极外侧型腰椎间盘突出症的微创外科治疗

Minimally invasive treatment for far-lateral lumbar disc herniation

目的 探讨极外侧型腰椎间盘突出症微创手术方式的临床手术策略和适应证选择。方法 2000年1月至2006年10月，对52例极外侧型腰椎间盘突出症患者采用微创外科手术治疗。男29例，女23例；年龄21-67岁，平均41．5岁。病史2个月～3．8年，平均9．5个月。椎间孔内型（Ⅰ型）32例，椎间孔外型（Ⅱ型）11例与混合型（Ⅲ型）9例。L2-3 1例，L3-4 5例，L4-5 37例，L5S1 9例。所有患者术前均行腰椎正、侧位X线检查和CT扫描，对部分患者还辅以脊髓和腰椎间盘造影、CTM和MR检查。分别采用YESS经侧后路椎间孔入路椎间盘摘除、椎间孔扩大成形术25例，METRx后路经横突间入路腰椎间盘摘除术13例，X—Tube后路经小关节突切除、椎间植骨融合内固定术14例。结果 52例患者经平均13．5个月随访，疗效按照疼痛视觉类比评分法（VAS）和Nakai分级评定。结果表明3种微创术式均能显著改善患肢放射性疼痛（P〈0．05）：术后优良率分别为：YESS手术84．0％，METRx手术84．6％和X—Tube手术92．9％：3组间优良率差异无统计学意义（P〉0．05）。临床比较：YESS术的麻醉方式最简单、手术时间最短和创伤最小，特别适于单纯Ⅰ型极外侧型腰椎间盘突出；METRx术特别适于单纯Ⅱ型极外侧型腰椎间盘突出；而X—Tube术适于伴有腰椎退行性失稳的极外侧型腰椎间盘突出。结论 临床上应依据腰椎间盘突出的不同类型，选择不同微创外科术式。

Objective To discuss minimally invasive strategies, options and surgical indications for far-lateral lumbar disc herniation. Methods From January 2000 to October 2006, 52 patients with far-lateral lumbar disc herniation were treated with minimally invasive techniques, including 29 male and 23 female patients aged 41.5 years old averagely. All the patients were assessed by X-ray and CT, while some plus the myelography, discography, CTM and MRI. YESS, METRx and X-Tube techniques were performed in 25, 13 and 14 cases, respectively. Results 52 patients were followed up for a mean period of 13.5 months. Clinical outcomes were assessed by Visual Analogue score （VAS） and Nakai criteria. The results indicated that all of the three sorts of procedures could significantly improve the radiating leg symptoms （P〈 0.05）. The postoperative overall excellent and good rate for YESS technique, METRx and X-Tube techniques were 84.0%, 84.6% and 92.9% respectively with no statistical significant difference between the three groups （P 〉0.05）. The YESS technique is fit for simple type Ⅰ far-lateral lumbar disc herniation with several advantages, including shortest operation time, simplest anesthesia and least trauma compared with the other two techniques, METRx technique was specially suitable for simple type Ⅱ. And the procedure of posterior endoscopic facetectomy, posterior lumbar interbody fusion and unilateral pedicle screw instrumentation using X- Tube was designed for far-lateral disc herniation combined with degenerative lumbar instability. Conclusion Minimally invasive strategies and options should be determined by different types of far-lateral lumbar disc herniation.