【Abstract】 Objective To evaluate
the therapeutic effects of lumbar disk herniation treated by semiconductor
laser. Methods One-hundred cases of lumbar disk herniation diagnosed by clinic
and CT or MRI within three months underwent percutaneous laser disk
decompression, including 65 cases of L4-5 and 35 cases of L5-S1 disk. Results
In this group of patients, the successful rate of penetration was 100% and the
rate of efficiency was 72%. There was no complication in the following 6-18
months. Conclusion Percutaneous laser disk decompression with semiconductor laser
was a convenient, safe, efficient and minimally invasive technique.
【Key words】 Diskectomy,
percutaneous; Laser surgery; Radiology, interventional
In
recent years, the author of semi-conductor laser therapeutic apparatus using
percutaneous laser disc decompression (percutaneous laser disk decompression,
PLDD) treatment of lumbar disc herniation, has achieved some results. Automatic
aspiration of the technology and compared to excision, a simple, safe, injury,
etc., are presented below.
Materials
and Methods
1.
Clinical data: 100 cases collected by the hospital to be diagnosed as clinical
lumbar disc herniation by CT or MRI in patients with a clear diagnosis for PLDD
treatment, follow-up of 6 to 18 months. 100 cases of patients, male 56 cases, 44
cases of women aged 17 ~ 72 years old, the average age of 48.5 years old.
Course of disease and clinical performance: the initial incidence of 2 months
to 20 years, clinical low back pain with radiation leg pain, inability to walk,
limp, the affected muscle atrophy, limb cold. Physical examination: unilateral
or bilateral limb elevation test positive, the level of the corresponding disc
next to the spinous process tenderness. After pre-treatment CT or MRI
examination. L4 ~ 5 of them were 65 cases of disc herniation, L5 ~ S1 disc
herniation, 35 cases have been more than six weeks of conservative treatment is
invalid or the result is not significant.
Semiconductor
Laser Therapeutic Apparatus used: wavelength 980 nm, the end of the maximum
output power 15 W. Optical fibers: 400 nm; 18G needle 2, a long 15 cm; Y-type switch 1.
Selected
for the following conditions have PLDD indications: (1) clinically diagnosed as
lumbar disc herniation, with recent (within 3 months) CT or MR for the
diagnosis of lumbar disc herniation were clear; (2) 6 weeks of conservative
treatment fails; (3) the extent of leg pain than back pain; (4) positive
straight leg raising test; (5) of sensory, motor response, tendon reflexes were
diminished. And for the following contraindications: (1) there is a serious
clinical bleeding tendency and who can not be corrected; (2) spondylolisthesis;
(3) disc was broken from the Free
State; (4) spinal stenosis (bony, ligament
thickening, calcification). (5) Marking the level of the history of trauma or
surgery has been the history of lumbar intervertebral disc or Chemonucleolysis
history; (6) significant stenosis in the vertebral space; (7) clear mental
disorder; (8) pregnant women.
2.
Operation Methods: Patients from lateral position (side up) in the DSA machine
tools, positioning under fluoroscopy puncture, topical 2% lidocaine anesthesia
5 ml (from the skin to the superficial muscle layer), with 18G, length 15 cm of the needle away from the open side of
vertebral spinous process centerline 8 ~ 14 cm Department (L4 ~ 5 to 8 ~ 12 cm, L5 ~ S1 for 10 ~ 14 cm), under the supervision of the
perspective from the rear side into the needle, needle sagittal direction of
the trunk surface and 45 ° ~ 60 ° angle. Needle is located in the best position
of the corresponding intervertebral space after the 1 / 3 the level of the
Agency (Figure 1), after the success of lateral puncture, rotating C-arm, is
situated to the perspective, the spinous process at the level of the needle
puncture nucleus, the L5 ~ S1 disc iliac wing due to stop before the needle
into the needle bent into approximately 160 ° around (Figure 2), after the
correct position, pull out the needle puncture needle core, will be 0.4 mm thick needle through the fiber-optic
delivery into, and beyond the top needle 0.5 cm, the use of Y-shaped lock switch and then to
the end of the output power 15 W, pulse time of 1 s, interval time of 5 s on
the nucleus points to 1 point or more laser decompression. Operation, when
patients have a bulging waist flu, with space needle by Y-switch liposuction,
each disc to the energy by about 1 200 ~ 1 300 J (L3 ~ 4, L5 ~ S1), 1 300 ~ 1
500 J (L4 ~ 5), the whole process about 20 ~ 30 min.
Results
100
cases of 100 patients with intervertebral disc, the success rate of puncture
was 100%, follow-up period was 6 to 18 months. Reference MacNab [1] to evaluate
the standard cure, 72% efficient. Of which 22 patients were cured and 50 cases
of effective, 28 cases were followed up for 6 months without improvement in
symptoms was considered null and void, without any complication. According to
the affordability of different patients, respectively after 3,6 months or
1,3,6,12-month CT or MRI follow-up visit, some cases (24/100) 1 month for only
the performance of the Department of nucleus density circular lower three
months after the performance of some patients to varying degrees for the disc
back to Steiner (49/100), part of cases (23/100) had no significant disc back
satisfied, but to improve symptoms in varying degrees.
Discussion
Principle
PLDD through laser vaporization of the nucleus pulposus for cutting, as well as
the solidification of the part of disc nucleus pulposus to reduce intradiscal
pressure and volume, so as to achieve the purpose of treatment of lumbar disc
herniation [2]. In recent years the use of laser disc decompression has been in
clinical and medical skills to gradually extend the awareness of staff and
patient acceptance, especially in recent years introduced by the British Diomed
diode laser treatment of lumbar disc herniation, more in line with the
interventional radiology Development trends and operation of micro-trauma of
the requirements, should be promoted as a new method for the treatment of disc
herniation [3].
1.
Percutaneous laser decompression of lumbar intervertebral disc with automatic
suction cutting head (APLD) comparison: in 1985, the United States and other
Onik [4] introduced APLD achieved good results, but relatively cumbersome to
operate, and compare the work of casing large, especially for the L5 ~ S1 disc
cutting treatment, certain difficulties, complications rate was about 1%,
mainly discitis, nerve root injury waist muscle hematoma [5]. Percutaneous
laser lumbar disc decompression, compared with a decrease of APLD procedures
for the replacement of equipment, only to be a 18G, diameter 1.0 ~ 1.2 mm, length 15 cm of the needle penetration in the TV monitor
under the lumbar intervertebral disc with prominent, and then through the
optical fiber directly into the puncture needle prominent lumbar intervertebral
disc, therefore, a more simple procedure, surgical process more secure,
virtually no complications.
2.
Puncture needle into the location of the relationship with the surrounding
structure: puncture is generally chosen from the open side of vertebral spinous
process centerline 8 ~ 14 cm
(L4 ~ 5:8 ~ 12 cm, L5 ~
S1: 10 ~ 14 cm) Office.
Anatomy shows that disc is located in the upper and lower vertebral body
between the central part of nucleus, nucleus enveloping the outside layer of
annulus fibrosus, vertebral body from top to bottom edge for the cartilage
plates, cartilage under pressure of the buffer plays a role in lateral After
the nerve root from the ramp to walk forward, the nerve root and the upper edge
of the next vertebral body and posterior facet joint security triangle.
Therefore, the necessary accuracy of needle from the intervertebral space after
the 1 / 3 into the nucleus of the central parts. In addition, the needle should
be avoided near the cartilage plate, in order to avoid its injury. If the
needle near the cartilage, then easy to damage [6], leading to ineffective
treatment or the occurrence of complications, I have the same experience.
3.
Laser energy: issues on the laser energy, Gangi, etc. [3] that the disc can be
used per 1 500 J, to 15 J is appropriate for each. This set of data showed that
average people better than 1 300 J, which may be smaller than the size of
foreign citizens who are small on the nucleus. In addition, any method of
treatment, the greater the damage to the organization, caused by swelling of
the opportunity to organize more, nucleus pulposus as well, around the nucleus
because of the lack of blood circulation, edema slower absorption. Therefore,
the energy is too large to give easy edema caused by nucleus pulposus and
annulus fibrosus, nerve root compression, resulting in the short term treatment
of patients with bad results, but over time, will gradually absorb edema. After
the follow-up 3 to 6 months, the majority of patients compared with the preoperative
symptoms in varying degrees to improve.
4.
The reasons for poor treatment and Countermeasures: Gangi, etc. [3] that 1 year
does not improve symptoms of treatment was designated as invalid. Follow-up
observation of this group showed that some patients with symptoms can be
alleviated, and some patients after 1 to 2 days or a few days’ symptoms are
repeated, the phenomenon may be related to puncture site of tissue injury and
repair. Kutschera, etc. [7] have on the disc after PLDD Biomechanical changes
in the studies, which show that the degree of intervertebral disc nucleus
pulposus to reduce or completely satisfied and will take about 1 to 6 months,
or even longer, this Some patients with symptoms that take longer time to
improve. According to this characteristic, I realize the necessary 6 months of
clinical observation, such as improvement of clinical symptoms without any
treatment can be confirmed invalid. According to my experience may be invalid
and the following factors: (1) laser points or relative shortage of energy, not
the purpose of decompression. (2) Puncture during the next facet more
periosteal injury, or other organizations, arising from chronic inflammatory
changes. (3) Indications of improper hands. In this regard, my experience is:
(1) single-point laser burn, the carbonization and necrosis of the scope of
smaller, multi-point laser burning can increase the scope of carbonization and
necrosis. (2) Efforts to improve the success rate of a puncture: puncture
process, to minimize damage from top to bottom needle synovial facet. (3) Strictly
PLDD indication is to improve the efficacy of the fundamental guarantee for
PLDD.
The
degree of postoperative intervertebral disc and 5.PLDD signal change and the
relationship between symptom improvement: Steiner, etc. [8] described the
technique PLDD, the dynamic changes of postoperative intervertebral disc, the
disc shows the performance for only a short period of time after the signal
changes the form of annulus fibrosus and no significant change, and that the
disc level and the signal change and symptom improvement in patients with
non-related, the group was followed up by CT or MRI also proved this point of
view.
6.
After processing: PLDD its easy to operate, on a small tissue injury, so patients
can be hospitalized for observation need to go home to rest, three days of oral
broad-spectrum antibiotic to prevent infection. No bed rest period, but the
need to avoid heavy work and cross waist movement across the flexor. Symptoms
such as repeated, to give help or partly inunction, after 6 months follow-up of
patients with no improvement in symptoms, and CT or MRI confirmed disc review
satisfied no significant return, and could be considered the 2nd line PLDD.
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