| Objective 1.To provide anatomic data for spinal endoscopy via percutaneous intervertebral foramen approach by dissecting the corpses of healthy Chinese adult to study the applied anatomy of L1-S1 intervertebral foramen.2.A comparative study of percutaneous intervertebral foramen approach and traditional open interlaminar fenestration in the treatment of posterior ring apophysis separation（PRAS）and to discuss the feasibility,safety,minimally invasive and efficacy of transforaminal spinal endoscopy in the treatment of PRAS.Methods 1.Twelve healthy adult Chinese corpses were dissected,the morphology of intervertebral foramen and the course of nerve root were observed,the width of upper,middle and lower intervertebral foramen on sagittal plane,the height of intervertebral foramen and the vertical distance from the lower edge of outlet nerve root to the inferior margin of intervertebral foramen,the vertical distance from the tip of the superior articular process（shoulder）to the outlet nerve root,the horizontal distance from the outlet nerve root above the midpoint of the posterior edge of the intervertebral disc to the posterior edge of the intervertebral foramen,the area of the intervertebral foramen,the distance between the longitudinal vertical line of the inner edge of the pedicle and the dural sac on the coronal plane were measured.The data of each group were recorded and statistically analyzed to explore the safety of spinal endoscopy through percutaneous intervertebral foramen approach.2.Forty patients with lumbar posterior edge amputation complicated with lumbar disc herniation were divided into two groups:minimally invasive group（n=22）and open group（n=18）.The preoperative and postoperative general conditions（incision length,intraoperative blood loss,operation time,intraoperative fluoroscopy times,postoperative ground time,postoperative hospital stay and complications）,laboratory indexes（preoperative and postoperative）were compared between the two groups.C-reactive protein,procalcitonin,interleukin-6,creatine kinase and aldosterone were measured on the 1st day and 3rd day after operation,VAS score and ODI index before and after operation.Modified MacNab criteria and postoperative imaging examination were used to evaluate the clinical efficacy.Results 1.（1）there was no significant difference between the left and right sides of the measured values of each segment of L1/L2-L5/S1（P>0.05）.Therefore,the mean values of bilateral combination were as follows:the upper width of intervertebral foramen in L1/2-L5/S1 was（8.59±0.67）,（11.23±0.96,9.55±0.80,8.80±0.62）and（7.67±0.69）mm;,respectively.The width of the middle intervertebral foramen was（5.34±0.29）,（7.09±0.38）,（6.45±0.48）,（5.93±0.48）,（5.19±0.41）mm;The width of the lower part of the hole:（4.86±0.62）,（6.37±0.86）,（5.82±0.85）,（5.16±0.62）,（4.55±0.58）mm;Vertical height of intervertebral foramen:（14.80±1.11）,（15.22±1.24）,（15.21±1.06）,（14.35±1.26）,（13.51±1.15）mm;The vertical distances from the inferior margin of the outlet nerve root to the inferior edge of the intervertebral foramen were（8.17±0.79）,（9.43±0.99）,（9.13±0.87）,（8.63±0.86）and（7.51±0.59）mm;The vertical distance from the tip of the superior articular process（shoulder）to the outlet nerve root was（3.62±0.89）,（4.35±1.18）,（4.13±1.10）,（3.87±1.08）,（3.15±1.00）mm;the horizontal distance of nerve root from the midpoint of intervertebral disc to the posterior edge of intervertebral foramen:（4.92±0.69）,（6.20±0.97）,（5.81±0.84）,（5.55±0.78）,（4.52±0.60）mm;Intervertebral foramen area:（109.17±18.04）,（120.42±20.07）,（117.14±19.08）,（112.24±19.59）,（99.56±17.30）mm2;The distance between the vertical line of the inner edge of the pedicle and the dural sac was（3.46±0.54）,（3.77±0.65）,（4.57±0.78）,（5.30±0.98）,（4.13±0.75）mm.2.All patients were followed up for 6 to 12 months（mean 7.3 to 1.9months）.The operation time in the minimally invasive group was longer than that in the open group,and the number of intraoperative X-ray fluoroscopy in the minimally invasive group was significantly longer than that in the open group（P<0.05）.The length of incision,the amount of blood loss during operation,the time of going down to the ground and the days of hospitalization in the minimally invasive group were significantly less than those in the open group.There was significant difference（P<0.05）.In the open group,there were 1 case of cerebrospinal fluid leakage,1 case of extensor dorsi muscle strength and 1 case of numbness of the affected limb,and 1 case of abnormal sensation of the affected limb after operation in the minimally invasive group.Postoperative imaging examination showed that 19 cases（86.4%）were completely resected and 3 cases（14.6%）were partially resected in the minimally invasive group.In the open group,16cases（88.9%）were completely resected,2 cases（11.1%）were partially resected,and all the herniated intervertebral disc tissues were completely resected.The VAS scores of low back pain and leg pain at 1 day,7 days,1 month and 6 months after operation in the two groups were significantly different from those before operation（P<0.05）.The VAS scores of low back pain in the minimally invasive group were lower than those in the open group on the 1st day and 7th day after operation.There was no significant difference in the VAS score of low back pain between the two groups at 1 month and 6 months after operation（P>0.05）,but there was no significant difference in the score of low back pain between the two groups at 1 month and 6 months after operation（P>0.05）.There was no significant difference in VAS score of leg pain between the two groups at 1 day,7 days,1 month and 6 months after operation（P>0.05）.There was significant difference in ODI score between the two groups at 1 month and 6 months after operation（P<0 05）,but there was no significant difference in ODI score between the two groups at 1 month and6 months after operation（P>0 05）.The modified Macnab standard was used to evaluate the clinical curative effect.the excellent and good rate was 90.9%in the minimally invasive group and 88.9%in the open group.The levels of C-reactive protein,calcitonin,interleukin-6,creatine kinase and aldosterone in the open group were significantly higher than those in the minimally invasive group on the 1st and 3rd day after operation（P<0.05）.Conclusions:（1）The upper and lower width of the normal intervertebral foramen was narrow and in the shape of inverted pear,the outlet nerve roots were mostly located in the upper part of the intervertebral foramen,and the height and area of the intervertebral foramen did not limit the diameter of the 7.5mm intervertebral foraminal working channel.when the TESSYS intervertebral foramen technique was used,It is necessary to carry out effective intervertebral foramination in order to facilitate the placement of working channels.（2）Both transforaminal endoscopy and open interlaminar fenestrationin the treatment of lumbar PRAS can achieve satisfactory results.the medium-term clinical effects of the two methods are similar,and the early advantages of transforaminal spinal endoscopy are obvious.Transforaminal spinal endoscopy in the treatment of lumbar PRAS has good safety,minimally invasive,feasibility and effectiveness,and also provides a new idea for the minimally invasive treatment of PRAS. |
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