RU2393799C1 - Method of treating lumbar spinal canal stenosis - Google Patents

Abstract

FIELD: medicine. ^ SUBSTANCE: invention refers to medicine, namely to vertebrology. The method involves transpedicular fixation of the lumbar spine. An intervertebral disc is removed. An autograft is introduced in an interbody space of the involved spinal segment. The transpedicular fixation is two-staged. At the first stage the vertebrae are fixed from the posterolateral approach at the stenosis level. After vertebrae traction, an additional symmetric incision on an opposite side of the spine is made to remove the zygapophysis and a degenerative vertebral disc. The second stage of the transpedicular fixation from the eliminated stenosis follows the autografting. ^ EFFECT: method reduces injures of tissues with restoring the height of the interbody space. ^ 1 ex

Description

The invention relates to medicine, namely to orthopedics.

There are various approaches to the surgical treatment of stenosis of the lumbar spine:

- rear decompression-stabilizing operations;

- front decompression and stabilizing operations;

- plastic percutaneous minimally invasive intervertebral disc surgery.

In neurosurgical practice, one of the most common interventions is posterior decompression operations, which differ in volume of surgical access [1]. The traditional surgical treatment of stenosis is accompanied by a large trauma to soft tissues, ligaments, resection of the arches or even articular processes, which significantly increases the length of hospital stay, leading to long-term rehabilitation and disability of patients in 60-70% of cases.

In the treatment of stenosis, the hemi- and laminectomy method is often used, which is as follows: the patient is placed on his stomach, the level of stenosis is determined under an electronic optical transducer, a midline incision is made along the spinous processes [2]. The affected segment is stupidly and sharply, i.e. spinous process, arches of the spine and arched joints. In order to eliminate stenosis, the spinous process, the arches of the spine are bitten out with special nippers and, if necessary, the arched joints are removed. Thus, we can well eliminate stenosis and prevent further neurological deficit. A purely neurosurgical tactic that does not take into account the supporting functions of the spine and basically solves the problem of compression of the nerve structures of the spinal canal. The disadvantages of this method are:

- The spinal canal is wide open, there is a risk of damage to nerve structures and blood vessels.

- A high risk of the formation of a postoperative scar-adhesion process in the spinal canal, which can lead to a relapse of stenosis.

- Leads to spinal instability at the operated level, which leads to repeated surgical interventions [3].

- A traumatic operation associated with a large wide incision and the duration of the operation.

The closest analogue is the method for the treatment of Caspara stenosis, which is the world standard for the treatment of stenosis of the lumbar spine [4]. For all its indisputable advantages (low invasiveness, a good overview of intra-channel structures, high-tech tools, low relapse rate), the operation has its significant drawbacks:

- Treatment of stenosis at one or more levels leads to a decrease in the height of the intervertebral space and, consequently, to a change in the statics and dynamics of the operated vertebral-motor segment (PDS). Such changes cause overload of the facet joints, which can lead to the appearance of a pain syndrome (the so-called facet syndrome), as well as to hypertrophy of the joints and ligaments of the PDS, which in the late postoperative period can lead to the development of stenosis of the lateral and intervertebral canals operations.

- When performing minimally invasive surgery, muscle, joint and ligamentous apparatus is damaged, leading to PDS instability in 2-18% of cases.

- During manipulations in the epidural space, a postoperative adhesion process develops, the epidural reserve spaces are limited by scar tissue, the spinal roots are fixed to the walls of the spinal canal, and even slight movements in the spinal motor segment, in case of instability, can cause tension and deformation of the root, relapse of the radicular syndrome .

- A significant decrease in the height of the intervertebral gap, provoking changes in the arched joints, occurs in 20% of patients undergoing this operation. To prevent these complications, it is necessary to maintain the height of the intervertebral gap, which can be achieved using intervertebral cages.

The technical result, the implementation of which the invention is directed, is to reduce the trauma of the method of treating stenosis and, thereby, shorten the rehabilitation of the patient.

The essence of the invention lies in the fact that in a method of treating stenosis of the spinal canal of the lumbar spine, including transpedicular fixation of the lumbar spine, removal of the intervertebral disc, taking an autograft and installing it in the interbody space of the affected segment of the spine, suturing the wound and installing drainage, transpedicular fixation two stages, while at the first stage from the posterolateral access fix the vertebrae at the level of stenosis, after traction of the vertebrae an additional symmetrical incision is made on the opposite side of the spine, from which the arched joint and the degenerative disc of the vertebra are removed, the autograft is taken from the posterior iliac crest and inserted into the interbody space of the operated vertebral segment, after which the second stage of transpedicular fixation of the vertebrae from the eliminated stenosis is performed.

Due to minor trauma to the ligamentous-muscular apparatus, the terms of rehabilitation are reduced, the patient is activated and discharged home on the second day after the operation. Due to the rigid fixation along the posterior column of the spine, favorable conditions have been created for the formation of true bone spinal fusion of the affected segment. The height of the intervertebral space was restored with an autobone from the posterior edge of the iliac wing. Thus, this method allows to eliminate stenosis of the spinal canal by means of minor trauma, to create optimal conditions for the formation of true bone fusion ("gold standard") and to activate the patient on the second day after surgery.

The method is as follows. A patient under endotracheal anesthesia is placed on the stomach and, using an electro-optical transducer, mark the site of the skin incision with a needle, which corresponds to the level of stenosis of the spinal canal. Prior to this, a computed tomography image determines which side is best to access the channel. At the first stage, from the posterolateral access, departing from the spinous processes of 4 cm, establish transpedicular fixation on one side of the operated vertebral segment. This gives additional stability during the operation on the symmetrically opposite side of the operated segment, providing access to the spinal canal for decompression. After installing transpedicular fixation on one side of the vertebral segment, it is slightly traced and the wound is plugged with a hydrogen peroxide napkin. Then, an additional posterolateral incision is made on the opposite side, the arched joint is secreted, which is carefully bite and removed, providing access to the spinal canal to the squeezed root and intervertebral disc. This method provides good access and visibility to eliminate stenosis and prepare the bed for an autograft in the interbody space of the damaged lumbar segment. Then the intervertebral disc is opened, the contents are removed, i.e. pulpous nucleus and fibrous rings, which can participate in stenosis of the structures of the spinal canal. Then they prepare the surfaces of the vertebral bodies, stripping them from the hyaline cartilage until the appearance of droplets of blood. Next, determine the size of the future autograft and take it from the same section or expanding slightly from the posterior iliac crest and install it in the space between the two vertebrae. At the second stage, on the side of the autograft placement, transpedicular fixation is installed in the previously prepared bed and a general, together with transpedicular fixation of the other side, minor compression is performed to prevent autograft migration. Leave a drainage tube. Seams in layers. Aseptic dressing.

Objective Evaluation Criteria

1. Radiologically confirmed signs of restoration of the height of the interbody gap and the formation of a true bone block between the vertebral bodies.

2. According to computed tomography, there are no signs of stenosis at the level of the damaged segment.

3. Clinically, after surgery, there are no pains of the type of lumbar ischalgia present before surgery. Early activation: the patient for 2 days gets up and moves independently without additional supporting immobilization.

Clinical example

A 47-year-old patient M. was admitted to the orthopedics department of City Clinical Hospital No. 13 in Moscow with complaints of severe pain in the lumbar spine with radiating pain along the outer surface of the thigh, left lower leg, numbness in the left thigh, left lower leg, and atrophy of the left limb. Pain in the lower extremity is disturbed for 3 years. Prior to admission to the clinic, the patient was repeatedly treated conservatively in a hospital setting. The treatment gave a temporary effect.

On examination, there is slight kyphosis in the lumbar region, tension of the lumbar muscles, a decrease in sensitivity along the outer surface of the lower leg and the back surface of the left foot are noted. The symptom of tension is sharply positive on the left to an angle of 40 °.

According to MP tomography herniation of the intervertebral disc LIV-LV up to 10 mm. Considering the data of preoperative spondylography, the patient was recommended and underwent surgery: transpedicular fixation of the lumbar spine at the level of the LIV-LV vertebra in the posterior column and decompression of the dural sac, removal of the herniation of the LIV-LV disc, interbody fusion with autobone from the iliac crest. On the second day after surgery, the patient was activated.

Information sources

1. Antipko L.E. Surgical treatment of spinal canal stenosis / L.E. Antipko // III Congress of Neurosurgeons of Russia: Abstracts. - SPb., 2002. - S.233-234.

2. White A. The place and role of surgical interventions in the treatment of diseases of the lumbar spine / A. White // Osteochondrosis of the spine: Materials of a scientific symposium. - M., 1992. - P.83-96.

3. Aganesov A.G. Minimally invasive interbody fusion in case of degenerative diseases of the lumbar spine / K.T. Meskhi, K.P. Miekaelyan, V.P. Shatrova // Bulletin of Traumatology and Orthopedics N.N. Priorova No. 2, 2006, p. 41-44.

4. Bailey S.I. Post-Laminectomy instability: Identification and managment / S.I. Bailey, J. Allen // The J. Of Bone and Joint surgery. - 1985. - Vol. 67. - IN 2). - N 9. - P.335-340.

Claims (1)

A method for the treatment of stenosis of the spinal canal of the lumbar spine, including transpedicular fixation of the lumbar spine, removal of the intervertebral disc, taking an autograft and installing it in the interbody space of the affected segment of the spine, suturing the wound and installing drainage, characterized in that the operation is carried out in two stages, while at the first stage, transpedicular fixation is performed from the posterolateral vertebral access at the level of stenosis, on the side of better access, after traction and vertebrae make an additional symmetrical incision on the opposite side of the spine, from which the arched joint and degenerative disc of the vertebra are removed, an autograft is taken from the posterior iliac crest and inserted into the interbody space of the operated vertebral segment, after which the second stage of transpedicular vertebral fixation is performed from the side of the removed stenosis.