Percutaneous Endoscopic Lumbar Discectomy via Transforaminal Approach Combined with Interlaminar Approach for L4/5 and L5/S1 Two-Level Disc Herniation.

OBJECTIVE: The purpose of the present study was to discuss a new surgical strategy that combines percutaneous endoscopic transforaminal discectomy (PETD) with percutaneous endoscopic interlaminar discectomy (PEID) for L4/5 and L5/S1 two-level disc herniation. METHODS: This was a retrospective study. A total of 19 patients with L4/5 and L5/S1 two-level lumbar disc herniation (LDH) who underwent percutaneous endoscopic lumbar discectomy (PELD) in our hospital from January 2015 to June 2016 were retrospectively examined. The average age of these 19 patients was 42.21 ± 14.88 years old, including 12 men and 7 women. One experienced surgeon who had carried out more than 3000 lumbar surgeries performed PELD for these patients. During the PELD surgery, the transforaminal approach was adopted for L4/5 level disc herniation and the interlaminar approach was adopted for L5/S1 level disc herniation. The demographic data, operation time (min), fluoroscopy times, hospital stay (days), and complications were recorded and analyzed. The visual analogue scale (VAS), Oswestry disability index (ODI) scores, and the modified MacNab criteria were used to evaluate the surgical outcomes. MRI was conducted to evaluate the radiographic improvement. RESULTS: All patients underwent PELD via the transforaminal approach combined with the interlaminar approach successfully and achieved satisfactory efficacy. The follow-up points were 3, 12, and 18 months. The average hospital stay (days) and the average follow up (months) were 3.32 ± 0.98 and 18.63 ± 3.84, respectively. The operation time and fluoroscopy times were 85.79 ± 12.90 min and 39.05 ± 4.59 times, respectively. The fluoroscopy times (frequency) for L4/5 and L5/S1 were 26.95 ± 6.41 and 12.11 ± 3.49 (t = 7.00, P < 0.05). Furthermore, there was no significant difference for fluoroscopy times between male and female patients (t = 0.89, P = 0.99). The preoperative back pain (VAS-Back) and the last follow-up VAS-Back were 5.58 ± 2.01 and 2.37 ± 1.01, respectively (t = 7.14, P < 0.05). The preoperative leg pain (VAS-Leg) and the last follow-up VAS-Leg were 7.00 ± 1.56 and 1.63 ± 1.01, respectively (t = 20.97, P < 0.05). There were significant differences between preoperative VAS-Back and the last follow-up VAS-Back in men (t = 4.61, P < 0.05) and women (t = 6.57, P < 0.05). In addition, there was significant differences between preoperative VAS-Leg and the last follow-up VAS-Leg in men (t = 13.48, P < 0.05) and women (t = 26.87, P < 0.05). There were significant differences between preoperative ODI scores (44.84 ± 10.82%) and the last follow-up ODI scores (11.12 ± 5.80%) (t = 10.92, P < 0.05). Preoperative ODI scores and the last follow-up ODI scores were significantly different for men (t = 8.80, P < 0.05) and women (t = 6.63, P < 0.05). All patients received significant pain relief and functional improvement after the surgery. Except for two cases of postoperative dysesthesia and one dural tear, no severe complications occurred. The dysesthesia symptoms of these two patients disappeared within 1 week with the application of dexamethasone and neurotrophic drugs and the dural tear case also recovered well as the dural laceration was small. No poor results were reported and 89.47% of patients achieved excellent or good recovery. CONCLUSION: Percutaneous endoscopic lumbar discectomy via the transforaminal approach combined with the interlaminar approach under epidural anesthesia can treat L4/5 and L5/S1 two-level disc herniation safely and effectively.

Lycium barbarum polysaccharides inhibit ischemia/reperfusion-induced myocardial injury via the Nrf2 antioxidant pathway.

Oxidative stress is considered to be one of main pathophysiological mechanisms in myocardial ischemia/reperfusion (I/R) injury. Lycium barbarum polysaccharides (LBP), the main ingredient of Lycium barbarum, have potential antioxidant activity. We aimed to investigate the effects of LBP on myocardial I/R injury and explore the underlying mechanisms. Myocardial I/R group was treated with or without LBP to evaluate oxidative stress markers and the role of Nrf2 signal pathway. Our results showed that I/R increased infarct size and the activities of creatine kinase (CK) and lactate dehydrogenase (LDH) when compared with control group. Meanwhile, the levels of reactive oxygen species (ROS), malondialdehyde (MDA), interleukin-6 (IL-6) and tumor necrosis factor-α (TNF-α) were enhanced and the activities of superoxide dismutase (SOD), glutathione peroxidase (GPX) and catalase (CAT) were decreased. These changes were associated with a significant increase in myocardial apoptosis, ultimately leading to cardiac dysfunction. LBP reduced infarct size (38.4 ± 2 % versus 19.4 ± 1.8 %, p < 0.05), CK and LDH activities and myocardial apoptotic index. Meanwhile, LBP suppressed the production of ROS and restored redox status. Additionally, LBP increased protein level of nuclear Nrf2 in vivo (2.1 ± 0.3 versus 3.8 ± 0.4, p < 0.05) and in vitro (1.9 ± 0.2 versus 3.8 ± 0.1, p < 0.05) and subsequently upregulated heme oxygenase 1 and NADPH dehydrogenase quinone 1 compared to I/R group. Interestingly, Nrf2 siRNA abolished the protective effects of LBP. LBP suppressed oxidative stress damage and attenuated cardiac dysfunction induced by I/R via activation of the Nrf2 antioxidant signal pathway.