经皮内镜下腰椎间盘摘除术治疗伴腰椎管狭窄的单节段腰椎间盘突症术后复发的影响因素

Influencing factors of postoperative recurrence of single-segment lumbar disc protrusion with lumbar spinal stenosis treated by percutaneous endoscopic lumbar discectomy

目的:探讨经皮内窥镜下腰椎间盘摘除术(percutaneous endoscope lumbar discectomy,PELD)治疗伴腰椎管狭窄的腰椎间盘突出症(lumbar disc herniation,LDH)患者术后中期复发与椎管变化的相关性。方法:回顾性分析2016年1月~2018年6月于我院通过PELD治疗的伴腰椎管狭窄的LDH患者155例,其中男性93例,女性62例,年龄41~63岁,平均51.9±9.3岁。于患者出院后进行为期2年的跟踪随访,根据随访期间LDH有无复发将患者分为复发组及未复发组。比较两组患者临床资料:年龄、病程、性别构成、体质指数(body mass index,BMI)、吸烟史、基础疾病、腰椎管狭窄分级、病变位置及分类、腰部视觉模拟评分(visual analogue scale,VAS)、下肢日本骨科协会(Japanese Orthopaedic Association,JOA)评分及Oswestry功能障碍指数(Oswestry disability index,ODI);并通过术前5~7d及术后7d腰椎MRI测量:手术前后椎管横截面积(intervertebral canal cross-sectional area,ICCA)、硬膜囊横截面积(dural sac cross-sectional area,DSCA)、椎间孔矢状径及侧隐窝宽度并计算手术前后的差值。采用Logistic回归分析术后复发的相关因素,而后以椎管狭窄类型为选择变量分析各不同种类的椎管狭窄复发的相关因素(P<0.1)。结果:共计155例患者完成随访,随访期间19例患者疾病复发。未复发组腰椎管狭窄分级:1级75例,2级47例,3级14例;复发组:1级5例,2级6例,3级8例,两组间差异具有统计学意义(P=0.002)。两组患者年龄、病程、性别构成、BMI、吸烟史、基础疾病、病变位置、术前VAS、下肢JOA及ODI评分比较差异无统计学意义(P>0.05)。未复发组患者ICCA(差值)(0.36±0.18cm^(2) vs 0.19±0.13cm^(2))、DSCA(差值)(0.23±0.09cm^(2) vs 0.09±0.04cm^(2))、椎间孔矢状径(差值)(1.22±0.48mm vs 0.93±0.53mm)及侧隐窝宽度(差值)(1.37±0.44mm vs 1.14±0.67mm)均高于复发组,差异具有统计学意义(P<0.05)。腰椎管狭窄分级、ICCA(差值)、DSCA(差值)及侧隐窝宽度(差值)与术后复发呈负相关(P<0.05)。DSCA(差值)与中央椎间管狭窄术后复发呈负相关(OR<0.001,P=0.001),ICCA(差值)(OR=0.001,P=0.006),椎间孔矢状径(差值)(OR=0.001,P=0.038)与椎间孔狭窄术后复发呈负相关,侧隐窝宽度(差值)(OR=0.004,P=0.009)与侧隐窝狭窄术后复发呈负相关。结论:LDH伴腰椎管狭窄行PELD术后复发与患者手术前后ICCA、DSCA、椎间孔矢状径及硬膜囊横截面积变化情况相关,这对于指导术中减压范围及临床手术效果判断具有积极的意义。

Objectives:To investigate the correlation between postoperative recurrence and spinal canal changes in patients with lumbar spinal stenosis and lumbar disc herniation(LDH)treated by percutaneous endoscope lumbar discectomy(PELD).Methods:A retrospective analysis of 155 patients with LDH and lumbar spinal stenosis who underwent PELD treatment in our hospital from January 2016 to June 2018,including 93 males and 62 females,with an average age of 51.9±9.3 years.After the patients were discharged from the hospital,they were followed up for a period of 2 years.The patients were divided into recurrence group and non-recurrence group according to the recurrence situation during the follow-up period.The clinical data of the two groups of patients were compared,including age,course of disease,gender composition,body mass index(BMI),smoking history,underlying disease,stenosis grade,lesion location and classification,waist visual analog score(VAS),and lower limb JOA and ODI scores.MRI examinations were performed on the patients 5 to 7 days preoperatively and 7 days after the operation,from which imaging examination related information(including the cross-sectional area of the spinal canal before and after the operation,the cross-sectional area of the dural sac,the sagittal diameter of the intervertebral foramina and the width of the lateral recess and their differences)was collected.Logistic regression was used to analyze the related factors of postoperative recurrence,andthe type of spinal stenosis was used as the selected variable to analyze the related factors of different types of spinal stenosis(P<0.1).Results:A total of 155 patients completed the follow-up,and 19 patients relapsed during the follow-up period.The difference of lumbar spine stenosis grading was statistically significant(P=0.002)between the non-recurrence group(75 cases in grade 1,47 cases in grade 2,14 cases in grade 3)and the recurrence group(5 cases in grade 1,6 cases in grade 2,and 8 cases in grade 3).There was no statistically significant differences between the two groups of patients in age,course of disease,gender composition,BMI,smoking history,underlying disease,lesion location,preoperative VAS,lower limb JOA and ODI scores.The ICCA(difference value)(0.36±0.18 cm^(2) vs0.19±0.13 cm^(2),P<0.001),DSCA(difference value)(0.23±0.09 cm^(2) vs 0.09±0.04 cm^(2),P<0.001),sagittal diameter of intervertebral foramina(difference value)(1.22±0.48 mm vs 0.93±0.53 mm,P=0.016)and lateral crypt width(difference)(1.37±0.44 mm vs 1.14±0.67 mm,P<0.001)in the non-recurrence group were higher than those of the recurrence group,and the differences were statistically significant.The grade of stenosis,ICCA(difference),DSCA(difference)and lateral recess width(difference)were negatively correlated with postoperative recurrence(P<0.05).DSCA(difference)was negatively correlated with recurrence of central intervertebral canal stenosis(OR<0.001,P=0.001).ICCA(difference)(OR=0.001,P=0.006)and sagittal foraminal diameter(difference)(OR=0.001,P=0.038)were negatively correlated with the recurrence of foraminal stenosis.The width of the lateral crypt(difference)(OR=0.004,P=0.009)was negatively correlated with the recurrence of lateral crypt stenosis.Conclusions:The recurrence of LDH with lumbar spinal stenosis after PELD is related to the changes of ICCA,DSCA,intervertebral foramina sagittal diameter and crosssectional area of the dural sac before and after the operation,which is of positive significance in guiding range of decompression and the judgment of the clinical operation.