腰椎间盘突出症伴椎体后缘骨软骨病的内镜手术治疗

Endoscopic surgical treatment of lumbar intervertebral disc herniation associated with vertebral osteochondrosis

目的探讨腰椎间盘突出症伴椎体后缘骨软骨病的内镜手术治疗效果和可行性。方法2008年6月至2015年12月采用内镜手术治疗腰椎间盘突出症伴椎体后缘骨软骨病276例，男185例，女91例；年龄16～65岁，平均39．2岁。均为单节段，累及L2，3，节段2例、L3，4节段9例、L4，5节段126例、L5S1节段139例。术前CT扫描示骨化物超过椎管横径或矢状径一半者89例，不超过椎管横径和矢状径一半者187例。均在症状严重侧行神经减压、髓核摘除术，采用可动式椎间盘镜181例，经皮内镜95例（经椎间孔入路61例、经椎板间入路34例）。随访时观察疗效及疼痛视觉模拟评分（visual analoguescale，VAS）、Oswestry功能障碍指数（Oswestry disability index，ODI）。结果术中在内镜下摘除突出和破碎的软性椎间盘物质，适度咬除致压的骨化物边缘，直至神经根和硬膜囊充分松弛，未完全切除骨化物。可动式椎间盘镜术中发生硬膜囊撕裂3例；经皮椎间孔镜术中转可动式椎间盘镜手术2例，发生出口神经根损伤1例。术后随访12～60个月，平均20．6个月。末次随访时疼痛VAS评分由术前（8．5±1．2）分降至（1．0±0．9）分；ODI由术前（40．2±8．6）分降至（3．1±3．0）分；Macnab疗效评定优89例、良154例、可33例，优良率88％。结论腰椎间盘突出症伴椎体后缘骨软骨病通过内镜行突出椎间盘摘除和神经减压可获得良好的疗效，推测椎间盘软性突出和椎管狭窄是其主要致病因素，手术时不必追求完全切除骨化物。

Objective To investigate the feasibility and effects of endoscopic surgical treatment of lumbar intervertebral disc herniation associated with vertebral osteochondrosis. Methods From June 2008 to December 2015, 276 cases of lumbar in- tervertebral disc herniation associated with vertebral osteochondrosis were treated with endoscopic surgery, including 185 men and 91 women, with an average 39.2 years old （range, 16-65 years old）. The involved level included L2.3 in 2 cases, L3.4 in 9 cases, L.5 in 126 cases and L5S1 in 139 cases. On preoperative axial CT, the diameter of ossification was more than half of the transverse or sagittal diameter of the spinal canal in 89 cases, and no more than half of the transverse and sagittal diameter of the spinal canal in 187 cases. All patients were operated on the side with serious symptom, 181 cases were operated with mobile microendoscopic diseectomy （MMED）, and 95 cases were operated with percutaneous endoscopic surgery, including percutaneous transforaminal endoscopic discectomy （PTED） in 61 cases and the percutaneous interlaminar endoscopic discectomy （PIED） in 34 cases. The operation and complications were analyzed. Results The soft herniation, broken disc material and the periphery of compressing ossifi- cation were removed under the endoscope in all cases, until the nerve was well decompressed. However, the ossification was not complete resected. Dural sac tear occurred in 3 cases of MMED. In the early stage of PTED, 2 cases converted to MMED because of intraoperative pain and difficulty, and one case had exiting nerve root injury. At the final follow-up of 12-60 months （average, 20.6 months）, visual analogue scale decreased from preoperative 8.5±1.2 to 1.0±0.9, Oswestry disability index decreased from preoperative 40.2±8.6 to 3.1±3.0. According to Macnab scale, the results were excellent in 89, good in 154 cases, moderate in 33 cases. Condusion For most lumbar intervertebral disc herniation associated with vertebral osteochondrosis, good results can be achieve by removal of herniated and broken intervertebral disc and decompression of nerve with endoscope. Therefore, we speculate that the soft disc herniation and spinal stenosis are main pathogenic factors, and that the complete resection of ossification is not needed.