极外侧腰椎间盘突出症的临床分型及手术方式选择

Clinical classification and surgical options of the far-lateral lumbar disc herniation

目的提出极外侧腰椎间盘突出症的新的临床分型，为手术方式的选择提供依据。方法按照椎间盘突出的位置及其临床症状将极外侧腰椎间盘突出症分为椎管内椎间孔内型（Ⅰ型）、椎间孔内型（Ⅱ型）和椎间孔外型（Ⅲ型）。据此对2002年1月至2007年1月收治的38例极外侧椎间盘突出症患者进行临床分型，并结合临床分型选择（1）经横突间椎间盘切除；（2）经椎管部分关节突切除、潜行椎间盘切除；（3）经椎管椎间盘切除＋经后路椎体间融合（PLIF）等手术方式。38例患者中男性25例，女性13例；平均58．4岁。其中L3-4 17例、L4～5，13例、L5S1 8例。单纯椎间盘突出23例，合并椎管狭窄15例。所有病例均表现为突出节段出口根受压的症状和体征，其中Ⅰ型中的7例同时伴有下位神经根受压的表现，15例合并椎管狭窄者存在间歇性跛行，21例有明确的腰痛症状。手术前后行根性疼痛VAS评分，术后采用MacNab方法进行临床疗效评定。结果按照新的临床分型，38例患者中Ⅰ型10例、Ⅱ型19例、Ⅲ型9例。经横突间行椎间盘切除5例，经椎管部分关节突切除、潜行椎间盘切除7例，经椎管椎间盘切除＋PLIF26例。随访时间6个月-4年10个月，平均2年11个月。VAS评分术前平均为7．4分，术后2周为2．7分，末次随访为3．1分。末次随访MacNab评定结果：优20例、良12例、可5例、差1例，优良率为84．2％。并发症：伤口表浅感染1例、减压不满意者1例、脑脊液漏1例。未见内固定断裂、松动等。结论新的临床分型，对认识极外侧腰椎间盘突出症的病理变化及选择手术方式等具有重要的意义。

Objectives To suggest the clinical classification of the far-lateral lumbar disc herniation and offer the considerations for clinical choice of different surgical procedures. Methods According to the locations of the herniated disc and relevant clinical symptoms, the far-lateral lumbar disc herniation was divided into three types ： Type I ： posterolateral and foraminal herniation （ double herniations ） ; Type Ⅱ ： foraminal disc herniation and Type Ⅱ ： extraforaminal herniation. From January 2002 to January 2007, 38 patients with far lateral lumbar disc herniation underwent surgery in the institute. The surgical options were decided by means of the classifieasion. The surgical procedures included （1） discectomy by inter-TP （ transverse process ） approach, （ 2 ） discectomy with partial facetectomy and （ 3 ） discetomy with facetectomy and PLIF （posterior lumbar interbody fusion）. Among the 38 patients, there were 25 males and 13 females. The mean age was 58.4 years old. The herniated discs located at L3-4 in 17, L4-5 in 13, and 8 cases at L5S1. Twenty-three patients were simple disc herniation, 15 cases with concomitant lumbar spinal stenosis. The symptoms and signs of exiting root compression at herniated disc level were presented in all patients and passing root compression presented in 7 Type Ⅰ cases as well; while intermittent claudication being presented in 15 and low back pain in 21 patients. The VAS （visual analog pain scale） of radicular leg pain was taken before and after the operation. The postoperative outcomes were evaluated through the MacNab＇s method in all the patients. Results By using the new classification system, the 38 patient were divided into Type Ⅰ 10 cases, Type Ⅱ 19 cases and Type Ⅲ 9 cases. The adopted surgeries included discectomy by intertransverse approach in 5, discectomy with partial facetectomy in 7, and discetomy with facetectomy and PLIF in the rest 26 cases. The mean follow-up period was ranging from 6 months to 4 years and 10 months, averagely 2 years and 11 months. The mean VAS scores of radicular pain was 7.4 preoperatively, 2. 7 at 2 weeks ＇after the operation and 3.1 at final follow-up. The final clinical outcomes by MacNab＇s method were as follow： excellent results in 20 cases, good in 12, fair in 5 and poor in 1 case. The overall improvement ratio was 84. 2%. The postoperative complications included superficial wound infection in 1 case, insufficient decompression in 1 case and leakage of cerebrospinal fluid in 1 case respectively. No breakage and loosening of internal fixation were detected. Conclusions A new clinical classification of far lateral lumbar disc herniation was suggested, which is significant to understanding the relevant pathology and choosing the surgical procedures.