经皮大直径全内镜下经椎板间入路治疗腰椎管狭窄症的疗效评价
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摘要
目的评价经皮椎板间入路大直径全内镜下治疗腰椎管狭窄症的临床效果。方法回顾性分析2016年1月～2018年5月西南医科大学附属成都363医院骨科收治的腰椎管狭窄症患者46例,均为单一节段狭窄,类型包括侧椎管狭窄、中央管狭窄及混合狭窄。根据狭窄类型,中央管狭窄采用经皮大直径全内镜下椎板开窗减压,侧方椎管狭窄及混合型狭窄采用内镜下椎板开窗+神经根管减压,伴有椎间盘突出同时行髓核部分摘除术,双侧狭窄时采用一侧入路双侧减压。采用腰痛及腿痛VAS评分,ODI指数和改良MacNab疗效评分评估术后短期疗效。结果 46例患者均顺利完成手术,手术时间(92.25±19.63)min,术中出血量(15.52±6.78)ml,住院时间5～10d,平均6.6d。患者均获随访,随访时间3～24个月,平均14个月。术前腰痛VAS评分为(5.55±0.83),术后即刻为(2.65±0.75)分,术后3个月为(2.35±0.67)分,术后6个月为(2.20±0.52)分及末次随访为(2.05±0.39)分。术前腿痛VAS评分为(5.65±1.13)分,术后即刻为(2.45±0.98)分,术后3个月为(2.35±0.87)分,术后6个月为(2.15±0.67)分及末次随访为(2.05±0.51)分。术前与术后VAS评分比较,差异有统计学意义(P<0.05)。术前ODI评分(73.15±9.92)%,术后即刻(29.20±7.81)%,术后3个月(25.55±5.01)%,术后6个月为(20.90±4.76)%,末次随访为(18.85±4.26)%,术后与术前相比,差异均有统计学意义(P<0.05)。末次随访采用改良MacNab评价疗效,其中优为35例,良为7例,可为3例,差为1例,优良率占91.3%。结论经皮大直径内镜系统治疗腰椎管狭窄症具有创伤小,恢复快等优点,是一种安全、高效的微创手术。
Objective To evaluate the clinical effect of percutaneous large diameter Full-endoscopic interlaminar approach in the treatment of lumbar spinal stenosis.Methods 46 patients of lumbar spinal stenosis admitted to AVIV 363 hospital from January 2016 to May 2018 with single level stenosis were involved in the present study. Types of stenosis included lateral spinal canal stenosis, central canal stenosis, and mixed stenosis. According to the type of stenosis, the central canal stenosis was decompressed by percutaneous full-endoscopic laminar fenestration, the lateral spinal canal stenosis and mixed stenosis were decompressed by percutaneous full-endoscopic Laminar fenestration and nerve root canal decompression. Partial excision of nucleus pulposus was performed with herniation of intervertebral disc and bilateral decompression via unilateral approach for bilateral stenosis.using the VAS of low back pain and leg pain, Oswestry disability index and a modified Macnab's criterion evaluate the short-term outcome. Results 46 cases successfully completed surgery. The operative time was(92.25±19.63) min, intraoperative bleeding volume(15.52±6.78) ml, hospitalization time 5-10 days(mean 6.6 days). All patients were followed up for 12-18 months(mean 14 months). The VAS score of low back pain was(5.55±0.83) score before operation,(2.65±0.75) score immediately after operation,(2.35±0.67) score at 3 months after operation,(2.20±0.52) score at 6 months after operation and(2.05±0.39)score at last follow-up. The VAS score of leg pain was(5.65±1.13) score before operation,(2.45±0.98) score immediately after operation,(2.35±0.87) score at 3 months after operation,(2.15±0.67) score at 6 months after operation and(2.05±0.51) score at last follow-up after operation. There was a significant difference between preoperative and postoperative VAS scores(P<0.05).The ODI scores were(73.15±9.92)% in preoperative,(29.20±7.81)% in immediate postoperation,(25.55±5.01)% in 3 months after operation,(20.90±4.76)% in 6 months after operation and(18.85±5.33)% in the last follow-up. Improved macnab was used to evaluate the curative effect. There were excellent in 35 cases, good in 7 cases, fair in 3 cases, poor in 1 case. The excellent and good rate was 91.3%.Conclusion Percutaneous large diameter endoscopy is a safe and effective minimally invasive operation for lumbar spinal stenosis.
Objective To evaluate the clinical effect of percutaneous large diameter Full-endoscopic interlaminar approach in the treatment of lumbar spinal stenosis.Methods 46 patients of lumbar spinal stenosis admitted to AVIV 363 hospital from January 2016 to May 2018 with single level stenosis were involved in the present study. Types of stenosis included lateral spinal canal stenosis, central canal stenosis, and mixed stenosis. According to the type of stenosis, the central canal stenosis was decompressed by percutaneous full-endoscopic laminar fenestration, the lateral spinal canal stenosis and mixed stenosis were decompressed by percutaneous full-endoscopic Laminar fenestration and nerve root canal decompression. Partial excision of nucleus pulposus was performed with herniation of intervertebral disc and bilateral decompression via unilateral approach for bilateral stenosis.using the VAS of low back pain and leg pain, Oswestry disability index and a modified Macnab's criterion evaluate the short-term outcome. Results 46 cases successfully completed surgery. The operative time was(92.25±19.63) min, intraoperative bleeding volume(15.52±6.78) ml, hospitalization time 5-10 days(mean 6.6 days). All patients were followed up for 12-18 months(mean 14 months). The VAS score of low back pain was(5.55±0.83) score before operation,(2.65±0.75) score immediately after operation,(2.35±0.67) score at 3 months after operation,(2.20±0.52) score at 6 months after operation and(2.05±0.39)score at last follow-up. The VAS score of leg pain was(5.65±1.13) score before operation,(2.45±0.98) score immediately after operation,(2.35±0.87) score at 3 months after operation,(2.15±0.67) score at 6 months after operation and(2.05±0.51) score at last follow-up after operation. There was a significant difference between preoperative and postoperative VAS scores(P<0.05).The ODI scores were(73.15±9.92)% in preoperative,(29.20±7.81)% in immediate postoperation,(25.55±5.01)% in 3 months after operation,(20.90±4.76)% in 6 months after operation and(18.85±5.33)% in the last follow-up. Improved macnab was used to evaluate the curative effect. There were excellent in 35 cases, good in 7 cases, fair in 3 cases, poor in 1 case. The excellent and good rate was 91.3%.Conclusion Percutaneous large diameter endoscopy is a safe and effective minimally invasive operation for lumbar spinal stenosis.
引文
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[15] Komp M,Hahn P,Merk H,et al.Bilateral operation of lumbar degenerative central spinal stenosis in full-endoscopic interlaminar technique with unilateral approach:prospective 2-year results of 74 patients[J].Journal of Spinal Disorders & Techniques,2011,24(5):281-287.
[16] Ruetten S,Komp M,Merk H,et al.Surgical treatment for lumbar lateral recess stenosis with the full-endoscopic interlaminar approach versus conventional microsurgical technique:a prospective,randomized,controlled study[J].Journal of Neurosurgeryspine Spine,2009,10(5):476-485.
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[18] Postacchini F.Lumbar spinal stenosis and pseudostenosis.Definition and classification of pathology[J].Italian Journal of Orthopaedics & Traumatology,1983,9(3):339-350.
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[21] 白一冰,李嵩鹏,简伟,等.椎间孔镜下侧隐窝减压治疗腰椎管狭窄的疗效分析[J].中国疼痛医学杂志,2014,20(12):919-921.
[22] 陈晓庆,张烽,于江,等.经皮椎间孔入路内镜下减压治疗老年腰椎侧隐窝狭窄症[J].中国脊柱脊髓杂志,2016,26(3):233-238.
[23] Ahn Y.Percutaneous endoscopic decompression for lumbar spinal stenosis[J].Expert Review of Medical Devices,2014,11(6):605-616.
[24] Lee C K,Rauschning W,Glenn W.Lateral lumbar spinal canal stenosis:classification,pathologic anatomy and surgical decompression[J].Spine,1988,13(3):313-320.
[25] Ciol MA,Deyo RA,Howell E,et al.An assessment of surgery for spinal stenosis:time trends,geographic variations,complications,and reoperations[J].Journal of the American Geriatrics Society,1996,44(3):285-290.
[26] 叶猛,王力文,王鸿晨.椎间孔镜手术出现失误及并发症的原因与预防措施[J].局解手术学杂志,2017,26(5):362-366.
[27] Yoganandan N,Knowles SA,Maiman DJ,et al.Anatomic study of the morphology of human cervical facet joint[J].Spine,2003,28(20):2317-2323.
[28] Wang B,L G,Patel AA,et al.An evaluation of the learning curve for a complex surgical technique:the full endoscopic interlaminar approach for lumbar disc herniations[J].Spine Journal,2011,11(2):122-130.
[29] Yadav YR,Parihar V,Kher Y,et al.Endoscopic inter laminar management of lumbar disease[J].Asian Journal of Neurosurgery,2016,11(1):1.
[2] Deyo RA,Gray DT,Kreuter W,et al.United States trends in lumbar fusion surgery for degenerative conditions[J].Spine,2005,30(12):1441-1445.
[3] Kalichman L,Cole R,Kim D H,et al.Spinal stenosis prevalence and association with symptoms:The Framingham Study[J].Spine Journal,2009,10(9):S34-S35.
[4] Ralph Jasper M,Jane L,Praveenan S,et al.Outcomes after decompressive laminectomy for lumbar spinal stenosis:comparison between minimally invasive unilateral laminectomy for bilateral decompression and open laminectomy:clinical article[J].Journal of Neurosurgery Spine,2014,21(2):179-186.
[5] 毛克亚,王岩,肖嵩华,等.微创手术治疗单节段腰椎管狭窄症的疗效评价[J].中国脊柱脊髓杂志,2011,21(2):113-117.
[6] Coseo MP,Saldua NS,Harris EB,et al.Adjacent Segment Disease:Natural History of Lumbar Degeneration or Consequence of Fusion[J].Springer Berlin Heidelberg,2016:311-319.
[7] 王亮,曾建成,宋跃明,等.经皮椎板间入路内窥镜下减压治疗退变性腰椎管狭窄症的疗效分析[J].中国脊柱脊髓杂志,2017,27(3):200-206.
[8] Huang TJ,Hsu RW,LI YY,et al.Less systemic cytokine response in patients following microendoscopic versus open lumbar discectomy[J].Journal of Orthopaedic Research,2005,23(2):406-411.
[9] 保国锋,李卫东,徐冠华,等.经皮椎板间隙入路270°椎管减压治腰椎管狭窄症[J].中国矫形外科杂志,2017,25(3):264-269.
[10] Wang CS,Chang JH,Chang TS,et al.Loading effects of anterior cervical spine fusion on adjacent segments[J].Kaohsiung Journal of Medical Sciences,2012,28(11):586-594.
[11] Hilibrand AS,Robbins M.Adjacent segment degeneration and adjacent segment disease:the consequences of spinal fusion[J].Spine Journal,2004,4(6):S190-S194.
[12] Park P,Garton HJ,Gala VC,et al.Adjacent segment disease after lumbar or lumbosacral fusion:review of the literature[J].Spine,2004,29(17):1938-1944.
[13] Ahn Y,Kim C H,Lee J H,et al.Radiation exposure to the surgeon during percutaneous endoscopic lumbar discectomy:a prospective study[J].Spine,2013,38(7):617.
[14] 聂鸿飞,曾建成,宋跃明,等.经皮椎板间入路与经皮椎间孔入路内窥镜下椎间盘切除术治疗L5/S1椎间盘突出症的短期疗效比较[J].中国脊柱脊髓杂志,2016,26(3):225-232.
[15] Komp M,Hahn P,Merk H,et al.Bilateral operation of lumbar degenerative central spinal stenosis in full-endoscopic interlaminar technique with unilateral approach:prospective 2-year results of 74 patients[J].Journal of Spinal Disorders & Techniques,2011,24(5):281-287.
[16] Ruetten S,Komp M,Merk H,et al.Surgical treatment for lumbar lateral recess stenosis with the full-endoscopic interlaminar approach versus conventional microsurgical technique:a prospective,randomized,controlled study[J].Journal of Neurosurgeryspine Spine,2009,10(5):476-485.
[17] Kreiner DS,Shaffer WO,Baisden JL,et al.An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (update)[J].Spine Journal,2013,13(7):734-743.
[18] Postacchini F.Lumbar spinal stenosis and pseudostenosis.Definition and classification of pathology[J].Italian Journal of Orthopaedics & Traumatology,1983,9(3):339-350.
[19] Ralph G,Simon R,Johann S,et al.Quantitative radiologic criteria for the diagnosis of lumbar spinal stenosis:a systematic literature review[J].Bmc Musculoskelet Disord,2011,12(1):1-9.
[20] Ahn Y.Percutaneous endoscopic decompression for lumbar spinal stenosis[J].Expert Rev Med Devices,2014,11(6):605-616.
[21] 白一冰,李嵩鹏,简伟,等.椎间孔镜下侧隐窝减压治疗腰椎管狭窄的疗效分析[J].中国疼痛医学杂志,2014,20(12):919-921.
[22] 陈晓庆,张烽,于江,等.经皮椎间孔入路内镜下减压治疗老年腰椎侧隐窝狭窄症[J].中国脊柱脊髓杂志,2016,26(3):233-238.
[23] Ahn Y.Percutaneous endoscopic decompression for lumbar spinal stenosis[J].Expert Review of Medical Devices,2014,11(6):605-616.
[24] Lee C K,Rauschning W,Glenn W.Lateral lumbar spinal canal stenosis:classification,pathologic anatomy and surgical decompression[J].Spine,1988,13(3):313-320.
[25] Ciol MA,Deyo RA,Howell E,et al.An assessment of surgery for spinal stenosis:time trends,geographic variations,complications,and reoperations[J].Journal of the American Geriatrics Society,1996,44(3):285-290.
[26] 叶猛,王力文,王鸿晨.椎间孔镜手术出现失误及并发症的原因与预防措施[J].局解手术学杂志,2017,26(5):362-366.
[27] Yoganandan N,Knowles SA,Maiman DJ,et al.Anatomic study of the morphology of human cervical facet joint[J].Spine,2003,28(20):2317-2323.
[28] Wang B,L G,Patel AA,et al.An evaluation of the learning curve for a complex surgical technique:the full endoscopic interlaminar approach for lumbar disc herniations[J].Spine Journal,2011,11(2):122-130.
[29] Yadav YR,Parihar V,Kher Y,et al.Endoscopic inter laminar management of lumbar disease[J].Asian Journal of Neurosurgery,2016,11(1):1.