RU2648007C1 - Method of surgical treatment of patients with kimmerle anomaly - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to neurosurgery and may be applicable to the treatment of patients with Kimmerle anomaly. Under the X-ray control, a metal needle is applied perpendicular to the line of the spinous processes of the cervical vertebrae in the region of the projection of the bone ring. Metal needle is applied to the posterior surface of the neck in a parallel way to the line of spinous processes in the Kimmerle anomaly projection. Point of intersection of these needles on the posterior surface of the neck corresponds to the center of the skin incision. Next, a skin incision is made 1–3.5 cm long caudal and cranial than the established point. Dissection of subcutaneous fat and aponeurosis is performed. By a blunt way, the muscle fibers of the trapezius muscle, the semispinal muscle of the head, the large posterior rectus muscle of the head are moved apart. Further, the visualization of the intervention zone is carried out using an operating microscope with a magnification of 4–6 times. To the apex of the bone ring, after a sequential expansion of the muscular canal, a tubular wound retractor is installed by means of the dilator system. Bone ring is skeletonized from all sides. Outer cortex and spongiosa layers of the bone ring are resected from the groove for vertebral artery C1 of the vertebra to the cranial margin of the bone ring. After visualization of the vertebral artery, the remaining part of the bone ring is removed.

EFFECT: method allows to reduce the traumatizing of the muscular system of the cervical spine.

1 cl, 11 dwg

Description

FIELD OF THE INVENTION

The invention relates to medicine, namely to neurosurgery, and can be used in the surgical treatment of patients with Kimmerle anomaly.

State of the art

The only known method of surgical treatment of patients with Kimmerle's anomaly is the method of performing decompression of the vertebral artery from the posterior median access (Chertkov A.K., Klimov M.E., Nesterova M.E. On the issue of surgical treatment of patients with vertebrobasilar insufficiency in Kimmerle abnormalities // Spinal Surgery. - 2005. - No. 1. - P. 69-73). According to this method, a skin incision is made along the posterior midline of the neck in the projection of the external occipital protuberance - the spinous process of the C2 vertebra, then the occipital bone is skeletonized, C1 to the lateral masses, C2 vertebra. The bone ring is resected from the arch of the atlas to the articular process (protrusion of the lateral mass C1 of the vertebra).

The main disadvantage of this access is its invasiveness, since this method uses the posterior median access (along the posterior midline of the neck) with the allocation of the occipital bone and posterior structures of C1-C2 vertebrae. In addition to a large skin incision with a cosmetic defect, with such accesses during skeletonization of the posterior vertebral structures, a severe injury is caused to the muscular apparatus of the cervical spine, which causes pain in the postoperative period in such patients, limitation of mobility due to muscular-tonic syndrome. A cavity is also created in the paravertebral space, which contributes to the formation of paraspinal hematomas and cerebrospinal fluid cysts in the case of even point damage to the dura mater in the area of the atlanto-axial membrane. The visualization of the bone ring is carried out at an acute angle, which complicates the full visualization of the vertebral artery and makes it inconvenient to manipulate the instrument (konhot, Kerrison nippers, high-speed boron) in the surgical wound.

Disclosure of invention

The objective of the invention is to provide the least invasive method of decompression of the vertebral artery, in accordance with which access to the Kimmerle abnormality through the intramuscular approach and complete resection of the bone ring and protrusion of the lateral mass around the vertebral artery.

The technical result to which the claimed invention is directed is the ability to perform decompression of the vertebral artery with direct visualization of pathology, minimal trauma to the muscular apparatus of the cervical spine and the least cosmetic defect, which results in a reduction in the risk of postoperative complications and faster healing of postoperative wounds.

The problem is solved in that the method of surgical treatment of patients with Kimmerley anomaly involves decompression of the vertebral artery by resection of the bone ring, first marking the skin access, for which, under X-ray control, a metal needle is applied perpendicular to the line of the spinous processes of the cervical vertebrae in the projection area of the bone ring, then apply a metal spoke to the back of the neck parallel to the line of the spinous processes in the projection of the Kimmerle anomaly, the point is crossed The stitches of these knitting needles on the back of the neck correspond to the center of the skin incision Then, a skin incision is made, for example, 1-2 cm more caudal and cranial than the established point, after which subcutaneous fat and aponeurosis are dissected, then the muscle fibers of the trapezius muscle, the penis muscle of the head, and the posterior rectus muscle of the head are diluted; Further, the visualization of the intervention zone is carried out using an operating microscope with an increase of 4-6 times, a tubular retractor is installed to the top of the bone ring after sequential expansion of the muscle channel through a system of dilators; skeletonize the bone ring from all sides, resect the outer cortical layer of the bone ring, the spongy layer of the ring from the groove of the vertebral artery C1 of the vertebra to the cranial edge of the bone ring, after visualization of the vertebral artery, the remainder of the bone ring is removed. Bone ring resection is performed on both sides.

In the claimed method, bilateral paravertebral access is performed directly to the bone ring on each side.

Decompression of the vertebral arteries is carried out not through the posterior median access with visualization of the Kimmerle abnormality at an acute angle to the sagittal plane, but by paravertebral access through the port of the tubular retractor, resulting in a smaller cosmetic defect (2 incisions are made, for example, 3.5 cm, as a rule corresponding to the hair growth zone instead of 1 large (at least 12 cm), see Fig. 5), as well as minimal injury to the muscular apparatus of the cervical spine.

C1 vertebra refers to the upper cervical level (it is craniovertebral), it differs anatomically and functionally from the lower cervical (joints C2-C3 and further C3-C7), thoracic and lumbar vertebrae. Previously, a tubular retractor was used on all parts of the spine, except the upper cervical, including the lower cervical level behind. A needle is inserted through the puncture to the vertebral joint, along which dilators are first carried out (tubes gradually increasing in thickness), and then the expander itself. Such pathogens were not established for C1 vertebral pathology due to the high probability of injury to the vertebral artery, which freely lies on the posterior C1 vertebral arch. In the claimed invention in the treatment of patients with Kimmerle's anomaly, the possibility of using tubular retractors was found, while the method does not use a sharp needle. To the anomaly itself, mini-access is first carried out under the control of a microscope without the use of sharp and cutting tools, and then, with the help of dilators, the channel in the muscles is expanded.

The installation of a tubular retractor is performed perpendicular to the bone ring of the anomaly and directly to the bone ring after dissection and dilution of muscle fibers to the sides, which avoids injury to the vertebral artery at the access stage.

The application of the developed method allows you to activate patients in the early stages after surgery and reduce the overall period of disability of patients.

The invention is illustrated by drawings.

In FIG. Figure 1 shows an intraoperative x-ray of the cervical spine in a lateral projection, the stage of marking a skin incision using a fragment of a metal spoke (1) in the projection of the bone ring of the anomaly.

In FIG. 2 shows an intraoperative photograph of a patient during marking of a skin incision. A spoke (1) is attached to the lateral surface of the neck in the projection of the bony ring of the abnormality under the image intensifier tube.

In FIG. 3 - intraoperative x-ray of the cervical spine in transoral styling, the marking stage of the skin incision. The spoke (1) is installed in the projection of the middle of the lateral mass of the atlant (C1), which corresponds to the location of the bone ring in patients with Kimmerle's anomaly.

In FIG. 4 - intraoperative photograph of the patient during the marking. The spoke (1) is applied in the projection of the Kimmerle anomaly under the image intensifier tube in transoral packing.

In FIG. 5 is an intraoperative photograph of skin incisions (2) during the minimally invasive method of surgical treatment of a patient with Kimmerle anomaly (the horizontal line corresponds to the anomaly in the axial plane).

In FIG. 6 is an intraoperative photograph of a patient. A tubular retractor (3) is installed through a skin incision (2).

In FIG. 7 is an intraoperative image from a microscope camera. From the minimally invasive approach, the bone ring of the anomaly (4) up to the C1 vertebra (5) and the compressed vertebral artery (6) are fully visualized.

In FIG. 8 is an intraoperative image from a microscope camera. Resection of the external cortical and spongy layers of the bone ring (4) was performed using high-speed boron (7).

In FIG. 9 - intraoperative image from a microscope camera. Resection of the inner cortical layer of the bone ring (4) using Kerrison nippers (8).

In FIG. 10 is an intraoperative image from a microscope camera. Most of the bone ring is removed. Removal of the residual part of the anomaly (4) is performed using high-speed boron (7). A microsurgical spatula (9) protects the vertebral artery (6) from damage.

In FIG. 11 is an intraoperative image from a microscope camera. A complete decompression of the vertebral artery (6) from the edge of the C1 vertebra (5) was performed, which is confirmed by the restoration of normal blood flow from it using data from an intraoperative ultrasound study (10).

The positions in the figures indicate: 1 - a spoke for marking a skin incision; 2 - marked skin incision; 3 - tubular retractor; 4 - bone ring of Kimmerle's anomaly; 5 - bow C1 of the vertebra; 6 - vertebral artery; 7 - high-speed boron; 8 - Kerrison nippers; 9 - microsurgical spatula; 10 - sensor for intraoperative ultrasound examination.

The implementation of the invention

The operation is performed in the position of the patient on the stomach in conditions of Halo-immobilization.

The first step is marking the skin access. Under X-ray control using a C-arc, a metal needle is applied first to the lateral surface perpendicular to the line of the spinous processes of the spine, respectively, of the projection of the bone ring (Fig. 1 and 2), then to the posterior surface of the neck parallel to the line of the spinous processes in the projection of the Kimmerle anomaly (Fig. 3 and four). The intersection point of these spokes on the back surface will be the center of the upcoming skin incision (Fig. 5). Next, a skin incision is made 1.5 cm more caudal and cranial than the established point. Subcutaneous fat and aponeurosis are dissected. Subsequent bundles m. trapezius, T. semispinalis capitis and m. rectus capitis posterior major does not cross, access is carried out by spreading muscle fibers to the sides with the help of a dissector and a tupfer. Further visualization is carried out using an operating microscope with an increase of 4-6 times. After the muscle layer, a bone ring is found under a thin layer of adipose tissue. A small dilator of the retractor is brought to the top of the ring. The small dilator performs sequential expansion of the muscle channel through a system of dilators and install a tubular retractor (Fig. 6).

The bone ring is carefully skeletonized from all sides (Fig. 7). Insufficient dissection can lead to severe bleeding from venous collectors that are located around the vertebral artery in subsequent stages of decompression.

Then, using the high-speed boron with a diamond mill, the outer cortical and spongy layers of the bone bridge are resected from the groove of the PA C1 vertebra to the cranial edge of the bone ring (Fig. 8). The inner cortical layer is removed using Kerrison's nippers (Fig. 9).

After visualization of the vertebral artery, the remaining part of the bone ring is removed with the help of boron (Fig. 10). After that, the achieved decompression effect is evaluated using intraoperative ultrasound examination (Fig. 11).

In this method, decompression of the vertebral arteries was performed in two patients.

Example 1. Patient B., 58 years old, was admitted to the research institute of the joint venture with the clinical picture of vertebro-vascular conflict against the background of severe Kimmerle anomaly. The pathology was manifested in the form of attacks of severe headache followed by depression of consciousness, as in the type of small epipresses. The patient was performed decompression of the vertebral arteries according to the claimed method. In order to reduce surgical trauma, posterolateral intramuscular access, a tubular retractor, and an operating microscope were used intraoperatively. The operation was performed according to the above method with complete resection of the bone bridge and protrusion of the lateral mass around the vertebral artery. In the postoperative period, pain and muscle tonic syndrome in the patient was absent. The patient was activated 12 hours after surgery. The size of the scars was 3 cm. The patient was discharged in satisfactory condition without pain in the neck. When assessing the immediate and long-term results of treatment, a significant decrease in the frequency and intensity of seizures was observed.

Example 2. Patient T., 53 years old, was admitted with complaints of severe headaches and dizziness, aggravated by turning the head to the side. The examination revealed compression of the right vertebral artery by the bone bridge of the Kimmerle abnormality. According to the claimed method, resection of the bone bridge was performed on the right, revision of the vertebral artery on the left. The minimally invasive execution of the operation according to the described technique made it possible to eliminate vertebro-vascular conflict without injuring the muscular apparatus of the neck. The patient was activated the day after the operation. The maximum scar size was 3 cm. The patient was discharged in satisfactory condition with complete regression of preoperative pain.

Claims (2)

1. A method of surgical treatment of patients with Kimmerle's anomaly, including decompression of the vertebral artery by resection of the bone ring, characterized in that they first mark the skin access, for which, under X-ray control, a metal needle is applied perpendicular to the line of the spinous processes of the cervical vertebrae in the projection area of the bone ring, then apply a metal spoke to the back of the neck parallel to the line of the spinous processes in the projection of the Kimmerle anomaly, the point of intersection of these spokes on the back her neck surface corresponds to the center of the skin incision; Then, a skin incision is made, 1-3.5 cm long, more caudal and cranial than the established point, after which subcutaneous fat and aponeurosis are dissected, then the muscle fibers of the trapezius muscle, the penis muscle of the head, and the posterior rectus muscle of the head are diluted; Further, the visualization of the intervention zone is carried out using an operating microscope with an increase of 4-6 times, a tubular retractor is installed to the top of the bone ring after sequential expansion of the muscle channel through a system of dilators; skeletonize the bone ring from all sides, resect the outer cortical and spongy layers of the bone ring from the groove of the vertebral artery C1 of the vertebra to the cranial edge of the bone ring, after visualization of the vertebral artery, the remainder of the bone ring is removed. 2. The method according to p. 1, characterized in that the resection of the bone ring is performed on both sides.

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