RU2619492C1 - Method for minimally invasive surgical treatment of chiari malformation - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: posterior atlanto-occipital membrane at the level of maximum constriction of the occipital-cervical funnel is sutured and tied with ligatures at a distance of 5 mm lateral to the midline on both sides, dissected between ligatures to the level of the outer layer of the dura mater, ligatures are fixed to the burr window edges on both sides in tension.

EFFECT: method allows to reduce operation duration, risk of bleeding, cerebrospinal fluid, pneumoencephalitis.

1 dwg

Description

The invention relates to medicine, namely to neurosurgery, and can be used in the treatment of Chiari malformation.

Known methods of surgical treatment for Chiari malformation (see, for example, patents No. 2290097, 2230521, 2122355), consisting in suboccipital cranioectomy, dissection of the dura mater (resection of the cerebellar tonsils with expanding plastic TMT.

A significant disadvantage of the known methods is the high morbidity due to dissection of the TMT, removal of the cerebellum, high risks of bleeding, cerebrospinal fluid, as well as the long duration of the operation. There is a method of surgical treatment of Chiari type 1 anomaly (patent No. 2194459), in which posterior foraminotomy, removal of a fragment of the scales of the occipital bone, posterior half ring C1, cleavage of the leaves of the dura mater with subsequent dissection of the outer sheet of TMT and fixing it on the sides of the bone defect are performed. The known method is adopted as a prototype of the claimed invention.

The disadvantages of this method are: an increase in the duration of the operation and anesthetic benefits due to the duration of microsurgical dissection during isolation and dissection of the external sheet of TMT, as well as the risk of bleeding from sinuses and veins, the risk of cerebrospinal fluid, pneumocephalus, and infectious complications due to violation of the integrity of the TMT.

The technical problem to which the invention is directed is to increase the effectiveness of surgical treatment of Chiari anomalies while minimizing the morbidity and duration of the intervention.

The technical problem is solved due to the fact that in the claimed method, which consists in the posteriorformal decompression and resection of the posterior half ring C1 of the vertebra, according to the invention, the posterior atlanto-occipital membrane at the level of maximum narrowing of the occipital-cervical funnel is sutured and ligated with ligatures at a distance of 5 mm lateral from the midline on both sides, the posterior atlanto-occipital membrane is dissected between the ligatures to the level of the outer leaf of the dura mater, the ligatures are fixed to the edges of the trepanation windows on both sides in tension.

The proposed method in comparison with the prototype has several advantages:

- surgical mobilization and dissection of the thickened sections of the posterior atlanto-occipital membrane with its subsequent pulling with bone sutures allows significant decompression of the craniovertebral transition structures and expansion of the cerebrospinal fluid, thereby increasing the efficiency of the operation;

- ligation of the atlanto-occipital membrane reduces the risk of bleeding from the sinuses and veins located in this anatomical region, the risks of air embolism are reduced;

- the absence of the need to open the outer sheet of TMT reduces the risk of postoperative liquorrhea, pneumocephalus and infectious complications;

- due to the absence of the need for microsurgical dissection of TMT, the total time of surgical intervention and anesthesia is reduced.

The method is as follows.

The position of the patient on the table lying on his stomach in the Concord position.

The head is placed in the flexion position on the soft headrest face down. Bony protrusions (eyebrows, iliac spine, knees) are laid with cotton. Soft cushions are placed under the chest and spine of the pelvis. The median skin incision is from the occipital protrusion to the spinous process of the C2 vertebra. Skeleton adjacent to the edge of the large occipital foramen portions of the occipital bone, the C1 arc, less often the vertex C2 arc. Bone decompression is performed using high-speed boron and laminectomy. Resection of the margin of the large occipital foramen and adjacent fragment of the scales of the occipital bone is performed, as well as resection of the posterior half-arc C1. The dimensions of the trepanation defect are determined by calculating half the distance from the edge of the large occipital foramen to the transverse sinus. The sizes of trepanation vary depending on the age of the child, but does not exceed 2 × 2 cm. The resection of the C1 arc of the vertebra in the lateral direction is carried out before the transition of the inner edge of the arc surface to the sagittal plane. The width of the resection is not more than 1.5 cm. The posterior atlanto-occipital membrane at the level of narrowing of the occipital-cervical funnel is sutured and tied with two ligatures at a distance of 5 mm to the sides of the midline, then the posterior atlanto-occipital membrane is dissected between the ligatures to the outer leaf of the solid the meninges, after which the ligatures in tension are fixed to the edges of the trepanation window from two sides. The wound is sutured in layers.

The inventive method is developed and passed clinical trials in the children's department of the Russian National Scientific Research Institute named after prof. A.L. Polenova. When applying this method, a positive result was obtained in the form of regression of cerebral, pyramidal symptoms, improved sensitivity, decreased frequency of postoperative liquorrhea and infectious complications.

Example

An example - an extract from the medical history is illustrated by images, where: the figure shows MRI images.

Patient S., 11 years old, was in RNHI on treatment with a diagnosis of Chiari malformation type 1. Operation performed: Posterior foraminotomy, microsurgical correction of Chiari anomaly.

In the position of the patient lying on his stomach in the Concord position. The head is laid in a bent position on the soft headrest face down. Bony protrusions (eyebrows, iliac spine, knees) were laid with cotton wool. Soft cushions were placed under the chest and spine of the pelvis. The median skin incision is from the occipital protrusion to the spinous process of the C2 vertebra. Sections of the occipital bone adjacent to the edge of the large occipital foramen, arc C1, less often the vertebra C2 are skeletonized. Bone decompression was performed using high-speed boron and laminectomy. A resection of the margin of the large occipital foramen and the adjacent fragment of the scales of the occipital bone 2 × 2 cm was performed, as well as the resection of the posterior half-arc C1 1.5 cm. The posterior atlanto-occipital membrane at the level of narrowing of the occipital-cervical funnel was stitched and tied with two ligatures at a distance of 5 mm sides from the midline, then the posterior atlanto-occipital membrane is dissected between the ligatures to the outer leaf of the dura mater, after which the ligatures are tensioned to the edges of the trepanation window on both sides. The wound is sutured in layers.

In the early postoperative period, episodes of tachy and bradyarrhythmias stopped, the intensity of headaches decreased, muscle strength in the lower extremities increased.

The course of the wound process without complications, the sutures were removed on the 10th day.

On the control MRI, compression of the trunk structures, cerebellum at the level of the BZO was eliminated, expansion of the anterior and posterior cerebrospinal fluid spaces. The results of the operation are reflected in the MRI images presented in the figures before and after the operation, which show the elimination of cerebellar compression at the level of the BZO, the expansion of the anterior and posterior cerebrospinal fluid spaces.

Thus, the method of decompression by dissecting the posterior atlanto-occipital membrane with its suturing and fixation to bone structures made it possible to obtain an adequate correction of the anomaly and an acceptable clinical result in the absence of risks of liquorrhea and infection.

Claims (1)

A method for the surgical treatment of Chiari malformation, which consists in posterior decompression and resection of the posterior half ring of the C1 vertebra, characterized in that the posterior atlanto-occipital membrane at the level of maximum narrowing of the occipital-cervical funnel is sutured and ligated at a distance of 5 mm lateral from the midline on both sides, the posterior atlanto-occipital membrane is dissected between the ligatures to the level of the outer leaf of the dura mater, the ligatures are fixed to the edges of the trepanation window from two sides n in tension.

Images