显微内窥镜下髓核摘除治疗腰椎间盘突出症术中并发症原因分析及防治措施

目的:分析显微内窥镜下髓核摘除术(MED)治疗腰椎间盘突出症术中并发症的发生原因,总结预防及处理办法。方法:回顾性分析2001年10月至2012年1月,采用显微内窥镜下髓核摘除治疗腰椎间盘突出症的患者851例,男469例,女382例;年龄16～75岁,平均42.5岁;病程1～18个月,平均3个月。突出间隙:L3,424例,L4,5418例,L5S1409例。主要症状为腰痛伴下肢放射性疼痛、麻木,其中单侧下肢症状者729例,双侧下肢症状者122例,相应神经支配区感觉、肌力、反射异常及肌肉萎缩4项检查至少2项出现异常,神经牵拉试验阳性,CT或MRI表现与临床症状、体征相吻合。851例患者未同时合并腰椎失稳、椎管狭窄患者,未包括高位腰椎间盘突出症及合并马尾神经综合征患者。记录术中并发症的发生情况。结果:依据Macnab标准,总体优良率为87.5%(745/851),与开放手术相似。1例因设备故障中转为切开手术,1例术后11d因突发心肌梗塞死亡,2例于术后1h内出现急性硬膜外血肿。发生硬脊膜损伤28例,发生率3.29%(28/851)。神经根牵拉伤38例,发生率4.46%(38/851);腹膜后血肿1例,不完全性马尾损伤2例,不完全性神经根断裂2例。结论:熟练的镜下止血技巧、精细的操作是预防MED术中并发症的重要因素,及时发现及时处理是防治显微内窥镜下髓核摘除术术中并发症的有效措施。     

显微内窥镜技术10年应用经验与思考

目的探讨后路显微内窥镜下椎间盘切除术（microendoscopic disectomy,MED）的适应证与存在的问题及对这些问题的思考。方法回顾分析自2000年开展MED手术以来的1 460例病例并进行随访,评价疗效、总结手术经验。结果根据Macnab标准,总体优良率为87.5%,与开放手术相似。1例因设备故障转为切开手术,1例术后11 d因突发心肌梗塞死亡。3例术后1年内行二次MED术。2例于术后1 h内出现急性硬膜外血肿。发生术后脑脊漏79例,一过性下肢肌力下降56例,椎间隙感染2例,切口感染7例,腹膜后血肿1例,均经卧床、对症治疗后痊愈。108例单Cage椎间融合术患者随访1年时融合率为79.6%,与开放手术相近;发生椎间融合器移位3例,发生率约为2.7%。同时行椎弓根钉内固25例,未发生Cage移位,融合情况尚在随访中。结论 MED下可完成单纯腰椎椎间盘突出症髓核摘除,还可应用于其他腰椎退变性疾病中,MED下还可进行椎间融合术,使MED的适应证逐渐扩大,但同时越来越多的并发症也随之出现。MED技术有漫长的学习曲线,熟练的镜下止血技巧、防范神经根硬脊膜损伤、及时发现并处理急性硬膜外血肿等并发症是顺利开展MED的重要条件。     

MED术中应用自制器械处理后纵韧带钙化及骨赘增生

目的探讨脊柱后路显微内镜(microendoscopic disectomy,MED)手术治疗腰椎间盘突出症合并后纵韧带钙化及椎体后缘骨赘增生的方法. 方法 MED手术中应用自制弧形纤维环刀和L形打入器治疗115例该类患者. 结果全组随访12～30个月,平均22个月,按MacNab标准:优、良109例,可5例,差1例,优良率94.8(109/115).未出现硬脊膜破裂及神经孙上,未发生椎间隙感染,无中转开放手术. 结论正确运用MED技术,配合采用自制器械及相应的改良方法,能较好地处理合并后纵韧带钙化及椎体后缘骨赘增生的难题,进一步扩大了手术适应证范围,提高了疗效及安全性.     

两种经皮脊柱内镜术式治疗腰椎管狭窄症的并发症分析

目的统计经椎间孔入路与经后路脊柱内镜减压术式(percutaneous spinal endoscopic decompression,PSED)治疗腰椎管狭窄症的并发症,分析原因并探讨其防治策略。 方法选取2014年6月至2016年5月解放军总医院单一脊柱外科日间手术中心行PSED治疗的276例(男147例、女129例)腰椎管狭窄症患者为研究对象,其中经椎间孔入路脊柱内镜减压术(transforaminal percutaneous spinal endoscopic decompression,t－PSED)治疗193例(A组),经后方入路脊柱内镜环神经减压术(posterior approach percutaneous spinal endoscopic decompression, p－PSED)治疗83例(B组),统计两组的并发症情况并比较其发生率,分析并发症原因,探讨其防治策略。 结果共15例(5.4%,A组8例、B组7例)患者发生并发症,其中包括硬脊膜破裂3例(A组1例、B组2例),均术毕严密缝合切口后愈合;不完全性神经损伤3例(A组1例、B组2例),对症治疗后6个月内症状缓解;术中严重出血2例及术后血肿形成1例(A组),加压包扎后控制并愈合;术中类脊髓高压综合征2例(B组),经调整冲洗液灌注压及短暂停歇手术后,症状缓解并得以最终完成手术;减压不彻底4例(A组3例、B组1例),仅1例行PSED返修术。无死亡,无截瘫、感染等严重并发症发生。 结论相比p－PSED术式,t－PSED术式的整体并发症发生率相似,但类脊髓高压综合征明显低于前者。术前明确诊断、精准评估并严格把握适应证,术中精细操作、仔细止血、彻底减压可以有效减少并发症的发生。另外,术中及术后的合理处理可有效控制或阻止并发症进一步恶化。     

Clinical Evaluation of Surgery for Single‐Segment Lumbar Spinal Stenosis: A Systematic Review and Bayesian Network Meta‐Analysis

To compare the efficacy and safety of different surgical procedures for patients with single‐segment lumbar spinal stenosis (LSS), Bayesian network meta‐analysis (NMA) was conducted in this study. Randomized controlled trials (RCTs) which reported 2 years'' results after surgery were searched from PubMed, Embase, and Cochrane Register of Controlled Trials up to February 2021. Eligible RCTs that contained at least two of the following surgical procedures, bilateral decompression via the unilateral approach (BDUL), decompression with conventional laminectomy (CL), decompression with fusion (DF), endoscopic decompression (ED), interspinous process devices only (IPDs), decompression with interlaminar stabilization (DILS), decompression with lumbar spinal process‐splitting laminectomy (LSPSL), and minimally invasive tubular decompression (MTD), would be included after screening based on the inclusion and exclusion criteria. The primary outcome was Oswestry Disability Index (ODI). Twenty eligible RCTs were included, with a total of 2201 patients enrolled. The NMA showed that the following surgical procedures ranked first (surface under the cumulative ranking) when compared with CL and DF: DILS for ODI (SUCRA 87.8%); LSPSL for back pain (95%); and MTD for leg pain (95.6%). MTD ranked among the top three surgical procedures for most outcomes. The quality of the synthesized evidence was low according to the Grading of Recommendations Assessment, Development, and Evaluation criteria. DILS, LSPSL, MTD, IPDs, and ED are the most effective procedures for patients with single‐segment LSS. Because of combining efficacy and safety, MTD may be the most promising routine surgical option for treating single‐segment LSS.     

腰椎管狭窄症手术治疗进展

随着人口老龄化及影像诊断技术的飞速发展,退变性腰椎管狭窄症发病率明显升高,成为是老年人腿痛的重要原因,也是腰椎手术的常见病。在治疗上主要有手术和非手术治疗两大类。本文就退变性腰椎管狭窄症手术治疗的方法,如椎板减压、融合固定、非融合固定及微创MED等的应用进展加以综述。     

后路椎间盘镜技术治疗游离型腰椎间盘突出症

目的研究腰椎后路椎间盘镜手术治疗游离型腰椎间盘突出症的手术方法、对策及效果。方法2000年9月至2004年6月利用后路腰椎间盘镜技术治疗游离型腰椎间盘突出症8例。结果8例患者均获得随访,时间9~54个月,平均27.2个月。本组优5例,良3例,优良率100%。本组病例无神经损伤、感染等并发症。结论采用腰椎后路椎间盘镜手术治疗,减压充分,损伤小,临床疗效满意。     

胰十二指肠切除术后并发症的防治体会

目的 探讨胰十二指肠切除术后并发症的预防方法.方法 回顾性分析60例胰十二指肠切除术后并发症的发生及防治方法.胰肠吻合全部采用贯穿缝合式胰肠吻合术.结果 术后胰瘘、胆瘘、出血、胃排空障碍等并发症共7例,发生率11.7％,无手术死亡.结论 胰十二指肠切除术手术范围广、吻合多、创伤大,一直具有较高的死亡率和并发症发生率,但精细的手术操作、简单可靠的胰肠吻合方法以及合理的技术改进可以减少手术后并发症的发生.     

脊柱结核一期手术治疗的围手术期并发症分析

目的总结脊柱结核一期手术治疗时围手术期并发症发生的原因。方法自1997年1月至2006年1月采用一期手术治疗胸、腰椎及腰骶段脊柱结核120例,男性75例,女性45例,年龄17～68岁,平均34．5岁。病变部位为T6～S1。其中采用经前路病灶切除、椎体间植骨融合并内固定术65例,经后路病灶清除并内固定术26例,后路内固定并前路病灶切除、椎体间植骨融合术29例。记录术中、术后1个月内出现的并发症,并分析相关原因。结果共10例出现围手术期并发症,发生率为8．3％,其中死亡1例。并发症的主要发生原因：手术时机选择不当1例;手术创伤2例;手术操作不当或失误5例;其他原因2例。结论脊柱结核的一期手术治疗的围手术期并发症多是因处理不当引起。做好术前评估,术中操作谨慎,术后处理妥当,将可减少并发症的发生。     

显微内镜下腰椎间盘切除术围手术期的并发症与处理

目的探讨显微内镜椎间盘切除术(microendoscopic discectomy,MED)围手术期的并发症处理对策。方法回顾性分析我院1999年10月~2006年10月1852例MED治疗腰椎间盘突出症中出现的140例(7.6%)手术并发症的临床资料。结果椎管内静脉丛出血48例:42例通过镜下止血后完成MED,6例改为开放椎间盘摘除术;定位错误47例,术中发现后调整腔镜位置完成手术;硬脊膜破裂21例,2例改为开放手术;髓核遗漏13例,二期再次行MED髓核摘除;神经根损伤6例,经1个月后完全恢复;术后椎间盘炎5例,1例保守治愈,其余4例行椎间病灶清除术后痊愈。结论采用适当的处理措施可有效的防止或减小MED并发症或失误后给患者造成的损害。     

Less-invasive decompression procedures can reduce risk of reoperation for lumbar spinal stenosis with diffuse idiopathic skeletal hyperostosis extended to the lumbar segment: analysis of two retrospective cohorts

Purpose

Clinical outcomes after decompression procedures are reportedly worse for lumbar spinal stenosis (LSS) with diffuse idiopathic skeletal hyperostosis (DISH), especially DISH extended to the lumbar segment (L-DISH). However, no studies have compared the effect of less-invasive surgery versus conventional decompression techniques for LSS with DISH. The purpose of this study was to compare the long-term risk of reoperation after decompression surgery focusing on LSS with L-DISH.

Methods

This study compared open procedure cohort (open conventional fenestration) and less-invasive procedure cohort (bilateral decompression via a unilateral approach) with ≥ 5 years of follow-up. After stratified analysis by L-DISH, patients with L-DISH were propensity score-matched by age and sex.

Results

There were 57 patients with L-DISH among 489 patients in the open procedure cohort and 41 patients with L-DISH among 297 patients in the less-invasive procedure cohort. The reoperation rates in L-DISH were higher in the open than less-invasive procedure cohort for overall reoperations (25% and 7%, p = 0.026) and reoperations at index levels (18% and 5%, p = 0.059). Propensity score-matched analysis in L-DISH demonstrated that open procedures were significantly associated with increased overall reoperations (hazard ratio [HR], 6.18; 95% confidence interval [CI], 1.37–27.93) and reoperations at index levels (HR, 4.80; 95% CI, 1.04–22.23); there was no difference in reoperation at other lumbar levels.

Conclusions

Less-invasive procedures had a lower risk of reoperation, especially at index levels for LSS with L-DISH. Preserving midline-lumbar posterior elements could be desirable as a decompression procedure for LSS with L-DISH.

     

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.     

椎间盘镜治疗70岁以上老年椎间盘突出症

目的：探讨椎间盘镜治疗老年椎间盘突出症的临床疗效和适用范围。方法：2007年12月至2010年6月,采用METRxⅡ椎间盘镜系统治疗70岁以上老年椎间盘突出症患者32例,其中男20例,女12例;年龄70～86岁,平均78.5岁;病程2周～30年,平均3.5年。患者主要以腰痛伴有明显下肢放射痛,疼痛多数位于膝关节以下。术后对患者的手术时间、出血量、并发症及临床症状进行观察。术后1周拍X线片比较手术前后患者腰椎生理曲度改变情况;术后1个月通过MRI比较患者术前术后影像学变化;术后3个月按照MacNab标准对疗效进行评定。结果：所有患者手术顺利,均获得随访,时间3～30个月,平均12.5个月。手术时间为30～120min,平均65min。术中出血量15～150ml,平均45ml。1例患者术中出现脑脊液漏,用脑棉压迫后继续手术。术中无神经根、血管损伤发生。1例患者清醒后症状加重,其余患者症状均有缓解。术后1周X线片提示25例患者生理屈度改善。术后1个月MRI提示8例患者仍然可见椎间盘或钙化组织部分残留。11例患者主诉患肢尚有少许麻木,但疼痛酸胀明显好转。术后3个月按照MacNab标准评定疗效：优25例,良6例,可1例。结论：椎间盘镜治疗老年椎间盘突出症能使患者早期下床活动,具有创伤小、出血少、疗效好的临床特点,适用于伴有明显下肢放射痛,膝关节以下疼痛为主,又无明显腰椎不稳的患者,对伴有轻中度椎管狭窄及根管狭窄的患者可同时处理。     

Complications in lumbar fusion surgery for chronic low back pain: comparison of three surgical techniques used in a prospective randomized study. A report from the Swedish Lumbar Spine Study Group

The reported complication rates after various surgical techniques used to create a lumbar fusion vary within wide ranges. In a previous paper, the Swedish Lumbar Spine Study Group have reported on the clinical outcome of lumbar spine fusion for chronic low back pain in a comparably homogeneous patient population where there were no significant differences between baseline sociodemographic, clinical and paraclinical characteristics. In this report we compared the complication rates of the surgical procedures used in that study and analyzed the association between complications and baseline variables, and between outcome results and complications. A multicenter randomized study was conducted where 211 patients aged 25-65 were treated with lumbar fusion according to three different surgical techniques: noninstrumented posterolateral fusion (PLF, n=71), instrumented posterolateral fusion (VSP, n=68), and in the third procedure we added an interbody fusion with solid autogenous bone grafts ("360", n=72). We categorized complications as: early/late, major/minor. The association between complications and sociodemographic characteristics (age, gender, comorbidity, previous surgery, smoking), and technical variables (surgical technique, levels fused, hospital category) was analyzed. The association between outcome variables (patient global assessment, pain, disability, depressive symptoms) and complications was analyzed. A literature review was conducted. There was no mortality. There was no significant difference in clinical outcome between the surgical groups after 2 years, although the power to detect such a difference was low. The total complication rate after 2 years in the PLF group was 12%, compared with 22% in the VSP group, and 40% in the "360" group (P=0.0003). After exclusion of complications, there was still no difference in outcome between the groups. The odds ratio (confidence intervals) of having a complication was 5.3 (2.2-12.7) when "360" was used compared with PLF, and 2.4 (1.1-5.3) for "360" compared with VSP. There was no association between clinical outcome and complications on a group level. The reintervention rate was 6% in the PLF group, 22% in the VSP, and 17% in the "360" group (P=0.020). The odds ratio (confidence intervals) of having a reintervention was 4.0 (1.3-11.9) when instrumentation was used compared with non-instrumented fusion. In this prospective randomized study comparing three lumbar fusion techniques in a comparably homogeneous patient population, complications increased significantly with increasing technicality of the surgical procedure. Even though we did not find a significant association between clinical outcome and complications after 2 years, the increased morbidity inflicted on an individual patient was not negligible. In this light, and as no fusion technique produced superior clinical outcome irrespective of whether complications were included or excluded in the analyses, the patient and the treating physician should carefully discuss the possible advantages and drawbacks of the different surgical options before making a decision. In order to make valid comparisons of both complication and reintervention rates after lumbar fusion, there is a need for a consensus in the spinal society regarding the definition of these entities.     

Endoscopic modified total laminoplasty for symptomatic lumbar spinal stenosis

Context/objective: At present, there is no consensus on the most effective surgical method for treating symptomatic lumbar spinal stenosis (LSS). Total laminectomy, which is frequently used at this time, destroys the posterior midline structure, causing many postoperative complications. We have designed a new surgical approach instead of total laminectomy. In this paper, we aimed to describe the surgical method of endoscopic modified total laminectomy for lumbar spinal stenosis as well as to explore its early efficacy.Participants: Patients with symptomatic LSS who underwent endoscopic modified total laminoplasty between August 2016 and August 2017 were eligible for our study.Outcome measures: Before surgery and one year after surgery, we measured lower limb pain and back pain by visual analog scale (VAS), disability via Oswestry Disability Index (ODI), and severity of back pain according to the Japanese Orthopedic Association Score for Back Pain (JOA), while any complications were also assessed.Results: Endoscopic modified total laminoplasty was performed on 22 LSS patients, including eight males and 14 females(mean age = 59.3 ± 9.6 years). We found statistically significant differences before and one year after surgery for VAS lower limb pain and back pain, ODI and JOA scores(P < 0.001). Complications included intraoperative dural tears(n = 1),and weak fusion between the lamina and the vertebral body (n = 1).Conclusion: Endoscopic modified total laminectomy is a promising surgical approach which reduces patient suffering and improves patient quality of life.     

预防护理对腰椎结核及腰椎爆裂骨折手术后腹胀的影响

目的降低腰椎结核(TB)及腰椎爆裂骨折择期手术患者术后腹胀发生率。方法将124例患者随机分为对照 组和观察组各62例,对照组按骨科手术常规护理,观察组在常规护理的基础上采取饮食指导、术后平卧、上腰围等 预防术后腹胀的措施。结果观察组腹胀率明显低于对照组(P<0.01),且不同手术入路及麻醉方式腹胀发生率差 异有显著性意义(P<0.05,P<0.01)。结论腰椎TB及腰椎爆裂骨折术后腹胀发生与麻醉及手术入路相关,术前 术后采取相应的预防措施,可有效降低术后腹胀发生率。     

内镜下腰椎间盘切除并发症的初步分析

通过对应用腰椎间盘镜技术(microendoscopic disectomy,MED)治疗腰椎间盘突出症并发症的分析和与常规开放式手术对比,探讨MED手术治疗腰椎间盘突出症的优、缺点.MED手术具有创伤小、手术时间短、术后恢复快、痛苦轻等优点,但并发症较多,需合理的掌握手术指征,不断提高技术技能.     

Microendoscopic discectomy for lumbar disc herniation with bony fragment due to apophyseal separation.

The purpose of this study was to elucidate the feasibility of microendoscopic discectomy (MED) for the treatment of lumbar disc herniation with a bony fragment due to apophyseal separation. Eighteen patients with low back pain and unilateral sciatic pain due to lumbar disc herniation with a bony fragment were treated by MED using the unilateral approach (15 males and three females; mean age, of 28.9 years; mean follow-up period, 21.1 months); 18 age-and sex-matched patients with lumbar disc herniation without a bony fragment treated by MED served as the control group. The clinical outcomes were evaluated using the Japanese Orthopedic Association Score for Low Back Pain (JOA scores; maximum score, 29 points). Evaluation of the results revealed that good surgical outcomes equivalent to those in the control group were obtained in the subjects of LDH with a bony fragment (JOA scores; 14.1+/-3.5 in the patient group vs.15.4+/-2.6 in the control group before surgery; 26.3+/-1.8 in the patient group vs. 26.9+/-1.3 at follow-up after the surgery). Although the mean surgical time was significantly longer in the patient group, there were no intra- or postoperative complications in either group. We conclude that MED using the unilateral approach is a feasible minimally invasive surgical option for patients of lumbar disc herniation with an apophyseal bony fragment.     

腰椎间盘突出症和椎管狭窄症手术并发症的回顾性分析

目的 回顾性分析腰椎间盘突出症和椎管狭窄症手术并发症发生的原因及对策。方法 自1992年5月～2002年5月手术治疗腰椎间盘突出症和椎管狭窄症2560例,发生并发症134例,发生率为5．23％,其中腰椎间盘突出症的并发症发生率为3.75％．腰椎间盘突出症伴侧隐窝狭窄为4．70％．单纯侧隐窝狭窄为5．13％．腰椎间盘突出症伴中央椎管狭窄为8.97％．单纯中央椎管狭窄为7．93％。器械使用不当引起的并发症为67例．其中椎板咬骨钳所致53侧．占79．1%。术后椎间盘炎8例．发生率0．3％,定位错误19例．发生率为0.74%。术后发生脑血栓2例、肺栓塞1例!2例L4全椎板切除术后发生继发性腰椎滑脱。3倒硬脊膜撕裂者术后发生脑脊液囊肿。复发性腰椎间盘突出症26例。切口血肿致神经根性放射痛12例,结果 19例定位错误者．其中15例术中纠正,4例再次手术。神经根损伤者18例,其中16例完垒恢复．马尾神经损伤者4例均不完全恢复。右髂外动脉破裂者经及时探查、修补后康复。除肺栓塞者经抢救无效死亡外,其余并发症通过处理痊愈。结论 要严格把好术前诊断、术中操作和术后处理关,以减少并发症的发生。     

Management of lumbar spinal stenosis: a survey among Dutch spine surgeons

Background

Various surgical and non-surgical treatments for lumbar spinal stenosis (LSS) are widely adopted in clinical practice, but high quality randomised controlled trials to support these are often lacking, especially in terms of their relative benefit and risk compared with other treatment options. Therefore, an evaluation of agreement among clinicians regarding the indications and the choice for particular treatments seems appropriate.

Methods

One hundred and six Dutch neurosurgeons and orthopaedic spine surgeons completed a questionnaire, which evaluated treatment options for LSS and expectations regarding the effectiveness of surgical and non-surgical treatments.

Results

Responders accounted for 6,971 decompression operations and 831 spinal fusion procedures for LSS annually. Typical neurogenic claudication, severe pain/disability, and a pronounced constriction of the spinal canal were considered the most important indications for surgical treatment by the majority of responders. Non-surgical treatment was generally regarded as ineffective and believed to be less effective than surgical treatment. Interlaminar decompression was the preferred technique by 68 % of neurosurgeons and 52 % orthopaedic surgeons for the treatment of LSS. Concomitant fusion was applied in 12 % of all surgery for LSS. Most surgeons considered spondylolisthesis as an indication and spinal instability as a definite indication for additional fusion.

Conclusions

The current survey demonstrates a wide variety of preferred treatments of symptomatic LSS by Dutch spine surgeons. To minimise variety, national and international protocols based on high-quality randomised controlled trials and systematic reviews are necessary to give surgeons more tools to support everyday decision-making.