椎间孔镜与椎板开窗治疗腰椎间盘突出症的前瞻性对照研究

目的：比较经皮椎间孔镜下髓核摘除术（percutaneoustransforaminalendoscopicdiscectomy， PTED）和传统椎板开窗髓核摘除术（fenestrationdiscectomy，FD）治疗腰椎间盘突出症的临床疗效及探讨PTED的临床应用特点。方法采用前瞻性随机对照研究的方法，将我科2011年2月至2012年9月确诊为单节段单侧腰椎间盘突出症的80例患者，根据随机数字表法分为经皮椎间孔镜组（试验组）和常规椎板开窗组（对照组），各40例。试验组在局部麻醉、G臂X线机引导下采用经皮椎间孔入路TESSYS穿刺技术，内镜下摘除突出的椎间盘髓核组织、进行神经根的减压和松解。对照组采用硬膜外麻醉，单侧椎板开窗减压、髓核摘除、神经根减压松解。术后随访13～29个月，平均19个月，按照Oswestry功能障碍指数（oswestrydisabilityindex，ODI）、疼痛视觉类比评分（visualanaloguescale，VAS）、JOA评分和改良的Macnab标准评定手术效果。结果两组病例均顺利完成手术及随访。PTED组平均手术切口（0.7±0.2）cm，手术出血量（7.2±2.1）ml，手术时间（73.7±11.2）min，术后卧床时间（13.1±5.2）h，术后住院时间（3.5±0.7）天。FD组平均手术切口长度（3.2±0.4）cm，手术出血量（47.5±11.3）ml，手术时间（52.4±8.5）min，术后卧床（98.7±19.6）h，术后住院时间（13.4±2.3）天。两组病例术后ODI、VAS与术前比较，均明显改善（P＜0.05），两组患者术后1年的JOA评分改善率差异无统计学意义（P＞0.05）；按照改良的MacNab法评定两组术后1年的疗效优良率差异无统计学意义（P＞0.05）。结论 PTED和FD均能有效治疗腰椎间盘突出症，在严格把握手术适应证的前提下，PTED具有手术创伤小、术后恢复快等优点。PTED近期疗效与FD相近，长期疗效有待进一步临床研究。

A prospective and controlled study of percutaneous transforaminal endoscopic diseectomy versus fenestrationdiscectomy for lumbar disc herniation

Objective To compare the clinical outcomes of percutaneous transforaminal endoscopic discectomy （ PTED ） and traditional fenestration discectomy （ FD ） in the treatment of lumbar disc herniation, and to explore the characteristics of clinical application of PTED. Methods In this prospective, randomized and controlled study, a total of 80 patients who were diagnosed as unilateral lumbar disc herniation with a single segment involved from February 2011 to September 2012 in our department were randomly divided into 2 groups, with 40 patients in each group. The patients in the experimental group was treated with PTED, and those in the control group was treated with FD. In the experimental group, percutaneous transforaminal endoscopic spine system （ TESSYS ） technique was used under local anaesthesia, which was guided by G-arm X-ray machine. The nucleus pulposus tissues were removed and the nerve roots were decompressed under the direct vision of the endoscope. In the control group, unilateral FD was performed under epidural anesthesia, with the nerve roots decompressed. All the patients were followed up for a mean period of 19 months （ range;13-29 months ）. The surgical results were evaluated according to the Oswestry Disability Index （ ODI ）, Visual Analogue Scale （ VAS ）, Japanese Orthopaedics Association （ JOA ） scale and modiifed MacNab criteria. Results All the operations were performed successfully and all the patients were followed up. In the PTED group, the average incision length was （ 0.7±0.2 ） cm. The intraoperative bleeding volume was （ 7.2±2.1 ） ml, and the operation time was （ 73.7±11.2 ） min. The postoperative bed time was （ 13.1±5.2 ） hr and the postoperative hospital stay was （ 3.5±0.7 ） d. In the FD group, the average incision length was （ 3.2±0.4 ） cm. The intraoperative bleeding volume was （ 47.5±11.3 ） ml, and the operation time was （ 52.4±8.5 ） min. The postoperative bed time was （ 98.7±19.6 ） hr, and the postoperative hospital stay was （ 13.4±2.3 ） d. The postoperative ODI and VAS scores in both groups were signiifcantly improved when compared with those before the operation （ P＆lt;0.05 ）. There were no statistically signiifcant differences between the 2 groups in the JOA score improvement rate （ P＆gt;0.05 ）. According to the modiifed MacNab criteria, there were no statistically signiifcant differences between the 2 groups in the excellent and good rate （ P＆gt;0.05 ）. Conclusions Both PTED and FD are effective in the treatment of lumbar disc herniation. However, PTED has the advantages of smaller incision and quicker recovery, if the operative indications are strictly mastered. The short-term outcomes of PTED are similar to that of FD, but the long-term outcomes should be further studied clinically.