经皮内镜治疗腰5骶1腰椎间盘突出症两种入路短中期疗效分析

Short-term and mid-term effect analysis of two approaches for percutaneous endoscopic treatment of lumbar 5-sacral 1 lumbar intervertebral disc herniation

目的对比脊柱微创手术中两种不同入路[椎间孔入路(PETD)/椎板间入路(PEID)]治疗L5/S1腰椎间盘突出症的短中期疗效。方法选取2019年9月至2021年12月锦州医科大学附属第三医院102例L5/S1间盘突出的患者作为研究对象,根据数字表分组,随机分成PETD组50例,PEID组52例,比较两组手术时间、C型臂使用次数、术后并发症、术后恢复时间以及短中期疗效。临床结果在术前、术后7天、术后6个月时进行测量。使用Oswestry残疾指数(the Oswestry disability index,ODI)和视觉模拟量表(Visual Analogue Scale,VAS)的测量特性评估下肢疼痛。日本骨科协会(Japanese Orthopaedic Association,JOA)评分系统和MacNab腰椎功能优良率评价术后效果,以及两组术后腰痛、足背麻木缓解时间。结果PETD和PEID两组通过术前与术后比较均明显好转,腰腿痛以及神经根受压症状明显改善,MacNab腰椎功能优良率分别为100%(52/52)、100%(50/50),两组差异无统计学意义(P>0.05)。两组术后恢复情况,PETD组与PEID组基本相同,差异无统计学意义(P>0.05)。VAS评分、JOA评分与ODI均比术前明显好转(均P<0.05);PEID组的短中期疗效与PETD组基本相似,差异无统计学意义(P>0.05)。手术过程,PEID组的手术时间、C臂投照次数明显低于PETD组(均P<0.05)。PEID组术后腰痛以及足背麻木时间较PETD组较短(P<0.05)。结论两种入路是各有千秋,当患者存在L5/S1高髂嵴影响手术操作的情况下,尽可能选择PEID手术入路,因其无论从患者角度还是医师角度都有较明显的优点。但是无论是PEID还是PETD两种入路都是可以进行L5/S1间盘突出病变髓核摘除的。建议当无明显高髂嵴和肥大L5/S1横突时,对于初学者应首先选择PETD治疗,因其为局部浸润麻醉,可以和患者进行沟通,避免一定程度的神经损伤风险;在熟练操作后两种入路通过合适的术前规划都可以达到完美的治疗目的。

【Objective】To compare the short-and mid-term effects of two different approaches(PETD/PEID)in the treatment of L5/S1 in minimally invasive spine.【Methods】A total of 102 patients with L5/S1 disc herniation treated in our hospital from September 2019 to December 2021 were selected,grouped by digital table,and randomly divided into 50 cases in PETD group and 52 cases in PEID group.Operation time,frequency of C-type arm use,postoperative complications,postoperative recovery time,and short-and mid-term efficacy were compared between the two groups.Clinical outcomes were measured preoperatively,7 days postoperatively,and 6 months postoperatively.Lower extremity pain was assessed using the Oswestry disability index(ODI)and a measurement characteristic of the Visual Analogue Scale.The Japanese Orthopaedic Association(JOA)Scoring Systems and the MacNab lumbar spine function rate were used to evaluate the postoperative effect,as well as the postoperative low back pain and back pain relief time of the two groups of patients.【Results】The PETD and PEID groups were significantly improved preoperatively and postoperatively.The symptoms of low back and leg pain and nerve root compression were significantly improved.The MacNab lumbar function excellent and good rates were 100%(52/52)and 100%(50/50),there was no significant difference between the two groups(P>0.05).The postoperative recovery of the two groups of patients was basically the same as that of the PETD group and the PEID group,and there was no statistical significance.The VAS score,JOA score and ODI were significantly better than those before operation(all P<0.05).The short-term and mid-term curative effect of PEID group was basically similar to that of PETD group,with no statistical significance(P>0.05).During the operation,the operation time and the number of C-arm projections in the PEID group were significantly lower than those in the PETD group(all P<0.05).The postoperative low back pain and dorsal numbness in the PEID group were shorter than those in the PETD group(P<0.05).【Conclusion】The two approaches have their own merits.When the patient has L 5/S 1 high iliac crest that affects the surgical operation,the PEID approach should be selected as much as possible,because it has obvious advantages from both the patient's and physician's perspectives.However,both PEID and PETD approaches can be used to extract the nucleus pulposus of L 5/S 1 disc herniated lesions.It is suggested that when there is no obvious high iliac crest and hypertrophy of the L 5/S 1 transverse process,PETD treatment should be selected first for beginners,because it is a local infiltration anesthesia,which can be communicated with the patient to avoid a certain degree of nerve damage risk;after skilled operation both approaches can achieve perfect therapeutic goals with appropriate preoperative planning.