Our Orthopaedic Department applies the international advanced spinal minimally invasive technology: lateral transforaminal foraminoscopic nucleus pulposus removal technique to treat lumbar disc herniation. The Department of Orthopaedics of our hospital has successfully performed nucleus pulposus removal surgeries for many patients with lumbar disc herniation by utilizing the internationally advanced minimally invasive spine technology —-joimax percutaneous intervertebral laminoscope (non-discoscopic) combined with the Tessys technique operated independently. The patients were all suffering from lumbar pain and unilateral radiating pain in the lower limbs, which were ineffective after traction, bed rest and other treatments, seriously affecting their work and life. After adequate preparation, the patient was treated under local anesthesia through the natural lumbar intervertebral foramen route, and the protruding portion of the disc was precisely removed under endoscopic visualization to relieve the compression of the nerve root, which immediately relieved the patient’s pain and preserved the portion of the disc that had not protruded. The patient was discharged from the hospital on the same day after the surgery, with relief of symptoms. Currently, as the most advanced minimally invasive technology worldwide that overturns traditional surgery, there is no other surgery that can match the safety, simplicity, minimally invasiveness, and immediate efficiency of intervertebral foraminoscopy! Many patients have come to us for consultation, so we would like to introduce this world’s most advanced minimally invasive spinal technique: Anatomical Basis The triangular working area is the appropriate and safe area for instrumentation at the beginning of the surgery. The outlet and traveling nerve roots are the anterolateral and medial boundaries of this triangle, respectively. Although the inferior vertebral body superior endplate is considered to be the lower boundary of the triangle, the inferior vertebral body superior endplate can be resected and the superior vertebral body inferior endplate can be partially resected if anterior column stabilization is required for disc surgery via the posterior posterolateral approach. This creates a more generous access to the disc and the upper and lower vertebral endplates. Principles of Tessys’ Minimally Invasive Intervertebral Spine Technique The purpose of Tessys’ minimally invasive intervertebral spine technique is to relieve pressure on the nerve roots and eliminate pain caused by nerve compression by completely removing the herniated or prolapsed nucleus pulposus and bony growths outside of the fibrous annulus of the disc in the safe triangle of the intervertebral foramen. The procedure is performed with a specially designed intervertebral foraminoscope and corresponding minimally invasive spinal surgical instruments, imaging and image processing systems, and an ellman dual-frequency radiofrequency machine, which together form a minimally invasive spinal surgical system. The surgery is performed under local anesthesia and puncture under the patient’s awake state, and the tiny skin incision is completed without interference to the spinal canal, and the protruding degenerated nucleus pulposus is removed under the intervertebral foramenoscope, which is less traumatizing, does not destroy the paravertebral muscles, ligaments, and does not affect the stability of spinal column, and the spinal canal and the nerve roots can be observed clearly through the intervertebral foramenoscope, and the protruding degenerated nucleus pulposus is removed under the endoscopic direct vision. While completely removing the protruding or prolapsed nucleus pulposus, it removes osteophytes, treats spinal stenosis, and can use radiofrequency technology to repair the broken annulus fibrosus. Since the minimally invasive intervertebral foraminoscopic spine technique operates outside of the annulus fibrosus, it can maximize the integrity of the annulus fibrosus and maintain spinal stability, resulting in the least traumatic injury to the patient and the best results among similar surgeries. The superiority of the minimally invasive intervertebral lens spine technique THESSYS minimally invasive intervertebral lens spine technique is a set of perfect and mature technology, by the famous German spine surgeon Thomas Hoogland (Tom Hoogland) and others. It was developed by renowned German spine surgeon Thomas Hoogland and others who performed more than a thousand successful surgeries before it was introduced to the world. It has the following main advantages: the patient only needs local anesthesia, not general anesthesia. Surgery is performed while the patient is fully awake. The patient’s reaction can be detected at any time during the operation. The surgical site is reached through a very small percutaneous incision, minimizing the risk of infection during and after surgery. Unlike microsurgical techniques, the foraminal approach does not require partial resection of the intervertebral ligaments (ligamentum flavum), cones, or intervertebral joints (conotruncal laminectomy) in order to locate and remove protruding or prolapsed nucleus pulposus. It also does not require severance of the trunk muscles, increasing postoperative stability and decreasing wound healing pain. Less bone tissue is injured, reducing blood leakage and scar formation in the nerve root area. Recovery from surgery is quick, allowing patients to return to work and ensure a high quality of life as soon as possible. The unique design of the cannula and surgical instruments allows for the discovery and protection of the nerve root, protection of the epidural and perineural venous system, prevention of venous stasis and chronic neuroedema. In addition, it reduces perineural and epidural scar formation. It does not damage good dural and nerve ligament structures and reduces the occurrence of nerve root tethering. The use of working trocars reduces injury to the paravertebral muscles and loss of innervation. In contrast, the stripping and pulling of paraspinal muscles during open surgery often damages the paraspinal muscles and renders them denervated. In addition, postoperative segmental instability and slippage can be prevented. In accommodative disc herniation, intradiscal surgical decompression surgery protects the integrity of the posterior annulus fibrosus and posterior longitudinal ligament, thereby reducing the chance of postoperative disc herniation recurrence. The published international literature reports success rates of over 90% and early recurrence rates of less than 5% at 1 and 2 years postoperative follow-up with the applied approach. In patients with recurrence, the success rate was more than 84%. The minimally invasive intervertebral foraminoscopic spine technique represents a new concept in minimally invasive surgery. It can perform herniated discs, foraminal molding and fibrous ring repair in all segments from cervical to lumbar 5 sacral 1. The satisfactory efficacy of the surgery can reach 75%-90%. Due to its many advantages, it is now recognized in the international spine surgery field that intervertebral foraminotomy will become as dominant as the well-developed arthroscopy in the field in the future. Comparison of minimally invasive interlaminar spine surgery with other minimally invasive surgeries Compared with indirect decompression techniques such as nucleus pulposus mechanical excision and decompression, chemical nucleus pulposus dissolution, or laser vaporization, intervertebral foraminotomy is a direct technique for targeted excision of protruding disc fragments and decompression of nerve roots. Although the widely recognized posterior discoscopic technique (MED) can be applied to various types of lumbar disc herniation in recent years, its minimally invasiveness is limited because its surgical access and procedure are the same as that of small-incision open surgery, which requires paraspinal muscle access and implementation of vertebral plate opening and resection of the muscular ligaments and bony structures. Intervertebral foraminoscopy has the obvious advantages of less trauma, less bleeding, easier anesthesia, faster postoperative recovery and less financial burden. Indications for minimally invasive intervertebral spine surgery The selection criteria for intervertebral or endoscopic microdiscectomy are not fundamentally different from those for laminotomy and discectomy. Patients with herniated discs selected for minimally invasive surgery must exhibit signs and symptoms of nerve root compression and must meet the following criteria: 1. Persistent or recurrent radicular pain. 2. 2. Radicular pain is more severe than low back pain. If the symptoms of low back pain is greater than leg pain in patients with less than moderate bulging can first do low temperature plasma myeloplasty. 3.Ineffective after strict conservative treatment. Including the use of steroidal or non-steroidal anti-inflammatory painkillers, physical therapy, homework or conditioning training program, it is recommended that at least 4-6 weeks of conservative treatment, but if there is a progressive aggravation of neurological symptoms, then immediate surgery is required. 4, No history of substance abuse or mental illness. 5, Positive straight leg raise test and difficulty in bending. 6, In order to accurately determine the location and nature of the protruding or prolapsed nucleus pulposus, as well as the condition of the intervertebral foraminal osteophytes, a thorough imaging examination should be performed prior to the surgery, especially CT and MRI are important means to accurately determine the size, location and nature of the nucleus pulposus. (e.g., lumbar 4-5 disc herniation right-sided type). 7. Evidence of neurologic injury or positive EMG manifestations. Surgical approach to minimally invasive intervertebral foraminoscopy of the spine: Operating room arrangement and patient position The patient lies on his side on the operating bed and spinal surgical frame. Appropriate patient positioning and precise design of the approach from the skin to the herniated disc are critical to obtaining good surgical results. The lateral or prone position can be chosen depending on the location and nature of the herniated or prolapsed nucleus pulposus. Anesthesia Most endoscopic microdiscectomy procedures require conscious sedation anesthesia plus local anesthesia. Puncture Positioning As shown in the figure: puncture needle placement Discography Staining Instrumentation Placement Placement of the working trocar Instrumentation is placed into the triangular working area, adjacent to the spinal canal, between the exiting nerve root and the traveling nerve root. In order not to irritate any nerves close to the intervertebral foramen and to ensure safe access to the spinal canal, the caudal portion of the intervertebral foramen (the safety zone) is enlarged 1 mm by 1 mm with a specially designed drill. The intervertebral foramen is inserted under radiographic control using a stepped guidewire and a 3-segment puncture cannula from a manual instrumented tray containing a variety of guide rods, catheters, working lumens, and the previously mentioned coronal do-drill. The intervertebral foramen is gradually widened by drilling through the bony material. This process allows safe access to the spinal canal cavity. As shown in the picture: placing the working trocar instrumentation to reach the intervertebral canal cavity disc herniation site As shown in the picture: inserting the laminoscope to explore the structure around the intervertebral foramen and the blue-stained herniated disc site Specific Treatment Example A case: lumbar 5-sacral 1 disc herniation (left-of-center type), with severe leg pain on the left side that prevented the patient from walking on the ground, was lifted by 120 ambulance and transported to our hospital. Video of the patient’s Nucleus pulposus removal under intervertebral foramenoscopy: http://v.youku.com/v_show/id_XMjgyNDQ3MTA4.html and video of discharge on the third day after the operation: http://v.youku.com/v_show/id_XMjgxODQyMjcy.html Patient information Intervertebral Intervertebral surgery is also an open procedure and is performed in a sterile operating room. Although the incidence of surgical complications is much lower than in conventional open surgery, theoretically all possible complications of open surgery can be encountered in minimally invasive surgery. There is certainly the possibility of recurrence of the herniated disc and reappearance of symptoms in about 5% of cases, which may require re-doing or switching to a second stage of open surgery in the future. Since the surgery is performed near the ganglion, cutaneous nociceptive hypersensitivity of the corresponding limb (sunburn syndrome) may occur within 4-5 days after surgery. Postoperative functional exercises and rehabilitation of the abdominal wall and paravertebral muscles play an important role in preventing recurrence of discogenic low back pain seen after surgery. Patients must understand that herniated discs are also dehydrated and degenerated disc tissue and that the degenerative process does not end with surgery. Sometimes disc degeneration can lead to new symptoms, sometimes requiring further medication or surgery. Patients with multisegmental degenerative disc disease and patients who have had sciatica for a longer period of time may have compromised results for microscopic or open surgery. The main cause may be chronic edema of the nerve root or perineural fibrosis.