经皮椎板间入路与经皮椎间孔入路内窥镜下椎间盘切除术治疗L5/S1椎间盘突出症的短期疗效比较

Percutaneous endoscopic lumbar discectomy by interlaminar approach or transforaminal approach for L5/S1 disc herniation: a control study of short-term results

目的 ：比较经皮椎板间入路内窥镜下椎间盘切除术（percutaneous endoscopic interlaminar discectomy,PEID）与经皮椎间孔入路内窥镜下椎间盘切除术（percutaneous endoscopic transforaminal discectomy,PETD）治疗L5/S1椎间盘突出症的短期临床疗效。方法：将2010年1月~2010年6月收治的60例L5/S1椎间盘突出症患者,分为PEID组与PETD组,各30例,分别采用PEID与PETD治疗。比较两组患者性别构成比、年龄、突出类型、手术时间、术中C型臂X线透视次数、术后卧床时间、住院时间、手术并发症及手术效果。术前和末次随访时进行Oswestry残障指数（ODI）评定和疼痛视觉模拟评分（VAS）,末次随访时采用改良Macnab标准评定疗效。结果：两组患者的性别构成比、年龄、突出类型均无统计学差异（P〉0.05）。PEID组的手术时间为65.0±14.9min,术中C型臂X线透视次数为3.0±1.1次,术后卧床时间为6.5±1.1h,住院时间为4.8±1.1d;PETD组分别为86.0±15.4min,37.5±7.5次,5.0±1.1h,4.6±1.2d,PEID组的手术时间、术中C型臂透视次数均明显低于PETD组（P〈0.01）,两组间术后卧床时间、住院时间无统计学差异（P〉0.05）。PEID组术后并发神经根痛2例,复发1例;PETD组术后并发神经根痛1例,无复发病例;两组间术后并发症发生率无统计学差异（P〉0.05）。PEID组随访27.2±3.7个月,PETD组随访28.2±3.9个月,两组比较无统计学差异（P〉0.05）。PEID组术前VAS、ODI分别为7.90±1.42分、（59.0±16.0）%,末次随访分别为2.20±1.37分、（20.4±7.7）%;PETD组术前VAS、ODI分别为7.60±1.40分、（60.1±13.7）%,末次随访分别为2.30±1.02分、（22.0±9.1）%。每组末次随访时的VAS评分和ODI均较术前明显改善（P〈0.01）,两组间术前、末次随访时的VAS评分和ODI均无统计学差异（P〉0.05）。按照改良Macnab疗效评定标准评定,PEID组优22例、良6例、可2例,优良率为93.3%;PETD组优20例、良7例、可3例,优良率90.0%,两组优良率比较无统计学差异（P〉0.05）。结论：PEID治疗L5/S1椎间盘突出症术后近期疗效与PETD相当,但PEID具有穿刺定位快、手术时间短、术中放射线暴露少的优势。

Objectives： To compare the short-term results of percutaneous lumbar discectomy for L5/S1 disc herniation via interlaminar approach and transforaminal approach. Methods： From January 2010 to June 2010,a total of 60 patients were divided to percutaneous endoscopic interlaminar discectomy（PEID） group and per-cutaneous endoscopic transforaminal discectomy（PETD） group, there were 30 patients in each group undergoing percutaneous endoscopic lumbar discectomy by either interlaminar approach or transforaminal approach. The sex, age, herniation type, operation time, intraoperative fluoroscopy times, postoperative bed rest time, length of hospital stay, complications and surgical results between 2 groups were compared. Both groups were fol-lowed up by using the following measurements： Oswestry disability index（ODI）, VAS and modified Macnab classification. Results： There was no significant difference in sex, age or herniation type between two groups（P〈0.05）. In PEID group, the operation time was 65.0±14.9mins, intraoperative fluoroscopy times were 3.0±1.1,postoperative bed rest time was 6.5±1.1 hours, hospital stay was 4.8±1.1 days; while in PETD group, the operation time was 86.0±15.4mins, intraoperative fluoroscopy times were 37.5±7.5, postoperative bed rest time was 5.0±1.1 hours, the mean hospital stay was 4.6±1.2 days. PEID group had less operation time and intraoperative fluoroscopy times than PETD group（P〈0.01）. There was no difference in postoperative bed rest time or length of hospital stay between 2 groups（P〈0.05）. In PEID group, 2 patients were complicated with postoperative dysesthesia and 1 patient had recurrent disc herniation, while in PETD group 1 patient occurred postoperative dysesthesia and 0 patient had recurrent disc herniation. There was no difference in complication rates or recurrent rates between 2 groups（P〈0.05）. The average follow-up time of PEID group and PETD group was27.2±3.7 months and 28.2±3.9 months respectively, which showed no difference between two groups（P〈0.05）.In PEID group, preoperative VAS was 7.90 ±1.42, ODI was（59.0 ±16.0）%; and the last follow-up VAS was2.20±1.37, ODI was（20.4±7.7）%. In PETD group, preoperative VAS was 7.60 ±1.40, ODI was（60.1±13.7）%;last follow-up VAS was 2.30±1.02, ODI was（22.0±9.1）%. Both groups had a significant change in ODI and VAS score（P〈0.01）. There was no difference in preoperative or last follow-up VAS, ODI scores between two groups（P〈0.05）. The satisfaction rate of modified Macnab classification in PEID group was 93.3%： there were22 excellent, 6 good, 2 fair; and the satisfaction rate in PETD group was 90.0%： there were 20 excellent, 7good, 3 fair. There was no difference between two groups（P 0.05）. Conclusions： The short-term clinical results of the PEID are equal to the PETD for the L5/S1 LDH. Compared with the transforaminal approach,the interlaminar approach is superior in less operation time and less radiation exposure.