经皮侧方入路内窥镜下椎间盘切除术的可行性及临床应用

Feasibility and clinic application of percutaneous lateral endoscopic discectomy

目的:探讨经皮侧方入路内窥镜下腰椎间盘摘除术的解剖学依据,观察临床应用效果。方法:28例L4/5椎间盘突出患者,俯卧位下经L4/5椎间盘进行CT断层扫描,观察从腰部外侧与椎管呈90°穿刺进入椎管的经皮穿刺点及穿刺路径上的解剖结构;测量经皮穿刺点至后正中线皮肤的距离和同侧上关节突前缘的距离。应用侧路内窥镜下椎间盘摘除术治疗椎间盘突出症患者66例(均为突出较严重并且是非间隙水平以外或游离型突出者),观察患者治疗结果和并发症。结果:侧路穿刺路径由浅入深的主要结构有腰背筋膜中层结构(腹外斜肌、腹内斜肌、腹横肌、腰方肌)、腰背筋膜深层、腰大肌、椎间孔和椎管。经皮穿刺点至后正中线皮肤的距离为18.08±1.88cm;至同侧上关节突前缘的距离为13.70±1.69cm。28例中27例可以直接穿刺进入椎管,不会损伤内脏、血管等解剖结构。临床应用66例中没有明显入路途径上的血管和内脏解剖结构损伤,2例发生了与穿刺无关的神经损伤,2例摘除失败行切开手术。结论:经皮侧方90°上关节突前缘进入椎管是可行的,为突出较严重并且是非间隙水平以外或游离型病例的微创治疗提供了可能。

Objective：To investigate the anatomic evidence of percutaneous lateral endoscopic discectomy and observe the result of clinical application.Method：28 patients of L4/5 disc herniation on the plane of L4/5 disc in prone position were examined by CT scan.To observe the anatomic structures from the point of percutaneous puncture to the vertebral canal and the pathway puncturing in 90° between lumbar lateral and vertebral canal,the distance between the point of puncture and the skin of posterior median line was measured.66 patients of lumbar disc herniation were treated using percutaneous lateral endoscopic discectomy,the results of treatment and complications were observed.Result：The important structures from outside to inside using lateral puncture were medium structures of lumbodorsal fascia（obliquus externus abdominis,obliquus internus abdominis,transversus abdominis,lumbar quadrate muscle）,deep lamella of lumbodorsal fascia,greater psoas muscle, intervertebra foramina and vertebral canal.The distance from puncture point to the posterior median line was 18.08±1.88cm.The distance between the puncture point to the superior articular process anterior border was 13.70±1.69cm.We punctured vertebral canal directly in 27 cases out of 28 patients,and had no any anatomic injury along puncture line.Two cases nerve injuries did not related with puncture action and two cases received secondary open operation.Conclusion：h is feasible to enter vertebral canal through anterior border of superior articular process from lateral side.It is one method to the cases of severe intercanal herniation that does not seat in the same plane of interspace treated with a minimal incision.