經(jīng)皮椎間孔鏡下椎間盤切除術(shù)治療中老年腰椎間盤突出癥

劉書中，王以朋,余可誼

(中國醫(yī)學(xué)科學(xué)院 北京協(xié)和醫(yī)學(xué)院 北京協(xié)和醫(yī)院骨科，北京 100730 )

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·現(xiàn)代醫(yī)學(xué)研究·

經(jīng)皮椎間孔鏡下椎間盤切除術(shù)治療中老年腰椎間盤突出癥

劉書中，王以朋,余可誼*

(中國醫(yī)學(xué)科學(xué)院 北京協(xié)和醫(yī)學(xué)院 北京協(xié)和醫(yī)院骨科，北京 100730 )

目的評(píng)價(jià)經(jīng)皮椎間孔鏡下腰椎間盤切除術(shù)(PELD)治療經(jīng)保守治療無效的中老年腰椎間盤突出癥的臨床效果。方法14例經(jīng)保守治療無效的中老年腰椎間盤突出癥患者，經(jīng)椎間盤造影證實(shí)14個(gè)椎間盤后方纖維環(huán)均撕裂，行PELD治療。比較術(shù)前、術(shù)后疼痛視覺模擬評(píng)分(VAS)和術(shù)前、末次隨訪時(shí)Oswestry功能障礙指數(shù)(ODI)，按改良Macnab標(biāo)準(zhǔn)評(píng)價(jià)臨床療效。結(jié)果手術(shù)時(shí)間60～120(96±18.1)min,術(shù)中出血量10～30(16±8．6)mL。住院時(shí)間3～9(4．6±1．3)d。14例均獲隨訪,時(shí)間2～12(6．9±4．3)個(gè)月。術(shù)中未發(fā)生腦脊液漏、脊髓神經(jīng)損傷。VAS術(shù)前為6～10(7．9±1．8)分，術(shù)后為0～3(1．8±1．2)分，差異有統(tǒng)計(jì)學(xué)意義(P<0．01)。ODI術(shù)前為52．0%～85．1%(78．1±17．3)%，末次隨訪時(shí)為10．8%～24．1%(16．2±5．2)%，差異有統(tǒng)計(jì)學(xué)意義(P<0．01)。根據(jù)改良Macnab標(biāo)準(zhǔn)：優(yōu)7例，良6例，可1例。結(jié)論P(yáng)ELD治療經(jīng)保守治療無效的中老年腰椎間盤突出癥患者具有創(chuàng)傷小、恢復(fù)快、住院時(shí)間短等特點(diǎn)，療效較好。

經(jīng)皮內(nèi)鏡腰椎間盤切除術(shù)；中老年；腰椎間盤突出癥；椎間盤造影

中老年腰椎間盤突出癥發(fā)病率較低，較易漏診，經(jīng)皮內(nèi)鏡腰椎間盤切除術(shù)(PELD)治療中老年腰椎間盤突出癥臨床報(bào)道較少。2014年5月—2015年11月，我院采用PELD治療14例經(jīng)保守治療無效的中老年腰椎間盤突出癥患者，經(jīng)過長期隨訪，治療效果滿意?，F(xiàn)總結(jié)報(bào)道如下。

1　資料與方法

1．1一般資料本組患者14例,男7例，女7例，年齡45～71歲。臨床表現(xiàn)：腰痛伴左下肢痛6例，腰痛伴右下肢痛6例，腰痛伴雙下肢痛2例，無椎管狹窄臨床表現(xiàn)。其中4例有腰部扭傷史，余患者無外傷史?；颊呔鶖z腰椎正側(cè)位、雙斜位、前屈后伸位X線片，并行CT、MRI及雙下肢B超檢查，排除其他引起腰腿痛的疾患。患者病程3個(gè)月～15年。MRI見14個(gè)退變間盤，節(jié)段分布:L3—L41例，L4—L55例，L5—S18例，按改良Pfirrmann椎間盤退變分級(jí)：II級(jí)6例，III級(jí)8例。

1．2納入標(biāo)準(zhǔn)經(jīng)持續(xù)超過3個(gè)月保守治療(包括理療、腰背肌鍛煉和藥物治療)無效，術(shù)前腰椎X線(正位、側(cè)位、動(dòng)力位)、CT及MRI檢查均顯示椎間盤退變、突出，造成神經(jīng)根、硬膜囊壓迫的中老年腰椎間盤突出癥患者。

1．3排除標(biāo)準(zhǔn)腰椎管狹窄癥患者；腰椎間隙高度減少20%以上者；腰椎感染、腫瘤和畸形患者；腰椎不穩(wěn)和腰椎滑脫患者。

1．4治療方法于背部穿刺點(diǎn)作一8 mm長皮膚切口,三級(jí)擴(kuò)張?zhí)坠苤鸺?jí)擴(kuò)張后連接鏡頭、光源線、0．9%生理鹽水沖洗液及吸引器，置入椎間孔鏡工作套管，保持術(shù)野清晰，徹底摘除染色、突出變性的髓核組織，持續(xù)生理鹽水灌洗，使用Ellman可屈性雙極射頻消融組織或突出物，止血，纖維環(huán)及髓核成形。術(shù)后第1天可帶腰圍下床活動(dòng)，1．5個(gè)月內(nèi)避免彎腰、旋轉(zhuǎn)等活動(dòng)。術(shù)中椎間盤造影觀察病變椎間盤形態(tài)改變?；颊呷?cè)臥位，按側(cè)后入路，局部麻醉后透視下穿刺針抵達(dá)椎間盤，注入有色造影劑(亞甲藍(lán)+歐乃派克+生理鹽水，1∶2∶2)，經(jīng)正、側(cè)位透視觀察椎間盤造影形態(tài)。

1．5療效標(biāo)準(zhǔn)術(shù)前、術(shù)后行疼痛視覺模擬評(píng)分(VAS)評(píng)價(jià)；術(shù)前、末次隨訪行Oswestry功能障礙指數(shù)(ODI)評(píng)定，ODI= (所得分?jǐn)?shù)/5×回答問題數(shù))×100%，按改良Macnab標(biāo)準(zhǔn)評(píng)價(jià)臨床療效。

2　結(jié)果

14例患者椎間盤造影顯示：椎間盤形態(tài)不規(guī)則、彌散，后方纖維環(huán)撕裂，造影劑滲漏至椎管。術(shù)中未發(fā)生腦脊液漏、脊髓神經(jīng)損傷。手術(shù)時(shí)間60～120(96±18．1) min，術(shù)中出血量10～30 mL，平均(16±8．6)mL。住院時(shí)間3～9 d，平均(4．6±1．3) d。14例均獲隨訪，時(shí)間2～12(6．9±4．3)個(gè)月。術(shù)中未發(fā)生腦脊液漏、脊髓神經(jīng)損傷。VAS術(shù)前為6～10分，平均(7．9±1．8)分；術(shù)后為0～3分，平均(1．8±1．2)分，差異有統(tǒng)計(jì)學(xué)意義(P<0．01)。ODI術(shù)前為52．0%～85．1%(78．1±17．3) %，末次隨訪時(shí)為10．8%～24．1%(16．2±5．2) %，差異有統(tǒng)計(jì)學(xué)意義(P< 0．01)。根據(jù)改良Macnab標(biāo)準(zhǔn)：優(yōu)7例，良6例，可1例，優(yōu)良率為92．9%(13/14)。

3　討論

中老年腰椎間盤突出癥(lumbar disc herniation,LDH)在臨床上較為多見，具有病程長、病情重、漸進(jìn)性發(fā)展的特點(diǎn)，常常出現(xiàn)突出局部的反復(fù)炎癥反應(yīng)，導(dǎo)致神經(jīng)根袖與硬膜囊發(fā)生粘連[1]。本組排除腰椎管狹窄癥的標(biāo)準(zhǔn)為無腰椎管狹窄癥臨床表現(xiàn)及X線、CT及MRI等檢查提示未達(dá)到椎管狹窄的診斷標(biāo)準(zhǔn)。但實(shí)際上，中老年患者除具備LDH的臨床癥狀及體征外，還有側(cè)隱窩狹窄、黃韌帶肥厚及椎間孔縮小等因素所致椎管狹窄的表現(xiàn)。部分中老年LDH經(jīng)保守治療可緩解，但對(duì)于保守治療無效的中老年LDH患者仍需手術(shù)治療[2-3]。

傳統(tǒng)開放手術(shù)是治療經(jīng)保守治療無效中老年LDH的有效方法，但由于創(chuàng)傷較大，存在造成椎旁肌肉、椎間韌帶及脊柱單元完整性破壞的風(fēng)險(xiǎn)，易導(dǎo)致椎間盤突出復(fù)發(fā)、腰椎不穩(wěn)及頑固性下腰痛，致使再手術(shù)風(fēng)險(xiǎn)增加且術(shù)后并發(fā)癥較多[4]。中老年腰椎后部結(jié)構(gòu)對(duì)腰椎的穩(wěn)定性起著重要作用，保持完整的脊柱后部結(jié)構(gòu)至關(guān)重要[5]。隨著脊柱微創(chuàng)技術(shù)的發(fā)展，椎間孔鏡下椎間盤切除術(shù)在治療中老年LDH領(lǐng)域也取得了良好的臨床效果。PELD經(jīng)后外椎間孔入路，采用逐級(jí)擴(kuò)張軟組織的方式建立工作通道,最大限度地降低對(duì)周圍軟組織的損傷[6]。工作通道經(jīng)椎間孔放置于目標(biāo)區(qū)域，整個(gè)手術(shù)過程大大降低對(duì)脊柱骨性結(jié)構(gòu)的破壞，維持了脊柱的穩(wěn)定性，保護(hù)了脊柱的生物力學(xué)功能，降低術(shù)后腰椎不穩(wěn)及下腰痛的風(fēng)險(xiǎn)[7]。術(shù)后24 h即可佩戴腰圍下床活動(dòng)，早期即能進(jìn)行功能康復(fù)鍛煉。術(shù)中應(yīng)用亞甲藍(lán)對(duì)椎間盤組織染色，可選擇性切除藍(lán)染退變組織，盡可能保留正常髓核組織，以促進(jìn)椎間盤修復(fù)及保持脊柱的穩(wěn)定性[8]。機(jī)械性切除部分椎間盤組織后，椎間盤內(nèi)壓力可明顯下降，以促進(jìn)突出椎間盤組織回縮。利用射頻消融可進(jìn)一步減低椎間盤內(nèi)壓力，促進(jìn)纖維環(huán)回縮、愈合及修復(fù)[9]。術(shù)中持續(xù)生理鹽水灌洗可將椎間盤內(nèi)炎性介質(zhì)及殘留退變組織沖出，有利于緩解疼痛癥狀。本研究結(jié)果表明隨著患者年齡的增加，術(shù)后疼痛癥狀的改善程度有所減低，這與年齡增加后，脊柱整體的退變較低齡患者更為明顯，且退變累及脊柱結(jié)構(gòu)較多，包括后方關(guān)節(jié)突骨贅形成、韌帶松弛、脊柱周圍肌肉軟組織維持脊柱穩(wěn)定的能力降低等因素有關(guān)[10]。中老年患者因長期腰部軟組織勞損、三關(guān)節(jié)復(fù)合體(椎間盤、關(guān)節(jié)突關(guān)節(jié))退變、關(guān)節(jié)突關(guān)節(jié)囊松弛等原因，更易合并節(jié)段性腰椎不穩(wěn)定[11]。因此，對(duì)于中老年LDH患者，選擇行PELD手術(shù)時(shí)，應(yīng)從嚴(yán)把握手術(shù)適應(yīng)證，注意排除合并腰椎明顯退變及節(jié)段性腰椎不穩(wěn)等[12]。

PELD治療中老年LDH具有創(chuàng)傷小、出血少、安全性高、恢復(fù)快等優(yōu)點(diǎn)，臨床療效滿意，為中老年LDH的治療提供了一種優(yōu)化選擇方案。但本組納入研究病例數(shù)有限，尚需積累資料進(jìn)一步深入探討，PELD技術(shù)在中老年LDH治療中的遠(yuǎn)期療效及安全性也有待進(jìn)一步隨訪觀察。

[1]KREINER D S,HWANG S W,EASA J E,et al.An evidence-based clinical guideline for the diagnosis and treatment of lumbar disc herniation with radiculopathy[J].Spine J,2014,14(1):180-191.

[2]WANG K,HONG X,ZHOU B Y,et al.Evaluation of transforaminal endoscopic lumbar?discectomy in the treatment of lumbar disc herniation[J].Int Orthop,2015,39(8):1599-1604.

[3]BAI Y B,XU L,XI J C,et al.Diagnosis and treatment of lumbar disc herniation by discography and percutaneous transforaminal endoscopicsurgery[J].Zhonghua Yi Xue Za Zhi,2012,92(47):3350-3353.

[4]DALBAYRAK S,YAMAN O,YILMAZ M,et al.Transforaminal approach in lumbar disc herniations:transforaminal microdiscectomy (TFMD) technique[J].Turk Neurosurg,2015,25(1):29-35.

[5]WANG H,HUANG B,ZHENG W,et al.Comparison of early and late percutaneous endoscopic lumbar discectomy for lumbar disc herniation[J].Acta Neurochir (Wien),2013,155(10):1931-1936.

[6]KOTIL K,K KSAL N S,KAYACI S,et al.Long term results of lumbar sequestrectomy versus aggressive microdiscectomy[J].J Clin Neurosci,2014,21(10):1714-1718.

[7]HUSSEIN M,ABDELDAYEM A,MATTAR M M.Surgical technique and effectiveness of microendoscopic discectomy for large uncontained lumbar discherniations:a prospective,randomized,controlled study with 8 years of follow-up[J].Eur Spine J,2014,23(9):1992-1999.

[8]WANG H,ZHOU Y,LI C,et al.Risk factors for failure of single-level percutaneous endoscopic lumbar discectomy[J].J Neurosurg Spine,2015,23(3):320-325.

[9]JIANG Y,SONG H W,WANG D,et al.Treatment of lumbar intervertebral disc herniation and sciatica with percutaneous transforaminal endoscopic technique[J].Zhongguo Gu Shang,2013,26(10):800-804.

[10]史航,朱裕成,馬軍,等.PTED治療不同年齡段腰椎間盤突出癥的療效比較[J].中國骨與關(guān)節(jié)損傷,2015,30(9):968-969.

[11]MCGIRT M J,PARKER S L,HILIBRAND A,et al.Lumbar surgery in the elderly provides significant health benefit in the US health care system:patient-reported outcomes in 4370 patients from the N2QOD registry[J].Neurosurgery,2015,77 Suppl 4:S125-135.

[12]SHAMJI M F,GOLDSTEIN C L,WANG M,et al.Minimally Invasive Spinal Surgery in the Elderly:Does It Make Sense[J].Neurosurgery,2015,77(Suppl 4):S108-115.

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

國家自然科學(xué)基金項(xiàng)目(81171770)。

劉書中(1991-)，博士研究生，主要從事骨關(guān)節(jié)疾病研究。

余可誼，副教授，電子信箱-yukeyi009@hotmail.com

R274.9

A

2095-6258(2016)05-1041-03

2015-07-08)