經(jīng)皮完全內鏡下脊柱手術技術的發(fā)展與現(xiàn)狀

侯樹勛

. 述評 Editorial .

經(jīng)皮完全內鏡下脊柱手術技術的發(fā)展與現(xiàn)狀

侯樹勛

現(xiàn)代經(jīng)皮內鏡下脊柱手術技術的發(fā)展是建立在 Yeung[1]發(fā)明的 YESS ( yeung endoscopic spine system ) 脊柱內鏡系統(tǒng)及 YESS 技術基礎之上的。Ruetten，Hoogland 等[2-3]在 YESS 脊柱內鏡系統(tǒng)基礎上進行改進，并提出完全內鏡技術 ( full-endoscopic technique ) 及 TESSYS ( transforaminal endoscopic surgical system ) 等概念。但這些脊柱內鏡系統(tǒng)都是使用帶工作通道的硬桿狀內鏡在持續(xù)生理鹽水灌洗下進行的微創(chuàng)脊柱手術，只是手術技術上不斷改進以適應更復雜的病例，所以都可以稱為完全內鏡下手術技術。目前主要用于頸、腰椎間盤突出癥、頸椎管狹窄癥、腰椎管狹窄癥及慢性腰痛等疾病的治療。

目前，經(jīng)皮完全內鏡下腰椎手術技術漸趨成熟。完全內鏡下腰椎間盤摘除術分為經(jīng)椎間孔入路和經(jīng)椎板間入路兩類技術[4]。最早的完全內鏡下腰椎間盤摘除術是使用 YESS 系統(tǒng)經(jīng)后外側椎間孔入路進行的由盤內至盤外的操作技術，適用于椎間孔型及極外側型椎間盤突出，對椎管內包含型突出及韌帶下型椎間盤脫出也可以有效處理，但對椎管內脫出及游離髓核無法有效切除[5]。Ruetten 等[6]采用側方入路技術可以將內鏡經(jīng)椎間孔置入椎管內，摘除脫出及游離髓核組織，使經(jīng)椎間孔完全內鏡下腰椎間盤摘除術適應證進一步擴大，但 L5～S1節(jié)段解剖與上位腰椎有諸多不同，使該技術運用困難。腰椎間孔擴大成形術的出現(xiàn)使這一難題的解決出現(xiàn)轉機，Knight 等[7-8]在治療腰痛時使用激光對腰椎間孔進行擴大以達到椎間孔減壓的效果，Hoogland等[3]在此基礎上發(fā)明的逐級環(huán)鋸系統(tǒng)，對腰椎間孔進行逐級擴大，使工作套管及內鏡直接進入椎管內進行脫出物的靶向切除，即由椎間盤外向內的 TESSYS 技術。

隨著腰椎間孔成形技術的出現(xiàn)及完善，可對大多數(shù)腰椎間盤突出癥進行有效治療[9-10]。但用于治療椎管內巨大型脫出及高度移位型椎間盤突出癥時，失敗率仍高達 15.7%[11]。

經(jīng)椎板間入路完全內鏡下腰椎間盤摘除術可以作為技術補充治療各種復雜的椎管內腰椎間盤突出癥，如巨大型或高度移位型椎間盤脫出。經(jīng)皮經(jīng)椎板間隙入路內鏡下腰椎間盤摘除術最早由 Choi 等[12]報道，盡管提出根據(jù)術前影像學資料確定穿刺路徑及工作區(qū)域 ( 腋路或肩路 ) 等理念，但由于工作套管進入椎管內的過程完全依賴 X 線透視引導及患者的反饋，無法確保工作套管置入過程中對椎管內神經(jīng)組織的保護，所以出現(xiàn)術中轉開放手術、硬膜撕裂、神經(jīng)根損傷、脫出物殘留等并發(fā)癥，總并發(fā)癥發(fā)生率高達 20.9%。而 Ruetten等[2]采用經(jīng)皮完全內鏡監(jiān)視下逐層進入、切開黃韌帶、經(jīng)走行神經(jīng)根外側 ( 肩路 ) 進入椎管內摘除脫出椎間盤組織的手術技術明顯提高了手術的安全性，優(yōu)良率達 92%，但復發(fā)率高達 5.7%，可能與術中只摘除椎管內脫出、游離椎間盤，而沒有處理椎間盤內松動的髓核有關，因此，該技術術后仍可出現(xiàn)神經(jīng)支配區(qū)感覺異常、硬膜撕裂等并發(fā)癥。李振宙等[13-14]結合 Choi 和 Ruetten 的技術優(yōu)點，提出根據(jù)椎間盤突出部位選擇合適椎管內工作區(qū)域的手術策略，大大增強了該手術的合理性及安全性。對于 L5～S1腋部 ( S1神經(jīng)根與硬膜囊之間 ) 脫出型，由于突出椎間盤組織相對固定，S1神經(jīng)根被擠向側隱窩，如果仍采用肩路 ( S1神經(jīng)根外側 ) 手術，神經(jīng)根可能嵌夾于脫出物和工作套管之間，造成神經(jīng)根損傷，而且 S1神經(jīng)根神經(jīng)節(jié)大多位于椎管內，擠壓神經(jīng)節(jié)會引起 S1皮節(jié)感覺異常；而對于腋部游離型，由于脫出物處于游離狀態(tài)，從肩路手術，可能將神經(jīng)根和游離脫出物一并推擠至對側，導致脫出物殘留，甚至引起對側神經(jīng)根受壓。解剖學研究發(fā)現(xiàn) S1神經(jīng)根從硬膜囊的發(fā)出角平均 22°，這個角度允許工作套管進入腋部進行手術操作[15-16]，而且 L5～S1腋型椎間盤脫出往往把 S1神經(jīng)根推向外側，增加神經(jīng)根硬膜囊之間的角度及空間，使腋路手術更加安全、容易。當然，對于腹型或肩型 L5～S1椎間盤突出，神經(jīng)根向內下移位，從神經(jīng)根肩部手術更為合理。對于 L2～5椎間盤突出癥，運用經(jīng)皮經(jīng)椎板間隙入路完全內鏡下腰椎間盤摘除術的手術策略更須小心謹慎：對肩型及腹型椎間盤突出，采用肩路手術；對腋型椎間盤突出，首先按 Suh 等[17]的方法確定走行神經(jīng)根發(fā)出點的位置，如果走行神經(jīng)根在硬膜囊的發(fā)出點位于椎間盤平面或椎間盤平面以上，單純采用腋路，將內鏡及工作套管直接置入走行神經(jīng)根腋部進行脫出物及椎間盤內松動髓核的摘除；如果走行神經(jīng)根在硬膜囊上的發(fā)出點位于椎間盤平面以下，先采用腋路，摘除腋部脫出或游離椎間盤組織，然后將工作區(qū)域移至走行神經(jīng)根肩部，摘除椎間盤內松動髓核組織 ( 腋路 - 肩路 )。

隨著經(jīng)皮內鏡下手術器械的改進與完善，經(jīng)皮經(jīng)椎板間隙入路完全內鏡下腰椎管減壓技術也獲得良好的臨床療效。經(jīng)皮經(jīng)椎板間隙完全內鏡下可以充分切除腰椎側隱窩骨性、肥厚韌帶、關節(jié)突關節(jié)囊腫及椎間盤來源的壓迫，Ruetten 等[18-19]比較經(jīng)椎板間隙完全內鏡下及顯微鏡下腰椎側隱窩減壓技術，兩者療效相近，但完全內鏡下手術并發(fā)癥明顯低于顯微鏡下腰椎管減壓技術。Komp 等[20]采用經(jīng)皮經(jīng)椎板間隙入路、單通道雙側減壓技術治療中央椎管狹窄也獲得 93% 的優(yōu)良率，與傳統(tǒng)手術結果相近，但并發(fā)癥發(fā)生率明顯降低。

經(jīng)皮腰椎內鏡技術在慢性腰痛的治療方面也取得優(yōu)異療效。采用側后路經(jīng)椎間孔下選擇性摘除、射頻熱凝纖維環(huán)成形術治療椎間盤源性腰痛[21-22]；采用內窺鏡下腰脊神經(jīng)背內側支切斷術治療腰椎小關節(jié)源性腰痛均獲得良好療效[23-24]。使大部分慢性腰痛的治療微創(chuàng)化、可視化、靶向化。

經(jīng)皮完全內鏡下胸椎手術技術運用較少[25]。Choi 等[26]采用局麻下完全內鏡下手術技術治療 14 例軟性胸椎間盤突出癥獲得良好的臨床療效，術中對上關節(jié)突外、下部分切除做椎間孔成形手術，創(chuàng)造內鏡進入胸椎管的通道，從而達到脫出物靶向切除的目的。

經(jīng)皮完全內鏡下頸椎手術技術目前有長足的發(fā)展。頸椎前路完全內鏡下椎間盤摘除、椎間孔成形、纖維環(huán)成形、椎管減壓等技術具有切口小、非融合、保留頸椎運動節(jié)段、費用低、恢復快、并發(fā)癥少、術后止痛藥使用少等優(yōu)點，無器械失敗風險、無假關節(jié)、術后吞咽不適、無融合手術后相鄰節(jié)段病變等并發(fā)癥，可以作為門診手術實施[27]。Ruetten 等[28]比較完全內鏡下頸椎前路椎間盤摘除術和傳統(tǒng)頸椎前路融合手術療效、兩者無明顯差異，完全內鏡下手術組優(yōu)良率高達 96%。完全內鏡下頸椎前路椎間盤摘除、椎間融合術也獲得至少 5 年的隨訪，臨床優(yōu)良率達 86.6%，椎間融合率高達 100%[29]。當然，頸椎前路完全內鏡技術也可能發(fā)生嚴重并發(fā)癥如頸部大血管、食道、脊髓等重要結構的損傷[30-31]。所以嚴格適應證選擇、完善手術技術對促進該技術的推廣至關重要[32]，Liu 等[33]采用經(jīng)椎間盤及硬膜外造影技術勾勒出頸脊髓前方壓迫形態(tài)，術中X 線監(jiān)視及內鏡監(jiān)視下減壓，可以減少頸脊髓損傷的幾率。Ruetten 等[34]運用頸椎后路完全內鏡下頸椎間孔切開、椎間盤摘除術治療側后方型頸椎間盤突出癥也獲得 96.6% 的優(yōu)良率，未發(fā)生明顯并發(fā)癥。

在中國微創(chuàng)脊柱外科醫(yī)生的努力下，國內的經(jīng)皮完全內鏡下手術技術也獲得可喜的發(fā)展。本期內容涵蓋經(jīng)椎間孔入路、經(jīng)椎板間隙入路完全內鏡下腰椎間盤摘除技術、腰椎管減壓技術、頸椎管減壓及頸椎間盤摘除技術等內容，客觀反映了國內、外運用經(jīng)皮完全內鏡下脊柱手術技術治療脊柱疾病的現(xiàn)狀和水平。衛(wèi)生部建立的脊柱內鏡手術技術的逐級培訓及準入制度，一定會促進該技術在國內的健康發(fā)展。希望經(jīng)皮完全內鏡下脊柱手術技術能得到科學、合理地運用及推廣，惠及廣大患者。

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( 本文編輯：李貴存 )

Development and present status of percutaneous full-endoscopic spine surgery

HOU Shu-xun. Orthopedic Institute of CPLA, the frst Affliated Hospital of the General Hospital of CPLA, Beijing, 100048, PRC

With the improvement of the instrument and development of the technique, the same curative effects can be achieved in modern percutaneous endoscopic spine surgery as in traditional open surgery in the treatment of lumbar disc herniation. And the occurrence rate of complications is obviously reduced. The percutaneous endoscopic technique can be performed via the interlaminar approach and the transforaminal approach. Lumbar spinal stenosis and joint bone cyst are effectively treated with percutaneous endoscopic spinal canal decompression. Good curative results will be obtained in percutaneous endoscopic cervical discectomy and cervical intervertebral foramen dissection via anterior and posterior approaches for cervical disc herniation, cervical foraminal stenosis and so on. With unique advantages and higher treatment effectiveness, the percutaneous endoscopic technique is also effective in the treatment of chronic cervical and lumbar pain.

Intervertebral disc displacement; Diskectomy, percutaneous; Nal diseases; Surgical procedures; Minimally invasive

10.3969/j.issn.2095-252X.2014.08.002

Th776.1, R687.3

100048 北京，解放軍總醫(yī)院第一附屬醫(yī)院骨科

2014-06-13 )