CONCLUSION: Percutaneous intervertebral foraminal spinal endoscopic subluxation technique for the treatment of lumbar disc herniation has the advantages of less trauma, less bleeding, quicker recovery, fewer complications, and exact efficacy. It is one of the best treatments for minimally invasive treatment of lumbar disc herniation of giant protrusion, prolapse, and free disc herniation. Since the 1970s, minimally invasive technology for lumbar disc herniation has been continuously introduced, due to the minimally invasive treatment of lumbar disc herniation has the advantages of less trauma, less bleeding, fewer complications without destroying the stability of the spinal column, less pain for the patient, quicker recovery, and satisfactory curative effect. It is well received by doctors and patients. However, because the indications are mainly inclusive of disc herniation, for huge herniation, prolapse, free type disc herniation is still mainly open surgery, so the traditional minimally invasive treatment method in the indications is greatly restricted. Percutaneous intervertebral foramen spinal endoscopic discectomy is a perfect combination of percutaneous nucleotomy and spinal endoscopic technology, which completely solves the deficiencies and shortcomings of traditional minimally invasive discectomy. Its advantage lies in the percutaneous endoscopic resection of the prolapsed, free and huge protruding nucleus pulposus tissue under direct vision without destroying the biomechanical stability of the spine, and the curative effect is exact. 1.Surgical instruments German-made SpinenDos Think spinal endoscopy 2.Surgical methods: (1) lesion disc localization line, the patient lying on the side of the X-ray translucent surgical bed, Kirschner’s needle on the surface of the body projected on the upper and lower lumbar vertebral spinous processes of the central point, fluoroscopy, and then draw a spinous process line, that is, the midline. And then mark the lesion disc axis transverse line, the midpoint of the two lines is the central point of the intervertebral disc. Kirschner’s needle lateral fluoroscopy to mark the disc axis of the lateral line, the disc axis line and the lateral line of the intersection of the two lines that is the puncture point. Adjust the distance between the spinous processes according to the patient’s weight and thinness. If the patient is thin, the spinous process will be opened 8-10 cm; if the patient is fat, the spinous process will be opened 12-14 cm. (2) Puncture imaging: Routine skin disinfection and spreading of sheets, infiltration anesthesia to the articular eminence with 15% lidocaine 15 ml penetrating the channel one by one, and then puncture the anterior and inferior margin of the upper articular eminence of the lower vertebrae with the 16G needles along the line of the skin under the fluoroscopic view of the X-ray, then pull out the core of the needles, and bend the tip of the 22G needles into a 15°, and then pierce along the 16G needle hole into the lower edge of the upper articular eminence. The tip of the 22G puncture needle was bent to 15°, and the middle and posterior 1/3 of the intervertebral disc was punctured along the hole of the 16G needle, (Figure) injected with the mixture of Omnipac + Mylan (4:1 volume ratio), and the distribution of the contrast medium was observed under fluoroscopy. (3) Establishment of working channel: Remove the 22G puncture needle, insert the guidewire along the 16G puncture needle into the epidural anterolateral space or the intervertebral disc, remove the 16G puncture needle, and make a skin incision of 8mm deep to the fascia with the guidewire as the center. Sequential dilatation tubes of 2.6 mm, 4.1 mm, and 5.1 mm were inserted along the guidewire. The guidewire and 2.6-mm-diameter dilatation guidewire were left in place, and a primary protective cannula and 5.1-mm-diameter ring drill were inserted along the 2.6-mm guidewire to resect a portion of the bone at the lateral margin of the superior articular eminence. The ring drill was seen to be located at the medial margin of the upper and lower pedicles on orthopedic fluoroscopy, and the ring drill was located at the posterior-superior margin of the lower vertebral body on lateral fluoroscopy. The guidewire was retained, and the ring drill, guide rod, and protective cannula were removed together, and then a 4.1-mm-diameter guide rod was inserted along the guidewire. The secondary protective cannula is inserted along the 4.1-mm-diameter guidewire, and a 6.6-mm (secondary) ring drill is inserted along the guidewire and slowly enlarged to resect the bone lateral to the superior articular process. The guide wire is retained, and the ring drill, guide rod, and protective sleeve are removed together. A 5.1-mm guide rod is inserted along the guide wire, a tertiary protective sleeve is inserted along the guide rod, and a 7.6-mm (tertiary) diameter ring drill is inserted along the guide rod, which is again enlarged to resect a portion of the bone of the superior articular eminence. If the ring drill did not reach the desired site in the front and side views, after hammering the end of the ring drill, the ring drill did not exceed the medial edge of the upper and lower pedicles in the front view, and the ring drill was located at the posterior-superior edge of the lower vertebral body in the side view. (Fig.) The annular drill, guide wire, and three-level protective sleeve were removed, and a 7.5-mm-diameter working sleeve with a beveled anterior end was inserted along the 5.1-mm guide rod, with the beveled end facing the disc side. (4) The endoscope was inserted to remove the intervertebral disc, and the connected endoscope was placed into the working trocar (length of 181 mm, diameter of 6.3 mm, inner diameter of the working cavity of 3.8 mm, field of view angle of 80 °, angle of view of 30 °, and magnification of 10 times), and the disc tissues that had protruded into the vertebral canal were removed under the microscope by various types of nucelar pincers and related instruments under the continuous rinsing of 3,000 ml of physiological saline + gentamicin 240,000 units. The intervertebral disc tissue (Fig.) was removed and the nucleus pulposus tissue behind the intervertebral disc was removed along the ruptured annulus fibrosus, the nerve root was explored and released (Fig.), and the anterior end of the bipolar radiofrequency that could be flexed was used to stop the hemorrhage and repair the fracture of the annulus fibrosus. No active bleeding was seen microscopically, and the dural sac was well pulsed. The operation was completed with one incision suture and dressing. (5) Postoperative treatment After the operation, intravenous broad-spectrum antimicrobial agents were administered for 1 day, dehydration and neurotrophic drugs were applied, and the patient was allowed to get out of bed for 3 hours after the operation with a girdle. Strengthen the lower limb straight leg raising exercise, prevent nerve root adhesion, avoid excessive activities and heavy labor within 3 months after surgery. 3, Discussion (1) Characteristics of percutaneous intervertebral foramen spine endoscopic techniques for lumbar disc herniation Since 1975, when Hijikata et al. reported on percutaneous nucleus pulposus resection, the minimally invasive percutaneous intervertebral disc treatment techniques have been developed rapidly, and in 1977 Yeung[2] developed a multi-channel, wide-angle spine endoscopic system (Yeung endoscopy spine system,YESS), called YESS system, for percutaneous posterior posterolateral approach discectomy, the most important feature of this technique is the inside-out technique (inside-out technique). Removing the nucleus pulposus tissue in the disc under direct vision is more direct and safer and more reliable than traditional discectomy. However, due to the positioning of the puncture needle in the middle and posterior 1/3 of the intervertebral disc, it is difficult to adjust the working channel to enter the spinal canal, and it is even more difficult to take out the dislodged disc tissues that are free from the spinal canal, and it is also difficult to release and decompress the nerve root under direct vision. In response to the shortcomings of the YESS technique Hoogland [3] and others invented a set of intervertebral foraminal spinal endoscopic equipment on the basis of the YESS technique, with the ring drill as a prominent feature, the operation of the operation by removing the articular eminence step by step, expanding the intervertebral foramina, so that the working cannula is inserted into the vertebral canal through the enlarged foramen to carry out the nerve root laxity and decompression directly (TESSYS technique. transforaminal endoscopic spine system, TESSYS), smoothly removing the nucleus pulposus tissues that are detached or free in the spinal canal, thus the intervertebral foraminal spinal endoscopic techniques for the treatment of lumbar intervertebral disc herniation have been deeply developed. All the enrolled cases in this group were prolapsed, free and massive herniations. According to the previous treatment methods, except for open surgery and posterior spinal endoscopic surgery, it is difficult to achieve the therapeutic goal in this group of cases. The invention and introduction of intervertebral foraminal spinal endoscopic subglottic technology has brought a mysterious weapon to the medical practitioners and a gospel to the patients. (2) Selection of surgical indications and operation concepts The greatest advantage of percutaneous intervertebral foramen endoscopic lumbar disc removal lies in the fact that the working cannula is directly inserted into the epidural cavity after the intervertebral foramen is enlarged, and the dislodged and free intervertebral discs that are compressing the nerve roots are removed under the direct vision of the endoscope. It can be said to be the real sense of the nucleus pulposus removal and nerve root direct decompression surgery. The best indications for this technique are prolapsed, free and large herniated discs, but for small and medium-sized inclusive herniated discs this technique is more traumatizing. Other minimally invasive treatments can be used with good results. A personalized treatment plan should be established for the choice of treatment. Based on the concept of achieving the best therapeutic effect with minimal trauma, this technique is an intravertebral operation that emphasizes a skillful, gentle, and ethereal approach, and should not damage any tissues in the spinal canal, especially the posterior longitudinal ligament, which should not be easily destroyed. For cases with large herniation and incomplete rupture of the lateral annulus fibrosus, the operation should look for a “bulging point” on the lateral side of the posterior longitudinal ligament, which is the point of nerve root compression or irritation, and the nucleus pulposus can be removed at the “bulging point” or the nucleus pulposus of the intervertebral disc can be removed under the posterior longitudinal ligament. Nucleus pulposus can be removed at the “bulge point” or under the posterior longitudinal ligament. This not only removes the herniated disc tissue, but also effectively protects the stable structure of the spine. (3) Operational skills and precautions The surgical skills of percutaneous intervertebral foramen spinal endoscopic technique for lumbar disc herniation come from the comprehensive mastery and proficiency of the technique. a. The 16G puncture needle must accurately reach the shoulder of the superior articular eminence, and the position is accurate in order to complete the surgery smoothly. b. How much resection of the articular process is appropriate? The author’s experience depends on the size of the intervertebral foramen, such as the intervertebral foramen is not narrow, the working trocar can also be accurately inserted into the anterolateral space of the epidural cavity after channel expansion. If the synchondrosis is hyperplastic and cohesive, and the intervertebral foramen is narrow, more synchondrosis must be removed so that the working trocar can be inserted into the anterolateral space of the spinal canal. c. What if there is a nerve root and dural sac in front of the mirror? In this case, the surgery can not be carried out, the position of the working trocar should be adjusted to avoid the nerve root and dural sac, and the working trocar should be inserted in the correct position so that the mirror can have a better view and the surgery can be completed successfully. d. Application skills of ring drill: when applying ring drill to remove the superior articular eminence, the ring drill should be firmly controlled, and should not be over-exerted and suddenly fall out of the air and injure the nerve roots and blood vessels. When the ring drill has a feeling of cutting bone and falling out of the air, X-ray positive and lateral fluoroscopy should be performed, such as the ring drill has not reached the required part, then the hammer should be used to gently knock the end of the ring drill downward until the exact position. When the ring drill does not have the feeling of cutting the bone, the hammer should be used to strike the end of the ring drill with force, which is very likely to cause the upper articular eminence to split, or even become a free bone block to compress the nerve root and the dural sac, resulting in undue damage, causing trouble for the operation and pain for the patient. e. Intraoperative bleeding problem. This is a problem that many colleagues are worried about. The authors experience that, in general, there are three kinds of bleeding, one is bleeding from subcutaneous blood vessels, the second is bleeding from muscle blood vessels, and the third is bleeding from blood vessels in the spinal canal. Usually subcutaneous and muscular vascular bleeding microscopic hemostasis is difficult, the application of mirror anterior and posterior pressure can be completely solved, and deep pressure hemostasis after completing the surgery. Intravertebral vascular hemorrhage such as radiofrequency still can not be stopped, you can use the mirror compression or increase the flow of water, such as still can not be stopped, the application of absorbable hemostatic gauze or absorbable hemostatic cotton, these substances are biologically based products, adsorption capacity, hemostatic effect is good, 3-5min after the removal of the ruptured blood vessels to find the ruptured blood vessels, using radiofrequency, thermal coagulation will be vascular closure, postoperative placement of drainage tubes for further observation. f. Intraoperative composite imaging is not available, the more degeneration of the nucleus pulposus, the heavier the staining, and the lighter the degeneration, the lighter the staining. Normal intervertebral disc tissue is tougher, has high water content, is elastic and is not stained. This is the reason why the nucleus pulposus is not stained after injection of contrast medium. For beginners, discography is necessary. g. Application and reform of intraoperative protective cannulae In conclusion, percutaneous disc spinal endoscopic technique nucleotomy for lumbar disc herniation has the advantages of less trauma, less bleeding, fewer complications, quicker recovery, basically does not destabilize the spinal biologic line of force, and further shortens the distance between the conservative treatment of lumbar disc herniation and open surgery. Among many minimally invasive treatment techniques, it is the real meaning of lumbar disc herniation nucleus pulposus resection and nerve root direct release decompression, which is worth applying and vigorously promoting.