可视化椎间孔成形技术在经皮椎间孔入路内镜下椎间盘切除术治疗巨大型腰椎间盘突出症中的应用

Application of visualization foraminoplasty in percutaneous endoscopic transforaminal discectomy for treatment of giant lumbar disc herniation

目的:探讨可视化椎间孔成形技术在经皮椎间孔入路内镜下椎间盘切除术(percutaneous endoscopic transforaminal discectomy, PETD)治疗巨大型腰椎间盘突出症(lumbar disc herniation, LDH)中的应用价值。方法:回顾性分析采用PETD治疗的67例巨大型LDH患者的病例资料,术中采用可视化椎间孔成形技术者归于可视化椎间孔成形组(31例),采用常规椎间孔成形技术者归于常规椎间孔成形组(36例)。比较2组患者术中X线透视次数、通道建立用时、手术时间、上关节突骨切除量、术后住院时间、临床综合疗效、并发症发生率、LDH复发率,以及手术前后不同时间点(术前、术后1周、术后1个月、术后3个月、末次随访时)的腰部、腿部疼痛视觉模拟量表(visual analogue scale, VAS)评分和Oswestry功能障碍指数(Oswestry disability index, ODI)。结果:(1)一般结果。可视化椎间孔成形组术中X线透视次数较常规椎间孔成形组少[(12.48±3.15)次,(23.58±7.07)次,t=-8.073,P=0.000],通道建立用时、手术时间较常规椎间孔成形组短[(21.61±6.09)min,(30.89±9.59)min,t=-4.637,P=0.000;(53.39±12.25)min,(65.31±11.76)min,t=-4.508,P=0.000],上关节突骨切除量较常规椎间孔成形组多[(0.69±0.16)cm^(3),(0.40±0.14)cm^(3),t=7.659,P=0.000];2组患者术后住院时间比较,差异无统计学意义[(3.74±1.48)d,(3.97±1.30)d,t=-0.678,P=0.500]。(2)腰部、腿部疼痛VAS评分。时间因素和分组因素均存在交互效应(F=216.417,P=0.000;F=275.367,P=0.000)。手术前后不同时间点之间腰部、腿部疼痛VAS评分的差异均有统计学意义,即均存在时间效应(F=219.335,P=0.000;F=281.412,P=0.000)。2组患者腰部、腿部疼痛VAS评分总体比较,组间差异均无统计学意义,即均不存在分组效应(F=0.016,P=0.899;F=0.258,P=0.613)。2组患者腰部、腿部疼痛VAS评分均随时间呈下降趋势,且2组的变化趋势一致[腰部疼痛VAS评分:(5.90±1.33)分,(2.52±0.72)分,(2.13±0.81)分,(1.71±0.64)分,(1.52±0.68)分,F=80.215,P=0.000;(5.78±1.07)分,(2.64±0.60)分,(2.17±0.78)分,(1.64±0.64)分,(1.47±0.65)分,F=153.720,P=0.000。腿部疼痛VAS评分:(6.61±1.26)分,(2.45±0.77)分,(1.84±0.74)分,(1.65±0.61)分,(1.42±0.62)分,F=118.069,P=0.000;(6.75±1.34)分,(2.50±0.81)分,(1.89±0.79)分,(1.72±0.66)分,(1.47±0.70)分,F=146.603,P=0.000]。(3)ODI。时间因素和分组因素存在交互效应(F=479.277,P=0.000)。手术前后不同时间点之间ODI的差异有统计学意义,即存在时间效应(F=476.994,P=0.000)。2组患者ODI总体比较,差异无统计学意义,即不存在分组效应(F=0.022,P=0.882)。2组患者ODI均随时间呈下降趋势,且变化趋势一致[(59.23±9.85)%,(24.39±6.08)%,(18.84±5.31)%,(13.81±3.55)%,(10.71±2.95)%,F=188.572,P=0.000;(57.83±8.42)%,(23.50±5.62)%,(18.89±5.39)%,(14.83±3.78)%,(11.33±3.28)%,F=327.092,P=0.000]。(4)临床综合疗效。可视化椎间孔成形组优19例、良8例、可3例、差1例,常规椎间孔成形组优18例、良12例、可4例、差2例;2组患者临床综合疗效比较,差异无统计学意义(Z=-0.898,P=0.369)。(5)并发症及LDH复发情况。2组患者均无神经血管损伤、椎间隙感染等并发症发生;常规椎间孔成形组术后髓核残留1例,二次行PETD治疗后症状缓解;2组患者并发症发生率比较,差异无统计学意义(P=1.000)。2组各有1例患者术后LDH复发,行腰椎融合术后症状缓解;2组患者LDH复发率比较,差异无统计学意义(P=1.000)。结论:PETD治疗巨大型LDH,术中采用可视化椎间孔成形技术与采用常规椎间孔成形技术,均可缓解腰腿疼痛、改善腰椎功能,二者疗效相当;在术后住院时间、安全性、LDH复发率等方面,二者也相当;但前者可减少术中射线辐射、缩短手术时间、提高椎间孔成形的效率。

Objective:To explore the application value of visualization foraminoplasty in percutaneous endoscopic transforaminal discectomy(PETD)for treatment of giant lumbar disc herniation(LDH).Methods:The medical records of 67 patients who underwent PETD for treatment of giant LDH were analyzed retrospectively.The visualization foraminoplasty was employed during the PETD in 31 patients(visualization foraminoplasty group),and the conventional foraminoplasty was employed during the PETD in 36 ones(conventional foraminoplasty group).The intraoperative X-ray exposure, time spent in building passageway, operative time, bone resection volume of superior articular process(SAP),postoperative hospital stay, clinical outcome, incidence rate of postoperative complication, recurrence rate of LDH as well as the lumbago-leg pain visual analogue scale(VAS)score and Oswestry disability index(ODI)measured before the PETD,on week 1,month 1,month 3 after the PETD and at the last follow-up were compared between the 2 groups.Results:(1)The intraoperative X-ray exposure was fewer, the time spent in building passageway and operative time were shorter, the bone resection volume of SAP was larger in visualization foraminoplasty group compared to conventional foraminoplasty group(12.48±3.15 vs 23.58±7.07 times, t=-8.073,P=0.000;21.61±6.09 vs 30.89±9.59 minutes, t=-4.637,P=0.000;53.39±12.25 vs 65.31±11.76 minutes, t=-4.508,P=0.000;0.69±0.16 vs 0.40±0.14 cm(3),t=7.659,P=0.000).There was no statistical difference in postoperative hospital stays between the 2 groups(3.74±1.48 vs 3.97±1.30 days, t=-0.678,P=0.500).(2)There was interaction between time factor and group factor in lumbago-leg pain VAS score(F=216.417,P=0.000;F=275.367,P=0.000).There was statistical difference in lumbago-leg pain VAS scores between different timepoints before and after the PETD,in other words, there was time effect(F=219.335,P=0.000;F=281.412,P=0.000).There was no statistical difference in lumbago-leg pain VAS scores between the 2 groups in general, in other words, there was no group effect(F=0.016,P=0.899;F=0.258,P=0.613).The lumbago-leg pain VAS scores presented a time-dependent decreasing trend in the 2 groups, and the 2 groups were consistent with each other in the variation tendency(lumbago VAS score: 5.90±1.33,2.52±0.72,2.13±0.81,1.71±0.64,1.52±0.68 points, F=80.215,P=0.000;5.78±1.07,2.64±0.60,2.17±0.78,1.64±0.64,1.47±0.65 points, F=153.720,P=0.000.leg pain VAS score: 6.61±1.26,2.45±0.77,1.84±0.74,1.65±0.61,1.42±0.62 points, F=118.069,P=0.000;6.75±1.34,2.50±0.81,1.89±0.79,1.72±0.66,1.47±0.70 points, F=146.603,P=0.000).(3)There was interaction between time factor and group factor in ODI(F=479.277,P=0.000).There was statistical difference in ODI between different timepoints before and after the PETD,in other words, there was time effect(F=476.994,P=0.000).There was no statistical difference in ODI between the 2 groups in general, in other words, there was no group effect(F=0.022,P=0.882).The ODI presented a time-dependent decreasing trend in the 2 groups, and the 2 groups were consistent with each other in the variation tendency(59.23±9.85,24.39±6.08,18.84±5.31,13.81±3.55,10.71±2.95 %,F=188.572,P=0.000;57.83±8.42,23.50±5.62,18.89±5.39,14.83±3.78,11.33±3.28 %,F=327.092,P=0.000).(4)The clinical outcome was evaluated at the last follow-up.Nineteen patients obtained an excellent result, 8 good, 3 fair and 1 poor in visualization foraminoplasty group;while 18 ones obtained an excellent result, 12 good, 4 fair and 2 poor in conventional foraminoplasty group.There was no statistical difference in the clinical outcome between the 2 groups(Z=-0.898,P=0.369).(5)No complications such as neurovascular injury and intervertebral space infection were found in the 2 groups.The postoperative residual nucleus pulposus was found in 1 patient in conventional foraminoplasty group, and the symptoms were relieved after another PETD.There was no statistical difference in the incidence rate of postoperative complication between the 2 groups(P=1.000).The postoperative LDH recurrence was found in 1 patient in visualization foraminoplasty group and conventional foraminoplasty group respectively, and the symptoms were relieved after lumbar spinal fusion.There was no statistical difference in the recurrence rate of LDH between 2 groups(P=1.000).Conclusion:Application of visualization foraminoplasty and conventional foraminoplasty in PETD can relieve lumbago-leg pain and improve lumbar function in treatment of giant LDH,and they are similar to each other in clinical outcome, postoperative hospital stay, safety and recurrence rate of LDH.However, the former surpasses the latter in reducing intraoperative radiation, shortening operative time and improving the efficiency of foraminoplasty.