经单孔分体内镜下单侧减压与双侧减压治疗单侧症状腰椎管狭窄症的临床疗效对比

A comparison of the clinical efficacies of unilateral decompression and bilateral decompression under one-hole split endoscope for lumbar spinal stenosis with unilateral symptom

中文关键词:  单孔分体内镜  腰椎管狭窄症  单侧减压  双侧减压  临床疗效

英文关键词:One-hole split endoscope  Lumbar spinal stenosis  Unilateral decompression  Bilateral decompression  Clinical efficacy

中文摘要:

  【摘要】 目的：探讨应用单孔分体内镜（one-hole split endoscope，OSE）技术行单侧减压或双侧减压治疗中老年单侧症状中重度腰椎管狭窄症（lumbar spinal stenosis，LSS）患者的早期临床疗效。方法：回顾性分析我科自2021年1月～2021年12月应用OSE技术行单侧减压与双侧减压治疗的中重度腰椎管狭窄症的中老年患者，根据纳入及排除标准，共120例患者纳入本研究，单、双侧减压组（A、B组）分别为60例。统计并比较两组患者住院时间、手术时间、切口长度，术中出血量、手术前后腰椎动力X线片的手术节段活动度（range of motion，ROM）及矢状位平移量（sagittal translation，ST）、入路侧关节面保留率及手术节段椎管横截面积（cross-sectional area of the canal，CAC）。术前及术后7d、3个月、18个月时采用疼痛视觉模拟评分（visual analogue score，VAS）评估腰痛和腿痛程度，采用改良Oswestry功能障碍指数（Oswestry disability index，ODI）评估功能改善情况，末次随访采用改良Macnab评估临床疗效，分析并比较两组手术前后临床疗效评估结果。结果：所有患者均顺利完成手术，A组与B组住院时间比较差异无统计学意义（P>0.05），但B组的手术时间、切口长度及术中出血量均大于A组，差异有统计学意义（P<0.05）。两组术后各时间点的腰痛及腿痛VAS评分、ODI均较术前明显降低（P<0.05），组内术后各指标随时间推移改善显著，两两比较差异均有统计学意义（P<0.05）；两组间术前比较差异无统计学意义（P>0.05），术后7d、3个月、18个月B组腰痛及腿痛VAS评分和ODI均较A组改善更明显（P<0.05）。两组手术节段ST、ROM手术前后比较差异均无统计学意义（P>0.05）。术后关节面保留率B组较A组更高（P＜0.05）。手术节段CAC术前两组间比较差异无统计学意义（P>0.05），但术后B组较A组更大（P<0.05），CAC改善率B组较A组更高（P<0.05）；两组术后CAC较术前均明显增大，差异有统计学意义（P<0.05），术后18个月的优良率A组为86.7%，B组为91.7%，两组间优良例数比较差异无统计学意义（P>0.05）。A组1例术后出现健侧下肢麻木不适症状，B组发生1例轻度硬脊膜撕裂。结论：OSE技术行单侧减压和双侧减压治疗中老年单侧症状的中重度中央管及双侧侧隐窝狭窄LSS安全有效，早期临床疗效确切，其中双侧减压较单侧减压更充分，临床疗效更优，但远期疗效需进一步随访。

英文摘要:

  【Abstract】 Objectives: To explore the early clinical efficacies of unilateral decompression and bilateral decompression by one-hole split endoscope(OSE) technique for moderate-severe lumbar spinal stenosis(LSS) with unilateral symptoms amongst middle aged and elderly people. Methods: A retrospective analysis was performed on the patients with moderate-severe LSS who underwent unilateral decompression and bilateral decompression using OSE technique between January 2021 and December 2021. According to the inclusion and exclusion criteria, a total of 120 patients were enrolled in this study, with 60 patients in the unilateral decompression group(group A) and 60 patients in the bilateral decompression group(group B). The length of hospitalization, operative time, incision length and intraoperative blood loss were counted and compared between group A and group B. Moreover, range of motion(ROM) and sagittal translation(ST) on lumbar dynamic X-ray, facet preservation rate on the approach side, and cross-sectional area of the canal(CAC) of the surgical segment before and after operation were recorded and compared. The visual analogue scale(VAS) of back and leg pain was used before surgery, and at 7 days, 3 months and 18 months after surgery, the Oswestry disability index(ODI) was used to evaluate the functional improvement, and the clinical efficacy was evaluated by modified Macnab criteria at the last follow-up. All the clinical scores of both groups were analyzed and compared between before and after surgery. Results: All the patients underwent surgical intervention successfully. There was no statistical significance in the length of hospitalization between groups A and B(P>0.05), but group B was longer in operative time, bigger in incision, and more in blood loss than group A, with statistical significance(P<0.05). The VAS for back and leg pain and the ODI after operation in both groups were all significantly lower than those before surgery, respectively (P<0.05), and the values at each postoperative time point within group were significantly different when compared pairwise(P<0.05); There was no significant difference between the two groups before surgery(P>0.05), but group B had more significant improvement than group A at 7 days, 3 months and 18 months after surgery(P<0.05). There was no statistical significance in ST and ROM of surgical segment before and after surgery between the two groups(P>0.05). The postoperative facet preservation rate was higher in group B than in group A(P＜0.05). There was no significant difference in the CAC of the surgery segment before operation between the two groups(P>0.05), however, the CAC of the surgical segment in group B was larger than that in group A(P<0.05). The rate of improvement in CAC was higher in group B than in group A(P<0.05). The CAC of the surgical segment postoperatively in both groups were significantly larger than before surgery, with statistical significance(P<0.05). Excellent-good rate at 18 months after surgery was 86.7% in group A and 91.7% in group B. There was no significant difference in the number of excellent and good cases between the two groups at 18 months after operation(P>0.05). One patient in group A had numbness and discomfort in the lower limb on the healthy side after surgery, and one case with mild dural tear in group B. Conclusions: Both unilateral decompression and bilateral decompression under OSE are safe and effective in the treatment of moderate and severe central canal and bilateral lateral recess stenosis with unilateral symptoms in the middle-aged and elderly people, with definite early clinical efficacy. Bilateral decompression is more complete and better in clinical efficacy than unilateral decompression, but further follow-up is required in the long term.