Dr. Asen Hadjiyanev: In discopathy with leg paresis, surgery is mandatory

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Dr. Asen Hadjiyanev: In discopathy with leg paresis, surgery is mandatory
Dr. Asen Hadjiyanev: In discopathy with leg paresis, surgery is mandatory
Anonim

Dr. Hadjiyanev, people are afraid of spine surgeries. When should a surgeon intervene in disc herniations and stenoses?

- Disc herniations and spinal stenosis are the most common degenerative diseases. They are treated by both neurologists and neurosurgeons. When there is no way to help with medication, physical therapy and rehabilitation, when the pain does not subside, then people turn to neurosurgery. We very often perform such operations on patients of different age groups. Disc herniations usually occur at a younger age, and spinal stenosis in people over 60 years old. It is indeed a normal reaction for patients to fear surgery and it is always left as a last resort. Everyone starts with medication - pills, system infusions. After that, the services of physiotherapists, rehabilitators are often used, and some resort to the "services" of chakrams. When the possibilities of all these methods of treatment are exhausted and when the pain does not subside after more than three months, then they start looking for consultations with a neurosurgeon. The pain can last 8-9 months, even a whole year, without abating. Only then does one decide on surgery.

But in the case of paresis (loss of function of a limb, for example the foot), surgery is imperative, and in the shortest possible time, otherwise the paresis may become irreversible. Very often these are tibial and peroneal paresis. In case of such a neurological deficit, surgery must be performed within 48 hours. Otherwise, a person risks becoming disabled. Pain in spinal stenosis is also very painful. Sometimes a person has to rest after 50-60 meters because he cannot continue due to pain. This is called neurogenic claudication and is a sure sign that the patient has stenosis - a narrowing of the spinal canal through which all the nerves pass. Consultation with a vascular surgeon may also be necessary to differentiate it from vascular claudication. In addition, when chronic pain is not treated, paralysis of the lower limbs, disturbances in the pelvic functions may also occur. They are also a sign that surgery is needed.

Explain what stenosis is and the nature of the operation?

- The spinal canal is formed by the vertebral bodies, arches and spinous processes, balancing joints and connections - ligaments. To alleviate the condition of a person with severe stenosis, the spinal canal must be opened - some of the arches and spinous processes must be removed and the compressed nerves released. Nerves exit through openings - neuroforamen, narrowings usually occur there as well. The spinal canal is most often opened from the back through the skin, the muscles are pushed to the side, part of the arches and spinous processes are removed, the openings (foramen) are expanded, from which the nerve roots and the nerves themselves exit. In practice, this is the operation. Patients

usually the next day they get relief, pain disappears almost 70%. Physiotherapy procedures can then be done. After a certain period of time passes after the operation, which is called a laminectomy, they feel fully recovered.

Isn't it risky for the stability of the spine after removing arches and spinous processes?

- The stability of the spine is based on a three-column system, in which elements of the vertebral body, arches and processes and ligaments participate. In orthopedics and neurosurgery, instability is considered if there is a disruption of more than two columns. We do not break stability as we keep two columns. In practice, the operation carries no risks. But if it is done at more levels - say at 4-5 levels, then strengthening surgery is also done, titanium or steel fixation systems are placed to further strengthen the spine. It is mandatory for vertebral fractures. But with narrowing of the spinal canal, only decompression can be done.

How is the presence of a herniated disc proven?

- The pain is typical, it starts in the lower back and goes down one leg, in the thigh, in the lower leg, there is numbness in the foot, there is pain when bending and extending. With these symptoms, the suspicion is always for a disc herniation. Imaging is done. Magnetic resonance imaging is much more informative than a regular scan and gives a very good idea of disc degeneration and nerve compression. At the same time, it is much more harmless than the scanner, where there is irradiation with ionizing rays.

When the presence of a herniated disc is proven, surgical treatment is always suggested. In a disc protrusion, the integrity of the disc is not compromised and that disc can retract back inward. Otherwise, it begins to protrude back, enter the spinal canal and press certain nerve structures. The disc is made up of cartilage and a nucleus pulposus in the middle, which has the role of a balancer. When a herniated disc occurs, we have a tear in the cartilage and the annulus fibrosus. Parts of the cartilage can enter the spinal canal and press the nerves and, accordingly, the spinal cord, if it is in the higher levels - the chest and neck. This cartilage cannot normally go back and disappear, but must be removed mechanically.

What is the surgical access?

- For cervical disc herniations, there are two access options. One is to operate from the back, and the other is an anterior cervical approach. In recent years, front access has been used more. With it, there is only one cut in the skin, and then all the soft tissues, muscles, vessels are pushed aside and the bodies of the vertebrae are reached, respectively - to the discs. Loose parts of the diseased disc that pose a potential risk of damaging nerve structures are pulled and removed. In place of the removed disk

an implant or artificial disc can be placed

Working under a microscope because this is microsurgery.

When there is a thoracic disc herniation, it is approached from behind or laterally, since the lung and heart are in front. Sometimes it is necessary to remove a pedicle - part of the vertebra - to reach the hernia and remove it.

Lumbar disc herniations are one of the most common - between the fourth and fifth vertebrae and S1 (the beginning of the coccyx). Interlaminectomy is most often used there - it is approached between the arcs and their integrity is not violated. And with a foraminectomy, it is approached through the opening from which the nerve roots exit. These are quite elegant operations with a minimal skin incision. Some even call them bloodless operations, although in practice there are no bloodless operations. There is always a violation of the integrity of the tissues and skin. But with this type of surgery, we have little tissue trauma and a very good outcome. When the cartilage is removed, there is immediate relief, the pain disappears.

How long does the patient recover after such an operation?

- The standard hospital stay is between three and five days. On the first day, preparations are made for the operation, consultations with an anesthesiologist and cardiologist, if the person has other diseases. After surgery, patients stay immobile overnight for observation, and the next day we get them up and moving. At first, they are more cautious, but when they feel that the pain is gone, they are ready to return to their normal rhythm of life. These are absolutely routine operations that have been done for at least 30 years.

Has a herniated disc been proven by imaging, with magnetic resonance imaging, are there cartilage fragments in the spinal canal, there is no other way to remove them except by surgery.

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