椎间盘纤维环损伤分型及其对腰椎间盘突出症患者纤维环缝合修复重建的指导作用

A classification of disc annulus fibrosus injury and its guiding role in the repair and reconstruction of annulus fibrosus in patients with lumbar disc herniation

中文关键词:  腰椎间盘突出症  纤维环损伤  分型  纤维环缝合

英文关键词:Lumbar disc herniation  Annulus fibrosus injury  Classification  Annulus fibrosus suture

中文摘要:

  【摘要】 目的：提出椎间盘纤维环损伤分型方法并探讨其对腰椎纤维环缝合修复重建的指导价值。方法：根据内镜手术中所见纤维环损伤程度及位置将其分为Ⅰ～Ⅳ型，Ⅰ型，纤维环无全层破裂，髓核摘除手术时需人为横向切开；Ⅱ型，纤维环有纵行破裂无缺损，并根据破裂长度不同分为ⅡA（＜1cm）、ⅡB（1～1.5cm）、ⅡC（＞1.5cm）三个亚型；Ⅲ型，纤维环中央破裂且有缺损，根据缺损最长径分为ⅢA（≤1cm）、ⅢB（>1cm）两个亚型；Ⅳ型，纤维环靠近终板破裂且有缺损，根据缺损最长径分为ⅣA（≤1cm）、ⅣB（>1cm）两个亚型。回顾性分析我院136例单节段腰椎间盘突出症患者，男75例，女61例，年龄36.5±10.3岁。按照上述分型方法，Ⅰ型11例，均采取常规单线线形缝合；Ⅱ型均采用近终板骨道法进行缝合，ⅡA型26例采取线形缝合，ⅡB型13例采取三角缝合，ⅡC型3例均选择放弃缝合；ⅢA型3例采取三角缝合、3例采取十字缝合，ⅢB型2例放弃缝合；Ⅳ型同样采用近终板骨道法进行缝合，ⅣA型52例采用三角缝合，15例采用平行线缝合，4例缝合失败，ⅣB型4例放弃缝合。术前、术后3个月及末次随访时采用视觉模拟量表（visual analogue scale，VAS）评估患者疼痛情况，采用Oswestry功能障碍指数（Oswestry disability index，ODI）评估患者腰椎功能状况；末随访复查MRI，观察纤维环愈合情况并对比术前椎间隙高度变化，最终采用MacNab评价标准评估疗效。结果：136例患者均顺利完成髓核摘除、神经根减压手术。术中无神经根损伤、硬膜囊撕裂、类脊髓高压综合征等并发症；手术时间36～50min，平均44.50（36.25，50.00）min。根据纤维环损伤分型，总体对127例实施了缝合，缝合率93.38%，123例成功完成缝合，成功率96.85%。136例患者均获随访，随访时间9～24个月，平均13.2个月。末次随访6例复发，ⅡC型1例（未缝合），ⅢA型1例（缝合），ⅣA型4例（3例缝合，1例缝合失败），复发率4.412%，椎间隙高度与术前无明显变化（P>0.05），术后3个月和末次随访的腰痛、腿痛VAS评分及ODI均较术前显著改善（P<0.05）。采用MacNab标准评价疗效，获优108例、良14例、可8例、差6，优良率89.71%。结论：腰椎间盘纤维环损伤分型简单、明确；采用与其分型相适宜的纤维环缝合修复手术，具有较高缝合成功率并可规避不必要的缝合，有一定的临床指导价值。

英文摘要:

  【Abstract】 Objectives: To propose a classification method of intervertebral disc annulus fibrosus injury and explore its guiding values for annulus fibrosus repair and reconstruction in lumbar spine. Methods: Based on the degree and location of annulus fibrosus injury observed during endoscopic surgery, injuries were classified into types Ⅰ-Ⅳ. Type Ⅰ, no full-thickness tear in the annulus fibrosus, requiring artificial transverse incision during nucleus pulposus removal surgery; Type Ⅱ, longitudinal tear in the annulus fibrosus without defect, and which was further subdivided into ⅡA(≤1cm), ⅡB(1-1.5cm), and ⅡC(≥1.5cm) based on the tear length; Type Ⅲ, central tear in the annulus fibrosus with defect, and which was subdivided into ⅢA(≤1cm) and ⅢB(>1cm) based on the longest diameter of the defect; Type Ⅳ, tear in the annulus fibrosus near the endplate with defect, which was subdivided into ⅣA(≤1cm) and ⅣB(>1cm) based on the longest diameter of the defect. A retrospective analysis was conducted on 136 patients with single-segment lumbar intervertebral disc protrusion in our hospital. There were 75 male cases and 61 female cases, with an age of 36.5±10.3 years. According to the classification method, out of the 136 patients, 11 cases were classified as type Ⅰ, underwent conventional single-line linear suturing; Type Ⅱ cases were treated with near-endplate bone tunnel method for suturing, with type ⅡA 26 cases using linear suturing, type ⅡB 13 cases using triangular suturing, and type ⅡC 3 cases were abandoned suturing; For type ⅢA, 3 cases used triangular suturing and 3 used cross suturing, while 2 type ⅢB cases were abandoned suturing; Type Ⅳ cases also used the near-endplate bone tunnel method for suturing, with 52 type ⅣA cases using triangular suturing, 15 using parallel line suturing, 4 cases were failed in suturing, and 4 type ⅣB cases were abandoned suturing. The visual analogue scale(VAS) was used to assess the pain of the patients, and the Oswestry disability index(ODI) was used to assess the lumbar function of the patients before operation, at postoperative 3 months and final follow-up. At final follow-up, MRI was reexamined to observe the healing of the annulus fibrosus and compare the changes from the preoperative intervertebral; The MacNab criteria were used to assess the therapeutic effect. Results: All the patients successfully underwent nucleus pulposus removal and nerve root decompression surgery. There were no intraoperative complications such as nerve root injury, dural sac tear, or pseudospinal hypertension syndrome. The operation time ranged from 36min to 50min, with an average of 44.50(36.25, 50.00)min. Overall, according to the classification of annulus fibrosus injury, suturing was performed in 127 cases, with a suturing rate of 93.38%, and among which 123 cases successfully completed suturing, with a success rate of 96.85%. All 136 patients were followed up for 9-24 months, averaged 13.2 months. At final follow-up, there were 6 recurrences, including 1 type ⅡC(not sutured), 1 type ⅢA(sutured), and 4 type ⅣA(3 sutured, 1 suturing failure), with a recurrence rate of 4.412%. The intervertebral space height measured at final follow-up showed no significant change compared to the preoperative height(P>0.05), while the VAS scores for low back pain and leg pain, and ODI at 3 months postoperatively and at final follow-up were significantly improved compared to the preoperative levels(P<0.05). According to the MacNab criteria, there were 108 excellent, 14 good, 8 fair, and 6 poor in outcomes, with an excellent and good rate of 89.71%. Conclusions: The classification of lumbar disc annulus fibrosus injury is simple and clear; Adopting corresponding annulus fibrosus suturing repair surgery that is suitable for such classification can yield a high success rate of suturing and avoid unnecessary suturing, which has certain values in guiding clinical practice.