The protocol follows the guidelines of the Ethics Committee of Cangzhou Central Hospital (No.: 20210205). Informed consent was obtained from the patients to include them, and the data were generated as part of this study.
1. Pre-operative preparation
<ol>
	<li>Select patients according to the following inclusion and exclusion criteria.
	<ol>
		<li>Follow the inclusion criteria mentioned below:
		<ol>
			<li>Include patients with lower waist pain caused by long-term sitting, ...

<ol>
	<li>Fujii, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Discogenic+back+pain:+Literature+review+of+definition,+diagnosis,+and+treatment.">Discogenic back pain: Literature review of definition, diagnosis, and treatment.</a> JBMR Plus. 3 (5), 10180 (2019).</li><li>Urits, I., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Low+back+pain,+a+comprehensive+review:+Pathophysiology,+diagnosis,+and+treatment.">Low back pain, a comprehensive review: Pathophysiology, diagnosis, and treatment.</a> Current Pain and Headache Reports. 23 (3), 23 (2019).</li><li>Geurts, J. W., Willems, P. C., Kallewaard, J. W., van Kleef, M., Dirksen, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+impact+of+chronic+discogenic+low+back+pain:+Costs+and+patients'+burden.">The impact of chronic discogenic low back pain: Costs and patients' burden.</a> Pain Research &amp; Management. 2018, 4696180 (2018).</li><li>Kallewaard, J. W., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Discogenic+low+back+pain.">Discogenic low back pain.</a> Pain Practice. 10 (6), 560-579 (2010).</li><li>Peng, B., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Prospective+clinical+study+on+natural+history+of+discogenic+low+back+pain+at+4+years+of+follow-up.">Prospective clinical study on natural history of discogenic low back pain at 4 years of follow-up.</a> Pain Physician. 15 (6), 525-532 (2012).</li><li>Bydon, M., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Lumbar+fusion+versus+nonoperative+management+for+treatment+of+discogenic+low+back+pain:+A+systematic+review+and+meta-analysis+of+randomized+controlled+trials.">Lumbar fusion versus nonoperative management for treatment of discogenic low back pain: A systematic review and meta-analysis of randomized controlled trials.</a> Journal of Spinal Disorders &amp; Techniques. 27 (5), 297-304 (2014).</li><li>Zhao, L., Manchikanti, L., Kaye, A. D., Abd-Elsayed, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Treatment+of+discogenic+low+back+pain:+current+treatment+strategies+and+future+options-a+literature+review.">Treatment of discogenic low back pain: current treatment strategies and future options-a literature review.</a> Current Pain and Headache Reports. 23 (11), 86 (2019).</li><li>Yagi, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Advantages+of+revision+transforaminal+full-endoscopic+spine+surgery+in+patients+who+have+previously+undergone+posterior+spine+surgery.">Advantages of revision transforaminal full-endoscopic spine surgery in patients who have previously undergone posterior spine surgery.</a> Journal of Neurological Surgery, Part A: Central European Neurosurgery. , (2022).</li><li>Okada, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Preoperative+planning+using+three-dimensional+printing+for+full-endoscopic+spine+surgery:+A+technical+note.">Preoperative planning using three-dimensional printing for full-endoscopic spine surgery: A technical note.</a> NMC Case Report Journal. 9, 249-253 (2022).</li><li>Zhou, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Unique+complications+of+percutaneous+endoscopic+lumbar+discectomy+and+percutaneous+endoscopic+interlaminar+discectomy.">Unique complications of percutaneous endoscopic lumbar discectomy and percutaneous endoscopic interlaminar discectomy.</a> Pain Physician. 21 (2), 105-112 (2018).</li><li>Wasinpongwanich, K., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Full-endoscopic+interlaminar+lumbar+discectomy:+Retrospective+review+of+clinical+results+and+complications+in+545+international+patients.">Full-endoscopic interlaminar lumbar discectomy: Retrospective review of clinical results and complications in 545 international patients.</a> World Neurosurgery. 132, 922-928 (2019).</li><li>Yin, J., Jiang, Y., Nong, L. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Transforaminal+approach+versus+interlaminar+approach:+A+meta-analysis+of+operative+complication+of+percutaneous+endoscopic+lumbar+discectomy.">Transforaminal approach versus interlaminar approach: A meta-analysis of operative complication of percutaneous endoscopic lumbar discectomy.</a> Medicine. 99 (25), 20709 (2020).</li><li>Manabe, H., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Thermal+annuloplasty+using+percutaneous+endoscopic+discectomy+for+elite+athletes+with+discogenic+low+back+pain.">Thermal annuloplasty using percutaneous endoscopic discectomy for elite athletes with discogenic low back pain.</a> Neurologia Medico-Chirurgica. 59 (2), 48-53 (2019).</li><li>Wang, L., Li, L., Cheng, C., Xue, Y. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+percutaneous+spinal+endoscopy+&amp;#34;isolation+zone&amp;#34;+technique+for+discogenic+low+back+pain:+a+case+series+study.">The percutaneous spinal endoscopy &amp;#34;isolation zone&amp;#34; technique for discogenic low back pain: a case series study.</a> European Journal of Medical Research. 27 (1), 200 (2022).</li><li>Tonosu, J., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Diagnosing+discogenic+low+back+pain+associated+with+degenerative+disc+disease+using+a+medical+interview.">Diagnosing discogenic low back pain associated with degenerative disc disease using a medical interview.</a> PLoS One. 11 (11), 0166031 (2016).</li><li>Momenzadeh, S., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+effect+of+percutaneous+laser+disc+decompression+on+reducing+pain+and+disability+in+patients+with+lumbar+disc+herniation.">The effect of percutaneous laser disc decompression on reducing pain and disability in patients with lumbar disc herniation.</a> Journal of Lasers in Medical Sciences. 10 (1), 29-32 (2019).</li><li>Zhang, Y., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Comparison+of+endoscope-assisted+and+microscope-assisted+tubular+surgery+for+lumbar+laminectomies+and+discectomies:+Minimum+2-year+follow-up+results.">Comparison of endoscope-assisted and microscope-assisted tubular surgery for lumbar laminectomies and discectomies: Minimum 2-year follow-up results.</a> BioMed Research International. 2019, 5321580 (2019).</li><li>Liu, K. C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Using+percutaneous+endoscopic+outside-in+technique+to+treat+selected+patients+with+refractory+discogenic+low+back+pain.">Using percutaneous endoscopic outside-in technique to treat selected patients with refractory discogenic low back pain.</a> Pain Physician. 22 (2), 187-198 (2019).</li><li>Zuo, R., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+clinical+efficacy+of+biportal+endoscopy+is+comparable+to+that+of+uniportal+endoscopy+via+the+interlaminar+approach+for+the+treatment+of+L5/S1+lumbar+disc+herniation.">The clinical efficacy of biportal endoscopy is comparable to that of uniportal endoscopy via the interlaminar approach for the treatment of L5/S1 lumbar disc herniation.</a> Frontiers in Surgery. 9, 1014033 (2022).</li><li>Yuan, C., Wen, B., Lin, H. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinical+analysis+of+minimally+invasive+percutaneous+treatment+of+severe+lumbar+disc+herniation+with+UBE+two-channel+endoscopy+and+foraminal+single-channel+endoscopy+technique.">Clinical analysis of minimally invasive percutaneous treatment of severe lumbar disc herniation with UBE two-channel endoscopy and foraminal single-channel endoscopy technique.</a> Oxidative Medicine and Cellular Longevity. 2022, 9264852 (2022).</li><li>Minamide, A., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Microendoscopic+decompression+for+lumbar+spinal+stenosis+with+degenerative+spondylolisthesis:+The+influence+of+spondylolisthesis+stage+(disc+height+and+static+and+dynamic+translation)+on+clinical+outcomes.">Microendoscopic decompression for lumbar spinal stenosis with degenerative spondylolisthesis: The influence of spondylolisthesis stage (disc height and static and dynamic translation) on clinical outcomes.</a> Clinical Spine Surgery. 32 (1), 20-26 (2019).</li><li>Yeung, A. T., Yeung, C. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=In-vivo+endoscopic+visualization+of+patho-anatomy+in+painful+degenerative+conditions+of+the+lumbar+spine.">In-vivo endoscopic visualization of patho-anatomy in painful degenerative conditions of the lumbar spine.</a> Surgical Technology International. 15, 243-256 (2006).</li><li>Shi, C., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Development+of+an+in+vivo+mouse+model+of+discogenic+low+back+pain.">Development of an in vivo mouse model of discogenic low back pain.</a> Journal of Cellular Physiology. 233 (10), 6589-6602 (2018).</li></ol>

LDH is a degenerative disease of the spine that seriously affects daily life and work. The main clinical manifestations are low back pain and sciatic nerve pain. Extreme waist movements, fixed posture, and physical labor can aggravate the symptoms4,15. If conservative treatment cannot alleviate the clinical symptoms, minimally invasive methods are used to treat patients with LDH. Momenzadeh et al. used percutaneous laser disc decompression (PLDD) to treat 30 pati...

LDH is a common degenerative disease of the spine. LDH is accompanied by multifactorial changes, such as degeneration of the intervertebral disc and the surrounding structures. The interaction between multifactorial degeneration and the nervous system causes pain1. The pain of this disease manifests as low back pain and leg pain, and sometimes LDH can be related to an inability to maintain the same posture or sensory-motor disorder of the lower limbs2. The severe clinical symptoms of LDH bring great pain to the patients and represent a serious medical and social problem3,4. For patients with obvious herniated intervertebral discs or a torn annulus fibrosus, traditional conservative treatments, including drug therapy, physical therapy, and rest, cannot effectively solve their problem5. Lumbar fusion surgery is usually used to treat patients with LDH for whom conservative treatment is ineffective6. However, this surgery has a high economic cost and causes large surgical trauma and destruction of the stable structure of the spine; additionally, the postoperative improvement in low back pain, sensory-motor disturbance of the lower limbs, and lumbar motion function, etc., is sometimes unsatisfactory7. The development of FESS has not only improved the curative effects of lumbar surgery but also reduced the cost and risk of surgery8,9. However, if the nucleus pulposus is not completely removed during endoscopic surgery and the treatment of the pain-inducing factors is not comprehensive, the patient will have low back pain, dysesthesia in the lower extremities, and other adverse reactions after surgery10,11,12,13.
To avoid inadequate removal of the nucleus pulposus during endoscopic surgery and the inadequate relief of postoperative neurological dysfunction, our research team applied a modified spinal endoscopic &#34;isolation zone&#34; technique. The &#34;isolation zone&#34; technology aims to block the pain transmission pathway of the sinus vertebra nerve and sciatic nerve by removing the herniated intervertebral disc, ruptured annulus fibrosus, and hyperplastic inflammatory tissue. In addition, pathogenic inflammatory mediators on the surface of the disc and intraspinal canal are removed13. The &#34;isolation zone&#34; technique can fully decompress the unilateral compressed spinal nerves. This technical strategy is more minimally invasive and effective than traditional surgical methods.

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>18 G puncture needle</td>
			<td>tong lu</td>
			<td>KB401.061</td>
			<td></td>
		</tr>
		<tr>
			<td>3.7 mm spinal endoscope</td>
			<td>joimax</td>
			<td>FS6342181C</td>
			<td></td>
		</tr>
		<tr>
			<td>4-0 nonabsorbent surgical suture</td>
			<td>Johnson &#38; Johnson</td>
			<td>WB761</td>
			<td></td>
		</tr>
		<tr>
			<td>7.5 mm working channel</td>
			<td>maxmore</td>
			<td>1001-ES04</td>
			<td></td>
		</tr>
		<tr>
			<td>Bone drill</td>
			<td>maxmore</td>
			<td>1001-BD(001-005)</td>
			<td>4 mm, 5 mm, 6 mm, 7 mm, 8 mm diameter</td>
		</tr>
		<tr>
			<td>C-arm X-ray machine</td>
			<td>GE</td>
			<td>OEC one</td>
			<td></td>
		</tr>
		<tr>
			<td>Catheters</td>
			<td>maxmore</td>
			<td>1001-DC 001</td>
			<td></td>
		</tr>
		<tr>
			<td>Expansion guide rod</td>
			<td>maxmore</td>
			<td>1001-DC 002</td>
			<td></td>
		</tr>
		<tr>
			<td>Flexible bipolar radiofrequency</td>
			<td>tian song</td>
			<td>G8002.2</td>
			<td></td>
		</tr>
		<tr>
			<td>Guide wire</td>
			<td>maxmore</td>
			<td>1001-GW 003</td>
			<td>1mm diameter</td>
		</tr>
		<tr>
			<td>Nucleus pulposus forceps</td>
			<td>maxmore</td>
			<td>1001-EF 001 003</td>
			<td>0&#176;and 15&#176;</td>
		</tr>
		<tr>
			<td>Tom Shidi locator</td>
			<td>maxmore</td>
			<td>1001-TS 001</td>
			<td></td>
		</tr>
	</tbody>
</table>

full-endoscopic isolation zone technique for the treatment of lumbar disc herniation

Lumbar disc herniation (LDH) is a type of serious sinus or sciatic nerve dysfunction caused by nucleus pulposus protrusion and annulus fibrosus tears. Its clinical symptoms often include severe low back pain, limited lumbar movement, sciatic nerve pain in the lower limbs, and even cauda equina syndrome. The common treatment for LDH is a conservative treatment scheme involving medicine, rest, and physical therapy. However, if the conservative treatment scheme is ineffective, a surgical treatment approach is adopted. Traditional open lumbar surgery has some disadvantages, including the potential for severe surgical trauma, severe blood loss during the operation, instability of the lumbar spine, and loss of the lumbar motor unit. Among the minimally invasive surgical schemes, full-endoscopic spine surgery (FESS) is undoubtedly the most appropriate and has the advantages of minimal trauma, high safety, quick postoperative recovery, and the retention of the stable structure and the motor unit of the lumbar spine. However, simultaneously, incomplete removal of the nucleus pulposus and residual nerve dysfunction after surgery can occur. To avoid these shortcomings, we studied a specific spinal endoscopy technique, the "isolation zone" surgical strategy, which can effectively block the pain from the nerve conduction pathway by completely relieving the nerve compression and nerve dysfunction through the orderly treatment of the protruding nucleus pulposus, the fissure of the annulus fibrosus, the sinus nerve, and the surrounding inflammatory soft tissues.

FESS with the &#34;isolation zone&#34; strategy was adopted in this study to treat LDH, and this method effectively relieved the patients&#39; low back pain and/or sciatic nerve pain. For all the patients who underwent surgery under local anesthesia, the operation did not have to be interrupted because of unbearable pain. The VAS score, ODI index, and the excellent and good rates of the modified MacNab criteria from the previous study are shown in Table 1.
The MRI re-examinati...

Watch this Scientific Journal Video about Full-Endoscopic Isolation Zone Technique for the Treatment of Lumbar Disc Herniation at JoVE.com

Full-Endoscopic Isolation Zone Technique for the Treatment of Lumbar Disc Herniation

Here, we present a protocol for the &#34;isolation zone&#34; technique in the treatment of lumbar disc herniation (LDH) under full-endoscopic spine surgery (FESS), including intervertebral foramen formation, targeted catheterization, nucleus pulposus resection, and annulus fibrosus formation, which together completely block the pain from the nerve conduction pathway.

Lumbar disc herniation (LDH) is a type of serious sinus or sciatic nerve dysfunction caused by nucleus pulposus protrusion and annulus fibrosus tears. Its ...

This protocol is standardized endoscopic decompression technique for spinal nerves, which can ensure good clinical effect. Some installations of technology can be used to compare symmetry to all the pathogenic factors of LDH with few residual symptoms after surgery, and more satisfactory treatment effects. This technique is of special significance for special types of DDD, such as, calcified disc herniation and discogenic low back pain.These two kinds of disease are controversial in endoscopic treatment. The procedure was demonstrated by Lu Wang and Xinbiao Yan from Department of Orthopedics, Cangzhou Central Hospital. After administering local anesthesia to the patient, puncture the bottom of the articular process using an 18 gauge puncture needle.Ensure that the tip of the puncture needle is located at the inner edge of the articular process in the antero posterior x-ray, and at the center of the intravertebral space or the upper edge of the distal vertebral body in the lateral X-ray. Place a thin guide wire through an 18 gauge puncture needle and make a seven millimeter skin incision. Place soft tissue expansion catheters with different diameters through the guide wire then place the Tom Sheety locator along the guide wire.Now fix the tip of the Tom Sheety locator on the tip of the superior articular process pointed toward the target of the herniated disc and gently hammer it to make it pass through the articular process bone. Adjust the depth of the Tom Sheety locator entering the spinal canal according to the position of the herniated disc. Then remove the Tom Sheety locator, replace the guide wire and use bone drills with different diameters along the guide wire to grind off part of the facet joints for intervertebral aminoplasty.Insert the guide rod along the guide wire after the intervertebral foramen is formed by a bone drill. Place the endoscope working channel along the guide rod and confirm that the working channel has reached the target point by intraoperative fluoroscopy again. Place a 7.5 millimeter diameter spinal endoscope with a 3.7 millimeter diameter working channel at the lumbar disc herniation to explore and clean the ligaments and the residual bone fragments in the intervertebral foramen area, the soft tissues in the spinal canal and the protruding lumbar intervertebral disc.Remove the proliferated inflamed soft red tissues scattered in the vertebral canal with microscopic surgical instruments. Use nucleus pulposus forceps to explore the torn area of the annulus fibrosis and remove the severely degenerated and inelastic tissue. Then use miniature surgical forceps to remove the ruptured part of the annulus fibrosis and the protruding nucleus pulposus.Use flexible bi-polar radio frequency to coagulate the annulus fibrosis and the nucleus pulposus to stop the bleeding, shrink, and denervate them. When there is enough space around the nerve root and the dural sac during the operation, use flexible bipolar radiofrequency to perform an annuloplasty and nucleoplasty on the residual annulus fibrosis and nucleus pulposus, respectively. Explore the nerve root with a miniature probe hook to ensure sufficient space and spontaneous pulsation.Remove the endoscope and its working channel, and suture the skin with a 4.0 nonabsorbent surgical thread suture. During the operation, always use the endoscopic instrument under continuous irrigation with normal saline. Choose appropriate intravenous hemostatic or analgesic drugs according to the patient's condition.After the operation, suture the skin and superficial fascia at the incision of the spinal endoscope without placing a drainage tube. Inject ropivacaine around the incision to relieve pain and discomfort around the incision. The MRI re-examination of the lumbar spine after the operation showed that the herniated intervertebral disc disappeared and the tear of the annulus fibrosis disappeared and healed well, forming an isolation zone on the ventral side of the dura mater and nerve root.The most important step use the Tom Sheety locator and bone drill for occurring that valuable foramen formation. And to use endoscopic holes for decompression. This technique explores the direction of endoscopic treatment of DDD represent by LDH and will be used for this spinal disease in the future.

full-endoscopic-isolation-zone-technique-for-treatment-lumbar-disc

Research

JoVE Journal

Medicine

371 vistas.  Tianjin Medical University. Este protocolo es una técnica estandarizada de descompresión endoscópica para los nervios espinales, que puede garantizar un buen efecto clínico. Algunas instalaciones de tecnología se pueden utilizar para comparar la simetría con todos los factores patogénicos de la LDH con pocos síntomas residuales después de la cirugía y efectos de tratamiento más satisfactorios. Esta técnica es de especial importancia para tipos especiales de DDD, como la hernia discal calcificada y el dolor l...