术前影像学评估在内窥镜下经椎间孔入路手术治疗腰椎间盘突出症中的作用

The preoperative imaging assessment in the endoscopic transforaminal approach for lumbar disc herniation

中文关键词:  腰椎间盘突出症  术前影像学评估  经椎间孔入路

英文关键词:Lumbar disc herniation  Preoperative imaging assessment  Transforaminal approach

中文摘要:

  【摘要】 目的：探讨术前影像学评估在制定内窥镜下经椎间孔入路治疗腰椎间盘突出症手术方案中的作用。方法：回顾性分析2008年7月~2012年12月我院191例采用内窥镜下经椎间孔入路治疗腰椎间盘突出症患者的影像学资料，术前影像学评估指标包括椎间盘突出节段、突出位置、髂嵴高度、髂嵴最高点和S1椎弓根内侧缘所连直线与S1椎体上缘水平线的夹角（α）、L5椎弓根下缘5mm（即L5椎弓根下缘距穿刺针的距离）与髂嵴最高点之间的连线（d）、椎间隙后缘高度（H1）、椎间孔的垂直高度（H2）。将d与S1椎体上缘相交的位置分为3个区域，1区：L5/S1椎间隙中点以及对侧区域；2区：L5/S1椎间隙中点（不含此点）到S1椎弓根内侧缘；3区：S1椎弓根内侧缘以外的区域。所有患者均观察椎间盘突出节段、突出位置并测量H1、H2，其中L5/S1椎间盘突出者加测髂嵴高度、α、d、d所落手术区域。H1≤4mm及H2≤15mm为椎间孔狭窄。记录术中18G穿刺针穿刺达到靶向手术区域的次数。结果：L5/S1椎间盘突出85例（44.50%），L4/5及以上突出106例（55.50%）。突出位置在中央区17例（8.90%），在侧隐窝区146例（76.44%），在椎间孔区24例（12.57%），在椎间孔外侧区（极外侧区）4例（2.09%）；椎间孔狭窄9例（4.71%）。85例L5/S1椎间盘突出患者中，髂嵴高度平对L4椎体中、上1/3者3例（3.53%），平对L4椎体下1/3及以下者82例（96.47%）；α≤30°者69例（81.18%），30°<α≤40°者16例（18.82%）；d落在1区68例（80.00%），2区14例（16.47%），3区3例（3.53%）。当髂嵴高度平对L5椎体及以下者时，穿刺次数平均为16次（12~41次）；平对L4椎体下1/3~L4/5椎间隙时，穿刺次数平均为29次（16~46次）；平对L4椎体中、上1/3时，穿刺次数平均为39次（36~44次）。结论：髂嵴高度、α、d及d所落手术区域主要影响L5/S1椎间盘突出的手术操作，对于突出节段在L4/5及以上者，穿刺针可水平进入而基本上不受上述影像学因素的影响。椎间盘突出节段、突出位置、H1、H2则对所有节段操作均有影响。

英文摘要:

  【Abstract】 Objectives: To discuss the role of preoperative imaging assessment in surgery potocol for transforaminal lumbar disc herniation. Methods: The imaging data of 191 patients with lumbar disc herniation and treated with endoscopic transforaminal approach was analyzed in our hospital from July 2008 to December 2012. Preoperative radiographic evaluation included the diseased disc segments, the protusion position, the height of iliac crest, the included angle between the line connecting the highest point of the iliac crest to the S1 pedicle medial edge and the horizontal line of the upper edge of S1 vertebra(α), the line connecting under 5mm of the L5 pedicle(the distance from lower edge of the L5 pedicle to the puncture needle) and the highest point of the iliac crest(d), posterior height of intervertebral space(H1), the vertical height of the intervertebral foramen(H2). The intersecting position of d and upper edge of S1 vertebral was divided into three regions: Region 1, the midpoint of L5/S1 intervertebral space and contralateral area; Region 2, the midpoint of L5/S1 intervertebral space(excluding this point) to the S1 pedicle medial edge; Region 3, outside of the S1 pedicle medial edge. The prominent disc segments, the prominent position and H1 and H2 was meassured in all cases. The height of iliac crest, α, d and the intersecting position of d and upper edge of S1 vertebra should be measured additionally in the 85 cases of L5/S1 disc herniation. H1≤4mm and H2≤15mm could be identified as the foraminal stenosis. The number of the 18G puncture needle reaching the targeted surgical area intraoperatively was recorded. Results: The L5/S1 disc herniation was noted in 85 cases(44.50%) and L4/5 or upper in 106 cases(55.50%); the prominent position in the central area, lateral recess area, intervertebral foramen area and outside area of the intervertebral foramen(extreme lateral area) was in 17 cases(8.90%), 146 cases(76.44%), 24 cases(12.57%) and 4 cases(2.09%) respectively; the foraminal stenosis was noted in 9 cases(4.71%). Among 85 cases with L5/S1 disc herniation, the height of iliac crest against the middle 1/3 or upper of L4 vertebral body was noted in 3 cases(3.53%), againsting the lower 1/3 or lower of L4 vertebral body was noted in 82 cases(96.47%); α≤30° was noted in 69 cases(81.18%), 30°<α≤40° was in 16 cases(18.82%); d on the region 1, 2 and 3 was in 68 cases(80.00%), 14 cases(16.47%) and 3 cases(3.53%) respectively. As the height of iliac crest against the L5 vertebral body or lower, the average number of puncture was 16 times(12-41 times). When againsting the lower 1/3 of L4 vertebral body to the intervertebral space of L4/5, the average number of puncture was 29 times(16-46 times). When againsting the middle 1/3 or upper of L4 vertebral body, the average number of puncture was 39 times(36-44 times). Conclusions: The height of iliac crest, α, d and the intersecting position of d and upper edge of S1 vertebra mainly affect the operating segments in L5/S1. For the operating segments in the L4/5 and above, the 18G puncture needle can be punctured horizontally irresponsible to the above radiographic factors. The herniated disc segments and position, H1 and H2 affect all the operating segments.