经皮内窥镜下腰椎椎间盘切除术手术入路分析

目的探讨经皮内窥镜下腰椎椎间盘切除术(percutaneous endoscopic lumbar discectomy,PELD)治疗L_4/L_5、L_5/S_1椎间盘突出症的入路选择、手术操作特点和适应证。方法 2013年9月~2014年10月,137例腰椎椎间盘突出症患者在本院接受PELD治疗,其中L_4/L_5节段75例,L_5/S_1节段62例。根据椎间盘突出的类型,L_4/L_5节段中央型21例,旁中央型48例,远外侧型6例;L_5/S_1节段中央型26例,旁中央型20例,远外侧型16例。75例L_4/L_5腰椎椎间盘突出病例采用侧后方经椎间孔入路经皮内窥镜下椎间盘切除术(percutaneous endoscopic transforaminal discectomy,PETD),46例L_5/S_1节段中央型和旁中央型病例采用后方经椎板间入路经皮内窥镜下椎间盘切除术(percutaneous endoscopic interlaminar discectomy,PEID),16例L_5/S_1节段远外侧型病例采用侧后方PETD。比较不同术式的手术时间、透视次数、术中患者耐受情况,通过手术前后疼痛视觉模拟量表(visual analogue scale,VAS)对下肢放射痛进行评分,Oswestry功能障碍指数(Oswestry disability index,ODI)评估患者术后改善情况。结果所有患者手术顺利完成。L_5/S_1后方PEID手术时间为(52.6±10.3)min,短于L_4/L_5和L_5/S_1侧后方PETD的(92.6±17.3)min及(91.5±15.5)min,差异具有统计学意义(P0.05)。L_5/S_1后方PEID术中透视次数(5.5±1.2)次,明显少于L_4/L_5和L_5/S_1侧后方PETD的(18.2±3.3)次及(20.5±4.2)次,差异具有统计学意义(P0.05)。术后卧床时间、住院时间各术式之间相比,差异无统计学意义(P0.05)。各术式术后即刻、术后3个月VAS评分和ODI与术前相比,差异均有统计学意义(P0.05)。结论对于L_5/S_1节段病例,中央型、旁中央型突出以及髂嵴高者适合采用后方PEID,手术时间短、术中透视次数少,但术中易损伤神经根;远外侧型突出者适合采用侧后方PETD。各种类型L_4/L_5椎间盘突出症患者均适合采用侧后方PETD。

Surgical approach analysis of percutaneous endoscopic lumbar discectomy

Objective To investigate the surgical approach choice, operating characteristics and indications of percutaneous endoscopic lumbar discectomy (PELD) via transforaminal or interlaminar approach for treating L₄/L₅ and L₅/S₁ disc herniation. Methods From September 2013 to October 2014, 137 cases suffering from lumbar disc herniation, including 75 cases of L₄/L₅ and 62 cases of L₅/S₁ were treated by PELD. According to the type of disc herniation, the cases were divided into 3 types: central 21 cases, paracentral 48 cases, far lateral 6 cases of L₄/L₅ herniation; and central 26 cases, paracentral 20 cases, far lateral 16 cases of L₅/S₁ herniation. All cases of L₄/L₅ disc herniation were treated by percutaneous endoscopic transforaminal discectomy (PETD), Forty-six cases of central and paracentral L₅/S₁ disc herniation were treated by percutaneous endoscopic interlaminar discectomy (PEID). Besides, 16 cases of far lateral L₅/S₁ disc herniation were treated by PETD. Operation time, X-ray perspective times and patients' tolerance during surgery were recorded. Leg radicular pain and daily life function were evaluated by the visual analog scale (VAS) score and Oswestry disability index (ODI). Results All the cases underwent operation successfully. The mean operation time of L₅/S₁ PEID group was (52.6±10.3) min, which was significantly shorter than that of L₄/L₅ and L₅/S₁ PETD group with (92.6±17.3) min and (97.5±15.5) min (P<0.05). X-ray perspective times in operation of PEID group was significantly less than that of PETD group, respectively (P<0.05); L₅/S₁ PEID group was 5.5±1.2, however, L₄/L₅ and L₅/S₁ PETD group were 18.2±3.3 and 20.5±4.2, respectively. There was no significant difference in postoperative bed time or length of hospital stay among different surgical approach treatments (P>0.05). The VAS scores and ODIs showed significant differences at any follow-up time points compared with those of pre-operation in different surgical approaches (P<0.05). Conclusion The cases suffering from L₅/S₁ central and paracentral type disc herniation, as well as the high iliac crest ones, are suitable for PEID. The advantages of the approach are the shorter operation time and less X-ray irradiation times, but it has the disadvantage of nerve root injury. PETD is suitable for L₅/S₁ far lateral type disc herniation and all types of L₄/L₅ disc herniation cases.