超声联合X线定位在经皮椎间孔镜腰椎间盘切除术中的应用价值

目的探讨超声引导联合X线定位在经皮椎间孔镜腰椎间盘切除术（PELD）穿刺置管中的应用价值。 方法选取2018年1月至2018年5月诊断为腰椎间盘突出症，于中国人民解放军总医院骨科行PELD治疗的患者60例，其中超声联合X线引导下PELD患者30例，单纯X线引导下PELD患者30例。对2组患者的穿刺时间、置管时间、手术时间、X线透视次数、辐射剂量、临床疗效以及不同手术节段、体质量指数（BMI）水平及髂嵴高度的患者的手术穿刺和置管时间进行比较分析。 结果超声联合X线组较单纯X线组的置管时间短［（2.60±0.83）min vs（3.03±0.71）min，P<0.05］。2组的穿刺时间和总手术时间比较，差异均无统计学意义（P均>0.05）。超声联合X线组接受了（3.10±0.40）次透视检查，较单纯X线组的（8.30±1.12）次少（P<0.001）。超声联合X线组接受的辐射剂量为（8.01±0.94）mGy，低于单纯X线组的（18.25±6.11）mGy（P<0.001）。进行L5-S1节段手术患者较L3-4、L4-5节段手术患者的穿刺时间长［（4.94±2.75）min vs（3.06±1.55）min，t=2.327，P<0.05］。在L3-4、L4-5节段手术患者中，BMI≥28 kg/m²的患者较BMI<28 kg/m²的患者穿刺时间长［（4.57±1.62）min vs（2.98±1.02）min，t=2.865，P<0.01］。在L5-S1节段手术患者中，高嵴型患者较低嵴型患者的穿刺时间长［（8.00±1.41）min vs（3.32±1.54）min，t=3.690，P<0.05］。在超声联合X线组与单纯X线组中，PELD术后1 h和术后3个月视觉模拟评分（VAS）均低于PELD术前，且差异均有统计学意义（超声联合X线组：t=30.115、38.760，单纯X线组：t=33.397、38.140，P均<0.001）。在超声联合X线组与单纯X线组中，PELD术后3个月的Oswestry残疾指数（ODI）均低于术前，差异均有统计学意义（t=132.628、123.120，P均<0.001）。2组患者均未观察到软组织或椎间盘感染、神经损伤等并发症。 结论与单纯X线引导相比，超声引导联合X线定位进行PELD穿刺置管可降低辐射剂量，提高手术效率，取得与传统X线引导相似的临床治疗效果，值得临床推广应用。

Application value of ultrasound combined with X-ray localization in percutaneous transforaminal endoscopic lumbar discectomy

ObjectiveTo evaluate the value of ultrasound combined with X-ray localization in percutaneous transluminal percutaneous endoscopic lumbar discectomy (PELD). MethodsSixty patients with lumbar disc herniation who underwent PELD surgery at the General Hospital of the People's Liberation Army were enrolled in the study and randomly assigned to an ultrasound combined with X-ray group and an X-ray alone group. The differences in puncture time, catheterization time, operation time, number of fluoroscopic examinations, and radiation dose were analyzed. The clinical effects of PELD were assessed using the straight leg raising test, visual analog scale (VAS), and Oswestry dysfunction index (ODI). ResultsThe catheterization time was significantly shorter in the combination group than in the X-ray alone group (2.60±0.83) min vs (3.03±0.71) min, t=2.161, P<0.05], although there was no significant difference in puncture time and total operation time between the two groups (P>0.05). The combination group received significantly fewer fluoroscopic examinations than the X-ray alone group (3.10±0.40) vs (8.30±1.12), t=23.954, P<0.001]. The radiation dose was significantly lower in the combination group than in the X-ray alone group (8.01±0.94) mGy vs (18.25 ± 6.11) mGy, t=9.074, P<0.001]. The puncture time in patients undergoing L5-S1 surgery was significantly longer than that of patients undergoing L3-4 and L4-5 surgery (4.94±2.75) min vs (3.06±1.55) min, t=2.327, P<0.05]. In patients undergoing L3-4 and L4-5 surgery, the puncture time of patients with a BMI≥28 kg/m² was longer than that of patients with a BMI<28 kg/m² (4.57±1.62) min vs (2.98±1.02) min, t=2.865, P<0.01]. In patients undergoing L5-S1 operation, the puncture time in patients with high-ridge type lesions was significantly longer than that in patients low-ridge type lesions (8.00±1.41) min vs (3.32±1.54) min, t=3.690, P<0.05]. VAS scores at 1 h and 3 mo after operation were significantly lower than those before PELD in both groups (t=30.115 and 38.760 in the combination group, and t=33.397 and 38.140 in the X-ray alone group, respectively; P<0.001). The ODIs at 3 mo after PELD were also significantly lower than that before operation in both groups (t=132.628 in the combination group, and t=123.120 in the X-ray alone group; P<0.001). No complications such as soft tissue or intervertebral disc infection and nerve injury were observed in either group. ConclusionCompared with X-ray guidance alone, PELD catheterization guided by ultrasound combined with X-ray localization can reduce the number of X-ray examinations and radiation dose and improve the efficiency of surgery. Ultrasound combined with X-ray localization can be used as a new method to guide PELD catheterization.