术前三维影像测量结合激光导航器辅助穿刺行经椎间孔入路经皮内窥镜下椎间盘切除术
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摘要
目的探索术前三维影像测量结合自行研制的激光导航器辅助穿刺行经椎间孔入路经皮内窥镜下椎间盘切除术(PETD)的临床效果。方法 2016年3月—2017年8月,共57例腰椎椎间盘突出症(LDH)患者接受PETD治疗,32例患者采用传统穿刺方式行PETD(对照组);25例患者采用激光导航器辅助穿刺行PETD(试验组)。术中记录穿刺次数、手术时间、透视次数及患者术中疼痛视觉模拟量表(VAS)评分,并进行比较。结果试验组穿刺次数、透视次数、手术时间及术中腰痛VAS评分均明显低于对照组,差异有统计学意义(P <0.05)。2组术后VAS评分与术前相比均明显改善,差异有统计学意义(P <0.05)。结论激光导航器结合三维影像测量辅助穿刺,能够有效减少PETD的穿刺次数、透视次数及手术时间,手术效果良好,可减少患者术中长期俯卧产生的不适感,降低医患人员辐射暴露剂量,间接降低PETD的学习曲线。
Objective To explore the clinical effect of percutaneous endoscopic transforaminal discectomy(PETD) combined with preoperative three-dimensional image measurement and self-developed laser navigation device assisted puncture.Methods From March 2016 to August 2017,57 patients with lumbar disc herniation(LDH) were treated with PETD.According to the fluoroscopy and clinical experience during the operation,32 patients underwent "exploratory" puncture(control group);25 patients underwent "targeted" puncture according to preoperative imaging examination and puncture angle simulated by software(experimental group). The punctures frequency,operation time,fluoroscopy frequency and visual analogue scale(VAS) score of the patients during the operation were recorded and compared during the operation. Results In the experimental group,the punctures frequency,operation time,fluoroscopy frequency and VAS score of the patients during the operation were significantly less than those in the control group,and the differences were statistically significant(P <0.05). The VAS scores of the 2 groups at post-operation were significantly less than those at pre-operation,and the differences were statistically significant(P < 0.05). Conclusion The laser navigation device combined with three-dimensional image measurement assisted puncture can effectively reduce the puncture frequency,operation time and fluoroscopy frequency of PETD,with a good clinical effect,thereby reducing the discomfort caused by long-term prone posture during operation,radiation exposure dose of doctors and patients,and learning curve of PETD indirectly.
Objective To explore the clinical effect of percutaneous endoscopic transforaminal discectomy(PETD) combined with preoperative three-dimensional image measurement and self-developed laser navigation device assisted puncture.Methods From March 2016 to August 2017,57 patients with lumbar disc herniation(LDH) were treated with PETD.According to the fluoroscopy and clinical experience during the operation,32 patients underwent "exploratory" puncture(control group);25 patients underwent "targeted" puncture according to preoperative imaging examination and puncture angle simulated by software(experimental group). The punctures frequency,operation time,fluoroscopy frequency and visual analogue scale(VAS) score of the patients during the operation were recorded and compared during the operation. Results In the experimental group,the punctures frequency,operation time,fluoroscopy frequency and VAS score of the patients during the operation were significantly less than those in the control group,and the differences were statistically significant(P <0.05). The VAS scores of the 2 groups at post-operation were significantly less than those at pre-operation,and the differences were statistically significant(P < 0.05). Conclusion The laser navigation device combined with three-dimensional image measurement assisted puncture can effectively reduce the puncture frequency,operation time and fluoroscopy frequency of PETD,with a good clinical effect,thereby reducing the discomfort caused by long-term prone posture during operation,radiation exposure dose of doctors and patients,and learning curve of PETD indirectly.
引文
[1]Ahn SS,Kim H,Kim DW,et al.Comparison of outcomes of percutaneous endoscopic lumbar discectomy and open lumbar microdiscectomy for young adults:a retrospective matched cohort study[J].World Neurosurg,2016,86:250-258.
[2]古伟文,徐峰,蔡贤华,等.经皮椎间孔镜靶向穿刺技术治疗腰椎椎间盘突出症的疗效分析[J].脊柱外科杂志,2013,11(3):149-153.
[3]尹西盟,穆胜凯,吴岩,等.经皮椎间孔镜与开放减压手术治疗老年腰椎椎管狭窄症疗效对比[J].脊柱外科杂志,2014,12(5):293-297.
[4]Forst R,Hausmann B.Nucleoscopy-a new examination technique[J].Arch Orthop Trauma Surg,1983,101(3):219-221.
[5]Yeung AT,Tsou PM.Posterolateral endoscopic excision for lumbar disc herniation:surgical technique,outcome,and complications in 307 consecutive cases[J].Spine(Phila Pa 1976),2002,27(7):722-731.
[6]Hoogland T,Schubert M,Miklitz B,et al.Transforaminal posterolateral endoscopic discectomy with or without the combination of a low-dose chymopapain:a prospective randomized study in 280 consecutive cases[J].Spine(Phila Pa 1976),2006,31(24):E890-E897.
[7]Wang H,Huang B,Li C,et al.Learning curve for percutaneous endoscopic lumbar discectomy depending on the surgeon’s training level of minimally invasive spine surgery[J].Clin Neurol Neurosurg,2013,115(10):1987-1991.
[8]Wu XB,Fan GX,Gu X,et al.Learning curves of percutaneous endoscopic lumbar discectomy in transforaminal approach at the L4/5 and L5/S1 levels:a comparative study[J].J Zhejiang Univ Sci B,2016,17(7):553-560.
[9]周跃,李长青,王建,等.椎间孔镜YESS与TESSYS技术治疗腰椎间盘突出症[J].中华骨科杂志,2010,30(3):235-237.
[10]殷乐,元虎.椎间孔镜下腰椎髓核摘除术学习曲线及其近期疗效分析[J].吉林医学,2017,38(9):1656-1658.
[11]Türk C,Kara N,Biliciler B,et al.Clinical outcomes and efficacy of transforaminal lumbar endoscopic discectomy[J].J Neurosci Rural Pract,2015,6(3):344-348.
[12]Wang K,Hong X,Zhou B,et al.Evaluation of transforaminal endoscopic lumbar discectomy in the treatment of lumbar disc herniation[J].Int Orthop,2015,39(8):1599-1604.
[13]杨林,廖绪强,赵新建,等.经皮椎间孔镜与椎间盘镜下手术治疗腰椎间盘突出症的治疗效果比较[J].中国内镜杂志,2015,21(9):962-965.
[14]赵伟,李长青,周跃,等.经皮椎间孔镜下TESSYS技术治疗腰椎间盘突出症[J].中国矫形外科杂志,2012,20(13):1191-1195.
[15]赵学军,左玲,傅志俭,等.经皮椎间孔镜下髓核摘除术治疗腰椎间盘突出症[J].中国疼痛医学杂志,2013,19(1):8-12.
[16]崔为良,王萍,廖忠.经皮椎间孔镜治疗腰椎间盘突出症的疗效分析及临床体会[J].中国骨与关节损伤杂志,2015,30(7):748-749.
[17]潘承波,刘法银,李嗣生.经皮椎间孔镜治疗腰椎间盘突出症的疗效观察[J].中国骨与关节损伤杂志,2015,30(1):94-95.
[18]柳百炼,熊鹰,顾邵,等.经皮椎间孔镜治疗腰椎间盘突出症的临床效果[J].实用医学杂志,2015,31(6):981-983.
[19]刘宝平,何强,范先东,等.经皮椎间孔镜治疗腰椎间盘突出症疗效观察[J].人民军医,2011,54(6):472-473.
[20]Gibson JN,Cowie JG,Iprenburg M.Transforaminal endoscopic spinal surgery:the future“gold standard”for discectomy?-A review[J].Surgeon,2012,10(5):290-296.
[21]吴波,赵庆豪,周潇齐,等.腰椎间孔镜的应用解剖[J].中国临床解剖学杂志,2017,35(1):5-8.
[22]左进步,余磊,黄凯,等.靶向定位THESSYS椎间孔镜技术治疗腰椎间盘突出症[J].中国疼痛医学杂志,2015,21(11):869-872.
[23]祝乃强,侯静怡,马桂云,等.改良TESSYS技术治疗老年性退变性腰椎管狭窄症的疗效分析[J].中国骨与关节杂志,2017,6(10):780-785.
[24]谢旭华,雷云坤,刘伟,等.经皮椎间孔镜治疗腰椎间盘突出症临床疗效观察[J].中国矫形外科杂志,2012,20(5):463-465.
[25]Park HK,Rudrappa S,Dujovny M,et al.Intervertebral foraminal ligaments of the lumbar spine:anatomy and biomechanics[J].Childs Nerv Syst,2001,17(4-5):275-282.
[26]Yuan SG,Wen YL,Zhang P,et al.Ligament,nerve,and blood vessel anatomy of the lateral zone of the lumbar intervertebral foramina[J].Int Orthop,2015,39(11):2135-2141.
[27]Amonoo-Kuofi HS,El-Badawi MG,Fatani JA.Ligaments associated with lumbar intervertebral foramina.1.L1 to L4[J].J Anat,1988,156:177-183.
[28]Amonoo-Kuofi HS,el-Badawi MG,Fatani JA,et al.Ligaments associated with lumbar intervertebral foramina.2.The fifth lumbar level[J].J Anat,1988,159:1-10.
[29]刘丰平,赵红卫,陈海丹,等.TESSYS椎间孔镜治疗腰椎间盘突出症的学习曲线及经验[J].中国矫形外科杂志,2016,24(3):235-241.
[30]Chen X,Cheng J,Gu X,et al.Development of preoperative planning software for transforaminal endoscopic surgery and the guidance for clinical applications[J].Int JComput Assist Radiol Surg,2016,11(4):613-620.
[31]Ahn Y,Kim C,Lee JH,et al.Radiation exposure to the surgeon during percutaneous endoscopic lumbar discectomy[J].Spine(Phila Pa 1976),2013,38(7):617-625.
[32]Wu R,Liao X,Xia H.Radiation exposure to the surgeon during ultrasound-assisted transforaminal percutaneous endoscopic lumbar discectomy:a prospective study[J].World Neurosurg,2017,101:658-665.
[33]Gupta RS,Wu X,Hong X,et al.Technique of percutaneous transforaminal endoscopic discectomy for the treatment of lumbar disc herniation[J].Open JOrthop,2015,5(7):208-216.
[34]扶青松.腰椎微创经皮内固定及椎间孔镜手术中的X线防护研究[D].苏州:苏州大学,2014.
[35]范国鑫,吴信波,管晓菲,等.经椎间孔内镜技术穿刺路径辅助定位器的设计与临床应用[J].中国脊柱脊髓杂志,2016,26(3):218-224.
[36]范国鑫,赵永昭,汪东冬,等.同心球定位导向技术对椎间孔镜术辐射暴露的影响[J].中国矫形外科杂志,2017,25(19):1756-1762.
[37]Fan G,Gu X,Liu Y,et al.Lower learning difficulty and fluoroscopy reduction of transforaminal percutaneous endoscopic lumbar discectomy with an accurate preoperative location method[J].Pain Physician,2016,19(8):E1123-E1134.
[38]谭海涛,黄圣斌,谢兆林,等.导航导杆在椎间孔镜穿刺定位的应用[J].中国脊柱脊髓杂志,2017,27(4):339-344.
[39]李承龙,李泽福,李勐,等.3D打印导板在经椎间孔内镜技术定位穿刺中的初步应用[J].滨州医学院学报,2017,40(4):252-256.
[2]古伟文,徐峰,蔡贤华,等.经皮椎间孔镜靶向穿刺技术治疗腰椎椎间盘突出症的疗效分析[J].脊柱外科杂志,2013,11(3):149-153.
[3]尹西盟,穆胜凯,吴岩,等.经皮椎间孔镜与开放减压手术治疗老年腰椎椎管狭窄症疗效对比[J].脊柱外科杂志,2014,12(5):293-297.
[4]Forst R,Hausmann B.Nucleoscopy-a new examination technique[J].Arch Orthop Trauma Surg,1983,101(3):219-221.
[5]Yeung AT,Tsou PM.Posterolateral endoscopic excision for lumbar disc herniation:surgical technique,outcome,and complications in 307 consecutive cases[J].Spine(Phila Pa 1976),2002,27(7):722-731.
[6]Hoogland T,Schubert M,Miklitz B,et al.Transforaminal posterolateral endoscopic discectomy with or without the combination of a low-dose chymopapain:a prospective randomized study in 280 consecutive cases[J].Spine(Phila Pa 1976),2006,31(24):E890-E897.
[7]Wang H,Huang B,Li C,et al.Learning curve for percutaneous endoscopic lumbar discectomy depending on the surgeon’s training level of minimally invasive spine surgery[J].Clin Neurol Neurosurg,2013,115(10):1987-1991.
[8]Wu XB,Fan GX,Gu X,et al.Learning curves of percutaneous endoscopic lumbar discectomy in transforaminal approach at the L4/5 and L5/S1 levels:a comparative study[J].J Zhejiang Univ Sci B,2016,17(7):553-560.
[9]周跃,李长青,王建,等.椎间孔镜YESS与TESSYS技术治疗腰椎间盘突出症[J].中华骨科杂志,2010,30(3):235-237.
[10]殷乐,元虎.椎间孔镜下腰椎髓核摘除术学习曲线及其近期疗效分析[J].吉林医学,2017,38(9):1656-1658.
[11]Türk C,Kara N,Biliciler B,et al.Clinical outcomes and efficacy of transforaminal lumbar endoscopic discectomy[J].J Neurosci Rural Pract,2015,6(3):344-348.
[12]Wang K,Hong X,Zhou B,et al.Evaluation of transforaminal endoscopic lumbar discectomy in the treatment of lumbar disc herniation[J].Int Orthop,2015,39(8):1599-1604.
[13]杨林,廖绪强,赵新建,等.经皮椎间孔镜与椎间盘镜下手术治疗腰椎间盘突出症的治疗效果比较[J].中国内镜杂志,2015,21(9):962-965.
[14]赵伟,李长青,周跃,等.经皮椎间孔镜下TESSYS技术治疗腰椎间盘突出症[J].中国矫形外科杂志,2012,20(13):1191-1195.
[15]赵学军,左玲,傅志俭,等.经皮椎间孔镜下髓核摘除术治疗腰椎间盘突出症[J].中国疼痛医学杂志,2013,19(1):8-12.
[16]崔为良,王萍,廖忠.经皮椎间孔镜治疗腰椎间盘突出症的疗效分析及临床体会[J].中国骨与关节损伤杂志,2015,30(7):748-749.
[17]潘承波,刘法银,李嗣生.经皮椎间孔镜治疗腰椎间盘突出症的疗效观察[J].中国骨与关节损伤杂志,2015,30(1):94-95.
[18]柳百炼,熊鹰,顾邵,等.经皮椎间孔镜治疗腰椎间盘突出症的临床效果[J].实用医学杂志,2015,31(6):981-983.
[19]刘宝平,何强,范先东,等.经皮椎间孔镜治疗腰椎间盘突出症疗效观察[J].人民军医,2011,54(6):472-473.
[20]Gibson JN,Cowie JG,Iprenburg M.Transforaminal endoscopic spinal surgery:the future“gold standard”for discectomy?-A review[J].Surgeon,2012,10(5):290-296.
[21]吴波,赵庆豪,周潇齐,等.腰椎间孔镜的应用解剖[J].中国临床解剖学杂志,2017,35(1):5-8.
[22]左进步,余磊,黄凯,等.靶向定位THESSYS椎间孔镜技术治疗腰椎间盘突出症[J].中国疼痛医学杂志,2015,21(11):869-872.
[23]祝乃强,侯静怡,马桂云,等.改良TESSYS技术治疗老年性退变性腰椎管狭窄症的疗效分析[J].中国骨与关节杂志,2017,6(10):780-785.
[24]谢旭华,雷云坤,刘伟,等.经皮椎间孔镜治疗腰椎间盘突出症临床疗效观察[J].中国矫形外科杂志,2012,20(5):463-465.
[25]Park HK,Rudrappa S,Dujovny M,et al.Intervertebral foraminal ligaments of the lumbar spine:anatomy and biomechanics[J].Childs Nerv Syst,2001,17(4-5):275-282.
[26]Yuan SG,Wen YL,Zhang P,et al.Ligament,nerve,and blood vessel anatomy of the lateral zone of the lumbar intervertebral foramina[J].Int Orthop,2015,39(11):2135-2141.
[27]Amonoo-Kuofi HS,El-Badawi MG,Fatani JA.Ligaments associated with lumbar intervertebral foramina.1.L1 to L4[J].J Anat,1988,156:177-183.
[28]Amonoo-Kuofi HS,el-Badawi MG,Fatani JA,et al.Ligaments associated with lumbar intervertebral foramina.2.The fifth lumbar level[J].J Anat,1988,159:1-10.
[29]刘丰平,赵红卫,陈海丹,等.TESSYS椎间孔镜治疗腰椎间盘突出症的学习曲线及经验[J].中国矫形外科杂志,2016,24(3):235-241.
[30]Chen X,Cheng J,Gu X,et al.Development of preoperative planning software for transforaminal endoscopic surgery and the guidance for clinical applications[J].Int JComput Assist Radiol Surg,2016,11(4):613-620.
[31]Ahn Y,Kim C,Lee JH,et al.Radiation exposure to the surgeon during percutaneous endoscopic lumbar discectomy[J].Spine(Phila Pa 1976),2013,38(7):617-625.
[32]Wu R,Liao X,Xia H.Radiation exposure to the surgeon during ultrasound-assisted transforaminal percutaneous endoscopic lumbar discectomy:a prospective study[J].World Neurosurg,2017,101:658-665.
[33]Gupta RS,Wu X,Hong X,et al.Technique of percutaneous transforaminal endoscopic discectomy for the treatment of lumbar disc herniation[J].Open JOrthop,2015,5(7):208-216.
[34]扶青松.腰椎微创经皮内固定及椎间孔镜手术中的X线防护研究[D].苏州:苏州大学,2014.
[35]范国鑫,吴信波,管晓菲,等.经椎间孔内镜技术穿刺路径辅助定位器的设计与临床应用[J].中国脊柱脊髓杂志,2016,26(3):218-224.
[36]范国鑫,赵永昭,汪东冬,等.同心球定位导向技术对椎间孔镜术辐射暴露的影响[J].中国矫形外科杂志,2017,25(19):1756-1762.
[37]Fan G,Gu X,Liu Y,et al.Lower learning difficulty and fluoroscopy reduction of transforaminal percutaneous endoscopic lumbar discectomy with an accurate preoperative location method[J].Pain Physician,2016,19(8):E1123-E1134.
[38]谭海涛,黄圣斌,谢兆林,等.导航导杆在椎间孔镜穿刺定位的应用[J].中国脊柱脊髓杂志,2017,27(4):339-344.
[39]李承龙,李泽福,李勐,等.3D打印导板在经椎间孔内镜技术定位穿刺中的初步应用[J].滨州医学院学报,2017,40(4):252-256.