经皮椎间孔入路内镜下减压治疗老年腰椎侧隐窝狭窄症

Percutaneous endoscopic decompression via transforaminal approach for lumbar lateral recess stenosis in elderly patients

目的 ：探讨经皮椎间孔入路内镜下减压治疗老年腰椎侧隐窝狭窄症的手术策略、安全性及有效性。方法：2012年1月～2014年6月,采用经皮椎间孔入路内镜下减压治疗27例单节段老年腰椎侧隐窝狭窄症患者,其中男19例、女8例,平均年龄78.9±8.5岁（70～93岁）。均采用经皮椎间孔入路内镜下对侧隐窝进行减压及椎间孔成形治疗,术后第2天复查腰椎CT评估椎间孔成形及侧隐窝减压的情况。记录术前、术后1个月、术后3个月、术后6个月、术后12个月五个时间点的腿痛视觉模拟评分（visual analogue scale,VAS）及Oswsetry功能障碍指数（Oswestry disability index,ODI）,统计分析比较术前及术后各时间点的差异。采用改良Mac Nab评价疗效。结果：本组中25例患者顺利完成手术,1例无法耐受疼痛转为开放手术,另1例有心肌缺血表现放弃手术。手术时间50～110min,平均75±28min。术后第2天复查CT显示椎间孔扩大明显,侧隐窝减压充分。24例患者获得随访,随访时间29±16个月（12～44个月）,腿痛VAS评分术前为8.52±1.11,术后1个月为1.80±0.63,术后3个月为1.33±0.89,术后6个月为1.05±0.69,术后12个月为0.71±0.50;ODI术前为59.43±10.04,术后1个月为29.42±10.33,术后3个月为20.13±8.18,术后6个月为13.98±6.16,术后12个月为9.86±5.03。术后四个时间点随访VAS评分及ODI指数均较术前改善（P〈0.01）。改良Mac Nab疗效为优18例,良3例,可3例,优良率为87.5%。1例患者术后出现下肢感觉麻木,予以保守治疗,术后2周时恢复,无永久性神经损伤、感染等手术并发症发生。结论：经皮椎间孔入路内镜下减压术在确保良好侧隐窝减压的同时能够明显减少手术创伤,且能够在局麻下进行,对患者的全身影响小,是治疗老年腰椎侧隐窝狭窄症患者安全、有效、微创的手术方法。

Objectives： To investigate the surgical strategy, safety and efficacy of percutaneous endoscopic decompression via transforaminal approach for lumbar lateral recess stenosis in elderly patients. Methods：From January 2012 to June 2014, 27 elderly patients（19 males and 8 females） with lumbar recess stenosis were performed percutaneous endoscopic decompression via transforaminal approach. The age of patients ranged from 70 years to 93 years with an average of 78.9 ±12.2 years. Percutaneous lumbar intervertebral foramen approach for decompression of lateral recess and treatment of intervertebral foramen were used on all cases. The lumbar CT images were reexamined at 2 days after operation to evaluate the foraminoplasty and decompression of the lateral recess. The leg pain VAS scores and Oswestry Disability Index（ODI） scores were recorded preoperatively and at 1 month, 3 months, 6 months and 12 months after operation, statistical analysis was performed. The Mac Nab scores were evaluated at 12 months after operation. Results： The operation was successfully completed on 25 patients, 1 case could not tolerate pain changed to open surgery,1 case had myocardial ischemia and gave up surgery. The average operation time was 75±28 minutes（range,50-110 minutes）. The lumbar CT images at 2 days after operation demonstrated the distinct enlargement of the foramen and the satisfactory decompression of lateral recess. 24 patients were followed up for a mean duration of 29 ±14 months（range, 12-44 months）. The leg pain VAS score decreased from 8.52 ±1.11 preoperatively to 1.80±0.63, 1.33±0.89, 1.05±0.69 and 0.71±0.50 at 1, 3, 6, 12 months after operation respectively. The ODI score also decreased from 59.43 ±10.04 preoperatively to 29.42 ±10.33, 20.13 ±8.18,13.98 ±6.16 and 9.86 ±5.03 at 1, 3, 6, 12 months after operation respectively. Statistically significant differences existed in both VAS score（F=8.33, P〈0.01） and ODI score（F=24.09, P〈0.01） at each postoperative follow-up time point when compared with the preoperative scores. There were 18 excellent cases, 3 good cases and 3 fair cases according to the modified Mac Nab criteria, and the excellent and good rate was 87.5%at 12 months after operation. There was no aggravation of the coexisting medical conditions after operation in this group. Only 1 case was found complicated with low extremity numbness, which recovered by conservative treatment for two weeks. No persistent neurological deficit and infect were founded in all patients.Conclusions： Percutaneous endoscopic decompression via transforaminal approach provides a safe, effective and less invasive alternative for treating lumbar lateral recess stenosis in elderly patients. This technique can be performed under simple local anesthesia and has less impact on the general condition of patients.