Orthopedic paper VII
Intervertebral disc excision in community health centers
OPERATIVE TREATMENT OF PROTRUSION OF THE LUMBAR INTERVERTEBRAL DISC IN A COMMUNE’S HEALTH CENTER
ABSTRACT
This is clinical review of 104 cases of protrusion of the lumbarintervertebral disc treated with surgery from 1974 to 1980 in a healthcenter of a people’s commune.
After the operation, all the cases were followed up for 2-8 yearswith an average of 5 years. The results of the 104 operated cases: excellent 68 (65.4%), good 22 (21.2%), fair 10 (9.6%), failure in 4(3.8%). The method and the result of the operative treatment arepresented and the experiences are described in detail
ABSTRACT
This is clinical review of 104 cases of protrusion of the lumbar intervertebral disc treated with surgery from 1974 to 1980 in a health center of a people’s commune. After the operation, all the cases were followed up for 2-8 years with an average of 5 years. The results of the 104 operated cases: excellent 68 (65.4%), good 22 (21.2%), fair 10 (9.6%), failure in 4 (3.8%). The method and the result of the operative treatment are presented and the experiences are described in detail.
椎间盘摘除术治疗腰间盘突出引起的腰腿痛，是一种公认的病因疗法。现在，在县以上的医院这种手术已相当普及，但在基层公社卫生院仍开展较少。于1974~1980年间，我们在许竞斌教授的直接指导下，在公社卫生院共做腰椎间盘摘除手术104例; 术后经2~8年的随访，绝大多数都取得了满意效果。现就在条件较差的基层卫生院如何提高手术效果问题，点滴体会如下:
Discectomy is an acknowledged etiological therapy for lumbocrural pain caused by lumbar disc herniation. At present, this kind of surgery has been quite popular in the hospitals above the county level, but it is still less carried out in the grass-roots commune hospitals. From 1974 to 1980, under the direct guidance of professor xu jingbin, 104 cases of lumbar disc extraction were performed in the commune hospital. After two to eight years of follow-up, the vast majority of patients have achieved satisfactory results. On the issue of how to improve the surgical effect in the grassroots hospitals with poor conditions, we have the following experiences to report.
一般资料
104例中，男85例，女19例，发病最大的年岁56岁，最小23岁; 腰 4、5 间突出49例，腰 5 骶 1 间突出31例，双突出22例，腰 3、4 间2例。其中椎间盘突出髓核破入椎管内2例，同时伴有骨赘形成12例。
根据马植尧等疗效评定标准 [2] 统计如下表:
手术效果
|
疗效 |
优 |
良 |
中 |
差 |
合计 |
|
例数 |
68 |
22 |
10 |
4 |
104 |
|
% |
65.4 |
21.2 |
9.6 |
3.8 |
100% |
General information
There were 85 males and 19 females in the 104 cases, and the oldest patient was 56 years old and the youngest was 23 years old. There were 49 cases with protrusion between the 4th and 5th lumbar vertebra, 31 cases with protrusion between the 1st lumbar vertebra and 5th sacral vertebra, 22 cases with double protrusion, and 2 cases with protrusion between the 3rd and 4th lumbar vertebra. There were two cases in which the herniated nucleus pulposus broke into the spinal canal, and 12 cases with osteophyte formation. According to Ma Zhiyao’s efficacy evaluation criteria [2], the statistics are shown in the following table:
Surgical effects
Experience
体 会
一、显露问题: 本组除8例半椎板切除外，其余全部采用“开窗”显露，包括12例铲除骨赘在内。通过手术实践的体会和观察，我们认为“开窗”与半椎板切除二种方法在显露效果上无明显差别，所以在显露问题上，除非真正特别需要外，如髓核破入椎管内，一般均可采用“开窗”法。这样一般不影响小关节突，损伤小，便于患者术后早期起床活动，减少神经根粘连的可能。本组“开窗”病例，都是术后3~5天开始起床活动，未发现异常。
1, Exposure problem: In this group, except for 8 cases with hemilaminectomy, all the others were exposed by “fenestration”, including the removal of osteophyte in 12 cases. Through the experience and observation of surgical practice, we believe that there is no significant difference in exposure effects between the two methods of “fenestration” and hemilaminectomy. Therefore, in the exposure problem, unless really necessary, such as nucleus pulposus breaking into the spinal canal, the “fenestration” method can be generally used. This generally does not affect the small articular process, small injury, easy for patients to get up early after surgery activities, reduce the possibility of nerve root adhesion. In the fenestration cases in our group, the patients started to get up 3–5 days after operation, and no abnormality was found.
二、减压问题: 手术治疗腰椎间盘突出症不满意的原因，1951年 Armstrong 氏指出，一是由于诊断错误，二为椎间盘突出病变实际存在，而手术未能完全解除其病因。随着医疗技术不断发展和提高，对于椎间盘突出症的误诊和手术遗漏的机会是越来越少，所以在手术中真正做到“完全减压”的问题，显得较为重要。我们在显露突出的椎间盘，保护好神经根后，用小尖刀沿突出椎间盘的外径环切一周，再用垂体钳取出突出的椎间盘及椎间隙内的退化组织，然后用刮匙刮取一些破碎的组织，基本上做到“掏空”; 而不是单纯摘取髓核部分。遇有骨赘病例, 在铲除骨赘后, 也同样做到“掏空”。我们体会这样对神经根彻底减压，不但疗效好，而且有利防止复发。
II. Decompression:
The cause of dissatisfaction with surgical treatment of LDH. Armstrong pointed out in 1951 that the first reason was due to incorrect diagnosis, and the second reason was the actual existence of LDH lesion, and surgery failed to completely remove the cause. With that continuous development and improvement of medical technology, the opportunity for misdiagnosis and surgical omission of disc herniation are becoming less and less, so the problem of truly achieve “complete decompression” in surgery appears to be relatively important. After revealing the herniated intervertebral disc and protecting the nerve root, we used a small sharp knife to make a circumferential cut along the outer diameter of the herniated intervertebral disc for one week, and then took out the herniated intervertebral disc and the degenerative tissues in the intervertebral space with a pituitary forceps. Then we used a curette to scrape out some broken tissues, and basically “hollowing out”. Rath than simply harvesting that nucleus pulposus portion. In case of osteophyte, “tunneling” is also performed after the osteophyte is removed. We realized that complete decompression of nerve root in this way not only had good curative effect, but was also beneficial to prevent recurrence.
三、防止感染问题: 感染是椎间盘术后严重的并发症之一，尤其是椎间隙感染，给病人带来很大的痛苦，恢复时间也较长。在条件设备尚不完好的基层卫生院，对这个问题更应该引起高度重视。为了防止感染，我们除严格执行各项无菌操作外，还对每个手术病人在术前用肥皂水反复刷洗腰背部皮肤，在切除椎间盘后，常规改用 1:1000 洗必太液加压冲洗被掏空的椎间隙，继后用洗必太湿纱布堵住创口，让整个创口在洗必太液里浸泡3分钟左右，再除去纱布。因为洗必太具有广谱高效，无耐药性的特点，对神经等组织无不良反应和刺激。这样反复冲洗和浸泡，使细菌和碎屑组织都不复存在的机会; 再结合抗生素的应用、引流等综合措施，对防止感染起着积极作用。
III. Prevention of infection:
Infection is one of the serious complications after intervertebral disc surgery, especially intervertebral space infection, which brings great pain to patients and requires a long recovery time. This problem should be paid more attention to in the basic level health centers with imperfect equipments. In order to prevent infection, in addition to strictly carrying out various aseptic operations, we also repeatedly washed the skin on the lower back of each patient undergoing surgery with soapy water before surgery. After the intervertebral disc was removed, we routinely switched to 1:1000 chlorhexidine solution to pressurize and wash the hollowed intervertebral space. Afterwards, the wound was blocked with chlorhexidine gauze, and the whole wound was immersed in the chlorhexidine solution for about 3 minutes, followed by gauze removal. Because chlorhexidine hydrochloride has the characteristics of broad spectrum and high efficiency, and no drug resistance, it has no adverse reaction or stimulation to nerves and other tissues. Such repeated washing and soaking, make bacteria and debris tissue no longer exist; Combined with the application of antibiotics, drainage and other comprehensive measures, to prevent infection plays a positive role.
四、防止椎管内继发血肿问题: 因为椎管内是不应存留任何异物的，所以对于椎管内出血既不宜用丝线结札，也不好用游离肌肉作填塞物，止血方法，一般来说只是压迫。因此术后椎管内少量出血是难免的。由于出血形成血肿，继发压迫神经根，甚至血肿机化、纤维化，造成神经根的粘连，从而影响了手术效果。对于这个问题，我们认为首先应该是术者操作熟炼、动作轻柔，在切除之前，要在突出椎间盘的上下方各填塞一个带线的棉球，待把突出椎间盘清楚暴露以后，在良好光线下直视切除。切勿盲目下刀和钳挟。由于暴露清楚，遇有小血管可以避开，做到尽可能不损伤小血管，这样椎管内出血机会就大为减少。尽管这是无菌手术，但是，我们是常规放置橡皮引流条，腰背筋膜这一层不缝合，术后患者仰卧位，以利引流。在冲洗创口时，我们有意让少量的洗必太液存留在创口内，即使创口内有少量出血，也被稀释，更易引流。我们从术后48小时拔除引流条时观察到，每患者引出的血水达40~250亳升左右 (以浸湿纱布的方法计算)。由此可见，恰当的引流是有裨益的。
IV. Prevention of secondary hematoma in the spinal canal: Because no foreign body should be left in the spinal canal, it is not advisable to use silk thread for internal hemorrhage in the spinal canal or use free muscle as stuffing to stop bleeding. Generally speaking, it is only compression. Therefore, a small amount of intraspinal hemorrhage after surgery is unavoidable. Hematoma is formed due to hemorrhage, which will lead to secondary compression of nerve root, and even organization and fibrosis of hematoma, resulting in adhesion of nerve root, thus affecting the operation effect. To solve this problem, we believe that the operator should first practice manipulation and perform gentle movements. Before resection, a cotton ball with a line should be inserted into the upper and lower parts of the herniated intervertebral disc. After the herniated intervertebral disc is clearly exposed, the disc should be excised under direct vision in a good light. Do not blindly under the knife and clamp. As the exposure is clear, it can be avoided in case of small blood vessels, so as not to damage the small blood vessels as much as possible, and thus the chance of intraspinal hemorrhage is greatly reduced. Although this was a sterile procedure, we routinely placed a rubber drainage strip without suturing this layer of the lumbar dorsal fascia, and the patient was in the supine position postoperatively to facilitate drainage. When washing the wound, we intentionally left a small amount of chlorhexidine hydrochloride in the wound, so that even if there was a small amount of bleeding in the wound, it would be diluted and easier to drain. We observed that about 40 to 250 ml (calculated by soaking gauze) of blood was drained from each patient when the drain was removed 48 hours after surgery. Thus, proper drainage is beneficial.
references
- Xu Jingbin. Analysis of the efficacy of LDH, Chinese Journal of Surgery 4421, 1956
- Ma Zhiyao et al. Effects of surgical treatment of LDH, Chinese Medical Journal 5:51, 1965
- Lu Yupu et al. Surgical treatment of LDH, Chinese Journal of Orthopedics 2:77, 1981
- OPERATIVE TREATMENT OF PROTRUSION OF THE LUMBAR INTERVERTEBRAL DISC IN A COMMUNE’S HEALTH CENTER Ding Ming-xiu
Nanling Health School, Anhui
By Mingxiu Ding, Jingbin Xu & Mingle Li, 09/01/1983
Proceedings of third orthopedic academic conference of Anhui
参考文献
[1] 许竞斌: 腰椎间盘突出症的疗效分析， 中华外科杂志4421，1956[2] 马植尧等: 手术治疗腰间盘突出症的效果，中华医学杂志 5:51，1965[3] 陆裕朴等: 腰椎间盘突出症的手术治疗，中华骨科杂志2:77，1981
Sept 1， 1983
安徽省第三届骨科学术会议交流资料
南陵县卫生进修学校丁明秀指导者:许竞斌 李名杰
