Novokuznetsky Institute of Postgraduate Education, Novokuznetsk, Russia
A high rate and rather early development of dystrophic diseases of the spine, leading to disability, condition social significance of this spread pathology.
Pathomorphologic substrates, responsible for certain syndromes of spinal osteochondrosis and spondylarthrosis, are various. A degenerative-dystrophic process affects neighboring intervertebral dis˝s and joints to this or that degree. For example, there can be hernia of an intervertebral disc in one spinal motor segment; pathologic mobility in the other (as a rule, above-lying) segment; initial pathologic changes, causing pathologic impulses and leading to numerous pain syndromes, in the third segment. We define clinically significant combinations of pathogenetic situations and syndromes, which are dependent on them, as a focus of dystrophic lesion of the spine.
The goal of the present study was substantiation of multimodality treatment of this focus, which should be aimed at elimination of not only the main syndrome (for example, compression), but also each syndrome, watched in a patient.
There were about 3500 cases, operated in the Novokuznetsky Neurosurgical Clinic for compression syndromes due to osteochondrosis; disc puncture was used in 1500 patients with reflex (non-compression) syndromes. We began to study clinical manifestations of spondylarthrosis in detail only 5 years ago. Surgical interventions for compression syndromes, caused by spondylarthrosis were performed in 182 cases; 102 patients with reflex (facet) syndromes were subject to denervation of arch-process articulations. We studied a problem of neurosurgical treatment of patients with osteochodrosis for more than 40 years. Our experience allowed us to classify clinical manifestations of this disease and to determine a rate of its syndromes.
Non-compression or reflex syndromes of osteochodrosis are usually dependent on pathologic impulses from impaired intervertebral discs, which can be eliminated by their dereception. Our study demonstrates, that disc hernias, revealed with the help of MRI, do not cause compression syndromes in almost 50% of cases. However, they can form reflex syndromes. These "hernial forms of reflex syndromes" can be easily treated by intradiscal methods; thus, there is no need of surgical interventions. Reflex syndromes of spondylarthrosis, described in foreign literature as facet syndromes, are treated by spirit-novocain block (dereception) of arch-process articulations or by other methods (laser, ultrasonic, high-frequency) of denervation of "articulation nerves".
While choosing a method of treatment, we do not take into account morphologic findings, revealed with CT or MRI, but pay attention to diagnosis of a focus of the spine dystrophic lesion, i.e. pain syndromes (3 of them on the average), watched in a patient and conditioned by a pathogenetic situation in adjacent affected segments.
Compression syndromes of dystrophic spinal diseases, caused by compression of the spinal cord, its vessels, roots or a vertebral artery, are treated surgically. We performed decompressive, decompressive-plastic, decompressive-stabilizing and stabilizing interventions. Many of these interventions were developed in our Clinic. Among them one can mention three versions of decompressive-stabilizing operations, used in compression of a vertebral artery by uncovertebral vegetations; reconstructive operations on a vertebral artery through an inter-transversal space in its combined (discogenic and non-discogenic) lesion; decompression of the spinal cord or a cerebrospinal nerve root through an intervertebral space and subsequent plasty of a removed disc with autoderma duplication; anterior foraminotomy by means of resection of posterolateral segments of intervertebral discs together with adjacent areas of vertebral bodies; decompressive-stabilizing intervention at a thoracic level with use of a lateral approach, etc.
We were the first in the country to develop various devices, made of an alloy with thermal mechanical memory and used for spondylodesis. Stabilization with porous titanium-nickel implants, which are characterized by good bone germination, absence of rejection and necessity of long-term immobilization in a postoperative period, is an alternative to expensive transpedicular fixation of vertebrae. Wide use of this method in our country is a bright proof of its merits.
We use a porous implant with a reinforced telescopic rod for replacement of several vertebral bodies.
Improving ways of spine stabilization, we pay great attention to development of methods, applied for decompression of neurovascular formations without subsequent spondylodesis. Dynamic examination of patients, operated for cervical osteochondrosis, shows, that bone fusion of vertebrae is often followed by progression of a dystrophic process in neighboring intervertebral discs, leading to necessity of repeated operation. An example of the above-mentioned decompressive operation (without spondylodesis) is resection of osteochondrous vegetations of uncovertebral junctions or lateral hernia of a disc with an extra-disc approach, performed between costal-transverse processes. One more way of preventing postoperative lesion of neighboring intervertebral discs includes decompressive-plastic operations or disc fenestration after performing decompressive manipulations. Plastic replacement of a disc with a pad from a patient's skin, containing no subcutaneous fat and epiderma, is effective. Even in case of scarry degeneration of a transplant, 60% of a normal volume of vertebrum mobility is still preserved.
We use transthoracic and lateral approaches for decompression of roots or the spinal cord at a thoracic level. An anterior suprapubic retroperitoneal approach and osteoplastic hemilaminectomy have been developed for decompression of lumbar roots. If root compression is combined with marked vertebral instability, we perform decompessive manipulations, which are followed by interbody spondylodesis with applying a porous implant and the same posterior approach to a vertebral canal. We use medial (from the side of a vertebral canal), lateral extravertebral or combined approaches in stenosing of an intervertebral foramen by osteochondrous vegetations, accompanied by disc hernia or without it.
A choice of a method of surgical treatment depends on an existing pathogenetic situation, underlying compression syndrome. It is expedient to perform an intra-discal therapeutic-and-diagnostic manipulation before operation. It is aimed at revealing dependence of accompanying reflex syndromes on pathologic impulses from neighbouring affected segment and their elimination.