显微镜下椎间盘摘除术

显微镜下椎间盘摘除术治疗腰椎间盘突出症

成本强彭新生龙朝仪

肇庆市第一人民医院骨外科中山大学附属第一医院脊柱外科

【摘要】：目的：观察在手术显微镜下完成腰椎间盘突出髓核摘除术的疗效。方法：分别选取40例住院行显微镜椎间盘切除术(microsurgical lumbar discectomy,MSLD)和传统手术(op en lumbar discectomy,OLD)治疗单节段腰椎间盘突出症的患者,比较2种手术的切口长度、手术时间、出血量、住院天数,手术后JOA、VAS和ODI改善率情况。结果：MSLD组及OLD组的切口长度分别为(2.6±0.8)cm和(5.4±1.8)cm,手术时间分别为(56.0±16.9)min和(71.0±30.5)min,出血量分别为(86.0±33.0)mL和(110.0±47.0)mL,住院天数分别为(9.2±2.5)d和(11.2±3.6)d,2组间差异有统计学意义(P0.01)。术后3个月随访时,MSLD组及OLD组的JOA改善率分别为85.3%±8.2%和84.9%±7.5%,VAS改善率分别为86.4%±1.8%和84.4%±2.0%,ODI改善率分别为81.5%±6.2%和80.8%±5.5%,两组间比较差异无统计学意义(P0.05)。结论：显微镜下完成腰椎间盘突出髓核摘除术的切口小,术中出血量少,视野清晰,可减少对神经根及硬

膜囊的手术刺激,安全、可靠,术后病人切口痛苦明显减少,术后恢复快及疗效满意,是治疗腰椎间盘突出症一种较好的手术方法。但显微镜下椎间盘摘除术的熟练操作需要较长时间的显微外科训练基础，学习时间曲线较长。

【关键词】腰椎间盘突出症；微创；显微镜

Clinical effects of Lumbar Disc Herniation by minimally invasive microscopy surgery Department of Orthopaedics，Beijing Tiantan Hospital affiliated to Capital Medical University

【Abstract】Objective: To evaluate the efficiency of surgical treatment of lumbar disc herniation by microsurgical lumbar discectomy(MSLD).Methods: A clinical review was conducted on the two surgical methods for single segment lumbar disc herniation (LDH) from April 2007 to June 2010, one group of 30 patients who underwent microsurgical lumbar discectomy(MSLD) and the other of 30 patients who underwent open lumbar discectomy(OLD). The factors considered included the length of skin incision, the operative time, amount of intraoperative bleeding, duration of hospitalization, pre- and postoperative assessment based on the criteria of Japanese Orthopaedic Association Scores, visual analog scaled(VAS), the Oswestry disability index(ODI).Results: The m ean length of skin incision was 2.8±0.8cm and 5.5±1.8cm, the operative time was 57.0±16.9 min and 72.0±30.5 min, the blood loss was 85±33ml and 110±48ml, the hospitalization time was 10.2±2.5days and 12.2±3.6days for MSLD and OLD respectively. All had significant difference(P<0.01).Three months after the operation, the improvement rate of JOA was（85.3±8.3）％and（84.9±7.6）％for MSLD and OLD respectively. The improvement rate of VAS score was（86.4±1.9）％.and（84.4±2.1）％for MSLD and OLD respectively. The improvement rate of ODI score was（81.5±6.3）％and （80.8±5.6）％for MSLD and OLD respectively. All showed no significant

difference s(P>0.05).Conclusion: MSLD has advantages of little cut, little bleeding, clear surgery field, safety , little hurt to nerve root and dura mater. But skilled operation requires a relatively long period of microsurgery training foundation. 【Key words】Lumbar Disc Herniation; minimally invasive; microscopy 随着现代脊柱外科的发展，腰椎间盘突出症的手术治疗从传统的开放手术向微创方向不断进行着研究和探讨。我科自2007年开展显微镜椎间盘切除术（microsurgical lumbar discectomy, MSLD），取得较好效果。笔者对显微镜椎间盘切除术和传统手术治疗腰椎间盘突出症的效果进行回顾性比较分析。

1 资料与方法

1.1 一般资料

从2007年4月～2010年6月在我科住院行显微镜椎间盘切除术和传统手术治疗单节段腰椎间盘突出症患者中分别选取30例，统计获得较完整随访病例的资料。所有病例均有下肢放射痛及不同程度腰痛。术前均行腰椎X线六位相片、CT和MRI检查。

病例纳入标准：①有不同程度的腰痛、伴或不伴单/双侧下肢麻木疼痛；②体检有明确的神经定位体征，直腿抬高试验及加强试验(+)；③MRI及CT检查显示明显的椎间盘突出，且突出节段与体征相符；④既往无腰椎间盘手术史；⑤术前至少经三个月的正规保守治疗，症状改善不明显、甚至加重。排除标准：①非神经根性、椎间盘源性疼痛；②伴椎间盘炎或其他感染：③广泛的椎管狭窄或脊柱失稳、滑脱：④原有椎间盘手术史或背部脊柱手术史；⑤保守治疗症状可缓解者。

MSLD组30例，男性18例，女性12例；年龄21～58岁，平均34岁，平均病程14个月。坐骨神经痛22例，神经根刺激症状24例，肌力减弱15例，直腿抬高试验(+)25例。椎间盘突出类型：中央型8例，旁中央型13例，外侧型6例．游离型3例。手术节段：L2/3 2例，L3/4 9例，L4/5 14例，L5/S1 5例。

传统手术组30例，男性16例，女性14例；年龄28～56岁，平均37岁，平均病程18个月。坐骨神经痛24例，神经根刺激症状23例，肌力减弱13例，直腿抬高试验(+)27例。椎间盘突出类型：中央型5例，旁中央型18例，外侧型5例．游离型2例。手术节段：L2/3 3例，L3/4 10例，L4/5 12例，L5/S1 5例。

两组病例在性别、年龄、手术节段、椎间盘突出类型和临床表现方面无显著性差异。

1.2.手术方法

1.2.1 MSLD组全麻满意后，患者俯卧位于脊柱外科手术床，腹部垫脊柱拱形托架，常规消毒铺巾，在C形臂X线机下确定病变椎间隙位置，取病变节段后正中线约2－3cm切口，逐层切开至椎板及关节突骨质，再次用C形臂X线机确认病变推间隙位置。切口处放置微型椎板拉钩，充分显露手术野。用无菌套袋套好手术显微镜，调整焦距和视野位置，选择4-8倍的放大率。清除遮挡手术野当中的软组织，双极电凝止血，分清上位椎体椎板下缘、黄韧带及关节突，剥离并咬除黄韧带，酌情咬除上位椎板下缘。认真分离出神经根，暴露部分硬膜囊，剥离神经根周围粘连，探查神经根管是否有狭窄，若神经根牵拉明显受限，则需扩大神经根管和侧隐窝，神经根游离移动达1cm左右。将神经根牵至手术野外加以保护，用显微直刀锋切开后纵韧带及纤维环，摘除突出髓核，用双极电凝静脉丛止血。彻底冲洗切口，放置