CAJ | 학술논문

目的设计经腰椎椎间孔开窗入路,探讨其可行性及临床应用效果.方法选取30具成人腰椎尸体标本,模拟L1～S1各节段经椎间孔开窗入路操作,充分显露出口神经根及椎间盘后外侧,实体测量完全显露椎间孔时椎板和关节突的切除和剩余范围；在开窗前、开窗后行CT扫描三维重建,测量切除和剩余范围.选取31例成人腰椎三维CT图像,测量L1～S1各节段经椎间孔开窗入路切除的骨结构范围.采用可动式脊柱内镜下经椎间孔开窗入路治疗腰椎极外侧椎间盘突出症10例,男4例,女6例.L3-4 2例,L4-5 4例,L5S1 4例.结果自L1至S1椎板峡部和关节突关节逐渐增宽,横突逐渐下移,峡部外缘和上关节突外缘到硬膜囊外缘的距离逐渐增大；在L1,2、L2,3和L3,4节段经椎间孔开窗入路切除较少的椎板峡部和关节突即可显露硬膜囊外缘和椎间盘后外侧；在L4,5尤其L5S1节段椎间孔开窗操作空间小,需切除较多的椎板峡部和关节突关节外缘才能显露椎间盘后外侧,硬膜囊显露较困难,下内侧月牙形开窗可保留较多的椎板和下关节突连接.临床应用10例手术均顺利完成,显露充分,彻底摘除了突出和游离的椎间盘髓核.随访6～24个月,末次随访时Macnab评分优8例、良2例,均无腰椎失稳表现.结论经腰椎椎间孔开窗入路可在保留椎板和下关节突连续性的基础上充分显露椎间孔,内镜下操作、下内侧月牙形开窗可以保留更多的骨性结构,治疗腰椎极外侧椎间盘突出症具有较好的可行性.
목적 설계경요추추간공개창입로,탐토기가행성급림상응용효과.방법 선취30구성인요추시체표본,모의L1～S1각절단경추간공개창입로조작,충분현로출구신경근급추간반후외측,실체측량완전현로추간공시추판화관절돌적절제화잉여범위；재개창전、개창후행CT소묘삼유중건,측량절제화잉여범위.선취31례성인요추삼유CT도상,측량L1～S1각절단경추간공개창입로절제적골결구범위.채용가동식척주내경하경추간공개창입로치료요추겁외측추간반돌출증10례,남4례,녀6례.L3-4 2례,L4-5 4례,L5S1 4례.결과 자L1지S1추판협부화관절돌관절축점증관,횡돌축점하이,협부외연화상관절돌외연도경막낭외연적거리축점증대；재L1,2、L2,3화L3,4절단경추간공개창입로절제교소적추판협부화관절돌즉가현로경막낭외연화추간반후외측；재L4,5우기L5S1절단추간공개창조작공간소,수절제교다적추판협부화관절돌관절외연재능현로추간반후외측,경막낭현로교곤난,하내측월아형개창가보류교다적추판화하관절돌련접.림상응용10례수술균순리완성,현로충분,철저적제료돌출화유리적추간반수핵.수방6～24개월,말차수방시Macnab평분우8례、량2례,균무요추실은표현.결론 경요추추간공개창입로가재보류추판화하관절돌련속성적기출상충분현로추간공,내경하조작、하내측월아형개창가이보류경다적골성결구,치료요추겁외측추간반돌출증구유교호적가행성.
Objective To explore the feasibility and clinical effects of transforaminal fenestration approach in lumbar spine.Methods Transforaminal fenestration approach was performed on 30 specimens of adult lumbar spine from L1 to S1 segments,with the exiting nerve root and posterior aspect of disc fully exposed.The resected structures were measured.The 3D CT was performed before and after fenestration,and the structure resected was measured.The 3D CT data of lumbar spine of 31 adult patients were collected and the resected structures were measured.Transforaminal fenestration approach was applied in 10 patients with far lateral lumbar disc herniation.Microendoscopic discectomy was performed with mobile endospine system at level of L3,4 in 2 cases,L4,5 in 4,L5S1 in 4.Results From L1 to S1,the isthmus and laminae gradually extends laterally,the transverse process gradually moves downward,and the distance between the dura sac and the lateral edge of lamina and facet increased.At the segment of L1,2,L2,3 and L3,4,only a small range of structure was resected.At the segment of L4,5 and L5S1,a large range of lamina and faceted were resected,and the dura sac can not be fully exposed.A crescentiform fenestration can preserve more connection of isthmus and lower facet.The transforaminal fenestration approach was successfully used in all the 10 patients,the herniation and sequestered nucleus was exposed fully and removed completely.The follow-up time was 12 months,excellent result was obtained in 8 patients,and good in 2 according to Macnab scale,without instability at dynamic film.Conclusion Transforaminal fenestration approach can provide enough exposition with the preservation of stable structure in lumbar spine,especially with endoscopic surgery and cresceutiform fenestration,and far lateral lumbar disc herniation can be effectively treated in this approach.