RU2536715C1 - Method of treating spinal arachnoidite and arachnoid cysts - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: spinal canal is decompressed; dura mater (DM) is exposed; sub-arachnoid adhesions and cyst walls are dissected until the sub-arachnoid spaces are reconstructed, and the DM is sutured together. The limited spinal cysts or single adhesions are approached directly above the compression point. The extended arachnoid cysts are approached in the central portion of the cyst with the skin and soft tissues are incised in a projection of the spinal segment of interest. After the visible sub-arachnoid adhesion are dissected, an ultra-fine flexible endoscope having a working surface of 2.8mm is inserted into the dorsal and/or ventral space of the dorsal space; the adhesions and cyst walls with the use of manipulators; cerebrospinal fluid space patency is restored, and the sub-arachnoid space is inspected widely in the cranial and caudal directions.

EFFECT: method enables reducing the therapeutic injuries of the spinal arahnoidite and arachnoid cysts and reducing postoperative complications that is ensured by a sparing technique of dividing scars and adhesions.

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Description

The invention relates to medicine, in particular to neurosurgery, and can be used for the surgical treatment of adhesive spinal arachnoiditis and arachnoid cysts.

Spinal arachnoiditis is more often localized in the thoracic and lumbar regions and in the region of the cauda equina. Four clinical forms of spinal arachnoiditis are distinguished: 1) radicular-sensitive; 2) motor-spinal; 3) radicular-spinal or mixed; 4) radicular-posterior [Polishchuk N.E., Korzh N.A., Fischenko V.Ya. Damage to the spine and spinal cord (mechanisms, clinic, diagnosis, treatment). - Kiev: Book Plus, 2001. - 388 p.].

With spinal arachnoiditis, acute, subacute and chronic flow patterns are possible. Acute spinal arachnoiditis is most characteristic of patients with severe systemic infections, such as sepsis and bacterial meningitis, and it proceeds severely, accompanied by hyperthermia, fever, acute phase response phenomena, in the most difficult situations complicated by hemorheological disorders, multiple organ failure, etc. Neurological symptoms develop rapidly, sometimes within a few days and even hours, and are in the nature of acute transverse myelitis with rough conduction symptoms. Subacute spinal arachnoiditis also proceeds against infections, however, it is more latent, developing over a period of months, against a background of normal or subfebrile temperature. In neurological status, radicular syndromes come first in the first place, and conduction symptoms join later. In chronic spinal arachnoiditis, a clear infectious agent often cannot be determined, and the disease itself progresses very slowly; gradually increasing phenomena of spastic and afferent paresis, as well as pelvic disorders [Di leva A, Barolat G, Tschabitscher M, et al. Lumbar arachnoiditis and thecaloscopy: brief review and proposed treatment algorithm., Cent Eur Neurosurg., 2010 Nov; 71 (4): 207-12].

As for arachnoid spinal cysts, they can clinically resemble an extramedullary tumor, which before the widespread introduction of neuroimaging sometimes led to diagnostic errors. Arachnoid cyst is manifested by slowly progressing conduction disorders, circulatory disorders, somewhat less radicular symptoms, usually corresponding to the localization of one of the adhesions that make up the cyst wall. [Warnke JP, Mourgela S. Endoscopic treatment of lumbar arachnoiditis. Minim Invasive Neurosurg., 2007 Feb; 50 (l): l-6].

Conservative treatment of spinal arachnoiditis and arachnoid cysts is used in the form of antibiotics, urotropin, iodine preparations, autohemotherapy, tissue therapy, air injection into the subarachnoid space. Surgical treatment takes first place, especially with limited cystic arachnoiditis. The main goal of operations with arachnoiditis is the removal or separation of the membranous adhesions, scars, cysts that press on the brain tissue or cause disturbances in the circulation of cerebrospinal fluid. Operations with spinal arachnoiditis are indicated in the presence of compression of the spinal cord, as well as with increasing motor, sensory disturbances and radicular pain associated with a limited adhesive process or with the formation of cysts. Surgical interventions for arachnoiditis are also indicated for the ineffectiveness of conservative therapy in the chronic or residual stage of the inflammatory process.

To date, there is a known method for the surgical treatment of spinal arachnoiditis and arachnoid cysts by laminectomy, while the dura mater is opened, subarachnoid commissures are separated to restore patency of the subarachnoid spaces (SP), cysts are emptied with mandatory careful suturing of the hard membrane. (Neurotraumatology. Handbook. Edited by A. N. Konovalov, LB Likhtman, A. A. Potapov, M., Phoenix, 1994, p. 5-7). However, this technique is invasive and traumatic. In addition, in the postoperative period, complications often arise in the form of an outbreak of a dormant infection, which can then lead to myelitis and the formation of repeated fusion of scars and adhesions.

The technical result of our proposed method is minimal invasiveness and trauma of the treatment of spinal arachnoiditis and arachnoid cysts and reduction of postoperative complications due to the most sparing technique of separation of scars and adhesions.

The technical result is achieved by the fact that for the treatment of spinal cystic arachnoiditis, decompression of the spinal canal, opening of the dura mater, dissection of the subarachnoid adhesions and walls of the cysts to restore patency of the subarachnoid spaces, followed by suturing of the dura mater, and after dissection of the visible subarachnoid and adhesions to the dorsa the ventral space of the dural sac is injected with an ultra-thin flexible endoscope with a working channel with a diameter of 1.2 mm and a diameter 2.8 mm of the working surface, the adhesions and walls of the cysts are separated using its manipulators, they restore the patency of the cerebrospinal fluid spaces and carry out a wide audit of the subarachnoid space in the cranial and caudal directions.

The method is as follows.

For the treatment of spinal arachnoiditis and arachnoid cysts, for the first time in domestic neurosurgery, we used the method of tecaloscopy. Thecaloscopy (thecaloscopy) is a minimally invasive surgical procedure based on the introduction of a flexible endoscope into a dural sac. For this, a flexible endoscope (fibroscope) manufactured by Karl Storz (Germany) is used. Figure 1 shows a general view of the endoscope. The length of two possible configurations of the endoscope is 40 cm and 70 cm, respectively. The latter option is enough to conduct a complete audit of the entire subarachnoid space from the roots of the cauda equina to the craniovertebral transition in an adult patient. The fiberscope is compatible with a standard endoscopic stand.

To control on the basis of the fiberscope, a manipulator is provided, which makes it possible to bend its distal part up to 270 degrees in two directions. This function allows for full visualization and revision of the ventral and dorsal subarachnoid spaces. The diameter of the working surface is 2.8 mm, while it has a light source, a video camera for broadcasting the image, and 1 working channel with a diameter of 1.2 mm (Fig. 2a, b). This channel is used for irrigation during surgical intervention, as well as for the introduction of manipulators under the control of vision, allowing to separate commissures and take a biopsy.

Intervention is carried out in the position of the patient lying on his stomach. Since tecaloscopy is a minimally invasive intervention, it can be performed both under endotracheal anesthesia and in conditions of local infiltration anesthesia with puncture access. In the case of surgery on the upper cervical spine, the patient's head is rigidly fixed with a Mayfleld bracket. An endoscopic stance is located opposite the operating surgeon. Intraoperative fluoroscopy is also used.

According to the principles of minimally invasive surgery, access should be as small as possible, but fully consistent with the objectives of the intervention. In accordance with this, various tactics of operational access are possible.

With limited spinal cysts or solitary adhesions, access is carried out directly above the compression site, which allows microsurgical excision of adhesions. Figure 3 shows delimited spinal adhesive arachnoiditis at the Th3 level. Figure 4 shows microsurgical adhesiolysis before the tecaloscopic stage of surgery.

With extended arachnoid cysts, access is carried out in the central part of the cyst. This allows you to equally conveniently manipulate the endoscope in both the cranial and caudal directions. Figure 5 shows an extended arachnoid post-traumatic cyst at the level of Th9-Th11.

When using open access, in accordance with the chosen tactics, under the control of intraoperative radiography, an incision is made of the skin and soft tissues in the projection of the necessary segment of the spinal cord. Spinous processes and vertebral arches are skeletonized at an interested level. Next, an economical bone resection is performed, which is typically limited to the arch of one vertebra (which corresponds to a skin incision of 5-7 cm). The section length of the dura mater often does not exceed 2 cm. Effective hemostasis (including using modern hemostatic materials) is of fundamental importance, since even minimal bleeding makes endoscopic imaging difficult.

After microsurgical dissection of visible adhesions and cyst walls, the main stage of surgical intervention is performed - tecaloscopy. The fiberscope is inserted into the dorsal subarachnoid space and / or into the ventral space by bending the distal end of the instrument with a manipulator (Fig. 6). If necessary, the position of the endoscope is monitored using an electron-optical converter. Manipulations for the separation of adhesions and fenestration of cysts are carried out by manipulators. All manipulations during thecaloscopy are carried out smoothly, without the use of force, in order to avoid a pronounced traction of the spinal cord and an increase in neurological symptoms. Bleeding, the source of which can be vessels of the arachnoid membrane, often pathologically altered, is stopped by prolonged irrigation with saline. In our practice, there was no significant bleeding in volume and duration. A semiconductor diode laser is also used to coagulate vessels.

In some cases, an airtight seam of the membrane is not enough and plastic surgery of the dura mater (TMT) is necessary, including with the use of collagen grafts.

Twenty-nine patients were operated on, of which 17 were for adhesive spinal arachnoiditis (8 for delimited forms, 9 for diffuse forms), 12 for spinal arachnoid cysts (7 for post-traumatic, 5 for idiopathic). Surgery for cystic and adhesive processes included the dissection of visible adhesions and cyst walls, then the insertion into the dorsal and / or ventral space of the dural sac of an ultrathin flexible endoscope with a working channel 1.2 mm in diameter and 2.8 mm in diameter, and tecaloscopic separation of adhesions, fenestration of the walls of cysts and exploration of the subarachnoid space is more caudal and cranial than the operative access site. The median follow-up was 11.4 months. Regression of neurological symptoms was noted during follow-up examinations in 87% of patients operated on for cystic-adhesive processes; the average improvement was 1.4 points on the modified Frankel scale and 1.8 points on the Ashworth scale (Fig. 7).

Fig. 7 shows the results of a follow-up examination of patients (average follow-up 11.4 months): a - modified Frankel scale (improvement of motor function by an average of 1.4 points) *; 6 - Ashworth scale (decrease in spasticity in the limbs by an average of 1.8 points) **.

* Modified Frankel scale: A (complete lesion) - motor functions and sensitivity below the lesion level are absent; B (sensitivity only) - partially retained sensitivity below the level of damage, no arbitrary movements; C - (minimal motor functions) - the preservation of motor functions with a significant reduction in strength to 2 points; D (motor functions preserved) - the preservation of motor functions below the level of damage with a strength of more than 3 points; the patient can move with or without it; E (normal functioning) - normal motor function and sensitivity.

** Modified Ashworth scale: 0 - no increase in tone; 1 - a slight increase in tone, felt when bending or unbending a segment of a limb in the form of slight resistance at the end of the movement; 1 * -a slight increase in tone, felt when bending or unbending a segment of a limb in the second half of the phase of movement; 2 - a moderate increase in tone, detected throughout the movement, but not obstructing the performance of passive movements; 3 - a significant increase in tone, making it difficult to perform passive movements; 4 - the affected segment of the limb is fixed in the position of flexion or extension (flexion or extensor contracture).

Transient disorders of deep sensitivity were observed in 9% of patients and regressed against the background of conservative therapy. With repeated MRI, relapse of the adhesive process was detected in 1 patient (3.1%). Postoperative complications included 1 wound cerebrospinal fluid and 1 case of transient intercostal neuralgia. There were no serious intraoperative complications (bleeding, perforation of the dura mater). The average hospital stay was 7.6 days. Thus, tecaloscopy is an effective and safe minimally invasive manipulation, which can be widely used in the surgical treatment of adhesive spinal arachnoiditis and arachnoid cysts. With a shorter hospital stay and volume of surgical aggression, the method provides quick recovery of patients. Further research will allow us to expand indications for tecaloscopy and evaluate the delayed results of surgical treatment.

An example of the method

Patient S., 29 years old. Disabled person of group I. Upon admission to the neurosurgical department of the FSBI NTSN RAMS complains of difficulty in movement, a feeling of spasticity in the legs, decreased sensitivity in the limbs, episodic incontinence of urine and feces. Walking short distances with support. At the age of 17, she received combined injuries during a criminal attack: closed craniocerebral trauma, brain contusion. Vertebral spinal injury at the level of the cervicothoracic transition. Multiple stab wounds of the neck, abdominal, thoracic cavities, pneumothorax on the left, rupture of the spleen. Immediately after the wounds received, there were completely no movements in the arms and legs, sensitivity, self-urination and defecation. Against the background of many years of rehabilitation, significant progress was noted, the patient began to walk long distances, the functions of the pelvic organs were partially restored. About 1.5 years before admission, she noted a slow deterioration in neurological symptoms, difficulty in moving limbs and increased numbness. Conservative therapy and rehabilitation were ineffective, in connection with which she was consulted by a neurosurgeon and suggested surgical treatment.

Diagnosis: Post-traumatic cystic-adhesive arachnoiditis at the level of C7-Th1. Myelopathy at the level of C7-Th1.

In neurological status - spastic tetraparesis up to 3 points in the lower extremities, 4 points in the upper extremities, a decrease in surface sensitivity from Th2 level, gross violations of deep sensitivity in the legs, impaired pelvic organs like a neurogenic bladder. MRI reveals a focus of myelopathy at the level of C7-Th1, a cystic-adhesive process at this level, and disturbances of cerebrospinal fluid dynamics (in the mode of MR myelography).

The patient underwent surgery - adhesiolysis at the level of Th1, tecaloscopic separation of adhesions. In this case, a gross adhesion was detected that fixed the spinal cord at the level of C7-Th1, which was excised. After dissection of the visible subarachnoid adhesions, an ultrathin flexible endoscope with a working channel 1.2 mm in diameter and 2.8 mm in diameter was introduced into the dorsal and ventral spaces of the dural sac. During tecaloscopy, caudal to the operative access site (level Th4-Th5), gross ventral and dorsal adhesions were found, which also fixed the spinal cord and served as the walls of arachnoid cysts. Using manipulators, the identified adhesions and cyst walls were endoscopically separated and dissected. After that, restoration of spinal cord pulsation and normalization of cerebrospinal fluid passage were noted.

The patient is activated the day after the intervention. There was a regression of neurological symptoms in the form of a decrease in spasticity (by 1 point on the Ashworth scale), the absence of pelvic disturbances, and an improvement in superficial and deep sensitivity. The wound healed by first intention, was discharged on the 6th day after the operation. During the follow-up examination after 6 months, the improvement in neurological status was stable, there is no data for relapse of the adhesive process. The patient walks on her own, continued her studies at a higher educational institution.

Thus, the deterioration of symptoms 11 years after the injury in the patient was probably due to decompensation of spinal circulation against the background of a progressive adhesive process at the site of traumatic injury with compression of the spinal cord and impaired cerebrospinal fluid dynamics. Autoimmune reactions are considered by some authors, by analogy with the delayed period of severe traumatic brain injury, to be a possible mechanism for the development of a delayed adhesive process in such patients. Thecaloscopy made it possible to efficiently perform fenestration of adhesions and decompression of the spinal cord, including caudal to the operative access site, where adhesions were not clearly verified in preoperative MRI. The method made it possible to achieve a stable regression of neurological symptoms, significantly improve the patient's quality of life, and contributed to early medical and social rehabilitation.

The method of tecaloscopy was applied by us for the first time in domestic neurosurgery. Based on the presented data on the treatment of spinal cystic arachnoiditis, tecaloscopy is an effective and safe minimally invasive manipulation that can be widely used in the surgical treatment of this pathology. Preliminary results of our work show that the method has an advantage over open microsurgical intervention, providing the best clinical result with a shorter hospital stay and the amount of surgical aggression, as well as faster recovery of patients. In addition, thecaloscopy allows biopsy of extramedullary volumetric formations, video-assisted with fixed spinal cord syndrome. Further research will allow us to expand indications for tecaloscopy and evaluate the delayed results of surgical treatment.

Claims (1)

A method of treating spinal cystic arachnoiditis, including decompression of the spinal canal, opening the dura mater, dissection of the subarachnoid adhesions and cyst walls until restoration of patency of the subarachnoid spaces, followed by suturing of the dura mater, characterized in that, with limited spinal cysts or single commissures, access is performed directly compression site, with extended arachnoid cysts, access is carried out in the central part of the cyst, with The incision of the skin and soft tissues is made in the projection of the interested segment of the spinal cord, after dissection of the visible subarachnoid adhesions, an ultra-thin flexible endoscope with a working surface of 2.8 mm is introduced into the dorsal and / or ventral space of the dural sac, the adhesions and cyst walls are separated using its manipulators, restore patency of cerebrospinal fluid spaces and carry out a wide revision of the subarachnoid space in the cranial and caudal directions.

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