经皮椎间孔镜下椎间盘摘除术治疗单节段脱垂型腰椎间盘突出症的疗效观察

目的 探讨经皮椎间孔镜下椎间盘摘除术(PELD)治疗单节段脱垂型腰椎间盘突出症的临床疗效。方法 回顾性分析2018年1月-2019年3月南京医科大学附属无锡市人民医院40例单节段脱出游离型腰椎间盘突出症患者的临床资料。其中男22例,女18例;年龄 18~52岁,平均 32 岁。病变节段:L_3/4 4例,L_4/5 29例,L₅/S₁ 7例。腰椎间盘突出的严重程度按照Lee分型标准,Ⅰ型3例,Ⅱ型7例,Ⅲ型21例,Ⅳ型9 例。40例患者均接受PELD ,其中采用椎间孔侧入路34例,椎板间入路6例。观察患者术后恢复情况和并发症发生情况,比较患者术前及术后第1天、1个月及6个月的疼痛视觉模拟评分(VAS) 、Oswestry功能障碍指数(ODI)。术后6个月复查MRI了解有无髓核再脱出情况,并采用MacNab 标准评定疗效。结果 患者均顺利完成手术,手术时间45.9~72.0(59.8±12.5)min,术中出血量均＜18 mL。术后椎间孔侧入路手术患者出现椎间隙感染1例,椎板间入路手术患者出现症状残留1例。40例患者均获随访,随访时间6~12(8.2±2.7)个月。术后第1天、1个月、6个月疼痛VAS 评分分别为(2.3±0.7)、(0.8±0.3)、(0.3±0.1)分,ODI分别为21.3%±3.4%、11.9%±2.9%、3.1%±1.5%,均低于较术前的(7.2±1.3)分、62.8%±5.5%,差异均有统计学意义(F=10.812、8.750, P值均＜0.05)。术后6个月复查MRI,1例椎板间入路手术患者存在脱出髓核残留,其余患者均未见髓核残留及复发。术后6个月按MacNab 标准评定疗效,优36例、良2例、可2例,优良率为95.0%。结论 PELD治疗单节段脱垂型腰椎间盘突出症临床疗效满意,但头、尾端高度脱垂移位的患者对手术者来说仍是一项挑战。

Percutaneous discectomy for the treatment of lumbar disc herniation with single-segment prolapse

Objective To observe the clinical efficacy, surgical techniques, and complications of percutaneous endoscopic lumbar discectomy (PELD) in the treatment of lumbar disc herniation with single- segment prolapse. Methods The clinical data of 40 patients (including 22 males and 18 females, aged 18-52 years old, with an average age of 32 years) with single-segment prolapse and free lumbar disc herniation from January 2018 to March 2019 in Wuxi People's Hospital affiliated to Nanjing Medical University were retrospectively analyzed. The diseased segment included L_3/4 (4 cases), L_4/5 (29 cases), and L₅/S₁ (7 cases). According to the Lee classification criteria, the severity of lumbar disc herniation was type Ⅰ in 3 cases, type Ⅱ in 7 cases, type Ⅲ in 21 cases, and type Ⅳ in 9 cases. All 40 patients were treated with PELD, 34 and 6 of which underwent the foraminal approach and interlaminar approach, respectively. The patients' postoperative recovery and complications were observed, and patients' visual analogue scale (VAS) and Oswestry disability index (ODI) were compared before operation and 1 day, 1 month, and 6 months after operation. At 6 months after the operation, the MRI was reviewed to determine whether the nucleus pulposus relapsed. The MacNab standard was used to evaluate the efficacy at 6 months after surgery. Results The operation was successfully conducted in all patients. The operation time was 45.9-72.0 (59.8±12.5) min. The intraoperative blood loss of all patients was less than 18 mL. One case of intervertebral space infection occurred in a postoperative patient with the foraminal approach, and one patient had residual symptoms after an interlaminar approach. All 40 patients were followed up after surgery. The follow-up time was 6-12 (8.2±2.7) months. The VAS scores were (2.3±0.7), (0.8±0.3), and (0.3±0.1) 1 day, 1 month, and 6 months after surgery, and the ODI was 21.3%±3.4%, 11.9%±2.9%, and 3.1%±1.5%, respectively, which were all lower than the preoperative values (7.2±1.3) and (62.8%±5.5%). The difference was statistically significant (F=10.812, 8.750, all P values＜0.05). MRI was re-examined 6 months after the operation. One patient that underwent the interlaminar approach had residual prolapsed nucleus pulposus, and none of the remaining patients showed residual nucleus pulposus or recurrence. According to the MacNab standard, the curative effect was evaluated at 6 months after operation. Thirty-six cases were rated as excellent, two cases were good, and two cases were fair. The rating of excellent and good curative effect was 95.0%. Conclusions PELD has satisfactory clinical effects in the treatment of single-segment prolapsed lumbar intervertebral disc herniation; however, treating patients with high prolapse and tail displacement is still challenging for surgeons.