CT引导经皮椎间孔镜治疗L_(3～4)椎间盘突出症

Treatment of L_(3～4) disc herniation by CT-guided percutaneous transforaminal endoscopic discectomy

目的探讨CT引导经皮椎间孔镜治疗L3-4椎间盘突出症的穿刺技巧及临床疗效。方法行CT引导经皮椎间孔镜手术治疗61例L3-4椎间盘突出患者,1例因既往行同节段开放手术椎间隙狭窄而采用侧前方穿刺入路,其余患者全部采用后外侧入路（神经根前/后）。其中L3-446例,L2-3、L3-41例,L3-4、L4-514例。通过64排CT后处理系统在患者术前腰椎CT上测量L3-4、L4-5椎间孔位置神经根的走行角度,并比较L3、L4出口根走行角度的差异。结果 61例患者均获随访,时间7-31（16.2±6.4）个月。术后未出现复发、脑脊液漏及神经根损伤,肢体遗留麻木6例（9.8%）。61例患者L3出口根走行角度平均为11.3°±3.2°,L4出口根走行角度平均为26.8°±6.9°,两者比较差异有统计学意义（t=11.42,P〈0.01）。JOA评分：术前（13.9±4.0）分,术后1周（25.8±2.7）分,末次随访时（26.9±3.2）分,术后1周及末次随访与术前比较差异均有统计学意义（P〈0.01）。其中优44例,良12例,一般5例,优良率91.8%。结论熟悉L3-4椎间孔的解剖,掌握该位置神经出口根的走行及其与L4-5的差异,辅以CT引导,可真正实现靶点穿刺、安全高效地摘除L3-4突出髓核组织。

Objective To explore the puncture technique and clinical efficacy of the CT-guided percutaneous transforaminal endoscopic discectomy for L3 - 4disc herniation. Methods 61 cases of L3 - 4disc herniation underwent CTguided percutaneous transforaminal endoscopic surgery. Except one case used the front side puncture approach because of its disc space narrowing after open surgery,the remaining cases were in all lateral approach（ nerve root before / after）. Among them,L3 - 446 cases,L2 - 3＋ L3 - 41 case,L3 - 4＋ L4 - 514 cases were included. Measurement and analysis the walk-angle of the patient with L3 - 4and L4 - 5intervertebral foramen nerve root in the 64-slice CT postprocessing system,compared the difference of L3,L4 nerve export root. Results All 61 patients were followed up for7 - 31（ 16. 2 ± 6. 4） months. Recurrence,cerebrospinal fluid leakage and nerve root injury didn＇ t appear,legacy numbness in 6 cases（ 9. 8%）. 61 cases of patients with L3 export root traveling angle for average of 11. 3° ± 3. 2°,L4 export root traveling angle for average of 26. 8° ± 6. 9°,the results were statistically significant（ t = 11. 42,P〈0. 01）. JOA scores： the preoperative was 13. 9 ± 4. 0,one week postoperation 25. 8 ± 2. 7,and the last follow-up26. 9 ± 3. 2. The last follow-up,one week postoperation and the preoperative JOA scores difference were statistically significant（ P〈0. 01）. Excellent in 44 cases,good 12 cases,fair 5 cases,with the excellent good rate of 91. 8%.Conclusions Familiar L3 - 4intervertebral foramen anatomy,grasp the position of nerve export root and differences between L4 - 5,combined with CT-guided,L3 - 4nucleus can be removed safely.