经皮椎间孔镜技术治疗脱出游离型腰椎间盘突出症的临床研究

Percutaneous transforaminal endoscopic lumbar discectomy for sequestered lumbar disc herniation

[目的]探讨经皮椎间孔镜技术治疗脱出游离型腰椎间盘突出症的临床疗效及技术要点。[方法]2013年3月~2016年7月,采用经皮椎间孔镜下腰椎间盘切除术治疗脱出游离型腰椎间盘突出症52例,均采用俯卧位侧方椎间孔入路,借助弯头导棒经皮靶向穿刺,逐级环锯定向偏心椎间孔扩大成形,建立工作通道后先切除椎间隙水平突出的髓核组织,然后调节套管鞘口至髓核脱出方向,用镜下磨钻增大操作空间,显露脱出游离的髓核,摘除剩余髓核组织。[结果]术中1例因显露困难改为椎间盘镜手术切除残留髓核。所有患者术后当天下肢放射痛均明显缓解,但5例患者术后短期内出现下肢感觉异常或异常加重,另外2例患者出现下肢肌力减退。随访12~36个月,平均18个月,术后3个月时,前述7例术后推测神经并发症者均逐渐恢复正常。随访进程中,所有患者均无复发及二次手术。VAS评分和ODI评分随术后时间延长而显著减小,差异较术前有统计学意义(P<0.05),而JOA评分随时间延长而显著增加,差异较术前有统计学意义(P<0.05)。按照MacNab标准,术后3 d、3个月、1年疗效优良率分别为84.62%、88.46%、94.23%。[结论]在把握手术适应证及掌握技术要点的前提下,经皮椎间孔镜技术治疗脱出游离型腰椎间盘突出症可获得显著的临床疗效。

[Objective] To investigate the clinical efficacy and technical points of percutaneous endoscopic lumbar discectomy for the sequestered lumbar disc herniation. [Methods] From March 2013 to July 2016, we used percutaneous endoscopic lumbar discectomy in the treatment of prolapsed and sequestered lumbar disc herniation in 52 patients. The operation was performed at prone position through lateral transforaminal approach. Subsequent to targeting puncture with the elbowed guide rod,and gradually enlarging the intervertebral foramen by multiple directional eccentric trephines was conducted. Firstly, the prominent nucleus pulposus tissue at the intervertebral space level was removed through established the working channel. Then, the sleeve scabbard was aimed to the direction of the nucleus pulposus prolapsed, and the operating space enlarged with an abrasion drill under the endoscopic vision. Finally, the remaining prolapsed or sequestered nucleus pulposus tissue was exposed and removed. [Results] During operation, one patient was changed to microendoscopic discectomy to remove residual nucleus pulposus due to difficult exposure. All patients got significant radicular pain relief of the lower limbs at the same day after operation.However, 5 patients were of exacerbated paresthesia, while the other 2 patients had a moderate muscle weakness of the lower limbs. The patients were followed up for 12 to 36 months, with an average of 18 months. At 3 months after operation, the aforesaid 7 patients with presumed neurological complication gradually recovered to normal. During the follow up, no any patients had recurrences which needed surgery once again. The visual analogue scale（VAS） and Oswestry disability index（ODI） statistically decreased（P〈0.05）, whereas the Japanese orthopedic association（JOA） considerably increased over time（P〈0.05）. In term of Mac Nab criterion, the excellent and good rate of outcomes achieved respectively 82.4 %（28/34） at 3 days, 88.2%（30/34） at 3 months and 94.1%（32/34） at 12 months postoperatively. [Conclusion] As long as grasping the indication and key points of the surgery, percutaneous endoscopic lumbar discectomy does get satisfactory outcomes for prolapsed and sequestered lumbar disc herniation.