微创与开放式髓核摘除术治疗腰椎间盘突出症术后再次手术原因分析

Analysis of reoperation causes of microinvasive endoscopic discectomy and that of open discectomy for the treatment of lumbar disc herniation

目的比较椎间盘镜下髓核摘除术（microendoscopic discectomy,MED）与开放式髓核摘除术治疗腰椎间盘突出症（lumbar disc herniation,LDH）的临床疗效,分析其再手术的原因。方法LDH患者1 862例,其中行MED术（MED组）1 276例,行开放式髓核摘除术（开放组）586例。采用改良Mcnab评分法评定治疗结果,随访8-60个月,平均随访39.2个月。结果1 518例获随访,MED组和开放组分别为1 059例和459例,术后最近随访满意率（Mcnab评分优良者）分别为91.31%和93.25%。MED组术中出血量、住院时间、恢复原工作的时间明显少于开放组（P〈0.05）,但住院费用高于开放组（P〈0.05）。MED组和开放组术后再手术率分别为6.89%（73/1059）和2.61%（12/459）,有显著差异（P〈0.05）;术后平均复发时间MED组早于开放组,分别为5.6个月和31.2个月（P〈0.05）。两组均未发生诊断错误和术中定位错误。结论侧隐窝狭窄未解除和原位椎间盘突出是MED术后复发的主要原因;继发性腰椎管狭窄和神经根黏连是开放式髓核摘除术后复发的主要原因。

Objective To compare the clinical results between microinvasive endoscopic discectomy and open discectomy for treatment of lumbar disc herniation, and analyze the reoperation causes for both methods. Methods A total of 1862 cases of lumbar disc herniation were divided into two groups,in which 1276 cases were treated with MED（ MED group ） and 586 cases were treated with open discectomy（ opening group ）. Modulated Mcnab criteria was used for the evaluation of clinical results. The patients were followed-up for 8 to 60 months ,with a mean of 39.2 months. Results The data of 1518 cases were obtained：,with 1059 cases from MED group and 459 cases from opening group. According to the Modulated Mcnab criteria, the satisfactory rate of recent follow-up was 91.31% and 93.25% for the MED group and opening group respectively,without significant difference（ P 〉0.05 ）, indicating that both operation methods gained good or excellent clinical results. The mean blood loss during operation, mean hospital stay and mean rehabilitation time after surgery of MED group were significantly less than those of opening group, but the mean cost during hospital stay of MED group was more than that of the opening group （ P 〈 0.05 ）. The rate of reoperation of MED group and the opening group was 6.89% （73/1059 ） and 2.61% （12/459 ） respectively,with significant difference（ P 〈0.05 ）. The mean time of recurrence after operation of MED group and opening group was 5.6 months and 31.2 months respectively（ P 〈 0.05 ）, indicating that the time of recurrence of the MED group was much earlier than that of opening group. No case of misdiagnosis or errors of intraoperative positioning was found. Conclusion The main causes for recurrences of MED were failures in releasing the stenosis of lateral recesses and in situ herniations of operated discs, and the main causes for recurrences of opening discectomy were secondary stenosis of the spinal canals and adhesions of the nerve roots.