经皮椎间孔入路内镜下治疗腰椎管狭窄症术后再手术的临床报告

摘要

Objective To analyze the causes of revision surgery after percutaneous transforaminal endoscopic discectomy (PTED) for lumbar spinal stenosis,and to provide references for indications and operative methods.Methods From January 2015 to October 2017,206,491 and 60 patients of lumbar spinal stenosis were treated with PTED in Tianjin Hospital,Shanxi People's Hospital,Ningbo Sixth Hospital,respectively;among them,4,10 and 4 cases received revision surgery.Another 13 patients of lumbar spinal stenosis were treated with revision surgery due to poor results after PTED in other hospitals.Among 31 cases of reoperation,there were 16 males and 15 females,aged 27-82 years (average,66.2±12.7 years).The lesion segments included 1 case of L3,4,23 cases of L4,5,5 cases of L5S1,1 cases of L3-L5,and 1 cases of L4-S1.Patients were followed up after reoperation from 3 to 24 months (average,12.1 months).The causes of poor result and revision surgery were analyzed according to preoperative,intraoperative and postoperative data.Results All of 757 cases of lumbar spinal stenosis were treated with PTED in three hospitals,of which 18 cases (2.4％) were re-operated.The causes of reoperation included:bone slice displacement in 1 case;nerve injury in 4 cases;lumbar instability in 4 cases;disc protrusion in 10 cases (residual or recurrence);insufficient decompression in 21 cases;planed staging operation in 4 cases with bilateral or two-level stenosis.32 revision surgeries were performed for 31 patients,including PTED in 15 cases,microendoscopic discectomy (MED) in 1 case,mobile MED (MMED) in 5 cases,MMED assisted fusion in 2 cases,transforaminal lumbar interbody fusion (TLIF) in 4 cases,Minimally invasive TLIF (Mis-TLIF) in 2 cases,and open decompression and fusion in 3 cases.All patients experienced relieve of symptoms after revision surgery.At final follow-up,VAS leg pain deceased form 7.1±3.9 before revision surgeries to 1.9±1.2,VAS low back pain decreased form 6.3±3.2 to 1.8±1.3,ODI score decreased from 35％± 14％ to 7.6％±5％.According to the MacNab score,the result was excellent in 11 cases,good in 16 cases,and fair in 4 cases.Conclusion The treatment of lumbar stenosis with PTED has high technical requirements,the indications of PTED for lumbar stenosis should be strictly controlled according to technical conditions,and appropriate operative methods should be chosen according to the specific conditions of the lesions.Insufficient decompression,disc protrusion,lumbar instability and nerve injury are the common causes of reoperation.Suitable indications and proper operation should be selected.%目的 探讨经皮椎间孔入路内镜下治疗腰椎管狭窄症术后再手术的原因.方法 2015年1月至2017年10月天津医院、山西省人民医院及宁波市第六医院分别采用经皮椎间孔入路内镜下治疗腰椎管狭窄症206例、491例和60例,术后分别有4例、10例和4例患者行再次手术;收集同期外院经皮椎间孔入路内镜下手术治疗腰椎管狭窄症后效果不佳在上述三家医院接受再次手术的患者13例.共31例患者纳入研究,男16例,女15例;年龄27～82岁,平均(66.2±12.7)岁.初次手术节段:L3.41例、L4.523例、L5S15例、L3～L51例,L4～S1 1例.再次手术后随访3～24个月,平均12.1个月.再手术后疗效评价采用疼痛视觉模拟评分(visual analogue scale,VAS)、Oswestry功能障碍指数(Oswestry disability index,ODI)及MacNab标准.对31例患者初次经皮椎间孔入路内镜下手术及再次手术的术前、术中、术后资料进行描述性分析,总结经皮椎间孔入路内镜下手术后效果不佳及再次手术的原因.结果 三家医院采用经皮椎间孔入路内镜下治疗腰椎管狭窄症757例,其中18例(2.4％)患者行再次手术.31例患者的再手术原因:骨块卡压神经1例;神经损伤3例;腰椎失稳4例次(包括1例因减压不彻底行再次手术,术后出现腰椎失稳行第3次手术);椎间盘突出10例(包括突出物残留或复发突出);减压不彻底21例;因双侧狭窄或双节段狭窄术前计划可能分期手术4例.31例患者共接受32次再手术,手术方式:经皮椎间孔入路内镜下手术15例、可动式显微内镜椎间盘切除术5例、可动式显微内镜下融合固定术2例、显微内镜椎间盘切除术1例、微创经椎间孔腰椎椎体间融合术2例(其中1例为第3次手术)、经椎间孔腰椎椎体间融合术4例、开放减压融合固定术3例.再手术后症状均得到明显缓解,末次随访时下肢痛VAS评分由再手术前(7.1±3.9)分降至(1.9±1.2)分,腰痛VAS评分由再手术前(6.3±3.2)分降至(1.8±1.3)分,ODI自再手术前35％±14％降至7.6％±5％.末次随访时根据MacNab标准,优11例、良16例、可4例,优良率为87.1％.结论 PTED治疗腰椎管狭窄症对技术要求较高,应根据技术条件严格掌握PTED适应证,根据病变具体情况选择合适的手术方法;其术后再手术的常见原因为减压不彻底、椎间盘突出、腰椎失稳、神经损伤等.