With the continuous improvement and development of percutaneous foraminoscopy ( PELD ) technology, modern PELD surgery can provide surgeons with high-quality images and clear anatomical structures of the spine, and can help physicians analyze the pathological causes of patients’ pain through diagnostic and therapeutic PELD minimally invasive lumbar spine surgery, which enhances our understanding and knowledge of discogenic diseases and thus improves our in-depth understanding of lumbar discogenic disorders. As this technology is widely carried out in China, many clinical problems and questions have arisen, for which I will give answers and comments from the following five aspects. First, is percutaneous foraminoscopy (PELD) a new technique? In the past five years, with the percutaneous foraminoscopy (PELD) technology in the rapid development of domestic, some doctors will be this technology is a newly developed new technology. In fact, PELD technology is one of the earliest minimally invasive spine surgery endoscopic technology, but also a new technology is being rejuvenated. The reason we say that PELD is one of the first minimally invasive spine surgery endoscopic techniques is because it has been through the history of minimally invasive spine surgery endoscopic techniques. Since Valls and Craig and others in the 1940s and 1950s applied the posterior-lateral approach to perform vertebral tissue biopsy, thus laying the foundation for minimally invasive surgery of the lumbar spine through the posterior-lateral approach. In 1997, Yeung et al. developed the third generation of spinal endoscopic YESS system (Yeung Endoscopy Spine System), marking the gradual maturation of this minimally invasive technique. The reason why we say that PELD technology is also a new technology that is being rejuvenated. This is because with the continuous improvement and development of spinal endoscopic technology and surgical instruments, as well as the clinical application of advanced surgical equipment such as laser, radiofrequency, surgical navigation and surgical robotic systems, the percutaneous foraminoscopic technique has been revolutionized. From the blind postero-lateral percutaneous lumbar disc resection in the early stage to the direct resection under direct endoscopic view today, from the indirect disc decompression through the Kambin safety triangle into the disc in the past to the direct removal of free disc tissue and release of adherent nerve roots through the intervertebral foramen approach today, from the simple inclusive lumbar disc herniation in the past to the ability to perform various types of The procedure has become the most promising and minimally invasive spinal endoscopic technique today, as it can only remove intervertebral discs, prolapse and free tissue masses, as well as percutaneous intervertebral foraminal stenosis, and can complete percutaneous lumbar intervertebral fusion. The most commonly used clinical procedures are the YESS (YeungEndoscopic Spine System) technique of indirect disc decompression through the Kambin safety triangle and the Hoogland et al. technique of entering the spinal canal through the intervertebral foramen. (TESSYS (TransforaminalEndoscopic Spine System) technique, which involves direct nerve root release and decompression internally. Although both techniques involve lumbar discectomy via a posterior lateral approach under local anesthesia, they differ in terms of surgical concept, direction of puncture, and placement of the surgical working cannula. The YESS technique is a rigid rod-shaped, combined, multi-canal, wide-angle percutaneous endoscopic system designed on the basis of the original lumbar lateral posterior percutaneous endoscope, and the end of the surgical working trocar is designed with different angled bevels. The epidural space, the inner and outer walls of the annulus fibrosus, and the intradiscal space can also be seen under the same wide-angle view. The YESS procedure is relatively simple and easy to perform, but it has narrow indications and is difficult to remove prolapsed and free disc tissue. disc tissue. Hoogland et al. designed a set of intervertebral reamers of different diameters to address the shortcomings of the YESS technique, and enlarged the intervertebral foramen by removing part of the anterior inferior border of the superior articular process of the inferior vertebrae step by step, placing the surgical working catheter directly into the spinal canal, and removing the prolapsed or free lumbar disc tissue directly under the anterior dural space under direct endoscopic vision. This technique not only allows for the management of various types of lumbar disc herniation or prolapse, but also allows for the direct removal of free disc tissue and simultaneous enlargement of the lumbar foramen. Since the TESSYS procedure is performed through the enlarged intervertebral foramen into the spinal canal, it is not only easier to place the surgical trocar, but also does not enter the disc through the narrow Kambin’s triangle, effectively avoiding and reducing the damage to the traveling nerve roots and dorsal root ganglia during the puncture and placement process. However, this technique also has the disadvantages of high operational difficulty, long learning curve, and easy to damage the intracanal vessels, traveling nerve roots and dural sac. We found that beginners who just started PELD surgery always ask: What is the YESS technique? What is the TESSYS technique? How to choose between the two clinically? Once the TESSYS technique is mastered, does it mean that the YESS technique should be abandoned. The YESS technique is most suitable for decompression of the nucleus pulposus and torn annuloplasty for discogenic low back pain, whereas the TESSYS technique is most suitable for direct removal of large disc prolapse and free disc tissue, and there is a complementary relationship between the two techniques. Therefore, we should not only master the correct operation methods of these two techniques in clinical practice, but also the correct selection of the best indications for these two procedures. The relationship between the percutaneous endoscopic interlaminar discectomy (PEID) and the percutaneous endoscopic interlaminar discectomy (PELD) was first described by Dr. Ruetten in 2005 as an important component of percutaneous endoscopic discectomy. It was first reported by Dr. Ruetten in 2005 and is mainly used for patients with herniated and prolapsed L5-S1 discs with high iliac crest and L5 transverse hypertrophy, where the percutaneous endoscopic approach (PELD) is particularly difficult. At present, a small number of scholars in China strongly advocate the PEID technique for the treatment of patients with various types of lumbar disc herniation, and even expand the technique to include disc herniation in segments such as L3, 4 and L4, 5, etc. It is believed that this technique has a surgical approach familiar to spine surgeons, quick puncture positioning, short intraoperative fluoroscopic X-ray exposure time, clear visibility of the dural sac, nerve roots and other important structures under the microscope, and easy protection. It is easy to protect, and the herniated or prolapsed disc tissue can be removed directly from the spinal canal, and the central and paracentral disc herniations can be completely decompressed under complete direct vision. I think PEID technology is an auxiliary technology evolved from PELD technology, mainly used in special cases of L5-S1 disc herniation patients, but can not be used as a conventional surgery for various types and multiple segments of lumbar disc herniation patients, more can not try to replace the classical PELD surgery with PEID technology. This is because the classic PELD procedure can be performed under local anesthesia through a lateral posterior approach to the lumbar spine into the disc or the anterior space between the nerve roots and the dural sac, which not only can directly remove the prolapsed or free disc tissue, but also does not require pulling the nerve roots and the dural sac, causing very little disturbance to the intradural environment and does not lead to the intradural adhesions caused by the traditional posterior approach through the interlaminar space. On the contrary, although the incision of PEID surgery is smaller than that of micro-MED surgery, it still requires incision of the ligamentum flavum and retraction of the nerve roots and dural sac with a working catheter, which inevitably causes different degrees of intracanal adhesions and even retraction injury of the nerve roots, just like the traditional transforaminal approach. Therefore, I believe that for the minimally invasive surgical treatment of lumbar disc herniation, in addition to individual special cases, should try to choose PELD surgical treatment. How to correctly treat the clinical value of PELD surgery and MED surgery Since Foley first reported the application of posterior microendoscopic discectomy (Microendoscopic Discectomy, MED) for the treatment of lumbar disc herniation in 1997, more than a thousand medical institutions around the world have carried out this operation and achieved more satisfactory results. The MED procedure draws on the advantages of traditional posterior laminectomy and minimally invasive endoscopic techniques to establish the surgical access through a series of dilated channels and to complete the 1.6 cm minimally invasive working channel to perform laminectomy, subtotal joint resection, nerve root canal decompression and disc removal that could only be done through open surgery in the past. The advanced video and camera system magnifies the operating field of view 64 times, compared with direct vision surgery, it can more accurately identify and protect the dural sac, nerve roots and vascular plexus in the surgical field of view, while the clear surgical field of view ensures a safer and more accurate completion of various surgical operations, effectively avoiding the shortcomings of small field of view, rough operation and large damage to bone and joint structures in traditional surgery, and maximizing the preservation of the posterior spinal ligament. Since its introduction to China in 1999, this technique has been performed in more than 600 medical institutions in China. Because of the advantages of less trauma, less bleeding and faster postoperative recovery, it has built a bridge between minimally invasive spine surgery technology and traditional surgery, thus promoting the development and progress of minimally invasive spine surgery in China. In recent years, with the rapid development of PELD technology in China, some beginners always ask whether it is better to choose PELD technology first? Or is it better to carry out MED surgery first? There are even some scholars believe that since there is PELD technology, does it mean that MED technology has become obsolete or should be eliminated by history. In my opinion, minimally invasive spine surgery is not a single technique, but a family of minimally invasive spine surgery techniques, each member has its unique function and role, and each technique has the best indications for surgery. The result is twice as good as the result with half the effort. For example, in the minimally invasive surgical treatment of lumbar central spinal canal and nerve root canal stenosis with lumbar disc herniation, MED surgery can be performed through a unilateral approach with bilateral subtle decompression, which not only decompresses adequately and effectively, but also destroys less bone and joint structures and preserves the small synovial structures on the opposite side of the decompression, thus effectively avoiding the disadvantages of traditional decompression surgery such as the need for fixation and fusion. PELD technology or PEID technology is still difficult to achieve the full decompression effect of MED surgery. Therefore, MED technology will not only be eliminated, and there is room for further development. In how to choose PELD or MED technology, each doctor should be based on their own technical level and the overall needs of the development of the discipline. MED technology is based on the development of the traditional classic posterior window surgery, the learning curve is short, easy to master the surgical operation, a wide range of surgical indications, no radiation damage. PELD surgery has a longer learning curve, more difficult surgical operation and greater X-ray damage to the surgeon, but it is the most minimally invasive surgical procedure for the treatment of lumbar disc herniation with less trauma, less interference in the spinal canal and faster patient recovery. effect. V. How to avoid surgical risks and complications of PELD surgery The most common risks of PELD surgery are postoperative intervertebral space infection, nerve root injury, tearing of the dural sac, bleeding in the spinal canal, and scar adhesions. Although, the above complications can occur in any spine surgery, the incidence of complications in PELD surgery is by far the lowest of all minimally invasive spine surgeries. Although, the complication rate of PELD surgery is clinically low, the surgical risk still exists, and once it occurs it will be catastrophic and must be understood and taken seriously for the surgeon. 1, the fibrous ring frontal penetration is a potential surgical risk, may lead to intestinal, vascular damage; 2, PELD surgery under the operation of another defect is the operation to be in the “two-dimensional” visual space, or “blind” state, so the operator’s mind The operator must be aware of the depth and direction of instrumentation, and protect the important anatomical structures when opening the window with the reamer. According to the literature, these bifurcation plexuses may be autonomic nerves, and once injured can cause impairment of sensory and motor function of the lower extremities. Sensory numbness is the most common complaint after percutaneous laminectomy, with an incidence of 5-15%, usually transient. The cause is unclear, but it may be related to postoperative neurological recovery, usually occurring days or weeks after surgery, or may be due to damage to the dorsal root ganglion. This condition cannot be completely avoided and the cause cannot be determined even with the use of the most sensitive nerve monitoring tools such as cortical somatosensory evoked potentials and continuous electromyography. In foraminoplasty, even if the traveling nerve roots are clearly identified and well protected, stimulation of the dorsal root ganglion of the traveling nerve roots, even with slight traction and stimulation can lead to postoperative skin sensory numbness. PELD surgery increases the risk of additional medical injury due to the special surgical approach. Local anesthesia is used to ensure the safety of the surgery because the patient is awake and can give rapid feedback to the surgeon about the pain sensation during surgery to help the surgeon understand and judge the safety of the surgery. For most herniated discs and discogenic pain, experienced surgeons choose a lateral posterior approach with percutaneous laminectomy as the treatment modality. Newer neuromonitoring instruments and devices can alert the surgeon when a nerve is being stimulated and provide sensitive feedback even when the instrument is not in direct contact with the nerve. The neuromonitoring serves as a reminder to surgeons who are new to percutaneous laminectomy. The future of percutaneous laminectomy is bright. The continued development and application of new technologies such as new imaging systems, endoscopes and surgical instruments will certainly contribute to the rapid development of this technique. Improvements in technology and the use of image navigation will help slow the learning curve. The future trends will be to promote repair of disc tissue rather than resection, to promote regeneration of disc tissue rather than allowing it to heal on its own, and to strive to preserve disc motion rather than excessive fusion.