Transforaminal percutaneous endoscopic discectomy in the treatment of far-lateral lumbar disc herniations in children

Purpose

The use of transforaminal percutaneous endoscopic discectomy for the treatment of far-lateral lumbar disc herniations has been applied mostly in adults. However, transforaminal percutaneous endoscopic discectomy in children has probably been rarely documented. The aim of this study was to assess the efficacy of transforaminal percutaneous endoscopic discectomy in the treatment of far-lateral lumbar disc herniations in children.

Methods

Overall, 12 cases of far-lateral lumbar disc herniations were treated with the procedure of transforaminal percutaneous endoscopic discectomy between January 2010 and December 2014. There were seven male and five female children included, with an average age of 12.6 years (11–16 years). Pre-operative and post-operative (6 weeks, 6 months and 12 months) clinical outcome data (back and leg visual analog scale [VAS] and Macnab criteria) were collected along with clinical assessments of motor strength (graded 0–5).

Results

All patients were discharged to home on the same day of surgery. The average leg VAS score improved from 8.6?±?1.6 to 2.1?±?0.4 (p?<?0.005). Six patients had excellent outcomes, five had good outcomes, one had fair outcomes, and none had poor outcomes, according to the Macnab criteria. Eleven of 12 patients had excellent or good outcomes, for an overall success rate of 91.6 %. No patients required re-operation. There were no incidental durotomies, infections, vascular or visceral injuries. There was one complication, a case of leg numbness caused by ganglion injury. The numbness improved after two weeks. After three months, it was obvious that the total area of numbness in the legs had become smaller. At last follow-up, the patient had no pain, and only a few areas with numbness remained and did not affect the patient’s activities of daily living.

Conclusions

Transforaminal percutaneous endoscopic discectomy achieved satisfactory results for children with far-lateral lumbar disc herniations.

     

Extraforaminal microscopic assisted percutaneous nucleotomy for foraminal and extraforaminal lumbar disc herniations

Background

Foraminal and extraforaminal lumbar disc herniations are uncommon. The main presentation is radicular pain related to the exiting nerve root at the affected level. Different approaches for surgical intervention have been described.

经皮内镜TESSYS-ISEE技术治疗腰椎间盘突出症

[目的]探讨经皮内镜TESSYS-ISEE技术治疗腰椎间盘突出症的安全性及有效性。[方法]回顾性分析本院2017年5月～2018年3月63例行经皮内镜下腰椎间盘切除术(PELD)患者的临床资料,其中30例行TESSYSISEE技术,33例行TESSYS技术。比较两组术中透视次数、通道建立时间、手术时间、切口长度、术后住院时间、手术并发症及复发情况。采用疼痛视觉模拟评分(VAS)、Oswestry功能障碍指数(ODI)评估临床疗效,采用改良Macnab评分标准评定优良率。[结果]两组患者均顺利完成手术,术中无严重神经、血管、内脏损伤及硬膜囊撕裂、血肿形成、椎间隙感染等并发症。TESSYS-ISEE组的透视次数、通道建立时间和手术时间均明显少于TESSYS组,差异具有统计学意义(P0.05);TESSYS-ISEE组切口长度大于TESSYS组,差异具有统计学意义(P0.05);但两组患者术后住院时间的差异无统计学意义(P0.05)。两组腰痛VAS和ODI评分均随时间推移显著减少,不同时间点间的差异具有统计学意义(P0.05);但相应时间点两组间VAS和ODI评分的差异均无统计学意义(P0.05)。末次随访时,根据改良MacNab评分标准,TESSYS-ISEE组优良率为93.33%,TESSYS组优良率为90.91%,差异无统计学意义(P0.05)。[结论] TESSYS-ISEE是一种安全、有效的技术,具有操作简便、射线暴露少、手术时间及学习曲线短等优点,且与传统TESSYS技术疗效相当。     

椎间孔与椎间孔外腰椎间盘突出的分型及治疗

椎间孔与椎间孔外腰椎间盘突出的临床表现轻重不一，非手术治疗的效果亦不相同。作者发现这种差异可能与腰椎间盘突出相对于椎弓根的位置有关，故依此将其分两型。Ⅰ型：突出椎间盘向头侧移位至椎弓根下缘；Ⅱ型：椎间盘向外侧突出为主伴有轻微的头侧移位。又根据是否合并后外侧突出，将每型分为ａ、ｂ两个亚型。ａ：单纯椎间孔或椎间孔外突出；ｂ：合并有后外侧突出。按此分型，本组２３例中，Ⅰａ型８例、Ⅰｂ型２例，Ⅱａ型７例、Ⅱｂ型６例。Ⅰ型组病情重，保守治疗效果差，均需手术治疗；Ⅱ型组病情较轻，甚至无症状，５０％的患者经保守治疗可愈。故建议对Ⅰ型病例积极手术治疗，Ⅱ型病例宜先予非手术治疗，如无效再予手术。本组采用经峡部外缘入路腰椎间盘切除术１２例，结果表明本法优于传统的手术治疗方式，适用于绝大部分病例。但对Ⅱｂ型以椎间盘后外侧突出为主的病例，仍可采用椎板与部分关节突切除的方法治疗。     

Transforaminal percutaneous endoscopic discectomy for lumbar disc herniation in athletes under the local anesthesia

BackgroundPercutaneous endoscopic discectomy (PED) has been reported to be less invasive and effective procedure for lumbar disc herniation (LDH). Damage to the back muscle is considered minimal, which is particularly important for athletes. However, the results of PED for LDH in athletes have not been reported well. The purpose of this study was to evaluate the clinical outcomes of PED for LDH in athletes.MethodsWe retrospectively analyzed 21 athlete patients with LDH who had undergone PED. All patients received athletic rehabilitation immediately after surgery. The clinical outcomes were evaluated from the visual analogue scale (VAS) for leg pain and low back pain (LBP), the Oswestry Disability Index (ODI), complications and periods of return to sport.ResultsThere were 18 men and 3 women, and the mean age at the time of surgery was 22.9 years (range: 15–43 years). The mean VAS scores for leg pain before and after surgery were 64.3 ± 2.7 mm and 12.4 ± 1.4 mm, respectively. The mean VAS scores for LBP before and after surgery were 62.1 ± 2.2 mm and 10.5 ± 1.1 mm, respectively. The mean ODI scores before and after surgery were 31.3 ± 14.0% and 14.6 ± 7.1%, respectively. The VAS for leg pain, as well as the LBP and ODI, significantly improved after surgery. There were no complications related to the surgery. Ninety-five percent (20/21) returned to play sports at the same performance level as before the procedure by an average of 9.2 weeks after PED.ConclusionsPED is a minimally invasive and effective procedure for patients with LDH, especially in athletes. Not only the patients' leg pain but also their discogenic LBP improved. PED has the benefits of preservation of normal posterior structures and a faster return to sports.     

椎间孔与椎间孔外腰椎间盘突出症的诊断与治疗

目的：探讨椎间孔型与椎间孔外型腰是盘突出症的诊断与治疗方法。方法：回顾分析手术治疗的３３４例腰椎间盘突出症患者的临床资料,其中１３例为椎间孔型或椎间孔外型腰椎间盘突出,占同期手术治疗病例的３．９％。９例采用椎板间入路,２例采用板侧方入路。结果：本症常累及同疗数神经根,且突出间隙以Ｌ４／５、Ｌ３／４居多。ＣＴ、ＭＲＩ检查与手术所见一致。经４个月～３年随访,疗效优１０例良２例,可１例。结论：薄层高分辩     

后路经皮内镜下颈椎间盘摘除术治疗外侧型颈椎间盘突出症

目的分析后路经皮内镜下颈椎间盘摘除术治疗外侧型颈椎间盘突出症的临床疗效。方法回顾性分析自2015-10—2018-01采用后路经皮内镜下颈椎间盘摘除术治疗的27例外侧型颈椎间盘突出症,比较术前与术后1、6、12个月疼痛VAS评分及NDI指数。结果 27例均顺利完成手术,随访时间24~41个月,平均29个月。手术时间67~210 min,平均80 min,住院时间2~10 d,平均3 d。1例术中出现硬脊膜撕裂,1例术后出现切口渗液,轻度红肿,发热,分泌物细菌培养阴性,对症处理后治愈。27例术后1 d上肢疼痛和颈部疼痛症状均有明显改善,25例术后1 d疼痛消失或者明显减轻,24例术后第1 d肌力得到明显改善。末次随访时5例手术节段椎间盘突出加重。27例术后1、6、12个月疼痛VAS评分与NDI评分较术前明显改善,差异有统计学意义(P<0.05),但术后1、6、12个月间疼痛VAS评分与NDI评分比较差异无统计学意义(P>0.05)。结论后路经皮内镜下颈椎间盘摘除术治疗外侧型颈椎间盘突出症安全有效,术后恢复快,值得临床推广。     

经皮内镜椎弓根锚定技术治疗高度游离型腰椎间盘突出症

目的:探讨经皮脊柱内镜经椎弓根锚定技术治疗高度脱垂游离型腰椎间盘突出症的临床疗效,分析其手术技巧。方法:2016年5月至2018年6月,运用经皮脊柱内镜技术经椎弓根入路治疗向下高度脱垂游离型腰椎间盘突出症患者24例。其中男11例,女13例;L_2,31例,L_3,45例,L_4,518例;年龄48～72(59.5±7.2)岁;病程8～26(16.2±6.3)个月。所有患者采用局部浸润麻醉,在术前1 d,术后1周及术后3、6、12个月运用疼痛视觉模拟评分(visual analogue scale,VAS)及Oswestry功能障碍指数(Oswestry Disability Index,ODI)评估患者症状改善情况,并采用改良Macnab评价体系评估临床疗效,对所取得的数据运用SPSS 22.0进行统计分析。结果:术后所有患者获得随访,时间12～24(17.5±5.3)个月。手术时间(69.8±14.2) min,1例出现脑脊液漏,术后平卧休息后好转,其余23例未出现手术并发症,术后所有患者腰腿部疼痛、下肢麻木有不同程度的好转...     

经椎间孔内窥镜脊柱系统技术治疗脱垂型腰椎椎间盘突出症

目的探讨经椎间孔内窥镜脊柱系统(TESSYS)技术治疗脱垂型腰椎椎间盘突出症的疗效、围手术期并发症及处置对策。方法 2014年6月—2016年6月,泰州市人民医院骨科应用TESSYS技术治疗28例脱垂型腰椎椎间盘突出症患者,记录术前及术后各随访时间点的疼痛视觉模拟量表(VAS)评分及Oswestry功能障碍指数(ODI),分析术中、术后并发症的发生情况,并探讨处置对策。结果所有患者随访3~24个月,平均11个月。患者术后VAS评分和ODI较术前明显降低,差异有统计学意义(P0.05)。未发生神经损伤、椎管内血肿、感染等严重并发症。26例患者一次性顺利摘除脱垂髓核;2例患者术后即刻疗效不佳,1例经非手术治疗好转,1例再次行微创手术,末次随访疗效满意。结论 TESSYS技术是治疗脱垂型腰椎椎间盘突出症的有效方法,具有创伤小、恢复快等特点,但需注意预防并发症,谨慎的术中操作和严格的围手术期处理可预防或减少并发症的发生。     

经皮内窥镜治疗腰椎间盘突出症的并发症及其处理

目的 总结经皮内窥镜腰椎间盘切除术( PELD)治疗腰椎间盘突出症中出现的并发症,探讨其处理对策.方法 2002年7月至2010年10月采用PELD治疗腰椎间盘突出症患者689例,男性448例,女性241例;年龄13 ～84岁,平均39.8岁.单间隙椎间盘突出669例,双间隙椎间盘突出19例,三间隙椎间盘突出l例.中央型突出66例,旁中央型365例,外侧型242例,极外侧型10例,游离型6例.观察术中和术后并发症及其处理.结果 术中髓核部分残留压迫神经根5例,2例术中改行开窗髓核切除术,2例二期行开窗髓核切除术,1例二期行经椎间孔腰椎体间融合术(TLIF);神经根纤维束部分损伤2例,术后3～6个月内完全恢复;硬脊膜破裂2例,给予缝合皮肤伤口后痊愈.689例患者随访6～96个月,平均33个月.出现椎间隙感染7例,1例保守治疗,4例给予经皮穿刺置管冲洗引流持续局部应用抗生素,2例行后路开窗感染腰椎间盘清除术,均痊愈;术后复发6例,4例患者再次行PELD术,2例患者采用TLIF治疗,术后症状缓解;术后神经根性痛觉过敏和灼样神经根痛19例,经过止痛药物、神经营养药及物理治疗后好转;腰椎管狭窄症行单个节段的PELD术,效果不佳,二期行多节段TLIF治疗10例.结论 术中主要并发症有髓核部分残留压迫神经根、神经根纤维束部分损伤、硬脊膜破裂;术后主要并发症有椎间隙感染、复发、神经根性痛觉过敏和灼样神经根痛等.严格的适应证选择、无菌、熟练操作及术后康复锻炼可以减少并发症的发生.     

显微内窥镜下微创治疗椎间孔外型腰椎间盘突出症

目的探讨显微内窥镜下微创治疗椎间孔外型腰椎间盘突出症的可行性。方法对15例椎间孔外型腰椎间盘突出症手术患者进行回顾性分析。突出间隙:L3~46例,L4~59例。手术选择后侧旁正中入路,采用MED系统完成神经根探查、减压和椎间盘髓核摘除。结果15例术后随访6~12个月,平均8·3个月。采用改良Macnab标准评价:优8例,良5例,可2例,优良率86·7%。结论显微内窥镜下微创经后侧旁正中入路治疗椎间孔外型腰椎间盘突出症具有创伤小、手术时间短、恢复快等特点,是一种安全有效的手术方法。     

三维椎间孔导向器的设计及其在经皮椎间孔镜下腰椎间盘切除术中的应用

目的:探讨三维椎间孔导向器在经皮椎间孔镜下腰椎间盘切除术的应用效果。方法:利用逆向定位原理,设计出三维椎间孔导向器。自2016年5月至2018年5月,将三维椎间孔导向器应用于临床,共40例单节段腰椎间盘突出症患者接受了经椎间孔入路腰椎间盘切除术,根据是否应用三维椎间孔导向器,分为导向器组和对照组,每组20例。导向器组男9例,女11例;年龄(46.0±11.0)岁;L_(3,4) 5例,L_(4,5) 15例;BMI(25.4±3.2) kg/m~2;使用三维导向器进行穿刺置管。对照组男10例,女10例;年龄(51.8±9.8)岁;L_(3,4) 4例,L_(4,5) 16例;BMI(24.8±3.5) kg/m~2;以术中经验进行常规穿刺置管。比较两组患者穿刺时间、透视次数和穿刺次数,以及手术前后下肢视觉模拟疼痛评分(visual analogue scale,VAS)及腰椎日本骨科协会评分(Japanese Orthopaedic Association,JOA)。结果:所有患者无严重手术并发症发生,并顺利完成手术。导向器组手术时间、透视次数和穿刺次数均小于对照组(P0.05)。两组患者术后3个月下肢VAS评分和腰椎JOA评分较术前均明显缓解(P0.05),但组间比较差异无统计学意义(P0.05)。结论:三维椎间孔导向器结构紧凑,操作简单,可以减少穿刺次数与辐射损伤,并能缩短初学者穿刺学习曲线,具有一定的临床可行性。     

侧路椎间孔镜与后路椎间盘镜治疗腰椎间盘突出症疗效比较

[目的]探讨经皮椎间孔镜微创技术治疗腰椎间盘突出症的临床疗效。[方法] 2016年3月～2017年6月120例经保守治疗无效的腰椎间盘突出症患者120例行手术治疗,其中60例行侧路椎间孔镜术,60例行后路椎间盘镜术。比较两组疼痛视觉模拟评分(visual analogue scale, VAS)、Oswestry功能障碍指数(Oswestry disability index,ODI)和Nakai分级。[结果] 120例患者均顺利完成手术。椎间孔镜组手术时间和透视时间显著长于椎间盘镜组(P0.05),椎间孔镜组术中失血量、术后下地时间和住院时间显著少于椎间盘镜组(P0.05)。两组患者术后VAS和ODI评分较术前均显著减少(P0.05)。术后1周时椎间孔镜组的VAS评分显著低于椎间盘镜组(P0.05)。术后3个月时椎间孔镜组的ODI评分显著低于椎间盘镜组(P0.05)。120例中88例(73.33%)患者获得随访6～12个月,其中椎间孔镜组52例,椎间盘镜组36例。随访过程中,椎间孔镜组有4例术后1～6个月复发,行翻修术,椎间盘镜组2例发生神经根牵拉伤,术后背伸无力,3个月后恢复。两组随访并发症发生率差异无统计学意义(P0.05)。椎间孔镜组优良率为90.38%(47/52),椎间盘镜组优良率为80.56%(29/36),两组间差异有统计学意义(P0.05)。[结论]经皮椎间孔镜腰椎间盘切除术较椎间盘镜有更好的疗效。     

Transforaminal percutaneous endoscopic lumbar discectomy for upper lumbar disc herniation: clinical outcome, prognostic factors, and technical consideration

Background

Compared with lower lumbar disc herniations, upper lumbar disc herniations at L1–L2 and L2–L3 have specific characteristics that result in different surgical outcomes after conventional open discectomy. There are no published studies on the feasibility of percutaneous endoscopic lumbar discectomy for upper lumbar disc herniation. The purpose of this study was to assess the clinical outcome, prognostic factors and the technical pitfalls of PELD for upper lumbar disc herniation.

Method

Forty-five patients with a soft disc herniation at L1–L2 or L2–L3 underwent percutaneous endoscopic discectomy. Posterolateral transforaminal endoscopic laser-assisted disc removal was performed under local anesthesia. Clinical outcomes was assessed using the Prolo scale. The prognostic factors associated with outcome were then analyzed.

Findings

The mean follow-up was 38.8 months (range, 25–52 months). The outcome of the 45 patients was excellent in 21 (46.7%), good in 14 patients (31.1%), fair in six patients (13.3%), and poor in four patients (8.9%). Four patients with a poor outcome underwent further open surgery. Mean scores on a visual analog scale decreased from 8.38 to 2.36 (P?<?0.0001). Age less than 45 years and a lateral disc herniation were independently associated with an excellent outcome (P?<?0.05).

Conclusions

Patient selection and an anatomically modified surgical technique promote a more successful outcome after percutaneous endoscopic discectomy for upper lumbar disc herniation.     

经椎间孔入路经皮内窥镜下腰椎椎间盘切除术治疗腰椎椎间盘突出症的研究进展

正腰椎椎间盘突出症(LDH)是脊柱外科的常见病和多发病。大部分LDH患者可通过非手术治疗达到一定临床疗效,但仍有部分患者经正规的非手术治疗后,其症状未见明显改善,需行手术治疗。目前手术治疗方法分为传统开放手术和微创手术两大类。与传统开放手术相比,微创手术具有创伤小、出血少、手术时间短、费用低、住院天数少、术后恢复快、并发症少等优点。近20年来,随着微创理念的推广和手术器械的改进,经椎间孔入路经皮内窥     

经皮椎间孔内窥镜下靶向穿刺椎间盘切除术治疗腰椎间盘突出症

目的:探讨经皮椎间孔内窥镜下靶向穿刺椎间盘切除术治疗腰椎间盘突出症的安全性及有效性。方法:选择2009年10月~2012年3月收治的237例单节段腰椎间盘突出症患者,男144例,女93例;平均年龄44.8岁,均存在明显腰腿痛,并经CT及MRI检查证实为单节段腰椎间盘突出。在局麻及影像学监视下行靶向穿刺,逐级扩张软组织,切除部分上关节突腹侧缘,安放工作通道,经皮椎间孔内窥镜下完成髓核摘除术。采用视觉模拟评分法(VAS评分)、Oswestry功能障碍指数(ODI)、MacNab评分等评定疗效。结果:平均手术时间53min,平均出血量20ml,无1例手术并发症发生,术后3h即可在硬腰围保护下下床活动。212例随访12～24个月,平均15.5个月,术前VAS评分为7.8±3.6分,术后12个月为1.8±1.1分,手术前后有显著性差异(P0.01);术前ODI为(53.2±13.5)%,术后12个月为(17.3±6.4)%,手术前后有显著性差异(P0.01);术后12个月MacNab评分优167例,良36例,中9例,优良率为95.8%。5例患者术后7~20个月复发,复发率为2.4%,均行后路内窥镜下椎间盘切除翻修术后恢复。结论:经皮椎间孔内窥镜下靶向穿刺椎间盘切除术是治疗腰椎间盘突出症安全、有效的微创手段。     

Transforaminal endoscopic surgery for symptomatic lumbar disc herniations: a systematic review of the literature

The study design includes a systematic literature review. The objective of the study was to evaluate the effectiveness of transforaminal endoscopic surgery and to compare this with open microdiscectomy in patients with symptomatic lumbar disc herniations. Transforaminal endoscopic techniques for patients with symptomatic lumbar disc herniations have become increasingly popular. The literature has not yet been systematically reviewed. A comprehensive systematic literature search of the MEDLINE and EMBASE databases was performed up to May 2008. Two reviewers independently checked all retrieved titles and abstracts and relevant full text articles for inclusion criteria. Included articles were assessed for quality and outcomes were extracted by the two reviewers independently. One randomized controlled trial, 7 non-randomized controlled trials and 31 observational studies were identified. Studies were heterogeneous regarding patient selection, indications, operation techniques, follow-up period and outcome measures and the methodological quality of these studies was poor. The eight trials did not find any statistically significant differences in leg pain reduction between the transforaminal endoscopic surgery group (89%) and the open microdiscectomy group (87%); overall improvement (84 vs. 78%), re-operation rate (6.8 vs. 4.7%) and complication rate (1.5 vs. 1%), respectively. In conclusion, current evidence on the effectiveness of transforaminal endoscopic surgery is poor and does not provide valid information to either support or refute using this type of surgery in patients with symptomatic lumbar disc herniations. High-quality randomized controlled trials with sufficiently large sample sizes are direly needed to evaluate if transforaminal endoscopic surgery is more effective than open microdiscectomy.     

经皮内窥镜下腰椎椎间盘切除术与椎板开窗椎间盘切除术治疗青少年腰椎椎间盘突出症

目的　比较经皮内窥镜下腰椎椎间盘切除术(PELD)与椎板开窗椎间盘切除术治疗青少年腰椎椎间盘突出症(LDH)的临床疗效。方法 2012年1月—2016年12月,海军军医大学附属长征医院收治青少年LDH患者82例,其中40例(A组)采用PELD治疗,42例(B组)采用椎板开窗椎间盘切除术治疗。记录并比较2组患者手术时间、术中出血量、术后卧床时间、咬骨体积,以及术前、术后1个月和末次随访时疼痛视觉模拟量表(VAS)评分、Oswestry功能障碍指数(ODI)。结果所有手术顺利完成,所有患者随访12个月。A组手术时间、术中出血量、术后卧床时间及咬骨体积均低于B组,差异有统计学意义(P 0.05)。2组患者术后VAS评分和ODI均较术前明显改善,差异有统计学意义(P 0.05);组间比较术后VAS评分和ODI,差异均无统计学意义(P 0.05)。末次随访时MacNab疗效评定优良率A组为92.50%(37/40),B组为90.48%(38/42),差异无统计学意义(P 0.05)。A组并发症发生率为5.0%(2/40),B组为7.1%(3/42),差异无统计学差异(P 0.05)。结论 PELD可取得与传统椎板开窗椎间盘切除术相近的临床疗效,且可降低出血量,减少骨性结构破坏,缩短患者术后卧床及康复时间,是较为理想的治疗青少年LDH的微创方法。