1 Clinical data.
1 This group of 26 cases with 29 gaps, 16 male cases and 10 female cases, aged 24-60 years, with an average disease duration of 10 months. Routine lumbar frontal and lateral and dynamic radiographs were taken, CT and MRI examinations were performed, 14 cases of L45 protrusion, 6 cases of L5S1 protrusion, 3 cases of L34 protrusion, 3 cases of L45 protrusion combined with L5S1 protrusion, and 3 cases of combined lumbar instability. There were 13 cases of central type protrusion and 14 cases of unilateral lateral paraspinal type protrusion. There were 16 cases of lumbar pain, 17 cases of unilateral leg pain, and 11 cases of bilateral leg pain. There were 24 cases of sensory disorders, 20 cases of muscle weakness, 13 cases of intermittent claudication, 8 cases of atypical cauda equina syndrome, manifesting as perineal swelling and discomfort, urinary effort or constipation, and 6 male patients with penile erectile dysfunction.
2. Surgical modality.
For 17 cases with huge central protrusion and bilateral leg pain, the surgery was performed by posterior total plate decompression with bilateral intervertebral nucleus pulposus removal and internal fixation with bone grafting, for 9 cases with unilateral lateral paraxial protrusion and unilateral leg pain, the surgery was performed by unilateral half plate decompression with nucleus pulposus removal and internal fixation with bone grafting, for 3 cases with L45 protrusion combined with L5S1 protrusion and 3 cases with combined lumbar instability, a total of 6 cases were fixed with 6 nails and two rods, and those with radicular symptoms The segments with radicular symptoms had intervertebral decompression nucleus extracted and interbody compression bone grafting, and the segments without radicular symptoms had posterior lateral bone grafting fusion.
3.Postoperative treatment.
Postoperative routine drainage, 24-48 hours to remove the drainage tube. After 4 weeks of bed rest, indoor activities with brace, after 8 weeks, outdoor activities, 12 weeks to resume normal work and life.
4. Treatment results.
All 26 cases were followed up for 3-24 months, with an average of 10 months. According to the surgical evaluation criteria of the Chinese Orthopedic Society Spine Group for low back pain, 25 cases were excellent and 1 case was good, with an excellent rate of 100%. In one case, a unilateral hemivertebral decompression nucleus pulposus removal intervertebral body compression implant internal fixation was used for a huge central protrusion with unilateral pain, intraoperative dural rupture cerebrospinal fluid leakage and cauda equina injury occurred, after repairing the dura, urinary effort and mild numbness in the perineum occurred, which completely recovered after 3 months. one case of deep vein thrombosis in the lower extremity occurred, which was relieved after treatment.
5. Discussion
Indications for surgery.
1, history of low back and leg pain for more than 6 months, after conservative treatment is ineffective;
2.Persons with cauda equina syndrome;
3.Persons with progressive muscle weakness and sensory numbness;
4. Recurrence after simple nucleus pulposus removal;
5 Extremely lateral type disc herniation.
The choice of decompression method: for the central type of huge herniation we advocate full plate decompression to facilitate a clear view, avoid excessive strain and direct side injury when stripping the dura and nerve roots, and perform bilateral nucleus pulposus removal intervertebral body compression implantation, which is safe and reliable. In this group, a case with unilateral pain in a central type of giant herniation was fixed with unilateral hemivertebral plate decompression, nucleus pulposus removal interbody compression bone grafting, and intraoperative dural rupture and cerebrospinal fluid leakage and cauda equina injury occurred, which is a lesson learned. Bone grafting with compression.
In 9 cases of unilateral lateral paramedian herniation and unilateral leg pain, unilateral hemi-laminar decompression with intervertebral body decompression and bone grafting was used, and in 6 cases of L45 herniation combined with L5S1 herniation and 3 cases of combined lumbar instability, 6 nails and two rods were used for fixation, and the segment with radicular symptoms was decompressed with intervertebral body decompression and bone grafting for fusion of the segment without radicular symptoms. The lumbar spine is stabilized and the trauma is relatively small, avoiding the risk of collateral damage and scar adhesions to the spinal canal and nerve roots on the healthy side.
Discussion of bone grafting: There is a contradiction between decompression and stability of the lumbar spine in laminectomy and nucleus pulposus removal surgery, and there is a risk of damage to the nerve roots if the decompression is inadequate, and there is also a risk of incomplete relief of radicular symptoms, which affects the recent outcome. After adequate and complete decompression, especially the decompression of nerve roots often has to damage the small vertebral joints and affect the stability of the lumbar spine. The use of bone graft fusion after surgery has been recognized by most authors and has been widely used in clinical practice. Intervertebral compression implant has the advantages of high fusion rate and no need to take another iliac bone, so it has been considered as the best implant method. According to Hao Dingjun et al, reliable fusion can be obtained by treating 45% of the intervertebral space, and we were able to achieve 75% by unilateral treatment of the intervertebral endplate, and reliable fusion was indeed achieved by clinical observation.
Post-operative management: Drainage tubes were routinely placed and removed at 48-72 hours. One case of deep vein thrombosis of the lower extremity occurred in this group, so we routinely applied low molecular heparin calcium at 72 hours for prophylaxis. The duration of bed rest was 4-6 weeks with external fixation brace and 8-12 weeks without external fixation brace depending on weight, age and strength of internal fixation. In our group, there was a case of wearing an external fixation support to get out of bed at 2 weeks after surgery, and a review at 12 weeks showed that the intervertebral implant block had a mild posterior displacement, although the patient had no clinical symptoms, it suggested that our internal fixation was not completely reliable, and the bed activity should be conservative.
Prognosis: The best postoperative results are obtained in those with pure radicular pain, and some patients show numbness after pain relief, which disappears in about 2-10 weeks. Recovery of skin numbness detected preoperatively is slow, complete recovery of muscle weakness is rare, and those who exhibit foot drop rarely recover and have the worst prognosis.
Although there are still problems such as accelerated degeneration of adjacent segments and decreased lumbar mobility after lumbar fusion, and non-fusion techniques are not yet widely accepted due to high costs and efficacy yet to be further observed, the fusion technique is still the most reliable technique in terms of efficacy after years of clinical application, and remains the mainstream technique for spine surgery. The fusion of intervertebral body with compression implant after full decompression nucleus pulposus removal is a safe, simple and reliable method for the treatment of giant lumbar disc herniation or lumbar spinal stenosis.