椎间孔镜微创髓核摘除术用于腰椎间盘突出症再手术的解剖学优势

Anatomic advantage of percutaneous endoscopic lumbar discectomy in the reoperation treatment of lumbar disc reherniation

目的：探讨经皮椎间孔镜技术用于腰椎间盘突出症复发后再手术解剖学优势及临床疗效。方法运用前瞻性随机对照研究方法,严格按纳入标准选择解放军第一一三医院脊柱外科2011年5月—2014年4月收治的椎间盘突出症单纯髓核摘除术后复发患者25例。根据患者住院 ID号尾数的奇偶分为2组：微创组13例,行侧后路椎间孔镜微创髓核摘除术；开放组12例,行后路开放髓核摘除植骨融合内固定术。观察并比较2组患者手术时间、术中出血的差异,以及采用 ODI 和VAS 评分评价术后3个月、1年的疗效。结果微创组手术时间（2.3±1.1）h,长于开放组的（1.9±0.8）h,术中出血量微创组（40±15）mL 也少于开放组的（340±150）mL,2组比较差异均有统计学意义（t 值分别为2.332,5.466, P 值均〈0.05）。2组患者术后平均随访时间20个月（微创组1例随访仅6个月）,末次随访时微创组患者临床疗效优11例、良2例,开放组临床疗效优9例、良2例、可1例。2组患者在术前、术后3个月、术后1年随访时的 ODI 和 VAS 评分差异均无统计学意义（P 值均〉0.05）；2组内术后3个月、术后1年的 ODI、VAS 评分均较术前低,差异均有统计学意义（P 值均〈0.01）。结论经皮椎间孔镜技术采用的是侧后入路,与首次手术时后路术式非同一解剖入路,针对来自神经根腹侧的复发致压突出物,无需牵开神经根硬膜囊即可摘除突出物。椎间孔镜技术具有创伤小、出血少、术后康复快、对脊柱生物力学影响小等优点,能够有效地应用于腰椎间盘突出症复发患者。

Objective To study the anatomic advantages and clinical outcomes of percutaneous endoscopic lumbar discectomy（PELD） in the reoperation treatment of lumbar disc reherniation. Methods Using the prospective randomized study method, 25 continuous patients （Department of Orthopaedics, the No. 113 Hospital of PLA） suffered with lumbar disc reherniation from May 2011 to Apr 2014 were enrolled in our study, and randomly divided into percutaneous endoscopic lumbar discectomy group （PELD group, 13 cases） and posterior lumbar interbody fusion（PLIF） group （PLIF group, 12 cases） according to odd or even of the mantissa number of the patients＇ hospital ID. We observed the differences in operative time, blood loss, complications, and clinical efficacy between the two groups. Results The operation time of PLED group [（2. 3 ± 1. 1）h] was longer than the PLIF group [（1. 9 ± 0. 8）h], but the blood loss of PLED group [（40 ± 15）mL] was obviously less than that of PLIF group [（340 ± 150）mL]（all P values 〈 0. 05）. After a mean follow-up of 20 months, the outcome of surgical treatment showed excellent in 11 cases and good in 2 cases in PLED group, and excellent in 9 cases, good in 2 cases and fair in 1 case in PLIF group. There was no statistically significant difference in VAS and ODI scores between the PLED and PLIF group before surgery, and at the 3 months and 1 year follow-up postoperatively （all P values 〉 0. 05）. The ODI and VAS score were obviausly lower than before surgery at the 3 months and 1 year follow-up postoperatively in the two groups（all P values 〈 0. 01）, respectively. Conclusions Percutaneous endoscopic lumbar discectomy was performed through the lateral approach, which was different from the back anatomic approach in the primary surgery. PLED could easily remove the herniated nucleus in the ventral of the nerve roots without retract the dural sac and nerve roots. Percutaneous endoscopic lumbar discectomy has many advantages such as small injury, less bleeding, shorter hospitalization period, faster postoperative recovery, less damage of the lumbar biomechanics, and so on. It can be effectively used in the treatment of lumbar disc reherniation.