显微镜辅助下小切口治疗腰椎间盘突出症

Microscopic-assisted Small-incision Surgery for Lumber Disc Herniation

目的探讨经后路显微镜辅助下小切口椎间盘切除术(microsurgery lumbar discectomy,MSLD)治疗腰椎间盘突出症的临床疗效。方法 2008年10月～2011年12月采用Leiea MC1型显微镜及特制椎板小拉钩对150例腰椎间盘突出症(单间隙突出90例,双间隙突出50例,三间隙突出10例,合并侧隐窝狭窄30例)行显微镜下椎间盘髓核切除术。术前X线精确定位手术间隙,全程显微镜下显露,切除部分黄韧带,初步显露硬膜,根据需要切除少许上位椎板下缘及关节突内缘,保护神经根,切除髓核组织。结果手术时间30～60 min,(35.5±6.4)min;术中出血20～95 ml,出血量(56.5±5.8)ml。手术切口长1.8～3.5 cm,(2.5±0.8)cm。术中硬脊膜破裂2例,行硬脊膜修补。术后切口均Ⅰ期愈合,无神经根、马尾神经损伤及感染等并发症发生。术后住院时间3.5～7.0 d,(5.5±2.0)d。单病种总医疗费用6000～8500元,(5500±1500)元。150例术后随访12～36个月,平均24.6月,按MacNab评价标准:优127例(84.6%),良13例(8.7%),可10例(6.7%),优良率93.3%(140/150)。结论 MSLD治疗腰椎间盘突出症术野清晰,神经根减压彻底,对脊柱稳定结构破坏小,术后疗效满意,是治疗腰椎间盘突出症的一种理想的微创手术。

Objective To evaluate the efficacy of microscopic lumbar discectomy （MSLD） for the treatment of lumbar disc herniation. Methods Between October 2008 and December 2011, we performed MSLD on totally 150 patients with lumbar disc herniation with Leica MC1 microscope and self-designed retractors. Among the patients, 90 were diagnosed with disc herniation in one space, 50 were in two spaces, and 10 were in three spaces; 30 of the patients were complicated with lateral crypt stricture. Before the MSLD, surgical space was positioned by C-arm X-ray. Under microscopic assistance, we partially resected ligamentum flavum to expose the dura mater, and then the bottom edge of the upper lamina and inner edge of the articular process were partially resected as needed, with the nerve roots being protected, the nucleus pulposus was removed. Results The operation time ranged from 30 to 60 min[ mean, （ 35.5 ± 6.4 ） min ], and intraoperative blood loss ranged from 20 to 95 ml [ mean, （56.5± 5.8 ） ml ]. The length of the incision was （2.5 ±0.8） cm in average （ranged from 1.8 to 3.5 cm）. During the procedure, rapture of the the dural sac occurred in two patients, and thus the dural sac was repaired. After the operation, stage I wound healing was achieved without injury or infection of the nerve roots or cauda equine. The mean postoperative hospital stay was （5.5 ±2.0） days （ ranged from 3.5 to 7.0 days）. For a single disease, the mean hospitaiization cost was （5500 ± 1500） RMB （ranged from 6000 to 8500 RMB）. The patients were followed up for 12 to 36 months with a mean of 24.6 months. According to MacNab standards, 127 （84.6%） of the patients were excellent, 13 （8.7%） were good, and 10 （6.7%） were fair, and the rate of excellent and good was 93.3% （140/150）. Conclusion MSLD is effective and optimal for lumbar disc herniation, for it creates clear surgical field, achieves complete nerve roots decompression, and protects spinal stability.