Pericutanous lumber discectomy

Pericutanous lumber discectomy(PLD) for the treatment of lumbar disc herniation has the advantages of small incision, less damage to the spinal structure and stability, fewer complications, and quick recovery. Since Hijikata reported it in 1975 Gradually rise and develop rapidly in the world. Since the early 1990s, there have been many domestic literature reports on the experience of PLD surgery. It indirectly relieves the mechanical compression of the nerve root by the protruding intervertebral disc and cuts and aspirates part of the nucleus pulposus to reduce intradiscal pressure. Our department used PLD technology to treat 22 cases of lumbar disc herniation from March 1999 to October 2004. The author conducted a retrospective study on 20 cases who were followed up after surgery, and discussed the efficacy of PLD and factors affecting the efficacy.

Materials and methods

1. General information
Among the 20 cases, 13 were male and 7 were female, aged 35 to 74 years old, and the disease duration ranged from 1 month to 3 years. All cases were taken preoperative anteroposterior and lateral radiographs of the lumbar spine, plain films of the pelvis, CT scans of the lumbar intervertebral discs, and some underwent MRI examinations of the lumbar spine. Combined with the medical history, clinical symptoms and signs, the diagnosis of lumbar disc herniation was confirmed. After conservative treatment, the results were poor. In total, PLD was performed on 22 diseased intervertebral discs in 20 patients, including 15 intervertebral discs at lumbar 4 and 5, and 5 intervertebral discs at lumbar 5 and sacral 1. There were 2 cases of two intervertebral disc herniations (L4.5+L5S1) at the same time.

2. Method
The Dutch PHILIPS BV-25C arm X-ray machine was used for fluoroscopic positioning. The instrument for puncture and resection of the intervertebral disc was an automatic percutaneous puncture and lumbar disc incision and suction treatment instrument produced by Shandong Jinan Longguan Company. The suction device was a negative pressure suction device produced in Shanghai. After routine disinfection and draping, take the prone position or the supine position with the affected side, and insert acupuncture on the affected side. Select the correct puncture point and needle insertion angle within 8 to 10 cm from the posterior midline. After reaching the position, gradually expand the skin, incise the skin 1.5 cm long, place and fix the working cannula, insert a trephine saw along the working cannula to cut the annulus fibrosus, and then Then use straight nucleus pulposus forceps and turning nucleus pulposus forceps to repeatedly clamp or crush the nucleus pulposus, and finally use an automatic nucleus pulposus cutting and aspiration instrument to cut and aspirate. Use 0.9% NS 2500ml-3000ml, and add 160,000 units of gentamicin to the last 500ml of aspiration solution for aspiration. Frequently adjust the position, depth, and direction of the side hole at the front end of the cutting instrument to cut and aspirate a sufficient amount of the nucleus pulposus as much as possible. When the tissue without nucleus pulposus is aspirated, take out the incision and aspiration instrument and working cannula under negative pressure, use a long puncture needle to inject 0.3ml of triamcinolone acetonide around the affected vertebral nerve root, remove the needle, suture the incision with 1 stitch, and cover the wound with a sterile dressing , the technique is completed. The nucleus pulposus tissue was routinely removed and sent for pathological examination.
For patients with lumbar 5-sacral 1 intervertebral disc herniation, the acupuncture method is determined based on the vertical distance between the highest point of the two iliac wings and the lumbar 5-sacral 1 intervertebral space, the degree of hypertrophy of the lumbar 5-sacral transverse process and the size of the lumbosacral angle. If it is vertical If the distance is >4cm and the lumbosacral angle is 70, the original work can be resumed. Significant improvement (good): Most of the symptoms have disappeared, with only mild or occasional waist (leg) pain, but it does not affect work and entertainment. The straight leg raising test is >60, and work can be resumed. Improvement (possible): Symptoms partially disappeared, straight leg raising test improved compared with before treatment, due to persistent or intermittent low back and/or lower limb symptoms, unable to engage in certain jobs, recreational activities limited, but can engage in lighter work Work. Invalid (poor): Symptoms are not significantly relieved, unable to work or surgery is required because symptoms persist. The results were excellent in 12 cases, good in 5 cases, fair in 2 cases, and poor in 1 case, with an excellent and good rate of 85%.

Discuss

Conventional surgery to treat intervertebral disc herniation is highly invasive. Although surgical methods have been continuously improved, surgical complications are still relatively high. Taking lumbar spine surgery as an example, Spangfolt reviewed 2504 cases of lumbar disc herniation. Only 60.2% of the patients found that both sciatica and low back pain were relieved, and 31.5% of the patients were relieved of low back pain. According to relevant statistics, only 60% of all patients who underwent conventional lumbar discectomy were completely cured, while 40% still had problems such as radiation pain, and 15% suffered from failed lumbar surgery syndrome (Failed Bacrk Surgery Syndrome), so many Scholars are committed to exploring an effective and safe method to treat intervertebral disc herniation. In 1975, Hijikata improved the technology on the basis of discography and took the lead in performing percutaneous discectomy and achieved success. Since then, many scholars have successively reported the application methods and efficacy of this technology. In 1985, 0nik first reported the use of an automatic resection device in percutaneous discectomy, which improved work efficiency and reduced the incidence of complications. In 1985, the American Academy of Orthopedics officially listed this method as a safe and effective method to treat non-complex lumbar disc herniation. Some authors further added discoscopy for surgery.

1. Mechanism of percutaneous puncture of intervertebral disc and nucleus pulposus aspiration
Percutaneous disc nucleectomy is a kind of local discectomy treatment. The therapeutic value of PLD is certain, with an excellent and good rate of 70% to 90.6%. It is generally believed that the main method is to reduce the pressure in the intervertebral disc and retract the herniated disc by opening a small window in the annulus fibrosus of the intervertebral disc and partially resecting the nucleus pulposus, thus relieving the stimulation of the nerve roots and pain receptors around the disc, thus achieving the desired outcome. To eliminate symptoms.
1. Significantly reduce the intravertebral disc pressure: Because the intervertebral disc itself has obvious bulk elastic modulus characteristics, when the annulus fibrosus is drilled and the nucleus pulposus is removed, the intravertebral disc pressure can be significantly reduced, from 24 kilopascals to 2.624 kilopascals, but Severe degeneration of the intervertebral disc leads to significant narrowing of the intervertebral space and significant decrease in the elastic modulus of the intervertebral disc. In this case, percutaneous puncture of the intervertebral disc nucleus pulposus is ineffective.
2. Reduce the protruding part of the intervertebral disc tissue: During percutaneous intervertebral disc nucleus pulposus aspiration, not only the nucleus pulposus in the central part of the intervertebral disc can be removed, thereby achieving the purpose of indirect decompression, but also part of the nucleus pulposus in the protruding part can be removed.
3. Change the direction of the herniation of the nucleus pulposus: Percutaneous puncture of the intervertebral disc nucleus pulposus not only removes the nucleus pulposus through the lateral approach, but also drills holes and opens windows on the posterolateral side of the annulus fibrosus of the intervertebral disc, so that the local annulus fibrosus can accommodate the nucleus pulposus. disappears. The existence of this window artificially changes the direction of the nucleus pulposus herniation, which plays an important role in long-term continuous decompression of the intervertebral disc.

2. Indications
Patient selection for percutaneous lumbar discectomy must be based on a comprehensive analysis of clinical symptoms, clinical signs, and imaging examinations. Two or more of the following should be present at the same time.
1. Sciatica. This patient does have low back and leg pain, and the leg pain is more severe than the low back pain.
2. Sensory and motor impairment of lower limbs.
3. Positive signs of spinal nerve compression, such as positive straight leg raising test.
4. After imaging examinations such as CT and MRI, the imaging manifestations were consistent with the clinical symptoms, and it was confirmed to be a simple intervertebral disc herniation.
5. The patient has poor results after 6 weeks of conservative treatment, or the patient insists on surgery despite a short medical history but great pain.

3. Factors affecting therapeutic efficacy
1. The relationship between therapeutic effect and intraoperative operation
(1) For PLD surgery, the needle should be inserted from the affected side. The puncture point should be as far away from the posterior midline as possible, usually 8 to 10 cm. The needle should be inserted at an angle of about 45°. The angle of needle insertion should be small rather than large, and try to keep the outer tube and The sagittal plane is vertical.
(2) During incision and suction, avoid the outer cannula head from protruding from the annulus fibrosus to prevent damage to the surface of the annulus fibrosus and surrounding small blood vessels, causing intraoperative bleeding, and postoperative hematoma re-oppressing nearby nerve roots.
(3) All surgical instruments should be sterilized by high temperature and high pressure, and strict aseptic operation should be performed during the operation. Antibiotics can be added to the rinsed saline to prevent intraoperative infection.
(4) When performing iliac drilling on one side of patients with lumbar 5-sacral 1 disc herniation, it is required to bluntly separate the muscles and soft tissues. When drilling, ensure that the direction of the hole is consistent with the puncture channel. There were a total of 5 intervertebral discs in the lumbar 5 sacral 1 in this group, among which only one case underwent drilling of the iliac bone on one side.2. The relationship between efficacy and postoperative use of local sealant
Some people believe that the main cause of clinical symptoms and signs caused by lumbar disc herniation is that cracks in the outer annulus of the intervertebral disc produce chemical substances that stimulate the surrounding nerve roots to produce inflammatory reactions or allergic reactions or immune reactions. At the same time, the protruding part puts pressure on the nerve roots, causing Nerve root compression and ischemia, and multiple recurrences of clinical symptoms can cause obvious inflammatory reactions around the nerve roots, resulting in adhesion between the annulus fibrosus and the surrounding nerve roots. At this time, CT and MRI show that the edge of the herniated intervertebral disc is blurred. For these patients, PLD will only Removal of the nucleus pulposus can immediately relieve the pressure on the nerve root from the protruding part and the pain disappears. However, adhesions still exist. Numbness or pulling pain in the lower limbs may occur about one month after the operation, which affects the efficacy of PLD. The author believes that for such patients, 3 ml of a mixture of triamcinolone acetonide and lidocaine hydrochloride should be injected between the annulus fibrosus and the peripheral nerve roots after PLD to reduce the inflammatory reaction or allergic reaction and promote adhesion between the annulus fibrosus and the peripheral nerve roots. Get relief and eliminate clinical symptoms.
3. The relationship between efficacy and postoperative treatment
Since the maximum outer cannula diameter was 4.4mm when PLD was performed in this group of patients, the amount of nucleus pulposus that was cut and aspirated by negative pressure was about 3 to 5g, which can quickly reduce the pressure in the intervertebral disc. At the same time, the buffering capacity of the intervertebral disc is weakened. At this time, the annulus fibrosus of the intervertebral disc is compressed, which may cause damage to the small blood vessels around the annulus fibrosus, and local stimulation can increase the degree of edema and affect clinical efficacy. Of course, PLD surgery has less trauma, less bleeding, and immediate improvement in symptoms and signs. The patient is still required to lie on a hard bed for 24 hours after the surgery, immobilize for 3 to 5 days, walk on the ground after 1 week, and avoid weight-bearing and bending work for 1 month. At the same time, appropriate post-operative physical therapy is provided to strengthen the functional exercise of the affected limb in bed, reduce surgical exudation, accelerate tissue repair, and achieve clinical cure.