经皮射频和内镜下射频切断脊神经背内侧支治疗小关节源性腰痛的前瞻性临床对照研究
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摘要
目的评价内镜下脊神经背内侧支切断术治疗慢性关节突关节源性腰痛的临床疗效。方法筛选符合关节突关节源性腰痛诊断标准的患者40例,随机分为经皮组(20例)和内镜组(20例)。经皮组行X线辅助下经皮穿刺脊神经背内侧支射频消融术(radiofrequency neurotomy,RN),内镜组行内镜辅助下脊神经背内侧支切断术,记录两组术前及术后不同随访时间(3周、6个月、1年、2年)的疼痛视觉模拟评分(visual analogue scale,VAS)、Oswestry功能障碍指数(oswestry disability index,ODI)和SF-36生活质量指数,进行组内对照和组间对照。结果 (1)经皮组3周时VAS评分、ODI评分和SF-36评分分别由术前的7.15±0.81,76.75±7.07,79.01±13.81改变为2.60±0.75,28.00±3.84,92.67±11.13,改善率(63.04±12.49)%,优良率100%,6个月时疗效开始下降,VAS评分、ODI评分和SF-36评分分别为3.85±0.88,32.50±4.44,87.32±17.20,改善率(45.68±13.18)%,优良率60%,2年时已与术前差异无统计学意义(P>0.05);(2)内镜组疗效优秀且维持时间较长,6个月时VAS评分、ODI评分和SF-36评分为3.15±0.57,27.50±2.96,87.89±14.49,改善率(55.45±9.01)%,优良率90%,术后1年疗效开始减低,VAS评分、ODI评分和SF-36评分分别为3.40±0.68,35.70±5.81,81.53±12.02,改善率(51.49±12.83)%,优良率仍高达80%,术后2年时疗效下降明显,VAS评分、ODI评分和SF-36评分分别为3.93±0.75,44.35±3.99,77.86±10.75,改善率降至(44.17±11.33)%,优良率降至45%,但是各项评分仍明显优于术前且差异有统计学意义(P<0.05);(3)组间对照方面,3周时两组间各观察指标差异无统计学意义(P>0.05),6个月及以后各个随访时间点的各观察指标,内镜组均优于经皮组且差异有统计学意义(P<0.05)。结论在治疗慢性关节突关节源性腰痛方面,经皮穿刺脊神经背内侧支RN和内镜下脊神经背内侧支切断术均能获得优秀的短期疗效,但内镜技术疗效更佳且更持久;内镜辅助下脊神经背内侧支切断术治疗慢性关节突关节源性腰痛是一种值得在临床推广的手术技术。
Objective To gather outcome data of percutaneous radiofrequency neurotomy and endoscopic rhizotomy of the lumbar medial branch for facetogenic chronic low back pain, and to compare treatment efficacy of the two approaches. Methods Forty facetogenic chronic low back pain patients were included and randomly assigned to receive percutaneous radiofrequency neurotomy( RN group, 20 cases) or endoscopic neurotomy of the lumbar medial branch( EN group, 20 cases). Endoscopic neurotomy was performed for the second group. Outcomes were obtained by VAS, ODI and SF-36 preoperatively and at 3 weeks, 6 months, 1 year and 2 years postoperatively. The results of two groups were compared. Results RN group demonstrated excellent results at 3 weeks after operation [ VAS Score decreased from( 7.15 ± 0.81) pre-operatively to( 2.60 ± 0.75) post-operatively; ODI Score decreased from( 76.75 ± 7.07) to( 28.00 ± 3.84); while SF-36 Score increased from( 79.01 ± 13.81) to( 92.67 ± 11.13). The treatment achieved an improve rate of( 63.04 ± 12.49) % and an excellence rate of 100% ]. At 6 months after operation, the clinical data VAS Score, ODI Score and SF-36 Score were( 3.85 ± 0.88),( 32.50 ± 4.44),( 87.32 ± 17.20), indicating less improvement with an improvement rate of( 45.68 ± 13.18) % and an excellence rate of 60%. At 2 years after the operation, patients' conditions became the same as 2 years ago( P > 0.05). EN group demonstrated prolonged excellent clinical outcomes compared with the RN group. At 6 months after operation, VAS Score, ODI Score and SF-36 Score were( 3.15 ± 0.57),( 27.50 ± 2.96),( 87.89 ± 14.49), indicating an improvement rate of( 55.45 ± 9.01) % and an excellence rate of 90%. At 1 year after operation, the efficacy declined. VAS Score, ODI Score and SF-36 QOF Score were( 3.40 ± 0.68),( 35.70 ± 5.81),( 81.53 ± 12.02), indicating an improvement rate of( 51.49 ± 12.83) % and an excellence rate of 80%. At 2 years after operation, the efficacy further declined. VAS Score, ODI Score and SF-36 QOF Score decreased to( 3.93 ± 0.75),( 44.35 ± 3.99),( 77.86 ± 10.75), indicating an improvement rate of( 44.17 ± 11.33) % and an excellence rate of 45%. The data showed significant improvement compared with pre-operative data( P < 0.05). There were no significant differences of VAS Score, ODI Score and SF-36 Score between the 2 groups at 3 weeks after operation( P > 0.05). At 6 months and later after operation, RN group demonstrated better outcomes( P < 0.05). Conclusions For facetogenic chronic low back pain, endoscopic neurotomy and X-ray assisted percutaneous radiofrequency neurotomy of the lumbar medial branch are both effective. Endoscopic lumbar medial branch neurotomy has the advantages of higher surgical precision and better long-term efficacy.
Objective To gather outcome data of percutaneous radiofrequency neurotomy and endoscopic rhizotomy of the lumbar medial branch for facetogenic chronic low back pain, and to compare treatment efficacy of the two approaches. Methods Forty facetogenic chronic low back pain patients were included and randomly assigned to receive percutaneous radiofrequency neurotomy( RN group, 20 cases) or endoscopic neurotomy of the lumbar medial branch( EN group, 20 cases). Endoscopic neurotomy was performed for the second group. Outcomes were obtained by VAS, ODI and SF-36 preoperatively and at 3 weeks, 6 months, 1 year and 2 years postoperatively. The results of two groups were compared. Results RN group demonstrated excellent results at 3 weeks after operation [ VAS Score decreased from( 7.15 ± 0.81) pre-operatively to( 2.60 ± 0.75) post-operatively; ODI Score decreased from( 76.75 ± 7.07) to( 28.00 ± 3.84); while SF-36 Score increased from( 79.01 ± 13.81) to( 92.67 ± 11.13). The treatment achieved an improve rate of( 63.04 ± 12.49) % and an excellence rate of 100% ]. At 6 months after operation, the clinical data VAS Score, ODI Score and SF-36 Score were( 3.85 ± 0.88),( 32.50 ± 4.44),( 87.32 ± 17.20), indicating less improvement with an improvement rate of( 45.68 ± 13.18) % and an excellence rate of 60%. At 2 years after the operation, patients' conditions became the same as 2 years ago( P > 0.05). EN group demonstrated prolonged excellent clinical outcomes compared with the RN group. At 6 months after operation, VAS Score, ODI Score and SF-36 Score were( 3.15 ± 0.57),( 27.50 ± 2.96),( 87.89 ± 14.49), indicating an improvement rate of( 55.45 ± 9.01) % and an excellence rate of 90%. At 1 year after operation, the efficacy declined. VAS Score, ODI Score and SF-36 QOF Score were( 3.40 ± 0.68),( 35.70 ± 5.81),( 81.53 ± 12.02), indicating an improvement rate of( 51.49 ± 12.83) % and an excellence rate of 80%. At 2 years after operation, the efficacy further declined. VAS Score, ODI Score and SF-36 QOF Score decreased to( 3.93 ± 0.75),( 44.35 ± 3.99),( 77.86 ± 10.75), indicating an improvement rate of( 44.17 ± 11.33) % and an excellence rate of 45%. The data showed significant improvement compared with pre-operative data( P < 0.05). There were no significant differences of VAS Score, ODI Score and SF-36 Score between the 2 groups at 3 weeks after operation( P > 0.05). At 6 months and later after operation, RN group demonstrated better outcomes( P < 0.05). Conclusions For facetogenic chronic low back pain, endoscopic neurotomy and X-ray assisted percutaneous radiofrequency neurotomy of the lumbar medial branch are both effective. Endoscopic lumbar medial branch neurotomy has the advantages of higher surgical precision and better long-term efficacy.
引文
[1]Boswell MV,Singh V,Staats PS,et al.Accuracy of precision diagnostic blocks in the diagnosis of chronic spinal pain of facet or zygapophysial joint origin[J].Pain Physician,2003,6(4):449-456.
[2]Bogduk N.Diagnosing lumbar zygapophysial joint pain[J].Pain Med,2005,6(2):139-142.
[3]陆迪,任宝松,张凡.腰神经后支的解剖结构探讨[J].中国误诊学杂志,2011,11(24):5896.
[4]何金鑫,毛军.腰神经后支及其骨纤维管的应用解剖[J].包头医学院学报,2014,30(2):1-4.
[5]Manchikanti L,Hirsch JA,Falco FJ,et al.Management of lumbar zygapophysial(facet)joint pain[J].World J Orthop,2016,7(5):315-337.
[6]Tessitore E,Molliqaj G,Schatlo B,et al.Clinical evaluation and surgical decision making for patients with lumbar discogenic pain and facet syndrome[J].Eur J Radiol,2015,84(5):765-770.
[7]Bogduk N.Evidence-informed management of chronic low back pain with facet injections and radiofrequency neurotomy[J].Spine J,2008,8(1):56-64.
[8]Shealy CN.Facet denervation in the management of back and sciatic pain[J].Clin Orthop Relat Res,1976,(115):157-164.
[9]Smuck M,Crisostomo RA,Trivedi K,et al.Success of initial and repeated medial branch neurotomy for zygapophysial joint pain:a systematic review[J].PM R,2012,4(9):686-692.
[10]Yeung AT.The evolution of percutaneous spinal endoscopy and discectomy:state of the art[J].Mt Sinai J Med,2000,67(4):327-332.
[11]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[J].Spine,2005,30(22):2570-2578.
[12]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,2006,31(24):E890-897.
[13]Ware J.SF-36 health survey:Manual and interpretation guide[J].Health Institute,1993,6:22.
[14]Manchikanti L.The role of radiofrequency in the management of complex regional pain syndrome[J].Curr Rev Pain,2000,4(6):437-444.
[15]Cohen SP,Stojanovic MP,Crooks M,et al.Lumbar zygapophysial(facet)joint radiofrequency denervation success as a function of pain relief during diagnostic medial branch blocks:a multicenter analysis[J].Spine J,2008,8(3):498-504.
[16]Maas ET,Ostelo RW,Niemisto L,et al.Radiofrequency denervation for chronic low back pain[J].Cochrane Database Syst Rev,2015,10:CD008572.
[17]Lee CH,Chung CK,Kim CH.The efficacy of conventional radiofrequency denervation in patients with chronic low back pain originating from the facet joints:a meta-analysis of randomized controlled trials[J].Spine J,2017,17(11):1770-1780.
[18]廖翔,熊东林,蒋劲,等.对退行性腰椎关节源性腰痛行脊神经后支标准射频手术治疗的随机对照研究[J].中国疼痛医学杂志,2013,19(7):406-410.
[19]张光明,唐坤,陈俊峰.射频毁损脊神经后内侧支治疗腰椎小关节病变所致慢性腰痛的疗效[J].中国临床医学,2011,18(5):680-681.
[20]van Tilburg CW,Stronks DL,Groeneweg JG,et al.Randomised sham-controlled double-blind multicentre clinical trial to ascertain the effect of percutaneous radiofrequency treatment for lumbar facet joint pain[J].Bone Joint J,2016,98-B(11):1526-1533.
[21]Al-Najjim M,Shah R,Rahuma M,et al.Lumbar facet joint injection in treating low back pain:Radiofrequency denervation versus SHAM procedure.Systematic review[J].J Orthop,2018,15(1):1-8.
[22]Bogduk N,Macintosh J,Marsland A.Technical limitations to the efficacy of radiofrequency neurotomy for spinal pain[J].Neurosurgery,1987,20(4):529-535.
[23]Staender M,Maerz U,Tonn JC,et al.Computerized tomography-guided kryorhizotomy in 76 patients with lumbar facet joint syndrome[J].J Neurosurg Spine,2005,3(6):444-449.
[24]Park CH.Comprasion of effectiveness of CT vs C-arm guided percutaneous radiofrequency lumbar facet rhizotomy[J].Korean J Pain,2010,23(2):137-141.
[25]Feigl GC,Mattersberger C,Rosmarin W,et al.Lumbar CTguided radiofrequency ablation of the medial branch of the dorsal ramus of the spinal nerve:Anatomic study and description of a new technique[J].Schmerz,2018,32(2):99-104.
[26]Jentzsch T,Sprengel K,Peterer L,et al.3D navigation of endoscopic rhizotomy at the lumbar spine[J].J Clin Neurosci,2016,23:101-105.
[27]Lau P,Mercer S,Govind J,et al.The surgical anatomy of lumbar medial branch neurotomy(facet denervation)[J].Pain Med,2004,5(3):289-298.
[28]Masala S,Nano G,Mammucari M,et al.Medial branch neurotomy in low back pain[J].Neuroradiology,2012,54(7):737-744.
[29]Kanchiku T,Imajo Y,Suzuki H,et al.Percutaneous radiofrequency facet joint denervation with monitoring of compound muscle action potential of the multifidus muscle group for treating chronic low back pain:a preliminary report[J].J Spinal Disord Tech,2014,27(7):E262-267.
[30]Haufe SM,Mork AR.Endoscopic facet debridement for the treatment of facet arthritic pain--a novel new technique[J].Inter J Med Sci,2010,7(3):120-123.
[31]Li ZZ,Hou SX,Shang WL,et al.Evaluation of endoscopic dorsal ramus rhizotomy in managing facetogenic chronic low back pain[J].Clin Neurol Neurosurg,2014,126:11-17.
[32]Klessinger S.Zygapophysial joint pain in post lumbar surgery syndrome.The efficacy of medial branch blocks and radiofrequency neurotomy[J].Pain Med,2013,14(3):374-377.
[33]Manchikanti L,Manchukonda R,Pampati V,et al.Prevalence of facet joint pain in chronic low back pain in postsurgical patients by controlled comparative local anesthetic blocks[J].Arch Phys Med Rehabil,2007,88(4):449-455.
[34]Lamer TJ,Smith J,Hoelzer BC,et al.Safety of lumbar spine radiofrequency procedures in patients who have posterior spinal hardware[J].Pain Med,2016,17(9):1634-1637.
[2]Bogduk N.Diagnosing lumbar zygapophysial joint pain[J].Pain Med,2005,6(2):139-142.
[3]陆迪,任宝松,张凡.腰神经后支的解剖结构探讨[J].中国误诊学杂志,2011,11(24):5896.
[4]何金鑫,毛军.腰神经后支及其骨纤维管的应用解剖[J].包头医学院学报,2014,30(2):1-4.
[5]Manchikanti L,Hirsch JA,Falco FJ,et al.Management of lumbar zygapophysial(facet)joint pain[J].World J Orthop,2016,7(5):315-337.
[6]Tessitore E,Molliqaj G,Schatlo B,et al.Clinical evaluation and surgical decision making for patients with lumbar discogenic pain and facet syndrome[J].Eur J Radiol,2015,84(5):765-770.
[7]Bogduk N.Evidence-informed management of chronic low back pain with facet injections and radiofrequency neurotomy[J].Spine J,2008,8(1):56-64.
[8]Shealy CN.Facet denervation in the management of back and sciatic pain[J].Clin Orthop Relat Res,1976,(115):157-164.
[9]Smuck M,Crisostomo RA,Trivedi K,et al.Success of initial and repeated medial branch neurotomy for zygapophysial joint pain:a systematic review[J].PM R,2012,4(9):686-692.
[10]Yeung AT.The evolution of percutaneous spinal endoscopy and discectomy:state of the art[J].Mt Sinai J Med,2000,67(4):327-332.
[11]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[J].Spine,2005,30(22):2570-2578.
[12]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,2006,31(24):E890-897.
[13]Ware J.SF-36 health survey:Manual and interpretation guide[J].Health Institute,1993,6:22.
[14]Manchikanti L.The role of radiofrequency in the management of complex regional pain syndrome[J].Curr Rev Pain,2000,4(6):437-444.
[15]Cohen SP,Stojanovic MP,Crooks M,et al.Lumbar zygapophysial(facet)joint radiofrequency denervation success as a function of pain relief during diagnostic medial branch blocks:a multicenter analysis[J].Spine J,2008,8(3):498-504.
[16]Maas ET,Ostelo RW,Niemisto L,et al.Radiofrequency denervation for chronic low back pain[J].Cochrane Database Syst Rev,2015,10:CD008572.
[17]Lee CH,Chung CK,Kim CH.The efficacy of conventional radiofrequency denervation in patients with chronic low back pain originating from the facet joints:a meta-analysis of randomized controlled trials[J].Spine J,2017,17(11):1770-1780.
[18]廖翔,熊东林,蒋劲,等.对退行性腰椎关节源性腰痛行脊神经后支标准射频手术治疗的随机对照研究[J].中国疼痛医学杂志,2013,19(7):406-410.
[19]张光明,唐坤,陈俊峰.射频毁损脊神经后内侧支治疗腰椎小关节病变所致慢性腰痛的疗效[J].中国临床医学,2011,18(5):680-681.
[20]van Tilburg CW,Stronks DL,Groeneweg JG,et al.Randomised sham-controlled double-blind multicentre clinical trial to ascertain the effect of percutaneous radiofrequency treatment for lumbar facet joint pain[J].Bone Joint J,2016,98-B(11):1526-1533.
[21]Al-Najjim M,Shah R,Rahuma M,et al.Lumbar facet joint injection in treating low back pain:Radiofrequency denervation versus SHAM procedure.Systematic review[J].J Orthop,2018,15(1):1-8.
[22]Bogduk N,Macintosh J,Marsland A.Technical limitations to the efficacy of radiofrequency neurotomy for spinal pain[J].Neurosurgery,1987,20(4):529-535.
[23]Staender M,Maerz U,Tonn JC,et al.Computerized tomography-guided kryorhizotomy in 76 patients with lumbar facet joint syndrome[J].J Neurosurg Spine,2005,3(6):444-449.
[24]Park CH.Comprasion of effectiveness of CT vs C-arm guided percutaneous radiofrequency lumbar facet rhizotomy[J].Korean J Pain,2010,23(2):137-141.
[25]Feigl GC,Mattersberger C,Rosmarin W,et al.Lumbar CTguided radiofrequency ablation of the medial branch of the dorsal ramus of the spinal nerve:Anatomic study and description of a new technique[J].Schmerz,2018,32(2):99-104.
[26]Jentzsch T,Sprengel K,Peterer L,et al.3D navigation of endoscopic rhizotomy at the lumbar spine[J].J Clin Neurosci,2016,23:101-105.
[27]Lau P,Mercer S,Govind J,et al.The surgical anatomy of lumbar medial branch neurotomy(facet denervation)[J].Pain Med,2004,5(3):289-298.
[28]Masala S,Nano G,Mammucari M,et al.Medial branch neurotomy in low back pain[J].Neuroradiology,2012,54(7):737-744.
[29]Kanchiku T,Imajo Y,Suzuki H,et al.Percutaneous radiofrequency facet joint denervation with monitoring of compound muscle action potential of the multifidus muscle group for treating chronic low back pain:a preliminary report[J].J Spinal Disord Tech,2014,27(7):E262-267.
[30]Haufe SM,Mork AR.Endoscopic facet debridement for the treatment of facet arthritic pain--a novel new technique[J].Inter J Med Sci,2010,7(3):120-123.
[31]Li ZZ,Hou SX,Shang WL,et al.Evaluation of endoscopic dorsal ramus rhizotomy in managing facetogenic chronic low back pain[J].Clin Neurol Neurosurg,2014,126:11-17.
[32]Klessinger S.Zygapophysial joint pain in post lumbar surgery syndrome.The efficacy of medial branch blocks and radiofrequency neurotomy[J].Pain Med,2013,14(3):374-377.
[33]Manchikanti L,Manchukonda R,Pampati V,et al.Prevalence of facet joint pain in chronic low back pain in postsurgical patients by controlled comparative local anesthetic blocks[J].Arch Phys Med Rehabil,2007,88(4):449-455.
[34]Lamer TJ,Smith J,Hoelzer BC,et al.Safety of lumbar spine radiofrequency procedures in patients who have posterior spinal hardware[J].Pain Med,2016,17(9):1634-1637.