这项工作得到了南山区卫生科技项目（批准号）NS2023002;NS2023044）、广东省医学科学研究基金（批准号：A2023195）、南山区卫生科技重大专项（批准号：）、广东省医学科学研究基金（批准号：号）、南山区卫生科技重大专项（批准号：号）、南山区卫生科技重大专项（批准号：NSZD2023023;NSZD2023026）、国家自然科学基金（批准号：82102640）和国家重点研发计划（批准号：2022YFC3602203）。

该协议遵守华中科技大学联合深圳医院伦理委员会制定的规定，该委员会已批准该协议。已获得患者的书面知情同意书。入组一名 31 岁的女性患者，她患有持续的左腿放射痛，视觉模拟量表 （VAS）7 等于 8。体格检查结果如下：（1）上半身右侧弯曲;（2）前倾和后倾的运动范围受限;（3）左直腿抬高试验和Braggard试验阳性;（4）左胫骨前力量4级;（5）左小腿外侧和左脚背侧麻木。MRI 证实腰椎 4-5 椎间盘突出症（左旁正中型）呈阳性。她接受过无效的门诊保守治疗，包括休息、非甾体抗炎药（塞来昔布 200 mg/天，持续 6 周）和针灸两个月。研究中使用的手术工具和设备列在 材料表中。
1.内窥镜下减压
<ol><li>体位和麻醉<ol><li>通过经椎间孔入路进行内窥镜腰椎间盘切除术8.将患者置于俯卧位，并在透视引导下标记皮肤穿刺点。局部消毒和悬垂后，将 0.5% 利多卡因 （10 mL） 注射到穿刺点。</li>
	</ol></li>
	<li>穿刺和套管放置<ol><li>使用 18 G 针在标记的穿刺点进行穿刺，并在透视下调整位置。逐步插入扩张套管（直径 3.7 毫米）并在透视下确认达到理想位置。</li>
	</ol></li>
	<li>内镜下腰椎减压术<ol><li>插入不同尺寸（直径 5 毫米、8 毫米和 10 毫米）的环钻锯并旋转以去除 L5 上关节突的颅、背和尾侧的骨头，以进行椎间孔成形术9。</li>
		<li>逐步暴露并去除软组织。观察椎间盘突出的疑似区域（丘陵状，通常与周围的平坦区域明显不同）。确定目标椎间盘突出和受压神经根10.</li>
		<li>识别并切除突出和松动的椎间盘（包括 AF、NP 和软骨终板）。检查减压的神经根，确认不存在残余椎间盘。 注意：为了确定目标突出，我们的经验是评估椎间盘材料的颜色、质地和形状。与周围的正常组织相比，破裂或突出的椎间盘可能会出现变色、碎裂或移位。为了检查减压神经根的状况，让患者咳嗽并观察减压神经根的“脉动”状态11。</li>
	</ol></li>
</ol>2. PLL-AF缝合技术
<ol><li>外侧 AF 撕裂的穿透<ol><li>使用一次性环形吻合器进行内窥镜缝合12.识别AF撕裂，并使用环形吻合器中的曲线形针头将第一针（丝制成，直径0.4 mm）穿透完整的横向AF组织（图1A）。检查并确认针脚已牢固固定（图 1B）。</li>
	</ol></li>
	<li>锁相环（PLL）缝合<ol><li>将第二针（丝质，直径 0.4 毫米）穿入 PLL 中，并确认它也穿透下方完整的内侧 AF。检查并确认针脚已牢固固定。然后，用方结拧紧第一针和第二针（图1C）。 注意：在减压后识别 PLL 有时可能具有挑战性。建议仔细操作并确定椎管的内侧和背侧区域。</li>
	</ol></li>
	<li>三、加强针脚<ol><li>在完整AF的侧面区域和第二针的颅骨位置（图1E）剪切第一针（图1D）并穿透第三针（丝绸制成，直径0.4毫米）。</li>
		<li>检查并确认针脚已牢固固定。打一个方结后剪断两针（图1F）。再次检查神经根，确保不存在压迫。</li>
	</ol></li>
</ol>3.术后管理
<ol><li>静脉注射 50 mg 氟比洛芬 axetil 治疗术后疼痛。</li>
	<li>手术后，在没有出现特殊情况或并发症的情况下，允许患者在术后一天离开床，并提供腰部支架13 （半刚性类型，带有金属或塑料支柱作为支撑）。</li>
</ol>

用于腰椎内窥镜纤维环修复的新型 PLL-AF 缝合技术

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本研究的作者声明不存在利益冲突。

在内窥镜下实现出色的 AF 缝合具有显着的好处。预计它可以减少由 AF 破裂或隆起引起的神经机械刺激，从而减少术后残留的椎间盘源性腰痛和/或坐骨神经痛 4,12。关闭环状泪门可以减少由椎间盘释放炎症介质引起的神经根刺激5.此外，患者可以在手术后早期更有信心地活动。这种信心有助于加速恢复过程，并在恢复力量和功能方面取?...

经皮经椎间孔内窥镜椎间盘切除术 （PETD） 是一种用于切除腰椎椎间盘突出的微创手术，使用内窥镜进行 - 内窥镜是一根细管，尖端带有摄像头和灯，使外科医生能够在监视器上观察内部组织和周围结构1。通过监视器上的实时图像引导，外科医生可以通过大约 1 厘米的小皮肤切口进行套管2 的定位、穿刺和放置。接下来在内窥镜下逐步暴露，包括切除周围的软组织和椎间孔成形术以扩大目标腰椎孔的开口。一旦获得清晰的视野和足够的手术空间，就通过移除受压碎片3 对腰神经进行完全减压。
预防椎间盘突出症术后复发仍然是脊柱外科医生长期关注的问题。在手术过程中，将复发风险降至最低的一种策略是切除所有疑似分离的髓核 （NP），即使它尚未疝入耳道。这是因为破裂的纤维环 （AF） 无法完全修复，因此，易受椎间盘内压力影响的脱落 NP 组织将来可能会再疝4。
尽管在修复和再生髓核 （NP） 和纤维环 （AF） 的组织工程方面取得了可喜的进展，但它们都没有被临床证明有效5.完全减压后直接闭合心房颤动撕裂是降低腰椎间盘突出症 （LDH） 复发风险的重要技术。目前，在内窥镜检查下，最常用的 AF 修复缝合技术是在泪液部位进行简单的缝合，只需缝一针6。除了担心单针是否能产生足够的张力外，内窥镜减压后，经常会遇到环状撕裂两侧缝合面积不足（无论是质量还是数量）不足的情况。
因此，本研究提出了一种在PETD减压后缝合AF的新技术，方法是将附近的后纵韧带（PLL）拉动并缝合在AF撕裂上，并缝合三针（PLL-AF缝合技术）。

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

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

全内窥镜检查下纤维环破裂 （AF） 的缝合技术仍然具有挑战性。在完全减压后直接缝合破裂的环状撕裂已被证明可以降低内窥镜手术期间腰椎间盘突出症的复发率。内窥镜检查下的传统缝合手术仅涉及对破裂的 AF 进行简单缝合。由于泪门周围的 AF 组织薄弱且质量差，因此在缝合过程中将该区域用作针插入点可能会导致张力不足和 AF 闭合成功率低。目前，尚无基于视频的腰椎全内镜下AF撕裂缝合的详细技术说明。我们创新性地提出了一种覆盖和缝合AF撕裂的方法，即在腰椎内镜检查下拉起后纵韧带（PLL），并使用三针（PLL-AF缝合技术）。接受新型缝合技术的患者取得了令人满意的效果。手术6个月后，腰椎MRI在门诊未显示复发迹象。

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

作者聚焦： 经皮经椎间孔内窥镜椎间盘切除术中用于环状纤维肌瘤修复的新型缝合技术的开发和应用

经皮经椎间孔内窥镜椎间盘切除术减压后纤维环破裂的缝合技术

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

在成功和充分的减压后，切除了L4/5处的突出椎间盘（图2A，A'）。在内窥镜下识别出局部 AF 撕裂（内侧和外侧撕裂边缘）和 PLL。第一次缝合确保外侧撕裂边缘得到控制和缝合。PLL 和内侧 AF 撕裂边缘与第一针一起被穿透并缝合。将第三针与第二针在第一针的颅侧绑在一起。该技术的关键点是穿透 PLL 和内侧完整 AF 并拉动以覆盖和缝合外侧 AF 撕裂。
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Watch this Scientific Journal Video about Author Spotlight: Development and Application of a Novel Suture Technique for Annular Fibrosus Repair in Percutaneous Transforaminal Endoscopic Discectomy at 

该方案描述了一种创新的缝合技术，用于在经皮经椎间孔内窥镜椎间盘切除术中破裂的环状纤维。

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

本研究描述了一种创新的缝合技术，用于经皮经椎间孔内窥镜椎间盘切除术中环状纤维破裂，我们提出了一种通过拉起腰椎下后纵韧带进行内窥镜检查来缝合环状纤维撕裂的方法。要进行腰椎疝症的内窥镜手术技术，外科医生必须具备丰富的经验。然而，并非每个腰椎疝患者都适合采用这种技术。在某些情况下，如果环状撕裂在减压后变得太窄，则可能不需要缝合。该技术提供了一种新的解决方案，可以解决由于传统的单碟缝合方法在腰椎内窥镜减压后出现的张力不足的问题。此外，环状纤维化撕裂周围的后纵韧带紧密可见，这有助于增加受压段处的腰椎管体积。

a-suture-technique-for-ruptured-annulus-fibrosus-following

Research

JoVE Journal

Medicine

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

538 次观看.  Huazhong University of Science and Technology Union Shenzhen Hospital. 本研究描述了一种创新的缝合技术，用于经皮经椎间孔内窥镜椎间盘切除术中环状纤维破裂，我们提出了一种通过拉起腰椎下后纵韧带进行内窥镜检查来缝合环状纤维撕裂的方法。要进行腰椎疝症的内窥镜手术技术，外科医生必须具备丰富的经验。然而，并非每个腰椎疝患者都适合采用这种技术。在某些情况下，如果环状撕裂在减压后变得太窄，则可能不需要缝合。该?...

视频: 作者聚焦： 经皮经椎间孔内窥镜椎间盘切除术中用于环状纤维肌瘤修复的新型缝合技术的开发和应用

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

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

作者聚焦： 经皮经椎间孔内窥镜椎间盘切除术中用于环状纤维肌瘤修复的新型缝合技术的开发和应用

作者聚焦：经皮经椎间孔内窥镜椎间盘切除术中用于环状纤维肌瘤修复的新型缝合技术的开发和应用