What is a herniated disc?
The spine consists of the cervical, thoracic, lumbar, sacral and coccygeal vertebrae. The disc-shaped structure between the vertebrae, called the intervertebral disc, acts as a cushion against gravity and external forces. It is surrounded by a dense fibrous ring. After degenerative changes of various parts of the lumbar intervertebral disc (including the nucleus pulposus, fibrous ring and cartilage plate), especially the nucleus pulposus, under the action of various factors, the fibrous ring of the disc ruptures and the nucleus pulposus protrudes (or prolapses) from the rupture site in the posterior or vertebral canal, resulting in stimulation or compression of the adjacent spinal nerve roots, resulting in a series of back pain, numbness and pain in one or both lower extremities, etc. This results in a series of clinical symptoms such as back pain, numbness and pain in one or both lower limbs. Herniated discs often involve the cervical and lumbar spine, causing cervical disc herniation and lumbar disc herniation.
The incidence of cervical and lumbar disc herniation has continued to rise in the population in recent years, reaching 15.2% at present, with a trend towards lower age.
How to classify herniated discs
1, according to the number of protruding discs, there can be a protrusion and double (multiple) protrusion;
2, according to the degree of protrusion, there are four kinds of bulging, protrusion, prolapse and free type.
3. According to the protrusion site, there are central type, lateral type and far lateral type, etc.
What is cervical spondylosis?
Cervical spondylosis is a disease in which the cervical spinal canal or intervertebral foramen is deformed and narrowed due to degenerative changes of the cervical spine, stimulating and compressing the cervical spinal cord and nerve roots, and causing corresponding clinical symptoms.
What are the causes?
1, mostly caused by cervical disc degeneration, cervical spine osteophytes, long-term local muscle, ligament, joint capsule injury, can cause local hemorrhagic edema, inflammatory changes, in the lesion area gradually appear inflammatory mechanization, and the formation of osteophytes. In the past, it was mostly seen in middle-aged and elderly people, but in recent years there is a tendency of youthfulness;
2, bad posture is another major cause of cervical spine injury. Long hours of low work, lying in bed watching TV, reading, like high pillows, long hours of computer operation, violent rotation of the neck or head, sleeping in a moving car, these poor posture will make the neck muscles in a long-term fatigue state, prone to injury. In the past, it was an occupational disease for accountants and teachers, but now it is a common disease in offices.
Pathogenesis?
Degeneration of the intervertebral disc is the basic pathological change, which leads to a series of pathological changes: 1.
1, early dehydration of the cervical intervertebral disc, reduction of the water content of the nucleus pulposus and swelling of the fibers of the annulus fibrosus, followed by degeneration and even rupture. After the degeneration of the cervical disc, the resistance to compression and the resistance to pulling are reduced. Restricted or widespread bulging around can occur, narrowing the intervertebral disc space, overlapping and misalignment of the articular processes, and reducing the longitudinal diameter of the intervertebral foramen.
2, causing secondary intervertebral instability, increased intervertebral mobility and mild slippage of the vertebral body, followed by osteophytes of the posterior tuberosity, hook vertebral joint and vertebral plate, degeneration of the ligamentum flavum and collateral ligament, chondrogenesis and ossification, and other changes. And the gap formed between the vertebral body and the protruding disc and ligament tissue, due to the accumulation of tissue fluid, coupled with the bleeding shaped by microscopic injury, so that this bloody fluid undergoes mechanization and then calcification and ossification, so that a bone superfluous is formed.
3, the laxity of the front and rear ligaments of the vertebral body, and make the cervical spine unstable, and increase the chance of trauma, so that the bone superfluous gradually increase. The bone superfluous together with the bulging fibrous ring, posterior longitudinal ligament and edema or fibrous scar tissue caused by the reaction to trauma, forms a mixture of protrusion into the spinal canal at the equivalent of the intervertebral disc, which has a compressive effect on the cervical nerve or spinal cord. The bony flab of the hook vertebral joint may protrude anteriorly to posteriorly into the intervertebral foramen to compress the nerve roots and vertebral artery.
What are the subtypes of cervical spondylosis?
(1) Nerve root type: The stimulation of cervical disc degeneration or osteophytes compresses the spinal nerve roots and causes sensory and motor dysfunction of the upper limbs, often manifesting as motor impairment or sensory numbness of one upper limb segment.
(2) Spinal cord type: cervical disc herniation, ligamentous hypertrophy and ossification or other causes of cervical spinal stenosis, spinal cord compression and ischemia, resulting in spinal cord conduction dysfunction. In some cases, the disease starts in the upper limbs and progresses to the lower limbs; in others, the disease starts in the lower limbs and progresses to the upper limbs. The main manifestations are unstable walking, numbness of the limbs, and difficulty in urination and defecation.
(3) Vertebral artery type: Due to the stimulation of degenerative changes of the hook vertebral joint, compression of the vertebral artery, resulting in inadequate blood supply to the basilar artery, often accompanied by dizziness, dark haze and other symptoms, related to the rotation of the neck.
(4) Sympathetic nerve type: The stimulation of degenerative changes of cervical discs, which compresses sympathetic nerve fibers in the neck and causes a series of reflex symptoms, is relatively rare clinically, and is often mixed with cardiovascular diseases and endocrine diseases, making it difficult to distinguish.
What are the symptoms of cervical spondylosis?
When the protruding nucleus pulposus and proliferating bone compress the adjacent nerve roots or soft tissues and blood vessels, symptoms such as dizziness, pain and numbness will occur, and even worse, the spinal cord will be compressed, eventually causing lower limb paralysis!
How to treat cervical spondylosis?
The treatment of lumbar disc herniation in many domestic hospitals is still very single, commonly known as “one trick”, such as masseurs only massage, surgeons only open surgery, pain physicians only analgesia, etc., while the pathogenesis of cervical spondylosis is very complex, you can imagine what the result of using a method of treatment for all patients with cervical spondylosis will be. In other words, cervical spondylosis requires systematic treatment, including conservative treatment (drugs, physical therapy, traction, etc.), minimally invasive treatment, surgery, and rehabilitation. The Spinal Cord Neurosurgery Center at Tsinghua University Yuquan Hospital integrates neurosurgery, spine surgery, pain medicine and rehabilitation to establish a systematic and minimally invasive treatment center for cervical spondylosis. This article introduces the minimally invasive treatment options of the Spinal Cord Neurosurgery Center of Tsinghua University Yuquan Hospital as follows.
Ozone technology
Ozone (O3) is a strong oxidizer, easily decomposed and soluble in water. It has the characteristics of high specific gravity, colorless, tasteless, easily soluble in water, easily decomposed, and has strong oxidizing power. Ozone has been widely used in clinical medicine since its appearance: In 1988, Verga injected ozone into the lumbaris major muscle and paravertebral space for the treatment of lumbar and leg pain, and ozone began to be used in the treatment of orthopedic diseases;
In 1998, Muto et al. reported that ozone was injected into the intervertebral disc and the paravertebral space for the treatment of lumbar disc herniation with an efficiency of 78%. 2002, Leonardi reported the results of a multi-institutional study of 6665 cases of lumbar disc herniation with an excellent rate of 80.9%. 2002, Gjonovich et al. used local ozone injection in patients with intractable pain due to shoulder capsule injury. As a result, 67% of the patients achieved efficacy. With the continuous development and innovation of medical treatment, the clinical application of ozone has changed qualitatively, and ozone nucleus pulposus ablation was born. By injecting ozone into the diseased disc, it destroys and dissolves the proteoglycan molecules in the nucleus pulposus matrix, causing the nucleus pulposus to atrophy, degenerate, and reduce in size, thereby allowing the annulus fibrosus to retract and relieving nerve root compression. Ozone also inhibits local immune response, reduces sterile inflammation of nerve roots, and eliminates nerve root edema, thus achieving anti-inflammatory and analgesic effects on diseased tissues.
Radiofrequency thermal coagulation targeting technology
Radiofrequency thermal coagulation target treatment is to denature and coagulate the nucleus pulposus at the protruding part directly under the precise guidance of the navigation system with accurate positioning under the C-x-ray machine, monitoring under digital subtraction, contraction and volume reduction, and release of compression. It does not hurt the normal nucleus pulposus tissue, while repairing the rupture of the fibrous ring, inactivating the nerve endings of the nascent lesions in the disc, directly blocking the release of glycoproteins and beta proteins in the nucleus pulposus fluid, and the warming effect plays a good therapeutic role on the injured fibrous ring, edematous nerve roots and inflammatory reactions in the spinal canal, and the symptoms disappear or are reduced immediately after treatment. This method removes the disease in whichever area is diseased, and does not hurt in the slightest where there is no disease. These safety measures are not available in any minimally invasive devices and methods. The safety and treatment issues that doctors and patients are most concerned about are brought to the extreme.
Radiofrequency mechanism of action
1.Improve local circulation and relieve pain
Radiofrequency current is a kind of high frequency alternating current with a frequency of 100kHz-3MHz, which is used to treat herniated discs by ablating the electrodes in the intervertebral discs and emitting radiofrequency energy through the exposed part of the rod tip, thus vaporizing part of the disc nucleus pulposus tissue. This technology not only ensures the contraction of the collagen molecular spiral structure, but also maintains the vitality of the nucleus pulposus cells, so that the volume of the nucleus pulposus of the intervertebral disc shrinks and achieves the decompression of the nerve roots, arteries, spinal cord and other tissues around the disc to eliminate and relieve clinical symptoms; at the same time, it can make the local temperature increase in a short period of time, so as to improve local circulation and relieve and improve the muscle spasm caused by pain.
2.Ease the pressure on nerve root and eliminate edema
The high thermal temperature of 60-94℃ generated by radiofrequency can produce obvious physical volume contraction of the nucleus pulposus at the protruding part, and the relative position of the nucleus pulposus and the nerve root under pressure will be changed immediately after the nucleus pulposus at the lesion is retracted and displaced. The thermal coagulation effect also facilitates the inactivation of inflammatory factors, pain-causing factors, sinus cone nociceptors and edema elimination.
Radiofrequency thermal coagulation target – six safety guarantees I. High efficiency and safety
The treatment electrode of RF instrument for nervous system is only 0.7mm, which is only a physical change process and has no side effects on human body.
Second, precise positioning
Radiofrequency thermal coagulation target treatment is accurately positioned in the C-arm X-ray machine, detected under digital subtraction, and directly acting on the nucleus pulposus of the lesion under the precise guidance of the navigation system, with data accurate to less than 1mm and angular error less than 1 degree, making the treatment more accurate and effective.
Third, identify the nerve
The nerve system is identified and stimulated precisely by the unique RF instrument, which can measure the nerve within 1cm of the treatment area.
Four, precise identification of tissue
The unique impedance display function of this device can accurately distinguish the nucleus pulposus fiber ring, calcification point, bone and blood vessel, and accurately display with tone and digital, making the treatment more accurate and safe.
V. Controllable temperature
RF instrument can adjust the temperature arbitrarily, the error is below 2℃, to ensure the safety of treatment, no infection and no thermal damage after treatment.
At present, the radiofrequency thermal coagulation target technology is a treatment method with the main purpose of repair, gradually replacing the previous treatment method with the main purpose of speeding up the degeneration of the intervertebral disc, which has epoch-making significance in the history of minimally invasive spinal treatment. At the same time, it has changed the history of treating intervertebral discs from a treatment method whose main purpose is to accelerate degeneration to a treatment method whose main purpose is to repair. It pushed the treatment of herniated disc, cervical spondylosis and spinal cord cervical spondylosis to the pinnacle of the medical world. Many spinal cord cervical spine patients who were paraplegic for more than half a year and could not be cured by open surgery have returned to work after using radiofrequency thermal coagulation target therapy, which has become the greatest miracle and highlight of spinal surgery in the 21st century and is currently the most minimally invasive, safest, least painful, fastest and least risky treatment method internationally.
The most advanced treatment for disc herniation: low-temperature plasma ablation
“Low-temperature plasma ablation is a medical instrument developed by the U.S. military technology and belongs to the fourth generation of physical therapy technology, which began to develop rapidly in clinical treatment after the FDA approved it in 1999. By the end of 2000, orthopedic and spine surgery had treated 1,500,000 people with excellent results. Subsequently, the technology was introduced to China and carried out successively. Due to its outstanding clinical performance, it has fully replaced traditional treatments such as open surgery, laser and microwave in the United States, Britain, France and Germany, and medical experts unanimously agreed that digital DNR plasma nucleus pulposus ablation represents the highest international level.
Professor of the British Institute of Minimally Invasive Orthopedics praised: “This treatment technology is a precise and controlled decompression and shaping of the intervertebral disc through plasma cryoablation and precise thermal wrinkling technology, which is the most advanced minimally invasive spinal surgery, with minimal damage to the tissue, just equivalent to a “needle” at the patient “With a diameter of only 1 mm, it is truly minimally invasive, safe and green.”
Jan, a member of the American Orthopaedic Association: “Treatment with minimally invasive interventional techniques makes surgery for patients with cervical and lumbar spondylosis as easy and natural as a walk or a natter, safe and painless. It also changes the history of treating intervertebral discs, changing the treatment method with the main purpose of accelerating degeneration to one with the main purpose of repair.
Treatment principle: Through the plasma knife, radiofrequency energy is applied to the interior of the intervertebral disc, vaporizing and ablating part of the nucleus pulposus, and using the thermal coagulation function to reduce the volume of the nucleus pulposus and decrease the pressure within the disc, thus relieving the pressure on the nerve root when the disc herniates and achieving the purpose of treatment.
Advantages:
1, plasma working temperature at 40-70 degrees, low temperature safety, no incision, small trauma, maximum protection of the wall of the annulus fibrosus; can effectively remove tissue; small postoperative degeneration of the disc; small impact on the stability of the spine, low rate of re-protrusion of the disc; small interference with the nerve root; short surgery time without hospitalization, 3-5 days after surgery can resume daily work.
2.Some patients may have slight neck discomfort on the day after surgery and should avoid activities.
3.A few patients may experience neck pain after waking up from sleep when the cervical brace is removed one week after surgery, bed rest and oral painkillers can be given to relieve the symptoms.
4.A few days after surgery, attention should be paid to the clean care of the neck wound.
5. 3 days after surgery, perform functional exercises of cervical health exercises
Cervical discoscopy technology
In 1998, Dr. Anthony Yeung (Chairman of American Minimally Invasive Science) pioneered the YESS technology; in 2002, Professor Hoogland (former Chairman of European Minimally Invasive Science) proposed the THESSYS technology based on the YESS technology, which made the intervertebral foraminoscopy technology mature.
Indications
1, spinal nerve root pain caused by disc herniation and intervertebral foraminal osteophytes, which is not effective by conservative treatment;
2, central, paracentral, lateral and extreme lateral cervical disc herniation;
3. Patients with cervical foraminal stenosis;
Contraindications
1.Patients with disc herniation with severe cardiac and renal insufficiency;
2, posterior longitudinal ligament, lateral ligament laxity, lumbar instability;
3.Patients with excessive osteophytes or severe calcification of the annulus fibrosus ligament;
4.Patients with bleeding disorders;
5.Those who are highly suspicious of this technology and unwilling to accept this surgery.
The advantages of intervertebral foraminoscopic disc removal are: the entire procedure is done under local anesthesia, and the patient is awake throughout, avoiding the risk of anesthesia and reducing the chance of nerve root injury. The patient’s skin incision is less than 1 cm, which is minimally invasive. No removal of the vertebral plate, no destruction of the paravertebral muscles and ligaments, little interference with nerves and structures in the spinal canal, and preservation of epidural fat reduce intraoperative bleeding and the formation of scar tissue in the spinal canal after surgery, and reduce the possibility of postoperative vertebral instability. The operation time is short, the postoperative recovery is fast, the hospitalization time is shortened, and the economic burden of the patient is reduced.
PLDD technique
In the late 1980s, PLDD was rapidly introduced to the clinic, centering on Europe and the United States; in the early 1990s, PLDD was applied to the treatment of herniated discs, and in 1997, experts did corresponding basic research on the safety and effectiveness of laser application in cervical spondylosis, and succeeded. China began to introduce this technology for clinical treatment at the end of the 20th century. Nowadays, PLDD (percutaneous laser disc decompression) is aimed at the pathology of intervertebral disc lesions, and can effectively relieve the disease in a comprehensive manner. The laser will vaporize part of the nucleus pulposus through the heat radiated by the laser, and achieve the purpose of treatment by reducing the internal pressure of the disc, eliminating inflammatory factors, and improving the blood circulation of the compressed nerve.