Lumbar disc herniation

Lumbar disc herniation is a common cause of low back pain. On the basis of lumbar disc degeneration, the damage of the waist tends to cause the nucleus pulposus and the damaged annulus fibrosis to protrude backward, and the nerve root is pressed to cause a series of clinical manifestations. However, the causes of sciatica are various, and sometimes the diagnosis is difficult. Clinically, lumbar tuberculosis or other diseases are misdiagnosed as disc herniation and surgery is performed; there is also a preoperative diagnosis of disc herniation, but no intraoperative findings; although some cases can be retracted by nucleus pulposus under anesthesia to explain However, it also explains the complexity of the diagnosis; in addition, the spinal canal, crypt, and root canal stenosis increase the difficulty of diagnosis, and must exclude tumors, deformities, and other diseases. Therefore, detailed examination before surgery, careful analysis, plus various auxiliary examinations, such as myelography, lumbar anterior epidural angiography, discography, etc., have certain value for diagnosis and localization. The clinical application of modern ct scan, ctm and mri has greatly improved the diagnostic accuracy. However, all these tests can still have false positives or false negatives, so they must not rely on instrumentation and ignore clinical examinations, and do not need to be used as a routine application. Non-surgical treatment is available early in the disease, and only some patients require surgery. The purpose of the surgery is to remove the prominent nucleus pulposus and free fibrous annulus tissue to relieve the nerve root compression. This operation is not a major operation, but requires meticulous and skillful, and the surgical results are satisfactory. For those cases where the diagnosis is not yet confirmed, non-surgical treatment should be performed first, and repeated examinations should be carried out to further confirm the diagnosis, and it is not possible to use the exploration as a means of diagnosis. The effect of lumbar disc herniation can be as good as 78% to 92%. Reports of poor results ranged from 4.6% to 8%, with most patients requiring reoperation. The reasons are mostly due to: 1 diagnosis error; 2 positioning error, disc herniation is not removed; 3 improper selection of indications; 4 techniques are unskilled or rough operation causes bleeding, nerve root adhesion or injury and other complications; 5 surgery is not complete; 6 postoperative infection; 7 nerve root compression time is too long. Therefore, affirmative diagnosis, strict indications, timely surgery, meticulous and careful operation and prevention of complications are fundamental measures to improve the efficacy of surgery. Treatment of diseases: lumbar disc herniation, thoracic disc herniation Indication 1. The diagnosis of lumbar disc herniation is clear, the nerve root compression is heavier, non-surgical treatment is ineffective, or repeated authors should be treated with surgery. 2. The central type of intervertebral disc protrudes, causing the feeling of lower limbs and perineum and muscle weakness, and those with difficulty in urinary and bladder should be treated early or in emergency. Preoperative preparation 1. Preoperative positioning is the most important. In general, according to detailed examinations (including sensory impairment areas, weak muscle strength, abnormal reflections, most obvious lumbar tenderness, etc.), it can be judged which disc protrusion and nerve root are compressed. See Table 1 for details: However, the herniated disc may have different symptoms and signs due to different parts or prominent pathology. The protruding portion can be a central type, a central side type, an outer type, and an outer side type. The prominent pathology can be bulging type, protruding type, prolapse type, and free type. The free form can exist in various parts of the spinal canal and even protrude into the dural sac. In addition, the presence of intervertebral disc herniation on the same side or both sides is not uncommon, and a few are prominent with the ringworm. Sometimes the above can also be combined to make the clinical symptoms and signs complex, which needs to be analyzed and judged, and further judged according to judgment. Perform the necessary auxiliary tests to make the correct preoperative diagnosis and positioning. 2. X-ray films should be taken routinely before surgery, except for lesions of the lumbar, atlas and ankle joints (such as vertebral tuberculosis, tumors, etc.) to avoid misdiagnosis. According to the change of the lumbar spine physiological curvature, the prominent intervertebral space is mostly narrow, and the long period of the disease can be seen in the vertebral body with lip-like hyperplasia, which can be helpful for diagnosis. In addition, x-ray films can also show congenital variation, the number of lumbar vertebrae and the height of the humeral condyle plane, which can be used as the basis for surgical positioning. For cases of suspected spinal stenosis, a ct check should be performed. 3. Patients need to stay in bed for 2 to 4 weeks after surgery. Preoperative attention should be paid to the practice of bed rest and urination in order to reduce the difficulty of postoperative bowel movements. 4. Generally, there is little bleeding during surgery, and there is no need for blood matching, but the blood should be matched for the weak. Surgical procedure 1. Position: For cases with unilateral protrusion, lateral position should be adopted, so that the interlaminar space can be performed satisfactorily for surgery; the abdomen will not be compressed, so as to avoid epidural venous plexus congestion, which can reduce intraoperative bleeding. When lying on the side, the diseased side is on, and the position of the spine, hip, and knee flexion is maintained to expand the interlaminar space. In order to fully expand the laminar space of the diseased side, a soft pillow can be placed on the waist or the waist bridge of the operating table can be raised. For bilateral disc herniation, central protrusion and combined spinal canal and root canal stenosis, prone position should be used for bilateral exploration and resection. Apply a long round soft pillow to the sides of the torso when lying down to avoid pressure on the abdomen. The ends of the operating table are shaken low, so that the lumbar vertebrae are located in the anterior flexion and the interlaminar space is deployed. 2. Incision, revealed: the incision was made from the midline of the 4th lumbar spine to the 1st sacral spinous process. First, close the spinous process on the disease side to cut the deep fascia, peel the sacral spine muscle under the periosteum [see the way of revealing the spine], and the lateral peeling should reach the posterior joint once, so as to avoid the peeling and hemostasis later and prolong the operation time. The incision can be opened by the automatic laminating hook, and the diseased side lamina and the ligamentum flavum can be clearly revealed. If you want to reveal the two sides of the lamina, you can expose the opposite side in the same way. Generally, only one side of the lamina can be revealed by simply protruding one side. 3. Enlarge the interlaminar space: After correct positioning, the intervertebral space of the waist 5~1 is large, and most of them do not need to be enlarged; but more than 4~5 of the waist need to be cut off part of the lamina to achieve sufficient exposure. When expanding, the lower edge of the upper lamina can be bitten by a rongeur and expanded to the required range, generally to accommodate the end of the little finger. Bone surface bleeding with bone wax to stop bleeding. 4. Resection of the ligamentum flavum: In the enlarged laminar space, use the tip of the sharp-edged knife to close the lower edge of the ligament of the ligament next to the spinous process, and lift it up with a hemostatic forceps. This cuts the ligamentum flavum in one piece upwards and outwards. During operation, the tip of the blade should be kept in the field of view, not exceeding the inner surface of the ligamentum flavum, and the blade surface should always be upward and carefully cut to avoid damage to the dura mater and nerve root in front of the ligamentum flavum. The ligamentum flavum, often in the intervertebral disc herniation, is thick and brittle, and is easily torn when pulled. It should be noted. The remaining ligamentum flavum can be removed with a nucleus pulposus. 5. Exploring and revealing disc herniation: After the ligamentum flavum is removed, the dura mater and its lateral nerve roots can be revealed. The dura mater and epidural fat were separated by a dura mater, the nerve roots were found, and the nerve hooks were gently pulled apart for direct visual exploration inside and outside. Most of the prominent sites are tensioned spherical bulges, and some have been ruptured. The damaged fibrous annulus tissue can be freed near the nerve roots in the spinal canal or at a distant location. If the disease is long, there are different degrees of adhesion around the nerve root and the nearby dura mater. It should be carefully separated, and do not damage the nerve root and dura mater. A few cases stand out and don't miss it. After finding the nucleus pulposus, it should be replaced with a nerve root puller. The nerve root pull hook should be circular arc shape, which is not easy to damage the nerve, and will not affect the surgical field when the protruding intervertebral disc is removed. When exposed, if the gap is insufficient to expand and affect the operation, the extent of laminectomy should be appropriately enlarged. When using a laminar rongeur to bite the bone, the epidural adhesion should be separated by a dura stripper, and then the anterior vertebral plate is inserted tightly against the front of the lamina to avoid injury to the dura mater and nerve. root. The bone chips should be removed at any time and should not be left in the spinal canal. 6. Excision of the nucleus pulposus and free annulus tissue: According to the prominent site, the nerve root is pulled to the medial or lateral side to reveal the prominent intervertebral disc. If the protrusion is high, the nerve root should not be pulled open. The partially protruding intervertebral disc should be removed first, so that the nerve root is relaxed and then pulled apart to avoid nerve root damage. Properly protect and pull open the nerve root and dura mater, clearly reveal all the spherical protrusions, and cut the protrusion with a sharp-edged knife + shape. Use a small and secure saw-like action when cutting, do not injure the surrounding important tissues, and try to avoid the dilated veins. If it cannot be avoided, it should be treated by bipolar coagulation. The disc with large tension protrudes. After the incision, there is a nucleus pulposus and a broken fibrous ring. The nucleus pulposus and a small curette can be inserted into the intervertebral disc to remove the free fibrous ring tissue to avoid residue and stand out in the future. However, care must be taken not to penetrate too far and bite too much of the annulus fibrosus to avoid breaking the intervertebral aorta and the inferior vena cava in front of the vertebral body. It should be removed within the sagittal diameter of the gap shown by the x-ray film. If there is lip-like hyperplasia at the posterior edge of the vertebral body, it should be carefully removed. The side crypt was explored without stenosis. The lateral ligamentum flavum was completely removed, and the nerve root canal was examined. The lateral movement of the nerve root was up to 1 cm. During the operation, bone or fiber ring fragments should be removed at any time to avoid being pushed and left around the dura mater and nerve roots, which will affect the efficacy in the future. Sometimes bleeding may occur, mostly due to damage to the anterior venous venules. You can use light black cotton with a black cotton thread to block the hemostasis. The operation can still be performed as usual. When the disc is removed, the cotton can be removed. Most of them no longer bleed. 7. Hemostasis and suture: Hemostasis must be thorough, including bleeding in the spinal canal and muscles, so as to avoid hematoma and adhesions and postoperative pain. In the process of hemostasis, the position of the spinal anesthesia should be removed, and the pressure on the large veins in the abdominal cavity should be relieved to stop the bleeding. All the occluded cotton sheets were taken out, and the epidural was covered with a free thin layer of fat sheets (taken from the skin), and after the negative pressure drainage, the wounds were washed and sutured layer by layer.