Lumbar process 3: Do you know what are the minimally invasive surgery for lumbar disc herniation?

in "Lumbar Process Two: Is Lumbar Disc Herniation Operated or Treated Conservatively? In the article, we explained the conservative treatment of lumbar disc herniation and the choice of surgical treatment. The general principle is to master the comprehensive treatment of indications and not one-sidedly deify a certain treatment method. Today, let's learn about the current types of minimally invasive surgery for lumbar disc herniation, so as to have a relatively comprehensive understanding of each treatment method. Only by understanding can we not be superstitious or completely negate. Compared with traditional surgery, minimally invasive surgery has the advantages of less trauma, faster recovery, and shorter course of treatment. It is highly valued by patients and doctors. At present, there are more and more minimally invasive surgical treatments for lumbar disc herniation, and the methods are getting more and more advanced. With the continuous accumulation of technical experience and the update of medical equipment, the indications for minimally invasive treatment of lumbar disc herniation will continue to expand and have a broader range The prospects for the development of traditional surgery will eventually squeeze the large space of traditional surgery. At present, there are several types of minimally invasive surgery for this disease:

chemical nucleolysis (chemonucleolysis, CN)

• . The basic principle is to use a dissolving agent to dissolve the intervertebral disc. At present, collagenase is more commonly used in China. Collagenase dissolves the nucleus pulposus and the annulus fibrosus without damaging adjacent structures, cell membranes and nerve cells, or other proteins. It can decompose collagen fibers at physiological pH and normal temperature. The main advantage of percutaneous disc nucleolysis is that it does not enter the epidural space, so it does not produce epidural scar formation caused by conventional disc surgery and the treatment cost is low. The excellent rate is 70%-80%.
• However, the same technology must strictly master the indications and strictly regulate the operation. It is generally believed that this technique is mainly used for relatively young patients with simple bulging or protrusion of the lumbar intervertebral disc but complete annulus fibrosis and consistent with clinical nerve root irritation symptoms and signs. In addition to general surgical contraindications, it is also not applicable to cases with free or obvious calcification of the nucleus pulposus, as well as cases with spinal canal stenosis and lateral recess stenosis. The main complication of nucleolysis is persistent low back pain with an incidence of 42%, followed by psoas spasm, and the most common cause is intervertebral space infection.

percutaneous lumbar discectomy (percutaneous lumbar discectomy, PLD)

• The principle of treatment is to cut and suck out part of the nucleus pulposus to reduce the pressure in the intervertebral disc, thereby reducing the stimulation of nerve roots and disc pain receptors. The effective rate of the technology reported in China is 80%-85%.
• This technique has the advantages of less trauma, fast recovery, no interference with the structure of the spinal canal, no influence on the stability of the spine, fewer complications, and simple operation.
• However, because the operation is performed under X-ray fluoroscopy and not under direct vision, the herniated disc tissue cannot be completely removed during the operation, and it is difficult to obtain complete decompression; therefore, its indications are more limited, only limited to simple and acute disc herniation. If the intervertebral disc is combined with lumbar spinal stenosis or nerve root canal stenosis, it is difficult to develop, otherwise it will affect the efficacy. Some scholars found in a randomized controlled study that the effective rate of treatment was only 37%-67%.

Arthroscopy microdiscectomy (arthroscopy microdiscectomy, AMD)

• Endoscopic discectomy and percutaneous discectomy both use percutaneous puncture approach, but the former is endoscopic observation, which can clearly show the nerve root canal The internal local anatomy structure directly removes the protruding nucleus pulposus tissue under direct vision and can observe the nerve root decompression to clear the condition, reducing the chance of nerve root injury. Domestic Tian Shijie and others reported 268 cases, 377 operations, 191 cases were followed up, average 2.5 years, and the excellent and good rate was 82.2%.
• endoscopic intervertebral disc operation has the advantages of small trauma, fast recovery, positive effect, does not affect the height of the intervertebral space, and is beneficial to maintaining the stability of the spine.
• However, this surgical equipment is expensive, and it is difficult to master endoscopic surgical techniques, requiring strict training and not easy to popularize. The main complications include nerve root injury, vascular injury, psoas muscle hematoma, intervertebral discitis and intestinal injury.

percutaneous laser disc decompression (PLDD) z6The basic principle of z

• is to use laser pulses to vaporize and cauterize the nucleus pulposus tissue until the cauterized disc tissue is no longer retracted. The diameter of the cave is preferably 0. 7-1. 0cm, so as to reduce the pressure in the disc and relieve the damage of the disc tissue. Stimulation of nerve roots and spinal cord to achieve the purpose of treatment. Cheng Jieping reported that 254 discs of 221 cases of lumbar disc herniation were treated with Nd: YAG laser. The excellent and good rate was 98.4% for the 17-40 year old group, 85.7% for the 41-60 year old group, and over 61 years old. Group is 73.7%.
• This operation has the advantages of simple operation, safe and effective, and low complication rate. Lumbar intervertebral disc bulging is not completely ruptured, which is the best indication; the posterior longitudinal ligament herniated and free lumbar disc herniation are contraindications. Since this technique is not performed under direct vision, its shortcomings are obvious, the clinical treatment effect is not significantly different from other techniques, and it requires more expensive laser equipment. There are few domestic developments before the export.

Radiofrequency ablation nucleoplasty (nucleoplasty)

• It uses cold fusion cutting low temperature (about 40 ℃) vaporization technology to remove part of the nucleus pulposus tissue to complete the remodeling of the nucleus pulposus in the intervertebral disc, and use warming (about 70 ℃) technology vaporizes, shrinks and solidifies the collagen fibers in the nucleus pulposus to reduce the total volume of the intervertebral disc, thereby reducing the pressure of the intervertebral disc to achieve the purpose of treatment. Long Hengguo et al. reported that 86 cases were treated with an excellent and good rate of 87.2 and an effective rate of 96.5.
• This operation has the advantages of simple operation, safety, and less trauma, but the disadvantage is that it requires expensive equipment investment. It is suitable for patients with mild to moderate disc herniation accompanied by low back pain or lower extremity pain and dynamic spinal canal imaging shows that the rear elastic structure is intact. The effect of decompression is best when the annulus fibrosus has not broken. If the annulus fibrosus and posterior longitudinal ligament are both broken, the operation is basically ineffective. For intervertebral disc herniation, nucleus pulposus free, lateral recess stenosis, intervertebral space stenosis, etc. are contraindications.

posterior microendoscopy discectomy (microendoscopy discectomy, MED)

• MED endoscopic surgery system consists of a display system, a surgical channel and surgical instruments. It organically combines the traditional open discectomy technique with the endoscopic technique, which is fundamentally different from the previous percutaneous discectomy. It was introduced and used in China in 1997. With the help of the clear and magnifying effect of the TV monitoring system, the surgeon can more accurately distinguish various tissues, clearly understand the relationship between the dural sac, nerve roots, and herniated intervertebral discs, and avoid damaging the nerve roots and dural sac. Zhen Wanxin et al. reported that the excellent and good rate of 65 cases was 93.8%. Zhang Chunlin and others reported that 1211 cases were followed up for 3 months to 4 years, and the excellent and good rate was 98%.
• This type of intervertebral disc mirror is relatively difficult to deal with extreme lateral or foraminal herniated disc herniation, but it is quite convenient for central disc herniation or the nucleus pulposus to free into the spinal canal, and can carry out lateral recess enlargement and vertebral Resection of osteophytes on the posterior edge of the body. However, this operation is not performed under direct vision, and the display image is a plane rather than a stereo image. It is necessary to re-establish the sense of position and stereo positioning under the mirror; therefore, the surgeon is required to have a lot of open surgery experience and master microsurgery techniques. In order to transform the traditional direct vision surgery into a "hand-eye separation" microscopic operation; and the motion range of the hand must be "shrinked" compared to the enlarged screen field of view to accurately separate and remove the diseased tissue in place. However, due to the limited operating space, positioning errors are prone to occur, the working channel is narrow, it is difficult to detect laterally, the residual nucleus pulposus outside the field of view is easily missed, the end of the channel is not adapted to the surface of the lamina and fixed, and there is no suturing of the dural equipment. It is still controversial whether to use this operation for multi-segment disc herniation.

ozone ablation of intervertebral disc

• The mechanism of action of ozone in the treatment of lumbar disc herniation is that it can inhibit spinal cord injury receptor fibers and activate the body's resistance system, stimulating inhibitory interneurons to promote the release of enkephalins and function. Through ozone, the nucleus pulposus cells are degenerated and necrotic, and the matrix is ​​fibrillated, so that the structure of the nucleus pulposus is destroyed, the volume of the nucleus pulposus is reduced, pyknosis, and the compression on the nerve root is relieved. Xing Xuehong and others used radiofrequency thermocoagulation ablation combined with ozone to treat lumbar disc herniationFollow-up for 3-6 months, the total effective rate of ozone group was 70.0%.
• Some domestic scholars believe that the indications for this operation are only limited to low back pain or lower limb radiating pain caused by a herniated intervertebral disc, except for free-type intervertebral disc herniation. The recurrence rate is higher than other operations, and it is often combined with collagenase injection.

Today I will mainly explain to you the relevant knowledge for creating treatment, I hope it will be helpful to you. (This article refers to "Overview of Minimally Invasive Surgical Treatment of Lumbar Intervertebral Disc Herniation", "Minimally Invasive Treatment of Lumbar Intervertebral Disc Herniation" and other related academic professional articles)

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