——— Neurosurgery Spinal Cord Specialty Group
On November 3, 2008, Director of Neurosurgery Feng Sugan performed the first minimally invasive surgery of microscopic spinal decompression in our hospital. The surgery went well and the patient’s symptoms improved significantly after the surgery. The patient was a 72-year-old woman who had pain in the right hip and right lower extremity 2 years ago and numbness in the left lower extremity 7 months ago. She had undergone “small needle knife” and collagenase intervention in an outside hospital, but her symptoms were not relieved, and she developed right foot pain. On examination after admission, the patient had an unstable gait; weak dorsiflexion and plantarflexion of both feet; reduced muscle strength of both lower extremities at grade 5; decreased sensation in the lateral left thigh, posterior right thigh and right foot; and hyperreflexia of the knee tendons bilaterally. Combined with MRI and CT, a diagnosis of lumbar spinal stenosis was made. The patient and her children had visited several hospitals and were advised to undergo surgery for spinal canal decompression plus internal fixation of the spinal arch, but considering the risks and costs of surgery, they had not been determined to undergo surgery. Considering the patient’s advanced age, poor cardiac function, and spinal stenosis mainly caused by hypertrophy of the ligamentum flavum, we adopted microdecompression surgery – that is, under a microscope, we used a high-speed mogul to grind away part of the patient’s hemivertebral plate and used the microscope to bite away the thickened ligamentum flavum from different angles to fully decompress the spinal canal and maintain the original stability of the spine. Currently, the patient has a good prognosis with significant relief of symptoms and was discharged 5 days after surgery. Wu Hao, Department of Neurosurgery, Xuanwu Hospital, Capital Medical University
There are many causes of spinal stenosis, which can be divided into primary and secondary. Secondary causes are common in clinical practice and are mainly caused by hypertrophy of the ligamentum flavum, small joint hyperplasia, lumbar disc herniation, calcification of the posterior longitudinal ligament, injury displacement, spinal slippage and medical origin. Because spinal stenosis is a chronic degenerative process, early symptoms are often not obvious. Patients often have a not very clear history of chronic low back pain and mild activity limitation, which may also manifest as low back pain, low back distension, and a feeling of lumbar girdling. These symptoms often worsen after activity or work and are relieved after rest, but the pain in the low back and buttocks usually does not disappear easily and immediately. Because the symptoms are mild, many patients do not take them seriously and consider them a normal phenomenon of human aging. As the condition develops, numbness, coldness, and even hypesthesia of the lower limbs may appear. Eventually the typical symptoms of lumbar spinal stenosis —– neurogenic intermittent claudication will appear, i.e. numbness and pain in the posterior or posterior lateral aspect of the lower limbs while walking, and usually this symptom moves from the lower back to the legs. A distinctive feature of neurogenic claudication is that the symptoms are aggravated when the lumbar spine is in an extension position and relieved when it is bent. This is because the volume of the lumbar spinal canal becomes smaller when in extension and larger when in forward flexion, so many patients with spinal stenosis feel normal when walking with a wheelchair or shopping cart, or riding a bicycle, but have increased pain when upright. These manifestations often develop chronically, and in severe cases, urinary and fecal incontinence, sexual dysfunction, and even paraplegia can occur. The diagnosis of degenerative lumbar spinal stenosis is usually not difficult to make by combining the patient’s symptoms, signs, and imaging examinations, especially CT and MRI.
The treatment for spinal stenosis is divided into surgical and non-surgical treatments. Non-surgical treatments include medications, functional exercises, epidural injections (hormones), and various physical therapies. The above-mentioned non-surgical treatments only relieve the symptoms to a certain extent, but when the pain develops to the extent that it continuously affects the patient’s normal life and work, then surgery should be considered. Surgical treatment: According to the pathological changes of spinal stenosis, the current surgical procedures for spinal stenosis are divided into three categories: simple decompression, decompression + fusion, and minimally invasive surgery. Traditionally, the surgical procedures for spinal stenosis are simple decompression and decompression + fusion, and laminectomy decompression and nerve root decompression are the standard procedures for lumbar spinal stenosis. The laminectomy and nerve root decompression is the standard procedure for lumbar spinal stenosis. When spinal stenosis is combined with some special conditions, it is difficult to obtain lasting results by decompression alone, and fusion should be performed simultaneously with decompression. Since lumbar fusion requires internal spinal fixation, the medical cost of fusion is significantly higher than that of simple decompression surgery, and the recovery time of patients after surgery is long with many complications. In recent years, minimally invasive surgery has been a major trend in surgery, and new minimally invasive procedures for spinal stenosis have been emerging. Neurosurgery has been carrying out the minimally invasive concept of neurosurgery throughout the spine surgery since it was launched, and the routine use of microscope and mensuration drill is the basis and condition for minimally invasive surgery. The procedure is performed under a microscope, and a high-speed molar drill is used to grind away part of the patient’s hemivertebral plate without injuring the small joints and spinous processes, and to bite away the thickened ligamentum flavum in the spinal canal from different angles, and to enlarge the lateral crypt on the affected side with adequate decompression in the spinal canal. Surgical features: only part of the hemivertebral plate on one side is ground away, preserving the spinous process and small joints, so the surgery is minimally traumatic and can be tolerated by most elderly patients, with almost no effect on the stability of the spine. The operation is performed with a microscope, so the field of vision is good and the nerve roots are better protected and complications are reduced. The patient was able to move around the next day after the surgery, and the length of hospital stay was greatly reduced, as were the costs associated with the surgery. The successful performance of this surgery is what allows us to better serve the majority of patients.