椎间孔镜与小切口治疗腰椎间盘突出症疗效对比

基金项目:辽宁省科学技术计划项目,项目编号:2013225305㊂
　作者简介:王炳文(1994),男,山东鱼台人,在读硕士研究生,主要研究方向为脊柱外科基础与临床㊂
　通讯作者:董明岩(1963),男,辽宁锦州人,主任医师,硕士学位,主要研究方向为脊柱外科基础与临床㊂
椎间孔镜与小切口治疗腰椎间盘突出症疗效对比
王炳文,董明岩,沈鑫鑫,王凯伦
(锦州医科大学附属第一医院骨脊柱病区,辽宁锦州121000)
摘要:目的　比较经皮椎间孔镜TESSYS 技术与传统小切口椎板开窗髓核摘除术治疗腰椎间盘突出症的相关手术指标与近期疗效㊂方法　按纳入标准选取2017年8月至2018年8月期间锦州地区患有单节段椎间盘突出症患者73例,随访6个月,失访13例,将完成随访的60例患者分为两组,观察组37例行PTED 治疗,对照组23例行小切口治疗㊂观察指标:年龄㊁性别㊁病程㊁病变阶段㊁手术时间㊁切口长度㊁卧床时间㊁住院时间㊂记录术前㊁术后1d ㊁术后1个月㊁术后3个月的视觉疼痛模拟评分(VAS 评分);术前,术后3个月腰椎JOA 评分;术前㊁术后3个月㊁6个月功能障碍指数问卷表(ODI );术后6个月改良MacNab 标准㊂结果　两组在切口长度㊁手术时间㊁住院时间㊁卧床时间的指标差异都有统计学意义(P <0.01)㊂两组术后VAS 评分较术前明显降低,术后1个月㊁术后3个月低于术后1d ,差异具有统计学意义(P <0.05)㊂术后两组间各时间点VAS 评分差异无统计学意义(P >0.05)㊂两组术后3个月JOA 评分明显高于术前,差异具有统计学意义(P <0.01)㊂术后3个月两组间JOA 评分差异无统计学意义(P >0.05)㊂两组术后ODI 评分明显低于术前,差异均有统计学意义(P <0.01),术后6个月显著低于术后3个月,差异均有统计学意义(P <0.01)㊂术后两组间各时间点ODI 评分的对比差异无统计学意义(P >0.05)㊂改良MacNab 标准观察组优良率89.2%,对照组91.3%,两组的优良率差异无统计学意义(P >0.05)㊂结论　经皮椎间孔镜TESSYS 技术治疗腰椎间盘突出症疗效确切,与传统小切口开窗术相当,
但TESSYS 技术是一种微创的手术方式,更易被接受,并且随着内镜技术的持续发展,有更好的应用前景㊁值得临床推广㊂
关键词:TESSYS 技术;经皮椎间孔镜技术(PTED );小切口椎板开窗术;腰椎间盘突出症;髓核摘除术中图分类号:R681.5 文献标志码:A 文章编号:2096-305X (2020)01-0013-06
Efficacy Comparison of the Intervertebral Foramen and Small
Incision in the Treatment of Lumbar Disc Herniation
Wang Bingwen,Dong Mingyan,Shen Xinxin,Wang Kailun
(Bone Spinal Disease Area,the First Affiliated Hospital of Jinzhou Medical University,Jinzhou 121000China)
Abstract :Objective　To compare the relevant operative index and the short-term curative effect of the percutaneous transforam⁃inal TESSYS technique and traditional small-incision laminectomy in the treatment of lumbar disc herniation.Methods　According to the inclusion criteria,73patients with single segment disc herniation in Jinzhou region from August 2017to August 2018were select⁃ed.The patients were followed up for 6months and 13were lost.60patients who completed the follow -up were divided into two groups.37patients in the observation group received PTED treatment and 23patients in the control group received small incision treat⁃ment.Observational indexes include age,gender,disease duration,stage of lesion,operative time,incision length,bed rest time and hospital stay.Visual pain analog scores (VAS scores)before and 1day,1month and 3months after operation,lumbar JOA
score before and 3months after operation,dysfunction index questionnaire before operation,3months after operation and 6months af⁃ter operation,and the improved MacNab standard 6months after operation were all recorded.Results　There were significant differ⁃
ences in operative time,incision length,bed rest time,and hospital stay between the two groups (P <0.01).The VAS scores of the two groups was significantly lower than those before operation,and significantly lower 1month and 3months after operation than 1day after operation,and there was significant difference between the two groups (P <0.05).There was no significant difference in VAS scores between the two groups at each time point (P >0.05).JOA scores were significantly higher than those before surgery in both groups 3months after operation,and the difference was statistically significant (P <0.01).There was no significant difference in JOA
score between the two groups 3months after operation (P >0.05).ODI scores of the two groups were significantly lower than those be⁃
3
1锦州医科大学学报J Jinzhou Medical University
2020Feb.41(1)
fore surgery,and the differences were statistically significant (P <0.01).The ODI scores 6months after surgery were significantly lower than those 3months after operation,with statistically significant difference (P <0.01).There was no significant difference in
ODI scores between the two groups at each time point (P >0.05).The improved MacNab standard showed an excellent rate of 89.2%in the observation group and 91.3%in the control group,with no significant difference (P >0.05).Conclusion　Percutaneous trans⁃foraminal TESSYS proves to be an effective treatment for lumbar disc herniation,which is similar to traditional small incision fenestra⁃tion.However,TESSYS is a minimally invasive surgical method,which is more acceptable,and with the continuous development of
endoscopic technology,it has a better application prospect and is worthy of clinical promotion.Key words :TESSYS technique;percutaneous transforaminal technique (PTED);small incision laminectomy;lumbar disc
herniation;nucleus pulposus removal
腰椎间盘突出症(lumbar disc herniation,
LDH)是临床脊柱常见病,有着较高的发病率[1]㊂临床上治疗腰椎间盘突出症的常用传统手术方式为后路椎板开窗髓核切除术[2]㊂近些年来,随着医
疗设备发展及在微创领域不断地探索,脊柱内镜技术发展迅速,临床应用已趋于成熟,经椎间孔内窥镜脊柱系统(transforaminal endoscopic spine system,TESSYS)技术[3-5]可避免脊柱生物力学损伤,保护脊柱结构,已经成为脊柱外科重要的发展方向之一㊂本文旨在通过对锦州地区住院患者行PTED 与
小切口椎板开窗髓核摘除术治疗腰椎间盘突出症的疗效对比,对PTED 的临床应用推广提供参考[6]㊂1　临床资料
1.1　一般资料　本研究的病例来自于2017年8月
至2018年8月期间在锦州地区住院行手术治疗的腰椎间盘突出症患者㊂研究对象纳入标准:(1)符合腰椎间盘突出症诊断标准;(2)年龄22~74岁的男性或女性患者;(3)症状表现与影像学检查
一致;(4)经过3个月严格保守治疗,无效;(5)身体状况良好,无手术禁忌㊂本研究回顾性分析60例腰椎间盘突出症手术治疗患者,分为观察组和对照组,观察组行PTED 手术,共37例,其中男22人,女15人;年龄21~72岁,平均年龄(50.46±11.61)岁,病程5个月~9年,平均(33.97±15.86)个月,L4~L5节段25例,L5~S1节段12例,术前VAS (7.11±0.77)分,术前JOA (12.03±2.59)分,术前ODI (60.73±8.55)分㊂对照组23人,男9人,女14人,年龄28~68岁,平均年龄(50.39±8.95)岁,病程6个月~6年,平均(30.56±13.09)个月,L4~L5节段16例,L5~S1节段7例,术前VAS (7.26±0.86)分,术前JOA (12.30±2.96)分,术前ODI (59.61±7.87)分㊂两组患者经统计分析,在性别㊁年龄㊁病程㊁病变阶段㊁术前VAS 评分㊁术前JOA 评分㊁术前ODI 评分差异无统计学意义(P >0.05),两组之间具有可比性,见表1㊁表2㊂
表1　两组患者一般资料情况
组别n 性别男女年龄节段
L4~L5L5~S1病程(月)PTED 37221550.46±11.61251233.97±15.86小切口23
9
14
50.39±8.9516
7
30.56±13.09
P 值
0.126
0.981
0.872
0.399
　注:两组患者性别㊁年龄㊁病变阶段及病程未见显著统计学差异(P >0.05)
表2　两组患者术前VAS ㊁JOA ㊁ODI 评分对比
组别n 术前VAS 术前JOA 术前ODI PTED 377.11±0.7712.03±2.5960.73±8.55小切口23
7.26±0.8612.30±2.9659.61±7.87t 值-0.711-0.3820.509P 值
0.480
0.704
0.613
1.2　手术方法
1.2.1　PTED 组　手术的器械为德国Joimax 公司
出产的THESSYS 内镜手术系统㊁显示器系统㊁电子动力系统㊁18号椎间盘穿刺针,自制关节突消磨环锯或可视化环锯及动力磨钻㊂患者体位均采取侧卧位且患侧朝上,于患者腰部放置侧卧位垫,始终保持髋㊁膝关节屈曲㊂沿棘突标记正中线,画出髂嵴体表投影,以克氏针在正位上DR 机确定责任间隙,画出过责任间隙横线㊂确定旁开距离,在L3~L4水平,选择在旁开中线8~10cm,L4~L5水平,选择在旁开中线10~12cm,在L5~S1水
41锦州医科大学学报　2020年2月,41(1)
平,选择在旁开中线12~14cm,术中的旁开距离还需要依病人的体格与间盘突出位置作适当调整,在旁开距离点上做后正中线的平行线㊂在侧位上,用克氏针在C臂透视下,选取过关节突尖部到下位椎体上缘为进针路线,此线与旁开线的交点即进针点㊂
术区消毒,铺无菌单,C臂套无菌镜套,以0.5%利多卡因逐层浸润麻醉,以18G的针穿刺至关节突,C臂透视下确定位置正确,关节突注入麻醉药㊂麻醉满意后,插入导丝并退出18G穿刺针,将导丝保留在原位㊂在进针点的皮肤切开一个约7.5mm的切口,顺着导丝逐级放置套管以向外扩张软组织,沿着套管放置环锯,以去掉关节突增生的骨质,用自制关节突成形环锯或可视化环锯及动力磨钻辅助扩大椎间孔,在C臂辅助下,不断调整消磨角度㊂完成椎间孔扩大成型后,取出环锯,置入工作套筒,用C型臂㊁DR确定工作套管的放置位置㊂连接椎间孔镜工作系统,调节合适的水流量和压力,保持手术视野的清晰㊂使用神经探钩㊁剪刀㊁抓钳㊁咬钳等,完成髓核摘除后,可以清楚地看到减压后神经根㊁硬膜囊,搏动良好㊂不断调整工作套管角度观看是否还有游离的髓核碎片㊂最后以双极射频止血㊁固缩周围软组织㊁封闭纤维环裂口,防止髓核脱出再次复发㊂操作完成后,术中检查直腿抬高试验㊁嘱患者咳嗽,镜下观察神经根㊁硬膜囊的搏动㊂缝合切口,包扎㊂
1.2.2　小切口组　患者全麻后置于俯卧位垫上,腹部悬空,以克氏针在C臂正位上确定责任间隙,术区常规消毒铺无菌单,以病变节段为中心,沿棘突取正中切口,长度约为5.8cm,逐层切开皮肤㊁皮下及筋膜,使用骨膜剥离子将肌肉沿椎板剥离至节突外侧,充分止血,置入椎板拉钩,充分暴露手术视野㊂咬除部分椎板开窗,暴露黄韧带,尖刀切开并以神经剥离子游离黄韧带及硬膜间隙,咬除黄韧带,显露硬膜囊及神经根,使用神经拉钩将硬膜囊㊁神经根牵往一侧保护,显露突出于纤维环之外的的髓核,使用髓核钳取出突出的髓核,并深入椎间隙尽可能取出松动的髓核,神经剥离子探查神经根减压情况㊂满意后,冲洗,置入引流管,逐层缝合,包扎㊂
1.3　术后处理　术后应用3d抗生素预防感染,常规甘露醇㊁甲强龙应用2d㊂PTED组患者术后当天可根据情况,佩戴腰围下床活动;小切口组术后2d拔出引流管,卧床休息1w后,可佩戴腰围下床活动㊂出院后均佩戴腰围保护6~8w,期间避免腰椎大幅度活动及负重,指导患者进行直腿抬高及腰背肌功能锻炼,每3天一换药,2w后拆线㊂
1.4　观察指标
1.4.1　手术相关指标　手术时间㊁切口长度㊁术后卧床时间㊁住院时间㊂
1.4.2　疗效评价指标　(1)VAS评分:分之范围0~10分,无痛为0分,10分为剧痛㊂分值递增表示疼痛递增,由患者根据自身感觉填写㊂术前㊁术后1天㊁术后1个月㊁术后3个月对患者进行评分;(2)腰椎JOA评分:术前㊁术后3个月进行评分,详细内容见表1;(3)ODI功能障碍指数:术前㊁术后3个月㊁术后6个月进行评分,详细内容见表2;(4)改良MacNab疗效评价:以末次随访做为评价,优为无痛活动自如,良为偶尔背或腿痛不影响起正常工作和生活,可为间断性疼痛致功能障碍,影响其正常工作和生活,但功能得到改善,差为疼痛无减轻,功能无明显改善或未改善,需要再次手术㊂
1.5　统计学方法　建立Excel原始数据库,采用SPSS19.0进行统计学分析,计量资料首先进行正态分布检验,对于符合正态分布资料进行独立样本t检验,以均数±标准差(⎺x±s)表示,计数资料的比较用χ2检验进行分析,P<0.05表示差异有统计学意义㊂
2　结 果
两组患者手术均顺利完成,术后无严重并发症出现且所有患者均获得有效随访㊂典型病例如下患者,女,42岁,L5~S1椎间盘突出症,术前的腰椎MRI显示L5~S1椎间盘偏右侧突出,见图1;椎间孔镜术中的穿刺㊁扩张与置管,见图2;术中神经根减压复位,见图3;取出的突出髓核组织,见图4㊂
2.1　手术相关指标　两组在手术时间㊁切口长度㊁卧床时间㊁出院时间均有显著差异(P<0.01), PTED组在手术时间长于小切口组,在切口长度㊁卧床时间㊁出院时间均低于小切口组,见表3㊂2.2　VAS评分　两组术后VAS评分较治疗前明显降低,差异有统计学意(P<0.01),所有患者术后疼痛明显缓解,说明两组治疗方案均有效;两组术后1个月㊁3个月VAS评分均低于术后1d㊁差异具有统计学意义(P<0.05);术后1个月㊁3个月VAS 评分无显著差异(P>0.05);两组间术后各时间点VAS评分对比无显著差异(P>0.05),见表4㊂
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王炳文,等:椎间孔镜与小切口治疗腰椎间盘突出症疗效对比
表3　两组手术指标对比
分组n手术时间(min)切口长度(cm)卧床时间(d)出院时间(d) PTED3789.19±3.5110.95±0.0931.70±0.6185.81±0.811小切口2360.96±4.6765.95±0.3196.83±0.71713.26±1.010 t值26.630-73.250-29.369-31.468 P值0.0000.0000.0000.000
表4　两组患者治疗前后VAS评分
组别n术前术后1d术后1个月术后3个月PTED377.11±0.7741.65±0.5381.49±0.5071.46±0.605小切口237.26±0.8641.78±0.7951.52±0.5111.43±0.590 t值-0.711-0.713-0.2610.155
P值0.4800.4810.7950.877
2.3　腰椎JOA评分　观察组JOA评分:术前(12.03±2.587)分㊁术后3个月(22.05±2.768)分;对照组JOA评分:术前(12.30±2.961)分㊁术后3个月(22.30±2.899)分㊂两组术后JOA评分较术前明显升高,差异有统计学意义(P< 0.01);术后两组间JOA评分对比无显著差异(P >0.05),见表5㊂
2.4　ODI功能障碍指数　两组术后ODI指数较术前明显降低,差异具有统计学意义(P<0.01);术后6个月显著低于术后3个月,差异具有统计学意义(P<0.01);术后两组间ODI指数对比无显著差异(P>0.05),见表6㊂
表5　两组患者治疗前后JOA
组别n术前术后3个月PTED3712.03±2.58722.05±2.768
小切口2312.30±2.96122.30±2.899
t值-0.382-0.334
P值0.7040.739
61锦州医科大学学报　2020年2月,41(1)
表6　两组治疗前后ODI指数
组别n术前术后3个月术后6个月PTED3760.73±8.54635.92±5.47925.35±3.182小切口2359.61±7.87336.57±4.47026.17±3.446 t值0.509-0.475-0.943
P值0.6130.6360.350
　注:两组术后较术前ODI指数显著降低,差异具有统计学意义(P<0.01);两组术后6个月较术后3个月ODI指数显著降低,差异具有统计学意义(P<0.01);两组间术后差异无统计学意义(P >0.05)
2.5　改良MacNab疗效评价　两组术后优良率差异无统计学意义(P>0.05),见表7㊂
表7　改良MacNab疗效评价
组别n优良可优良率(%) PTED37258489.10小切口23165291.30
χ2值0.073
P值0.964
3　讨 论
腰椎间盘突出症是脊柱外科常见病,是腰腿痛和下肢神经感觉异常的主要病因㊂目前LDH导致腰腿痛的机制主要有3种:机械压迫,是指脱出间盘组织直接压迫和刺激了后方的神经根;炎症化学刺激,椎间盘破裂产生的局部炎症刺激神经根;自身免疫,因为密闭的髓核脱出,引发机体的免疫反应而产生[7-8]㊂虽然经过严格的保守治疗,80%~ 90%腰椎间盘突出症患者症状能得到缓解,但部分患者保守治疗效果不稳定或症状无明显改善,如不及时治疗远期可能加重神经损伤,影响远期手术效果,因此对于有手术指征的患者,手术仍是首选治疗方案㊂
腰椎间盘突出症手术方式主要有:全椎板切除㊁半椎板切除㊁小切口椎板开窗㊁椎间孔镜技术㊁腰椎融合术[9]㊂全椎板㊁半椎板切除减压,效果显著,但对肌肉及脊柱后方结构损伤较大,术后容易硬膜粘连及瘢痕填充造成术后复发,且容易造成脊柱不稳,目前在临床上已经较少使用[10]㊂腰椎融合术主要用于有广泛的椎管狭窄及退变引起的腰椎不稳,融合手术效果确切,能够对椎管做大范围减压,椎间盘清除彻底,复发率几乎为零,但手术需广泛剥离肌肉,损伤较大,对后方结构影响大,恢复慢,术后并发症较多,对于单纯的间盘突出采用融合手术患者难以接受,尤其是年轻患者㊂目前临床上治疗腰椎间盘突出症最常用的开放手术是小切口椎板开窗髓核摘除术,从发明到用于临床已80余年,靳安民等对此术式进行了5~11年的长期随访,其术后优良率可达到97%㊂手术遵循减压与稳定原则,通过咬除上下椎体少许椎板及椎板间黄韧带,显露突出的间盘,直视下摘除,进行神经根及硬膜囊的充分减压㊂手术避免了大量破坏脊柱后柱结构,维持脊柱稳定性,在最大程度上保留腰椎后方结构的完整性,对椎管内结构干扰较小,避免术后硬膜粘连及瘢痕填充造成椎管狭窄,且手术创伤小,时间短,术后恢复快,可尽早下地行功能锻炼[11]㊂
微创脊柱技术作为脊柱外科的重要分支,相对于传统手术,有创伤小㊁出血少㊁恢复快㊁手术时间短㊁术后卧床时间短㊁疗效同传统手术相当等优点,越来越受到广大医务工作者和患者的欢迎[12]㊂自从脊柱内镜技术用于治疗椎间盘疾病以来,发展十分迅速,伴随着脊柱内镜技术的成熟和器械的发展与更新,椎间孔镜技术的诞生代表了一种全新的脊柱微创手术概念㊂常用的经皮椎间孔内镜术式分为两种,分别为YESS系统和TESSYS系统㊂两种技术都是在局麻下后外侧入路腰椎间盘摘除,但是在手术理念和穿刺方向㊁手术工作套筒的位置均有不同[13]㊂1997年Yeung[14]等首创YESS技术,经Kambin安全三角进入椎间盘内,由盘内向外逐步切除椎间盘组织,完成神经根减压㊂Yeung和Tsou[15]总结了307例侧后路经椎间孔脊柱内镜下腰椎间盘切除手术,术后优良率为89.3%,满意率90.7%,并发症发生率为3.5%㊂2003年Hoogland[16]等研究了TESSYS系统,是在YESS技术基础上的继续发展,其关键和创新是在于椎间孔成形,通过环锯磨除部分上关节突前缘,将通道正对椎管内,完整显露椎管内结构,达到神经根松解与硬膜减压的目的,使经椎间孔脊柱内镜技术走向成熟,将脊柱内镜技术由椎间盘内操作转为椎管内操作,直接作用于靶点,由盘外向内进行减压,并且保留正常的椎间盘组织,得到了广大微创领域学者的广泛认同㊂TESSYS是一种由外向内的技术,在椎管内完成突出髓核摘除和神经根松解后,再进入椎间盘内处理终板及后侧松动的椎间盘[17-18]㊂由于是在椎管内操作,所以比YESS技术有着更广的适应证,对于移位㊁中央型突出㊁脱垂及合并侧隐窝狭窄的病例均有效㊂Hoogland[19]报道280例腰椎间盘突出症应用TESSYS技术后1年内优良率89.6%㊂就两种术式来说,都有其最佳适应证,对
71
王炳文,等:椎间孔镜与小切口治疗腰椎间盘突出症疗效对比
于单纯膨出㊁盘源性腰痛㊁极外侧突出首选YESS
技术,对于存在髓核脱垂㊁侧隐窝狭窄㊁髓核移位
或游离㊁或者合并腰椎管狭窄㊁椎间孔狭窄时,首
选TEYESS技术[20]㊂就TEYESS技术特点而言,理论上可以解决任何类型的间盘突出,本文中均采
用TEYESS技术㊂
本文的研究数据表明,TESSYS技术和小切口
在治疗LDH时疗效相当㊂但TESSYS技术更为微
创,术后恢复更快,对肌肉软组织损伤更小[21]㊂有研究表明,术后血清检测CRP㊁IL-6和CPK等炎症和组织损伤指标,TESSYS组明显低于小切口组[22]㊂并且对于椎间孔手术失败或者复发患者,不影响二次手术,对于初次选择椎间孔镜治疗,也更符合阶梯治疗原则㊂
4　结 论
经皮椎间孔镜TESSYS技术是一种更为微创的
手术方式,疗效与小切口开窗术相当,但随着内镜
技术的持续发展,能够更有效的提高手术效率,规
避手术过程中的风险,减少术后并发症的产生,扩
大适应症,有更好的发展前景,非常值得临床推广㊂参考文献:
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收稿日期:2019-10-12
81锦州医科大学学报　2020年2月,41(1)。