腰椎经皮内镜手术后疗效不佳的原因分析

Unsuccessful percutaneous endoscopic lumbar discectomy for lumbar degenerative diseases

目的 总结腰椎经皮内镜手术后疗效不佳的临床资料,并分析其手术失败的原因。方法 收集2011年1月至2017年1月期间因腰椎疾患接受经皮内镜手术后出现疗效不佳患者的相关资料。疗效不佳定义为：①术后腰部及下肢疼痛、麻木等症状无缓解需即刻行再次手术者;②术后腰部及下肢疼痛、麻木、无力等症状加重,需即刻行再次手术或经保守治疗1~3个月无缓解需行再次手术者;③术后出现下肢疼痛、麻木、无力等新发症状者;④术后3个月以上随访,仍存在腰部中、重度疼痛（VAS评分〉5分）,严重影响生活、工作者;⑤术后即刻症状缓解,随访中症状复发,影像学显示原手术节段同侧复发需行再次手术者。共46例,男31例,女15例;年龄20~81岁,平均（46±11）岁。腰椎间盘突出症43例、腰椎管狭窄症3例。单节段42例,双节段4例。初次手术方式包括经皮内镜椎间孔入路髓核摘除术（percutaneous transforaminal endoscopy discectomy,PTED）和经皮内镜椎板间入路髓核摘除术（percutaneous interlamina endoscopy discectomy,PIED）。接受过1次经皮内镜手术者45例（PTED 41例,PIED 1例,经皮脊柱内镜下腰椎管减压术3例）, 2次经皮内镜手术者1例（PTED）。结果 诊断失误或不明确10例（股骨头坏死误诊为腰椎间盘突出症2例;漏诊脊髓型颈椎病1例;焦虑型抑郁症1例;中、重度腰椎管狭窄症误诊为腰椎间盘突出症者3例;术前影像学表现与临床症状不符,最终诊断不明确且术后症状无缓解者3例）;手术适应证掌握不佳10例（术前单纯腰痛、无下肢症状行PTED术后出现中、重度腰痛症状加重或无改善6例;相邻同侧责任节段未处理,术后短期症状加重者1例;重度腰椎中央椎管狭窄选择经椎间孔减压,术后疗效不佳3例）;手术技术导致疗效不佳者12例次（出口根损伤1例,即前述漏诊颈椎病者;椎间盘残留11例）;术后3个月以上症状复发9例（PTED 8例,PIED 1例）;术后顽固性腰痛6例（均为PTED,术后下肢症状缓解满意,但出现中、重度腰痛且持续6个月以上）。结论 腰椎经皮脊柱内镜手术后疗效不佳原因主要包括术前诊断及手术适应证掌握不佳、突出椎间盘切除不彻底及复发等多种因素。提高诊断、适应证选择水平及手术技术,有利于提高手术疗效。

Objective To analysis causes of surgical failure of percutaneous lumbar endoscopic discectomy （PLED） for lumbar degenerative diseases. Methods Forty-six patients （31males, 15 females）, who underwent unsuccessful PLED （including percutaneous transforaminal endoscopy discectomy, PTED; percutaneous interlamina endoscopy discectomy, PIED） or percutaneous endoscopic lumbar decompression, were included in this study. Unsuccessful surgeries included no relieve of lumbar and limb pain and numbness right after surgeries; aggravated after surgeries that need revision 1~3 moths after surgeries; new symptoms appeared after surgeries; still had severe low back pain （VAS 〉5 points） 3 months after surgeries; had recurrence of lumbar disc herniation at the same level. The average age was 46±11 years old （20-81 years old）. The primary diagnosis was lumbar disc herniation in 43 cases, and lumbar spinal canal stenosis in 3 cases. Forty-two cases accepted single level surgeries, others accepted two-level surgeries. One case underwent PLED twice, others underwent one-time surgery. Results The causes of surgical failure included misdiagnosis in 10 cases, inappropriate surgical indication in 10 cases, inappropriate surgical technique in 12 cases, recurrent disc herniation in 9 cases, and persistent low back pain in 6 cases. Misdiagnosis cases included avascular necrosis of femoral head in 2 cases, missed diagnosis of cervical myelopathy in 1 case, mental disorder in 1 case, severe central spinal canal stenosis in 3 cases, and unidentified diagnosis in 3 cases. Inappropriate surgical indication cases included performing PLED for severe central spinal canal stenosis in 3 cases, PLED for only low back pain in 6 cases, untreated responsible disc herniation at adjacent level in 1 cases. Inappropriate surgical technique cases included incomplete removal of protruded disc in 11 cases, nerve root injury in 1 case. Conclusion The causes of surgical failure of PLED mainly included misdiagnosis, inappropriate surgical indication, incomplete removal of protruded disc, and recurrent disc herniation. Improving diagnosis and indication selecting ability may help to avoid surgical failure.