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      Comment on “Effective Range of Percutaneous Posterior Full-Endoscopic Paramedian Cervical Disc Herniation Discectomy and Indications for Patient Selection”

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          Abstract

          We read with great interest the article by Wen et al. [1], concerning the effective range of percutaneous posterior full-endoscopic paramedian cervical disc herniation discectomy and indications for patient selection. We would like to congratulate the authors for their interesting paper, but we would like to make some comments because we are a little bit concerned with the measurement method they apply to define the vertical distance between the lateral border of the dural sac and the peak of the herniated disc (DSPHD); the vertical distance between the lateral border of the dural sac and the intersection of the dural sac and the medial border of the herniated disc (DSMHD); and the vertical distance between the lateral border of the dural sac and the intersection of the dural sac and the medial border of discectomy (DSMD). To the patients with huge paramedian cervical disc herniation, the lateral border of the dural sac usually becomes obscured (Figure 1), which could not be easily and accurately delineated as shown in the figure. The medial margin of the uncovertebral joint seems to be more appropriate (red arrow). DSMD is measured based on the magnetic resonance imaging (MRI) at 3 days after surgery. Different from the traditional open or microendoscopic discectomy, percutaneous endoscopic surgery is performed under the continuous saline irrigation. The evaluation of the region of discectomy is likely to be affected by the residual fluid and the adjacent edematous tissue. In order to avoid the interference from the residual fluid, the axial T1-weighted MRI seems to be more appropriate to locate the medial border of discectomy at the early stage postoperatively. In the postoperative follow-up, the authors found that the distance between the edge of the dural sac and the inside edge of the intervertebral disc was significantly smaller than between the edge of the dural sac and the inside edge of the herniated disc. It should be that postoperative DSMD is less than the preoperative DSMHD. They considered the retraction of the protruding nucleus pulposus after the intradiscal decompression and explained why the incomplete removal of the nucleus pulposus also resulted in the improvement of clinical outcome. We believed that the phenomenon should be verified by further MRI measurement. Additionally, we considered that the symptoms' relief was also related with the indirect neural decompression. After foraminal unroofing and resection of ligamentum flavum, the spinal canal was enough to accommodate the endoscope and available for the spinal cord and nerve root to compensate the compression from the ventral-protruded nucleus pulposus.

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          Effective Range of Percutaneous Posterior Full-Endoscopic Paramedian Cervical Disc Herniation Discectomy and Indications for Patient Selection

          The objective was to investigate the effective and safe range of paramedian CDH by percutaneous posterior full-endoscopy cervical intervertebral disc nucleus pulposus resection (PPFECD) to provide a reference for indications and patient selection. Sixteen patients with CDH satisfied the inclusion criteria. Before surgery the patients underwent cervical spine MRI, and the distance between the dural sac and herniated disc was measured. An assessment was performed by MRI immediately after surgery, measuring the distance between dural sac and medial border of discectomy (DSMD). The preoperative average distance between the dural sac and peak of the herniated disc (DSPHD) was 3.87 ± 1.32 mm; preoperative average distance between dural sac and medial border of herniated disc (DSMHD) was 6.91 ± 1.21 mm and an average distance of postoperative DSMD was 5.41 ± 1.40 mm. Postoperative VAS of neck and shoulder pain was significantly decreased but JOA was significantly increased in each time point compared with preoperative ones. In summary, the effective range of PPFECD to treat paramedian CDH was 5.41 ± 1.40 mm, indicating that DSMHD and DSPHD were within 6.91 ± 1.21 mm and 3.87 ± 1.32 mm, respectively. PPFECD surgery is, therefore, a safe and effective treatment option for patients with partial paramedian cervical disc herniation.
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            Author and article information

            Contributors
            Journal
            Biomed Res Int
            Biomed Res Int
            BMRI
            BioMed Research International
            Hindawi
            2314-6133
            2314-6141
            2020
            4 April 2020
            : 2020
            : 3548194
            Affiliations
            1Department of Spine Surgery, Honghui Hospital, Xi'an Jiaotong University, No. 76 Nanguo Road, Xi'an, Shaanxi 710054, China
            2Department of Orthopedics, The Second Affiliated Hospital, Chongqing Medical University, Chongqing, China
            Author notes

            Academic Editor: Francesco Doglietto

            Author information
            https://orcid.org/0000-0001-7892-2898
            https://orcid.org/0000-0002-0959-025X
            Article
            10.1155/2020/3548194
            7160712
            0b625062-9ff0-436f-a24c-b4d040a05768
            Copyright © 2020 Jun-Song Yang et al.

            This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

            History
            : 3 May 2019
            : 29 January 2020
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