三种经皮内镜椎间盘髓核摘除术治疗伴有高髂嵴的L5～S1椎间盘突出症

目的：回顾性分析51例伴有高髂嵴的L5～S1椎间盘突出症接受3种不同手术入路的经皮内镜腰椎间盘髓核摘除术（percutaneousendoscopiclumbardiscectomy，PELD）的手术安全性及临床疗效，并探讨3种不同手术入路的适应证。方法2010年8月至2013年4月，采用椎间孔、椎板间和经髂骨椎间孔3种手术入路的PELD治疗的伴有高髂嵴的L5～S1椎间盘突出症的51例，其中男31例，女20例；平均年龄39（29～72）岁，平均病程6.7（3～23）个月，记录治疗方案选择及手术中转情况，手术时间、术中透视时间、术中及术后并发症发生情况。采用术前、术后3、6、12个月的视觉模拟评分（visualanaloguescales，VAS）评价患者腰痛、腿痛情况，Oswestry功能障碍指数（oswestrydisabilityindex，ODI）评定功能恢复，术后12个月评价责任神经根功能。结果所有手术均完成，2例采用椎间孔入路的病例（椎间孔外合并椎间孔内型）中转为经髂骨入路完成手术。经髂骨入路平均手术时间长于经椎间孔入路和经椎板间入路，分别是75（65～110）min，45（35～80）min，50（40～90）min（P＜0.05）；术中透视次数经椎间孔入路16.5次、经椎板间入路2.6次、经髂骨入路33.4次。所有病例均获至少12个月随访，均无神经损伤、感染等并发症，经髂骨入路组有1例骶髂关节面的损伤，目前尚无复发病例。术后各组内各时间点腰痛VAS、腿痛VAS及ODI均较术前明显降低（P＜0.05）。椎间孔入路组：腰痛VAS、腿痛VAS及ODI分别由术前（28.1±5.9）分、（71.8±7.5）分、（38.6±4.5）分降至术后1年（3.3±2.5）分、（4.4±4.6）分、（7.2±2.6）分（P＜0.05）；椎板间入路组：腰痛VAS、腿痛VAS及ODI分别由术前（28.5±5.2）分、（71.0±5.8）分、（37.7±4.3）分降至术后1年（7.0±3.6）分、（4.7±4.7）分、（8.1±4.2）分（P＜0.05）；经髂骨入路组：腰痛VAS、腿痛VAS

Three approaches of percutaneous endoscopic lumbar discectomy for L5-S1 disc herniation with high iliac crest

Objective To retrospectively analyze the safety and effectiveness of 3 approaches of percutaneous endoscopic lumbar discectomy （ PELD ） in the treatment of L5-S1 disc herniation combined with high iliac crest in 51 patients, and to explore the proper indications of these approaches. Methods From August 2010 to April 2013, 51 consecutive patients with L5-S1 disc herniation combined with high iliac crest were included in the study and treated with PELD through interlaminar, transforaminal and transiliac approaches respectively. There were 20 females and 31 males, whose average age was 39 years old （ range：29-72 years ）. The average duration of symptoms＆amp;nbsp;was 6.7 months （ range：3-23 months ）. The selection of treatment plans and the switching of surgical approaches, operation time, intraoperative X-ray exposure time and intraoperative and postoperative complications were recorded. The Visual Analogue Scale （ VAS ） was used to evaluate low back pain and sciatica, and the Oswestry Disability Index （ ODI ） to assess the functional recovery preoperatively and at 3 months, 6 months and 12 months after the operation. The functional status of the irritated nerve roots was evaluated at 12 months after the operation. Results The operation was completed in all the patients. A transforaminal approach was planned for 2 patients, which was switched to a transiliac approach at last. The average operation time was 75 min （ range：65-110 min ） in the transiliac group, 45 min （ range：35-80 min ） in the transforaminal group and 50 min （ range：40-90 min ） in the interlaminal group, and it was longer in the transiliac group than that in other groups. The X-ray exposure times were 33.4 in the transiliac group, 16.5 in the transforaminal group and 2.6 in the interlaminal group. There were no nerve injuries or infections. A patient with injuries on the superior surface of the sacroiliac joint was found in the transiliac group. Reoccurrence was not noticed so far. The postoperative ODI scor