Objective To evaluate the feasibility and clinical efficacy of bilateral decompression via unilateral fenestration and interbody fusion for complex lumbar spinal stenosis with mobile microendoscopic discectomy (MMED) technique.Methods Sixty-eight complex lumbar spinal stenosis patients with an average age of 67 years old (range,56-76),including 39 men and 29 women,were treated by this procedure using MMED technique.Among them,49 and 19 of these patients had degenerative spondylolisthesis and scoliosis respectively.All patients complained of lumbar or leg pain combined with intermittent claudication,and the index levels L4、5 involved in 57 patients,L5S1 in 6 patients,L3-L5 in 4 patients and L4-S1 in 1 patient.Pre-operative Oswestry disability index (ODI) was 43.8％± 10.4％,visual analogue scale (VAS) 6.3± 3.3 for lumbar pain,and 6.1± 3.8 for leg pain.Through a 2.5-3.5 cm incision medial to puncture sites of pedicle,unilateral fenestration and bilateral decompression was performed under MMED,and the disc space was curetted and prepared adequately.The inner tube was removed,and the disc space was released,tested and grafted,followed by suitable cage,whose position was confirmed under fluoroscopy.Percutaneous transpedicular screws were installed under fluoroscopy,followed by reduction and fixation.The operative time and blood loss were recorded,and the patients were followed to evaluate the clinical results.Results Surgery was successful in all patients,without nerve injury or conversion to open surgery.The mean operative time was 120 min (range,100-180 min),with a mean blood loss of 100 ml (range,50-200 ml).The post-operative X-ray and CT scans showed sufficient decompression and improvement of spinal alignment,with the ratio of spondylolisthesis improved from 17.9±6.2 to 11.8±4.8.All patients were followed up for more than 6 months,while 61 of them were followed for 12-24 months,with ODI score of 8.9±7.4,VAS of lumbar 1.2±1.1 and VAS of leg 0.9±0.9 at final follow-up,that were significantly decreased compared to pre-operative scores.The clinical results were excellent in 41 cases,good in 25,and fair in 2 based on the MacNab scale.Conclusion Complex lumbar spinal stenosis can be treated by bilateral decompression via unilateral fenestration and interbody fusion with MMED technique.This procedure can also provide satisfactory results in short-term follow-up.%目的 探讨可动式椎间盘镜(mobile microendoscopic discectomy,MMED)下单侧开窗双侧减压椎体间融合术治疗复杂腰椎管狭窄症的疗效.方法 2013年3月至2014年9月采用MMED下单侧开窗双侧减压椎体间融合术治疗复杂的腰椎管狭窄症患者68例,男39例,女29例;年龄56～76,平均67岁.49例伴退行性滑脱,19例伴退行性侧凸.责任节段包括L4,5 57例,L5S1 6例,L3～L5 4例,L4～S1 1例.患者均有腰腿痛和间歇性跛行症状,术前Oswestry功能障碍指数(Oswestry disability index,ODI)为43.8％±10.4％,疼痛视觉模拟评分(visual analogue scale,VAS)腰痛(6.3±3.3)分、腿痛(6.1±3.8)分.在症状严重侧行纵行切口,放置MMED,用磨钻扩大开窗,沿神经根通道减压,摘除椎间盘,充分刮除终板软骨,处理椎间隙;潜行咬除对侧黄韧带,松解对侧神经根;退出内套管,直视下试模撑开椎间隙,用自体骨与异体骨混合植骨,放置cage,移除外套管.透视下经椎弓根穿刺,放置空心椎弓根螺钉,仍有滑脱者预设复位距离,经皮插入连接棒复位固定.结果 1例术中转开放手术,所有病例均未发生神经损伤.手术时间100～180 min,平均120 min;术中出血50～200 ml,平均100 ml.术后影像学检查示脊柱序列改善,减压充分,合并滑脱者滑脱比由术前17.9±6.2降低至11.8±4.8.61例患者随访12～24个月,其他7例随访6～9个月.末次随访时ODI降低至8.9％±7.4％,VAS评分下降至腰痛(1.2±1.1)分、腿痛(0.9±0.9)分,MacNab法疗效评定结果为优41例、良25例、可2例.结论 MMED下单侧开窗双侧减压椎体间融合术治疗复杂的腰椎管狭窄症能明显缓解症状、改善脊柱功能,术后近期疗效良好.
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