經(jīng)皮內(nèi)鏡椎板間入路治療鈣化型腰椎間盤突出癥早期臨床療效分析

李 軍 付 強(qiáng)

. 脊柱微創(chuàng)外科 Minimally invasive spine surgery .

經(jīng)皮內(nèi)鏡椎板間入路治療鈣化型腰椎間盤突出癥早期臨床療效分析

李 軍 付 強(qiáng)

目的探討經(jīng)皮內(nèi)鏡椎板間入路技術(shù)治療鈣化型腰椎間盤突出癥的臨床療效及手術(shù)技巧。方法2011 年 11月 至 2013 年 6 月，我院收治的鈣化型腰椎間盤突出癥患者共 56 例，分別采用經(jīng)皮內(nèi)鏡椎板間入路手術(shù) ( I 組，28 例 ) 和傳統(tǒng)開窗手術(shù) ( II 組，28 例 ) 治療。于術(shù)前及術(shù)后 1 天、3 個(gè)月、6 個(gè)月，采用 Oswestry 功能障礙指數(shù) ( oswestry disability index，ODI )、視覺疼痛模擬評(píng)分 ( visual analogue scale，VAS )和 MacNab 改良的療效評(píng)定標(biāo)準(zhǔn)對(duì)患者進(jìn)行評(píng)估，并統(tǒng)計(jì)手術(shù)時(shí)間、術(shù)中出血量、切除骨量、術(shù)后并發(fā)癥、住院時(shí)間等指標(biāo)。結(jié)果兩組手術(shù)療效明顯，術(shù)后 1 天、3 個(gè)月、6 個(gè)月兩組 VAS 評(píng)分分別為 ( 3.52±0.23，2.99±0.11，3.15±0.19；4.02±0.23，3.48±0.13，3.03±0.04 )，較術(shù)前 ( 7.36±0.29；7.29±0.28 ) 均有明顯改善；ODI 指數(shù)分別從術(shù)前 ( 70.18±1.63；69.82±1.31 ) 降至 ( 34.24±1.39，32.84±1.38，33.33±1.40；36.51±1.39，33.50±1.50，32.48±2.87 )，術(shù)后 6 個(gè)月兩組 VAS 評(píng)分和 ODI 指數(shù)差異均無統(tǒng)計(jì)學(xué)意義( P＝0.34，P＝0.80 )。術(shù)后 6 個(gè)月，依據(jù) MacNab 標(biāo)準(zhǔn)，兩組患者優(yōu)良率差異無統(tǒng)計(jì)學(xué)意義 ( 96.4%∶92.9%，P＝0.62 )。I 組在術(shù)中出血量、切除骨量、住院時(shí)間均明顯優(yōu)于 II 組 ( P＜0.001 )；手術(shù)時(shí)間 I 組長于 II 組( 52.93±6.66 分：41.79±7.85 分，P＜0.001 )。術(shù)后并發(fā)癥，I 組 2 例下肢麻木，1 例硬膜破裂；II 組 1 例下肢麻木，4 例經(jīng)保守對(duì)癥治療后均痊愈，無永久性神經(jīng)損害或癥狀加重。結(jié)論與傳統(tǒng)開窗手術(shù)相比，經(jīng)皮內(nèi)鏡椎板間入路技術(shù)治療鈣化型腰椎間盤突出癥可以達(dá)到相同的臨床療效，同時(shí)具有組織損傷小、手術(shù)時(shí)間及住院康復(fù)時(shí)間短等優(yōu)勢。

腰椎；椎間盤移位；鈣化，生理性；椎間盤切除術(shù)，經(jīng)皮；內(nèi)窺鏡檢查

鈣化型腰椎間盤突出癥 ( calcified lumbar disc herniation ) 是腰椎間盤突出癥中一種較為特殊的類型，是在椎間盤退行性病變的基礎(chǔ)上伴發(fā)椎間盤鈣化，多發(fā)生于中老年患者[1-3]。以往多采用傳統(tǒng)開放手術(shù)治療，但該手術(shù)方式存在組織損傷大、并發(fā)癥多、手術(shù)時(shí)間及住院時(shí)間長等諸多不足之處。因鈣化的椎間盤組織堅(jiān)硬，并多伴有神經(jīng)根壓迫、硬膜囊粘連，在經(jīng)皮內(nèi)鏡下切除鈣化的椎間盤組織存在一定的困難與挑戰(zhàn)，既往認(rèn)為鈣化型腰椎間盤突出癥是經(jīng)皮內(nèi)鏡手術(shù)的禁忌證。近年來，隨著內(nèi)鏡微創(chuàng)手術(shù)技術(shù)及手術(shù)器械的不斷提高和完善，少數(shù)脊柱微創(chuàng)外科醫(yī)生對(duì)此進(jìn)行了探索。目前，經(jīng)皮內(nèi)鏡椎板間入路技術(shù)治療鈣化型腰椎間盤突出癥病例數(shù)仍然較少，文獻(xiàn)報(bào)道少見。2011 年 11 月至 2013 年6 月，我院對(duì) 28 例鈣化型腰椎間盤突出癥患者采用經(jīng)皮內(nèi)鏡椎板間入路技術(shù)進(jìn)行治療，現(xiàn)報(bào)道如下。

資料與方法

一、一般資料及研究分組

2011 年 11 月至 2013 年 6 月，我院收治鈣化型腰椎間盤突出癥患者共計(jì) 56 例，其中經(jīng)皮內(nèi)鏡椎板間入路技術(shù)治療 28 例 ( I 組，男 20 例，女 8 例 )中，平均年齡 35.71±13.03 ( 19～66 ) 歲，平均病程48.07±10.36 ( 30～72 ) 個(gè)月；L4～5椎間隙 11 例，L5～S1椎間隙 17 例。傳統(tǒng)開窗手術(shù)組 28 例 ( II 組，男 21 例，女 7 例 ) 中，平均年齡 36.89±13.01 ( 18～65 ) 歲，平均病程 50.25±9.04 ( 38～68 ) 個(gè)月；L4～5椎間隙 12 例，L5～S1椎間隙 16 例。分別對(duì)患者的術(shù)前一般情況、手術(shù)情況、手術(shù)療效及恢復(fù)狀況進(jìn)行記錄并評(píng)價(jià)，包括手術(shù)時(shí)間、術(shù)中出血量、切除骨量、術(shù)后并發(fā)癥、住院時(shí)間、術(shù)后 ODI 指數(shù)、術(shù)后 VAS 評(píng)分和 MacNab 標(biāo)準(zhǔn)評(píng)估。

二、納入標(biāo)準(zhǔn)及排除標(biāo)準(zhǔn)

1. 納入標(biāo)準(zhǔn)：( 1 ) 腰背痛伴單側(cè)下肢放射痛和( 或 ) 麻木感，直腿抬高試驗(yàn)＜70°；( 2 ) 術(shù)前 CT 證實(shí)為明顯的鈣化型腰椎間盤突出；( 3 ) 癥狀嚴(yán)重，經(jīng)正規(guī)保守治療 2 個(gè)月以上無效或病史＞1 年，影響正常工作和生活；( 4 ) 均為單一節(jié)段突出[4]。

2. 排除標(biāo)準(zhǔn)：( 1 ) 初發(fā)病程短，癥狀輕，且影像學(xué)表現(xiàn)不明顯者；( 2 ) 非鈣化型腰椎間盤突出患者；( 3 ) 合并脊柱腫瘤占位性病變、腰椎不穩(wěn)、嚴(yán)重腰椎管狹窄、腰椎結(jié)核、感染等病變者；( 4 )伴有凝血功能障礙、慢性心肺疾病等不能耐受手術(shù)者[5]。

三、手術(shù)治療

1. 術(shù)前準(zhǔn)備：術(shù)前評(píng)估腰椎 X 線、CT、MRI 等影像學(xué)資料，仔細(xì)觀察突出鈣化椎間盤組織大小、位置及神經(jīng)根和硬膜囊的毗鄰關(guān)系；分析關(guān)節(jié)突關(guān)節(jié)、側(cè)隱窩、神經(jīng)根管、椎間孔大小和髂脊高度等情況，根據(jù)以上資料綜合確認(rèn)切口部位。術(shù)前仔細(xì)檢查并按量表進(jìn)行評(píng)分。

2. 手術(shù)過程：I 組全身麻醉成功后，患者取俯臥位，術(shù)野常規(guī)碘伏消毒鋪無菌巾，在“C”型臂X 線機(jī)輔助下確定病變椎間隙，于病變椎間隙棘突旁取一長約 8 mm 的縱行切口。切開皮膚、皮下組織及筋膜，逐級(jí)置入擴(kuò)張管抵達(dá)椎板間隙，鈍性剝離黃韌帶及椎板上附著肌肉組織。置入外徑 7 mm 工作套管至椎板間黃韌帶后方，放入內(nèi)鏡。在鏡下用punch 鉗切除部分黃韌帶后，探查神經(jīng)根、硬膜囊位置。從神經(jīng)根肩部推入工作套管 ( 斜口向內(nèi) )，確定推至椎間隙深度后，旋轉(zhuǎn)套管將神經(jīng)根向內(nèi)側(cè)推移出視野。探查椎間盤突出及鈣化情況，采用鏡下磨鉆、環(huán)鉆、工作套管、激光、骨鑿及咬骨鉗等工具將鈣化組織切除。髓核鉗取出突出的椎間盤組織，嚴(yán)密止血，探查確認(rèn)神經(jīng)根、硬膜囊無受壓。取出工作套筒及內(nèi)鏡，縫合切口[6]( 圖 1 )。

II 組按常規(guī)開窗手術(shù)進(jìn)行。

3. 術(shù)后處理：術(shù)后 6 h 內(nèi)絕對(duì)臥床，給予脫水劑、地塞米松、抗生素等處理，并監(jiān)測患者基本生命體征。術(shù)后 1 天進(jìn)行神經(jīng)系統(tǒng)檢查和相應(yīng)評(píng)分；術(shù)后第 1 天可進(jìn)行翻身、攙扶慢走，下床活動(dòng)時(shí)給予腰圍保護(hù)。術(shù)后 7～10 天內(nèi)仍以臥床休息為主，囑患者術(shù)后 3 個(gè)月內(nèi)避免從事重體力勞動(dòng)，并減少彎腰、持重物等活動(dòng)。

四、統(tǒng)計(jì)學(xué)處理

所有獲得數(shù)據(jù)應(yīng)用 SPSS 19.0 軟件進(jìn)行統(tǒng)計(jì)學(xué)分析，計(jì)量資料以±s 表示，采用 t 檢驗(yàn)，計(jì)數(shù)資料采用 χ2檢驗(yàn)，P＜0.05 為差異有統(tǒng)計(jì)學(xué)意義。對(duì)兩組組內(nèi)手術(shù)前、后各項(xiàng)評(píng)價(jià)指標(biāo)分別進(jìn)行配對(duì) t 檢驗(yàn)，探討兩種手術(shù)方法的臨床療效如何；對(duì)兩組組間手術(shù)前、后各項(xiàng)指標(biāo)分別進(jìn)行獨(dú)立樣本 t 檢驗(yàn)，對(duì)比分析兩種手術(shù)方法治療療效是否存在差異。

圖 1 患者，男，37 歲，下腰痛伴坐下左下肢放射性疼痛 2 年，加重 1 個(gè)月 a：術(shù)前 CT 橫切位示鈣化灶 ( 鈣化灶 )；b：術(shù)前 CT 示向下方脫出的髓核組織；c：術(shù)前MRI T1WI 示 L5 ～ S1 髓核脫出；d：術(shù)前 MRI T2WI示 L5 ～ S1 髓核脫出，混雜低信號(hào)影；e：術(shù)前 MRIT2WI 橫切位示 L5 ～ S1 椎間盤左側(cè)突出，混雜低信號(hào)影；f：鏡下見鈣化灶 (?鈣化灶 )；g：在鏡下用環(huán)鋸切除鈣化灶；h：鈣化灶切除后可見下面的椎間盤及向下方脫出的髓核 (?脫出的髓核 )；i：術(shù)中切除的鈣化灶及脫出髓核組織 (?切除的鈣化灶；切除的髓核組織 )；j：術(shù)后 CT 橫切位示鈣化灶被切除Fig.1 A 37-year-old male patient with low back pain combined with radiating pain in the left lower limb for 2 years which were aggravated for 1 month a: The preoperative transverse section CT showed the calcifcation (?calcifcation ); b: The preoperative CT showed the nucleus pulposus protruded downward; c: The preoperative saggital MRI showed the protruded nucleus pulposus of level L5-S1 on T1-weighted images; d: The preoperative saggital MRI showed the protruded nucleus pulposus was combined with hypointensity rim of level L5-S1 on T2-weighted images; e: The preoperative transverse section MRI showed the L5-S1 intervertebral disc protruded to the left side and was combined with hypointensity rim; f: The calcifcation was exposed under the endoscope (?calcifcation ); g: The resection of the calcifcation under the endoscope by a trephine; h: The disc and protruded nucleus pulposus could be seen after the resection of the calcifcation (?protruded nucleus pulposus ); i: The excisional calcifed tissues and parts of the protruded nucleus pulposus (?calcifed tissues;?protruded nucleus pulposus ); j: The postoperative transverse section CT showed the calcifcation had been removed

結(jié) 果

對(duì)各項(xiàng)記錄指標(biāo)進(jìn)行統(tǒng)計(jì)分析：VAS 評(píng)分術(shù)前與術(shù)后 1 天、3 個(gè)月、6 個(gè)月隨訪比較，I 組分別從術(shù)前 7.36±0.29 降至 3.52±0.23，2.99± 0.11，3.15±0.19 ( P＜0.001 )；II 組分別從術(shù)前7.29±0.28 降至 4.02±0.23，3.48±0.13，3.03±0.04 ( P＜0.001 )。ODI 指數(shù)術(shù)前與術(shù)后 1 天、3 個(gè)月、6 個(gè)月隨訪比較，I 組分別從術(shù)前 70.18±1.63 降至 34.24±1.39，32.84±1.38，33.33±1.40 ( P＜0.001 )；II 組分別從術(shù)前 69.82±1.31 降至36.51±1.39，33.50±1.50，32.48±2.87 ( P＜0.001 ) ( 表 1 )。兩組間比較：術(shù)后 1 天 VAS 評(píng)分，I 組( 3.52±0.23 ) 優(yōu)于 II 組 ( 4.02±0.23 ) ( P＜0.01 )；術(shù)后 6 個(gè)月，兩組 VAS 評(píng)分差異無統(tǒng)計(jì)學(xué)意義 ( P＝0.34 )。術(shù)后 1 天 ODI 指數(shù)，I 組 ( 34.24±1.39 ) 優(yōu)于II 組 ( 36.51±1.39 ) ( P＜0.05 )；術(shù)后 6 個(gè)月兩組 ODI指數(shù)差異無統(tǒng)計(jì)學(xué)意義 ( P＝0.80 )。術(shù)后 6 個(gè)月隨訪時(shí)根據(jù)改良 MacNab 標(biāo)準(zhǔn)評(píng)價(jià)術(shù)后療效，其中 I 組優(yōu)24 例、良 3 例、可 1 例、差 0 例，優(yōu)良率為 96.4% ( 27 / 28 )；II 組優(yōu) 23 例、良 3 例、可 2 例、差 0 例，優(yōu)良率為 92.9% ( 26 / 28 )，兩組差異無統(tǒng)計(jì)學(xué)意義( P＝0.62 ) ( 表 2 )。I 組術(shù)中平均出血量、切除骨量及術(shù)后平均住院時(shí)間均優(yōu)于 II 組，各項(xiàng)指標(biāo)差異均有統(tǒng)計(jì)學(xué)意義 ( P＜0.001 )；I 組平均手術(shù)時(shí)間長于II 組 ( 52.93±6.66 分：41.79±7.85 分，P＜0.001 )。并發(fā)癥：術(shù)后 I 組發(fā)生下肢麻木 2 例，硬膜破裂1 例；II 組發(fā)生 1 例下肢麻木。4 例經(jīng)保守對(duì)癥治療后均痊愈，無永久性神經(jīng)損害或癥狀加重者，兩組并發(fā)癥比較差異無統(tǒng)計(jì)學(xué)意義 ( P＝0.31 ) ( 表 3 )。術(shù)中所切除的突出椎間盤組織均切取標(biāo)本送病理檢查，鏡下見纖維環(huán)斷裂、腫脹，為致密結(jié)締組織包繞并有軟骨細(xì)胞浸潤，髓核明顯變性鈣化，基質(zhì)中有鈣鹽沉著。

表2 兩組術(shù)前、術(shù)-后 1 天、3 個(gè)月、6 個(gè)月 VAS 評(píng)分、ODI 指數(shù)及 MacNab 比較 (±s )Tab.2 Comparison of the VAS, ODI and MacNab scores preoperatively and at 1- day, 3months and 6 months after the surgery between the 2 groups (±s )

表2 兩組術(shù)前、術(shù)-后 1 天、3 個(gè)月、6 個(gè)月 VAS 評(píng)分、ODI 指數(shù)及 MacNab 比較 (±s )Tab.2 Comparison of the VAS, ODI and MacNab scores preoperatively and at 1- day, 3months and 6 months after the surgery between the 2 groups (±s )

指標(biāo) I 組 II 組 P 值術(shù)前 VAS 7.36±0.29 7.29±0.28 0.21術(shù)后 1 天 VAS 3.52±0.23 4.02±0.23 ＜0.01術(shù)后 3 個(gè)月 VAS 2.99±0.11 3.48±0.13 ＜0.05術(shù)后 6 個(gè)月 VAS 3.15±0.19 3.03±0. 04 0.34術(shù)前 ODI 70.18±1.63 69.82±1.31 0.42術(shù)后 1 天 ODI 34.24±1.39 36.51±1.39 ＜0.05術(shù)后 3 個(gè)月 ODI 32.84±1.38 33.50±1.50 0.18術(shù)后 6 個(gè)月 ODI 33.33±1.40 32.48±2.87 0.80 MacNab優(yōu)24 ( 85.71% ) 23 ( 82.14% ) 0.62良3 ( 10.71% ) 3 ( 10.71% )可1 ( 3.52% ) 2 ( 7.14% )差0 0

表3 患者一般指標(biāo)比較 (±s )Tab.3 Comparison of patient demographics and characteristics at baseline (±s )

表3 患者一般指標(biāo)比較 (±s )Tab.3 Comparison of patient demographics and characteristics at baseline (±s )

指標(biāo) I 組 II 組 P 值病例數(shù) 28 28 -性別 ( 男 / 女 ) 20 / 8 21 / 7 0.77年齡 ( 歲 ) 35.71±13.03 36.89±13.01 0.099病史 ( 月 ) 48.07±10.36 50.25± 9.04 0.21手術(shù)時(shí)間 ( 分 ) 52.93± 6.66 41.79± 7.85 ＜0.001術(shù)中出血量 ( ml ) 20.08± 1.82 40.14± 3.65 ＜0.001切除骨量 ( g ) 2.57± 0.48 13.71± 1.50 ＜0.001住院時(shí)間 ( 天 ) 3.20± 0.38 7.38± 0.54 ＜0.001并發(fā)癥 3 ( 10.71% ) 1 ( 3.57% )切口感染 0 ( 0 ) 0 ( 0 )硬膜破裂 1 ( 3.57% ) 0 ( 0 ) 0.31下肢麻木 2 ( 7.14% ) 1 ( 3.57% )

表1 I、II 兩組術(shù)前與術(shù)后 1 天、3 個(gè)月、6 個(gè)月 VAS 評(píng)分、ODI 指數(shù)比較 (±s )Tab.1 Comparison of the VAS and ODI scores preoperatively and at 1 day, 3months and 6 months after the surgery in group I and group II (±s )

表1 I、II 兩組術(shù)前與術(shù)后 1 天、3 個(gè)月、6 個(gè)月 VAS 評(píng)分、ODI 指數(shù)比較 (±s )Tab.1 Comparison of the VAS and ODI scores preoperatively and at 1 day, 3months and 6 months after the surgery in group I and group II (±s )

注：a術(shù)后 1 天與術(shù)前比較；b術(shù)后 6 個(gè)月與術(shù)前比較Notice:aMeant the comparison between the preoperative scores and the scores at 1 day after the operation;bMeant the comparison between the preoperative scores and the scores at 6 months after the operation

組別 指標(biāo) 術(shù)前 術(shù)后 1 天 P 值a 術(shù)后 3 個(gè)月 術(shù)后 6 個(gè)月 P 值bI 組 VAS 7.36±0.29 3.52±0.23 ＜0.001 2.99±0.11 3.15±0.19 ＜0.001 ODI 70.18±1.63 34.24±1.39 ＜0.001 32.84±1.38 33.33±1.40 ＜0.001 II 組 VAS 7.29±0.28 4.02±0.23 ＜0.001 3.48±0.13 3.03±0.04 ＜0.001 ODI 69.82±1.31 36.51±1.39 ＜0.001 33.50±1.50 32.48±2.87 ＜0.001

討 論

近年來，鈣化型腰椎間盤突出癥發(fā)病率越來越高，據(jù)文獻(xiàn)報(bào)道發(fā)生率在 4.7%～15.9%[1-2]，且有逐年升高的趨勢。其發(fā)病機(jī)制尚不明確，國內(nèi)外學(xué)者進(jìn)行了相關(guān)研究[7-10]。Wu 等[11]研究認(rèn)為隨著年齡增加，軟骨終板逐漸鈣化，引發(fā)椎間盤的退變、鈣化，而椎間盤的鈣化這一病理過程，會(huì)極大影響椎間盤的營養(yǎng)供應(yīng)及其自身代謝，因而又會(huì)加速椎間盤的退行性變，這就形成了一個(gè)惡性循環(huán)；Peng等[12]的研究也驗(yàn)證了椎間盤鈣化與椎間盤退變之間的關(guān)系。根據(jù)本組資料顯示，鈣化型腰椎間盤突出癥的發(fā)病年齡逐步年輕化。分析原因大多數(shù)患者都有應(yīng)用多種中醫(yī)藥或者介入治療史，且病程較長。在椎間盤退行性病變的基礎(chǔ)上，合并各種外界因素的刺激作用，使得局部血管等組織增生機(jī)化，從而加速椎間盤的鈣化[2]。

與單純性腰椎間盤突出癥相比，鈣化的椎間盤組織多與硬膜囊、神經(jīng)根等周圍組織粘連緊密，不能輕易分離，故保守治療不僅無效，還可能會(huì)加重突出物對(duì)神經(jīng)根的卡壓，進(jìn)而加重對(duì)神經(jīng)根的損害。故患者一旦出現(xiàn)明顯神經(jīng)壓迫癥狀，明確診斷后應(yīng)積極采取手術(shù)治療。

由于脊柱微創(chuàng)手術(shù)水平、微創(chuàng)器械、傳統(tǒng)理念等多方面因素的限制，大多數(shù)醫(yī)生仍采用開放手術(shù)治療鈣化型腰椎間盤突出癥。開放手術(shù)在直視下操作，清除鈣化組織徹底，療效顯著。開放手術(shù)一般采用開窗、半椎體板切除術(shù)、全椎體切除術(shù)加內(nèi)固定等方式。但為切除鈣化椎間盤組織，須切除較多骨性結(jié)構(gòu)以充分暴露鈣化灶。且鈣化的椎間盤組織多與硬膜囊、神經(jīng)根等周圍組織粘連緊密，缺乏專門的手術(shù)器械分離將其分離，故傳統(tǒng)開窗手術(shù)存在出血量大、損傷程度重、恢復(fù)慢等不足之處。

隨著脊柱微創(chuàng)手術(shù)技術(shù)的不斷成熟和手術(shù)器械的不斷發(fā)展，鈣化型腰椎間盤突出癥已不再是經(jīng)皮內(nèi)鏡技術(shù)的禁忌證。本組 28 例鈣化型腰椎間盤突出癥患者采用經(jīng)皮內(nèi)鏡椎板間入路手術(shù)治療，在鏡下磨鉆、環(huán)鉆、工作套管、激光、骨鑿及咬骨鉗等專門的微創(chuàng)器械的輔助下，可切除壓迫硬膜囊、神經(jīng)根的鈣化椎間盤組織，將神經(jīng)根徹底減壓。與開放手術(shù)不同，經(jīng)皮內(nèi)鏡下手術(shù)操作空間有限，須充分止血。另外經(jīng)皮內(nèi)鏡下完整切除鈣化的椎間盤組織相對(duì)較困難，操作需更加謹(jǐn)慎，往往需結(jié)合多種手術(shù)器械，對(duì)術(shù)者的操作技巧和手術(shù)經(jīng)驗(yàn)要求更高[13]。根據(jù)我們的經(jīng)驗(yàn)，部分病例并不需要將鈣化灶完全切除，僅需切除壓迫神經(jīng)的部分即可達(dá)到減壓的目的。

在本研究中，兩組術(shù)后 ODI 指數(shù)、VAS 評(píng)分等評(píng)價(jià)指標(biāo)較術(shù)前均有明顯下降，說明經(jīng)皮內(nèi)鏡椎板間入路手術(shù)與傳統(tǒng)開窗手術(shù)同樣為治療鈣化型腰椎間盤突出癥的有效手段。另外，經(jīng)皮內(nèi)鏡椎板間入路手術(shù)切口較小，手術(shù)過程中保留了關(guān)節(jié)突、棘突、椎板、黃韌帶等復(fù)合結(jié)構(gòu)，從而對(duì)脊柱穩(wěn)定性的影響較小[14]，術(shù)后可短時(shí)間恢復(fù)，術(shù)后 1 天 VAS評(píng)分、ODI 指數(shù) I 組即優(yōu)于 II 組，住院時(shí)間也縮短為 3 天。

手術(shù)入路方面，經(jīng)椎間孔側(cè)后入路暴露范圍有限，很難對(duì)鈣化灶完整暴露，特別對(duì)于髂嵴較高的L5～S1節(jié)段。同時(shí)這一入路鏡下分離鈣化灶與神經(jīng)根之間粘連的操作比較困難。經(jīng)后側(cè)椎板間入路更加符合外科醫(yī)生的手術(shù)習(xí)慣，可充分暴露鈣化灶，手術(shù)視野清晰。探查范圍廣泛可充分切除鈣化灶、分離神經(jīng)根，進(jìn)行充分減壓。本組 28 例鈣化型腰椎間盤突出癥病患，均采用后側(cè)椎板間入路，手術(shù)效果良好。

術(shù)后 I 組出現(xiàn) 2 例下肢麻木，1 例硬膜破裂，經(jīng)積極對(duì)癥治療后緩解。II 組因切口大、組織結(jié)構(gòu)破壞重，增加了手術(shù)部位與外界接觸的機(jī)會(huì)，故切口感染可能性增加，術(shù)前術(shù)后應(yīng)進(jìn)行相應(yīng)對(duì)癥治療，避免切口感染的發(fā)生。兩種手術(shù)方式，在術(shù)中都不可避免的觸及神經(jīng)組織，導(dǎo)致神經(jīng)根水腫，繼發(fā)術(shù)后下肢麻木。術(shù)中發(fā)現(xiàn)鈣化的椎間盤組織往往與周圍組織結(jié)構(gòu)如硬膜囊、神經(jīng)根等粘連，并常合并繼發(fā)性椎管狹窄或側(cè)隱窩狹窄，增加了手術(shù)難度，而且易使神經(jīng)根過度牽拉，因此術(shù)中應(yīng)仔細(xì)、輕柔操作，避免不必要的醫(yī)源性損傷，盡可能減少硬膜破裂、切口感染等并發(fā)癥[15]。

盡管經(jīng)皮內(nèi)鏡技術(shù)有以上諸多優(yōu)勢，但并不是所有的患者均適合開展此類手術(shù)。術(shù)前應(yīng)充分評(píng)估患者病情，結(jié)合 CT、MRI 等影像學(xué)指標(biāo)，以臨床經(jīng)驗(yàn)為輔助，充分進(jìn)行術(shù)前規(guī)劃，并預(yù)測術(shù)中可能出現(xiàn)的狀況及處理手段，嚴(yán)格執(zhí)行診斷、納入標(biāo)準(zhǔn)及排除標(biāo)準(zhǔn)，從而保證手術(shù)療效與安全性[16]。

本組結(jié)果提示這一技術(shù)可有效治療鈣化型腰椎間盤突出癥，但術(shù)者須具有一定的手術(shù)技巧和多種配套微創(chuàng)器械。經(jīng)皮內(nèi)鏡技術(shù)治療腰椎間盤突出癥的學(xué)習(xí)曲線陡峭，有一個(gè)較長的學(xué)習(xí)過程[17-18]。脊柱微創(chuàng)外科醫(yī)師需要接受良好的培訓(xùn)，并隨著手術(shù)操作熟練程度的提高，可逐漸擴(kuò)大手術(shù)適應(yīng)證。

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( 本文編輯：馬超 )

An analysis of short-term clinical outcomes of percutaneous endoscopic interlaminar approach for calcified lumbar disc herniation

LI Jun, FU Qiang. Department of Orthopedics, Changhai Hospital, the second Military Medical University, Shanghai, 200433, PRC Corresponding author: FU Qiang, Email: johson.f@163.com

ObjectiveTo investigate the clinical outcomes and surgical techniques of percutaneous endoscopic interlaminar approach for calcifed lumbar disc herniation.MethodsFrom November 2011 to June 2013, 56 patients with calcifed lumber disc herniation were adopted, who were then divided into 2 groups. The patients in Group I ( n=28 ) were treated with percutaneous endoscopic interlaminar approach, and the patients in Group II ( n=28 ) underwent traditional open surgery. The assessment was performed using the Oswestry Disability Index ( ODI ), Visual Analogue Scale ( VAS ) and the modifed Macnab criteria preoperatively and at 1 day, 3 months and 6 months after the operation. The parameters were recorded such as the operation time, intraoperative blood loss, amount of removed bone, postoperative complications, hospital stays and so on.ResultsThe surgical results in both groups were satisfactory. The preoperative VAS scores were 7.36±0.29 points in Group I, which were signifcantly improved to 3.52±0.23, 2.99±0.11 and 3.15±0.19 points at 1 day, 3 months and 6 months after the surgery. The preoperative VAS scores were 7.29±0.28 points in Group II, which were signifcantly improved to 4.02±0.23, 3.48±0.13 and 3.03±0.04 points at 1 day, 3 months and 6 months after the surgery. The preoperative ODI scores were 70.18±1.63 points in Group I, which were decreased to 34.24±1.39, 32.84±1.38 and 33.33±1.40 points at 1 day, 3 months and 6 months after the surgery. The preoperative ODI scores were 69.82±1.31 points in Group II, which were decreased to 36.51±1.39, 33.50±1.50 and 32.48±2.87 points at 1 day, 3 months and 6 months after the surgery. No obvious differences in the VASscore and ODI score at 6 months after the surgery were noticed between the 2 groups ( P=0.34, P=0.80 ). According to the MacNab criteria, the excellent and good rates were 96.4% and 92.9%, without statistically signifcant differences between the 2 groups ( P=0.62 ). When it came to the intraoperative blood loss, amount of removed bone and hospital stays, Group I was signifcantly superior to Group II ( P＜0.001 ). The operation time in Group I was 52.93±6.66 min, which was longer than 41.79±7.85 min in Group II ( P＜0.001 ). In terms of the postoperative complications, 2 patients had lower limb numbness and 1 patient experienced dural tear in Group I, whereas, 1 patient had lower limb numbness in Group II. All the 4 patients were treated conservatively and recovered, and there was no permanent nerve root injury or aggregation.ConclusionsThe clinical outcomes of percutaneous endoscopic interlaminar technique are equal to that of traditional open surgery in the treatment of calcifed lumbar disc herniation, with the advantages of less tissue injury and reduced operation time and rehabilitation period. All in all, percutaneous endoscopic interlaminar technique is worthy of clinical application.

Lumbar vertebrae; Intervertebral disc displacement; Calcifcation, physiologic; Diskectomy, percutaneous; Endoscopy

10.3969/j.issn.2095-252X.2014.08.006

Th776.1, R681.5

200433 上海，第二軍醫(yī)大學(xué)附屬長海醫(yī)院脊柱外科

付強(qiáng)，Email: johson.f@163.com

2014-05-28 )