经椎板间隙入路完全内窥镜下椎间盘摘除术治疗L5/S1非包含型椎间盘突出症

Full-endoscopic discectomy through interlaminar approach for the treatment of L5/S1 non-contained lumbar disc herniation

中文关键词:  腰椎间盘突出症  经皮内窥镜下椎间盘摘除术  经椎板间隙入路

英文关键词:Lumbar disc herniation  Percutaneous endoscopic discectomy  Interlaminar approach

中文摘要:

  【摘要】 目的：前瞻性研究经椎板间隙入路完全内窥镜下椎间盘摘除术治疗L5/S1非包含型椎间盘突出症的临床疗效。方法：2011年4月~2011年12月采用经椎板间隙入路完全内窥镜下L5/S1椎间盘摘除术治疗L5/S1椎管内非包含型椎间盘突出症患者72例，其中男36例，女36例；年龄18~78岁，平均40.5岁；脱出型51例，游离型21例。将椎管内L5/S1椎间盘非包含型突出按照突出物与同侧S1神经根的位置关系分为腋型（30例）、腹型（28例）及肩型（14例）。对于腋型突出采用腋路，将内窥镜及工作套管直接置入S1神经根腋部进行脱出物及椎间盘内松动髓核的摘除；对肩型及腹型突出采用肩路，将内窥镜及工作套管置入S1神经根肩部进行手术。术后第2天及术后3个月复查腰椎MRI评估突出物切除的彻底性。记录术前、术后3个月、术后6个月及术后12个月的腰痛视觉模拟评分（visual analogue scales，VAS）、腿痛VAS及Oswestry功能障碍指数（Os?鄄westry disability index，ODI）并比较术前及术后各时间点的统计学差异。评估术后12个月时MacNab腰椎功能评分及S1神经根功能状态。结果：手术均顺利完成，手术时间20~80min，平均45min。无神经损伤、感染及其他手术并发症。术后第2天复查MRI显示致压突出物完全切除率为100%。1例术后2个月椎间盘突出复发，采用显微内窥镜下椎间盘摘除术翻修；其余71例术后3个月腰椎MRI显示椎间盘后缘获良好塑形。术后各时间点腰痛VAS、腿痛VAS及ODI均较术前明显降低（P<0.05）。术后12个月时MacNab评分，优44例，良26例，可1例，差1例。术后1年随访S1神经根支配区感觉、肌力明显恢复（P<0.01），跟腱反射无明显恢复（P>0.05）。结论：根据椎间盘突出部位选择腋路或肩路经椎板间隙完全内窥镜下椎间盘摘除术治疗L5/S1椎管内非包含型椎间盘突出症安全、合理，短期疗效较好。

英文摘要:

  【Abstract】 Objectives: To prospectively investigate the clinical outcome of full-endoscopic discectomy through interlaminar approach for L5/S1 non-contained lumbar disc herniations. Methods: From April 2011 to December 2011, 72 cases with L5/S1 imtracanalicular non-contained disc herniations were treated with full-endoscopic discectomy through interlaminar approach. There were 36 females and 36 males. The average age was 40.5 years(range, 18-78y). 51 cases presented with disc protrusion and 21 with sequesteration. L5/S1 disc herniation was divided into three types according to position of herniated disc related to ipsilateral S1 nerve root: axilla type(30 cases), ventral type(28 cases), shoulder type(14 cases). As for axilla type, the endoscope and working channel was placed between S1 nerve root and dural sac, while as for shoulder and ventral type, the endoscope and working channel was placed laterally to S1 nerve root. MRI was pereformed 1 day and 3 months after operation to evaluate the residue nuclear pulposus. Visual analogue scales(VAS) of low back pain and sciatica, Oswestry disability index(ODI) of preoperation, 3 months, 6 months and 12 months postoperative was recorded and compared. MacNab scores and functional status of S1 nerve root were evaluated at the 12-month follow-up. Results: All operations were completed successfully. The average operation time was 45min(20-80min). Reoccurrence was noted in only 1 case 2 months after primary operation and revisional microendoscopic discectomy was performed. The other 71 patients achieved good MRI outcomes 3 months after operation. No nerve injury and infection were noted. Postoperative ODI and VAS of low back pain and sciatica significantly decreased at each time point(P<0.05). MacNab scores of 12-month follow-up included 44 excellent, 26 good, 1 fair and 1 poor; functional status of S1 nerve root showed significant recovery. Conclusions: Based on the sites of prolapsed or sequestered disc materials, full-endoscopic L5/S1 discectomy through interlaminar approach is safe, rational and minimal invasive, its short-term clinical outcome is reliable.