anterior commissuretomy

The secondary nerve fibers that transmit pain are emitted from the posterior horn of the spinal cord and enter the contralateral spinal thalamus side by anterior commissure. Therefore, the anterior white commissure is cut off along the midline of the spinal cord by a single operation, which can make the painful temperature of the bilateral body segmental. Loss to relieve pain in the area, while not damaging other spinal conduction pathways, avoiding serious complications. This surgery began in Armour and Greenfield (1926), and later in Putnam (1934), Lerich (1936), Wertheimer (1949), Arutiunov (1952), and Lermbcke (1964). They used a lower chest or a anterior cholangioplasty to relieve pelvic or lower abdominal organ cancer, such as prostate cancer, cervical cancer, rectal cancer and colon cancer. According to Wertheimer (1953), in a group of more cases of lumbar spinal cord anterior commissure in the treatment of lower limbs, pelvis and perineal pain, root pain, lower limb paresthesia, lower extremity muscle weakness can occur after surgery. , sphincter dysfunction, several of which died, and the morbidity rate is higher. After the follow-up, 33% of the pain was relieved, 32% improved, and 35% was ineffective. Dargent (1963) followed this group of patients and found that the operation was only effective for vaginal and visceral pain in the long term, and the rectal and lower extremity pain was not as good as the anterior and posterior spinal cord incision. Later, Cook (1977), King (1977) and other microsurgical techniques for this type of surgery, the scope of spinal cord incision is longer, and the treatment range extends to the upper and lower cervical spinal cord anterior commissures in addition to the aforementioned. In order to relieve the upper abdomen, chest, and even upper limbs, the pain caused by lung cancer, breast cancer and stomach cancer, among them, a small number of pain caused by non-neoplastic diseases (such as arachnoiditis, spinal cord trauma, etc.) The effect is better than before. Treatment of diseases: spinal arachnoiditis Indication Spinal cord commissures are applied to: The operation is suitable for refractory pain in the chest, abdomen, pelvis, perineum or lower limb caused by pelvic or thoracic or abdominal malignant tumors. After one operation, the pain on both sides can be relieved. In addition, it is also suitable for intractable pain caused by non-malignant tumors such as spinal arachnoiditis, trauma, and radiculitis. Preoperative preparation 1. General preparation of the whole body According to the condition and examination, the patient's general condition is actively improved, and various necessary supplements and corrections are given. 2, those with constipation, pre-operative laxatives, enema during the night before surgery. Those with dysuria should be catheterized before surgery and indwelling catheter. 3, neck lesions affect the respiratory, preoperative should be deep breathing, cough and other training, a few days before surgery can start aerosol inhalation, if necessary, antibiotics. 4, postoperative need to prone, should be prone position training in advance, so that patients can adapt to this lying position. 5, sedatives before the operation, phenobarbital 0.1g. 6, fast within 6 ~ 8h before surgery. 7, the day before surgery to prepare the surgical skin, cleaning shaving, the range should be more than 15cm around the incision. Neck surgery should shave the occipital hair. 8. According to the needs of anesthesia, give medication before anesthesia. 9, preoperative positioning should be determined before the scheduled removal of the spine position of the lamina, the easiest way is to locate according to the body surface markers. Commonly used body surface markers are: 1 the posterior spine of the 1st posterior sacral spine is the 7th cervical spine; 2 arms naturally sag, the scapula slings are connected through the 3rd thoracic spinous process; 3 pairs The arm is naturally drooping, and the line connecting the lower scapula of the shoulder is passed through the 6th thoracic spinous process; 4 umbilical level is equivalent to the third lumbar spinous process; 5 is the highest point of the bilateral iliac crest, passing through the 4th lumbar spinous process; The posterior superior iliac spine line is equivalent to the second vertebral body. Due to the difference in body shape, there may be 1 or 2 spine errors in the positioning of the above markers. In order to avoid the error, it can be positioned according to the body surface marker, and then a type of lead is glued on the body surface of the corresponding spinous process. After taking the X-ray film, the surgical site is verified from the position of the lead on the X-ray film. Surgical procedure The choice of surgical plane depends on the pain. Since the pain secondary nerve fibers are still crossed above the three segments after being emitted from the posterior horn of the spinal cord, the cutting range of the anterior spinal cord commissures must be higher than the highest segment of the pain zone except for the pain segment. Three body sections. The specific cutting range is roughly summarized as: upper limb pain: neck 4 ~ chest 1; chest pain; chest 2 ~ 8; abdominal cavity, pelvic and lower limb pain: chest 7 ~ waist 1. The operation was performed with laminectomy and the midline was used to cut the dura mater. The midline of the spinal cord should be carefully identified during surgery. Generally, it is difficult to judge according to the position of the median vein or the arachnoid mediastinum on the back of the spinal cord. Sourek (1969) proposed to use a fine needle to stimulate the back of the spinal cord to check the position of the midline, that is, the surface of the cable can often cause pain after stimulation with a needle. The closer the acupuncture point is to the midline, the closer the pain is to the distal end of the body, and the closer to the outside, the pain The closer to the proximal end of the body. After using this method to determine the midline of the spinal cord, the blood vessels on the surface of the spinal cord are pushed away. Under the operating microscope, the soft meninges are cut along the midline with a very thin blade, and the spinal cord is longitudinally cut into two from the midline. half. The spinal cord incision must be strictly along the median sagittal plane. The ventral side of the incision reaches the bottom of the anterior median sulcus. The soft meninges covering the anterior median sulcus are not cut to avoid damage to the anterior spinal artery. The incision must be deep enough, generally 7 to 8 mm to reach the front commissure. The small bleeding points in the incision are pressed with cotton pads to avoid electrocautery as much as possible. The length of the incision varies from author to author. Sourek (1969) consists of 2 to 3 individual sections, and Cook (1977) and King (1977) have a cut length of 110 mm. If the incision does not deviate from the midline, it will generally not cause damage to the pyramidal bundle. The incision should not reach the conical section, otherwise it can cause permanent sphincter disorders. Individual cases of King (1977) can reach 1 level. Patients with awake or local anesthesia can check for changes in pain during surgery to determine if spinal incision is adequate. complication Lateral limb weakness or dysuria may occur after surgery, mostly due to spinal edema, which may gradually improve. The degree of disappearance of skin pain after surgery is very inconsistent, and sometimes the symmetry hypoglycemia of the corresponding segment may occur, and it may not completely disappear. Due to the wide distribution of cross fibers, it is impossible to completely cut off the surgery, and the analgesic effect is incomplete. Therefore, some people think that the analgesic effect is due to blocking the pain-induced non-specific conduction pathway, or due to damage or stimulation of the back bundle. Analgesic effect: The short-term effect is better. Comprehensive literature and early observation of all cases of postoperative pain have alleviated or disappeared; among them, 70% are excellent, 20% are good, and 10% are poor. Among them, patients with malignant tumors can relieve pain or stop taking painkillers until they do not relapse before death. The effect can be maintained for 6 to 10 months. Benign diseases such as spinal arachnoiditis can survive long-term survival, more than a few months to 1 year after recurrence, and all are ineffective after 2 to 5 years. Some patients need to undergo surgery for spinal cordectomy or enlarge the length of the anterior commissure of the spinal cord to relieve the pain.

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