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Yuldashev Ravshan Muslimovich, Republican Scientific Centre of Neurosurgery of Ministry of Health of Republic of Uzbekistan, Senior Researcher,
E-mail: [email protected]
OUR EXPERIENCE IN TREATING PATIENTS WITH SPINAL HYDATID CYSTS
Abstract: The Purpose is to analyze the patients who has tumors of the spine in the thoracic and lumbar spine and present the results of surgical treatment. The results of the research and treatment of 51 patients with tumours of the spine, conducted between 2009 and 2011. We studied the intensity of pain (VAS), a neurological condition (scale ASIA), and radiographic parameters which characterizing the degree of deformation of the spinal column. The Results. Excellent result of treatment (group A) was observed in 14 (27%) patients. Good (group B) and satisfactory (Group C) results of treatment are marked in 9 (19%) and 14 (27%) patients respectively. In 14 (27%) patients received poor treatment outcomes (group D). In this group died 2 (4%) patients. The Analysis of neurological disorders in groups A and B on the lower extremities showed improvement (on average) to 1.04 ± 0.56 degree scale ASIA/IMSOP. Regression of neurological disorders occurred in all 11 patients with primary tumours of the spine. Marked decrease in pain (on average) to 3.17 ± 1.07 degrees in VAS. In A and C groups, decrease in the angle of local kyphosis was (on average) 10.91 ± 6.44. The best results were observed in vertebral compression index (9.45% ± 8.50%), than in vertebral strain wedge index (6.55% ± 9.86%).
Conclusion. The Operation of posterolateral approach with the stabilization of the spine improved neurological status and/or local kyphosis angle for tumours to 73% of cases. In remote control studies there have been documented good treatment results in 27% of patients with tumours of the spine.
Keywords: spinal tumors, posterolateral surgical approach.
Introduction. Echinococcosis in humans is severe Research objective is to analyze patients with echi-
parasitic disease that is widespread in many regions nococcosis of the spine in the thoracic and lumbar spine
of the Republic of Uzbekistan. Among rare forms of and study the results of surgical treatment.
echinococcus diseases damage by echinococcus cyst of Materials and research methods
the spine and neurovascular structures of spinal canal Material for this work is the results of researches and
(spinal cord, its vessels and roots) is the most severe. treatment of26 patients with echinococcosis ofthe spine,
Both hematogenic invasion and cystic invasion from which were carried out within the period from 2010 to
adjacent formations through intervertebral foramen 2014 in a clinic of the Republican Scientific-Research
can be the reasons for spinal canal echinococcosis de- Centre of Neurosurgery of the Ministry of Health of the
velopment. Following to data of the researchers han- Republic of Uzbekistan. Patients' age varied from 14 to
dling with echinococcosis problem, parasite localiza- 55 years old; of which there were 18 man and 8 women.
tion in spinal canal is occurred in 0.4-1% of patients Average age of patients was 36 years old.
[1; 2]. Literature analysis suggests that such observa- All patients have passed complete clinical research. The
tions are generally reported as case histories and are diagnosis was verified during operation and was confirmed
based on few number of patients (from 1 to 3 cases by hystologically. Pain syndrome intensity was assessed ac-
each author) [3]. cording to visual analogue scale (VAS). ASIA/IMSOP
scale was used in order to characterize neurological status. Damage of spinal column was assessed by X-ray research methods: direct radiography, computed tomography (CT), magnetic resonance imaging (MRI). Vertebral compression factor (VCF) and vertebral wedge-shaped deformation factor (VWDF) were used for the purpose of objectivization of extent of damage. VCF assesses the loss level of anterior height of damaged vertebral body in relation to anterior body height of two adjacent vertebrae. VWDF indicates the value ofvertebral body reduction resulted from wedge-shaped deformation. Deformation of spinal axis was assessed based on angle measurement of local kyphosis (Cobb) and anterior displacement of vertebrae. Amount ofspinal canal narrowing was also taken into account based on the data of computed tomography (CT) and magnetic-resonance (MR) researches. The condition for selection to surgical treatment was the lack of damage of brain and lungs by echinococcosis. Surgical treatment supposed decompression of spinal cord at the level of damage from posterolateral approach with removal of echinococcus cysts, removal of chitinous covers, and partial resection of damaged body. The operation was completed by transpedicular stabilization with drainage tube being left, by which flushing of epidural cavity was carried out within 3-4 days using 15% sodium chloride solution. During preoperative and postoperative period the patients were subjected to chemotherapy by antiparasitic drugs.
Results. Echinococcus cysts localization by regions of the spine was as follows: thoracic spine - 9 (35%); lumbar spine - 17 (65%). Out of 26 patients, 16 (61.5%) had recurrent echinococcosis, 10 (38.5%) patients have sought medical advice for the first time.
Neurological manifestations measured by ASIA-IM-SOP scale were presented as follows. Number of patients referred to A group was 2 (7.7%), B group - 4 (15.4%), C group - 7 (27%), D group - 9 (34.5%), E group -4 (15.4%). Therefore, total number of patients with compressive myelopathy syndrome (A, B, C groups) amounted to 13 (50%) patients. The same number of patients had disc syndrome (D, E groups).
The patients were distributed by pain syndrome intensity (VAS scale) as follows. 2 (7.7%) patients with thoracic spine echinococcosis and 6 (23%) patients with lumbar spine echinococcosis were complained of minor pain (3-4 scores). 5 (19.2%) and 8 (30.8%) patients, respectively, were complained of moderate pain (5-7 scores). 2 (7.7%) patients with thoracic spine echinococcosis and 3 (11.5%) with lumbar spine echinococcosis were complained of severe pain (8 scores and more).
Assessment of spinal injury based on radiological examinations is presented in Table 1. Mean values were as follows: VWDF - 19.26% ± 15.34%, VCF -24.57% ± 18.34%, spinal canal narrowing - 32.25% ± ± 17.33%. Mean value of local kyphosis angle amounted to 14.06 ± 13.44. II degree (65.3% patients) predominated during assessment of spinal column injury. Changes referred to I degree were observed in 34.7% of patients. During assessment according to vertebra destruction scale, changes of the 1st degree (12 patients - 46.2%) occurred most often. Changes of the 2nd degree were observed in 9 (34.6%) patients. 5 (19.2%) patients were referred to the 3rd degree.
Indicators Values
VWDF (n = 26) interval from 0% to 55% 19.26% ± 15.34%
VCF (n = 26) interval from 0% to 80% 24.57% ± 18.34%
Spinal canal narrowing (n = 26) interval from 12% to 80% 32.25% ± 17.33%
Angle of local kyphosis (n = 26) interval from 14 to 39 14.06 ± 13.44
Number of damaged spinal columns (degrees) I - two II - three (n = 26) 9 (34.7%) 17 (65.3%)
Spine deformation scale (degree) 1 - compression fracture 2 - fracture with predominant compression 3 - fracture with predominant wedge-shaped deformation (n = 26) 12 (46.2%) 9 (34.6%) 5 (19.2%)
Table 1. - Assessment of the spine damages based on X-ray studies
Magnetic resonance assessment of the spine that was made to all 26 patients has found compression of neurological manifestations of spinal canal, and in 19 (73%) cases - appropriate compressions of signal intensity change (under T1 and T2) in spinal cord.
Types of posterolateral surgical approach are presented in (Table 2). The 1st and the 2nd economic ap-
proaches were performed in 6 (23%) cases. The 3rd and the 4th broad surgical approaches were performed in 20 (77%) cases. Operation with bilateral decompression of vessels and nervous formations of spinal canal was performed in 19 (73%), and with unilateral one - in 7 (27%) patients.
Table 2. - Type of surgical approach
№ Type of surgical approach Number of cases (n = 26)
1. Resection ofvertebral arch, arch root, and upper intervertebral joint 2 (7.7%)
2. Resection ofvertebral arch, arch root, and upper/lower intervertebral joints 4 (15.4%)
3. Hemilaminectomy or laminectomy, removal of arch root, articular processes and transverse process in lumbar spine 16 (69.1%)
4. as in item 3+ removal of costotransverse joint, head and part of rib in thoracic spine 4 (7.7%)
Broad surgical approach was used more often both in lization was performed in 12 (46.2%) patients. As for the thoracic spine (73% cases) and lumbar spine (62% cases). rest 14 (53.8%) patients, they were not subjected to stain hystologic studies, echinococcus vesicles and chi- bilization and metal implants were not applied to them. tinous covers were verified in all cases. Short stabilization (3 segments) was used in 10 (83.3%) Stablization of the spine from a perspective of verte- cases. Long stabilization (4 segments) was performed in brae injury is presented in Table 3. Transpedicular stabi- thoracic spine in 2 (16.7%) patients.
Table 3. - Stabilization of the spine
Stabilization Number of cases n = 26 Extent of the spine damage
Th3-Th12 L1-L4
Type
Transpedicular 12 (46.2%) 3 9
Without stabilization 14 (53.8%) 6 8
Number of stabilized segments n = 12
3 4 10 (83.3%) 2 8
2 (16.7%) 2 0
Table 4. - Early treatment results
Results Number of cases (n = 26)
A - good 17 (65%)
B - satisfactory 8 (31%)
C - poor 1 (4%)
improvement
By ASIA/IMSOP scale (degrees)+ 1.46 ± 0.77
By VAS scale (scores)+ 4.35 ± 1.33
Local kyphosis angle++ 11.87 ± 7.12
VWDF++ 7.55% ± 8.86%
VCF++ 9.45% ± 8.50%
+ refers to results in A and B groups ++refers to results in A and C groups
Early treatment result is presented in (Table 4). Good treatment result (A group) was observed in 17 (65.4%) patients. Satisfactory (B group) treatment result was observed in 8 (30.8%) patients. In 1 (3.8%) case poor treatment result (C group) was obtained. Mild paraplegia has developed in the patient after operation. Analysis of neurological disorders in A and B groups by function of lower extremities indicated the improvement (on average) to 1.46±0.77 degree by ASIA/IMSOP scale. Regress of neurological disorders occurred in all 25 patients. Reduction of pain syndrome was observed (on average) to 4.35±1.33 degree by VAS scale. Reduction of angle of local kyphosis in A and C groups amounted to (on averTable 5. - Results
Discussion. Spinal canal echinococcosis is rare localization of echinococcosis. It should be noted that about 50% of bone echinococcosis damages vertebral column and spreads extradurally and paravertebrally [1; 3; 4]. Although the spinal canal echinococcosis is rare, its differential diagnostics and surgical treatment are often the great challenge. Use of CT methods, MRI diagnostics and detailed medical history not always allow making a correct diagnosis on the spinal canal echinococcosis. Echinococcosis cysts are subject to differentiation with other pathological processes which are similar to neuroimaging manifestations. The treatment result is of great importance both for the a surgeon and for a patient. Considering the fact that the spinal canal echinococcosis is characterized by multiple cysts and their invasive growth, it is becoming apparent that a complex of measures oriented to prevention of postoperative recurrence should be taken. Thus, Turtas et al. [5] reported on 18 patients with the spine echinococcosis which underwent surgery, of which 9 (50%) had recurrence of disease. The current information indicate to pro-
age) 11.87° ±7.12°. Best results were observed in VCF (9.45%±8.50%) than in VWDF (7.55% ±8.86%).
Control studies were carried out in 11 (35%) patients (Table 5). Late good treatment result was observed in 8 (81.8%) cases, poor one - in 3 (18.2%) cases. Improvement by ASIA/IMSOP scale, on average, amounted to 0.21±0.43 degree, and by VAS scale -0.34±0.52 degree. Deterioration of neurological status by ASIA/IMSOP scale, on average, amounted to 0.25±1.71 degree, and by VAS scale - 0.43±0.57 degree. Deterioration of mean value of the angle of local kyphosis to 2.32°±1.86°was also occurred in this group.
of control study
spectiveness of chemical prophylaxis of postoperative recurrence of the spine echinococcosis. In particular, use of Mebendazol for the purpose of prevention of recurrence of disease during postoperative period results in good treatment results. Based on cooperative research of 38 neurosurgery centres of Turkey and literature review within the period from 1990 till 2000 there were observed 63 and 111 cases of the spine echinococcosis, respectively. The recurrence was observed in 14.28% (at that, chemotherapy is applied in 33 neurosurgical centres) and 24.32% of patients [6]. Calculations of indicators characterizing deformation ofbone structures of the spine were performed in 26 patients based on radiological researches. Mean values prior to operation were as follows: VWDF - 19.26% ± 15.34%, VCF - 24.57% ± 18.34%, the spinal canal narrowing indicator - 32.25% ± 17.33%. Mean value of local kyphosis angle amounted to 14.06 ± 13.44. Use of such indicators allowed us to objec-tivize the treatment results. It is found that improvement was observed in 25 (96%) patients as a result of surgical
Results Number of cases (n = 11)
Good 8 (81.8%)
Poor 3 (18.2%)
Changes in a group of patients with good results n = 8
By ASIA/IMSOP scale 0.21 ± 0.43
By VAS scale 0.34 ± 0.52
Changes in a group of patients with poor results n = 3
By ASIA/IMSOP scale 0.25 ± 1.71
By VAS scale 0.43 ± 0.57
Local kyphosis angle 2.32 ± 1.84
operation. Lack of similar data in available references reliable internal stabilization will reduce pain syndrome
does not allow comparing the obtained results. as well as neurological disorders.
Conclusions 2. In remote control studies good treatment result
1. Operation by posterolateral approach with re- was registered in 81.1% of patients with the spine echi-
moval of echinococcus cysts of the spinal canal, resec- nococcosis. tion of vertebral bodies damaged by echinococcosis with
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