颈椎间盘突出症的经皮内镜治疗策略

The strategy and results of percutaneous endoscopic surgery for cervical disc herniation

目的探讨颈椎间盘突出症的经皮内镜的治疗策略。方法2015年6月至2017年3月采用后路和前路经皮内镜治疗颈椎间盘突出症51例，男32例，女19例；年龄28～66岁，平均52.2岁。患者均有神经根性症状，23例有轻度脊髓病症状（Nurick分级0～3级），3例多节段椎管狭窄者合并巨大突出者有严重脊髓病症状（Nurick分级4～5级）。术前轴位MRI显示椎间盘突出顶点位于脊髓外侧者31例，为外侧型；椎间盘突出顶点不超过脊髓外缘者20例，为中央型。除3例外侧型突出伴骨化和椎间孔狭窄外，其余48例均为软性突出。手术均采用全身麻醉，外侧型突出采用后路经皮内镜，在椎板间隙外缘和关节突内缘交界处的＂V＂点呈＂钥匙孔＂（keyhole）样开窗，显露硬膜囊外缘和神经根，沿神经根减压松解、摘除突出或游离的髓核；中央型突出采用前路经皮内镜，于内脏鞘与血管鞘之间经皮穿刺，X线透视下经椎间盘置入工作套管到达椎间隙后缘突出物基底部，摘除突出髓核直至硬膜囊松弛、搏动良好；3例合并多节段严重椎管狭窄者同期行后路椎管扩大成形术。记录术中情况，术后随访6～18个月，平均12.1个月，评估术后疗效和影像学表现。结果后路脊柱内镜手术时间45～150 min，平均90 min。3例椎间盘突出骨化伴椎间孔狭窄者未发现突出髓核，充分显露松解神经根后症状缓解；1例开窗偏外暴露了椎动脉，未能显露脊髓和神经根，术后症状部分缓解；27例摘除突出或游离的髓核，其中1例术后出现手术侧肌力一过性下降，2例出现脑脊液漏；随访时疼痛视觉模拟评分（visual analogue scale，VAS）自术前（8.9±1.6）分降至（0.5±0.4）分；Oswestry功能障碍指数（Oswestry disability index，ODI）自术前32.8%±4.2%降至2.3%±1.9%。前路内镜手术时间45～120 min，平均80 min。均摘除突出和破碎的髓核，探查后纵韧带和硬膜囊，其中1例因显示不清咬破硬膜囊；随访时VAS自术前（6.9±2.3）分降至（0.9±0.8）分，ODI自术前40.1%±8.6%降至5.6%±3.0%，26例合并脊髓病症状者均改善Nurick分级1级或以上。随访时两组患者影像学显示颈椎序列良好，椎间隙高度后路组较术前降低（0.4±0.3）mm，前路组较术前降低（1.0±0.6）mm，均未见后凸畸形。结论经皮内镜为部分神经根性症状为主的颈椎间盘突出症提供了微创治疗措施，椎间盘突出顶点在脊髓外侧者可以采用后路脊柱内镜，椎间盘突出顶点在脊髓腹侧的软性突出、无明显椎间隙塌陷、失稳者可以选择前路脊柱内镜，但术后存在椎间隙塌陷，远期效果及应用价值有待观察。

ObjectiveTo evaluate the strategy and clinical effects of percutaneous endoscopic surgery for cervical disc herniation.MethodsFifty-one patients with cervical disc herniation were treated with percutaneous endoscopic surgery from June 2015 to March 2017, including 32 men and 19 women, with an average age of 52.2 years （range, 28-66 years）. Radicular symptoms were present in all patients, while 23 patients had mild myelopathy （Nurick Grade： 0-3） and 3 patients of multilevel stenosis had severe myelopathy （Nurick Grade： 4-5）. According to axial image of preoperative magnetic resonance imaging （MRI）, 31 patients had lateral herniation that was located lateral to the edge of spinal cord, 20 patients had central herniation that was located within the lateral edge of spinal cord. Among them, 48 patients had soft herniation and 3 patients had ossified lateral herniation combined with foraminal stenosis. All surgery was carried out under general anesthesia, while posterior and anterior percutaneous endoscopic surgeries were performed for lateral herniation and central herniation respectively. Posterior endoscopic surgery was performed with ＂keyhole＂ fenestration at ＂V＂ point （the junction of lateral edge of lamina space and inner edge of facet）. Lateral edge of thecal sac and nerve root were exposed and decompressed, soft herniation was explored and removed. Anterior endoscopic surgery was performed through puncture and 4mm tube between the visceral sheath and vascular sheath. The tube was inserted through disc to the base of herniation under fluoroscopy. The herniation was removed until the dura sac was exposed and relaxed. One stage open-door laminoplasty was performed for 3 patients with severe multiple segmental stenosis and huge central herniation. The operative time and blood loss were recorded, and patients were followed-up （range, 6-18 months, average 12.1 months） to evaluate the clinical efficacy.ResultsThe mean operative time of posterior endoscopic surgery was 90 min （range, 45-150 min）. The nerve root was not well exposed, and the fenestration was too lateral in 1 patient, with partial relieve of symptoms; and simple nerve root decompression was performed for 3 patients of ossified herniation combined with foraminal stenosis. Herniated or sequestered nucleus pulposus was removed for 27 patients, one of them had transient paralysis ipsilateral limb and 2 of them had linkage of cerebrospinal fluid. The Visual Analogue Score （VAS） score improved form preoperative 8.9±1.6 to 0.5±0.4, and the Oswestry Disability Index （ODI） score improved form 32.8±4.2 to 2.3±1.9 at final follow-up. For anterior percutaneous endoscopic surgery, the mean operative time was 80 min （range, 45–120 min）. Herniated or free nucleus was successfully removed for all patients. The thecal sac was lacerated due to unclear exposure in 1 case. The VAS score improved form preoperative 6.9±2.3 to 0.9±0.8, and the ODI score improved form 40.1±8.6 to 5.6±3.0 at final follow-up, with improvement of myelopathy at least one Nurick Grade. During follow-up, the alignment of cervical spine was well preserved without kyphosis for two groups, while the height of intervertebral space decreased with 0.4±0.3 mm and 0.9±0.6 mm in posterior and anterior surgery respectively.ConclusionPercutaneous endoscopic surgery provides minimally invasive alternatives for some cervical disc herniation with predominant radicular pain. Posterior endoscopic surgery is suitable for lateral herniation, and anterior endoscopic discectomy is suitable for some central soft herniation without obvious collapse and instability. However, the long-term results of disc space collapsed after anterior approach remains unclear.