Method of percutaneous endoscopic interlaminar removal of synovial cysts of intervertebral joints

Abstract

FIELD: neurosurgery.SUBSTANCE: used for percutaneous endoscopic interlaminar removal of cysts using X-ray and visual endoscopic control. The operation is performed with the patient lying on his stomach under general anesthesia. The working cannula is placed at the lateral edge of the interlaminar window under X-ray control. Then, a medial facetectomy is performed until the lateral edge of the cyst is detected, the yellow ligament and the cyst wall at the lateral edge are opened, followed by emptying and internal decompression of the cyst. After this, the yellow ligament is opened medially to the cyst wall. The yellow ligament is cut out in the form of an “apron” with the base towards the cyst, turned laterally and used to create tension between the medial wall of the cyst and the dural sac, which ensures visualization of the adhesions between the cyst wall, dural sac and root and their safe dissection. After this, the cyst walls are removed using microinstruments.EFFECT: method reduces the risk of damage to the dural sac and spinal roots, reduces the likelihood of epidural bleeding and scarring, and reduces the likelihood of cyst recurrence by opening the yellow ligament and the cyst wall at the lateral edge, followed by emptying and internal decompression and forming an “apron”-shaped ligament with the base towards the cyst and creating tension between the medial wall of the cyst and the dural sac.1 cl, 1 ex

Description

[0001] The invention relates to medicine, namely to neurosurgery, and can be used for synovial paraarticular cysts of the intervertebral joints of the lumbar spine.

[0002] The traditionally accepted method for microsurgical removal of synovial cysts of the lumbar spine facet joints involves performing an interlaminectomy or hemilaminectomy after a skin incision up to 4 cm long, skeletonization of the arches and spinous processes. Next, the facet joint cyst is incised and removed, followed by separation and removal of the cyst wall from the dural sac and nerve root. This approach allows for complete removal of the intervertebral joint cyst, but requires a fairly large skin incision, separation of the muscles from the bony structures, and, in some cases, a hemilaminectomy or facetectomy followed by fixation of the spinal motion segment.In addition, epidural bleeding and the lack of continuous irrigation with saline complicate the separation of the cyst wall from the dural sac and contribute to epidural scarring in the late postoperative period [1) Landi A, Marotta N, Tarantino R, Ruggeri AG, Cappelletti M, Ramieri A, et al. Microsurgical excision without fusion as a safe option for resection of synovial cyst of the lumbar spine: Long-term follow-up in mono-institutional experience. Neurosurg Rev 2012; 35:245-53. 2) Gupta A, Lutz GE: Synovial cysts: to fuse or not to fuse? Spine J 10:817–819, 2010].

[0003] Endoscopic transpedicular removal of facet joint cysts is known. This technique allows for a lateral approach to the cyst, opening the wall, and draining it. However, a significant drawback of this method is the inability to separate and remove the medial cyst wall from the dural sac without risking damage to the dura mater (DM) due to limited visibility; limited mobility of the working cannula; and the risk of pedicle fracture, with subsequent instability of the segment, as a canal approximately 8-9 mm in diameter is formed within it. In general, this technology is only applicable to cysts with a thin medial wall (Guntram Krzok, Albert Edward Telfeian, Ralf Wagner, Menno Iprenburg. Transpedicular endoscopic surgery for lumbar spinal synovial cyst—report of two cases. Spine Surg. 2016;2(4):310-313. doi: 10.21037 / jss.2016.09.02).

[0004] Endoscopic transforaminal removal of facet joint cysts is known. This technique is applicable to the removal of facet cysts primarily in foraminal-extraforaminal locations, as well as cysts with limited medial extension. However, a significant drawback of this method is the lack of endoscopic visibility of the boundary between the cyst wall and neural structures, and, accordingly, safe dissection at the boundary of these formations, in the case of paramedian and median synovial cysts (Hyeun-Sung Kim, Sagar Bhupendra Sharma, Harshavardhan Dilip Raorane. How I do it? Transforaminal endoscopic decompression of intraspinal facet cyst. Acta Neurochirurgica, doi.org / 10.1007 / s00701-019-03995-1).

[0005] The closest to the claimed method is the method of endoscopic removal of cysts of the facet joints of the lumbar spine described by M. Komp et al., who used the endoscopic interlaminar approach in 90% of cases (M. Komp, P. Hahn, S. Ozdemir, H. Merk, R. Kasch, G. Godolias, and S. Ruetten. Operation of Lumbar Zygoapophyseal Joint Cysts Using a Full-Endoscopic Interlaminar and Transforaminal Approach: Prospective 2-Year Results of 74 Patients. Surgical Innovation, published online March 25, 2014. DOI: 10.1177 / 1553350614525668). The use of this method is convenient for a number of cyst localization options, however, with severe compression and dorsal displacement of the dural sac and roots, opening the yellow ligament, dissection in a narrow space and an attempt to remove the cyst may be accompanied by a violation of the integrity of the dura mater, exit and irreversible damage to the spinal cord roots.

[0006] Disadvantages of the prototype:

[0007] - A significant and significant drawback of the prototype is the increased risk of damage to the dural sac and spinal nerve roots during incision and resection of the ligamentum flavum, dissection at the cyst wall-dural membrane interface, and attempts to remove the cyst under conditions of significant spinal canal structure compression. This is due to the fact that large synovial cysts significantly compress and displace neural structures, increasing the area of ​​adhesion formation between the dura mater and the cyst, which impairs visibility, mobility, and visualization of the interface between the cyst wall and the dural sac.

[0008] The invention aims to create a method for minimally invasive percutaneous endoscopic interlaminar removal of synovial cysts of the intervertebral joints. This method reduces the risk of damage to the dural sac and spinal nerve roots; it enables complete, visually controlled internal decompression of the cyst and dissection at the cyst-dural membrane interface, followed by separation and complete removal of the cyst walls.

[0009] The stated technical result in the implementation of the present invention is achieved by sequentially inserting the working cannula at the lateral edge of the interlaminar window under X-ray control in two projections. A medial facetectomy is performed until the lateral border of the cyst is determined. Next, the ligamentum flavum and the cyst wall are opened at the lateral edge, followed by cyst drainage and internal decompression, thereby reducing the cyst volume and the pressure and traction it exerts on the dural sac and spinal nerve roots. This allows for safe opening of the ligamentum flavum medial to the cyst wall. The ligamentum flavum is then dissected out as an apron with its base facing the cyst, turned laterally, and used to create tension between the medial cyst wall and the dural sac using the beveled end of the working cannula.We believe this adhesion tension is a crucial technique, as it allows for clear visualization of all adhesions between the cyst wall, dural sac, and root, allowing for safe excision along their entire length. Only after adhesion dissection and complete separation of the dural sac from the cyst is it possible to safely remove the cyst. The cyst walls are then removed using micronizers and microscissors, achieving complete decompression of the neural structures.

[0010] The method is as follows:

[0011] The operations were performed under general anesthesia in the prone position with radiographic control in two projections. A dilator and working cannula are sequentially inserted at the lateral edge of the interlaminar window. The dilator is then removed, an endoscope is inserted, and the operation is performed under constant visual control and irrigation with saline. Soft tissue is dissected up to the lateral edge of the interlaminar window, and a medial facetectomy is performed using special burs until the lateral edge of the cyst is identified. The ligamentum flavum and the cyst are then incised at the lateral edge, followed by cyst drainage and internal decompression. Next, the ligamentum flavum is safely incised medial to the cyst wall. The yellow ligament is cut out in the form of an apron with the base towards the cyst, turned laterally and used to create tension between the medial wall of the cyst and the dura mater using the beveled end of the working cannula.After tensioning the adhesions, they are safely excised along their entire length. Next, the cyst walls are resected using micronippers and microscissors. A radiofrequency coagulator was used for tissue preparation and hemostasis, as well as for coagulation of the synovial lining of the joint cavity. Patients are typically mobilized within 2-3 hours, and discharge occurs the same day or the following day.

[0012] The claimed method was developed at Dr. Mereji's Pain Treatment Clinic LLC and underwent clinical trials in the treatment of 15 patients, with the following results obtained.

[0013] We give a clinical example.

[0014] Patient Shch., born in 1975, was admitted with complaints of pain along the posterolateral surface of the left leg, numbness, and weakness in the left leg. These complaints have persisted for 7 months. The disease has a progressive course. No improvement has been observed with conservative treatment. Neurological examination revealed radicular pain radiating in the area of ​​the L5 and S1 roots on the left and S1 on the right, weakness of the extensor and flexor muscles of the left foot (grade 4), and hypoesthesia in the innervation zone of the L5 and S1 roots on the left. Tension symptoms are sharply positive on the left. Examination of the lumbar spine reveals straightening of the lumbar lordosis and tension in the back muscles. An MRI of the lumbar spine revealed a paraarticular synovial cyst of the intervertebral joint L4-L5 with significant compression and displacement of the dural sac and spinal cord roots.

[0015] Diagnosis: Paraarticular synovial cyst of the intervertebral joint L4-L5 on the left. Compression radiculopathy L5, S1 on the left, S1 on the right.

[0016] Given severe compression of neural structures, the lack of response to conservative therapy, and progressive focal neurological symptoms, the patient underwent surgery using the technique described above. Immediately after surgery, complete regression of radicular pain in the legs was observed, along with a reduction in the severity of hypoesthesia and weakness in the left leg. The patient was active 4 hours after surgery and discharged the following morning. A moderately restricted regimen was recommended, and she returned to her normal daily activities within 3 weeks.

[0017] The use of the proposed method eliminates damage to the dural sac and spinal roots; enables minimally invasive, complete, visually controlled internal cyst decompression and dissection at the cyst-dural membrane interface, followed by safe separation and complete removal of the cyst walls; enables intra-articular coagulation of synovial tissue, which significantly reduces the likelihood of recurrence of such cysts; eliminates epidural bleeding with subsequent scarring and the development of associated post-surgical syndrome; and promotes early postoperative patient activation and recovery.

Claims

A method of percutaneous endoscopic interlaminar removal of synovial cysts of the intervertebral joints, characterized in that the working cannula is placed at the lateral edge of the interlaminar window; medial facetectomy is performed until the lateral edge of the cyst is detected; the yellow ligament and the cyst wall are opened at the lateral edge with emptying and internal decompression of the cyst; then the yellow ligament is opened medial to the cyst wall, cut out in the form of an apron with the base towards the cyst and turned laterally; using the beveled end of the working cannula, tension is created between the medial wall of the cyst and the dural sac; adhesions between the cyst wall, dural sac and root are visualized and excised; after complete separation of the dural sac from the cyst, the cyst is removed.