DOI: https://doi.org/10.21203/rs.3.rs-1624036/v1
Background Lumbar disc herniation(LDH) is rare in pediatric diver. Because of the particularity of age and occupation, which makes the treatment concept of pediatric diver lumbar disc herniation quite different from that of the general population. In this case report, we report a rare case of using percutaneous endoscopic interlaminar discectomy (PEID) successfully treats a 12-year-old professional diver.
Lumbar disc herniation (LDH) is rare among in children [1], especially pediatric diver under the age of 12. With the rapid development of spinal endoscopy technology, percutaneous endoscopic lumbar discectomy (PELD) has been introduced into the treatment of pediatric LDH with the characteristics of less trauma, good outcomes and rapid recovery [2]. Different from the treatment of lumbar disc herniation in pediatric and adults, the treatment of lumbar disc herniation in pediatric diver is more difficult and meaningful because the pediatric diver's spine is still in the stage of rapid growth, the nucleus pulposus have more hydrated, good elasticity, soft and viscous, and have higher requirements for the curative effect of surgery [3]. Therefore, we report a rare case of using percutaneous endoscopic interlaminar discectomy successfully treats a 12-year-old professional diver.
A 12-year-old male professional diver developed low back pain and radiation pain in his right lower limb for more than 9 months and aggravated symptoms for 2 months. Due to the poor response to strict conservative treatment, the patients were admitted to our hospital. Apart from his father suffering from lumbar disc herniation, there were no other diseases reported in the family. Physical examination: The right straight leg raising test result is positive (50 degrees). The muscle strength of the right lower limb decreased slightly. Preoperative imaging showed that L5 / S1 level huge disc herniation (Figure 1).
Surgical technique
All operations were performed under local anesthesia. The patient was placed in prone position on a radiolucent operating table. Using C-arm X-ray fluoroscopy to confirm the operative segment (Figure 2A). The 18 G needle trajectory was introduced with its tip pointed at the lateral edge of interlaminar window until the bony structure (facet joint) was felt (Figure 2B-C). When the puncture needle reaches the appropriate position, inject the contrast medium (Figure 2D). The needle was removed with a 1-mm-diameter guide wire inserted. And then, a dilator was inserted with its tip reached the posterior rim of the lamina. Then, turn the dilator with appropriate force to break through the surface of the ligamentum flavum (Figure 2E). The bevelled working sheath was introduced through the dilator with its beveled opening toward the spinal canal (Figure 2F-G). After that, the endoscope was introduced through the working cannula. In our case, when we inserted the working cannula into the intervertebral disc, huge nucleus pulposus entered the working channel due to the high intradiscal pressure and block the line of our sight. After this part of nucleus pulposus was removed the thecal sac and the traversing nerve root was visualized (Figure 2H). We used limited discectomy for ventral decompression that is just remove some loose pieces of nucleus pulposus. Before taking out the working channel and endoscope, the shoulder and axillary sides of nerve roots should be explored. Collect nucleus pulposus tissue and suture skin (Figure 2I). The whole operation lasted 50 minutes and the amount of intraoperative bleeding was less than 50ml. The patient's straight leg raising increased from 50 to 90 degrees after PELD. The visual analog scale (VAS) score decreased from 8 points before operation to 1 point on the first day after operation. Asymptomatic residual disc tissue was observed on magnetic resonance imaging (MRI) 3 months after operation (Figure 3). Six months after operation, the patient returned to his original high level of activity and returned to the national team in good condition without low back pain. There were no complications during the follow-up.
Recently, gadjradj reported that PELD was successfully performed in a 9-year-old patient with sciatica [4]. However, our patient is different from ordinary children. He has a more important identity as a national diver, which has higher requirements for the efficacy of PELD. At present, there is no relevant report on whether PELD surgery can help the pediatric diver return to original high level of activity without low back pain. After comprehensive consideration, we propose to use limited nucleus pulposus removal [5]. During the operation, we accurately remove the nucleus pulposus tissue that compresses the nerve, which is the key to the success of the operation. We will consciously remove less intervertebral discs on the ventral side of the dural sac [6]. For this patient, the integrity of the inner part of the ring should be maintained as much as possible, because proteoglycan synthesis is the most active in the inner part of the ring [7], and the intervertebral disc tissue may regenerate when the inner ring is kept intact [8]. In this case, residual disc tissue was observed on magnetic resonance imaging (MRI) 3 months after operation, which is also the result of limited discectomy (Figure 4). However, the asymptomatic " Nerve root compressed residual disc tissues " on MRI in the early postoperative period did not affect the surgical outcomes after PELD [9-10]. During the follow-up, the pediatric diver had no complications. In March 2022, the patient returned to his original high level of activity and returned to the national team in good condition without low back pain.
In summary, percutaneous interlaminar lumbar discectomy with limited nucleus pulposus removal may be a good choice for pediatric diver LDH.
Ethics approval and consent to participate
All procedures performed in this case report were in accordance with the ethical standards of the institution and the 1964 Helsinki Declaration. Informed consent for participation was obtained from the patient and his parents.
Consent for publication
Written informed consent was obtained from the patient and his parents for publication of this case report and accompanying images and pictures.
Availability of data and materials
The original contributions generated for the study are included in the article/Supplementary Material, and further inquiries can be directed to the corresponding author.
Competing interests
All authors certify that they have no affiliations with or involvement in any organization or entity with any financial interest or non-financial interest in the subject matter or materials discussed in this manuscript.
Funding
No funding was provided for this study.
Authors' contributions
Hui Wu performed the literature search and collection and drafted the manuscript. Sikuan Zheng supervised and participated in the literature review. Dingwen He and Xigao Cheng completed all examinations and confirmed the final diagnosis. All authors read, edited, and approved the final version of the manuscript.
Acknowledgements
We express our sincere gratitude to the patient and his parents for their support.