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.     

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。     

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。     

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。     

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。     

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。     

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.     

全可视化脊柱内镜技术治疗极外侧型腰椎间盘突出症疗效分析

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的临床效果。方法：2018年5月-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极外侧型椎间盘突出症患者39例。采用视觉模拟评分法( visual analog scale,VAS)、Oswestry功能障碍指数( Oswestry disability index,ODI)、日本骨科协会评估治疗分数( Japanese Orthopaedic Association Scores,JOA)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、脑脊液瘘等并发症发生。所有病人均获得随访,随访时间18-40月,平均时间28.8月。所有患者术前VAS评分、ODI指数及JOA指数与术后1天、3月、12月分别进行比较,结果显示差异均具有统计学意义( P＜0.05)。结论：全可视化脊柱内镜技术治疗极外侧型腰椎间盘突出症临床疗效确切,安全性高,值得临床推广。     

The lateral microsurgical approach to the “extracanalicular” lumbar disc herniation

Summary The main aim in the surgery of the canalicular and extra-canalicular lumbar disc herniation is to remove safely the hidden fragment without complete destruction of the normal facet joint, without damage to the nerve root and with minimal compromise of the stability of the spinal column.This report describes a lateral approach for operations of extracanalicular lumbar disc herniations in which full visual control allows a decompression of the respective spinal nerve or ganglion and removal of the herniated disc. With this approach, there is minimal resection of bone and facet joint and minimal risk of injury to neural structures. If necessary, this approach can easily be combined with the classical interlaminar exposure.     

射频消融髓核成形术治疗腰椎间盘突出症

目的：探讨射频消融髓核成形术治疗腰椎间盘突出症的手术技巧、疗效和适应证。方法：对86例腰椎间盘突出症患者采用经皮穿刺射频消融髓核成形术(nucleoplasty)治疗，并对其疗效进行观察分析。结果：86例患者经3～18个月随访，根据“中华医学会骨科分会脊柱学组腰背痛手术评定标准”，术后疗效优10例，良65例，可6例，差3例，优良率87．2％，有效率为96．5％。无相关并发症发生。结论：射频消融髓核成形术操作简单、安全，是治疗腰椎问盘突出症的有效微创手术。     

Surgical observations in extremely lateral lumbar disc herniation

About 10% of lumbar disc herniations are localized in an extreme lateral position refered to as extracanalicular. The clinical syndrome is a typical one with compression signs of the lateral, extra-formainal nerve root and minimal lumbar pain. A reliable diagnosis can be made only since high resolution spinal computed tomography has become available. Surgical treatment will be rendered difficult by the hidden localisation of the disc fragments. A total number of 15 patients has been operated on in our department during the last year. In 10 patients, we used the lateral microsurgical approach proposed by Reulen, in five cases a combined procedure with lateral sequestrotomy and medial nucleotomy. In the first group, re-sequestration occured in three cases and further surgery including medial nucleotomy was performed then. A good result with remission could be achieved in 13 cases, whereas in two cases with additional spondylolisthesis, lumbar back pain continued, but the radicular symptoms were reduced.     

微创可扩张通道辅助经横突间入路手术治疗极外侧腰椎间盘突出症

[目的]评价微创可扩张通道辅助下经横突间入路手术治疗极外侧腰椎间盘突出症的临床效果及手术技巧。[方法]2008年1月～2010年12月,42例极外侧型椎间盘突出症患者,男18例,女24例;平均年龄57.4岁。其中椎间孔内突出型24例,椎间孔外突出型18例。均采用经横突间入路微创可扩张通道辅助下的椎间盘切除手术治疗。手术前后行下肢疼痛VAS评分,术后采用改良MacNad标准进行临床疗效评定。[结果]平均手术时间86 min,平均失血82 ml,与同时期相同入路但未使用微创通道的12例患者相比,两项指标均明显减少(P<0.05)。42例患者平均随访时间28个月。VAS评分术前平均为7.6,术后2周平均为2.3,术后半年为1.3。术后半年MacNad评定结果:优26例、良10例、可6例;优良率85.7%。椎间孔内型组和椎间孔外型组术后优良率分别为83.3%和88.9%。两组间优良率差异无统计学意义(P>0.05)。术后并发症为1例术后伤口血肿。[结论]应用微创可扩张通道辅助下经横突间入路手术治疗极外侧腰椎间盘突出症创伤小、安全性好,近期效果良好,可以作为极外侧型腰椎间盘突出症微创手术方式的选择之一。     

Microsurgical anatomy and operative technique for extreme lateral lumbar disc herniations

Summary The anatomy of the lateral aspect of the lumbar spine and our lateral microsurgical technique for extreme lateral lumbar disc herniations (ELLDH) is described. This study was based on the microdissection of 4 cadavers, on the morphometric evaluation of these as well as 6 dried cadaver spines and 8 lumbar CT scans, and on the use of this technique on over 200 cases.Level dependent changes in the posterior arch cause a shift of the disc space distally relative to the facet joint, an increasing amount of bone to overlie the intervertebral foramen, and a decreasing amount of working space within the exposure in the caudal direction. Therefore, more bone removal from the lateral aspect of the pars interarticularis and supero-lateral aspect of the facet joint is required in the lower lumbar spine. When the exposed ligamentum flavum is resected, the dorsal root ganglion is seen and access to the herniation and disc space is achieved. Level dependent changes in the pedicles and transverse processes lead to an alteration in the course and relationships of the nerves, thereby influencing the pathophysiology of and surgical technique for the ELLDH. The operative target is the lateral aspect of the pars interarticularis and not the intertransverse space as has been previously described.Our techniques allows for the early identification of the nerve with minimal risks of injury to it, to the adjacent vessels and to the structural integrity of the facet joint and pars interarticularis.Abbreviations DRG dorsal root ganglion - ELLDH extreme lateral lumbar disc herniation - ESA erector spinae aponeurosis - ITL intertransverse ligament - L lumbar - LA lumbar artery - LF ligamentum flavum - LIPC lateral interpedicular compartment - m. muscle - S sacral - TP(s) TP(s) transverse process(es)     

极外侧型腰间盘突出症的临床特点及术式选择

目的 分析极外侧型腰椎间盘突出症(FLLDH)的临床特点,探讨合理的术式。方法 回顾总结18例FLLDH的临床资料：分别应用经椎板间入路(术式1)、经峡部外缘入路(术式2)和经横突间入路(术式3)三种术式单独或联合进行治疗。结果 经平均1年2个月随访,依据Macnab疗效标准,优12例,良5例,可1例,差无,优良率为9414％结论 本症多具有较高神经节段受损的症状和体征。结合临床的椎间孔区高质量CT检查是诊断FLLDH的关键一本组所选术式既能彻底摘除致压髓核组织,又最大限度地保留了脊柱的完整性．     

显微镜与椎间盘镜辅助腰椎间盘切除术治疗腰椎间盘突出症疗效的对比分析

目的 报道显微镜辅助直视下腰间盘切除术与椎间盘镜辅助腰间盘切除术两种不同手术方法治疗单节段腰椎间盘突出症的临床疗效.方法 比较分析显微镜与椎间盘镜辅助下的两种不同手术方法治疗单节段腰椎间盘突出症病例,治疗病例分别为33例和36例.比较手术时间、术中出血量、并发症、住院天数、术前及术后腰腿疼痛的JOAS(Japanese Orthopaedic Association Score)及VAS(Visual Analog Scales)评分、围手术期并发症等指标.结果 所有病例平均随访2年2个月(11个月至4年),2组术前及术后腰腿疼痛的JOAS及VAS评分、围手术期并发症、住院天数差异无统计学意义(P＞0.05),而在手术时间、术中出血量上差异具有统计学意义(P＜0.05).结论 显微镜辅助直视下腰间盘切除术与椎间盘镜辅助腰间盘切除术治疗单节段腰椎间盘突出症均疗效满意,均为理想的微创手术方法.     

微创经椎间孔腰椎间融合术治疗高位腰椎间盘突出症

目的评价微创经椎间孔入路腰椎间融合术（MIS-TLIF）治疗高位腰椎间盘突出症的中短期临床疗效。方法对自2009-01—2012—12收治的高位腰椎间盘突出症22例行MIS—TLIF术,根据患者症状、体征及影像学资料,切除单侧减压、对侧潜行减压或两侧开窗减压,并行自体及同种异体骨椎间植骨、椎间融合器融合、经皮椎弓根钉内固定。结果所有患者获平均（12±3）个月的随访,出现椎间植骨不融合1例,椎间植骨融合时间为（7．2±1．3）个月。术后下肢放射痛VAS评分及腰背痛ODI评分与术前比较,差异有统计学意义（P〈0．05）。改良MacNab标准评价优良率为86．4％。结论MIS-TLIF治疗高位腰椎间盘突出症是安全、有效的方法。     

CT-observations of the intra- and extracanalicular disc herniation

Summary A retrospective analysis of 45 patients with intra- and extracanalicular lumbar disc herniations (ICDH, ECDH), collected over a 3 year period, is presented. When an intra- or extracanalicular DH was suspected, 1.5 mm axial cuts were made with a GE 9800 from the cranial pedicle through the intervertebral canal to the pedicle of the lower vertebral body. Constructions were then made in coronal and paraxial planes to identify the pathology and its relation to the nerve root. 47% of all ICDH and ECDH were found at the level L4/5, 24% each at the levels L3/4 and L5/S1 respectively and 4% at the level L2/3. In 78% of our patients, the disc fragment was extruded and found well above the level of the disc space, in 22% at the level of the disc space. The coronal reformated views were in general better for demonstrating the course of the compressed nerve root at the levels L2/3–L4/5, while at L5/S1 the paraxial reformated view may yield better images. The distance from the midline of the spinal canal to the medial and lateral edge of the ECDH averages 16.4±3.4 and 33.3±3.6 mm and in some cases the lateral edge was found 39–44 mm from the midline. Pitfalls in the diagnosis of ECDH may be caused by scar tissue, sometimes by an upwardly displaced nerve root or ganglion and, very rarely, by a neurinoma. Pitfalls in therapy, i.g. false negative intraspinal exploration in cases of intraor extracanalicular disc herniations or exploration of the wrong intervertebral canal, may result due to insufficient neuroradiological analysis or from insufficient consideration of the anatomical situation by the neurosurgeon.     

极外侧型腰椎间盘突出症诊治

目的对极外侧型腰椎间盘突出症的诊治进行分析,进一步提高对该病的认识。方法采用不同手术入路治疗12例极外侧型腰椎间盘突出症。结果3例出现延误诊断。12例均获得随访,优11例,良1例。结论极外侧型腰椎间盘突出症常累及同序数神经根,CT扫描是较好的检查手段;手术可选取不同的术式,单纯极外侧者以椎旁肌间隙为佳。缺乏系统认识是其延误诊断的主要原因。     

Quadrant通道下经Wiltse入路治疗老年人极外侧腰椎间盘突出症的疗效分析

目的探讨Quadrant通道下经wiltse入路微创治疗老年人极外侧腰椎间盘突出症的临床效果。方法收集2010-01-2013-01手术治疗的31例老年人极外侧腰椎间盘突出症患者资料,其中Quadrant微创通道经wiltse入路组18例,TLIF治疗13例,随访12月,统计手术时间、出血量、切口长度,对术前、术后1周视觉模拟疼痛评分（visual analogue scales,VAS）,术前、术后3月、12月JOA评分进行比较。结果两种方法均能有效缓解疼痛,但quadrant组手术时间短,切口小,出血量少（P〈0.01）。Quadrant组术后VAS评分,JOA评分优于TLIF组（P〈0.01）。结论 Quadrant通道下经wiltse入路治疗老年人极外侧椎间盘突出症创伤小、恢复快,疗效确切。     

人工髓核置换治疗腰椎间盘突出症

介绍一种骨科新技术,人工髓核置换治疗腰椎间盘突出症。通过其适应证与禁忌证、型号大小和手术方法,结合作者手术经验和短期观察进行讨论,部分患者术后出现短暂的剧烈腰痛,口服药物后缓解。在人工椎间盘置换和椎间隙最终行融合之前,恢复脊柱节段的功能,是脊柱外科的发展趋势,人工髓核是一种选择。