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SynopsisSpinal cord injury is considered to be one of the most serious traumas leading to severe disability and denoting a life-long medical care for patients both in clinics and at home. The state has to spend vast amounts of money on treatment and nursing care. The frequency of spinal cord traumas varies in different countries from 11 to 112 cases for every million citizens a year. In the general statistics of nervous system injuries the spinal cord traumas constitute 4.5 - 5.3 per cent. One of the crucial problems of modern surgery is to work out some new reconstructive microsurgical methods for treating severe spinal cord traumas. The surgical methods which are used nowadays for stabilizing a severely injured spinal column with the help of decompressive laminectomy turn out to be insufficient. The author aims to improve the existing revascularization and reinnervation surgery based on Goldsmith methodics as well as the surgical procedure of replacing the intercostal nerve to the spinal cord and nerve roots. The author worked out the following operations on cadaver material: microsurgical omentomyelopexia surgery and the operation of shifting a vascular — nervous fascicle to the spine cord. Revascularization process of the omentum segment was carried out using intercostal and occipital vessels. However, even these operations, performed for 24 patients with spinal cord trauma, brought about just an improvement of segmental spinal cord activity. A further research and elaboration of new reconstructive surgery showed that the main goal should be a reconstruction of the anatomical structures of spinal cord and its membranes (meninges), i. e., it is necessary to reconstruct the dimensional integrity of the spinal cord by using combined vascular-nervous transplants as well as to restore cerbro-spinal fluid circulation in subdural space, using the plastic surgery of the dura mater and bearing in mind that the size of the spinal cord will be increased after the transplantation. The absence of the normal cerebro-vascular fluid circulation in the spinal column disrupts the blood circulation and prevents the spinal cord from functioning as an integtal whole, which stops almost completely the transmittance of the nerve electric signal along intact nerve fibers. All the attempts to normalize the spinal cord function without preserving its dimensionakl integrity, as well as without restoring the liquor circulation in the subdural space are bound to fail. As far as the additional sources of blood supply for the spinal cord are concerned, our experience shows that even in case of heaviest injury thereis alwats a sufficient amount of functioning vessels (mostly in the arachnoid meninx), which will be able to compensate the deficit of the spinal blood circulation after eliminating the intraspinal compression. Thus the plastic surgery on the spinal cord should secure the dimensional integrity of the spinal cord at the place of its traumatic injury demontrates that besides a reliable fixing of the spinal cord, it is necessary to perform a reconstructive plastic surgery on the spinal cord itself, as well as on its dura mater and pia mater. Microsurgical technique ought to be emploued after opening dura mater. It is very important to restore the spinal cord with the help of transplants consisting of the intact anatomic structures (autovessels and peripheral nerves) in order to restore the normal cerebrospinal fluid circulation, as well as to create a link between the injured spinal nerves for promoting the subsequent axonogenesis. After implanting the combined vascular neural transplant into the injured area of the spinal cord, the dura mater plasty musy certainly be performed. It is connected with the fact that the spinal cord increases in size after the implantation, and any stich on dura mater will cause the spinal cord stenosis. If there is a complete scar occlusion of dural sack, it is necessary to perform a circular surgical repair of the entire dure mater. In this case the restored spinal cord will be washed from all sides with the cerebro-spinal fluid, and it is very important for producing a neurotrophic effect. The principales of th reconstructive and restoring operations on the traumatized spinal cord worked out by us are similar to the principles of the vascular surgery. It is well known that the area of vessel occlusion is replaced with a vascular autotransplant. For reconstructing the integrity of dura mater, an autovenous transplant is also used. In vascular plastic surgery the blood flow in the principal veins and arteries is restored, while in spinal plastic surgery it is the cerebro-spinal fluid circulation which should be restored. Autovenous plasty of dura mater is carried out with the help of Currel vessel suture, because this technique enables to turn the vessel inside out, with the intima on the outer surface. A suture like this provides a reliable and durable hermetic sealing, which is most important for prophylaxis of cerebro-spinal fluid leakage. A specific feature of an early postoperative period (from 3 to 6 months after the surgery) is presence of a positive dynamics in the neuro and psychic status (considerable reduction of asthenic syndrome), in motion functions (a decrease and even a complete disappearance of spasmodic movements in the lower limbs, the appearance of muscle twitching of some elements of movement in various muscle groups), in sense organs (the activation of sweating, improvement of pelvis functions — i. e. a feeling of full bladder and the will-induced delay of involuntary urination, improvement in reactions of nervous system), the improvement of trophies (decubitus healing). Evaluating clinic and instrumental data, it was observed an activation of sympatic vasomotoric fiber function (decrease in the strength and the size of sole surface hyperthermia as compared to the pre-operating data, activation of neurogenous sympathetic rhythms of the skin blood circulation). In some cases it was observed an activating process of trophic sensory pertidergic fibers (activation of the sensory peptidergic bloodflow rhythm according to LF data), the improvement in cerebro-spinal fluid data. In certan cases there was a noticeable increase in permeability of the spinal vessels according to the data of control spinal angiography. All the abovementioned postoperative effects were observed despite the absence of impulse transmittance between the traumatized spinal cord ends. These phenomena are connected with neuronotrophic effect effect of the restored cerbero-spinal fluid circulation, facilitating the nutritive delivery, as well as the trophic factors recovery (neurotrophic factors, angiogenesis and growth factors) to the neurons of the spinal cord and brain. An important role may be played by the transplant surgery of the damaged area, which is performed to support the spinal cord structure, and in certain cases to decrease the spinal cord ischemia. The combination of all these sanogenetic components promotes the neuron activity as well as starts the process of compensating the spinal cord functions (segmentary, suprasegmentary and intersystemic). The most strongly manifested effects are represented by the activation and reconstruction in vegetative system and in the process of supplying the trophies of denervated tissues, which are represented on the periphery by delicate (including also perivascular) nervous fibers. См: Степанов Г.А. Новые методы реконструктивной микрохирургии спинного мозга при тяжелой травме Предыдущая страница | Следующая страница Похожие материалы:
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