Collagenase lysis
I. Equipment and materials
1, X-ray imaging equipment: high-definition X-ray machine capable of frontal and lateral fluoroscopy of the lumbar spine, C-arm is preferred.
2, X-ray machine room: sterilization equipment, good ventilation, and a preparation room for preoperative hand washing.
3, materials: domestic collagenase, disposable 18-20G lumbar puncture needle, 1% lidocaine, 5ml empty needle, 1ml empty needle, lumbar puncture dressing kit.
II. Indications: Simple lumbar disc herniation.
III. Relative indications
1.Recurrence of lumbar disc herniation after surgical treatment;
2, lumbar disc herniation with partial calcification;
3.The diameter of lumbar disc herniation is greater than 10mm;
4, lumbar disc herniation after one treatment to reduce the symptoms, can be the second treatment as appropriate.
IV. Contraindications
1, combined with bony spinal stenosis or hypertrophy of the ligamentum flavum;
2, combined with severe cauda equina symptoms;
3.Protruding disc calcification or ossification;
4, vertebral body more than II degree slippage;
5, bleeding tendency; allergic body;
6.Patients with mental illness or who cannot cooperate during surgery;
7, pregnant women and children under 14 years of age;
8, serious organic disorders of heart, liver, lung and brain; patients referred by the neurology department for cervical disc treatment did not have any problems at that time, but after 10 days at home, they had difficulty in whistling and bloody cerebral crest fluid, suggesting that preoperative physical examination and related examination are very important.
V. Choice of collagenase lysis method.
1, simple lumbar disc lateral-posterior herniation, or central type herniation, prefer extra-disc injection.
2, bulging, preferred intradiscal injection, but do not exceed 100U collagenase 1ml.
3, protrusion diameter greater than 10mm, the effect of extra-disc injection is not satisfactory, can choose the combined injection inside and outside the disc, or protrusion direct injection, as appropriate.
Six, collagenase lysis operation methods and steps.
(A) Preoperative preparation.
1.Check blood routine, urine routine, blood clotting time, liver function, kidney function, blood sedimentation and electrocardiogram, etc.
2.Pre-operative fully introduce to the patient and family about the possible accidents and possible complications that may occur during and after the operation, and sign the surgical consent form.
3.Introduce the treatment method to the patient, eliminate preoperative tension, and give appropriate amount of sedation and analgesic if necessary.
4.Slowly push dexamethasone 5mg plus 25% glucose solution 20ml intravenously half an hour before surgery.
5.In severe cases of radiculitis, anti-inflammatory and dehydration treatment should be given 2 days before surgery.
(B) Intervertebral foramen access extra-disc injection lysis operation method.
1, positioning, local skin disinfection: the patient lies on his side on the fluoroscopic examination bed, the corresponding vertebral space is opened 6-8 cm next to the midline, and the puncture point is marked with gentian violet. Disinfect the skin with the puncture point as the center, and lay a disinfectant towel.
2.Local anesthesia: local anesthesia is done layer by layer with 1% lidocaine from the puncture point, and it is not appropriate to anesthetize the nerve root.
3.Puncture: locate the puncture point through the skin and use a lumbar intervertebral disc puncture needle at an angle of 45º to 60º to the lumbosacral region, and the puncture needle should be tilted to the cephalad side at an angle of 20º to 25º when puncturing L5-S1, and punctured against the corresponding intervertebral foramen.
4, needle tip position: the tip of the needle in lateral fluoroscopy is located at the junction of the upper 1/3 and lower 2/3 of the intervertebral foramen. The tip of the needle is located at the medial edge of the vertebral arch in orthotropic fluoroscopy.
5.Aspiration by empty needle, no cerebral crest fluid outflow.
6, measurement of negative pressure: a small amount of air is pumped within the empty needle as little as possible or not used, to use can choose 1ml ozone? The negative pressure can be measured by pushing the needle through the puncture needle, and no resistance means that the tip of the needle is located in the epidural cavity.
7, epidural cavity imaging: use a small amount of non-ionic contrast agent Ou Nai Pike, iodophile 1 ~ 2ml, epidural cavity imaging, contrast agent is located in the anterolateral space, fluoroscopic contrast agent shows a narrow band, contrast agent is located in the posterior edge of the vertebral body, the anterior space of the dural sac, contrast agent shows a narrow strip.
8.Inject collagenase: After front and side fluoroscopy, negative pressure measurement, epidural contrast, etc., confirm that the needle tip is located in the epidural space, then inject collagenase.
9.Dose: collagenase 1200u diluted with 5ml saline, then injected slowly by the puncture needle, after injection, pull out the needle and apply band-aid to the needle eye.
10, postoperative position: according to the location of the herniated disc, let keep the affected side downward lateral or forward lying, 6-8h. prevent the flow of injected collagenase, affecting the efficacy.
(C) Intradiscal injection lysis operation method.
1, positioning, local skin disinfection: the patient lies on the examination bed, abdomen is padded with a pillow, the corresponding vertebral space is opened 6-8 cm to the affected side in the midline, and the puncture site is marked with gentian violet. Skin disinfection, lay sterile towel.
2, anesthesia: 1% lidocaine as local anesthesia.
3, puncture: from the skin marker point, the needle body and lumbosacral at an angle of 45º ~ 60º, aligned with the corresponding intervertebral space puncture. l5 ~ S1 intervertebral disc puncture, the needle body tilted to the cephalad side about 20º ~ 25º, the tip of the needle punctures the fibrous ring when there is astringent sensation.
4, fluoroscopic needle tip position: orthotropic needle tip reaches the midline, lateral position is located at the junction of the middle and posterior 1/3 of the intervertebral disc.
5, collagenase dose: 100 ~ 200u/1ml?
6.Method of injecting collagenase: inject into the disc with a 1ml syringe several times in small amounts and slowly along the puncture needle. Inject a little gas to push the residual collagenase inside the puncture needle into the disk. Then back the needle tip to the fibrous ring, stop 1~2min, then pull out the puncture needle and use a band-aid to dress the eye of the needle.
7. Body position: 5-7d postoperative bed rest.
(D) Combined intradiscal and intradiscal injection lysis operation method.
Combined intradiscal and intradiscal injection, i.e., the combined application of the above extradiscal injection and intradiscal injection.
(E) Trans-sacral fissure pre-dural space placement method.
The patient is placed in the prone position with pillow under the abdomen, and the sacral horn on both sides is first felt from the tip of the coccyx, and then explored upward from the sacral horn to the middle sacral crest, and the sacral fissure is found in the soft tissue downward concavity, which is well marked, the skin is routinely disinfected, sterile towel is applied, and the needle is entered at a right angle to the skin with a short No. 7 needle, and a mound is made first, and when the needle crosses the sacrococcygeal ligament, there is an obvious feeling of falling into the sacral lumen as a sign of entering the sacral canal. Use 18-gauge short oblique puncture needle, pierce from the mound, the needle stem is 15-30°C with the skin, the tip of the needle is pierced into the head end at a depth of about 4-6 cm, the depth of the needle should not exceed the plane of the posterior superior iliac spine line, after that, connect the syringe, back to the aspiration without blood or brain crest fluid after injecting air without resistance, that is, the symptomatic needle has entered the sacral canal. Place the epidural catheter to the diseased intervertebral disc, placement depth calculation method: the distance from the spinous process gap of the diseased intervertebral disc plane to the entrance of the puncture needle cm plus 3cm, inject 1-2ml of contrast agent, positive and lateral fluoroscopy symptomatic contrast agent in the epidural cavity and distributed on the protruding surface, inject 3ml of 1.3% lidocaine heavy specific gravity solution, 15-20 minutes later, observe no crestal numbness and delayed crestal numbness phenomenon, inject The puncture needle and epidural catheter were withdrawn and local pressure was applied.
(vi) Trans-lateral saphenous puncture method.
The patient is placed in a prone position with a pillow on the lower abdomen to make the physiological anterior convexity of the lumbar spine shallow or slightly posterior. After fluoroscopic or CT observation of the maximum transverse diameter of the medial ligamentous crawl area of the upper and lower articular processes along the skin projection area is the puncture point, and after local anesthesia, a puncture needle is used to enter the skin vertically through the puncture point, and after penetrating the skin, the needle is tilted slightly outward 30-50 to reach the bone, i.e., the dorsal side of the articular process. Exit to the subcutaneous adjustment for vertical needle, can touch the small joint inner edge, the needle tip beveled close to the inner edge of the joint continue to enter the needle, encounter resistance that is the yellow ligament.
The end of the needle is connected to the syringe with air, and the needle is advanced while applying pressure, and once the resistance disappears, the tip of the needle enters the lateral saphenous fossa. Gently pull back, no blood, no fluid, inject 1-2ml of contrast agent, observe that the contrast agent is located in the anterolateral epidural space, or 3ml of 1.3% lidocaine, observe that there is no crepitus for 15-20 minutes, inject 3-5ml of 1200u collagenase, pull out the needle and apply pressure and bandage.
(VII) Postoperative treatment
1.Go back to the ward after the operation to maintain the required position for rest, observe the body temperature, pulse, inspiration, heart rate, and any delayed allergic reaction.
2.Patients are required to lie on the affected side in a downward or forward position for 6-8h after surgery.
3.Conventional anti-inflammatory, dehydration, neurotrophy, physiotherapy and other symptomatic treatment on the second postoperative day.
4.Rehab guidance, including bed rest, lumbar muscle exercise, elastic lumbar girth protection, precautions, etc.