三维可视化穿刺置管辅助经椎间孔入路经皮内窥镜下腰椎椎间盘切除术治疗腰椎椎间盘突出症

Three-dimensional visualization of puncture and catheterization assisted percutaneous endoscopic transforaminal discectomy for lumbar disc herniation

目的探讨三维可视化穿刺置管技术辅助经椎间孔入路经皮内窥镜下腰椎椎间盘切除术(PETD)治疗腰椎椎间盘突出症(LDH)的临床疗效。方法回顾性分析2017年1月-2019年9月在南京中医药大学附属张家港医院接受PETD治疗的42例单节段LDH患者临床资料,采用半随机法分为观察组与对照组,观察组(20例)术前使用Mimics软件模拟PETD工作通道,规划术中穿刺角度及关节突打磨程度,参考模拟结果行PETD;对照组(22例)采用常规C形臂X线机透视穿刺行PETD。记录2组穿刺置管时间、术中透视次数及并发症发生情况。术前、术后1周、术后3个月及末次随访时采用疼痛视觉模拟量表(VAS)评分、Oswestry功能障碍指数(ODI)、日本骨科学会(JOA)评分评估患者疼痛程度及腰椎功能。结果所有手术顺利完成,所有患者随访(8.19±2.23)个月。观察组穿刺置管时间、术中透视次数与对照组相比明显减少,差异均有统计学意义(P < 0.05)。2组术后各时间点VAS评分、ODI、JOA评分较术前均显著改善,差异均有统计学意义(P < 0.05);术后各时间点组间比较差异无统计学意义(P > 0.05)。2组各发生1例神经根减压不彻底术后遗留部分腰腿痛,经非手术治疗后恢复;对照组1例发生小骨片卡压神经根致腰腿痛较术前加重,行开放手术取出卡压骨块,并行后路减压植骨融合内固定术治疗后症状消失。结论三维可视化穿刺置管辅助PETD可明显缩短穿刺置管时间、减少术中透视次数,做到更精准、快速置管,更少的辐射暴露,具有良好的临床应用价值。

Objective To investigate the clinical efficacy of three-dimensional visualization of puncture and catheterization assisted percutaneous endoscopic transforaminal discectomy(PETD)in the treatment of lumbar disc herniation(LDH).Methods The clinical data of 42 patients with single-segment LDH admitted to Zhangjiagang Affiliated Hospital of Nanjing University of Chinese Medicine from January 2017 to September 2019 were analyzed retrospectively.They were divided into observation group and control group by semi random method.In the observation group(20 cases),the Mimics software was used to simulate the working channel of PETD before operation,plan the puncture angle and grinding degree of the articular process and perform PETD according to the simulation results.The control group(22 cases)underwent conventional C-arm fluoroscopy and puncture for PETD.The puncture and catheterization time,intraoperative fluoroscopy frequency and complications of the 2 groups were recorded.The visual analogue scale(VAS)score,Oswestry disability index(ODI),and Japanese Orthopaedic Association(JOA)score were used to evaluate the severity of pain and lumbar function at pre-operation,postoperative 1 week,postoperative 3 months,and the final follow-up.Results All the operations were completed successfully and all the patients were followed up for(8.19±2.23)months.The puncture and catheterization time and intraoperative fluoroscopy frequency in the observation group were significantly decreased compared with the control group,and the differences were statistically significant(P<0.05).VAS scores,ODI and JOA scores of the 2 groups were significantly improved at each postoperative time point compared with those at pre-operation,and the differences were statistically significant(P<0.05).There was no significant difference at each postoperative time point between the 2 groups(P>0.05).One patient in each group suffered from incomplete nerve root decompression,and some low back and leg pain was left after operation,which recovered after non-surgical treatment.In the control group,1 case suffered from low back and leg pain caused by nerve root entrapment by small bone fragments,which was aggravated compared with that before operation.The patient underwent open surgery to remove the entrapment of bone fragment,and the symptoms disappeared after posterior decompression,bone grafting,fusion and internal fixation.ConclusionPETD assisted by three-dimensional visualization of puncture and catheterization can significantly shorten the time of operation,reduce the intraoperative fluoroscopy,achieve more accurate and rapid catheterization,less radiation exposure,thus has good clinical application value.