Symptomatic lumbar disc herniation (LDH) is widely treated using percutaneous endoscopic lumbar discectomy (PELD). In the present PELD surgery, performing decompression under endoscope still takes a long time to explore the rupture site of annulus fibrosus, resulting in prolonged operation time and over‐invasion of the undegenerated annulus fibrosus. A wide range of intraoperative exploration also induces an iatrogenic injury of the normal annulus fibrosus, even aggravating intervertebral disc degeneration, which may lead to early postoperative recurrence in severe case. Hence, it is important to seek a precise decompression in PELD surgery. Under this kind of realization, more spinal surgeons possibly choose a disc staining before performing decompression. However, the classical disc staining technique still has its shortcomings. First of all, an appropriate dose of staining cannot be accurately mastered, even induces unqualified staining effect. Second, the duration of surgery and the times of fluoroscopy will be increased. Finally, what surgeons see under the endoscope is the staining result but not the staining process. Hence, this is accomplished more effectively by designing procedures that perform fully visible disc staining under spinal endoscope. There is no specific research to discuss the technique note of endoscopic staining in PELD surgery. We have come up with a new original technology of endoscopic staining with methylene blue injection in PELD for treatment of LDH.
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This current study is to display a series cases using a new and original endoscopic disc staining. This modified technique can fully observe the process of disc staining. It also minimizes the iatrogenic injury of the intraoperative undegenerated annulus fibrosus. In addition, the learning curve is smooth and it is easy to master this technique for experienced orthopedic and neurosurgical spine specialists.
To date, symptomatic lumbar disc herniation (LDH) has been widely treated using percutaneous endoscopic lumbar discectomy (PELD) because of its advantages. The PELD operation was superior in terms of tissue injury, bleeding volume and recovery period 1 , 2 . This inception does accord with spinal surgery's basic principle, which is to treat diseases effectively with minimal structure invasion of normal anatomy. Since PELD has become a representative, minimally invasive spine surgery for LDH, there also exists limitations. Some modified procedures in the process of PELD have emerged and improved surgical solution. Li et al. designed protective working cannula in the original Tessys technique and used a trephine cut the bony structure of superior articular process through the tube 3 . Meanwhile, we also researched the efficacy and safety of trephine for axillary‐type LDH. Using a trephine with protective working cannula for foraminoplasty of superior articular process have shown its safety and high efficiency 4 . Hence, appropriate modification is necessary in surgical solution and possibly improves clinical outcomes. Endoscopic spine surgery has evolved gradually through improvements in endoscope design, instrumentation, and surgical techniques.
In the present PELD surgery, performing decompression under endoscope still takes a long time to explore the rupture site of annulus fibrosus, resulting in prolonged operation time and over‐invasion of the undegenerated annulus fibrosus. Sometimes the boundary between normal annulus fibrosus tissue and degenerated nucleus pulposus could not be clearly and quickly distinguished intraoperatively. So, a long intraoperative probe is inevitably required. Moreover, a wide range of intraoperative exploration will induce an iatrogenic injury of the normal annulus fibrosus, even aggravating intervertebral disc degeneration, which may lead to early postoperative recurrence in severe cases. Undegenerated annulus fibrosus prevents the nucleus pulposus from herniating or leaking out of the disc by sealing the nucleus and evenly distributing any pressure and force imposed on the intervertebral disc 5 . Based on this reason, some studies considered it will lead to an iatrogenic injury 6 and increase the risk of early postoperative recurrence 7 . So, it is important to seek a precise decompression in PELD surgery. Under this kind of realization, more spinal surgeons possibly choose a disc staining before performing decompression 8 , 9 , 10 . Moreover, disc staining can better distinguish between a nucleus pulposus and a nerve root, and decrease the risk of injury to the exiting and traversing nerve roots. The technique of disc staining can date back to the 1980s. Schreiber et al. and Suezawa et al. published their bilateral approach for a percutaneous nucleotomy under endoscopic control and described injecting indigo carmine into the disc space to stain the abnormal nucleus pulposus and annulus fibrosus 11 , 12 , 13 . This is based on a strong relationship for usefulness of the application of methylene blue for selective endoscopic intervertebral nuclectomy in degenerated nucleus. Kim et al. have demonstrated that methylene blue is highly reactive with acidic extracellular matrix in the degenerated nucleus pulposus 14 .
A classical disc staining technique is performed by injecting methylene blue into the disc in accordance with the puncture approach of discography. He et al. performed a chromo‐discography using a mixture of iohexol and methylene blue to disc, inducing less chance of iatrogenic lumbar instability and the formation of intracanal scar tissue 15 . Several studies involved large numbers of cases have shown that the disc staining technique has become common for PELD surgery 16 , 17 . However, this classical technique still has its shortcomings. First of all, an appropriate dose of staining cannot be accurately mastered and can even induce unqualified staining effect. Second, the duration of surgery and the times of fluoroscopy will be increased. Finally, what surgeons see under the endoscope is the staining result but not the staining process. Hence, this is being accomplished more effectively by designing procedures that perform fully visible disc staining under a spinal endoscope.
The aim of this work is to display a series of cases using a new and original endoscopic disc staining. To our knowledge, there is no specific research to discuss the technique note of endoscopic staining in PELD surgery. This modified technique not only recognizes stained nucleus pulposus, but also fully observes the process of disc staining. Our strategy also avoids the excessive removal of the nucleus pulposus and minimizes the iatrogenic injury of the intraoperative undegenerated annulus fibrosus, to help maintain long‐term disc function in the movement of the spinal functional unit.
Endoscopic discectomy is the least invasive and most effective surgical technique for treating spinal disc herniation patients. With endoscopic spine surgery, surgeons do not need to remove bones and muscles in order to remove herniated discs. Surgeons can see the spine with a camera, smaller than a smartphone camera, through a small surgical port (tube). Large incisions are avoided. The procedure does not traumatize your spine as traditional spine surgeries do. The whole process for disc herniation takes about 30 minutes. The patient goes home in 2-3 hours when the surgery is done in a surgery center.
Endoscopic discectomy , a common type of endoscopic spinal surgery, is a minimally invasive surgical procedure used to remove herniated disc material that is causing pain in the lower back and legs (lumbar), mid back (thoracic), or neck and arms (cervical).
Endoscopic discectomy is the least invasive and most effective surgical technique for treating spinal disc herniation patients. With endoscopic spine surgery, surgeons do not need to remove bones and muscles in order to remove herniated discs. Surgeons can see the spine with a camera, smaller than a smartphone camera, through a small surgical port (tube). Large incisions are avoided. The procedure does not traumatize your spine as traditional spine surgeries do. The whole process for disc herniation takes about 30 minutes. The patient goes home in 2-3 hours when the surgery is done in a surgery center.
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After your doctor recommends a discectomy and why you need one, you will probably have many questions. It is so important to write them down and ask at your next appointment or email them. You may want to know if there are any alternatives and what happens if you elect not to have the surgery. What are the benefits of surgery, and how long do they last? Are there any risks? What does the recovery process entail? Take notes or have someone there with you to help with questions. Your insurance provider should be able to provide your out-of-pocket cost.
With our discectomy procedure, the patient is brought to the operative room, and intravenous sedation is administered. Under anesthesia, a small metal tube is inserted into the spine for direct visualization. This tube serves as a passage for the surgical tools so that the patient’s muscles do not have to be torn or cut. Then, the annular tear, bulging disc, or herniated disc can be found easily under direct visualization by looking through the tube.
Under the guidance of the x-ray fluoroscopy and direct visualization, a piece of the herniated disc is removed with a grasper. A small disc bulge or annular tear can be treated with a laser, which vaporizes disc material, kills pain nerves inside the disc, and hardens the disc to prevent further leakage of disc material to the surrounding nerves. Finally, the tube is removed, and the incision is closed with a stitch or two.
Fortunately, complications are rare, but lumbar endoscopic discectomy may be associated with prolonged bleeding, infection, pain, nerve injury, and spinal fluid leakage. Although rare, in the occurrence of spinal fluid leakage, the patient will be asked to lie down for 24 to 48 hours to enable the leak to seal.
If you have been told by your doctor or think you need lumbar discectomy surgery, herniated disc surgery, bulging disc surgery, slipped disc surgery, or back surgery for a herniated disc, all these will entail the partial removal of a disc. The rewards, recovery, and risks are similar in all of these.
Usually, the patient goes home the same day as the surgery. Your doctor will give you instructions for the first three weeks following the procedure—these help to protect the spine and ensure a full and healthy recovery.
Avoid any task involving lifting, bending, twisting, high-impact activities, and repetitive range of motion of the lower back, including many household chores. Though not required for all patients, the surgeon may recommend a back brace to be worn for comfort. Walking reduces the probability of blood clots and increases blood flow when ready. A proper diet, particularly vitamin A, is essential for healing wounds and tissues post-surgery.
After six weeks, patients are x-rayed to check the spine’s alignment, and incisions are evaluated for healing. Most patients will return to work one to two weeks after surgery, but patients with physically demanding occupations will take up to six weeks to return to work. Prescribed pain medication is usually no longer needed, but extremely high-impact activities are discouraged.
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