RU2723766C1 - Method for surgical management of degenerative foraminal stenosis on the cervical spine - Google Patents

Abstract

FIELD: medicine.SUBSTANCE: invention refers to medicine, namely traumatology and orthopedics, and can be used for surgical management of degenerative foraminal stenosis on the cervical spine. Anterolateral surface of the cervical spine is exposed, a neurovascular formation of the intervertebral opening is decompressed on the cervical spine by resection of the hypertrophic uncus. Decompression is followed by an interbody fusion. Performing decompression: long muscles of head and neck are stripped to the base of costal-transverse processes of cervical vertebras, segmental distraction of the operated vertebral segment is performed, total discectomy is performed, adjacent bone end plates are cleaned to pinpoint bleeding, posterior longitudinal ligament is resected, posterior edges of adjacent vertebral bodies are resected from center of posterior surface of vertebral bodies in lateral direction from pedicle to pedicle of underlying vertebra. From interbody access, perform thinning of the uncus by kerfing an internal cortical plication of uncus in the base in a lateral direction through the interbody body above the pedicle of the underlying vertebra in the plane of the cranial closure plate until floatation of the resected uncus is observed. Then uncus is broken, dislocated in interbody space and removed.EFFECT: method provides preserving the support ability of bodies of fixed vertebrae, increases the possibility of segmental correction due to uncus resection with a single unit, which enables to perform a wide and safe decompression of the neurovascular formation of intervertebral foramen on the cervical spine.1 cl, 11 dwg, 1 ex

Description

The invention relates to medicine, namely to neurosurgery, traumatology and orthopedics, and can be used to perform microsurgical decompression of neurovascular formations (structures) of the intervertebral foramen on the cervical spine.

Closest to the technical nature of the proposed method is an anterior foraminotomy by resection of the unco-vertebral joint (Lutsik A. A. Compression syndromes of osteochondrosis of the cervical spine. Novosibirsk. 1997. S. 138-142.).

The essence of the anterior foraminotomy is to use the anterolateral access to expand the intervertebral foramen by removing its anteromedial wall.

On the compression side, the lateral surface of the vertebrae and costal-transverse processes skeletonize, separating the long muscles of the neck and head from them. The canal of the vertebral artery is opened by stratification of the transverse muscle. With a thin raspator, an array of bone growths of uncus is isolated subperiostally. After that, the vertebral artery is mobilized and taken away. A cylindrical drill with a diameter of 18-20 mm at the level of the intervertebral foramen eccentrically (closer to the pathology side) drill a hole to the spinal canal. An acute bone spoon deep in the bone wound is expanded to the intervertebral foramen. The anteromedial wall of the intervertebral foramen (the uncus with its bone-cartilaginous growths) is resected with bone forceps by inserting a flat jaw of forceps medial to the displaced vertebral artery, the other jaw is grasped by the bone wall from the side of the interbody groove and thus the uncus is gradually resected. After root decompression, interbody fusion is carried out with a bone graft or a porous metal implant of the appropriate size.

The described variant of resection of the uncus in the presence of degenerative foraminal stenosis can be performed with anterolateral access only after complete skeletonization of the transverse processes at the appropriate level, by peeling and stratification of the paravertebral muscles of the neck, resection of the costal-transverse processes, exposing the vertebral arteries, which increases the risk of damage to the elements of the cervical sympathetic trunk, phrenic nerve and vertebral artery itself. A significant drawback of the described method is the need to perform extensive resection of the end plates of adjacent vertebral bodies at the lesion level by forming a large diameter cylindrical channel in the plane of the disk with a drill of 18-20 mm in diameter, which in turn significantly reduces the supporting ability of the bodies of the fixed vertebrae, which can lead to to loss of correction in the operated segment, reduces the possibilities of segmental correction itself, disruption of the processes of formation of the interbody block (false joints, lengthening of the consolidation period), makes intervention on two or more vertebral segments technically difficult, extends the period of immobilization and disability. The author of the methodology himself warns that the implementation of such an operation carries the risk of damage to the vertebral artery and spinal roots. In addition, with bilateral foraminal stenosis, the full implementation of the above described decompression technique of the intervertebral foramen on the opposite side of the access becomes difficult or completely technically not feasible.

The objective (technical result) of the present invention is to create a method for the surgical treatment of degenerative foraminal stenosis in the cervical spine, free from the above disadvantages.

The problem is solved in that the method of surgical treatment of degenerative foraminal stenosis on the cervical spine consists in accessing the antero-lateral surface of the cervical spine, decompressing the neurovascular formations of the intervertebral opening in the cervical spine by resecting the hypertrophic uncus, after decompression, interbody fusion is performed. According to the invention, decompression is performed as follows: exfoliate the long muscles of the head and neck to the base of the costal-transverse processes of the cervical vertebrae, perform segmental distraction of the operated vertebral segment, perform total discectomy, strip adjacent bone closure plates to “blood dew”, resect the posterior longitudinal ligament, from the center of the back surface of the vertebral bodies in the lateral direction, the posterior edges of the adjacent vertebral bodies from the pedicle to the pedicle of the underlying vertebra are resected; from the interbody access, the throat is thinned by sawing the internal cortical plastic of the uncus in the base in the lateral direction through the interbody space above the pedicle of the underlying vertebral vertebra in the cranial plane the plates until the flotation of the resected uncus occurs, then the uncus is broken, dislocated into the interbody space and removed.

In the proposed method, the uncus is resected with a completely single unit without the need to expose the transverse processes, resection of the costal-transverse processes, and isolation of the vertebral artery, which allows for wide and safe decompression of the neurovascular formations of the intervertebral opening in the cervical spine. In addition, the integrity of the end plates of adjacent vertebral bodies is maintained, which ensures the preservation of the supporting ability of the bodies of the fixed vertebrae, increases the possibility of segmental correction.

The invention is illustrated by figure 1, which shows a schematic representation of foraminal stenosis due to hypertrophy of the uncus in the frontal plane; figure 2, which shows a schematic representation of the underlying vertebra with a hypertrophic uncus in the frontal plane; figures 3, 4, 5, which represent the stages of resection of hypertrophic uncus. In FIG. 6, 7, 8 show the results of MSCT of the cervical spine of patient B. in three planes before surgery. In FIG. 9, 10, 11 presents the results of MSCT of the cervical spine of patient B. in three planes after surgery.

The proposed method is as follows.

Access to the anterolateral surface of the cervical spine. They perform decompression of the neurovascular formations of the intervertebral opening on the cervical spine as follows: exfoliate the long muscles of the head and neck to the base of the costal transverse processes of the cervical vertebrae, perform segmental distraction of the operated vertebral segment, perform total discectomy, strip adjacent bone closure plates to blood dew, the posterior longitudinal ligament is resected, the posterior edges of the adjacent vertebral bodies from the pedicle to the pedicle of the underlying vertebra are resected from the center of the posterior vertebral bodies in the lateral direction, from the interbody access thinning of the uncus 1 is performed (Fig. 3) by sawing the internal cortical plastic of the uncus in the base in the lateral direction through the interbody space above the pedicle of the underlying vertebra until the resection of the resected uncus appears (Fig. 4), then the uncus is broken, dislocated into the interbody and removed (Fig. 5). After decompression, interbody fusion is performed.

Clinical example

Patient B. 61, was admitted with complaints of pain in the cervical spine with radiation to the right hand, numbness in it, headaches. After a comprehensive clinical and radiological examination, including examination by specialists, radiography, MSCT and MRI, a clinical diagnosis was made: Osteochondrosis of the cervical spine, uncovertral arthrosis, foraminal stenosis at the level of C5-C6-C7 on the right, compression of C6, C7 roots on the right, persistent pain syndrome .

Under anesthesia in the position of the patient, the operation was performed on the back. Access to the antero-lateral surface of the cervical spine was made, long muscles of the head and neck were detached to the base of the costal transverse processes of the cervical vertebrae, C5-C6 segmental distraction was performed, total discectomy was performed, adjacent bone closure plates were cleaned to “blood dew”, the back was resected longitudinal ligament, from the center of the back surface of the vertebral bodies in the lateral direction, the posterior edges of adjacent vertebral bodies from the pedicle to the pedicle C6 of the vertebra. Further, according to the claimed method, resection of a hypertrophic uncus was performed. From the interbody access, the throat was thinned by sawing the internal cortical plastic in the base laterally above the pedicle of the underlying vertebra in the plane of the cranial closure plate until the resection of the resected uncus flotation occurs, then the uncus is broken, dislocated into the interbody space and removed. Similarly, decompression was performed at the level of C6-C7. Next, interbody fusion was performed with implants made of porous titanium nickelide, an Atlantis plate was installed. The wound is sutured tightly. The duration of the operation is 2 hours 40 minutes, intraoperative blood loss is 300 ml. No complications were noted. After surgery, a MSCT of the lumbar spine was performed for control purposes. The results of MSCT before and after surgery are presented in FIG. 6-11.

Claims (1)

A method of surgical treatment of degenerative foraminal stenosis in the cervical spine, which consists in accessing the anterolateral surface of the cervical spine, decompressing the neurovascular formations of the intervertebral foramen on the cervical spine by reserving the hypertrophic uncus, after the decompression, the interbody that decompression is performed as follows: exfoliate the long muscles of the head and neck to the base of the costal-transverse processes of the cervical vertebrae, perform segmental distraction of the operated vertebral segment, perform total discectomy, strip adjacent bone closure plates to “blood dew”, resect the posterior longitudinal ligament, from from the center of the back surface of the vertebral bodies in the lateral direction, the posterior edges of the adjacent vertebral bodies from the pedicle to the pedicle of the underlying vertebra are resected, from the interbody access thinning of the uncus is performed by sawing of the internal cortical plastic of the uncus in the base in the lateral direction through the interbody space above the pedicle of the underlying vertebra in the plane of the cranial closure plate until flotation of the resected uncus occurs, then the uncus is broken, dislocated into the interbody space and removed.

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