两种术式治疗腰椎间盘突出症的疗效比较

EFFECTIVENESS COMPARISON OF TWO SURGICAL PROCEDURES ON LUMBAR DISC PROTRUSION

目的比较显微椎间盘切除术与传统椎板开窗椎间盘切除术治疗单节段腰椎间盘突出症的临床效果。方法 2002年11月-2005年10月,对241例单节段腰椎间盘突出症患者采用显微椎间盘切除术(A组,93例)和传统椎板开窗椎间盘切除术(B组,148例)治疗。A组:男51例,女42例;年龄18～47岁,平均32.3岁。病程1～18个月,平均8.5个月。突出型23例,脱出型52例,游离型18例。椎间盘突出位于L2、38例,L3、411例,L4、535例,L5、S139例。B组:男81例,女67例;年龄16～50岁,平均31.8岁。病程1～20个月,平均9.3个月。突出型37例,脱出型85例,游离型26例。椎间盘突出位于L2、39例,L3、415例,L4、563例,L5、S161例。两组患者年龄、性别、突出节段、突出类型和病程比较,差异均无统计学意义(P>0.05),具有可比性。结果术后225例(93.4%)患者腰腿痛得到即刻缓解。术后1周A组患者满意度为91.4%,B组为87.8%,差异无统计学意义(P>0.05)。A组切口长度、术中出血量、术后引流量和住院时间明显少于B组(P<0.05),手术时间长于B组,但差异无统计学意义(P>0.05)。术中A组4例、B组5例发生硬膜撕裂;B组5例发生切口浅表感染,4例椎间隙感染;A组1例发生硬膜外血肿。A、B组围手术期并发症发生率分别为5.4%(5/93)和9.5%(14/148),A组明显低于B组(P<0.05)。术后A组4例(4.3%)、B组9例(6.1%)腰椎间盘突出症复发,差异无统计学意义(P>0.05);其中11例接受再手术治疗,2例保守治疗。241例均获随访,随访时间36～77个月,平均51.4个月。两组术前及末次随访时视觉模拟疼痛评分(VAS)和Oswestry功能障碍指数(ODI)评分比较差异均无统计学意义(P>0.05),术后1周VAS评分组间差异有统计学意义(P<0.05);组内术后1周及末次随访时VAS和ODI评分与术前比较均有明显改善(P<0.05)。两组末次随访时VAS和ODI评分改善率比较差异均无统计学意义(P>0.05)。末次随访时根据改良Macnab标准评价临床疗效,A组优良率为90.3%,B组为86.5%,组间比较差异无统计学意义(P>0.05)。结论两种手术方式均能有效治疗腰椎间盘突出症,但与传统椎板开窗椎间盘切除术比较,显微椎间盘切除术创伤更小,住院时间更短,是手术治疗单节段椎间盘突出症的有效方法之一。

Objective To compare the effectiveness of microdiscectomy and macrodiscectomy on the single-level lumbar disc protrusion （LDP）. Methods Between November 2002 and October 2005, 241 patients with LDP underwent 2 surgical procedures： microdiscectomy （group A, 93 cases） and macrodiscectomy （group B, 148 cases）. All patients had single-level LDP. In group A, there were 51 males and 42 females with an average age of 32.3 yeares （range, 18-47 years）; there were 23 cases of protrusion, 52 cases of prolapse, and 18 cases of sequestration with an average disease duration of 8.5 months （range, 1-18 months）, including 8 cases at L2,3 level, 11 cases at L3,4 level, 35 cases at L4,5 level, and 39 cases at L5, S1 level. In group B, there were 81 males and 67 females with an average age of 31.8 years （range, 16-50 years）; there were 37 cases of protrusion, 85 cases of prolapse, and 26 cases of sequestration with an average disease duration of 9.3 months （range, 1-20 months）, including 9 cases at L2,3 level, 15 cases at L3,4 level, 63 cases at L4,5 level, and 61 cases at L5, S1 level. There was no significant difference in age, sex, segment level, type, or disease duration between 2 groups （P〈0.05）. Results Immediate back and sciatic pain relief was achieved in 225 （93.4%） patients after operation. The satisfactory rates were 91.4% in group A and 87.8% in group B at 1 week after operation, showing no significant difference （P〈0.05）. The length of incision, amount of bleeding, amount of drainage, and hospitalization time in group A were significantly fewer than those in group B （P〈0.05）; while the operative time in group A was longer than that in group B, but showing no significant difference （P〈0.05）. Dural laceration occurred in 4 cases of group A and 5 cases of group B, superficial infections of incision occurred in 5 cases of group B and intervertebral space infections occurred in 4 cases of group B, and epidural hematoma occurred in 1 case of group A. The perioperative complication rate （5.4%, 5/93） in group A was significantly lower （P〈0.05） than that in group B （9.5%, 14/148）. LDP recurred in 4 cases （4.3%） of group A and in 9 cases （6.1%） of group B postoperatively, showing no significant difference （P〈0.05）; of them, 11 cases received second operation and 2 cases were treated conservatively. All cases were followed up 36-77 months （mean, 51.4 months）. There were significant differences in visual analog scale （VAS） and Oswestry disability index （ODI） between 2 groups at the last follow-up and preoperation （P〈0.05）, but there was significant difference in VAS at 1 week postoperatively between 2 groups （P〈0.05）. VAS and ODI were obviously improved at 1 week and last follow-up when compared with preoperation （P〈0.05）. There was no significant difference in the improvement rates of VAS and ODI between 2 groups at last follow-up （P〈0.05）. According to clinical evaluation of Modified Macnab criteria, the excellent and good rate was 90.3% in group A and 86.5% in group B at final follow-up （P〈0.05）. Conclusion Both macrodiscectomy and microdiscectomy are effective for LDP, furthermore microdiscectomy is less invasive than macrodiscectomy. Microdiscectomy is recommended to treat single-level LDP.