大通道全内镜下经椎板间入路腰椎间盘切除术治疗重度向下移位型腰椎间盘突出症的临床疗效

Clinical effectiveness of large channel interlaminar endoscopic lumbar discectomy in the treatment of highly downward migrated-lumbar disc herniation

中文关键词:  腰椎间盘突出症  重度向下移位  大通道内镜  经椎板间隙入路内镜下腰椎间盘切除术  开窗

英文关键词:Lumbar disc herniation  Highly downward migration  Large channel endoscopy  Interlaminar endoscopic lumbar discectomy  Fenestration

中文摘要:

  【摘要】 目的：探讨大通道内镜下经椎板间入路腰椎间盘切除术治疗重度向下移位型腰椎间盘突出症（highly downward migrated-lumbar disc herniation，HDM-LDH）的临床疗效。方法：回顾性分析2020年12月~2024年6月在我院接受手术治疗的单节段HDM-LDH患者的临床资料，其中83例采用大通道内镜下经椎板间隙入路腰椎间盘切除术，男56例，女27例，年龄16～79岁（42.6±13.3岁），随访23.7±6.6个月，纳入内镜组；73例采用开放式椎板开窗髓核摘除术，男49例，女24例，年龄18～72岁（39.5±13.4岁），随访23.1±5.8个月，纳入开窗组。两组患者基线数据无显著性差异（P>0.05），具有可比性。统计并比较两组患者手术时间、切口长度、术中透视次数、术中出血量、术后引流量和术后住院时间；记录两组患者术前和术后3个月、12个月及末次随访时的腰腿痛视觉模拟量表（visual analogue scale，VAS）评分和Oswestry功能障碍指数（Oswestry disability index，ODI）；测量术前、术后12个月及末次随访时的椎间盘前后径和硬膜囊横截面积以评价椎间盘切除情况和椎管减压效果；末次随访时采用改良MacNab标准评价临床疗效。结果：两组手术时间无统计学差异（P>0.05），内镜组切口长度（1.3±0.2cm）、术中出血量（19.0±7.5mL）、术后住院时间（2.8±0.6d）少于开窗组（分别为4.5±0.5cm、65.3±41.1mL、5.1±0.8d），差异均有统计学意义（P<0.05）。内镜组术中透视次数多于开窗组（2.4±0.5次 vs 1.3±0.4次，P<0.05）。开窗组术后引流量为40.0±13.1mL，内镜组无需引流。两组术后各时间点腰腿痛VAS评分、ODI、椎间盘前后径和硬膜囊横截面积较术前均有显著性改善（P<0.05），两组间同时间点比较均无显著性差异（P>0.05）。末次随访时，根据改良MacNab标准评定，内镜组优良率为92.7%，开窗组为91.8%，差异无统计学意义（P>0.05）。结论：与开放式椎板开窗髓核摘除术相比，大通道内镜下经椎板间隙入路内镜下腰椎间盘切除术治疗HDM-LDH时不仅临床疗效满意，还具有创伤小、出血量少、术后住院时间段且术后无须引流等优势。

英文摘要:

  【Abstract】 Objectives: To explore the clinical effectiveness of large channel interlaminar endoscopic lumbar discectomy in the treatment of highly downward migrated-lumbar disc herniation(HDM-LDH). Methods: A retrospective analysis was conducted on the clinical data of patients with single-level HDM-LDH who underwent surgical treatment at our hospital between December 2020 and June 2024. Among them, 83 cases treated with large channel interlaminar endoscopic lumbar discectomy(56 males and 27 females, age range 16-79 years, average age 42.6±13.3 years) with a follow-up period of 23.7±6.6 months, were included in the endoscopy group. A control group of 73 cases underwent mini-open fenestration discectomy(49 males and 24 females, age range 18-72 years, average age 39.5±13.4 years) with a follow-up period of 23.1±5.8 months, were included in the fenestration group. There was no statistical differences between the two groups in age, gender or follow-up period(P>0.05). The operative time, incision length, intraoperative fluoroscopy frequency, intraoperative blood loss, postoperative drainage, and postoperative hospital stays were compared between the two groups. The visual analogue scale(VAS) score for pain and Oswestry disability index(ODI) were recorded preoperatively, at 3 months and 12 months postoperatively, and final follow-up visit. At preoperation, postoperative 12-month, and final follow-up, the anterior-posterior diameter of the intervertebral disc and cross-sectional area of the dural sac were measured to evaluate the disc removal and spinal decompression effects. At final follow-up, clinical efficacy was evaluated by the modified MacNab criteria. Results: No statistical difference was observed in operative time between the two groups(P>0.05). The endoscopy group was shorter in incision length(1.3±0.2cm vs 4.5±0.5cm), less in intraoperative blood loss(19.0±7.5mL vs 65.3±41.1mL), and shorter in postoperative hospital stays(2.8±0.6d vs 5.1±0.8d) than the fenestration group, with statistically significant differences(P<0.05). The number of intraoperative fluoroscopy times was higher in the endoscopy group(2.4±0.5 vs 1.3±0.4, P<0.05). The fenestration group had a postoperative drainage of 40.0±13.1mL, while no drainage was required in the endoscopy group. Both groups showed significant improvements in VAS score, ODI, anterior-posterior diameter of the intervertebral disc and the cross-sectional area of the dural sac at all postoperative time points(P<0.05), with no significant differences between the two groups at the same time points(P>0.05). At final follow-up, the clinical efficacy according to the modified MacNab criteria showed an excellent-good rate of 92.7% in the endoscopy group and 91.8% in the fenestration group, with no significant difference(P>0.05). Conclusions: For the treatment of HDM-LDH, large channel interlaminar endoscopic lumbar discectomy can offer advantages such as smaller trauma, less intraoperative blood loss, shorter postoperative hospital stays, and no need for drainage postoperatively, which can achieve clinical effectiveness comparable to mini-open fenestration discectomy.