The following is the text of our own minimally invasive learning course combined with the technology we have mastered, we hope it will be helpful to our friends!
Common knowledge of minimally invasive concepts and treatment options for common spinal diseases
1. Common diseases: cervical spondylosis, lumbar disc herniation, lumbar spinal stenosis, lumbar discogenic pain, lumbar instability, osteoporotic vertebral compression fracture, spinal metastases (illustrated); Du Zhicai, Department of Cervical Surgery, Second Affiliated Hospital of Inner Mongolia Medical University
2. the incidence and impact on society and family and the expenditure of funds at home and abroad (graphic)
3. the concept of minimally invasive spine concept.
① concept: to implement treatment for common spinal diseases with the help of advanced instruments, equipment and special instruments, so as to obtain the best curative effect with the least damage and to protect and restore the patient’s working ability to the greatest extent.
② Concept: simple but not complex, conservative but not surgical, minimally invasive but not open.
4. Minimally invasive techniques and methods.
① Percutaneous puncture class: radiofrequency, laser, ozone, incision and suction or complementary, ballooning and shaping, etc.
② microendoscopic-assisted class: posterior trans-laminar intervertebral discoscopic technique, lateral trans-intervertebral foraminoscopic technique (graphic).
③ percutaneous internal fixation class: pedicle screws and intervertebral fusion devices.
5. Minimally invasive concept.
① Minimally invasive access concept: that is, “full exposure” without incision or minimal incision, using minimally invasive endoscopic system can achieve direct “full exposure”. (Figure) The combination of 64 times magnified field of view and C-arm X-ray positioning effectively reduces the trauma of the approach.
The concept of minimally invasive repositioning: the repositioning of the body with minimal trauma, with the help of imaging technology and anesthesia, is painless and non-fearful for the patient. (Graphic)
③ Minimally invasive resection concept: to achieve both complete removal of the diseased tissue and adequate and effective decompression, and to involve as little damage as possible to the surrounding normal tissues. (Graphic) For example, lesion removal is completed with high definition, precision and high resolution with the help of imaging systems and endoscopic systems.
④ The concept of minimally invasive fixation: it is to obtain the maximum stability with the least possible fixation and the simplest operation, such as percutaneous internal fixation and microscopic internal fixation are specific concepts of the concept of minimally invasive fixation. (Graphic)
⑤ Minimally invasive fusion concept: based on the above four concepts and operations, to achieve strong, effective and reasonable minimally invasive fusion, i.e. to minimize the fusion range and to preserve as much of the motion phase as possible to ensure the normal physiological range of motion. (Graphic)
6. Common spinal disorders and indications for minimally invasive technique selection.
①Cervical disc herniation
a. Neurogenic: the disc protrudes on the lateral side of the cervical spinal canal, compressing or stimulating the nerve root on one side causing neck and shoulder pain and upper limb numbness, and the imaging changes match the clinical manifestations, and those who are ineffective with conservative treatment, the best minimally invasive technique is to choose percutaneous puncture plasma radiofrequency myeloablative decompression, which is non-invasive, simple to operate, and has significant efficacy, with an operation time of 8-10 minutes and 3-5 days discharge. (Graphic)
b. Sympathetic nerve type:The disc protrudes in the center of the cervical spinal canal and protrudes toward the front of the spine and medulla, stimulating the sympathetic nerve component in this area, causing neck pain, stiffness and discomfort, and inducing vertigo, often accompanied by nausea and vomiting, often associated with head and neck rotation or changing posture. Radiofrequency ablation or percutaneous suction decompression with medical O3 oxidation is the best technical choice. (Graphic)
c. Spinal cord type:manifesting as stiffness of the limbs and unstable walking, anterior intervertebral discoscopy technique is chosen.
②Cervical osteoporotic vertebral compression fracture
Women over 60 years old, men over 70 years old, due to severe osteoporosis, minor trauma can cause cervical vertebral compression wedge, mainly manifested as neck pain, aggravated by head and neck activities, affecting the quality of life of patients, in addition to imaging (X-ray, CT, MRI) can clarify the location, degree and nature of the compressed vertebral body, bone densitometry can support the degree and diagnosis of osteoporosis. If conservative treatment fails to relieve pain in 4-6 weeks, the most effective minimally invasive technique is percutaneous balloon-expandable posterior kyphoplasty (PKP) (Figure)
(iii) Cervical vertebral metastases: the primary site is not in the cervical spine, but metastasized from other sites or organs, sometimes it is difficult to find the primary site, and the main manifestation is neck pain, which is worse at night. The PKP or PVP technique is applicable, provided that the integrity of the spinal canal is normal. (Figure)
④Lumbar disc herniation: It occurs in young adults, and is common in L4-5 and L5-SI. The main manifestations are to pain with radiating numbness in the lower extremities, or weakness in walking on the foot and ankle, and even disorders in urination and defecation or sexual function (in men) (central type herniation).
CT or MRI shows soft tissue shadow of the disc protruding into the spinal canal, less than 1/3 of the sagittal diameter of the spinal canal, with clear boundary, smooth surface, uniform density, and no sharp angle formation. (Figure)
Minimally invasive technique selection: incision and suction, ozone, radiofrequency or a combination of each other’s application
b. Rupture type protrusion: the disc is ruptured in its entirety, but the posterior longitudinal ligament is intact and the soft tissue of the nucleus pulposus is protruding in front of the posterior longitudinal ligament; the protruding disc is less than 1/2 of the sagittal diameter of the spinal canal, with clear boundaries, uneven density and sharp angle formation as seen in CT or MRI. (Figure)
Minimally invasive technique of choice: posterior microendoscopic herniated disc resection or excision and aspiration
The nucleus pulposus enters the spinal canal through the fibrous annulus and posterior longitudinal ligament, and can be seen on CT or MRI in three ways: horizontal protrusion, upward protrusion, and downward protrusion (flow injection). (Figure) can occupy more than 1/2 of the sagittal diameter of the spinal canal.
Minimally invasive technique of choice: posterior microendoscopic removal of the nucleus pulposus (MED)
d. Calcified herniation: refers to a long history of disc herniation with recurrent symptoms, usually around 5 years, and some patients may have alternating symptoms in the lower extremities, such as the left leg in the past, but suddenly the right leg symptoms appear recently and are more severe than the left leg. Calcified herniation (i.e., new disc protrusion) is the alternating protrusion of the nucleus pulposus from the weak zone of the annulus fibrosus, i.e., calcified (hard) versus non-calcified (soft), under pressure, resulting in lower extremity symptoms. (Figure)
Minimally invasive technique selection: MED, depending on the site of calcification, size, and either unilateral access or bilateral access can be chosen.
e. Extremely lateral type of herniation:The direction of herniation of the disc is not in the spinal canal but in the intervertebral foramen or outside the intervertebral foramen, with predominantly radicular symptoms, i.e., radiating numbness and pain in the lower extremities. CT or MRI (Figure)
Minimally invasive technique selection: non-ruptured type with a small herniation, with the option of excisional suction plus O3.
ruptured type with larger protrusion, optional foraminoscopic technique. (b).
⑤ lumbar spinal canal stenosis: it occurs in middle and old age, due to degeneration of the intervertebral disc, relaxation and instability of the chase gap, and the body, in order to rebuild its stability, makes the intervertebral disc or fibrous ring protrude into the spinal canal under the action of long-term repeated micromotor force, the yellow ligament thickens significantly, and the joint protrusion joint hypertrophy coalesces in the spinal canal, which can make the central spinal canal or the heel canal appear narrow, with discomfort in early lumbar pain and intervertebral claudication of different degrees in late stage, walking distance In the early stage, there is discomfort of low back pain, and in the late stage, there is varying degrees of intervertebral claudication, walking distance, and unbearable numbness and pain of lower limbs.
The minimally invasive technique of choice:MED can achieve a small incision and bilateral decompression, which can relieve the symptoms of both lower limbs. (Figure)
(6) Lumbar instability: also called lumbar instability, on the basis of intervertebral disc degeneration, the lumbar intervertebral joints cannot maintain the physiological alignment relationship under normal loading, and a super normal range of motion and a series of clinical symptoms caused by this, forward flexion and backward extension by X-ray film shows intervertebral body sagittal displacement of 4mm (Figure) intervertebral into angle 10°. The main manifestations are: a “fractured feeling” in the lumbar region after standing for a long time, a sudden “restricted” feeling in the lumbar region during lumbar flexion and extension activities, sudden lumbar pain caused by slight activities, the symptoms are obviously reduced after lying down, “step “If the pain is relieved or disappears after appropriate braking or external fixation with a brace, it strongly suggests lumbar instability. Long-term instability can be secondary to spinal stenosis, and in addition to lumbar pain, hip and lower extremity pain, numbness and discomfort, and intermittent claudication can also occur; manifestations of imaging instability: bone flab around the vertebral body, narrowing of the intervertebral space, asymmetric collapse of the intervertebral disc or “double arc shadow” at the posterior edge of the disc (CT film), disorganization of the sagittal plane of the vertebral body, abnormal displacement of the vertebral body during forward flexion and backward extension, or abnormal displacement of the vertebral body during forward flexion and backward extension. abnormal displacement of the vertebral body or slippage of the vertebral body. (X-ray)
Minimally invasive technique selection: MED subvertebral decompression with intervertebral fusion is selected for intervertebral body power slice displacement of 4 mm or intervertebral angle of 10°.
For intervertebral power slice displacement of 4 mm or intervertebral angle of 10° within the first degree of slippage, percutaneous pedicle screw fixation, endoscopic lumbar spinal canal decompression, and intervertebral fusion are selected; (unilateral screw system or bilateral screw system are available)
(7) Osteoporotic compression fracture of the thoracic spine
In the elderly, due to the physiological decrease of hormone level in the body, bone metabolism appears to grow, mainly bone resorption, long-term accumulation leads to bone loss, bone density decreases, bone quality and quantity are reduced to appear osteoporosis, so that bone strength is seriously reduced, brittleness increases, and finally the mechanical properties of bone are reduced, under the action of stress, local rupture occurs in the vertebral body through the transfer of stress in the intervertebral disc, mostly due to flexion stress, so the vertebral body is wedge-shaped Compression, the violence required for fracture is usually small, there is obvious low back pain after fracture, and the injured vertebra with wedge shape change is visible on X-ray; CT can see the rupture of the injured vertebra and can understand the integrity of the spinal canal, MRI can understand whether the injured vertebra is fresh compression (high signal) or old fracture (low signal), which is important to determine whether minimally invasive surgery is needed.
Minimally invasive technique options: 1, PVP (percutaneous vertebroplasty) is adapted to the injured spine with mild cuneiform degeneration, and the normal angle of the vertebral body can be reset or restored in the prone hyperextension position.
2, PKP (percutaneous vertebral body kyphoplasty) is adapted to those whose vertebral body compression does not exceed 50%.
Requirements: osteoporotic compression fracture is fresh, within six months, with significant thoracic and lumbar back pain (when moving), which affects self-care.
MRI showed: the injured vertebra was high signal (T1-weighted) and bone densitometry diagnosed osteoporosis. CT or MRI showed the posterior edge of the vertebral body was intact. Figure: X-ray, CT, MRI (preoperative and postoperative)
The pain was relieved 24 hours after surgery, and he was able to move around on the ground for 3 days.
Previously, conservative treatment required 2-3 months of bed rest, and for the elderly, they were prone to lung infection, urinary tract infection, decubitus ulcers, lower limb thrombosis and phlebitis, and even life-threatening complications such as pulmonary infarction, heart attack and cerebral infarction could occur.