RU2508909C1 - Method of approaching spinal canal for constrictive lesion of lumbosacral spine - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention concerns medicine, particularly neurosurgery. What is involved is a unilateral skeletonisation of an interspinous space in a projection of a constrictive lesion depending on its lateralisation. That is followed by a transspinal approach to the spinal column by sawing off a base of a spinous process in the contralateral direction in an oblique horizontal plane. A microsurgical repair of the spinal canal is performed with preserving an opposite outer wall of the spinal canal and facet joints from both sides. A hypertrophied portion of a yellow ligament is dissected and incised on the side of the constrictive lesion up to a dural sac with preserving adjacent ligaments - supraspinal and interspinous. When repairing a posterior wall of the spinal canal, a stump of the spinous process is fixed to a musculo-ligamentous apparatus on the operated side.

EFFECT: method enables providing the decompression and stabilisation in the operated spine with a minimal operated wound.

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Description

The present invention relates to medicine, namely to neurosurgery, and can be used in surgical treatment of unilateral stenotic compression lesions of the lumbosacral spine for minimally traumatic reconstruction of the spinal canal, maximum decompression of the neural structures (by increasing the size of the spinal canal) and preserving the natural biomechanics in the operated vertebral-motor segments (due to the absence of a destabilizing effect).

The mechanical causes of radicular syndrome are narrowing of the spinal canal and intervertebral foramen due to both static (disc herniation, ligament hypertrophy, narrow canal, osteophytes, thickening of the capsules of the intervertebral joints), and dynamic stenoses (due to instability), or a combination of them [1, 2 ].

To eliminate compression of the nerve structures of the lumbosacral spine, a large number of accesses are currently used, among which are the front, anterolateral, lateral, posterolateral and posterior. Varieties of the latter are closest to the claimed access.

A known method of osteoplastic laminotomy in a single unit [3], including a longitudinal section along the midline over the spinous processes of the skin, thoracolumbar fascia, supraspinatus ligament. Sequential layer-by-layer skeletonization of the spinous processes and plates of the vertebral arches, the formation of a single bone-ligamentous block, for which, in the region of the upper edge of the most cranial and lower edges of the caudal vertebral arches, a yellow ligament is cut from both sides. Then, along the entire length of the incision, plates of vertebral arches are sequentially bilaterally dissected and, pulling the laminotomy bone-ligamentous block, held by the supraspinatus, interspinous and yellow ligaments, pull over the upper spinous process, intersect these ligaments at the cranial border level. The resulting non-free bone-ligamentous laminotomized single block, which remained fixed in the wound at its caudal end due to the supraspinatus and interspinous ligaments, is bent down and to the side, opening the surgical field. Then, the back wall of the spinal canal is restored by laying the laminated tomo-ligamentous block in place and fixed, starting from the caudal end of the wound, with 8-shaped sutures with silk threads sequentially on each side of the layer-by-layer wound closure.

The disadvantages of this method are:

- the complexity of intracanal manipulations with a narrow incision and a long non-free bone-ligamentous block;

- the risk of complete separation and loss of trophic bone-ligamentous block;

- degradation and / or ossification of the yellow ligament due to trophic disturbances;

- the possibility of development in the long-term postoperative period of instability of the spine during laminectomy in the lumbar spine;

- preservation of disco-radicular conflict (due to the inability to manipulate the intervertebral disc).

Closest to the proposed method is the approach to the spinal cord, which represents a bone-plastic laminectomy in single blocks [4], which includes dissecting the posterior wall of the spinal canal by longitudinal parallel sections along the articular processes while maintaining their integrity. At the same time, the arches are dissected in the oblique plane near the articular processes, dissect the posterior wall of the spinal canal from below or from above with the formation of mobile P-, H- or C-shaped flaps on the legs, consisting of vertebral arches, spinous processes and ligaments (including yellow - on both sides), with their leading up, down or to the side. After performing intracanal manipulations on the spinal cord, the P-, H- or C-shaped flaps on the legs are put in place, with the vertebral arches fixed with transosseous sutures or bone nails, and the ligaments with nodal sutures. The postoperative wound is sutured without osteoplastic fixation of the spine.

However, the known method of access to the spinal canal has significant disadvantages:

- great trauma in relation to the musculo-ligamentous apparatus of the operated vertebral-motor segment;

- the impossibility of manipulation of the intervertebral discs;

- lack of adequate visualization of the spinal roots;

- degradation and / or ossification of the yellow ligament due to trophic disturbances;

- the risk of reducing the flexibility of the spine due to dissection and removal of the yellow ligament during resection of the vertebral arch and violation of the biomechanics of the operated vertebral-motor segment (PDS);

- the risk of disco-radicular conflict with disorientation of the articular sites (against the background of a rough degenerative process), the possibility of repeated spinal stenosis.

Based on the analysis of known sources of information that reveal the features of access to the spinal canal during surgical treatment of stenotic compression lesions of the lumbosacral spine, as well as addressing the shortcomings of known technologies, the task was to expand the spinal canal while maintaining stability and flexibility of the spine in the postoperative period with unilateral localization pathological process of the spine due to the exclusion of the intersection of the supraspinatus, interspinous and yellow with yazok, and provide access to more gentle spinal canal due to the lack of rough skeleting interspinous gap and save the contralateral structures with unilateral lesions of the spine.

The task of the proposed "Method of access to the spinal canal with stenotic lesion of the lumbosacral spine" is solved as follows.

Minimally invasive access to the spinal canal in case of stenotic lesion of the lumbosacral spine includes the following manipulations: skeletonization of the interspinous gap in the stenotic process, dissection of the vertebral arches, mobilization of the posterior wall of the spinal canal, intracanal manipulations, restoration of the integrity of the posterior wall of the spine. New in the proposed method is that they produce unilateral skeletonization of the interspinous gap in the projection of the stenosing process, depending on its lateralization. Then carry out transspinous access to the spinal canal with a cut of the base of the spinous process contralaterally in the oblique horizontal plane. After this, microsurgical reconstruction of the spinal canal is performed, preserving the opposite outer wall of the spinal canal and the arched joints of the vertebrae on both sides, the hypertrophied part of the yellow ligament on the side of the stenotic process is stratified and excised to the dural sac, while maintaining the adjacent ligaments supraspinous and interspinous. After performing the planned operation, the posterior wall of the spinal canal is restored with fixation of the stump of the spinous process of the vertebra to the muscular-ligamentous apparatus of the ipsilateral (operated) side.

We explain the essential distinguishing features of the proposed access to the spinal canal.

Access to the spinal canal by unilateral skeletonization of the interspinous gap only in the projection of the stenosing process, depending on its lateralization, reduces postoperative pain vertebrogenic syndrome and improves the quality of life of patients in the postoperative period by limiting surgical aggression, keeping the anatomical paravertebral structures intact and reducing trophic disorders of the ligamentous apparatus and muscle tissue due to the absence of direct damage to them.

Transspinal access to the spinal canal with a cut of the base of the spinous process of the vertebra in the contralateral plane in the oblique horizontal plane is necessary for: minimally traumatic access to the spinal canal while maintaining supportability of the paravertebral muscles; the maximum possible visualization of neural structures without deficiency of intracanal manipulations (not only the dural sac, but also the cuffs of the spinal roots).

Performing microsurgical reconstruction of the spinal canal while preserving the opposite outer wall of the spinal canal and the arched joints of the vertebrae on both sides, stratification and excision of the hypertrophic part of the yellow ligament on the side of the stenotic process to the dural sac, while maintaining adjacent ligaments of the supraspinous and interspinous, minimizes postoperative biomechanical prophylaxis, compression of neural structures.

Restoration of the posterior wall of the spinal canal with fixation of the stump of the spinous process to the musculo-ligamentous apparatus of the ipsilateral (operated) side allows us to restore the stability of the posterior supporting complex and enable early activation of patients.

Patent studies and analysis of scientific and medical information reflecting the current level of technologies for surgical treatment of stenotic lesions of the lumbosacral spine, namely access to the spinal canal, did not reveal methods that are identical to the proposed one. In this connection, we can conclude that the claimed technical solution meets the criteria of the invention of "novelty."

The sequence and interconnection of the methods of the proposed method ensure the achievement of a new technological medical result in solving the problem, namely:

- reduce the morbidity of access due to the absence of gross damage to the paravertebral muscles and ligaments;

- the ability to preserve natural biomechanics and prevent the formation of instability in the operated vertebral-motor segments (PDS) by preserving the posterior supporting structures (adjacent supraspinatus and interspinous ligaments) and facet joints;

- prevent re-stenosis at the operational level due to a wide reconstruction of the spinal canal;

- maximum revision of the spinal canal: dural sac and spinal roots.

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

Access constituting the claimed invention is intended for use in healthcare and can be used in neurosurgery. The possibility of its implementation is confirmed by the methods and means set forth in the application, therefore, the proposed solution meets the criteria of the invention "industrial applicability".

The essence of the proposed minimally invasive access to the spinal canal with stenotic lesion of the lumbosacral spine is illustrated by the drawings, which show:

Figure 1 - one-sided abduction of paravertebral muscles;

Figure 2 - cut the base of the spinous process;

Figure 3 is a view of the formed bone window;

Figure 4 is a view of the sutured postoperative wound.

To explain the figures, we present a breakdown of the positions in the figures in the appendix to the application description:

1 - intervertebral disc;

2 - spinous process;

3 - paravertebral muscles;

4 - a dural bag.

The essence of the proposed "Method of access to the spinal canal with stenotic lesion of the lumbosacral spine" is as follows.

After treating the surgical field with an antiseptic solution, under intravenous anesthesia using mechanical ventilation, in the patient’s position “lying on his stomach” with discharge rollers under the chest and pelvis, a longitudinal incision is made of the skin and subcutaneous fat in the projection of the spinous processes of the vertebrae in the area of the stenotic process. Unilateral skeletonization of the interspinous gap is made depending on its lateralization (see the appendix to the description, FIG. 1). Then, using a high-speed drill, a trans-spinous approach to the spinal canal is carried out with a cut of the base of the spinous process contralaterally in the oblique horizontal plane (see the appendix to the description, FIG. 2). Subsequently, with the help of the end nozzle, microsurgical reconstruction of the spinal canal is performed while maintaining the outer wall of the contralateral arch and the arcuate joints of the vertebrae on both sides (see the appendix to the description, Fig. 3). The identified yellow ligament is stratified and removed using a neurotome, conchotome, and / or pistol nippers in the area where its hypertrophy is determined. If the yellow ligament is not changed, then only its mobilization from the underlying bone is carried out. Pistol nippers produce unilateral foraminotomy. Unilateral access to the spinal canal and its reconstruction allow revision of the dural sac and spinal roots mainly from the side of damage to the structures of the spinal cord and eliminate the cause of the disco-radicular conflict. Subsequently, the posterior wall of the spinal canal is restored with fixation of the stump of the spinous process to the musculo-ligamentous apparatus of the ipsilateral (operated) side using 2-3 ligatures (see the appendix to the description, Fig. 4). The wound is washed with an antiseptic solution, stitches are applied layer by layer to the wound and aseptic dressing.

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

Patient L., born in 1963, was hospitalized in the neurosurgical department of the NIH Road Clinical Hospital at the station Irkutsk-Passenger JSC "Russian Railways" with complaints of severe pain in the lumbosacral region that occur during dynamic loads that radiate to both buttocks in the posterolateral surface of both thighs, in the left shin, with a projection into all fingers of the left foot, the pain intensifies with coughing, sneezing. Numbness in the area of pain of the left lower limb. Weakness in the left lower limb, appearing after a long walk. The patient is sick for about 17 years, with annual exacerbations at least 4 times.

Neurological examination: Cranial nerves and upper limbs are intact. The patient occupies an antalgic position. Walking with a cane, limping on his left leg. Lumbar lordosis is smoothed. Movements in the lumbosacral spine are sharply painful, blocked. Symptom of Lasegue D = 60 *, S = 45 *. Knee reflexes D => S, Achilles reflexes: D => S. Defense of paravertebral muscles of the II Art. There are no pathological reflexes. Muscle tone in the hands is normal; in the legs (distal parts of the right lower limb) - moderate weakness of the extensors of the left foot. Sensory impairment in the form of hypesthesia spots along the L5, S1 roots on the left. No pelvic abnormalities.

When conducting a march test with a load (performing 10 squats), a progression of neurological deficit with an expansion of the hypesthesia zone in the left lower limb, an increase in tension symptoms from the left from an angle of 35 ° were revealed.

Examination performed: MRI of the lumbosacral spine. Osteochondrosis of the lumbosacral spine, 2-3 period. The central protrusion of the disks L _III- L _IV is 3.0 mm, L _IV -L _V is 5.5 mm, L _V -S _I is 6.5 mm. Pronounced hypertrophy of the yellow ligament at the level of L _IV -L _V , L _V -S _I on the left.

Electroneuromyography 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.

Lumbar spondylography with functional tests: osteochondrosis of the lumbosacral spine. No signs of instability were detected.

Diagnosis: Vertebrogenic syndrome. Aggravation. Osteochondrosis of the lumbosacral spine. Disc protrusions L _III -L _IV , L _IV -L _V , L _V -S _I.

Left-sided spinal stenosis at the level of L _IV -L _V , L _V -S _I due to hypertrophy of the yellow ligament. Radiculoneuritis L5, S1 on the left. Lumbar ischialgia syndrome on both sides, more on the left. Elements of CPC syndrome (caudogenic intermittent claudication). Severe recurrent pain and muscle-tonic syndromes.

Considering 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 - reconstruction of the spinal canal at the level of L _IV -L _V , L _V -S _I. There are no signs of PDS instability and there is no need to install an orthopedic component.

Surgical treatment was performed using the proposed minimally invasive unilateral access to the spinal canal with stenotic lesion of the lumbosacral spine at the level of L _IV -L _V , L _V -S _I from the left transspinal access. Meningoradiculolysis, foraminotomy for L5, S1 roots on the left.

Under intravenous anesthesia using artificial ventilation of the lungs, in the patient’s position “lying on his stomach” with unloading rollers, after treating the surgical field with an antiseptic solution, a longitudinal incision was made in the skin and subcutaneous fat in the projection of the spinous processes of L _IV , L _v vertebrae. Under the intraoperative control of the image intensifier, the position and direction of the bone structures described above are determined.

Produced unilateral (left-side) skeletonization of interspinous spaces L _IV -L _V , L _V -S _I. With the help of a high-speed drill, transspinous access was made with an oblique horizontal cut of the base of the spinous process to the right (contralaterally). Using the end nozzle, a microsurgical reconstruction of the spinal canal was performed while preserving the outer wall of the right arch and the arcuate joints of the L _IV , L _V vertebrae on both sides. The identified yellow ligament is stratified by a neurotome, conchotome and pistol nippers, its hypertrophic areas on the left are removed. The spinal canal was revised with foraminotomy performed along the L5, S1 roots on the left. The mobility of the dural sac and spinal roots at the indicated levels has been fully restored; no signs of ongoing compression have been detected. Remodeling of the spinal canal did not require manipulation of the intervertebral discs. Microsurgical hemostasis of epidural veins. The restoration of the posterior wall of the spinal canal with fixation of the stump of the spinous process to the musculo-ligamentous apparatus of the ipsilateral (operated) side was performed using 3 ligatures. Layered closure of the wound, aseptic dressing.

In the postoperative period: antibacterial, symptomatic, vasoactive, vitamin therapy, exercise therapy, massage, dressings, a course of hyperbaric oxygenation.

At discharge, the patient's condition is satisfactory. In neurological status, insignificant muscular-tonic syndrome and slight hypesthesia along the L5, S1 roots of the left side remained, the extensors of the left foot are not weak. When assessed by a visual analogue scale (VAS), the level of pain was 3 mm, which corresponds to the minimum value.

3 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 her previous career.

Using the proposed method, 6 patients were operated on with two- and three-level unilateral stenosing compression lesions of the lumbosacral spine.

Pain syndrome, assessed by the visual analogue scale (VAS) of pain, significantly decreased after surgery in all patients. A follow-up examination after 3 and 6 months after surgery in all patients showed no progression of the degenerative process with the formation of hernias of the intervertebral discs, the appearance of segmental instability and worsening neurological symptoms. To study the range of motion in the operated spine, the functional spondylography method was used. When analyzing the X-ray data at the time intervals indicated by the protocol, there were no signs of hypermobility or instability in the operated and adjacent to the operation of the vertebral-motor segments (PDS).

The quality of life, assessed on the Oswestry scale from the preoperative level of 60 (32; 74) points, significantly improved after surgery and by 6 months of follow-up was 14 (9; 15) points (P _w <0.001). Blood loss amounted to 70 (40; 75) ml. The operation time when performing the proposed method was 50.4 (50; 85) minutes, which is significantly less compared to performing similar operations by known methods. After the operation, when using the claimed access to the spinal canal, patients are activated on the second day and can be allowed to go home on days 8-9, which is significantly less than with known methods.

The average length of hospitalization of patients operated on by the claimed method was 8 days (8; 9), which is statistically significantly less than with the method of decompressive laminectomy 12 (11; 14) and decompression-stabilizing method 11 (10; 13) performed by that the same surgical team (p = 001). Operated according to the proposed methodology, patients returned to their previous labor activities on average within 60 (55; 70) days after surgery. While after decompression and decompression-stabilizing laminectomy, labor rehabilitation looked as follows: 45% returned to their work after 90 days, 20% - after 180 days, 35% - after 240 days after surgery.

The proposed “Method of access to the spinal canal in case of stenotic lesion of the lumbosacral spine” made it possible, with minimal surgical trauma, to create maximum conditions for performing the necessary manipulations on the spinal canal with unilateral access to the focus of the stenotic process, to restore the quality of life, labor and social rehabilitation of patients. In the distant postoperative period, there was no need for additional decompression or decompression-stabilizing interventions on the operated vertebral-motor segment.

Information sources

1. Etebar S., Cahill D.W. Risk factors for adjacent-segment failure following fixation with rigid instrumentation for degenerative instability.// J Neurosurg. - 1999 Apr. - Vol. 90. Suppl. 2. - P. 163-169.

2. Hansraj K.K., O'Learly P.F., Camissa F.P. J., et al. Decompression, fusion, and instrumentation surgery for complex lumbar spinal stenosis // Clin. Orthop.Relat. Res. - 2001 .-- Vol. 384. - P. 18-25.

3. Raimondi A.J., Gutierrez E.A., Di Rocco C. // J. Neurosurg (P.555-560). - 1976.-Vol. 45.

4. The method of approach to the spinal cord: Pat. 2142748 Ros. Federation: MKI А61В 17/56 / Kushhabiev V.I., Akhriev H.R .; Applicant and patent holder of Kabardino-Balkarian State University. 01/30/96; publ. 12/20/99.

Claims (1)

A method of accessing the spinal canal in case of stenotic lesion of the lumbosacral spine, including skeletonization 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, intracanal manipulations, restoration of the integrity of the posterior wall of the spine, characterized in that they perform unilateral skeletonization the interspinous gap in the projection of the stenosing process, depending on its lateralization, then transspinous access to the spinal canal with a cut of the base of the spinous process of the vertebra is contralateral in the oblique horizontal plane, then microsurgical reconstruction of the spinal canal is performed, while maintaining the opposite outer wall of the vertebral canal and the arcuate joints of the vertebrae on both sides, delaminate and excise the hypertrophic part of the yellow wall to the dural sac, while maintaining adjacent ligaments supraspinous and interspinous, while restoring the posterior c tenni of the spinal canal by the stump of the spinous process of the vertebra are fixed to the musculo-ligamentous apparatus of the ipsilateral side.

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