| Objective: Lumbar Disc Herniation(LDH)is a common disease in spine surgery and the most important cause of Lumbar and leg pain.Severe cases may result in difficulty urinating and defecating and paralysis of the lower limbs.With the progress of society,the incidence of lumbar disc herniation is gradually rising as people sit for a long time and sit at their desks for a long time,which poses a great threat to patients’ health.For LDH patients,unless there is serious neurological dysfunction,the first conservative treatment;If conservative treatment fails,surgery is required.Spinal surgery can be divided into traditional open surgery and minimally invasive surgery.Open surgery has many disadvantages,such as large trauma,hemorrhage and postoperative spinal epidural scar adhesion,which affects the recovery of postoperative spinal function and long-term efficacy.Minimally invasive spine surgery is favored by more and more patients and doctors because of its advantages of less trauma,less bleeding and fast postoperative recovery.If the protrusion occurs again on the same side of the same level as in previous discetomy after the operation,it is called the recurrence of LDH.With the development and progress of minimally invasive spinal surgery techniques and instruments,spinal endoscopic surgery is becoming more and more popular,and the surgical indications are gradually expanding.However,the number of recurrences and secondary surgeries after spinal endoscopy is gradually increasing,and the secondary surgeries bring tremendous pressure to patients psychologically,physiologically and economically.Percutaneous Endoscopic Lumbar Discectomy(PELD)can be divided into two types according to different paths: Percutaneous Transforaminal Endoscopic Discetomy PTED)and Percutaneous Endoscopic Interlaminal Discetomy(PEID).1.This study evaluated and compared the clinical efficacy of two groups(PTED group and PEID group)through multiple scoring criteria,and studied the postoperative efficacy of two different approaches for spinal endoscopic surgery.To summarize and analyze the risk factors for recurrence after spinal endoscopy,to provide theoretical basis for the prevention of recurrence of lumbar disc herniation after endoscopy,and to reduce the probability of recurrence after surgery.2.Currently,the clinical treatment of recurrent LDH after spinal endoscopy is not clear.Through the evaluation and analysis of various treatment strategies for patients with postoperative recurrence,the treatment plan for patients with postoperative recurrence was studied to further improve the treatment effect of recurrent LDH.3.PTED removal of the nucleus pulposus requires the formation of intervertebral foramen and removal of facet joints in order to avoid nerve damage.Facet joints play an important role in the stability of lumbar spine,and lumbar instability is one of the main reasons for poor postoperative efficacy.The size and location of the removed facet joints are of great significance to the biomechanics and clinical efficacy of lumbar spine.Under the same working conditions,different biomechanical models of foraminoplasty were used to compare and analyze the influence of stepwise resection of the superior articular process on the range of motion and stability of the lumbar spine,so as to obtain reasonable model parameters,so as to avoid iatrogenic lumbar instability to a certain extent.Methods: A total of 2383 patients were treated with PTED or PEID in our hospital from January 2013 to October 2019.Among the patients who met the inclusion and exclusion criteria of this study,66 patients were selected for recurrence after spinal endoscopy and a second operation,and 132 patients were selected for non-recurrence according to the 1:2 matching scheme(same age,same gender).A total of 198 patients were included in the study.According to different surgical approaches,198 subjects were divided into PTED and PEID groups,including 134 cases of PTED and 64 cases of PEID.The specific research methods are as follows:1.Relevant clinical indicators(gender,age,smoking,diabetes,body mass index,Lee division,Modic change,etc.)and VAS,JOA,NRS,ODI of patients before surgery,1 week,1month,3 months,6 months after surgery and 1 year after surgery were analyzed in PTED and PEID groups.Macnab and other scoring criteria were evaluated and compared.Objective To study the postoperative efficacy of two different approaches for spinal endoscopic surgery.To analyze the factors related to recurrence after spinal endoscopy and explore the risk factors of recurrence after spinal endoscopy.2.The surgical methods and preoperative and postoperative clinical indicators of 66 patients with recurrence and secondary operation after spinal endoscopy were observed during the first operation,and the scores of VAS,JOA,NRS,ODI and Macnab at 1 week,1 month,3 months,6months after surgery and 1 year after surgery were analyzed.3.Import the lumbar CT scan cross-sectional image data obtained by the imaging Center of our hospital into Mimics software;The three-dimensional model of lumbar spine was constructed,the material properties were given,the mesh of the model was divided,the contact surface,boundary conditions and loads were set.The lumbar stability was compared between the unilateral superior facet resection model and the normal lumbar model.Results: 1.VAS,JOA,NRS,ODI and Macnab scores of PATIENTS in PTED and PEID groups showed no statistically significant differences between the two groups;The advantages of PTED and PEID surgery are comparable.There were no statistically significant differences in gender,age,smoking status,diabetes status and other variables between the two groups(66 cases with recurrence and second operation after endoscopic surgery,132 cases without recurrence after endoscopic surgery).The results of logistics regression analysis showed that the history of trauma,duration of disease,body mass index,postoperative work intensity,Modic sign and lumbar motion were risk factors for postoperative recurrence of patients.2.In this study,the main treatment strategies for 66 patients with postoperative recurrence and surgery were foraminoscopy,laminoscopy and fusion fixation,of which 35 cases were foraminoscopy,10 cases were laminoscopy and 21 cases were fusion fixation,accounting for53.03%,15.15% and 31.82% respectively.VAS,JOA,NRS,ODI and Macnab scores were significantly improved in all patients after secondary surgery.3.The maximum Angle of normal lumbar spine model is 5.62° under forward bending condition,2.81° under extension condition,3.71° under lateral bending condition and 2.14° under torsion condition.For the half resection model,the maximum Angle is 6.04° under forward bending,2.89° under extension,4.20° under lateral bending,and 2.29° under torsion.In the complete resection model,the maximum Angle was 7.45° under forward bending,2.98° under extension,4.86° under lateral bending,and 3.32° under torsion.Conclusions: 1.Perioperative clinical baseline data of PTED and PEID groups were isostatic,and the postoperative efficacy evaluation of PTED and PEID groups was the same;Patients with a history of trauma,Modic sign,lumbar mobility,and obesity(BMI ≥28)are prone to recurrence after surgery,and the best surgical plan should be fully evaluated before surgery.Postoperative high intensity workers are easy to relapse,so postoperative appropriate rest and gradually strengthen the lumbar back muscle functional exercise.2.Reendoscopic surgery or fixed fusion surgery can achieve good results.Patients undergoing secondary surgery had difficulties such as nerve root adhesion and unclear anatomical structure.Surgeons with rich clinical experience formulated personalized surgical plans according to the specific conditions of patients.3.When PTED may adopt the articular process on grading resection(removal of the size less than or equal to one half)or directly to resection,articular process on the ventral articular process according to the different status of intervertebral disc herniation can take joint way of two kinds of resection,resection of quantity is less than or equal to one half or directly to removal of articular process on the ventral does not affect the stability of the spine.In this paper,the research results on the biomechanical mechanism of spinal endoscopic foraminoplasty by finite element method have certain clinical guiding significance for the standardization and unification of spinal endoscopic foraminoplasty,which may benefit more patients in the future. |
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