Pericutanous lumber discectomy (PLD) for lumbar disc herniation has the advantages of small incision, less damage to spinal structure and stability, fewer complications, and faster recovery. In China, since the early 1990s, there has been more experience with PLD, which indirectly relieves the mechanical compression of nerve roots by lowering the intradiscal pressure through a window in the herniated disc and partial aspiration of the nucleus pulposus. In our department, PLD technique was used to treat 22 cases of lumbar disc herniation from March 1999 to October 2004. The author conducted a retrospective study of 20 cases that were followed up after surgery and discussed the efficacy of PLD and the factors affecting the efficacy. Data and methods 1. General data Among the 20 cases, 13 were male and 7 were female, aged 35-74 years, with a disease duration of 1 month to 3 years. All cases were diagnosed with lumbar disc herniation by taking lumbar frontal and lateral radiographs, pelvic radiographs, lumbar disc CT scans and some lumbar MRI examinations before surgery, and combined with medical history, clinical symptoms and signs, and the effect of conservative treatment was not good. There were two cases with two disc herniations (L4.5+L5S1) at the same time. 2. Methods Fluoroscopic positioning was performed with a Dutch PHILIPS BV-25C arm X-ray machine, the puncture and disc removal instrument was an automatic percutaneous percutaneous lumbar disc cut and suction treatment instrument produced by Shandong Jinan Longguan Company, and the suction device was a negative pressure suction device produced in Shanghai. After routine disinfection and towel laying, the patient was placed in prone position or on the affected side, and the needle was inserted on the affected side. The correct puncture point and needle angle were selected within 8-10 cm from the posterior midline, and the skin was dilated step by step after it was in place, the skin was cut 1.5 cm long, the working cannula was placed and fixed, the ring saw was placed along the working cannula to cut the fibrous ring, and then the nucleus was repeatedly clamped or crushed with straight and steering nucleus forceps, and finally the nucleus was cut and aspirated with the self-control nucleus cutter. Use 0.9% N.S 2500ml-3000ml, and add 160,000 units of gentamicin to the last 500ml of aspiration solution for aspiration. Adjust the position, depth and direction of the lateral hole at the front of the cutter frequently to cut and aspirate enough nuclei as much as possible. When no nucleus pulposus tissue is aspirated, remove the cutting and aspiration instrument and working cannula under negative pressure, inject 0.3 ml of tretinoin around the affected nerve root with a long puncture needle, withdraw the needle, close the incision with 1 stitch, cover the wound with sterile dressing, and finish the operation. The medullary nucleus tissue was removed and routinely sent for pathology. For patients with lumbar 5 sacral 1 disc herniation, preoperatively follow the vertical distance between the line connecting the highest point of the two iliac wings and the lumbar 5 sacral 1 intervertebral space, the degree of lumbar 5 transverse process hypertrophy and the size of the lumbosacral angle to determine the needle approach, if the vertical distance >4cm and the lumbosacral angle 70, the original work can be restored. Significant progress (good): symptoms mostly disappear, only mild or occasional lumbar (leg) pain, but does not affect work and recreation, straight leg elevation test > 60, can resume work. Improvement (good): symptoms partially disappeared, straight leg elevation test improved compared to before treatment, unable to perform some work due to persistent or intermittent low back and/or lower extremity symptoms, recreational activities limited, but lighter work possible. Ineffective (poor): no significant reduction in symptoms, unable to work or requiring surgical treatment because of persistent symptoms. The results were excellent in 12 cases, good in 5 cases, acceptable in 2 cases and poor in 1 case, with an excellent rate of 85%. Discussion Conventional surgical treatment of herniated discs is more traumatic, and although surgical methods have been continuously improved, surgical complications are still relatively high, taking lumbar spine surgery as an example, Spangfolt reviewed 2504 cases of lumbar disc herniation and found that only 60.2% of the total number of patients who underwent conventional surgery had relief of both sciatica and lower back pain, and 31.5% had relief of low back pain. According to the statistics, only 60% of all patients who underwent conventional lumbar discectomy were completely cured, while 40% still had problems such as radiological pain and 15% suffered from Failed Bacrk Surgery Syndrome, so many scholars have devoted themselves to exploring an effective and safe method of treating herniated discs. In 1975, Hijikata was the first to perform a successful percutaneous discectomy by improving the technique on the basis of discography. Since then, many scholars have reported the application of this technique and its efficacy. 1985 0nik reported for the first time the use of an automatic resector in percutaneous discectomy, which improved efficiency and reduced the incidence of complications. 1985 the American Academy of Orthopaedic Surgery officially listed this method as a safe and effective treatment for uncomplicated lumbar disc herniation, and some authors further attached intervertebral discoscopy for surgery. I. Mechanisms of percutaneous puncture disc myelotomy Percutaneous puncture disc myelotomy is a limited discectomy treatment, and the therapeutic value of PLD is positive, with an excellent rate of 70% to 90.6% . It is generally believed that the main purpose is to eliminate the symptoms by reducing the pressure in the disc through small openings in the disc fibrous ring and partial removal of the nucleus pulposus, which causes the herniated disc to retract, thus relieving the irritation of the nerve roots and nociceptive receptors around the disc. 1. Significantly reduce the intradiscal pressure: Because the intervertebral disc itself has obvious volume-elastic modulus characteristics, when the nucleus pulposus is removed after drilling in the annulus fibrosus, the intradiscal pressure can be significantly reduced from 24 kPa to 2.624 kPa, but the degenerative degeneration of the intervertebral disc is severely altered, resulting in significant narrowing of the intervertebral space, and the elastic modulus of the intervertebral disc is significantly reduced, in such cases, the efficacy of percutaneous perforator disc myelotomy is In such cases, the efficacy of percutaneous percutaneous disc nucleotomy is not good. 2.Reducing the herniated disc tissue: In percutaneous percutaneous disc myelotomy, not only the central nucleus pulposus can be removed, thus achieving indirect decompression, but also part of the herniated nucleus pulposus can be removed. 3, change the direction of the herniated nucleus pulposus: percutaneous puncture disc myelotomy not only removes the partial nucleus pulposus through the lateral approach, but also drills and opens a window on the posterior side of the intervertebral disc’s annulus fibrosus, so that the local inclusion of the nucleus pulposus by the annulus fibrosus disappears, and the existence of this window artificially changes the direction of the herniated nucleus pulposus, which plays an important role in the long-term sustainable decompression of the intervertebral disc. The selection of patients for percutaneous lumbar discectomy must be combined with a comprehensive analysis of clinical symptoms, clinical signs and imaging examinations. Two or more of the following should be present at the same time. 1. Sciatica, this patient does have back and leg pain, and the leg pain is more intense than the back pain. 2. Sensory and motor disorders of the lower extremities. 3. Positive signs of spinal nerve compression, such as positive straight leg raise test. 4. The imaging examination such as CT and MRI is consistent with the clinical symptoms and confirmed as simple disc herniation. 5. After 6 weeks of conservative treatment with poor results, or a short history of disease, but painful, the patient firmly requested surgery. Factors affecting the efficacy 1, the relationship between efficacy and intraoperative operation (1) PLD surgery puncture should be from the affected side into the needle, puncture point from the distance of the posterior midline as far as possible, generally 8-10cm, about 45 & deg; angle into the needle, into the needle angle rather small than large, try to keep the cuff and sagittal plane vertical. (2) Avoid dislodging the cuff head from the fibrous ring when cutting and suctioning to prevent injury to the surface of the fibrous ring and the surrounding small vessels causing intraoperative bleeding and postoperative hematoma again compressing the nearby nerve roots. (3) All surgical instruments should be disinfected by high temperature and pressure, and the operation should be strictly aseptic, and antibiotics can be added to the rinsed saline to prevent intraoperative infection. (4) When performing iliac bone drilling on one side of a patient with lumbar 5 sacral 1 disc herniation, blunt separation of muscles and soft tissues is required, and the direction of the hole should be consistent with the puncture channel when drilling. In this group, there are 5 lumbar 5 sacral 1 discs in total, among which only 1 case was performed with iliac bone drilling on one side. 2, the relationship between the efficacy and postoperative use of local seal It is believed that the main reason for clinical symptoms and signs caused by lumbar disc herniation is that the outer layer of the disc fibrous annulus produces chemical substances that stimulate the surrounding nerve roots to produce inflammatory reactions or produce allergic reactions or immune reactions, while the protruding part presses on the nerve roots causing nerve root pressure and ischemia, and the repeated recurrence of clinical symptoms can make the inflammatory reaction around the nerve roots obvious. At this time, CT and MRI show that the edges of the herniated disc are blurred. In such patients, PLD is performed only to remove the nucleus pulposus, which can immediately release the pressure of the herniated part on the nerve root and make the pain disappear, but the adhesions still exist, and numbness or pulling pain of the lower limbs can occur about one month after surgery, which affects the efficacy of PLD. The author believes that for such patients, 3 ml of a mixture of tretinoin and lidocaine hydrochloride should be injected between the fibrous ring and the peripheral nerve root after PLD to promote the reduction of inflammatory or allergic reactions, so that the adhesions between the fibrous ring and the peripheral nerve root can be loosened and the clinical symptoms can be eliminated. 3, the relationship between efficacy and postoperative treatment As the maximum outer canal diameter was 4.4mm when PLD was performed in this group of cases, the amount of pulp nuclei cut and combined with negative pressure suction was about 3-5g, which could make the pressure in the disc decrease quickly. At the same time, the cushioning capacity of the intervertebral disc is weakened, and the pressure on the intervertebral disc fibrous ring at this time may cause damage to the small blood vessels around the fibrous ring, and local irritation may increase the degree of edema and affect the clinical efficacy. Of course, PLD surgery is less invasive, less bleeding, and immediate improvement of symptoms and signs, but patients are still required to lie flat on a hard bed for 24 hours after surgery, brake for 3-5 days, walk on the ground after 1 week, and avoid weight bearing and bending labor for 1 month. At the same time, the postoperative period is supplemented with appropriate physical therapy to strengthen the functional exercise of the affected limb in bed, reduce surgical exudation, accelerate tissue repair and achieve clinical cure.