经皮全内镜下颈后路椎间盘切除术治疗颈椎间盘突出症临床分析

Clinical outcomes of cervical disc herniation treated by posterior percutaneous endoscopic cervical discectomy

目的 评价经皮全内镜下颈后路椎间盘切除术（PPECD）治疗颈椎间盘突出症的临床疗效与安全性.方法 对广东省中医院脊柱外科2014年8月至2016年4月施行PPECD的23例患者的临床资料进行回顾性研究.23例患者中,男性17例,女性6例,年龄31～61岁,平均年龄49.5岁;23例患者均有单侧上肢放射痛症状,其中13例患者为右上肢放射痛,10例患者为左上肢放射痛患者;17例患者伴有颈部疼痛症状.颈椎间盘突出节段：左侧C4-5椎间盘突出者1例,右侧C4-5椎间盘突出者2例,左侧C5-6椎间盘突出者4例,右侧C5-6椎间盘突出者8例,左侧C6-7椎间盘突出者5例,右侧C6-7椎间盘突出者3例.记录手术时间、住院时间及手术相关并发症发生情况;采用颈部残障功能指数（NDI）评价神经功能,采用疼痛视觉模拟评分法（VAS）评价颈部和上肢疼痛程度,按照Odom标准评价优良率.采用Harrison法测量颈椎曲度,在过伸过屈位X线片上测量手术节段Cobb角度,计算手术节段的活动度（ROM）,并比较手术前后的颈椎曲度和手术节段ROM变化.采用SPSS 13.0统计软件包进行统计学分析,测量数值用均数±标准差（x^-±s）表示.手术前后NDI、VAS评分的差异比较采用配对t检验,P〈0.05为差异有统计学意义.结果 23例患者手术时间80～150 min,平均94.1 min;平均住院时间4.8 d;随访时间15～35个月,平均23.5个月.术前上肢VAS为（7.0±0.9）分,术后1周为（2.1±0.7）分,末次随访时为（1.0±0.9）分;术前颈部VAS为（3.0±0.8）分,术后1周为（1.5±0.5）分,末次随访为（0.6±0.8）分;术前NDI为（58.5±5.0）％,术后1周为（33.7±4.7）％,末次随访为（19.2±3.2）％;术前颈椎曲度为（14.2±3.1）°,术后1周为（14.6±2.9）°,末次随访时为（14.6±2.7）°;术前手术节段ROM为（5.4±1.8）°,术后1周为（5.5±1.5）°,末次随访时为（5.6±1.5）°.结果显示,术后1周与术前相比,上肢VAS、颈部VAS及NDI均有明显改善,差异有统计学意义（P〈0.01）;末次随访与术后1周相比,上肢VAS、颈部VAS及NDI有进一步改善,差异有统计学意义（P〈0.01）;术后1周颈椎曲度较术前有所改善,差异有统计学意义（P〈0.05）,但至末次随访时,颈椎曲度与术前相比并无明显差别（P〉0.05）.术前、术后1周和末次随访时的手术节段ROM比较,差异无统计学意义（P〉0.05）.按照Odom标准,23例患者末次随访时,优16例、良5例、中2例,优良率91.3％.本组患者均未发生神经根损伤、硬膜囊撕裂、伤口感染或血肿等并发症.结论 PPECD治疗颈椎间盘突出症的近期疗效确切,而且对颈椎稳定性无明显影响.

Objective To evaluate the clinical outcomes of posterior percutaneous endoscopic cervical discectomy （ PPECD） for cervical disc herniation. Methods A total of 23 patients who underwent PPECD for cervical disc herniation at Department of Spine Surgery, Guangdong Provincial Hospital of Chinese Medicine from August 2014 to April 2016 were reviewed. The mean age of the 17 males and 6 females was 49. 5 years （ range from 31 to 61 years ） . All patients had unilateral upper limb radiating symptoms, 13 patients with right upper limb radiating pain and 10 patients with left upper limb radiation pain, 17 patients with neck pain symptoms. Responsible segment： left C4-51 case, right C4-52 cases, left C5-64 cases, right C5-68 cases, left C6-75 cases, right C6-73 example. Operating time, length of hospitalization, complications, neck and arm Visual analog scale（ VAS） , and Neck Disability Index（ NDI） were evaluated. The excellent and good rate of surgery was evaluated by using the Odom criteria. Harrison method was used to measure cervical curvature. The Cobb angle of the surgical segment was measured on the X-ray, and the range of motion （ ROM ） was calculated. The changes of the cervical curvature and the surgical segment ROM were compared pre-and post-operation. Results The operation time was 94. 1 min （ range from 80 to 150 min） . The average length of hospital stay was 4. 8 days. The mean follow-up period was 23. 5 months （range from 15 to 35 months）. The preoperative arm VAS score was 6. 95±0. 88, 1-week postoperative arm VAS score was 2. 09 ± 0. 67, the last follow-up arm VAS score was 1. 04 ± 0. 98. The preoperative neck VAS score was 3. 04±0. 77, 1-week postoperative neck VAS score was 1. 52±0. 51 and the last follow-up neck VAS score was 0. 61 ± 0. 78. The 1-week postoperative and last follow-up arm and neck VAS scores were significantly reduced compared with pre-operation （ P〈0. 01） . Compared with 1 week after surgery, the last follow-up of the arm and neck VAS score further reduced, the difference was statistically significant （ P〈0. 01 ） . The preoperative NDI was （ 58. 52 ± 4. 98 ）%, the 1-week postoperative NDI was （33. 74±4. 72）%, the last follow-up NDI was （19. 22±3. 23）%. The 1-week postoperative and last follow-up NDI was significantly improved compared with pre-operation （ P〈0. 01 ） . Compared with 1 week after surgery, the last follow-up of the NDI further improved, the difference was statistically significant （ P〈0. 01） . The 1-week postoperative cervical curvature was （ 14. 65 ± 2. 89 ） ° , and it was improved compared with preoperative（14. 23±3. 06）°, the difference was statistically significant （P〈0. 05） . The last follow-up was cervical curvature （ 14. 64 ± 2. 68 ） ° , there was no significant difference compared with preoperative （ P〉0. 05）. The preoperative surgical ROM was（5. 37±1. 83）°, 1-week postoperative was（5. 53±1. 52）°, and the last follow-up was （5. 62±1. 48）°, there was no significant difference pre-operative and post-operation （P〉 0. 05）. The excellent and good rate was 91. 3% （excellent in 16 cases, good in 5 cases, 2 cases）. There was no nerve root injury, cerebrospinal fluid leakage, wound infection, and other complications. Conclusions PPECD is a sufficient and safe supplement for cervical disc herniation, its recent clinical efficacy was good. And it has no significant effect on cervical stability.