RU2644922C1 - Method for surgical access to invertebral disc during lumbar spine degenerative instability treatment - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: median longitudinal incision of the skin and subcutaneous fat is made in the projection of the spinous processes of the operated vertebrae. The latero-thoracolumbar fascia is exposed laterally and opened with a longitudinal incision from the posterior aorta of the ilium up along the outer edge of the long back muscle. Through the fascial space between the square back muscle and the long muscle, the posterior access is performed to the transverse processes L3, L4, L5, lateral sacrum mass, L3-L4, L4-L5, L5-S1 joints. Intertransverse muscle and fascia from the upper edge of the transverse processes of the lumbar vertebrae and the lateral sacrum mass are cut. Extra-granular access to the intervertebral disc in the Cambina triangle is performed through resection of the extraphoraminal part of the fibrous ring.

EFFECT: method allows to reduce the risk of neural structures injury, to reduce cicatricial changes in the surgery area.

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Description

The invention relates to medicine, namely to neurosurgery and orthopedics, and can be used in the surgical treatment of patients with spondylolisthesis of the lumbar spine of various etiologies.

A known method of access to the intervertebral disc of the lumbar spine (Briggs H, Milligan P. Chip fusion of the low back following exploration of the spinal canal. J Bone Joint Surg. 1944; 26: 125-130), in which the skin and subcutaneous tissue are dissected. along the spinous processes, the superficial sheet of the thoracolumbar fascia is cut off from the supraspinatus ligament, the spinous processes of the vertebral arches, intervertebral joints are skeletonized, followed by traction in the lateral direction of the paravertebral muscles. Access to the intervertebral disc is performed through the spinal canal, after partial or complete resection of the arches and removal of the yellow ligament. Visualization of the posterior longitudinal ligament and intervertebral disc provide traction of the spine and dural sac in the medial direction.

The disadvantages of the method are:

- the need for skeletonization of the spinous processes, arches and arched joints at the operated and adjacent levels;

- violation of the biomechanics of the operated segment due to partial destruction of the elements of the posterior backbone complex of the spine, cutting off the muscles from the place of their attachment, as well as a violation of the blood supply and innervation of the divided muscle and the arched joints. In the postoperative period, this is manifested by a local pain syndrome, and is also one of the factors for the progression of degenerative changes at adjacent levels. The development of these consequences, due to the technique of performing surgical access, has a significant impact on the quality of life of the patient and in some cases requires repeated surgical treatment.

Closest to the claimed is a method of access to the intervertebral disc of the lumbar spine (Wiltse LL, Bateman JG, Hutchinson RH, Nelson WE: The paraspinal sacrospinalis-splitting approach to the lumbar spine. J. Bone Joint Surg Am. 50: 919-926, 1968), adopted as a prototype. In the known method perform a midline incision of the skin and subcutaneous adipose tissue in the projection of the operated segment. 2 cm laterally moving away from the spinous process, the long back muscle is pulled apart and extended to the sides for the length necessary to visualize the base of the superior articular and transverse processes, joints and lateral sections of the arches of the operated segment. At the same time, the divided muscle is cut off from the upper articular process and the lower edge of the lamellar part of the vertebral arch. Decompression of the elements of the spinal canal and access to the intervertebral disc is performed by flavectomy, foraminotomy or medial facetectomy with dissection of the posterior longitudinal ligament after traction of the root and dural sac medially.

The disadvantages of the prototype are:

- the need to cut off the multi-divided muscle and its intense traction to provide the necessary overview, which increases the morbidity of access, the need for postoperative pain relief and complicates the early activation of patients;

- the risk of complications caused by direct trauma to the neural structures, as well as traction and cicatricial changes in the area of operation, since the main manipulations are performed through the spinal canal with traction of the root and dural sac medially.

The present invention solves the problem of developing a method of surgical access to the intervertebral disc in the treatment of degenerative instability of the lumbar spine.

The positive effect obtained by using the claimed method consists in providing a wide view in the surgical wound, reducing trauma and preventing complications caused by direct trauma to the neural structures.

The technical problem is solved due to the fact that in the claimed method, including performing a median longitudinal section of the skin and subcutaneous adipose tissue in the projection of the spinous processes of the operated vertebrae, the lateral thoracolumbar fascia is exposed and opened with a longitudinal incision from the posterior iliac spine upward along the outer edge of the long back muscle , through the fascial space between the square muscle of the back and the long muscle of the back, access to the transverse processes of L3, L4, L5, the lateral mass of the sacrum, joints L3-L4, L4-L5 , L5-S1, then cut off the transverse muscles and fascia from the upper edge of the transverse processes of the lumbar vertebrae and the lateral mass of the sacrum and perform extraforaminal access to the intervertebral disk in the Cambridge triangle.

The proposed method, in comparison with the prototype, has several advantages:

- performed in it access to the arched joints and transverse processes through the posterior group of back muscles laterally from the midline excludes the cut-off muscle from being cut off from the attachment points to the bone and does not impair its function in the postoperative period;

- eliminates the need for razvlecheniya long muscle of the back;

- access to the intervertebral disk is performed lateral to the arched joint, which eliminates the need for resection of the articular facets and traction of the nerve roots in the spinal canal;

- it is possible to visualize the intervertebral joints, transverse processes, the lateral half of the arches and yellow ligaments, as well as the intervertebral discs.

In addition, the proposed method of access to the intervertebral discs, performed laterally more than the arched joints, without cutting off the divided muscle of the back from the places of its attachment to the elements of the posterior support complex, which does not violate its innervation and blood supply, allows discectomy to eliminate stenosis without the need for manipulation through the spinal canal .

The method is as follows.

A midline longitudinal incision is made of the skin and subcutaneous adipose tissue in the projection of the spinous processes of the operated vertebrae. The thoracolumbar fascia is exposed laterally and opened with a longitudinal incision from the posterior iliac spine upward along the outer edge of the long back muscle. Through the fascial space between the square muscle of the back and the long muscle of the back, access to the transverse processes of L3, L4, L5, the lateral mass of the sacrum, joints L3-L4, L4-L5, L5-S1. Then cut off the transverse muscles and fascia from the upper edge of the transverse processes of the lumbar vertebrae and the lateral mass of the sacrum. Thus visualize the lumbar nerves at the level of exit from the radicular openings. In the Cambin triangle, formed from above by the lumbar nerve, from below by the upper edge of the underlying transverse process, by the medially lower articular facet of the arched joint, extraforaminal access to the intervertebral disk is performed. Access to the intervertebral disc is via resection of the extraforaminal portion of the fibrous ring.

The inventive method is developed and passed clinical trials on the basis of the neurosurgery department of the Federal State Budget Scientific Institution Scientific Research Center named after V.A. Almazova "of the Ministry of Health of Russia in the treatment of 6 patients with multilevel degenerative spondylolisthesis, accompanied by foraminal stenosis. All patients managed to achieve adequate decompression, reduction and stabilization of the operated segments, all patients showed regression of radicular and vertebrogenic pain syndromes, an increase in walking volume. Performing decompressing and stabilizing manipulations, bypassing the spinal canal, avoided traction and direct damage to neural structures - there was no increase in neurological deficit in the early postoperative period, no liquorrhea was observed in any case. Reducing surgical trauma allowed all patients to verticalize on the first day after surgery, to reduce the duration of postoperative analgesia to 1-3 days. All patients were discharged in satisfactory condition 5-7 days after surgery. There were no infectious complications in any case. Clinical results were tracked for more than two years. None of the patients during the observation showed instability of fixation, the resumption of pain and signs of the progression of degenerative changes at an adjacent level.

We give an example - an extract from the medical history.

Patient M., born in 1959. Diagnosis: Multilevel degenerative spondylolisthesis, bilateral foraminal stenosis L3-L4-L5-S1, lower flaccid paraparesis, lumbar spine instability syndrome, vertebrogenic pain syndrome.

MRI of the lumbar spine from 03/12/2014: multilevel spondylolisthesis L3 I degree, L4 I degree, L5 II degree, diffuse disc herniation L3-L4, L4-L5, L5-S1, secondary stenosis of the radicular canals L3-L4, L4-L5, L5-S1. CT scan of the lumbar spine from 03/23/2014: multilevel spondylolisthesis. The body L3 is shifted forward by 0.4 cm, the body L4 is shifted forward by 0.6 cm, the body L5 is shifted forward by 1.3 cm, a vacuum phenomenon in the discs L3-L4, L4-L5, L5-S1. X-ray of the lumbar spine from 03/29/2014: in a standing position, the displacement of the L3 body anteriorly by 0.4 cm, L4 body anteriorly by 0.6 cm, L5 body anteriorly by 1.3 cm is determined. When performing functional tests, instability is detected in L3 segments -L4, L4-L5, L5-S1.

Given the presence of multilevel degenerative instability of the lumbar spine, confirmed by neuroimaging data, clinically manifested by syndromes of instability of the lumbar spine, bilateral neurocompression syndrome, the ineffectiveness of conservative treatment, in order to stop the leading clinical manifestations, a planned surgical intervention was performed on 04/04/2014. Decompression of the spinal canal, correction of deformity, interbody fusion with autologous bone and cage, transpedicular fixation of L3-L4, L4-L5, L5-S1 from the posterior lateral intramuscular access.

According to the claimed method: a mid-longitudinal section of the skin and subcutaneous fatty tissue is made in the projection of the spinous processes of L2-S1. The thoracolumbar fascia is laterally exposed and is opened by a longitudinal incision from the posterior iliac spine upward along the outer edge of the long back muscle. A bilateral approach to the transverse processes of L3, L4, L5 and the lateral mass of the sacrum, joints L3-L4, L4-L5, L5-S1 was made through the fascial space between the square muscle of the back and the long muscle of the back. Under the control of the image intensifier, screws are passed transpedicularly into the bodies L3, L4, L5 and S1. The transverse muscles are cut off in stages from the upper edge of the transverse processes L4, L5 and the lateral mass of the sacrum to the right. Thus, the right nerves L3, L4 and L5 are visualized at the level of exit from the radicular opening. Nerves L3, L4 and L5 are sequentially laterally displaced, which provided lateral extraforaminal access to the intervertebral discs L3-L4, L4-L5, L5-S1. The height of the discs L3-L4, L4-L5, L5-S1 is reduced, the root openings are deformed due to hypertrophy of the articular facets, pathological mobility at visualized levels is determined. By resection of the extraforaminal part of the fibrous ring, the apical part of the superior articular processes of the bodies L4, L5 and S1, the posterior edges of adjacent closure plates of the bodies L3, L4, L5 and S1, direct decompression of the nerve was performed and access to the intervertebral disk was provided. On the transpedicular screws, longitudinal beams are mounted on both sides in the distraction position. Against the background of distraction, diskectomy, mobilization and reduction of segments L3-L4, L4-L5, L5-S1 were performed. In the interbody spaces L3-L4, L4-L5, L5-S1 implanted support cages with autobone and osteoinductive material. The design is transferred to the position of moderate contraction and fixed permanently. Wounds are sutured in layers.

The postoperative period was uneventful; neuro-compression and vertebrogenic pain syndromes regressed in neurological status. Local pain in the area of the postoperative wound was easily stopped by non-steroidal analgesics, postoperative analgesia was not required after 3 days. The patient is vertical on the first day after surgery. The sutures were removed on the seventh day, the wound healed by primary intention.

On the control radiographs and computed tomograms of the lumbar spine - the displacement of the L3 vertebra anteriorly - 0.1 cm, L4 vertebra - 0.2 cm, L5 vertebra - 0.4 cm. In the interbody spaces L3-L4, L4-L5, L5-S1 bone crumbs, metal tags of cages are determined. The height of the interbody spaces L3-L4 and L4-L5 is 0.8 cm, L5-S1 is 1 cm. The segments L3-L4, L4-L5, L5-S1 are fixed with eight transpedicular screws. The position of the screws and cages is correct, stable.

Using the claimed method of surgical access to the lumbar spine allows you to perform decompression, reduction and stabilization of the operated level without cutting off the long back muscles from the places of its attachment to the elements of the back support complex and while maintaining its blood supply and innervation. In addition, this access option allows you to perform an approach to the lower intervertebral discs lateral to the arched joints, which allows discectomy to eliminate central stenosis without the need for manipulation through the spinal canal. Reducing the morbidity of access leads to a decrease in the duration and intensity of the postoperative pain syndrome, eliminates the violation of the statics of the operated and adjacent segments and reduces the frequency of infectious complications.

The applicant asks to consider the submitted application materials "Method of surgical access to the intervertebral disc in the treatment of degenerative instability of the lumbar spine" for the grant of a patent of the Russian Federation for the invention.

Claims (1)

A method of surgical access to the intervertebral disc in the treatment of degenerative instability of the lumbar spine, including performing a mid-longitudinal section of the skin and subcutaneous adipose tissue in the projection of the spinous processes of the operated vertebrae, characterized in that the lateral thoracic lumbar fascia is exposed and opened with its longitudinal section from the posterior spine along the outer edge of the long back muscle, through the fascial space between the square muscle of the back and the long muscle of the back access the transverse processes of L3, L4, L5, the lateral mass of the sacrum, the joints L3-L4, L4-L5, L5-S1, then cut off the transverse muscles and fascia from the upper edge of the transverse processes of the lumbar vertebrae and the lateral mass of the sacrum and perform in the Cambridge triangle extraforaminal access to the intervertebral disc through resection of the extraforaminal part of the fibrous ring.