[Etiopathogenetic substantiation of surgical treatment of neurogenic pain syndromes]. / Etiopatogeneticheskoe obosnovanie khirurgicheskogo lecheniya neirogennykh bolevykh sindromov.

The purpose of the study was to improve classification of neurogenic (neuropathic) pain syndromes. This will make it possible to define the indications for appropriate analgesic surgery for each type of drug-resistant neurogenic pain syndrome. Incorrect management of neurogenic pain syndromes is usually associated with underestimation of pathogenetic prerequisites for its occurrence. Differentiation of compression, deafferentation and mixed neurogenic pain syndromes makes it possible to determine appropriate surgery and avoid tactical errors. Moreover, this approach allows you to save patients from unreasonable long-standing suffering. Patients with chronic pain syndromes often become disabled, sometimes in the prime of life, and isolated from society and family. Therefore, treatment of chronic pain is currently an urgent problem.

[Clinical diagnostic features of surgical treatment for thoracic outlet syndrome].

The thoracic outlet syndrome is characterized by a variety of clinical signs due to multiple causes resulting in compression of a neurovascular bundle in a relatively narrow anatomical space. Despite the frequently encountered clinical symptoms, inadequate attention is paid to their analysis, and their diagnostic and surgical aspects require a modern approach. The study included 46 patients. The main clinical sign is a persistent pain syndrome of the cervico-occipital localization that affects the shoulder girdle, suprascapular and infrascapular regions and spreads to the arm in combination with trophic, sensory and vascular disorders. SCT angiography of the superior thoracic outlet structures has been used as a priority instrumental method of research. The macro- and micro factors of compression are the main cause for the development of neurological symptoms, and their removal is the main task of surgical treatment. Surgical approaches were planned depending on the nature and extent of injury. 36 patients underwent 42 surgical interventions. The proper assessment of the neurological status in combination with modern paraclinical diagnostic methods and selection of an adequate surgical approach provided satisfactory outcomes in 33 cases.

[Myelopathies in impairment of extravertebral venous blood circulation].

Development of myelopathies of venous genesis is based on venous hypertension inside vertebral canal which was initially described by J. Aboulker. According to anatomical and functional features of epidural venous system, two factors contribute in development of venous congestion: decreased outflow and increased inflow. Clinical manifestation is presented by spastic movement disorders. Morphological study performed in 18 cadavers allowed to discover so called 'narrow areas' which cause impaired circulation through large feeders of caval veins, which can be discovered by selective phlebography. Main phlebographic features include stenosis, compression, atresia, thrombosis and retrograde flow towards epidural venous plexus. We examined 58 patients with spastic para- and tetraparesis of unknown nature. Phlebographic signs of venous dyscirculation were revealed in 34 cases. 28 surgical operations were performed: 24 on feeders of vena cava superior and 4 on feeders of vena cava inferior. In 18 cases we obtained satisfactory results. This investigation should be continued.

[The specific features of clinical manifestations and surgical treatment of spastic and pain syndromes after injury to the vertebral column and spinal cord].

The purpose of the investigation was to study the clinical manifestations of spastic syndrome after injury to the vertebral column and spinal cord and to devise its surgical treatment policy. The investigation included 21 patients with significant spasticity or pain syndrome after severe injury to the vertebral column and spinal cord without any potential of motor recovery. All the patients were observed to have severe inferior paraplegia, cacesthesia following the radicular and conduction with total hypo- or anesthesia. Pain was rated, by using the visual analogue scale and the McGill questionnaire, spasticity was estimated by the Ashworth scale. The patients' motor activity was also evaluated. Bilateral rhizomyeolotomy of the dorsal root entry zone (DREZ) was performed in 10 patients with pain syndrome; posterior partial rhizidiotomy was made in 8 patients with spastic syndrome; 3 patients underwent epidural spinal cord stimulation. Groups with a preponderance of pain (47%) and spastic (53%) syndromes were identified. A clinically equal combination of spastic and pain components occurred rarely. Pain was maximally pronounced, neuropathic, metamerically radicular, in dermatomes from the level of injury. Leg spasticity was more marked and concurrent with contracture. The efficiency of lateral rhizomyelotomy of DREZ in the treatment of pain was 89% in the early period and 63% in the late (as long as 4 years) one. That of bilateral posterior partial rhizodiotomy in the treatment of spasticity was 75 and 75% in the early and late (as long as 2.5 years), respectively. Rhizomyelotomy of DREZ is a pathogenetically grounded and effective procedure when there is a preponderance of neuropathic metamerically radicular pain from the level of injury. Bilateral posterior partial rhizidiotomy is the method of choice in treating significant spasticity.

[Modified posterior subscapular approach to the trunks of the brachial plexus].

In 1993 A. Dubuisson et al. describe a posterior subscapular approach to treating different forms of lesions of the trunks of the brachial plexus in detail. However, during a surgical intervention, the authors encountered some inconveniences hampering the course of an operation. Therefore they modified the above approach, by changing a patient's position on the operating table and the line and shape of a skin incision, and used a current system of retractors. Fifteen patients were operated on, by applying the modified posterior subscapular approach. The authors arrived at the conclusion that this approach substantially facilitates surgical manipulations, provides a good imaging of neurovascular and osseous structures, by protecting them against unnecessary traumatism, noticeably decreases the duration of a surgical intervention, and reduces the risk of postoperative complications.

[Angular approach in the surgical treatment of the axillary neurovascular bundle pathologies].

Different surgical approaches have been developed in the surgical treatment of various isolated and combined lesions of the axillary neurovascular bundle. The angular approach favorably differs from others and has a number of advantages. The angular approach was used to operate on 16 patients with varying abnormalities at this site, including 6 patients with traumatic lesion of the secondary trunks of the brachial plexus and 6 with space-occupying lesion, and 1 patient with the superior thoracic aperture; the remaining 6 patients with significant neurovascular compression syndrome, who had been operated on for various causes. The authors have made certain that the angular approach lightens a surgical intervention and shortens its duration substantially, by reducing the risk of postoperative pyoinflammatory complications, keloid cicatrices, and contractures. The surgical approach applied by the authors is universal and may be used in the treatment of pathology of the secondary trunks of the brachial plexus and vascular lesions, tumors, and pyoinflammatory processes of the axillary space.

[Hematoma of the cerebral peduncle]. / Gematoma nozhki mozga.

The paper presents a rare case of surgical treatment for hematoma of the cerebral peduncle in a 30-year-old woman found to have progressive neurological focal disorders due to mesaticephalic and thalamic lesions. Computed tomography and magnetic resonance imaging (MRI) revealed a round mass (26 x 3 x 25 mm) in the left cerebral peduncle and thalamus without surrounding edema. The focus showed characteristic signs of subacute parenchymatous hematoma. The interpeduncular cistern was explored via transsylvian approach and hematoma was removed by making a small incision of the left cerebral peduncle. Histological examination of a surgical specimen demonstrated no vascular malformation. The postoperative period was complicated by left oculomotor nerve palsy which regressed following several months. A small slit-like cyst communicating with the interpeduncular cistern was detected in the left cerebral peduncle by MRI at follow-up.

[The selective phlebography of the large tributaries of the vena cava system in the diagnosis of venous circulatory disorders in the spinal complex]. / Selektivnaia flebografiia krupnykh pritokov sistemy polykh ven v diagnostike narushenii venoznogo krovoobrashcheniia v pozvonochnom komplekse.

As any other organ, the spinal cord also suffers in chronic congestion. Since the epidural venous system drains into the vena cava system and participates in collateral circulation, there is increased inflow with impaired blood flow along its large tributaries in the vertebral canal along with poor outflow, resulting in intracanal hypertension and chronic congestion. Venous hemodynamic disorders are found beyond the vertebral canal and detected by selective phlebography of the large tributaries of the vena cava system. The technique was used to examine 46 patients with spastic paraparesis or tetraparesis of unclear etiology, which provides evidence for the fact that vena cava stenoses, compressions, atresia, and thromboses can be responsible for impaired venous hemodynamics in the vertebral apparatus and its surgical correction is possible.

[Diagnosis of venous circulation disorders in the cervical portion of the spine and spinal cord using selective phlebography]. / Diagnostika narushenii venoznogo krovoobrashcheniia v sheinom otdele pozvonochnika i spinnogo mozga s pomoshch'iu selektivnoi flebografii.

Selective phlebography of the major branches of the vena cava superior, supplemented, if necessary, by selective catheterization of the spinal vein, was employed to study the disorders in the cervical section of the spine and cord. Twenty-five patients with myelopathies of obscure origin were examined. The main symptoms were stenoses and atresias of the orifices of the internal jugular veins and compression and stenoses of the brachiocephalic trunks. The possibility of a reverse venous blood stream from the nonspinal veins to the epidural ones and backward was confirmed. Therefore, a disorder of the venous outflow from the spinal channel, on the one hand, and intensification of the venous blood inflow, on the other, may develop under certain conditions, resulting in intrachannel hypertension. Eight patients with pathologic changes in the veins (decompressions and angiolysis) were operated on.

[Selective epidural phlebography in the diagnosis of tumors of the cervical spinal cord and of the cauda equina roots]. / Selektivnaia épidural'naia flebografiia v diagnostike opukholei sheinogo otdela spinnogo mozga i koreshkov konskogo khvosta.

The method of selective epidural phlebography (SEP) was applied in the diagnosis of tumors of the cervical segment of the spinal cord and the roots of cauda equina in 45 patients. The diagnosis was confirmed in 32 of the 37 patients who were operated on. The SEP method does not produce serious complications and allows circulatory disorders in the vertebral venous plexuses to be revealed. The diagnostic value of the method is higher in tumors of superocervical localization and hourglass tumors.

[Transfemoral lumbar epidural phlebography in the diagnosis of intervertebral disk hernia]. / Transfemoral'naia poiasnichnaia épideural'naia flebografiia v diagnostike gryzh mezhpozvonokovogo diska.

The diagnosis of herniated disks with the use of lumbar epidural phlebography is discussed. Fifty patients were examined. The diagnosis was verified during the operation in 38 of 44 patients. Proper technical performance of the procedure provides the possibility for localizing the herniated disk with high precision, which is very important in surgical management. The relatively simple techniques, the absence of serious complications, and the exactness of the diagnosis provide the grounds for recommending transfemoral lumbar epidural phlebography for wide use.

[Microsurgery of the vertebral arteries in vertebrobasilar insufficiency]. / Mikrokhirurgiia pozvonochnykh arterii pri vertebral'no-baziliarnoi nedostatochnosti.

The low efficacy of nonoperative management of patients with vertebrobasilar insufficiency (VBI) made the development of a surgical method necessary. Twenty-eight patients with VBI were examined and operated on. Transient circulatory disorders in the vertebrobasilar channel were the main indications for the operation. Of special value among the instrumental diagnostic methods was ultrasonic dopplerography, particularly the Doppler clinical test with digital compression of the vertebral artery (VA). Angiography helped in precise determination of the character and level of the pathological process. Three approaches to three extracranial parts of the VA were used, 15 operations were conducted on the initial part of the VA, 6--on the VA in the osteomuscular canal, and 2--at the level of C1-C2. The abnormal twisting was corrected during the operation, the thyrocervical trunk was ligated, and different variants of decompression of the VA compressed by adhesions, changed muscles, osteophytes, etc. were applied. The operations were carried out with the use of a microscope and microsurgical instruments as a result of which the number of complications reduced. There were no fatal outcomes, a favourable result was produced in 21 patients, the operation had no effect in 2 patients. Microsurgical treatment of VBI is a highly effective method which causes little injury.