经皮椎间孔入路内镜下治疗复发性腰椎椎间盘突出症的临床研究

摘要

目的 探讨经皮椎间孔入路内镜下微创手术治疗复发性腰椎间盘突出症的临床应用价值.方法 选择2011年5月至2015年12月共47例诊断为复发性腰椎间盘突出症且经保守治疗无效的患者,男31例,女16例;年龄29～62岁,平均(43.45±13.37)岁.突出复发的椎间盘位于L3,4节段4例,L4.5节段32例,L5S1节段11例.初次手术至再次手术的时间间隔为10～185个月,平均49个月.初次手术方式为显微内镜椎间盘切除术11例,椎板开窗减压椎间盘髓核摘除术36例.再次手术均采取俯卧位局麻下经皮穿刺椎间孔入路内镜下微创手术,术中行椎管及神经根管减压、摘除椎间盘髓核组织、探查松解神经根.术后定期随访,采用Oswestry功能障碍指数(Oswestry disability index,ODI)、疼痛视觉模拟评分(visual analogue scale,VAS)和改良Macnab标准评定手术疗效.根据术前、末次随访时腰椎侧位X线片观察手术节段椎间隙高度变化,腰椎动力位X线片测量椎间角度,并计算腰椎活动度(range of motion,ROM).结果 所有患者均顺利完成内镜手术,手术时间平均(63.5±11.6) min,手术出血量平均(10.3±2.7) ml.所有患者术后均获得随访,随访时间18～52个月,平均(35.5±5.1)个月.ODI由术前平均51.35％± 15.29％下降至末次随访时3.31％±2.17％,差异有统计学意义(P＜0.05);VAS评分由术前平均(8.11±1.05)分下降至末次随访时(1.03±0.81)分,差异有统计学意义(P＜0.05),术后疼痛明显改善;末次随访按照改良MacNab标准评定疗效,优32例、良9例、可6例,优良率为87.2％.手术前后及末次随访时手术节段椎间隙前、后缘高度的差异无统计学意义(P＞0.05),手术节段腰椎ROM的差异亦无统计学意义(P＞0.05).术中及术后随访期间均未发生神经根损伤、硬脊膜损伤、脑脊液漏、肌力下降、二便障碍、腰椎不稳等严重并发症.结论 在严格把握手术适应证的前提下,经皮椎间孔入路内镜下微创手术治疗复发性腰椎间盘突出症临床疗效可靠.该术式采用侧方入路,不影响术后的脊柱稳定性,具有创伤小、并发症少、安全有效等优点.%Objective To analyze the clinical value of transforaminal endoscopic minimally invasive surgery for the treatment of recurrent lumbar disc herniation.Methods Strictly included in the criteria,47 patients diagnosed with recurrent lumbar disc herniation who was treated unsuccessfully with conservative treatment were selected from our department from May 2011 to December 2015.There were 31 males and 16 females,with an average age of 43.45 ±3.37 years old (29-62 years old).There were L3,4 section in 4 cases,L4,5 section in 32 cases,and L5S1 section in 11 cases.The interval between the first operation and the reoperation was between 10 and 185 months,with an average of 49 months.In the first operation,there were 11 cases of posterior intervertebral disc endoscopy (MED) surgery,and 36 cases of decompression of vertebral disc nucleus pulposus surgery.Take a prone position under local anesthesia percutaneous puncture intervertebral foramen in the endoscopic minimally invasive surgery,intraoperative decompression of vertebral canal and nerve root canal,removal of intervertebral disc nucleus pulposus tissue,explore and release nerve root.The Oswestry disability index (ODI),visual analogue scale (VAS) and improved Macnab standard were used to assess the efficacy of the operation.Operation segments intervertebral height change,lumbar power X-ray slice of intervertebral Angle was measured according to preoperative and last follow-up of lumbar lateral X-ray observation,and lumbar spine motion (the range of motion,ROM) was calculated.Results All cases were successfully performed,no open surgery,and all cases were followed up.The average surgical blood volume was 10.3± 2.7 ml,the operation time was 63.5±11.6 min,no nerve root injury,dural injury,cerebrospinal fluid leakage,muscle strength decline,secondary obstruction,lumbar instability or other serious complications occurred.The follow-up time was from 18 to 52 months,with an average of 35.5±5.1 months.The preoperative ODI 51.35± 15.29 decreased to 3.31 ±2.17 at the last postoperative follow-up,the preoperative VAS score 8.11 ± 1.05 decreased to (1.03± 0.81) at the last postoperative follow-up,and the difference was statistically significant (P ＜ 0.05).As to the last follow-up evaluation of curative effect,according to the modified MacNab method,the fine rate was 87.2％;At the time of the last follow-up,surgery intervertebral disc height of front and rear section before and after surgery had no significant differences (P ＞ 0.05),the motion of operation segmental lumbar (the range of motion,ROM) had no significant difference (P ＞ 0.05).Conclusion Under the premise of strict control of surgical indications,the clinical efficacy of minimally invasive surgery for the treatment of recurrent lumbar disc herniation is reliable.The transforaminal approach does not affect the stability of the spine.The operation has the advantages of small trauma,fewer complications,and is safe and effective.