Palea Ovidiu, Granville Michelle, Jacobson Robert E
Anesthesiology and Pain Management, Provita Hospital.
Miami Neurosurgical Center, University of Miami Hospital.
Cureus. 2018 Jan 20;10(1):e2091. doi: 10.7759/cureus.2091.
The clinical effectiveness of percutaneous and transforaminal endoscopic discectomy procedures has been evaluated by the system used or compared to open laminectomy or micro-discectomy but are not evaluated based on the location and characteristics of the abnormal disc. This review proposes that outcomes are primarily related to disc size, biomechanics, location, and associated segmental fibrotic and bone changes as well as the surgeon's skill in using various systems rather than the specific system used. In these cases, the surgeon needs to decide if the goal of the procedure is simply internal decompression of an abnormal but contained herniated disc or release of the entrapped nerve root by a large contained disc, extruded and migrated disc fragment, or coexistent foraminal stenosis. Percutaneous and tubular transforaminal procedures are quite different, technically ranging from simple discectomy aspirating probes to larger endoscopic systems, providing the capability to remove large extruded free disc fragments, with or without foraminotomy. Recently, the ability to perform interbody fusion has been added to the range of procedures able to be performed endoscopically. At the same time, biologic solutions to disc degeneration are rapidly evolving and may have a place in combination with these procedures. This article reviews the interrelationship between clinical signs and symptoms, radiologic findings, and the biochemistry and biomechanics of the affected disc segment. Understanding the role played by all these factors enables the surgeon to evaluate both the disc and surrounding bone structures pre-operatively to determine if the clinical signs and symptoms are related to enlargement and displacement of a contained disc or compression or impingement of the nerve root. Based on this, the surgeon can choose different surgical systems, allowing simple decompression of a contained disc, possibly adding biologics, with a 'small' system, while a large herniated disc, or extruded fragment, causing root impingement, would require a 'larger' system that provides direct endoscopic visualization within the epidural space, foraminal decompression with drills, and direct surgical manipulation and freeing of the nerve root. By choosing the surgical system based on characteristics such as disc size, location, and associated inflammatory and fibrotic changes, the effectiveness of minimally invasive procedures will be more consistent and improve as the surgeon's diagnostic and operative skills improve.
经皮和经椎间孔内镜下椎间盘切除术的临床疗效已通过所使用的系统进行评估，或与开放椎板切除术或显微椎间盘切除术进行比较，但未根据异常椎间盘的位置和特征进行评估。本综述提出，手术结果主要与椎间盘大小、生物力学、位置、相关节段的纤维化和骨质改变以及外科医生使用各种系统的技能有关，而非所使用的特定系统。在这些情况下，外科医生需要决定手术的目标是单纯对异常但局限的椎间盘进行内部减压，还是通过大型局限椎间盘、脱出和移位的椎间盘碎片或并存的椎间孔狭窄来松解受压的神经根。经皮和管状经椎间孔手术有很大不同，技术上从简单的椎间盘切除吸引探头到更大的内镜系统，具备切除大型脱出游离椎间盘碎片的能力，可进行或不进行椎间孔切开术。最近，椎间融合术的能力已被添加到可在内镜下进行的手术范围内。与此同时，针对椎间盘退变的生物治疗方法正在迅速发展，可能与这些手术联合应用。本文综述了临床体征和症状、影像学表现以及受累椎间盘节段的生物化学和生物力学之间的相互关系。了解所有这些因素所起的作用，能使外科医生在术前评估椎间盘及周围骨质结构，以确定临床体征和症状是否与局限椎间盘的增大和移位有关，或者与神经根的受压或卡压有关。基于此，外科医生可以选择不同的手术系统，对于局限椎间盘，可使用“小型”系统进行单纯减压，可能还需添加生物制剂；而对于导致神经根受压的大型椎间盘突出或脱出碎片，则需要“大型”系统，该系统可在硬膜外间隙提供直接的内镜视野，使用钻头进行椎间孔减压，并直接进行手术操作和松解神经根。通过根据椎间盘大小、位置以及相关炎症和纤维化改变等特征选择手术系统，随着外科医生诊断和手术技能的提高，微创手术的有效性将更加稳定并得到改善。
