极外侧型腰椎间盘突出症的诊断及手术方式选择

The diagnosis and surgical options for extreme lateral lumbar disc herniation

目的探讨极外侧型腰椎间盘突出症（ELLDH）的诊断方法,评估个体化手术治疗的临床效果。方法回顾性分析2004年2月至2012年2月武汉大学人民医院收治的26例ELLDH手术患者的临床资料,其中椎板开窗椎间盘摘除术7例;椎板部分切除减压、椎弓根螺钉固定、后路腰椎椎间融合（PLIF）8例;经峡部关节突切除、椎间盘摘除、椎弓根螺钉固定、经椎间孔腰椎椎间融合（TLIF）11例。比较单纯腰椎CT、MRI检查及联合CT、MRI检查的诊断准确率;记录患者术前及末次随访日本骨科学会（JOA）评分,观察植骨融合及并发症发生情况。结果单纯腰椎CT扫描、单纯MRI检查、联合CT和MRI检查的诊断准确率分别为92%（24/26）、88%（23/26）和100%（26/26）,3者诊断准确率比较,差异无统计学意义（χ2=2.992,P=0.224）。术后患者下肢痛均完全缓解。随访时间2~6年,平均随访时间3.5年。随访期间未见腰椎间盘再突出,无翻修病例。末次随访时JOA评分为（25.8±4.2）分,明显优于术前的（11.5±2.8）分,两者比较,差异有统计学意义（t=14.445,P=0.000）,术后JOA评分平均改善率为85%。7例行开窗术患者中1例术后5年出现腰痛及腰椎失稳,其余患者随访情况良好;PLIF和TLIF患者末次随访时融合良好,未见假关节形成,未见椎弓根螺钉松动、断裂,未有Cage移位、下沉或脱出。结论 ELLDH临床表现复杂,联合应用CT和MRI检查有助于该病的诊断和治疗;选择个体化手术方式治疗ELLDH能够明显缓解疼痛症状,植骨融合良好,并发症少,远期效果满意。

Objective To investigate the diagnosis and individualized surgery options for extreme lateral lumber disc herniation（ELLDH）. Methods From February 2004 to February 2012, 26 consecutive patients with ELLDH were treated surgically in People＇s Hospital of Wuhan University, and their clinical data were retrospectively analyzed in this study. Fenestration laminectomy and discectomy was performed in 7 cases,posterior lumbar interbody fusion（PLIF） with partial laminectomy and pedicle screw fixation was done in 8patients while transforaminal lumbar interbody fusion（TLIF） with trans-isthmus facet joint excision, discetomy and pedicle screw fixation was performed in 11 patients. Accuracy rate of diagnosis was compared among 3radiological methods of CT scanning, MRI, MRI combined with CT scanning; Japanese Orthopaedic Association（JOA） scores were evaluated before the surgery and at the last follow-up, grafting bony fusion and complications were also observed. Results Accuracy rate of diagnosis was respectively as 92%（24/26） in CT scanning, 88%（23/26） in MRI, and 100%（26/26） in MRI combined with CT scanning, the differences among 3 methods had no statistical significance（χ2= 2.992,P = 0.224）. Pain symptoms in all patients had been relieved fully. The average follow-up was 3.5 years（2 to 6 years）. No disc re-herniation were found and none of them needed revision surgery. The differences of JOA score between preoperation and the last follow-up had statistical significance[（11.5 ± 2.8） vs（25.8 ± 4.2）; t = 14.445, P = 0.000], and the mean JOA improvement rate was 85%. Of 7patients who underwent fenestration laminectomy and discectomy, there was one patient suffered from low back pain and instability in lumbar spine 5 years later, while others showed good effects; And those patients with PLIF or TLIF obtained solid bony fusion without pseudarthrosis. No loosening or breakage of the pedicle screws were found and no Cage subsidence or dislocation had happened. Conclusions ELLDH is characterized by complicated clinical symptoms and is relatively difficult to diagnosis, MRI combined with CT scanning is helpful for the diagnosis of ELLDH; ELLDH patients could obtain long-term effects with satisfied pain relief, good bony fusion and less complications by the individualized surgery.