RU2717370C1 - Method of surgical treatment of multi-level degenerative diseases of lumbar spine - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely to neurosurgery, and can be used in surgical management of multi-level degenerative compression lumbar injuries. Method involves paramedic approach to the spinal canal, resection of a zygapophysial joint, a discectomy, a transforamal setting of the cage, separation of the inter-spine gangue at the adjacent level, inter-spine stabilization with the implant. Paramedian approach is performed by incision of skin and subcutaneous fat 3 cm laterally from median spinal line and incision of thoraco-lumbar fascia by 1 cm medial to skin incision. That is followed by performing a discectomy, decompression and installation of an interbody fuse and screws on an involved spinal segment, through the same access at level of installation of interspinous implant, pseudo-lumbar fascia is peeled from spinous processes by blunt method, without damaging supraspinous ligament, and interosseous implant is installed on adjacent segment.

EFFECT: method provides reduced iatrogenic skin damage and paravertebral soft tissues, reduced pain syndrome, reduced risk of degeneration of the adjacent spinal level due to use of single access for caged insertion and inter-osteal stabilization by the implant and preservation of the integrity of the thoracolumbar and periosteal ligaments.

1 cl, 9 dwg, 2 tbl

Description

The invention relates to medicine, namely to neurosurgeons, and can be used in the surgical treatment of multilevel degenerative compression lesions of the lumbar spine.

Degenerative diseases of the lumbar spine, combined with stenosis of the spinal canal and instability of the spinal motor segment (PDS), contribute to the formation of degenerative changes in the intervertebral disc and the arched joints (DS) at adjacent levels, in the vast majority of cases of the overlying segment [1] (Kim M. C, Wang N. S, Ju CI, Kim SW Severe Retrolisthesis at the Adjacent Segment after Lumbar Fusion Combined with Dynamic Stabilization. Korean J Neurotrauma. 2017 Apr; 13 (1): 50-53).

Currently, the tactics for most degenerative diseases of the PDS are based on the use of decompression-stabilizing operations at the affected level [2] (Khominets V.V., Nadulich K.A., Nagorny E.B., Kudyashev A.L., Teremshonok A. B. Features of surgical tactics in the treatment of patients with lumbar degenerative spondylolisthesis // Journal of Clinical and Experimental Orthopedics named after G.A. Ilizarov 2018. Volume 24, No. 2. P. 221-228).

The unsatisfactory results of rigid decompression-stabilizing interventions on the lumbar segments include: severe postoperative reflex pain and a decrease in the quality of life due to significant damage to the paravertebral tissues, as well as accelerated degeneration of the adjacent segment due to biomechanical overload [3] (Afaunov A.A., Basankin I .V., Kuzmenko A.V., Shapovalov V.K. Analysis of the causes of revision operations in the surgical treatment of patients with lumbar stenosis of degenerative etiology // Ubanskii Research Medical Gazette. 2013. №7. pp 173-176).

The “gold standard” for the surgical treatment of degenerative diseases of the lumbar spine is posterior decompression with classic open transpedicular fixation and interbody fusion, including a longitudinal section along the midline above the spinous processes, layer-by-layer skeletonization of the spinous processes, vertebral arches, resection of the facet implant joint, . Subsequently, the screws are installed through the legs of the vertebrae on both sides, the longitudinal beams are laid and fixed with nuts. The wound is then sutured in layers with drainage [4] (Logroscino CA, Proietti L, Pola E, et al. A minimally invasive posterior lumbar interbody fusion for degenerative lumbar spine instabilities. Eur Spine J. 2011; 20 Suppl 1: S41-45. doi: 10.1007 / s00586-011-1762-1).

The disadvantages of this method are:

- damage to the musculo-ligamentous apparatus and a significant amount of blood loss caused by rough subperiosteal skeletonization of the spinous processes, vertebral arches;

- severe postoperative pain syndrome associated with significant damage to paravertebral tissues;

- a long recovery period due to persistent pain and low physical activity;

- increased risk of developing degeneration of an adjacent level associated with the redistribution of the axial load on the PDS during rigid stabilization with screws.

Also known is a method of interspinous stabilization, including a longitudinal incision of the skin and subcutaneous adipose tissue in the projection of the spinous processes of the vertebrae, bilateral linear section of the thoraco-lumbar fascia, sequential skeletonization of the spinous processes, removal of the supra- and interspinous ligaments to the dural sac, selection of the required implant size and its installation, tight fixation to the spinous processes and layered wound closure [5] (Pawar, SG, Dhar, A., Prasad, A., Munjal, S., & Ramani, PS Internal decompression for spinal stenosis (IDSS) for decompression and use of inte rlaminar dynamic device (CoflexTM) for stabilization in the surgical management of degenerative lumbar canal stenosis with or without mild segmental instability: our initial results. Neurological Research 2017, 39 (4), 305-310).

The disadvantages of this method are:

- skeletonization of the intersternal gap is accompanied by local atrophy of the paravertebral muscles;

- interspinous stabilization is not rigid enough and fixation may be ineffective with increasing segmental instability at the operated level.

A.,

N.G., Ciancio A.M., Gagliardi М., Falavigna A. How to perform the Wiltse posterolateral spinal approach: Technical note. Surg Neurol Int. 2018. Vol. 9. P. 38).Closest to the claimed is a method of minimally invasive spinal fusion with transpedicular fixation and interspinous stabilization of an adjacent segment, which is carried out in stages from different approaches [6] (Guiroy A.,

A.,

NG, Ciancio AM, Gagliardi M., Falavigna A. How to perform the Wiltse posterolateral spinal approach: Technical note. Surg Neurol Int. 2018. Vol. 9. P. 38).

A.,

N.G., Ciancio A.M., Gagliardi М., Falavigna A. How to perform the Wiltse posterolateral spinal approach: Technical note. Surg Neurol Int. 2018. Vol. 9. P. 38), заключающиеся в том, что хирургический доступ, этапы декомпрессии и стабилизации выполняются в следующем порядке:The first stage is posterolateral access, interbody fusion and stabilization according to Wiltse [7] (Guiroy A.,

A.,

NG, Ciancio AM, Gagliardi M., Falavigna A. How to perform the Wiltse posterolateral spinal approach: Technical note. Surg Neurol Int. 2018. Vol. 9. P. 38), consisting in the fact that surgical access, stages of decompression and stabilization are performed in the following order:

a) the patient is in the “lying on his stomach” position, under the control of an electron-optical transducer (EOP), markings are made on the surface of the skin in the area of the proposed surgical intervention, then two cuts of the skin and the chest-lumbar fascia are performed 3-4 cm from the median lines;

b) stratify paravertebral muscles in a "blunt" way;

c) visualize the junction of the transverse process and the arched joints (DS);

d) removal of the arched joints (DS) and parts of the arch of the overlying vertebra, discectomy, transforaminal interbody fusion in the decompression area, then transpedicular screws are installed, first in the decompression area, and then from the contralateral side.

The next step in the operation is the installation of an interspinous implant, which is performed according to the following scheme:

a) perform an additional midline incision of the skin and thoracolumbar fascia at the site of the proposed surgical intervention;

b) skeletonize the paravertebral muscles from the spinous processes;

c) fragmentation of the supraspinous and interspinous ligaments;

g) make the installation of interspinous implant.

The disadvantages of this method include:

- significant operational aggression associated with several skin incisions and projective damage to paravertebral tissues;

- a long time of surgical intervention and anesthetic management, justified by the implementation of each access in stages;

- the long healing period of the surgical wound due to a violation of the blood supply to the surrounding tissues due to closely located skin incisions;

- the development of significant local pain in the early postoperative period associated with multiple skin incisions and dissection of paravertebral tissues.

Based on the analysis of known sources of information that reveal the features of minimally invasive surgical treatment of degenerative diseases of the lumbar spine, as well as addressing the shortcomings of known technologies, an improved method of surgical treatment is proposed, the technical result of which is:

- performing surgical manipulations on adjacent segments with less damage to the paravertebral muscles due to the use of one access with transforaminal cage installation and interspinous stabilization with an implant;

- maintaining the integrity of the thoracolumbar fascia and supraspinatus ligament when performing interspinous stabilization;

- reduction of postoperative pain, reducing the risk of degeneration of the adjacent level of the spine;

- reducing the time of surgery and the duration of anesthesia in the surgical treatment of multilevel degenerative compression lesions of the lumbar spine.

The result of the proposed invention is achieved by the fact that the proposed method for the surgical treatment of multilevel degenerative diseases of the lumbar spine includes performing a single skin incision, resection of the arched joint, discectomy, transforaminal cage installation, separation of the interspinous gap at an adjacent level, interspinous stabilization with an implant. Through one paramedian access, a discectomy and transforaminal cage installation are performed first. Then, discectomy and transforaminal interbody fusion with implant placement are performed. Access to the spinal canal is made lateral to the midline of the spine, stratifying subcutaneous fat and additionally perform a fascia incision medial to the skin incision. Before installing the interspinous implant, the lumbar fascia is exfoliated from the spinous processes at the level of the proposed installation of the interspinous implant using a blunt method without damaging the supraspinatus ligament.

Access to the spinal canal through one paramedian access allows to reduce the number of skin incisions, to reduce the damaging factor on the paravertebral muscles and thoracic-lumbar fascia.

Access to the spinal canal is lateral to the midline of the spine, with stratification of subcutaneous fat and an additional fascia incision medial to the skin incision, which makes it possible to adequately visualize all stages of surgical intervention at the level of rigid stabilization and in the adjacent segment.

Before installing the interspinous implant, the thoracolumbar fascia is exfoliated from the spinous processes at the level of the proposed installation of the interspinous implant using the "blunt" method without damaging the supraspinatus ligament, which allows them to maintain their integrity and stability of the posterior support complex of the spine.

After the clinical application of the proposed method and the analysis of the results obtained, the authors found that improved surgical techniques allowed the functional and trophic disorders of the spine to be less traumatic and the postoperative appearance of the patient’s back was aesthetically pleasing.

Patent research on subclass A61B 17/00 and analysis of other sources of information reflecting the current level of technologies for surgical treatment of degenerative lesions of the lumbar spine did not reveal methods identical to the proposed one. A comparative analysis of this technical solution and existing technologies allowed us to conclude that the proposed method is distinguished by the above methods and meets the criterion of "novelty."

Based on the analysis of the clinical application of the proposed method for the treatment of multilevel diseases of the lumbar spine, the authors established the following advantages:

- a decrease in the severity of pain due to the absence of gross damage to the paravertebral muscles and ligaments, since two-stage surgical treatment is performed from one incision, in contrast to known methods, where an additional incision is made to install an interbody implant;

- the ability to effectively visualize the spinal canal in the area of surgical intervention without performing an additional skin incision to install the implant;

- the absence of ischemia of the skin flap and the rapid healing of the wound due to fewer incisions, delamination of the thoracolumbar fascia from the spinous processes by the "blunt" method, without damaging the supraspinatus ligament, as well as reducing the duration of surgery;

- restoration of working capacity and social adaptation of patients in a shorter period - 79 days, in contrast to the known - 90 days;

- maximum preservation of external aesthetics in the area of surgical intervention due to the reduction in the number of skin incisions.

From the foregoing, it follows that the claimed method meets the criteria of patentability "inventive step".

The proposed "Method of surgical treatment of multilevel degenerative diseases of the lumbar spine" is intended for use in healthcare and can be used in neurosurgery and traumatology. The possibility of its implementation is confirmed by the techniques described in the application, is available for use by neurosurgeons, therefore, the proposed method meets the criteria of the invention "industrial applicability".

The method is illustrated by illustrations, which show:

FIG. 1 is a diagram of a preoperative marking of access to the lumbar spine in the area of surgical intervention;

FIG. 2 is a diagram of a phased incision of the skin, subcutaneous fat and fascia;

FIG. 3 is a diagram of installed implants;

FIG. 4 - MRI of the lumbosacral spine of patient B. before surgery: a - sagittal projection at level L _IV - S _I , b - axial projection at level Lv-S _I , c - axial projection at level L _IV - L _V ;

FIG. 5 is a view of the sutured postoperative wound of patient B .;

FIG. 6 - spondylography of the lumbosacral spine of patient B. after surgery: a - lateral projection, b - direct projection;

FIG. 7 - MRI of the lumbar spine of patient B. 12 months after surgery: a - sagittal projection at the level of L _IV - S _I , b - axial projection at the level of L _V -S _I , c - axial projection at the level of L _IV - L _V ;

FIG. 8 - table No. 1 - features of surgical interventions and postoperative management of patients of the studied groups;

FIG. 9 - table No. 2 - degenerative changes of the adjacent affected segment in patients of the studied and control groups.

We explain some of the positions used in the presented illustrations, reflecting the stages of surgical treatment:

1 - leather

2 - subcutaneous fat,

3 - fascia,

4 - paravertebral muscles,

5 - arched joint,

6 - vertebral body,

7 - the average distance from the midline to the alleged skin incision,

8 - the average distance from the midline to the proposed section of the fascia,

9 - installed interspinous implant,

10 - installed transpedicular system (two screws, longitudinal beam).

The essence of the proposed "Method of surgical treatment of multilevel degenerative diseases of the lumbar spine" is as follows.

The patient is in the “lying on his stomach” position with unloading rollers. Before the operation, access markings are made on the skin of the patient’s back (see the appendix to the description of the application for the invention, Fig. 1). Perform paramedian access to the spinal canal via Wiltse at a distance of 2.5-3 cm lateral to the midline of the spine at the level of degeneratively altered vertebrae. The skin is dissected, subcutaneous fatty tissue is stratified and an additional incision is made of the thoraco-lumbar fascia 1 cm medial to the skin incision (see the appendix to the description of the application for the invention, Fig. 2). Using minimally invasive tubular retractors, transforaminal access is performed. Then, through this paramedian access, discectomy, decompression and installation of the interbody cage and screws on the affected segment of the spine are first performed. Then, through the same paramedian access, using the tubular retractor, the thoracic lumbar fascia from the spinous processes is peeled off using the “blunt” method, without damaging the supraspinous ligament, and an interspinous implant is placed on the adjacent segment (see the appendix to the description of the application for the invention, Fig. 3 ) A thorough hemostasis of the vessels of the muscle, subcutaneous fat layers is carried out and the surgical wound is sutured. Apply an aseptic dressing.

The essence of the proposed method is illustrated by an example of a specific implementation.

Patient B., born in 1978, was hospitalized with complaints of severe pain in the lumbar spine, arising from dynamic loads, radiating to the left buttock, along the back-side surface of the left thigh, lower leg, fingers of the left foot. Numbness in the area of pain.

A comprehensive preoperative assessment of the level of pain according to the visual analogue scale (VAS) in the lumbar spine was 92 mm, in the left lower limb 96 mm, the level of functional status according to ODI was 68 points. Sick for more than 5 years, with annual exacerbations up to 4 times, the last exacerbation lasted for 6 weeks, conservative treatment was ineffective.

Neurological status: Cranial nerves and upper limbs are intact. Movement in the lumbar is sharply painful, limited. Symptom Laseg D = 70 °, S = 40 °. Knee reflexes D = S, live, Achilles D = S, reduced. Defense of paravertebral muscles of the III degree. Sensory impairment in the form of hypesthesia in the area of dermatome S1 on the left. Strength in the lower extremities 5 points. Pelvic abnormalities were not detected.

An MRI scan of the lumbar spine was performed (an appendix to the description of the application for an invention, Fig. 4 a, b, c). Conclusion: MP-signs of osteochondrosis, left-sided paramedian disc herniation L _V -S _I , protrusion of the disc L _IV -L _V.

Electroneuromyography (ENMG) of the lower extremities: a decrease in the amplitude of the maximum M-response during stimulation of the tibial and peroneal nerves on the left.

Diagnosis at admission: “Dorsopathy. Aggravation. Osteochondrosis of the lumbar spine. Herniated disc L _V -S _I. Protrusion of the intervertebral disc L _IV -L _V. Radiculoneuritis S1 on the left. Lumbar ischialgia syndrome on the left. Severe pain and muscle-tonic syndromes. "

Taking into account the data of clinical and neurological examination, the results of additional research methods, severe pain syndrome resistant to conservative therapy, the risks of progression of compression of the cauda equina roots, as well as the risks of progression of the degenerative process at the level of L _IV -L _V , the patient is shown surgical treatment in the amount of - minimum -invasive decompression, interbody fusion and transpedicular fixation L _V -S _I , interspinous stabilization L _IV -L _V according to the proposed method.

The operation in the patient's position "lying on his stomach" with unloading rollers. After treating the surgical field with antiseptics under intravenous anesthesia using artificial lung ventilation, skin markings were made in the projection of the articular pairs L _V -S _I 3 cm lateral from the midline of the spine. An incision was made in the skin, subcutaneous fat and thoraco-lumbar fascia 1 cm medial to the skin incision. A tubular retractor is installed. The interventricular gap L _V -S _{I was} allocated on the left - a total facetectomy with canal decompression was performed, microsurgical discectomy L _V -S _I followed by transforaminal interbody fusion (the cage cavity was filled with autobone). Through the roots of the arcs, transpedicular screws were installed in the bodies of the L _V and S _I vertebrae under the control of the EOP. The rods are laid in the screw heads, and the transpedicular system is mounted on both sides. Through the same access, the thoraco-lumbar fascia is separated from the spinous processes at the level of L _IV -L _V using a tuffer, along with the skin and subcutaneous fatty tissue laterally. The spinous processes of L _IV -L _{V are} visualized. Retractor installed. Peeling of the lumbar fascia from the spinous processes at the installation level of the interspinous implant was performed using the “blunt” method without damaging the supraspinatus ligament. The interspinous ligament was fragmented. An interspinous implant was installed. A thorough hemostasis of the vessels of the muscular, subcutaneous fat layers was carried out. Produced layer-by-layer suturing of the surgical wound (see the appendix to the description of the application for the invention, Fig. 5). An aseptic dressing is applied.

The duration of the operation was 2 hours 10 minutes. The duration of using the x-ray control is 16 seconds.

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

Spondylography of the lumbosacral spine was performed on the 7th day after the operation (see the appendix to the description of the application for the invention, Fig. 6): the position of the installed structures is correct, there are no signs of migration and instability.

At discharge (10 days after surgery) the patient's condition is satisfactory. In neurological status, complete regression of radicular pain and muscle-tonic syndromes. A comprehensive assessment on scales: the level of pain according to YOUR in the lumbar spine was 4 mm, in the left lower limb 1 mm, the level of functional status according to ODI was 8 points.

1.5 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.

During the follow-up examination after 3, 6 and 12 months after surgery, the pain syndrome is absent and the optimal functional state is maintained.

On an MRI gram of the lumbosacral spine, performed 12 months after the operation, there was no muscle atrophy in the field of rigid stabilization, there was no progression of the degenerative process at an adjacent level (see the appendix to the description of the application for the invention, Fig. 7).

Using the proposed method, 12 patients with multilevel degenerative diseases of the lumbar spine at the age of 44 (37; 58) years were operated, the ratio of men and women was 2: 1, the growth was 177 (169; 181) cm, weight - 84 (72; 90 ) kg and control group - 15 patients.

Pain syndrome, assessed by the visual-analogue pain scale, decreased significantly after surgery in all patients (p = 0.005). ODI functional status improved significantly from the preoperative level - 80 (72; 88.5) points to 12 (8; 16) points in the long-term postoperative period (p = 0.003).

When analyzing postoperative complications in the studied group of patients, only 1 case was identified associated with the formation of intermuscular hematoma without signs of infection.

The results of the technical features of the interventions and the parameters of postoperative management of patients are presented in table 1 (see the appendix to the description of the application for the invention, Fig. 8), where, in comparison with the control group, it is shown that the proposed method allowed to reduce the time of surgery, the amount of blood loss and the total amount of skin cut.

Changes in the adjacent segment are shown in table 2 (see the appendix to the description of the application for the invention, Fig. 9). In the studied patients, significant degenerative changes in the segment adjacent to the rigid stabilization were not recorded in the long-term postoperative period (p> 0.05).

Operated according to the proposed methodology, patients returned to their previous labor activity on average 79 (71; 85) days after surgery, and during treatment with known methods - 90 days or more.

Thus, the proposed “Method for the surgical treatment of multilevel degenerative diseases of the lumbar spine” allowed creating the maximum conditions for restoring the quality of life, labor and social rehabilitation, reducing iatrogenic damage to the skin and paravertebral soft tissues, reducing the severity of pain and restoring functional status with minimal operational trauma. as well as reduce the risks of degeneration of an adjacent level.

None of the patients in the long-term period had the need for additional decompression or decompression-stabilizing interventions on the operated and adjacent vertebral-motor segments. The surgical capabilities of this method are high, it is designed for the joint work of a surgeon and an experienced assistant.

Sources of information taken into account:

1. Kim M. C, Wang N. S, Ju CI, Kim S. W. Severe Retrolisthesis at the Adjacent Segment after Lumbar Fusion Combined with Dynamic Stabilization. Korean J Neurotrauma. 2017 Apr 13 (1): 50-53.

2. Khominets B. B., Nadulich K. A., Nagorny E. B., Kudyashev A. L., Teremshonok A. V. Features of surgical tactics in the treatment of patients with lumbar degenerative spondylolisthesis // Journal of Clinical and Experimental Orthopedics named after G.A. Ilizarova 2018. Volume 24, No. 2. S. 221-228.

3. Afaunov A.A., Basankin I.V., Kuzmenko A.V., Shapovalov V.K. Analysis of the causes of revision operations in the surgical treatment of patients with lumbar stenosis of degenerative etiology // Kuban Scientific Medical Bulletin. 2013. No. 7. S. 173-176.

4. Logroscino CA, Proietti L, Pola E, et al. A minimally invasive posterior lumbar interbody fusion for degenerative lumbar spine instabilities. Eur Spine J. 2011; 20 Suppl 1: S41-45. doi: 10.1007 / s00586-011-1762-1.

5. Pawar, SG, Dhar, A., Prasad, A., Munjal, S., & Ramani, PS Internal decompression for spinal stenosis (IDSS) for decompression and use of interlaminar dynamic device (CoflexTM) for stabilization in the surgical management of degenerative lumbar canal stenosis with or without mild segmental instability: our initial results. Neurological Research 2017, 39 (4), 305-310.

6. Reginald J. Davis, MD, * Thomas J. Errico, MD, t Hyun Bae, MD, * and Joshua D. Auerbach, MD. Decompression and Coflex Interlaminar Stabilization Compared With Decompression and Instrumented Spinal Fusion for Spinal Stenosis and Low-Grade Degenerative Spondylolisthesis. SPINE Volume 38, Number 18, pp 1529-1539.

A.,

N.G., Ciancio A.M., Gagliardi M., Falavigna A. How to perform the Wiltse posterolateral spinal approach: Technical note. Surg Neurol Int. 2018. Vol. 9. P. 38.7. Guiroy A.,

A.,

NG, Ciancio AM, Gagliardi M., Falavigna A. How to perform the Wiltse posterolateral spinal approach: Technical note. Surg Neurol Int. 2018. Vol. 9. P. 38.

Claims (1)

A method for the surgical treatment of multilevel degenerative diseases of the lumbar spine, including paramedian access to the spinal canal, resection of the arched joint, discectomy, transforaminal cage installation, separation of the interspinous gap at an adjacent level, interspinous stabilization with an implant, characterized in that the paramedaned and intermediated access fatty tissue 3 cm lateral to the midline of the spine and section of the thoraco-lumbar fascia per 1 cm of media of the skin incision, then through this access, discectomy, decompression and installation of the interbody cage and screws on the affected segment of the spine are performed, through the same access, at the level of the interosseous implant installation, the thoracic lumbar fascia is peeled from the spinous processes by the blunt method, without damaging the supraspinatus ligament and the interspinous ligament is established implant on an adjacent segment.

Images