黄韧带整体显露技术在经皮微创通道减压术治疗中央型腰椎管狭窄症中的应用

Application of the whole exposure technique of the ligamentum flavum in the treatment of central lumbar spinal stenosis by percutaneous minimally invasive decompression

目的探讨黄韧带整体显露技术在经皮微创通道单侧椎旁入路双侧减压术治疗中央型腰椎管狭窄症中的作用。方法回顾性分析解放军联勤保障部队第九〇四医院神经外科2019年3月至2020年6月采用经皮微创通道单侧椎旁入路双侧减压术治疗的中央型腰椎管狭窄症患者的临床资料,共24例。患者术中均采用黄韧带整体显露技术,观察术后关节突关节及硬膜囊的横径和矢状径的改变,评估术后1 d、7 d、1个月、3个月、6个月的日本骨科学会(JOA)评分、疼痛视觉模拟评分(VAS)及Oswestry功能障碍指数(ODI)较术前的改善情况。结果24例患者均未发生与手术相关的神经损伤、脑脊液漏及感染。腰椎单节段的手术时间为(72.0±16.1)min。术后CT显示关节突关节保护良好;MRI显示黄韧带切除完全,硬膜囊横径由术前的(9.4±2.6)mm增大至(16.0±3.0)mm,硬膜囊矢状径由术前的(10.2±1.9)mm增大至(15.1±1.9)mm,差异均有统计学意义(均P<0.05)。术后6个月随访显示,JOA由术前的(14.8±3.6)分恢复至(26.9±1.3)分,VAS评分由术前的(7.1±1.5)分减少至(0.5±0.2)分,ODI由术前的(68.4±11.8)%减少至(12.7±7.5)%,差异均有统计学意义(均P<0.05)。结论显微镜下经皮微创通道单侧椎旁入路双侧减压术中应用黄韧带整体显露技术治疗中央型腰椎管狭窄症疗效确切、椎管减压充分、关节突关节损伤小、不影响术后腰椎稳定性和活动度。

Objective To explore the application of the whole exposure technique of the ligamentum flavum in the treatment of central lumbar spinal stenosis by percutaneous minimally invasive decompression.Methods A retrospective analysis was conducted on the clinical data of 24 patients with central lumbar spinal stenosis treated with bilateral decompression using percutaneous minimally invasive channel through unilateral paravertebral approach from March 2019 to June 2020 at the Department of Neurosurgery,the 904th Hospital of Joint Logistic Support Force of the PLA.The technique of whole exposure of the ligamentum flavum was used for all patients during the operation.We documented the changes of the facet joints and the transverse and sagittal diameters of dural sac after the operation.At 1 d,7 d,1 month,3 months,and 6 months post operation,the improvement of Japanese Orthopaedic Association(JOA)score,visual analog scale(VAS),and Oswestry disability index(ODI)compared with presurgical conditions were assessed.Results None of the 24 patients had nerve damage,cerebrospinal fluid leakage,or infection related to surgery.The operation time for a single segment of the lumbar spine was 72.0±16.1 min.Postoperative CT showed that the facet joints were well protected.MRI showed that the ligamentum flavum was completely removed,the transverse diameter of the dural sac increased from 9.4±2.6 mm before the operation to 16.0±3.0 mm,the sagittal diameter of the dural sac was increased from 10.2±1.9 mm before the operation to 15.1±1.9 mm,and the differences were statistically significant(all P<0.05).At 6-month follow-up post operation,the JOA score changed from 14.8±3.6 before surgery to 26.9±1.3,the VAS score decreased from 7.1±1.5 before surgery to 0.5±0.2,and the ODI decreased from preoperative 68.4±11.8%to 12.7±7.5%,and the differences were statistically significant(all P<0.05).Conclusion Microscopic percutaneous minimally invasive bilateral decompression through unilateral paravertebral approach using the whole exposure technique of the ligamentum flavum has a definite effect in the treatment of central lumbar spinal stenosis,which is associated with sufficient decompression of the spinal canal,small damage to the facet joints,and no impact on postoperative lumbar stability or mobility.