保留黄韧带的显微内镜下腰椎间盘切除术的临床探讨

Clinical Study on Spared Ligamenta Flavum in Microendoscopic Discectomy

目的探讨在内镜下保留黄韧带的腰椎间盘髓核摘除术的手术方法、适应证和疗效。方法 2008年1月～2009年12月,筛选腰椎间盘突出症患者70例,根据临床症状、体征、CT扫描和/或MRI检查确诊。常规内镜操作下显露腰椎板间隙,用微型手术刀切开并剥离黄韧带,将黄韧带向中线卷曲剥离,用神经根拉钩将神经根拉向内侧以充分显露突出的腰椎间盘,椎间盘摘除和神经根松解后将黄韧带瓣恢复到原来解剖部位。结果 70例手术顺利,无中转开放手术。手术时间(140.3±26)min(120～180)min,切口均呈Ⅰ/甲愈合,无神经根损伤、椎间隙感染、脑脊液漏等并发症。60例随访6～18个月,平均12.4个月,疗效评定按Nakai疗效评定标准:优38例,良27例,可5例,差0例,优良率92.7%(65/70)。结论保留黄韧带的显微内镜下腰椎间盘切除术,完全可以实现,而且能降低术后椎管内瘢痕粘连,临床疗效好。

Objective To study microendoscopic discectomy surgical methods,indication and clinical efficacy for spared ligamenta flavum. Methods From January 2008 to December 2009,70 patients with lumbar disc herniation were enclosed in the study. The diagnosis was confirmed with clinical symptoms,signs,CT scanning and/or MRI examination. The Microscope Endoscopic Tubular Retractor System was used to access the interlaminar space. The superior,inferior and lateral edges of the ligamentum flavum were released using a micro-scalpel. The nerve root was retracted medially with a nerve root retractor to expose the herniated lumbar disc for performing the discectomy. The dissociative ligament was restored anatomically after disc removal and the decompression of the nerve root. Results The operation was completed smoothly in all patients without conversions to open surgery. The operation time was （140.3±26） minutes,ranged from 120 minutes to 180 minutes. The wound healed by first intention in all the patients without nerve root injuries,intervertebral infection,or cerebrospinal fluid leakage. A follow-up was carried out for 6-18 months （mean,12.4 months）. According to the Nakai classification,excellent results were achieved in 38 patients,good in 27 patients,fair in 5,and poor in 0. The rate of excellent or good outcomes was 92.7% （65/70）. Conclusion Spared ligamenta flavum in microendoscopic discectomy is entirely capable of achieving. It is an effective way of preventing the scar formation and adhesion after the operation of disc herniation,and the clinical response is satisfactory.