经皮内窥镜下腰椎间盘切除术中椎间孔成形的适应证研究
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摘要
目的:探讨经皮内窥镜下腰椎间盘切除术中椎间孔成形的适应证。方法:选取经椎间孔入路行经皮内窥镜下腰椎间盘切除术的单节段腰椎间盘突出症患者,其中36例患者术中进行了椎间孔成形(椎间孔成形组),50例患者术中未进行椎间孔成形(椎间孔未成形组)。在患者术前的CT图像上测定病变节段的椎间隙高度、椎间孔宽度、椎板角,在术前X线片上测定患者的髂嵴高度,在术前MRI上测定突出椎间盘的下移程度。结果:椎间孔成形组椎间隙高度低于椎间孔未成形组[(5.92±1.22)mm,(6.74±0.92)mm,t=-3.555,P=0.004],突出椎间盘向下重度移位者所占比例高于椎间孔未成形组(P=0.031);2组患者的椎间孔宽度、椎板角及髂嵴高度比较,组间差异均无统计学意义[(6.92±1.03)mm,(7.07±1.20)mm,t=-0.606,P=0.566;99.52°±10.62°,98.23°±8.77°,t=0.616,P=0.739;(33.38±1.06)mm,(32.69±2.24)mm,t=1.713,P=0.164]。L5S1腰椎间盘突出症患者中,椎间孔成形组的椎间隙高度、椎间孔宽度均小于椎间孔未成形组[(4.13±1.22)mm,(5.19±0.92)mm,t=-3.198,P=0.006;(5.89±1.38)mm,(7.28±1.28)mm,t=-3.387,P=0.002],髂嵴高度大于椎间孔未成形组[(35.26±3.44)mm,(32.78±2.86)mm,t=2.549,P=0.001];2组患者的椎板角、突出椎间盘下移程度比较,组间差异均无统计学意义(96.52°±8.62°,95.23°±6.77°,t=0.542,P=0.173;P=0.476)。中央型腰椎间盘突出症患者中,椎间孔成形组的椎间隙高度小于椎间孔未成形组[(5.66±0.75)mm,(6.93±0.92)mm,t=-3.499,P=0.006],椎板角大于椎间孔未成形组(103.58°±5.32°,92.38°±4.37°,t=5.426,P=0.001);2组患者的椎间孔宽度、髂嵴高度、突出椎间盘下移程度比较,组间差异均无统计学意义[(5.86±1.46)mm,(7.18±1.41)mm,t=-2.152,P=0.472;(33.25±2.01)mm,(34.03±1.63)mm,t=0.289,P=0.775;P=0.455]。结论:病变节段椎间隙狭窄的腰椎间盘突出症、突出物向下移位严重的腰椎间盘突出症、髂嵴较高的L5S1椎间盘突出症、病变节段椎板角较大的中央型腰椎间盘突出症,均应视为经皮内窥镜下腰椎间盘切除术中椎间孔成形的适应证。
Objective: To explore the indications of foraminoplasty in percutaneous endoscopic lumbar discectomy( PELD). Methods:Eighty-six patients with single-segment lumbar disc herniation( LDH) who received PELD through intervertebral foramina approach were selected. The foraminoplasty was performed on 36 patients( foraminoplasty group) and was not performed on 50 patients( non-foraminoplasty group) during the PELD. The intervertebral space height,the intervertebral foramina width and the vertebral plate angle of diseased segment were measured on patients' preoperative CT images. The iliac crest height and the downward-displacement degree of herniated intervertebral disc were measured on patients' preoperative CT images and preoperative MRI respectively. Results: The intervertebral space heights were lower,and the proportion of patients with severe downward-displacement of herniated intervertebral discs was higher in foraminoplasty group compared to non-foraminoplasty group( 5. 92 +/-1. 22 vs 6. 74 +/-0. 92 mm,t =-3. 555,P = 0. 004; P = 0. 031).There was no statistical difference in intervertebral foramina width,vertebral plate angle and iliac crest height between foraminoplasty group and non-foraminoplasty group( 6. 92 +/-1. 03 vs 7. 07 +/-1. 20 mm,t =-0. 606,P = 0. 566; 99. 52 +/-10. 62 vs 98. 23 +/-8. 77 degrees,t = 0. 616,P = 0. 739; 33. 38 +/-1. 06 vs 32. 69 +/-2. 24 mm,t = 1. 713,P = 0. 164). For patients with L5-S1 LDH,the intervertebral space heights and the intervertebral foramina widths were smaller and the iliac crest heights were greater in foraminoplasty group compared to non-foraminoplasty group( 4. 13 +/-1. 22 vs 5. 19 +/-0. 92 mm,t =-3. 198,P = 0. 006; 5. 89 +/-1. 38 vs 7. 28 +/-1. 28 mm,t =-3. 387,P = 0. 002; 35. 26 +/-3. 44 vs 32. 78 +/-2. 86 mm,t = 2. 549,P = 0. 001),while there was no statistical difference in vertebral plate angle and downward-displacement degree of herniated intervertebral discs between foraminoplasty group and non-foraminoplasty group( 96. 52 +/-8. 62 vs 95. 23 +/-6. 77 degrees,t = 0. 542,P = 0. 173; P = 0. 476). For patients with central-type LDH,the intervertebral space heights were smaller and the vertebral plate angles were larger in foraminoplasty group compared to non-foraminoplasty group( 5. 66 +/-0. 75 vs 6. 93 +/-0. 92 mm,t =-3. 499,P = 0. 006; 103. 58 +/-5. 32 vs 92. 38 +/-4. 37 degrees,t = 5. 426,P = 0. 001),while there was no statistical difference in intervertebral foramina width,iliac crest height and downward-displacement degree of herniated intervertebral discs between foraminoplasty group and non-foraminoplasty group( 5. 86 +/-1. 46 vs 7. 18 +/-1. 41 mm,t =-2. 152,P =0. 472; 33. 25 +/-2. 01 vs 34. 03 +/-1. 63 mm,t = 0. 289,P = 0. 775; P = 0. 455). Conclusion: LDH with narrow intervertebral space at diseased segment,LDH with severe downward displacement of herniated disc,L5-S1 LDH with high iliac crest and central-type LDH with large vertebral plate angle at diseased segment should be regarded as the indications of foraminoplasty in PELD.
Objective: To explore the indications of foraminoplasty in percutaneous endoscopic lumbar discectomy( PELD). Methods:Eighty-six patients with single-segment lumbar disc herniation( LDH) who received PELD through intervertebral foramina approach were selected. The foraminoplasty was performed on 36 patients( foraminoplasty group) and was not performed on 50 patients( non-foraminoplasty group) during the PELD. The intervertebral space height,the intervertebral foramina width and the vertebral plate angle of diseased segment were measured on patients' preoperative CT images. The iliac crest height and the downward-displacement degree of herniated intervertebral disc were measured on patients' preoperative CT images and preoperative MRI respectively. Results: The intervertebral space heights were lower,and the proportion of patients with severe downward-displacement of herniated intervertebral discs was higher in foraminoplasty group compared to non-foraminoplasty group( 5. 92 +/-1. 22 vs 6. 74 +/-0. 92 mm,t =-3. 555,P = 0. 004; P = 0. 031).There was no statistical difference in intervertebral foramina width,vertebral plate angle and iliac crest height between foraminoplasty group and non-foraminoplasty group( 6. 92 +/-1. 03 vs 7. 07 +/-1. 20 mm,t =-0. 606,P = 0. 566; 99. 52 +/-10. 62 vs 98. 23 +/-8. 77 degrees,t = 0. 616,P = 0. 739; 33. 38 +/-1. 06 vs 32. 69 +/-2. 24 mm,t = 1. 713,P = 0. 164). For patients with L5-S1 LDH,the intervertebral space heights and the intervertebral foramina widths were smaller and the iliac crest heights were greater in foraminoplasty group compared to non-foraminoplasty group( 4. 13 +/-1. 22 vs 5. 19 +/-0. 92 mm,t =-3. 198,P = 0. 006; 5. 89 +/-1. 38 vs 7. 28 +/-1. 28 mm,t =-3. 387,P = 0. 002; 35. 26 +/-3. 44 vs 32. 78 +/-2. 86 mm,t = 2. 549,P = 0. 001),while there was no statistical difference in vertebral plate angle and downward-displacement degree of herniated intervertebral discs between foraminoplasty group and non-foraminoplasty group( 96. 52 +/-8. 62 vs 95. 23 +/-6. 77 degrees,t = 0. 542,P = 0. 173; P = 0. 476). For patients with central-type LDH,the intervertebral space heights were smaller and the vertebral plate angles were larger in foraminoplasty group compared to non-foraminoplasty group( 5. 66 +/-0. 75 vs 6. 93 +/-0. 92 mm,t =-3. 499,P = 0. 006; 103. 58 +/-5. 32 vs 92. 38 +/-4. 37 degrees,t = 5. 426,P = 0. 001),while there was no statistical difference in intervertebral foramina width,iliac crest height and downward-displacement degree of herniated intervertebral discs between foraminoplasty group and non-foraminoplasty group( 5. 86 +/-1. 46 vs 7. 18 +/-1. 41 mm,t =-2. 152,P =0. 472; 33. 25 +/-2. 01 vs 34. 03 +/-1. 63 mm,t = 0. 289,P = 0. 775; P = 0. 455). Conclusion: LDH with narrow intervertebral space at diseased segment,LDH with severe downward displacement of herniated disc,L5-S1 LDH with high iliac crest and central-type LDH with large vertebral plate angle at diseased segment should be regarded as the indications of foraminoplasty in PELD.
引文
[1]LI ZZ,HOU SX,SHANG WL,et al.New instrument for percutaneous posterolateral lumbar foraminoplasty:case series of 134 with instrument design,surgical technique and outcomes[J].Int J Clin Exp Med,2015,8(9):14672-14679.
[2]RASOULI MR,RAHIMI-MOVAGHAR V,SHOKRANEH F,et al.Minimally invasive discectomy versus microdiscectomy/open discectomy for symptomatic lumbar disc herniation[J].Cochrane Database Syst Rev,2014,(9):CD010328.
[3]LEE SH,KANG B,AHN Y,et al.Operative failure of percutaneous endoscopic lumbar discectomy:A radiologic analysis of 55 cases[J].Spine(Phila Pa 1976),2006,31(10):285-290.
[4]KNIGHT MT,VAJDA A,JAKAB GV,et al.Endoscopic laser foraminoplasty on the lumbar spine—early experience[J].Minim Invasive Neurosurg,1998,41(1):5-9.
[5]顾红林,张烽,周敦,等.改良椎间孔成形术在经椎间孔脊柱内镜中的应用[J].江苏医药,2017,43(7):511-513.
[6]CHOI KC,PARK CK.Percutaneous Endoscopic Lumbar Discectomy for L5-S1 Disc Herniation:Consideration of the Relation between the Iliac Crest and L5-S1 Disc[J].Pain Physician,2016,19(2):301-308.
[7]梁慧,马克,林春强.椎间孔镜下经椎板间入路L5S1椎间盘髓核摘除的疗效观察[J].中国民康医学,2017,29(13):12-14.
[8]陈果,曾建成,宋跃明,等.经皮椎板间入路微创治疗腋下型L5S1椎间盘突出症[J].中国矫形外科杂志,2014,22(13):1169-1175.
[9]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.
[10]CHOI KC,KIM JS,RYU KS,et al.Percutaneous endoscopic lumbar discectomy for L5-S1 disc herniation:transforaminal versus interlaminar approach[J].Pain Physician,2013,16(6):547-556.
[11]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[J].Spine(Phila Pa 1976),2008,33(15):508-515.
[12]SCHUBERT M,HOOGLAND T.Endoscopic transforaminal nucleotomy with foraminoplasty for lumbar disk herniation[J].Oper Orthop Traumatol,2005,17(6):641-661.
[13]LEE CW,YOON KJ,HA SS,et al.Foraminoplastic superior vertebral notch approach with reamers in percutaneous endoscopic lumbar discectomy:technical Note and clinical outcome in limited indications of percutaneous endoscopic lumbar discectomy[J].J Korean Neurosurg Soc,2016,59(2):172-181.
[2]RASOULI MR,RAHIMI-MOVAGHAR V,SHOKRANEH F,et al.Minimally invasive discectomy versus microdiscectomy/open discectomy for symptomatic lumbar disc herniation[J].Cochrane Database Syst Rev,2014,(9):CD010328.
[3]LEE SH,KANG B,AHN Y,et al.Operative failure of percutaneous endoscopic lumbar discectomy:A radiologic analysis of 55 cases[J].Spine(Phila Pa 1976),2006,31(10):285-290.
[4]KNIGHT MT,VAJDA A,JAKAB GV,et al.Endoscopic laser foraminoplasty on the lumbar spine—early experience[J].Minim Invasive Neurosurg,1998,41(1):5-9.
[5]顾红林,张烽,周敦,等.改良椎间孔成形术在经椎间孔脊柱内镜中的应用[J].江苏医药,2017,43(7):511-513.
[6]CHOI KC,PARK CK.Percutaneous Endoscopic Lumbar Discectomy for L5-S1 Disc Herniation:Consideration of the Relation between the Iliac Crest and L5-S1 Disc[J].Pain Physician,2016,19(2):301-308.
[7]梁慧,马克,林春强.椎间孔镜下经椎板间入路L5S1椎间盘髓核摘除的疗效观察[J].中国民康医学,2017,29(13):12-14.
[8]陈果,曾建成,宋跃明,等.经皮椎板间入路微创治疗腋下型L5S1椎间盘突出症[J].中国矫形外科杂志,2014,22(13):1169-1175.
[9]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.
[10]CHOI KC,KIM JS,RYU KS,et al.Percutaneous endoscopic lumbar discectomy for L5-S1 disc herniation:transforaminal versus interlaminar approach[J].Pain Physician,2013,16(6):547-556.
[11]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[J].Spine(Phila Pa 1976),2008,33(15):508-515.
[12]SCHUBERT M,HOOGLAND T.Endoscopic transforaminal nucleotomy with foraminoplasty for lumbar disk herniation[J].Oper Orthop Traumatol,2005,17(6):641-661.
[13]LEE CW,YOON KJ,HA SS,et al.Foraminoplastic superior vertebral notch approach with reamers in percutaneous endoscopic lumbar discectomy:technical Note and clinical outcome in limited indications of percutaneous endoscopic lumbar discectomy[J].J Korean Neurosurg Soc,2016,59(2):172-181.