Ramicotomy

RAMICOTOMY (ramicotomia), the severing of the communicating branches (rami communicantes) of the sympathetic nerve. R. was first performed on humans by Royle and Hunter (1923) for spastic paralysis of the upper limbs. At present, the scope of application for this operation has significantly expanded. R. gives in many cases quite satisfactory results for spastic paralysis based on lesions of the cerebral cortex, for parkinsonism with symptoms of increased plastic tone, for injuries to the spinal cord, as well as for certain disorders of the trophic and vasomotor functions of the nervous system. In recent years, Leriche (1924) proposed to apply R. (severing the communicating branches between the stellate ganglion and the roots C7-D1, as well as the vertebral nerve and the trunk between the middle ganglion and the inferior ganglion) for angina pectoris. Attempts were also made by Leriche and some other authors to apply R. for painful amputation stumps and causalgias, but the results obtained so far are rather contradictory and do not allow for final conclusions. Technique of ramicotomy. Cervical ramicotomy rr. communicantes C7-D1 n. sympathici (Royle's method). An incision in the skin from the attachment point of the sternocleidomastoid muscle to the clavicle, perpendicular to the edge of the trapezius through the middle of the lateral triangle of the neck. The skin, superficial fascia, and platysma myoides are incised layer by layer; the external jugular vein is ligated; the fascia colli is incised, exposing the brachial plexus and the anterior scalene muscle. If necessary, the superficial cervical artery and the transverse cervical artery are also ligated and severed. The omohyoid muscle is retracted downward or severed. Orienting to the position of the thoracoabdominal nerve (on the anterior surface of the anterior scalene muscle), they proceed to expose the rr. communicantes. R. communicantes C7 are exposed for severing on the anterior surface of the m. scaleni ant. or near the intervertebral foramina (do not damage the white ramus communicans). The most difficult is the exposure of the r. c. C8-D1. For this purpose, the subclavian artery is retracted forward and downward, exposing the thyrocervical trunk and posterior to it the vertebral artery. The stellate ganglion with the r. c. D8, C8, C7 lying deeper between the mentioned artery and the spine. Thoracic ramicotomy (Gaza operation). The most frequent indications for severing the r. c. within the lower thoracic segments D9-D11. The operation consists of three acts. I act. Exposure of the transverse processes of the corresponding vertebrae and finding the rr. posteriores of the corresponding thoracic nerves. A skin incision 12-15 cm long parallel to the spinous processes of the vertebrae, offset 3 cm to the appropriate side. The skin, superficial fascia, lower parts of the trapezius and broad muscles of the back, the superficial lamina of the lumbo-dorsal fascia are incised layer by layer, exposing the mm. longissimus dorsi and spinalis dorsi; when these muscles are retracted to the side, the contours of the transverse processes are palpated, and at the same time the posterior branches of the intercostal nerves are found. II act. Removal of the transverse processes and exposure of the intervertebral foramina (technically the most difficult part of the operation). The transverse processes are skeletonized from the ligaments connecting them to each other and to the ribs, as well as from the long and short muscles of the back attached to them (mm. longissimus dorsi, spinalis dorsi, multifidus, rotatores, etc.). It is necessary to be careful not to injure the pleura through the intercostal space with a periosteal elevator. After separating the transverse processes, they are broken with a chisel directly at the base and retracted outward with a sharp hook, simultaneously severing the ligaments that tense at this time. When the long muscles of the back are moved away together with the remnants of the transverse processes, the rami posteriores of the thoracic nerves tense, using them as a guide, they go downward and medially to the common nerve bundle in the intervertebral foramen. III act. Severing of the mm. levatores costarum breves and exposure of the rr. communicantes. By pulling on the ram. posterior of the thoracic nerve, the node located in the intervertebral foramen is brought down. To obtain convenient access to the ramus communicans, the mm. levatores costarum breves are severed. Further outward pulling on the ram. posterior makes it possible to see the entire bundle of the thoracic nerve. After exposing and mobilizing the ram. anterior of the thoracic nerve for a length of 1-1.5 cm, the ramus communicans is found and severed, which is usually located 3/4-1 cm away from the end of the ganglion. The operation ends with layer-by-layer closure of the incision. Operative approaches to the segments above and below (D8-D12) and (L1-L5) are technically more difficult; however, indications for them are significantly rarer. Lumbo-sacral ramicotomy. Two main operative approaches to the rr. com. of the lumbo-sacral region are distinguished: intraperitoneal and retroperitoneal. The first is used for bilateral R., the second mainly for unilateral. Many surgeons generally prefer to use only the intraperitoneal route in all cases. Ramicotomy lumbo-sacralis intraperitonaealis. The abdominal cavity is opened along the linea alba from the pubis to a point 4-6 cm above the navel. The small pelvis is freed from intestinal loops (Trendelenburg position). For R. on the right side, the posterior leaf of the peritoneum is incised along a line connecting the right upper sacral foramen with a depression located laterally and in immediate proximity to L1 on the right side. The incision is extended upward so that its middle lies on the line of intersection of the iliac vessels. The edges of the incised peritoneum are bluntly dissected below the iliac vessels toward the sacrum and in the area of the medial edge of the sacral foramina (S1-S5) the sympathetic trunk and the rr. communicantes branching backward from it are found, which are severed (good illumination is necessary). By carefully retracting the Bujalsky retractor upward and laterally, the iliac vessels can expose behind the v. iliaca comm. the sympathetic ganglion L1 with the branching rr. communicantes. To expose the higher nodes of the lumbar part of the sympathetic trunk, it is necessary to extend the incision of the posterior leaf of the peritoneum upward, running it parallel to the inferior vena cava. By blunt dissection, the loose fatty and connective tissue surrounding the v. cava inf. is separated and the vein is retracted medially (it is necessary to exercise extreme caution not to tear the wall of the vein or its lateral branches). On the anterior surface of the exposed m. psoas, immediately next to the spine, there will be a thin thread of the sympathetic trunk with spindle-shaped nodes and the branching rr. communicantes, which are sequentially severed. The operation ends with the application of a continuous suture to the posterior leaf of the peritoneum and layer-by-layer closure of the abdominal wall. For R. in the lumbo-sacral region on the left side, the posterior leaf of the peritoneum is incised for a length of 15-20 cm along the line of transition of the parietal peritoneum into the mesosigmoideum. The peritoneum together with the S-shaped colon is bluntly separated medially to the intervertebral foramina. Further, the operation proceeds the same as on the right side, only instead of the inferior vena cava, one has to deal with the abdominal aorta. Ramicotomy lumbo-sacralis extraperitonaealis iliaca. The skin incision is started 1-2 transverse fingers below the end of the XI rib and is carried to the anterior superior spine of the ilium; not reaching the latter 3-4 cm, it is turned medially toward the rectus abdominis muscle, running it parallel to the Poupart ligament (2 transverse fingers above it); the incision ends at the lateral edge of the m. rectus abdominis. The skin with subcutaneous fat, superficial fascia, external and internal oblique and transverse abdominal muscles are incised layer by layer; it is necessary to be careful not to injure the XI and XII intercostal nerves. After retracting the muscles with hooks, the fascia transversalis is bluntly dissected. Upon entering the loose preperitoneal fat, the peritoneum is dissected upward and medially. Following the course of the iliac vessels, one reaches the lateral edge of the aorta if operating on the left, or the lateral edge of the inferior vena cava if operating on the right. Further, the operation proceeds the same as with the intraperitoneal approach. To expose the nodes L1-S1-S5 and the rr. branching from them, it is necessary to dissect the peritoneum downward and medially from the anterior surface of the iliac vessels and the anterior surface of the sacrum. The fairly frequent bleeding observed at this time is stopped by tamponade. The operation ends with layer-by-layer closure of the tissues without drainage.