Abstract OBJECTIVE: To investigate the indications, contraindications, treatment methods and efficacy of percutaneous puncture lumbar disc laser removal. METHODS: Percutaneous puncture laser removal of the disc was used to treat 66 patients by puncturing into the diseased disc under the bi-directional guidance of the C-arm and vaporizing the nucleus pulposus tissue with the laser, thus reducing the disc pressure. This was accompanied by anti-inflammatory, dehydration, nerve nutrition and absolute bed rest. RESULTS: In 66 patients, 31 of them were excellent, 17 were good, 14 were acceptable, and 4 were poor. The efficiency was 93%. None of the cases had complications. CONCLUSION: Percutaneous puncture lumbar disc laser removal is a safe and effective method with less trauma, less pain and faster prognosis.
Lumbar disc herniation is a common disease in clinical practice. Percutaneous puncture lumbar disc minimally invasive intervention for lumbar intervertebral disc herniation is a new interventional treatment technique widely used at home and abroad in recent years, and has achieved satisfactory efficacy. However, there are many kinds of them, and laser removal of percutaneous puncture lumbar disc has been applied in our hospital for one year, and the efficacy has been confirmed. Its high safety, low trauma and few complications are increasingly accepted by doctors and patients. However, the selection of its indications, intraoperative disc puncture technique and operation of laser fiber, postoperative treatment and other issues. It has been a matter of concern and discussion. The experience and efficacy in treatment are reported as follows.
Keywords: laser; disc herniation;
1.Data and methods
1.1 General information
There were 66 patients with L3-L4 disc, L4-L5 disc or L5-S1 disc herniation, including 10 cases of L3-L4 disc, 39 cases of L4-L5 disc and 17 cases of L5-S1 disc; 36 cases were male and 30 cases were female, aged from 21 to 60 years old, with an average of 42 years old.
1.2 Clinical characteristics
All patients in this group had preoperative symptoms of lumbar distension, or (and) radiating pain and numbness in the lower limbs; lumbar pressure pain, or (and) straight leg raising test (+). Some patients have [signs such as reduced dorsiflexion or plantar flexion of the toes and decreased skin tenderness.
1.3 Imaging manifestations
CT or MRI scans of the lumbar spine were suggestive of disc bulge or herniation.
1.4 Treatment method
The patient was placed prone on the fluoroscopy bed with a soft pillow on the abdomen. L4-L5 was used as an example. A marker was made at 8-10 cm of the interspinous level of L4-L5, routinely disinfected, and a towel was laid. Local infiltration anesthesia with 2% lidocaine was applied here, and the needle was inserted at 45° with an 18G puncture needle, and the tip of the puncture needle was seen to reach the middle and posterior 1/3 of the L4 to L5 interspinous space under X-ray fluoroscopy. The needle core was withdrawn, a tee tube was attached, and the laser fiber was inserted with the end of the fiber exposed to the needle tip for approximately 5 mm, and saline was injected into the tee tube. The laser was turned on and the parameters were adjusted to continuous pulse mode, power of 8W, pulse interval of 1.0S, pulse width of 1.0S, and then the treatment was started. During the treatment process, the patient develops obvious lumbar distension, lumbar pain and lower limb radiating pain. The laser output can be suspended and the treatment can be started after 5S-10S. When the total energy, up to 600J-800J, exit the fiber and use a syringe to aspirate the gas after vaporization of the nucleus pulposus, which helps to reduce the response of lumbar distension and pain. Sometimes the gas is seen to spill directly during the treatment and the smell of burning can be detected. At the end of the treatment, the puncture needle was removed, the puncture wound was disinfected, and the puncture wound was covered with a band-aid. After being pushed back to the ward with a flat cart, he was instructed to lie in a supine position with his knees bent and given anti-inflammatory, dehydration and nerve nutrition treatments.
2. Results
All patients in this group were followed up for 1-3 months. According to the modified Macnab evaluation criteria: excellent: pain disappeared, no motor dysfunction, resumed normal work and activities. Good: occasional pain, not affecting normal work and life. Possible: some improvement, still painful, mildly affecting normal work and life. Poor: no symptom reduction, no improvement in function, need to operate again. 66 patients, of which 31 cases were excellent, 17 cases were good, 14 cases were OK, 4 cases were poor; 4 cases were changed to other minimally invasive interventions. The total effective rate was 93%. None of the cases had complications.
3. Discussion
3.1 Therapeutic principle of laser lumbar disc extraction by percutaneous puncture
The principle of laser disc removal is to place a laser fiber through a puncture needle in the intervertebral disc and use high power laser output or prolonged laser stay in the tomb to dehydrate and vaporize the nucleus pulposus tissue, resulting in carbonization of the nucleus pulposus tissue. This reduces the volume of the diseased disc, decreases the pressure within the disc, decreases the tension of the herniated disc, causes the herniated material to retract, reduces or relieves the compression of the herniated material on the dural sac and nerve roots, and thus achieves the purpose of treatment. Qi Qiang et al. demonstrated through animal experiments that the pressure in the disc began to decrease after laser vaporization, and the decrease increased with the increase of radiation energy. At the same time, the nucleus pulposus tissue carbonized, which also reduced the chance of recurrence. Since this technology was first used clinically and successfully in 1986 by Choy in the United States, there has been continuous development and improvement regarding laser and fiber optic technology, and the HT-M15 semiconductor laser therapy instrument used in this group of cases.
3.2 Selection of indications and contraindications for percutaneous perforator laser disc removal
Because the principle of percutaneous puncture laser disc removal is mainly to reduce disc tension, the selection of cases is crucial. Young patients with intact annulus fibrosus and nucleus pulposus tissue still surrounded by the annulus fibrosus should be the main target of treatment; firstly, the nucleus pulposus tissue of young patients has not yet dehydrated and degenerated. The nucleus pulposus tissue is easily vaporized and carbonized during laser output. Secondly, imaging suggests disc bulging or herniation, which is not difficult to identify from the gap of the corresponding disc, the site of protrusion, morphology, size, etc.; finally, through the clinical symptoms and signs of the patient. Contraindications include: vertebral instability; degenerative disc changes with a gap <3 mm; calcification of the herniated material; bony spinal stenosis; prolapse accompanied by cauda equina syndrome; and vertebral endplate inflammation. In short, the selection of indications is a prerequisite for the effectiveness of the entire treatment.
3.3 Intervertebral disc puncture technique and laser fiber operation in percutaneous percutaneous laser disc removal
The choice of the puncture point is very critical in the whole treatment. The puncture point is often chosen to be 8-10 cm from the affected side of the diseased disc level, and for the central type, both sides can be chosen. Secondly, the puncture angle and depth are also crucial. A good puncture reduces the occurrence of complications such as infection and bleeding, and at the same time can achieve good therapeutic results. The puncture angle is too large to cause paravertebral tissue damage, and too small to damage the contents of the spinal canal and nerve roots. The puncture depth should not be too deep, as close as possible to the nucleus pulposus tissue, and avoid being too close to the upper and lower vertebral plates to avoid thermal damage to the plates. Finally, the treatment of laser fiber is also a link that should not be ignored. After the fiber enters the puncture needle, the tip of the needle should be exposed so that it is in full contact with the nucleus pulposus tissue to facilitate good vaporization. At the same time, the fiber should be constantly moved during the treatment to avoid excessive damage caused by irradiating the same tissue for a long time. After the treatment, the fiber should be slowly pulled out and the front end should be checked for integrity, because the fiber is more brittle and easily broken after use, to avoid the stump from breaking in the intervertebral disc. In this group, only a single disc was involved in the treatment. If other discs need to be treated at the same time, it is necessary to change the surgical bag and fiber to avoid cross infection. In conclusion, the operation of intraoperative standardized puncture and fiber optics is the guarantee of the effectiveness of the whole treatment.
3.4 Postoperative treatment of percutaneous puncture laser disc removal
Postoperatively, patients were required to lie in supine position with knees flexed for 6 hours to relax the muscles of the low back and reduce the pain in the low back. Absolute bed rest was given for 3 days after surgery. Small doses of hormonal anti-inflammatory, dehydrating and nerve-nourishing treatment were also given for 3-4 days. Prevention of disc infection and reduction of irritation of carbonized nucleus pulposus tissue and edema of the vertebral plate. The symptoms of lumbar and leg pain were reduced in some patients 3 days after surgery, while some patients showed distension and distress of the lumbar region, or even increased. This is mainly due to the better vaporization of the nucleus pulposus during the treatment, and some of the gas was not discharged in time during the operation, resulting in the accumulation of gas in the disc resulting in a temporary increase of pressure in the disc. After the above treatment, all of them were reduced. In two of the male patients, the back pain was aggravated and it was difficult to turn over in bed due to premature movement to the ground. After prolonged time out of bed and timely anti-inflammatory and dehydration treatment, they both resolved on their own. The importance of bed rest can be seen. 3-4 days later, the patients were allowed to move to the ground, but they were asked to do so in “small amounts and many times”. After discharge from the hospital, rest is still required for 2 months. In conclusion, the corresponding postoperative treatment should not be neglected, and a strict treatment plan will facilitate the patient’s early recovery.