Neck, shoulder, low back and leg pain is a common and prevalent clinical condition and an internationally prevalent disease. It is the occupational disease with the highest incidence, and herniated discs cause enormous social expense and loss of workforce and are of worldwide concern. According to statistics, 75%-85% of people will have neck, shoulder, back and leg pain in their lifetime.
I. Introduction of pathology
The main change is the dehydration of the nucleus pulposus, and the disc loses its normal elasticity and tension after dehydration, on the basis of which the fibrous ring is broken or ruptured due to gravity, heavy trauma or repeated inconspicuous injuries, and the nucleus pulposus protrudes from the rupture and compresses the nerve root and produces signs of nerve root injury; if the fibrous ring is completely ruptured, the broken nucleus pulposus At the same time, since there is no blood supply in the nucleus pulposus, the protrusion comes into contact with the venous plexus at the posterior edge of the vertebral body, resulting in expansion of the venous plexus at the posterior edge of the vertebral body, increased exudation and local inflammatory rejection, which can further aggravate the pain symptoms. If the herniation protrudes backward and compresses the cauda equina nerve, it can cause urinary and fecal disorders, restricted movement of the lower limbs, etc., which can lead to paraplegia in severe cases. Because of the heavy load and activities in the lower back, disc herniation mostly occurs in the lumbar discs, especially in the lumbar 4, 5 and lumbar 5 sacral 1 discs. Another cervical spine and thoracic spine can also occur disc herniation, but the symptoms and signs, as well as treatment methods in the cervical and lumbar spine are different.
Second, the onset of causes
The disease occurs for five major reasons.
1, increased abdominal pressure: such as pregnancy, violent cough, constipation when straining to defecate, nausea, etc.
2, improper lumbar posture: when the lumbar in a flexed position, such as a sudden rotation is easy to induce a herniated nucleus pulposus, long-term sleep in a soft bed or long time sitting position is also easy to lead to disc protrusion.
3, sudden weight: when not fully prepared, suddenly make the lumbar load increase, easy to cause herniated nucleus pulposus.
4, lumbar trauma: acute trauma can affect the fibular ring, cartilage plate and other structures, and make the degenerated nucleus pulposus protrude.
5, occupational factors: such as car drivers in a sitting position and bumpy state for a long time, easy to induce disc protrusion.
Third, treatment methods
Conservative treatment, surgical treatment, interventional therapy, minimally invasive intervertebral foramenoscopy treatment.
1.Conservative treatment
Conservative treatment – including bed rest, drugs, traction, massage, acupuncture and closure, etc., is suitable for cases with initial or mild disease. The purpose of the therapy is to reduce symptoms, improve local blood circulation, and increase the vertebral space to reduce the compression and stimulation of the nerve root, but most of this therapy can not completely eliminate and retract the herniated disc. At present, conservative treatment combined with other treatments are mostly used to achieve satisfactory results.
2.Surgical treatment
Open disc surgery or posterior disc surgery can eliminate the herniated disc and achieve the purpose of cure. Although the effect is significant, the surgery is more traumatic, difficult and dangerous, and the removal of part of the disc during the surgery may affect the stability of the spine after the surgery, which often discourages patients. Usually the postoperative recovery period takes 3 months, which seriously affects the patient’s work, study and quality of life.
The purpose of surgical treatment is to relieve nerve root irritation or compression, eliminate nerve inflammation, and promote nerve repair, etc. It is characterized by quick results. However, it is more traumatic, risky and has strict clinical indications, including: severe pain; really cannot be relieved after long-term non-surgical treatment; large disc herniation or adhesions and calcification leading to severe lateral saphenous fossa and spinal stenosis (non-ligamentous hypertrophy and other muscular stenosis); lower limb muscle atrophy caused by nerve root irritation or impaired vascular blood supply after compression, with significant decrease in muscle strength; large disc herniation causing cauda equina syndrome; free disc herniation, etc.
Of course, surgery also has infection, nerve damage, fibrous scar tissue formation, so that nerve root adhesions, etc., causing “postoperative recurrent pain”; and poor stability of the lumbar spine, causing chronic low back pain (i.e., postoperative low back syndrome), has also been plagued by patients and is a more difficult clinical complications. —— most of the current surgical treatment of lumbar disc herniation has been gradually replaced by minimally invasive treatment
3.Interventional treatment
There are more methods of interventional treatment for disc herniation, such as intervertebral disc excision and suction, ozone nucleus oxidation, collagenase chemical nucleolysis, radiofrequency ablation, laser ablation, plasma ablation, intervertebral foraminal nucleus removal, etc. Each treatment method has its own indications and limitations, and disc herniation is a complex disease, and each patient’s symptoms, signs, and imaging tests are different, so Since 1997, our department has been conducting research on the interventional treatment of disc herniation, and has conducted in-depth research on the pathogenesis, pathogenesis, clinical manifestations and imaging manifestations of disc herniation, and has proposed the method of comprehensive interventional treatment of disc herniation. A total of more than 5,000 patients were treated, and the total effective rate reached 93%. Satisfactory curative effect has been achieved.
(1) Ozone nucleus pulposus oxidation
Ozone has strong oxidizing ability and can be injected into the nucleus pulposus of the herniated disc to oxidize and decompose the proteoglycans and other macromolecular polymers in the nucleus pulposus, causing the nucleus pulposus to lose water and atrophy, thus reducing the pressure in the disc and eliminating the pressure on the nerve roots. Ozone also has an anti-inflammatory effect by antagonizing immune complexes and improving sterile inflammation of the nerve roots; improving microcirculation and reducing venous plexus stasis at the posterior edge of the vertebral body to achieve the purpose of treatment and eliminate symptoms. The treatment concentration of ozone does not cause any damage to other tissue structures. Ozone injection into the paravertebral lumbar muscle can eliminate lumbar muscle strain and lumbar 3 transverse synovial syndrome.
Advantages of ozone for lumbar disc herniation.
1.High safety factor. Under the guidance of imaging equipment, the positioning is accurate and the operation is flexible.
2. Minimally invasive treatment is less risky and painless. It also eliminates the pain of surgery.
3, high efficacy, treatment of herniated disc, generally only need 1 to 2 injections, fast results.
4, ozone itself has a disinfection effect, the chance of infection is very low.
5.Ozone is injected into the tissue around the intervertebral disc at the same time, which can treat cervical and lumbar muscle strain.
6.With a wide age adaptation range, it is safe and effective for senior patients, especially for low back and leg pain caused by senile intervertebral disc degeneration.
7.At present, it is recognized as the best means of treating herniated discs that both eliminates the need for surgery and has good efficacy.
(2) Collagenase lysis
①.Technology introduction
Collagenase lysis refers to an interventional therapy that involves percutaneous puncture and injection of collagenase into or outside the diseased disc to dissolve the herniated material and the collagen in the nucleus pulposus, thereby dissolving the herniated material, reducing the intradiscal pressure and eliminating the symptoms.
Collagenase, or collagen hydrolase, can effectively dissolve type I and II collagen in the nucleus pulposus and fibrous ring, degrading them into amino acids and being absorbed by the body without destroying tissue cells and nerve cells. It has no damage to proteins such as HB, lactic acid protein, and keratin sulfate. Collagenase lysis time can reach 3 months. Postoperative patients have increased scoliosis and straight leg raising angle, and the reduction of paravertebral pressure pain appears earlier. Lower extremity weakness and nerve numbness recovered more slowly. The collagenase was injected into the herniated area accurately and unerringly to achieve effective and rapid degradation of the disc herniation, and the efficacy was significantly improved. The overall excellent rate is over 85%. Collagenase nucleolysis is between conservative treatment and surgical treatment, with the characteristics of less trauma, reliable effect and less complications. Even if the treatment is not effective, it does not affect the conservative treatment and surgery. Therefore, it has become one of the most effective means of treating disc herniation at home and abroad.
②.Technical characteristics
It has the characteristics of no incision, small trauma, fast recovery, good efficacy, short period and high safety. It is one of the conventional methods for interventional treatment of disc herniation.
③.Operation method
According to the injection site, it is divided into: intra-disc, at the protrusion (inner/peripheral) and combined injection.
According to the route of puncture: through the safety triangle, through the sacral fissure, through the posterior midline of the spine, through the intervertebral foramen, through the external incision of the vertebral plate (anatomically this position is: the inferior incision of the vertebral arch) and through the medial margin of the small joint (anatomically this position is: the medial margin of the vertebral plate gap), etc.
④. Factors affecting the efficacy of treatment
Can we achieve “needling the affected area and enzyme reaching the substrate”? Collagenase is a biologically active agent, which must be combined with the substrate in order to work, so collagenase injection should be accurately injected into the site of the substrate (protrusion), so that collagenase and the protrusion can be fully contacted to form an intermediate complex and then decomposed into amino acid + enzyme. In the early days, collagenase injection was usually injected into the disc, but since collagenase causes increased pain due to edema in the process of dissolution, nowadays, collagenase is mostly injected outside the disc for treatment, which avoids the severe pain caused by intradiscal treatment and also achieves good treatment purpose.
(3) Discotomy and aspiration
Percutaneous puncture disc nucleotomy and aspiration is a method of entering the intervertebral disc through the safety triangle of the intervertebral foramen by percutaneous puncture, expanding the puncture channel to establish a working channel, and performing nucleus pulposus removal and negative pressure aspiration through the working channel to reduce the pressure in the intervertebral disc, thus relieving the pressure on the nerve roots and nociceptive receptors around the disc and achieving the purpose of eliminating symptoms.
Intervertebral disc excision and aspiration has.
(①) significantly reduce the intradiscal pressure: because the disc itself has obvious volume-elastic modulus characteristics, when the nucleus pulposus is drilled in the annulus fibrosus and removed, the intradiscal pressure can be significantly reduced.
(ii) Reduce the inclusion of the herniated part of the disc: during percutaneous puncture disc nucleotomy and aspiration, not only can the nucleus pulposus in the central part of the disc be removed, thus achieving the purpose of indirect decompression, but also part of the herniated part of the nucleus pulposus can be removed.
③, change the direction of the herniated nucleus pulposus: percutaneous puncture disc myelotomy not only removes part of the nucleus pulposus through the lateral approach, but also drills and opens a window on the posterior side of the intervertebral disc’s annulus fibrosus, so that the local inclusion of the nucleus pulposus by the annulus fibrosus disappears, and the existence of this window artificially changes the direction of the herniated nucleus pulposus, which plays an important role in the long-term sustainable decompression of the intervertebral disc.
The efficacy of percutaneous puncture discectomy and aspiration in the treatment of lumbar disc herniation is certain and similar to that of surgical treatment. The success rates reported vary from 67% to 96% due to different indications and different means of examination. The greatest advantage is that it overcomes postoperative spinal instability and secondary low back pain caused by nerve root adhesions and epidural fibrosis caused by surgical procedures. The second advantage is that it is less traumatic to the body, faster recovery, easier operation, and fewer surgical complications. Discotomy is mainly used for inclusive disc herniation because it uses intradiscal nucleus pulposus removal, and is less effective for patients with herniated discs that are large, prolapsed or free.
(4), radiofrequency ablation
It refers to puncturing the radiofrequency needle into the nucleus pulposus cavity or herniation of the herniated disc using radiofrequency electrodes to heat up the herniation, causing protein coagulation and retraction of the herniation due to the reduction of the internal pressure of the nucleus pulposus, while repairing the annulus fibrosus and relieving the compression and irritation of the nerve to achieve the effect of not affecting the nucleus pulposus in the disc. At the same time, because the local temperature increases for a short period of time, it can achieve the improvement of local circulation, so that the muscle spasm caused by pain can be relieved. Radiofrequency ablation of the intervertebral disc is mainly used for discogenic low back pain. It is not effective for larger herniation, nucleus pulposus prolapse and free.
(5) Minimally invasive intervertebral foraminoscopic treatment
Intervertebral foraminoscopy is a C-arm X-ray guided percutaneous puncture through the intervertebral foramen to establish a working channel. Under direct endoscopic vision, the herniated nucleus pulposus, nerve roots, dural sac and hyperplastic bone tissue can be clearly seen. Then the herniated tissue is removed using various types of grasping forceps, the bone is removed microscopically, and the broken fibrous ring is repaired with radiofrequency electrodes. At the same time, the nerve root and dural sac adhesions are separated, and the clinical application of this technology will become the mainstream treatment method for larger disc herniation and spinal stenosis.
The basic principle of the operation is to remove the pressure on the nerve roots by entering the spinal canal through the intervertebral foramen and completely removing the herniated or prolapsed nucleus pulposus and hyperplastic bone outside the disc fibrous ring, separating the adherent nerve roots and dural sac, restoring the mobility of the nerve roots and the independent pulsation of the dural sac, and eliminating the painful symptoms caused by nerve compression and irritation.
Indications for this technique: It can deal with almost all types of disc herniation, spinal stenosis, foraminal stenosis, calcification and other bony lesions. Endoscopic treatment of discogenic pain using special radiofrequency electrodes, feasible fibrous annuloplasty and annular nerve branch block.
Advantages of intervertebral foraminoscopy technique.
(1) Wide range of indications: can be used for all disc herniation and spinal stenosis, foraminal stenosis, calcification, etc.
(2) Through the lateral posterior approach through the natural foramina of the human body to directly reach the location of the lesion, avoiding the interference of the posterior surgery on the spinal canal, without biting off the vertebral plate, without destroying the paravertebral muscles and ligaments, and without adhesions to the stability of the spine. It can also prevent postoperative segmental instability and slippage.
(3) High safety, the patient only needs local anesthesia, and the patient’s reaction can be observed and communicated with at any time during the operation.
(4) Less traumatic complications, with minimal risk of nerve injury and thrombosis.
(5) The skin incision is only 7 mm, and the recovery is fast, and the patient can go down to the floor to relieve urine and feces 2 hours after the operation, and can go down to the floor for activities the next day, and return to normal work and physical exercise in 3-6 weeks on average.
(6) High patient satisfaction, high comfort, immediate pain relief, mild postoperative pain, self-care of urination and defecation, simple care.
(7) The calcified disc can be removed at the same time; the special bipolar radiofrequency electrode can perform good hemostasis and fiber ring repair and molding in disc surgery.
(8) Published international literature has reported success rates of over 90% at 1 and 2 years postoperative follow-up, with early recurrence rates of less than 5%. The success rate exceeds 84% in patients with reopen surgical recurrence.