纤维环修复对微创髓核摘除术后脊柱运动功能恢复的意义

Clinical significance of annulus fibrosus repair for the recovery of spinal motor function after minimally invasive nucleus pulposectomy

目的探讨椎间孔镜下髓核摘除术中纤维环修复方法及其对术后临床疗效的影响。方法采用腰椎侧后路微创椎间孔镜治疗128例腰椎间盘突出症患者。均行椎间孔镜下髓核摘除术(采用TESSYS技术)。对照组32例,单纯摘除髓核后,直接撤出工作通道而常规不进行任何处理;试验组术前根据纤维环修复方法不同分为3组:射频组32例,采用双极射频对破裂的纤维环消融皱缩成型;蛋白胶组32例,于手术结束前,应用医用生物蛋白胶对纤维环破损处进行局部封闭。人工硬膜组32例,纤维环破损处放置人工硬脊膜切片(5 mm×5 mm)。对4组疼痛视觉模拟评分(visual analogue scales,VAS)、Oswestry功能障碍指数(Oswestry disability index,ODI)、MRI T2加权像信号强度、髓核摘除量(cm 3)、腰椎曲度指数(lumbar curvature index,LCI)、椎间隙高度等进行比较。结果术后患者切口均Ⅰ期愈合,均无术后早期并发症发生。患者均获随访,随访时间10~22个月,平均18个月;患者随访期间无典型术后髓核突出复发症状。患者随访期间均无典型术后髓核突出复发症状。术后随访未显示生物蛋白胶、人工硬脊膜两种可吸收植入材料的不良反应。随访期间无椎间隙感染、脑脊液漏、硬膜外血肿等并发症发生。术前各组间ODI评分、下腰痛VAS评分及双下肢疼痛VAS评分比较差异均无统计学意义(P>0.05)。术后2年随访时各组3个指标均较术前显著改善(P<0.05);4组比较差异均无统计学意义(P>0.05)。术前各组椎间盘MRI T2加权像信号强度比较差异均无统计学意义(P>0.05);术后2年随访时与术前比较差异有统计学意义(P<0.05);4组术后2年随访时椎间盘MRI T2加权像信号强度比较差异有统计学意义(P<0.05)。术前,4组LCI和椎间隙高度比较差异均无统计学意义(P>0.05);术后2年随访时,4组LCI和椎间隙高度均低于术前(P<0.05),4组LCI比较差异无统计学意义(P>0.05),射频组、蛋白胶组、人工硬膜组椎间隙高度均高于对照组(P<0.05)。射频组、蛋白胶组、人工硬膜组术中髓核摘除体积分别为(4.1±1.8)cm 3、(4.2±1.4)cm 3、(4.0±1.6)cm 3,大于对照组髓核摘除体积(3.9±1.9)cm 3,差异有统计学意义(P<0.05)。术后3个月和6个月,频组、蛋白胶组、人工硬膜组脊柱运动功能测定优于对照组(P<0.05)。结论腰椎侧后路微创椎间孔镜术中修复纤维环的近期临床疗效良好,远期疗效还需要进一步的随访观察评估。

Objective To investigate different ways of annulus fibrosus repair after transforaminal endoscopic nucleus pulposectomy in the treatment of lumbar disc herniation and clinical outcomes.Methods In total,128 patients with lumbar disc herniation were treated with minimally invasive transforaminal endoscopic nucleus pulposectomy via the lateral-posterior approach.All patients underwent transforaminal endoscopic nucleus pulposectomy(using TESSYS technology).Thirty-two patients in the control group were directly withdrawn from the working channel without any routine treatment after simple removal of the nucleus pulposus.The experimental group was divided into three groups according to different repair methods of annulus fibrosus repair before surgery:the radiofrequency group(n=32)was treated with bipolar radiofrequency to ablate and shrink the ruptured fibrous ring;32 patients in the protein glue group were treated with medical biological protein glue to locally seal the damaged area of the fibrous ring before the end of the surgery.Another 32 patients in the artificial dura mater group were treated with artificial dura mater slices(5 mm×5 mm)placed at the damaged area of the fibrous ring.Visual analog scale(VAS)pain score,Oswestry disability index(ODI),MRI T2 weighted image signal intensity,and nucleus pulposus removal volume(cm 3)lumbar curvature index(LCI)and intervertebral space height were compared in the four groups.Results The incisions of all postoperative patients healed in stage I,and there were no early postoperative complications.All patients were followed up for 10-22 months,with an average of 18 months.During the follow-up period,the patient had no typical symptoms of postoperative nucleus pulposus protrusion.Postoperative follow-up did not show any adverse reactions of two absorbable implant materials,biological protein glue and artificial dura mater.During the follow-up period,there were no complications such as intervertebral space infection,cerebrospinal fluid leakage,and epidural hematoma.There was no statistically significant difference in preoperative ODI score,lower back VAS pain score,and lower limb VAS pain score among groups(P>0.05).At the 2-year follow-up after surgery,all three indicators in each group showed significant improvement compared with those before surgery(P<0.05).There was no significant difference among four groups(P>0.05).There was no significant difference in signal intensity of T2 weighted MRI images of intervertebral discs among the groups before surgery(P>0.05).There was a significant difference between the 2-year follow-up after surgery and before surgery(P<0.05).There was a significant difference in signal intensity among four groups of intervertebral disc MRI T2 weighted images at 2-year follow-up(P<0.05).Before surgery,there was no significant difference in LCI and intervertebral space height among four groups(P>0.05).And the 2-year follow-up after surgery,the LCI and intervertebral space height of the four groups were all lower than those before surgery(P<0.05),and there was no significant difference in LCI among four groups(P>0.05).The intervertebral space height of the radiofrequency group,protein glue group,and artificial dura mater group was higher than that of the control group(P<0.05).The volume of nucleus pulposus removal during surgery in the radiofrequency group,protein glue group,and artificial dura mater group was(4.1±1.8)cm 3,(4.2±1.4)cm 3,and(4.0±1.6)cm 3,respectively,which was greater than the volume of nucleus pulposus removal in the control group[(3.9±1.9)cm 3],and the difference was significant(P<0.05).At 3 and 6 months after surgery,the spinal motor function measurements in the frequency group,protein glue group,and artificial dura mater group were better than those in the control group(P<0.05).Conclusion Application of transforaminal endoscopic nucleus pulposectomy and annulus fibrosus repair in the treatment of lumbar disc herniation have great clinical outcomes.More to the point,longer-term results will need further follow-up observation.