Liu Cong1, Liu Bin, He Yongxiong, Peng Yunsheng, Wang Dongsheng
(1. Department of Spine Surgery, People’s Hospital of Inner Mongolia Medical College, Hohhot, Inner Mongolia 010020, China)
Abstract: To investigate the clinical efficacy of microintervertebral foraminoscopic percutaneous lumbar discotomy and aspiration for lumbar discogenic pain. METHODS: Thirty patients with lumbar discogenic pain were treated with coaxial microforaminoscopic lumbar discectomy and aspiration. RESULTS: Operative time: 25 minutes to 60 minutes; follow-up time: 6 to 16 months. The postoperative efficacy was evaluated according to the Nakano criteria: 21 cases were excellent, 5 cases were good, and 4 cases were acceptable, with an excellent rate of 87%, and no serious complications occurred. Conclusion: The treatment of lumbar discogenic pain by percutaneous lumbar discotomy and irrigation is less invasive, simple to operate, and has satisfactory recent efficacy. Liu Cong, Department of Orthopedics, First Hospital of Hohhot City
Keywords lumbar discogenic back pain (DLBP); microendoscopic foraminoscopy; discotomy and aspiration
Micro-endoscopic Automated percutaneous lumbar discectomy for the discogenic low back pain
Liu Cong 1, Ying He ping 1, Wu Yi Min 1, Li Shu Wen 1, Bai Ming 1, CaoZhenHua 1
(Department of Micro invasion spine surgery, Second Affiliated Hospital of InnerMongolia Medical College, Hohhot 010030)
Abstract Objective: To investigate the curative effect of discogenic low back pain with micro-endoscopic automated percutaneous lumbar discectomy (APLD)treatment. Methods: 30 patients with discogenic low back pain were treated by coaxial endoscopic automated percutaneous lumbar discectomy. Results:Operation time: 25 minutes to 60 minutes;mean follow-up time was 6～16 months after surgery. Clinical outcomes were determined using the modified MacNab criterion: which revealed that 21patients had excellent result , 5 patients good , 4 patients fair, the rate of the excellent and good :87%, no serious complications. Conclusion: Micro-endoscopic automated percutaneous lumbar discectomy is a efective method for discogenic low back pain with lesser trauma, simple operation and satisfied with the short-term effect.
Key words DPLD; Micro-endoscope ; APLD
Lower back pain is a common clinical condition with different etiology, pathology, and diagnosis and treatment. In recent years, cases of discogenic low back pain (DLBP) due to disorders of the internal structure of the lumbar discs have received much attention in the front line of clinical practice. From February 2007 to December 2007, 30 patients with DLBP who had been treated conservatively with poor results were treated with automated percutaneous lumbardiscectomy (APLD) under the premise of strict selection of indications, and good recent results were achieved.
1 Clinical data
1.1 General data
There were 30 patients in this group, 19 males and 11 females, aged 27 to 65 years old, with an average of 43 years old. The duration of the disease ranged from 6 to 16 months, with an average of 10 months. There were 36 lesioned spaces, vertebral spaces, including L3-46 cases, L4-521 cases, and L5S19 cases. All patients had received 2-6 months of preoperative non-surgical treatment without significant relief of symptoms.
1.1.1 Clinical manifestations: all patients had deep pain in the lumbar region and could not sit or stand for a long time; 15 patients could be relieved to varying degrees after rest, 2 cases were aggravated after rest and slightly relieved after activity; the symptoms were mainly in the lumbar region alone, 18 cases were not accompanied by lower limb symptoms; 4 cases were accompanied by bilateral posterior hip, anterior or posterior thigh pain or throbbing pain, 8 cases were unilateral; 14 cases had varying degrees of pressure pain in the diseased intervertebral space, 3 cases had no pressure pain in the low back, 2 cases had paravertebral There were 2 cases of paravertebral muscle spasm and 12 cases of paravertebral muscle atrophy of different degrees; all 30 cases had functional limitation of the lumbar region; no
There were no signs of nerve damage in the lower limbs, and the straight leg raising test was negative.
1.1.2 Imaging performance: preoperative X-ray lumbar ortholateral, hyperextension/hyperflexion, CT and MRI examinations were routinely performed. 7 cases had narrowing of the intervertebral space on X-ray, 23 cases had normal height; 18 cases had different degrees of bone redundancy at the anterior and posterior edges of the lesioned intervertebral body; the hyperextension/hyperflexion position suggested no obvious instability of the lumbar spine. 17 cases had disc bulge on CT scan without nerve root compression, the lesioned intervertebral space was >7 mm, and the intervertebral disc image was clearly defined, with smooth edges and uniform density. CT scan showed 17 cases of disc bulging without nerve root compression, with a clear intervertebral space of >7 mm, smooth margins and uniform density; 19 cases without disc bulging; and 15 cases of small joint osteoarthritic degeneration. All intervertebral discs showed MRI T2 low signal, 36 in total, including L3-46, L4-521 and L5S19; T2 restricted high signal zone (Hight intensity zone (HIZ)) appeared in the posterior part of the intervertebral disc fibrous ring in 7 cases (see Figure a), including 2 in L3/4 and 4 in L4/5, and HIZ and endplate signal alteration existed simultaneously in 3 cases. Intraoperative discography, 24 cases induced original pain, including 2 cases of L3/4, 17 cases of L4/5, and 5 cases of L5S1, and two discs could induce pain at the same time of imaging, L3/4, L4/5 1 case, and L4/5 3 cases. In 12 cases, no pain was induced during injection, and only a feeling of lumbar distension was observed.
1.2 Surgical method
Position: prone position with 45 degrees of hip flexion and knee flexion each, avoiding back tilt, C-arm X-ray fluoroscopy: orthostatic lumbar vertebrae with linear parallelism of the upper and lower endplates, disappearance of the cup shadow, and the spinous process located at the midpoint between the two vertebral arches. Under local infiltration anesthesia, puncture is performed on the symptomatic side, and the puncture point in the gap above L4/5 is located at 8-10 cm from the midline after the affected side of the collateral opening, and L5/S1 should be at 6-8 cm; the angle of the puncture needle: L4/5 and above, the angle between the needle body and the back is 35-40 degrees; L5/S1 is 40-45 degrees. After successful puncture, the tip of the needle was located on the centerline of the lesion space and on the line of the inner edge of the ipsilateral upper and lower pedicles in the C-arm X-ray. The tip of the needle in the lateral position was located in the middle and posterior 1/2 of the intervertebral space.
After successful puncture, compound iodophoresis was injected and discography was performed (see Figure e) until back pain of the same nature as before was induced, and the volume of the push was recorded. The microscopic intervertebral foraminoscope is placed into the inner wall of the working cannula and fixed (see Figure b), and observed under monitor surveillance (see Figure d). The degenerated disc is clamped in different directions and at different depths with nucleus pulposus forceps until no significant nucleus pulposus remains (see Figure f). An automatic rotary cutter was placed through the same working channel and an automatic negative pressure flushing device was connected to flush and clean the residual nucleus pulposus tissue.
After 3 days of postoperative antimicrobial treatment, functional exercises such as straight leg elevation were started after 1 day. 5 days after surgery, the lumbar and leg pain was relieved significantly or disappeared and the patient could intermittently get out of bed. 7 days after surgery, the patient was completely out of bed. Avoid weight-bearing for 3 months after discharge from the hospital, and insist on lumbar and back muscle exercises for at least 6 months.
1.3 Evaluation of efficacy
Before surgery and at 1 week, 4 weeks and 12 weeks after surgery, functional assessment was performed using a questionnaire based on the Oswestry Dysfunction Index (ODI), with the last item about sexual function removed from the questionnaire, i.e., a full score of 45. difference. The postoperative efficacy was also determined according to the Nakano [1] criteria. Excellent: symptoms completely disappeared and work resumed; good: low back pain remained, no effect on daily life; acceptable: same symptoms or mild change; poor: symptoms worsened. The follow-up period was 6-16 months.
2 Results
Operative time: 25 minutes to 50 minutes, average 35 minutes; all 30 patients were followed up for 6-16 months average 10 months; no postoperative complications such as infection and nerve root injury occurred. The postoperative efficacy was determined by Nakano’s standard in 21 cases, 5 cases, and 4 cases, with an excellent rate of 87%. The preoperative and 4-week postoperative ODI scores of the patients were processed by SPSS13.0 statistical software, which showed significant differences (p<0.01), Table 1; the ODI scores at 12 weeks postoperative were compared with those at 4 weeks postoperative, and the differences were significant (p<0.01), Table 2.
Table 1. Comparison of patients’ preoperative and 4-week postoperative ODI self-score results (`x ± s, n = 30)
Preoperative 3 weeks postoperative t-value P
ODI 31.40 ± 4.49 17.23 ± 2.78 13.49 <0.01
Table 2. Comparison of patients’ ODI self-score results at 4 weeks postoperative and 12 weeks postoperative (`x ± s, n = 30)
4 weeks postoperative 12 weeks postoperative t-value P
ODI 17.23±2.78 13.03±2.50 7.67 <0.01
3. Discussion
3.1 Diagnosis of DLBP
Despite the high incidence of DLBP, there are many different clinical perceptions about its onset, progression and regression as well as treatment methods, and there are many difficulties in screening a large number of cases of low back pain to confirm the diagnosis. Jeffery believes that the following criteria must be met: (1) history of recurrent symptoms with or without trauma, and duration of > 6 months. (2) typical clinical manifestations such as soreness and pain in the lumbar region, posterior iliac region, posterior gluteal region, inguinal region, anterior femoral region, posterior femoral region, and greater trochanter, etc., and (3) positive CT discography or MRI with typical single-segment signal reduction and high signal areas in the posterior part of the fibrous ring [2]. However, many scholars have differed on this diagnostic criteria. We believe that the diagnosis can be considered starting from the following aspects: firstly, non-spinal origin of low back pain, such as lumbar dorsal myofasciitis and supraspinal neuritis should be excluded; among the spinal origin of low back pain, then lumbar instability, slippage, lumbar spinal stenosis, ankylosing spondylitis, as well as infection, tuberculosis and tumor should be excluded; finally, the following diagnostic conditions should be considered1 History of typical lower back pain, unable to sit and stand for more than 6 months with recurrent episodes;2 Physical signs. Restricted lumbar movement, lumbago can occur with extreme knee and hip flexion or increased abdominal pressure; 3 MRI of the lumbar spine showing abnormal signals of the black disc, HIZ or end plate; 4 Discography pain replication. It should be noted that the above articles are not specific, especially MRI manifestations, which can also occur in cases without lumbar pain, which needs to be further investigated.
3.2 Understanding the etiology and treatment rationale of DLBP
It has been demonstrated that less than 30% of patients with lower back pain have symptoms due to nerve compression by a herniated lumbar disc, and it is even thought to be less than 1% [3]; whereas DLBP is the most common type of chronic lower back pain, with a proportion of about 40%, and the exact mechanism of its pathogenesis has not been elucidated [4].
Crock [5] suggested that intradiscal disorders are the main cause of DLBP, and the so-called intradiscal disorders refer to the pathological changes of degeneration of the nucleus pulposus and radiolucencies extending to the outer layer of the fibrous ring without structural abnormalities of the disc and nerve root compression, which can trigger lower back pain under the action of certain mechanical or chemical irritants.The study by Freemont [6] et al. concluded that the pain-producing There are more injury receptor endings in the endplate, annulus fibrosus and nucleus pulposus of the disc than in the degenerated disc alone. In contrast, Burke [7] et al. found that the pathological basis of DLBP is the accumulation of a large number of inflammatory mediators within the diseased disc, and Peng [8] et al. suggested that the widely distributed nerve fiber endings within the granulation tissue growing into the posterior fibrous annulus fissure of the disc are the pathological basis for DLBP and the replication of contrast pain.
In the treatment of DLBP, the principle of conservative first and then surgery is mostly advocated. Our microdiscectomy is a combination of percutaneous discectomy and aspiration (APLD) and microendoscopic technique. The advantages of this procedure are that the extent of disc degeneration can be clearly observed under surveillance, the scope and depth of dissection can be grasped, and the lesion can be avoided, which overcomes the blindness of APLD and improves the accuracy and safety of the procedure. Meanwhile, the addition of gentamicin and dexamethasone injection to the irrigation solution can prevent infection and inhibit immune response. We believe that the pathogenic mechanism of DLBP can be blocked by the treatment, which is reflected in: reducing the intradiscal pressure; removing the inflammatory tissue; terminating the autoimmune response, and finally changing the intrinsic environment of the intervertebral disc.
Microdiscectomy meets the requirements of minimally invasive concept and has the advantages of low trauma, low impact on spinal stability, easy operation, short bed time, low cost and easy acceptance by patients. The evaluation of its efficacy still needs long-term follow-up observation of a large number of cases. Although this technique cannot replace lumbar discectomy and vertebral body fusion, it is a better treatment method for patients who are not suitable for open surgery and for whom non-surgical treatment is ineffective.
4. References
1. NakanoN.NakanoT: Surgicaltechbiqur of anterior extraper itoneal lumbar discectomy to the lumbar disc herniation [J]. Operation, 1987. 41-45.
2.Jeffery S ,Fischgrund ,David M. Diagnosis and treatment of discogenic low back pain[J ] . Orthopadic Review ,1993 ,3 :311-317.
3. Ito M, Incorvaia KM, Yu SF, et al . Predictive signs of discogenic lumbar pain on magnetic resonance imaging with discography correlation. spine.1998 Jun 1;23(11):1252-8.
4. Schwarzer AC, Aprill CN, Derby R,et al. The prevalence and clinical features of internal disc disruption in patients with chronic low back pain. Spine.1995 Sep 1;20(17):1878-83.
5. Crock HV. Internal disc disruption : A chanllenge to disc praplas fifty years on. Spine , 1986 , 11 : 650
6. Freemont AJ, Watkins A, Le Maitre C, et al. Nerve growth factor expression and innervation of the painful intervertebraldisc[J].J Pathol, 2002, 197( 3) : 286- 292.
7. Burke JG, Watson RWG, McCormack D, et al. Human nucleuspulposus can respond to a pro- inflammatory stimulus [J].Spine, 2003, 28( 24) : 2685- 2693.
8. Peng B , Wu W, Hou S , et al . The pathogenesis of discogenic low back pain. j Bone Joint Surg (Br) , 2005 , 87 (1) : 62
a. MRI of a DPLD diagnostic case with arrows pointing to the “black disc” and HIZ; b. Successful puncture followed by placement of a 6.4 mm diameter working trocar; c. C-arm fluoroscopy showing puncture and trocar placement; d. Monitor showing degeneration of the diseased disc nucleus pulposus; e. C-arm showing contrast injection; f. C-arm showing the clamping of the nucleus pulposus