OBJECTIVE: To investigate the method and efficacy of percutaneous laminectomy with radiofrequency targeted thermocoagulation combined with ozone ablation in the treatment of lumbar disc herniation.
Methods: 100 patients with single-segment lumbar disc herniation were randomly divided into two groups: 50 patients in the observation group were treated by percutaneous laminectomy and 50 patients in the control group were treated by radiofrequency targeted thermocoagulation combined with ozone nucleus pulposus ablation, and the efficacy of surgery was evaluated using the modified Macnab criteria, Oswestry dysfunction index (ODI) and visual analog scale VAS. The efficacy of the procedure was evaluated using modified Macnab criteria, Oswestry Dysfunction Index (ODI) and visual analog scale VAS.
Results: Patients were followed up for 3 months on average, and the VAS scores of low back and leg pain were significantly reduced at all time points after surgery compared with those before surgery (P<0.01). 80%.
Conclusion: Percutaneous laminectomy and radiofrequency targeted thermocoagulation combined with ozone ablation are less invasive, have fewer complications, have faster postoperative recovery, and have more reliable recent efficacy than radiofrequency targeted thermocoagulation combined with ozone ablation.
Lumbar disc herniation is a common clinical orthopedic condition, the main causes of which are rupture of the annulus fibrosus, disc degeneration, compression of the nerve root or cauda equina, or irritation of the herniated nucleus pulposus. The prevalence of lumbar disc herniation is on the rise and tends to be younger, and has plagued numerous patients. Treatment methods include conservative treatment, surgery, and minimally invasive treatment. At present, the minimally invasive treatment methods commonly used in China include low-temperature plasma ablation, percutaneous laser disc decompression, radiofrequency targeted thermal coagulation, ozone ablation, collagenase lysis, posterior discoscopic nucleus pulposus removal, percutaneous intervertebral foraminotomy and so on. Minimally invasive surgery has the superiority that cannot be compared with traditional surgery, such as less trauma, faster recovery and fewer complications.
1.Data and methods
1.1 General data 100 patients with single-segment lumbar disc herniation who had failed conservative treatment were randomly divided into two groups. In the observation group, there were 50 cases, including 32 males and 18 females; age 18-73 years, average 48.6 years, duration of disease 1 month-6 years, hospitalization 7-12 days, average 8.5 days; in the control group, there were 50 cases, including 23 males and 27 females; age 21-71 years, average 50.2 years, duration of disease 2.5 months-13 years, hospitalization 6-10 days, average 6.87 days.
The main clinical symptoms were low back pain with radiating pain, numbness and weakness in one or both lower limbs. All patients were diagnosed by CT or MRI and had poor results and recurrent episodes after more than 1 month of regular conservative treatment. The preoperative imaging data confirmed the herniated disc segments: L3-4 in 8 cases, including 3 cases in the observation group and 5 cases in the control group; L4-5 in 59 cases, including 27 cases in the observation group and 22 cases in the control group, and L5-S1 in 43 cases, including 20 cases in the observation group and 23 cases in the control group.
Case inclusion criteria: those with lumbar disc herniation confirmed by MRI or CT and ineffective conservative treatment for more than 1 month. Exclusion criteria: ? Lumbar spinal stenosis; stable spinal slip of degree I, spinal slip of degree II or more; ? spinal infection, tumor, tuberculosis, etc.; inclusive mild and moderate lumbar disc herniation and simple lumbar disc degeneration.
1.2 Surgical instruments SPINENDOS intervertebral foramoscope, 120IEC radiofrequency machine with bipolar flexible electrodes and handle made by Ellman Company, USA; HUMARES MEDOZON ozone generator, Germany; Beiqi radiofrequency therapy instrument and 18 G radiofrequency puncture trocar needle with bare end marker.
1.3 Surgical method Observation group: Patients were placed in prone position, routinely disinfected, spread sheets, and given 0.5% lidocaine local anesthesia. Take the midline paracentral opening 12-14 cm, C-arm positioning under the puncture needle inserted into the superior articular eminence position, here give 0.25% lidocaine 10 ml; then pull out the needle core, place the guide wire, use the reaming drill step by step, polish the superior articular eminence, expand the intervertebral foramen; put in the working cannula, observe from the orthogonal position that the front end of the cannula exceeds the line of the inner edge of the articular eminence, lateral position see up to the posterior edge of the vertebral body, indicating the position is satisfactory, use methylene blue, iodophoresis (1:9) to perform discography and stain the degenerated nucleus pulposus tissue; connect the intervertebral foramen with an infusion set, saline (3000 ml) for continuous flushing, use a nucleus pulposus clamp to remove the stained nucleus pulposus tissue or the nucleus pulposus tissue protruding outside the fibrous ring and free into the vertebral canal, and use a flexible bipolar radiofrequency electrode for nucleus pulposus ablation and fibrous ring thermoplasty; microscopically observe the nerve root and dural sac retraction and see good pulsation of the dural sac, the patient was instructed to cough that no nucleus pulposus was extruded from the disc, adequate hemostasis was achieved, the working cannula was withdrawn, the skin of the incision was sutured, sterile dressing was applied to the wound, and the lumbar girth could be worn for activities 24 hours after surgery, and the lumbar girth was braked for 4 weeks.
Control group: Patients were lying prone on the CT bed, and CT scan was performed to determine the site and size of the herniated disc. The needle entry point, angle of needle entry and depth were measured. Then the cavity towel was disinfected and laid. Local anesthesia was applied with 1% lidocaine. The CT scan determines that the needle is inserted into the disc, the needle core is removed, and 10-15 ml of ozone at a concentration of 60 μg/ml is extracted from a 5 ml syringe, and the needle is withdrawn until the location of the protrusion is the same as the preoperative design target, indicating that the target has been accurately penetrated. Place the electrode into the puncture cannula needle and connect the wire. Physiological stimulation with high frequency (50Hz) current (0.8~1.0mA) was given first, and the patient had no severe pain in the lower limb, which proved that there was no sensory nerve in the area of destruction; then low frequency (2Hz) current (1.2mA→2.0mA→3.0mA) was given, and the patient had no muscle contraction in the lower limb, which proved that there was no motor nerve in the area of destruction. The patient’s maximum tolerated treatment temperature was tested by gradually increasing the temperature from low to high from 65℃→70℃→80℃→85℃ in sequence. The maximum tolerated temperature was determined based on the patient’s maximum tolerance to pain, and the patient was treated with the maximum tolerated temperature for 4 consecutive cycles of 120 seconds each. When the temperature of the radiofrequency machine dropped to 41℃, the electrode needle was pulled out, and the puncture needle was rapidly withdrawn under negative pressure and covered with sterile dressing.
1.4 Criteria for determining the efficacy The visual analogue score (VAS score) of pain before, 1 week, 1 month and 3 months after the operation was recorded, and the efficacy of the two groups after treatment was judged according to the modified Macnab criteria. Poor: no difference before and after treatment, or even aggravated.
1.5 Statistical methods: SPSS 19.0 statistical software was applied to process the data, and the data were expressed as mean ± standard deviation, and paired t-test was used to compare the measurement data such as intra-group and inter-group scores, and X2 test was used to compare the count data.
The difference was considered statistically significant with P<0.05.
2. Results
2.1 Comparison of surgery-related indexes The observation group had incision (0.8 cm), longer operation time, and longer hospitalization days compared with the control group (p<0.01< span="">); the difference was not significant ( p>0.05) when comparing the postoperative return to work rate between the two groups, see Table 1. the incidence of complications in the observation group and the control group were: 18% and 6%, respectively, and the difference was not significant ( p>0.05) when comparing the two groups. 0.05), postoperative nociceptive allergy in the observation group of 9 cases compared with the control group of 3 cases, the difference was not significant ( P>0.05), the efficacy of conservative treatment given to patients were satisfactory.
2.2 Comparison of preoperative and postoperative VAS scores ODI indices Postoperative low back pain and leg pain VAS scores and ODI indices of patients in the observation group and the control group showed significant improvement compared with those before surgery (p<0.01)< span="">; the difference between groups was not significant ( p>0.05).
2.3 Follow-up results 100 patients were effectively returned, according to the modified Macnab criteria by the efficacy evaluation, of which 42 cases were excellent, 4 cases were good, 3 cases could be, and 1 case was poor, of which 2 patients did not comply with medical advice, went home to labor recurrence, and then performed the second surgery, the efficacy was satisfactory; 31 cases were excellent, 9 cases were good, 7 cases could be, and 3 cases were poor in the control group. The postoperative ODI index and VAS scores of patients in both groups were significantly lower than those before surgery, and the difference was statistically significant (P<0.05).
3, Discussion
Lumbar disc herniation is a common and frequent disease in orthopedics, and is the most common cause of low back and leg pain, which seriously affects the quality of life of patients, so it has also been a hot spot for orthopedic surgeons and researchers to study. The treatment methods include traditional interlaminar openings, hemilaminectomy, and total laminectomy, which can cause damage to the paravertebral muscles and ligaments, and remove part of the synovial joint and bone of the vertebral plate, which may lead to the risk of destabilization of the spine. With the development of spine surgery, minimally invasive treatment techniques such as radiofrequency thermal coagulation ablation myeloplasty, ozone injection, collagenase lysis, and posterior discoscopic nucleus pulposus removal are a new step forward in the treatment of disc herniation. As the most promising technology, percutaneous foraminoscopy is gradually gaining popularity among spine surgeons for its less invasive nature, faster recovery, better efficacy, and fewer complications. The greatest advantage of percutaneous foraminoscopy is that the herniated disc tissue can be removed from the outside to the inside under direct vision through the foramen with an endoscope. The two most commonly used percutaneous foraminoscopic techniques in clinical practice are the YESS technique proposed by Yeung et al. and the TESSYS technique proposed by Hoogland et al.
The TESSYS technique designed by Hoogland removes the prolapsed or free disc tissue from the outside to the inside, which is a more ideal decompression method and is mainly applicable to prolapsed, free, and giant disc herniations, etc. In this observation group, the TESSYS technique was used to remove the herniated disc and ablate it under direct vision through the enlarged intervertebral foramen with a catheter, which directly decompresses the nerve with definite effect and comparable efficacy compared with traditional surgical treatment, while the surgical incision is reduced, the bleeding is decreased, the postoperative recovery is fast, and the long-term efficacy is not significantly different from that of traditional surgical treatment.
Radiofrequency thermocoagulation is the radiofrequency current through the destruction electrode to reach the protruding nucleus pulposus tissue, causing ionic oscillation and heat generation, and the heat generated acts on the nucleus pulposus, causing the nucleus pulposus tissue to vaporize and shrink, reducing the volume, decreasing the pressure in the intervertebral disc, and reducing the compression on the peripheral nerves, and also destroying the sinus nerve endings around the electrode, directly relieving the pain of disc origin. In addition, radiofrequency electric field stimulation and thermal effect can also improve blood circulation in the spinal canal, improve nerve metabolism, regulate local immune response, reduce local inflammatory mediators, thus indirectly relieving the symptoms of disc herniation. Ozone is a strong oxidant that decomposes proteins and macromolecular polysaccharide polymers in the nucleus pulposus, destroys the structure of the nucleus pulposus, reduces the volume of the nucleus pulposus and solidifies it, and relieves the compression on the dural sac and nerve roots. At the same time, ozone also has the effect of eliminating chemical stimulation and autoimmunity to achieve the purpose of anti-inflammation and pain relief. The combined application of radiofrequency thermocoagulation and ozone injection can not only reduce the compression but also achieve the purpose of anti-inflammation and pain relief, so that the patient’s symptoms are obviously relieved, and with the extension of time, the structure of the nucleus pulposus gradually shrinks and solidifies under the action of ozone, which makes the long-term postoperative efficacy more ideal.
In conclusion, both percutaneous laminectomy and radiofrequency thermal coagulation combined with ozone ablation for the treatment of lumbar disc herniation are efficacious, safe, less invasive, minimally painful, and stable, and can be repeatedly treated in multiple steps. However, the ODI index, excellent rate and VAS score of the observation group were significantly higher than those of the control group, suggesting that the improvement effect of both low back pain and leg pain of the patients in the observation group was significantly better than that of the control group, which confirmed the superiority of percutaneous intervertebral foraminoscopy. Percutaneous foraminoscopy can promote the complete removal of the nucleus pulposus, improve the effect of decreasing the intravertebral disc pressure, improve the edema and adhesion of nerve roots, and thus significantly reduce the pain caused by lumbar disc herniation in patients, which has great application prospects and development.