腰椎经皮椎间孔镜下椎间盘摘除术后再手术

Reoperation after percutaneous endoscopic lumbar discectomy

[目的]探讨经皮椎间孔镜腰椎间盘切除术后再手术的特点及翻修手术的临床效果。[方法]回顾性分析2014年1月~2019年12月行经皮内镜腰椎间盘切除术2 781例患者的临床资料,共有35例符合纳入标准,纳入本研究。其中,男性29例,女性6例;L_(4/5)节段18例,L_(5)/S_(1)节段15例,L_(4)~S_(1)节段2例,分析再次手术原因、再次手术时机、初次手术节段及手术方式。应用VAS评分和MacNab标准评价翻修术的临床效果。[结果] 35例再手术患者中,同节段再突出27例,包括同节段同侧26例,同节段对侧1例;邻近节段再突出1例;血肿形成1例;椎间盘囊肿形成1例;继发腰椎狭窄或不稳5例。再次手术方式包括经皮内镜腰椎间盘切除术17例,椎间盘镜3例,融合手术15例。再次手术间隔9 d~36个月,平均(9.92±1.74)个月。35例患者均顺利再次手术,术中无血管、神经损伤,无感染。再次术后随访时间10~29个月,平均(19.24±3.62)个月。随术后时间延长,VAS评分显著下降(P<0.05)。末次随访时,按MacNab标准评定临床效果,优31例,良2例,可1例,差1例,优良率为94.29%。[结论]再突出是经皮内镜椎间盘切除术后再次手术的主要因素;血肿形成、椎间盘囊肿及腰椎继发性狭窄症或腰椎不稳症是次要因素。恰当的手术方式是再手术取得满意疗效的关键。

[Objective] To explore the clinical characteristics and outcomes of reoperation after percutaneous endoscopic lumbar discectomy(PELD). [Methods] A retrospective study was done on 2781 patients who underwent percutaneous endoscopic lumbar discectomy for lumbar disc herniation from January 2014 to December 2019. Of them, 35 patients who had reoperation after PELD were enrolled in this study. The causes of reoperation, the time elapsed between primary PELD and reoperation, the segment of primary operation and the method of operation were analyzed in the 35 patients of reoperation. The VAS scores for low back pain and leg pain, as well as Mac Nab criteria were used to evaluate the clinical consequences. [Results] Among the 35 patients undergoing reoperation, 27 cases were of re-protrusion at the same segment, including 26 cases on the same side of the same segment and 1 case on the opposite side of the same segment;1 case of disc protrusion of adjacent segments;1 case of hematoma formation;1 case of intervertebral disc cyst formation;and 5 cases had secondary lumbar spine stenosis or instability. The reoperation methods were revision PELD in 17 cases, microendoscopic discectomy(MED) in 3 cases, open discectomy and instrumented fusion in 15 cases. The interval between the primary PELD and reoperations was from 9 days to 36 months, with an average of(9.92±1.74) months. All the 35 patients were successfully operated again without any vascular or nerve damage or infection, and followed up for another 10 to 29 months again with an average of(19.2±3.62) months. The VAS score decreased significantly over time postoperatively(P<0.05). At the last follow-up, the clinical results were graded as excellent in 31 cases, good in 2, fair in 1 and poor in 1, with the excellent and good rate of 94.29%, according to the Mac Nab’s criteria. [Conclusion] Disc re-protrusion is the main cause of reoperation after PELD, while hematoma formation, disc cyst and lumbar secondary stenosis or lumbar instability are the secondary causes. Appropriate surgical technique is the key to satisfactory results of reoperation.