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

摘要

目的 探讨经椎弓根肩上入路结合内窥镜技术治疗向远端重度脱垂椎间盘突出症的可行性. 方法 2012年11月~2015年8月,阜阳市人民医院收治向远端高度脱垂腰椎间盘突出症14例,突出节段L2/3 1例,L3/4 1例,L4/5 8例,L5/S1 4例.复发性突出1例.采用内窥镜下经椎弓根肩上入路,磨钻磨除部分椎弓根肩部,直视下摘除脱垂的髓核.统计术前、术后2日及末次随访时腰腿痛视觉模拟评分(visual analogue scale,VAS)及Oswestry功能障碍指数(Oswestry disability index,ODI),用MacNab标准评价手术效果. 结果 手术时间65~210 min,平均105 min.术后右下肢麻木1例,经保守治疗后症状完全缓解,左侧 背伸无力1例,1个月后症状消失,余12例无手术相关并发症.14例随访时间11~43个月,平均27.3月,术前腰、腿痛VAS分别为(6.0±2.1)、(7.4±1.9)分,术后第2日(2.1±0.8)、(1.8±1.1)分,末次随访时为(1.9±0.8)、(1.7±0.9)分,术前、术后2日及末次随访时ODI分别为(19.3±7.4)%、(10.5±4.1)%、(6.5±2.3)%.根据MacNab标准,术后2日优12例,良2例,末次随访时优13例,良1例. 结论 内窥镜下经椎弓根肩上入路治疗向远端重度脱垂型腰椎间盘突出症安全、有效、可行.%Objective To investigate the feasibility of transforaminal percutaneous endoscopic lumbar discectomy via superior border of inferior pedicle approach for severe down-migrated intracanal disc herniations.Methods From November 2012 to August 2015, a total of 14 patients with severe down-migrated disc herniations were treated with transforaminal percutaneous endoscopic lumbar discectomy via superior border of inferior pedicle approach in the First People's Hospital of Fuyang.There were 1 case of L2/3 disc herniation, 1 case of L3/4 disc herniation, 8 cases of L4/5, and 4 cases of L5/S1.Among them 1 case was reherniation after open window decompression.During the surgery, the vertebral pedicle was removed partially with abrasive drilling via superior border of inferior pedicle approach.The pulposus was removed under direct vision.The data of back/leg pain VAS and ODI before surgery, immediately after operation, the 2nd day after operation and last follow-up were collected and analyzed.The clinical effect was evaluated with the MacNab standard.Results The mean operation time was 105 min, ranged from 65 min to 210 min.One patient had right leg numbness and was recovered after conservative treatment.One patient suffered from left thumb dorsal extension asthenia and got fully recovered 1 month later.No surgery related complications were noted in other patients.All the 14 patients were followed up for 11-43 months (mean,27.3 months).The preoperative VAS of back and leg pain was 6.0±2.1 and 7.4±1.9, respectively, on the 2nd day after surgery was 2.1±0.8 and 1.8±1.1, respectively,and at last follow-up was 1.9±0.8 and 1.7±0.9, respectively.The ODI before surgery, on the 2nd day after operation and last follow-up was (19.3±7.4)%, (10.5±4.1)%, and (6.5±2.3)%, respectively.According to the MacNab classification, 12 cases were excellent and 2 cases were good on the 2nd day after operation.At the most recent follow-up, 13 cases got excellent and 1 got good results.Conclusion Transforaminal percutaneous endoscopic lumbar discectomy via superior border of inferior pedicle approach is an effective and safe alternative for severe down-migrated disc herniations.