腰椎间盘突出症微创治疗的临床疗效分析

摘要

目的 探讨经皮内窥镜下腰椎间盘切除术(percutaneous endoscopic lumbar discectomy,PELD)、后路显微内窥镜下腰椎间盘切除术(microendoscopic discectomy,MED)及Quadrant通道下腰椎椎体间融合术(minimally invasive transforaminal lumbar inter-body fusion,MIS-TLIF)微创系统治疗腰椎间盘突出症(lumbar disc herniation,LDH)的临床疗效对比及阶梯治疗理念.方法 我院自2013年10月至2016年4月通过微创手术治疗单节段不同类型LDH病人169例,男97例、女72例,年龄为24~63岁,平均(37.64±4.34)岁.根据手术方式分为三组:采用PELD手术62例(PELD组),采用MED手术54例(MED组),采用Quadrant通道辅助下MIS-TLIF手术53例(QDT组).观察、比较不同组病人手术时间、术中出血量、下床时间、住院时间、住院费用.采用Oswestry功能障碍指数(Oswestry disability index,ODI)、疼痛视觉模拟量表(visual analogue scale,VAS)及MacNab标准评估临床疗效,比较三组术中、术后指标及并发症情况.结果 所有病人均顺利完成手术,均通过电话及门诊复查等方式随访,随访时间为10~24个月.PELD组的手术时间、术中出血量、下床时间、住院时间、住院费用均优于其他两组,MED组优于QDT组,差异均有统计学意义(均P<0.05).所有病人术后10个月VAS评分、ODI与术前比较均明显改善(均P<0.05).术后10个月,病人对手术经历和疗效的问卷调查各组优良率:MED组(92.59%)>QDT组(92.45%)>PELD组(91.94%),改良MacNab标准评定各组优良率:PELD组(95.16%)>MED组(94.44%)>QDT组(94.34%).术后并发症:PELD组手术有2例复发,经MED(1例)或MIS-TLIF(1例)手术后治愈.结论 在严格选择手术适应证的前提下,对于单节段LDH病人,PELD、MED、Quadrant均有微创性;相对于传统手术方式更经济、安全、有效、恢复快,这种阶梯式治疗方式的理念及个体化的选择病人更容易接受.%Objective To investigate the clinical curative effects and the idea of stepped care of the percutaneous endoscopic lumbar discectomy (PELD), microendoscopic discectomy (MED) and minimally invasive transforaminal lumbar interbody fusion (MIS-TLIF) under Quadrant channel (QDH) in the treatment of lumbar disc herniation (LDH). Methods One hundred and sixty-nine patients with different types of mono-segmental LDH treated by minimally invasive surgery from October 2013 to April 2016 were enrolled in this study, including 97 males and 72 females. The age ranged from 24 to 63 years old, with an average of (37.64 ± 4.34) years old. They were divided into three groups according to the surgical procedures: PELD group (62 cases), MED group (54 cases), and QDT group (53 cases). The operation time, the amount of peroperative bleeding, the time out of the bed, the hospital stay and the cost of hospitalization were observed and compared among the different groups. Oswestry disability index (ODI), visual analogue scale (VAS) and MacNab standard were used to evaluate the clinical efficacy, so as to compare the perioperative and postoperative indexes and complications among the three groups. Results All patients completed the operations successfully, and they were followed up by telephone and outpatient reexamination. The follow-up time was 10-24 months. The operation time, the amount of perioperative bleeding, the time out of the bed, the hospital stay (days) and the cost of hospitalization in the PELD group were superior to those of the other two groups, and those in group MED were superior to those in the QDT, and the differences were statistically significant (both P<0.05). Ten months after the operation, all patients were significantly improved in VAS and ODI scores as compared with those before the operation (all P<0.05). Based on a questionnaire survey of the experience and efficacy of the patients for more than 10 months after surgery, the excellent rates were investigated:MED group (92.59%)>QDT group (92.45%)>PELD group (91.94%). Evaluation of the excellent rates of each group by modified MacNab standard revealed PELD group (95.16%)>MED group (94.44%)>QDT group (94.34%). For postoperative complications, 2 cases had recurrences in PELD group, and cured by MED (1 case) and MIS-TLIF (1 case) operation. Conclusion In the case of strict selection of surgical indications, PELD, MED, and Quadrant are minimally invasive for mono-segmental LDH patients. As compared with the traditional surgical procedure, PELD, MED, and Quadrant are economical, safe and effective, and have fast recovery. The idea and individualized choice of this stepped care are more acceptable for patients.