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随着脊柱微创外科技术的不断创新与发展,经皮内镜腰椎间盘摘除术(percutaneous endoscopic lumbar discectomy, PELD)因其较开放手术更好地保留了椎旁组织、更少的出血量和住院时间,以及更快的术后康复,在腰椎间盘突出症(lumbar disc herniation, LDH)的外科治疗中,已经成为一种主流的手术方式[1-2]。目前L5/S1节段LDH的经皮内镜治疗,手术解剖入路主要有经椎间孔和经椎板间隙两种,两种入路在手术适应证、麻醉方式、手术难度上均有不同[3-4],但相关的临床对比研究报道较少。本文回顾性研究了43例自2016年8月来我科采用经椎间孔入路与经椎板间入路经皮内镜椎间盘摘除手术治疗的L5/S1节段LDH的病人,比较分析2组的治疗情况和术后随访结果,为L5/S1节段LDH的微创治疗提供临床经验,现作报道。
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本研究选取2016年8月至2017年6月我院骨科收治的43例经皮内镜下治疗L5/S1单节段LDH病人。纳入标准:(1)年龄≥18岁;(2)典型的L5/S1 LDH临床症状和体征;(3)与临床表现相符的L5/S1单节段LDH的MRI和/或CT影像学表现;(4)术前正规保守治疗3个月无效;(5)行L5/S1节段经皮内镜椎间盘摘除手术。排除标准:合并重度椎管狭窄、腰椎不稳、腰椎滑脱、腰椎骨折、腰椎肿瘤、脊柱侧凸畸形、马尾综合征以及严重的心脑血管疾病。根据所采取的手术入路分为椎间孔入路组(21例)和椎板间入路组(22例)。2组病人术前的一般临床资料差异均无统计学意义(P>0.05)(见表 1),具有可比性。全部病例随访6个月以上,并仍在持续随访中。
分组 n 男 女 年龄/岁 BMI/(kg/m2) 椎间盘突出类型 中央型 旁中央型 脱垂游离型 椎间孔入路组 21 13 8 41.14±12.43 23.49±2.78 5 10 6 椎板间入路组 22 12 10 41.27±14.44 23.32±2.69 6 8 8 t — 0.24* 0.03 0.21 0.58* P — >0.05 >0.05 >0.05 >0.05 *示χ2值 表 1 2组病人一般资料比较(x±s)
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脊柱椎间孔镜手术系统(德国Spinendos公司)。
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病人取俯卧位,沿棘突标记后正中线和患侧髂嵴体表投影线,C臂正位透视标定出L5/S1椎间隙,侧位透视标记出小关节突连线为安全线。按照传统TESSYS技术定位体表穿刺点[3]。0.5%利多卡因局麻表皮和针道麻醉后,调整合适的穿刺角度缓慢进针,透视下针尖正位位于椎弓根中线,侧位位于下位椎体后上缘,抽出针芯、置入导丝、拔出穿刺针,于穿刺点处切开皮肤约1 cm后逐级置入扩张套管,用相应直径环锯切除部分上关节突尖部及腹侧进行椎间孔扩大成形,置入工作通道并透视确定验证,而后置入椎间孔镜成像系统,持续冲洗下摘除突出的髓核组织,彻底减压神经根,直至硬脊膜和神经根搏动良好,使用双极射频彻底止血、纤维环成形,拔出工作通道,缝合包扎后术毕。
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病人全身麻醉成功后取俯卧位。用C臂透视确认L5/S1节段,以患侧椎板间隙下缘、下关节突内侧为进针点插入穿刺针,直致黄韧带层面。在进针点切开皮肤约1 cm,而后逐级置入扩张套管及工作通道,用C臂透视再次确定间隙和深度正确,置入椎间孔镜成像系统。切除部分黄韧带,使用RUETTEN法[4]旋转工作套管逐层进入椎管,充分显露下方硬脊膜及神经根,将神经根、硬膜囊轻推向对侧保护,术中持续0.9%氯化钠注射液冲洗,摘除突出的髓核组织,彻底减压神经根,直至硬脊膜和神经根搏动良好,使用双极射频彻底止血、纤维环成形,拔出工作通道,缝合包扎后术毕。
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记录2组病人的手术时间、术后卧床时间、术后住院时间、总住院费用,术前、术后1、3、6个月腰背部视觉模拟评分(visual analogue scale, VAS)、腿部VAS评分以及术后6个月改良MacNab评分。
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采用t检验、χ2检验、方差分析和q检验。
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椎间孔入路组的术后卧床时间、住院时间和总住院费用较椎板间入路组均明显降低(P < 0.01)。2组手术时间差异无统计学意义(P>0.05)(见表 2)。
分组 n 手术
时间/min术后
卧床时间/h术后
住院时间/d总住
院费用/元椎间孔入路组 21 111.67±15.92 6.90±1.12 1.67±0.73 19 788.52±950.30 椎板间入路组 22 112.73±17.84 21.91±6.41 3.86±0.99 25 210.91±1 227.72 t — 0.21 10.57 8.22 16.14 P — >0.05 < 0.01 < 0.01 < 0.01 表 2 2组临床观察指标比较(x±s)
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2组的术后腰背部VAS评分、腿部VAS评分较术前均明显好转(P < 0.05),2组对应时间点VAS评分差异无统计学意义(P>0.05)(见表 3)。术后6个月椎间孔入路组优14例,良4例,可3例,差0例,优良率为85.71%,椎板间入路组优13例,良5例,可4例,差0例,优良率为81.82%,2组差异无统计学意义(χ2=0.12,P>0.05)(见表 3)。
评分 椎间孔入路组(n=21) 椎板间入路组(n=22) t P 腰背部VAS评分 术前 5.95±2.20 5.41±1.92 0.86 >0.05 术后1个月 2.90±1.34* 2.77±1.34* 0.32 >0.05 术后3个月 2.10±1.14* 2.68±1.76* 1.28 >0.05 术后6个月 1.48±1.33* 1.86±1.46* 0.89 >0.05 F 34.01 19.54 — — P < 0.01 < 0.01 — — MS组内 2.43 2.68 — — 腿部VAS评分 术前 7.19±1.60 6.55±1.60 1.31 >0.05 术后1个月 3.29±1.31* 3.05±1.25* 0.61 >0.05 术后3个月 2.00±1.05* 2.05±1.00* 0.16 >0.05 术后6个月 1.24±1.09* 1.50±1.19* 0.75 >0.05 F 89.54 69.21 P < 0.01 < 0.01 — — MS组内 1.64 1.63 — — 与术前比较*P < 0.05 表 3 腰背部、腿部VAS评分(x±s)
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2组病人均顺利完成手术,术后未见感染、神经或大血管损伤等严重并发症。椎板间入路组1例中年女性病人术后出现短暂的会阴区麻木感,无大小便功能障碍,无肛门括约肌以及双下肢肌力下降,予以甲钴胺等营养神经保守治疗2周后症状基本消失。
经椎间孔入路与经椎板间入路经皮内镜椎间盘摘除手术治疗L5/S1腰椎间盘突出症的临床回顾性研究
Comparison study between intervertebral foramen approach and interlaminar approach percutaneous endoscopic lumbar discectomy in the treatment of L5/S1 disc herniation
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摘要:
目的探讨经皮内镜椎间盘摘除手术经椎间孔入路与经椎板间入路治疗L5/S1腰椎间盘突出症的临床疗效。 方法43例L5/S1腰椎间盘突出症病人根据手术入路不同分为椎间孔入路组(21例)和椎板间入路组(22例)。按照术后疼痛视觉模拟(VAS)评分和改良MacNab评分判断临床效果,比较2组手术时间、术后卧床时间、术后住院时间、总住院费用、术后并发症情况。 结果43例病人全部顺利完成手术,术后随访6个月以上。椎间孔入路组术后卧床时间、术后住院时间、总住院费用均低于椎板间入路组(P < 0.01)。2组病人术后1、3、6个月腰背部、腿部VAS评分均低于术前(P < 0.05),2组手术时间以及术前、术后各随访时间点腰背部、腿部VAS评分组间差异均无统计学意义(P>0.05)。改良MacNab评分椎间孔入路组优14例,良4例,可3例,差0例,椎板间入路组优13例、良5例、可4例、差0例,组间比较差异无统计学意义(P>0.05)。2组病人术后均未见严重并发症发生。 结论经椎间孔入路与经椎板间入路经皮内镜下治疗L5/S1椎间盘突出症都具有安全、有效的特点;但相比之下,椎间孔入路创伤更小、恢复更快、手术禁忌更少,更加符合微创的理念。 -
关键词:
- 椎间盘移位 /
- 椎间盘切除术, 经皮 /
- 椎间孔镜
Abstract:ObjectiveTo investigate the clinical effects between intervertebral foramen approach and interlaminar approach percutaneous endoscopic lumbar discectomy in the treatment of L5/S1 disc herniation. MethodsForty-three patients with L5/S1 disc herniation were divided into the intervertebral foramen approach group (n=21) and interlaminar approach group (n=22).The clinical efficacy was assessed using Visual Analog Scale (VAS) and modified MacNab evaluation criteria.The operation time, postoperative ambulation time, postoperative hospitalization time, in-patient cost and postoperative complication were compared between two groups. ResultsAll opereations were successful.The patients were followed up for mone than 6 months.The bed time, postoperative hospitalization time, total hospitalization expense in intervertebral foramen approach group were lower than those in interlaminar approach group (P < 0.01).The VAS scores of back and leg in two groups after 1 month, 3 months and 6 months of operation were significantly lower than those before operation (P < 0.05).The differences of the operation time and VAS scores of back and leg in two groups between before and after operation were not statistically significant (P>0.05).The excellent in 14 cases, good in 4 cases, fair in 3 cases and poor in 0 case in intervertebral foramen approach group, and excellent in 13 cases, good in 5 cases, fair in 4 cases and poor in 0 case in interlaminar approach group were identified using improved MacNab scale, respectively, and the difference of which between two groups was not statistically significant (P>0.05).No severe complication in two groups was found after operation. ConclusionsThe intervertebral foramen approach and interlaminar approach percutaneous endoscopic lumbar discectomy in the treatment of L5/S1 disc herniation are safe and effective.Compared with the interlaminar approach, the intervertebral foramen approach has little invasion, quick recovery and few contraindications, which is more suitable to the concept of minimally invasive surgery. -
表 1 2组病人一般资料比较(x±s)
分组 n 男 女 年龄/岁 BMI/(kg/m2) 椎间盘突出类型 中央型 旁中央型 脱垂游离型 椎间孔入路组 21 13 8 41.14±12.43 23.49±2.78 5 10 6 椎板间入路组 22 12 10 41.27±14.44 23.32±2.69 6 8 8 t — 0.24* 0.03 0.21 0.58* P — >0.05 >0.05 >0.05 >0.05 *示χ2值 表 2 2组临床观察指标比较(x±s)
分组 n 手术
时间/min术后
卧床时间/h术后
住院时间/d总住
院费用/元椎间孔入路组 21 111.67±15.92 6.90±1.12 1.67±0.73 19 788.52±950.30 椎板间入路组 22 112.73±17.84 21.91±6.41 3.86±0.99 25 210.91±1 227.72 t — 0.21 10.57 8.22 16.14 P — >0.05 < 0.01 < 0.01 < 0.01 表 3 腰背部、腿部VAS评分(x±s)
评分 椎间孔入路组(n=21) 椎板间入路组(n=22) t P 腰背部VAS评分 术前 5.95±2.20 5.41±1.92 0.86 >0.05 术后1个月 2.90±1.34* 2.77±1.34* 0.32 >0.05 术后3个月 2.10±1.14* 2.68±1.76* 1.28 >0.05 术后6个月 1.48±1.33* 1.86±1.46* 0.89 >0.05 F 34.01 19.54 — — P < 0.01 < 0.01 — — MS组内 2.43 2.68 — — 腿部VAS评分 术前 7.19±1.60 6.55±1.60 1.31 >0.05 术后1个月 3.29±1.31* 3.05±1.25* 0.61 >0.05 术后3个月 2.00±1.05* 2.05±1.00* 0.16 >0.05 术后6个月 1.24±1.09* 1.50±1.19* 0.75 >0.05 F 89.54 69.21 P < 0.01 < 0.01 — — MS组内 1.64 1.63 — — 与术前比较*P < 0.05 -
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