RU2567824C1 - Method for spinal canal repair in spinal cord tumour - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: spinal canal is approached. An apex of a spinous process is layered with preserving its main part; the spinous process is excavated to the root. The layered parts of the spinous process are driven apart together with attached muscles and ligaments. Arches of over- and underlying spines are excised with preserving facet joints. A yellow ligament is mobilised from the underlying bone. The spinal column is repaired along spinal roots at the level of the tumour, and a dural sac is inspected. A dura mater is opened in the middle. After the spinal cord tumour is removed and the dura mater is repaired, the apex of the spinous process is sutured together.

EFFECT: method enables reducing injures and providing the deepest possible inspection of the spinal cord tumour, reducing the risk of postoperative stenosis of the spinal cord.

6 dwg

Description

The invention relates to medicine, namely to neurosurgery, oncology, and can be used for dorsally located extramedullary tumors of the spinal cord (relative to the spinal canal).

The mechanical causes of radicular syndrome are direct compression of nerve structures by a growing tumor, more pronounced against degenerative diseases of the spine - narrowing of the spinal canal and intervertebral foramen, caused as static (disc herniation, ligament hypertrophy, narrow canal, osteophytes, thickening of the capsules of the intervertebral joints), and dynamic stenoses (due to instability) or their combination [1, 2].

Currently, a large number of methods for reconstruction of the spinal canal are known. But in modern sources, information on the treatment of combined neoplastic and degenerative polysegmental stenosing compression lesions that require expansion of the spinal canal is absent [3].

To date, signs of instability of the vertebral-motor segment (PDS) are essential for determining surgical tactics. In the presence of the latter, the question arises of installing an orthopedic component, but in the absence of instability, there is no advisability in spinal fusion. The latter circumstance is especially relevant for large spinal cord tumors, when multilevel (affecting more than 2 vertebrae) resection of bone structures can lead to signs of hypermobility or instability of the spinal motor segment (PDS) [4, 5].

Many experimental and analytical studies have confirmed the destabilizing effect of extended and / or multilevel laminectomies, and the study of indicators confirming damage to the paravertebral muscles during prolonged exposure to traction and the associated pain in the lumbar region after surgery stimulate the development of less traumatic approaches and techniques for their exercise in tumors of the spinal cord.

A known method of surgical treatment of diseases of the spine and spinal cord [6], including a skin incision along the line of the spinous processes, an arcuate dissection of the thoracolumbar fascia on both sides of the spinous processes with a bulge outward, blunt separation from the spinous processes and arches of the vertebrae of the paravertebral muscles, sequential bilateral resection with exposure of the dural sac and roots, resection of the vertebral arches, while maintaining the spinous process, supra- and interspinous ligaments, to which, with subsequent ynom suturing wounds, fix the paravertebral muscles.

The disadvantages of this method are:

- a small area of the surgical field and lack of visualization;

- the impossibility of a multilevel surgical intervention;

- weakening of the supporting functions of the posterior structures of the spine, as well as a decrease in its flexibility due to the removal of the yellow ligament;

- the risk of disco-radicular conflict with disorientation of the articular sites.

There is also known a method of osteoplastic laminotomy as a single unit [7], including a longitudinal section along the midline above the spinous processes of the skin of the lumbar 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 the most cranial and lower margin of the caudal arch of the vertebrae on both sides dissect the yellow ligament. Then, along the entire length of the incision, the plates of the arches are sequentially bilaterally dissected, and pulling the laminotomy bone-ligamentous block, held by the supraspinatus, interspinous and yellow ligaments, pulling over the superior spinous process, the aforementioned ligaments are intersected at the cranial border of the section. Then yellow ligaments intersect bilaterally along the incision. 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 fixing, starting from the caudal end of the wound, 8-shaped sutures with silk threads sequentially suture the wound from each side.

The disadvantages of the above method are:

- the complexity of intracanal manipulations with a narrow incision and a long non-free bone-ligamentous block;

- the risk of complete separation and loss of trophic bone-ligamentous block;

- degradation and / or ossification of the yellow ligament due to trophic disturbances;

- the possibility of development in the long-term postoperative period of instability of the spine during laminectomy on the lumbar spine;

- preservation of the disc-radicular conflict.

Closest to the proposed method is the approach to the spinal cord, which represents a bone-plastic laminectomy in single blocks [8], including dissection of the posterior wall of the spinal canal by longitudinal parallel sections along the articular processes while maintaining their integrity. In this case, the arches are dissected in the oblique plane near the articular processes, dissect the posterior wall of the spinal canal from below or from above with the formation of mobile Π-, H- or C-shaped flaps on the legs, consisting of arches, spinous processes and ligaments, with their removal upward and downward or to the side and laying in its place after performing intra-channel manipulations. Moreover, the arches are fixed with transosseous sutures or bone nails, and the ligaments are fixed with interrupted sutures, followed by suturing of the surgical wound without bone-plastic fixation of the spine.

The disadvantages of this method are:

- degradation and / or ossification of the yellow ligament due to trophic disturbances;

- the risk of decreased flexibility of the spine due to excision of the yellow ligament during resection of the arches;

- the risk of a disco-radicular conflict during disorientation of the articular sites, as compression of the roots of the spinal cord occurs;

- difficulties in conducting intracanal manipulations to remove a tumor of the spinal cord, especially with a multilevel lesion, due to insufficient disclosure of the affected area.

Based on the analysis of known sources of information that reveal the features of operative posterior access to the spine in the treatment of spinal cord tumors, as well as eliminating the disadvantages of known technologies, the task was set to provide a less traumatic expansion of the spinal canal for the maximum possible revision of the spinal cord tumor with multilevel lesions, and also preserve the natural biomechanics of the spine and prevent stenosis of the spinal canal in the postoperative period.

The problem is solved as follows.

Reconstruction of the spinal canal with a tumor of the spinal cord includes access to the lesion, exposure of the posterior wall of the spinal canal, resection of the vertebral arches, and manipulation of the spinal cord.

New in solving this problem is that when accessing the spinal canal, the apex of the spinous process is stratified, retaining most of it and carry out its layer-by-layer drilling to the base. Dissected parts of the spinous process are bred together with the attached muscles and ligaments. The arcs above and below the lying vertebrae are resected, preserving the facet joints. Then mobilize the yellow ligament from the underlying bone. The spinal canal is reconstructed along the roots of the spinal cord at the level of the tumor location and the dural sac is revised, the dura mater is opened in the center, and the spinal cord tumor is removed. After removal of the spinal cord tumor and restoration of the dura mater, the apex of the spinous process is sutured.

We explain the essential distinguishing features of the proposed "Method for the reconstruction of the spinal canal with a tumor of the spinal cord."

Access to the spinal canal by delaminating the apex of the spinous process, preserving most of it, and performing its layer-by-layer drilling to the base and subsequent dilution of the dissected parts of the spinous process together with the attached muscles and ligaments is necessary for minimally traumatic access to the spinal canal while maintaining supportiveness of the paravertebral muscles reduce intracanal postoperative scar adhesions after removal of a spinal cord tumor.

Resection of the arch above and below the lying vertebrae while preserving the facet joints provides sufficient visualization of the affected segment of the spinal cord, while maintaining the stability of the operated spine.

Mobilization of the yellow ligament from the underlying bone helps reduce the risk of damage to the dura mater when performing vertebral arch resection.

Reconstruction of the spinal canal along the roots of the spinal cord at the level of the location of the tumor and revision of the dural sac, opening of the dura mater in the center ensure safe mobilization of the tumor formation (without risk of damage to the spinal roots), as well as the possibility of hermetic closure of the dura mater for the prevention of postoperative cerebrospinal fluid.

After removal of the spinal cord tumor, the dura mater is restored and the apex of the spinous process is sutured together with the muscles and ligaments attached to it, which allows to restore the stability of the posterior supporting complex of the spine, enable early activation of patients and eliminate the need for stabilizing structures.

The reconstruction of the spinal canal and removal of the tumor by the proposed method allows us to visualize the pathological focus, the source of its growth and blood supply, as well as to monitor neural and vascular formations located nearby during surgical treatment, to preserve the natural biomechanics of the operated vertebral-motor segments due to the absence of damage to the main musculo-ligamentous back supporting structures of the spine. Unlike standard laminectomy, aimed at expanding only the spinal canal, this access allows you to visualize not only the dural sac, but also the roots of the spinal cord.

The technical result of the proposed method for the reconstruction of the spinal canal with a spinal cord tumor is to reduce trophic disorders of the ligamentous apparatus and muscle tissue due to the absence of direct damage to them, reduce the morbidity of surgical access while maintaining the supporting function of the posterior structures of the spine, provide the possibility of early activation of patients, reduce postoperative pain and improving the quality of life, maximizing the recovery of patients in the region possible time.

A comparative analysis of the proposed method and known technologies shows that the proposed method differs in the above methods. In this connection, we can conclude that the claimed technical solution meets the criteria of the invention of "novelty."

From the analysis of patent and specialized literature, the authors found that the proposed technical solution has features that distinguish it not only from the prototype, but also from other known technical solutions in this field of medicine. We have not found a method for reconstructing the spinal canal when removing a spinal cord tumor containing the distinctive techniques of the proposed method.

In addition, based on the analysis of clinical material, the authors of the proposed method revealed the following advantages:

- reducing the morbidity of access due to the absence of gross damage to the paravertebral muscles and ligaments;

- the ability to preserve natural biomechanics and prevent the formation of instability in the operated VDS due to the preservation of the rear supporting structures (adjacent supraspinatus and interspinous ligaments) and facet joints;

- prevent re-stenosis at a given level of the spine due to a wide reconstruction of the spinal canal;

- the possibility of maximum revision of the spinal canal: dural sac and spinal roots, tumor formation.

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 with a spinal cord tumor is intended for use in healthcare and can be used in neurosurgeons and oncology. 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 of reconstruction of the spinal canal with a tumor of the spinal cord" is illustrated by illustrations, which show:

FIG. 1 - stratification of the apex of the spinous process;

FIG. 2 - layered drilling of the spinous process with its dilution together with the attached muscles and ligaments;

FIG. 3 is a view of the formed bone window;

FIG. 4 is a view of a sutured postoperative wound after revision of a spinal cord tumor;

FIG. 5 - MRI of the lumbar spine of patient B. before surgery;

FIG. 6 - MRI of the lumbar spine of patient B. after surgery.

To clarify the above illustrations, we present a transcript of the indicated positions:

1 - intervertebral disc,

2 - spinous process,

3 - paravertebral muscles,

4 - dural bag,

5 - a tumor of the spinal cord of patient B. before surgical treatment.

The essence of the proposed "Method of reconstruction of the spinal canal with a spinal cord tumor" is as follows.

After processing the surgical field with an antiseptic solution, under intravenous anesthesia using mechanical ventilation, in the position of the patient "lying on his stomach" with unloading 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 area of the stenotic process (spinal cord tumor). Then, with the help of a high-speed drill, the apex of the spinous process is stratified, retaining most of it (see the appendix to the description of the application for the invention, Fig. 1) and it is further drilled in layers to the base with dilution of the dissected parts of the spinous process along with the attached muscles and ligaments (see Appendix to the description of the application for an invention, Fig. 2). Perform mechanical microsurgical resection of the arches above and below the lying vertebrae with the mandatory preservation of facet joints (see the appendix to the description of the application for the invention, Fig. 3). The identified yellow ligament is stratified and mobilized from the underlying bone using a neurotome, conchotome, and / or pistol nippers at the location of the spinal cord tumor. Foraminotomy along the “interested” roots of the spinal cord is made with pistol nippers. A wide reconstruction of the spinal canal allows the revision of the dural sac and spinal roots, as well as manipulations with volumetric formation. Subsequently, the apex of the spinous process is sutured using 2-3 ligatures (see the appendix to the description of the application for the invention, 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 B., born in 1958, was hospitalized in the neurosurgical department of the NIH Road Clinical Hospital at the Irkutsk-Passenger station of Russian Railways on 03/03/2014 with complaints of severe pain in the lumbar spine radiating to both legs, numbness in both legs zone of pain syndrome of a periodic nature, resistant to conservative treatment.

The patient has a long history of the disease in excess of 30 years, with annual exacerbations 3-4 times. 2 years before hospitalization, the patient's condition worsened, the pain syndrome intensified. According to the neuroimaging methods of examination, a tumor-like formation was revealed.

During a neurological examination of the cranial nerves: the upper limbs are intact. The defense of paravertebral muscles of the II-III degree. Lumbar lordosis is smoothed. Palpation and percussion of the spinous processes of L _III , L _IV , L _V painful. Movements in the lumbosacral region are painless, unlimited. The symptom of Lasseg [9] is negative. The knee-jerk reflexes are alive. There are no pathological reflexes. Muscle tone in the hands is normal; in the legs - normal. Paresis of the extensor 1 toe of the right foot. Pelvic abnormalities are absent. There are no meningeal signs. Coordination tests - right. In the Romberg position - steady.

When conducting a march test with a load (performing 10 squats), a progression of neurological deficiency was revealed with an expansion of the polyradicular hypesthesia zone, loss of knee reflexes on both sides, the appearance of symptoms of tension - from the right - from an angle of 65 °, from the left - from an angle of 80 °.

An MRI scan of the lumbar spine was performed: an extramedullary lesion was found at the level of L _IV vertebra (more data for neuroma of the root). MP signs of spondylopathy. Protrusion of the intervertebral discs L _III -L _IV , L _IV -L _V , L _V -S _I (see the appendix to the description of the application for the invention, Fig. 5).

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.

Diagnosed with Volumetric extramedullary, intradural formation at the level of L _IV vertebra. Right vertebral radiculopathy L5 syndrome (mild paresis). Lumbar ischialgia syndrome on both sides. Pain and muscle tonic syndromes.

Given the data of clinical and neurological and other methods of examination, the presence of severe pain syndrome resistant to conservative therapy, the patient is shown surgical treatment - removal of the volumetric formation at the level of L _IV vertebra. Since there are no signs of instability and there is no need to stabilize the PDS, it was decided to perform minimally invasive reconstruction of the spinal canal transpinously.

04/04/14. The operation was performed - total microsurgical removal of extramedullary volumetric formation of L4 root (neurinoma) from transpinous access by the proposed method for reconstruction of the spinal canal.

Under intravenous anesthesia using mechanical ventilation, in the patient’s position “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 , L _V vertebrae. Under the intraoperative control of the image intensifier, the position and direction of the bone structures described above are determined. Using a high-speed drill, the spinous process of the LIV vertebra was stratified at its apex and it was drilled to the base in layers, dissected parts of the spinous process of the L _IV vertebra were divorced together with the attached muscles and ligaments. The spinal canal was reconstructed in the form of a resection of the arches above and below the lying vertebrae L _III , L _V with preservation of facet joints. The yellow ligament lying above the dural sac is stratified and mobilized from the underlying bone. Using microsurgical technique, a linear dissection of the dura mater (TMT) was performed in the center. TMO sheets along with the arachnoid membrane were taken on 8 holders (prolen 6-0). After dilution of the roots ventrally with a dislocation to the right at the level of the middle body of the L _IV vertebra, a voluminous formation of gray-yellow color, rounded shape, dense-elastic consistency was revealed. A volumetric formation up to 1.0 cm in diameter occupies a middle position and causes significant compression of the ponytail roots. With the help of microsurgical dissection in the acute way (microscissors), it was possible to isolate the tumor completely, to separate it from the soldered and adjacent roots. A typical neurinoma that grows from the membranes of the L4 root is visualized. The allocation of the upper and lower poles of volumetric education. Under a 14-16-fold increase, after preliminary coagulation of the vessels, the tumor is separated from the normal membranes of the L4 root. Microsurgical hemostasis at 120/80 mmHg Transparent cerebrospinal fluid arrives. When revising the compression of the roots in the spinal canal at the indicated level was not detected. Dura mater (TMT) is stitched tightly by continuous sutures (prolen 6-0). When performing samples, there is no visible liquorrhea. Mild epidural bleeding that is stopped using Sugicel and microcoagulation. To reduce the severity of cicatricial commissural epiduritis, Tachocomb was applied to TMT. No signs of ongoing compression have been identified, and therefore the above-described 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 imposition of 2 ligatures on the apex of the spinous process. Layered closure of the wound, aseptic dressing.

In the postoperative period, antibacterial, symptomatic, vasoactive and vitamin therapy, exercise therapy, massage, dressings, a course of hyperbaric oxygenation were performed.

At discharge, the patient's condition is satisfactory. In neurological status, a minor muscle-tonic syndrome, physiological partial pelvic disorders of the type of urinary retention remained. When assessed by a visual analogue pain scale (VAS), the level of pain was 4 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.

According to MRI of the lumbosacral spine 6 months after the operation (see the appendix to the description of the application for the invention, Fig. 6), no data were obtained for tumor growth, there are no signs of secondary stenosis and instability of the operated vertebral-motor segments.

The proposed method for the reconstruction of the spinal canal with a spinal cord tumor was used in 10 patients with the location of the pathological focus on the thoracic and lumbosacral spine. Pain syndrome, assessed by the visual analogue pain scale (VAS) [10], significantly decreased in all patients after surgery. A follow-up examination after 3 and 6 months after surgery did not reveal cases of recurrence of tumor growth, the appearance of segmental instability of the spine and worsening neurological symptoms. To study the range of movements in the operated spine, the method of functional spondylography was used, it was found that there were no signs of instability. When analyzing the X-ray data at the time points indicated 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 [10], significantly improved after surgery: from the preoperative level - 58 (30; 72) points, and by 6 months of follow-up was 10 (8; 12) points (P _W <0.001). The operation time when performing the proposed method was 2.8 (1.7; 3.8) hours. Blood loss amounted to 130 (85; 175) ml, 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 after the operation and can be allowed to go home on days 8–9, which is significantly less than with known methods. The median term for hospitalization of patients operated by the claimed method was 8 days (8; 9), which is statistically significantly less than when using the methods of decompressive laminectomy for 12 days (11; 14), and the decompression-stabilizing method, 11 days (10; 13 ) performed by the same team (p = 0.01). Operated according to the proposed methodology, patients returned to their previous labor activities on average within 65 (60; 75) days after surgery. While after decompression laminectomy and decompression-stabilizing methods of surgical treatment, labor rehabilitation looked as follows: 45% returned to their work after 90 days, 20% - after 180 days, 35% - after 240 days after the operation.

The proposed “Method for the reconstruction of the spinal canal with a spinal cord tumor” made it possible to create maximum conditions for restoring the quality of life, labor and social rehabilitation with minimal surgical trauma. None of the patients in the long-term period had the need for additional decompression or decompression-stabilizing interventions on the operated vertebral-motor segment. The surgical capabilities of this method are high, it is designed for the joint work of a surgeon and an experienced assistant.

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) Rameshvili T.E. Degenerative-dystrophic lesions of the spine. Guide for doctors / T.E. Rameshvili, G.E. Trufanov, B.V. Gaidar, V.E. Parfyonov. - SPb .: ELSBI-SPb, 2011 .-- 218 p.

4) Gunzburg R., Szpalski Μ. (Eds). Lumbar Spinal Stenosis. // Lippincott Williams and Wilkins, Philadephia. - 2000. - 414 pp.

5) Gunzburg R., Szpalski M. (Eds). Lumbar Disc Herniation in the third millennium. // Lippincott Williams and Wilkins, Philadephia. - 2002. - 300 pp.

6) Patent RU No. 2154430, A61B 17/56, from 08.13.97, publ. 08/20/2000.

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

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

9) Gaidar, B.V. Practical neurosurgery: a guide for doctors / B.V. Gaidar. - SPb., 2002 .-- S. 533-539.

10) Byvaltsev V.A., Belykh E.G., Alekseeva N.V., Sorokovikov V.A. The use of scales and questionnaires in the examination of patients with degenerative lesions of the lumbar spine // Textbook: FSB “SC RVH” SB RAMS, Irkutsk, 2013. 32 p.

Claims (1)

A method for reconstructing the spinal canal with a spinal cord tumor, including access to the lesion, exposing the posterior wall of the spinal canal, resection of the vertebral arches, performing manipulations on the spinal cord, characterized in that when accessing the spinal canal, the apex of the spinous process is stratified, retaining most of it , and carry out its layer-by-layer drilling to the base, dissected parts of the spinous process together with the attached muscles and ligaments, dissect the arches above and below the lying of retained facets, then mobilize the yellow ligament from the underlying bone, reconstruct the spinal canal along the roots of the spinal cord at the level of the location of the tumor and revise the dural sac, open the dura mater in the center, after removal of the spinal cord tumor and restoration of the dura the spinous process is stitched.

Images