经皮脊柱内镜下三种入路治疗脱垂型腰椎间盘突出症的比较

Comparison of the clinical outcomes of percutaneous endoscopic lumbar discectomy through three approaches for migrated disc herniation

目的]比较脊柱内镜不同入路治疗脱垂型腰椎间盘突出症的临床疗效。[方法]回顾性分析本院2014年10月～2016年11月782例明确诊断腰椎间盘突出症患者,其中85例为脱垂型突出,男51例,女34例;年龄17～75岁;受累节段L_(2/3)3例,L_(3/4)8例,L_(4/5)34例,L_5S_140例;脱垂椎间盘采用Lee分区法:Ⅰ区18例,Ⅱ区13例,Ⅲ区28例,Ⅳ区26例。手术经椎间孔组52例,经椎弓根组22例,经椎板间组11例;腰腿痛采用VAS评分、ODI指数对所有患者在术前、术后即刻进行评定,改良MacNab标准评定末次随访时恢复情况。通过配对样本t检验分析三组患者术前、术后的腰腿痛VAS评分及ODI指数改善情况。[结果]所有患者均顺利完成手术,手术时间平均(90.21±8.56)min,无手术直接并发症。经椎间孔组1例术后3个月并发椎间盘囊肿,1例11个月复发予以开窗减压手术;经椎弓根组1例术后麻木症状一过性加重,术后第6周时恢复正常。经椎板间组术后1例合并椎间隙感染,经抗炎处理后控制。所有患者随访(16.21±6.47)个月,三组患者术后即刻与末次随访VAS评分、ODI指数均较术前明显改善(P<0.05),改良Mac Nab标准评定:优69例,良12例,可3例,差1例,优良率94.29%。[结论]术前根据脱垂椎间盘的位置与分区合理选择入路方式,经皮脊柱内镜下摘除脱垂型腰椎间盘可获得良好效果。

[Objective] To compare the clinical outcomes of percutaneous endoscopic lumbar discectomy through 3 ap- proaches for migrated disc herniation. [Methods] The data of 782 consecutive patients diagnosed of lumbar disc herniation were analyzed retrospectively from October 2014 to Noverber 2016. Of them, 85 patients, including 51males and 34 females aged from 17 to 75 years, were diagnosed of migrated lumbar disc herniation, which involved L2/3 in 3 cases, L3/4 in 8, L4/5 in 34 and L5/S1 in 40 respectively. In term of Lee classification for migration of the prolapsed disc, 18 patients were in the region I, 13 in region II, 28 in region III and 26 in region IV. Based on the migration, 52 patients had operation performed through the traditional transforaminal approach （the transforaminal group） , while 22 patients underwent the superior vertebral pedicle approach （the pedicle group） and the remaining 11 patients received operation through the interlaminar approach （the interlaminar group） . The visual analogue score （VAS） of pain, Oswestry disability index （ODI） and modified MacNab criteria were used to assess the clinical outcomes. [Results] The surgical operation was carried out successfully in all patients with average operation time of （90.21 ±8.56） minutes, while without any direct surgery-related complications. Regarding to complications after operation, one patient in the transforaminal group got an intervertebral disc cyst at 3 months after operation, and another patient suffered from recurrence which were managed well by open lumbar micro-discectomy ; one patients in the pedicle group had transient deteri- oration of numbness which recovered to normal at the 6^th week after operation; and one patients in the interlaminar group got intervertebral space infection which healed after antibiotic therapy. All the patients were followed up for an average of （16.21±6.47） months. Compared with those before operation, the VAS and ODI statistically significantly decreased, while the JOA score significantly increased in the 3 groups immediately after operation and at the latest follow up （P〈0.05）. In term of Modified MacNab criteria, 69 patients got results graded as excellent, while 12 as good, 3 as fair and 1 as poor, associated with excellent and good rate of 94.29%. [Conclusion] Percutaneous endoscopic lumbar discectomy for migrated disc hernia- tion does achieve satisfactory results, if the proper surgical approach is selected in accordance with the location of migrated disc.