CAJ | 학술논문

背景:近年来经皮激光椎间盘减压术在国内逐步开展.但缺乏经皮激光椎间盘减压术适应证,禁忌证的细致研究.目的:分析经皮激光椎间盘减压术适应证的选择对疗效的影响.设计:以患者为观察对象的病例配对观察分析.单位:解放军第四七四医院放射科.对象:于1998-08/2004-12选取解放军第四七四医院经皮激光椎间盘减压术治疗的住院患者为观察对象.纳入病例对照68例.按照性别相同、年龄最接近(如同年龄的病例在2个或2个以上时,选择病程最接近的1个)的原则选择配对病例分两组,适应证不良组和适应证良好组,每组34例.方法:患者俯卧于血管造影床上,透视下在体表标记症状较重侧.局部麻醉.根据患者胖瘦不同,于患侧后正中线旁8～12 cm进针,调整角度在神经根下方"安全三角"进入椎间盘,使其前端5 mm裸露段,正好完全超出针尖.用15 W激光烧灼,每持续1 s,间隔4 s,根据椎间盘面积调整激光总输出功率,一般1 200-1 700 J.烧灼过程中将产生的气体抽出,至少抽3次,如患者出现胀痛的感觉要随时抽吸.术毕拔出穿刺针和光导纤维.局部贴创可贴.患者仰卧,检查疼痛缓解情况和功能恢复情况.出院时按照改良Macnab标准进行疗效评定.评估标准:优:疼痛消失,无运动功能受限,恢复正常工作和活动;良:偶有疼痛,能做轻工作;可:有些改善,仍有疼痛,不能工作;差:有神经受压表现,须进一步手术.将疗效优和良合并,作为疗效良好;可和差合并,作为疗效不佳.采用配对计数资料的x2检验.主要观察指标:①所有病例出院时根据改良Macnab标准进行的适应证不良组和适应证良好组总体疗效评价;②椎间盘突出≥0.6 cm组与椎间盘突出＜0.6 cm组疗效比较;③合并椎管狭窄组与椎管正常组疗效比较;④其他适应证不良组与适应证良好组疗效比较.结果:68例患者全部进入结果分析.①适应证良好组疗效良好明显高于适应证不良组,差异有显著性意义[85%(29/34),56%(19/34),x2=5.06,P＜0.05].②椎间盘突出＜0.6 cm组疗效良好明显高于椎间盘突出≥0.6cm组,但差异无显著性意义[75%(6/8),50%(4/8),x2=0.25,P＞0.05].③椎管正常组疗效良好与合并椎管狭窄组接近,差异无显著性意义[80%(12/15),73(11/15),x2=0,P＞0.05].④适应证良好组疗效良好明显高于无其他适应证不良组,差异有显著性意义[100%(11/11),36%(4/11),x2=5.14,P＜0.05].结论:适当地选择适应证能够有效地提高激光椎间盘减压术的治疗效果. 揹景:近年來經皮激光椎間盤減壓術在國內逐步開展.但缺乏經皮激光椎間盤減壓術適應證,禁忌證的細緻研究.目的:分析經皮激光椎間盤減壓術適應證的選擇對療效的影響.設計:以患者為觀察對象的病例配對觀察分析.單位:解放軍第四七四醫院放射科.對象:于1998-08/2004-12選取解放軍第四七四醫院經皮激光椎間盤減壓術治療的住院患者為觀察對象.納入病例對照68例.按照性彆相同、年齡最接近(如同年齡的病例在2箇或2箇以上時,選擇病程最接近的1箇)的原則選擇配對病例分兩組,適應證不良組和適應證良好組,每組34例.方法:患者俯臥于血管造影床上,透視下在體錶標記癥狀較重側.跼部痳醉.根據患者胖瘦不同,于患側後正中線徬8～12 cm進針,調整角度在神經根下方"安全三角"進入椎間盤,使其前耑5 mm裸露段,正好完全超齣針尖.用15 W激光燒灼,每持續1 s,間隔4 s,根據椎間盤麵積調整激光總輸齣功率,一般1 200-1 700 J.燒灼過程中將產生的氣體抽齣,至少抽3次,如患者齣現脹痛的感覺要隨時抽吸.術畢拔齣穿刺針和光導纖維.跼部貼創可貼.患者仰臥,檢查疼痛緩解情況和功能恢複情況.齣院時按照改良Macnab標準進行療效評定.評估標準:優:疼痛消失,無運動功能受限,恢複正常工作和活動;良:偶有疼痛,能做輕工作;可:有些改善,仍有疼痛,不能工作;差:有神經受壓錶現,鬚進一步手術.將療效優和良閤併,作為療效良好;可和差閤併,作為療效不佳.採用配對計數資料的x2檢驗.主要觀察指標:①所有病例齣院時根據改良Macnab標準進行的適應證不良組和適應證良好組總體療效評價;②椎間盤突齣≥0.6 cm組與椎間盤突齣＜0.6 cm組療效比較;③閤併椎管狹窄組與椎管正常組療效比較;④其他適應證不良組與適應證良好組療效比較.結果:68例患者全部進入結果分析.①適應證良好組療效良好明顯高于適應證不良組,差異有顯著性意義[85%(29/34),56%(19/34),x2=5.06,P＜0.05].②椎間盤突齣＜0.6 cm組療效良好明顯高于椎間盤突齣≥0.6cm組,但差異無顯著性意義[75%(6/8),50%(4/8),x2=0.25,P＞0.05].③椎管正常組療效良好與閤併椎管狹窄組接近,差異無顯著性意義[80%(12/15),73(11/15),x2=0,P＞0.05].④適應證良好組療效良好明顯高于無其他適應證不良組,差異有顯著性意義[100%(11/11),36%(4/11),x2=5.14,P＜0.05].結論:適噹地選擇適應證能夠有效地提高激光椎間盤減壓術的治療效果.
배경:근년래경피격광추간반감압술재국내축보개전.단결핍경피격광추간반감압술괄응증,금기증적세치연구.목적:분석경피격광추간반감압술괄응증적선택대료효적영향.설계:이환자위관찰대상적병례배대관찰분석.단위:해방군제사칠사의원방사과.대상:우1998-08/2004-12선취해방군제사칠사의원경피격광추간반감압술치료적주원환자위관찰대상.납입병례대조68례.안조성별상동、년령최접근(여동년령적병례재2개혹2개이상시,선택병정최접근적1개)적원칙선택배대병례분량조,괄응증불량조화괄응증량호조,매조34례.방법:환자부와우혈관조영상상,투시하재체표표기증상교중측.국부마취.근거환자반수불동,우환측후정중선방8～12 cm진침,조정각도재신경근하방"안전삼각"진입추간반,사기전단5 mm라로단,정호완전초출침첨.용15 W격광소작,매지속1 s,간격4 s,근거추간반면적조정격광총수출공솔,일반1 200-1 700 J.소작과정중장산생적기체추출,지소추3차,여환자출현창통적감각요수시추흡.술필발출천자침화광도섬유.국부첩창가첩.환자앙와,검사동통완해정황화공능회복정황.출원시안조개량Macnab표준진행료효평정.평고표준:우:동통소실,무운동공능수한,회복정상공작화활동;량:우유동통,능주경공작;가:유사개선,잉유동통,불능공작;차:유신경수압표현,수진일보수술.장료효우화량합병,작위료효량호;가화차합병,작위료효불가.채용배대계수자료적x2검험.주요관찰지표:①소유병례출원시근거개량Macnab표준진행적괄응증불량조화괄응증량호조총체료효평개;②추간반돌출≥0.6 cm조여추간반돌출＜0.6 cm조료효비교;③합병추관협착조여추관정상조료효비교;④기타괄응증불량조여괄응증량호조료효비교.결과:68례환자전부진입결과분석.①괄응증량호조료효량호명현고우괄응증불량조,차이유현저성의의[85%(29/34),56%(19/34),x2=5.06,P＜0.05].②추간반돌출＜0.6 cm조료효량호명현고우추간반돌출≥0.6cm조,단차이무현저성의의[75%(6/8),50%(4/8),x2=0.25,P＞0.05].③추관정상조료효량호여합병추관협착조접근,차이무현저성의의[80%(12/15),73(11/15),x2=0,P＞0.05].④괄응증량호조료효량호명현고우무기타괄응증불량조,차이유현저성의의[100%(11/11),36%(4/11),x2=5.14,P＜0.05].결론:괄당지선택괄응증능구유효지제고격광추간반감압술적치료효과.
BACKGROUND: In recent years, percutaneous laser disc decompression (PLDD) has been developed gradually in China. But there have been fewer further studies on the indications and contraindications for the use of the therapy.OBJECTIVE: To analyze the therapeutic effect after the choice of the indications for PLDD.DESIGN: A case-paired observational analysis with the patients as the subjects.SETTING: The Department of Radiology and Department of Soft Injuries of the 474 Hospital of Chinese PLA.PARTICIPANTS: We recruited inpatients of the 474 Hospital of Chinese PLA after PLDD between August 1998 and December 2004 as subjects for this research. Totally 68 cases were involved. According to the same gender, the closeness in age, the cases were matched and divided into 2 groups (eg. If there were 2 or more than 2 cases with the same age, the case whose disease course is the closest one was chosen): poor indication group (n=34) and good indication group (n=34).METHODS: A pillow was put under the belly of the patient who lay face down on the angiographic bed with the side with serious symptoms near the outside of the bed (the side where doctor operated). Symbols were marked on the body surface under the fluoroscopy. The waist was subjected to conventional sterilization and was paved with a piece of sterile cloth. 5 Ml of lydocaine was used for anesthesia. 8-12 cm to the posterior central midline of the diseased side, an incision was made to insert the needle according to the fat and thinness of the patients, and attention to the angle adjustment was needed to enter the intervertebral disc through "the secure triangle"beneath the nerve root so that 5 mm of the exposed front segment covered the needle end completely. Cautery was made with 15 W laser for every 1s after an interval of 4 s. The total output power of laser was adjusted according to the area of intervertebral disc, which was usually 1 200-1 700joules. The gas produced should be drawn out during the cautery, and this was done at least for 3 times. If the patient felt the distending pain, drawing out gas should be performed at any time. The puncturing needle and fiberoptics were pulled out after the operation, and band-aid was applied to the local area. The patients lay at the supine position to let the doctor examine the remission and functional recovery. When the patients were discharged, modified Macnab standard was used to evaluate the therapeutic effect. Evaluation criteria: According to the modified Macnab standard, the therapeutic effect can be classified into the following types: excellent means disappearance of pain, no limitation in motor function, with complete recovery of normal working and movement; good means that the patients showed occasional pain, but were able to do light job; passable means that the patients showed partial improvement, but still felt pain, and were not able to work and move; poor means that the patients showed signs of nerve compression that further operation was needed. The therapeutic effect of being excellent and good was combined as good therapeutic effect,and that of being passable and poor was combined as poor therapeutic effect. X2test was performed to the paired numerative data by the author.MAIN OUTCOME MEASURES: ① General evaluation of the therapeutic effect of the poor indication group and good indication group according to modified Macnab standard when the patients were discharged from the hospital; ② Comparison of the curative effect between the group with intervertebral disc herniation ≥ 0.6 cm and the group with intervertebral disc herniation ＜ 0.6 cm; ③ Comparison of the therapeutic effect of the group complicated with spinal canal stenosis and the group with normal spinal canal; ④ Comparison of the therapeutic effect between the group with good indications and other groups with poor indications.RESULTS: All the 68 patients entered the result analysis. ①The therapeutic effect in the good indication group was obviously better than that in the poor indication group, with a significant difference [85%(29/34),56%(19/34) ,χ2=5.06,P ＜ 0.05]. ② The therapeutic effect was significantly better in the group with intervertevbral disc herniation ＜ 0.6 cm than in the group with intervertevbral discs herniation ≥ 0.6 cm, but without significant difference [75 % (6/8), 50% (4/8),χ2=0.25, P ＞ 0.05]. ③The therapeutic effects were close in the group complicated with spinal canal stenosis and the group with normal spinal canal, but without significant difference [80% ( 12/15 ), 73 ( 11/15 ) ,χ2=0,P ＞ 0.05].④ The therapeutic effect in the group with good indications was obviously better than that in other groups with poor indications, with a significant difference [100%( 11/11 ), 36%(4/11), χ2=5.14,P ＜ 0.05].CONCLUSION: It could improve the therapeutic effects of PLDD when indications were properly chosen.