椎间孔镜单通道治疗重度脱出移位型腰椎间盘突出症
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摘要
[目的]探讨椎间孔镜靶向单通道下髓核摘除术(TO-PETD)治疗青年重度脱出移位型腰椎间盘突出症(HMLDH)的安全性和有效性。[方法] 2014年3月～2017年12月入住本院且手术治疗的重度脱出移位型青年腰椎间盘突出症患者51例,椎板开窗单纯髓核摘除术(FD) 18例。比较两组VAS腿痛和腰痛评分、ODI评分和改良MacNab评分、手术节段椎间隙高度变化。[结果] TO-PETD组在术中出血量、术后止痛药应用比例及住院时间方面小于FD组,差异有统计学意义(P<0.05),TO-PETD组手术时间长于FD组,差异有统计学意义(P<0.01)。两组早期并发症发生率差异无统计学意义(P>0.05)。随访12～36个月,平均(21.68±7.52)个月。两组手术前后VAS-下肢痛评分差异无统计学意义(P>0.05)。术后1 d、术后1个月VAS-腰痛评分及术后1个月ODI评分,TO-PETD组小于FD组,差异有统计学意义(P<0.05)。两组末次随访VAS、ODI评分差异无统计学意义。两组改良MacNab评定临床优良率和椎间隙高度丢失度的差异无统计学意义(P>0.05)。[结论]椎间孔镜靶向单通道下髓核摘除术治疗重度脱出移位型青年腰椎间盘突出症不但可达到与椎板开窗单纯髓核摘除术同样的安全性和有效性,且创伤更小、恢复更快。
[Objective] To evaluate the safety and efficiency of targeted one-level percutaneous transforaminal endoscopic discectomy(TO-PTED) for highly migrated lumbar disc herniation(HMLDH). [Methods] A retrospective study was conduct on51 patients who underwent surgical treatment for HMLDH from March 2014 to Dec 2017. Of them, 23 patients received TOPETD, while the remaining 18 patients underwent conventional fenestration discectomy(FD). The visual analogue scale(VAS)for leg pain and low back pain, Oswestry disability index(ODI), clinical results graded by modified MacNab criteria and intervertebral disc height measured radiographically were compared between the two groups. [Results] The TO-PETD group took significantly less intraoperative blood loss, less analgesic consumed and shorter hospital stay than the FD group(P<0.05), although the TO-PETD group had significantly longer operation time than the FD group(P<0.05). No statistically significant difference was proved in early complication rate between the two groups(P>0.05). The follow-up period lasted for 12-36 months with an average of(21.68±7.52) months. There were no statistically significant differences in VAS-leg pain score between the two group at any corresponding time points before and after operation(P>0.05). The TO-PETD group proved significantly less VAS-low back pain score at 1 day and 1 month, and significantly less ODI score at 1 month postoperatively than the FD group(P<0.05), despite of the fact that no statistically significant differences regarding to VASs and ODI at the latest follow up between them(P>0.05). In addition, the excellent and good rate of clinical consequences graded by modified MacNab criteria and loss of intervertebral disc height at 12 months postoperatively proved no statistically significant differences between them(P>0.05). [Conclusion] The target-ed one-level percutaneous transforaminal endoscopic discectomy is safe and effective treatment for highly migrated lumbar disc herniation similar to conventional fenestration discectomy, however, the former takes advantages of minimized iatrogenic trauma and fast recovery over the latter.
[Objective] To evaluate the safety and efficiency of targeted one-level percutaneous transforaminal endoscopic discectomy(TO-PTED) for highly migrated lumbar disc herniation(HMLDH). [Methods] A retrospective study was conduct on51 patients who underwent surgical treatment for HMLDH from March 2014 to Dec 2017. Of them, 23 patients received TOPETD, while the remaining 18 patients underwent conventional fenestration discectomy(FD). The visual analogue scale(VAS)for leg pain and low back pain, Oswestry disability index(ODI), clinical results graded by modified MacNab criteria and intervertebral disc height measured radiographically were compared between the two groups. [Results] The TO-PETD group took significantly less intraoperative blood loss, less analgesic consumed and shorter hospital stay than the FD group(P<0.05), although the TO-PETD group had significantly longer operation time than the FD group(P<0.05). No statistically significant difference was proved in early complication rate between the two groups(P>0.05). The follow-up period lasted for 12-36 months with an average of(21.68±7.52) months. There were no statistically significant differences in VAS-leg pain score between the two group at any corresponding time points before and after operation(P>0.05). The TO-PETD group proved significantly less VAS-low back pain score at 1 day and 1 month, and significantly less ODI score at 1 month postoperatively than the FD group(P<0.05), despite of the fact that no statistically significant differences regarding to VASs and ODI at the latest follow up between them(P>0.05). In addition, the excellent and good rate of clinical consequences graded by modified MacNab criteria and loss of intervertebral disc height at 12 months postoperatively proved no statistically significant differences between them(P>0.05). [Conclusion] The target-ed one-level percutaneous transforaminal endoscopic discectomy is safe and effective treatment for highly migrated lumbar disc herniation similar to conventional fenestration discectomy, however, the former takes advantages of minimized iatrogenic trauma and fast recovery over the latter.
引文
[1] Gun Choi, Hitesh N Modi, Nicolas Prada, et al. Clinical results of XMR-assisted percutaneous transforaminal endoscopic lumbar discectomy[J]. J Orthop Surg Res, 2013, 8(1):14-21.
[2] Choi KC, Lee JH, Kim JS, et al. Unsuccessful percutaneous endoscopic lumbar discectomy:a single-center experience of 10 228cases[J]. Neurosurgery, 2015, 76(4):372-381.
[3] Wu X, Fan G, Gu X, et al. Surgical outcome of two-level transforaminal percutaneous endoscopic lumbar discectomy for far-migrated disc herniation[J]. BioMed Res Int, 2016, 2016:1-6..
[4] Kim HS, Yudoyono F, Paudel B, et al. Suprapedicular circumferential opening technique of percutaneous endoscopic transforaminal lumbar discectomy for high grade inferiorly migrated lumbar disc herniation[J]. BioMed Research Internationa, 2018, 2018:1-7.
[5] Yao Y, Liu H, Zhang H, et al. Risk factors for recurrent herniation after percutaneous endoscopic lumbar discectomy[J]. World Neurosurg, 2017, 100:1-6.
[6] Lee S, Kim SK, Lee SH, et al. Percutaneous endoscopic lumbar discectomy for migrated disc herniation:classification of disc migration and surgical approaches[J]. Eur Spine J, 2007, 16(3):431-437.
[7]李长青,周跃,王建,等.经皮椎间孔内窥镜下靶向穿刺椎间盘切除术治疗腰椎间盘突出症[J].中国脊柱脊髓杂志, 2013, 23(3):193-197.
[8] Reed MD, Van Nostran W. Assessing pain intensity with the visual analog scale:a plea for uniformity[J]. J Clin Pharmacol, 2014, 54(3):241-244.
[9] Macnab I. Negative disc exploration. An analysis of the causes of nerve-root involvement in sixty-eight patients[J]. J Bone Joint Surg Am, 1971, 53(5):891-903.
[10] DG Chang, RM Healey, Snyder AJ, et al. Lumbar spine paraspinal muscle and intervertebral disc height changes in astronauts after long-duration spaceflight on the International Space Station[J].Spine, 2016, 41(24):1917-1924.
[11]焦伟,申才良,崔西龙,等.内窥镜下经椎弓根肩上入路治疗重度远端脱垂腰椎间盘突出症[J].中国微创外科杂志, 2017, 17(5):441-445.
[12]麻凤玉,王叶新,孟纯阳,等. TESSYS技术治疗脱垂型腰椎间盘突出症穿刺头倾角的安全范围[J].中国矫形外科杂志,2017, 25(11):978-983.
[13] Lee CW, Yoon KJ, Ha SS, et a1. Foraminoplastic superior vertebral notch approach with reamers in percutaneous endoscopic lumbar discectomy:technical note and clinical outcome in limited indications of percutaneous endoscopic lumbar discectomy[J]. J Korean Neurosurg Soc, 2016, 59(2):172-181.
[14] Ying J, Huang K, Zhu M, et a1. The effect and feasibility study of transforaminal percutaneous endoscopic lumbar discectomy via superior border of inferior pedicle approach for down-migrated intracanal disc herniations[J]. Medicine, 2016, 95(8):e2899.
[15] Ahn Y, Jang IT, Kim WK. Transforaminal percutaneous endoscopic lumbar discectomy for very high-grade migrated disc herniation[J]. Clin Neurol Neurosurg, 2016, 147:11-17.
[16]段丽群,张文志,贺瑞,等.经皮椎间孔镜下髓核摘除术治疗脱垂移位型腰椎间盘突出症的临床疗效[J].中国矫形外科杂志,2016, 24(15):1368-1374.
[17]桑裴铭,张明,陈斌辉,等.靶向成形椎间孔镜技术治疗游离脱垂型腰椎间盘突出症[J].中国骨伤, 2018(4):302-305.
[18]董健文,戎利民,刘斌,等.椎间孔入路经皮内镜技术摘除脱出髓核36例报告[J].中国骨与关节杂志, 2014, 3(8):615-620.
[19]马信龙,骆巍,张弢,等.后部结构分级切除对下腰椎稳定性影响的实验研究[J].中华骨科杂志, 2009, 29(8):760-764.
[20]钱军,余水生,刘建军,等.全脊柱内镜下椎间孔成型对腰椎生物力学的影响[J].中华医学杂志, 2018, 98(13):1013-1018.
[21]周跃,罗刚,初同伟,等.腰椎单侧小关节突分级切除的生物力学影响及微创外科的修复与重建[J].中华医学杂志, 2007, 87(19):1334-1338.
[22]李慧友,朱青安,李桂兰,等.双侧小关节分级切除对腰椎稳定性影响的三维运动研究[J].中华骨科杂志, 1995, 15(10):692-694.
[23]李振宙,吴闻文,侯树勋,等.经皮侧后路腰椎间孔成形手术器械的设计及临床应用[J].中华骨科杂志, 201l, 31(10):1026-1032.
[2] Choi KC, Lee JH, Kim JS, et al. Unsuccessful percutaneous endoscopic lumbar discectomy:a single-center experience of 10 228cases[J]. Neurosurgery, 2015, 76(4):372-381.
[3] Wu X, Fan G, Gu X, et al. Surgical outcome of two-level transforaminal percutaneous endoscopic lumbar discectomy for far-migrated disc herniation[J]. BioMed Res Int, 2016, 2016:1-6..
[4] Kim HS, Yudoyono F, Paudel B, et al. Suprapedicular circumferential opening technique of percutaneous endoscopic transforaminal lumbar discectomy for high grade inferiorly migrated lumbar disc herniation[J]. BioMed Research Internationa, 2018, 2018:1-7.
[5] Yao Y, Liu H, Zhang H, et al. Risk factors for recurrent herniation after percutaneous endoscopic lumbar discectomy[J]. World Neurosurg, 2017, 100:1-6.
[6] Lee S, Kim SK, Lee SH, et al. Percutaneous endoscopic lumbar discectomy for migrated disc herniation:classification of disc migration and surgical approaches[J]. Eur Spine J, 2007, 16(3):431-437.
[7]李长青,周跃,王建,等.经皮椎间孔内窥镜下靶向穿刺椎间盘切除术治疗腰椎间盘突出症[J].中国脊柱脊髓杂志, 2013, 23(3):193-197.
[8] Reed MD, Van Nostran W. Assessing pain intensity with the visual analog scale:a plea for uniformity[J]. J Clin Pharmacol, 2014, 54(3):241-244.
[9] Macnab I. Negative disc exploration. An analysis of the causes of nerve-root involvement in sixty-eight patients[J]. J Bone Joint Surg Am, 1971, 53(5):891-903.
[10] DG Chang, RM Healey, Snyder AJ, et al. Lumbar spine paraspinal muscle and intervertebral disc height changes in astronauts after long-duration spaceflight on the International Space Station[J].Spine, 2016, 41(24):1917-1924.
[11]焦伟,申才良,崔西龙,等.内窥镜下经椎弓根肩上入路治疗重度远端脱垂腰椎间盘突出症[J].中国微创外科杂志, 2017, 17(5):441-445.
[12]麻凤玉,王叶新,孟纯阳,等. TESSYS技术治疗脱垂型腰椎间盘突出症穿刺头倾角的安全范围[J].中国矫形外科杂志,2017, 25(11):978-983.
[13] Lee CW, Yoon KJ, Ha SS, et a1. Foraminoplastic superior vertebral notch approach with reamers in percutaneous endoscopic lumbar discectomy:technical note and clinical outcome in limited indications of percutaneous endoscopic lumbar discectomy[J]. J Korean Neurosurg Soc, 2016, 59(2):172-181.
[14] Ying J, Huang K, Zhu M, et a1. The effect and feasibility study of transforaminal percutaneous endoscopic lumbar discectomy via superior border of inferior pedicle approach for down-migrated intracanal disc herniations[J]. Medicine, 2016, 95(8):e2899.
[15] Ahn Y, Jang IT, Kim WK. Transforaminal percutaneous endoscopic lumbar discectomy for very high-grade migrated disc herniation[J]. Clin Neurol Neurosurg, 2016, 147:11-17.
[16]段丽群,张文志,贺瑞,等.经皮椎间孔镜下髓核摘除术治疗脱垂移位型腰椎间盘突出症的临床疗效[J].中国矫形外科杂志,2016, 24(15):1368-1374.
[17]桑裴铭,张明,陈斌辉,等.靶向成形椎间孔镜技术治疗游离脱垂型腰椎间盘突出症[J].中国骨伤, 2018(4):302-305.
[18]董健文,戎利民,刘斌,等.椎间孔入路经皮内镜技术摘除脱出髓核36例报告[J].中国骨与关节杂志, 2014, 3(8):615-620.
[19]马信龙,骆巍,张弢,等.后部结构分级切除对下腰椎稳定性影响的实验研究[J].中华骨科杂志, 2009, 29(8):760-764.
[20]钱军,余水生,刘建军,等.全脊柱内镜下椎间孔成型对腰椎生物力学的影响[J].中华医学杂志, 2018, 98(13):1013-1018.
[21]周跃,罗刚,初同伟,等.腰椎单侧小关节突分级切除的生物力学影响及微创外科的修复与重建[J].中华医学杂志, 2007, 87(19):1334-1338.
[22]李慧友,朱青安,李桂兰,等.双侧小关节分级切除对腰椎稳定性影响的三维运动研究[J].中华骨科杂志, 1995, 15(10):692-694.
[23]李振宙,吴闻文,侯树勋,等.经皮侧后路腰椎间孔成形手术器械的设计及临床应用[J].中华骨科杂志, 201l, 31(10):1026-1032.
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