The purpose of the study — to develop the most optimal surgical tactics for treating methods of patients with multilevel displacements of lumbosacral intervertebral discs, based on the features of their clinical manifestations. Material and methods. During 2014 to 2018 inclusively, 3045 patients with lumbosacral radiculopathies due to displacements lumbosacral intervertebral discs (LIDs) were examined and treated. The average age of the subjects was 42.6±5.4 years. In the regional Mechnikov hospital examined and treated 72% of patients with a multilevel displacement of the LIDs, 27% of patients at the Endoscopic Neurosurgery Medical Center and 7% of the patients with multilevel displacement of the LIDs were treated at the Clinic of Family Medicine. All patients underwent a thorough neurological examination with an assessment of the static-dynamic function of the spine. Computer tomography (CT) scan was
performed in 36% of patients, magnetic resonance imaging (MRI) — in 47% and 19% of patients were examined on CT and MRI. Spondylography were performed in 56% of patients, spondylography with functional loads were performed in 82% of cases. In the remaining 18% of cases, functional spondylography were not performed due to severe pain. The effectiveness of the surgical treatment was evaluated according to the VAS scale in 2-3 weeks after the operation, 2.5-3 months and in the long term 3-5 years after surgery. Neurological status and biomechanical functions of the spine were also evaluated in dynamics at the same dates. All groups of surgical methods were used for the study: puncture laser microdisectomy (PLM), endoscopic discectomy (EDE) and microsurgical discectomy (MDE), which, if necessary, ended with instrumentation of the operated segment. The results were statistically processed using Microsoft Excel and the software product STATISTICA for Windows 6.1 (Microsoft). Results. The duration of the radicular syndrome ranged from 3 weeks to 1.5 years, an average of 1.82±0.56 months (p<0.05). In the clinical picture, the following were identified: vertebral, monoradicular and biradicular syndromes. Monoradicular syndrome occurred in 968 patients (74%). In 275 (21%) patients, monoradicular syndrome was combined with vertebral. Biradicular syndrome was detected in 36 (2.5%) patients, and in 35 (2.5%) patients it was combined with lumbalgia. The pain intensity according to VAS on average was 7.5±1.7 points. A decrease in the surface types of sensitivity in the same dermatome was noted by 78.6% of patients, and in 16.1% hyperesthesia was noted. A decrease in tendon reflexes (knee, Achilles and plantar) was detected in 72% of patients, and in 28% — the corresponding reflex was absent. Paresis of the flexors or extensors of the foot was detected in 30% of patients with monoradicular syndrome. There was no statistically significant difference between the severity of pain with hernias up to 8 mm in size and with larger hernias (p≥0.1). But a statistically significant dependence of the severity of
pain on the localization of the hernia was revealed: with lateral and back lateral hernias, the pain intensity according to VAS was on 2.3±0.5 points higher than with paramedian and median displacements of the discs (p≤0.05) Patients with monoradicular syndromes caused by unsecured LIDs, more often performed PLM. If monoradicular syndrome was combined with lumbalgia due to protrusion or non-sequestrated hernia at other levels, PLM was performed in 100% of cases. In cases where the monoradicular syndrome was due to sequestered hernia, the latter was removed using the MDE or EDE method. Of the 162 patients whose sequestration was not removed, during a three-year follow-up, only in 10 (6%) cases, previously asymptomatic hernia began to disturb them, which required surgical treatment. In 94% of cases, these hernias remained asymptomatic. Findings. The clinical picture of multilevel displacements of LIDs depends not only on the level and size of the protrusion or hernia, but also on the level and duration of the discoradicular conflict. Patients with two or more displacements of the intervertebral discs the monoradicular syndrome dominates in the clinical picture. Comparing the effectiveness of various surgical techniques for multilevel protrusions and hernias in the lumbosacral spine, taking into account the long follow-up observation of the operated patients, the best results were obtained using the PLM and EDE methods.
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