经皮椎间孔镜治疗L_(4-5)与L_5-S_1椎间盘突出症的对比研究

Comparison of effect of percutaneous endoscopic lumbar discectomy for L_(4-5) and L_5-S_1 disc herniation

目的前瞻性对比经皮椎间孔镜治疗L_(4-5)和L_5-S_1两个不同节段腰椎间盘突出症的临床效果。方法序贯性纳入经皮椎间孔镜治疗L_(4-5)和L_5-S_1腰椎间盘突出症患者各40例。临床评价指标包括手术时间、射线暴露时间、术后VAS、ODI评分改善程度及改良Mac Nab疗效评价。结果随访时间1年。L_(4-5)组手术时间为(91.0±18.1)min,L_5-S_1组为(114.5±17.7)min,差异有统计学意义(P<0.05)。L_(4-5)组、L_5-S_1组评价射线暴露时间分别为(8.5±2.3)s和(16.9±2.3)s,差异有统计学意义(P<0.05)。L_(4-5)组平均VAS改善程度为5.9±1.7,L5-S1组为5.5±1.5,差异无统计学意义(P>0.05);而平均ODI改善程度则分别为20.2±4.0和19.6±4.4,差异无统计学意义(P>0.05)。改良Mac Nab评价中,L_(4-5)组为优26例,良9例,可2例,差3例,优良率为87.5%;L_5-S_1组为优22例,良10例,可5例,差3例,优良率为80%,两组比较差异亦无统计学意义(P>0.05)。结论:经皮椎间孔镜治疗单节段腰椎间盘突出L_5-S_1节段手术较L_(4-5)节段难度大,但均能取得较好的临床效果。因此,开展PELD应先从相对简单的L_(4-5)椎间盘突出入手,积累到一定经验后再开展L_5-S_1节段。

Objective To evaluate the treatment results of pereutaneous endoscopic lumbar discectomy （PELD）for L4-5 level and L4-S1 level. Methods 40 cases who were treated with PELD for L4-5 and L5-S1 disc herniation respectively in our department between August 2014 and December 2014 were reviewed. The operation time, radiation exposure time, visual analogue scale（VAS） score, oswestry disability index （ODI）score and MacNab at preoperation and the 1-year follow-up were evaluated. Results The patients were followed up for 1 year. The operation time was（91.0±18.1 ） min（L4-5 level） and （114.5±17.7） min （L5-S1 level）, showed significant difference （P〈0.05）. The average X-ray exposure period was （8.53±2.3） s at L4-5 level and （16.9±2.3） s at L5-S1 respectively, showed significant difference （P〈0.05）. The improvement of VAS score was （5.9±1.7） at L4-5 level, and （5.5±1.5） at L5-S1 respectively, showed no significant difference（P〉0.05 ）. The improvement of ODI score was（20.2±4.0） at L4-5 level and （19.6±4.4） at L5-S1 respectively, showed no significant difference （P〉0.05）. According to the modified MacNab criteria,26 eases obtained excellent result, 9 cases were good,2 eases were fair and 3 cases were bad at L4-5 level, while 22 cases obtained excellent result, 10 cases were good,5 cases were fair and 3 cases were bad at L4-5 level, showed no significant difference （P〉0.05）. Conclusions There were more operation time and more radiation exposure time in the L5-S1 level than in the L4-5 level. Excellent clinical and minimally invasive outcomes could be obtained in PELD for both L4-5 level and L5-S1 level. We recommend the new minimally invasive spine surgeons choose patients with L4-5 disk herniation present with predominant radicular pain for initial cases, and then expand for L5-S1 level.