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, standing, walking, and waist activities, with or without typical sciatic nerve pain.</li>
			<li>Include patients with preoperative X-ray, CT, MRI, or other imaging data showing single-segment intervertebral disc herniation or an annulus fibrosus tear, an intervertebral space that does not collapse, and no bony spinal stenosis.</li>
			<li>Include patients with a physical examination showing obvious neurological dysfunction of the lower limbs and a positive straight leg elevation test.</li>
			<li>Include patients with ineffective systematic conservative treatment for at least 6 weeks and clinical symptoms seriously affecting their work and life.</li>
			<li>Include patients with low back pain without lower limb nerve pain. For these patients, perform a selective nerve block by using a mixture of low-concentration lidocaine and triamcinolone acetonide through the intervertebral foramen. This decreases the visual analog scale (VAS) of low back pain by more than 50% within 48 h.</li>
		</ol>
		</li>
		<li>Follow the exclusion criteria mentioned below:
		<ol>
			<li>Exclude patients with lumbar instability or spondylolisthesis.</li>
			<li>Exclude patients with lumbar intraspinal tumors or spinal cord tumors.</li>
			<li>Exclude patients with ligamentum flavum hypertrophy or contralateral recess stenosis.</li>
			<li>Exclude patients with mental disorders.</li>
			<li>Exclude patients with coagulation dysfunction.</li>
			<li>Exclude patients who are unwilling to undergo surgery. 
			&#8203;NOTE: The anesthesia mode was local infiltration anesthesia, and the surgical position was lateral. The procedures were performed on patients in the side-lying position under the guidance of a G-arm or C-arm X-ray machine.</li>
		</ol>
		</li>
	</ol>
	</li>
</ol>
2. Anesthesia and lesion exposure
<ol>
	<li>Administer local anesthesia to all the patients (15 mL of 2% lidocaine + 10 mL of 1% ropivacaine + 45 mL of 0.9% saline). 
	NOTE: The anesthesia level is the skin, the superficial subcutaneous fascia, the thoracolumbar fascia, the facet joint, and the surface of the annulus fibrosus of the intervertebral disc.</li>
	<li>Use an 18 G puncture needle to puncture the bottom of the articular process. Ensure that the tip of the puncture needle is located at the inner edge of the articular process in the anteroposterior X-ray and at the center of the intervertebral space or the upper edge of the distal vertebral body in the lateral X-ray.</li>
	<li>Place a thin guide wire through an 18 G puncture needle, and make a 7 mm skin incision. Place soft tissue expansion catheters with different diameters through the guide wire, and then pace the Tom Shidi locator along the guide wire (Figure 1A).</li>
	<li>Fix the tip of the Tom Shidi 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 Shidi locator entering the spinal canal according to the position of the herniated disc (Figure 1C, D).</li>
	<li>Remove the Tom Shidi locator, replace the guide wire, and use bone drills with different diameters to operate along the guide wire (Figure 1B), which is used to grind off part of the facet joints for intervertebral aminoplasty (Figure 1E, F). 
	NOTE: The high-intensity zone of the L4/5 segment intervertebral disc annulus fibrosus and the nucleus pulposus protrusion can be seen in the preoperative lumbar MRI (Figure 2A, B).</li>
	<li>After the intervertebral foramen is formed by a bone drill (4 mm, 5 mm, 6 mm, 7 mm, and 8 mm diameter), insert the guide rod along the guide wire. Place the endoscope working channel along the guide rod, and confirm that the working channel has reached the target point by intraoperative fluoroscopy again (Figure 2C, D).</li>
</ol>
3. &#34;Isolation zone&#34; technique of spinal endoscopy
<ol>
	<li>Percutaneously and transforaminally place a 7.5 mm diameter spinal endoscope with a 3.7 mm diameter working channel at the lumbar disc herniation at the appropriate level 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.</li>
	<li>Remove the proliferated, inflamed, and red soft tissues scattered in the vertebral canal with microscopic surgical instruments. Use nucleus pulposus forceps to explore the torn area of the annulus fibrosus, and remove the severely degenerated and inelastic tissue.</li>
	<li>Remove the ruptured part of the annulus fibrosus and the protruding nucleus pulposus using miniature surgical forceps. Use flexible bipolar radiofrequency to coagulate the annulus fibrosus and the nucleus pulposus to stop the bleeding and shrink and denervate them.</li>
	<li>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 fibrosus and nucleus pulposus, respectively.</li>
	<li>Explore the nerve root with a miniature probe hook to ensure that it has sufficient space and spontaneous pulsation (Figure 2E). Remove the endoscope and its working channel, and suture the skin with a 4-0 nonabsorbent surgical thread suture.</li>
</ol>
4. Intraoperative drug application
<ol>
	<li>During the operation, always use the endoscopic instrument under continuous irrigation with normal saline. According to the condition of the patient, choose appropriate intravenous hemostatic drugs (e.g., preoperative intravenous drip of 1 g of tranexamic acid) or analgesic drugs (e.g., preoperative intravenous drip of 100 mg of flurbiprofen axetil).</li>
	<li>If the patient is sensitive to pain or has severe nerve stimulation during the operation, ask the anesthesiologist for help with the application of sedative and analgesic drugs during the operation.</li>
	<li>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.</li>
</ol>
5. Post-operative care
<ol>
	<li>Provide postoperative analgesia with oral or intravenous drugs (for example, oral diclofenac sodium sustained-release tablets at 75 mg/day or intravenous flurbiprofen axetil at 100 mg/day) for 3-5 days, neurotrophic drugs (oral mecobalamin tablets, 5 mg each time, three times per day) for 6 weeks, and the appropriate symptomatic treatment.</li>
	<li>On the first day after the operation, advise the patient to get out of bed and move around while wearing a lumbar orthosis. Under the protection of the lumbar orthosis, advise the patient to exercise their limbs. Instruct the patient to carry out functional exercises of the lumbar back muscles, straight leg lifting (SLR) exercises, and functional exercise plans every day.</li>
</ol>

<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>

The authors have no conflicts of interest in this research.

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><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 &amp;amp; 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&amp;deg;and 15&amp;deg;</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 ...

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

Research

JoVE Journal

Medicine

490 Views.  Tianjin Medical University. Here, we present a protocol for the "isolation zone" 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.

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

A Mobile Outside-in Technique of Transforaminal Lumbar Endoscopy for Lumbar Disc Herniations

Percutaneous endoscopic transforaminal lumbar discectomy (PETLD) has now become a standard of care for the management of lumbar disc disease. There are two techniques for the introduction of a working cannula with respect to disc&#8212;outside-in and inside-out. The aim of this prospective study is to describe the technical aspects of a novel mobile outside-in method in dealing with different types of disc prolapse. A total of 184 consecutive patients with unilateral lower limb radiculopathy due to lumbar disc prolapse were operated on with the mobile outside-in technique of PETLD. Their clinical outcomes were evaluated based on the type of disc prolapse they had, a visual analog scale (VAS) leg pain score, the Oswestry Disability Index (ODI), and the Macnab criteria. The completeness of the decompression was documented with a postoperative magnetic resonance imaging. The mean age of the patients was 50 &#177; 16 years and the male/female ratio was 2:1. The mean follow-up was 19 &#177; 6 months. A total of 190 lumbar levels were operated on (L1&#8211;L2: n = 4, L2&#8211;L3: n = 17, L3&#8211;L4: n = 27, L4&#8211;5: n = 123, and L5&#8211;S1: n = 19). Divided into types, the patient distribution was central: n = 14, paracentral: n = 74, foraminal: n = 28, far lateral: n = 13, superior-migrated: n = 8, inferior migrated: n = 38, and high canal compromise: n = 9. The mean operative time was 35 &#177; 12 (25 - 56) min and the mean hospital stay was 1.2 &#177; 0.5 (1&#8211;3) days. The VAS score for leg pain improved from 7.5 &#177; 1 to 1.7 &#177; 0.9. The ODI improved from 70 &#177; 8.3 to 23 &#177; 5. According to the Macnab criteria, 75 patients (40.8%) had excellent results, 104 patients (56.5%) had good results, and 5 patients (2.7%) had fair results. Recurrence (including early and late) was seen in 15 out of the 190 levels that were operated on (7.89%). This article presents a novel outside-in approach that relies on a precise landing within the foramen in a mobile manner and does not solely depend upon the enlargement of the foramen. It is more versatile in application and useful in the management of all types of disc prolapse, even in severe canal compromise and high migration.

Here we present a protocol of a novel outside-in technique of transforaminal endoscopic discectomy for lumbar disc herniations. The technical aspects of the technique, the wide indications of use, and the results of the treatment in 184 patients are described in detail.

Percutaneous endoscopic transforaminal lumbar discectomy (PETLD) has now become a standard of care for the management of lumbar disc disease. There are ...

Transtubular Endoscopic Posterolateral Decompression for L5-S1 Lumbar Lateral Disc Herniation

We report a novel technique for C-arm free transtubular L5 nerve decompression under CT-based navigation to reduce the radiation hazard. This procedure is performed under general anesthesia and neuromonitoring. The patient is placed in a prone position on an operating carbon table. A navigation reference frame is placed percutaneously into the contralateral sacroiliac joint or spinous process. Then, CT scan images are obtained. After instrument registration, the L5-S1 foraminal level is confirmed with a navigated probe, and the entry point is marked. Using an approximately 2 cm skin incision, the subcutaneous tissue and muscles are dissected. The navigated first dilator is aimed at the L5-S1 Kambin&#39;s triangle, and sequential dilation is performed. The 18 mm tube is used and fixed to the frame. The bone around the Kambin&#39;s triangle is removed with a navigated burr. For lateral disc herniation, the L5 nerve root is identified and retracted, and the disc fragment is removed. The navigation-guided tubular endoscopic decompression is an effective procedure. There is no radiation hazard to the surgeon or the operating room staff.

Presented here is a novel technique of C-arm free transtubular posterolateral decompression for lumbar foraminal stenosis and lateral disc herniation under O-arm navigation.

We report a novel technique for C-arm free transtubular L5 nerve decompression under CT-based navigation to reduce the radiation hazard. This procedure is ...

Neuroscience

Full-Endoscopic Transforaminal Approach for Lumbar Discectomy

With technical advancements, the full-endoscopic transforaminal approach for lumbar discectomy (ETALD) is gaining popularity. This technique utilizes various tools and instruments, including a dilator, a beveled working sleeve, and an endoscope with a 20-degree angle and 177 mm length, equipped with a 9.3-diameter oval shaft and a 5.6 mm diameter working channel. Additionally, the procedure involves using a Kerrison punch (5.5 mm), rongeur (3-4 mm), punch (5.4 mm), tip control radioablator applying a radiofrequency current of 4 MHz, fluid control irrigation and suction pump device, 5.5 mm oval burr with lateral protection, burr round, and the diamond round. During the surgery, it is essential to identify significant landmarks, including the caudal pedicle, ascending facet, annulus fibrosis, posterior longitudinal ligament, and the exiting nerve root. The steps of the technique are relatively easy to follow, especially when utilizing the appropriate instruments and having a good understanding of the anatomy. Research studies have demonstrated comparable outcomes to open microdiscectomy techniques. ETALD presents itself as a safe option for lumbar discectomy, as it minimizes tissue disruption, results in low postoperative surgical site pain, and allows for early mobilization.

The present protocol describes the full-endoscopic transforaminal approach for lumbar discectomy, which is a safe technique that does not require muscle retraction or bone removal.

With technical advancements, the full-endoscopic transforaminal approach for lumbar discectomy (ETALD) is gaining popularity. This technique utilizes ...

Full Endoscopic Transforaminal Thoracic Discectomy Operative Technique

Thoracic disc herniations are a degenerative pathology of the thoracic spine wherein a portion of nucleus pulposis herniates into the epidural space, potentially causing spinal cord or nerve root compression. Traditional surgical treatment for patients with thoracic disc herniations requires relatively invasive anterior or posterolateral approaches that involve extensive muscular dissection and removal of bone in order to access and remove the disc herniation without causing undue compression of the spinal cord. Full endoscopic thoracic discectomy is a minimally invasive technique which allows for the resection of thoracic disc herniations through a small (1 cm) incision, minimizing collateral tissue trauma and obviating the need for the extensive muscle dissection and bony removal required for traditional surgical approaches. In this article, we describe in detail the operative technique for full endoscopic thoracic discectomy and discuss the pearls and pitfalls of the technique. We also provide a review of the outcomes and complications as seen in the literature.

This protocol demonstrates the surgical technique for full endoscopic transforaminal resection of thoracic disc herniations.

Thoracic disc herniations are a degenerative pathology of the thoracic spine wherein a portion of nucleus pulposis herniates into the epidural space, ...

Full-Endoscopic Interlaminar Approach for Decompression of Lateral Recess Stenosis

For lateral recess stenosis, extensive decompression with laminectomy is still performed in most centers. However, tissue-sparing surgeries are becoming more common. Full-endoscopic spinal surgeries have the advantages of being less invasive and offering a shorter recovery time. Here, we describe the technique of the full-endoscopic interlaminar approach for the decompression of lateral recess stenosis. The full-endoscopic interlaminar approach for the lateral recess stenosis procedure took approximately 51 min (range of 39-66 min). Blood loss could not be measured due to continuous irrigation. However, no drainage was required. There were no dura mater injuries reported in our institution. Furthermore, there were no injuries to the nerves, no cauda equine syndrome, and no hematoma formation. The patients were mobilized on the same day as surgery and discharged the next day. Therefore, the full-endoscopic technique for lateral recess stenosis decompression is a feasible procedure that lowers the operational time, complications, traumatization, and rehabilitation duration.

Technical advances and increased experience in full-endoscopic spinal surgeries enable these procedures to be performed with minimal incision, muscle retraction, and bone removal.

For lateral recess stenosis, extensive decompression with laminectomy is still performed in most centers. However, tissue-sparing surgeries are becoming ...

Full Endoscopic Interlaminar Approach for Paracentral L5-S1 Disc Herniation

The full endoscopic interlaminar approach (FEILA) is a minimally invasive technique for lumbar discectomy. It has multiple advantages over other conventional discectomy methods, including less traumatization of the soft tissues, fewer complication rates (dural injury, bleeding), rapid rehabilitation, quick return to daily life activities, and preferable cosmetic results. FEILA is a surgery with a relatively steep learning adaptation. Endoscopic surgery is a closed tubular approach, and all surgical maneuvers are performed within a uniportal single working channel. Also, the technique has not yet been standardized and well-documented. Therefore, the early learning stages of this technique may not be easy for most surgeons. Despite these, FEILA is easy, and the operation length is comparable to and even shorter than other techniques of lumbar discectomy. FEILA for lumbar discectomy could be considered a safe and effective alternative procedure for paracentral L5-S1 disc herniation. Here, we describe the technique of FEILA, including every cutoff step required to reach technical proficiency for surgeons who want to start applying this approach.

Here, we present a protocol to describe the full endoscopic interlaminar approach (FEILA) technique, including every cutoff step required to reach technical proficiency. FEILA is a surgery with a relatively steep learning adaptation. Despite this, any surgeon capable of microdiscectomy can perform FEILA with enough practice and suitable patient selection.

The full endoscopic interlaminar approach (FEILA) is a minimally invasive technique for lumbar discectomy. It has multiple advantages over other ...

A 3-Channel Endoscopic Technique for Lumbar Stenosis and Contralateral Herniation

The Third Channel-Assisted Unilateral Biportal Endoscopic Technique for Lumbar Spinal Stenosis Combined with Contralateral Disc Herniation

Unilateral biportal endoscopic (UBE) spine surgery is an emerging minimally invasive surgical (MIS) technique that has gained popularity for treating lumbar spinal stenosis, particularly in Eastern Asia. The traditional UBE technique, with two portals on one side, can achieve successful unilateral laminotomy for bilateral decompression (ULBD) and, therefore, demonstrates favorable clinical outcomes. However, in the case of lumbar spinal stenosis combined with contralateral disc herniation, it is very difficult to remove the contralateral disc herniation, especially the loose disc fragment within the deep disc. Here, a third channel of the traditional UBE technique was developed to do the discectomy within the ipsilateral endoscopic vision, with which the instruments can go vertically into the contralateral disc, allowing easy discectomy. This technique can not only achieve adequate decompression of the bilateral spinal canal but also effectively remove contralateral herniated disc fragments. This technique avoids performing another UBE procedure on the opposite side, which can potentially shorten the duration of the operation, minimize blood loss and tissue damage, and ensure sufficient neural decompression. This paper will introduce the indications and surgical operation procedures, as well as present a classical case report and follow-up data, to facilitate the application of the third channel-assisted UBE (T-UBE) technique for spine surgeons.

Author Spotlight: Unveiling the Potential of TUBE Technique in Spinal Surgery

Here, we present the third channel-assisted UBE technique, which allows for the vertical removal of herniated disc fragments. This technique can effectively address the limitations of traditional UBE techniques. This article will systematically elaborate on this procedure.

Unilateral biportal endoscopic (UBE) spine surgery is an emerging minimally invasive surgical (MIS) technique that has gained popularity for treating ...

Unilateral Biportal Endoscopy for the Treatment of Lumbar Disc Herniation

Unilateral biportal endoscopy (UBE) is a minimally invasive spinal surgery technique increasingly employed in treating degenerative lumbar diseases, such as lumbar disc herniation, lumbar spinal stenosis, and spondylolisthesis. In UBE, two independent yet interconnected surgical channels are established-one for the endoscope and the other for surgical instruments-providing a broad and clear surgical field of view. UBE offers several advantages over traditional open surgery, including reduced tissue damage, shorter hospital stays, and faster recovery times. Additionally, it combines the benefits of microscopic surgery and interlaminar endoscopy, enhancing flexibility, accuracy, and reliability during the procedure. The learning curve for UBE is shorter than that for transforaminal endoscopy, as the surgical processes closely resemble those of conventional open surgery. Despite its favorable clinical outcomes, such as reduced blood loss and shorter hospitalization, UBE carries potential complications, including epidural hematoma, dural injury, and compression of the outlet nerve root. To mitigate these risks, it is crucial to ensure appropriate patient selection, apply the correct surgical technique, and engage in careful postoperative monitoring. This article provides a detailed summary of the step-by-step surgical techniques used in UBE for treating lumbar disc herniation. It serves as a comprehensive guide to enhance practitioners' understanding of UBE. The presentation also underscores the importance of rigorous training and expertise to ensure optimal patient outcomes.

Presented here is a step-by-step surgical protocol of unilateral biportal endoscopy (UBE), a minimally invasive approach for treating lumbar disc herniation. By using two ports, surgical accuracy and flexibility are enhanced. This article provides a comprehensive description of UBE and highlights the practical application of this approach in clinical practice.

Unilateral biportal endoscopy (UBE) is a minimally invasive spinal surgery technique increasingly employed in treating degenerative lumbar diseases, such ...

Treating Lumbar Spinal Stenosis with a Minimally Invasive Spine Surgery

Percutaneous Endoscopic Unilateral-Approach Bilateral Decompression for Lumbar Spinal Stenosis

Lumbar spinal stenosis (LSS) involves the narrowing of the spinal canal due to degenerative changes in the vertebral joints, intervertebral discs, and ligaments. LSS encompasses central canal stenosis (CCS), lateral recess stenosis (LRS), and intervertebral foramen stenosis (IFS). The utilization of lumbar endoscopic unilateral laminotomy for bilateral decompression (LE-ULBD) has gained popularity in the treatment of CCS and LRS. This popularity is attributed to the rapid development of endoscopic instruments and the progress of endoscopic philosophy.
In this technical report, a detailed introduction to the steps and key points of LE-ULBD is provided. Simultaneously, a retrospective review of 132 consecutive patients who underwent LE-ULBD for central canal and/or lateral recess stenosis was conducted. The outcomes after more than two years of follow-up were assessed using the visual analogue score (VAS), Oswestry Disability Index (ODI), Japanese Orthopaedic Association (JOA) scores, and the modified MacNab criteria to evaluate surgical efficacy. All 132 patients underwent LE-ULBD successfully. Among them, 119 patients were rated as "excellent," while 13 patients were rated as "good" based on the modified MacNab criteria during the last follow-up. Incidental dural tears occurred in four cases, but there were no post-operative epidural hematomas or infections. The experience demonstrates that LE-ULBD is a less invasive, effective, and safe approach. It can be considered as an alternative option for treating patients with lumbar central canal stenosis and/or lateral recess stenosis.

Author Spotlight: Scope of LE-ULBD as a Safe, Effective, and Minimally Invasive Approach to Treat Lumbar Spinal Stenosis

The present protocol describes the steps and key points of lumbar endoscopic unilateral laminotomy for bilateral decompression for the treatment of degenerative lumbar spinal stenosis.

Lumbar spinal stenosis (LSS) involves the narrowing of the spinal canal due to degenerative changes in the vertebral joints, intervertebral discs, and ...

Full-Endoscopic Foraminoplasty and Lumbar Discectomy for Single-Level Lumbar Disc Herniation

The Transforaminal Endoscopic Surgical System (TESSYS) technique has gained popularity for the treatment of lumbar disc herniations. Foraminoplasty is the key procedure in TESSYS. However, it requires advanced skills and long-term learning, which hinder its widespread adoption among surgeons. Recently, the introduction of full-endoscopic solutions has made the process more manageable. The main difference from traditional single-portal endoscopic surgery is that full-endoscopic surgery is equipped with a larger working channel, allowing full visualization of foraminoplasty and decreasing reliance on intraoperative fluoroscopy. Recently, published studies have shown that full-endoscopic foraminoplasty and lumbar discectomy (FEFLD) could achieve comparable results to conventional microdiscectomy in terms of pain relief and functional outcomes, while enhancing postoperative recovery. This study describes the technique of FEFLD in detail, including every crucial step, such as patient positioning, puncture trajectory, endoscopic dissection of the superior articular process (SAP), endoscopic foraminoplasty, and more. We hope this will be helpful to beginners who wish to apply this approach.

Compared to conventional transforaminal endoscopic surgery, full-endoscopic foraminoplasty and lumbar discectomy (FEFLD) is a unique technique that allows full visualization of foraminoplasty and reduces the need for intraoperative fluoroscopies. This article describes the surgical steps involved in the FEFLD technique, shedding light on surgical tips and potential pitfalls to ensure outstanding performance.

The Transforaminal Endoscopic Surgical System (TESSYS) technique has gained popularity for the treatment of lumbar disc herniations. Foraminoplasty is the ...