显微椎间盘镜下预防椎间盘术后椎管内粘连的临床观察

Prevention of dura adherence in spinal canal after microendoscopic discectomy by different methods:a clinical study of 165 cases

目的探讨显微椎间盘镜下不同方法预防椎间盘切除术后椎管内瘢痕粘连的作用。方法165例腰椎间盘突出症病人随机分为3组:A 组为透明质酸钠组;B 组为保留黄韧带组;C 组为保留黄韧带结合透明质酸钠组。分别进行微创显微椎间盘镜下椎间盘切除术,A 组切除黄韧带,髓核摘除后关闭切口前透明质酸钠均匀喷洒于椎板间隙;B 组保留黄韧带;C 组保留黄韧带同时喷洒透明质酸钠。分别于术后2、4、8周,1年及2年进行随访。采用日本(JOA)标准进行评分,计算改善率,并行 CT 复查。结果术后2周,3组改善率差异无统计学意义,术后4周、8周、1年及2年时 B 组及 C组改善率与 A 组比较,差异有统计学意义(t 值分别为0.602、0.701、0.623、0.654和0.833、0.759、0.714、0.771,均 P<0.05),均优于 A 组,但是 B 组及 C 组之间改善率差异无统计学意义(t 值分别为0.041、0.135、0.980、0.530、0.103,均 P>0.05)。A 组中,术后2周改善率和术后其他时间改善率差异有统计学意义(P<0.05),术后1年和2年的平均改善率较术后4周和8周时稍有升高,但是无统计学意义。B 组和 C 组术后不同时间内改善率差异无统计学意义。结论保留黄韧带能有效地预防椎间盘术后椎管内瘢痕粘连,且远期预防效果良好。透明质酸钠短期内能较好的预防椎管内瘢痕粘连,但远期效果欠佳。在保留黄韧带的基础上加以透明质酸钠并没有起到更好的预防作用。

Objective To evaluate the effects of different methods in prevention of post-operational scar formation and dura adherence in the spinal canal after microendoscopic discectomy （MED）. Methods 165 patients undergoing MED were randomly divided into 3 equal groups： Group A, with the yellow ligament dissected and with the space between vertebral laminae sprinkled with sodium hyaluronate before the closing of the incision ; Group B, with the yellow ligament reserved; and Group C, with the yellow ligament reserved and with the space between vertebral laminae sprinkled with sodium hyaluronate before the closing of the incision. All the patients were followed up 2, 4, and 8 weeks, and 1 and 2 years after the operation. Japanese Orthopedic Association （ JOA ） scoring system was used to evaluate the outcomes. Results The JOA scores 2 weeks after MED were not significantly different among the 3 groups; and from then on the JOA scores of Groups B and C were all higher than those of group A （ A and B ： t4w = 0. 602,ts, =0. 701 ,t1y =0. 623 ,t2y =0. 654;A and C： t4w =0. 833 ,tsw =0. 759 ,t1y =0. 714,t2y =0. 771 ,all P 〈 0. 05 ） , however, there were not significantly differences at all time points between Groups B and C （ B and C： t2w =0. 041 ,t4w=0. 135 ,tsw =0. 980,t1y =0. 530,t1y =0. 103 ,all P 〉0.05）. CT showed that a great amount of scar was seen, surrounding the dura mater sac and nerve roots in Group A, and there was a great amount of scar outside the yellow ligament and no remarkable compression of dura mater sac and nerve roots in Groups B and C, Conclusion Reservation of yellow ligament effectively prevents scar adhesion inside the vertebral canal after MED. Sprinkling of sodium hyaluronate is also effective, however, its effect only lasts a short time.