With the continuous improvement and development of percutaneous intervertebral laminectomy ( PELD ) technology, modern PELD surgery is able to provide surgeons with high-quality images and clear anatomical structures of the spine, and can help surgeons to analyze the pathological causes of the patient’s pain, and through diagnostic and therapeutic minimally invasive lumbar spine surgery of PELD, it has enabled us to have a further understanding and awareness of discogenic diseases, which has increased our understanding of the in-depth understanding of lumbar discogenic diseases. With the extensive development of this technology in China, a number of clinical problems and questions have arisen, for which I give answers and comments from the following five aspects. I. Is percutaneous intervertebral laminectomy ( PELD ) surgery a new technique? In the past 5 years, with the rapid development of percutaneous intervertebral laminectomy (PELD) technology in China, some doctors have mistaken this technology as a newly developed new technology. In fact, PELD is one of the earliest minimally invasive endoscopic techniques in spine surgery, and it is also a new technique that is rejuvenating. We say that PELD is one of the earliest minimally invasive spinal endoscopic techniques because it has been developed through the history of minimally invasive spinal endoscopic techniques. Since Valls and Craig et al. applied the posterior-lateral approach for vertebral tissue biopsy in the 1940s and 1950s, thus laying the foundation for minimally invasive lumbar spine surgery via the posterior-lateral approach. This minimally invasive technique has undergone percutaneous nucleus pulposus chemolysis, percutaneous puncture nucleus pulposus excision and aspiration, percutaneous laser discectomy, and arthroscopic-assisted discectomy, and was brought to maturity in 1997 with the development of the third-generation spinal endoscopy, the Yeung Endoscopy Spine System (YESS) by Yeung and others. We say that PELD technology is also a new technology that is rejuvenating. This is because percutaneous endoscopic techniques have been revolutionized with the continuous improvement and development of spinal endoscopic techniques and surgical instruments, as well as the clinical application of advanced surgical equipment such as lasers, radiofrequency, surgical navigation and surgical robotic systems. From the early blind posterolateral percutaneous lumbar disc excision to the direct excision under direct endoscopic vision, from the indirect disc decompression through Kambin’s safety triangle into the intervertebral disc in the past, to the direct removal of the free disc tissue block and the release of the adherent nerve root through the intervertebral foramen approach in the present day, and from the past can only be done for purely inclusive lumbar disc herniation, to the development of the completion of all types of From the past can only do simple inclusive lumbar disc herniation, to be able to complete all types of lumbar disc herniation, prolapse and free tissue block of direct surgical removal, as well as percutaneous foraminal enlargement of foraminal stenosis, from the past can only do the removal of the disc, the development of percutaneous lumbar intervertebral fusion, the procedure has become today’s most promising and minimally invasive endoscopic spine technology. Second, how to choose the correct YESS technology and TESSYS technology At present, the most commonly used clinical procedures are YESS (Yeung Endoscopic Spine System) technology introduced by Yeung et al. to enter the intervertebral disc through the Kambin Safety Triangle for indirect disc decompression and Hoogland et al. to enter the spinal canal through the foramen ovale for direct neurogenic decompression and spinal canal fusion. The TESSYS (Transforaminal Endoscopic Spine System) technique, which performs direct nerve root release and decompression, was designed by Hoogland et al. Although both techniques involve lumbar discectomy under local anesthesia via a posterior lateral approach, they differ in surgical concept, direction of puncture, and placement of surgical trocars. The YESS technique is a rigid rod-shaped, combined, multi-channel, wide-angle percutaneous intervertebral endoscopic system designed on the basis of the original lumbar lateral posterior percutaneous intervertebral endoscopy, and at the same time, the end of the surgical working trocars is designed as a beveled surface with different angles, which not only enables the operator to complete the discectomy and nerve root decompression under the direct vision under a wide-angle surgical field of view via a single channel, but also to see the epidural discs and nerve roots under a wide-angle field of view at the same time, and to see the epidural discs under local anesthesia. These designs not only enable the operator to perform discectomy and nerve root decompression under direct vision with a single channel under a wide-angle surgical field of view, but also to see the epidural space, the inner and outer lateral walls of the annulus fibrosus, and the intradiscal space under the same wide-angle view. In terms of specific surgical operation techniques, the YESS surgery adopts a single- or double-channel technique of entering the intervertebral disc through the intervertebral Kambin safety triangle, gradually removing disc tissues from inside the intervertebral disc to the outside, and expanding the intervertebral foramen with the assistance of high-speed grinding drills, bipolar radiofrequency, and lateral foraminal laser. The YESS procedure is relatively simple and easy to perform, but it has a relatively narrow indication and is difficult to remove prolapsed and free disc tissue. To address the shortcomings of the YESS technique, Hoogland et al. designed a set of intervertebral foraminal reamers with different diameters to enlarge the intervertebral foramina by removing part of the bony structure of the anterior and inferior margins of the superior articular processes of the inferior vertebrae step by step, and then placing the surgical catheter into the spinal canal directly to remove the prolapsed or free lumbar disc tissues directly under the endoscopic vision via the anterior dural space. This technique not only deals with all types of lumbar disc herniation or prolapse, but also directly removes the free disc tissue and simultaneously enlarges the lumbar intervertebral foramen. Since the TESSYS procedure enters the spinal canal through the enlarged intervertebral foramen, not only is it easier to place the surgical cannula, but it also does not enter the intervertebral disc through the narrow Kambin’s Triangle, which effectively avoids and reduces the damage to the traveling nerve roots and dorsal root ganglia in the course of the puncture and cannulation. However, this technique also has the disadvantages of higher operating difficulty, longer learning curve, and easy to damage the intravertebral vessels, traveling nerve roots, and dural sac, etc. We found that the beginners who have just started the 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. In our opinion, although these two techniques are different in operation methods, they both have their own optimal indications; YESS technique is the most suitable for nucleus pulposus decompression and torn annuloplasty for discogenic low back pain, while TESSYS technique is the most suitable for the direct removal of huge disc prolapse and free disc tissue, and there is a complementary and mutually reinforcing relationship between the two techniques. Therefore, we should not only master the correct operation method of these two techniques in the clinic, but also master the correct selection of the best indications for these two surgeries. How to view the relationship between Percutaneous Endoscopic Interlaminar Discectomy (PEID) and Percutaneous Endoscopic Interlaminar Discectomy (PELD) The Percutaneous Endoscopic Interlaminar Discectomy (PEID) was introduced by Dr. Ruetten in 2005, as an important component of Percutaneous Endoscopic Discectomy (PED) by Dr. Ruetten in Germany. Dr. Ruetten was the first to report it in 2005, and it is mainly used for patients with L5-S1 disc herniation and prolapse who have high iliac crest and L5 transverse process hypertrophy, and the transforaminal puncture approach (PELD) is particularly difficult. At present, a small number of scholars in China strongly advocate the use of PEID technology to treat patients with various types of lumbar disc herniation, and even expand the technology to the disc herniation of L3, 4 and L4, 5 and other segments, and believe that this technology has a surgical approach familiar to spine surgeons, fast puncture localization, intraoperative fluoroscopic X-ray exposure time is short, and important structures such as dural sacs, nerve roots and other structures can be clearly visualized under the mirror, facilitating protection, and direct resection, and can be directly removed. It is easy to protect, and can directly remove the herniated or prolapsed disc tissue in the spinal canal, and completely decompress the central and paracentral herniated discs under direct vision. In my opinion, the PEID technique is an auxiliary technique derived from the PELD technique, which is mainly used for patients with L5-S1 disc herniation under special circumstances, and cannot be used as a conventional surgical procedure for lumbar disc herniation of various types and segments, let alone replacing the classic PELD surgery with the PEID technique. This is because the classic PELD procedure can be performed under local anesthesia through the lumbar lateral posterior approach into the intervertebral disc or the anterior interspace between the nerve root and the dural sac, not only can it directly remove the prolapsed or free disc tissue, but also does not need to pull the nerve root and the dural sac, which has a very small interference with the intraspinal environment, and does not lead to the intraspinal adhesion due to traditional posterior transforaminal approach. On the contrary, although the PEID surgery has a smaller incision than the microMED surgery, it still requires incision of the ligamentum flavum and the use of a working catheter to retract the nerve root and the dural sac, which inevitably causes different degrees of intraspinal adhesions, and even nerve root retraction injury, as in the traditional transforaminal approach. Therefore, I think that for minimally invasive surgical treatment of lumbar intervertebral disc herniation, except for some special cases, we should try our best to choose PELD surgical treatment. How to correctly treat the clinical value of PELD surgery and MED surgery Since 1997, when Foley first reported the application of posterior microendoscopic discectomy (MED) for lumbar disc herniation, more than one thousand medical institutions around the world have carried out this surgery and achieved more satisfactory results. MED surgery draws on the advantages of the traditional posterior intervertebral space opening technology and endoscopic minimally invasive technology, through a series of dilatation channels to complete the establishment of the surgical access, and through the 1.6cm minimally invasive working channel to complete the past only through the open surgery can be accomplished by the intervertebral plate windowing, small joints resection, decompression of the nerve root canal, and discectomy and other operations. Due to the advanced camera and video system enlarging the operation field by 64 times, compared with the surgery under direct vision, the dural sac, nerve root and intravertebral vascular plexus in the operation field can be more accurately identified and protected, and the clear operation field ensures that all kinds of operation can be completed more safely and precisely, which effectively avoids the drawbacks of the traditional surgery such as small field of vision, rough operation and large destruction of bone and joint structure, and maximizes the preservation of the posterior spinal ligament. After the introduction of this technique into China in 1999, it has been carried out in more than 600 medical institutions in China. Due to the advantages of less trauma, less bleeding and faster postoperative recovery, PELD has bridged the gap between minimally invasive spine surgery 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 to perform MED surgery first. Or is it better to carry out MED surgery first? Some scholars even think that since PELD technology is available, does it mean that MED technology is outdated or should be eliminated by history. I think that minimally invasive spine surgery is not a single technology, but a big family aggregated by various minimally invasive spine surgery technologies, each member has its unique function and role, and each technology has the best surgical indications. An excellent minimally invasive spine surgeon not only needs to understand and master more new minimally invasive spine surgery technologies, but also learns to choose and apply them correctly, so as to achieve twice the result with half the effort. For example, in the minimally invasive surgical treatment of lumbar central canal and nerve root stenosis with lumbar disc herniation, MED surgery can be performed through a unilateral approach with bilateral submerged decompression, which is not only sufficient and effective in decompression, but also less destructive of the osteoarticular structure, and completely preserves the structure of the small articular eminence of the opposing side of the decompression, which effectively avoids the shortcomings of the traditional decompression surgery such as the need for immobilization and fusion, etc. At this point, the current PELD technique or PEID technique is not only effective, it also has the same effect as the conventional decompression surgery. In this regard, the current PELD technique or PEID technique can hardly achieve the full decompression effect of MED surgery. Therefore, MED technology is not only not obsolete, but also has room for further development. In choosing between PELD and MED techniques, each surgeon should base on his/her own technical level and the overall needs of the discipline, MED technique is developed on the basis of the traditional classic posterior window surgery, which has a shorter learning curve, is easy to master, has a wide range of indications, and has no radiological damage. PELD surgery has a longer learning curve, higher difficulty in surgical operation, and greater X-ray damage to the surgeon, but the surgery is less traumatic, less interference in the spinal canal, and the patient recovers faster, which makes it the most minimally invasive surgical procedure for treating lumbar disc herniation, and at the same time, in the minimally invasive surgical revision of recurrent lumbar disc herniation and lower lumbar spine post-surgical failure syndrome, it has a unique surgical effect that is unparalleled to the traditional revision surgery. Effect. How to avoid the surgical risks and complications of PELD surgery The most common risks of PELD surgery are infection of the intervertebral space, nerve root injury, tearing of the dural sac, bleeding in the spinal canal, and scar adhesion. Although, the above complications can occur in any spinal surgery, the complication rate of PELD surgery is by far the lowest of all minimally invasive spinal surgical procedures. Although the complication rate of PELD surgery is clinically low, the surgical risks remain, and when they do occur, they are catastrophic and must be understood and taken seriously by the surgeon. 1. Anterior penetration of the fibrous ring is a potential surgical risk, which can lead to intestinal and vascular injuries. 2. Another drawback of surgery under PELD is that the surgical operation has to be performed in a “two-dimensional” visualization space. 3. Another drawback of PELD surgery is that the surgical operation has to be carried out in “two-dimensional” visualization space, or “blind” state, so the operator must be clear in his mind about the depth and direction of the placement of the instrumentation, and protect the important anatomical structures when using reamer to open the window, and the spinal nerve roots may be attached to the discs and annulus fibrosus, and may be removed by the scalpel or other cutting systems together with the discs. The operator must be aware of anatomical and nerve root variations such as bifurcation of the nerve root, which may be embedded in the fat of the annulus fibrosus, with a bifurcating plexus attached nearby. It has been reported in the literature that these bifurcating plexuses may be autonomic nerves, which can cause sensory and motor impairment of the lower extremities if injured. 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 neurologic recovery, which usually occurs days or weeks after surgery, or it may be the result of damage to the dorsal root ganglia. This cannot be completely avoided, and its cause cannot be determined even with the most sensitive means of neuromonitoring such as dermatomal somatosensory evoked potentials and continuous electromyography. In vertebroplasty, stimulation of the dorsal root ganglion of the traveling nerve root can lead to postoperative numbness of skin sensation, even if the traveling nerve root is clearly identified and well protected, and even slight pulling and stimulation can lead to numbness. PELD surgery increases the risk of additional medical injury due to the special surgical access, and local anesthesia is used to ensure the safety of the surgery, because the patient is awake and can give rapid feedback of intraoperative pain to the surgeon to help the surgeon understand and judge the safety of the surgery. For most herniated discs and discogenic pain, experienced surgeons choose the percutaneous laminectomy lateral posterior approach as a treatment modality. Newer nerve monitoring 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. Neuromonitoring serves as a reminder to surgeons who are new to percutaneous laminectomy. The future of percutaneous laminectomy is bright. The continuous 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 have helped to slow down the learning curve. Future trends are to promote repair of disc tissue rather than removal, regeneration of intervertebral tissue rather than leaving it to heal on its own, and efforts to preserve disc motion rather than excessive fusion.