经后方极外侧入路治疗胸椎及胸腰段椎间盘突出症

Surgical treatment of the thoracic and thoracolumbar disc herniations through the posterior far lateral approach

目的 探讨经后方极外侧入路治疗胸椎及胸腰段椎间盘突出症的可行性、安全性及有效性.方法 2005年4月至2010年6月,采用经后方极外侧人路治疗胸椎及胸腰段（T10～L2）椎间盘突出症患者24例,男15例,女9例;年龄25～69岁,平均53.6岁.椎间盘突出的节段：T4-5、T5-6、T6-7 1例,T9-101例,T10-11 2例,T10-11、T11-12、T12-L1 1例,T11-12 3例,T11-12、T12L1 3例,T12L1 4例,T12L1、L1-23例,L1-2 6例,即单间隙突出16例、双间隙突出6例、三间隙突出2例.其中16例患者合并椎体后缘离断、骨赘、椎间盘钙化或后纵韧带骨化.术前椎间盘突出节段局部脊柱的后凸Cobb角平均为10.5°;患者的神经功能Frankel分级为：C级5例、D级16例、E级3例.结果 手术时间2.0～4.5 h,平均3.5 h;术中出血量300～4000 ml,平均800 ml.术后突出节段局部脊柱的后凸Cobb角平均为4.6°,平均矫正率为56.2%.24例患者术后均获得随访,随访时间1～62个月,平均18个月.按照日本骨科协会（Japanese Orthopaedic Association,JOA）29分法疗效评定标准,术后改善率优12例（50.0%）,良9例（37.5%）,可3例（12.5%）,优良率为87.5%,有效率100%.术后Frankel分级情况为：C级1例,D级2例,E级21例.术中、术后无一例发生并发症,术后随访期内全部患者的症状均有不同程度的恢复和改善,无复发病例.结论 借助＂安全三角区＂的解剖特点进行操作和通过手术节段后方加压改善脊柱局部后凸畸形的方法治疗胸椎及胸腰段椎间盘突出症具有术野直视、清晰,操作简便、安全,切除减压彻底、有效的优点.

Objective To evaluate the feasibility,safety and efficacy of surgical treatment of the thoracic and thoracolumbar disc herniations through the posterior far lateral approach,Methods From April 2005 to June 2010,24 consecutive patients with thoracic or thoracolumbar disc herniations were treated surgically,using the posterior far lateral approach.There were 15 males and 9 females with the mean age of 53.6 years old（range,25-69 years）.The levels of herniated discs were located in T4-s,T5-6,T6-7 for 1 case,in T9-10 for 1 case,in T10-11 for 2 cases,in T10-11,T11-12,T12L1 for 1 case,in T11-12 for 3 eases,in T11-12,T12L1 for 3 cases,in T12L1 for 4 cases,in T12L1,L1-2 for 3 cases,and in L1-2 for 6 eases.There were one level disc herniation in 16 cases,two levels disc herniation in 6 cases and three levels disc herniation in 2 cases.16 out of 24 cases had ＂bony protrusions＂,including bony separation of the endplate,bony spur,disc calcification or OPLL.The average preoperative Cobb angle of localized kyphosis was 10.5°.According to the Frankel grading system,5 cases were classified as C,16 as D,and 3 as E,preoperatively.Results Average operation time was 3.5 h（2.0-4.5 h）,and mean blood loss was 800 ml（300-4000 ml）.Postoperative localized kyphosis was an average of 4.6°,with average correction rate of 56.2%.24 cases were followed up for 1 to 62 months,with an average of 18 months.According to Japanese Orthopaedic Association（JOA）criteria system,there were 12 cases（50.0%）with excellent outcome,9 cases（37.5%）with good outcome,and 3 cases（12.5%）with fair outcome.The postoperative Frankel grading were C for 1 case,D for 2 cases,and E for 21 cases.There were no complications intraoperatively and postoperatively.The symptoms were improved in all patients.Conclusion By using ＂safe triangular zone＂ and dekyphosis stabilization,the posterior far lateral approach was a relatively safe,reliable,effective and better view surgical procedure for the treatment of the thoracic and thoracolumbar disc herniations.