Method for operative access for developing large occipital cisterna at arnold-chiari's syndrome

FIELD: medicine, neurosurgery.

SUBSTANCE: in case of laser coagulation of cerebellar tonsils one should fulfill resection of occipital bone at the size of 2x1 cm so, that the upper edge of occipital bone's defect should be at the level of the lower edge of cerebellum, and lower one - at the level of the upper department of lowered tonsils. Due to keeping important anatomical sites of posterior supporting complex of patient's vertebral column and cranium the innovation suggested enables to decrease traumatism of operative interference.

EFFECT: higher efficiency.

4 dwg, 1 ex

 

The invention relates to medicine, namely to neurosurgery, and can be used to improve the clinical results of treatment of patients with pathology of the cerebrospinal transition syndrome, Arnold-Chiari.

Known surgical access for a large occipital tanks in the pathology of the cerebrospinal transition syndrome (Arnold-Chiari), which consists in conducting resection of the greater part of the occipital bone and the posterior paladugu Atlanta (Ochirov S.I. abstract. Kida. the honey. Sciences. Diagnosis and microsurgical treatment of patients with syringomyelia. - M., 1988. 12).

A significant drawback of this method is the high invasiveness, as this resecured important anatomical education skull (a large part of the occipital bone) and spine (back paladugu Atlanta). In the future, this advanced and traumatic access often leads to the development of pronounced pain in the place of operative intervention, instability in the region craniovertebral transition and poor functional results. All this leads to lengthy and costly conservative therapy and increases the stay of the patient in the hospital.

Closest to the claimed is surgical access described Myshkin O.A., Sheveleva I.N., Mahmudov U.B., et al. // So the ICA surgical treatment of Chiari malformation in adults / Second Congress of neurosurgeons of the Russian Federation. 16-19 June 1998. Nizhny Novgorod. - St.-Petersburg, 1998, s-118). The authors use as a surgical access syndrome, Arnold-Chiari marginal resection of the occipital bone in the great occipital foramen to 1/3 of its area and resection of the posterior paladugu Atlanta at a distance of 3 cm, and sometimes arcs C2 vertebra length 3 cm

This method is not organoboranes. It is traumatic, as it is linked with the destruction of a significant part of the occipital bone in the area of occipital foramen to 1/3 of its area and rear paladugu C1 vertebra 3 see Sometimes, if mindlike lowered below the arc 2 cervical vertebra, the authors resetinput spinous process and the rim of the C2 vertebra. This formed a large bone defect - the top edge of the defect in the occipital bone is located at the secondary level departments of the cerebellar vermis, and the bottom - below the bottom of the lowered mingalyov. All this leads to a weakening of the support function of the spine in the area craniovertebral transition.

Technical equipment neurosurgeon can not form the occipital tank, restore liquorto at this level, while retaining the important anatomical education skull and spine, and, of course, leads to functional failure of the spine and worsening outcomes.

The objective of the proposed method I have is to reduce the morbidity of surgical access, the preservation of important anatomical structures of the skull and posterior spinal support complex, preventing the development of a syndrome of functional insolvency of the spine.

The solution of this problem allows to achieve a positive treatment effect significantly improve functional results of treatment in this group of patients, a positive economic impact by reducing the length of stay of the patient on the bed.

The technical result is achieved due to the preservation of anatomical structures of the skull and posterior spinal support complex, which is possible when using during the reconstruction of the ND-YAG laser.

The problem is solved due to the fact that economical conduct resection of the occipital bone in the great occipital foramen sufficient for photocoagulation of mingalyov ND-YAG laser, with a $ 2×1 cm so that the upper edge of the occipital bone defect was located at the level of the lower edge of the cerebellar vermis, and the lower level of the upper section of the lowered mingalyov.

The method was as follows:

On admission the patient with pathology of the cerebrospinal transition (syndrome, Arnold-Chiari 2-4 anatomical variant with scheduling mingalyov in the great foramen and disorders clinic of liquorices level b is Lishou occipital tanks) it is proposed surgery to rekonstruktsii large occipital tank and restore liquorices at this level.

In the sitting position under endotracheal anesthesia, the patient performed a linear incision of soft tissue in the neck and occipital region from the large occiput along the line of the spinous processes to the C3 vertebra. Skeletonize the occipital bone and paladugu C1 vertebra. Under increase of 4.4 spent economical resection margin of the occipital bone in the area of the great occipital foramen width 2 and height 1 cm with preservation of the posterior paladugu Atlanta and the arms of the C2 vertebra. The upper edge of the occipital bone defect with our access is located at the lower edge of the cerebellar vermis, and the lower level of the upper parts omitted mingalyov. Then expose the Dura and conduct reconstruction occipital tanks, restore liquorices at this level by photocoagulation of mingalyov ND-YAG laser with a capacity of 8-10 watts for 3-4 minutes.

Specific example

Patient P., born in 1947, And a/B No. 476/01, was admitted to the Department of neurosurgery, research Institute with a diagnosis of the Syndrome, Arnold-Chiari.

MRI brain: characteristics of the syndrome, Arnold-Chiari moderately severe hydrocephalus of the lateral and third ventricles. Mindlike cerebellum increased in size and lowered until the lower edge of the C1 vertebra. They are completely plugging the great foramen and squeeze bulbar segments of the trunk of the brain, located in the a (1).

R-graphy of the skull in the back polyaxial projection pathology is not observed (figure 2).

On the basis of clinical and tomographic studies patient was diagnosed Pathology of cerebrospinal transition: the Syndrome, Arnold-Chiari with the incursion of mingalyov in the great foramen, with hypertension-hydrocephalic syndrome (3 anatomical variant).

10.04.01) underwent surgery: the Formation of a large occipital tanks using ND-YAG laser.

Online access to behind-the tank was carried out in the position of the patient "sitting". Under endotracheal anesthesia, the patient spent a linear incision of soft tissue in the neck and occipital region from the large occiput along the line of the spinous processes to the C3 vertebra. Skeletonema occipital bone and paladugu C1 vertebra. With the use of surgical optics (under increase of 4.4) held only appeal to the resection margin of the occipital bone in the area of the great occipital foramen width 2 and height 1 see the Rear part of the C1 vertebra (back paladugu Atlanta) and shackle C2 vertebra remained intact, they did not resocialise. Formed bone defect, the upper edge of which was located at the level of the lower edge of the cerebellar vermis, and the lower level of the upper parts omitted mingalyov. Then opened the Dura and rehabilitated Stylo the Noah tanks and restored liquorices at this level by photocoagulation of mingalyov ND-YAG laser power 8-10 watts for 3-4 minutes. Organ-preserving access is possible with the use of modern technical equipment neurosurgeon.

In the postoperative period, taking into account the safety of the rear support complex spine, the patient is allowed to sit on the next day after the surgery, go through 2 days.

Control MRI of the brain and spinal cord at the level of craniovertebral transition has confirmed the effectiveness of surgical approach: large occipital tank was well formed, the dynamics at this level did not suffer (figure 4).

R-graphy of the skull in the back polyaxial projection - visible small defect in the occipital bone in the area of the great occipital foramen. Paladugu Atlanta stored (figure 3).

The patient was discharged from the hospital two weeks after surgery in satisfactory condition. 3 months after surgery, the patient's condition is good. Organic symptoms in neurological status is not revealed. Pain in the spine in place of operative intervention not.

The way to rapid access syndrome, Arnold-Chiari, including resection of the occipital bone in the great occipital foramen, characterized in that when laser photocoagulation of mingalyov cerebellar carry out resection of the occipital bone size 2×1 thus, to the top edge of the occipital bone defect was located at the level of the lower edge of the cerebellar vermis, and the lower level of the upper section of the lowered mingalyov.



 

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