椎间孔与椎间孔外腰椎间盘突出的分型及治疗

椎间孔与椎间孔外腰椎间盘突出的临床表现轻重不一，非手术治疗的效果亦不相同。作者发现这种差异可能与腰椎间盘突出相对于椎弓根的位置有关，故依此将其分两型。Ⅰ型：突出椎间盘向头侧移位至椎弓根下缘；Ⅱ型：椎间盘向外侧突出为主伴有轻微的头侧移位。又根据是否合并后外侧突出，将每型分为ａ、ｂ两个亚型。ａ：单纯椎间孔或椎间孔外突出；ｂ：合并有后外侧突出。按此分型，本组２３例中，Ⅰａ型８例、Ⅰｂ型２例，Ⅱａ型７例、Ⅱｂ型６例。Ⅰ型组病情重，保守治疗效果差，均需手术治疗；Ⅱ型组病情较轻，甚至无症状，５０％的患者经保守治疗可愈。故建议对Ⅰ型病例积极手术治疗，Ⅱ型病例宜先予非手术治疗，如无效再予手术。本组采用经峡部外缘入路腰椎间盘切除术１２例，结果表明本法优于传统的手术治疗方式，适用于绝大部分病例。但对Ⅱｂ型以椎间盘后外侧突出为主的病例，仍可采用椎板与部分关节突切除的方法治疗。

Foraminal and extraforaminal lumbar disc herniations

The severity of the clinical presentations of the foraminal or extraforaminal lumbar disc herniation (FLDH or EFLDH) and its response to conservative treatment were different. In order to make clear the reasons for that and then chose the best method of treatment, two types of FLDH or EFLDH were classified in a group of 23 cases according to the location of the protruded disc shown in the films of CT or MRI. Type I: the disc protruded up to the superior pedicle closely. Type II: the disc protruded laterally mainly with slight moving up. Then two subtypes were made, subtype a: symple FLDH or EFLDH: subtype b: if combined with posterior lateral disc herniation. In total of 23 cases there were 10 of type (I a: 8, I b: 2) and 13 of type II (II a: 7, II b: 6), among of which there were 14 FLDHs and 9 EFLDHs. The clinical presentations and the results of conservative treatment were compared between the two types. The results of statistical analysis showed that the severity of damage to the nerve root and its response to conservative treatment were mainly related to the location of the protruded disc to the superior pedicle rather than the protruded disc in the foramen or extraforamen. All of cases of type I had more severe symptoms and signs, poorer results of conservative treatment and were operated on finally. However some cases of type II only had slight or even no symptoms and signs at all, 50% of the patients in the type II were cured by nonsurgical methods. So it was suggested that the cases of type I be treated surgically mainly, whereas the type II initially be treated conservatively and if failed, go to operation. The approach lateral to the pars interarticularis for the discectomy had more advantages than the other methods and could be applied in most of cases. If combined posterior lateral disc herniation was the main pathologic change in the cases of type II laminectomy with partial facetectomy might be used. The classification is reliable as it is well consisten with the findings of operations. So it is valuable for the guidance of determining the method of nonsurgical or surgical treatment.