局所 痲醉下側方位에서의 腰椎間部 手術方法 = Lumbar disc surgery in lateral position under local anesthesia

다국어 초록 (Multilingual Abstract)

Surgical treatment for low back pain with or without sciatica has been one of perplexing problem in the field of clinical neurosurgery. There has no clearcut explanation yet been given on an exact cause of lumbago in spite that most neurosurgeon has spent their considerable time and effort in complete relief of low back pain.
Although there reveal many different types of low back pain associated with various kind of neurological signs, it would be important for the neurosurgeon to clarify that what exactly cause such pain or trouble. An active attempt on searching true site of the pain has been carried out by the author during the disc surgery in the past nine years.
Conservative treatment with a bed rest should of course be applied to the patient before the surgery decided. If there is no adequate effect and if there show a persistent pain and positive neurological signs one should decide performing a laminectomy.
To confirm the accurate pain origin during the surgery mechanical and electronic stimulation on and around the nerve root must be at tempted with the patient under local anestesia. These stimulations should also be applied on posterior longitudinal ligament, annulus fibrosus, part of ligamentum flavum and dura. The patient is placed in the operating table iu lateral position so that some clinical tests including Lasegue's maneuver, active pelvic movement and coughing could be instructed on him during the disc exploration.
Local infiltration with 2% procaine HCL solution to the skin and 0.5% procaine solution to the subsequent layers should be used. Partial heminectomy can be done without pain. Ligamentum flavum is then be removed in one piece with a pointed knife and the wound is enlarged by a rongeur laterally in order to get the nerve root in view. At this point 0.3-0.5% procaine solution is injected to the root with a #26 needled syringe. The anesthesia is immediate and the nerve root may then be dissected and displaced without pain.
After the complete removal of ruptured and degenerated nucleus pulposus through a circular incision made on annulus fibrosus, one should start detecting any pain remaind in the disc area by means of various stimulations and clinical tests in cooperation with the patient. By the time finishing the total removal of degenerated nucleus pulposus the surgeon may notice the nerve root become sensitive to the stimulation as anesthetic getting absorbed and this would help the pain detection procedure. Pain associated with adhered loops and tissue inflammation can easily be detected and relieved by section of the adhered loop and inflamed posterior longitudinal ligament. After the thorough hemostasis and irrigation with saline the wound is closed meticulously in routine fashion. No blood transfusion or Ⅳ. infusion required during the surgery. There was no operative mortality. Satisfactory and excellent surgical result revealed in 99.5% of 405 cases treated during past nine years at author's hospitarl^(9).
Advantages by the method are:
1. No special pre-Op or post-Op care required.
2. Patient is placed in lateral position at ease during surgery.
3. Myelography is not necessarily required.
4. The surgery can be applicable in aged or illed patients.
5. No blood transfusion or Ⅳ. infusion is required except for the bad conditioned patient.
6. Lateral position allows the confirmation of pain origin and it's relief during the surgery.
7. Minimal or no mortality.
8. Early ambulation can be started.