胸腔镜辅助下侧前路减压融合术治疗腰椎间盘突出症伴椎体后缘骨软骨病

目的探讨胸腔镜辅助下侧前路减压融合术治疗胸腰段或高位腰椎间盘突出症(lumbar disc herniation,LDH)伴椎体后缘骨软骨病(vertebral osteochondrosis,VO)的可行性及其临床效果。方法回顾性分析2017年12月至2019年12月采用胸腔镜辅助下侧前路减压融合术治疗胸腰段或高位LDH伴VO 10例患者的病历资料,男6例,女4例;年龄37~65岁,平均49.2岁。手术节段均为单节段,累及T₁₂L₁节段5例、L_1,2节段2例、L_2,3节段3例。4例患者为单纯胸腰段或高位LDH伴VO;6例患者合并黄韧带增生、骨化致椎管狭窄或后凸畸形,联合后路减压内固定术或矫形手术。主要观察指标为疼痛视觉模拟评分(visual analogue scale,VAS)、Oswestry功能障碍指数(Oswestry disability index,ODI)及椎间隙前、后缘高度,根据改良MacNab标准评估临床疗效。结果10例患者均顺利完成手术,术中在胸腔镜辅助下能清晰显露并彻底去除突出的椎间盘和骨化物,脊髓、神经根和硬膜囊得到充分减压。手术时间(115.4±23.8)min(范围70~180 min);术中失血量(122.6±21.3)ml(范围40~310 ml)。术后随访时间为12~36个月,平均21.6个月。末次随访时10例患者VAS评分由术前(7.2±1.9)分降至(1.8±1.1)分,ODI由术前64.3%±13.9%降至16.3%±5.1%,椎间隙前缘高度由术前(7.8±1.5)mm改善至(11.9±2.3)mm,椎间隙后缘高度由术前(4.5±1.1)mm改善至(7.4±1.6)mm,差异均有统计学意义(P<0.05)。末次随访时改良MacNab疗效评定为优9例、良1例。结论胸腔镜辅助下侧前路减压融合术治疗胸腰段或高位LDH伴VO,可提供清晰的手术视野,能够充分显露、彻底去除突出的椎间盘及骨化物,术后近期疗效满意。

Thoracic endoscopic-assisted anterior-lateral decompression and fusion for lumbar disc herniation associated with vertebral osteochondrosis

Objective To investigate the feasibility and clinical effects of thoracic endoscopic-assisted anterior-lateral decompression and fusion for thoracolumbar or upper lumbar disc herniation(LDH)associated with vertebral osteochondrosis(VO).Methods From December 2017 to December 2019,10 patients of thoracolumbar or upper LDH associated with VO were treated with thoracic endoscopic-assisted anterior-lateral decompression and fusion,including 6 men and 4 women,with an average 49.2 years old(range,37 to 65 years old).The involved levels included T₁₂L₁ in 5 cases,L_1,2 in 2 cases and L_2,3 in 3 cases.There were 4 cases of simple thoracolumbar or upper LDH associated with VO and 6 cases of thoracolumbar or upper LDH associated with VO combined with ligamentum flavum hyperplasia and ossification or kyphosis(combined with posterior decompression and internal fixation or posterior correction surgery).The visual analogue scale(VAS),Oswestry disability index(ODI)and anterior and posterior height of intervertebral space were evaluated at follow-up.The clinical effects were evaluated according to the modified MacNab criteria.Results The operation was performed successfully in all the patients.During the operation,the herniated disc and ossification were clearly exposed and completely removed,with the sufficient decompression of spinal cord,nerve root and dural sac.The operation duration was 115.4±23.8 minutes(range,70 to 180 mins).Intraoperative bleed loss was 122.6±21.3 ml(range,40 to 310 ml).The patients were followed up for averagely 21.6 months(range,12 to 36 months).At the final follow-up,VAS score decreased from preoperative 7.2±1.9 to 1.8±1.1,and ODI decreased from preoperative 64.3%±13.9%to 16.3%±5.1%(P<0.05).The anterior height of intervertebral space recovered from preoperative 7.8±1.5 mm to 11.9±2.3 mm,and the posterior height of intervertebral space recovered from preoperative 4.5±1.1 mm to 7.4±1.6 mm(P<0.05).According to modified MacNab criteria,the results were excellent in 9 cases and good in 1 case.Conclusion For thoracolumbar or upper LDH associated with VO,thoracic endoscopic-assisted anterior-lateral decompression and fusion provided clear vision of the surgical field,fully exposed and completely removed the herniated disc and ossification,which achieved satisfactory short-term results.