| Background: Lumbar disc herniation is a common disease in the field of spine surgery.Lumbar disc herniation refers to the lumbar disc degenerative changes after the external force,some or all of annulus rupture.Prominent nucleus pulposus to the nerve root and result in low back pain as the main symptom of the disease.In the late 1990 s,with the emergence of coaxial endoscopic spine system(Yeung Endoscopic Spine System,YESS),percutaneous endoscopic lumbar discectomy(PELD)is gradually applied to clinical treatment.Because of the anatomical feature of Lamina,intervertebral foramen and in the space(L4/5 laminar space is relatively narrow),the traditional view is that interlaminar approach PELD could undergo some risk such as nerve injury.Most clinicians advocate transforaminal approach of surgical treatment.For some patients with protruding disc tissue down or backward shift,clinicians need to abrade the facet joints and pedicle bone part.Occasionally,sometimes patients complain of postoperative leg pain.The lumbar MRI examination revealed that protruding disc tissue is not thoroughly removed.Objective: In this study,we measure the height and width of the laminar space to evaluate whether it is feasible to take laminectomy approach PELD to treat L4/5 disc herniation.We compared between the transforaminal approach and laminectomy approach PELD to evaluate the clinical efficacy of two surgical methods.Methods: A retrospective analysis of 107 patients with L4/5 disc herniation who underwent PELD,including 58 patients underwent interlaminar approach surgery,49 patients underwent transforaminal approach surgery.This study was divided into two parts.Part one: 58 laminectomy approach PELD surgery patients take flexion kneeling position.Doctor use C-arm to take X-ray of the lumbar spine and measure the height and width of L4/5 laminar space.Then we measure the height and width of the X-ray of the prone position lumbar spine of these patients.We use paired samples t-test to handle the data and verify whether there are statistical differences between the two position.Part two: We collect the data of the two surgical approach such ai operation time,preoperative leg pain and back pain visual analog scale(Visual Analogue Scale,VAS)score and VAS of the first day,3 months,6 months after surgury,Oswestry Disability index(Oswestry Disability index,ODI)score of preoperative time and ODI of the first day,3 months,6 months after surgury,modified Macnab evaluation standard result 6 months after the surgery,the number of days in hospital after the surgery.We use independent sample t test to handle the measurement data,and use rank sum test to handle ranked data and verify whether there are statistical differences between the two surgical approach.Result:The X-ray of lumbar spine at flexion kneeling showed that the height of L4/5 laminar space vary from 9.3 ~ 18.3mm,mean(14.55 ± 2.34)mm.The X-ray of lumbar spine at prone position showed that the height of L4/5 laminar space vary from 12.5 ~ 20.5mm,mean(16.75 ± 2.23)mm.The height of laminar space of flexion kneeling position significantly increase in L4/5 compared with the prone position.The difference is statistically significant(P <0.05).The X-ray of lumbar spine at flexion kneeling showed that the with of L4/5 laminar space vary from 21.5 ~ 25 mm,mean(23.94 ± 0.61)mm,.The X-ray of lumbar spine at prone position showed that the width of L4/5 laminar space vary from 21.6 ~ 25 mm,mean(23.97 ± 0.55)mm.The two values are of no statistically significant difference(P> 0.05).All patients were followed up for more than six months.The average surgical time of the patients underwent interlaminar approach PELD patients is(55.50 ± 14.34)min;preoperative leg pain VAS score was 7.84 ± 0.46,low back pain VAS score was 3.54 ± 0.28;leg pain VAS score was 1.14 ± 0.38 and back pain VAS score was 1.51 ± 0.22 the first day after the surgery;leg pain VAS score was 0.61 ± 0.41 and low back pain VAS score was 0.53 ± 0.37 3 months after the surgery;leg pain VAS score was 0.61 ± 0.41 and low back pain VAS score of 0.53 ± 0.37 6 months after the surgery;The preoperative ODI score was(81.29 ± 6.05)%,ODI score was(15.97 ± 4.77)% the first day after the surgery and was(13.60 ± 3.88)% 3 months after the surgery,and was(13.16 ± 3.70)% 6 months after the surgery;Modified Macnab evaluation standard for efficacy evaluation 6 months after the surgery: excellent in 38 cases,good in 12 cases,moderate in 8 cases.The average postoperative hospital stay time was(2.62 ± 0.49)days.The average surgical time of the patients underwent transforaminal approach PELD patients is(55.63 ± 10.90)min;preoperative leg pain VAS score was 7.85 ± 0.43,low back pain VAS score was 3.55 ± 0.28;leg pain VAS score was 1.18 ± 0.36 and back pain VAS score was 1.52 ± 0.21 the first day after the surgery;leg pain VAS score was 0.59 ± 0.40 and low back pain VAS score was 0.56 ± 0.35 3 months after the surgery;leg pain VAS score was 0.59 ± 0.40 and low back pain VAS score of 0.56 ± 0.35 6 months after the surgery;The preoperative ODI score was(80.84 ± 6.06)%,ODI score was(16.08 ± 4.80)% the first day after the surgery and was(13.80 ± 4.00)% 3 months after the surgery,and was(13.10 ± 3.70)% 6 months after the surgery;Modified Macnab evaluation standard for efficacy evaluation 6 months after the surgery: excellent in 35 cases,good in 10 cases,moderate in 4 cases.The average postoperative hospital stay time was(2.61 ± 0.49)days.The were no statistically different between the two groups of patients of leg pain and low back pain VAS score before operation time and 1 day,3 months,6 months after the operation time,ODI score 6 months after the operation and modified Macnab evaluation standard outcomes(P> 0.05).Conclusion: The lumbar curvature can significantly reduce when patients take flexion kneeling position,increasing the activity of working channel and safety of interlaminar approach surgery.Surgeon could reduce vertebral lamina bone resection when patients under this position.This surgical approach is safe and feasible.When the treatment of interlaminar approach compared with transforaminal approach at the operation time,leg pain and low back pain VAS score before operation time and 1 day,3 months,6 months after the operation time,ODI score 6 months after the operation and modified Macnab evaluation standard outcomes,there were no statistically difference.Interlaminar approach is safe and effective minimally invasive surgical approach. |
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