CAJ | 학술논문

目的：分析椎间孔入路经皮内镜技术治疗脱出型腰椎间盘突出症的困难性及其处理对策。方法2011年2月至2014年2月，采用椎间孔入路经皮内镜技术治疗36例脱出型腰椎间盘突出症，男21例，女15例，平均年龄41岁。突出节段L3～42例、L4～523例、L5～S111例。基于Lee分类法，将36例脱出分类为重度头端脱出5例、轻度头端脱出7例、轻度尾端脱出15例、重度尾端脱出9例。首先采用“Between”技术摘除椎间隙平面脱出物并行硬膜外松解获得操作空间，然后将鞘管移向脱出方向采用“椎管内”技术镜下摘除剩余脱出物。结果平均手术时间为108min。术后短期大腿前方麻木4例、短期髂腰肌肌力下降1例、硬脊膜损伤合并多根神经根损伤1例、出口神经根损伤1例且脱出髓核摘除不彻底，其余35例脱出髓核摘除彻底。平均随访时间16(3～38)个月，术后第1天腰痛VAS)、腿痛VAS评分(visualanaloguescale)较术前改善(P＜0.01)，术后3个月VAS、JOA腰痛评分(japaneseorthopaedicassociationscores)、Oswestry功能障碍指数(oswestrydisabilityindex，ODI)指数较术前改善(P＜0.01)，MacNab疗效优25例、良7例、可3例、差1例。随访期内无复发与再手术。结论椎间孔入路经皮内镜结合应用“Between”技术与“椎管内”技术治疗绝大部分脱出型腰椎间盘突出症可获得良好的疗效，椎间孔扩大成形、初始通道建立与鞘管椎管内移动、镜下脱出髓核的准确判断是其技术关键，但对重度脱出仍然是一项挑战，其手术失败率、并发症发生率较高。
목적：분석추간공입로경피내경기술치료탈출형요추간반돌출증적곤난성급기처리대책。방법2011년2월지2014년2월，채용추간공입로경피내경기술치료36례탈출형요추간반돌출증，남21례，녀15례，평균년령41세。돌출절단L3～42례、L4～523례、L5～S111례。기우Lee분류법，장36례탈출분류위중도두단탈출5례、경도두단탈출7례、경도미단탈출15례、중도미단탈출9례。수선채용“Between”기술적제추간극평면탈출물병행경막외송해획득조작공간，연후장초관이향탈출방향채용“추관내”기술경하적제잉여탈출물。결과평균수술시간위108min。술후단기대퇴전방마목4례、단기가요기기력하강1례、경척막손상합병다근신경근손상1례、출구신경근손상1례차탈출수핵적제불철저，기여35례탈출수핵적제철저。평균수방시간16(3～38)개월，술후제1천요통VAS)、퇴통VAS평분(visualanaloguescale)교술전개선(P＜0.01)，술후3개월VAS、JOA요통평분(japaneseorthopaedicassociationscores)、Oswestry공능장애지수(oswestrydisabilityindex，ODI)지수교술전개선(P＜0.01)，MacNab료효우25례、량7례、가3례、차1례。수방기내무복발여재수술。결론추간공입로경피내경결합응용“Between”기술여“추관내”기술치료절대부분탈출형요추간반돌출증가획득량호적료효，추간공확대성형、초시통도건립여초관추관내이동、경하탈출수핵적준학판단시기기술관건，단대중도탈출잉연시일항도전，기수술실패솔、병발증발생솔교고。
Objective To analyze the pitfalls and technical notes of percutaneous transforaminal endoscopic surgery for migrated lumbar disc herniation. Methods Thirty-six consecutive patients with different types of migrated lumbar disc herniation received percutaneous transforaminal endoscopic discectomy from February 2011 to February 2014. There were 21 males and 15 females, with an average age of 41 years old. There were 2 cases of migrated L3-4 disc, 23 cases of migrated L4-5 disc and 11 cases of migrated L5-S1 disc. Based on Lee’s classiifcation of migrated disc, there were high-grade upward migration in 5 cases, low-grade upward migration in 7 cases, low-grade downward migration in 15 cases and high-grade downward migration in 9 cases. The disc fragments at the intervertebral level were removed ifrst by“between”technique, and then the epidural space was released to create manipulation space. Finally, the beveled cannula was manually advanced along the migration direction to perform endoscopic discectomy for the remanent migrated disc, which was called “intracanal” technique. Results The mean operation time was 108 minutes. The postoperative complications included transient numbness in the anterior thigh in 4 cases, transient iliopsoas weakness in 1 case, multiple nerve root injuries caused by dura tears in 1 case and exit nerve root injuries as well as incomplete endoscopic discectomy in 1 case. Complete removal of migrated disc was conifrmed in the other 35 cases. All the patients were followed up for a mean duration of 16 months ( range: 3-38 months ). The Visual Analogue Scale ( VAS ) scores of low back pain and leg pain at 1 day after the surgery were signiifcantly improved when compared with that preoperatively ( P<0.01 ). The low back pain VAS score, leg pain VAS score, Japanese Orthopedic Association ( JOA ) score and Chinese Oswestry Disability Index ( ODI ) score at 3 months after the surgery were signiifcantly improved when compared with that preoperatively ( P<0.01 ). According to the Macnab criteria, the clinical results were excellent in 25 cases, good in 7 cases, fair in 3 cases and bad in 1 case respectively. There was no recurrence or revision during the follow-up. Conclusions Good clinical results can be achieved by percutaneous transforaminal endoscopic surgery combined with“between”technique and“intracanal”technique in most patients with migrated lumbar disc herniation. The technical notes include proper foraminotomy, satisfactory initial position of beveled cannula, manipulation of beveled cannula along the direction of migration in the epidural space and accurate discrimination of migrated disc materials. It’s still a challenge to treat high-grade migration via the transforaminal approach, due to a higher failure rate and a higher incidence of complications.