完全内窥镜下经椎板间入路手术治疗腰椎间盘突出症术中转为开放手术的原因分析

Analysis of the causes of intraoperative conversion to open surgery for full endoscopic interlaminar disectomy

中文关键词:  腰椎间盘突出症  椎间盘摘除术  内窥镜  椎板间入路  开放手术

英文关键词:Lumbar disc herniation  Discectomy  Endoscopy  Interlaminar approach  Open surgery

中文摘要:

  【摘要】 目的：总结分析在完全内窥镜（full endoscopic，FE）下经椎板间入路手术治疗腰椎间盘突出症术中转为开放手术的原因，并提出相应的预防措施。方法：回顾性分析2008年8月~2010年8月应用单通道FE经椎板间入路手术治疗的50例单节段腰椎间盘突出症患者的临床资料，总结术中转为开放手术的病例，分析其发生原因，并提出相应预防措施。结果：共5例（10%）转为开放手术，其中男3例，女2例，年龄29～44岁，平均36.2岁；病程35～105d，平均58.4d；L5/S1 4例，L4/5 1例，侧方型突出3例，旁中央型突出1例，游离型突出1例。1例因工作鞘位置不佳造成黄韧带鉴别困难而转为开放；1例大块髓核脱出且病程较长患者术中神经根明显粘连，由于神经根分离与止血困难而改为开放，该例同时合并硬膜损伤；3例因FE术中无法暴露神经根而转为开放，开放手术时见神经根起始点位置低于操作间隙下位椎板，需切除部分侧隐窝骨结构才能显露神经根。开放手术后，3例下肢痛消失，2例减轻。结论：操作通道定位不佳、适应证选择不当和神经根走行变异是在FE下经椎板间入路手术治疗腰椎间盘突出症术中转为开放手术的原因，术者丰富的微创经验、合理病例选择与术前腰神经根走向影像学检查可有效预防FE手术转为开放手术。

英文摘要:

  【Abstract】 Objective：To analyze the causes of intraoperative conversion to open surgery for full endoscopic interlaminar disectomy，and to provide the correspondence prevention.Method：Retrospectively analyze 50 patients who had single-level lumbar disc herniation and undergone unilateral full endoscopic interlaminar discectomy from August 2008 to August 2010.The causes of intraoperative conversion to open surgery were summarized，and the effective preventions were also analyzed.Result：5 cases were converted to open surgery，with the conversion rate of 10%.There were 3 males and 2 females with the mean age of 36.2（range，29-44 years） years old.The average course duration was 58.4 days（range，35-105 days）.L5/S1 was involved in 4 cases and L4/5 in 1.The pathological type was lateral extrusion in 3 cases，paramedian extrusion in 1 and sequestration in 1.Of 5 cases of conversion to open surgery，misplacement of working portal was noted in 1 case；difficulty in dissection of nerve root and followed by hemostasis in 1 case who was complicated with dural injury；unavailability of exposure of nerve root in 3 cases.During the open procedure，the starting point of the nerve root at the dura lower than inferior laminar edge wa found.Therefore，partial removal of bony structures along lateral recesses was necessary in order to expose the nerve root.3 cases had lower extremity pain relieved and 2 alleviated after open surgery.Conclusion：The causes of intraoperative conversion to open surgery for full endoscopic interlaminar disectomy include imprecise placement of working portal，wrong indication and nerve root variation.The surgeon′s endoscopic experiences，right indications，and preoperative radiological examination of nerve root orientation can prevent full endoscopic interlaminar disectomy being converted to open surgery.