Lumbar disc nucleus pulposus removal 【Preoperative preparation】 1. Preoperative positioning is most important. Generally speaking, according to the detailed examination (including the area of sensory impairment, muscle weakness, abnormal reflexes, the most obvious place of lumbar pressure pain, etc.), it is possible to determine which disc is herniated and the nerve root is compressed. However, herniated discs can have different symptoms and signs depending on the location or the pathology of the herniation. The site of herniation can be central, paracentral, lateral, or extreme lateral. Protrusion pathology can be bulging, herniated, prolapsed, or free. The free type can exist in various parts of the spinal canal and even protrude into the dural sac. It is not uncommon for the disc to protrude on the same side or both sides, and there are a few cases of protrusion with the epiphysis, and sometimes the above can be combined, making the clinical symptoms and signs complex, requiring good analysis and judgment, and further necessary auxiliary examinations according to the judgment, in order to make the correct preoperative diagnosis and positioning. 2.X-ray should be routinely taken before surgery to exclude lesions of lumbar and sacral spine and sacroiliac joint (such as vertebral tuberculosis and tumor) to avoid misdiagnosis. According to the change of the physiological arc of the lumbar spine, the protruding vertebral space is mostly narrowed, and the vertebral body can be seen to have labyrinthine hyperplasia and other manifestations for a long period of disease, which can help the diagnosis. In addition, X-rays can also show congenital variation, and the number of lumbar vertebrae and the height of the iliac crest plane can be used as a basis for positioning during surgery. In cases of suspected spinal stenosis, CT and MRI examinations should be improved. 3.Patients need to be bedridden for about 2 to 4 weeks after surgery. Patients should be emphasized and instructed to practice bedridden defecation and urination before surgery to reduce the difficulty of defecation after surgery. 4, general intraoperative bleeding is very little, no need to match blood, but for the weak should match blood backup. The procedure should be performed in a prone position, so that both sides can be explored and resected. When lying prone, apply long round soft pillows on both sides of the trunk to avoid pressure on the abdomen. The ends of the operating table are swung down so that the lumbar spine is in the anterior flexion position and the lamina gap is spread. A longitudinal skin incision is made in the back and the sacrospinous muscle is pulled away to reveal the vertebral plate and the ligamentum flavum. 2. Incision and exposure: A straight incision is made along the midline of the spinous process. First, cut the deep fascia on the affected side close to the edge of the spinous process, and peel the sacrospinous muscle under the periosteum. The vertebral plate automatic pulling hook is used to pull open the incision and clearly reveal the vertebral plate and the yellow ligament on the affected side. If it is necessary to reveal both sides of the vertebral plate, reveal the opposite side according to the same method. 3.Expansion of the vertebral plate gap: the vertebral plate gap from lumbar 5 to sacral 1 is large, and most of them do not need to be expanded; however, more than lumbar 4 to 5 need to remove part of the vertebral plate in order to achieve sufficient exposure. When expanding, the lower edge of the upper vertebral plate can be removed by biting forceps and expanded to the required range, generally to accommodate the end of the little finger. Bone surface bleeding with bone wax to stop bleeding. 4.Excision of the ligamentum flavum: In the enlarged intervertebral space, cut the lower edge of the ligamentum flavum with the tip of the sharp-edged knife close to the upper edge of the next vertebral plate next to the spinous process, and lift it upward with hemostatic forceps, thus removing the ligamentum flavum in one piece upward and outward. The knife is operated with the tip of the blade facing upward, and the operation is performed delicately so as not to damage the dura mater and nerve roots in front of the ligamentum flavum. The ligamentum flavum of the intervertebral disc herniation is thick and brittle, and it is easy to tear when pulling, so care should be taken. Remaining ligamentum flavum can be removed with pulpal forceps. 5.Probe and reveal the herniated disc: After removal of the ligamentum flavum, the dura mater and its lateral nerve roots can be revealed. Separate the dura and epidural fat with a dural stripper, find the nerve root, gently pull it away with a nerve hook, and perform a direct visual exploration on its inner and outer side. The prominence is mostly a tense spherical bulge, or it may have ruptured and the broken fibrous ring tissue may be free near or farther from the nerve root in the spinal canal. In long-standing cases, there are varying degrees of adhesions around the nerve roots and even in the nearby dura mater, which should be carefully separated without damaging the nerve roots and dura mater. In a few cases, the nucleus pulposus is protruding outward, so do not miss it. After finding the herniated nucleus pulposus, replace it with a circular nerve root pulling hook to pull, carefully protect the nerve and remove the herniated disc. 6.Excision of the nucleus pulposus and free fibrous ring tissue: After properly protecting and pulling away the nerve roots and dura mater and clearly revealing all the spherical protrusions, the protrusion is incised with a sharp-edged knife + shape. The incision should be made with a small but steady saw-like movement, so as not to injure the surrounding vital tissues and to avoid the dilated veins as much as possible. If this is not possible, bipolar electrocoagulation should be used. For disc herniation with large tension, the nucleus pulposus and broken annulus fibrosus burst out after incision, so use nucleus pulposus forceps and small scrapers to reach into the disc and remove the free annulus fibrosus to avoid residual and future re-protrusion. At the same time, care should be taken not to penetrate too deeply so as not to break through the disc and damage the abdominal aorta and inferior vena cava in front of the vertebral body. Removal should be performed within the sagittal diameter of the gap shown on the x-ray. If there is a labral growth at the posterior edge of the vertebral body, it should be carefully removed. During surgery, bone or fiber ring fragments should be removed at any time to avoid being pushed and remaining around the dura mater and nerve roots, which may later affect the efficacy. 7. Hemostasis and suturing: Hemostasis must be complete to avoid postoperative pain due to hematoma and adhesions. After negative pressure drainage, the wound is flushed and sutured layer by layer. Postoperative treatment】 1. It is advisable to lie flat for several hours after surgery, with a thin pillow at the waist to accommodate its anterior convexity, to achieve effective compression and hemostasis; and pay attention to the smooth flow of negative pressure drainage. After that, you can turn around casually. 2.Encourage the patient to urinate automatically. 3.After that, bed rest for 2 to 4 weeks is appropriate to facilitate local healing. 4.After discharge, insist on exercising the lumbar and back muscles and avoid pulling heavy objects. Generally, light work can be resumed 1 month after surgery, and the original work can be resumed after 3 months, but it is advisable to avoid heavy physical work.