RU2761600C1 - Method for revision surgical intervention on the lumbar spine - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention can be used in medicine, namely in neurosurgery, and can be used for revision surgical intervention on the lumbar spine. Guide wires are installed in the superjacent and subjacent vertebral bodies through the roots of the arches, then an incision of the skin, subcutaneous fat and thoracolumbal fascia is made between the wires on the side contralateral to the primary surgical intervention at a step of 3.5 to 4 cm from the middle line. The multifidus muscle up to the zygapophysial joint is divided by blunt dissection, a tubular retractor is installed, an interlaminar gap is isolated. The base of the spinous process is resected, the free fragment whereof together with the soft tissues is mobilised contralateral to the access. An interlaminar access to the spinal canal is provided and a semi-arch is resected. After visualising the unaltered dura mater, a view of the part of the spinal canal and intervertebral foramen is performed on the side contralateral to the access. Meningoradiculolysis is performed in the scar area, and the semi-arch contralateral to the access, scar tissue, hypertrophied ligamenta flava over the isolated area of dura mater are resected. In the course of resection of the bone tissue, the retractor blades are spread, the soft tissues and scar are mobilised to the cuff of the root on the side contralateral to the access and up to the intervertebral foramen. The dural sac is displaced, the peridural spaces are revised, the compressing substrate is removed, and a foraminotomy contralateral to the access is performed. Also, the disk cavity is curetted and an interbody cage is installed. Upon completing the decompression transpedicular screws are installed on the side of the access under X-ray control through the previously installed guide wires through the roots of the arches. Transcutaneous transpedicular stabilisation is performed on the side contralateral to the access.

EFFECT: method provides a reduction in the trauma rate, duration of surgery, and volume of blood loss due to a safe approach from the side of unaltered tissues, adequate visualisation of the neural structures, and preserved integrity of the multifidus lumbar muscle.

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Description

The invention relates to medicine, namely to neurosurgery, and can be used for revision surgery in case of recurrence of pain syndrome with the progression of the degenerative process at a previously operated level in the lumbar spine.

Despite the constant improvement of technologies for the diagnosis and surgical treatment of degenerative diseases of the lumbar vertebral segments, the number of unsatisfactory postoperative results is 10-30%. One of the main reasons for the formation of such unfavorable clinical outcomes is the recurrence of herniated intervertebral disc (IVD) at the previously operated level, often requiring reoperation [1]. The traditional method of mobilizing neural structures is their isolation from scar tissue. Performing such a revision intervention is accompanied by certain technical difficulties, the risk of intraoperative damage to the dura mater (TMT) of the dural sac and spinal roots with the development of liquorrhea, a high probability of the formation of infectious complications, and an increase in the duration of surgery increases.

It is known to use the method of modified laminectomy for the treatment of recurrent IVD hernia [2], in which access to the posterior support complex is performed using a laminectoma or a cutter, grooves are cut on both sides of the spinous cane, at its very base. Then, along these grooves, the final cutting off of the spinous process from the arches is performed using Kerison's pistol clippers. The spinous process, separated from the arches, is retracted laterally, exposing the gap between the halves of the bone arch. Further resection of the spinous process and the yellow ligament is performed from the center to the periphery, which minimizes the possibility of damage to the dura mater of the dural sac, roots and venous plexuses. After eliminating the causes of compression, in order to expand the spinal canal, the base of the spinous process is resected. Hemostasis, visual control and layer-by-layer wound closure. The paravertebral muscles are fixed to the spinous processes and occupy a physiological position. The ligament and aponeurosis are sutured separately with interrupted sutures. After suturing the subcutaneous tissue, the skin is sutured with a continuous suture.

The disadvantages of using this technology in the surgical treatment of recurrent IVD hernia are as follows. High invasiveness of access with significant damage to the multifidus muscle, its denervation, extended atrophy and fatty degeneration in the long term. Predisposition to the development of spinal instability in the postoperative period due to the lack of additional stabilization of the spine.

Closest to the proposed is a method for mobilizing neural structures with epidural fibrosis of the spinal canal, patent RU No. 2525203 C1 [3]. The method consists in the fact that the surgical treatment is carried out with the patient lying on his stomach. A linear incision is cut through the skin and subcutaneous tissue to the thoracolumbar fascia. Staged hemostasis is performed. The retractors are used to remove the skin and subcutaneous tissue. The thoracolumbar fascia is dissected from the side of the pathological substrate along the line of the spinous processes. In the access area, the posterior bone structures are skeletonized. The muscles are retracted to the side with dilators, the arches and spinous processes open. The edges of the adjacent vertebral arches are resected at the required level. Resection of cicatricial tissue is performed from the posterior and lateral surfaces of the dural sac in the area of the intercutaneous space for its mobilization. Further, free abduction of neural structures is performed and subsequent revision (decompression) of the anterior surface of the dural sac. After elimination of the compressing substrate at the final stage, according to the generally accepted technology, interbody fusion is performed. Hemostasis. Layer-by-layer wound closure, aseptic dressing.

The disadvantages of the proposed method are as follows. The absence of normal anatomical landmarks in the wound due to muscle, paravertebral and epidural cicatricial changes increases the invasiveness of access, the duration of the operation, and the amount of blood loss. In addition, during revision surgery, operative access to the affected segment directly through the scar tissue with their excision is associated with a high risk of trauma to the dura mater of neural structures due to the fact that the latter are tightly fused with the epidural scar. Also, manipulations on the contralateral side are significantly difficult.

Based on the analysis of the closest analogue and known sources of information that reveal the features of the technique of repeated interventions for recurrent IVD hernias of the lumbar spine, the task was set to reduce the invasiveness of access, the duration of the operation, the volume of blood loss during revision surgery on the lumbar spine by developing an operative access, which with minimal surgical trauma, it will provide radical access, which, with minimal surgical trauma, will ensure radical surgical treatment with maximum preservation of the integrity of the supporting structures and create the possibility of revision in case of a bilateral pathological process, provided that minimally invasive technologies are used.

The essence of the invention lies in the fact that in the method of revision surgery on the lumbar spine, including dorsal access to the spinal canal, excision of epidural scars and bone structures with further mobilization and decompression of neural structures, it is proposed to initially install the guide wires in the above and the underlying vertebral bodies through the roots of the arches, then from the contralateral side to the primary surgical intervention, departing from the midline 3.5-4 cm, between the needles make an incision of the skin, subcutaneous fat and thoracolumbar fascia, bluntly divide the multifidus muscle to the facet joint, set tubular retractor, isolate the interlaminar gap, then resect the base of the spinous process, the free fragment of which, together with soft tissues, mobilize the contralateral access, then carry out interlaminar access to the spinal canal and resect the half-arc, after visualization of the unchanged dura mater, review the contralateral part of the spinal canal and the intervertebral foramen of the surgical wound, then carry out meningoradiculolysis in the scar zone on the contralateral side of the access and resection the contralateral access of the half-arc, scar tissue, hypertrophied yellow ligament over the isolated area of the dura mater , as the bone tissue is resected, dilute the retractor blades, mobilize soft tissues and the scar to the root cuff on the contralateral side of the access and the intervertebral foramen, then displace the dural sac, revise the epidural spaces, remove the compressing substrate, contralateral foraminotomy to the access, and also perform juorettage of the disc cavity , the installation of the interbody cage, and, upon completion of the decompression stage on the access side under radiological control, through the previously installed guide wires, install the pedicle screws s through the roots of the arches, then on the side contralateral from the access to perform transcutaneous transpedicular stabilization. A view of the contralateral part of the spinal canal and the intervertebral foramen without additional expansion of the surgical wound can be provided by deflecting the operating table to the side opposite to the intervention until an adequate view is achieved with a corresponding change in the angle of inclination of the operating microscope, and upon completion of the decompression stage, the table is brought to a horizontal position.

The base of the spinous process can be resected with a high-speed bur. If necessary, an ipsilateral facetectomy can be performed.

Let us explain the essential distinguishing features of the proposed method of revision surgery on the lumbar spine.

New in the proposed method is that with minimal surgical trauma, a safe approach is carried out from the side of unchanged tissues, adequate visualization of neural structures, while maintaining the integrity of the multifaceted psoas muscle.

In contrast to the approach through scar-altered paravertebral tissues, the implementation of the paraspinal approach from the side of intact anatomically unaltered tissues is safe and less traumatic. Performing such an intermuscular access allows maintaining the innervation of the muscles, preventing their degeneration. The use of a tubular retractor ensures the expansion of the multifidus muscle without damaging it, and therefore there is no need for long-term hemostasis, adequate visualization in the surgical wound is provided, and the intensity of postoperative pain syndrome decreases. The approach from the side of the unaltered dura mater allows effective visualization of neural structures, safe meningoradiculolysis, greatly simplifying decompression in the area of cicatricial adhesions. Changing the tilt angle of the operating table and microscope improves visibility by reducing muscle traction and eliminating the need for increased access. The described operative access technology also allows performing decompression measures on the access side - facetectomy, foraminotomy, microdiscectomy. Traction of neural structures from unaltered tissues is safer and easier, which will significantly simplify the procedure for performing disc juorettage and minimally invasive transforaminal interbody fusion. Resection of the spinous process base with a high-speed bur helps to reduce the trauma of the method. The sequence and interrelation of the techniques of the proposed method ensure the achievement of the claimed technical result when solving the problem, which is as follows.

Increases the safety of meningoradiculolysis and traction of neural tissue when approached from the intact side, that is, from the side of unchanged tissues.

Full visualization of neural structures (dural sac and spinal roots) and IVD improves.

The safety of traction of the dural sac on the intact side is increased, in contrast to traction from the side of scar tissue.

The possibility of bilateral visualization of neural structures is provided.

Provides the ability to preserve the innervation of the multifidus muscle by performing the paraspinal transmuscular access, which makes it possible to ensure the functionality of the spinal motion segment in the long term.

The essence of the proposed method is illustrated by figures 1-4.

FIG. 1 - intramulcular access, installation of guide wires, tubular retractor, interlaminectomy on the intact side, longitudinal section.

FIG. 2 - resection of the spinous process base, meningoradiculolysis of cicatricial neural tissue in the area of the previously performed operation, a longitudinal section.

FIG. 3 - mobilization of the dural sac, removal of recurrent IVD hernia, revision of the epidural space, longitudinal section.

FIG. 4 - transforaminal installation of the interbody cage, transpedicular screws, longitudinal section wound suturing.

FIG. 1-4 are presented:

1 - high-speed bur;

2 - blades of a tubular retractor;

3 - bundles of the multifidus muscle;

4 - spinous process;

5 - bundles of the multifidus muscle;

6 - postoperative scar;

7 - the area of the resected half-arc of the vertebra;

8 - dural sac;

9 - recurrent disc herniation;

10 - the root of the vertebral arch;

11 - guide spoke;

12 - vertebral body;

13 - spinal root;

14 - intervertebral foramen;

15 - pedicle screw.

The method is carried out as follows. Under intravenous anesthesia with the use of mechanical ventilation, the patient is placed on the operating table in the prone position with discharge rollers under the chest and pelvis. The operating field is treated with an antiseptic solution. Under X-ray control, guide pins (11) are installed in the upper and lower vertebral bodies through the roots of the arches using a Jamshidi needle, under X-ray control, Fig. 1. Then, from the side of intact tissues, departing from the midline of 3.5-4 cm, an incision of the skin, subcutaneous tissue and thoracolumbar fascia is made between the needles. Further, the muscle is dividing in a blunt way, to the level of the facet joint, a tubular retractor (2) is installed, and the interlaminar gap is isolated. Using a high-speed bur (1), the base of the spinous process (4) is cut safely, fig. 2, a free fragment of which, together with soft tissues, is mobilized contralateral to the access, FIG. 3. Then interlaminar access to the spinal canal is performed, a half-arc is resected (7). The unchanged dura mater is visualized, the operating table deviates as much as possible to the side of the contralateral approach, with a corresponding change in the angle of the operating microscope, which improves the view of the contralateral part of the spinal canal and the intervertebral foramen, without the need for additional expansion of the surgical wound. Then meningoradiculolysis is performed in the area of scar tissue on the opposite side. Further, over the highlighted area of the dura mater, resection of the contralateral approach of the half-arc, scar tissue, and hypertrophied ligamentum flavum is performed. As the bone resection is carried out, the retractor blades (2) are dilated to expand the surgical wound. Subsequently, the membrane scar is mobilized up to the root cuff (13) on the opposite side and the intervertebral foramen (15). Further, the mobilized dura mater is safely displaced for revision of the epidural spaces, removal of the compressing substrate, contralateral foraminotomy access, additional curettage of the IVD cavity, and transforaminal interbody cage placement. Upon completion of the decompression stage, the operating table is brought to a horizontal position, on the access side, under X-ray control, transpedicular screws are inserted through the previously installed guide wires (15), Fig. 4.

Then the spokes are removed and the screws are connected with a rigid beam. The tubular retractor is then removed. The edges of the muscle are closed, layer-by-layer wound closure is carried out. Then, on the contralateral side of the access, departing from the midline 3.5-4 cm, guide wires (I) are installed transcutaneously through 2 skin incisions 1-1.5 cm long. On which, with the help of a dilator, the pedicle screws are installed. The spokes are removed and the screws are connected with a rigid bar. After the final X-ray control of the position of the fixing elements, the wounds are sutured in layers.

The effectiveness of the proposed method of treatment is confirmed by the following clinical example.

Patient A., born in 1968, was admitted to the Neurosurgery Center of the ChUZ KB RZD-Medicine, Irkutsk with complaints of severe pain in the lumbar spine, aggravated by dynamic loads, radiating to the left leg along the antero-lateral surface of the thigh , shins, with irradiation to the 1st finger. Numbness in the area of pain. Weakness in the left foot.

From the anamnesis: pain in the lumbar region has been troubling for 15 years. 5 years ago, he was hospitalized in a specialized neurosurgical clinic with a diagnosis of lumbar osteochondrosis. Liv-Lv IVD hernia, radicular pain syndrome along the L5 root on the left ”, operated on - Liv-Lv microdiscectomy was performed on the left. In the postoperative period, no complaints were reported for 4 years. 6 months ago, after physical exertion, he began to notice the appearance of numbness in the left lower limb and weakness in the foot. Conservative treatment for 3 months is ineffective.

Neurological examination revealed: the cranial nerves and upper limbs are intact. The patient takes an antalgic position, walks with a limp on his left leg. The lumbar lordosis is smoothed. Movements in the lumbosacral spine are sharply painful and blocked. Lassegh's symptom S = 55 °. Knee reflexes D> S, Achilles: D => S. Stage III paravertebral muscle defense. No pathological reflexes. Muscle tone in the arms is normal; in the legs - dorsiflexion paresis of the left foot, with a decrease in strength to 3 b. Sensory disturbances in the form of hypesthesia along the L5 root on the left. There are no pelvic disorders. The level of pain syndrome according to the VAS in the lumbar spine was 85 mm, in the left leg - 92 mm. Functional status on the Oswestry scale - 76 points.

When carrying out a march test with a load (performing 10 squats), a progression of neurological deficit with an expansion of the zone of hypesthesia of a radicular nature, an increase in symptoms of tension - on the left from an angle of 40 °.

Examination was performed: MRI of the lumbar spine: osteochondrosis 2-3 period, spondylosis, spondyloarthrosis, recurrence of herniated disc Liv-Lv up to 8 mm, in the paramedian zone on the left, left-sided epidural fibrosis, with stenosis of the intervertebral foramen at the level of Liv-Lv on the left. Electroneuromyography of the lower extremities: a decrease in the amplitude of the maximum M-response during stimulation of the peroneal nerve on the left.

Lumbar spondylography was performed with functional tests: osteochondrosis of the lumbar spine, instability at the level of the Liv-Lv PDS, with sagittal translation of the Liv vertebra up to 5 mm.

Diagnosed. Revealed: dorsopathy, osteochondrosis of the lumbar spine. Condition after microdiscectomy Liv-Lv on the left of 2015. Recurrent disc herniation Liv-Lv. Instability in the Liv-Lv segment. Cicatricial adhesive epiduritis. L5 radiculopathy on the left. Lumboischialgia syndrome on the left. Pronounced recurrent 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 patient is shown surgical treatment in volume - revision surgery using the proposed access at the Liv-Lv level, decompression of neural structures, removal of recurrent disc herniation Liv - Lv. Considering repeated surgery, the presence of clinical and radiological signs of instability of the Liv-Lv segment, it is shown that decompression of neural structures and interbody fusion at this level with rigid bilateral transpedicular fixation are performed.

Under intravenous anesthesia with the use of mechanical ventilation, the patient is placed on the operating table in the prone position with discharge rollers under the chest and pelvis. The operating field is treated with an antiseptic solution. Under X-ray control, the guide wires were inserted into the bodies Liv, Lv of the vertebrae, through the roots of the arches, using a "Jamshidi" needle. Having deviated from the midline by 3.5 cm to the right, a skin incision was made between the knitting needles from the side of healthy tissues,

subcutaneous fat and thoracolumbar fascia. Further, the multifidus muscle was bluntly divided to the level of the facet joint, a tubular retractor was installed, and the interlaminar gap was highlighted.

With the help of a high-speed bur, the base of the spinous process was cut, the free fragment of which, together with soft tissues, was mobilized to the left. Interlaminar access to the spinal canal was performed, a half-arc was resected.

The unchanged dura mater is visualized, the operating table is maximally deflected to the left, i.e. on the opposite side with a corresponding change in the angle of the operating microscope, meningoradiculolysis was performed in the scar area on the left, hemilaminectomy was performed on the left, removal of scar tissue, hypertrophied ligamentum flavum, over the isolated area of dura mater. In the course of the measures taken, it was possible to mobilize muscle tissues, and the epidural scar up to the cuff of the root and the intervertebral foramen for the L5 root on the left. At the next stage, the dural sac was retracted from left to right, a dense fibrosed sequestration was removed in several fragments. Curettage of the IVD cavity was performed on both sides, the table was brought to a horizontal position after the completion of decompression, and an interbody cage was installed. At the end of the decompression stage on the access side, under X-ray control, through the previously installed guide wires alternately into the Liv and Lv vertebral bodies under X-ray control, 4.5 × 50 mm polyaxial screws were installed through the roots of the arches, the wires were removed, the screws were connected by a rigid bar. The wound was sutured in layers. On the left side, in the projection of the previously installed guide wires, 1.5 cm skin incisions were made, and when using a dilator, pedicle screws 4.5 × 50 were installed on the right in the Liv, Lv vertebral bodies, the wires were removed, the screws were connected with a rigid bar. The wound was sutured in layers. Operation time - 105 minutes. Blood loss - 50 ml.

In the postoperative period, the following was carried out: antibacterial, symptomatic, vasoactive, vitamin therapy, exercise therapy, massage, dressings.

At discharge, the patient's condition is satisfactory. In the neurological status, insignificant muscular-tonic syndrome and mild hypesthesia along the L5 root on the left remained, there was no weakness of the extensors of the left foot. At discharge, the level of pain syndrome according to the VAS in the lumbar spine was 22 mm, in the left leg - 3 mm. Functional status on the Oswestry scale - 18 points.

3 months after the operation, during the control objective and clinical examinations, no neurological deficit was revealed, there was no pain syndrome, and the working capacity was restored. The patient resumed his previous work activity, with admission to driving an electric locomotive.

Using the proposed method, 16 patients with relapses of pain after single-level microdiscectomies in the lumbar spine were operated on.

Pain syndrome, assessed on a visual analogue pain scale, significantly decreased after surgery in all patients. Control examination 3 and 6 months after surgery in all cases did not reveal the progression of the degenerative process with damage to the adjacent level. When analyzing X-ray data, there were no signs of hypermobility or instability in the operated and adjacent PDS.

The quality of life, assessed on the Oswestry scale from the preoperative level of 70 (40; 80) points, significantly improved after surgery and by 6 months of observation was 15 (10; 18) points (Pw <0.001). The blood loss was 100 (60; 115) ml. The operation time when performing the proposed method was 90.7 (78; 110) minutes, which is significantly less compared to performing such operations by known methods. After performing the operation by the claimed method, the patients are activated on the second day and can be discharged from the hospital for 5-6 days, which is also significantly less than with the known methods. The patients operated on according to the proposed method returned to their previous work activity on average within 80 (65; 85) days after the operation. While after traditional decompression laminectomy and with stabilization, labor rehabilitation looked like this: 45% returned to their work after 90 days, 20% - after 180 days, 35% - 240 days after the operation. In the long-term postoperative period, the patients did not show signs of damage to the adjacent segment, and signs of fatty degeneration of the multifidus muscle. That is, the proposed method allows you to restore the quality of life, contributes to the labor and social rehabilitation of patients.

Thus, the proposed method for revision surgery on the lumbar spine allows, with minimal surgical trauma, to create safe conditions for performing the necessary manipulations on altered cicatricial neural structures by a safe approach from intact tissues.

Sources of information taken into account:

1) Simonovich A.E., Baikalov A.A. Surgical treatment of recurrent pain syndromes after removal of herniated lumbar intervertebral discs. // Spine surgery. - 2005. - No. 3. - With. 87-92.

2) Gioev P.M., Davydov E.A. Repeated surgical interventions for degenerative diseases of the lumbar spine // Traumatology and Orthopedics of Russia 1 (51) - 2009 pp. 91-95.

3) Patent RU No. 2525203 Cl, А61В 17/56, Application: 2013104598/14, 02/04/201.

Claims (4)

1. A method of revision surgery on the lumbar spine, including dorsal access to the spinal canal, excision of epidural scars and bone structures with further mobilization and decompression of neural structures, characterized in that the guide wires are initially inserted into the upper and lower vertebral bodies through the roots arcs, then from the contralateral side to the primary surgical intervention, departing from the midline of 3.5-4 cm, an incision of the skin, subcutaneous fat and thoracolumbar fascia is made between the needles, the multifaceted muscle is bluntly divided to the facet joint, a tubular retractor is installed, an interlaminar interval, then the base of the spinous process is resected, the free fragment of which, together with soft tissues, is mobilized contralaterally to the access, then interlaminar access to the spinal canal is performed and the half-arc is resected, after visualization of the unchanged solid the second meninges, a part of the spinal canal and the intervertebral foramen are reviewed from the side, the contralateral access, then meningoradiculolysis is performed in the scar area and the half-arc resection, contralateral access, scar tissue, hypertrophied yellow ligament over the isolated area of the dura mater, while the bone tissue is resected, the blades are bred retractor, mobilize soft tissues and a scar up to the root cuff on the contralateral side from the access to the intervertebral foramen, then displace the dural sac, revise the epidural spaces, remove the compressing substrate, contralateral foraminotomy access, also perform curettage of the disc cavity, insert the interbody cage, the stage of decompression on the access side under X-ray control through the previously installed guide wires, the installation of pedicle screws is carried out through the roots of the arches, then a transcutaneous transpedicular is performed on the contralateral access side stabilization. 2. The method of revision surgery on the lumbar spine according to claim 1, characterized in that the visualization of the unchanged dura mater is carried out by deflecting the operating table to the side opposite to the intervention until an adequate view is achieved with a corresponding change in the angle of inclination of the operating microscope, and upon completion of the stage the decompression table is brought to a horizontal position. 3. The method of revision surgery on the lumbar spine according to claim 1, characterized in that the base of the spinous process is resected with a high-speed bur. 4. The method of revision surgery on the lumbar spine according to claim 1, characterized in that, if necessary, an ipsilateral facetectomy is performed.

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