Percutaneous posterior cervical disc herniated nucleus pulposus resection

Resection of cervical disc herniation through the posterior approach was initiated in the 1940s and was mainly used for lateral cervical disc herniation in shoulder and shoulder pain. Spurling et al. (1953) used a dental drill to drill holes between the lamina and articular surfaces. Scoville called it a key hole for amenotomy. Some authors also used semi-laminar resection, even with articular surfaces. Most or all of them are removed. It is generally believed that total articular surface resection can affect the stability of the cervical spine. Many authors have used cervical anterior approach to remove various types of cervical disc herniation, but anterior surgery for lateral compression patients with nerve compression seems to be too large. Curing disease: Indication Percutaneous posterior cervical disc herniation of the nucleus pulposus is applicable to the lateral (or posterolateral) type of cervical disc herniation, causing severe shoulder and arm pain, numbness and weakness of the affected limb, and ineffective by conservative therapy. Contraindications 1. The central and lateral central (or ventrolateral) type of cervical disc herniation, the posterior surgery is highly damaging. 2. Cervical spondylotic myelopathy is difficult after posterior surgery. Preoperative preparation 1. General preparation of the whole body According to the condition and examination, actively improve the general condition of the patient, and give all necessary supplements and corrections. 2. Those with constipation, laxatives were given before surgery, and enema was given on the night before surgery. Those with dysuria should be catheterized before surgery and indwelling catheter. 3. If you need a prone position after surgery, you should perform prone position training in advance so that the patient can adapt to this position. 4. A sedative was given before the operation, and phenobarbital 0.1 g. 5. Fasting within 6-8 hours before surgery. 6. Prepare the surgical skin before surgery and clean the shaving. The range should be more than 15cm around the incision. 7. Give medication before anesthesia according to the needs of anesthesia. 8. Preoperative positioning should determine the position of the spine that is scheduled to remove the lamina. The easiest way is to locate according to the body surface markers. Due to the difference in body shape, the marker positioning may have an error of 1 or 2 spinous processes. In order to avoid the error, it can be positioned according to the body surface marker, and then a type of lead is glued on the body surface of the corresponding spinous process. After taking the X-ray film, the surgical site is verified from the position of the lead on the X-ray film. Surgical procedure Surgical incision The midline neck incision is 6-8 cm long, and the incision is 4-5 cm during microsurgery. 2. Intraoperative positioning According to the surface anatomy of the seventh cervical spine, in the estimated lesion plane, the injection needle is inserted into the interspinous ligament 1 to 1.5 cm deep, and the cervical X-ray lateral radiograph is taken to determine the intervertebral space. 3. Reveal the lamina and articular surface The paravertebral muscle was exfoliated from the spinous process and the lamina to the articular surface with a periosteal screwdriver. The upper and lower lamina of the intervertebral space were exposed, and the paravertebral muscle was pulled to the lateral side by a single-sided automatic retractor. Soft tissue on the articular surface. 4. Keyhole-like window A high-speed micro-drill is drilled in the vicinity of the lamina and the articular surface, and the medial part of the articular surface is excised no more than 1/2 of the total articular surface to form a bone window of about 1 cm in diameter. After the bone window is formed, the ligamentum flavum is removed and the extradural fat should be removed. Be careful not to damage the venous plexus. Once the venous plexus is bleeding, the amount of bleeding is often many. It can be bipolar electrocoagulation to stop bleeding. It can also be used to stop bleeding with a cotton thread. The lateral part of the dural sac and the nerve root cuff are exposed. The thick sensation root is in the shallow part, and the fine movement root is deep, and the protruding intervertebral disc tissue is tightly squeezed. 5. Nucleus pulpectomy Generally, the nerve root is pulled upward, and the protruding portion of the intervertebral disc can be cut, but according to recent data, it is easy for many patients to see that the nucleus pulposus or its fragments have been detached from the rupture of the annulus fibrosus and the posterior longitudinal ligament. Excision with nucleus pulposus, and then check for the presence of scattered nucleus pulposus fragments in the adjacent epidural space. There is no prominent nucleus pulposus tissue in the intervertebral space. It is removed at the time of discovery, but it is generally not recommended to enter the deep intervertebral space. Intervertebral disc tissue. 6. Suture incision The deep fascia, subcutaneous tissue and skin are sutured layer by layer. complication 1. During the operation, the nerve roots are excessively pulled, causing numbness and weakness of the postoperative limbs, and most of them are temporary. 2. Epidural hematoma Paravertebral muscles, vertebrae and epidural venous plexus are not completely hemostasis. Hematoma can form after operation, resulting in aggravation of limb paralysis, which occurs within 72 hours after surgery. A hematoma can occur even when the drainage tube is placed. If this phenomenon occurs, it should be actively checked to remove the hematoma and completely stop bleeding. 3. Spinal cord edema is often caused by surgical operation to damage the spinal cord, and the clinical manifestations are similar to hematoma. The treatment is mainly dehydration and hormones; in severe cases, the dura mater has been sutured, and the operation can be performed again to open the dura mater. 4. Cerebrospinal fluid leakage is caused by loose suture of the dura mater and/or muscle layer. If there is drainage, it should be removed in advance. If the leakage is less, the dressing is observed. If it cannot be stopped or the fluid is leaked, the leak should be sutured in the operating room. 5. Incision infection and rupture are generally poor, and the wound healing ability is poor or cerebrospinal fluid leakage is easy to occur. Intraoperative attention should be paid to aseptic operation. In addition to antibiotic treatment, it should actively improve the general condition, paying special attention to the supplement of protein and multivitamins. Special parts such as between the shoulder blades should be reinforced with muscle layer sutures.