Surgical options for patients with recurrent lumbar disc herniation after PELD
At present, most of the reoperations for recurrence after LDH surgery are clinically performed with tunnel-assisted nucleus pulposus removal combined with lumbar fusion, which often requires stripping the muscle and soft tissue behind the spine, cutting the lamina, and facet joints, and entering the spinal canal, which increases the number of postoperative complications. Spinal instability, chronic back pain, and neurological and vascular risks [9]. The thoracoscopy-assisted percutaneous minimally invasive nucleosome is a minimally invasive spine surgery (MISS) technique that has several advantages over posterior open surgery: preservation of skeletal muscle structure, shorter hospital stay, and smaller incisions [9]. However, due to the formation of scar tissue on the side of the intervertebral foramen after lateral foraminal surgery, it is difficult to perform lateral minimally invasive surgery again. The external percutaneous single-channel transforaminal technique is not conducive to exploration in all directions of the spinal canal because the working channel and the visual field channel are coaxial, the visual field is fixed, and the movable range of the working channel in the interlaminar approach is small. When performing L5-S1 intervertebral disc herniation surgery, the lateral transforaminal approach is often blocked by the high iliac spine, pedicle, and articular process, which makes it difficult to accurately target the cannula [10]. Lowering down on the management of patients with recurrent lumbar disc herniation presents challenges in terms of complete enucleation of the re-herniated nucleus pulposus and satisfaction with spinal canal exploration. In addition, due to the destruction of the lateral intervertebral foramen and the inner structure of the spinal canal after the lateral approach, the ligament flavum was partially removed, and a large number of scars proliferated. The original residual ligamentum flavum adhered to the dura mater and became the main structure of the scar tissue. Invasive surgery is difficult, and damage to the dura mater leads to a relatively high probability of cerebral fluid leakage and nerve root damage. Posterior proctoscopy requires special equipment for the DELTA large channel and has a long learning curve. Many primary orthopedic surgeons cannot master this technology.
UBE technique can avoid the scar tissue formed after the lateral approach. It adopts two independent channels that do not interfere with each other, one is the observation channel and the other is the operation channel, which can effectively remove the protruding nucleus pulposus in all directions in the spinal canal [11–13]. UBE enables high-resolution visualization in very small muscle dissections, allowing almost unlimited access to all laminectomy instruments [14]. High-definition endoscopic vision makes intraoperative exposure and dissection easier, operates in a water environment, has minimal bleeding under flowing sterile saline pressure, and has a clear field of vision. The surgical operation can be endoscopically assisted like traditional posterior surgical techniques. Surgical nucleosome technique. Due to the use of two independent channels, more detailed observations can be obtained compared to microscopic surgery, and good surgical results can be achieved. UBE is a new method that combines the advantages of endoscopy and microsurgery. Foramoscope use with single-channel systems is limited because the combined channels (viewing and instrumentation) limit the independent movement of the instruments. In contrast, the UBE system uses independent operating channels for the instruments, so movement and observation are not restricted. UBE technique is an endoscopic-assisted surgical nucleosome. It has a short learning curve, a good microscopic field of view, thorough surgical decompression, and less intraoperative blood loss. The intraoperative dual-channel can be replaced by an arthroscopic working system. Many primary hospital doctors This technique can be mastered and carried out [9].
In this study, 21 patients with recurrence after lateral PELD treatment of LDH were fully removed from the prolapsed lumbar intervertebral disc by UBE, and the nerve root was completely decompressed. Postoperative MRI showed that the nerve root was adequately decompressed. The symptoms of waist and leg symptoms disappeared after the operation in all patients, and the VAS scores were significantly lower than those before the operation.
Techniques For Using Radiofrequency In Surgery
The radio frequency currently used clinically during the operation of UBE technology includes high-frequency radio frequency and plasma radio frequency. The range of high-frequency radio frequency is point-like, while the plasma radio frequency has a large area. Therefore, it is necessary to clarify whether the video equipment used is high-frequency radio frequency or plasma radio frequency during the operation. Plasma radiofrequency is highly efficient for cauterizing muscle and soft tissue outside the spinal canal, but blindly applying plasma radiofrequency for cauterization and hemostasis after removing the ligamentum flavum and entering the spinal canal may damage the dura, leading to dura rupture, cerebrospinal fluid leakage, and cauda equina nerve damage. Therefore, the plasma radio frequency is used outside the spinal canal, and the high-frequency radio frequency can be operated after entering the spinal canal, which is safer and the probability of damaging the dura and nerve roots is greatly reduced.
UBE is exposed from the posterior approach, so be careful after removing the ligamentum flavum and entering the spinal canal. The lateral foraminal surgery has already been done, so there is scar tissue adhesion between the nerve root and part of the lateral dura. During the operation, we used the nerve stripper to operate carefully and gently. We used the intraoperative water pressure to increase the water pressure and reduce the bleeding. Under the microscope, we used the laminae rongeur to remove part of the bone at the medial border of the inferior articular process, expand the operating space, and expose the nerve root on the shoulder. There is a large operating space on the shoulder of the nerve root, and radiofrequency hemostasis is performed. After exposing and separating the nerve from the shoulder of the nerve root, the soft tissue is cauterized by radiofrequency, and the protruding nucleus pulposus is searched and completely removed.
Limitations Of This Study
This study is a single-center retrospective study, with few included cases, short follow-up time, and no control group, so there is a certain bias in the results. It is hoped that a multicenter study will be conducted in future studies with more cases and longer follow-ups.