To explore the treatment of multi-segmental lumbar disc herniation and spinal canal stenosis by laminectomy, removal of nucleus pulposus, fusion of intra-transverse process and general spine system(GSS) fixation. Methods From January 2004 to January 2006, 21 patients with multi-segmental lumbar disc herniation and spinal canal stenosis were treated by laminectomy, removal of nucleus pulposus and GSS pedicle screw spinal system. There were 14 males and 7 females with an average age of 53 years ranging from 46 to 61 years, and with an average disease course of 18 months ranging from 8 months to 15 years. All of the patients were examined by X-ray with AP position, lateral position and dynamic lateral position, CT and MRI, and all of them proved to be with multi-segmental lumbar disc herniation and different degrees of spinal canal stenosis. A total of 47 nucleuses were picked out, and 47 instable segments were filled in with granule selfbone. Results There were 21 patients who were followed up for 1 to 2 years with an average of 13 months. All patients achieved successful fusion and bony union postoperative from 8 to 12 months, and no artificial joint was formed. As to the cl inical results in 21 cases, according to the Macnab outcome criteria, 14 were excellent, 6 were good and 1 was poor, the excellent and good rate was 95.2%. Conclusion The methods of laminectomy, removal of nucleus pulposus, fusion of intra-transverse process and GSS system fixation are effective in treatment of multi-segmental lumbar disc herniation and spinal canal stenosis．
ObjectiveTo identify effect of quantitative indicators of ilium height on approach of percutaneous endoscopic lumbar discectomy (PELD) treatment in patients with L5, S1 lumbar disc herniation.MethodsA retrospective study between May 2014 and March 2016 was conducted, including 100 patients with disc herniation at L5, S1, who were initially enrolled for the PELD treatment. Among them, 66 patients were successfully treated with PELD (group A), and the other 34 patients failed to perform puncture, catheterization, or microscopical operation due to the influence of iliac bone and other peripheral bone structures and treated with alternative surgical plans. By analyzing the X-ray films of lumbar vertebrae (including bilateral ilium) of the two groups before operation, the concept of ilium height rate and ilium angle rate was put forward innovatively. The ilium height rate and ilium angle rate of the two groups were measured and compared, and the diagnostic critical points of ilium height rate and ilium angle rate were determined by ROC curve analysis.ResultsThe ilium height rate was 0.61±0.09, 0.74±0.05 and the ilium angle rate was 0.66±0.08, 0.80±0.08 in groups A and B, respectively, showing significant differences between the two groups (F=69.729, P=0.000; F=65.165, P=0.000). ROC curve analysis showed that the critical point of ilium height rate was 0.71 (area under ROC curve was 0.927, P=0.000), and the critical point of ilium angle rate was 0.75 (area under ROC curve was 0.965, P=0.000).ConclusionPELD is not recommended for patients with L5, S1 intervertebral disc herniation, when the ilium height rate is greater than 0.71 and/or the ilium angle rate is greater than 0.75. Other surgical plans such as transpedicular approach, transpedicular approach, or open surgery, should be recommended to reduce the risk of surgery and the pain of patients.
Objective To investigate the feasibility, effectiveness, and security of percutaneous endoscopic spine surgery for treatment of lumbar spine disorders with intraspinal ossification. Methods Between July 2008 and June 2016, 96 patients with lumbar spine disorders (lumbar disc herniation or lumbar spinal stenosis) with intraspinal ossification were treated with percutaneous endoscopic spine surgery. There were 59 males and 37 females, aged from 13 to 57 years (mean, 29.5 years). The disease duration was 3-51 months (mean, 18.2 months). Fifty-one cases had trauma history. Ninety-two cases were single segmental unilateral symptom, 4 cases were bilateral symptom. The ossification property was posterior ring apophysis separation in 89 cases, and ossification of the fibrous ring or posterior longitudinal ligament in 7 cases. There were 32 cases of lateral type, 13 cases of central type, and 51 cases of mixed type. The pressure factors, such as nucleus pulposus, hyperplasia of the yellow ligament, joint capsule, or articular osteophyma, were removed under the microscope. Local anesthesia or continuous epidural anesthesia was performed in the transforaminal approach with 50 cases, and continuous epidural anesthesia or general anesthesia was performed in the interlaminar approach with 46 cases. The visual analogue scale (VAS) score was used to evaluate the degree of leg pain preoperatively and at last follow-up. The effectiveness was evaluated at last follow-up according to the modified Macnab criteria. Results All patients were successfully operated. Via transforaminal approach, the mean operation time was 53 minutes and the mean intraoperative fluoroscopy times was 8 times; and via interlaminar approach was 58 minutes and 3 times, respectively. The mean bed rest time after operation was 6.5 hours and the mean hospitalization time was 4.7 days. All patients were followed up 6-18 months (median, 11 months). Postoperative lumbar CT scan and three-dimensional reconstruction after 3 days of operation showed that ossification tissues of 26 cases were not resected, 12 cases were resected partly, and 49 cases were resected completely. Postoperative lumbar MRI after 3 months of operation showed that spinal cord and nerve root were not compressed. At last follow-up, VAS score of leg pain was 0.7±1.1, which was significantly lower than preoperative score (5.8±1.1) (t=1.987, P=0.025). At last follow-up, according to modified Macnab criteria, the results were excellent in 87 cases, good in 5 cases, and fair in 4 cases, and the excellent and good rate was 95.8%. Conclusion Percutaneous endoscopic spine surgery for treatment of lumbar spine disorders with intraspinal ossification is an effective, safe, and minimal invasive alternative, and the short-term effectiveness is reliable. Accounting for the treatment of intraspinal ossification, comprehensive analysis should be made by combining clinical symptoms, imaging characteristics, and risk assessment.
ObjectiveTo investigate the effect and effectiveness analysis of different approaches of transforaminal endoscope on extirpation amount of nuclues pulposus.MethodsBetween August 2011 and December 2014, a total of 165 patients with lumbar disc herniation were retrospectively enrolled and were treated with nucleus pulposus discectomy through transforaminal endoscope. The patients were randomly divided into 4 groups according to different approach of transforaminal endoscope. The posterolateral approach (Yeung’s technology) was used in group A (42 cases), transforaminal endoscopic spine system (TESSYS) technology was used in group B (40 cases), improved transforaminal endoscopic access (ITEA) technology was used in group C (43 cases), and interlaminar approach (40 cases) was used in group D (40 cases). There was no significant difference in gender, age, disease duration, symptomatic side, and segments among 4 groups (P>0.05). The extirpation amount of nuclues pulposus was calculated and compared among 4 groups; the effectiveness was evaluated by pre- and post-operative visual analogue scale (VAS) score, Oswestry disability index (ODI), lumbar curvature index (LCI), and intervertebral height.ResultsThe discectomy amount of nucleus pulposus was (3.7±0.8), (3.6±0.7), (4.5±1.1), and (3.0±0.8) cm3 in groups A, B, C, and D, respectively. The amount of group C was significantly larger than that of the other 3 groups (P<0.05), and the amount of group D was significantly smaller than that of the other 3 groups (P<0.05); no significant difference was found between groups A and B (P>0.05). Cerebrospinal fluid leakage was found in 1 case; no other postoperative complications including intervertebral space infection and epidural hematoma was found. All the incisions healed by first intension. All the patients were followed up 12-24 months (mean, 18 months), and no typical symptoms of recurrence was found during the follow-up period. There was no significant difference in preoperative lower back pain VAS score, lower extremities VAS score, and ODI scores among 4 groups (P>0.05). The above scores at last follow-up were significantly improved when compared with preoperative ones in each group (P<0.05), but no significant difference of above scores and recovery values was found among 4 groups (P>0.05). The difference in LCI and intervertebral height at preoperation and at last follow-up were not significant between 4 groups (P>0.05). The difference in LCI and intervertebral height of each group between at preoperation and last follow-up were not significant (P>0.05). And the recovery value of LCI and the lost of height at last follow-up also showed no significant differences between 4 groups (P>0.05).ConclusionThe ITEA technology can give a wider field of view than other technologies. It is more convenient to find and remove the nucleus pulposus. However, the appropriate operative approaches should be chosen according to the symptoms and characteristics of lumbar disc herniation.
Objective To compare the clinical efficacy and safety of unilateral biportal endoscopy discectomy (UBED) versus percutaneous uniportal endoscopic interlaminar discectomy (PEID) for the treatment of single lumbar disc herniation (sLDH). Methods A retrospective analysis was conducted on 52 patients with sLDH who underwent UBED or PEID at the Affiliated Hospital of Southwest Medical University between January 2022 and June 2023. Surgical parameters, clinical outcomes, and imaging indicators were compared between the two groups. For normally distributed quantitative data, mean ± standard deviation was used for representation, while for non-normally distributed data, median (lower quartile, upper quartile) was used for representation. Results No significant difference was observed between the two groups in terms of gender, age, disease duration, affected segments, preoperative Visual Analogue Scale (VAS) scores for low back and leg pain, preoperative Oswestry Disability Index (ODI) scores, preoperative disc height ratio (DHR), or preoperative sagittal rotation angle (SRA) (P>0.05). All patients successfully underwent surgery. In the UBED group, one case of cerebrospinal fluid leakage and one case of pseudomeningocele syndrome occurred postoperatively. In the PEID group, two cases of pseudomeningocele syndrome occurred postoperatively, and one case of recurrence was observed 1.5 years after surgery. Both groups showed significant improvements in VAS scores for low back and leg pain and ODI scores postoperatively and during follow-up compared to preoperative values (P<0.05). Significant differences were found between the UBED and PEID groups in terms of operation time [(138.3±28.0) vs. (113.5±34.2) min], intraoperative blood loss [(58.6±24.4) vs. (45.7±20.3) mL], postoperative drainage volume [(48.7±16.9) vs. (30.0±13.4) mL], postoperative ambulation time [3.4 (3.0, 4.0) vs. 2.3 (2.0, 3.0) d], and VAS scores for low back pain on postoperative Day 1 (2.87±0.55 vs. 2.24±0.65) (P<0.05). No significant difference was observed in intraoperative fluoroscopy frequency, VAS scores for leg pain on postoperative Day 1, VAS scores for low back and leg pain 6 months and 1 year after operation, postoperative hospital stay, postoperative complication rates, ODI scores 1 year after operation, DHR 1 year after operation, SRA 1 year after operation, or MacNab evaluation 1 year after operation (P>0.05). Conclusions Both UBED and PEID are safe and effective treatments for sLDH, with similar complication rates and clinical outcomes. However, PEID demonstrates advantages in reducing soft tissue damage and accelerating perioperative recovery.
Objective To investigate the effectiveness of unilateral biportal endoscopic discectomy (UBED), percutaneous endoscopic lumbar discectomy (PELD), and traditional fenestration discectomy (FD) in the treatment of lumbar disc herniation (LDH). Methods The clinical data of 347 LDH patients who met the selection criteria and underwent discectomy between January 2017 and December 2021 were retrospectively analyzed. They were divided into FD group (160 cases), PELD group (86 cases), and UBED group (101 cases) according to operation methods. There was no significant difference in gender, age, surgical level distribution, disease duration, and preoperative visual analogue scale (VAS) score and Oswestry disability index (ODI) between groups (P>0.05). The operation time, hospitalization stay, treatment cost, and incidence of surgery-related complications were recorded and compared between groups. The patients’ pain and functional recovery were evaluated by VAS score and ODI before and after operation. Results The operation time of FD group was significantly shorter than that of PELD group and UBED group, and the hospitalization stay was significantly longer than that of PELD group and UBED group (P<0.05); there was no significant difference between PELD group and UBED group (P>0.05). The treatment cost in UBED group was significantly higher than that in PELD group, and in PELD group than in FD group (P<0.05). All the patients were followed up 6-24 months, with an average of 14.6 months. VAS score of lower extremity and ODI in 3 groups significantly improved after operation when compared with that before operation (P<0.05). At 1 day after operation, VAS score of lower extremity of UBED group was significantly better than that in PELD group and FD group (P<0.05), but there was no significant difference between PELD group and FD group (P>0.05). There was no significant difference in VAS scores of lower extremity between the 3 groups at 1 and 3 months after operation (P>0.05). The difference of ODI before and after operation in FD group and UBED group was slightly better than that in PELD group (P<0.05), and there was no significant difference between FD group and UBED group (P>0.05). Incidence of surgery-related complications in FD group (20.0%) was significantly higher than that in PELD group (12.8%) and UBED group (6.9%), and PELD group was significantly higher than UBED group (P<0.05). All the incision infection occurred in FD group (12 cases), symptomatic disc cyst and myeloid hypertension-like occurred in 1 case each in PELD group.Conclusion UBED, PELD, and FD have similar effectiveness on lower extremity pain in early LDH. Compared with FD, UBED and PELD have the advantage of shorter hospitalization stay and fewer complications.
Objective To investigate the effectiveness of digital three-dimensional (3D) assisted unilateral biportal endoscopy (UBE) in the treatment of highly isolated lumbar disc herniation (LDH) with translaminar approach. Methods The clinical data of 59 patients who met the selection criteria and underwent UBE treatment due to highly isolated LDH between January 2022 and December 2023 were retrospectively analyzed. Among them, 25 cases were treated with digital 3D assisted translaminar approach (observation group) and 34 cases were treated with interlaminar approach (control group). There was no significant difference in gender, age, disease duration, surgical segment, and preoperative visual analogue scale (VAS) score and Oswestry disability index (ODI) between the two groups (P>0.05). The operation time, intraoperative blood loss, and lateral articular surface preservation rate were recorded and compared between the two groups. VAS score and ODI were used to evaluate the improvements of pain and function before operation and at 3 and 6 months after operation. The modified MacNab criteria was used to evaluate the effectiveness at last follow-up. Results One patient in the control group had dural tear, and the other patients had no nerve injury, infection, dural tear, or other related complications. There was no significant difference in operation time and intraoperative blood loss between the two groups (P>0.05). Patients in both groups were followed up 6-13 months, with an average of 8.3 months. The lateral articular surface preservation rate in the observation group was significantly higher than that in the control group (P<0.05). Three patients in the observation group and 2 patients in the control group had calf muscle venous thrombosis, which was cured after anticoagulant treatment with rivaroxaban and delayed exercise time. There was no recurrence or second operation during the follow-up period. The VAS score and ODI of the two groups at 3 and 6 months after operation significantly improved when compared with those before operation (P<0.05). There was no significant difference between the two groups at each time point after operation (P>0.05). At last follow-up, the effectiveness was evaluated according to the modified MacNab criteria, and there was no significant difference in the evaluation grade and excellent and good rate between the two groups (P>0.05). Conclution UBE via translaminar approach is safe and effective for the treatment of highly isolated LDH, which is beneficial to protect the facet joint, maintain spinal stability, and reduce soft tissue injury. With the assistance of digital 3D technique, preoperative planning can be performed accurately.
Objective To investigate the short-term effectiveness of uni-portal non-coaxial spinal endoscopic surgery (UNSES) via crossing midline approach (CMA) in the treatment of free lumbar disc herniation (FLDH). MethodsBetween March 2024 and June 2024, 16 patients with FLDH were admitted and treated with UNSES via CMA. There were 9 males and 7 females with an average age of 55.1 years (range, 47-62 years). The disease duration was 8-30 months (mean, 15.6 months). The pathological segments was L3, 4 in 4 cases, L4, 5 in 5 cases, and L5, S1 in 7 cases. The preoperative pain visual analogue scale (VAS) score was 6.9±0.9 and the Oswestry disability index (ODI) was 57.22%±4.16%. The operation time, intraoperative bleeding volume, postoperative hospital stay, and incidence of complications were recorded. The spinal pain and functional status were evaluated by VAS score and ODI, and effectiveness was evaluated according to the modified MacNab criteria. CT and MRI were used to evaluate the effect of nerve decompression. ResultsAll 16 patients underwent operation successfully without any complications. The operation time was 63-81 minutes (mean, 71.0 minutes). The intraoperative bleeding volume was 47.3-59.0 mL (mean, 55.0 mL). The length of hospital stay after operation was 3-4 days (mean, 3.5 days). All patients were followed up 1-3 months, with 15 cases followed up for 2 months and 14 cases for 3 months. The VAS score and ODI gradually decreased over time after operation, and there were significant differences between different time points (P<0.05). At 3 months after operation, the effectiveness was rated as excellent in 12 cases and good in 2 cases according to the modified MacNab criteria, with an excellent and good rate of 100%. CT and MRI during follow-up showed a significant increase in the diameter and cross-sectional area of the spinal canal, indicating effective decompression of the canal. ConclusionWhen using UNSES to treat FLDH, choosing CMA for nerve decompression has the advantages of wide decompression range, large operating space, and freedom of operation. It can maximize the preservation of the articular process, avoid fracture and breakage of the isthmus, clearly display the exiting and traversing nerve root, and achieve good short-term effectiveness.
Objective To investigate the relationships between the bony structures, nerve, and indentations of ligamentum flavum of the upper lumbar spine by using CT three-dimensional reconstruction technique, in order to guide the unilateral biportal endoscopy (UBE) technique via contralateral approach in the treatment of upper lumbar disc herniation (ULDH). Methods Twenty-one ULDH patients who were admitted between June 2019 and July 2021 and met the selection criteria were selected as the research subjects. There were 12 males and 9 females with an average age of 62.1 years (range, 55-72 years). The disease duration was 1-12 years (mean, 5.7 years). There was 1 case of L1, 2, 4 cases of L2, 3, and 16 cases of L3, 4. The CT myelography data of T12-S3 segment was saved in DICOM format and imported into Mimics21.0 software for three-dimensional reconstruction. The relationship between the intersection (point Q) of spinous process and the inferior margin of lamina, the indentation of superior margin of ligamentum flavum, the inferior margin of nerve root origin, intervertebral space, and foramen were observed. The Mimics21.0 software was used to create a 3-mm-diameter cylinder to simulate the UBE channel and measure its abduction angle (∠b1), as well as measure the following lumbar vertebra-related indicators: in L1,2-L3,4 segments, the vertical distance from the point Q to the inferior margin of the contralateral lumbar pedicle of the same lumbar vertebra (a1), the superior margin of the contralateral pedicle of the lower lumbar vertebra (a2), the lower endplate of the same lumbar vertebra (a3), the upper endplate of the lower lumbar vertebra (a4); the vertical distance from the lower endplate of lumbar vertebra to the inferior margin of the lumbar pedicle (c1), the vertical distance from the upper endplate of the lower lumbar vertebra to the superior margin of the lumbar pedicle (c2); the vertical distance from the inferior margin of the nerve root origin to the superior margin (d1) and the inferior margin (d2) of the lumbar pedicle, respectively; the vertical distance from the intersection (point P) of the indentation of superior margin of ligamentum flavum and the medial margin of the lumbar pedicle to the superior margin (e1) and the inferior margin (e2) of the lumbar pedicle, respectively; the horizontal distance from the lateral margin of the dural mater (f1) and the narrowest part of the lumbar isthmus (f2) to the facet joint space, respectively. Thirteen of the patients included in the study chose the UBE surgery via contralateral approach. There were 8 males and 5 females with an average age of 63.3 years (range, 55-71 years). The disease duration was 2-12 years, with an average of 6.2 years. There were 3 cases of L2, 3 and 10 cases of L3, 4. The perioperative complications and surgical decompression were recorded. And the effectiveness were evaluated by visual analogue scale (VAS) score, Oswestry disability index (ODI), and short form-36 health survey (SF-36) score. Results The imaging results showed that there was no significant difference in a1, a3, a4, e1, e2, f1, and f2 between segments (P>0.05), and there were significant differences (P<0.05) in a2 and c2 between L1, 2 and L3, 4 segments, in ∠b1 and d2 between L1, 2, L2, 3 segments and L3, 4 segments, and in c1 and d1 between L1, 2 and L2, 3, L3, 4 segments. The 87.30% (110/126) of point Q of L1, 2-L3, 4 segments corresponded to the inferior articular process, and 78.57% (99/126) of the lower endplate corresponded to the level of the isthmus. All 13 patients completed the UBE surgery via contralateral approach, and none were converted to open surgery. All patients were followed up 12-17 months (mean, 14.6) months. The VAS score of low back pain and leg pain, ODI, and SF-36 score at 6 and 12 months after operation significantly improved when compared with those before operation (P<0.05), and further improved at 12 months after operation when compared with 6 months after operation (P<0.05). The imaging review results showed that the herniated disc was removed and the dura mater was decompressed adequately. Conclusion The point Q, the superior margin of ligamentum flavum, and lumbar pedicle can be used as the markers for the treatment of ULBD with UBE surgery via contralateral approach, making the procedure safer, more precise, and more effective.
ObjectiveTo determine the feasibility and effectiveness of percutaneous endoscopic transforaminal discectomy (PETD) for recurrent lumbar disc herniation (RLDH). MethodsBetween June 2009 and December 2011, 56 patients with RLDH underwent PETD after local anesthesia, including 30 males and 26 females, with a mean age of 50 years (range, 24-70 years). The involved segments were L3, 4 in 3 cases, L4, 5 in 34 cases, and L5-S1 in 19 cases. Of 56 patients, 48 suffered from ipsilateral re-herniation, and 8 suffered from contralateral re-herniation. All the patients had a mean pain-free interval of 5.5 years (range, 6 months to 27 years). The visual analogue scale (VAS) score for back pain was 6.18±1.44 and the VAS score for leg pain was 7.66±1.03. Postoperative effectiveness was assessed based on the VAS score and modified MacNab criteria. ResultsThe mean operation time was 60.4 minutes (range, 30-100 minutes) and the mean duration of hospital stay was 5.1 days (range, 3-6 days). All patients were followed up 28.2 months on average (range, 24-56 months). Patients obtained immediate pain relief postoperatively. The postoperative VAS scores of back and leg pain at 1 month, 3 months, 12 months, and last follow-up were significantly decreased when compared with preoperative score (P<0.05). Based on the modified MacNab criteria, the results were excellent in 39 cases, good in 9 cases, fair in 5 cases, and poor in 3 cases at 12 months after operation, and the excellent and good rate was 85.7%. Surgery-related complications were found in 5 cases (8.9%); one patient (1.8%) suffered from recurrence at 18 months postoperatively, and the symptom was relieved after open lumbar discectomy and intervertebral fusion surgery. ConclusionPETD has several advantages in treating RLDH, such as avoiding from the old scar tissue, decreasing operation-related complications, shortening operation time, reducing trauma, and obtaining rapid postoperative recovery. This technique is feasible and effective for RLDH.