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 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 ...

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

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Medicine

431 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

Thermal Ablation for the Treatment of Abdominal Tumors

Percutaneous thermal ablation is an emerging treatment option for many tumors of the abdomen not amenable to conventional treatments. During a thermal ablation procedure, a thin applicator is guided into the target tumor under imaging guidance. Energy is then applied to the tissue until temperatures rise to cytotoxic levels (50-60 &deg;C). Various energy sources are available to heat biological tissues, including radiofrequency (RF) electrical current, microwaves, laser light and ultrasonic waves. Of these, RF and microwave ablation are most commonly used worldwide.
During RF ablation, alternating electrical current (~500 kHz) produces resistive heating around the interstitial electrode. Skin surface electrodes (ground pads) are used to complete the electrical circuit. RF ablation has been in use for nearly 20 years, with good results for local tumor control, extended survival and low complication rates1,2. Recent studies suggest RF ablation may be a first-line treatment option for small hepatocellular carcinoma and renal-cell carcinoma3-5. However, RF heating is hampered by local blood flow and high electrical impedance tissues (eg, lung, bone, desiccated or charred tissue)6,7. Microwaves may alleviate some of these problems by producing faster, volumetric heating8-10. To create larger or conformal ablations, multiple microwave antennas can be used simultaneously while RF electrodes require sequential operation, which limits their efficiency. Early experiences with microwave systems suggest efficacy and safety similar to, or better than RF devices11-13.
Alternatively, cryoablation freezes the target tissues to lethal levels (-20 to -40 &deg;C). Percutaneous cryoablation has been shown to be effective against RCC and many metastatic tumors, particularly colorectal cancer, in the liver14-16. Cryoablation may also be associated with less post-procedure pain and faster recovery for some indications17. Cryoablation is often contraindicated for primary liver cancer due to underlying coagulopathy and associated bleeding risks frequently seen in cirrhotic patients. In addition, sudden release of tumor cellular contents when the frozen tissue thaws can lead to a potentially serious condition known as cryoshock 16.
Thermal tumor ablation can be performed at open surgery, laparoscopy or using a percutaneous approach. When performed percutaneously, the ablation procedure relies on imaging for diagnosis, planning, applicator guidance, treatment monitoring and follow-up. Ultrasound is the most popular modality for guidance and treatment monitoring worldwide, but computed tomography (CT) and magnetic resonance imaging (MRI) are commonly used as well. Contrast-enhanced CT or MRI are typically employed for diagnosis and follow-up imaging.

A thermal tumor ablation procedure is described. The entire procedure is detailed, including pretreatment planning and imaging studies, anesthesia, adjuvant techniques to facilitate a percutaneous approach, imaging guidance of the ablation device to the tumor, thermal treatment, post-treatment care and follow-up.

Percutaneous thermal ablation is an emerging treatment option for many tumors of the abdomen not amenable to conventional treatments. During a thermal ...

The Measurement and Treatment of Suppression in Amblyopia

Amblyopia, a developmental disorder of the visual cortex, is one of the leading causes of visual dysfunction in the working age population. Current estimates put the prevalence of amblyopia at approximately 1-3%1-3, the majority of cases being monocular2. Amblyopia is most frequently caused by ocular misalignment (strabismus), blur induced by unequal refractive error (anisometropia), and in some cases by form deprivation.
Although amblyopia is initially caused by abnormal visual input in infancy, once established, the visual deficit often remains when normal visual input has been restored using surgery and/or refractive correction. This is because amblyopia is the result of abnormal visual cortex development rather than a problem with the amblyopic eye itself4,5 . Amblyopia is characterized by both monocular and binocular deficits6,7 which include impaired visual acuity and poor or absent stereopsis respectively. The visual dysfunction in amblyopia is often associated with a strong suppression of the inputs from the amblyopic eye under binocular viewing conditions8. Recent work has indicated that suppression may play a central role in both the monocular and binocular deficits associated with amblyopia9,10 .
Current clinical tests for suppression tend to verify the presence or absence of suppression rather than giving a quantitative measurement of the degree of suppression. Here we describe a technique for measuring amblyopic suppression with a compact, portable device11,12 . The device consists of a laptop computer connected to a pair of virtual reality goggles. The novelty of the technique lies in the way we present visual stimuli to measure suppression. Stimuli are shown to the amblyopic eye at high contrast while the contrast of the stimuli shown to the non-amblyopic eye are varied. Patients perform a simple signal/noise task that allows for a precise measurement of the strength of excitatory binocular interactions. The contrast offset at which neither eye has a performance advantage is a measure of the "balance point" and is a direct measure of suppression. This technique has been validated psychophysically both in control13,14 and patient6,9,11 populations.
In addition to measuring suppression this technique also forms the basis of a novel form of treatment to decrease suppression over time and improve binocular and often monocular function in adult patients with amblyopia12,15,16 . This new treatment approach can be deployed either on the goggle system described above or on a specially modified iPod touch device15.

Amblyopia is a developmental disorder of the visual cortex that is often accompanied by strong suppression of one eye. We present a new technique for measuring and treating interocular suppression in patients with amblyopia that can be deployed using virtual reality goggles or a portable iPod Touch device.

Amblyopia, a developmental disorder of the visual cortex, is one of the leading causes of visual dysfunction in the working age population. Current ...

The Goeckerman Regimen for the Treatment of Moderate to Severe Psoriasis

Psoriasis is a chronic, immune-mediated inflammatory skin disease affecting approximately 2-3% of the population. The Goeckerman regimen consists of exposure to ultraviolet B (UVB) light and application of crude coal tar (CCT). Goeckerman therapy is extremely effective and relatively safe for the treatment of psoriasis and for improving a patient's quality of life. In the following article, we present our protocol for the Goeckerman therapy that is utilized specifically at the University of California, San Francisco. This protocol details the preparation of supplies, administration of phototherapy and application of topical tar. This protocol also describes how to assess the patient daily, monitor for adverse effects (including pruritus and burning), and adjust the treatment based on the patient's response. Though it is one of the oldest therapies available for psoriasis, there is an absence of any published videos demonstrating the process in detail. The video is beneficial for healthcare providers who want to administer the therapy, for trainees who want to learn more about the process, and for prospective patients who want to undergo treatment for their cutaneous disease.

Psoriasis is a chronic, immune-mediated inflammatory skin disease. The Goeckerman regimen, formulated for the treatment of psoriasis, consists of exposure to ultraviolet B (UVB) light and application of crude coal tar (CCT). The following protocol is for the administration of Goeckerman therapy for the treatment of moderate-to-severe psoriasis.

Psoriasis is a  chronic, immune-mediated inflammatory skin disease affecting approximately 2-3%  of the population. The Goeckerman regimen consists of ...

Network Analysis of Foramen Ovale Electrode Recordings in Drug-resistant Temporal Lobe Epilepsy Patients

Approximately 30% of epilepsy patients are refractory to antiepileptic drugs. In these cases, surgery is the only alternative to eliminate/control seizures. However, a significant minority of patients continues to exhibit post-operative seizures, even in those cases in which the suspected source of seizures has been correctly localized and resected. The protocol presented here combines a clinical procedure routinely employed during the pre-operative evaluation of temporal lobe epilepsy (TLE) patients with a novel technique for network analysis. The method allows for the evaluation of the temporal evolution of mesial network parameters. The bilateral insertion of foramen ovale electrodes (FOE) into the ambient cistern simultaneously records electrocortical activity at several mesial areas in the temporal lobe. Furthermore, network methodology applied to the recorded time series tracks the temporal evolution of the mesial networks both interictally and during the seizures. In this way, the presented protocol offers a unique way to visualize and quantify measures that considers the relationships between several mesial areas instead of a single area.

This protocol describes a procedure to track the evolution of mesial network measures in temporal lobe epilepsy (TLE) patients. It is based on the combination of intracranial recordings with a novel numerical technique for data analysis. Specifically, we present a protocol for network analyses of foramen ovale recordings.

Approximately 30% of epilepsy patients are refractory to antiepileptic drugs. In these cases, surgery is the only alternative to eliminate/control ...

Ovine Lumbar Intervertebral Disc Degeneration Model Utilizing a Lateral Retroperitoneal Drill Bit Injury

Intervertebral disc degeneration is a significant contributor to the development of back pain and the leading cause of disability worldwide. Numerous animal models of intervertebral disc degeneration have been developed. The ideal animal model should closely mimic the human intervertebral disc with regard to morphology, biomechanical properties and the absence of notochordal cells. The sheep lumbar intervertebral disc model fulfils these criteria. We present an ovine model of intervertebral disc degeneration utilizing a drill bit injury through a lateral retroperitoneal approach. The lateral approach significantly reduces the incision and potential morbidity associated with the traditional anterior approach to the ovine spine. Utilization of a drill-bit method of injury affords the ability to produce a consistent and reproducible injury, of precise dimensions, that initiates a consistent degree of intervertebral disc degeneration. The focal nature of the annular and nucleus pulposus defect more closely mimics the clinical condition of focal intervertebral disc herniation. Sheep recover rapidly following this procedure and are typically mobile and eating within the hour. Intervertebral disc degeneration ensues and sheep undergo necropsy and subsequent analysis at periods from eight weeks. We believe that the drill bit injury model of intervertebral disc degeneration offers advantages over more conventional annular injury models.

Intervertebral disc degeneration is a significant contributor to back pain and a leading cause of disability worldwide. Numerous animal models of intervertebral disc degeneration exist. We demonstrate an ovine model of intervertebral disc degeneration, utilizing a drill bit, which achieves a consistent disc injury and reproducible level of disc degeneration.

Intervertebral disc degeneration is a significant contributor to the development of back pain and the leading cause of disability worldwide. Numerous ...

Trans-Tympanic Drug Delivery for the Treatment of Ototoxicity

The systemic administration of protective agents to treat drug-induced ototoxicity is limited by the possibility that these protective agents could interfere with the chemotherapeutic efficacy of the primary drugs. This is especially true for the drug cisplatin, whose anticancer actions are attenuated by antioxidants which provide adequate protection against hearing loss. Other current or potential otoprotective agents could pose a similar problem, if administered systemically. The application of various biologicals or protective agents directly to the cochlea would allow for high levels of these agents locally with limited systemic side effects. In this report, we demonstrate a trans-tympanic method of delivery of various drugs or biological reagents to the cochlea, which should enhance basic science research on the cochlea and provide a simple way of directing the use of otoprotective agents in the clinics. This report details a method of trans-tympanic drug delivery and provides examples of how this technique has been used successfully in experimental animals to treat cisplatin ototoxicity.

We present a technique for localized administration of drugs through the trans-tympanic route into the cochlea. Drug delivery through this route would not interfere with the anti-cancer efficacy of the chemotherapeutic drugs such as cisplatin.

The systemic administration of protective agents to treat drug-induced ototoxicity is limited by the possibility that these protective agents could ...

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 ...

Isolation of Adipose Derived Regenerative Cells for the Treatment of Erectile Dysfunction Following Radical Prostatectomy

Stem cells are used in many research areas within regenerative medicine in part because these treatments can be curative rather than symptomatic. Stem cells can be obtained from different tissues and several methods for isolation have been described. The presented method for the isolation of adipose-derived regenerative cells (ADRCs) can be used within many therapeutic areas because the method is a general procedure and, therefore, not limited to erectile dysfunction (ED) therapy. ED is a common and serious side effect to radical prostatectomy (RP) since ED often is not well treated with conventional therapy. Using ADRC&#8217;s as treatment for ED has attracted great interest due to the initial positive results after a single injection of cells into the corpora cavernosum. The method used for the isolation of ADRC&#8217;s is a simple, automated process, that is reproducible and ensures a uniform product. Furthermore, the sterility of the isolated product is ensured because the entire process takes place in a closed system. It is important to minimize the risk of contamination and infection since the stem cells are used for injection in humans. The whole procedure can be done within 2.5-3.5 hours and does not require a classified laboratory which eliminates the need for shipping tissue to an off-site. However, the procedure has some limitations since the minimum amount of drained lipoaspirate for the isolation device to function is 100 g.

Precise disclosure of methods and protocols is crucial for large scale uptake of stem cell therapies. Here, we present a protocol to isolate adipose-derived regenerative cells, used for a single intracavernous injection as treatment of erectile dysfunction (ED) following radical prostatectomy (RP).

Stem cells are used in many research areas within regenerative medicine in part because these treatments can be curative rather than symptomatic. Stem ...

Transaxillary First Rib Resection for Treatment of the Thoracic Outlet Syndrome

Thoracic outlet syndrome (TOS) is a common disorder that causes a significant loss of productivity. The transaxillary first rib resection (TFRR) protocol has been used for the decompression of trapped neurovascular structures in the TOS. Among the other surgical procedures, the advantage of the TFRR is that it has the smallest rate of recurrence and better cosmetic outcomes. The disadvantage of TFRR is that it provides a narrow, and deep working corridor that makes obtaining vascular control challenging.

Here, we present a protocol of the transaxillary resection of the first rib for treatment of thoracic outlet syndrome caused by compression of the brachial plexus, subclavian vein and artery.

Thoracic outlet syndrome (TOS) is a common disorder that causes a significant loss of productivity. The transaxillary first rib resection (TFRR) protocol ...

Laparoscopy-endoscopy Cooperative Surgery for the Treatment of Gastric Gastrointestinal Stromal Tumors

In view of the shortcomings of endoscopic or laparoscopic surgeries alone in the treatment of gastric gastrointestinal stromal tumors (G-GISTs), this approach makes an innovative improvement in the treatment of G-GISTs that are less than 5 cm in size. Laparoscopy-endoscopy cooperative surgery (LECS) is used to combine endoscopic and laparoscopic surgeries, fully realizing their respective advantages and avoiding their drawbacks. The main steps are as follows. First, gastroscopy and laparoscopy are combined to confirm the location and boundary of the tumor. Tumor resection is carried out laparoscopically, guided by a gastroscope. The specimen is removed orally and the gastric wound closed laparoscopically. Then, gastroscopy and laparoscopy are combined to determine whether there is wound bleeding, if the suture is satisfactory, and if the gastric cavity is deformed.
LECS has natural advantages in the treatment of G-GISTs that are less than 5 cm in size. The accurate estimation of tumor location and boundary greatly improves the complete resection rate of tumors. The risk of tumor rupture is substantially reduced, and the long-term prognosis of patients is significantly improved. The process allows for accurate resection of the tumor, maximum preservation of normal gastric tissue and organ function, and avoids postoperative gastric deformation. The patient's postoperative rehabilitation is greatly accelerated, and oral feeding can resume on the day of the operation. The specimen is taken out through the mouth to avoid the need for an extended abdominal incision. This greatly reduces the patient's postoperative pain and scarring. The method greatly shortens the postoperative hospital stay (i.e., discharge is possible on the day after the operation), increasing the turnover of hospital beds.

Laparoscopy-endoscopy cooperative surgery is appropriate for the treatment of gastric gastrointestinal stromal tumors less than 5 cm in size. It can achieve the respective advantages of endoscopic and laparoscopic surgeries while avoiding their drawbacks.

In view of the shortcomings of endoscopic or laparoscopic surgeries alone in the treatment of gastric gastrointestinal stromal tumors (G-GISTs), this ...