经皮内镜下改良经椎间孔入路技术治疗腰椎侧隐窝狭窄症

Percutaneous endoscopic modified transforaminal approach in the treatment of lumbar lateral recess stenosis

目的探讨经皮内镜下改良经椎间孔入路技术治疗腰椎侧隐窝狭窄症的安全性和早期疗效。方法 2016 年 1 月至 2017 年 6 月,我科收治 82 例单节段腰椎侧隐窝狭窄症患者,其中 45 例接受改良经椎间孔入路手术,37 例接受常规经椎间孔入路手术。分别比较两组患者年龄、性别、体质量指数 (body mass index,BMI)、手术节段、术中透视次数、内镜引入时间、手术时间、术中出血量和住院时间。使用疼痛视觉模拟评分 (visual analogue scale,VAS) 评估腿痛的程度,使用 Oswestry 功能障碍指数 (oswestry disability index,ODI) 评估腰部功能,末次随访时使用改良 MacNab 标准评估临床治疗效果。结果两组患者年龄、性别、BMI、手术节段等一般资料差异无统计学意义 (P>0.05)。改良组术中透视次数、内镜引入时间、手术时间和术中出血量分别为 (3.38±0.61) 次、(9.60±1.07) min、(69.56±15.03) min 和 (10.18±2.88) ml,常规组中对应值分别为 (9.70±1.33) 次、(20.08±1.23) min、(78.78±15.20) min 和 (12.57±3.84) ml,改良组中术中透视次数、内镜引入时间、手术时间和术中出血量均明显低于常规组,差异有统计学意义 (P<0.01),两组患者的住院时间差异无统计学意义 (P>0.05)。改良组中术前、术后 1 天、1 个月、3 个月、6 个月及 12 个月的腿痛 VAS 分别为 7.53±1.27、2.87±0.92、2.38±0.75、1.91±0.79、1.62±0.61 和 1.42±0.66,相应时间点的 ODI 分别为 71.11±8.94、25.56±4.80、22.13±5.00、19.11±4.68、16.36±4.50 和 14.04±4.10。常规组中相应时间点上腿痛 VAS 分别为 7.43±1.30、2.73±0.87、2.22±0.67、1.78±0.71、1.54±0.69 和 1.32±0.75,相应时间点的 ODI 分别为 68.54±8.12、23.73±5.78、20.70±5.10、18.05±4.82、15.24±4.23 和 13.08±3.58。两组组内术后 1 天、1 个月、3 个月、6 个月及 12 个月的腿痛 VAS 和 ODI 较术前明显降低,差异有统计学意义 (P<0.01),而两组同一时间点上组间比较腿痛 VAS 和 ODI 差异无统计学意义 (P>0.05)。末次随访改良 MacNab 标准评估疗效,改良组优 15 例,良 24 例,可 5 例,差 1 例,优良率 86.67%;常规组优 11 例,良 20 例,可 5 例,差 1 例,优良率 83.78%,两者比较差异无统计学意义 (P>0.05)。改良组和常规组中各有 2 例复发,复发率分别为 4.44% 和 5.41%,两者比较差异无统计学意义 (P>0.05)。常规组中有 1 例 (2.70%) L5~S1 侧隐窝狭窄患者出现术后感觉迟钝,给予药物及理疗后 3~4 周症状完全缓解。结论经皮内镜下改良经椎间孔入路技术是治疗腰椎侧隐窝狭窄症安全且高效的手术方法,可有效降低术中辐射。

Objective To explore the safety and short-term clinical efficacy of modified transforaminal approach for lumbar lateral recess stenosis.Methods From January 2016 to June 2017,82 patients with single-segment lumbar lateral recess stenosis were divided into two groups.Forty-five patients underwent modified transforaminal approach surgery,and 37 underwent conventional transforaminal approach.The age,gender,body mass index (BMI),surgical segment,intraoperative fluoroscopy,cannula introduction time,operation time,intraoperative blood loss and hospital stay were compared between the two groups.Visual analogue scale (VAS) was used to evaluate the leg pain,Oswestry disability index (ODI) was applied to assess lumbar functions,and MacNab criteria was performed to estimate clinical effects at the last follow-up.Results There were no significant differences in age,gender,BMI and surgical segment between the two groups (P > 0.05).The number of fluoroscopy times,cannula introduction time,operation time and intraoperative blood loss were (3.38±0.61),(9.60±1.07) min,(69.56±15.03) min,(10.18±2.88) ml respectively in the modified group,and (9.70±1.33),(20.08±1.23) min,(78.78±15.20) min,(12.57±3.84) ml in the conventional group.The number of fluoroscopy times,cannula introduction time,operation time and intraoperative blood loss in the modified group were significantly lower than those in the conventional group (P < 0.01),while no significant differences in the hospital stay between the two groups (P > 0.05).VAS scores of the leg pain before surgery,1 day,1 month,3 months,6 months,and 12 months after surgery were (7.53±1.27),(2.87±0.92),(2.38±0.75),(1.91±0.79),(1.62±0.61),(1.42±0.66) respectively in the modified group,while (7.43±1.30),(2.73±0.87),(2.22±0.67),(1.78±0.71),(1.54±0.69),(1.32±0.75) respectively in the conventional group.ODI scores at the same time points were (71.11±8.94),(25.56±4.80),(22.13±5.00),(19.11±4.68),(16.36±4.50),(14.04±4.10) respectively in the modified group,while (68.54±8.12),(23.73±5.78),(20.70±5.10),(18.05±4.82),(15.24±4.23),(13.08±3.58) respectively in the conventional group.VAS and ODI scores were significantly lower than those before surgery (P < 0.01),while no significant differences between the two groups(P > 0.05).Modified MacNab efficacy evaluation:excellent in 15 patients,good in 24,fair in 5,poor in 1,excellent and good rate 86.67% in the modified group;excellent in 11 patients,good in 20,fair in 5,poor in 1,excellent and good rate 83.78% in the conventional group;no statistical differences between the two groups (P > 0.05).Recurrence occurred in 2 patients in the modified group,and 2 patients in the conventional group with recurrence rate 4.44%,5.41%,respectively,but no significant differences were noted (P > 0.05).One patient (2.70%) with L5-S1 lateral recess stenosis in the conventional group experienced postoperative dysesthesia,and the symptoms were significantly relieved after 3-4 weeks of administration with drug and physiotherapy.Conclusions Percutaneous endoscopic modified transforaminal approach is safe and effective in the treatment of lumbar lateral recess stenosis,which can effectively reduce intraoperative radiation.