刘书中,王以朋,余可谊
(中国医学科学院 北京协和医学院 北京协和医院骨科,北京 100730 )
·现代医学研究·
经皮椎间孔镜下椎间盘切除术治疗中老年腰椎间盘突出症
刘书中,王以朋,余可谊*
(中国医学科学院 北京协和医学院 北京协和医院骨科,北京 100730 )
目的评价经皮椎间孔镜下腰椎间盘切除术(PELD)治疗经保守治疗无效的中老年腰椎间盘突出症的临床效果。方法14例经保守治疗无效的中老年腰椎间盘突出症患者,经椎间盘造影证实14个椎间盘后方纤维环均撕裂,行PELD治疗。比较术前、术后疼痛视觉模拟评分(VAS)和术前、末次随访时Oswestry功能障碍指数(ODI),按改良Macnab标准评价临床疗效。结果手术时间60~120(96±18.1)min,术中出血量10~30(16±8.6)mL。住院时间3~9(4.6±1.3)d。14例均获随访,时间2~12(6.9±4.3)个月。术中未发生脑脊液漏、脊髓神经损伤。VAS术前为6~10(7.9±1.8)分,术后为0~3(1.8±1.2)分,差异有统计学意义(P<0.01)。ODI术前为52.0%~85.1%(78.1±17.3)%,末次随访时为10.8%~24.1%(16.2±5.2)%,差异有统计学意义(P<0.01)。根据改良Macnab标准:优7例,良6例,可1例。结论PELD治疗经保守治疗无效的中老年腰椎间盘突出症患者具有创伤小、恢复快、住院时间短等特点,疗效较好。
经皮内镜腰椎间盘切除术;中老年;腰椎间盘突出症;椎间盘造影
中老年腰椎间盘突出症发病率较低,较易漏诊,经皮内镜腰椎间盘切除术(PELD)治疗中老年腰椎间盘突出症临床报道较少。2014年5月—2015年11月,我院采用PELD治疗14例经保守治疗无效的中老年腰椎间盘突出症患者,经过长期随访,治疗效果满意。现总结报道如下。
1.1一般资料本组患者14例,男7例,女7例,年龄45~71岁。临床表现:腰痛伴左下肢痛6例,腰痛伴右下肢痛6例,腰痛伴双下肢痛2例,无椎管狭窄临床表现。其中4例有腰部扭伤史,余患者无外伤史。患者均摄腰椎正侧位、双斜位、前屈后伸位X线片,并行CT、MRI及双下肢B超检查,排除其他引起腰腿痛的疾患。患者病程3个月~15年。MRI见14个退变间盘,节段分布:L3—L41例,L4—L55例,L5—S18例,按改良Pfirrmann椎间盘退变分级:II级6例,III级8例。
1.2纳入标准经持续超过3个月保守治疗(包括理疗、腰背肌锻炼和药物治疗)无效,术前腰椎X线(正位、侧位、动力位)、CT及MRI检查均显示椎间盘退变、突出,造成神经根、硬膜囊压迫的中老年腰椎间盘突出症患者。
1.3排除标准腰椎管狭窄症患者;腰椎间隙高度减少20%以上者;腰椎感染、肿瘤和畸形患者;腰椎不稳和腰椎滑脱患者。
1.4治疗方法于背部穿刺点作一8 mm长皮肤切口,三级扩张套管逐级扩张后连接镜头、光源线、0.9%生理盐水冲洗液及吸引器,置入椎间孔镜工作套管,保持术野清晰,彻底摘除染色、突出变性的髓核组织,持续生理盐水灌洗,使用Ellman可屈性双极射频消融组织或突出物,止血,纤维环及髓核成形。术后第1天可带腰围下床活动,1.5个月内避免弯腰、旋转等活动。术中椎间盘造影观察病变椎间盘形态改变。患者取侧卧位,按侧后入路,局部麻醉后透视下穿刺针抵达椎间盘,注入有色造影剂(亚甲蓝+欧乃派克+生理盐水,1∶2∶2),经正、侧位透视观察椎间盘造影形态。
1.5疗效标准术前、术后行疼痛视觉模拟评分(VAS)评价;术前、末次随访行Oswestry功能障碍指数(ODI)评定,ODI= (所得分数/5×回答问题数)×100%,按改良Macnab标准评价临床疗效。
14例患者椎间盘造影显示:椎间盘形态不规则、弥散,后方纤维环撕裂,造影剂渗漏至椎管。术中未发生脑脊液漏、脊髓神经损伤。手术时间60~120(96±18.1) min,术中出血量10~30 mL,平均(16±8.6)mL。住院时间3~9 d,平均(4.6±1.3) d。14例均获随访,时间2~12(6.9±4.3)个月。术中未发生脑脊液漏、脊髓神经损伤。VAS术前为6~10分,平均(7.9±1.8)分;术后为0~3分,平均(1.8±1.2)分,差异有统计学意义(P<0.01)。ODI术前为52.0%~85.1%(78.1±17.3) %,末次随访时为10.8%~24.1%(16.2±5.2) %,差异有统计学意义(P< 0.01)。根据改良Macnab标准:优7例,良6例,可1例,优良率为92.9%(13/14)。
中老年腰椎间盘突出症(lumbar disc herniation,LDH)在临床上较为多见,具有病程长、病情重、渐进性发展的特点,常常出现突出局部的反复炎症反应,导致神经根袖与硬膜囊发生粘连[1]。本组排除腰椎管狭窄症的标准为无腰椎管狭窄症临床表现及X线、CT及MRI等检查提示未达到椎管狭窄的诊断标准。但实际上,中老年患者除具备LDH的临床症状及体征外,还有侧隐窝狭窄、黄韧带肥厚及椎间孔缩小等因素所致椎管狭窄的表现。部分中老年LDH经保守治疗可缓解,但对于保守治疗无效的中老年LDH患者仍需手术治疗[2-3]。
传统开放手术是治疗经保守治疗无效中老年LDH的有效方法,但由于创伤较大,存在造成椎旁肌肉、椎间韧带及脊柱单元完整性破坏的风险,易导致椎间盘突出复发、腰椎不稳及顽固性下腰痛,致使再手术风险增加且术后并发症较多[4]。中老年腰椎后部结构对腰椎的稳定性起着重要作用,保持完整的脊柱后部结构至关重要[5]。随着脊柱微创技术的发展,椎间孔镜下椎间盘切除术在治疗中老年LDH领域也取得了良好的临床效果。PELD经后外椎间孔入路,采用逐级扩张软组织的方式建立工作通道,最大限度地降低对周围软组织的损伤[6]。工作通道经椎间孔放置于目标区域,整个手术过程大大降低对脊柱骨性结构的破坏,维持了脊柱的稳定性,保护了脊柱的生物力学功能,降低术后腰椎不稳及下腰痛的风险[7]。术后24 h即可佩戴腰围下床活动,早期即能进行功能康复锻炼。术中应用亚甲蓝对椎间盘组织染色,可选择性切除蓝染退变组织,尽可能保留正常髓核组织,以促进椎间盘修复及保持脊柱的稳定性[8]。机械性切除部分椎间盘组织后,椎间盘内压力可明显下降,以促进突出椎间盘组织回缩。利用射频消融可进一步减低椎间盘内压力,促进纤维环回缩、愈合及修复[9]。术中持续生理盐水灌洗可将椎间盘内炎性介质及残留退变组织冲出,有利于缓解疼痛症状。本研究结果表明随着患者年龄的增加,术后疼痛症状的改善程度有所减低,这与年龄增加后,脊柱整体的退变较低龄患者更为明显,且退变累及脊柱结构较多,包括后方关节突骨赘形成、韧带松弛、脊柱周围肌肉软组织维持脊柱稳定的能力降低等因素有关[10]。中老年患者因长期腰部软组织劳损、三关节复合体(椎间盘、关节突关节)退变、关节突关节囊松弛等原因,更易合并节段性腰椎不稳定[11]。因此,对于中老年LDH患者,选择行PELD手术时,应从严把握手术适应证,注意排除合并腰椎明显退变及节段性腰椎不稳等[12]。
PELD治疗中老年LDH具有创伤小、出血少、安全性高、恢复快等优点,临床疗效满意,为中老年LDH的治疗提供了一种优化选择方案。但本组纳入研究病例数有限,尚需积累资料进一步深入探讨,PELD技术在中老年LDH治疗中的远期疗效及安全性也有待进一步随访观察。
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Percutaneous endoscopic lumbar discectomy for treatment of lumbar disc herniation
LIU Shuzhong,WANG Yipeng,YU Keyi*
(Chinese Academy of Medical Sciences,Beijing Union Medical College,Department of Orthopaedic,Beijing Union Medical College,Beijing 100730,China)
ObjectiveTo evaluate the clinical outcomes of percutaneous endoscopic lumbar discectomy (PELD) for middle-aged and elderly patient with lumbar disc herniation failing to conservative treatment.MethodsThe 14 middle-aged and elderly patients with lumbar disc herniation failing to conservative treatment were treated.Discography showed positive response,fluoroscopy confirmed annulus fibrosus tears of posterior intervertebral disc in 14 discs.PELD was performed.Visual analogue scale (VAS) and Oswestry disability index (ODI) were evaluated before operation and after operation.The clinical outcome was determined by modified Macnab criteria at the final follow-up.ResultsThe operation time was 60-120 (96±18.1) minutes,mean blood loss was 10-30(16±8.6)ml and length of hospital stay was 3-9 (4.6±1.3) days.14 cases were followed up for 2-12 (6.9±4.3) months.There was no cerebrospinal fluid leakage and nerve damage.VAS score before operation,after operation were 6-10 (7.9±1.8) and 0-3 (1.8±1.2) scores respectively,indicating there were significant differences compared with preoperative score (P< 0.01).ODI before operation,at the final follow-up were 52.0%-85.1% (78.1%±17.3%) and 10.8%-24.1% (16.2%±5.2%) respectively,indicating there were significant differences compared with preoperative scores (P< 0.01).According to the modified Macnab criteria,4 cases were graded as excellent,6 as good,4 as fair.ConclusionPELD is effective in treating middle-aged and elderly patients with lumbar disc herniation failing to conservative treatment.It has the advantages of less trauma,quick recovery and less length of hospital stay.
percutaneous endoscopic lumbar discectomy;middle-aged;lumbar disc herniation;discography
10.13463/j.cnki.cczyy.2016.05.057
国家自然科学基金项目(81171770)。
刘书中(1991-),博士研究生,主要从事骨关节疾病研究。
余可谊,副教授,电子信箱-yukeyi009@hotmail.com
R274.9
A
2095-6258(2016)05-1041-03
2015-07-08)