腰椎间盘脱出程度矢状位分度与内窥镜治疗策略

Classification of prolapsed disc migration on sagittal CT and endoscopic therapy strategy

[目的]通过回顾总结脱出型腰椎间盘突出症患者的影像和临床资料,探讨椎间盘脱出程度的矢状位分度方法与髓核残留的关系以及内窥镜治疗策略。[方法]选择2010年6月~2015年12月在本院行CT定位+脊柱内窥镜治疗的脱出型腰椎间盘突出症患者986例,其中L_(4/5)521例,L5/S1465例。将所有患者仰卧位64排螺旋CT扫描数据传入GE AW4.3图像后处理系统,将椎体后缘四等分,以此描述椎间盘矢状位脱出程度,分为Ⅰ、Ⅱ、Ⅲ、Ⅳ度;统计脱出程度与髓核残留的关系。椎间盘脱出程度矢状位分度统计结果:521例L_(4/5)脱出者Ⅰ度232例、Ⅱ度196例、Ⅲ度67例、Ⅳ度26例,465例L5/S1脱出者Ⅰ度187例、Ⅱ度215例、Ⅲ度50例,Ⅳ度13例;髓核残留统计结果:986例脱出者中126例髓核残留,Ⅰ度12例、Ⅱ度54例、Ⅲ度35例、Ⅳ度25例,椎间盘在矢状面上脱出的程度越远,髓核越容易残留。[结果]所有患者随访10~76个月,平均37.60个月,JOA评分由术前的(8.40±3.20)分,增加到术后1周的(24.90±2.70)分,末次随访时为(27.30±3.90)分,与术前比较差异均有统计学意义(P<0.01)。[结论]将椎间盘脱出程度进行矢状位分度,对于准确评估手术的可行性、预测可能出现的问题、指导手术入路的设计、保证手术的安全性、提高手术疗效具有十分重要的意义。

[Objective] To investigate the relationship between sagittal migration of the prolapsed disc and the residual of nucleus pulposus after surgery by a retrospective review of the clinical and image data for improving endoscopic surgery strategy. [Methods] Consecutive 986 patients with prolapsed lumbar disc underwent CT-guided percutaneous endoscopic discectomy from June 2010 to December 2015, including 521 cases involved the L4/5 and 465 cases involved the L5/S1 disc. The pre- operative CT images of all patients were assessed using the GE AW 4.3 image processing system. The posterior margin of verte- bral body was divided into quarters on sagittal CT, in this way, the migration of the prolapsed disc was graded as four degrees in extent based on its position. Additionally whether or not nucleus pulposus was residual on postoperative CT was reviewed. The Japanese Orthopedic Association （JOA） score was recorded before surgery, at 1 week after surgery and at the final follow up. The appropriate surgical approach was adopted corresponding to the extent of migration and relative anatomical differences. [Results] According to the classification on sagittal CT, there were 232 in I°, 196 in II°, 67 in III° and 26 in IV°of migration of the prolapsed disc among the 521 patients with L4/5 involved, while 187 in I°, 215 in II°, 50 in III° and 13 IV° among the 465 patients of L5/S1 involved. Residual of nucleus pulposus after operation was noted in 126 patients, including 12 in I°, 54 in II°, 35 in III° and 25 in IV°. There was significantly difference between the residual of nucleus pulposus and the extent of migration of the prolapsed disc （P 〈 0.01 ） . All patients were followed up from 10 to 76 months. The JOA score significantly increased from 8.40±3.20 preoperatively to 24.90±2.70 at 1 week after surgery, further to 27.30±3.90 at the latest follow-up （P〈0.01） . [Conclusion] The classification of migrated prolapsed disc on sagittal CT will be of great help to accurately eval- uate the feasibility of surgery, predict possible problems, guide the surgical approach design, guarantee the safety of the operation and improve the surgical outcome.