RU2628653C1 - Method for microsurgical decompression of nervous-vascular structures of spinal canal during lumbosacral stenosis treatment - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: access to the spine is performed by blunt muscle stratification in the intermuscular sulcus through 3-4 cm skin incisions when performing parasagittal access. Interlaminar access to the vertebral canal is performed, the spinous process of the corresponding vertebra is cut off at the base of attachment to the vertebral arch. The spinous process is removed along with soft tissues to the opposite side. The vertebral arch from the side of the spinal canal is dome-cut. The yellow ligament and hypertrophied medial parts of the contralateral facet joint are removed.

EFFECT: method creates sufficient spinal canal capacity during its stenosis, reduces the number of complications.

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Description

The invention relates to medicine, namely to neurosurgery, traumatology and orthopedics, and can be used to perform microsurgical decompression of the neurovascular structures of the spinal canal in the treatment of stenosis of the lumbosacral spine.

A known method of decompression-stabilizing interventions from traditional posterior-median access with skeletonization of the posterior spinal column (Results of decompression-stabilizing surgeries from unilateral access for spinal canal stenosis at the lumbar level / A.V. Krutko // Surgery Issues named after N.N. Burdenko . 2012. No. 2, p. 33-41). In this method, decompression is performed from a unilateral parasagittal section according to Wiltse using tubular retractors. A blunt muscle stratification is performed, then decompression, interbody stabilization, installation of transpedicular screws and installation of the structure are performed on the one hand, and transcutaneous transpedicular stabilization is performed on the opposite side. Access to intracanal formations is performed transforaminally with unilateral resection of the articular pair. Decompression of the nerve root and dural sac is performed while maintaining the supra- and interspinous ligaments, as well as facet joints on the opposite side of the access; expansion of the central part of the spinal canal was achieved by dome-shaped resection of the arch and resection of the yellow ligament. The base of the spinous process was resected using a high-speed drill to expand the spinal canal dorsally. Resection of hypertrophied bone-cartilaginous growths, ligaments from the access side and on the opposite side was performed. When the free lateral edge of the spinal root was visualized on the opposite side, convinced of its mobility and the presence of reserve spaces, then decompression was considered adequate.

The disadvantage of this method is the complexity of the full decompression of the contralateral side with severe spinal stenosis due to insufficient visualization of the contralateral side and overhanging paraspinal soft tissues and interspinous ligaments. In addition, ischemia of muscles squeezed between the retractor and the corresponding spinous process fixed to the arch of the vertebra is possible.

A known method of microsurgical reconstruction of the spinal canal (RF patent for the invention No. 2508909, IPC АВВ 17/00, publ. 03/10/2014) with stenotic lesion of the lumbosacral spine. This method includes one-sided skeletonization of the interspinous gap in the projection of the stenotic process, depending on its lateralization, transspinous access to the spinal canal with a cut of the base of the spinous process of the vertebra contralaterally in the oblique horizontal plane. After performing microsurgical reconstruction of the spinal canal, the stump of the spinous process of the vertebra to the muscular-ligamentous apparatus of the ipsilateral side is fixed.

The disadvantage of the method according to the patent of the Russian Federation No. 2508909 is blood loss and a high probability of developing soft tissue necrosis from compression by retractors with further fatty degeneration of muscle tissue due to the use of traumatic median access. This leads to additional risks and costs, as well as persistent postoperative back pain due to prolonged muscle retraction.

Closest to the proposed is a method of reconstruction of the spinal canal in the treatment of stenosis of the lumbosacral spine (RF patent for the invention No. 2531927, IPC AB 17/70, publ. 10.27.2014). This method includes one-sided skeletonization of the interspinous gap in the projection of the maximum stenosing process. Then, during transspinal access to the spinal canal, the selected spinous process of the vertebra is conditionally divided into three parts - distal, middle and proximal. The apex 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 that, muscles that attach to the base of the spinous process of the vertebra on the opposite side are additionally skeletonized, and the central and lateral zones of the spinal canal are expanded, preserving the arcuate joints of the vertebrae on both sides. The hypertrophic part of the yellow ligament on the side of the stenosing process is stratified and excised to the dural sac, while maintaining the adjacent ligaments supraspinous and interspinous. The back wall of the spinal canal is restored, fixing the previously cut stump of the apex of the spinous process of the vertebra to the musculo-ligamentous apparatus of the ipsilateral (operated) side.

In the method according to RF patent No. 2408316, resection of the spinous process by 2/3 from the base entails damage to the musculo-ligamentous apparatus attached to the spinous process and interspinous ligaments from the access side and the opposite side of the access. This leads to the development of instability in adjacent segments of the spine, the appearance of additional wound cavities, which serve as a place for the formation of hematomas.

The objective (technical result) of the present invention: to develop a method of microsurgical decompression of the neurovascular structures of the spinal canal in the treatment of stenosis of the lumbosacral spine, free from the above disadvantages.

The problem is solved in that in the method of microsurgical decompression of the neurovascular structures of the spinal canal in the treatment of stenosis of the lumbosacral spine, access to the spine is made, an interspinous gap is allocated in the region of the stenotic process, the vertebral arch is resected in the required volume, the posterior semicircle of the dural sac is mobilized, perform intracanal manipulations. According to the invention, access to the spine is made by blunt stratification of the muscles in the intermuscular groove through 3-4 cm skin incisions when performing parasagittal access. The allocation of the interspinous gap is carried out with the release of the articular pair in the projection of the stenosing process. Then, interlaminar access to the spinal canal is carried out, the spinous process of the corresponding vertebra is cut off at the very base at the place of attachment to the vertebral arch, the mobilized spinous process along with soft tissues is removed to the opposite side, the vertebral arch from the side of the spinal canal is dome-shaped. The hypertrophic yellow ligament and the overgrown medial parts of the contralateral facet joint, which compresses the dural sac and the spinal root on the contralateral side, are removed.

Cutting off the spinous process from the place of attachment to the arch of the vertebra ensures the integrity of the spinous process, places of attachment of ligaments and muscles from the access side and the opposite side. In conjunction with parasagittal access, this eliminates damage to the midline, supraspinatus, interspinous ligament, and the attachment point of the fascia of the latissimus dorsi, which is thrown from its side to the opposite side of the spinous process. Preservation of the anatomical integrity of the musculo-ligamentous apparatus ensures stability and normal function of adjacent segments of the spine.

Together with the abstraction of the spinous process together with soft tissues on the opposite side, better visualization of the structures of the posterior backbone complex of the spine due to the absence of "sagging" of the paraspinal soft tissues over the decompression area, which allows a wider and safer resection of the hypertrophic articular processes and the yellow ligament on the contralateral side , create sufficient capacity of the spinal canal. This will provide sufficient visibility without additional injury to the muscles and ligamentous apparatus when they are shifted to the opposite side, since the ischemia of the muscles squeezed between the retractor and the spinous process cut off from the vertebral arch is minimized.

In addition, the spinous process itself is preserved and after the operation is completed within 8-12 months, it consolidates at the cut-off from the vertebral arch.

Thus, the proposed combination of essential features provides a solution to the problem.

The invention is illustrated by drawings, where, schematically in FIG. 1 shows parasagittal access to the spinal canal; FIG. 2 - cut off spinous process from the base of the arch of the vertebra, in FIG. 3 - abduction of the muscle along with the spinous process to provide extensive visualization of the contra-lateral side.

In FIG. 4 is a snapshot of magnetic resonance imaging (MRI) of the spinal canal of patient A. before surgery, FIG. 5 is a snapshot of multispiral computed tomography (MSCT) with contrasting of the dural sac of patient A. before surgery, FIG. 6 is a snapshot of MSCT with contrasting the dural sac of patient A. after surgery.

In FIG. 7 is an MRI image of the spinal canal of patient B. before surgery, FIG. 8 is a snapshot of MSCT of the spinal canal of patient B. after surgery, FIG. 9 - a snapshot of the MSCT of the spine of patient B. after surgery.

The proposed method is as follows.

Access to the spine is carried out parasagittally by blunt stratification of the muscles in the intermuscular groove between the fibers of muscle 1 and muscle 2 through skin incisions of about 3-4 cm when performing parasagittal access, for example, by Wiltse using tubular retractors (Fig. 1). An interspinous gap is distinguished in the projection 3 of the stenosing process. Perform interlaminar access to the spinal canal (Fig. 2). The spinous process 4 of the vertebra is cut off at the base at the place of attachment to the arch 5 of the vertebra, the spinous process 4 with the soft tissues of muscle 1 is removed on the opposite side (Fig. 3). Thus, the diagonal access going from the access site dorsally above the dural sac in the direction of the contralateral side of the spinal canal is fully visualized. When the dural sac 6 and the cuff of the spine 7 are sufficiently decompressed, the vertebral arch 5 from the side of the spinal canal is resected dome-shaped. The yellow ligament and medial parts of the ipsilateral facet joint are removed to achieve decompression. Turning the operating table slightly and adjusting the angle of the microscope, visualize the diagonal passage 3 extending dorsally above the dural sac 6 and remove the yellow ligament 8 and hypertrophied medial parts of the contralateral facet joint 9.

Thus, decompression of the dural sac 6, two adjacent spinal roots 7 from this and the opposite side is carried out (Fig. 2, 3).

Decompression of the opposite spinal root 7 is considered adequate with its good visualization, sufficient mobility and the availability of reserve spaces.

Clinical example

Patient K., 54 years old, was admitted to the neurosurgical department No. 2 of Novosibirsk NIIIT with complaints about:

1) pain in the lumbar spine, aggravated by physical exertion, sitting position;

2) periodically occurring pains on the outer surface of the left thigh and lower leg, aggravated by walking;

3) numbness on the outer surface of the thighs, legs;

4) due to the appearing weakness and pronounced numbness in the lower extremities, it cannot pass more than 100 meters without rest.

Medical history: Lumbar pain has been a concern for 10 years. Periodic exacerbations with a satisfactory effect from conservative therapy. In August 2010, another exacerbation, for the first time, intense pain appeared on the front-outer surface of the left thigh and lower leg to the rear of the foot. Against the background of conservative therapy, the pain regressed within 3 months. In January 2013, pain in the lumbar region and left leg resumed. Conservative therapy without effect. Received for surgical treatment.

Survey data

R-gr of the lumbar spine - ostechondrosis of the lumbar spine, segmental instability at the level of L4-L5. Spondylarthrosis L4-L5. Degenerative spondylolisthesis of L4 vertebra 1 tbsp. (10%). Lumbar hyperlordosis.

MRI of the lumbar spine - Degenerative changes in the intervertebral discs L3 / 4, L4 / 5, L5 / S1. Circular protrusion of the L3 / 4 disk. L4 / 5 circular protrusion with left-side lateralization. Circular protrusion of the L5 / S1 disc. Degenerative stenosis of the spinal canal mainly at the level of L4 / 5. Narrowing of the intervertebral foramen L4 / 5 on the right, L5 / S1 on the left. Spondylarthrosis 2 tbsp.

Myelography of the lumbar spine - on the lumbar myelograms, uneven narrowing and deformation of the dural sac due to the arcuate squeezing of the anterior and lateral walls at the level of L3-4, L4-5 intervertebral discs (narrowing of the sagittal size d / m at the level of L3-L4 to ~ 5, are determined 5 mm, L4-L5 up to ~ 6.5 mm; the medial sections of the cuffs of the spinal roots are made with a contrast medium (Figure 9).

On functional MG instability is noted at the level of L3-L4, L4-L5 segments; during flexion, the sagittal size d / m at the L3-L4 level increases to 8 mm, at the L4-L5 level it does not change significantly.

MSCT of the lumbar spine with contrasting dural sac - an arcuate squeezing of the ventral contour of the contrasted dural sac at the level of the L4-5 disc with a narrowing of the sagittal size of the spinal canal to 7 mm, circular protrusion of the disc by 4.5 mm and due to antelisthesis of the L4 vertebral body by 3 mm .

Deformation of the cuffs of the spinal roots is not determined.

Clinical diagnosis: Osteochondrosis of the lumbar spine with a primary lesion of L4-L5, degenerative spondylolisthesis L4, degenerative spinal stenosis at the level of L4-L5, compression radicular syndrome L5 on the left, syndrome of neurogenic intermittent claudication.

Operation: A linear incision of soft tissues in the projection of the articular pairs L4-L5 on the left, retreating from the spinous processes of 3 cm. Dull muscle stratification in the intermuscular groove. The articular pair L4-L5 on the left is highlighted. A Qudrant tubular retractor is installed. The intersternal gap L4-L5 on the left is highlighted. Using a microscope (magnification x2,2-4,4) interlaminectomy, foraminotomy L4-L5 left. Rough stenosis of the spinal canal is noted at the L4-L5 level: the roots and dural sac are compressed by hypertrophic articular pairs, hypertrophic yellow ligament. The spinous process was cut off from the place of attachment to the arch of the vertebra. The spinous process with soft tissues and muscles was taken to the opposite side. A medial facetectomy was performed at the L4-L5 level on the left, a hypertrophic yellow ligament was resected, the vertebral arch was resected dome-shaped, the yellow ligament and medial parts of the contralateral facet joint were removed, thereby achieving bilateral decompression of the dural sac and roots at the L4-L5 level. Compression is eliminated, the roots straightened, lie freely, a distinct ripple of the dural sac appeared. Hemostasis control: dry. Liquor does not leak into the wound. Layered stitches on the wound. Iodine. Aseptic dressing. Blood loss was 150 ml.

Postoperative course without features. She noted moderate pain in the area of the postoperative wound, pain in the lower extremities was not disturbed. Later, when walking to a distance of more than 500 m, pain and numbness in the lower extremities were not disturbed.

The wound healed by primary intention. Cosmetic intradermal sutures, did not need removal.

On the seventh day after the operation, the patient was discharged in satisfactory condition under the supervision of a neurologist at the place of residence.

The proposed method allows to create a sufficient capacity of the spinal canal with its mono-polysegmental stenosis at the lumbar level while reducing trauma, reducing the duration of surgery, improving the quality of life in the postoperative period, and reducing the number of complications.

Claims (1)

A method of microsurgical decompression of the neurovascular structures of the spinal canal in the treatment of stenosis of the lumbosacral spine, including access to the spine, separation 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, performing intracanal manipulations, characterized in that access to the spine is made by blunt stratification of the muscles in the intermuscular groove through 3-4 cm skin incisions when performing the parasus ottal access, then provide interlaminar access to the spinal canal, the spinous process of the corresponding vertebra is cut off at the place of attachment to the vertebral arch, the spinous process is removed along with soft tissues to the opposite side, thus fully visualizing the diagonal access going from the access point dorsally above the dural sac into direction of the contralateral side of the spinal canal, the vertebral arch from the side of the spinal canal is resected dome-shaped, the yellow ligament and hypertro are removed veneered medial parts of the contralateral facet joint.

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