后路经皮内镜椎间盘切除术治疗单节段神经根型颈椎病的临床疗效

Clinical outcomes of posterior percutaneous endoscopic cervical discectomy for single level cervical spondylotic radiculopathy

目的探讨颈椎后路经皮内镜椎间盘切除术（percutaneous endoscopic cervical discectomy, PECD）治疗单节段神经根型颈椎病（cervical spondylotic radiculopathy, CSR）的临床疗效。方法收集2015年10月至2016年6月采用PECD治疗且完成定期随访的33例单节段神经根型颈椎病患者的临床资料。男23例，女10例；年龄30～85岁，平均（54.0±12.2）岁。收集手术相关信息（手术时间、术中出血量、住院时间、并发症等），通过颈椎功能障碍指数（neck disability index，NDI）、颈部及上肢疼痛视觉模拟评分（visual analog scale，VAS）评估临床疗效，通过改良Macnab标准评价手术效果，比较手术前后椎间隙高度、节段角、C2～C7 Cobb角，活动度（range of motion, ROM）等变化。结果32例患者完成PECD手术，手术时间40～120 min，平均（76.4±26.6）min；术中出血量20～80 ml，平均（30.2±15.6）ml；住院时间2～8 d，平均（3.5±1.1）d。术后随访时间12～22个月，平均（13.5±4.6）个月。颈肩痛VAS评分、上肢痛VAS评分、NDI术后各随访时间点圴较术前下降（P〈 0.05）。末次随访时手术整体效果评价：优20例（20/33, 60.6%），良7例（7/33，21.2%），一般6例（6/33，18.2%）。患者术后各时间点椎间隙高度较术前下降，差异有统计学意义（F=95.1，P〈 0.01）。术后手术节段角（F=35.4，P〈 0.01）、上邻椎节段角（F=30.1，P〈 0.01）、下邻椎节段角（F=11.7，P〈 0.01）、脊柱功能单元节段角（F=22.2，P〈 0.01）、颈椎整体Cobb角（F=14.5，P〈0.01）相对术前均有一定程度增加，差异均有统计学意义。术后手术节段ROM（F=8.1，P〈 0.01）、上邻椎ROM（F=64.0，P〈 0.01）相对术前有所增加，差异均有统计学意义；而术后下邻椎ROM（F=1.5，P=0.23）、脊柱功能单元ROM（F=2.9，P=0.06）以及颈椎整体ROM（F=0.6，P=0.56）和术前比较，差异均无统计学意义。1例患者因手术区域止血效果不佳影响视野改行颈前路减压植骨融合内固定术。另1例患者术后症状未见好转，术后第3天行颈前路减压植骨融合内固定术治疗。未发生颈脊髓、神经损伤、脑脊液漏、感染、复发等并发症。结论PECD具有创伤小、疗效好、恢复快的特点，能较好地维持颈椎的正常活动度和椎间隙高度，但颈椎经皮内镜手术的开展需要具备丰富的开放手术经验，以便能随时转换手术方式。

ObjectiveTo investigate the clinical outcomes using posterior percutaneous endoscopic cervical discectomy （PECD） for single level cervical spondylotic radiculopathy （CSR）.MethodsFrom October 2015 to June 2016, 33 patients （23 men, 10 women, mean age 54.0 years, range from 30 to 85 years） who had single level CSR were treated by PECD, and the medical records were reviewed. All patients were followed up for an average of 13.5±4.6 months （range from 12 to 22 months）. The operation related parameters （operation time, estimated blood loss, length of hospitalization, complications） and clinical parameters, including neck visual analog scale （Neck-VAS）, arm visual analog scale （Arm-VAS）, neck disability index （NDI） and the modified Macnab criteria were assessed at 3, 6, and 12 months postoperatively and last follow-up. Disc height, shell angle, C2-C7 Cobb angle and range of motion were recorded preoperatively and at 3 months, 6 months, 12 months and last follow-up postoperatively.ResultsThe mean operation time was 76.4±26.6 minutes （range from 40 to 120 minutes）, the mean estimated blood loss was 30.2±15.6 ml （range from 20 to 80 ml）, and the mean length of hospitalization was 3.5±1.1 days （range from 2 to 8 days）. There was significant decrease at different time points postoperatively in Neck-VAS, Arm-VAS, and NDI when compared with preoperatively （P〈0.05）. According to the modified Macnab criteria, there was excellent concordance in 20 patients （60.6%）, good in 7 patients （21.2%） and fair in 6 patients （18.2%） at the last follow-up. The disc height was significantly decreased at postoperative 3 months and 1 year compared with at preoperative （F=95.1, P〈0.01）. The shell angle of index level （F=35.4, P〈0.01）, upper adjacent level （F=30.1, P〈0.01）, lower adjacent level （F=11.7, P〈0.01） as well as spinal function units （F=22.2, P〈0.01） were increased significantly at postoperative compared with at preoperative. The range of motion of index level （F=8.1, P〈0.01） and upper adjacent level （F=64.0, P〈0.01） increased significantly at postoperative compared with at preoperative. The range of motion in lower adjacent level （F=1.5, P=0.23）, spine functional unit of index level （F=2.9, P=0.06）, as well as C2-C7 （F=0.6, P=0.56） had no significant difference between preoperative and postoperative 1 year （P〉0.05）. One patient turned into traditional ACDF procedure because of hemorrhage limiting the vision during PECD operation. Upper extremity numbness and pain deteriorated in one case after a PECD procedure and was revised with ACDF at last. No other complications, like spinal cord injury, cervical root injury, cerebral spinal fluid leakage, infection as well as recurrence were found.ConclusionPECD, which can maintain normal cervical range of motion and intervertebral disc height, is a minimally invasive and essential procedure for CSR treatment with minor trauma, excellent outcome and quick recovery. Surgeon＇s experience, however, is needed in case of turning into open surgery for good outcome.