经皮椎间孔及椎板间隙入路脊柱内镜治疗腰4/5向下游离型椎间盘突出症的临床比较

目的 评价2种入路脊柱内镜治疗L_4~5向下游离型椎间盘突出的临床疗效及优缺点。 方法 对55例2014年6月-2016年12月间在温州医科大学附属第一医院脊柱外科行经椎间孔(A组)或经椎板间隙入路(B组)治疗的L_4~5向下游离型椎间盘突出患者资料进行分析,比较2组手术时间、住院时间、手术相关并发症等情况,并对2组术前术后腰椎功能障碍(ODI)评分、下肢疼痛视觉模拟评分(VAS)、Macnab's临床疗效等级评分进行比较;同时根据游离程度不同再将2组分为低度游离组(AL、BL)、高度游离组(AH、BH),并对各指标进行比较。 结果 A组患者31例(AL组16例,AH组15例),B组患者24例(BL组13例,BH组11例),获得至少6个月随访,平均手术时间B组显著小于A组(P<0.05),平均住院时间差异无统计学意义(P>0.05)。2组术后VAS评分及ODI评分均较术前显著改善(P<0.05),且B组的平均改善率优于A组(P<0.05),低度游离组间(AL vs. BL)的VAS评分改善率及ODI评分改善率差异无统计学意义(P>0.05),但在高度游离组间(AH vs. BH)存在显著性差异(P<0.05),BH组优于AH组;2组均无手术相关并发症。 结论 2种入路脊柱内镜均可用于治疗L_4~5向下游离型椎间盘突出,且安全有效,但对于高度向下游离的突出,经椎板间隙入路较经椎间孔入路更有优势。 

Trans-foraminal and inter-laminar percutaneous endoscopic lumbar discectomy treatment for L4-5 down-migrating disc herniating

Objective To compare advantages and disadvantages of trans-foraminal (TF) and inter-laminar (IL) percutaneous endoscopic lumbar discectomy (PELD) for the treatment of down migrating L_4-5 lumbar disc herniation. Methods A total of 55 consecutive patients with down-migrated lumbar disc herniation at L_4-5 level who were treated percutaneous transforaminal and interlaminar endoscopic discectomy from June, 2014 to December, 2016 were included in this retrospective study. The patients were divided into two groups according to the treatment they received. Group A was treated by percutaneous interlaminar endoscopic discectomy and group B was treated by percutaneous transformational endoscopic discectomy. The age, sex, degree of herniated disc migration, surgical time, length of hospital stays and related surgical outcomes were all reviewed. Clinical outcomes were measured using pre-operative and post-operative visual analogue scoring (VAS), Oswestry Disability Index (ODI) and Macnab's scoring. The MRI characteristic of different migration degree was also compared. Results The average follow-up time for the 55 patients was 6 month. Compared with group A, group B showed a shorter operative time (P<0.05). The mean VAS and ODI after surgery were improved dramatically in both groups (P<0.05). However, the rate of this change was better in group B as compared group A (P<0.05). There was no significant difference in average rate of change in VAS and ODI score among low-grade down migrating disc herniation group (AL vs. BL), P<0.05. However, among the high grade down migrating disc herniation (AH vs. BH), average rate of change in VAS and ODI score was better in BH than AH group (P<0.05). There were no complications such as dural tear, nerve root injury, infection and hematoma formation in both groups. Conclusion TF and IL PELD are safe and effective surgical approach for down migrating L_4-5 lumbar disc herniation. Compared with TF-PELD, IL-PELD can be more effective treatment for high grade down migrating disc herniation, and it is associated with potential advantages, including surgical time and average rate of change in VAS and ODI score.