Zhang Lu
Zhengzhou People’s Hospital
Abstract: To investigate the superiority and indications of posterior spinal microendoscopy in the treatment of lumbar disc herniation in order to improve the surgical efficacy. METHODS: After the posterior disc surgery system was positioned under C-arm or X-ray, a 1.5-cm longitudinal incision was made in the posterior median of the lumbar back, and the endoscope was inserted after the lamina was opened and the fibro-soft or bony tissues embedded in the dura and nerve roots were released under television surveillance. RESULTS: A total of 216 cases of lumbar disc herniation were treated in this group, with a follow-up of 3-24 months, of which 184 cases were excellent, 21 cases were good, and 9 cases could be treated, with an excellent rate of 95% (205/216). Conclusion: This procedure can completely release the fibro-soft tissue or bony tissue embedded in the dura and nerve roots, with less bleeding and less trauma, and maintains the stability of the spine. Zhang Lu, Department of Orthopedics, Zhengzhou People’s Hospital
Keywords: lumbar disc herniation, endoscopic, minimally invasive treatment
Lumbar disc herniation is a common and frequent disease in orthopedics. The traditional surgical method is to remove the lumbar disc nucleus pulposus with open surgery, which has a long time of bed rest and slow recovery after surgery, and also easily causes distant spinal instability, thus affecting people’s quality of life. Therefore, since May 2000, our hospital has adopted the posterior spinal microendoscopic surgical system produced by Storz, Germany, for the treatment of lumbar disc herniation and achieved good results. It is reported as follows.
1 Information and methods
1.1 General data There were 216 patients in this group, including 138 males and 78 females, aged 19-76 years old, with an average of 50.85 years old, 48 cases with simple lumbar pain, 52 cases with pain in one lower limb alone, and 116 cases with lumbar pain and unilateral lower limb pain. According to the classification of lumbar disc herniation proposed by Carragee(1), there were 25 cases of type I, 56 cases of type II, 78 cases of type III, 67 cases of type IV; 198 cases of Lasegue Sign(+), 208 cases of anterolateral calf numbness, 192 cases of reduced dorsiflexion of the affected limb bunions, 15 cases of hyperalgesia in the saddle area, follow-up time 3-24 months, operation time 45 minutes-110 minutes, bleeding volume 50-300ml.
1.2 Surgical method
(1) Position Prone position, abdomen slightly suspended, positioned under C-arm or X-ray, routine disinfection, towel laying, 0.5% lidocaine 20ml local infiltration anesthesia.
(2) Incision A longitudinal incision of 1.5 cm long was made in the posterior dorsal space, depending on the side of the lesion, and the periosteal stripper was separated, filled with gauze to stop bleeding, a guide needle was inserted, sequential expansion was performed, and the arch was opened perpendicular to the vertebral plate by the loop drill.
(3) Establishment of working channel A tapered working channel is placed and the surrounding soft tissue is cleaned, a speculum trocar is attached, and the focal length and the direction of the field of view are adjusted.
(4) Nerve root decompression The dura mater and nerve roots are exposed by separating and biting the ligamentum flavum with a dissecting hook. The nerve root can be retracted with a nerve retractor, and the degenerated and protruding nucleus pulposus tissue in front of the nerve root can be explored.
(5) Decompression criteria The affected nerve roots can move freely for 1 cm, and the central canal stenosis can move freely for the affected dura and nerve roots.
(6) Postoperative treatment Thorough flushing of the vertebral canal to stop bleeding. For hypertensive patients, rubber drainage strips were routinely placed postoperatively and removed after 24 hours, and they could generally leave the bed for urination and defecation on the day after surgery, and passive straight leg raising exercises were started on the second day, and they could move freely after 7 days.
2 Results
According to the Stauffer-Coventry (SC) lower lumbar spine postoperative scoring standard ① efficacy score: excellent: lumbar and leg pain completely disappeared after surgery (>90%) and normal work resumed; good: lumbar and leg pain mostly disappeared after surgery (70%-90%) and normal work could be participated, but functional activities of lumbar and leg were somewhat restricted; may: lumbar and leg pain partially disappeared after surgery (30%-69%), can barely participate in work, with limited functional activities of the lumbar region, and often need to take analgesics; poor: lumbar and leg pain did not disappear or worsened or slightly improved (0-29%), unable to participate in work, with significantly limited functional activities of the lumbar region, and need to take analgesics. After 3-24 months of follow-up, 184 cases were excellent, 21 cases were good, 9 cases were acceptable, and 2 cases were poor; the excellent rate was 95%. In this group, the operation time was 45min-110min, mean 65.8min; bleeding volume was 60ml-300ml, mean 112ml; hospitalization time was 5d-7d, mean 5.85d; time to get out of bed was 1d-4d, mean 1.2d; return to work was not possible. mean 1.2d; return to work time 3w-6w, mean 3.6w; among them, there were 2 cases of slight cerebrospinal fluid leakage, which were cured after bed rest in head-low foot-high position after surgery; 1 case of sudden onset of lumbar pain six months after surgery, which was examined as lumbar metastasis of bladder cancer; 1 case of severe lumbar back pain after rest three months after surgery, which could not be relieved by oral tramadol 100mg/d, which was examined as Multiple myeloma, none of the cases in this group had nerve injury or death.
3 Discussion
With the development of science and technology, the superiority of “minimally invasive” treatment for lumbar disc herniation has been recognized by scholars more and more obviously. Its characteristics of small incision, small trauma, less bleeding, short operation time and minimal interference with the stability of the spine are in stark contrast to the traditional open lumbar disc removal surgery with large incision, extensive tissue stripping, more bleeding, serious damage to the posterior structures of the lumbar spine, long bed time, slow recovery and easy to cause instability of the lumbar spine. “Minimally invasive” treatment can completely release the pressure-causing tissues around the nerve roots, avoiding interference, bleeding and postoperative adhesions in the spinal canal as much as possible (3). The posterior spinal microendoscopic surgery system from Storz, Germany, combines traditional direct vision surgery with endoscopic technology to effectively prevent long-term spinal instability, slippage, and other complications. Zhen Wanxin believes that 70% of traditional surgeries are suitable for this procedure (4).
3.1 Indications for surgery
(1) those who have gradually worsened after the onset of the disease and have been ineffective with non-surgical treatment for more than three months; (2) those with progressive worsening of neurogenic symptoms such as radiating lower limb pain and weakness of dorsal extension of bunions; (3) those with hypoesthesia in the saddle area and dysfunction of urination and defecation; (4) those with lumbar disc herniation combined with spinal stenosis; (5) those with sudden onset of the disease, which continues to worsen and affects life and workers. However, those who have had open surgery, unstable spinal slippage and huge central herniation with calcification should be regarded as contraindications to surgery.
3.2 Surgical experience
3.2.1 Superiority of the Storz posterior discoscopic surgical system
The Storz posterior discoscopic system is a minimally invasive and endoscopic adaptation of traditional treatment methods. The literature reports excellent recent outcomes of this procedure (4, 5). It has: ① clear field of view, high resolution, 64 times magnification of the image, and clearer anatomical structure; ② more complete decompression without disturbing the normal biomechanical structure of the spine, effectively preventing and reducing postoperative lower lumbar instability; ③ less bleeding, less trauma, less expense, and shorter bed rest and hospital stay; ④ special safety drill and supporting surgical instruments, more convenient window opening, less likely to damage the dura and nerve roots; shrink the operation time ⑤ local anesthesia, you can eat after surgery, and you can get out of bed in six hours (except for multi-stage opening); ⑥ small incision, surgical emergency reaction and postoperative pain, easier to be accepted by patients than traditional surgery. (7) Rehabilitation exercises can be performed early after surgery, which can help prevent adhesions of nerve roots. (8) This operation can be performed unilaterally, bilaterally, or in multiple stages of opening and decompression, and the working channel can move longitudinally on the surface of the vertebral plate to expand the scope of tooth reduction.
3.2.2 Complications and their prevention
Since this surgery breaks the conventional surgical mode, which separates the eye, brain and hand, causing operational inconvenience, the following points should be noted when this surgery is carried out in the early stage: ① Positioning error: carefully read CT or MRI, X-ray films, carefully examine the patient, pay attention to the side of the lesion and the presence of sacral lumbarization and lumbar sacralization to prevent positioning error; ② Injury to the dura: Since in the early stage of carrying out this surgery, the Hand-eye cooperation is not appropriate, bleeding adhesions can easily damage the dura mater, forming cerebrospinal fluid leakage and affecting the surgical process. Therefore, it is crucial to maintain a clear surgical field and to operate carefully; ③ Difficulties in intraoperative hemostasis: due to the limited space for microscopic operation, once the intravertebral plexus ruptures, it is difficult to stop the bleeding, which affects the operation and also leads to postoperative nerve root adhesions and affects the postoperative results. We have a case of intra-vertebral plexus rupture at the beginning of the operation leading to hemorrhagic shock, the operation was terminated in time and resuscitation was given without consequences; ④ prevertebral vascular injury: it is reported that the rate of injury to the large vessels in the abdominal cavity in intervertebral disc surgery is 1.6%, and when removing the nucleus pulposus the operating protocol should be strictly adhered to, the clamp depth should be less than 3 cm, and the disc tissue should not be clamped with violence too deep. ⑤ The safety drill should be used to open the window close to the arch plate to enter the spinal canal, with even force to minimize the extrusion of nerve roots to prevent aggravation of nerve root edema; ⑥ excessive pulling of nerve roots should be prevented during surgery to artificially aggravate nerve root injury; ⑦ during decompression of the spinal canal, the fat and yellow ligament behind the dural sac should be preserved as much as possible to prevent excessive exposure of the dura to reduce bleeding and postoperative adhesions. Therefore, we believe that this procedure should be performed by a physician who has experience in traditional open-heart surgery and is familiar with local anatomy, and who is familiar with the instruments used and has undergone formal training to perform this procedure.
References
1 Lu Yu P, Shi KJ, Huang YT, et al. Surgical treatment of lumbar intervertebral disc herniation (with 238 cases treated). [J] Chinese Journal of Orthopedics, 1981.1(2):24-25
2 Yuan ZG, Fang Y. Treatment of lumbar spinal canal lateral saphenous fossa stenosis with sodium hepaticoside . Chinese Journal of Spinal Cord . [J] 2002.10(5):334
3 Zhang Z, Lu KW, Wang Y, et al. Comparison of the efficacy of bilateral enlarged openings and total laminectomy for lumbar spinal cord stenosis. [J] Chinese Journal of Spinal Cord, 2002,12(6):462
4 Zhen Wanxin, Wang Yucai, Ma Lequn, et al. Posterior spinal microendoscopy for lumbar disc herniation. [J] Chinese Journal of Orthopaedics, 1999.9(8):460-462
5 DeAntoni DJ,CLARO ML,poehling GG,et al. Translaminal lumbar epidural endoscopy:technique and clinical results [J]. Jsouth Orthop Assoc, 1998.7(1):6-12
[Note]
Zhang Chunlin, M.D., First Affiliated Hospital of Zhengzhou University, Head of Minimally Invasive Spine Group, Henan Orthopaedic Society
Tieliang Zhang, President of Henan Provincial People’s Hospital, Chairman of Henan Orthopaedic Academic Committee
Figure 1 Preoperative MRI Figure 2 Preoperative CT