经皮椎间孔入路内镜下神经根减压治疗腰椎管狭窄症的短期随访

目的：了解经皮椎间孔入路内镜下神经根减压治疗单侧神经根症状的腰椎管狭窄症的可行性。方法： 选择北京大学第一医院骨科2011年7月至2016年4月经皮椎间孔入路行内镜下神经根减压治疗单侧神经根症状的腰椎管狭窄症患者96例进行回顾分析和随访，患者均有单侧下肢神经根刺激症状和体征，神经源性间歇跛行小于500 m。影像学检查（CT或MRI）证实单节段腰椎退行性改变所致椎管狭窄，或多节段狭窄经诊断性神经根封闭明确为单节段狭窄所致症状，患者男55例，女41例，平均年龄（71.6±5.4）岁（47～89岁），记录术中出血量、手术时间、术中并发症、术后并发症、术后下地时间及出院时间，术前和术后随访时，采用腿痛视觉疼痛模拟（visual analogue scale, VAS）评分和Oswestry残疾指数（Oswestry disability index, ODI）评分对患者疼痛及腰部功能进行评价，应用Nakai标准评价临床疗效。结果： 所有患者以环锯去除部分上关节突腹侧扩大椎间孔，内镜下使用髓核钳、射频刀头等去除盘黄间隙的黄韧带显露神经根，摘除椎间盘，进行侧隐窝及神经根管的减压，减压范围为头侧至上位椎体椎弓根下缘，尾侧至下位椎体椎弓根上缘的整个椎间孔区域。探查发现神经根无受压，水压变动时神经根搏动良好, 患者术后当天下地，无明显不适症状时出院。68例患者获得随访，平均随访时间12.1个月（6~63个月），VAS评分各测量时间点比较差异均有统计学意义（F=491.60，P<0.001），ODI评分各测量时间点比较差异均有统计学意义（F=189.91，P<0.001）。应用Nakai评价的优良率为79．4％(优42例，良12例，可10例，差4例)。1例术后出现硬膜外血肿，1例术后足下垂,6例二期行开放手术。结论： 有单侧神经根刺激症状的腰椎管狭窄症患者采取椎间孔镜技术进行神经根减压，手术创伤小、恢复快，近期治疗效果满意。

Efficacy of transforaminal endoscopic nerve root decompression in the treatment of degenerative lumbar spinal stenosis

Objective:To evaluate the feasibility of transforaminal endoscopic nerve root decompression for degenerative lumbar spinal stenosis (DLSS).Methods: From July 2011 to April 2016,96 cases of single segment DLSS were involved.All the patients had unilateral lower extremity neurological symptoms,signs,neurogenic intermittent claudication of less than 500 m.Imaging examinations (CT or MRI) or diagnostic nerve root block confirmed single segment degeneration.The mean age was (71.6±5.4) years,male: 55 cases,female: 41 cases.Their intraoperative blood loss,operation time,complications,ambulation time and discharge time were recorded.Leg pain VAS,ODI were used to evaluate the pain and lumbar function of the patients.The clinical efficacy was evaluated by Nakai evaluation.Results: All the patients were performed endoscopic decompression of the lateral recess and nerve root by removing the ventral part of the superior facet joint,the ligamentum flavum and the intervertebral disc.The decompression range was from the inferior edge of the upper pedicle to the superior edge of the lower pedicle.The nerve root was detected to have no compression and the pulse of nerve root returned to normal.The patient got ambulant on the operation day and discharged if he had no discomfort symptom.In the study,68 cases got follow up.The mean follow-up time was 12.1 months (6-63 months).The VAS at dif-ferent follow-up time points was improved relative to the baseline,and the difference was statistically significant (F=491.60,P<0.001).The ODI at different follow-up time points was improved relative to the baseline,and the difference was statistically significant (F=189.91,P<0.001).The excellent and good rates of Nakai evaluation were 79.4％ (excellent in 42 cases,good in 12 cases,fair in 10 cases and poor in 4 cases).The mean intraoperative blood loss was (49.29±11.86) mL.The mean operation time was (92.46±21.34) min.The mean ambulation time was 1.8 h.The mean discharge time was 2.3 days.Postoperative epidural hematoma was found in 1 case.Foot drop was found in 1 case.Second stage open surgery was performed in 6 cases.Conclusion: We can apply transforaminal endoscopic decompression for the patients of lumbar spinal stenosis who have unilateral nerve root irritation.Patients with transforaminal endoscopic decompression can get less surgical trauma,quick recovery and obtain good short-term outcome.