经皮脊柱内镜通过骨性隧道治疗游离型腰椎间盘突出症

目的：探讨经皮脊柱内镜通过骨性隧道治疗游离型腰椎间盘突出症的临床疗效。方法：对2015年10月至2018年12月椎间孔镜手术治疗的游离型腰椎间盘突出症42例进行回顾性分析。其中男26例，女16例；年龄39~71（58.55±7.16）岁；受累节段L_3，4 7例，L_4，5 24例，L₅S₁ 11例；改良游离髓核分型A1型3例，A2型6例，B1型8例，B2型8例，C1型6例，C2型11例。42例中采用经椎弓根入路22例（经椎弓根入路组），A2型6例，B2型6例，C2型10例；经椎板入路20例（经椎板入路组），A1型3例，B1型8例，C1型6例，B2型2例，C2型1例。记录两组患者的手术时间，术中、术后并发症，运用疼痛视觉模拟评分（visual analogue scale，VAS）及Oswestry功能障碍指数（Oswestry Disability Index，ODI）对术前、术后即刻以及术后12个月患者的临床症状改善情况进行评估，并采用改良Macnab评价体系评估临床疗效。结果：两组患者手术时间69~105（88.29±9.85）min；无神经血管损伤、硬脊膜撕裂等术中并发症出现。其中经椎弓根入路组1例患者因出现局麻不耐受，后经全麻椎板入路摘除。所有患者获得随访，时间13~34（13.71±3.56）个月；两组患者术后即刻与术后12个月随访VAS评分、ODI指数较术前明显改善（P<0.05），按照改良Macnab标准评定：优27例，良11例，可3例，差1例。随访期内患者均未出现腰椎骨折、术后感染等术后并发症。结论：对于游离型椎间盘突出症，术前可根据改良游离髓核分型，进行术前精确靶点预估，选择合理骨性隧道入路可获得良好效果。

Treatment of migrated lumbar intervertebral disc herniation by percutaneous spinal endoscopy through bone tunnel

Objective: To investigate the clinical effect of percutaneous endoscopic lumbar discectomy (PELD) through bone tunnel in the treatment of migrated lumbar intervertebral disc herniation.Methods: The clinical data of 42 patients with migrated lumbar intervertebral disc herniation treated through PELD techniques were retrospectively analyzed from October 2015 to December 2018. There were 26 males and 16 females, aged from 39 to 71 years old with a mean of(58.55±7.16) years. There were 7 cases where the affected segment was L_{3, 4}, 24 cases of L_{4, 5}, and 11 cases of L₅S₁. According to modified free nucleus pulposus classification, 3 cases of type A1, 6 cases of type A2, 8 cases of type B1, 8 cases of type B2, 6 cases of type C1, and 11 cases of C2. Among these 42 cases, 22 patients were treated with transpedicular approach (transpedicular approach group), 6 cases were type A2, 6 cases were type B2 and 10 cases were type C2, and 20 cases with translaminar approach(translaminar approach group), 3 cases were type A1, 8 cases were type B1, 6 cases were type C1, 2 cases were type B2 and 1 case was type C2. The operation time, intraoperative and postoperative complications of the two groups were recorded, and the pain visual analogue scale (VAS) and Oswestry Disability Index (ODI) were used to assess the improvement of the clinical symptoms before surgery, immediately after surgery, and 12 months after surgery, and the modified Macnab evaluation system was used to evaluate the clinical efficacy.Results: The operative time was from 69 to 105 min with a mean of (88.29±9.85) min;and no intraoperative complications such as neurovascular injury or dural tear were occurred in all patients. One case in the transpedicular approach group was changed to general anesthesia and translaminar approach due to local anesthesia intolerance. All the patients were followed up from 13 to 34 months, with a mean of (13.71±3.56) months. VAS and ODI were significantly improved in two groups immediately after surgery and 12 months after surgery(P<0.05). According to modified Macnab criteria, 27 cases obtained excellent results, 11 good, 3 fair, and 1 poor. There were no postoperative complications such as lumbar fractures and postoperative infections in the follow-up patients.Conclusion: For migrated intervertebral disc herniation, the modified nucleus pulposus classification can be used to estimate the precise target before operation, and the reasonable bone tunnel approach can be selected to obtain good results.