经皮椎间孔入路与椎板间入路椎间孔镜治疗L_5/S_1游离型腰椎间盘突出的对比分析

目的对比经皮椎间孔入路椎间盘切除术(percutaneous endoscopic transforaminal discectomy,PETD)与椎板间入路椎间盘切除术(percutaneous endoscopic interlaminar discectomy,PEID)治疗L5/S1游离突出型椎间盘的临床疗效。方法回顾分析我科2016年9月至2017年12月收治的L5/S1椎间盘游离突出型的患者99例,男45例,女54例;年龄21～65岁,平均(49.95±8.73)岁。病例分别采用PETD(51例)与PEID(48例)治疗,根据手术方式的不同分为PETD组与PEID组。记录手术时间、术中出血量、术中透视次数、住院时间以及并发症发生情况。手术效果按Oswestry功能障碍指数评分(ODI)、视觉疼痛模拟评分(VAS)和改良MacNab标准,对比分析。结果患者均顺利完成手术,PETD组手术时间为(89.7±23.4)min,术中透视次数为(27.2±6.5)次;PEID组手术时间为(64.0±18.2)min,术中透视次数为(7.4±2.9)次。PETD组,2例患者术后出现减压神经根支配区麻木加重,1例出现局部痛觉过敏,经保守治疗后好转; 1例患者术后12周复发,行后路融合手术; PEID组,1例复发行椎间盘单摘术,1例患者术后出现短暂的下肢感觉异常,1例患者术中硬脊膜撕裂,经保守治疗后好转。两组术前、术后3 d、术后3个月、术后12个月随访时VAS和术后1个月、3个月、12个月ODI评分分别与术前比较均有显著改善,差异有统计学意义(P0.05),两组间随访时评分比较,差异无统计学意义(P0.05)。根据改良MacNab标准,术后末次随访时,PETD组优良率88.2%; PEID组优良率91.7%,差异无统计学意义(P0.05)。结论 PETD与PEID治疗L5/S1游离型椎间盘突出症效果显著,但PEID手术时间短、辐射暴露少,临床中应根据解剖特点、患者症状特征确定入路,选择合适的手术方法,以获得最佳治疗效果。

Comparison of percutaneous endoscopic lumbar discectomy for L5/S1 sequestered disc herniation: transforaminal versus interlaminar approach

Objective To assess the clinical outcomes of percutaneous endoscopic via the interlaminar versus the transforaminal approach in the treatment of L5/S1 sequestered disc herniation. Methods A total of 99 patients of L5/S1 lumbar sequestered disc herniation from September 2016 to December 2017 were selected in this retrospective study, including 45 males and 54 females, ranged from 21 to 65 years, with an average age of (49.95±8.73) years. All patients were divided into two groups: percutaneous endoscopic transforaminal discectomy (PETD) and percutaneous endoscopic interlaminar discectomy (PEID). The operation time, blood loss, fluoroscopy time, length of stay and surgical complications were recorded. The (VAS) score and (ODI) score were evaluated pre-postoperatively. Results All surgeries were completed successfully without severe complication. The mean operation time was (89.7±23.4) min and the perspective times were (27.2±6.5) in PETD group; while in PETD group, the operation time was (64.0±18.2) min and the perspective times were (7.4±2.9). In PETD group, two cases were found complicated with severe numbness in lower limbs and one case suffered hyperalgesia which were relieved after the conservative treatment. One case of recurrence was found at 12 weeks who was treated by lumbar fusion surgery. In PEID group, one case occurred recurrence were treated with discectomy, one patient had short-term lower limb paresthesia, one case had intraoperative dural tear, improved after conservative treatment. The postoperative VAS scores for back and leg pain at 3 days, 3 months and 12 months, as well as the ODI at 1,3,12months showed significant improvement compared with preoperative score (P<0.05), but change between the two groups without significant (P>0.05). In PETD group, the effects were excellent in 37 cases, whereas in PEID group was 35 cases, modified MacNab criteria achieved a satisfactory rate at 88.2% and 91.7% respectively. Conclusion Statistically significant improvement of L5/S1 sequestered disc herniation discectomy via interlaminar and transforaminal was observed. However, PEID has a short operation time and less radiation exposure. The surgery approach may be selected based on anatomical features and patient symptoms in order to obtain the best therapeutic effect.