COMMISSUROTOMY OF THE SPINAL CORD

From Big Medical Encyclopedia

COMMISSUROTOMY OF THE SPINAL CORD (Latin comissura connection, a joint + grech, tome a section, a section) — operation of crossing of a spinotalamichesky path in front gray commissure of a spinal cord.

Idea of operation K. the page of m belongs to the English neuropathologist J. G. Greenfield who called it «chordotomia mediolongitudinalis». For the first time it was carried out an amer. the neurosurgeon D. Armour in 1926. This operation was for the first time manufactured in the USSR by A. L. Polenov in 1935 which gave it the name «commissurotomy of a spinal cord».

Indications and Contraindications

Indications: the heavy pain syndromes which are not giving in to conservative therapy and surgical interventions on peripheral parts of the nervous system at nonresectable tumors (including metastatic) top and bottom extremities, a pelvic girdle, urogenital system, etc., effects of a spine injury, a spinal cord and a horse tail.

Contraindications: extreme degree of exhaustion, it is purulent - septic diseases.

Technology of operation

On level, on Krom cut front commissure of a spinal cord, distinguish upper (cervical and upper chest segments), average (average chest segments) and lower (the lower chest segments) To. page of m. During the determination of level of a commissurotomy it is necessary to consider that decussation of fibers of a spinotalamichesky path (see. Conduction paths ), going from the lower extremities and a pelvic girdle, begins only at the level of Th12 of a segment of a spinal cord and completely comes to an end within three — four overlying segments. Decussation of the fibers of a spinotalamichesky path going from a trunk and upper extremities occurs within three — six overlying segments. Thus, the quantity of segments over which there is decussation increases in the cranial direction. These topographical distinctions of a spinotalamichesky path determine analgetic effect and the nature of disturbances by a longitudinal axis of a spinal cord painful and a thermoesthesia depending on level, on Krom at To. pages of m cut the crossed fibers of a path. At a section of the crossed fibers in the lower chest segments (Th8-12) of disturbance painful and a thermoesthesia in underlying areas of an innervation (a pelvic girdle, the lower extremities) usually have conduction character, at a section on average (Th3-7) and verkhnegrudny and cervical (Th2-C5) departments of a spinal cord — segmented character.

Very important circumstance determining level lower To. the page of m, is the above-stated fact of the beginning of decussation of fibers of a spinotalamichesky path only at the level of Th12 of a segment of a spinal cord. It allows to leave a cone of a spinal cord intact.

the Diagrammatic representation of provision of a commissurotome at a front commissurotomy: 1 — a front crack of a spinal cord; 2 — white commissure of a spinal cord; 3 — gray commissure of a spinal cord; 4 — a commissurotome.

To. pages of m make under the general anesthesia in position of the patient on a stomach. After a linear section of soft tissues over the corresponding acanthas of a backbone make laminectomy (see) 2 — 3 vertebrae. The firm meninx is cut longwise on the centerline. Open an arachnoid membrane over the dorsal surface of a spinal cord and produce liquid. Section of front commissure is carried out by a longitudinal section of a spinal cord strictly on the centerline a thin flat knife — a commissurotome (the flat ophthalmic scalpel, an edge of a safety razor can be also used). A commissurotome stick in the area of a back median furrow of a spinal cord, edges it konturirutsya usually well. Then by easy pressure it is carried out ventrally strictly in the sagittal plane through the mid-feather separating from each other back cords of a spinal cord. At the same time it is necessary to consider that even the insignificant deviation of a commissurotome on this piece leads to damage of back columns aside. At further advance of a commissurotome cut back and front gray commissures of a spinal cord (fig.) forward. Crossing of white commissure in most cases does not manage to be avoided, but the tip of a commissurotome because of danger of wound of a front spinal artery shall not get into a front crack of a spinal cord far at all. The only measure of prevention of its damage is immersion of a commissurotome in a spinal cord no more than on 2/3 its diameters. Extra care concerning spinal arteries needs to be shown at interventions at the nizhnegrudny level of a spinal cord, blood supply to-rogo, unlike overlying departments, has no segmented character, and at switching off of the main spinal artery of an ishemization all lower part of a spinal cord is exposed.

Complications

At some patients are observed passing dysfunctions of pelvic bodies in the form of a delay of an urination and defecation which usually disappear in the first week of the postoperative period. More serious violations of spinal blood circulation at the level of a commissurotomy and underlying departments of a spinal cord which are shown by segmented and conduction disturbances in motive and sensitive spheres.

An outcome

After lower To. pages of m of pain usually disappear right after operation. At upper To. pages of m at some patients can remain not intensive pain in the struck segments. The analgetic effect of operation at a number of patients can decrease in the subsequent, but intensity of pains usually does not reach initial degree.

See also Spinal cord .


Bibliography: Arutyunov A. I. Surgical treatment of some forms of unsatiable pains commissurotomy, Doctor business, No. 2, pages 1 17, 1952; Salman A. Ya. Mielotomiya in surgery of pains, Saturday. nauch. works, posvyashch. to the 25 anniversary of the prof. deyateln. A. L. Polenova, page 159, L., 1941; Le ri with h e R. La Chirurgie de la douleur, P., 1937; W h i t e J. C. a. S w e e t W. H. Pain and the neurosurgeon, Springfield, 1969.


H. Ya. Vasinonim

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