摘要
1研究背景
腰椎间盘突出症(Lumbar Disc Herniation,LDH)是下腰痛的重要病因,多数患者可经非手术治疗治愈,但仍有10～20%的患者因保守治疗无效,需接受手术治疗。1997年Yeung首次报道通过使用杨氏脊柱内窥镜系统(Yeung EndoscopicSpinal Systerm,YESS)行经皮内窥镜下腰椎间盘切除术(Percutaneous EndoscopicLumbar Discectomy,PELD)治疗腰椎间盘突出症,取得了良好的临床疗效。近年来PELD在国内几家大医院开展,由于用于临床时间短,国内的文献报道不多。
腰椎间盘造影术(Lumbar discography)是诊断腰椎间盘源性疼痛的唯一可靠检查方法。PELD术前均常规行腰椎间盘造影术,通过造影X线透视下成像可观察髓核退变程度及纤维环是否完整,反映椎间盘的病理特点。此外,在造影时注入美兰使退变髓核蓝染,可指导手术切除范围。
目前PELD技术主要用于L_(3/4)、L_(4/5)椎间盘突出症患者,由于L_5/S_1椎间盘穿刺时受髂嵴阻挡,PELD操作较为困难,髂嵴较高的L_5/S_1椎间盘突出症被认为是PELD的手术禁忌症。
本研究通过临床病例随访,总结和分析了PELD的手术要点和临床疗效;针对腰5/骶1椎间盘这一穿刺困难部位,又进行了相关应用解剖研究;比较了腰椎间盘造影成像和磁共振成像(Magnetic Resonance Imaging,MRI)在反映椎间盘退变方面的相关性和意义。通过以上研究,为今后PELD的临床应用和拓宽适应证提供理论依据。
2研究目的
2.1.探讨PELD治疗腰椎间盘突出症的临床疗效、适应证、禁忌证、并发症,初步评价PELD的临床应用价值。
2.2分析腰椎间盘造影成像与MRI评估腰椎间盘退变的意义及其相关性,探讨腰椎间盘造影术在腰椎间盘退行性疾病中的应用。
2.3通过对腰骶椎的局部解剖结构观测,为经皮内窥镜技术治疗L_5/S_1椎间盘突出症提供详尽的应用解剖学数据。
3材料与方法
3.1经皮内窥镜下腰椎间盘切除术的临床研究
自2006年3月～2006年12月南方医院脊柱骨病科完成了经皮内窥镜下腰椎间盘切除术52例(男34例,女18例),患者平均年龄为38.5岁(17～63岁)。腰椎间盘突出节段:L_4/S_1 3例,L_(4/5) 43例,L_(3/4) 6例。病程3～156个月,平均34.5个月。采用VAS评分(Visual Analogue Scale,VAS)、Oswestry功能障碍指数问卷表(Oswestry Disability Index,ODI)和改良MacNab标准来评价手术疗效。
3.2腰椎间盘造影术与MRI评估腰椎间盘退变的比较研究
自2006年3月～2007年12月,腰腿痛患者72例(男46例,女26例),平均38.7岁(17～65岁),椎间盘74个(双间盘造影2例),节段分别为:L_(3/4) 13个,L_(4/5) 57个,L_5/S_1 4个,均行腰椎间盘造影术,术中C臂成像,并根据MRI和腰椎间盘造影成像对椎间盘退变分级进行评估。
3.3经皮内窥镜下腰椎间盘切除术的应用解剖研究
21具成人防腐固定腰椎标本,观察L_5/S_1 1椎间盘侧方血管神经及毗邻结构的走行、分布及毗邻关系,模拟穿刺,探讨L_5/S_1椎间盘侧方入路的可行性。
4结果
4.1所有患者均顺利完成手术。随访时间12～24个月,平均15.4个月。手术时间为20～60分钟,平均33.1分钟;术中出血量为1～50ml,平均9.4ml:住院时间3～6天,平均4天。腰痛VAS评分:术前7.8±0.9,术后1天3.0±1.5(P=0.000),术后1周1.6±1.3(P=0.000),末次随访0.5±1.4(P=0.000);下肢痛VAS评分:术前7.3±1.2,术后1天2.8±1.5(P=0.000),术后1周1.5±1.3,(P=0.000),末次随访0.6±1.3(P=0.000);ODI:术前63.0±5.8,术后1周35.2±7.6(P=0.000),术后3个月27.3±8.1(P=0.000),末次随访19.9±9.9(P=0.000);临床疗效以改良MacNab标准评定:优47例(90.3%),良2例(3.8%),可2例(3.8%),差1例(2.1%)。
4.2腰椎终板退变分型:0型41例,Ⅰ型10例,Ⅱ型13例,Ⅲ型10例;椎间盘退变的造影分级:1级34例,2级16例,3级10例,4级11例,5级3例;椎间盘退变的MRI分级:1级13例,2级48例,3级13例。统计学分析表明,终板退变与椎间盘退变的造影分级有显著的相关性(r=0.785,P=0.000);椎间盘退变的MRI分级与造影分级存在较显著的相关性(r=0.728,P=0.000);椎间盘退变的MRI分级和终板退变存在较显著的相关关系(r=0.616,P=0.000)。
4.3 L5-S1椎间盘外侧有一个无神经干和大血管的可进行穿刺的安全区域,左侧区域大于右侧。
5结论
5.1.经皮内窥镜下腰椎间盘切除术具有创伤小、出血少、视野清晰、操作精细,术后恢复快等特点,手术效果优良,是治疗腰椎间盘突出症的良好术式。
5.2腰椎间盘造影术能够显示椎间盘纤维环撕裂及髓核撕裂等病理改变,是一种有效、可靠和安全的诊断腰椎间盘源性疼痛的方法,同时腰椎终板改变与腰椎间盘退变存在密切的相关性。
5.3 L5-S1侧方区域可作为内窥镜手术治疗椎间盘疾患的靶区。
Backgrouds
Lumbar disc herniation is a common disease causing the low-back pain and sciatica.10%-20%of patients who did not improve after conservative treatment accept surgical management.In 1997,Yeung first reported that patients underwent Percutaneous endoscopic lumbar discectomy(PELD) using Yeung endoscopic spine systerm(YESS) instruments.The clinical outcomes of PELD were satisfied.PELD has been developed recently in China,but the clinical research about PELD was rare. Lumbar discography is only an efficient and safe method of diagnosing with discogenic low back pain.Lumbar discography is routinely performed before PELD, fluoroscopic monitoring after lumbar discography was essential to observe the degeneration of nucleus and integrity of annular fibrosus.In addition,Discography was operated by using methylene blue for the staining of the disc material,which is useful to guide the extent of discectomy.
Lumbar disc herniation at L3/4、L4/5 levels was suitable for PELD.LS/S1 disc is thought to be inaccessible or inadequately accessed by the endoscopic technique due to the high iliac crest,so herniations with high iliac crest at L5/S1 level may be excluded from PELD.
The purpose of this study was to analyses the surgical outcomes and the cliniacl application of PELD.Because access to the L5/S1 level can be difficult,the objective of this study was to perform the anatomical study of L5-S1 segmental and make a comparison between lumbar discography with MRI in diagnosing with lumbar disc degeneration.All above researches were to provide theory foundation for the clinical application of PELD.
Objectives
1.To investigate the clinical outcome,indication,contraindication,complication of PELD and initially evaluate the clinical value of PELD.
2.To determine the correlation between discography with MRI in reflecting the lumbar disc degeneration.
3.To investigate the adjacent structures of L5-S1 disc and provide anatomic data for PELD through the lateral approach.
Materials and Methods
1.Fifty-two patients with lumbar disc herniation underwent PELD from March 2006 to decemember 2006.The mean age of the patients was 38.5 years(range17 to 63years).The levels of lumbar disc hemiations were L3/4 in 6 cases,L4/5 in 43 cases, LS/S1 in 3 cases.The median course of disease was 34.5 months(range 3 to 156 months).The patients were evaluated for their pain on a Visual Analog Scale(VAS) and functional assessment by a patient-based questionnaire(Oswestry Disability Index,ODI).
2.Seventy-four lumbar intervertebral discs(L3/L4 13 cases,L4/L5 57 cases,LS/S1,4 cases)of 72 patients(46 men,26 women) were examined from March 2006 to decemember 2007.The mean age of the patients was 38.7 years(range 17 to 65 years).74 intervertebral discs underwent discography guided by fluoroscopy monitoring.This study was to evaluate the degeneration of lumar intervertebral disc from the results of discography and MRI.
3.This study was to study 21 human cadavers to record their adjacent strucutres of lower L5-S1 disc and investigate the feasibility of lateral approach into the L5/S1 disc.
Results
1.All the patients were performed with PELD successfully.The average period of follow up were 15.4 months(range 12 to 24 months).The mean operative time was 68.1 mins(range 40 to130mins);the mean blood loss was 9.4 ml(range 1 to 50 ml); the mean hospital time was 7 days(range 5 to 12 days).Mean VAS score for back pain improved from7.8 to 0.5,mean VAS score for leg pain improved from 7.3 to 0.6, mean ODI imprvoed from 63 to 19.The improvements in VAS and ODI were statistically significant(P=0.000).Based on the MacNab criteria,90.3%showed excellent outcomes,3.8%showed good outcomes,3.8%showed fair outcomes,2.1% showed poor outcomes.
2.Lumbar Modic endplate classification:Type 0,41 discs;TypeⅠ,10 discs;TypeⅡ, 13 discs;TypeⅢ,10 discs;The grade of lumbar disc degeneration from the results of lumbar discography:Grade 1,34discs;Grade 2,6 discs;Grade 3,10 discs;Grade 4,11 discs;Grade 5,3 discs;The grade of lumbar disc degeneration based on the results of MRI:Gradel,13 discs;Grade2,48 discs;Grade3,13 discs.There was positive correlation between the Modic degeneration of lumbar endplate on the basis of MRI with the disc degeneration of lumbar intervertebral observed on fluoroscopy discography(r=0.785,P=0.000);There was positive correlation between the disc degeneration of lumbar intervertebral from MRI with the disc degeneration of lumbar intervertebral from discography(r=0.728,P=0.000),There was positive correlation between the disc degeneration of lumbar intervertebral observed on MRI with the Modic degeneration of lumbar end-plate observed on MRI(r=0.616,P=0.000).
3.There is a safety region in lateral suface of the L5-S1 disc,the left region is bigger than the right region.
Conclusions
1.PELD is suitable for lumbar disc herniation with the advantages of smaller incision,less bleeding,less tissue trauma,better visual exposure,more careful manipulation and quicker recovery,therefore PELD is safe and effective technique in the treatment of lumbar disc herniation.
2.Lumbar discography may reflect intervertebral disc degeneration pathology,and is an efficient and safe assistant diagnostic tools for discogenic low pain.There was positive association between the degeneration of lumbar endplate with the disc degeneration of lumbar intervertebral.
3.Lateral area of the L5-S1 disc can be used as an alternative target region for the treatment of intervertebral disc disease.It is possible to peform the PELD in the L5/S1 segment through the lateral approach.
引文
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