The influence of automated percutaneous lumbar discectomy (APLD) on the biomechanics of the lumbar intervertebral disc. An experimental study.

Twenty human lumbar motion segments were prepared and tested in an electromechanical materials testing machine in order to investigate the biomechanical changes, i.e. intradiscal pressure, radial extension and height of the intervertebral disc, after automated percutaneous lumbar discectomy (APLD) developed by Onik. The biomechanical data were statistically analyzed with the Friedman test (significance level p < 0.05). The APLD lasted 45 minutes in every segment. The mean weight of material removed was 4.6 g. The removal of 4.6 gram of nucleus pulposus material reduced the height of the disc by an average of 1.42 mm. The intradiscal pressure also decreased by an average of 5.7 bar. The radial bulge increased by an average of 0.45 mm. Our results show that the mechanism improving radicular pain in patients with herniated disc after treatment with percutaneous nucleotomy is still in question. While clinical studies show an improvement of 70% to 85% of patients treated with APLD for herniated disc, this in vitro study showed clearly that radial bulge increases after removal of nuclear material. We postulate that loss of height of the disc and, as a consequence, reduction of tension in the affected nerve root, plays a major role with regard to this improvement.     

Biomechanical changes of the lumbar intervertebral disc after automated and nonautomated percutaneous discectomy: an in vitro investigation

Summary A total of 40 human lumbar motion segments were prepared and tested in an electromechanical materials testing machine to investigate the biomechanical changes, i.e., intradiscal pressure, radial extension, and height of the intervertebral disc, after percutaneous discectomy. In 20 discs (group A) the nuclear material was excised using the nonautomated percutaneous lumbar discectomy technique (NAPLD). In the other 20 (group B) the material was removed with the automated percutaneous lumbar discectomy method (APLD). The results of the two groups were analyzed statistically and compared to each other. In the NAPLD group the removal of 0.1 g freeze-dried nucleus pulposus material reduced the height of the disc an average of 0.32 mm, versus 0.47 mm in the APLD group. The radial bulge increased in both groups after the removal of 0.1 g freeze-dried nucleus pulposus material, on average 0.10 mm versus 0.15 mm. The intradiscal pressure also decreased in both groups after the removal of 0.1 g freeze-dried nucleus pulposus material, on average 0.94 bar versus 1.88 bar. The differences between the biomechanical data of the two groups were statistically significant for all three parameters (P<0.05). Our results show that the mechanism for improving radicular pain in patients with herniated disc after treatment with percutaneous discectomy is still in question. We postulate that loss of height of the disc and, as a consequence, reduction of tension in the affected nerve root, plays a major role with regard to this improvement.     

经皮穿刺双间隙髓核摘除术治疗复合型腰椎间盘突出症

目的 以一个经皮穿刺点行双间隙髓核摘除,治疗复合型腰椎间盘突出症。方法 在应用经皮穿刺法为403例腰椎间盘突出症患者进行髓核摘除术中。选择L4,5、L5S1复合型椎间盘突出者35例（8．7％）,采用同一穿刺点对同侧不同侧椎间盘髓核突出的相邻的双间隙作髓核摘除术。结果 接受本术式治疗的35例复合型椎间盘突出症者,其穿刺的成功率为100％,穿刺的有效率为100％。结论 以一个穿刺点作经皮穿刺髓核摘除治疗复合型腰椎间盘突出症创伤小、恢复快,具有创新性。     

Restriction of indication for automated percutaneous lumbar discectomy based on computed tomographic discography.

This report details the authors' early experience using the automated percutaneous lumbar discectomy (APLD) procedure, developed by Onik et al., in 97 patients with a disc protrusion. In the evaluation of a herniated disc, we used computed tomography (CT) discography. According to the distribution of the dye inside the disc, five different disc types can be differentiated. With a follow-up after 3-7 months, the short-term outcomes of the first 40 APLD-treated patients varied, depending on the shape of the protruded nuclear material. Patients with a broad dye base on CT discography had better short-term outcomes than patients with a narrow dye base. In the next 57 patients we treated with APLD, this tendency was confirmed. The success rate of a consecutive group of patients with a disc protrusion with a broad dye base, treated with APLD, was 80%. In comparison, the patients with a disc protrusion with a narrow dye base had an overall success rate of only 53%. The difference is statistically significant (P < 0.05). The message of this report is that APLD is a useful invasive treatment for patients with a disc protrusion. The outcome depends, however, on the shape of the protruded nuclear material as shown by CT discography, which makes this examination as a conditio sine qua non before treating patients with a disc protrusion with APLD.     

经皮内窥镜治疗腰椎间盘突出症的并发症及其处理

目的 总结经皮内窥镜腰椎间盘切除术( PELD)治疗腰椎间盘突出症中出现的并发症,探讨其处理对策.方法 2002年7月至2010年10月采用PELD治疗腰椎间盘突出症患者689例,男性448例,女性241例;年龄13 ～84岁,平均39.8岁.单间隙椎间盘突出669例,双间隙椎间盘突出19例,三间隙椎间盘突出l例.中央型突出66例,旁中央型365例,外侧型242例,极外侧型10例,游离型6例.观察术中和术后并发症及其处理.结果 术中髓核部分残留压迫神经根5例,2例术中改行开窗髓核切除术,2例二期行开窗髓核切除术,1例二期行经椎间孔腰椎体间融合术(TLIF);神经根纤维束部分损伤2例,术后3～6个月内完全恢复;硬脊膜破裂2例,给予缝合皮肤伤口后痊愈.689例患者随访6～96个月,平均33个月.出现椎间隙感染7例,1例保守治疗,4例给予经皮穿刺置管冲洗引流持续局部应用抗生素,2例行后路开窗感染腰椎间盘清除术,均痊愈;术后复发6例,4例患者再次行PELD术,2例患者采用TLIF治疗,术后症状缓解;术后神经根性痛觉过敏和灼样神经根痛19例,经过止痛药物、神经营养药及物理治疗后好转;腰椎管狭窄症行单个节段的PELD术,效果不佳,二期行多节段TLIF治疗10例.结论 术中主要并发症有髓核部分残留压迫神经根、神经根纤维束部分损伤、硬脊膜破裂;术后主要并发症有椎间隙感染、复发、神经根性痛觉过敏和灼样神经根痛等.严格的适应证选择、无菌、熟练操作及术后康复锻炼可以减少并发症的发生.     

Automated percutaneous discectomy

Automated percutaneous discectomy is a new, safe procedure for treating herniated lumbar discs still contained by the annulus or posterior longitudinal ligament. In 1985, one of the authors reported a percutaneous nucleus aspiration technique using a 2-mm aspiration probe. This small probe produced minimal tissue damage, allowing the procedure to be done on an outpatient. In this series, 518 patients were treated using this technique for an overall success rate of 85%. Compensation patients, elderly patients, and patients with previous surgery were treated successfully using percutaneous discectomy on an outpatient basis. No intraoperative or postoperative complications occurred.     

CT value analysis and clinical significance before and after percutaneous lumbar discectomy

OBJECTIVE: To provide theoretical basis for effect and mechanism of percutaneous lumbar discectomy in clinic. METHODS: A total of 180 patients with lumbar intervertebral disc herniation were evaluated by CT on the fifth day before and after operation. Meanwhile, CT value was measured in the determined level and region. RESULTS: After operation, CT value of the central and posterior determined point of herniated intervertebral disc was lower significantly than that before operation (P<0.01), but CT value of the anterior determined point was different insignificantly. The excellent and good results of the patients together were 83% postoperatively. CONCLUSIONS: The curative effect of percutaneous lumbar discectomy is achieved through reduction of lumbar intradiscal pressure.     

切吸联合不同溶核疗法治疗腰椎间盘突出症

目的分析比较3种不同联合疗法治疗突出型L4,5椎间盘突出症的临床疗效,并观察其不良反应。方法本组59例,男36例,女23例;年龄19～69岁,平均(38.18±10.24)岁。将所有病例随机分为3组进行相应治疗切吸+盘内法组(A组)15例,切吸+盘外法组(B组)26例,切吸+盘内外法组(C组)18例。结果59例术后进行了4个月以上的随访,近期总优良率72.88%,总有效率96.61%;远期总优良率72.88%,总有效率86.44%。但各组间近、远期疗效差异均无显著性意义(P>0.05)。结论以上3种不同联合疗法均是临床治疗突出型腰椎间盘突出的有效方法,且不良反应少。     

Percutaneous automated discectomy. A new approach to lumbar surgery

An automated technique for percutaneous lumbar discectomy applies the principle of suction cutting. The indications are leg pain greater than back pain (sciatica) and failure of all conservative therapy. The typical neurological and roentgenographic abnormalities of a contained herniated lumbar disc are mandatory. The procedure is performed with a Nucleotome (Surgical Dynamics, San Leandro, California) that is a specially designed, 2-mm blunt-tipped suction-cutting device inserted via a posterolateral approach into the affected disc using fluoroscopic control. The results that can be expected with the technique are similar to chymopapain and are in the 70% success range. Automated percutaneous discectomy has a demonstrably low morbidity and can be performed under local anesthesia on an outpatient basis.     

经皮穿刺腰椎间盘切吸术治疗合并腰椎管狭窄的腰椎间盘突出症

目的：总结采用经皮穿刺腰椎间盘切吸术（APLD）治疗合并腰椎管狭窄的腰椎间盘突出症的经验。方法：对12例经CT扫描确诊为腰椎间盘突出症合并有腰椎管狭窄患者，术前行轴位牵引下直腿抬高试验检查。对属可逆性腰椎间突出患者，使用APLD治疗。结果：经3个月以上随访，优7例，良4例，可1例。近期优良率91．7％，未出现并发症。结论：合并腰椎管狭窄的腰椎间盘突出症不应列为APLD治疗的禁忌证。对术前行轴位牵引下直腿抬高试验检查属可逆性腰椎间盘突出的患者，仍可行APLD治疗。     

轴位牵引下直腿抬高试验在腰椎间盘突出切吸术中的应用价值

目的 在术前区别可逆性及不可逆性腰椎间盘突出症,明确经皮穿刺椎间盘切吸术适应证,提高ＡＰＬＤ手术优良率。方法 将轴位牵引下直腿抬高试验引入ＡＰＬＤ术前检查中,将８６例适合ＡＰＬＤ患者分为应用ＡＴ－ＳＬＲＴ前,后两组进行疗效比较。结果 应用ＡＴ－ＳＬＲＴ前组手术优良率９０．６％,应用ＡＴ－ＳＬＲＴ后组优良率１００％。结论ＡＴ－ＳＬＲＴ能为ＡＰＬＤ术前筛选,预测ＡＰＬＤ术后疗效提供较准确的参考依据,具     

经皮椎间孔镜下腰椎间盘摘除术并发症分析

目的:分析局麻下经皮椎间孔镜技术在治疗腰椎间盘突出症的并发症,探讨如何避免椎间孔镜手术并发症的发生。方法:对2013年10月至2015年6月采用经皮椎间孔镜下腰椎间盘摘除术治疗的132例腰椎间盘突出症患者进行回顾性分析,其中男85例,女47例;平均年龄42.9岁;L3,4突出6例,L4,5突出68例,L5S1突出58例。统计术中、术后并发症发生率,分析各类并发症发生原因。结果:132例患者中,术中发生硬膜损伤1例(硬膜与髓核粘连),术后未出现脑脊液漏,术后肌力感觉较术前无下降,创口愈合良好;术中减压不满意立即改为开放手术2例,为伴有椎间孔狭窄及髓核粘连患者,均取得满意疗效;短期(3个月)内复发2例,术后髓核残留3例,均通过翻修手术治疗,取得满意疗效;术后发生室上性心动过速1例,经询问原有心脏病史。术中发生高脑脊液压2例。结论:经皮椎间孔镜学习曲线陡峭,初学者在开始椎间孔镜手术前,必须有一定的开放手术经验,严格把握手术指征。在熟悉解剖和经皮椎间孔镜技术的前提下,经皮椎间孔镜下治疗腰椎间盘突出症是安全可靠的。     

经皮髓核切吸联合突出物溶解术治疗腰椎间盘突出症

目的探讨经皮腰椎间盘髓核切吸(APLD)联合突出物溶解术治疗腰椎间盘突出症，提高突出物溶解率和治愈率，缩短疗程，减少、减轻单一疗法所致的并发症。方法采用随机对照研究。治疗组77例行APLD后留置工作导管并推进到对侧纤维环下。另行穿刺将胶原酶注入突出物，与对照组84例对比分析。对161例中的151例(治疗组73例，对照组78例)进行了跟踪随访。结果两组均随访18．7个月。治疗组73例，优良率94．5％，突出物溶解率91．5％，患者恢复工作时间57d。对照组78例，优良率79．5％，突出物溶解率71．2％，患者恢复工作时间110d。结论突出物内注射胶原酶是一项创新技术，将其与APLD联合来治疗腰椎间盘突出症是提高疗效的关键，克服了单纯APLD的疗效不足和单纯胶原酶溶核术致疼痛和康复时间长等缺点。     

Early course and long-term follow-up after automated percutaneous lumbar discectomy.

In this prospective study, the clinical outcome in the early course as well as the long-term results were analyzed after automated percutaneous lumbar discectomy (APLD). Thirty consecutive patients are included, all with a contained lumbar disc herniation on magnetic resonance imaging. There was a significant reduction in the sciatic pain and straight leg raising (SLR) test postoperatively at all the different measurements in the early course except for the sciatic pain at 2 weeks. On the same occasions, there was no change in the back pain or the Oswestry score. Ten patients needed subsequent open surgery. For the remaining patients, the long-term result showed a significant and unchanged improvement in the sciatic pain and SLR. In addition, the Oswestry score had now significantly improved. The failure rate of APLD turned out to be unacceptably high in this study, because 38% of the patients needed subsequent open surgery. However, an early satisfactory course also seemed to imply a beneficial long-term prognosis.     

Automated percutaneous lumbar nucleotomy

Surgical Principles The disc space is evacuated with the help of a percutaneously inserted Nucleotome® Probe. The herniated nucleus pulposus material is suctioned through an opening in the probe, cut off with a cutting device and aspirated through the probe. The automated percutaneus nucleotomy can be performed in patients with small or medium sized encapsulated herniated lumbar discs, when conservative treatment failed and prior to considering a lumbar discoidectomy.     

腰椎后纵韧带在椎间盘切吸术中的临床研究

目的 通过自动经皮椎间盘切吸术(APLD)临床疗效与腰椎管脊髓造影(Dynemic myelography,DM)影像的分析,探讨腰椎后纵韧带在腰椎间盘突出时的作用以及与手术适应症的选择.方法 临床诊断腰椎间盘突出患者行腰椎管脊髓造影,分别测量病变椎间隙在侧卧过伸位、过屈位硬膜囊受压深度,过伸位减过屈位数值,我们称之为弹性指数,以此判断腰椎后纵韧带弹性大小和椎间盘纤维环的完整性.设定为:弹性指数值≥0.5cm为弹性好,0.5-0.3cm为弹性较好,＜0.3cm为弹性差.统计分析106例APLD患者临床效果.结果 APLD术后51例显效,41例有效,14例无效,分析弹性指数与效果的相关性,各组之间有统计学意义.结论 腰椎后纵韧带对椎间盘突出髓核有动力源性的还纳作用.其弹性作用在腰椎间盘突出症行椎间盘切吸术疗效中起重要作用,通过DM对其弹性指数分析,可以作为椎间盘突出症患者实行APLD手术的适应症之一.     

椎间孔镜下髓核摘除术治疗椎间盘退变性腰腿痛

目的探讨椎间孔侧路镜下髓核摘除术治疗腰椎间盘退变性腰腿痛的临床效果。方法2010-08-2011-11,我科对31例经保守治疗无效的腰椎间盘退变性腰腿痛患者实施了椎间孔侧路镜下髓核摘除微创手术。结果 YESS法穿刺15个间盘,TESSYS法穿刺19个间盘。随访3～6个月,平均4.2个月,失访2例。术前术后腰腿痛VAS评分有统计学意义(P<0.01)。术后3个月疗效MacNab评定:优17例,良8例,可3例,差1例,优良率86.2%。结论椎间孔镜技术治疗腰椎间盘退变性腰腿痛具有更微创、效果良好、恢复快优点,掌握好病例选择是关键。     

经皮腰椎间盘髓核摘除术和胶原酶溶核术的疗效比较

目的　比较经皮腰椎间盘摘除术 (APLD)和胶原酶溶核术 (CCNL)对腰椎间盘突出症的治疗作用。方法　符合治疗标准的腰椎间盘突出症 2 34例 ,其中APLD组 118例 ,CCNL组 116例。两治疗组采用统一的病例选择标准 ,疗效判别标准和3个月以上的随访。经X线引导完成全部治疗过程。结果　APLD组有效率 89 8% ,无效率 10 2 % ;CCNL组有效率 78 4% ,无效率 2 1 6 % ,两治疗组的有效率和无效率有明显统计学差异 (P <0 0 5 )。结论　作者认为 :(1)APLD为包容性腰椎间盘突出症的首选治疗方法 ,但必须严格掌握禁忌证和适应证。 (2 )CCNL的盘外注射法其疗效低于APLD ,但具有简便迅速无创伤痛苦少的优点 ,而盘内注射法尚需作进一步研究     

Percutaneous endoscopic lumbar discectomy and interbody fusion with B-Twin expandable spinal spacer

Background  

Posterior lumbar interbody fusion (PLIF) is biomechanically sound as it ablates the degenerated disc, restores the intervertebral height, relieves foraminal stenosis, and positions the bone graft along the weight-bearing axis. But this conventional procedure also results in significant traction on the dural sac and the cauda equina and is thereby a potential source of neurologic damage. Therefore, we performed a minimally invasive technique: percutaneous endoscopic discectomy and interbody fusion (PEDIF) with B-Twin expandable spinal spacer (B-twin ESS) to treat symptomatic lumbar degenerative disc disease and explored the clinical outcome.     

Imaging evaluation of the candidate for percutaneous lumbar discectomy

Percutaneous lumbar discectomy has been advocated as an alternate means of treating lumbar disc disease. A disc treatable by this method must not be free in the spinal canal and cannot be above or below the disc space. Magnetic resonance imaging, computed tomography, and discography all can be valuable in selecting patients for percutaneous lumbar discectomy.