三种经皮内镜椎间盘髓核摘除术治疗伴有高髂嵴的L5～S1椎间盘突出症
삼충경피내경추간반수핵적제술치료반유고가척적L5～S1추간반돌출증
Three approaches of percutaneous endoscopic lumbar discectomy for L5-S1 disc herniation with high iliac crest
  • 万方数据
    中国骨与关节杂志 중국골여관절잡지
    Chinese Journal of Bone and Joint
    2014年 8期 608-614 ,共7页

    杨进%孔清泉%宋跃明

    양진%공청천%송약명

    椎间盘移位%内窥镜检查%椎板切除%腰椎%髂骨%外科手术,微创性 椎間盤移位%內窺鏡檢查%椎闆切除%腰椎%髂骨%外科手術,微創性
    추간반이위%내규경검사%추판절제%요추%가골%외과수술,미창성
    Intervertebral disc displacement%Endoscopy%Laminectomy%Lumbar vertebrae%Ilium%Surgical procedures,minimally invasive
    目的：回顾性分析51例伴有高髂嵴的L5～S1椎间盘突出症接受3种不同手术入路的经皮内镜腰椎间盘髓核摘除术(percutaneousendoscopiclumbardiscectomy，PELD)的手术安全性及临床疗效，并探讨3种不同手术入路的适应证。方法2010年8月至2013年4月，采用椎间孔、椎板间和经髂骨椎间孔3种手术入路的PELD治疗的伴有高髂嵴的L5～S1椎间盘突出症的51例，其中男31例，女20例；平均年龄39(29～72)岁，平均病程6.7(3～23)个月，记录治疗方案选择及手术中转情况，手术时间、术中透视时间、术中及术后并发症发生情况。采用术前、术后3、6、12个月的视觉模拟评分(visualanaloguescales，VAS)评价患者腰痛、腿痛情况，Oswestry功能障碍指数(oswestrydisabilityindex，ODI)评定功能恢复，术后12个月评价责任神经根功能。结果所有手术均完成，2例采用椎间孔入路的病例(椎间孔外合并椎间孔内型)中转为经髂骨入路完成手术。经髂骨入路平均手术时间长于经椎间孔入路和经椎板间入路，分别是75(65～110)min，45(35～80)min，50(40～90)min(P＜0.05)；术中透视次数经椎间孔入路16.5次、经椎板间入路2.6次、经髂骨入路33.4次。所有病例均获至少12个月随访，均无神经损伤、感染等并发症，经髂骨入路组有1例骶髂关节面的损伤，目前尚无复发病例。术后各组内各时间点腰痛VAS、腿痛VAS及ODI均较术前明显降低(P＜0.05)。椎间孔入路组：腰痛VAS、腿痛VAS及ODI分别由术前(28.1±5.9)分、(71.8±7.5)分、(38.6±4.5)分降至术后1年(3.3±2.5)分、(4.4±4.6)分、(7.2±2.6)分(P＜0.05)；椎板间入路组：腰痛VAS、腿痛VAS及ODI分别由术前(28.5±5.2)分、(71.0±5.8)分、(37.7±4.3)分降至术后1年(7.0±3.6)分、(4.7±4.7)分、(8.1±4.2)分(P＜0.05)；经髂骨入路组：腰痛VAS、腿痛VAS及ODI分别由术前(28.5±4.5)分、(69.7±6.2)分、(38.4±4.3)分降至术后1年(5.0±3.4)分、(5.5±5.1)分、(8.3±4.2)分(P＜0.05)。术后1年3组的责任神经根支配区感觉、肌力均明显恢复(P＜0.01)，除椎间孔入路组的外侧型突出症影响的是L5神经根，故该组踝反射无明显改善外(P＞0.05)，其它2组踝反射均明显恢复(P＜0.05)。术后经椎板间入路组腰痛加重1例，复查MRI未见髓核突出复发，腰椎动力位未见明显节段不稳和滑脱，目前仍在随访中。结论3种PELD手术方式治疗合并高髂嵴的L5～S1椎间盘突出症均是安全、有效的，但每种手术方式的适应证不一：椎间孔入路(靶向穿刺)对于椎间孔外型有效；椎板间入路的内镜手术，对于中央型、旁中央型以及混合型伴或不伴有轻度脱垂的突出类型能够取得较好的临床疗效；经髂骨椎间孔入路可以有效地治疗椎间孔型、椎间孔合并椎间孔外型、旁中央型合并部分椎间孔内型，对伴有脱垂时需谨慎。
    목적：회고성분석51례반유고가척적L5～S1추간반돌출증접수3충불동수술입로적경피내경요추간반수핵적제술(percutaneousendoscopiclumbardiscectomy，PELD)적수술안전성급림상료효，병탐토3충불동수술입로적괄응증。방법2010년8월지2013년4월，채용추간공、추판간화경가골추간공3충수술입로적PELD치료적반유고가척적L5～S1추간반돌출증적51례，기중남31례，녀20례；평균년령39(29～72)세，평균병정6.7(3～23)개월，기록치료방안선택급수술중전정황，수술시간、술중투시시간、술중급술후병발증발생정황。채용술전、술후3、6、12개월적시각모의평분(visualanaloguescales，VAS)평개환자요통、퇴통정황，Oswestry공능장애지수(oswestrydisabilityindex，ODI)평정공능회복，술후12개월평개책임신경근공능。결과소유수술균완성，2례채용추간공입로적병례(추간공외합병추간공내형)중전위경가골입로완성수술。경가골입로평균수술시간장우경추간공입로화경추판간입로，분별시75(65～110)min，45(35～80)min，50(40～90)min(P＜0.05)；술중투시차수경추간공입로16.5차、경추판간입로2.6차、경가골입로33.4차。소유병례균획지소12개월수방，균무신경손상、감염등병발증，경가골입로조유1례저가관절면적손상，목전상무복발병례。술후각조내각시간점요통VAS、퇴통VAS급ODI균교술전명현강저(P＜0.05)。추간공입로조：요통VAS、퇴통VAS급ODI분별유술전(28.1±5.9)분、(71.8±7.5)분、(38.6±4.5)분강지술후1년(3.3±2.5)분、(4.4±4.6)분、(7.2±2.6)분(P＜0.05)；추판간입로조：요통VAS、퇴통VAS급ODI분별유술전(28.5±5.2)분、(71.0±5.8)분、(37.7±4.3)분강지술후1년(7.0±3.6)분、(4.7±4.7)분、(8.1±4.2)분(P＜0.05)；경가골입로조：요통VAS、퇴통VAS급ODI분별유술전(28.5±4.5)분、(69.7±6.2)분、(38.4±4.3)분강지술후1년(5.0±3.4)분、(5.5±5.1)분、(8.3±4.2)분(P＜0.05)。술후1년3조적책임신경근지배구감각、기력균명현회복(P＜0.01)，제추간공입로조적외측형돌출증영향적시L5신경근，고해조과반사무명현개선외(P＞0.05)，기타2조과반사균명현회복(P＜0.05)。술후경추판간입로조요통가중1례，복사MRI미견수핵돌출복발，요추동력위미견명현절단불은화활탈，목전잉재수방중。결론3충PELD수술방식치료합병고가척적L5～S1추간반돌출증균시안전、유효적，단매충수술방식적괄응증불일：추간공입로(파향천자)대우추간공외형유효；추판간입로적내경수술，대우중앙형、방중앙형이급혼합형반혹불반유경도탈수적돌출류형능구취득교호적림상료효；경가골추간공입로가이유효지치료추간공형、추간공합병추간공외형、방중앙형합병부분추간공내형，대반유탈수시수근신。
    Objective To retrospectively analyze the safety and effectiveness of 3 approaches of percutaneous endoscopic lumbar discectomy ( PELD ) in the treatment of L5-S1 disc herniation combined with high iliac crest in 51 patients, and to explore the proper indications of these approaches. Methods From August 2010 to April 2013, 51 consecutive patients with L5-S1 disc herniation combined with high iliac crest were included in the study and treated with PELD through interlaminar, transforaminal and transiliac approaches respectively. There were 20 females and 31 males, whose average age was 39 years old ( range:29-72 years ). The average duration of symptoms&nbsp;was 6.7 months ( range:3-23 months ). The selection of treatment plans and the switching of surgical approaches, operation time, intraoperative X-ray exposure time and intraoperative and postoperative complications were recorded. The Visual Analogue Scale ( VAS ) was used to evaluate low back pain and sciatica, and the Oswestry Disability Index ( ODI ) to assess the functional recovery preoperatively and at 3 months, 6 months and 12 months after the operation. The functional status of the irritated nerve roots was evaluated at 12 months after the operation. Results The operation was completed in all the patients. A transforaminal approach was planned for 2 patients, which was switched to a transiliac approach at last. The average operation time was 75 min ( range:65-110 min ) in the transiliac group, 45 min ( range:35-80 min ) in the transforaminal group and 50 min ( range:40-90 min ) in the interlaminal group, and it was longer in the transiliac group than that in other groups. The X-ray exposure times were 33.4 in the transiliac group, 16.5 in the transforaminal group and 2.6 in the interlaminal group. There were no nerve injuries or infections. A patient with injuries on the superior surface of the sacroiliac joint was found in the transiliac group. Reoccurrence was not noticed so far. The postoperative ODI scores and VAS scores of low back pain and sciatica were signiifcantly decreased at each time point when compared with the preoperative scores in 3 groups ( P<0.05 ). The VAS score of low back pain in the transforanminal group was reduced from ( 28.1±5.9 ) points preoperatively to ( 3.3±2.5 ) points at 1 year after the operation. The VAS score of sciatica was reduced from ( 71.8±7.5 ) points preoperatively to ( 4.4±4.6 ) points at 1 year after the operation. The ODI score was reduced from ( 38.6±4.5 ) points preoperatively to ( 7.2±2.6 ) points at 1 year after the operation ( P<0.05 ). The VAS score of low back pain in the interlaminal group was reduced from ( 28.5±5.2 ) points preoperatively to ( 7.0±3.6 ) points at 1 year after the operation. The VAS score of sciatica was reduced from ( 71.0±5.8 ) points preoperatively to ( 4.7±4.7 ) points at 1 year after the operation. The ODI score was reduced from ( 37.7±4.3 ) points preoperatively to ( 8.1±4.2 ) points at 1 year after the operation ( P<0.05 ). The VAS scores of low back pain and sciatica and ODI score in the transiliac group were reduced from 28.5±4.5, 69.7±6.2 and 38.4±4.3 points preoperatively to 5.0±3.4, 5.5±5.1 and 8.3±4.2 points at 1 year after the operation respectively ( P<0.05 ). Obvious recovery was achieved in the sensation and muscle strength of the irritated nerve roots at 1 year after the operation in 3 groups ( P<0.01 ). The L5 nerve root in a patient with lateral lumbar disc herniation was affected in the interlaminal group, and no significant improvement was found in the ankle reflex ( P>0.05 ). But obvious recovery was achieved in the ankle reflex in the other 2 groups ( P>0.05 ). A patient who underwent interlaminal PELD had more severe low back pain. The MRI and dynamic X-ray showed that there was no reoccurrence or the proof of unstablization or spondylolisthesis of the lumbar spine. The patient was still supervised. Conclusions The 3 approaches of PELD for L5-S1 disc herniation with high iliac crest are safe and effective, but the proper indications of these approaches may be different. The transforaminal surgery (targeted biopsy) may treat extraforaminal type more effectively. The interlaminal method may be more effective in the treatment of central, paracentral and central with paracentral L5-S1 disc herniation with or without mild prolapse. The transiliac approach can well deal with intraforanminal, intraforanminal with extraforaminal and intraforanminal with paracentral types, but we should be more cautious for migrated disc herniation when using this method.
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