Method of removing paramedian hernia of the intervertebral discs of the lumbar-sacral spine
The invention relates to medicine, namely to neurosurgery. During the operation, when we approach the hernia and the detection voltage of dural SAC and the cuff of the spine spinal cord provide traction and produce puncture of the subarachnoid space in the region of dural SAC 4-5 mm above the compression and evacuate metered 25-30 ml of liquor. Then produce hernia repair under endoscopic control. The method reduces the invasiveness of the surgery. 2 Il.The invention relates to medicine, namely to neurosurgery, and can be used to improve the clinical results of treatment of patients with paramedian by herniated intervertebral discs of the lumbar spine.Known surgical method for the treatment paramedian hernia of the intervertebral discs, which consists in conducting a traditional rear bilateral access. Depending on the size and location of the hernia is Hemi - or laminectomy above - and underlying vertebrae (Helimski, A. M. Chronic discogenic pain syndromes of the cervical and lumbar degenerative disc disease. Khabarovsk 2000, S. 135-139).A significant disadvantage of this known method is high is nick. In the future all this, of course, leads to instability of the spine in this segment and the development of pronounced pain syndrome. In addition, when this localization hernia it intraoperative visualization and removal is always associated with significant traction of the nerve root and dural SAC. All this with the direct manipulation for disc herniation leads to additional trauma of the cauda equina roots, and often to the deepening of neurological symptoms that worsen clinical outcomes.A known method of surgical treatment of paramedian hernia of the intervertebral discs, which consists in microsurgical access using special tools and microscope, allowing a good view of the hernia and its relationship with surrounding structures (Musatova H. A., Avanesov A., Surgical rehabilitation radicular syndrome with osteochondrosis of the lumbar spine. M, “Medicine”, 1998, S. 49-56).The disadvantage of this method is that it is also quite traumatic. Because of the dramatic tension and bad smesimosti dural SAC to remove paramedian button hernia can, as a rule, bilateral access. Mean the frame of brain, which ultimately leads to the development of persistent pain in the form of paresis of the foot and dysfunction of the pelvic organs.Closest to the claimed method is described by Darbuka Y. A., Parfenov Century, that is, Toptygin C. C. (the Value of intraoperative nucleosome when open microdiscectomy in preventing recurrence of the lumbosacral radiculitis. VI international Symposium. Modern minimally invasive techniques. SPb., 2001, S. 162-163).The authors use microsurgical one - or two-way access to the herniated disc using endividamento on the most critical stages of the operation. This method is also quite traumatic, as the approach to hernia is often on both sides. Because of the pronounced voltage dural SAC, resulting from its compression by herniated and a large accumulation in it of the liquor, endoscopic visualization of the hernia is very difficult, and sometimes impossible. In addition, the approach and the hernia is always accompanied by a very rude traction of the nerve root and dural SAC, lying on the hernia. All this also leads to traumatic nerve lesions and worsening of clinical outcomes.The objective of the proposed method I have of zvanicnika and cauda equina roots.The solution of this problem allows to achieve a positive therapeutic effect sooner activate the patient, to exclude neurological deficit, to reduce the stay of the patient on the cot and significantly improve the immediate and long-term postoperative results of treatment in this group of patients.The technical result is achieved due to the use of a neurosurgeon techniques by which of unilateral microsurgical access it is possible to reduce the pressure in the cuff of the spine spinal cord, dural bag, to significantly improve their mobility (without special efforts to displace them with hernia) and improving the endoscopic review of the epidural space in the localization of the hernia and then totally remove it.The problem is solved due to the fact that at the time of the traction make the puncture of the subarachnoid space in the region of dural SAC 4-5 mm above the compression and evacuate metered 25-30 ml of cerebrospinal fluid to reduce the stress in dural bag and the cuff of the spine spinal cord.The method is as follows.On admission the patient with suspicion on the paramedian disc herniation about the and (MRI of the spine). Upon confirmation of intervertebral disc herniation in the lumbar-sacral spine, he was offered surgery.In position on the side under endotracheal anesthesia was performed on the patient side localization hernia linear paramedian incision of soft tissues. At the level of localization hernia skeletonema palubicki adjacent vertebrae. In miguelon space was escalas yellow ligament and implemented approach to the cuff sdavlenija of the spine spinal cord and the dural SAC.Further manipulations associated with the approach and removal of herniated disc, was carried out by micro tools under the control of endovideoscopy. But in the localization of disc herniation always revealed a pronounced voltage dural SAC and the cuff of the spine spinal cord. They were always pushed to the back and pinned to the sides of the vertebrae. Additional resection of part of the above and downstream edges of the bows (interlaminate) were not allowed to approach the hernia, because it prevented the continued tension of the Dura. Attempts to shift the cuff of the spine and just dural SAC was unsuccessful - they were still and gross manipulation on them could cause injury to the roots of the spin is to visualize the hernia.To relieve tension in the cuff of the spine spinal cord and dural bag and create a good mobility and prevent injuries at the moment traction needle was used to puncture of the subarachnoid space in the region of dural SAC on 4-5 mm above its compression. Gradually evacuated 25-30 ml of cerebrospinal fluid up to the full tension of the Dura.This method allowed then no effort to hold the offset of the root and dural SAC with a herniated disc, it is good to expose the epidural space. Then enter the endoscope to visualize the disc herniation and under its control and totally atraumatic to remove it.After removal of herniated disc tension of the Dura disappeared, spine stretch. This operation was completed. Superimposed deaf stitches on the wound.Specific examplePatient A., 1952 R., And B/W No. 1182, was admitted to the neurosurgical Department of the goose KKB diagnosed with Osteochondrosis of the lumbar spine, paramedian disc herniation L4-L5 on the right.From history revealed that lumbar osteoarthritis affects about 4-5 years old when he began to notice the pain in the lumbar spine. The last 4 months appeared and began prog is key atrophy of the muscles of the legs. Courses of treatment by a neurologist within two months without effect. Hospitalized in the neurosurgery Department.In neurological status at admission the patient was detected irritative pain radicular syndrome L5 and S1 with two sides, signs of atrophy of the muscles of the legs, straightening of the lumbar lordosis. Local tenderness to palpation of the spinous process of the L5 with irritating pain in the popliteal region and the back surface of the thighs. Disorders of sensitivity on the radicular type in the area of innervation of L5 and less pronounced S1 c both sides by type gipestesia.Review R-grams of the spine in 2 planes marked signs of osteochondrosis of the lumbar spine, reducing the height of the disc L4-L5.Mr imaging of the spine: at the level of L4-L5 vertebrae identified paramedian right-hand sequestered herniated disc size is 13 mm with impact on dural bag and his rough compression (see Fig.1).On the basis of clinical and tomographic studies patient was diagnosed with Osteochondrosis of the lumbar spine, right paramedian hernia L4-L5 disk.In position on the healthy side under endotracheal anesthesia to the patient on the right has made Lin is palubicki C4 and C5 vertebrae. In miguelon space isikli yellow ligament and made the approach to the cuff L4 nerve root of the spinal cord and the dural SAC on the level of the hernia.The further course of the operation and all operations associated with the approach and removal of herniated disc, was carried out by micro tools under the control of endovideoscopy. In the localization of disc herniation was determined pronounced stress dural SAC and the cuff of the spine the spinal cord due to their compression by a herniated L4-C5 disc. They have been pushed to the back and pinned to the sides of the vertebrae. To mobilize the dural SAC was resected part of the above and downstream edges of the bows (interlaminate). But it didn't help, because it prevented the continued tension of the Dura. Attempts to shift the cuff of the spine and just dural SAC were not successful. They were almost motionless and gross manipulation on them could cause injury to the roots of the spinal cord. This whole situation does not allow for the introduction of the endoscope into the epidural space and to visualize the hernia.For her permission and release tension in the cuff of the spine spinal cord and dural bag and create a good mobility and prevent injuries at the moment traction Ave is. Gradually evacuated 28 ml of cerebrospinal fluid. This led to the complete withdrawal of the voltage Dura and led to efforts to hold the offset of the root and dural SAC with a disc herniation and well to expose the epidural space. It introduced an endoscope and visualized sequestered herniated disc size 22,5. She was performmove posterior longitudinal ligament and the front squeezed L4 nerve root and dural SAC. Using the surveillance, perform hernia removed completely.After removal of herniated disc tension of the Dura disappeared, spine rigid. This operation failed. Imposed deaf stitches on the wound.In the postoperative period, taking into account the safety of the rear support complex and the absence of depression neurological symptoms, the patient is allowed to walk on the second day after surgery. Radicular pain is gone immediately after surgery.Control MRI confirmed the absence of a hernia (see Fig.2). The patient was discharged from the hospital 9 days after surgery. After 4 months, no pain. Remains easy hypesthesia in the area of the L4 nerve root on the right. Started to work.Thus, the developed method aigaleo space can significantly reduce the voltage cuff root and dural SAC, without efforts to conduct its traction and completely remove paramedian hernia with good functional results.
ClaimsMethod of removing paramedian hernia of the intervertebral discs of the lumbar-sacral spine by performing approach to localization hernia and remove it under control individuele, characterized in that during the operation at the approach to the hernia and the detection voltage of dural SAC and the cuff of the spine the spinal cord, producing a puncture of the subarachnoid space in the region of dural SAC 4-5 mm above the compression and evacuate metered 25-30 ml of cerebrospinal fluid.
FIELD: medicine, orthopedics, traumatology.
SUBSTANCE: one should isolate and dissect the tendons of anterior tibial and long fibular muscles to dissect the tendon of posterior tibial muscle against the site of fixation and direct it towards plantar rear area in front of internal ankle through the tunnel in subcutaneous fiber, then one should subcutaneously direct dissected tendons of anterior tibial and long fibular muscles onto plantar rear area to suture them so to leave free the tendinous end of posterior tibial muscle which should be intraosseously fixed to median wedge bone that keeps the process of foot repulsion during walking.
EFFECT: higher efficiency of therapy.
5 dwg, 1 ex