RU2258484C1 - Method for keeping yellow ligament at microsurgical discectomy - Google Patents

Abstract

FIELD: medicine, neurosurgery.

SUBSTANCE: the present innovation deals with treating patients with hernias of intervertebral lumbar disks: out of yellow ligament one should cut "an apron" and on a ligature the latter should be applied towards spinous processes, after removing disk hernia the "apron" of yellow ligament should be put into inter-arch space to be fixed with a suture that does not restrict the survey of operational field and keeps normal anatomical interactions in inter-arch space, prevents the development of postoperational muscular-membranous cicatrix and adhesive process in epidural fiber.

EFFECT: higher efficiency.

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Description

The invention relates to medicine, namely to neurosurgery, and can be used in surgical treatment of patients with hernias of the intervertebral lumbar discs.

At the present stage of neurosurgery, the most optimal method for removing hernias of the intervertebral lumbar discs is microsurgical discectomy (Musalatov X.A., Aganesov A.G. Surgical rehabilitation of radicular syndrome in osteochondrosis of the lumbar spine. - M .: Medicine, 1998. - P. 49- 56).

One of the stages of microsurgical discectomy is the removal of the yellow ligament in the required intersternal gap. There are several ways to resect the yellow ligament: complete removal of the ligament throughout the intersternal gap (Musalatov X.A., Aganesov A.G. Surgical rehabilitation of radicular syndrome in osteochondrosis of the lumbar spine. - M .: Medicine, 1998. - P.31) ; partial removal of the yellow ligament - a lateral or medial portion, depending on the location of the hernia of the intervertebral disc (Semenov V.V.The use of microsurgical techniques for the treatment of compression syndromes of lumbar osteochondrosis: Author. Diss. Candidate of Medical Sciences. - Kemerovo, 2000. - 21 p. .)

The above methods are very convenient for revision of the roots and discectomy, but the changes that then occur in the operated spinal canal in the form of the formation of the epidural and periradicular adhesions, muscle fibrosis, lead to a relapse of the radicular pain. The closest is the method of preserving the yellow ligament, which has a number of significant advantages over traditional methods (Slynko E.I., Verbov V.V. Microdisectomy with preservation of the yellow ligament. Results of the clinical application of the technique // Ukrainian Neurosurgical Journal. - 2003. - No. 1 - S.54-61). The authors propose to resect only the upper layer of the yellow ligament, and carefully separate the inner layer using a dissector. Further manipulations on the roots of the spinal cord and hernia are performed through the hole formed in the yellow ligament. The use of this method reduces the formation of the postoperative epidural adhesive process, since the preserved yellow ligament is adjacent to the dura mater and roots of the spinal cord and is a natural anatomical and physiological barrier that prevents the formation of a gross muscular-shear scar and postoperative hematoma.

However, this method has its drawbacks. Firstly, the difficulty of stratification of the yellow ligament and the existing danger of perforation of the dura mater. Secondly, the small size of the hole formed in the yellow ligament leads to technical inconvenience of manipulations in the spinal canal, an incomplete review of the spinal canal, difficulties in detecting the root and difficulties in coagulation of the epidural veins, which can affect the immediate and long-term results of the operation.

The objective of the invention: to develop a method for preserving the yellow ligament during microsurgical discectomy, not limiting the overview of the surgical field and allowing optimal manipulations on the structures of the spinal canal.

The problem is solved due to the fact that a “apron” is cut out of the yellow ligament and taken to the spinous processes on the ligature, after removal of the disc herniation, the “apron” of the yellow ligament is placed in the intersternal gap and fixed with a suture.

The method is as follows: after dissection of the lumbodorsal fascia, the long muscles of the back are removed from the bone structures, the intersternal gap is skeletonized. Before dissection of the yellow ligament, the size of the intersternal gap is estimated. The proposed method is carried out with a wide intersternal gap, the absence of spondylarthrosis and osteoarthritis, more often at the level of L5-S1. In the medial sections of the intersternal gap, after pretensioning the yellow ligament with tweezers or an aspirator, parallel to the underlying arch of the vertebra, it is cut with a scalpel until the appearance of epidural tissue or dura mater. Then, under visual control, with the help of microsurgical instruments (scalpels or scissors), the yellow ligament is cut out in the form of an “apron” throughout the intersternal gap (see drawing) and is taken to the spinous processes on the ligature. After removal of the hernia of the disc, the “apron” of the yellow ligament is placed in the intersternal gap and fixed with a suture. To carry out the proposed method, it is mandatory to use a binocular magnifier (LBVO) or an operating microscope.

According to the proposed method, 28 patients were operated on in the neurosurgical department of the KKB of Krasnoyarsk from 2001 to 2004. The immediate results are excellent. Long-term results were tracked over two years.

Clinical example 1. Patient K., 38 years old, was admitted to the NHL KKB (medical history No. 23495 for 2002) with complaints of pain in the lumbar region with radiation to the left leg along the back of the thigh and lower leg. Clinically, radiologically, and according to MRI, a lateral hernia of the L5-S1 disk was diagnosed on the left, with compression of the spine S1 on the left. The operation was performed: removal of the lateral hernia of the L5-S1 disk from the left by interlaminar access with a flavotomy by cutting out an “apron”. After surgery, the pain syndrome was copied, radicular symptoms regressed. The long-term result (in a year) - there is no pain.

Clinical example 2. Patient I., 32 years old, was admitted to the NHL KKB (medical history No. 24765 for 2001) with complaints of constant pain in the lumbar region with radiation to the right leg, along the back of the thigh. Conservative outpatient treatment - no effect, the pain syndrome has become permanent. Clinically, radiologically, and according to MRI, the patient was diagnosed with a paramedian herniation of the L5-S1 disk on the right, which compresses the root S1 on the right. The operation was performed: removal of the paramedian that broke through the posterior longitudinal ligament of the hernia of the L5-S1 disc on the right with interlaminar access with a flavotomy by cutting out an “apron”. After surgery, radicular pain stopped. Long-term result (after 2 years) - no radicular pain.

The proposed method for preserving the yellow ligament allows you to maintain normal anatomical relationships in the spinal canal and prevents the development of postoperative muscular-shear scar and adhesions in the epidural tissue. The main advantage of the proposed method is that, while maintaining the yellow ligament, it does not limit the review of the surgical field and does not complicate the technique of manipulations on the structures of the spinal canal, which contribute to the improvement of the immediate and long-term results of surgical treatment of patients with herniated discs.

Claims (1)

A method of preserving the yellow ligament during microsurgical discectomy, consisting in the fact that a "apron" is cut out of the yellow ligament with the base to the spinous processes and removed on the ligature, and after removal of the disc herniation, the "apron" of the yellow ligament is laid back into the intersternal gap and fixed with a suture.