单侧双通道脊柱内镜技术对侧椎板下入路治疗腰椎侧隐窝狭窄合并同节段椎间孔狭窄的早期疗效

Short-term effectiveness of unilateral biportal endoscopy technique in treatment of lumbar lateral saphenous fossa combined with intervertebral foramina stenosis via contralateral sublaminar approach

目的探讨单侧双通道脊柱内镜技术(unilateral biportal endoscopy,UBE)对侧椎板下入路治疗腰椎侧隐窝狭窄合并同节段椎间孔狭窄的早期疗效。方法回顾分析2021年9月—2023年12月收治且符合选择标准的15例腰椎侧隐窝狭窄合并同节段椎间孔狭窄患者临床资料。男5例,女10例;年龄46~83岁,平均70.3岁。手术节段:L_(4)、512例,L_(5)、S_(1)3例。病程12~30个月,平均18.7个月。所有患者均接受UBE对侧椎板下入路手术治疗。记录手术时间、术中出血量、术后住院时间以及并发症发生情况。手术前后采用疼痛视觉模拟评分(VAS)评价腰腿痛程度,日本骨科协会(JOA)评分以及Oswestry功能障碍指数(ODI)评价腰部功能,术后6个月采用MacNab标准对患者疗效进行评价。术后复查MRI和CT,观察侧隐窝和椎间孔狭窄是否去除,测量椎管横截面积(cross-sectional area of the spinal canal,CSA-SC)、椎间孔横截面积(cross-sectional area of the intervertebral foramen,CSA-IVF)和小关节横截面积(cross-sectional area of the facet joint,CSA-FJ)。结果手术时间55~200 min,平均127.5 min;术中出血量10~50 mL,平均27.3 mL;术后住院时间3~12 d,平均6.8 d。患者均获随访,随访时间6~12个月,平均8.9个月。术后1 d及1、3、6个月腰、腿痛VAS评分以及ODI均较术前降低,且随时间延长呈逐渐下降趋势;JOA评分则呈逐渐增高趋势;上述指标各时间点间差异均有统计学意义(P<0.05)。术后6个月根据MacNab标准评估手术疗效:优10例、良4例、可1例,优良率93.33%。影像学复查示侧隐窝及椎间孔所受压迫已明显解除,最大程度保留患侧关节突关节;术后3 d CSA-SC及CSA-IVF较术前增加、CSA-FJ较术前减小,差异均有统计学意义(P<0.05)。结论UBE对侧椎板下入路能在保留双侧关节突关节同时,对侧隐窝及同节段椎间孔进行充分减压,早期疗效较好,有望避免腰椎医源性不稳所致的融合手术,但中、远期疗效有待进一步随访明确。

Objective To investigate the short-term effectiveness of unilateral biportal endoscopy(UBE)in treatment of lumbar lateral saphenous fossa combined with intervertebral foramina stenosis via contralateral sublaminar approach.Methods A clinical data of 15 patients with lumbar lateral saphenous fossa combined with intervertebral foramina stenosis,who were admitted between September 2021 and December 2023 and met selective criteria,was retrospectively analyzed.There were 5 males and 10 females with an average age of 70.3 years(range,46-83 years).Surgical segment was L_(4),5 in 12 cases and L_(5),S_(1) in 3 cases.The disease duration was 12-30 months(mean,18.7 months).All patients were treated by UBE via contralateral sublaminar approach.The operation time,intraoperative blood loss,postoperative hospital stay,and the occurrence of complications were recorded.The visual analogue scale(VAS)score was used to evaluate the degree of lower back and leg pain before and after operation;the Japanese Orthopaedic Association(JOA)score and the Oswestry disability index(ODI)were used to evaluate the lumbar function;and the clinical outcome was evaluated using the MacNab criteria at 6 months after operation.Postoperative MRI and CT were taken to observe whether the lateral saphenous fossa and intervertebral foramen stenosis were removed or not,and the cross-sectional area of the spinal canal(CSA-SC),cross-sectional area of the intervertebral foramen(CSA-IVF),and cross-sectional area of the facet joint(CSA-FJ)were measured.Results The operation time was 55-200 minutes(mean,127.5 minutes);the intraoperative blood loss was 10-50 mL(mean,27.3 mL);the length of postoperative hospital stay was 3-12 days(mean,6.8 days).All patients were followed up 6-12 months(mean,8.9 months).At 1 day,1 month,3 months,and 6 months after operation,the VAS scores of low back and leg pain and ODI scores after operation were significantly lower than preoperative scores and showed a gradual decrease with time;the JOA scores showed a gradual increase with time;the differences in the above indexes between different time points were significant(P<0.05).The clinical outcome was rated as excellent in 10 cases,good in 4 cases,and poor in 1 case according to the MacNab criteria at 6 months after operation,with an excellent and good rate of 93.33%.Imaging review showed that the compression on the lateral saphenous fossa and intervertebral foramina had been significantly relieved,and the affected articular process joint was preserved to the maximum extent;the CSA-SC and CSA-IVF at 3 days after operation significantly increased compared to the preoperative values(P<0.05),and the CSA-FJ significantly reduced(P<0.05).Conclusion The UBE via contralateral sublaminar approach can effectively reduce pressure in the lateral saphenous fossa and the intervertebral foramina of the same segment while preserving the bilateral articular process joints.The short-term effectiveness is good and it is expected to avoid fusion surgery caused by iatrogenic instability of the lumbar spine.However,further follow-up is needed to clarify the mid-and long-term effectiveness.