| ?Objective?To explore the applied value of anterior cervical endoscopy,side-firing Ho:YAG laser and Lateral Lumbar Interbody Fusion(LLIF);modify mobile microendoscopic discectomy(MMED),then apply to anterior cervical decompression;to summarize the surgical strategy of MMED and percutaneous transforaminal endoscopic discectomy(PTED)for lumbar disc herniation(LDH)associated with vertebral osteochondrosis(VO).?Methods? In the first part,we explored From May 2015 to February 2017,thirty patients with cervical spondylotic myelopathy(CSM)underwent anterior cervical decompression assisted with microscope or MMED.Among them,conventional transverse anterior cervical incisions were used,and intervertebral distractors were placed in order to complete the decompression,then the fusion and fixation procedure were conducted under direct vision,and the operative time and intraoperative blood loss were recorded.Of 30 cases,15 cases were in microscope cohort(anterior cervical discectomy and fusion,ACDF 12 cases;anterior cervical corpectomy and fusion,ACCF 3 cases),including 4 males and 11 females with a mean age of54±11.10 years(range,32-71 years).Another 15 cases were in MMED cohort(ACDF13 cases,ACCF 2 cases),including 9 males and 6 females with a mean age of59.60±11.10 years(range,39-73 years).Neurological and cervical function were evaluated before surgery and at the follow-up according to the Japanese Orthopaedic Association(JOA)and the neck disability index(NDI)scores,and the neurologic improvement grade(NIG)was used to evaluate the neurological function.In the second part,it involved 6 patients with multisegmental cervical stenosis and giant disc herniation confirmed by MRI.Among them,there were 4 males and 2females,with ages from 56-61.All patients showed significant paresthesia or weakness,and were treated between September and November 2016.The surgery was performed by first the ODLP that made spinal cord back shift,and then APECD for the second step.The visual analog scale(VAS)and neck disability index(NDI)were assessed before and after operation.In the third part,26 patients received PELD assisted with side-firing Ho:YAGlaser from May 2018 to September 2018.The lateral transforaminal or posterior interlaminar approach was performed respectively according to the index level.The side-firing Ho:YAG laser was used to remove the hypertrophic ligamentum flavum,osteophytes and the intervertebral disc to decompress the dura sac and nerve root under percutaneous endoscopy.The clinical improvement was evaluated using VAS(Leg)score and ODI before and after the procedure,and the efficacy was evaluated according to the modified Macnab criteria..For the fourth one,214 cases of LDH with VO were treated by MMED from June 2008 to Feburay 2018,including 128 men and 86 women,with an average 39 years old(range,11-67 years old).The involved level included L3/4 in 2 cases,L4/5in 95 cases and L5/S1 in 117 cases.The visual analogue scale(VAS)score and Oswestry dysfunction index(ODI)were used to evaluate the improvement of symptoms and function at last follow-up,and the efficacy was evaluated according to the modified Macnab criteria.For the fifth one,82 cases of LDH with VO were treated by PTED,including 52 men and 30 women,with an average 39.2 years old(range,16-65 years old).On preoperative axial CT,the diameter of ossification was less than half of the transverse or sagittal diameter of the spinal canal,and all patients were operated on the side with serious symptom.The clinical outcomes were evaluated using VAS ? ODI and modified MacNab criteria.At last,we performed a search of PubMed for English-language literature published between 2006 and 2016,and also extracted reference lists from relevant articles.Two independent investigators assessed the strength of evidence considering quality of studies,quantity of studies and consistency of results across studies.?Results ? 1.Both the microscope and MMED cohort underwent decompression successfully,and the visual field was clear.No neurological sympymp.toms became worse.For the microscope,its lens and the instrument had to be adjusted separately,whereas MMED lens could move synchronously with the instrument.It was easier for MMED to reveal the posterior edge of the vertebral body and the left and right side of the spinal canal.The operation time of the microscope cohort was 90-180 min,with an average of 124.67±36.4 min;the MMED cohort was operated for 80-130 min withan average of 110.00±15.12 min,and there was no significant difference between the two cohorts(t=1.440,P=0.161).The intraoperative blood loss for microscope cohort was 20-200 ml,with an average of 66.0±49.11 ml;MMED cohort was 30-150 ml with an average of 60±35.25 ml;there was no significant difference between the two cohorts(t=0.384,P=0.704).The JOA score of the microsurgery cohort improved from8.67±3.20 preoperatively to 15.93±1.53 at the latest follow.up,and its difference was significant(t=8.687,P=0.000).According to NIG,neurological improvement was excellent in 12 cases and good in 3 cases,giving an excellent to good rate of 100%.NDI was reduced from 18.00%±9.75% preoperatively to 5.93%±2.58% at the latest follow.up,with significant difference(t=5.137,P=0.000).The JOA score in MMED cohort improved from 8.87±3.11 preoperatively to 15.53±1.69 at the latest follow.up,and its difference was significant(t=9.413,P=0.000)and Among these 15 patients,11 were excellent and 4 were good,giving an excellent.good rate 100%.NDI decreased from 17.13%±8.00% preoperatively to 5.80%±2.43% at the latest follow.up,and its difference was significant(t=5.592,P=0.000).There was no significant difference in JOA(t=0.680,P=0.502),NIG(P=1.000)and NDI(t=0.146,P=0.885)between the two cohorts at the latest follow.up.2.The VAS and NDI scores were improved two weeks after operation.No adverse events like spinal cord injury and vascular injury were found during the operation.After operation,no patients were found incision infection,hematoma formation,cerebrospinal fluid leakage,dysphagia,trachyphonia and so on.3.The procedure was successful for all patients,and the neurological symptoms were relieved,with VAS score decreasing from preoperative(6.33±0.74)to postoperative(1.33±0.47),ODI scores decreased from preoperative(39.9±10.1)to(3.1±1.2).According to the modified Macnab scale,the results were excellent in 20 cases,good in 6 cases,no cases with moderate or poor outcome;the satisfactory rate had reached up to 100%(26/26).The side-firing Ho:YAG laser could remove the osteophyte and soft tissue that decompresses the nerve or dural sac.For the migrated nucleus pulposus that is difficult to reach for the forcep,the laser could be used to ablate the nucleus pulposus with the nerve root and dural sac released without tension.4.The soft herniation and the periphery of compressing ossification were removed via MMED in all cases,until the nerve was well decompressed.However,the ossification was not complete resected.Except 3 cases of dural tear and 1 case of non healing wound,other patients underwent MMED successively.At the final follow-up of 12-60 months(average,21.8months),VAS decreased from preoperative7.66±1.25 to 0.64±0.78,ODI scores decreased from preoperative 45.52±12.31 to4.66±5.84.ODI and VAS after operation showed significant difference compared to that before operation(P<0.05).According to the modified Macnab scale,the results were excellent in 83,good in 114 cases,moderate in 17 cases;the satisfactory rate had reached up to 92%(197/214).5.In the early stage of PTED,2 cases converted to MMED because of intraoperative pain and difficulty,and one case had exiting nerve root injury.At the final follow-up of 12-60 months(average,20.6 months),VAS decreased from preoperative 7.88±1.20 to 0.70±0.83,ODI decreased from preoperative 46.00±11.71 to 4.80±5.90.According to Macnab scale,the results were excellent in 36,good in 39 cases,moderate in 7 cases,the satisfactory rate had reached up to 91.46%(75/82).6.A total of 315 articles were initially screened,with 42 ultimately meeting inclusive criteria.The incidence of transpsoas-related neurological complications ranged considerably from 0.6% to 75%.Also,among those reports,14 reported all sensorimotor symptoms disappeared completely within 6 months.In the last follow-up,however,some of patients were not free of residual symptoms.Eleven studies reported risk factors associated with neurological symptoms,but most of them need more studies to validate their reliability.?Conclusion? Anterior cervical endoscopy can preserve cervical intervertebral disc and motion segments,therefore delaying the degeneration of adjacent segments with clinical significance.The side-firing Ho:YAG laser could remove the bony compression and adhesive scar.Hence,the application of Ho:YAG laser made the endoscopic surgery safer with thorough decompression.Given that risk factors for LLIF are controversial,current preventive measures still require further studies in clinical practice.Secondly,MMED could provide a clear and magnified field of view,which was beneficial for the anterior cervical decompression and VO to ensure betterclinical results.In contrast to MMED,PTED is still suitable for part of LDH with VO.All in all,it is promising to achieve the same or better effectiveness compared to open surgery with the promotion of new technology and modification of original technology in the field of minimal invasive surgery for degenerative spinal diseases. |
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