Full-Endoscopic Isolation Zone Technique for the Treatment of Lumbar Disc Herniation

This protocol is standardized endoscopic decompression technique for spinal nerves, which can ensure good clinical effect. Some installations of technology can be used to compare symmetry to all the pathogenic factors of LDH with few residual symptoms after surgery, and more satisfactory treatment effects. This technique is of special significance for special types of DDD, such as, calcified disc herniation and discogenic low back pain.

These two kinds of disease are controversial in endoscopic treatment. The procedure was demonstrated by Lu Wang and Xinbiao Yan from Department of Orthopedics, Cangzhou Central Hospital. After administering local anesthesia to the patient, puncture the bottom of the articular process using an 18 gauge puncture needle.

Ensure that the tip of the puncture needle is located at the inner edge of the articular process in the antero posterior x-ray, and at the center of the intravertebral space or the upper edge of the distal vertebral body in the lateral X-ray. Place a thin guide wire through an 18 gauge puncture needle and make a seven millimeter skin incision. Place soft tissue expansion catheters with different diameters through the guide wire then place the Tom Sheety locator along the guide wire.

Now fix the tip of the Tom Sheety locator on the tip of the superior articular process pointed toward the target of the herniated disc and gently hammer it to make it pass through the articular process bone. Adjust the depth of the Tom Sheety locator entering the spinal canal according to the position of the herniated disc. Then remove the Tom Sheety locator, replace the guide wire and use bone drills with different diameters along the guide wire to grind off part of the facet joints for intervertebral aminoplasty.

Insert the guide rod along the guide wire after the intervertebral foramen is formed by a bone drill. Place the endoscope working channel along the guide rod and confirm that the working channel has reached the target point by intraoperative fluoroscopy again. Place a 7.5 millimeter diameter spinal endoscope with a 3.7 millimeter diameter working channel at the lumbar disc herniation to explore and clean the ligaments and the residual bone fragments in the intervertebral foramen area, the soft tissues in the spinal canal and the protruding lumbar intervertebral disc.

Remove the proliferated inflamed soft red tissues scattered in the vertebral canal with microscopic surgical instruments. Use nucleus pulposus forceps to explore the torn area of the annulus fibrosis and remove the severely degenerated and inelastic tissue. Then use miniature surgical forceps to remove the ruptured part of the annulus fibrosis and the protruding nucleus pulposus.

Use flexible bi-polar radio frequency to coagulate the annulus fibrosis and the nucleus pulposus to stop the bleeding, shrink, and denervate them. When there is enough space around the nerve root and the dural sac during the operation, use flexible bipolar radiofrequency to perform an annuloplasty and nucleoplasty on the residual annulus fibrosis and nucleus pulposus, respectively. Explore the nerve root with a miniature probe hook to ensure sufficient space and spontaneous pulsation.

Remove the endoscope and its working channel, and suture the skin with a 4.0 nonabsorbent surgical thread suture. During the operation, always use the endoscopic instrument under continuous irrigation with normal saline. Choose appropriate intravenous hemostatic or analgesic drugs according to the patient's condition.

After the operation, suture the skin and superficial fascia at the incision of the spinal endoscope without placing a drainage tube. Inject ropivacaine around the incision to relieve pain and discomfort around the incision. The MRI re-examination of the lumbar spine after the operation showed that the herniated intervertebral disc disappeared and the tear of the annulus fibrosis disappeared and healed well, forming an isolation zone on the ventral side of the dura mater and nerve root.

The most important step use the Tom Sheety locator and bone drill for occurring that valuable foramen formation. And to use endoscopic holes for decompression. This technique explores the direction of endoscopic treatment of DDD represent by LDH and will be used for this spinal disease in the future.