椎间孔镜不同入路方式对髓核摘除量的影响及临床疗效分析

Effect and effectiveness analysis of different approaches of transforaminal endoscope on extirpation amount of nuclues pulposus

目的探讨椎间孔镜不同入路方式的选择对术中髓核摘除量的影响及术后临床疗效分析。方法 2011年8月—2014年12月采用腰椎侧后路微创椎间孔镜髓核摘除术治疗165例腰椎间盘突出症患者。根据术中椎间孔镜不同入路方式将患者分为4组:A组42例采用后外侧入路(Yeung技术),B组40例采用经典椎间孔入路[经椎间孔内窥镜脊柱系统(transforaminal endoscopic spine system,TESSYS)技术],C组43例采用改良椎间孔入路(improved transforaminal endoscopic access,ITEA),D组40例采用椎板间入路。各组患者性别、年龄、病程、侧别、病变节段等一般资料比较差异无统计学意义(P>0.05),具有可比性。计算并比较4组患者髓核摘除量;临床疗效采用疼痛视觉模拟评分(VAS)、Oswestry功能障碍指数(ODI)、腰椎曲度指数(lumbar curvature index,LCI)和椎间隙高度等进行评估。结果 A、B、C、D组术中髓核摘除体积分别为(3.7±0.8)、(3.6±0.7)、(4.5±1.1)、(3.0±0.8)cm3,C组体积显著大于其余3组,D组体积显著小于其余3组,差异均有统计学意义(P<0.05);A、B组间比较差异无统计学意义(P>0.05)。术中出现脑脊液漏1例,无术后椎间隙感染、硬膜外血肿等并发症发生。术后患者切口均Ⅰ期愈合。患者均获随访,随访时间12～24个月,平均18个月;随访期间无典型术后髓核突出复发症状。术前各组间ODI评分、下腰痛VAS评分及双下肢VAS评分比较差异均无统计学意义(P>0.05);末次随访时各组上述评分均较术前显著改善(P<0.05);各组间比较差异均无统计学意义(P>0.05);各评分改善值各组间比较差异均无统计学意义(P>0.05)。术前及末次随访时各组间比较LCI及椎间隙高度差异均无统计学意义(P>0.05);各组末次随访时与术前比较以及末次随访时各组间LCI变化值和椎间隙高度丢失比较差异亦无统计学意义(P>0.05)。结论腰椎侧后路微创椎间孔镜术中,采用ITEA技术的手术操作范围更大,术中探查及摘除责任髓核更彻底;但需要根据患者腰椎间盘突出的症状及特点选择合适的手术入路方式。

Objective To investigate the effect and effectiveness analysis of different approaches of transforaminal endoscope on extirpation amount of nuclues pulposus. Methods Between August 2011 and December 2014, a total of 165 patients with lumbar disc herniation were retrospectively enrolled and were treated with nucleus pulposus discectomy through transforaminal endoscope. The patients were randomly divided into 4 groups according to different approach of transforaminal endoscope. The posterolateral approach（Yeung＇s technology） was used in group A（42 cases）, transforaminal endoscopic spine system（TESSYS） technology was used in group B（40 cases）, improved transforaminal endoscopic access（ITEA） technology was used in group C（43 cases）, and interlaminar approach（40 cases）was used in group D（40 cases）. There was no significant difference in gender, age, disease duration, symptomatic side,and segments among 4 groups（P〉0.05）. The extirpation amount of nuclues pulposus was calculated and compared among4 groups; the effectiveness was evaluated by pre-and post-operative visual analogue scale（VAS） score, Oswestry disability index（ODI）, lumbar curvature index（LCI）, and intervertebral height. Results The discectomy amount of nucleus pulposus was（3.7±0.8）,（3.6±0.7）,（4.5±1.1）, and（3.0±0.8） cm3 in groups A, B, C, and D, respectively. The amount of group C was significantly larger than that of the other 3 groups（P〈0.05）, and the amount of group D was significantly smaller than that of the other 3 groups（P〈0.05）; no significant difference was found between groups A and B（P〉0.05）.Cerebrospinal fluid leakage was found in 1 case; no other postoperative complications including intervertebral space infection and epidural hematoma was found. All the incisions healed by first intension. All the patients were followed up12-24 months（mean, 18 months）, and no typical symptoms of recurrence was found during the follow-up period. There was no significant difference in preoperative lower back pain VAS score, lower extremities VAS score, and ODI scores among 4 groups（P〉0.05）. The above scores at last follow-up were significantly improved when compared with preoperative ones in each group（P〈0.05）, but no significant difference of above scores and recovery values was found among 4 groups（P〉0.05）. The difference in LCI and intervertebral height at preoperation and at last follow-up were not significant between 4 groups（P〉0.05）. The difference in LCI and intervertebral height of each group between at preoperation and last follow-up were not significant（P〈0.05）. And the recovery value of LCI and the lost of height at last follow-up also showed no significant differences between 4 groups（P〉0.05）. Conclusion The ITEA technology can give a wider field of view than other technologies. It is more convenient to find and remove the nucleus pulposus. However, the appropriate operative approaches should be chosen according to the symptoms and characteristics of lumbar disc herniation.