黄韧带劈开与开窗在经椎板间入路经皮内窥镜下椎间盘切除术中的比较

Comparison study between splitting and clipping of ligamentum flavum during percutaneous endoscopic interlaminar discectomy

目的比较黄韧带（ligamentum flavum,LF）劈开与开窗在经椎板间入路经皮内窥镜下椎间盘切除术（percutaneous endoscopic interlaminar discectomy,PEID）中的适应证及临床疗效。方法收集2013年9月-2014年3月本院采用PEID治疗的腰椎椎间盘突出症患者资料214例,其中男126例,女88例。根据术中LF突破方式,将病例分为LF劈开组（91例,其中L5/S1节段59例,L4/L5节段32例）,LF开窗组（123例,其中L5/S1节段68例,L4/L5节段55例）,比较2种术式的手术时间、适应证、疗效及并发症。采用疼痛视觉模拟量表（visual analogue scale,VAS）、Oswestry功能障碍指数（Oswestry disability index,ODI）、改良Mac Nab疗效评定标准、MRI硬膜外瘢痕形成率、椎间不稳率及复发率评价临床疗效。结果所有患者随访12-25个月,平均18个月。手术时间：LF劈开组（30.7±9.5）min,LF开窗组（35.2±8.6）min,2组相比差异具有统计学意义（P〈0.05）。2组术后1周及6个月腰痛和腿痛VAS评分及ODI与术前相比,差异均具有统计学意义（P〈0.05）;2组间各时间点VAS评分及ODI比较,差异均无统计学意义（P〉0.05）。末次随访时改良Mac Nab疗效评定,LF劈开组优良率91.9%,LF开窗组优良率92.2%;MRI示硬膜外粘连形成率LF劈开组5.7%,LF开窗组7.8%;腰椎不稳率LF劈开组2.3%,LF开窗组4.3%;复发患者LF劈开组1例,LF开窗组2例。结论 PEID中LF劈开与LF开窗2种术式具有相似的临床疗效及并发症,可根据病例特点选择术式或者根据需要联合应用。

Objective To compare the indications and clinical efficacy of splitting of ligamentum flavum（ LF） with clipping of LF during percutaneous endoscopic interlaminar discectomy（ PEID）. Methods From September 2013 to March2014,214 patients（ 126 males and 88 females） suffering from lumbar disc herniation and operated with PEID were analyzed respectively. According to the operation mode,214 cases were divided into LF splitting group（ 91 cases,L5/ S159 cases,L4/ L532 cases）,and LF clipping group（ 123 cases,L5/ S168 cases,L4/ L555 cases）. Operation time,indications,clinical efficacy and complications were compared on the basis of different operation modes. The clinical efficacy was evaluated by visual analogue scale（ VAS） score,Oswestry disability index（ ODI）,modified Mac Nab criteria,epidural adhesion formation rate,intervertebral instability rate and recurrence rate. Results All the patients were followed up by a mean time of 18months（ range,12-25 months）. The operation time of LF splitting group was（ 30. 7 ± 9. 5） min,and time of LF clipping group was（ 35. 2 ± 8. 6） min. There was statistically significant between 2 groups（ P〈0. 05）. The VAS scores of back and leg pain and ODIs at 1 week and 6 month follow-up were statistically different from those of pre-operation in both groups（ P〈0. 05）. At the final follow-up,according to modified Mac Nab criteria,the excellent and good rate of LF splitting group was91. 9%,and LF clipping group was 92. 2%. There were 5. 7% cases in LF splitting group and 7. 8% cases in LF clipping group,which showed severe epidural adhesion formation on MRI. And the lumbar intervertebral instability rates in 2 groups were 2. 3% and 4. 3%, respectively. One case in LF splitting group and 2 cases in LF clipping group relapsed.Conclusion Similar clinical efficacy and complications are found in PEID regardless of splitting or clipping of LF. Approach or combination can be chosen according to patient＇s peculiarity.