Spinal decompression: how the operation is performed, indications and complications

Microsurgical spinal decompression is a surgical treatment using optical intraoperative devices aimed at eliminating compression of the neurovascular structures of the spinal canal. To release compressed spinal nerve formations and blood vessels in neurosurgical practice, low-traumatic methods with a high degree of visualization of the operated field are used. Modern spinal canal decompression surgery is performed through a mini-access, ranging in size from 1 cm to 4 cm.

Drainage after surgery eliminates swelling.

Vertebral compression syndrome includes serious neurological disorders. They are accompanied by painful local and/or referred pain in the back and other parts of the body, disturbances in the sensory and musculoskeletal functions of the limbs, and dysfunction of internal organs, in particular the pelvic organs. These symptoms are more often caused by degenerative diseases (advanced osteochondrosis in 80%), post-traumatic complications and tumors that provoked a narrowing of the cavity of the spinal canal. As a result, the factor of pathological pressure and tissue trauma begins to influence the nerve fibers and blood vessels, which is expressed by the above symptoms.

Cervical stenosis due to hernial protrusion.

Treatment of compression of the cervical spine, lumbosacral or thoracic, should not be delayed! Long-term compression can cause the death of vital structures, ultimately leading to paralysis of the arms or legs, severe irreversible brain damage, critical failure of the genitourinary system, heart, and respiratory center. A neurologist, neurosurgeon, or orthopedist can professionally assess the seriousness of the clinical case and competently recommend one or another type of therapy.

Decompression is always prescribed only under compelling circumstances when the following exist:

• life-threatening and disability-threatening spinal diagnoses, central nervous system disorders;
• persistent or progressive inhibition of motor functions of the musculoskeletal system, despite completing a course of complex conservative treatment;
• persistent or frequently recurring severe pain that is not relieved by medications or all possible non-surgical methods;
• disorders of defecation, urination, reproductive system.

The intervention consists of surgical elimination of pathological defects that cause blocking of the spinal canal and compression of nerve and vascular formations. These may be intervertebral hernias, marginal bone growths of the vertebrae, hypertrophied ligaments, benign or malignant neoplasms, hematomas, and adhesions.

Efficiency of decompression

In most cases, a microsurgical operation, the price of which ranges from 60 thousand to 200 thousand rubles, allows one to achieve significant relief of the patient’s condition. The chances of a full recovery, provided it is carried out in a timely manner, are quite high. The main part of the manipulations (70%-80%) is performed at the lumbar levels, since the lumbar area is characterized as the most loaded and mobile part of the ridge, easily vulnerable to degeneration and injury. The second most common area for decompression is the neck.

Approximately 95% of patients initially admitted to the hospital with cervical and lumbar nerve entrapment are discharged after decompression with noticeable functional improvements. Many of them note a noticeable reduction in pain and muscle weakness of the limbs already in the first hours, day or two after the operation. In approximately 3%, symptoms remain unchanged, and in 1%-2%, the condition worsens.

The stated efficiency percentages here take into account the entire range of possible pathologies that are generally subject to decompression microsurgery. Therefore, prognostic data may differ depending on the specific diagnosis, initial neurological status, individual characteristics of the body, method and category of complexity of the intervention.

Symptoms of the disease

In the initial stages, lumbar spinal stenosis does not manifest itself in any way. But as the disease progresses, pain in the lower back is detected, the sensitivity of the legs decreases, and gait is disturbed. The patient cannot walk for a long time, he needs rest every 100-200 meters.

Fig - MRI Multilevel stenosis L3-L4 instability

Diagnostics

To make a correct diagnosis, use:

• radiography;
• CT, MRI;
• Ultrasound;
• computed tomographic myelography;
• electroneuromyography.
• scintigraphy.

Decompression and stabilization surgery

Decompressive surgeries are sometimes combined with implantation of a stabilizing system if there is a need to eliminate or prevent vertebral instability. Fixation (stabilization) after the release of neurovascular formations involves fastening vertebrae prone to abnormal displacement with special structures and implants of a fixed or dynamic type.

A fixed connection tactic is placing a bone graft or cage into the intervertebral foramen to immobilize and form spinal fusion (fusion) of two or more vertebrae, followed by fixation of the stabilized area with a titanium metal structure. Bone material for transplantation is usually taken from the patient's iliac crest; allografts are less commonly used.

Dynamic stabilization is the implantation of prosthetic devices that reliably stabilize the pathological area, but do not completely block mobility between the vertebral bodies. The range of motion will not exceed the threshold of physiologically acceptable values.

Diagnosis of injury

Many people wonder what it is, a decompression fracture of the spine. Since it is caused not by compression, but by stretching, radiography rarely helps determine the results of the injury.

The best solution is MRI. The magnetic resonance imaging method makes it possible to determine the condition of the tissues and whether there is damage to the processes and intervertebral discs. This technique also allows you to check the spinal cord - damage to it most often causes paralysis.

Endoscopic view

Endoscopic surgery in spinal neurosurgery has been used relatively recently; it began to be introduced abroad in the mid-90s, in Russia only 10 years later. Endoscopy for decompression is the most minimally invasive technique for resection of pathological tissues through a small incision (1-1.5 cm) using a telescopic probe and a set of instruments that are inserted into its working cavity. A session lasts on average 45 minutes. Rehabilitation takes approximately 60 days.

During the operation.

The technique, when the surgeon performs resection measures through a thin endoscopic tube with a diameter of only 6-8 mm, is the most correct in relation to healthy skin and surrounding muscle-ligamentous structures. Thanks to this, the patient endures the recovery stages easier and faster.

Endoscopy minimizes the risks of intra- and postoperative complications due to the highest possibilities for increasing the surgical field with a clear transmission of its image to the surgical monitor in real time. Surgery with an endoscope also has unique access methods:

• TESSYS (transforaminal);
• CESSYS (anterolateral);
• iLESSYS (dorsal, dorsolateral) and other highly promising technologies in terms of safety and minimal invasiveness.

The following information will help you get an idea of ​​how the endoscopic method is used to release the compressed components of the nervous and circulatory system in the spine:

1. As a rule, the operation is performed under local anesthesia, but it is also possible to use general endotracheal anesthesia.
2. This is followed by treatment of the skin of the back with an antiseptic solution if access is created from behind. A small incision (no more than 1.5 cm) is made with a scalpel on the skin in the projection of the lesion site.
3. A dilator (expander) is inserted into the created hole under the control of the image intensifier into the safe zone of the spinal space, then the working sleeve is inserted through it, and the endoscope tube is installed through the sleeve. In the main device, a camera and a light guide are connected.
4. Under multiply magnified video surveillance, using interchangeable instruments that are placed inside the endoscope, the surgeon performs the necessary manipulations. The specialist carefully removes the source of the compression syndrome, for example, osteophytes with bone nippers, or a disc herniation with a microprobe. In this way, decompression of nerves or vessels is achieved, which can recover in a short time.
5. The excised structures are removed through the endoscopic system compartment, the cavity of the spinal canal is thoroughly washed with saline solution to remove surgical “garbage”. Next, the device is removed, after which the wound is disinfected and several stitches are placed on it.

Endoscopy is contraindicated in the presence of severe lateral and circular stenosis, bilateral caudogenic claudication, severe paresis, median hernias, and paravertebral tumors. Installing stabilizing devices in most cases is an impossible task with this tactic.

Forecast

• Decompressive laminectomy successfully reduces leg pain in 70% of patients, resulting in significant improvements in function (ability to perform normal daily activities) and markedly reduced levels of pain and discomfort. However, back pain does not always improve, and 17% of older people require repeat surgery. Symptoms may return after a few years.
• Decompression laminotomy successfully reduces back pain (72%) and leg pain (86%) and improves walking ability (88%). Endoscopic laminotomy results in reduced blood loss, shorter hospital stay, and less need for pain medications in the postoperative period than open laminotomy.
• The results of surgery largely depend on the patient. It is important to maintain a positive attitude and diligently perform physical exercises (physical therapy) that should be selected by a physical therapy doctor. Maintaining weight can significantly reduce pain. Don't expect your back to be like that of a healthy person.

Operation with a microscope

Surgery under microscope control is recognized as the most successful and productive tactic of decompressive surgery. It allows for a wider range of manipulations for a huge number of diagnoses, in contrast to endoscopic treatment. As for visualization, modern microscopes provide a 40-fold magnification, and this satisfies 100% all the requirements for high-precision surgical manipulations on any part of the spinal column.

In addition, all kinds of reconstructive and stabilizing measures of varying degrees of complexity are subject to operations with a microscope. Surgical aggression is much less than with classical open interventions, therefore this technology is also classified as minimally invasive neurosurgery. The incision for high-quality implementation of microsurgical decompression at the 1st level is about 3-4 cm, anesthesia is provided only by general anesthesia. The procedure lasts from 1 to 3 hours. The duration of postoperative recovery is on average 2-3 months.

We will describe below how to expand the spinal canal, where the neural structures are compressed, a widely practiced method of surgical intervention is performed with a microscope.

1. The patient is put into a deep state of sleep through inhalational multicomponent anesthesia.
2. The most advantageous access is created in the area of ​​the stenotic lesion in order to leave the structures of the supporting spinal complex as intact as possible.
3. Monitoring the progress of the surgical process through a super-powerful microscope, the microsurgeon moves the pinched nerve to a safe place.
4. Using miniature instruments (burs, pliers, etc.), the specialist removes those parts of the joints, ligaments, vertebrae, and cartilage tissue that have grown excessively and led to compression. If necessary, the spine is stabilized with implants.
5. At the final stage, the wound is washed, disinfected and sutured with a cosmetic suture.

The patient is usually allowed to get up and walk around in the late afternoon after the procedure or the next morning. The minimum period of hospitalization is 4 days.

What is a decompression fracture of the spine?

Along with compression fracture, there is also a decompression fracture of the spine. In the first case, the vertebrae are severely compressed, causing them to crack and collapse and lose some of their height. In the second case, the injury occurs due to severe stretching. In such a situation, the vertebra remains intact, but various connecting elements of the spinal column, processes, discs, and muscles suffer greatly. The worst situation is one in which the spinal cord and nerve fibers are damaged.

A decompression fracture of the cervical vertebra is less common because a sprain is more difficult to develop than a strong compression under the influence of external loads.

Most often, the injury is diagnosed after road traffic accidents and sudden lifting of heavy weights. Athletes, elderly people, and children are at risk.

A decompression simulator is not an alternative to surgery

For advanced neurological and functional disorders, only surgery can be effective. No non-surgical methods are capable of fully expanding the spinal canal and forever freeing the neurovascular structures from the oppression of formed degenerations and neoplasms. Having a complex diagnosis, there is no point in relying on the miraculous effect of popular decompression simulators. It is appropriate for them to undergo decompressive therapy exclusively for degenerative-dystrophic pathologies in uncomplicated forms of manifestation, for example, in the initial and middle stages of osteochondrosis, disc protrusions.

If a large hernia has formed in a diseased spine or coarse massive bone growths have appeared on the joints and vertebrae, which were the provocateurs of a difficult neurogenic pathogenesis, they will not resolve and will not disappear, no matter how you stretch the spine on the simulator. Even if an anti-compression effect suddenly occurs, relapses in such difficult situations, unfortunately, cannot be avoided. In addition, the famous decompression and anti-gravity training systems can seriously harm some patients, for example:

• it is easy to injure muscles, tendons, and ligaments weakened by the disease;
• increase the progression of the existing pathology, aggravate the already severe symptoms;
• provoke some other pathology of the musculoskeletal complex.

One cannot, of course, completely deny the benefits of special simulators; they may well provide invaluable benefits for a selected category of people, namely:

• unload the spine;
• increase elasticity and muscle endurance;
• reduce swelling of the nerve root, reduce pain.

But only if the training prescribed by a specialist does not go against the indications and contraindications. Therefore, you must obtain permission and referral for such classes exclusively from a highly specialized doctor. Take them only under the supervision of an experienced kinesitherapy instructor with excellent recommendations.

Scar after surgery.

Recommendations

• If the patient has undergone fusion surgery, it is recommended that nonsteroidal anti-inflammatory drugs (NSAIDs) (eg, aspirin, ibuprofen, Advil, Motrin, etc.) be avoided for six months after surgery. NSAIDs can cause bleeding and interfere with bone healing.
• It is not recommended to move for 2-4 weeks after surgery or until activity has been approved by the attending surgeon.
• Sitting for long periods of time should be avoided.
• Do not lift anything heavier than 4-5 kg. Do not bend and rotate the spine
• Doing housework and yard work should also be avoided as directed by your doctor.
• It is recommended to postpone sexual activity for a while, until the surgeon gives permission.
• No smoking. Smoking delays tissue healing, increasing the risk of complications (such as infections) and interferes with the ability of bones to heal.

Complications and consequences of injury

When the doctor does not fully understand what it is, a decompression fracture of the spine, serious complications can arise. Among them:

• intervertebral disc herniation;
• paralysis of limbs;
• progressive muscle spasms;
• the appearance of hematomas and bleeding;
• disruption of the normal circulation of substances in the body and the functioning of internal organs;
• stenosis;
• thromboembolism;
• ligament rupture;
• and much more.

To prevent this from happening, it is important to correctly diagnose the cause of the injury and the extent of tissue damage. Proper treatment and rehabilitation after injury is the secret to a successful recovery without complications.