椎間孔入路經(jīng)皮內(nèi)鏡技術(shù)摘除脫出髓核 36 例報(bào)告

董健文 戎利民 劉斌 王其友 馮豐 陳瑞強(qiáng) 謝沛根 張良明

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

椎間孔入路經(jīng)皮內(nèi)鏡技術(shù)摘除脫出髓核 36 例報(bào)告

董健文 戎利民 劉斌 王其友 馮豐 陳瑞強(qiáng) 謝沛根 張良明

目的分析椎間孔入路經(jīng)皮內(nèi)鏡技術(shù)治療脫出型腰椎間盤突出癥的困難性及其處理對(duì)策。方法2011 年 2 月至 2014 年 2 月，采用椎間孔入路經(jīng)皮內(nèi)鏡技術(shù)治療 36 例脫出型腰椎間盤突出癥，男 21 例，女 15 例，平均年齡 41 歲。突出節(jié)段 L3～42 例、L4～523 例、L5～S111 例?；?Lee 分類法，將36 例脫出分類為重度頭端脫出 5 例、輕度頭端脫出 7 例、輕度尾端脫出 15 例、重度尾端脫出 9 例。首先采用“Between”技術(shù)摘除椎間隙平面脫出物并行硬膜外松解獲得操作空間，然后將鞘管移向脫出方向采用“椎管內(nèi)”技術(shù)鏡下摘除剩余脫出物。結(jié)果平均手術(shù)時(shí)間為 108 min。術(shù)后短期大腿前方麻木 4 例、短期髂腰肌肌力下降 1 例、硬脊膜損傷合并多根神經(jīng)根損傷 1 例、出口神經(jīng)根損傷 1 例且脫出髓核摘除不徹底，其余 35 例脫出髓核摘除徹底。平均隨訪時(shí)間 16 ( 3～38 ) 個(gè)月，術(shù)后第 1 天腰痛 VAS )、腿痛 VAS評(píng)分 ( visual analogue scale ) 較術(shù)前改善 ( P＜0.01 )，術(shù)后 3 個(gè)月 VAS、JOA 腰痛評(píng)分 ( japanese orthopaedic association scores )、Oswestry 功能障礙指數(shù) ( oswestry disability index，ODI ) 指數(shù)較術(shù)前改善 ( P＜0.01 )，MacNab療效優(yōu) 25 例、良 7 例、可 3 例、差 1 例。隨訪期內(nèi)無(wú)復(fù)發(fā)與再手術(shù)。結(jié)論椎間孔入路經(jīng)皮內(nèi)鏡結(jié)合應(yīng)用“Between”技術(shù)與“椎管內(nèi)”技術(shù)治療絕大部分脫出型腰椎間盤突出癥可獲得良好的療效，椎間孔擴(kuò)大成形、初始通道建立與鞘管椎管內(nèi)移動(dòng)、鏡下脫出髓核的準(zhǔn)確判斷是其技術(shù)關(guān)鍵，但對(duì)重度脫出仍然是一項(xiàng)挑戰(zhàn)，其手術(shù)失敗率、并發(fā)癥發(fā)生率較高。

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

椎間孔入路經(jīng)皮內(nèi)鏡技術(shù)近年來(lái)在國(guó)內(nèi)發(fā)展迅速，尤其是 TESSYS ( transforaminal endoscopic spine system ) 技術(shù)幾乎可應(yīng)用于治療所有類型的腰椎間盤突出癥[1-7]，包括脫出型[8-12]。然而，由于鏡下手術(shù)視野的局限性，即使是采用完全 TESSYS 即椎管內(nèi)技術(shù)，對(duì)于脫出髓核尤其是嚴(yán)重脫出者也不能確保在可視情況下能將其完全取出，易造成脫出髓核殘留而導(dǎo)致手術(shù)失敗[8,13]。本研究旨在分析椎間孔入路經(jīng)皮內(nèi)鏡技術(shù)運(yùn)用于脫出型腰椎間盤突出癥的療效和針對(duì)各種技術(shù)困難的相應(yīng)對(duì)策。

資料與方法

一、一般資料

2011 年 2 月至 2014 年 2 月，采用椎間孔入路經(jīng)皮內(nèi)鏡技術(shù)治療 36 例脫出型腰椎間盤突出癥，男 21 例，女 15 例，平均年齡 41 ( 17～76 ) 歲。突出節(jié)段 L3～42 例、L4～523 例、L5～S111 例。在 Lee分類法基礎(chǔ)上[8]，將脫出超過(guò)上位椎弓根下緣以下3 mm 平面定義為重度頭端脫出、脫出位于上位椎體下終板與上位椎弓根下緣以下 3 mm 之間為輕度頭端脫出、脫出位于下位椎體上終板與下位椎弓根中部之間為輕度尾端脫出、超過(guò)下位椎弓根中部為重度尾端脫出 ( 圖 1 )， 按照此分類方法，矢狀面脫出包括重度頭端脫出 5 例、輕度頭端脫出 7 例、輕度尾端脫出 15 例、重度尾端脫出 9 例。重度脫出中 1 例頭端脫出超出上位椎弓根上緣、2 例尾端脫出超出下位椎弓根下緣 ( 表 1 )、4 例游離；水平面脫出包括中央、旁中央、椎間孔內(nèi)、椎間孔外脫出，依次為 4 例、27 例、4 例、1 例。合并側(cè)隱窩與 ( 或 ) 椎間孔狹窄 8 例、突出鈣化 5 例。

圖 1 矢狀面脫出分類示意圖Fig.1 Classifcation of disc migration on the sagittal plane

表1 各種類型脫出分布情況Tab.1 Distribution of different types of disc migration

納入標(biāo)準(zhǔn)：?jiǎn)蝹?cè)下肢放射性疼痛麻木 ( 伴 / 不伴腰痛 )、相應(yīng)神經(jīng)根支配區(qū)感覺(jué)與肌力減退或缺失、直腿抬高試驗(yàn)陽(yáng)性，CT、MRI、椎管照影、CTM 征象與臨床相符、保守治療效差或反復(fù)發(fā)作，其中術(shù)前背伸與 ( 或 ) 踝背伸癱瘓 3 例。排除標(biāo)準(zhǔn)：多節(jié)段突出、合并馬尾綜合征、腰椎不穩(wěn)、病變節(jié)段既往手術(shù)史。

手術(shù)由同一組脊柱外科醫(yī)師完成，采用設(shè)備為 SPINENDOS 脊柱內(nèi)鏡系統(tǒng) ( SPINENDOS Gmbh，Germany ) 與 Ellman 等離子消融刀頭系統(tǒng) ( Ellman Innovation，New York，USA )。

二、手術(shù)方法

側(cè)臥位，患側(cè)在上，腰部墊枕。術(shù)前僅標(biāo)記后正中線與患側(cè)髂脊體表投影線，L4～5、L5～S1節(jié)段穿刺點(diǎn)分別位于后正中線旁開(kāi) 12 cm、14 cm 髂脊上緣稍高處，L3～4穿刺點(diǎn)為其椎間隙水平線于后正中線旁開(kāi) 10 cm 處。皮膚、筋膜層與關(guān)節(jié)突周圍采用0.5% 利多卡因分層浸潤(rùn)麻醉，術(shù)中輔助靜滴氟比洛芬酯 100 mg。根據(jù)髓核脫出部位、椎間孔形態(tài)大小確定穿刺靶點(diǎn)，對(duì)無(wú)需椎間孔擴(kuò)大成形者穿刺靶點(diǎn)直接選擇 AP 透視位于椎弓根內(nèi)緣、側(cè)位透視位于椎間盤后緣中點(diǎn)處，對(duì)需行椎間孔擴(kuò)大成形者尤其是L5～S1節(jié)段穿刺靶點(diǎn)選擇偏向背側(cè)或上關(guān)節(jié)突尖部。G 型臂透視引導(dǎo)下將 18 號(hào)穿刺針針尖穿刺到達(dá)靶向部位，置入導(dǎo)絲后取出穿刺針，作 8 mm 皮膚切口，導(dǎo)絲引導(dǎo)下逐級(jí)擴(kuò)張軟組織，采用環(huán)鋸清除椎間孔內(nèi)韌帶軟組織，對(duì)須進(jìn)行椎間孔擴(kuò)大成形者去除部分上關(guān)節(jié)突前外側(cè)骨質(zhì)，在軟組織擴(kuò)張與椎間孔擴(kuò)大成形過(guò)程中均可對(duì)穿刺靶點(diǎn)不滿意者進(jìn)行微調(diào)，置入工作鞘管，根據(jù)脫出方向，側(cè)位透視顯示鞘管斜面可稍高于或低于椎間盤后緣中點(diǎn)、且斜面各 50% 橫跨于椎間隙與椎管 ( 即 Between 技術(shù) )[14]，椎間盤髓核藍(lán)染造影可在穿刺過(guò)程中或鞘管置入后進(jìn)行。

鏡下操作首先摘除脫出髓核基底部，顯露確認(rèn)鏡下解剖關(guān)系，進(jìn)一步清除椎間隙后部松動(dòng)或游離髓核碎片，確認(rèn)硬膜囊搏動(dòng)以及其與纖維環(huán)后緣之間隙，如為旁中央型與中央型脫出，須顯露后縱韌帶并探查其深、淺面。采用等離子射頻消融、止血與纖維環(huán)成形，同時(shí)松解纖維環(huán)與硬膜囊之間隙，以利于根據(jù)脫出方向?qū)⒐ぷ髑使芟蝾^端或尾端于椎管內(nèi)傾斜，此時(shí)部分鞘管斜面位于椎體后方。如為輕度脫出，則可直視下將脫出物完全取出，如為重度脫出尤其是遠(yuǎn)端超出椎弓根范圍，則先采用等離子刀頭松解脫出物周圍，盡可能將其大塊完整取出，如脫出物碎裂無(wú)法整塊取出，則需反復(fù)用等離子刀頭探查椎弓根內(nèi)側(cè)區(qū)域，如患者疼痛麻木主述癥狀消失、鏡下硬膜囊神經(jīng)根搏動(dòng)恢復(fù)良好、取出脫出物量與術(shù)前影像學(xué)相符，則可結(jié)束手術(shù)( 圖 2，3 )。

圖 2 a：術(shù)前前后位；b：術(shù)前側(cè)位；c：術(shù)前 MRI 示 L5～ S1椎間盤重度尾端脫出；d：術(shù)前 MRI 軸位示 L5～ S1椎間盤巨大旁中央脫出；e：手術(shù)側(cè)臥位與穿刺點(diǎn)體表標(biāo)記；f：術(shù)中前后位透視示工作通道鞘管位于椎弓根內(nèi)緣；g：術(shù)中側(cè)位透視示工作通道鞘管斜面位于椎間盤后緣中點(diǎn)、各 50% 橫跨于椎間隙與椎管；h：鞘管椎管內(nèi)移向尾端，顯示完全椎管內(nèi)技術(shù)；i：鞘管到達(dá) S1椎體后硬膜外間隙，將脫出物摘除，硬膜囊搏動(dòng)良好；j ～ k：術(shù)后 MRI 示脫出物摘除徹底Fig.2 a: The preoperative anteroposterior ( AP ) X-ray image; b: The preoperative lateral X-ray image; c: The preoperative MRI sagittal image showed L5-S1high-grade downward migration; d: The preoperative MRI axial image showed L5-S1huge paracentral extrusion; e: The superfcial marker of the puncture point in the lateral position; f: The AP fuoroscopic view showed the position of the beveled cannula at the medial pedicular line; g: The lateral fuoroscopic view showed the beveled cannula was “half-and-half” positioned across the disc space to the epidural space; h: The beveled cannula was advanced along the direction of migration in the epidural space which was called complete “intracanal” endoscopic technique; i: The remanent fragments migrated downward were completely removed and a good visualization of dura sac pulsation was achieved; j-k: The postoperative MRI images showed the L5-S1down-migrated disc was removed completely

三、術(shù)后處理

術(shù)后次日戴腰圍下床行走，術(shù)后即刻復(fù)查三維CT 或 MRI 了解脫出髓核摘除與椎間孔擴(kuò)大成形情況，術(shù)后 1～2 天出院，戴腰圍 6 周。術(shù)后 1 個(gè)月、3 個(gè)月、半年、1 年、2 年定期復(fù)查，采用 MacNab療效評(píng)定、視覺(jué)模擬評(píng)分 ( visual analogue scale，VAS )、JOA 腰痛評(píng)分與 Oswestry 功能障礙指數(shù)( oswestry disability index，ODI ) 評(píng)價(jià)療效。

四、統(tǒng)計(jì)學(xué)分析

對(duì)所有數(shù)據(jù)采用 SPSS 21.0 軟件 ( SPSS Inc，Chicago，IL，USA ) 進(jìn)行統(tǒng)計(jì)學(xué)分析處理，采用非參數(shù)檢驗(yàn)方法對(duì) JOA 評(píng)分、ODI 指數(shù)、VAS 評(píng)分等不符合正態(tài)分布的數(shù)據(jù)進(jìn)行分析，P＜0.05 為差異顯著性標(biāo)準(zhǔn)。

結(jié) 果

平均手術(shù)時(shí)間為 108 min。4 例術(shù)后短期大腿前方麻木，1 例重度頭端脫出為 L4～5椎間盤向上脫出至 L3～4椎間隙平面，術(shù)前踝背伸與趾背伸肌力0 級(jí)，術(shù)中 L4神經(jīng)根損傷，術(shù)中造影顯示仍存在壓迫改開(kāi)放手術(shù)，發(fā)現(xiàn)上位椎弓根下緣以上脫出部分殘留，術(shù)后神經(jīng)功能無(wú)恢復(fù) ( 圖 4 )，其余35 例術(shù)后復(fù)查 MRI 或 CT 均顯示脫出髓核摘除徹底。1 例 L4～5重度尾端脫出術(shù)中損傷硬脊膜，術(shù)后出現(xiàn)多根神經(jīng)根損傷表現(xiàn)，對(duì)癥治療后部分恢復(fù)；1 例 L3～4頭端重度脫出術(shù)后短期髂腰肌肌力下降，對(duì)癥治療后恢復(fù)。平均隨訪 16 ( 3～38 ) 個(gè)月，術(shù)后第 1 天腰痛 VAS、腿痛 VAS 評(píng)分分別為 1.95±0.53、1.01±0.56，均較術(shù)前改善 ( P＜0.01 )，術(shù)后 3 個(gè)月腰痛 VAS、腿痛 VAS、JOA、ODI 依次為 0.58±0.42、0.51±0.38、27.44±1.36、11.78±2.65，均較術(shù)前改善 ( P＜0.01 ) ( 表 2 )。改良 MacNab 療效為優(yōu) 25 例、良 7 例、可 3 例、差1 例，優(yōu)良率 88.89%，各種脫出類型療效優(yōu)良率依次為輕度脫出 100%、重度頭端脫出 80%、重度尾端脫出 66% ( 表 3 )。隨訪期內(nèi)無(wú)復(fù)發(fā)與再手術(shù)。

圖 3 a：術(shù)前前后位；b：術(shù)前側(cè)位；c：術(shù)前 MRI 示L4～5椎間盤輕度尾端脫出；d：術(shù)前 MRI 軸位示 L4～5椎間盤旁中央脫出；e ～ f：術(shù)中 AP、側(cè)位透視示初始工作鞘管位置良好；g ～ h：術(shù)后 MRI 示脫出物摘除徹底Fig.3 a: The preoperative AP X-ray image; b: The preoperative lateral X-ray image; c: The preoperative MRI sagittal image showed L4-5low-grade downward migration; d: The preoperative MRI axial image showed L4-5paracentral extrusion; e-f: The AP and lateral fluoroscopic images showed satisfactory initial position of the beveled cannula; g-h: The postoperative MRI images showed the L4-5down-migrated disc was removed suffciently

圖 4 a：術(shù)前 MRI 示 L4～5椎間盤重度頭端脫出；b ～ c：術(shù)中前后位、側(cè)位位透視示初始工作鞘管位置良好；d：鞘管椎管內(nèi)移向頭端；e：鏡下顯示 L4椎體后空間脫出物已摘除，4 點(diǎn)鐘為 L4神經(jīng)根損傷，改開(kāi)放手術(shù)證實(shí) L4椎弓根下緣以上脫出物殘留Fig.4 a: The preoperative MRI sagittal image showed L4-5high-grade upward migration; b-c: The AP and lateral fuoroscopic images showed satisfactory initial position of the beveled cannula; d: The beveled cannula was advanced towards the head in the epidural space; e: The endoscopic image showed the L4-5upward migrated disc behind the posterior wall of L4vertebrae was removed and L4nerve root was incompletely injured at 4 o’clock. Residual migrated fragments beyond the inferior margin of L4pedicle were found during the subsequent open surgery

討 論

根據(jù)北美脊柱協(xié)會(huì)、美國(guó)脊柱放射學(xué)協(xié)會(huì)、美國(guó)神經(jīng)放射學(xué)協(xié)會(huì)聯(lián)合推薦腰椎間盤突出癥命名與分類方法，如椎間盤突出物離開(kāi)其突出部位，不論是否與其基底部連續(xù)，均視為脫出型，其中無(wú)連續(xù)性者特別命名為游離型[15]。矢狀面上椎管內(nèi)脫出椎間盤組織可向頭端或尾端脫出，而在水平面上可向中央、旁中央、椎間孔內(nèi)、椎間孔外脫出，臨床大多數(shù)為向尾端旁中央脫出[15-16]，本組病例脫出類型分布與既往文獻(xiàn)報(bào)道一致。椎間孔入路經(jīng)皮內(nèi)鏡TESSYS 技術(shù)采用不同直徑的環(huán)鋸逐級(jí)去除上關(guān)節(jié)突前外側(cè)部分骨質(zhì)以行椎間孔擴(kuò)大成形，故工作鞘管可置入椎管內(nèi)直接摘除突出髓核與直接神經(jīng)根松解減壓，已被運(yùn)用于治療包括脫出型在內(nèi)的各種類型腰椎間盤突出癥。水平面上不論是中央型還是椎間孔外型脫出，通過(guò)調(diào)整工作鞘管進(jìn)入的深度均可直視脫出物，故對(duì)于椎間孔入路而言將其摘除并不困難。然而，對(duì)于矢狀面上的脫出，由于鏡下視野的局限性，當(dāng)脫出超出上位椎弓根下緣與下位椎弓根上緣時(shí)，脫出物遠(yuǎn)端并不可見(jiàn)，即使脫出物與其基底部相連，也難以確保通過(guò)夾住其基底部而將其完整取出以避免殘留，如脫出物已游離甚至碎裂，即使被藍(lán)染也難以被確認(rèn)與整塊或分塊取出。盡管TESSYS 技術(shù)可將工作鞘管在椎管內(nèi)移動(dòng)以盡可能接近脫出物遠(yuǎn)端，但這種可調(diào)整性與椎間孔大小及其擴(kuò)大成形效果有關(guān)，對(duì)于 L5～S1節(jié)段髂脊較高位者尤其困難，由于存在這些技術(shù)局限性，因而對(duì)于通過(guò)椎間孔入路經(jīng)皮內(nèi)鏡摘除脫出尤其是重度脫出物而言無(wú)疑是一種挑戰(zhàn)。

表2 術(shù)前-、術(shù)后第 1 天、術(shù)后 3 個(gè)月 VAS、JOA 評(píng)分、ODI 指數(shù)比較 (±s )Tab.2 Comparison of VAS, JOA and ODI- scores preope-ratively and at 1 day and 3 months after the operation (±s )

表2 術(shù)前-、術(shù)后第 1 天、術(shù)后 3 個(gè)月 VAS、JOA 評(píng)分、ODI 指數(shù)比較 (±s )Tab.2 Comparison of VAS, JOA and ODI- scores preope-ratively and at 1 day and 3 months after the operation (±s )

注：P 值為術(shù)后 3 個(gè)月與術(shù)前比較Notice: P referred to the comparison between the preoperative scores and that at 3 months after the operation

隨訪時(shí)間 腰痛 VAS 腿痛 VAS JOA ODI術(shù)前 6.98±1.72 7.10±0.96 15.80±1.63 33.83±8.87術(shù)后第 1 天 1.95±0.53 1.01±0.56 24.94±1.62 -術(shù)后 3 個(gè)月 0.58±0.42 0.51±0.38 27.44±1.36 11.78±2.65 P 值 0.0001 0.0001 0.0001 0.0001

表3 術(shù)后 3 個(gè)月改良 MacNab 療效評(píng)價(jià)Tab.3 Modifed MacNab evaluation at 3 months after the operation

與處理非脫出椎間盤不同的是，對(duì)于脫出型包括游離型，椎間孔擴(kuò)大成形與脫出物周圍松解在技術(shù)要求上顯得格外重要。即使是椎間孔狹窄不明顯者，適當(dāng)?shù)臄U(kuò)大成形也有利于鞘管的置入及其位置微調(diào)，而 L5～S1椎間孔常存在不同程度的狹小，且鞘管置入角度相對(duì)較大，受髂脊影響，鞘管往往難以向頭端傾斜調(diào)整，因此，良好的椎間孔擴(kuò)大成形是保證其手術(shù)成功的前提條件。不論是輕度還是重度脫出，工作鞘管在矢狀面的初始位置建議仍然選擇在椎間盤后緣中點(diǎn)附近，其斜面各 50% 橫跨于椎間隙與椎管，即“Between”技術(shù)，其優(yōu)點(diǎn)在于易于辨別解剖關(guān)系與處理椎間隙后部松動(dòng)或游離髓核碎片、即脫出基底部，這有別于經(jīng)典 TESSYS 技術(shù)，從某種意義上說(shuō)其實(shí)是一種由盤內(nèi)到盤外操作技術(shù)。如果將鞘管初始位置直接向脫出方向置于椎管內(nèi)，在尚未辨明解剖關(guān)系的情況下就貿(mào)然摘除脫出物易造成神經(jīng)組織損傷，也缺乏對(duì)脫出狀況整體的認(rèn)識(shí)而易遺漏。摘除基底部脫出物后可形成下一步操作的空間，也能初步判斷硬膜囊搏動(dòng)情況，對(duì)于中央型脫出需將鞘管深入，探查后縱韌帶深、淺面。采用等離子射頻消融刀頭松解硬膜囊與脫出物、椎體后緣間隙，直至上位椎弓根下緣或下位椎弓根上緣可見(jiàn)，處理相應(yīng)椎弓根上下緣與椎體上下終板后角與椎體后緣周圍軟組織以獲得充足的椎管內(nèi)空間，如椎間孔擴(kuò)大成形不理想導(dǎo)致上關(guān)節(jié)突影響視野與操作，可在鏡下采用骨鑿與 Pounch 鉗處理上關(guān)節(jié)突及其深面附著黃韌帶，將鞘管沿脫出方向在椎管內(nèi)移動(dòng)，所有操作均在硬膜囊前方進(jìn)行，至此可完全顯露輕度脫出物，對(duì)于重度脫出也可大部分顯露。

由此可見(jiàn)，對(duì)于輕度脫出，不論是頭端還是尾端脫出，既往文獻(xiàn)與本組病例研究結(jié)果均表明通過(guò)椎管內(nèi)技術(shù)完全可將其完整摘除以獲得良好的療效，而對(duì)于重度脫出，尤其是超出鏡下可視范圍時(shí)，能否徹底摘除仍然是存在諸多不確定性。盡管通過(guò)脫出物周圍充分松解以盡可能將其大塊取出，鏡下可見(jiàn)脫出物摘除完畢后再使用等離子刀頭反復(fù)探查椎弓根區(qū)域，并結(jié)合患者主觀癥狀消失、鏡下硬膜囊神經(jīng)根搏動(dòng)、取出量與術(shù)前影像學(xué)相符等方面綜合判斷可提高徹底摘除成功率，但仍然存在殘留可能。嚴(yán)格選擇病例有助于減少手術(shù)失敗率，正如 Lee 等[8]則對(duì)于脫出超出上位椎弓根下緣與游離超出下位椎弓根中部者不主張采用椎間孔入路，可見(jiàn)對(duì)于重度頭端脫出尤其需更加慎重，臨床上向頭端脫出更多發(fā)生于高位間隙[16]，由于神經(jīng)走行解剖原因，在建立通道與鏡下操作易造成出口根損傷，本組病例中 1 例 L3～4重度頭端脫出術(shù)后短期髂腰肌肌力下降便與通道建立有關(guān)。對(duì)于病史較長(zhǎng)、經(jīng)過(guò)反復(fù)甚至過(guò)度按摩等保守治療的重度脫出，極有可能游離，則更增加了手術(shù)難度，既不易整塊取出，也由于粘連不易松解且易硬膜外出血而影響操作。

顯然，椎間孔入路本身的局限性與目前普遍采用硬鞘管內(nèi)鏡系統(tǒng)是造成無(wú)法確保徹底摘除重度脫出椎間盤組織的根本原因，即使有學(xué)者采用極外側(cè)入路、或是對(duì)于重度尾端脫出采用椎弓根上入路與去除部分下位椎弓根上緣骨質(zhì)以增大視野，也無(wú)法從根本上克服這一缺陷[9,17]。Kim 等[18]對(duì) 5 例重度尾端脫出從對(duì)側(cè)椎間孔入路置入鞘管并逐漸到達(dá)患側(cè)脫出物處，這一大膽的技術(shù)嘗試?yán)碚撋峡山鉀Q患側(cè)椎弓根與上關(guān)節(jié)突對(duì)脫出物的遮擋，但幾乎需要摘除大部分后方纖維環(huán)甚至后縱韌帶以獲得操作空間，且鞘管在硬膜囊前方表面橫跨椎管內(nèi)也大大增加了神經(jīng)損傷的風(fēng)險(xiǎn)，同時(shí)對(duì)技術(shù)掌握要求極高。因此，對(duì)側(cè)椎間孔入路目前尚不能為大多數(shù)術(shù)者所接納，且是否有必要采用這樣一種有可能創(chuàng)傷更大、風(fēng)險(xiǎn)更高的技術(shù)去處理重度脫出椎間盤值得商榷，而采用椎板間入路，不論是顯微內(nèi)鏡 ( MED ) 還是全脊柱內(nèi)鏡 ( PELD ) 技術(shù)[19-20]，會(huì)較椎間孔入路更易將脫出物徹底摘除。

本研究表明，椎間孔入路經(jīng)皮內(nèi)鏡結(jié)合應(yīng)用“Between”技術(shù)與“椎管內(nèi)”技術(shù)，可成功摘除絕大部分的椎間盤脫出物并獲得良好的療效，椎間孔擴(kuò)大成形、初始通道建立與鞘管椎管內(nèi)移動(dòng)、鏡下脫出髓核的準(zhǔn)確判斷是其技術(shù)關(guān)鍵，但對(duì)于重度脫出尤其是 L5～S1節(jié)段手術(shù)操作困難且手術(shù)失敗率、并發(fā)癥發(fā)生率較高，需與患者良好的溝通，如術(shù)前或術(shù)中判斷脫出物無(wú)法徹底摘除，需及時(shí)改用其它術(shù)式。

[1]Hoogland T, Schubert M, MikliIz B, et a1. Transforaminal posterolateral endoscopic discectomy with or without the combination of a low-dose chymopagain: a prospective randomized study in 280 consecutive cases. Spine, 2006, 3l(24):E890-897.

[2]Jang JS, An SH, Lee SH. Transforaminal percutaneous endoscopic discectomy in the treatment of foraminal and extraforaminal lumbar disc herniations. J Spinal Disord Tech, 2006, 19(5):338-343.

[3]Ruetten S, Komp M, Merk H. Full endoscopic interlaminar and transforaminal lumbar discectomy versus conventional microsurgical technique: a prospective randomized, controlled study. Spine, 2008, 33(9):931-939.

[4]Hoogland T, Sehubert M, Miklitz B, et a1. Endoscopic transforaminal discectomy for recurrent lumbar disc herniation: a prospective, cohort evaluation of 262 consecutive cases. Spine, 2008, 33(9):973-978.

[5]周躍, 李長(zhǎng)青, 王建, 等. 椎間孔鏡YESS與TESSYS技術(shù)治療腰椎間盤突出癥. 中華骨科雜志, 2010, 30(3):225-231.

[6]Nellensteijn J, Ostelo R, Bartels R, et al. Transforaminal endoscopic surgery for symptomatic lumbar disc herniations: a systematic review of the literature. Eur Spine J, 2010, 19(2):181-204.

[7]Gibson JN, Cowie JG, Iprenburg M. Transforaminal endoscopic spinal surgery: the future ‘gold standard’ for discectomy? - A review. Surgeon, 2012, 10(5):290-296.

[8]Lee S, Kim SK, Lee SH, et al. Percutaneous endoscopic lumbar discectomy for migrated disc herniation: classifcation of disc migration and surgical approaches. Eur Spine J, 2007, 16(3):431-437.

[9]Kim HS, Ju CI, Kim SW, et al. Endoscopic transforaminal suprapedicular approach in high grade inferior migrated lumbar disc herniation. J Korean Neurosurg Soc, 2009, 45(2):67-73.

[10]Choi G, Lee SH, Lokhande P, et al. Percutaneous endoscopic approach for highly migrated intracanal disc herniations by foraminoplastic technique using rigid working channel endoscope. Spine, 2008, 33(15):E508-515.

[11]Jasper GP, Francisco GM, Telfeian AE. Endoscopic transforaminal discectomy for an extruded lumbar disc herniation. Pain Physician, 2013, 16(1):E31-35.

[12]隰建成, 馬遠(yuǎn)征, 崔旭, 等. 椎間孔鏡治療脫出型腰椎間盤突出癥療效分析. 中國(guó)疼痛醫(yī)學(xué)雜志, 2013, 19(1):35-38.

[13]Lee SH, Kang BU, Ahn Y, et al. Operative failure of percutaneous endoscopic lumbar discectomy: a radiologic analysis of 55 Cases. Spine, 2006, 31(10):E285-E290.

[14]Liu KX, Massoud B. Transforaminal endoscopic lumbar procedure for disc herniations: a “between” technique. Surg Technol Int, 2010, 19:203-210.

[15]Fardon DF, Milette PC. Nomenclature and classification of lumbar disc pathology. Recommendations of the combined task forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology. Spine, 2001, 26(5):E93-113.

[16]Daghighi MH, Pouriesa M, Maleki M, et al. Migration patterns of herniated disc fragments: a study on 1,020 patients with extruded lumbar disc herniation. Spine J, 2013, Pii: s1529-9430(13)01985-2.

[17]Ruetten S, Komp M, Godolias G. An extreme lateral access for the surgery of lumbar disc herniations inside the spinal canal using the full-endoscopic uniportal transforaminal approachtechnique and prospective results of 463 patients. Spine, 2005, 30(22):2570-2578.

[18]Kim JS, Choi G, Lee SH. Percutaneous endoscopic lumbar discectomy via contralateral approach: a technical case report. Spine, 2011, 36(17):E1173-1178.

[19]Ikuta K, Tono O, Senba H, et al. Translaminar microendoscopic herniotomy for cranially migrated lumbar disc herniations encroaching on the exiting nerve root in the preforaminal and foraminal zones. Asian Spine J, 2013, 7(3):190-195.

[20]Kim CH, Chung CK, Woo JW. Surgical outcome of percutaneous endoscopic interlaminar lumbar discectomy for highly migrated disc herniation. J Spinal Disord Tech, 2012, [Epub ahead of print].

( 本文編輯：馬超 )

Percutaneous transforaminal endoscopic surgery for migrated lumbar disc: 36 cases

DONG Jian-wen, RONG Li-min, LIU Bin, WANG Qi-you, FENG Feng, CHEN Rui-qiang, XIE Pei-gen, ZHANG Liang-ming. Department of Spinal Surgery, the third affliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, 510630, PRC

ObjectiveTo analyze the pitfalls and technical notes of percutaneous transforaminal endoscopic surgery for migrated lumbar disc herniation.MethodsThirty-six consecutive patients with different types of migrated lumbar disc herniation received percutaneous transforaminal endoscopic discectomy from February 2011 to February 2014. There were 21 males and 15 females, with an average age of 41 years old. There were 2 cases of migrated L3-4disc, 23 cases of migrated L4-5disc and 11 cases of migrated L5-S1disc. Based on Lee’s classifcation of migrated disc, there were high-grade upward migration in 5 cases, low-grade upward migration in 7 cases, low-grade downward migration in 15 cases and high-grade downward migration in 9 cases. The disc fragments at the intervertebral level were removed frst by “between” technique, and then the epidural space was released to create manipulation space. Finally, the beveled cannula was manually advanced along the migration direction to perform endoscopic discectomy for the remanent migrated disc, which was called “intracanal” technique.ResultsThe mean operation time was 108 minutes. The postoperative complications included transient numbness in the anterior thigh in 4 cases, transient iliopsoas weakness in 1 case, multiple nerve root injuries caused by dura tears in 1 case and exit nerve root injuries as well as incomplete endoscopic discectomy in 1 case. Complete removal of migrated disc was confrmed in the other 35 cases. All the patients were followed up for a mean duration of 16 months ( range: 3-38 months ). The Visual Analogue Scale ( VAS ) scores of low back pain and leg pain at 1 day after the surgery were signifcantly improved when compared with that preoperatively ( P＜0.01 ). The low back pain VAS score, leg pain VAS score, Japanese Orthopedic Association ( JOA ) score and Chinese Oswestry Disability Index ( ODI ) score at 3 months after the surgery were signifcantly improved when compared with that preoperatively ( P＜0.01 ). According to the Macnab criteria, the clinical results were excellent in 25 cases, good in 7 cases, fair in 3 cases and bad in 1 case respectively. There was no recurrence or revision during the follow-up.ConclusionsGood clinical results can be achieved by percutaneous transforaminal endoscopic surgery combined with “between” technique and “intracanal” technique inmost patients with migrated lumbar disc herniation. The technical notes include proper foraminotomy, satisfactory initial position of beveled cannula, manipulation of beveled cannula along the direction of migration in the epidural space and accurate discrimination of migrated disc materials. It’s still a challenge to treat high-grade migration via the transforaminal approach, due to a higher failure rate and a higher incidence of complications.

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

10.3969/j.issn.2095-252X.2014.08.009

Th776.1, R681.5

510630 廣州，中山大學(xué)附屬第三醫(yī)院脊柱外科

2014-06-01 )