神经内镜手术治疗脊髓拴系综合征的疗效及其对尿动力学指标的影响

Neuroendoscopic surgery for the treatment of tethered cord syndrome and its influence on urody-namic indexes

目的探讨神经内镜手术治疗脊髓拴系综合征(TCS)的疗效及其对尿动力学指标的影响。方法回顾性分析2016年1月至2018年4月海南省人民医院神经外科收治的62例TCS患者的临床资料。根据治疗方式分为神经内镜组(n=32)和显微镜组(n=30)。比较两组患者的基线资料,术中脊髓拴系松解情况等手术指标,术后3个月的临床疗效,术后3年的脊髓再拴系、腰椎失稳、神经轻微损伤等远期随访结果;比较两组手术前后的尿动力学指标,包括膀胱安全容量、膀胱残余尿量及逼尿肌漏尿点压。结果两组患者的年龄、性别、病程、3项术前尿动力学指标的差异均无统计学意义(均P>0.05)。两组患者的手术均顺利完成。术后无一例出现神经损伤、术区血肿、颅内感染等并发症。神经内镜组与显微镜组比较,脊髓拴系完全松解者占比的差异无统计学意义[分别为93.8%(30/32)、90.0%(27/30),P>0.05];神经内镜组较显微镜组术中出血量少[分别为(281.4±30.3)ml、(333.9±35.7)ml]、手术时间短[分别为(81.5±10.1)min、(96.7±8.3)min]、住院时间短[分别为(12.9±2.5)d、(14.7±1.4)d],差异均有统计学意义(均P<0.05)。两组患者均完成术后3年随访。术后3个月,神经内镜组患者治愈8例,显效15例,好转6例,无效3例,与显微镜组比较,临床疗效的差异无统计学意义(P>0.05)。术后3年,两组脊髓再拴系、腰椎失稳、神经轻微损伤者占比的差异均无统计学意义(均P>0.05);与显微镜组比较,神经内镜组膀胱安全容量大[分别为(264.4±28.7)ml、(245.8±25.8)ml]、膀胱残余尿量少[分别为(106.3±16.5)ml、(118.5±22.7)ml]、逼尿肌漏尿点压低[分别为(30.5±9.1)cmH_(2)O(1 cmH_(2)O=0.098 kPa)、(36.4±9.1)cmH_(2)O],差异均有统计学意义(均P<0.05);与术前比较,术后3年两组的膀胱安全容量均上升、膀胱残余尿量均减少、逼尿肌漏尿点压降低,差异均有统计学意义(均P<0.05)。结论神经内镜手术治疗TCS患者的近、远期临床疗效均较好,未观察到与显微镜手术的疗效差异,但神经内镜手术的手术时间短、术中出血少、住院时间短,且术后患者的尿动力学指标恢复更好。

Objective To explore the neuroendoscopic surgery for the treatment of tethered cord syndrome(TCS)in the near and long terms and its influence on urodynamic indexes.Methods The clinical data of 62 patients with TCS admitted to the Department of Neurosurgery,Hainan Provincial People′s Hospital from January 2016 to April 2018 were retrospectively analyzed.According to the treatment method,all patients are divided into neuroendoscopy group(n=32)and microscopy group(n=30).We then compared the baseline data of the two groups of patients,intraoperative spinal cord loosening and other surgical indicators,clinical efficacy at 3 months after surgery,and long-term follow-up of spinal cord retethering,lumbar instability,and minor nerve injury at 3 years after surgery.The urodynamic indexes before and after the operation were compared between the two groups,including safety bladder capacity(SBC),postvoid residual urine volume(PRUV)and detrusor leak point pressure(DLPP).Results There were no significant differences in age,gender,course of disease,or 3 preoperative urodynamic indexes between the two groups(all P>0.05).The operations of the two groups of patients were successfully completed.No postoperative complications such as nerve injury,hematoma in the operation area,or intracranial infection occurred.Comparing between the neuroendoscopy group and the microscopy group,there was no statistically significant difference in the proportion of patients with complete spinal cord loosening[93.8%(30/32)vs.90.0%(27/30),P>0.05];the neuroendoscopy group had less intraoperative blood loss than the microscopy group(281.4±30.3 ml vs.333.9±35.7 ml),shorter operation time(81.5±10.1 min vs.96.7±8.3 min),shorter hospital stay(12.9±2.5 d vs.14.7±1.4 d),and the differences were statistically significant(all P<0.05).Both groups of patients completed the 3-year follow-up after surgery.At 3 months post operation,8 patients in the neuroendoscopy group were cured,15 were markedly effective,6 were improved,and 3 were ineffective.There was no significant difference in clinical efficacy between the neuroendoscopy and microscopy groups(P>0.05).Three years after operation,there was no significant difference in the proportion of patients with spinal cord retethering,lumbar instability,and minor nerve injury between the two groups(all P>0.05).Compared with the microscopy group,the neuroendoscopy group had a larger SBC(264.4±28.7 ml vs.245.8±25.8 ml),lower PRUV(106.3±16.5 ml vs.118.5±22.7 ml),lower DIPP(30.5±9.1 cmH_(2)O vs.36.4±9.1 cmH_(2)O,1 cmH_(2)O=0.098 kPa),and the differences were statistically significant(all P<0.05).Compared with preoperative conditions,both groups reported larger SBC,lower PRUV and DIPP at 3 years post operation,and the differences were statistically significant(all P<0.05).Conclusions Neuroendoscopic surgery has good short-term and long-term clinical effects for TCS patients,and no difference in therapeutic effect from microscopic surgery has been observed.However,neuroendoscopic surgery has a shorter operation time,less intraoperative bleeding,and shorter hospital stay and the patient′s urodynamic indexes recover better.