脊髓造影辅助经皮椎板间孔内窥镜下髓核摘除术治疗L5/S1椎间盘突出症

摘要

目的:评估术中脊髓造影辅助经皮椎板间孔入路内窥镜下髓核摘除术治疗L<,5>/S<,1>椎间盘突出症的临床价值.方法:选择确诊为L5/S1单节段腰椎间盘突出症患者共40例,采用随机数字表的方法将患者分为A组和B组,每组各20例.A组在脊髓造影辅助下行经皮椎板间孔入路内窥镜下髓核摘除术,B组不实施脊髓造影操作,其它方法同A组.记录两组穿刺到目标椎间盘所需时间,一次性穿刺成功率,穿刺过程中神经根刺激症状和神经根、硬膜囊损伤发生率,脊髓造影相关的并发症.两组病例均随访6～12个月.采用疼痛VAS评分、Oswestry功能障碍指数(ODI)、改良的MacNab分级标准为疗效观察指标.结果:A组穿刺到目标椎间盘时间为9.67±1.45min,B组14.40±2.35min(P<0.01);A组一次性穿刺成功率95%(19/20例),B组60%(12/20例)(P<0.05);A组穿刺过程中神经根刺激症状发生率15%(3/20例),B组55%(11/20例)(P<0.05);A组无神经根和硬膜囊损伤发生,B组神经根和硬膜囊损伤各1例.按照改良MacNab疗效评定标准,A组优良率85%,B组优良率80%,两组无显著性差异(P>0.05).两组患者术后VAS和ODI评分较术前明显改善(P<0.05),但两组间比较无差异(P>0.05).A组中未见和脊髓造影相关并发症发生.结论:脊髓造影辅助经皮椎板间孔入路内窥镜下髓核摘除术治疗L<,5>/S<,1>椎间盘突出症的优点是减少目标椎间盘的穿刺时间,提高一次性穿刺成功率,降低并发症的发生率.%Objective: To evaluate the clinical vaule of myelography during percutaneous endoscopic discectomy for treatment of L5/S1 disc herniation via interlaminar approach. Methods: In this prospective randomized controlled study, a total of 40 matched patients preoperatively diagnosed as L5/S1 disc herniation were randomly and evenly divided into two groups, 20 patients in each. Patients in goup A were treated with percutaneous endoscopic discectomy assisted by myelography; group B were treatment by the same procedure without myelography. We compared two groups by the time needed for the needle placement into the right trajector, the sucessful rate of one time penetration and the occurance of complications.The Oswestry disability index(ODI), visual analogue scale (VAS) for pain, and modified MacNab criteria were employed to measure the clinical outcomes. Results: All the procedures were performed successfully. The averge time for the needle placement into the right trajector in group A was 9.67 ± 1.45 min,and 14.40 ±2.35 min in group B. There was significant difference in this between the two groups(P ＜0.01 ). The first sucessfully rate of the procedure was 95％ (19/20) in group A,and 60％ (12/20) in group B (P ＜ 0. 05 ). 3 ( 15％ ) cases of never roots stimulation syndromes were found in group A, and 12 ( 55％ ) in group B( P ＜0.05 ). one case of never roots injury and dura tears were found in group B. According to the modified Macnab criteria,85％ of patients in group A showed excellent and good outcomes while 80％ of patients in group B had such outcomes. There was no significant difference in the two groups (P ＞ 0. 05 ). VAS and ODI were significantly improved in the two groups compared with those before operation (P ＜0.05 ) ,but there were no significant difference in those between the two groups( P ＞0. 05). There were no complications observed as a result of myelography in group A. Conclusion: Percutaneous endoscopic discectomy via interlaminar approach assisted by myelography has the advantages of less time for the needle placement into the right trajector, more successfully rate and less complications.