经皮腰椎间孔镜手术的穿刺定位策略

目的探讨经皮腰椎间孔镜手术穿刺定位的策略。方法 2009年12月～2011年6月对218例下腰椎疾病行经皮腰椎间孔镜手术240次,根据患者的病史、临床表现及X线片等影像学资料,确定腰椎疾病的不同类型,术前制定定位麻醉计划,结合术中C形臂X线机定位,决定穿刺点及穿刺方向。结果 228例次(228/240,95.0%)一次穿刺成功,12例次(12/240,5.0%)重新定位穿刺。麻醉穿刺时间5～18 min,平均9.8 min。5例发生脑脊液漏:2例硬膜囊内镜下明显破裂、神经根损伤,术后并发患肢麻木无力,经保守治疗逐渐好转;3例硬膜囊无明显破裂,未特殊处理。2例发生手术椎间隙感染。2例穿刺过程中出现腹痛,经调整穿刺方向后症状减轻消失。218例术后随访4～18个月,平均13.5月,其中88例随访超过1年,术前功能障碍指数(Oswestry disability index,ODI)56.5±21.1,术后末次随访25.4±9.1,85.2%(75/88)的患者有改善;术前视觉模拟评分(visual analog score,VAS)为(6.9±3.1)分,术后末次随访为(2.8±2.2)分,88.6%(78/88)的患者有改善。结论椎间盘突出偏后外侧尤其是椎间孔附近、包容性椎间盘突出拟行髓核射频消融或纤维环成形者,穿刺角度与中央型突出穿刺路径区别对待;侧位观穿刺要紧贴上关节突边缘,针尖对准椎间盘中央。腰椎间孔狭窄、侧隐窝狭窄病人,若主要为椎体后缘增生钙化,路径稍向前平移,若主要由椎小关节增生引起,穿刺线向后平移。

Orientation Strategy in Transforaminal Percutaneous Endoscopic Lumbar Surgery

Objective To investigate the orientation strategy for transforaminal percutaneous endoscopic lumbar surgery.Methods Totally 218 patients with lumbar diseases,who received transforaminal percutaneous endoscopic lumbar surgery(240 procedures) in our hospital between December 2009 and June 2011,were enrolled into this study.The anesthesia and orientation strategy were determined by the patients’ medical history,clinical signs and symptoms,type of the lumber disease,and X-ray examination.During the procedure,the puncture site and orientation was made under the guidance by C-arm X-ray.Results One-session success rate of puncture was 95.0%(228/240),in 12 of the 240 procedures,the puncture was made twice.The mean puncture time was 9.8 min(5-18 min).After the procedure,five patients developed cerebrospinal fluid leakage;two of them had leg paraesthesia and weakness because of a ruptured thecal sac and injury to the nerve root,both the patients were then cured by conservative therapy;the other three patients showed no obviously ruptured thecal sac,and thus received no treatment.Two patients had postoperative intradiscal infection,which were controlled by intravenous antibiotic administration and then transforaminal endoscopic lavage,debridement and drainage.Two patients complained of abdominal pain during the procedure,the pain was then relieved by adjusting the direction of the puncture.The patients were followed up for 4 to 18 months with a mean of 13.5 months(> 1 year in 88 cases).At the end of the follow-up,the mean Oswestry disability index(ODI) decreased from 56.5±21.1 preoperatively to 25.4±9.1,85.2%(75/88) of the patients were improved;and the mean visual analog score(VAS) decreased from 6.9±3.1 preoperatively to 2.8±2.2,88.6%(78/88) of the patients were improved.Conclusions For posterolateral herniation of the lumber disc,especially the contained herniated disc close to the intervertebral foramen,for which coblation nucleoplasty or intradiscal electrothermal annuloplasty are planned,the orientation strategy is different from that for central disc protrusion.At the lateral side,the puncture shall be made along the edge of the superior articular process,with the needle pointing at the central point of the disc.For lumbar foramen stenosis and lateral recess stenosis,the puncture approach shall be moved forward in those who had calcification and osteophyte of the posterior lumbar border,and moved backward in patients with hypertrophy of the articular process.