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.     

Automated percutaneous lumbar discectomy with and without chymopapain pretreatment versus non-automated,discoscopy-monitored percutaneous lumbar discectomy

Summary Percutaneous lumbar discectomy has gained growing interest during recent years as an alternative to open surgery for protrusions and non-sequestrated subligamentous intervertebral disc herniations. As a less invasive method it competes with chemonucleolysis. At least two modifications are known to date: automated percutaneous lumbar discectomy (APLD) with a 2-mm suction probe and non-automated, discoscopy-monitored percutaneous lumbar discectomy with a suction rongeur and a motor-driven shaver (NAPLD). In this study these two methods are compared for the amount of material extracted, dependence upon the degree of degeneration of the disc and intrinsic technical problems, using 20 human cadaver lumbar specimens for experimental testing. Total nucleotomy was not possible with either method. APLD yielded significantly less material and proved to be less effective in severely degenerated intervertebral discs than the NAPLD procedure, as preexisting gaps within the degenerated nucleus pulposus allowed the tissue to shift away from the tip of the 2-mm probe and facilitated displacement of the probe within the anulus fibrosus. By contrast, the rongeur, which first cuts the material to be removed and then carries it away by suction, was much more effective. Further data to support the advantages of non-automated percutaneous nucleotomy are discussed. Pretreatment of the disc with chymopapain did not result in a higher yield of nucleus material when combined with APLD.     

经皮穿刺切吸治疗腰椎间盘突出症

方法：本文通过１９６例腰椎间盘突出症的ＡＰＬＤ治疗及平均１２个月的临床观察,优良率达９５．４％,从适应症选择,禁忌症,髓核切吸量与疗效关系,再次切吸问题,并发症发生及预防措施等方面,详细论述了该技术运用中的一些具体问题。强调了伴有椎间盘钙化和椎体后缘骨赘形成时,仍可选择就诊前病史中有缓解期,本次发病不超过６个月的病例做为适应症。结论：认为该技术与保守治疗,传统手术一样,将成为治疗腰椎间盘突出症的主     

Changes in the lumbar disk following use of non-automated percutaneous discectomy. A biomechanical study]

For a biomechanical study 8 specimens of the lumbar spine (L1-S1) were scanned with MRI. After that 21 motion segments were prepared for the experiments. The paraspinal musculature as well as the posterior elements were removed. From each disc 1,0 g, 2,0 g, and 3,0 g of nuclear material were consecutively removed under an axial load of 500 N. At the beginning of every standardized experiment of a motion segment, as well as after the excision of every gram of nuclear material, intradiscal pressure, the height of the disc and the contour of the disc were determined with an axial load on the motion segment of 1000 N. The change in radial bulging of the disc was measured using the computer-assisted recordings of each disc contour. All the data were statistically analyzed using the Friedman-test. The nuclear material removed from the discs ('in-vitro nuclear material') was placed in isotonic saline over 45 minutes and again weighted ('wet weight'). Af that the nuclear material was freeze-dried ('dry weight'). The results of this study showed that after the excision of every gram of nuclear material the height of the disc decreased in average 0,77 mm. Also intradiscal pressure reduces significantly: from the initial stage, on average, 9, 19 bar to the endstage (= after the removal of 3,0 g), on average, 2, 58 bar. Radial bulge increases with every gram removed, on average 0,23 mm. The weight of the wet nuclear material is 2,6 times as much as that of the in-vitro nuclear material and 11 times as much as that of the freeze-dried material.     

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。     

经皮穿刺切吸术治疗伴钙化的腰椎间盘突出症35例体会

从1993年9月以来,我们使用APLD技术治疗伴钙化的腰椎间盘突出症35例,其中28例获优良级疗效,4例可,3例差;随访3～16个月,优良率80%.我们体会到只要患者有间断性发作或近期内有中间缓解期病史,CT片显示间盘突出阴影所占比例或成份大于钙化影时,则可使用经皮穿刺切吸技术.对经皮切吸治疗无效者,一般不宜进行二次切吸治疗,应选择手术治疗.     

两种方法治疗腰椎间盘突出症的疗效比较

目的比较显微内窥镜下椎间盘切除术(MED)和经皮椎间孔镜下椎间盘切除术(PTED)治疗腰椎间盘突出症的临床疗效。方法将96例单节段腰椎间盘突出患者按治疗方法不同分为MED组(48例,采用MED治疗)和PTED组(48例,采用PTED治疗)。比较两组手术情况,采用疼痛VAS评分及改良MacNab标准评价疗效。结果手术时间和住院费用PTED组长(多)于MED组(P<0.05)。住院时间两组比较差异无统计学意义(P>0.05)。术后并发症MED组2例、PTED组3例。患者均获得6个月随访。VAS评分:两组术后第1天均较术前明显降低(P<0.05),两组术后第1天比较差异无统计学意义(P>0.05)。术后3个月采用改良MacNab标准评价临床疗效:MED组优良率为87.50%,PTED组优良率为89.58%,两组优良率比较差异无统计学意义(P>0.05)。结论MED和PTED治疗腰椎间盘突出症均有良好的效果,MED手术时间短、住院费用低,但PTED更微创。     

经皮切吸治疗腰椎间盘突出症远期疗效下降原因探讨

目的　分析经皮切吸治疗腰椎间盘突出症远期疗效下降的原因 ,探讨改进措施。方法　对 34例经皮切吸治疗的病例进行分类、对比和近、远期疗效观察 ,结合CT检查了解远期病例椎管内改变。结果　该项技术治疗的腰椎间盘突出症的近期优良率 91 18% ,远期优良率下降至 70 83% ,近远期疗效有显著差异 (P <0 0 5 )。除已公认的因素外 ,还应注意 :①优先选择病程短、单纯局限性膨出的病例 ,病程大于 3年和腰椎间盘后外侧突出型不作经皮切吸的首选。②对切吸头进行技术改进 ,有利于增加切吸量。③椎管造影检查同期作切吸可以更好的指导切吸效果。结论　该项技术的指征、操作方法有待进一步规范。     

Chemonucleolysis. Development, experience, perspectives

Concerning the so-called minimal invasive procedures currently available for the treatment of lumbar disc prolapse (percutaneous endoscopic discectomy, APLD, laser decompression, chemonucleolysis), the intradiscal application of Chymopapain represents the method with the longest period of clinical use and experience. Long-term studies have shown good clinical results. When considering of the indication and the few contraindications--particularly allergic diathesis--chemonucleolysis provides a low-risk, efficient, minimally invasive therapy that closes the therapeutic window between conservative and open surgical treatment.     

经皮穿刺臭氧髓核消融术治疗腰椎间盘突出症

目的探讨经皮穿刺腰椎间盘髓核臭氧消融术的手术方法、临床疗效及手术适应证。方法选择300例腰椎间盘突出症患者,采用经皮穿刺髓核臭氧消融术治疗,根据髓核突出程度分类,分为A组：膨出型91例;B组：突出型127例;C组：脱出型82例,分别采用安全三角区入路、安全三角区入路＋选择性神经根阻滞和小关节内侧缘入路,行经皮穿刺腰椎间盘髓核臭氧消融术,经6～18个月随访,采用Macnab疗效评定标准,评价其临床疗效。结果 A组有效率82.6%,B组有效率85.7%,C组有效率80.4%,明显高于文献报道,三组间差异无统计学意义（P〉0.05）。结论不同类型腰椎间盘突出症采用不同入路方法的经皮穿刺髓核臭氧消融术,其治疗效果对比无显著性差异,应根据患者腰椎间盘突出症类型选择适合的手术入路方法。     

经皮腰椎间盘摘除术和经皮激光椎间盘减压术的疗效比较

目的对比分析经皮腰椎间盘摘除术（autoed percutaneous lumbar diskectomy,APLD）和经皮激光腰椎间盘减压术（percutaneous laser disc decompression,PLDD）对腰椎间盘突出症的治疗效果和治疗机理,以便选择最佳治疗方法。方法选择符合治疗标准的腰椎间盘突出症261例,其中APLD组183例,PLDD组78例,两治疗组采用统一的病例选择标准,疗效判别标准和随访3个月以上。治疗过程均在C型臂X线机透视下完成。结果PLDD组有效率96．1％,无效率3．9％：APLD组有效率95．1％,无效率4．9％。两治疗组的有效率和无效率无明显统计学差异（P〉0．05）,但PLDD组术后即时疼痛减轻率高及总体恢复时间短。结论APLD和PLDD同为包容性腰椎间盘突出症安全有效的治疗方法,但必须严格掌握禁忌证、适应证以及规范的操作;PLDD具有手术更简便迅速、即时疼痛减轻率高,创伤小和术后恢复时间短的优点。     

单侧椎弓根内固定椎间融合术治疗复发性腰椎间盘突出症疗效分析

目的比较传统髓核摘除术（A组）及单侧椎弓根内固定椎间融合术（B组）治疗复发性腰椎间盘突出症的临床疗效。方法对自2000一01—2012—02收治的复发性腰椎间盘突出症86例行手术治疗,包括行单纯传统髓核摘除术52例,行单侧椎弓根内固定椎间融合术34例。结果B组末次随访VAS、ODI及JOA评分均优于A组,差异有统计学意义（P〈O．05）;2组间并发症发生率比较,差异无统计学意义（P〉O．05）。结论采用单侧椎弓根内固定椎间融合术治疗复发性腰椎间盘突出症较传统髓核摘除术能取得更好的临床疗效。     

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。     

经皮内窥镜激光椎间盘摘除术治疗腰椎间盘突出症的近期疗效

[目的]探讨经皮内窥镜激光椎间盘摘除术对腰椎间盘突出症的近期治疗效果.[方法]2008年7月～2009年1月,36名腰椎间盘突出症患者在本院接受利用结合侧方发射激光和Ellman高频射频装备的经皮内窥镜椎间盘摘除术,疗效判断采用了术前及术后腰痛及腿痛视觉模拟评分(VAS)的变化情况,术后1年时MacNab功能评分.[结果]全部手术均顺利完成,手术时间为30～70 min,平均42 min,无术中并发症发生,手术成功率为97%,手术复发率为3%.所有患者最终随访时间均为1年,腰痛VAS评分术前6.19分,术后1年2.25分;腿痛VAS评分术前8.25分,术后1年1.75分;术后腰痛和腿痛的VAS评分较术前均明显降低(P<0.01).按照MacNab评分标准,术后1年随访时,优28例,良6例,优良率94%.[结论]经皮内窥镜激光椎间盘摘除术治疗腰椎间盘突出症创伤小、安全,而且近期疗效好.     

经皮椎间盘切除、射频消融治疗包容性腰椎间盘突出症36例

目的探讨Disc-FX系统经皮椎间盘切除、射频消融术治疗包容性腰椎间盘突出症的并发症及处置对策。方法选择自2010年7月至2011年6月在我院应用Disc-FX系统经皮椎间盘切除、射频消融术治疗包容性腰椎间盘突出症患者36例,其中男16例,女20例;年龄18～77岁,比较术前、术后即刻、1周、3个月、6个月、1年的日本骨科协会（Japanese orthopaedic association,JOA）、视觉模拟疼痛（visual analogue scale,VAS）及Oswestry（2.0版本）评分,分析术中、术后并发症的情况。结果本组均获随访,随访时间3个月～1年,平均8个月,36例患者术后JOA评分较术前明显升高,术后VAS和Oswestry评分较术前明显降低,有统计学意义（P〈0.01）。术中并发症包括：a）导针断裂1例;b）神经根挫伤1例。术后并发症包括：a）术后水肿反应24例;b）终板炎1例;c）椎间隙感染1例;d）手术局部血肿1例。结论 Disc-FX系统经皮椎间盘切除、射频消融术是治疗包容性腰椎间盘突出症的有效方法。严格的围手术期处理和谨慎的术中操作可预防或减少并发症的发生。     

PLD术后影像学改变与临床疗效关系——术前后CT或MRI比较

目的 为了进一步明确经皮穿刺椎间盘切除术（ＰＬＤ）的治疗机理。方法 本文对５８例经皮穿刺椎间盘切除术的病人进行了随访,并将术前术后的ＣＴ或ＭＲＩ进行比较。结果：ＰＬＤ术后椎间盘突出无明显的形态学改变。结果 经皮穿刺椎间盘切除术后椎间盘的变态变化不是经皮穿刺椎间盘切除术症状级解的原因,而椎间盘减压和神经根周围的化学变化可能是症状缓解的机理。     

Water jet discotomy with microinvasive approach--in vitro testing and initial clinical aspects of a new procedure

AIM: The difference in consistence of the nucleus pulposus and the annulus fibrosus allows the water jet to selectively remove the nucleus in a closed vertebral disc at a certain pressure range. The aim of the study was to investigate the use of water jet cutting in microinvasive spinal surgery. METHODS: A comparison in terms of efficiency between the water jet and those of the laser and APLD (automatic percutaneous lumbar discotomy) was achieved by plastic reconstruction of the resected spaces using the in-vitro-model of the spinal column of young pigs. The in-vitro-study was followed by a prospective clinical study with 21 patients. RESULTS: The in-vitro-employment of the three different methods showed that there were no significant differences in volume of the removed nucleus material. During the use of the hydro jet at 50 bar and simultaneous suction the intradiscal pressure measured in vitro remained below 1 bar. Clinical tests on the 21 patients showed good to very good results in 71% of the patients tested (mean follow-up 5.8 months). No complications were found. As working mechanism the pure mechanical effect and the influence on chemical processes within the nucleus remain points for discussion. CONCLUSION: The current studies results demonstrate that hydrojet spinal surgery might be a safe new method for surgery of disc protrusion and contained prolapse.     

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