腰椎经皮内镜双侧椎间孔一次成形的有限元分析

目的 采用有限元分析法分析腰椎经皮内镜双侧椎间孔一次成形对腰椎生物力学的影响.方法 选取1例健康成年男性志愿者,通过腰椎CT三维重建检查获取腰椎CT数据,通过Solidworks 15.0软件建立椎间盘及关节软骨模型,建立正常L4,5椎体三维有限元模型(A模型).模拟双侧椎间孔入路经皮内镜腰椎间盘切除术过程,在A模型的...     

Endoscopic laser foraminoplasty and a aware-state surgery: a treatment concept and 2-year outcome analysis

Aware-state surgery has been used in this unit to identify the source of spinal pain in over 2500 patients as part of a process termed “viviprudence”. This process consists of clinical analysis, dynamic radiology and scanning tested by differential discography, endoscopy and patient feedback. This replaces guesswork with sighted diagnosis and allows keyhole tissue-preserving techniques to be used not only for the treatment of compressive radiculopathy but also for back pain, failed back syndrome, perineural scarring, multilevel degenerative disc disease, lateral recess stenosis and dynamic listhesis. This has led to the identification of new pathology and the refinement of the inclusion criteria for laser disc decompression and endoscopic laser foraminoplasty. Since 1994, an endoscopic system has been developed to explore the intervertebral foramen and epidural space via the postero-lateral route. The system has been used to address lateral recess stenosis, epidural scarring, osteophytosis, settlement, listhesis, disc extrusion and sequestration and failed back syndrome. The objective has been the endoscopic aware-state definition of the source of pain with decompression of the foramen, mobilisation and neurolysis of the exiting and transiting nerves and ablation of osteophytes and other causes of failed back syndrome confirmed endoscopically. This prospective study involved day-case endoscopic laser foraminoplasty performed on 101 men, and 99 women with an average age of 56 years (range, 22–83 years). They were followed for an average period of 34 months (range, 26–43 months). The average preoperative duration of symptoms was 5.6 years (range, 5–11 years). A total of 46 patients had had one to four previous open operations, and 14 patients were on narcotic analgesics prior to surgery. At other centres, 106 of these patients were evaluated and open surgical procedures were not deemed appropriate or likely to benefit. A cohort integrity of 96% was maintained at the final follow-up. Back, buttock and leg pain were separately compared and analysed using the Oswestry Disability Index, a patient satisfaction scoring scale, a visual analogue pain scale and a patient target achievement score. Using an Oswestry Disability Index of 50 or more to determine good and excellent outcomes, 55% of patients exceeded this score for back pain, 52% for buttock pain and 53% for leg pain. In patients with one prior operation, the corresponding figures were 51%, 33% and 29%. These results indicate that endoscopic laser foraminoplasty provides a minimalist means of exploring the extraforaminal zone, the foramen and the epidural space and performing discectomy, osteophytectomy and neurolysis. It incorporates the prophylactic advantage of foraminal undercutting and provides a promising means of identifying and treating the pain of failed back surgery and back pain and sciatica of indeterminate origin. It serves to identify and localise the source of pain generation. Endoscopic laser foraminoplasty avoids the morbidity associated with open spinal surgery and serves as a useful means of effecting keyhole neurolysis without extensive exploration and fusion. Current improvements in equipment promise wider application and more encouraging results in the future.      

可视化椎间孔成形技术在脊柱内镜下治疗腰椎侧隐窝狭窄中的临床应用价值*

目的探讨可视化椎间孔成形技术在脊柱内镜下治疗腰椎侧隐窝狭窄的临床应用价值。方法收集该院2016年2月-2017年3月诊断为侧隐窝狭窄症患者共65例,经皮椎间孔脊柱内镜系统(TESSYS)组31例采用标准TESSYS技术行椎间孔成形,可视化组34例采用可视化椎间孔成形技术椎间孔成形,分别比较两组患者性别、年龄、病变节段、术中C臂透视次数、手术时间、手术相关并发症及临床效果,利用术前及术后各时段随访时患者腰痛和腿痛视觉模拟评分(VAS),末次随访时利用Macnab疗效评定标准评价患者临床疗效。结果两组患者性别、年龄及病变节段差异无统计学意义(P0.05),可视化组术中透视次数及手术时间明显低于TESSYS组,差异有统计学意义(P 0.05);两组患者术后腰痛及腿痛VAS评分较术前均明显降低,差异有统计学意义(P 0.05)。两组间术前及术后各时间点腰痛、腿痛VAS评分相比差异无统计学意义(P0.05)。根据Macnab疗效评定标准,两组患者末次随访时优良率比较差异无统计学意义(P0.05)。结论可视化椎间孔成形技术治疗腰椎侧隐窝狭窄症的近期临床疗效与标准TESSYS椎间孔成形技术相当,可视化椎间孔成形技术具有术中透视次数少、操作程序简化、手术时间短、安全、对腰椎关节稳定性干扰小的优势。     

克氏针引导大直径环锯一次性椎间孔成形技术在椎间孔镜治疗腰椎间盘突出症中的应用*

目的：观察克氏针引导大直径环锯一次性椎间孔成形技术在椎间孔镜治疗腰椎间盘突出症中的应用效果。方法：选择62例椎间盘突出症患者,随机分为观察组32例和对照组30例,对照组采用Joimax公司常规绿色、黄色和红色环锯依次扩大椎间孔,观察组椎间孔成形采用克氏针引导直径8.5 mm环锯一次性成形技术。比较两组椎间孔成形时间、成形过程中透视次数、手术总时间、手术前后视觉模拟评分(visual analogue scale, VAS)和术后疗效。结果：观察组术中椎间孔成形时间、成形过程透视次数、手术总时间均显著少于对照组(P＜0.05)。两组术后VAS评分均显著低于术前,两组间术后VAS评分差异无统计学意义(P＞0.05)。观察组术后优良率(96.9%)与对照组(96.7%)比较差异无统计学意义(P＞0.05)。观察组中出现一过性L4出口神经根损伤1例,对照组出现椎间隙感染1例,两组均未出现硬脊膜破裂、大血管损伤。结论：克氏针引导大直径环锯一次性椎间孔成形的技术在椎间孔镜手术中取得良好效果,能够明显减少椎间孔成形的操作步骤、椎间孔成形时间及X线暴露次数,缩短手术时间。     

The effect of irrigation on peak temperatures in nerve root, dura, and intervertebral disc during laser-assisted foraminoplasty

BACKGROUND AND OBJECTIVE: The Holmium: YAG (Ho: YAG) laser has been used for the ablation of prolapsed discs but alternative techniques are available, and this application remains controversial. It also has potential for the decompression of nerve roots within narrowed foraminae with the technique of endoscopic laser foraminoplasty. Traditional methods of decompression necessitate a major surgical procedure with potential destabilisation of the lumbar spinal segment. Nevertheless, minimally invasive techniques are attractive only if serious complications can be avoided. This study reports the peak temperatures reached in surrounding tissues with and without saline irrigation. STUDY DESIGN/MATERIALS AND METHODS: Investigation of the hypothesis was carried out in excised sheep lumbar spines. T-type thermocouples were used for the measurement of tissue temperatures during laser ablation of nerve root foraminae. The temperature was assessed in the nerve root, dura mater, and disc space. RESULTS: The Ho: YAG laser was effective in widening the foraminae by approximately 1.5 mm with a total energy of 4.60 kJ. This was statistically significant in both vertical and horizontal directions (P < 0.0003 and P < 0.00005, respectively). The mean temperature of the nerve root, dura, and disc space during the procedure was 44 +/- 3.1 degrees C, 42.8 +/- 4.7 degrees C, and 41 +/- 3.4 degrees C respectively. There were transient high peaks seen in the temperature profiles. Using saline irrigation at 27 ml/minutes these temperatures were reduced to 34.1 +/- 1.8 degrees C (P = 0.0002), 34.9 +/- 1.5 degrees C (P = 0.002), and 37.2 +/- 1.2 degrees C (P < 0.014), for nerve roots, dura, and disc space respectively. CONCLUSIONS: Laser ablation of bone and ligament for nerve root decompression using the Ho: YAG laser may offer substantial advantages, but the risk of serious complication may only be avoided if the technique is combined with saline irrigation.     

自制自攻环锯在可视化椎间孔镜治疗腰椎间盘突出症中的应用价值

目的:探讨用自制自攻环锯行可视下椎间孔扩大成形术在椎间孔镜治疗腰椎间盘突出症中的价值。方法:选择2016年1月至2018年12月使用椎间孔镜技术治疗腰4/5、腰5/骶1椎间盘突出症患者64例,其中术中使用普通环锯与自制自攻环锯行椎间孔扩大成形术各32例。分别记录患者椎间孔扩大成形时间、术中透视次数、住院天数、术后相关并发症;对比术前、术后1 d、术后6个月患者的腰腿痛视觉模拟评分(visual analogue scale,VAS)与Oswestry功能障碍指数(Oswestry disability index,ODI);术后6个月采用改良Macnab法进行疗效评价。结果:自制环锯组椎间孔扩大成形时间、手术时间、术中透视次数少于普通环锯组,差异有统计学意义(P<0.05);两组患者住院天数差异无统计学意义。两组患者术中均无腹腔脏器与大血管破裂发生,无复发。普通环锯组、自制环锯组组内患者腰腿疼痛术前VAS与术后1 d、术后6个月评分差异有统计学意义(P<0.05),术前ODI评分与术后1 d、术后6个月评分差异有统计学意义(P<0.05);普通环锯组与自制环锯组患者组间各时间点VAS、ODI评分差异无统计学意义。普通环锯组术后6个月疗效优良率与自制环锯组患者差异无统计学意义[93.8%(30/32)vs 96.9%(31/32)]。结论:自制自攻环锯在可视下椎间孔镜治疗腰椎间盘突出症中的应用安全有效,具有置管步骤简便、直视下进行椎间孔扩大成形、透视次数少的优点。     

导航辅助脊柱内镜经椎间孔入路穿刺和椎间孔成形的临床研究

目的观察电磁导航辅助下脊柱内镜系统经椎间孔入路穿刺及椎间孔成形的临床应用价值。方法本研究为前瞻性队列研究。选取河南洛阳正骨医院脊柱外科2018年4月至2019年4月诊断为腰椎间盘突出症伴侧隐窝狭窄的患者60例,采用随机数字表法分为两组。观察组30例接受电磁导航辅助下经椎间孔入路内窥镜脊柱系统(transforaminal endoscopic spine system,TESSYS)行椎间孔成形,其中男18例,女12例;年龄(40.73±5.90)岁。对照组30例采用标准TESSYS技术行椎间孔成形,其中男19例,女11例;年龄(42.67±6.40)岁。两组患者性别、年龄、身体质量指数(body mass index,BMI)、术前视觉模拟评分(visual analogue scale,VAS)及病变节段差异无统计学意义(P>0.05)。记录两组术中定位穿刺时间、关节突成形时间、手术时间、透视次数、与穿刺和椎间孔成形相关的并发症、改良MacNab评分并进行比较。结果观察组透视次数、定位穿刺时间、关节突成形时间及手术时间低于对照组,差异有统计学意义(P<0.05)。改良MacNab评分两组比较差异无统计学意义(P>0.05)。术中并发症发生率观察组为6.7%(2/30),对照组为16.7%(5/30),两组比较差异无统计学意义(P>0.05)。结论电磁导航辅助下进行腰椎内镜TESSYS技术操作,有利于精准穿刺定位和椎间孔成形,能够有效减少术中透视次数,降低医患辐射暴露剂量,缩短手术时间,降低青年医师的学习曲线。     

Zessys椎间孔成型术与传统椎间孔成型术治疗远处脱垂型腰椎间盘突出症的临床疗效比较

目的比较Zessys椎间孔成型术与传统椎间孔成型术治疗远处脱垂型腰椎间盘突出症的临床疗效。方法选择2017-08~2019-02漯河医学高等专科学校第二附属医院收治的34例远处脱垂型腰椎间盘突出症患者的临床资料,其中17例采用Zessys椎间孔成型术治疗(A组),另17例采用传统椎间孔成型术治疗(B组)。比较两组手术时间、透视次数、术中出血量,并比较两组术前、术后第3天、术后第6个月患者的疼痛视觉模拟量表(VAS)评分、Oswestry功能障碍指数(ODI)评分、日本骨科协会评估治疗分数(JOA)评分。结果A组手术时间短于B组,术中透视次数少于B组,差异有统计学意义(P<0.05)。两组术中出血量比较差异无统计学意义(P>0.05)。两组术后第3天、第6个月的VAS、ODI评分显著低于术前(P<0.05),JOA评分显著高于术前(P<0.05);但两组在术前及术后不同时间点的VAS、ODI、JOA评分比较差异均无统计学意义(P>0.05)。结论与传统椎间孔成型术比较,Zessys椎间孔成型术在治疗远处脱垂型腰椎间盘突出症中可缩短手术时间,减少术中医患X线暴露,值得推广。     

Transforaminal Endoscopic Lumbar Discectomy for Lumbosacral Junction Adolescent Lumbar Disc Herniation with High Iliac Crests

ObjectiveTo investigate the clinical results of transforaminal endoscopic lumbar discectomy for lumbosacral junction adolescent lumbar disc herniation with high iliac crest.MethodsFrom February 2014 to September 2020, a retrospective analysis of 96 patients less than 21 years old with intervertebral disc herniation was carried out. We enrolled 44 patients diagnosed with lumbosacral junction disc herniation with high iliac crest who required transforaminal endoscopic lumbar discectomy. Pain in the back and the lower extremity was scored on Numeric Rating Scales (NRS) scores. Patient outcomes were graded as excellent, good, fair, and poor using modified MacNab criteria. The NRS scores before and after the operation were compared using the Wilcoxon two‐sample test.ResultsThere were 30 male patients and 14 females. One patient underwent repeat surgery for an intervertebral disc pseudocyst. The NRS scores decreased significantly in both early and late follow‐up evaluations (p < 0.05). At the last follow‐up, 42 patients (95.45%) had an excellent outcome, one patient (2.27%) had a good outcome, and one patient (2.27%) had a fair outcome. The overall success rate was 97.7%.ConclusionThis study''s data suggest that targeted individualized foraminoplasty can effectively overcome the lumbosacral anatomical obstacles, and transforaminal endoscopic lumbar discectomy is an effective and valid option for lumbosacral junction adolescent lumbar disc herniation with high iliac crest.