Surgical outcome of percutaneous endoscopic technique for highly migrated disc herniation via three different ap-proaches

目的:分析不同入路脊柱内窥镜下治疗重度脱垂游离型腰椎间盘突出症的临床疗效.方法:对2011年6月至2014年6月接受微创内窥镜治疗的68例重度脱垂游离型腰椎间盘突出症患者进行回顾性分析,应用3种不同入路完成手术.其中采用经椎间孔入路45例(A组),经椎板间隙入路15例(B组),经椎弓根入路8例(C组).男43例,女25例;L2,3节段1例,L3,4节段12例,L4,5节段36例,L5S1节段19例;头端移位23例,尾端移位45例;年龄11~77岁,平均(42.29±15.92)岁.术前通过MRI证实诊断,术后复查MRI明确摘除情况.记录手术时间、出血量、术中及术后并发症、术后返回工作岗位时间(术后恢复时间),观察术前及末次随访时的腿痛视觉疼痛模糊评分(visual analog scale,VAS)及JOA(Japanese Orthopedic Association)评分,应用MacNab评价标准评定其临床疗效.结果:所有手术顺利完成,68例患者均获得随访,时间12~40个月,平均(18.0±15.9)个月.术后7例(A组3例,B组3例,C组1例)患者出现患肢短暂性感觉异常(痛觉过敏或皮节支配区减退),予以对症营养神经药物治疗后缓解,末次随访无残留症状.B组1例推挤管道时硬膜撕裂,未予处理,术后无头痛及皮肤窦道等并发症.A、B、C组术前腿痛VAS评分分别为6.93±1.34,6.33±1.23,6.13±1.73,末次随访时分别为0.80±0.87,0.73±0.70,0.38±0.52;JOA评分术前分别为9.09±2.62,9.80±2.31,10.50±2.93,末次随访时分别为26.82±1.53,25.93±1.58,26.50±1.51;3组间各数据比较差异无统计学意义(P>0.05),3组术后的VAS及JOA评分较术前均有明显改善(P<0.05).3种手术入路在出血量、术后返回工作岗位上差异无统计学意义(P>0.05),而经椎板间入路手术时间较短.依据MacNab评价标准评定疗效,优42例,良21例,可5例.结论:微创内窥镜技术可以很好地治疗重度脱出移位型腰椎间盘突出症,3种不同入路应依据术前患者解剖学特点选择,经椎弓根入路摘除向尾端重度脱出移位髓核直接方便,但对手术技术及设备要求较高.Objective:To analyze the clinical effects of percutaneous endoscopic technique via three different approaches for highly migrated lumbar disc herniation. Methods:The clinical data of 68 patients underwent percutaneous endoscopic tech-nique from June 2011 to June 2014 were retrospectively analyzed. There were 43 males and 25 females ,aged from 11 to 77 years old with an average of (42.29 ±15.92) years. The patients were divided into three groups according to different operative ap-proaches,of them,45 cases were by transforaminal approach (group A),15 cases by translaminar approach (group B),and 8 cases by transpedicular approach (group C). There was 1 case in level L2,3,12 cases in L3,4,36 cases in L4,5,19 cases in L5S1. The herniated disc was migrated superiorly in 23 patients ,inferiorly in 45 patients. MRI were available to confirm migrated disc pre and post operatively. Operation time,loss blood volume,intraoperative and postoperative complications,time of back to work (postoperative recovery time ) were recorded. Preoperative and postoperative VAS were used to evaluate low back pain and sciat-ica and JOA and MacNab criteria were used to evaluate functional recovery. Results:All the operations were successful and all the patients were followed up from 12 to 40 months with an average of (18.0±15.9) months. Seven patients(3 cases in group A,3 cases in group B,1 case in group C) complicated with transient paraesthesia (hyperalgesia or hypesthesia),and the symptoms relieved after symptomatic treatment with neurotrophic medicine ,at final follow up,no symptoms were left. One case in group B complicated with dura mater tearing during operation and it was untreated ,there was no resulted complications such as headache and sinus tract of skin. In group A,B,C,the mean VAS score of sciatica improved from preoperative 6.93±1.34,6.33±1.23,6.13± 1.73 to 0.80 ±0.87,0.73 ±0.70,0.38 ±0.52 at final follow up;and JOA score improved from preoperative 9.09 ±2.62,9.80 ±2.31,10.50±2.93 to 26.82±1.53,25.93±1.58,26.50±1.51 at final follow up,respectively(P<0.05). There was no significant dif-ference among three groups (P>0.05). There was no significant difference in loss blood volume ,postoperative recovery time a-mong three groups. But operation time of group B was shorter than other two groups. According to MacNab criterion to assess the clinical effects,42 cases got excellent results,21 good,5 fair. Conclusion:Percutaneous endoscopic technique is a safe and ef-fective method for surgical treatment of highly migrated herniation. The decision of operative approach should be made by charac-ters of anatomy. By tanspedicular approach the lesion could be found directly. However ,it depends on good skill and equipment.2100-1043