臭氧髓核消融术失败的原因及治疗策略

Failure of Ozone Nucleolysis for Lumbar Disc Herniation:Etiology and Treatment Strategies

目的总结椎间盘臭氧消融术失败的原因,探讨其治疗策略及临床效果。方法行臭氧髓核消融术患者112例,其中臭氧消融术失败需再次治疗者12例(10.7%),7例(58.3%)是由于适应证掌握不当,2例(16.7%)由于技术操作不当,3例(25.0%)由于病情进展。除1例椎间隙感染患者运用2周抗生素行保守治疗外,其余11例均再次手术:1例因L1椎管内脊膜瘤行后路全椎板减压、脊膜瘤切除术,1例椎间隙感染经椎间孔镜下椎间隙冲洗、引流,1例同节段椎间盘同侧复发行经典开窗髓核摘除术,1例同节段椎间盘对侧复发合并神经根功能障碍行后路减压、椎间植骨融合术(PLIF),1例同节段椎间盘复发无根性症状再次行髓核臭氧消融术,3例因腰椎失稳或减压范围较大出现医源性不稳行经椎间孔椎间植骨融合术(TLIF),3例因髓核脱出游离或合并单侧侧隐窝狭窄患者行后路内窥镜下髓核摘除术(MED)。结果臭氧髓核消融术和再次治疗间隔时间为4.0个月(1周～19个月)。均获得随访,平均22.4(1～43)个月,终末期随访时OD I评分为24.0(18～38),较再次手术或抗生素治疗前的76.2(64～92)显著改善(P<0.05)。结论臭氧髓核消融术的并发症不可忽视,严格把握手术指证、规范掌握术中操作技巧是防治并发症的关键,针对失败原因选择合适的治疗策略可以取得满意的疗效。

Objective To identify the causes of failed ozone nucleolysis for lumbar disc herniation and to describe the treatment strategies for revision surgery.Methods There were 112 subjects treated with ozone nucleolysis for lumbar disc herniation and 12 patients（10.7%） needed revision surgery or antibiotics.Of 12 patients,7（58.3%） caused by incorrect indication,2（16.7%） by technique-related factors,and 3（25.0%） by disease progression.Except for 1 subject with pyogenic discitis treated with clindamycin,the other 11 patients received revision surgery,including 1 meningioma at L1 received tumor resection with lamina decompression,1 pyogenic discitis were treated by water washing and drainage with transforaminal endoscope,1 patient with ipsilaterally recurrent disc herniation and low back pain received classic discectomy,1 patient with contralaterally recurrent disc herniation and disfunction of nerve root received PLIF,1 patient with ipsilaterally recurrent disc herniation who received ozone nucleolysis again,3 patients with lumbar instability received TLIF and 3 patients with nucleus pulposus extrusion/sequestration or lateral recess stenosis received MED.Results The mean time interval between the ozone nucleolysis and second treatment was 4.0 months（range,1 week～19 months）.All patients after second treatment were followed up for 22.4 months（range,1～43 months）,whose ODI were significantly declined from 76.2（64～92） to 24.0（18～38）（P〈0.05）.Conclusions The complication of ozone nucleolysis for lumbar disc herniation can not be ignored.And both to select correct patients and to standardize detals of ozone nucleolysis are keypoints to avoid the complication.According to the causes,proper intervention for failure of ozone nucleolysis can get good outcomes.