经皮内窥镜下手术治疗腰椎间盘突出症的并发症及其防治策略

Percutaneous endoscopic lumbar discectomy：the complications and their interventions

中文关键词:  腰椎间盘突出症  经皮内窥镜下腰椎间盘切除术  并发症

英文关键词:Lumbar disc herniation  Percutaneous endoscopic lumbar discectomy  Complication

中文摘要:

  【摘要】 目的：总结经皮内窥镜下腰椎间盘切除术（PELD）治疗腰椎间盘突出症的手术并发症，并探讨其防治策略。方法：2005年5月~2011年12月采用PELD共治疗腰椎间盘突出症患者893例（YESS技术234例，TESSYS技术659例），男524例，女369例；年龄14～83岁，平均44．3岁。46例为复发性腰椎间盘突出症。患者均存在明显腰腿痛，并经CT及MRI检查证实为腰椎间盘突出或术后复发，无椎间盘钙化或椎体后缘离断及腰椎不稳或滑脱；经保守治疗3个月以上无效。旁中央型突出371例，外侧型突出417例，极外侧型突出37例，游离型突出58例，中央型突出10例；L2/3 4例，L3/4 26例，L4/5 552例，L5/S1 296例，L3/4、L4/5 10例，L4/5、L5/S1 5例。均在局麻及影像监视下行PELD。观察术中、术后并发症及其处理方法。结果：共发生并发症59例次，发生率为6.61%。其中6例髓核部分残留患者残留髓核压迫神经根，再次行后路内窥镜下椎间盘切除术（MED）后痊愈。1例术中硬脊膜撕裂，为复发性椎间盘突出症患者，术中即发现脑脊液渗漏，予胶原蛋白海绵覆盖破口，严密缝合伤口并加压包扎后痊愈。3例神经损伤，均为一期行同侧L3/4、L4/5 PELD患者，予以神经营养、理疗等治疗，2例术后3～6个月内完全恢复，1例未恢复。2例术后椎间隙感染，经抗感染、卧床休息等保守治疗后痊愈。1例发生腹膜后血肿，予以加压包扎、卧床休息，血肿逐渐吸收。24例患者术后出现感觉异常，经神经营养及理疗1~3周后均恢复。术后随访6~75个月，平均31.6个月，共有22例复发，14例二次行MED术，8例行微创腰椎融合术（MIS-TLIF）。结论：PELD手术的并发症并不少见，应严格掌握手术适应证，提高手术技巧，并做好相应的应对措施。

英文摘要:

  【Abstract】 Objectives: To summarize and analyze the complications in percutaneous endoscopic lumbar discectomy(PELD) for lumbar disc herniation, and to investigate their interventions． Methods: A retrospective review was performed on 893 patients(524 males and 369 females) with lumbar disc herniation treated by PELD between May 2005 and December 2011. The average age was 44.3 years old. 234 patients underwent YESS and 659 underwent TESSYS. Among them, there were 46 cases with recurrent lumbar disc herniation. All of the patients had typical low back pain and leg pain which was not respond to conservative treatment for at least 3 months, and were confirmed as lumbar disc herniation or recurrence LDH and no evidence of disc calcification, lumbar body posterior bony edges separation, instability and spondylolisthesis by CT and MRI. The types of herniaton were para-central protrusion in 371 cases, lateral protrusion in 417 cases, far lateral extrusion in 37 cases, sequestration in 58 cases, and central protrusion in 10 cases. The levels of herniation were L2/3 in 4 cases, L3/4 in 26 cases, L4/5 in 552 cases, L5/S1 in 296 cases, L3/4 and L4/5 in 10 cases, L4/5 and L5/S1 in 5 cases. After local anesthesia, PELD was performed assisted by C-arm monitoring. The complications during operation and after operation were studied retrospectively． Results: The complications were found in 59 cases, with the incidence rate of 6.61%. Dural tear was found in 1 patient, which recovered after the tear repairing and covered with collagen sponge and tightly suturing the incision. Fragment omissions were noted in 6 patients, who recovered after underwent second discectomy by MED. 3 patients had nerve root injury, 2 of them recovered completely in 3-6 months after operation, however the other one showed no improvement． Postoperative spondylodiscitis was noted in 2 patients and retroperitoneal hematoma in 1 patient, all healed after conservative treatment. Postoperative dysesthesia was noted in 24 patients, which was resolved by neurotrophy and physiotherapy in 1-3 weeks. The mean follow-up period was 31.6 months(range，6-75 months). Recurrent disc herniation occurred in 22 patients, with the recurrence rate of 2.5%. 14 patients underwent second discectomy by MED, and 8 patients underwent MIS-TLIF. Conclusions: The complications in PELD are not uncommon, as a result, PELD should be indicated strictly and managed properly.