经皮射频和内镜下射频切断脊神经背内侧支治疗小关节源性腰痛的前瞻性临床对照研究

摘要

目的 评价内镜下脊神经背内侧支切断术治疗慢性关节突关节源性腰痛的临床疗效.方法 筛选符合关节突关节源性腰痛诊断标准的患者40例,随机分为经皮组(20例)和内镜组(20例).经皮组行X线辅助下经皮穿刺脊神经背内侧支射频消融术(radiofrequency neurotomy,RN),内镜组行内镜辅助下脊神经背内侧支切断术,记录两组术前及术后不同随访时间(3周、6个月、1年、2年)的疼痛视觉模拟评分(visual analogue scale,VAS)、Oswestry功能障碍指数(oswestry disability index,ODI)和SF-36生活质量指数,进行组内对照和组间对照.结果 (1)经皮组3周时VAS评分、ODI评分和SF-36评分分别由术前的7.15±0.81,76.75±7.07,79.01±13.81改变为2.60±0.75,28.00±3.84,92.67±11.13,改善率(63.04±12.49)%,优良率100%,6个月时疗效开始下降,VAS评分、ODI评分和SF-36评分分别为3.85±0.88,32.50±4.44,87.32±17.20,改善率(45.68±13.18)%,优良率60%,2年时已与术前差异无统计学意义(P>0.05);(2)内镜组疗效优秀且维持时间较长,6个月时VAS评分、ODI评分和SF-36评分为3.15±0.57,27.50±2.96,87.89±14.49,改善率(55.45±9.01)%,优良率90%,术后1年疗效开始减低,VAS评分、ODI评分和SF-36评分分别为3.40±0.68,35.70±5.81,81.53±12.02,改善率(51.49±12.83)%,优良率仍高达80%,术后2年时疗效下降明显,VAS评分、ODI评分和SF-36评分分别为3.93±0.75,44.35±3.99,77.86±10.75,改善率降至(44.17±11.33)%,优良率降至45%,但是各项评分仍明显优于术前且差异有统计学意义(P<0.05);(3)组间对照方面,3周时两组间各观察指标差异无统计学意义(P>0.05),6个月及以后各个随访时间点的各观察指标,内镜组均优于经皮组且差异有统计学意义(P<0.05).结论 在治疗慢性关节突关节源性腰痛方面,经皮穿刺脊神经背内侧支RN和内镜下脊神经背内侧支切断术均能获得优秀的短期疗效,但内镜技术疗效更佳且更持久;内镜辅助下脊神经背内侧支切断术治疗慢性关节突关节源性腰痛是一种值得在临床推广的手术技术.%Objective To gather outcome data of percutaneous radiofrequency neurotomy and endoscopic rhizotomy of the lumbar medial branch for facetogenic chronic low back pain, and to compare treatment efficacy of the two approaches. Methods Forty facetogenic chronic low back pain patients were included and randomly assigned to receive percutaneous radiofrequency neurotomy ( RN group, 20 cases ) or endoscopic neurotomy of the lumbar medial branch ( EN group, 20 cases ). Endoscopic neurotomy was performed for the second group. Outcomes were obtained by VAS, ODI and SF-36 preoperatively and at 3 weeks, 6 months, 1 year and 2 years postoperatively. The results of two groups were compared. Results RN group demonstrated excellent results at 3 weeks after operation [ VAS Score decreased from ( 7.15 ± 0.81 ) pre-operatively to ( 2.60 ± 0.75 ) post-operatively; ODI Score decreased from ( 76.75 ± 7.07 ) to ( 28.00 ± 3.84 ); while SF-36 Score increased from ( 79.01 ± 13.81 ) to ( 92.67 ± 11.13 ). The treatment achieved an improve rate of ( 63.04 ± 12.49 ) % and an excellence rate of 100% ]. At 6 months after operation, the clinical data VAS Score, ODI Score and SF-36 Score were ( 3.85 ± 0.88 ), ( 32.50 ± 4.44 ), ( 87.32 ± 17.20 ), indicating less improvement with an improvement rate of ( 45.68 ± 13.18 ) % and an excellence rate of 60%. At 2 years after the operation, patients' conditions became the same as 2 years ago ( P > 0.05 ). EN group demonstrated prolonged excellent clinical outcomes compared with the RN group. At 6 months after operation, VAS Score, ODI Score and SF-36 Score were ( 3.15 ± 0.57 ), ( 27.50 ± 2.96 ), ( 87.89 ± 14.49 ), indicating an improvement rate of ( 55.45 ± 9.01 ) % and an excellence rate of 90%. At 1 year after operation, the efficacy declined. VAS Score, ODI Score and SF-36 QOF Score were ( 3.40 ± 0.68 ), ( 35.70 ± 5.81 ), ( 81.53 ± 12.02 ), indicating an improvement rate of ( 51.49 ± 12.83 ) % and an excellence rate of 80%. At 2 years after operation, the efficacy further declined. VAS Score, ODI Score and SF-36 QOF Score decreased to ( 3.93 ± 0.75 ), ( 44.35 ± 3.99 ), ( 77.86 ± 10.75 ), indicating an improvement rate of ( 44.17 ± 11.33 ) % and an excellence rate of 45%. The data showed significant improvement compared with pre-operative data ( P < 0.05 ). There were no significant differences of VAS Score, ODI Score and SF-36 Score between the 2 groups at 3 weeks after operation ( P > 0.05 ). At 6 months and later after operation, RN group demonstrated better outcomes ( P < 0.05 ). Conclusions For facetogenic chronic low back pain, endoscopic neurotomy and X-ray assisted percutaneous radiofrequency neurotomy of the lumbar medial branch are both effective. Endoscopic lumbar medial branch neurotomy has the advantages of higher surgical precision and better long-term efficacy.