This work was supported by the Nanshan District Health Science and Technology Project (Grant No. NS2023002; NS2023044), the Medical Scientific Research Foundation of Guangdong Province of China (Grant No. A2023195), the Nanshan District Health Science and Technology Major Project (Grant No. NSZD2023023; NSZD2023026), the National Natural Science Foundation of China (Grant No. 82102640), and the National Key Research and Development Program of China (Grant No. 2022YFC3602203).

The protocol adheres to the regulations stipulated by the ethical committee of Huazhong University of Science and Technology Union Shenzhen Hospital, which has granted approval for the protocol. The written informed consent from the patient was obtained. A 31-year-old female patient was enrolled, who had suffered from consistent left leg radiating pain with a visual analogue scale (VAS)7 equal to 8. Physical examination findings were as follows: (1) upper body side bending to the right; (2) restri...

Novel PLL-AF Suture Technique for Annulus Fibrosus Repair in Lumbar Endoscopy

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W. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Clinically+significant+changes+in+pain+along+the+visual+analog+scale.">Clinically significant changes in pain along the visual analog scale.</a> Ann Emerg Med. 38 (6), 639-643 (2001).</li><li>Chen, Z., 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=Percutaneous+transforaminal+endoscopic+discectomy+versus+microendoscopic+discectomy+for+lumbar+disc+herniation:+Two-year+results+of+a+randomized+controlled+trial.">Percutaneous transforaminal endoscopic discectomy versus microendoscopic discectomy for lumbar disc herniation: Two-year results of a randomized controlled trial.</a> Spine (Phila Pa). 45 (8), 493-503 (2020).</li><li>Sairyo, K., Chikawa, T., Nagamachi, A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=State-of-the-art+transforaminal+percutaneous+endoscopic+lumbar+surgery+under+local+anesthesia:+Discectomy,+foraminoplasty,+and+ventral+facetectomy).">State-of-the-art transforaminal percutaneous endoscopic lumbar surgery under local anesthesia: Discectomy, foraminoplasty, and ventral facetectomy).</a> J Orthop Sci. 23 (2), 229-236 (2018).</li><li>Hoogland, T., Van Den Brekel-Dijkstra, K., Schubert, M., Miklitz, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Endoscopic+transforaminal+discectomy+for+recurrent+lumbar+disc+herniation:+A+prospective,+cohort+evaluation+of+262+consecutive+cases.">Endoscopic transforaminal discectomy for recurrent lumbar disc herniation: A prospective, cohort evaluation of 262 consecutive cases.</a> Spine (Phila Pa). 33 (9), 973-978 (2008).</li><li>Kim, J. 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J., Phan, K., Diwan, A. D., Ong, C. S., Mobbs, R. 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The authors in this study declare that no conflict of interest exists.

Achieving excellent AF suturing under the endoscope has significant benefits. It is expected to reduce the nerve mechanical stimulation caused by AF rupture or bulge, thereby decreasing postoperative residual discogenic low back pain and/or sciatica pain4,12. Closing the annular tear portal can reduce nerve root irritation caused by the release of inflammatory mediators from the intervertebral disc5. Additionally, patients can feel more co...

Percutaneous transforaminal endoscopic discectomy (PETD), a minimally invasive procedure used to remove herniated discs in the lumbar spine, is performed with an endoscope - a thin tube with a camera and light at the tip that enables the surgeon to visualize internal tissues and surrounding structures on a monitor1. With real-time image guidance on the monitor, surgeons can perform positioning, puncture, and placement of the cannula2 through a small skin incision of approximately 1 cm. Step-by-step exposure under the endoscope follows, including the removal of surrounding soft tissue and foraminoplasty to enlarge the opening of the targeted lumbar foramen. Once a clear view and sufficient operating space are achieved, complete decompression of the lumbar nerve is performed by removing the compressive fragments3.
Preventing postoperative recurrence of disc herniation remains a long-term concern for spine surgeons. One strategy during surgery to minimize the risk of recurrence is to remove all suspected detached nucleus pulposus (NP), even if it has not yet herniated into the canal. This is because a ruptured annulus fibrosus (AF) cannot be fully repaired, and as a result, detached NP tissue susceptible to intradiscal pressure may potentially reherniate in the future4.
Despite promising advancements in tissue engineering for repairing and regenerating the nucleus pulposus (NP) and annulus fibrosus (AF), none of them have been clinically proven effective5. The direct closure of the AF tear after full decompression is an important technique for reducing the risk of recurrence in lumbar disc herniation (LDH). Currently, the most frequently used suture technique for AF repair under endoscopy involves performing a simple suture with one single stitch at the site of the tear6. Apart from concerns about whether a single stitch can generate enough tension, an insufficient suture area (both in terms of quality and quantity) on both sides of the annular tear is frequently encountered after endoscopic decompression.
Therefore, this study proposes a new technique for suturing the AF after decompression of PETD by pulling and suturing the nearby posterior longitudinal ligament (PLL) over the AF tear with three stitches (PLL-AF suture technique).

<table border="1" fo:keep-together.within-page="1" fo:keep-with-next.within-page="always">
	<tbody>
		<tr>
			<td>0.5% lidocaine&#160;</td>
			<td>Beijing Tide Pharmaceutical Co., Ltd</td>
			<td>H37022768</td>
			<td>For postoperative pain</td>
		</tr>
		<tr>
			<td>Dilatation cannula</td>
			<td>Beijing Tianqi Medical technology Co., Ltd., Beijing</td>
			<td>ZJ289019</td>
			<td>Cannulation</td>
		</tr>
		<tr>
			<td>Disposable annular stapler&#160;</td>
			<td>Medical Science &#38; Technology Co., Ltd., Beijing</td>
			<td>SMILE-L, 2020</td>
			<td>Suture</td>
		</tr>
		<tr>
			<td>Disposable stitches</td>
			<td>Medical Science &#38; Technology Co., Ltd., Beijing</td>
			<td>SMILE-L, 2020-022</td>
			<td>Stitch</td>
		</tr>
		<tr>
			<td>Flurbiprofen axetil&#160;</td>
			<td>Shandong Hualu Pharmaceutical Co., Ltd.</td>
			<td>H20041508</td>
			<td>For postoperative pain</td>
		</tr>
		<tr>
			<td>Puncture needle</td>
			<td>Beijing Tianqi Medical technology Co., Ltd., Beijing</td>
			<td>ZJ289033</td>
			<td>Puncture</td>
		</tr>
		<tr>
			<td>Trephine saws&#160;</td>
			<td>Beijing Tianqi Medical technology Co., Ltd., Beijing</td>
			<td>ZJ289036</td>
			<td>Foraminoplasty</td>
		</tr>
	</tbody>
</table>

a suture technique for ruptured annulus fibrosus following decompression under percutaneous transforaminal endoscopic discectomy

The suture technique for a ruptured annulus fibrosus (AF) under full-endoscopy remains challenging. Direct suturing of a ruptured annular tear after full decompression has been shown to decrease the recurrence rate of lumbar disc herniation during endoscopic surgery. Traditional suture operations under endoscopy involve only simple suturing of the ruptured AF. Due to the weak and poor quality of the AF tissue around the tear portal, using this area as needle insertion points during suturing may lead to insufficient tension and a low success rate of AF closure. Currently, there is no detailed technical illustration based on video for AF tear suturing under lumbar full-endoscopy. We innovatively propose a method of covering and suturing the AF tear by pulling up the posterior longitudinal ligament (PLL) under lumbar endoscopy and using three stitches (PLL-AF suture technique). The patient who received the novel suture technique achieved satisfactory results. Six months after the operation, lumbar MRI showed no evidence of recurrence in the outpatient clinic.

Author Spotlight: Development and Application of a Novel Suture Technique for Annular Fibrosus Repair in Percutaneous Transforaminal Endoscopic Discectomy

A Suture Technique for Ruptured Annulus Fibrosus Following Decompression Under Percutaneous Transforaminal Endoscopic Discectomy

This research describes an innovative suture technique for ruptured annular fibrosus during percutaneous transforaminal endoscopic discectomy We proposed a method of suturing the annular fibrosus tear by pulling up the posterior longitudinal ligament under lumbar for endoscopy. To perform the surgical technique of endoscopic operations for lumbar herniation, surgeons must possess extensive experience. However, not every patient with lumbar herniation is suitable for this technique.In some cases, suturing may not be necessary if the annular tear becomes too narrow after decompression. This technique offers a new solution that tackle the insufficient tension that occurs due to the conventional single dish suturing method following endoscopic decompression of the lumbar spine. Moreover, the posterior longitudinal ligament was tightly seen about the annular fibrosis tear, which helped increase the lumbar canal volume at the compressed segment.

After successful and sufficient decompression, the herniated disc at L4/5 (Figure 2A,A&#39;) was resected. Local AF tear (both medial and lateral tear edges) and PLL were identified under the endoscope. The first stitch ensured that the lateral tear edge was contained and sutured. The PLL and the medial AF tear edge were penetrated and stitched along with the first stitch. A third fastened stitch was tied with the second stitch at the cranial side of the first stitch. The ke...

Watch this Scientific Journal Video about Author Spotlight: Development and Application of a Novel Suture Technique for Annular Fibrosus Repair in Percutaneous Transforaminal Endoscopic Discectomy at 

This protocol describes an innovative suture technique for ruptured annular fibrosus during percutaneous transforaminal endoscopic discectomy.

The suture technique for a ruptured annulus fibrosus (AF) under full-endoscopy remains challenging. Direct suturing of a ruptured annular tear after full ...

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Research

JoVE Journal

Medicine

Posterior Longitudinal Ligament (PLL)-Annulus Fibrosus (AF) Suture Technique

490 Views.  Huazhong University of Science and Technology Union Shenzhen Hospital.  This protocol describes an innovative suture technique for ruptured annular fibrosus during percutaneous transforaminal endoscopic discectomy. 

Novel PLL-AF Suture Technique for Annulus Fibrosus Repair in Lumbar Endoscopy

Summary