Использование диффузионно-тензорной магнитно-резонансной томографии при эндоскопическом удалении грыжи шейного отдела позвоночника. Клинические наблюдения

Abstract

Minimization of surgical intervention is one of the global trends in spinal surgery, primarily by using endoscopic technologies. The indications for endoscopic treatment are expanding every year. Thus, the application of percutaneous endoscopic lumbar discectomy (PELD) more and more often becomes an alternative for open opearation. However, the use of endoscopy on cervical level has a number of limitations due to the peculiarities of anatomical structure in this spinal segment. Anterior cervical discectomy and fusion (ACDF) is currenlty a gold standard, implying total discectomy, additional instrumentalization, and associated risks. Endoscopy is also rarely used because it is only suitable for the treatment of radiculopathy and inapplicable for patients with stenosis followed by the formation of myelopathic focus in the spinal cord. In order to expand the indications for endoscopic treatment, in the present research we have used diffusion tensor imaging (DTI), allowing to detect subclinical signs of myelopathy. Referring to such parameters as fractional anisotropy (FA), establishing myelopathic focus can be identified in the region of spinal cord stenosis, and use this for differentiated treatment. In our study 9 patients with cervical radiculopathy have been operated, 3 of them using endoscopic method, and 6 of them treated with standard ACDF. Patients with clinical manifestations of myelopathy were excluded from the study. We have received high satisfaction with treatment in all cases. In a similar situation all patients would have been treated with ACDF in the majority of cases, however, DTI has allowed to detect the absence of myelopathy, thus providing the performance of endoscopic treatment with no fear of future manifestation of myelopathy, as well as to avoid potential risks associated with open surgery. According to our study, presurgical diagnostics is crucial for choosing the adequate surgical treatment. The use of DTI solves two problems at once, as it provides both conventional T2 and T1 images needed for surgical orientation, and estimates FA, suggesting the presence of developing myelopathic focus, and visualize corticospinal tracts if required. Patient selection is an important step in endoscopic treatment of cervical radiculopathy, due to several limitations of this approach. The use of endoscopy in treatment of vertebrogenic radiculopathy is a very perspective method and concords with the global trend towards minimally invasive surgery.