经皮椎间孔镜下腰椎间盘切除术后效果不佳的相关因素分析

Related factors associated with poor results after percutaneous endoscopic lumbar discectomy

目的探讨经皮椎间孔镜下腰椎间盘切除术(percutaneous endoscopic lumbar discectomy,PELD)后效果不佳的原因。方法回顾性分析三峡大学附属仁和医院骨科2014年1月至2018年12月采用PELD手术治疗的346例腰椎间盘突出症病人的临床资料,其中男146例,女200例,年龄为17~68岁。比较术后效果良好和效果不佳病人之间在年龄、性别、术前美国麻醉医师协会(America Society of Anesthesiologists, ASA)分级、是否髓核残留、是否椎间孔减压成型、是否规范康复训练、术中出血与否、是否合并腰椎管狭窄、术后有无并发症、是否椎间盘复发这10个方面的差异,对上述结果中有差异的变量进一步采用二分类Logistic回归分析导致PELD术后效果不佳的危险因素。结果 346例病人平均随访12个月,其中31例术后效果不佳,发生于术后3~30个月,平均为16个月。术后效果良好和效果不佳病人间在年龄、是否髓核残留、是否椎间孔减压成型、是否规范康复训练、是否合并腰椎管狭窄、术后有无并发症以及是否椎间盘复发这7个方面比较,差异均有统计学意义(P均<0.05)。Logistic回归分析显示:髓核残留[OR=4.008,95%CI(1.643,9.773),P=0.002]、合并腰椎管狭窄[OR=9.134,95%CI(3.604,23.150),P<0.001]、椎间盘复发[OR=2.489,95%CI(0.948,6.533),P=0.044]及术后有相关并发症[OR=2.031,95%CI(0.912,5.892),P=0.041]是PELD术后效果不佳的危险因素。椎间孔减压成型[OR=0.483,95%CI(0.280,10.833),P=0.009]是PELD术后效果的保护因素。结论突出椎间盘髓核残留、合并腰椎管狭窄、椎间盘复发及术后相关并发症是PELD术后效果不佳的危险因素,需严格把握手术适应证、椎管内及椎间孔彻底减压,可减少术后效果不佳的发生。

Objective To explore the causes of poor outcomes after percutaneous endoscopic lumbar discectomy(PELD). Methods The clinical data of 346 patients with lumbar disc herniation in Renhe Hospital Affiliated to Three Gorges University from January 2014 to December 2018 were retrospectively analyzed. Of the 346 patients, there were 146 males and 200 females, aged from 17 to 68 years old. The age, sex, American Society of Anesthesiologists(ASA) grade before surgery, and the conditions of nucleus pulposus residue,decompression of intervertebral foramen, standardized rehabilitation training, intraoperative bleeding,concomitant lumbar stenosis, complications, disc recurrence between the patients with good or poor outcome were compared. The variables with differences in the above results were further analyzed using binary classification Logistic regression analysis as a risk factor for poor postoperative PELD. Results All the 346 cases were followed up for an average period of 12 months, and 31 patients had poor postoperative results,which occurred from 3 to 30 months with an average of 16 months. The differences of age, nucleus pulposus residue, decompression of intervertebral foramen, standardized rehabilitation training, lumbar stenosis,complications, disc recurrence between the patients with good or poor outcome had statistically significant(P<0.05 for all). Binary Logistic regression analysis showed that nucleus pulposus residue[OR=4.008, 95% CI(1.643, 9.773), P=0.002], lumbar stenosis[OR=9.134, 95% CI(3.604, 23.150), P<0.001], recurrence[OR=2.489, 95% CI(0.948, 6.533), P=0.044]and postoperative complications[OR=2.031, 95% CI(0.912, 5.892),P=0.041]were major factors for poor outcomes. Depression of intervertebral foramen[OR=0.483, 95% CI(0.280, 10.833), P=0.009]was protective factors for postoperative effects of PELD. Conclusion Nucleus pulposus residue, lumbar stenosis, recurrence and complications lead to poor outcomes, which can be reduced by strict operation indication, complete decompression in spinal canal and intervertebral foramen.