经皮椎间孔镜与显微镜下手术治疗腰椎间盘突出症近期疗效对比

A comparison of preliminary surgical results between percutaneous transforaminal endoscopic discectomy and microsurgical lumbar discectomy for lumbar disc herniation

目的比较经皮椎间孔镜与显微镜下手术治疗腰椎间盘突出症(LDH)的近期临床疗效及对胺椎稳定性的影响,总结临床经验。方法回顾性分析2010年8月至2011年9月期间在我科接受手术治疗的单节段LDH患者106例,其中接受经皮椎间孔镜腰椎间盘切除术(PTED)患者48例,接受显微镜下腰椎间盘切除术(MSLD)患者58例。比较两种手术切口长度、手术时间、出血量、住院天数及花费、恢复工作时间及返岗率、并发症、二次手术情况。手术效果按照视觉疼痛模拟评分(visual analogue scale,VAS)、JOA评分(JapaneseOrthopaedic Association Scores)、Oswestry功能障碍指数(oswestry disability index,ODI)和改良MacNab标准进行评定。末次随访时通过测量比较患者术前、术后腰椎曲度(Cobb's角)、椎间水平位移和角位移评估腰椎稳定性变化。结果 PTED组及MSLD组的切口长度、出血量、住院天数及花费、恢复工作时间组间比较差异均有统计学意义(P<0.01),手术时间及返岗率差异无统计学意义(P>0.05)。PTED组和MSLD组并发症发生率分别为:6.3%(3/48)和20.7%(12/58),PTED组少于MSLD组(P<0.01)。3例患者行PTED失败或术后复发,择期行MSLD后疗状缓解。PTED组和MSLD组患者术后随访时间平均为16.7个月和17.3个月,两组术后各随访时间点腰腿痛VAS评分、JOA评分、ODI指数较术前均明显改善(P<0.01),但MSLD组术后3个月内腰痛VAS评分均高于PTED组。PTED组和MSLD组患者末次随访时按改良Macnab标准评定优良率分别为:91.4%和92.3%,组间比较差异无统计学意义(P>0.05)。PTED组患者术前、术后腰椎曲度无明显变化(P>0.05);MSLD组患者术后腰椎曲度较术前减小(P<0.05),两组患者术后均未出现腰椎失稳。结论 PTED与MSLD治疗单节段腰椎间盘突出症均可取得满意的近期临床疗效。但PTED具有创伤小、出血少和恢复快等特点,对患者腰椎稳定性影响较小,是更为理想的微创手术方法。

Objective To compare the preliminary clinical efficacy of percutaneous transforaminal endoscopic discectomy （PTED） and microsurgical lumbar discectomy （MSLD） for lumbar disc herniation （LDH） and their effects on lumbar spinal stability, and further to summarize the clinical experience. Methods The data of 106 patients with single segment LDH who were adopted by our department from August 2010 to September 2011 were retrospectively studied. All patients were divided into 2 groups, including 48 patients undergoing PTED and 58 patients undergoing MSLD respectively. The factors including the length of skin incision, operation time, amount of intraoperative bleeding, duration and cost of hospitalization, time and rate of returning to work, complications and second operation were compared. The visual analogue scale （VAS）, Japanese Orthopedic Association （JOA） scores, Oswestry Disability Index （ODI） and modified MacNab criteria were used to measure the clinical outcomes. In the latest follow-up, the changes in lumbar spinal stability were evaluated by measuring and comparing lumbar curves （Cobb＇s angle）, horizontal displacement （HD） and angular displacement （AD） before and after surgery. Results There were significant differences in the observation factors such as the skin incision length, amount of intraoperativebleeding, duration and cost of hospitalization and time of returning to work between the PTED and MSLD groups （P〈0.01）, without significant differences in operation time and rate of returning to work （P〉0.05）. The incidence of complications in the PTED group was 6.3% （3/48）, which was less than 20.7% of the MSLD group （12/58） （P〈0.01）. PTED failed or postoperative recurrence occurred in 3 cases, and then MSLD was performed to improve the symptoms. After surgery, the patients in both groups were followed up for 16.7 months and 17.3 months on average respectively. The postoperative back and leg pain VAS scores, JOA scores and ODI at each follow-up time point in both groups were significantly improved when compared with the preoperative ones （P〈0.01）. However, 3 months after surgery back pain VAS scores in the MSLD group were higher than that in the PTED group. According to the modified MacNab criteria, the excellent and good rates were 91.4% and 92.3% respectively in the PTED and MSLD groups in the latest follow-up, and the differences between the 2 groups were not statistically significant （P〉0.05）. There was no significant difference in lumbar curves before and after surgery for the patients in PTED group （P〉0.05）, and the postoperative lumbar curves in MSTD group decreased when compared with that before surgery （P〈0.05）. Postoperatively none of the patients complained about lumbar spinal instability. Conclusions The preliminary clinical efficacy of both PTED and MSLD in the treatment of single segment LDH is satisfactory. However, PTED is a better minimally invasive surgical method with such advantages as less trauma, less blood loss, early function recovery, less effect on lumbar spinal stability and so on.