RU2748252C2 - Method for destruction of medial branch of spinal nerve - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to neurosurgery and vertebrology, and can be used to treat destruction of the medial branch of the spinal nerve in patients with osteochondrosis of the lumbosacral spine, accompanied by severe recurrent facet syndrome. In surgical treatment with posterolateral access, a puncture is performed in the projection of the facet joint until the needle with a mandrel stops at the junction of the transverse process and the facet joint under X-ray control. Then the mandrel is replaced with a fiber-optic light guide and the medial branch of the spinal nerve is destroyed by pulsed laser radiation in the 970 nm mode 3 times with an interval of 5 seconds with a gradual reverse traction of the mandrel with the light guide by 3 mm along the lateral surface of the facet joint. The laser radiation frequency is 9 Hz, the power is 3 W in the total heat release dose of 100 J. The exposure time is no more than 15 seconds.

EFFECT: method provides increased period of remission of the disease, decreased damage to surrounding tissues during surgical treatment due to the destruction of the medial branch of the spinal nerve by pulsed laser radiation in the specified mode.

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Description

The proposed invention relates to medicine, namely to neurosurgery and vertebrology, and concerns the treatment of destruction of the medial branch of the spinal nerve in patients with osteochondrosis of the lumbosacral spine, accompanied by severe recurrent facet syndrome.

The known method, which consists in chemical (medication) denervation of the facet joints of the spine. The essence of the method lies in the dereception of the medial branch of the spinal nerve in the facet joints with an alcoholic solution of an anesthetic (96% ethyl alcohol with a local anesthetic (for example: 2% lidocaine or 2% novocaine) in a 1: 1 ratio). The procedure is carried out under the control of an image intensifier (electronic optical converter). Punctures are performed with a needle with a mandrel in the projection of the facet joint. The needle is passed all the way to the junction of the transverse process and the facet joint. Mandrain is replaced with a syringe with a mixture. The volume of solution injected simultaneously into the area of the affected facet joint is 0.1-0.5 ml and is selected taking into account the anatomical features revealed by the results of additional research methods (CT, MRI, X-ray). For persistent denervation of the facet joint area, 3-4 times administration is required, until the last administration is completely painless. This indicates the onset destruction ("chemical cutting") of the nerve endings of the facet joint area [1] (see Lutsik AA Diagnostics and neurosurgical treatment of osteochondrosis of the spine // Recommended protocol. Novokuznetsk - 2006. - 38 p.).

The disadvantages of this method include the spread of the neurolytic mixture to adjacent tissues, which increases the zone of destruction.

The closest method is radiofrequency denervation of the medial branch of the spinal nerve with slight variations in the technique of radiofrequency thermocoagulation, target points, techniques for monitoring the position of the active electrode tip and coagulation parameters. Radiofrequency denervation is performed with insulated needles 100-150 mm long with a working bare end at a cut of 5-10 mm. Under visualization control, the distal end of the needles is placed exactly on the side of the facet joints at the place where the median primary branch of the spinal nerve passes [2] (Konovalov N.A., Proshutinsky S.D., Nazarenko A.G., Korolishin V.A. joints in the treatment of facet pain syndrome / NA Konovalov // Problems of neurosurgery. - 2011. - S. 51-55).

After installing the needles, stimulation is performed with a low current with a frequency of 50 (100) Hz for sensory fibers and 2 Hz for motor fibers, while the patient's tingling sensation at a power of less than 0.5 W indicates the optimal approach of the needle to the nerve. After injecting a small amount of local anesthetic, the needle tip is heated to 70-80 degrees C for 60-90 seconds. This leads to coagulation of the nerve, but also causes minor thermal damage to the surrounding tissue. Then a certain amount of a mixture of local anesthetics and methylprednisolone is injected, the needle is removed.

The disadvantages of the prototype are:

1. Development of recurrence of pain syndrome within 12 months after the destruction of the nerve.

2. Decrease in efficiency after radiofrequency denervation within 12 months to 50-60%.

The objective of the proposed technical solution is to develop a method that ensures the destruction of the medial branch of the spinal nerve in patients with osteochondrosis of the lumbosacral spine and complete regression of the pain syndrome.

The technical result of the proposed method is to increase the period of remission, reduce damage to surrounding tissues.

The technical result of the proposed method is achieved by the fact that the posterolateral approach is punctured with a needle with a mandrel in the projection of the facet joint until it stops at the junction of the transverse process and the facet joint under X-ray control, then the mandrel is replaced with a fiber optic light guide and electrocoagulative destruction of the medial nerve of the spinal cord is performed laser in 970 nm mode.

It is also new that the radiation is carried out 3 times with an interval of 5 seconds with a gradual reverse traction of the mandrel with a light guide by 3 mm along the lateral surface of the facet joint, while the exposure time is no more than 15 seconds, the laser radiation frequency is 9 Hz, the power 3 W, total heat dissipation 100 J. The total exposure time is no more than 15 seconds.

Comparative analysis with the prototype showed that the proposed method differs from the known one by the above methods. From the analysis of the patent and special literature, the authors found that the proposed method has features that distinguish it not only from the prototype, but also from other technical solutions in this field of medicine.

Thus, the proposed method meets the criterion of the invention "novelty".

The relationship and interaction of essential techniques of the proposed method provides a new result in solving the problem, namely: achieving complete regression of pain syndrome, reducing damage to surrounding tissues.

The destruction of the medial branch of the nerve, coupled with a gradual reverse traction of the light guide by 3 mm along the lateral surface of the facet joint, provides complete regression of pain syndrome without the development of relapse, causing guaranteed nerve transection, which is explained by the variable location of the nerve on the surface of the facet joints.

The use of a low frequency 9 Hz laser with a power of 3 W, as well as short time intervals of 5 seconds during denervation, ensure the least damage to adjacent tissues. This achieves a frequency of oscillations similar to the frequency of peripheral nervous structures, as well as the required heating temperature, which makes it possible to create destruction of only the nervous tissue.

The exposure time is no more than 15 seconds and the total heat release of 100 J is sufficient for complete transection of the medial branch of the nerve, while not causing significant damage to the surrounding tissues, which also positively affects the almost complete absence of local pain syndrome in the area of needle insertion in the early postoperative period.

The foregoing allows us to conclude that the technical solution meets the criterion of the invention "inventive step".

The proposed method for the destruction of the medial branch of the spinal nerve can be successfully and repeatedly used in practical health care in neurosurgery departments, does not require large financial costs for its implementation and improves the social status of patients. The technology meets the criterion of the invention "industrial applicability".

The essence of the method is illustrated by illustrations, where: Fig. 1 is a diagram of the lumbar spine with the image of the injection site of the needle into the spinal nerve in the frontal plane;

FIG. 2 is a diagram of the lumbar spine showing the site of needle insertion into the spinal nerve in the sagittal plane;

FIG. 3 - intraoperative X-ray image of the position of the needle in the projection of the spinal nerve of the lumbar spine of patient T;

FIG. 4 - intraoperative photo of the general position of the needle with the installed light guide.

We explain the positions used in the figures:

1 - facet joint,

2 - the medial branch of the spinal nerve,

3 - a needle with a mandrel,

4 - transverse process of the vertebra,

5 - light guide.

"Method for destruction of the medial branch of the spinal nerve" is as follows:

The patient is in the prone position with a discharge roller in the lumbar spine. The operating field is treated with an antiseptic solution using Sol local anesthesia. Lidocaini 2%, 5 ml. Then, under the control of an image intensifier (electronic optical converter), a posterolateral approach is used to puncture with a needle with a mandrel in the projection of the affected facet joint. The needle is passed until it stops at the junction of the transverse process and the facet joint under X-ray control (see the appendix to the description of the application, Figs. 1 and 2). Then the mandrel is replaced with a fiber optic light guide and electrocoagulation destruction of the medial branch of the spinal nerve of the facet joint is performed with simultaneous reverse traction of the light guide by 3 mm along the lateral surface of the facet joint. Exposure to pulsed laser radiation in the 970 nm mode, 3 times with an interval of 5 seconds, frequency 9 Hz, power 3 W in a total dose of 100 J. The total exposure time is no more than 15 seconds. After removing the light guide, a syringe with hydrocortisone is attached to the needle, 15 mg is injected. The needle is removed, an aseptic bandage is applied. After the procedure for the destruction of the spinal nerve, the patient is in the hospital for 1-2 days under dynamic observation.

The proposed method is illustrated by a clinical example. Patient T., 47 years old, turned to the Neurosurgery Center of the Road Clinical Hospital of the Irkutsk-Passazhirskiy station of JSC Russian Railways with complaints of severe pain in the lumbosacral spine, aggravated mainly by dynamic loads, radiating along the posterior surface of the right lower limb to the popliteal pits.

Comprehensive clinical preoperative assessment: the level of pain syndrome according to the visual analogue scale (VAS) - 92 mm, the level of quality of life according to ODI - 65 points. From the anamnesis: According to the patient, he considers himself ill for 5 years. He was periodically treated conservatively with the use of non-steroidal anti-inflammatory drugs (NSAIDs) without significant positive dynamics.

Neurological status on admission: Antalgic position. There is no pain in the percussion of the thoracic spine. Smoothness of the lumbar lordosis is noted. Movement in the lumbosacral spine is painful, limited when bending back and forth. Lasegue's symptom is negative. There is pain during percussion and palpation in the projection of the facet joints LIV-LV, more on the right, with irradiation to the right lower extremity to the popliteal fossa. Knee reflexes D = S live, Achilles reflexes S = D live. Defense of the paravertebral muscles of the III degree from both sides. Muscle tone in the arms is normal; in the legs is normal. Muscle strength of the upper and lower extremities - 5 points. No sensitivity disorders were found at the time of examination. There are no meningeal signs. Performs coordination tests correctly.

Results of additional examination methods: MRI of the lumbosacral spine. There are degenerative-dystrophic changes in the segments L _IV -L _v , L _V -S _I presented in the form of marginal bone growths, a decrease in the intensity of the signal from the intervertebral discs, and a decrease in their height. Facet joint hypertrophy at the level of L _IV -L _V.

After a detailed study of the clinical data and the results of additional examination methods, the following diagnosis was made: Dorsopathy. Aggravation. Osteochondrosis of the lumbosacral spine. Facet syndrome L _IV -L _V on the right (grade IV according to Fujiwara A). Lumboischialgia syndrome on the right. Severe pain and muscle-tonic syndromes.

To relieve recurrent pain syndrome and the ineffectiveness of conservative treatment methods, the patient is recommended treatment according to the proposed method - destruction of the medial branch of the spinal nerve of the facet joints L _IV -L _V on the right.

After treatment of the operating field with an antiseptic solution with the use of local anesthesia Sol. Lidocaini 2% 5 ml under image intensifier control, posterolateral access was performed with a needle with a mandrel in the projection of the facet joint on the right. The needle was held up to the stop at the junction of the transverse process and the facet joint. Executed R-control - the needle is in the projection of the posterior medial branch of the root L4 on the right (see the appendix to the description of the application Fig. 3). The mandrin was replaced with a fiber optic light guide (see the appendix to the description of the application, Fig. 4), electrocoagulation destruction of the medial branch of the spinal nerve of the facet joint L _IV -L _{V was} performed on the right with simultaneous traction of the mandrin with a 3 mm light guide by pulsed laser radiation of 970 nm, frequency 9 Hz (impulse 5 sec., interval 5 sec.) with a power of 3 W, in a total dose of 100 J. The total exposure time is 15 seconds. The light guide was replaced with a hydrocortisone syringe. Introduced 15 mg of hydrocortisone. Aseptic dressing.

The patient is conscious, the procedure was well tolerated. Stable hemodynamics: blood pressure - 110/70 mm Hg, Ps - 68 per minute. Achieved analgesia of the paravertebral region of the lumbar spine. Operation time is 30 minutes. No blood loss. The postoperative period was uneventful.

Pain syndrome in the patient's right lower extremity was arrested. During hospitalization, anti-inflammatory therapy with NSAIDs and antibacterial therapy - Ceftriaxone 1.0 × 1 time per day for 2 days were carried out.

Neurological status at discharge: Percussion of the thoracic spine is painless. The lumbar lordosis is smoothed. Movement in the lumbosacral region is slightly painful. There are no symptoms of tension. Knee reflexes D = S live. Achilles reflexes S = D are alive. There are no pathological symptoms. Muscle tone in the arms is normal, in the legs normal. Muscle strength of the upper limbs - 5 points, of the lower limbs - 5 points. No sensitivity disorders were found at the time of examination. There are no meningeal symptoms. Performs coordination tests correctly.

Comprehensive clinical postoperative assessment: the level of pain syndrome according to a visual analogue scale of 4 mm, the level of quality of life according to ODI - 15 points. The patient was discharged under the supervision of a neurologist at the place of residence with complete regression of neurological symptoms. It is recommended to limit physical activity within a period of up to 2 weeks. Examined 2 months later by a neurosurgeon: complete social and professional rehabilitation.

Using the proposed method, 30 patients were operated on for the period 2017 - 2019 with osteochondrosis of the lumbosacral spine, accompanied by severe facet syndrome.

Clinical efficacy in terms of pain level according to VAS and quality of life according to ODI were:

The results confirm the persistent effect after using the proposed method of laser destruction of the medial branch of the spinal nerve in patients with osteochondrosis of the lumbosacral spine, accompanied by severe painful recurrent facet syndrome.

Therefore, the proposed "Method for the destruction of the medial branch of the spinal nerve" provides a complete regression of pain syndrome, and also allows you to reduce damage to surrounding tissues during surgical treatment.

Information sources:

1. Lutsik A.A. Diagnostics and neurosurgical treatment of spinal osteochondrosis // Recommended protocol. Novokuznetsk - 2006 .-- 38 p.

2. Konovalov N.A., Proshutinsky S.D., Nazarenko A.G., Korolishin V.A. Radiofrequency denervation of intervertebral joints in the treatment of facet pain syndrome / N.A. Konovalov // Questions of neurosurgery. - 2011. - S. 51-55).

Claims (1)

A method of destruction of the medial branch of the spinal nerve, including denervation of the medial branch of the spinal nerve by puncture with a needle with a mandrel in the area of the affected facet joint, characterized in that the posterolateral access is performed in the projection of the facet joint to the stop of the needle with a mandrel at the junction of the transverse process X-ray control, then the mandrel is replaced with a fiber-optic light guide and the medial branch of the spinal nerve is destroyed by pulsed laser radiation in the 970 nm mode 3 times with an interval of 5 seconds with gradual reverse traction of the mandrel with a 3 mm light guide along the lateral surface of the facet joint, the laser radiation frequency is 9 Hz, power 3 W in a total dose of heat release of 100 J, while the exposure time is no more than 15 seconds.

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