RU2578860C1 - Method of treatment of spinal cord injuries - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to neurorehabilitation, neurology, neurosurgery, neurophysiology, physiotherapy. Carry impact exponential constant electric current of 50 Hz, pulse duration 50 ms, voltage of 10-40 V, parcels from continuous to pulse 20 in exponential form. Exposure is carried out on the region of the back so that the area of stimulation of the spinal cord segments were on the level of destruction, above and below that level. Duration of exposure 25 minutes directly. Then, for 10-15 minutes exercise influence on the neuromuscular structures denervated organs. At lower spastic paraplegia - the muscles of the outer surface of the femur and tibia of both legs, with sluggish lower paraplegia - on a projection of the sciatic nerve in the back surface of the femur and tibia of both legs, if not functional bladder - on a projection of the sacral region and roots, innervating the pelvic organs, and on a projection of the bladder in the lower third of the stomach. Course of treatment - 10-20 daily procedures.

EFFECT: method allows to increase the efficiency of recovery of disturbed functions, which is achieved through the restoration of relations with the spinal cord as the center, and with denervated organs.

2 cl, 2 ex

Description

The invention relates to medicine, namely to neurosurgery, neurorehabilitation, neurology, neurophysiology, physiotherapy and can be used to treat patients with traumatic injuries of the spinal cord due to spinal cord injury, after removal of benign tumors of the spinal cord, in some cases with degenerative-dystrophic lesions the spine.

A known method of treating traumatic injuries of the spinal cord by electrostimulation (ES) during surgery and the early postoperative period through electrodes implanted subdurally and intramedullary above and below the level of damage to the spinal cord. ES parameters: biphasic pulses 0.7 ms, frequency 30 Hz, voltage 7.5 V, duration of bursts 3-5 s (AS USSR No. 1333341, publ. 30.08.1987). However, the method is invasive, performed during surgery - at a time of high risk of surgical complications. In the first few days after surgery on the spinal cord, degenerative processes dominate, therefore, stimulation of neuroregeneration during this period is not effective enough (Odinak M.M. Nerve tissue growth factors in the central nervous system. / M.M. Odinak, N.V. Tsygan // - St. Petersburg: Nauka, 2005 .-- 157 p.). The method does not restore parabiosis nerve conductors of the spinal cord, providing feedback with denervated organs.

A known method of treating traumatic injuries of the spinal cord (RF Patent No. 2130326, publ. 05/20/1999), by ES through an epidural wire electrode and a cutaneous plate electrode on the opposite front surface of the abdomen implanted at the level of Th12-L1 vertebrae in the position of a patient with suspended bent legs, which during ES carry out coordinated locomotor movements. Current parameters: rectangular shape, duration 0.5-1.0 ms, frequency 3-5 Hz with potentiation frequencies 30-60 and 100 Hz, amplitude 4-20 mA. After the operation, the ES is carried out through the skin electrodes located at an identical level with an amplitude of 30-85 mA. However, the method is invasive, surgical complications are possible. Exposure to the stomach in the Th12-L1 projection irritates the internal organs and autonomic structures of the upper third of the abdomen (Sinelnikov, RD Atlas of human anatomy. T. 2. / RD Sinelnikov, Ya. R. Sinelnikov - M .: Medicine , 1996 .-- S. 94-97). This can cause adverse reactions, especially of the pancreas and the regimen of insulin production. In addition, the method does not restore the feedback of the spinal cord with denervated organs.

A known method of treating traumatic injuries of the spinal cord by ES sinusoidal modulated current (SMT) transcutaneously (Physiotherapy and balneology / edited by V. M. Bogolyubov. - Book III. - M .: Publishing house BINOM, 2012. - P. 25-32) . For ES of the spinal cord, plate electrodes are located paravertebrally at the level of spinal cord injury. SMT parameters: rectified mode, type I of work, frequency 150 Hz. With spastic paresis, ES of spastic muscle antagonists is performed. With flaccid paresis, ES of paralyzed muscles is performed. For lower extremity ES, a bipolar electrode of 6 ms * in diameter is used. With neurogenic bladder dysfunction, plate electrodes are applied abdominally and sacredly. SMT parameters: variable mode, II type of work, frequency 20-100 Hz, send-pause for 2-5 s. ES courses at different levels are divided by time, each level of the course consists of 10-25 procedures with a duration of each procedure of 12-20 minutes.

The method is used only to restore the functions of the musculoskeletal system in case of spinal cord injury. ES begin only 3-4 months after the injury, while a genetically determined program of neuroregeneration is deployed in the next day after damage to the spinal cord. Long duration of treatment - at least 3 months. The ES of the level of damage to the spinal cord with low-intensity pulses significantly limits the activation of the spinal cord itself and the restoration of its connections with the center and denervated organs.

Closest to the claimed one is a method of treating traumatic injuries of the spinal cord (Tyshkevich T.G. Multilevel stimulation in the early rehabilitation of neurosurgical patients. Author. Diss. Doc. Medical Sciences. - St. Petersburg, 2014. - P. 8, 12, 20 ) adopted as a prototype. Magnetic stimulation of the spinal roots innervating the tertiary limbs is carried out with an amplitude of magnetic induction of intensity up to 3.0 T, and immediately after this the ES of the lower extremities of SMT. A bipolar electrode with an interelectrode distance of 1.5-3.0 cm is used. In spastic lower paraplegia, they act on the tibial and fibular nerves in the ankle and on the muscles of the foot. SMT parameters: variable mode, III type of work, frequency 50 Hz, parcel-pause ratio 2: 3. With lower flaccid paraplegia, paralyzed muscles are stimulated. SMT parameters: rectified mode, II type of work, frequency 10-30 Hz, parcel-pause ratio 2: 3.

However, the prototype is not effective enough, since it does not fully restore the lost connections of the damaged spinal cord with the center and denervated organs, since magnetic stimulation is carried out only at the level of the spinal roots innervating the paret limbs -L5-S1. This does not always coincide with the level of damage to the spinal cord, therefore, there is a limited effect on the damaged spinal cord. The prototype is not applicable in patients with metal structures, usually installed to ensure the statics of the spine after severe traumatic fractures of the spine. In addition, the prototype does not provide for the restoration of the functions of a denervated bladder. Also, the prototype ES is painful.

The invention is directed to the creation of a method for the treatment of traumatic injuries of the spinal cord, which provides an increase in the effectiveness of treatment by restoring the connections of the spinal cord at all levels - with the center and denervated organs and restoring their functions.

The specified technical result in the implementation of the invention is achieved by the fact that in the known method of treating traumatic injuries of the spinal cord, including stimulation of the spinal cord and denervated organs, the feature is that the exposure is carried out by a constant exponential electric current with a frequency of 50 Hz, a pulse duration of 50 ms, voltage 10-40 V, sending pulses from continuous to 20 s in exponential form, the effect is carried out on the back so that in the stimulation zone segments of the spinal cord fell at the lesion level, above and below this level with a duration of exposure of 25 minutes, immediately after that they act on the neuromuscular structures of denervated organs for 10-15 minutes: with lower spastic paraplegia - on the muscles of the outer surface of the thigh and lower leg both legs, with a sluggish lower paraplegia - on the projection of the sciatic nerve on the back of the thigh and lower leg of both legs, with a non-functioning bladder - on the projection of the sacral region and the roots innervating the pelvis s bodies, and on the projection of the urinary bladder in the lower third of the stomach, a course of treatment - 10-20 daily procedures. In addition, if necessary, stimulation of two denervated organs, the effects on them alternate every other day.

Exposure to the back area by exponential electric current causes a reduction in the numerous superficial and deep muscles of the back down to the prevertebral muscles and nerve roots. A powerful afferent impulse to the spinal cord occurs through nerves activated from the vast proprioceptive field of stimulated muscles. Afferentation to the spinal cord through cutaneous nerves activated from an extensive receptor skin field in the ES zone is enhanced. Afferent information is actively transmitted to a significant number of sensitive neurons of the spinal cord and via biological feedback to spinal cord motor neurons. Through the pathways of the spinal cord, a stream of impulses enters the brain and causes a centrifugal response stream of impulses to the denervated organs. The active impulse metabolism includes fibers of the sympathetic chain and parasympathetic nerve fibers, which increase the effect of activation of somatic nerve elements, in particular according to the laws of cutaneous visceral reflexes.

Against the background of an excited spinal cord, after its stimulation, ES of denervated lower extremities removes nerve structures from parabiosis, stimulates the neuromuscular apparatus, activates the production of neuro-growth factors and their delivery to neurons of the spinal cord, significantly enhances the functioning of neuroregenerative systems.

In case of lower spastic paraplegia, simultaneous ES of muscles with a low tonus on the anterior outer surface of both legs against the background of activated spinal cord causes an enhanced effect of multifaceted stimulation of the leg muscles - centripetal impulse to the spinal cord from the proprioreceptive apparatus in case of ES of paralyzed muscles and centrifugal impulse to paralyzed limbs in ES of the spinal cord .

A similar effect is obtained with simultaneous ES of the posterior surface of both legs in the projection of the sciatic nerves with flaccid lower paraplegia. The afferent impulse flow includes impulses of the motor, sensory and sympathetic innervation of the legs. This creates a powerful flow of centripetal impulse into the spinal cord. The versatility of the ES of the legs is supported by centrifugal impulse in ES of the spinal cord.

Afferentation centripetal impulse in bladder ES and centrifugal impulse in spinal cord ES enhance the stimulating effect of the autonomic nervous system. Links of the sympathetic chain located outside the spinal canal and parasympathetic centers in the caudal region of the spinal cord innervate the bladder.

Such a multi-level ES allows in the shortest possible time - during the treatment process, immediately after treatment and in the immediate history to significantly improve or restore the functions of the affected spinal cord and denervated organs. And also restore the feedback between the spinal cord and denervated organs.

The type of exponential current used, formed into specific exponential packs, as well as the dimensions of the electrodes, make the ES procedure practically painless.

The method is as follows.

Immediately before starting treatment, an electroneuromyographic study (ENMG) and diagnostic transcranial magnetic stimulation are performed.

To perform the ES procedure, a physiotherapeutic electric stimulator with a set of electrodes of a large area is used, for example, an electric stimulator “MV 6.03” (Markelov simulator) of the MBBARBELL trademark (Petrozavodsk). The affected spinal cord and denervated organs are affected by a constant exponential electric current with a frequency of 50 Hz, a pulse duration of 50 ms, a voltage of 10-40 V, and sending pulses from continuous to 20 s in exponential form.

The patient is laid on a couch on his back. The electrode is installed in the area of the affected spinal cord so that segments of the spinal cord fall into the affected area at the level of the lesion, above and below this level. ES backs are carried out daily. The central part of the electrode measuring 55.0 × 29.0 cm with a 1.5-centimeter dividing indifferent strip separating the cathode and anode is placed over the affected spinal cord, acted by the “back” code in series of 1-2-3-4-5 packages 5 minutes each. Duration of exposure 25 min.

Then perform ES denervated organs for 10-15 minutes

In case of lower spastic paraplegia, 2 paired electrodes of 12.0 × 10.0 cm and 7.0 × 10.0 cm are applied from two electrical stimulators to the muscles of the outer thigh and lower leg (mm. Vastus lateralis, peronei, extensor digitorum longus) of both legs . They are affected by the “foot” code in series 1-2 for 5 minutes each. Duration of exposure 10 min.

With a sluggish lower paraplegia, two paired electrodes of 12.0 × 10.0 cm and 7.0 × 10.0 cm are applied from two electrical stimulators to the projection of the sciatic nerve on the posterior surface of the thigh (middle third) and lower leg (popliteal region and upper third of the lower leg ) both legs. They are affected by the “foot” code in series 1-2 for 5 minutes each. Duration of exposure 10 min.

With a non-functioning bladder, the patient lies on his back. Impose one electrode with a size of 17.0 × 19.0 cm on the projection of the sacral region and the roots innervating the pelvic organs, and another electrode of 10.0 × 12.0 cm in size on the projection of the bladder in the lower third of the abdomen. They are affected by the “back” code in series of 3-4-5 for 5 minutes each. Duration of exposure 15 minutes.

If necessary, the ES of only one denervated organ (legs or bladder) of this organ is performed daily. If necessary, stimulations of two denervated organs of ES of these organs alternate every other day.

The voltage of the electric current is determined by the sensations of the strength of the “comfortable” contraction and tension of the muscles and muscle fibers. The duration of daily exposure is 35-40 minutes. The course of treatment includes 10-20 daily procedures.

After a course of treatment, a control ENMG study is performed. Repeated courses are performed after 6 months - 1 year. In the period between courses of treatment, positive dynamics continue, provided that therapeutic physical and sports exercises are performed.

The method has undergone clinical trials in the clinic of the PMI RAS in the treatment of 7 patients aged 17 to 72 years. 2 patients suffered a severe spinal cord injury with a fracture of the vertebral bodies. 3 patients were operated on due to the presence of a benign tumor of the membranes of the spinal cord. In 2 patients, spinal cord dysfunctions are caused by degenerative-dystrophic lesions of the spine.

Clinically revealed a violation of the statics and dynamics of the spinal column, axial muscle weakness (back, abdomen), neurogenic bladder dysfunction and plegia of both or one leg, impaired sensitivity up to anesthesia in accordance with the level of spinal cord injury.

Immediately after treatment, all patients had a positive dynamics, which consisted in improving the statics and dynamics of the spine, the restoration of regular independent urination. All had catheters or cystostomy removed from the bladder, or there was a refusal to install a cystostomy due to the restoration of control of the pelvic functions. The volume of active leg movements, the strength of the muscles of the paretic limbs increased. Patients began to get up with help, then walk with the help of relatives and orthopedic appliances. Patients felt a surge of strength, self-confidence, emotional recovery. Strength in hands increased. Patients could serve themselves. Some returned to work, albeit limited. We achieved the main thing - improving the quality of life of our patients.

A significant improvement in the functions of the affected spinal cord was observed in 3 and improvement in 4 patients. Moreover, the ES procedure was comfortable due to painlessness and convenient fixation of the electrodes.

We give examples - extracts from medical records.

Example 1. Patient A., 28 years old. The term of hospitalization is September 16-16, 2013. Diagnosis: Severe spinal injury. Complicated compression rupture fracture of Th12-L1 bodies. Severe spinal cord injury. Condition after laminectomy of Th12-L1 and metal spondylosis Th11-L4. She suffered a car accident in March 2012 Objectively: Lower flaccid paraplegia. Deep paresis of axial muscles (back and abdomen) from Th7 level. Deep hypesthesia without hyperpathy (1 point) with Th2 and anesthesia of the lower third of the abdomen and both legs. With deep palpation of the lower third of the abdomen, pain is determined in the projection of the bladder. Pressure ulcers of the sacral-gluteal regions with flaccid granulations. During the examination, the young man of a manly appearance was deeply depressed, had a pronounced negative emotional background, although he controlled himself perfectly.

In an ENMG study prior to treatment on September 18, 2013, no convincing data were obtained for the presence of evoked potentials either during transcranial magnetic stimulation or in ENMG.

Conclusion: signs of conduction along motor paths have not been established.

From September 19, 2013 to October 15, 2013, an ES course of 20 daily procedures was completed according to the claimed method. Used physiotherapeutic electrostimulator "MV 6.03". The electrode was first placed on the back region, centered at the level of Th12-L1. Spin ES was performed for 25 minutes daily. Then 2 paired electrodes were placed on the back surface of the thigh and lower leg of one and the second leg. Stimulated for 10 minutes using two electrical stimulators. Feet stimulated every other day. The next day, a double electrode was applied so that one of the poles was located on the lumbosacral region, the other on the lower abdomen, bladder ES was performed 15 minutes every other day.

An ENMG study was carried out immediately after treatment on 10/15/2013. During transcranial magnetic stimulation from the legs, a cortical evoked muscle response of reduced amplitude began to be determined. The latent period was 41-52 ms on the right and 40-49 ms on the left. Segmental evoked muscle response is sharply dispersed, its latency was 20 ms from both legs. The evoked motor potential from the lumbar enlargement was determined, from a level above its parameters sharply decreased.

Conclusion: conduction along motor paths along the entire length with a significant slowdown at the level of injury was revealed. The degree of preservation of conductivity is more pronounced on the left. The distinct evoked motor responses are convincing with respect to constant amplitude.

Neurological examination at discharge revealed a clear positive trend: there were active contractions of the abdominal muscles, spontaneous contractions of the feet and fingers of both legs (1-2 points), pain in the muscles of the legs and fasciculation of the fibers of various muscles of both legs upon palpation, restoration of leg sensitivity to 1-2 points . With deep palpation of the bladder, severe pain (2 points, hyperpathy). Catheter removed from the bladder. Restored urination. The planned operation of the cystostomy installation was abandoned. During the examination, the patient smiled, and in his eyes there were tears of joy.

Repeated admission for examination 09/19/2014. Neurological examination: lower flaccid paraparesis 1-2 points. The function of the axial muscle group was restored 4-5 points. The strength of the muscles of the hands has increased. The patient stands with support. The sensitivity of the legs within 1-2 points. The patient feels the urge to urinate and defecate. The emotional sphere is calm, even, the patient smiles and thanks.

ENMG study 06/17/14: when studying the conduct of the peroneal and tibial nerves, an increase in distal latency of the right tibial nerve was established. The amplitude of the M-response is reduced by 80% at the distal and proximal points. The rate of propagation of excitation through the nerves is reduced by 20%. An indistinct M-response during electrical stimulation of the peroneal nerves and the left tibial nerve. With needle ENMG, spontaneous activity of the right anterior tibial muscle was detected, and the emerging potentials of the motor units with an amplitude reduced by 60% were established.

Conclusion: continuing positive dynamics mainly due to the formation of potentials of motor units and a decrease in spontaneous activity.

From the presented example it follows that despite the absence of signs of neuroregeneration after 1 year 7 months after a severe vertebral-spinal injury with complete transverse damage to the spinal cord at the level of lumbar thickening immediately after a course of ES according to the claimed method, distinct symptoms of neuroregeneration, signs of restoration of spinal cord conductivity were established, prolonged over the next year.

Example 2. Patient D., 36 years old. The term of hospitalization is 02-27.12.2013. Diagnosis: Meningioma at the Th7-8 level. 12.12.2013 a neurosurgical intervention was performed: Th7-8 laminectomy, removal of mid-lateral meningioma on the right with a size of 3 × 2, 5 × 2 cm.

After surgery, lower paraplegia, anesthesia from Th9 level, and lack of urination control were observed. There is no tumor in the MRI on December 13, 2013; spinal cord edema and depletion of the tracts were revealed.

On December 16, 2013, an ES course was completed according to the claimed method of 10 procedures. Spinal ES of 25 minutes and ES of both legs were performed daily for 10 minutes using 2 electrical stimulators every other day, alternating with ES of the bladder for 15 minutes.

When extracting the movement of the right foot 0-1 points with a sensitivity of 1-2 points, the left foot 1-2 points with a sensitivity of 0-1 points, and therefore the support on the left foot was sharply weakened. Partial urination control appeared.

Re-entry 01/13/2014. During the examination 13.01.2014 the patient got up! With the help of staff. I stood for 1 min. I was very pleased. I didn’t want to sit down, but I had to, because my numb left leg began to “slide” back, and the support on the feet was gone.

According to the claimed method, an ES course of 14 procedures was carried out. ES of the back of 25 minutes and ES of both legs were performed daily for 10 minutes using 2 electrical stimulators every other day, alternating with ES of the bladder for 15 minutes.

ENMG study 01/30/2014 conducted immediately after treatment. The latency of the M-response is normal during electrical stimulation of the peroneal and tibial nerves, the amplitude is reduced by 40-50%. The speed of propagation of excitation along the nerves is normal. The amplitude of the potentials of the motor units is increased. The EMG pattern is picket. The number of functioning potentials of motor units is reduced.

Conclusion: activity of the denervation process was not detected. Diagnostic transcranial magnetic stimulation dysfunction of the motor paths with a pronounced delay in the cortico-spinal tract at the level of Th8-9.

A neurological examination at discharge showed the restoration of active leg movements up to 3.5 points, sensitivity up to 2-3 points, complete restoration of urination control. The patient began to walk with help. The level of neurological disorders was significantly better than before surgery.

This example showed that in the absence of spinal cord conductivity after removal of a benign tumor of the spinal cord, conducting ES according to the claimed method in the early postoperative period showed excellent clinical and electrophysiological results.

Using the proposed method provides an increase in the effectiveness of the treatment of traumatic injuries of the spinal cord by restoring the connections of the spinal cord at all levels - with the center and denervated organs and restoring their functions. In addition, the painlessness of ES is an advantage.

Claims (2)

1. A method of treating traumatic injuries of the spinal cord, including stimulation of the spinal cord and denervated organs, characterized in that the exposure is carried out by a constant exponential electric current with a frequency of 50 Hz, a pulse duration of 50 ms, a voltage of 10-40 V, and sending pulses from continuous to 20 s in exponential form, the impact is carried out on the back so that segments of the spinal cord fall on the level of the lesion at the level of the lesion, above and below this level for the duration of exposure I’m 25 minutes, immediately after that, they act on the neuromuscular structures of the denervated organs for 10-15 minutes: with lower spastic paraplegia - on the muscles of the outer thigh and lower leg of both legs, with flaccid lower paraplegia - on the projection of the sciatic nerve on the back surface the hips and lower legs of both legs, with a non-functioning bladder - on the projection of the sacral region and the roots innervating the pelvic organs, and on the projection of the bladder in the lower third of the abdomen, the course of treatment 10-20 - daily procedures. 2. The method according to p. 1, characterized in that, if necessary, stimulation of two denervated organs, the effects on them alternate every other day.