比较内窥镜腰椎椎间盘切除术与传统腰椎椎间盘切除术的组织伤害
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摘要
背景：外科手术是对机体的一种特殊形式的创伤,在引起局部组织损伤的同时也引发全身炎症反应。术后炎症反应的程度与手术对机体的损伤程度相关。经皮显微内窥镜下椎间盘髓核摘除术(percutaneous endoscopic lumbar discectomy, PELD))是目前治疗腰椎间盘突出症的微创手术之一,与传统开放椎间盘髓核摘除术(Open Disceetomy, OD)相比术后疼痛轻,切口小,出血少,术后住院时间短等优势,疗效与开放手术相近。开放性脊柱手术必须破坏脊柱部份肌肉骨骼系统,手术较易产生神经粘连及脊柱结构破坏,术后出现不稳定的并发症,由手术引起的组织创伤会引起身体内一系列的反应如：压力荷尔蒙上升、组织炎症因子的产生,异常的代谢现象如：脂肪分解或者高血糖,并且组织破坏后产生的组织炎症因子对人体重要器官免疫系统更会产生一连串不良的反应。微创手术的目的是希望由特殊仪器(如内视镜、雷射钬激光等)的改变及手术技术的进步,达到对人体组织结构最少的损伤,从而减少因手术造成的组织伤害所引起组织炎症因子对人体器官及免疫系统的伤害。
目的：探讨经皮椎间孔镜下椎间盘髓核切除术与开放手术在治疗腰椎间盘突出症时患者组织炎性细胞因子和CRP、CPK的变化以及术后的临床疗效,证实PELD对组织损伤小的临床价值。
方法：此为前瞻性研究,自2010年10月到2011年4月共有20例有症状腰椎间盘突出患者纳入此研究。手术分为两个比较组,经皮穿刺内窥镜腰椎椎间盘切除手术组及传统腰椎椎间盘切除术组。每组以随机方式收集10位患者。手术的适应症：腰椎间盘突出压迫神经根,经过三个月的保守疗法无效。手术排除马尾神经症候群、脊柱不稳定、严重的运动神经受损、系统性的疾病如糖尿病与肝病、感染特性的疾病、复发性椎间盘突出的患者。
内窥镜下腰椎间盘切除术分为YESS椎间孔镜技术和TESSYS椎间孔镜技术,传统手术组为开放椎板间开窗髓核摘除术。
(一)术前准备采用局麻,术中部分患者会出现不同程度的疼痛,术前应取得患者的理解与支持。采用透X线的手术床和手术架,准备C型臂X线机。准备1瓶10ml欧莱派克椎间盘造影剂和1支2ml无菌美蓝染料,将9ml欧莱派克造影剂与lml美蓝混合。准备术中持续灌洗液,生理盐水3000ml+庆大霉素16万单位+肾上腺素0.5ml。
(二)YESS腰椎间盘切除减压术
1.体位：患者俯卧于Wilson腰架上,腰部稍后凸,使椎间隙后侧充分张开、扩大Kambin穿刺三角区的面积。
2.定位：在前后位X线透视下用克氏针沿腰椎棘突中点标定一条纵线,再沿椎间隙中央标定一条横线,两线交点为正位像椎间盘中心点。在上、下椎弓根之间标定纤维环安全穿刺三角区。在侧位X线透视下沿椎间盘的倾斜方向标定出椎间盘的侧位线,该侧位线与经椎间的横线之间的交点为穿刺点。L2-3和L3-4的穿刺点位于棘突中线外侧8-10cm,L4-5和L5-S1穿刺点位于棘突中线外侧12-14cm。根据患者椎间孔的大小和体形调整穿刺点的位置,椎间孔越小、身体越胖,穿刺点越偏外侧。
3.穿刺：体积分数1%利多卡因局麻后,在C型臂X线机前后位透视下,用18号穿刺针按术前标定的椎问盘方向,与腰部皮肤表面成25°-30°角穿刺。当穿刺针尖触及骨质或到达椎弓根内缘时,调整C型臂X线机,在侧位X线透视引导下调整穿刺方向和角度,逐渐将穿刺针向前推进至Kambin安全三角区纤维环内。当穿刺针尖穿破纤维环时,可感到针尖有突破感。标准的YESS穿刺点为C型臂X线机正位透视下穿刺针尖位于上、下椎弓根中心点的连线上；侧位透视下穿刺针尖位于上、下椎体后缘连线上。这表明穿刺针尖正好位于Kambin安全三角区纤维环上。将穿刺针逐渐刺入椎间盘内。正位透视下穿刺针尖应位于棘突连线上,侧位透视下位于椎间盘中、后1/3连线上。
4.造影：椎间盘造影以判定椎间盘破损程度、破损类型和渗漏方向,并询问患者的疼痛反应。
5.安放工作套管：经18号穿刺针插入导丝,以导丝为中心切一条长约8mm的直切口。将直径7.2mm、尖端呈钝性锥状、中央和旁侧各开有孔槽的特制锥状导棒沿导丝插入到纤维环上。在C型臂X线机监控下,用骨锤将锥状导棒击入椎间盘内。沿导棒将直径7.5mm、前端呈斜面的工作套管插入椎间盘内。
6.椎间盘减压：取出锥状导棒,经工作套管置人椎间孔镜。在椎间孔镜监视下经3.7mm内镜中央工作通道,使用各种型号和角度的髓核钳和髓核剪切除及取出突出、脱出或游离的椎间盘组织。在双极射频辅助下行椎间盘消融减压和纤维环撕裂口的皱缩与成形术。
(三)TESSYS腰椎间盘切除减压术
1.麻醉及定位：患者俯卧位或侧卧位。于C型臂X线机正位透视下标定腰椎棘突中线和经椎间盘上缘的水平线,侧位透视下沿椎间隙倾斜方向标定一条经下位椎体后上缘的侧位线,该侧位线与经椎间盘上缘水平线的交点为穿刺点。对L5-S1椎间盘,应在正位透视下标定髂嵴最高点连线和经L5-S1椎间盘上缘的水平线,侧位透视下标定一条经S1上关节突到S1椎体后上缘的侧位线,该侧位线与髂嵴最高点连线的交点为穿刺点。穿刺方向为S1椎体后上缘,通常L4-5的外展穿刺角为30°-40°,L5-S1为40～50°。体积分数1%利多卡因2-3ml局麻。
2.穿刺与造影：在正、侧位X线透视下,用18号穿刺针沿标定线方向穿刺至下位椎的上关节突前下缘,并在关节突周围注射体积分数0.5%的利多卡因2ml。将前端弯曲(15°～20°)的22号穿刺针通过18号穿刺针经椎间孔插人椎间隙或脱出的椎间盘内,行椎间盘造影。
3.安放工作套管：取出22号穿刺针,经18号穿刺针插入导丝,小心拔出穿刺针,以导丝为中点切一条8mm长的皮肤切口。沿导丝插入直径2mm的扩张导棒(酌情可选择直棒或弯棒),并沿导棒逐级插入3.5、4.5和5.5mm扩张导管扩大手术通道。逐级取出3.5mm和4.5mm扩张导管,沿2mm直径扩张导棒插入3mm直径锯齿状绞刀,绞除上关节突外侧缘部分骨质。插入导丝,取出绞刀和导棒,再沿导丝插入3mm直径的导棒,取出导丝。在C型臂X线机透视下将导棒紧贴上关节突前下缘,敲入椎管内。标准TESSYS手术穿刺点为正位X线透视下导棒头端位于棘突中线上,侧位X线透视下导棒头端位于下位椎体后上缘。沿导棒分别置入5.0、6.5和7.5mm直径绞刀,绞除上关节突外侧缘部分骨质,扩大神经孔,并置入7.5mm直径工作套管。
4.椎间盘减压：经工作通道置入椎间孔镜,在椎间孔镜监视下经3.7mm内镜中央工作通道,使用各种型号和角度的髓核钳和髓核剪切除和取出突出、脱出或游离的椎间盘组织,探查和松解神经根,双极射频辅助下行椎间盘消融减压和纤维环撕裂口的皱缩与成形术。
5.术后处理
术毕经工作套管注射7.5mg利美达松+体积分数1%的利多卡因2ml,拔出工作通道。询问患者下肢疼痛缓解程度,检查患肢直腿抬高试验是否改善。术后嘱患者卧床4-6h后带腰围下床活动。静脉输注广谱抗生素1d。术后3个月内避免过度体力活动和剧烈体育锻炼。
(四)传统开放腰椎间盘切除术
患者俯卧于脊柱托架上,C型臂X光机下针头定位目标间隙。取后正中长约4cm纵切口,用15cm宽的椎板拉钩将椎旁肌牵开,显露椎板间隙,X线再次确定目标间隙。用电刀将上位椎板下缘及下关节突内侧显露,用磨钻去除部分上位椎板及少许下关节突,用刮匙将浅层黄韧带刮起,并切除,此时可见黄韧带深层与下位椎板上缘。用刮匙将黄韧带深层止自下位椎板上缘分开,可进人椎管。切除剩余造成压迫或影响操作的黄韧带。显露出硬膜与神经根,根据需要决定是否向外扩大侧隐窝或扩大神经根孔减压。将神经根和硬膜囊牵向对侧,显露出突出椎间盘。如髓核脱出可直接取出,如未脱出,用尖刀环形或十字切开后纵韧带及纤维环,用小髓核钳取出所有游离的、容易取出的髓核组织,用反向刮匙刮椎间隙及后纵韧带下,并反复用小髓核钳钳取,以避免游离的髓核组织残留,并用盐水反复冲洗间隙清除碎屑。松开并检查神经根,决定是否需行神经根管减压。如担心术后血肿可能,放置小胶管引流,关闭切口。术后均常规应用抗生素预防感染1d,术后24—48h拔除引流。术后7d可允许患者佩戴腰围下地。术后3个月内避免过度体力活动和剧烈体育锻炼。
(五)PELD与OPEN的临床疗效观察：
使用ELISA来测量CRP、CPK、IL-6、IL-8、IL-10、IL-1p等在术前、术后1hr、6hr、12hr、24hr及48hr的变化。观察两组病人术中及术后失血量(m1)、住院时间(天数)、伤口大小(cm)、术前和术后VAS(Visual Analog Scale)及改良MacNab标准来评估术后的结果。
结果：两组患者术后均无椎间隙感染、定位错误、脑脊液漏、切口感染等严重并发症,但内窥镜组有一例发生有神经麻痛,但两周后症状自行改善,神经麻痛原因可能是病人椎孔间隙较小,内视镜套管相对较大压迫到部份神经根节所导致。所有患者均痊愈出院。
1.内窥镜组和传统手术组的术后失血量、住院时间、伤口大小比较：内窥镜组相对于传统手术组的患者在术后失血量、住院时间、伤口大小比较有统计学意义(P<0.01)。有较少的流血量(8.35±2.99ml vs.99.0±22.33ml P<0.01),更短的住院时数(1.9±0.74天vs.5.6±1.26天P<0.01),更小的手术伤口(0.51±0.02vs.4.9±1.29cm P<0.01)。
2.内窥镜组和传统手术组的术后6个月VAS的比较：两组术前疼痛指数(VAS)差异无统计学意义(内窥镜组为7.5±1.65(范围6～9),在开放手术组为7.5±1.08(范围7-9)P>0.05。两组疼痛指数术后差异无统计学意义(内窥镜组为1.8±0.79,开放手术组为1.9±0.74,P>0.05),表明PELD组与OD组术后6个月近期疗效无显著性差异。使用改良MacNab标准来评估术后六个月的临床满意度,在内窥镜组有90%满意度(8/10非常满意；1/10满意),而在开放手术组同样有90%满度(7/10非常满意,2/10满意)。
3.内窥镜组和传统手术组的血清CRP水平比较：
两组血清CRP在术前、术后1小时、6小时、12小时有差异无统计学意义(P>0.05)。但在术后24小时及48小时,开放手术组较内窥镜组CRP值均升高有统计学意义(P<0.01)。术后24小时：(1.84±0.74mg/dl vs.0.18±0.09mg/dlP<0.01)；术后48小时：(2.61±0.93mg/dl vs.0.10±0.04mg/dl P<0.01)。
4.内窥镜组和传统手术组的血清CPK水平比较：
两组血清CPK术前无显著性差异(P>0.05),术后均明显升高。传统手术组术后CPK在5个时间点升高程度均明显高于内窥镜组,两组差异均有统计学意义(P<0.01)：术后1小时(64.28±4.69vs.78.03±7.17,P<0.01)；术后6小时(220.54±23.49vs.105.05±17.23,P<0.01)；术后12小时(298.11±26.03vs.121.82±22.03,P<0.01)；术后24小时(270.87±43.50vs.123.56±13.08,P<0.01)及48小时(185.5±21.06vs.102.41±14.68,P<0.01)。
5.内窥镜组和传统手术组的血清IL-6水平比较：
在内窥镜组IL-6术前与术后差异无统计学意义(P>0.05)。但IL-6在开放手术组术后逐渐升高,且从术后6小时以后开放手术组相对内窥镜组在4个时间点均升高有统计学意义：术后6小时(0.87±0.05vs.0.26±0.05P<0.01)；术后12小时(0.93±0.12vs.0.22±0.07,P<0.01)；术后24小时(0.98±0.09vs.0.26±0.05,P<0.01)；术后48小时(1.07±0.10vs.0.25±0.06,P<0.01)。6.内窥镜组和传统手术组IL-1p、IL-8、IL-10产生的值太小无法由血液中测得。
结论：经皮椎间孔镜髓核摘除术与传统开放手术相比具有切口小,术中出血少,手术时间短,术后疼痛轻,术后住院时间短等优势,同时具有与开放手术相同的近期疗效；经皮椎间孔镜髓核摘除术对手术局部肌肉组织损伤轻微,对患者全身创伤反应影响明显低于开放手术,具有微创性。PELD在临床上有很明确的推广价值。
Background:Surgery is a special trauma, themagnitude of the tissue damage from surgery impacts the traumatic response, This response is proportional to the severity of surgical stress. percutaneous endoscopic lumbar discectomy (PELD) recently become more and more popular for treating Lumbar Disc Hemiation (LDH) because of the less postoperative pain, less bleed, shorter hospital stay, and is associated with good clinical outcomes compared with Open Discectomy(OD). The spinal musculoskeletal system had to be destroyed in the open surgery, which could easily produce neural adhesion, spinal structural damages, instability and other complications. Therefore, the caused trauma could lead to a series of reactions in vivo, such as:ascent of stress hormones, production of pro-inflammatory cytokines, as well as abnormal metabolic phenomenon, such as:lipolysis or hyperglycemia. And the production of systemic cytokines caused by tissue damages could produce a series of adverse reactions more often to the important organs in human immune system. The minimally invasive surgery aimed to achieve the least amount of trauma to human body by changes of special instruments (such as endoscopes, laser, etc.) and progresses of surgical technologies, so as to reduce the damage of human organs and immune system caused by systemic cytokines due to the tissue damage from this surgery. Therefore, the volume of production of systemic cytokines could be used to assess the postoperative tissue damages. Percutaneous endoscopic lumbar discectomy (PELD) was a new type of spinal minimally invasive surgery in recent years, which needed not general anesthesia and with different surgery way and method from the traditional surgery. Compared to the traditional open lumbar discectomy (OD), PELD had the same clinical curative effect, but there were no objective experimental data to confirm that PELD could cause less tissue damages than the traditional surgery. This study aimed to compare the clinical results (including intraoperative and postoperative blood loss, hospital stay, wound size, VAS, postoperative satisfaction, how long to return to work) of percutaneous endoscopic lumbar discectomy (PELD) and traditional open lumbar discectomy (OD) and analyze preoperative and postoperative changes of systemic cytokines to confirm PELD could cause less damages to human tissues than the traditional surgery, with quicker recovery time and shorter hospital stay in patients. PELD had a very clear promotional value in clinical.
Objective:This study aimed to compare the clinical efficacies of percutaneous endoscopic lumbar discectomy (PELD) and traditional open lumbar discectomy (OD), postoperative changes of CRP, CPK and systemic cytokines as well as tissue damages.
Methods:20patients with symptomatic disc herniation from October2010to April2011were included in this prospective study. They were randomly divided into two comparison groups, percutaneous endoscopic lumbar discectomy group and traditional lumbar discectomy group, with10patients in each group. The indication for this surgery was herniated disk compressing the spinal nerves. The patients, which were invalid after three months of conservative treatment, were excluded, with following characters①cauda equina syndrome, nerve,②spinal instability,③serious motor nerve damages,④systemic diseases, such as diabetes and hepatic diseases,⑤infectious diseases,⑥recurrent disc herniation. This study was conducted in accordance with the declaration of Helsinki. This study was conducted with approval from the Ethics Committee of the Peoples Hospital of Sanshui District, Foshan. Written informed consent was obtained from all participants
Percutaneous endoscopic lumbar discectomy:The patients underwent local anesthesia in the prone position on the see-through operating table. Additional2-5μg/kg Fentanyl was added to alleviate the pain and maintain the sober situation in patients to communicate to the doctor. The joimax lumbar endoscopic system was used, with an external diameter of7mm and pipeline of3.1mm. Along the import pathways, the spinal coordinate direction was confirmed with10-14cm far from the center line mostly from the rear lateral position. The guide needle was inserted at an angle of10～25degrees to the horizontal plane followed by the pipeline into the periphery of intervertebral foramen and after cutting open a5-7mm wound on the skin. The spinal endoscope was put into the relevant position. The rear pathway was applied in the L5-S1and some free herniated discs. All processes were under the C-arm fluoroscopy. The catheter was put in the lesion position. Ellman bipolar radiofrequency was used for hemostasis and vaporizing tissues and Ho-Yag laser was used for assisted resection of some proliferated bone and herniated disc. At the same time, the intervertebral disc clips with different sizes were used to clip out of the loose herniated nucleus pulposus.
Traditional surgery:The intervertebral discs were excised from spinal laminectomy under general anesthesia.
Index detection and surgical assessment:The intraoperative and postoperative blood loss, hospital stays and wound size of patients in the two groups were recorded. Enzyme-Linked immunosorbent assay (ELISA) was used to measure preoperative and postoperative1h,6h,12h,24h and48h changes of IL-1β, IL-6, IL-8, IL-10, CRP, CPK, etc. Visual Analog Scale (VAS) and Modified MacNab Criteria were used to evaluate the postoperative results.
Results:The overall results showed PELD group had less blood loss (mean8.35±2.99vs.99.0±22.33ml P<0.01), less hospitastay(1.9±0.74vs.5.6±1.26days P<0.01), less skin incision size(0.51±0.02vs.4.90±1.29cm P<0.01)than OD group. Using the modified MacNabcriteria, the clinical outcomes were90%(9/10) in PELD and90%(9/10) in OD group at6months postoperative follow up. Meanwhile, the pain index (preoperative VAS) was7.4±0.8(range6-9) in the endoscopic group and7.6±0.9(range7-9) in the open surgery group, P>0.05In addition, the postoperative pain index was1.8±0.79(range1-3) in the endoscopic group and1.9±0.74in the open surgery group, P>0.05. CRP level showed significantly difference at24hours and48hours between two group (24hr:1.84±0.74mg/dl vs.0.18±0.09mg/dl P<0.01,48hr:2.61±0.93mg/dl vs.0.10±0.04mg/dl P<0.01). CPK level also showed statistically significant difference between two groups (P<0.01).1hr:64.28±4.69vs.78.03±7.17, P<0.01), postoperative6hr:220.54±23.49vs.105.05±17.23,P<0.01. postoperative12hr:298.11±26.03vs.l21.82±22.03,P<0.01.postoperative48h24hr:270.87±43.50vs.123.56±13.08,P<0.01),postoperative48hr:185.5±21.06vs.102.41±14.68, P<0.01. Serum IL-6level showed statistically significant difference between two group after6hours post-operation.6hr (0.87±0.05vs.0.26±0.05P<0.01),12hr (0.93±0.12vs.0.22±0.07, P<0.01), postoperative24hr(0.98±0.09vs.0.26±0.05, P<0.01), postoperative48hr (1.07±0.10vs.0.25±0.06, P<0.01). The systemic IL-6, CRP and CPK was significantly less following.
Conclusion:The endoscopic discectomy surgery had less damage to human tissues than the traditional open surgery. PELD had a clear promotional value in clinical.
目的：探讨经皮椎间孔镜下椎间盘髓核切除术与开放手术在治疗腰椎间盘突出症时患者组织炎性细胞因子和CRP、CPK的变化以及术后的临床疗效,证实PELD对组织损伤小的临床价值。
方法：此为前瞻性研究,自2010年10月到2011年4月共有20例有症状腰椎间盘突出患者纳入此研究。手术分为两个比较组,经皮穿刺内窥镜腰椎椎间盘切除手术组及传统腰椎椎间盘切除术组。每组以随机方式收集10位患者。手术的适应症：腰椎间盘突出压迫神经根,经过三个月的保守疗法无效。手术排除马尾神经症候群、脊柱不稳定、严重的运动神经受损、系统性的疾病如糖尿病与肝病、感染特性的疾病、复发性椎间盘突出的患者。
内窥镜下腰椎间盘切除术分为YESS椎间孔镜技术和TESSYS椎间孔镜技术,传统手术组为开放椎板间开窗髓核摘除术。
(一)术前准备采用局麻,术中部分患者会出现不同程度的疼痛,术前应取得患者的理解与支持。采用透X线的手术床和手术架,准备C型臂X线机。准备1瓶10ml欧莱派克椎间盘造影剂和1支2ml无菌美蓝染料,将9ml欧莱派克造影剂与lml美蓝混合。准备术中持续灌洗液,生理盐水3000ml+庆大霉素16万单位+肾上腺素0.5ml。
(二)YESS腰椎间盘切除减压术
1.体位：患者俯卧于Wilson腰架上,腰部稍后凸,使椎间隙后侧充分张开、扩大Kambin穿刺三角区的面积。
2.定位：在前后位X线透视下用克氏针沿腰椎棘突中点标定一条纵线,再沿椎间隙中央标定一条横线,两线交点为正位像椎间盘中心点。在上、下椎弓根之间标定纤维环安全穿刺三角区。在侧位X线透视下沿椎间盘的倾斜方向标定出椎间盘的侧位线,该侧位线与经椎间的横线之间的交点为穿刺点。L2-3和L3-4的穿刺点位于棘突中线外侧8-10cm,L4-5和L5-S1穿刺点位于棘突中线外侧12-14cm。根据患者椎间孔的大小和体形调整穿刺点的位置,椎间孔越小、身体越胖,穿刺点越偏外侧。
3.穿刺：体积分数1%利多卡因局麻后,在C型臂X线机前后位透视下,用18号穿刺针按术前标定的椎问盘方向,与腰部皮肤表面成25°-30°角穿刺。当穿刺针尖触及骨质或到达椎弓根内缘时,调整C型臂X线机,在侧位X线透视引导下调整穿刺方向和角度,逐渐将穿刺针向前推进至Kambin安全三角区纤维环内。当穿刺针尖穿破纤维环时,可感到针尖有突破感。标准的YESS穿刺点为C型臂X线机正位透视下穿刺针尖位于上、下椎弓根中心点的连线上；侧位透视下穿刺针尖位于上、下椎体后缘连线上。这表明穿刺针尖正好位于Kambin安全三角区纤维环上。将穿刺针逐渐刺入椎间盘内。正位透视下穿刺针尖应位于棘突连线上,侧位透视下位于椎间盘中、后1/3连线上。
4.造影：椎间盘造影以判定椎间盘破损程度、破损类型和渗漏方向,并询问患者的疼痛反应。
5.安放工作套管：经18号穿刺针插入导丝,以导丝为中心切一条长约8mm的直切口。将直径7.2mm、尖端呈钝性锥状、中央和旁侧各开有孔槽的特制锥状导棒沿导丝插入到纤维环上。在C型臂X线机监控下,用骨锤将锥状导棒击入椎间盘内。沿导棒将直径7.5mm、前端呈斜面的工作套管插入椎间盘内。
6.椎间盘减压：取出锥状导棒,经工作套管置人椎间孔镜。在椎间孔镜监视下经3.7mm内镜中央工作通道,使用各种型号和角度的髓核钳和髓核剪切除及取出突出、脱出或游离的椎间盘组织。在双极射频辅助下行椎间盘消融减压和纤维环撕裂口的皱缩与成形术。
(三)TESSYS腰椎间盘切除减压术
1.麻醉及定位：患者俯卧位或侧卧位。于C型臂X线机正位透视下标定腰椎棘突中线和经椎间盘上缘的水平线,侧位透视下沿椎间隙倾斜方向标定一条经下位椎体后上缘的侧位线,该侧位线与经椎间盘上缘水平线的交点为穿刺点。对L5-S1椎间盘,应在正位透视下标定髂嵴最高点连线和经L5-S1椎间盘上缘的水平线,侧位透视下标定一条经S1上关节突到S1椎体后上缘的侧位线,该侧位线与髂嵴最高点连线的交点为穿刺点。穿刺方向为S1椎体后上缘,通常L4-5的外展穿刺角为30°-40°,L5-S1为40～50°。体积分数1%利多卡因2-3ml局麻。
2.穿刺与造影：在正、侧位X线透视下,用18号穿刺针沿标定线方向穿刺至下位椎的上关节突前下缘,并在关节突周围注射体积分数0.5%的利多卡因2ml。将前端弯曲(15°～20°)的22号穿刺针通过18号穿刺针经椎间孔插人椎间隙或脱出的椎间盘内,行椎间盘造影。
3.安放工作套管：取出22号穿刺针,经18号穿刺针插入导丝,小心拔出穿刺针,以导丝为中点切一条8mm长的皮肤切口。沿导丝插入直径2mm的扩张导棒(酌情可选择直棒或弯棒),并沿导棒逐级插入3.5、4.5和5.5mm扩张导管扩大手术通道。逐级取出3.5mm和4.5mm扩张导管,沿2mm直径扩张导棒插入3mm直径锯齿状绞刀,绞除上关节突外侧缘部分骨质。插入导丝,取出绞刀和导棒,再沿导丝插入3mm直径的导棒,取出导丝。在C型臂X线机透视下将导棒紧贴上关节突前下缘,敲入椎管内。标准TESSYS手术穿刺点为正位X线透视下导棒头端位于棘突中线上,侧位X线透视下导棒头端位于下位椎体后上缘。沿导棒分别置入5.0、6.5和7.5mm直径绞刀,绞除上关节突外侧缘部分骨质,扩大神经孔,并置入7.5mm直径工作套管。
4.椎间盘减压：经工作通道置入椎间孔镜,在椎间孔镜监视下经3.7mm内镜中央工作通道,使用各种型号和角度的髓核钳和髓核剪切除和取出突出、脱出或游离的椎间盘组织,探查和松解神经根,双极射频辅助下行椎间盘消融减压和纤维环撕裂口的皱缩与成形术。
5.术后处理
术毕经工作套管注射7.5mg利美达松+体积分数1%的利多卡因2ml,拔出工作通道。询问患者下肢疼痛缓解程度,检查患肢直腿抬高试验是否改善。术后嘱患者卧床4-6h后带腰围下床活动。静脉输注广谱抗生素1d。术后3个月内避免过度体力活动和剧烈体育锻炼。
(四)传统开放腰椎间盘切除术
患者俯卧于脊柱托架上,C型臂X光机下针头定位目标间隙。取后正中长约4cm纵切口,用15cm宽的椎板拉钩将椎旁肌牵开,显露椎板间隙,X线再次确定目标间隙。用电刀将上位椎板下缘及下关节突内侧显露,用磨钻去除部分上位椎板及少许下关节突,用刮匙将浅层黄韧带刮起,并切除,此时可见黄韧带深层与下位椎板上缘。用刮匙将黄韧带深层止自下位椎板上缘分开,可进人椎管。切除剩余造成压迫或影响操作的黄韧带。显露出硬膜与神经根,根据需要决定是否向外扩大侧隐窝或扩大神经根孔减压。将神经根和硬膜囊牵向对侧,显露出突出椎间盘。如髓核脱出可直接取出,如未脱出,用尖刀环形或十字切开后纵韧带及纤维环,用小髓核钳取出所有游离的、容易取出的髓核组织,用反向刮匙刮椎间隙及后纵韧带下,并反复用小髓核钳钳取,以避免游离的髓核组织残留,并用盐水反复冲洗间隙清除碎屑。松开并检查神经根,决定是否需行神经根管减压。如担心术后血肿可能,放置小胶管引流,关闭切口。术后均常规应用抗生素预防感染1d,术后24—48h拔除引流。术后7d可允许患者佩戴腰围下地。术后3个月内避免过度体力活动和剧烈体育锻炼。
(五)PELD与OPEN的临床疗效观察：
使用ELISA来测量CRP、CPK、IL-6、IL-8、IL-10、IL-1p等在术前、术后1hr、6hr、12hr、24hr及48hr的变化。观察两组病人术中及术后失血量(m1)、住院时间(天数)、伤口大小(cm)、术前和术后VAS(Visual Analog Scale)及改良MacNab标准来评估术后的结果。
结果：两组患者术后均无椎间隙感染、定位错误、脑脊液漏、切口感染等严重并发症,但内窥镜组有一例发生有神经麻痛,但两周后症状自行改善,神经麻痛原因可能是病人椎孔间隙较小,内视镜套管相对较大压迫到部份神经根节所导致。所有患者均痊愈出院。
1.内窥镜组和传统手术组的术后失血量、住院时间、伤口大小比较：内窥镜组相对于传统手术组的患者在术后失血量、住院时间、伤口大小比较有统计学意义(P<0.01)。有较少的流血量(8.35±2.99ml vs.99.0±22.33ml P<0.01),更短的住院时数(1.9±0.74天vs.5.6±1.26天P<0.01),更小的手术伤口(0.51±0.02vs.4.9±1.29cm P<0.01)。
2.内窥镜组和传统手术组的术后6个月VAS的比较：两组术前疼痛指数(VAS)差异无统计学意义(内窥镜组为7.5±1.65(范围6～9),在开放手术组为7.5±1.08(范围7-9)P>0.05。两组疼痛指数术后差异无统计学意义(内窥镜组为1.8±0.79,开放手术组为1.9±0.74,P>0.05),表明PELD组与OD组术后6个月近期疗效无显著性差异。使用改良MacNab标准来评估术后六个月的临床满意度,在内窥镜组有90%满意度(8/10非常满意；1/10满意),而在开放手术组同样有90%满度(7/10非常满意,2/10满意)。
3.内窥镜组和传统手术组的血清CRP水平比较：
两组血清CRP在术前、术后1小时、6小时、12小时有差异无统计学意义(P>0.05)。但在术后24小时及48小时,开放手术组较内窥镜组CRP值均升高有统计学意义(P<0.01)。术后24小时：(1.84±0.74mg/dl vs.0.18±0.09mg/dlP<0.01)；术后48小时：(2.61±0.93mg/dl vs.0.10±0.04mg/dl P<0.01)。
4.内窥镜组和传统手术组的血清CPK水平比较：
两组血清CPK术前无显著性差异(P>0.05),术后均明显升高。传统手术组术后CPK在5个时间点升高程度均明显高于内窥镜组,两组差异均有统计学意义(P<0.01)：术后1小时(64.28±4.69vs.78.03±7.17,P<0.01)；术后6小时(220.54±23.49vs.105.05±17.23,P<0.01)；术后12小时(298.11±26.03vs.121.82±22.03,P<0.01)；术后24小时(270.87±43.50vs.123.56±13.08,P<0.01)及48小时(185.5±21.06vs.102.41±14.68,P<0.01)。
5.内窥镜组和传统手术组的血清IL-6水平比较：
在内窥镜组IL-6术前与术后差异无统计学意义(P>0.05)。但IL-6在开放手术组术后逐渐升高,且从术后6小时以后开放手术组相对内窥镜组在4个时间点均升高有统计学意义：术后6小时(0.87±0.05vs.0.26±0.05P<0.01)；术后12小时(0.93±0.12vs.0.22±0.07,P<0.01)；术后24小时(0.98±0.09vs.0.26±0.05,P<0.01)；术后48小时(1.07±0.10vs.0.25±0.06,P<0.01)。6.内窥镜组和传统手术组IL-1p、IL-8、IL-10产生的值太小无法由血液中测得。
结论：经皮椎间孔镜髓核摘除术与传统开放手术相比具有切口小,术中出血少,手术时间短,术后疼痛轻,术后住院时间短等优势,同时具有与开放手术相同的近期疗效；经皮椎间孔镜髓核摘除术对手术局部肌肉组织损伤轻微,对患者全身创伤反应影响明显低于开放手术,具有微创性。PELD在临床上有很明确的推广价值。
Background:Surgery is a special trauma, themagnitude of the tissue damage from surgery impacts the traumatic response, This response is proportional to the severity of surgical stress. percutaneous endoscopic lumbar discectomy (PELD) recently become more and more popular for treating Lumbar Disc Hemiation (LDH) because of the less postoperative pain, less bleed, shorter hospital stay, and is associated with good clinical outcomes compared with Open Discectomy(OD). The spinal musculoskeletal system had to be destroyed in the open surgery, which could easily produce neural adhesion, spinal structural damages, instability and other complications. Therefore, the caused trauma could lead to a series of reactions in vivo, such as:ascent of stress hormones, production of pro-inflammatory cytokines, as well as abnormal metabolic phenomenon, such as:lipolysis or hyperglycemia. And the production of systemic cytokines caused by tissue damages could produce a series of adverse reactions more often to the important organs in human immune system. The minimally invasive surgery aimed to achieve the least amount of trauma to human body by changes of special instruments (such as endoscopes, laser, etc.) and progresses of surgical technologies, so as to reduce the damage of human organs and immune system caused by systemic cytokines due to the tissue damage from this surgery. Therefore, the volume of production of systemic cytokines could be used to assess the postoperative tissue damages. Percutaneous endoscopic lumbar discectomy (PELD) was a new type of spinal minimally invasive surgery in recent years, which needed not general anesthesia and with different surgery way and method from the traditional surgery. Compared to the traditional open lumbar discectomy (OD), PELD had the same clinical curative effect, but there were no objective experimental data to confirm that PELD could cause less tissue damages than the traditional surgery. This study aimed to compare the clinical results (including intraoperative and postoperative blood loss, hospital stay, wound size, VAS, postoperative satisfaction, how long to return to work) of percutaneous endoscopic lumbar discectomy (PELD) and traditional open lumbar discectomy (OD) and analyze preoperative and postoperative changes of systemic cytokines to confirm PELD could cause less damages to human tissues than the traditional surgery, with quicker recovery time and shorter hospital stay in patients. PELD had a very clear promotional value in clinical.
Objective:This study aimed to compare the clinical efficacies of percutaneous endoscopic lumbar discectomy (PELD) and traditional open lumbar discectomy (OD), postoperative changes of CRP, CPK and systemic cytokines as well as tissue damages.
Methods:20patients with symptomatic disc herniation from October2010to April2011were included in this prospective study. They were randomly divided into two comparison groups, percutaneous endoscopic lumbar discectomy group and traditional lumbar discectomy group, with10patients in each group. The indication for this surgery was herniated disk compressing the spinal nerves. The patients, which were invalid after three months of conservative treatment, were excluded, with following characters①cauda equina syndrome, nerve,②spinal instability,③serious motor nerve damages,④systemic diseases, such as diabetes and hepatic diseases,⑤infectious diseases,⑥recurrent disc herniation. This study was conducted in accordance with the declaration of Helsinki. This study was conducted with approval from the Ethics Committee of the Peoples Hospital of Sanshui District, Foshan. Written informed consent was obtained from all participants
Percutaneous endoscopic lumbar discectomy:The patients underwent local anesthesia in the prone position on the see-through operating table. Additional2-5μg/kg Fentanyl was added to alleviate the pain and maintain the sober situation in patients to communicate to the doctor. The joimax lumbar endoscopic system was used, with an external diameter of7mm and pipeline of3.1mm. Along the import pathways, the spinal coordinate direction was confirmed with10-14cm far from the center line mostly from the rear lateral position. The guide needle was inserted at an angle of10～25degrees to the horizontal plane followed by the pipeline into the periphery of intervertebral foramen and after cutting open a5-7mm wound on the skin. The spinal endoscope was put into the relevant position. The rear pathway was applied in the L5-S1and some free herniated discs. All processes were under the C-arm fluoroscopy. The catheter was put in the lesion position. Ellman bipolar radiofrequency was used for hemostasis and vaporizing tissues and Ho-Yag laser was used for assisted resection of some proliferated bone and herniated disc. At the same time, the intervertebral disc clips with different sizes were used to clip out of the loose herniated nucleus pulposus.
Traditional surgery:The intervertebral discs were excised from spinal laminectomy under general anesthesia.
Index detection and surgical assessment:The intraoperative and postoperative blood loss, hospital stays and wound size of patients in the two groups were recorded. Enzyme-Linked immunosorbent assay (ELISA) was used to measure preoperative and postoperative1h,6h,12h,24h and48h changes of IL-1β, IL-6, IL-8, IL-10, CRP, CPK, etc. Visual Analog Scale (VAS) and Modified MacNab Criteria were used to evaluate the postoperative results.
Results:The overall results showed PELD group had less blood loss (mean8.35±2.99vs.99.0±22.33ml P<0.01), less hospitastay(1.9±0.74vs.5.6±1.26days P<0.01), less skin incision size(0.51±0.02vs.4.90±1.29cm P<0.01)than OD group. Using the modified MacNabcriteria, the clinical outcomes were90%(9/10) in PELD and90%(9/10) in OD group at6months postoperative follow up. Meanwhile, the pain index (preoperative VAS) was7.4±0.8(range6-9) in the endoscopic group and7.6±0.9(range7-9) in the open surgery group, P>0.05In addition, the postoperative pain index was1.8±0.79(range1-3) in the endoscopic group and1.9±0.74in the open surgery group, P>0.05. CRP level showed significantly difference at24hours and48hours between two group (24hr:1.84±0.74mg/dl vs.0.18±0.09mg/dl P<0.01,48hr:2.61±0.93mg/dl vs.0.10±0.04mg/dl P<0.01). CPK level also showed statistically significant difference between two groups (P<0.01).1hr:64.28±4.69vs.78.03±7.17, P<0.01), postoperative6hr:220.54±23.49vs.105.05±17.23,P<0.01. postoperative12hr:298.11±26.03vs.l21.82±22.03,P<0.01.postoperative48h24hr:270.87±43.50vs.123.56±13.08,P<0.01),postoperative48hr:185.5±21.06vs.102.41±14.68, P<0.01. Serum IL-6level showed statistically significant difference between two group after6hours post-operation.6hr (0.87±0.05vs.0.26±0.05P<0.01),12hr (0.93±0.12vs.0.22±0.07, P<0.01), postoperative24hr(0.98±0.09vs.0.26±0.05, P<0.01), postoperative48hr (1.07±0.10vs.0.25±0.06, P<0.01). The systemic IL-6, CRP and CPK was significantly less following.
Conclusion:The endoscopic discectomy surgery had less damage to human tissues than the traditional open surgery. PELD had a clear promotional value in clinical.
引文
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