内窥镜下不同入路治疗L_5S_1椎间盘突出症

目的 探讨局麻下经皮后外斜入路与椎板间孔入路内窥镜手术治疗L_5S_1椎间盘突出症的临床疗效.方法 自2003年6月至2008年10月,对57例L_5S_1椎间盘突出症患者应用内窥镜下髓核摘除术进行治疗.男32例,女25例;年龄17～79岁,平均42岁.内窥镜手术入路分别采用后外斜入路与椎板间孔入路.应用Oswestry功能障碍指数对患者手术前、后腰椎功能状况进行评价,分析不同入路的治疗结果、并发症、二次开放手术等情况.结果 57例患者均获得随访,最长5年4个月,最短12个月,平均22.4个月.采用后外斜入路22例,椎板间孔入路35例,其中各有1例患者接受二次手术,各有1例术后出现感染.后外斜入路突出的部位更靠外侧.椎板间孔入路不考虑髂棘的高低,突出部位为中央型和旁中央型.后外斜入路组手术前、后平均Oswestry功能障碍指数分别为74.36,13.91(P<0.001),椎板间孔入路为77.45,12.56(P<0.001),术前和术后两者之间的差异无统计学意义.按照MacNab标准,末次随访时手术疗效后外斜入路优良率为86%.椎板间孔入路优良率为89%.结论 两种入路各有不同的适应证,手术过程明显不同,但只要选择恰当,均能达到很好的临床疗效.

Treatment of L_5S_1 disc herniation under endoscope via postlateral transforaminal and interlaminar approach

Objective To discuss the clinical effects of the percutaneous endoscopic discectomy of L_5S_1 disc herniation through different approaches: postlateral transforaminal and interlaminar approach. Methods From June 2003 to October 2008, 57 patients with L_5S_1 disc herniation were included in the study. There were 32 males and 25 females, with a mean age of 42, ranging from 17 to 79.22 patients un-derwent percutaneous endoscopic diseectomy through postlateral transforaminal approach while the other 35 patients through interlaminar approach. Oswestry Function Index was used to evaluate preoperative and post-operative lumbar vertebrae, function. The clinical outcome, indications and the risk of secondary operation of two approaches were analyzed. Results All of the patients had followed up, with an average period of 13.4 months, ranging from 12 to 64 months. There is no difference in age and blood loss during operation in two groups. One revision were needed in each groups. One ease of postoperatve infection was found in each group. When far lateral disc herniations were identitied postlateral transforaminal approach was applied, the high iliac crest had to be considered. When intracanalicular disc herniations at the L_5S_1 level were found, Interlaminar approach was suitable. For postlateral transforaminal approach , the average OFI had improved from 74.36 to 13.91. For interlaminar approach, the average OFI had improved from 77.45 to 12.56. There is no difference in OFI between the two groups According to MacNab's criteria, Overall excellent-to-good re-sults were 86% and 89% in the patients underwent postlateral transforaminal approach and those underwent interlaminar approach. Conclusion Both postlateral transforaminal approach and interlaminar approach are safe, effective, and minimally invasive procedure for the treatment of disc herniations at the L_5S_1 level in properly selected cases.