全可视化脊柱内镜技术治疗极外侧型腰椎间盘突出症的疗效分析

目的 探讨全可视化脊柱内镜技术治疗极外侧型腰椎间盘突出症（far lateral lumbar disc herniation,FLLDH）的临床效果。方法 2018年5月至2020年6月,我院采用经椎弓根上缘穿刺全可视化经皮脊柱内镜技术治疗FLLDH病人39例。男21例,女18例,年龄为52~72岁,平均60.5岁。采用疼痛视觉模拟量表（VAS）评分、Oswestry功能障碍指数（ODI）、日本骨科协会（JOA）评分评估临床疗效。结果 39例病人均顺利完成手术。伤口均甲级愈合,无伤口感染、神经根损伤、脑脊液漏等并发症发生。所有病人均获得随访,随访时间为18~40个月,平均28.8个月。所有病人术后1 d、3个月、12个月VAS评分、ODI指数及JOA评分与术前比较,差异均有统计学意义（P＜0.05）。结论 全可视化脊柱内镜技术治疗FLLDH临床疗效确切,安全性高,值得临床推广。     

显微内镜手术治疗极外侧型腰椎间盘突出症

目的介绍显微内镜手术治疗极外侧型腰椎间盘突出症的方法,分析其临床效果。方法16例极外侧型腰椎间盘突出症(椎间孔内型7例,椎间孔外型9例)接受显微内镜手术。5例椎间孔内型采用常规显微内镜椎间盘髓核摘除术入路,切除部分椎板、椎弓峡部和小关节。2例椎间孔内型采用经关节突入路,使用X-tube工作通道,切除大部分关节突。9例椎间孔外型采用横突间入路,工作导管置于横突间,部分切断横突间韧带。所有手术均需找到受压神经根并松解,切除突出椎间盘。结果术后平均随访8·3个月,采用改良MacNab标准评定临床结果,优12例,良3例,可1例。平均住院日13·8d,平均手术时间78min,平均术中出血68ml。结论显微内镜手术治疗极外侧腰椎间盘突出症具有小切口和组织损伤轻的优点,能够充分直接探查松解神经根压迫。     

极外侧型腰椎间盘突出症

极外侧型腰椎间盘突出症（ｆａｒｌａｔｅｒａｌｌｕｍｂａｒｄｉｓｃｈｅｒｎｉａｔｉｏｎ）是腰椎间盘突出症的一种特殊类型，指椎间盘突出物压迫了自同一椎间隙水平发出的神经根。该症最早由Ａｂｄｕｌａｈ等于１９７４年报道，其发生率约占腰椎间盘突出症患者总数的...     

极外侧型腰椎间盘突出症

极外侧型腰椎间盘突出症李明全，袁志，陈拱诒极外侧型腰椎间盘突出症国内报道甚少。此型腰椎间盘突出位于侧隐窝外侧、椎间孔、甚至椎间孔外。临床表现为典型的本间隙神经根受压症状￣［１］。手术中切除骨质范围较一般腰椎间盘突出为大，包括椎板、椎间孔和大部分关节突...     

极外侧型腰椎间盘突出症显微内镜手术与开放手术治疗的比较

目的：比较显微内镜手术和开放手术治疗极外侧型腰椎间盘突出症，评价显微内镜手术方式的临床价值。方法：对36例极外侧型腰椎间盘突出症手术患者进行回顾性比较研究。16例接受显微内镜手术，平均年龄42．6岁(35～60岁)。20例经开放手术，平均年龄45．5岁(30～64岁)显微内镜手术分别采用经椎板间隙人路、经关节突人路和经横突间人路，在内镜下完成神经根探查、减压和椎问盘髓核摘除。开放手术采用经椎板间隙人路和经横突间人路，进行神经根减压和椎间盘髓核摘除。结果：显微内镜手术组平均随访8．3个月，平均手术时间78min，平均术中失血68ml，平均住院日13．8d。开放手术组平均随访14个门，平均手术时间74min，平均术中失血95ml，平均住院日16．5d。显微内镜手术组手术后切口疼痛轻，镇痛治疗显著少于开放手术组。采用改良MaeNab标准评价随访结果，显微内镜手术组12例患者达优，3例良，1例可。开放手术组14例患者达优，4例良，2例可。结论：显微内镜手术治疗极外侧型腰椎问盘突出症，与开放手术比较有相似的近期临床效果，但具有切口小、组织损伤轻和恢复较快的特点，能够尽可能维持腰椎稳定。     

极外侧型腰椎间盘突出症

极外侧型腰椎间盘突出症张国庆１腰椎间盘突出症手术探查阴性的原因不外乎定错了间隙，或虽在同一间隙，但探查范围过小或偏内而遗漏。极外侧型腰椎间盘突出症由于压迫位于椎间孔处的同节段神经根，若按神经系统常规定位，则将错开上一椎间隙；在同一间隙，若不向椎间孔内...     

后路脊柱显微内窥镜治疗极外侧腰椎间盘突出症

Smith等在1995年首先报道内窥镜辅助下进行治疗极外侧腰椎间盘突出，而MED是显微外科技术和内窥镜技术的完美结合，镜下的操作与开放性椎间盘切除术相似，我科自2002年8月至今开展的MED治疗极外侧腰椎间盘突出6例，除1例术中改用开放手术外．余5例效果良好，总结如下：     

极外侧型腰椎间盘突出症的诊断与治疗

极外侧型腰椎间盘突出症的诊断与治疗翁文杰陈亮朱丽华椎间孔与椎间孔外腰椎间盘突出症，亦称为极外侧型腰椎间盘突出症，是指椎间盘突出或脱出位于椎弓根内、外缘之间或椎弓根外缘以外，压迫相应的神经根而引起的一系列症状和体征。１９４４年Ｌｉｎｄｂｌｏｍ及１９５４...     

极外侧型腰椎间盘突出症显微内镜手术与开放手术治疗的比较

目的:比较显微内镜手术和开放手术治疗极外侧型腰椎间盘突出症,评价显微内镜手术方式的临床价值.方法:对36例极外侧型腰椎间盘突出症手术患者进行回顾性比较研究.16例接受显微内镜手术,平均年龄42.6岁(35～60岁).20例经开放手术,平均年龄45.5岁(30～64岁)显微内镜手术分别采用经椎板间隙入路、经关节突入路和经横突间入路,在内镜下完成神经根探查、减压和椎间盘髓核摘除.开放手术采用经椎板间隙入路和经横突间入路,进行神经根减压和椎间盘髓核摘除.结果:显微内镜手术组平均随访8.3个月,平均手术时间78min,平均术中失血68ml,平均住院日13.8d.开放手术组平均随访14个月,平均手术时间74min,平均术中失血95ml,平均住院日16.5d.显微内镜手术组手术后切口疼痛轻,镇痛治疗显著少于开放手术组.采用改良MacNab标准评价随访结果,显微内镜手术组12例患者达优,3例良,1例可.开放手术组14例患者达优,4例良,2例可.结论:显微内镜手术治疗极外侧型腰椎间盘突出症,与开放手术比较有相似的近期临床效果,但具有切口小、组织损伤轻和恢复较快的特点,能够尽可能维持腰椎稳定.     

极外侧型腰椎间盘突出症

极外侧型腰椎间盘突出症包括突出物位于椎间孔处和椎间孔外，临床上比较少见，国内报道甚少。根据我们对此病的认识结合国外文献，对此病型作一讨论。典型病历患者女性，68岁。主诉为腰扭伤后腰痛伴左大腿疼痛不能活动半月。查体：L3、4在棘突旁压痛，左股四头肌肌力四级，左膝反射下降，左直腿抬高试验阴性，加强试验阴性，左大腿前方针刺觉下降。腰椎X线显示L3、4间隙变窄。CT扫描显示L3、4左侧椎间孔水平间盘突出（图1）。MR矢状面显示L3、4间盘突出上移，在椎间孔处压迫神经根，脂肪间隙消失（图2）c人院诊断：极外侧型腰椎间盘突出…     

Minimally invasive transmuscular approach for the treatment of lumbar far lateral disc herniation

Background

The purpose of this study was to evaluate a minimally invasive surgical technique for the treatment of lumbar far lateral disc herniation. This technique combines the tubular retractor with the operative microscope.

Objective and methods

This retrospective study analyzed the files of 26 patients: 15 men and 11 women. The average age was 56 years (range, 19-83 years). The most commonly operated level was L3-L4 (46%), then L4-L5 (30.5%) and finally L2-L3 (15.5%). All patients were operated under general anesthesia. The intraoperative radioscopic location was absolutely necessary. A 12-15 mm paramedian incision was made on the side of the herniation (30 mm from the medial line). We then inserted the tubular muscular retraction system followed by the 14 mm diameter working channel. Guided by operating microscope, the articular isthmus was reamed to expose the root and the disc. The disc herniation was then removed after opening and removing the inter-transverse ligament.

Results

The average duration of the surgery was 55 min. This operating time decreased as the surgeons gained experience. The radicular pain, estimated using the analogical visual scale, varied from seven before surgery to two during the postoperative period. All the patients were standing up the day after surgery. The average duration of the postoperative stay in the hospital was three days (range, 1-5 days). We noted no complications from the surgical procedure.The average duration of the follow-up was two years (range, 6-36 months).

Conclusion

This technique combines the advantages of endoscopic surgery (less muscular and osseous damage) and microscope-guided surgery (three-dimensional vision) and provided good functional results in this series.     

A new technique for the treatment of lumbar far lateral disc herniation: technical note and preliminary results

A newly designed technique for a minimally invasive approach to the laterally herniated disc is presented. Fifteen patients suffering from far lateral disc herniation (extraforaminal) were operated according to this technique. Through a small skin incision (1.5 cm), the paraspinal muscles are spread by dilators, until a working channel of 9 mm inner diameter and 11 mm outer diameter can be placed. The next steps are done through this channel using the surgical microscope. No bone resections are necessary and the facet joints are left untouched. However, partial resection of the intertransverse ligament may be necessary. The mean follow-up period for these 15 patients was 11.5 months, and they were evaluated by using the visual analogue scale (VAS) and the Oswestry Disability Index (ODI). The average surgical time was 43 min. The ODI improved from 30.6 (preoperative) to 14.3 (postoperative). The VAS of leg pain improved from 7 (preoperative) to 3.6 (postoperative), which represented a statistically significant improvement at the significance level of (P<0.01). No intra-operative or early postoperative complications occurred. However, one recurrence did occur, which was treated by the same technique. This technique combines the advantages of three-dimensional visual control (operating microscope) with the minimal surgical trauma of endoscopic techniques, while avoiding some of the shortcomings of both the microsurgical and endoscopic techniques.     

腰5骶1极外侧型腰椎间盘突出症的手术治疗

目的探讨腰5骶1极外侧型腰间盘突出症(L5S1FLLDH)的合理手术方案。方法回顾总结L5S1FLLDH资料。我们采用后正中入路,切除内侧部分关节突、间盘切除、关节突植骨、椎弓根系统内固定。结果突出间盘切除彻底,依据Macnab评价标准及术前术后JOA评分比较疗效可靠。结论L5S1FLLDH采用此种手术方法可靠。     

选择性神经根封闭治疗极外侧型腰椎间盘突出症的疗效研究

目的 观察选择性神经根封闭治疗极外侧型腰椎间盘突出症（far lateral lumbar disc herniation, FLLDH）的效果。方法 回顾性分析本院脊柱外科2013年3月至2018年12月收治的43例FLLDH病人的临床资料,均采用选择性神经根封闭治疗并获得完整随访。43例病人按照椎间盘突出或脱出的部位分为椎间孔内组（19例）和椎间孔外组（24例）,收集并比较两组病人治疗后2 h、治疗后3 d及末次随访的腰腿疼痛视觉模拟量表（visual analogue scale, VAS）评分、Oswestry功能障碍指数（Oswestry disability index, ODI）、末次随访时的MacNab疗效评定标准以及治疗后的手术率。结果 43例病人的随访时间为（16.22±9.12）个月（6~24个月）。椎间孔内组病人治疗后2 h、治疗后3 d的VAS评分及ODI均较治疗前显著改善,椎间孔外组治疗后2 h、治疗后3 d及末次随访的VAS评分及ODI均较治疗前明显下降,与术前比较,差异均有统计学意义（P均＜0.05）。椎间孔外组治疗后3 d及末次随访时的VAS评分及ODI均显著低于椎间孔内组,两组间比较,差异均有统计学意义（P均＜0.05）。参照MacNab疗效评定标准,椎间孔内组和椎间孔外组的优良率分别为36.8%（7/19）、75.0%（18/24）,两组的优良率比较,差异有统计学意义（χ²=6.344,P=0.012）。椎间孔内组与椎间孔外组的手术例数分别为13例和8例,手术率分别为68.4%和33.3%,两组间比较,差异有统计学意义（χ²=5.225,P=0.022）。结论 选择性神经根封闭术可作为治疗FLLDH的供选方案,椎间孔外型的疗效优于椎间孔内型,病人出现神经损害症状时仍需积极手术治疗。     

经皮椎间孔镜技术治疗极外侧型腰椎间盘突出症

目的探讨经皮椎间孔镜技术治疗极外侧型腰椎间盘突出症的手术技巧及临床疗效。方法2013-08-2015-01,共有21例极外侧型腰椎间盘突出症患者在我院行经皮穿刺椎间孔镜下髓核摘除、神经根减压术。采用视觉模拟评分法(VAS)对腰腿疼痛缓解情况进行评价,采用ODI功能评分及改良Mac Nab标准进行临床疗效评价。结果 21例患者均顺利完成,手术时间55~125 min,平均85 min,住院时间3~6 d,平均4 d,手术切口均一期愈合。平均随访18个月,手术前腰腿痛VAS评分术前为(8.6±2.5)分,术后当天为(2.0±1.1)分,末次随访(1.8±0.8)分,手术前后差异有统计学意义(P0.05)。术前ODI为(65.4±21.8),末次随访为(12.6±4.3),差异有统计学意义(P0.05)。术后3例患者出现感觉异常;1例出现髓核残留,另有1例术后9个月复发,均行经椎间孔入路椎间融合术翻修后症状缓解。按照Macnab标准评定,其优良率为90.5%。结论经皮椎间孔镜技术是一种治疗极外侧型腰椎间盘突出症安全有效的微创手术方式。     

Frequency and specific surgical management of far lateral lumbar disc herniations

Summary Frequency of Far Lateral Lumbar Disc Herniation The analysis of pre-operative computer-assisted tomograms and myelograms in a series of 694 operated lumbar disc herniations showed that a far lateral disc prolapse occured in 7% of the cases. Within the group of those far laterally herniated discs 3% of the herniations were predominantly located in the intervertebral foramen, whereas 4% of the protruded discs were mainly situated extraforaminally compressing the spinal nerve in its paravertebral course.Surgical Management of Extraforaminal Far Lateral Lumbar Disc Herniation By March 1988 40 patients had been operated on for an extraforaminal disc protrusion making use of an external microsurgical exposure (in two cases by a transmuscular approach and in 38 cases via an enlarged midline approach). A medium-term follow-up of these 40 patients revealed a substantial clinical relief of pain in 34 cases (85%). Based on these gratifying results we regard the external exposure of the extraforaminally protruded disc as the treatment of choice.     

极外侧型腰椎间盘突出症的诊治分析

目的探讨极外侧型腰椎间盘突出症（FLLDH）的诊治特点和术式选择。方法23例FLLDH患者中,其中椎间孔型14例,椎间孔外型9例。23例患者中腰痛8例（占31％）,下肢痛21例（占91％）,直腿抬高试验10例（43％）,CT或MRI可清楚地显示位于椎间孔或孔外缘突出的椎间盘。分别采用经后正中入路椎板扩大开窗术,椎间孔切开和椎弓根内固定植骨融合术,或经肌间隙入路髓核摘除术。疗效按Macnab标准评估。结果22例患者经平均3．6年随访,优15例,良4例,可3例,无差,优良率达86％。在可的3例中,其中1例为经旁正中入路手术,另2例为椎间孔型FLLDH,周缘钙化。结论症状和体征表现常以较高神经节段受损为主,下肢痛是主要症状,CT或MRI是诊断的主要依据。对椎间孔型FLLDH可采用椎板间扩大开窗术;对椎间孔外型FLLDH则需行经椎间孔切开术并辅以经椎弓根内固定植骨融合,亦可采用经肌间隙入路髓核摘除术。     

髓核成形术治疗颈、腰椎间盘突出症的疗效分析

目的：探讨髓核成形术治疗颈、腰椎间盘突出症的手术技术、适应证及疗效。方法：采用ArthroCare 2000射频汽化仪对颈、腰椎间盘突出症患者实施髓核成形术。其中颈椎间盘突出症患者43例(A组)，平均年龄47岁；腰椎间盘突出症患者39例(B组)，平均年龄36岁。术前及术后随访时采用症状缓解率(VAS评分)和患者主观满意度分级进行疗效评估。结果：A组术后即刻症状缓解率平均为68％，主观满意度优良率达95％，B组术后即刻症状缓解率平均为61％，主观满意度优良率为87％。A组平均随访17．6个月，症状缓解率为49％，主观满意度优良率为63％。末次随访时B组39例中16例症状接近术前，主观满意度优良率为3l％，其中5例接受了开放手术。结论：髓核成形术创伤小、安全，治疗包含性颈椎间盘突出症疗效较好，但治疗腰椎间盘突出症疗效欠稳定。     

极外侧型腰椎间盘突出症椎旁肌间隙入路与后正中入路的病例对照研究

目的：比较经椎旁肌间隙入路与后正中入路对极外型腰椎间盘突出症手术疗效的影响。方法：回顾分析2004年1月至2011年1月收治的32例行手术治疗的极外侧型腰椎间盘突出症患者的临床资料。其中行椎旁肌间隙入路17例,男11例,女6例;后正中入路15例,男10例,女5例,均经椎间孔腰椎椎体间融合术（transforaminal lumbar interbody fusion,TLIF）治疗。所有患者获得随访,时间12-18个月,平均15.3个月。记录手术时间、术中出血量和术后引流量,并比较两组术前术后的疼痛视觉模拟（visual analogue scale,VAS）评分和Oswestry功能障碍指数（Oswestry Disability Index,ODI）。结果：椎旁肌间隙入路组手术时间、术中出血量及术后引流量明显少于后正中入路组（P〈0.05）。末次随访时两组间VAS评分比较差异无统计学意义（P〉0.05）,椎旁肌间隙入路组ODI评分少于后正中入路组（P〈0.05）。结论：极外型腰椎间盘突出症经椎旁肌间隙入路比传统后正中入路对椎旁肌损伤更小,具有更好的临床疗效。