超前镇痛辅助精准局麻、术中找纤维环破口在椎间孔镜治疗腰椎间盘突出症中的应用

Application of Advanced Analgesia Assisted with Precise Local Anesthesia and Intraoperative Fiber Ring Puncture in Treatment of Lumbar Disc Herniation under Intervertebral Foramen Endoscopy

目的观察超前镇痛、精准局麻、术中找纤维环破口在椎间孔镜治疗腰椎间盘突出症中的临床疗效。方法回顾分析2019年10月-2021年10月因为腰腿痛就住本院并接受椎间孔镜治疗的121例患者,入院诊断为腰椎间盘突出症。在本院行椎间孔镜下髓核摘除+神经根管扩大减压术,其中椎间孔入路90例,板间入路31例。术前予以超前镇痛,术中精准局部麻醉,术中边操作边鼓励患者咳嗽,增加腹压,找到纤维环破口,从原纤维环破口进入椎间隙并摘除间隙内退变明显、疏松的髓核组织。结果121例患者均得到随访,术中均无神经根脊髓损伤,2例患者术中出现颈痛及心率加快,考虑出现高颅压综合征,予以降低灌注压及“边停边做”后顺利完成手术,其他患者心率及血压相对平稳,没有明显的疼痛及呼吸困难等不良反应,术后即刻下肢疼痛症状均改善明显,术后即刻下肢直腿抬高试验由术前阳性转变成阴性,VAS评分由术前7~9分变为术后1~2分。术后平均随访9~15个月,5例术后复发,其中2例再次接受椎间孔镜治疗、3例行椎间融合手术。结论超前镇痛辅助精准局部麻醉能降低术中疼痛,让患者术中体验感更好、手术更安全,手术过程患者神志清醒,术者与患者交流降低了神经根脊髓损伤等的风险,同时可以判断疗效,判断减压是否彻底。术中鼓励患者咳嗽,增加腹压,便于找到纤维环破口,减少医源性纤维环破口,降低术后复发或髓核残留的发生率。

Objective To explore clinical effect and experience of advanced analgesia,precise local anesthesia and intraoperative fiber ring puncture in treatment of lumbar disc herniation under intervertebral foramen endoscopy.Methods The paper reviewed and analyzed 121 lumbocrural pain patients with Percutaneous transforaminal endoscopic discectomy in our hospital from October 2019 to October 2021,diagnosed with lumbar disc herniation or lumbar disc herniation,treated with intervertebral foramen endoscopic nucleus pulposus removal and nerve root canal expansion decompression surgery in our hospital,including 90 cases through intervertebral foramen approach and 31 cases through interlaminar approach.Patients were treated with preoperative advanced analgesia,precise local anesthesia during surgery,patients were encouraged to cough during the procedure to increase abdominal pressure,and find fiber ring break,enter intervertebral space from original fiber ring break and remove significantly degenerative and loose nucleus pulposus tissue.Results All 121 patients were followed up and there were no nerve root or spinal cord injuries during the surgery.Two patients experienced neck pain and heart rate increase during the surgery,who were considered to have high intracranial pressure syndrome.After reducing perfusion pressure cases with intervertebral fusion surgery.Conclusion Advanced analgesia assisted with precise local anesthesia can reduce intraoperative pain,improve intraoperative experience of patients and make surgery safe.During the surgery,consciousness of patients is clear and communication between surgeon and patient can reduce risk of nerve root and spinal cord injury.At the same time,surgeon can determine curative effect and whether decompression is complete.Surgeon encourages patients to cough during surgery,to increase abdominal pressure,facilitate identification of fibrous ring breaks,reduce iatrogenic fibrous ring breaks and postoperative recurrence or residual nucleus pulposus.