椎间孔镜技术结合中医综合疗法治疗高龄腰椎管狭窄症临床研究

Clinical Study on Technique of Percutaneous Transforaminal Endoscopic Discectomy Combined with Comprehensive Therapy of Chinese Medicine for Lumbar Spinal Stenosis in Elderly Patients

目的:观察椎间孔镜技术结合中医综合疗法治疗高龄腰椎管狭窄的临床疗效。方法:将腰椎管狭窄症高龄患者(≥70岁) 90例为研究对象,随机分为3组各30例,治疗组采用椎间孔镜技术结合中医综合疗法方案治疗,中医疗法组采用中医综合疗法方案治疗,孔镜组采用单纯椎间孔镜手术治疗,观察3组治疗前及治疗3月后自觉及临床症状[采取腰痛、下肢疼痛及下肢麻木视觉模拟评分法(VAS)评分,Oswestry功能障碍指数问卷表(ODI)、腰椎骨科协会评分(JOA评分)、SF-36量表进行评估]的变化情况,采取改良MacNab标准评价临床疗效,同时记录椎间孔高度或面积(CT测量)和椎间隙高度、矢状位及横断面椎管前后径(MRI测量)变化情况,统计相关并发症及随访情况。结果:术后3个月,手术疗效优良率治疗组为90.0%,孔镜组为60.0%,2组比较,差异有统计学意义(P <0.05);自觉及临床症状治疗前后比较:3组腰痛、下肢疼痛及下肢麻木VAS评分均较治疗前明显下降,各组前后比较,差异有统计学意义(P <0.05);且治疗组评分下降程度优于孔镜组、中医疗法组(P <0.05),孔镜组评分下降程度优于中医疗法组(P <0.05);治疗后,3组ODI评分较治疗前明显下降,JOA、SF-36评分均较治疗前明显上升,各组间前后比较,差异有统计学意义(P <0.05),且治疗组ODI、JOA、SF-36评分改善程度均优于孔镜组、中医疗法组(P <0.05)。项影像学指标比较:中医疗法组患者左右椎间孔高度、左右椎间孔面积、椎间隙高度、矢状位椎管前后径、横断面椎管前后径值治疗前后比较,差异无统计学意义(P> 0.05);治疗后,治疗组、孔镜组上述各项指标均较治疗前及中医疗法组治疗后明显改善(P <0.05),但2组间比较无统计学意义(P> 0.05)。3组并发症发生率均比较低,且3组间比较,差异无统计学意义(P> 0.05)。治疗组疼痛症状复发率、间歇性跛行发生率明显低于中医疗法组、孔镜组,差异均有统计学意义(P <0.05)。结论:在椎间孔镜术治疗高龄腰椎管狭窄患者基础上加用中医综合治疗,利于术后残留病症改善,且其临床疗效、症状改善及中期随访结果均优于单纯孔镜组和单纯中医治疗方案,有临床推广价值。

Objective:To observe the clinical effect of the technique of percutaneous transforaminal endoscopic discectomy combined with comprehensive therapy of Chinese medicine for lumbar spinal stenosis in elderly patients.Methods:A total of 90 cases of elderly patients with lumbar spinal stenosis as the research subjects were randomly divided into three groups,30 cases in each group.The treatment group received the technique of percutaneous transforaminal endoscopic discectomy combined with comprehensive therapy of Chinese medicine for treatment;the Chinese medicine therapy group was treated with comprehensive therapy of Chinese medicine,and the percutaneous transforaminal endoscopic discectomy group simply received the technique of percutaneous transforaminal endoscopic discectomy.The changes of the subjective and clinical symptoms before treatment and after three months of treatment in the three groups were observed by the assessment of the score of the Visual Analogue Scale(VAS)of lower back pain,lower limbs pain and numbness of lower limbs,the questionnaire of Oswestry Dysfunction Index(ODI),the score of Japanese Orthopedic Association(JOA)and the36-Item Short Form Health Survey(SF-36).The clinical effect was assessed by the modified MacNab Criteria,and meanwhilethe changes in the height and area of intervertebral foramina measured by computed tomography(CT),the height of vertebrae interval,and the front and rear diameter of the sagittal view and the transverse section of the vertebral canal measured by magnetic resonance imaging(MRI)were recorded.The relevant complications and follow-up situations were statistically analyzed.Results:Three months after operation,the excellent and good rate of operation was 90.%in the treatment group and 60.0%in the percutaneous transforaminal endoscopic discectomy group.There was significant difference between the two gruops(P<0.05).In terms of the comparison of the subjective and clinical symptoms before and after treatment,the VAS scores of lower back pain,lower limbs pain and numbness of lower limbs in the three groups were significantly decreased when compared with those before treatment,the difference being significant(P<0.05);the decrease in the treatment group was better than that in the percutaneous transforaminal endoscopic discectomy group and the Chinese medicine therapy group(P<0.05);the decrease in the percutaneous transforaminal endoscopic discectomy group was superior to that in the Chinese medicine therapy group(P<0.05).After treatment,the scores of ODI in the three groups were significantly decreased,and the scores of JOA and SF-36 were significantly increased when compared with those before treatment,the difference being significant(P<0.05).The improvement of the scores of ODI,JOA and SF-36 in the treatment group was better than that in the percutaneous transforaminal endoscopic discectomy group and the Chinese medicine therapy group respectively(P<0.05).In terms of the results of the imaging indexes,there was no significant difference being found in the comparisons of the height and area of the left and right intervertebral foramina,the height of vertebrae interval,and the front and rear diameter of the sagittal view and the transverse section of the vertebral canal in the Chinese medicine therapy group before and after treatment(P>0.05).After treatment,the indexes above in the treatment group and the percutaneous transforaminal endoscopic discecto my group were improved when compared with those before treatment(P<0.05),but no significant difference was found in the comparison between the two groups(P>0.05).The incidence of complications in the three groups were relatively low,there being no significance in the difference between the three groups(P>0.05).The recurrence rate of pain symptoms and the incidence of intermittent claudication in the treatment group were significantly lower than those in the Chinese medicine therapy group and the percutaneous transforaminal endoscopic discectomy group,differences being significant(P<0.05).Conclusion:The additional use of Chinese medicine therapy based on the percutaneous transforaminal endoscopic discectomy in treating lumbar spinal stenosis in elderly patients,is good for the improvement of postoperative residual diseases and symptoms,whose clinical effect and improvement of symptoms as well as the results of mid-term follow-up are superior to those of pure percutaneous transforaminal endoscopic discectomy and pure comprehensive therapy of Chinese medicine,which is worthy of clinical application and promotion.