but despite this) access is significantly traumatic for muscular -ligamentous apparatus of the operated vertebral-motor segment and contributes to the violation of the biomechanics of the operated vertebral-motor gmenta (PDS).

Based on the analysis of known sources of information that reveal the features of spinal canal reconstruction during surgical treatment of stenotic compression lesions of the lumbosacral spine, as well as eliminate the disadvantages of known technologies, the task was set to completely eliminate spinal stenosis due to the full and minimally traumatic expansion of the spinal canal stability and flexibility of the spine in the postoperative period with bilateral localization of the patho ogicheskogo process by eliminating the intersection nadostistoy, interspinous ligament and yellow, as well as the lack of rough skeleting interspinous gap with maximum preservation of the opposite access soft tissue.

The task of the proposed "Method of reconstruction of the spinal canal in the treatment of stenosis of the lumbosacral spine" is solved as follows.

Reconstruction of the spinal canal in the treatment of stenosis of the lumbosacral spine includes skeletonization of the interspinous gap in the area of the stenotic process, dissection of the vertebral arches, mobilization of the posterior wall of the spinal canal, intracanal manipulations and restoration of the integrity of the posterior wall of the spine. New in the proposed method is that they produce unilateral skeletonization of the interspinous gap in the projection of the maximum stenosing process. Then, during transspinous access to the spinal canal, the selected spinous process of the vertebra is conditionally divided into three parts - the distal, middle and proximal, and the apex of the spinous process of the vertebra is cut off counter-laterally in a horizontal plane at the boundary between the distal and middle parts. Then, additionally skeletonize the muscles that attach to the base of the spinous process of the vertebra, on the opposite side. They expand the central and lateral zones of the spinal canal, preserving the arcuate joints of the vertebrae on both sides, exfoliate and excise the hypertrophied part of the yellow ligament on the side of the stenotic process to the dural sac, preserving adjacent ligaments of the supraspinous and interspinous, and restore the posterior wall of the spinal canal. The previously cut stump of the apex of the spinous process of the vertebra is fixed to the muscular-ligamentous apparatus of the ipsilateral (operated) side.

Explain the salient features of the proposed method.

Access to the spinal canal by unilateral skeletonization of the interspinous gap (even with bilateral localization of the pathological process) allows to reduce postoperative pain vertebrogenic syndrome and improve the quality of life of patients in the postoperative period by limiting surgical aggression, keeping most of the paravertebral structures intact, on the one hand, and reducing trophic disorders of the ligamentous apparatus and muscle tissue, since there is no direct damage to them denia.

Transspinal access to the spinal canal with a cut of the apex of the spinous process of the vertebra is contralateral in the horizontal plane is necessary for: minimally traumatic access to the spinal canal while maintaining supportability of the paravertebral muscles; the maximum possible visualization of neural structures without deficiency of intracanal manipulations (not only the dural sac, but also the cuffs of the spinal roots).

Conditional division of the spinous process of the vertebra into 3 parts (distal, middle and proximal) is necessary for a more accurate approach to the cut of the tip of the spinous process of the vertebra, taking into account the individual characteristics of the bone structure. The defined boundary between the distal and middle third, taken as a guideline for resection of the apex of the spinous process of the vertebra, is a necessary site for adequate restoration of the posterior supporting complex.

Performing microsurgical reconstruction of the spinal canal while preserving the arcuate joints of the vertebrae on both sides, stratification and excision of the hypertrophic part of the yellow ligament on the side of the stenotic process to the dural sac, while maintaining adjacent ligaments supraspinous and interspinous, minimizes postoperative biomechanical disturbances, and prevents secondary compression of neural structures. And also to provide the widest possible reconstruction of the spinal canal with the ability to visualize not only the dural sac, but also the cuffs of the spinal roots and intervertebral discs.

The restoration of the posterior wall of the spinal canal with fixation of the previously cut stump of the apex of the spinous process of the vertebra to the muscular-ligamentous apparatus of the ipsilateral (operated) side allows restoring the stability of the posterior supporting complex, realizing the possibility of early activation of patients and eliminating the need to install stabilizing structures.

Patent studies and analysis of scientific and medical information reflecting the current level of technologies for surgical treatment of stenotic lesions of the lumbosacral spine, namely, access to the spinal canal with its reconstruction, did not reveal methods that are identical to the proposed one. In this connection, we can conclude that the claimed technical solution meets the criteria of the invention of "novelty."

The sequence and interconnection of the methods of the proposed method ensure the achievement of a new technological medical result in solving the problem, namely:

- Extensive reconstruction of the spinal canal, preventing re-stenosis at the operational level.

- Full visualization of nerve structures (dural sac and spinal roots) and intervertebral disc.

- Reducing the morbidity of access due to the absence of gross damage to the paravertebral muscles and ligaments on one side of the spinal canal.

- The ability to preserve natural biomechanics, prevent the formation of instability in the operated vertebral-motor segments (PDS) and eliminate the need for the combined use of stabilizing structures due to minimally invasive reconstruction while maintaining the back supporting structures (adjacent supraspinatus and interspinous ligaments) and facet joints.

From the foregoing, it follows that the claimed method meets the criteria of patentability "inventive step".

The proposed method for the reconstruction of the spinal canal is intended for use in healthcare and can be used in neurosurgery. 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 for the reconstruction of the spinal canal in the treatment of stenosis of the lumbosacral spine is illustrated by drawings, which show:

Figure 1 - one-sided abduction of paravertebral muscles; conditional division of the spinous process of the vertebra into 3 parts (distal, middle and proximal), the red line shows the cutoff level of its apex - the border between the distal and middle third;

Figure 2 - cut the tops of the spinous process;

Figure 3 is a view of the formed bone window;

Figure 4 is a view of the sutured postoperative wound.

To clarify the above figures, we present a breakdown of the positions in the figures presented in the appendix to the description of the application:

1 - intervertebral disc;

2 - spinous process;

3 - paravertebral muscles;

4 - a dural bag.

The essence of the proposed "Method of reconstruction of the spinal canal in the treatment of stenosis of the lumbosacral spine" is as follows.

After processing the surgical field with an antiseptic solution, under intravenous anesthesia using mechanical ventilation (mechanical ventilation), in the position of the patient “lying on his stomach” with discharge rollers under the chest and pelvis, a longitudinal incision is made of the skin and subcutaneous fat in the projection of the spinous processes of the vertebrae in the field of stenosing process. Unilateral skeletonization of the interspinous gap is performed depending on its maximum narrowing or more pronounced neurological symptoms (see the appendix to the description, FIG. 1). Then, using a high-speed drill, a trans-spinous approach to the spinal canal with a cut of the apex of the spinous process of the vertebra is performed contralaterally in the horizontal plane (see the appendix to the description, Fig. 2). Before cutting, the spinous process of the vertebra along its length is conventionally divided into 3 parts (distal, middle and proximal), the border between the distal and middle parts is a guide for resection of the apex of the spinous process of the vertebra (see the appendix to the description, Fig. 1). Subsequently, with the help of the end nozzle, microsurgical reconstruction of the spinal canal is performed, expanding the central and lateral zones of the spinal canal, preserving the arcuate joints of the vertebrae from two sides (see the appendix to the description, Fig. 3). If it is damaged, the identified yellow ligament is stratified and excised using a neurotome, conchotome, and / or pistol nippers in the area where its hypertrophy is determined. If the yellow ligament is not changed, then only its mobilization from the underlying bone is carried out. Pistol nippers produce bilateral foraminotomy. Unilateral access to the spinal canal and its reconstruction allow revision of the dural sac and spinal roots from two sides, eliminating stenotic lesions of the spinal canal and the cause of disco-radicular conflict. Subsequently, the posterior wall of the spinal canal is restored with fixation of the stump of the apex of the spinous process of the vertebra to the muscular-ligamentous apparatus of the ipsilateral (operated) side using 2-3 ligatures (see the appendix to the description, Fig. 4). The wound is washed with an antiseptic solution, stitches are applied layer by layer to the wound and aseptic dressing.

The essence of the proposed method is illustrated by an example of a specific implementation.

Patient A., born in 1948, was hospitalized in the neurosurgical department of the NIH Road Clinical Hospital at the station Irkutsk-Passenger JSC "Russian Railways" 12/19/2011 with complaints of severe pain in the lumbosacral region that occur during dynamic loads; radiating to both buttocks, along the antero-lateral surface of both thighs, legs, with a projection into all fingers of both feet, more to the right, aggravated by coughing, sneezing. Numbness in the area of pain. Weakness in both lower limbs, appearing after a long walk.

The patient is sick for about 25 years, with annual exacerbations in an amount of 5 times. Conservative treatment for 3 months is ineffective.

Neurological examination: cranial nerves and upper limbs are intact. It occupies an antalgic position. Walks with one crutch, limps on his right leg. Lumbar lordosis is smoothed. Movements in the lumbosacral spine are sharply painful, blocked. Symptom of Lasegue D = 40 *, S = 55 *. Knee reflexes D <S, Achilles reflexes: D => S. Defense of paravertebral muscles of the III century There are no pathological reflexes. Muscle tone in the hands is normal; in the legs (distal parts of the right lower limb) - paresis of the extensors of the right foot. Sensitivity disorders in the form of hypesthesia spots along the L4, L5 roots on both sides. Pelvic abnormalities are absent.

When conducting a march test with a load (performing 10 squats), a progression of neurological deficit was revealed with an expansion of the polyradicular hypesthesia zone, loss of knee reflexes on both sides, increased tension symptoms - from the right from 30 ° to the left from 40 °.

Examination completed: MPT of the lumbosacral spine. Conclusion: Osteochondrosis of the lumbosacral spine, 2-3 period. Central protrusion of the discs L _II- L _III 4.5 mm, L _III- L _IV 5.0 mm, L _IV -L _V up to 6.5 mm. Against the background of severe hypertrophy of the arched joints at the level of L _III -L _IV , L _IV -L _V on both sides.

Electroneuromyography of the lower extremities: a decrease in the amplitude of the maximum M-response during stimulation of the tibial and peroneal nerves on both sides, more to the right.

Lumbar spondylography with functional tests: Osteochondrosis of the lumbosacral spine. No signs of instability were detected.

Diagnosis: Vertebrogenic syndrome. Aggravation. Osteochondrosis of the lumbosacral spine. Disc protrusions L _II -L _III , L _III -L _IV , L _IV -L _V. Degenerative spinal stenosis at the level of L _III -L _IV , L _IV -L _V due to hypertrophy of the yellow ligament and arthrosis of the arched joints. Radiculoneuritis L4, L5 on both sides. Lumbar ischialgia syndrome on both sides, more on the right. Caudogenic intermittent claudication syndrome. Severe recurrent pain and muscle-tonic syndromes.

Given the data of clinical and neurological examination, the results of additional research methods, severe pain syndrome resistant to conservative therapy, the patient is shown surgical treatment in volume - reconstruction of the spinal canal at the level of L _III- L _IV , L _IV -L _V , with partial resection of the medial sections arched joints. Given the absence of signs of instability and the need for stabilization of the PDS (spinal motion segment), it was decided to perform minimally invasive reconstruction of the spinal canal with right-side access through the spinous process of the vertebra.

Performed a microsurgical reconstruction of the spinal canal at the level of L _III -L _IV , L _IV -L _V , from the right transspinal access with partial resection of the arched joints L _III -L _IV , L _IV -L _V from two sides according to the claimed method. Meningoradiculolysis, foraminotomy for L4, L5 roots on two sides.

Under intravenous anesthesia using artificial lung ventilation (IVL), in the position of the patient “lying on his stomach” with unloading rollers, after treating the surgical field with an antiseptic solution, a longitudinal incision was made in the skin and subcutaneous fat in the projection of the spinous processes of L _III , L _IV vertebrae. Under the intraoperative control of the image intensifier, the position and direction of the bone structures described above are determined. Produced unilateral (left-side) skeletonization of interspinous spaces L _III -L _IV , L _IV -L _V. Using a high-speed drill, transspinous access was made with a horizontal saw cut of the apex of the spinous process of the LIV vertebra to the right (contralateral), muscles were additionally skeletonized in the region of the base of the spinous process of the L _IV vertebra on the right. Using the end cap, a microsurgical reconstruction of the spinal canal was performed with resection of the medial sections of the arcuate joints of the L _III , L _IV , L _V vertebrae from two sides, but with the preservation of their integrity. The identified yellow ligament is stratified, with the help of a neurotome, conchotome and pistol nippers, its hypertrophic sections on both sides are removed. The spinal canal was revised with foraminotomy along the L4, L5 roots on both sides. The mobility of the dural sac and spinal roots at the indicated levels has been fully restored; no signs of ongoing compression have been detected. Remodeling of the spinal canal has led to the absence of the need for manipulation of the intervertebral discs. Microsurgical hemostasis of epidural veins. The restoration of the posterior wall of the spinal canal with fixation of the stump of the spinous process of the LIV vertebra to the muscular-ligamentous apparatus of the ipsilateral (operated) side was performed using 3 ligatures. Layered closure of the wound, aseptic dressing.

In the postoperative period was carried out: antibacterial, symptomatic, vasoactive, vitamin therapy, exercise therapy, massage, dressings, a course of hyperbaric oxygenation.

At discharge, the patient's condition is satisfactory. In neurological status, insignificant muscular-tonic syndrome and mild hypesthesia along the L4, L5 roots on both sides were preserved, there was no weakness of the extensors of the right foot. When assessed by YOUR (visual-analogue pain scale), the level of pain was 6 mm, which corresponds to the minimum value.

3 months after the operation, a control objective and clinical examination of a neurological deficit was not detected, there was no pain syndrome, and working capacity and quality of life were restored. The patient began his previous career with access to control a tower crane.

Using the proposed method, 4 patients with 2- and 3-level stenosing compression lesions of the lumbosacral spine were operated on.

Pain syndrome, assessed by the visual analogue pain scale (VAS), decreased significantly after surgery in all patients. A follow-up examination after 3 and 6 months after surgery in all patients showed no progression of the degenerative process with the formation of hernias of the intervertebral discs, the appearance of segmental instability and worsening neurological symptoms. To study the range of movements in the operated spine, the method of functional spondylography was used. When analyzing the X-ray data, at the time points marked by the protocol, there were no signs of hypermobility or instability in the operated and adjacent to the operation PDS.

The quality of life, assessed on the Oswestry scale from the preoperative level of 70 (40; 80) points, significantly improved after surgery and by 6 months of follow-up was 15 (10; 18) points (P _w <0.001). Blood loss was 100 (60; 115) ml. The operation time when performing the proposed method was 90.7 (78; 110) minutes, which is significantly less compared to performing such operations by known methods. After performing the operation of the claimed method, patients are activated on the second day and can be allowed to go home on days 8–9, which is also significantly less than with known methods. The duration of inpatient treatment of patients operated on by the claimed method was 9 days (8; 10), which is statistically significantly less than with the decompressive laminectomy method - 12 (11; 14) days and the decompression-stabilizing method - 11 (10; 13) days performed by the same operating team (p = 001). Operated according to the proposed methodology, patients returned to their previous labor activities on average within 80 (65; 85) days after surgery. While after decompression laminectomy and decompression-stabilizing technique, labor rehabilitation looked as follows: 45% returned to their work after 90 days, 20% - after 180 days, 35% - after 240 days after surgery.

The proposed “Method for the reconstruction of the spinal canal in the treatment of stenosis of the lumbosacral spine” made it possible to eliminate the narrowing of the spinal canal and minimize conditions for the necessary manipulations on the spinal cord with unilateral access to the focus of the stenotic process, to restore the quality of life, labor and social adaptation of patients. In the distant postoperative period, there was no need for additional decompression or decompression-stabilizing interventions on the operated vertebral-motor segment.

Information sources

1) Etebar S., Cahill D.W. Risk factors for adjacent-segment failure following fixation with rigid instrumentation for degenerative instability. // J Neurosurg. - 1999 Apr. - Vol. 90. Suppl. 2. - P.163-169.

2) Hansraj K.K., O'Learly P.F., Camissa F.P. Jr., et al. Decompression, fusion, and instrumentation surgery for complex lumbar spinal stenosis // Clin. Orthop.Relat. Res. - 2001 .-- Vol. 384. - P.18-25.

3) Raimondi A.J., Gutierrez E.A., Di Rocco C. // J. Neurosurg (P.555-560). - 1976. - Vol. 45.

4) Patent RU No. 2142748, A61B 17/56, dated 01.30.96, publ. 12/20/1999.

Claims (1)

A method of reconstructing the spinal canal in the treatment of stenosis of the lumbosacral spine, including skeletonization of the interspinous gap in the stenotic process, dissection of the vertebral arches, mobilization of the posterior wall of the spinal canal, performing intracanal manipulations, restoring the integrity of the posterior wall of the spine, characterized in that they perform unilateral skeletonization of the interspinous gap in the projection of the maximum stenosing process, then during the implementation of transspinosis After access to the spinal canal, the selected spinous process of the vertebra is conventionally divided into three parts - the distal, middle and proximal, the tip of the spinous process of the vertebra is cut off contralaterally in the horizontal plane at the boundary between the distal and middle parts, after which the muscles attaching to the base of the spinous process are additionally skeletonized vertebra from the opposite side, expand the central and lateral zones of the spinal canal, preserving the arcuate joints of the vertebrae on both sides, vayut excised and hypertrophied ligamentum flavum part of stenotic process on the side to the dural sac, ligaments adjacent retaining nadostistuyu and interspinous and reduced back wall of the spinal canal, previously severed stump fixing apex vertebra to the spinous process of the musculo-ligamentous apparatus ipsilateral (operated) side.

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