Keywords: microendoscopy, traditional open surgery, lumbar disc herniation, surgical treatment, Chen Zhiquan, Orthopedic Injury Diagnosis and Treatment Center, The First Affiliated Hospital of Henan Traditional Chinese Medicine College, China Lumbar disc herniation (LDH) is the most common cause of low back pain, and most or even the vast majority of them can be treated by non-surgical treatment [1], and only a few of them need to be treated by surgical treatment. Minimally invasive technology is one of the modern surgical trends, and endoscopic discectomy (MED) has been widely used both at home and abroad because of its low trauma and other advantages. However, MED technology also has its own shortcomings [2], the surgical operation is technically demanding and difficult, the complications are higher than those of traditional surgery [3] [4], and the indications for surgery are relatively narrow. Under the inspiration of the concept of MED technology, the authors have applied microendoscopy with traditional open surgery to treat 42 cases of lumbar disc herniation not suitable for the application of MED technology from 2000.1 to 2005.12, with excellent results, as reported below. 1 Data and Methods 1.1 Indications for Surgery In this group of cases, we chose (1) lumbar intervertebral discs with centralized and massive herniation, (2) free type, (3) multiple segments, (4) postoperative ipsilateral recurrence of the original segment, (5) calcified type, (6) calcified type or combined with stenosis or severe lateral fossa stenosis, etc., which are not suitable for MED; and those who have difficulty in MED operation and need to be transferred to traditional open surgery are also considered as indications for the surgery. Indications. 1.2 General information The 42 cases in this group: 29 males and 13 females. The average age was 36.5±3.4 years, ranging from 21 to 59 years. Duration of the disease ranged from 3 months to 4 years, with an average of 1.8±1.4 months. There were 26 cases of single segment (lumbar 3~4 4 cases; lumbar 4~5 13 cases; lumbar 5~sacral 1 9 cases), among which there were 9 cases of central type of massive herniation, 5 cases of calcified type, 6 cases of combined with spinal stenosis or lateral fossa stenosis, 3 cases of free type, 2 cases of conversion to open type in MED operation, and 1 case of ipsilateral recurrence of the original segment after operation; and there were 14 cases of two segments (lumbar 4~5 and lumbar 5~sacral 1 11 cases; lumbar 3~4 and lumbar 4~5 3 cases). 5 3 cases). Two cases in three segments (both lumbar 3~4, lumbar 4~5 and lumbar 5~sacral 1). 1.3 Surgical methods 1.3.1 Preoperative preparation: all cases were diagnosed by CT scan. Preoperative lumbar spine front and side X-rays were routinely taken to fully understand the lumbosacral spine and to determine the surgical clearance. Those who were suspected to have combined spinal stenosis were examined by MRI to confirm the diagnosis and determine the scope and method of surgical decompression. Other preoperative preparations were the same as general surgery. 1.3.2 Position, anesthesia and intraoperative positioning: continuous epidural block anesthesia was used in all cases. Those with unilateral openings were placed in the bent-knee position, while those with bilateral openings were placed prone on the spinal bridge, with the abdomen suspended and the lumbar vertebrae appropriately protruded to enlarge the intervertebral plate space, which was convenient for accessing the spinal canal during the operation. C-arm machine was applied to locate and mark the incision line before operation, and C-arm machine was applied to reconfirm the intervertebral plate gap before the intraoperative vertebral plate opening. 1.3.3 Methods of operation: According to the preoperative localization marking corresponding to the lesion segment, a longitudinal incision of about 3~4 cm was made in the middle of the posterior part of the lesion segment, and the skin, subcutaneous, and lumbar dorsal fascia were incised sequentially (adjacent to the affected side of the spinous process), and subperiosteal dissection was performed with a periosteal stripping subperiosteum along the spinous process and the pars plana muscle was retracted by applying the pars plana pulling hook to expose the corresponding intervertebral plate space and medial margin of the articular eminence. The hooks were secured to the side of the surgical bed with a sterile bandage, without the support of an assistant. For “stacked” vertebrae and those with small intervertebral spaces, the lumbar safety drill developed by Zhang Chunlin et al [5] was used to drill a round bone window in the intervertebral space, keeping the drill perpendicular to the surface of the vertebral plate when drilling. Install and adjust the focal length of the endoscope, so that the endoscopic monitor has a clear view of the incision, the operator can operate according to the endoscopic image, and if necessary, can be operated under the direct visualization of the naked eye, the assistant supports the endoscope and suction, and observes the situation of the deep part of the surgical incision through the monitor, to keep the surgical field clean and clear, and to cooperate with the operator in the operation. Enlarge the intervertebral space and remove the ligamentum flavum. For those with obvious narrowing of the spinal canal or lateral fossa, use a bone biting forceps to remove the hypertrophied ligamentum flavum and hyperplastic bony structures in the lateral fossa, expand the spinal canal, lateral fossa, and nerve root canal, and distract and protect the nerve roots, i.e., the protruding or calcified intervertebral discs can be seen. The herniated and degenerated nucleus pulposus was routinely removed, and the calcified portion of the herniated disc was chiseled with an L-shaped chisel. The operation was concluded after complete decompression of the nerve roots and spinal canal. 1.3.4 Postoperative treatment: Rubber strip drainage was routinely placed in the incision for 24~48h after the operation, lying down for 6h after the operation, applying antibiotics and hormone therapy for 3d and then switching to oral antibiotics depending on the patient’s condition. After 2~3d postoperatively, appropriate bed activities, 10~12d removal of stitches, 2~3 weeks after the gradual resumption of daily activities. 2 Results: the operation time of this group is 40~60min, average 45min. Intraoperative blood loss was 50~150ml, average 80ml. no dural or nerve root injury occurred during the operation. There was no postoperative infection of the incision and intervertebral space, and the incision was Ⅰ/A healed. Postoperative follow-up 12~34 months, average 18 months, efficacy according to NaKai standard grading [6]: 36 cases of excellent, 4 cases of good, may be 2 cases, excellent rate of 95.2% (40/42). 3. Discussion: spinal surgery micro-trauma, limited, with minimal trauma to get the best therapeutic effect, which is not only the painstaking pursuit of several generations of medical workers, but also the majority of patients’ greatest wish, is the general trend [7]. With the development of imaging, biomechanics and material science, endoscopic technology and the application of minimally invasive concepts, endoscopic discectomy (MED) has been increasingly used in clinical practice, and excellent clinical results have been achieved. However, MED technology has its own shortcomings: difficult surgical operation, long training period, and relatively narrow surgical indications. The traditional open surgery surgery incision is long, the damage is big, intraoperative bleeding is more, postoperative condition recovery time is long and other shortcomings are also more and more unacceptable to the patients. If the traditional open surgical method simply promotes small incision (less than 5cm), due to the deeper incision and insufficient light, only the operator himself can see the deep incision, and even the operator can not see the deep tissue structure, and the assistant can not see the situation in the operation, and it is difficult to cooperate with the operator during the operation, which often affects the smooth progress of the operation, increases the operation time and the amount of bleeding, and also increases the risk of dura and nerve root injury during the operation, which is even more unfavorable to the patient. It also increases the risk of dural and nerve root injury during surgery, and is not conducive to the training and improvement of young physicians. For cases in which MED technology is not suitable, how to minimize intraoperative injuries, but also more clearly reveal the surgical field and facilitate the operation is an issue worth exploring by clinicians. MED was originally designed for simple discectomy, and its best indications are single-segment disc herniation, herniated size not exceeding 50% of the spinal canal or prolapse without obvious displacement, and no previous surgical history [8]. With the wide application of this technique and the improvement of instrumentation, the scope of this technique has been expanded, but for centralized, massive herniation, free-standing, multisegmental, recurrent, and calcified or combined with However, for central type, huge herniation, free type, multisegmental type, recurrent and calcified type or combined with spinal stenosis, due to the large scope of the lesion, the process of removing bone and other tissues and other revealing processes are not much different from the open surgery, and at the same time, due to the limitation of the MED revealing, it is easy to injure other tissues, which is completely contrary to the original intention of “minimally invasive” [9]. Therefore, traditional open surgery is still appropriate. Wang Pei [10] suggested that minimally invasive lumbar disc removal of the diseased nerve root is more meaningful than minimally invasive incision. The core of minimally invasive technology is the implementation of “limited surgery under the effective premise”. Removal of herniated disc tissue and complete decompression of the spinal canal, including the nerve root canal, is the fundamental guarantee of a satisfactory outcome [11]. Therefore, the real purpose of surgery for lumbar disc herniation and lateral fossa and nerve root canal stenosis should be to ensure the best postoperative results with minimal trauma. Steady, accurate, and light operation with no side damage to the dura mater and nerve root, and complete removal of the herniated, prolapsed, or free nucleus pulposus, is the real meaning of minimally invasive. In view of the respective advantages and disadvantages of MED technology and traditional open surgery, combined with the author’s lessons learned from more than ten years of MED and traditional open surgery, the use of microendoscopy with traditional open surgery technology for the treatment of lumbar disc herniation that should not be treated with MED has fully absorbed the advantages of small incision and trauma of the MED technology, with direct and adequate illumination, clear magnification of imaging, and the ability to detect small fragments of nucleus pulposus, extradural fatty fibrosis, and spinal disc herniation without any side injury. Extracapsular fat fibrosis, dura mater and nerve root external fascia adhesion and other small lesions are better than the advantages of traditional surgery [5], but also overcome a series of technical problems brought by MED pipelining, non-direct vision operation, hand-eye separation, such as the absence of peripheral vision, narrow space, a single direction of operation, the lack of direct tactile sensation and can not be three-dimensional imaging, resulting in localization, access to the spinal canal, hemostasis and safe and effective resection of the It is difficult to locate, enter the spinal canal, stop bleeding, and safely and effectively remove all the compressive tissues of the nerve root (including the inner edge of the superior articular eminence and the anterior ligamentum flavum) [10] [12]. The establishment of a less traumatic, safe and effective surgical channel that can be operated both under direct vision and microscopic operation has fundamentally solved the biggest problem of traditional small incision surgery due to the small incision, narrow channel, and the difficulty of deep illumination, which makes it impossible to operate under direct vision. As the opening of MED cold light source catheter directly extends into the deep part of the incision and directly illuminates in the deep part of the operation field, the operator can operate under direct vision while the light obscures the hesitation, and can operate under the mirror with the assistant at the same time, which overcomes the problems of single MED surgical indications, difficulties in surgical operation, and intra-operative collateral injuries. Microscopic endoscopy with traditional surgery, the surgical incision is only 3~4cm, compared with MED, only 1~2cm long, but the surgical channel is much larger than MED, because the vertebral plate hook is not a closed pipeline, the tissue structure around the channel such as the vertebral plate, articular protrusion, intervertebral ligament, and its adjoining relationship are clearly discernible, with a clear visual field and a strong sense of three-dimensionality, which greatly improves the surgical efficiency, and reduces the possibility of dura and nerve injury during the operation. The possibility of intraoperative dural and nerve injury is reduced. This procedure is a “limited surgery” between MED and traditional open surgery, and the surgical plan meets the requirements of “minimally invasive”, and the indications for surgery are exactly the same as those of traditional open surgery. The lumbar safety drill was used to open the intervertebral plate, and the time for intervertebral opening was greatly shortened, and it only took 30s~1min to open a round bone window with a diameter of about 14mm in the intervertebral plate after skillful mastery of the drill. The safety stop on the drill can also prevent the drill bit from suddenly plunging into the spinal canal, which is most favorable for the “stacked” vertebral plate opening [5]. This procedure can be gradually trained to adapt to microscopic operation on the basis of traditional surgery, gradually achieve hand-eye separation, so that the MED operation is more skillful, but also conducive to the training and improvement of young physicians. References: [1] Zhang Guangbao. Problems in the diagnosis and treatment of intervertebral disc herniation［J］. Chinese Spinal Cord Journal, 2004,14(6):325-326. [2] Lv Hongle, Liu Quanxi, Xin Lun, et al. A review of microendoscopic surgery for lumbar disc herniation［J］. 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