Patients The patients were from June 2016 to June 2018 in the orthopedic department of our medical center. Finally, 14 patients in Key-hole group and 16 patients in ACDF group were included.
Materials ACDF group used anterior cervical plate internal fixation system from Medtronic Inc. and artificial bone implant fusion cage from Sichuan guona Technology Co., Ltd, while Key-hole group used bipolar spherical radiofrequency ablation electrode of Joimax GmbH.
Applicants inclusion criteria
(1)In accordance with the diagnostic criteria of CSR[9]; (2)Patients with unilateral nerve root involvement due to single segment disc herniation; (3) After regular conservative treatment for 2 months (no more than 6 months) [7], the patients had no obvious relief of symptoms, or the pain was acute and intolerable, and there were surgical indications; (4)Patients with good stability of cervical spine before operation; (5) All operations were performed by the same surgeon and his treatment team.
Applicants exclusion criteria
(1) Does not meet any of the inclusion criteria; (2)Patients with spinal tuberculosis, spinal tumor, cervical fracture and dislocation, severe osteoporosis and other diseases; (3)Ossification of posterior longitudinal ligament, ossification of ligamentum flavum and other bone compression; (4) Patients with cardiovascular and cerebrovascular accidents or mental disorders, which affect postoperative functional recovery and curative effect evaluation.
Group
According to different surgical methods, they were divided into observation group (Key-hole group) and control group (ACDF group). All patients have expressed informed consent to the treatment plan, which has been approved by the hospital ethics committee.
Methods
Preoperative Preparation (1) Before operation, detailed medical history was inquired, systematic review and specialized physical examination were completed repeatedly, and imaging examination was combined to ensure accurate positioning; (2)The patients in ACDF group were given trachea shift training and respiratory function exercise 3–5 days before operation[10]; (3) Because of the particularity of the operation site of the neck, there is a risk of vascular and nerve injury. Blood was prepared routinely before operation, and methylprednisolone and mannitol were brought into the operating room.
ACDF Group Operation Process In supine position, the right anterior cervical incision was taken to expose the anterior space of platysma muscle and sternocleidomastoid muscle. The vascular sheath and visceral sheath were pulled to both sides. The anterior cervical fascia was cut to expose the longus cervical muscle. The vertebral body was marked with injection needle, and the responsible disc was determined by C-arm. Subsequently, the intervertebral disc tissue and vertebral hyperosteogeny were removed, the local posterior longitudinal ligament was removed, and the posterior wall of decompression was sneaked to the uncinate joint. The decompression of nerve root canal was expanded, and the dura mater and nerve root were explored to ensure that there was no pressure substance. According to the measurement results of vertebrae, the appropriate length of fusion cage, steel plate and locking nail were fixed in order. The position of the fusion cage was confirmed by fluoroscopy again. After decompression, the fusion cage was completely hemostatic. The wound was sutured layer by layer. Appropriate amount of cocktail (tranexamic acid + ropivacaine + compound betamethasone) was injected around the wound. The drainage tube was indwelled, he neck bracket was protected, and the operation was closed (Figs. 1).
Key-hole Group Operation Process In the Key-hole group, patients were placed in prone position with head high and feet low, and neck was fixed in slightly forward flexion position. Under fluoroscopy, the incision was made 1.0-1.5 cm away from the posterior midline of the neck. The 18 needle was used to puncture the bone surface of the lower edge of the upper lamina near the articular process. A 2 cm longitudinal incision was made. The 3-stage sleeve was expanded step by step (always pay attention to the puncture needle and expansion tube on the surface of the hard bone), and the working channel, lens and monitor were installed in turn. Under endoscope, the corresponding intervertebral space and upper and lower lamina were exposed. After the lower edge of the upper lamina and the upper edge of the lower lamina were thinned by the power grinding drill, part of the lamina and ligamentum flavum were removed by the bone biting forceps under the endoscope. If necessary, part of the facet joints should be removed, the nerve roots were exposed and pulled out, and the protruding nucleus pulposus tissue should be explored and removed by using endoscopic nucleus pulposus forceps. After confirming that the decompression was sufficient, bipolar radiofrequency electrocoagulation was used for hemostasis, proper amount of cocktail was injected along the channel, the working sleeve was pulled out, and the wound was sutured (Figs. 2).
Postoperative treatment (1)Two groups of patients were given routine symptomatic support, and did a good job in the prevention of laryngeal edema, epidural hematoma and other critical situations; (2)Perioperative pain management, using intravenous drip, intramuscular, oral multi-mode combined pain; (3)Perioperative fluid management, intravenous antibiotics were applied 24 hours after operation, and routine application of dexamethasone and mannitol is to reduce edema 3 days after operation. According to the preoperative Caprini thrombus risk assessment scale, if there was a high risk of thrombosis, low molecular weight heparin was used for anticoagulation 24 hours after operation; (4)In ACDF group, the drainage device was removed 1 day after operation (in case of unobstructed drainage, the drainage volume was less than 30 ml in 12 hours or less than 50 ml in 24 hours).
Outcome measures (1)The operation time, hospitalization time and treatment cost were recorded (the treatment cost was related to surgery, including examination cost, operation cost, perioperative management, complication treatment cost, etc. (2) The SF-MPQ pain score, NDI and JOA function scores were recorded 1 day before operation, 7 days after operation, 3 months after operation and the last follow-up; (3)Follow up the whole process and record the complications at any time.
Statistical analysis SPSS 25.0 statistical software package was used for data analysis. The counting data was analyzed by Fisher exact test, the rank data was analyzed by Mann-Whitney test, and the measurement data was expressed by`x ± s. The independent sample t-test was used for inter group comparison, and the paired sample t-test was used for comparison at each time point within the group. The difference was statistically significant (P < 0.05).