等离子射频消融髓核后椎间盘内外注射小剂量胶原酶的溶核效应

Effect on nucleus pulposus of small dose collagenase injected into exterior and interior of lumbar intervertebral disc after radiofrequency ablation

背景:胶原酶溶核是通过对胶原的溶解和消除周围水肿而达到治疗目的,临床应用往往采用单一的方案。目的:评估等离子射频消融髓核后盘内外小剂量注射胶原酶对重度腰椎间盘突出的溶核治疗效果。设计:回顾性病例分析。对象:2005-12/2006-12湖北省郧阳医学院附属十堰市太和医院收治的46例椎间盘突出症患者,平均病程9.5个月。纳入标准:腰腿痛明显,严重影响生活和工作;经过2～4周常规保守治疗效果欠佳;CT或MRI扫描证实椎间盘病变存在,突出程度超过椎管前后径50%或压迫椎间孔;病变椎间盘周围无明显椎管骨性狭窄;胶原酶由辽宁味邦生物制药有限公司生产,System2000型等离子发生装置为美国ArthroCare公司产品。方法:椎间盘穿刺后,先经穿刺针管向髓核内置入射频电极作髓核消融,然后将胶原酶600u溶解于2mL生理盐水中,经穿刺针管向髓核内注入0.5mL,将穿刺针退至纤维环外,经造影或利多卡因试注证实针尖位于硬膜外腔后,再注入1.5mL胶原酶溶液,拔针包扎后严格卧床休息6h。疗效判定优为症状完全消失,无运动功能受限,恢复正常工作和活动;良为症状基本消失,能作轻工作或坚持工作。主要观察指标:注射后效果及并发症。结果:46例患者均完成3个月随访。胶原酶注射后1周疗效较差,优良率仅为80.4%(37/46);注射后1个月和3个月的疗效基本接近,优良率分别达91.3%(42/46)和93.5%(43/46),均未发生出血、腰肌血肿、感染和神经损伤等并发症。结论:等离子射频消融结合盘内外小剂量胶原酶溶核治疗可明显提高重度腰椎间盘突出的疗效。

BACKGROUND： Lumbar disc herniation is treated with collagenase chemonucleolysis either by dissolving collagenase or reducing peripheral edema in clinic. OBJECTIVE： To explore efficacy of small dose collagenase injected into interior and exterior of disc after radiofrequency ablation in the treatment of severe lumber intervertebral disc herniation. DESIGN： Retrospective case analysis. PARTICIPANTS： Forty-six patients with lumbar disc herniation with 9.5 months average duration, who were admitted in Affiliated Taihe Hospital of Yunyang Medical College from December 2005 to December 2006 were enrolled. Inclusion criteria： patients who suffered from severe lumbocrural pain, affected their daily life and work, and there was no improvement after 2 to 4 weeks normal conservative therapy. MRI and CT film revealed that there was intervertebral disc disorder. The degree of disc protrusion was 50% of vertebral canal or it compressed intervertebral foramen; there was not obviously spinal stenosis around intervertebral disk. Collagenase was produced by Liaoning Weibang Biopharm Co., Ltd （China）, the System2000 plasma reactor was purchased from ArthroCare Company （USA）. METHODS： After intervertebral disc puncture, radio-frequency electrode was implanted in nucleus gelatinosus by transfixion pin to resolve nucleus gelatinosus. 600 u collagenase was dissolved with 2 mL normal saline, and 0.5 mL of collagenas solution was injected into nucleus gelatinosus by transfixion pin. When digital subtraction angiography or Lidocaine injection test showed needle tip of transfixion pin staying in posterior epidural space, 1.5 mL collagenase solution was injected into the lateral region of lumbar vertebrae. The patients were limited to bed rest for 6 hours after surgery. Criteria of curative effects： Excellent： the symptoms disappeared, patients could live and work without restriction; Good： the symptoms alleviated, and patients could insist on working. MAIN OUTCOME MEASURES： Effects and complications after injection. RESULTS： All of 46 patients received 3-month follow ups. The evident effective rate was 80.4% at 1 week after operation, while 91.3% （42/46） and 93.5% （43/46） at 1 month and 3 months post-operation. No complication occurred. CONCLUSION： Small dose collagenase injection after radiofrequency ablation is an effective method in treating severe lumbar disc herniation.