应用可视骨凿精准成形在全可视脊柱内镜下手术治疗腰椎间盘突出症的疗效分析

The efficacy of accurate foraminoplasty technique with visualized chisel under full-visualized spinal endoscopy in treating lumbar disc herniation

中文关键词:  腰椎间盘突出症  精准成形技术  全可视脊柱内镜技术  脊柱微创

英文关键词:Lumbar disc herniation  Accurate foraminolplasty technique  Full visualized spinal endoscopy  Spinal minimally invasive surgery

中文摘要:

  【摘要】 目的：探讨应用可视骨凿精准成形技术在全可视脊柱内镜（full-visualized spinal endoscopy，FVSE）下手术治疗腰椎间盘突出症的临床疗效。方法：回顾性分析2020年7月~2022年12月在我院行FVSE下手术治疗的143例单节段腰椎间盘突出症患者的临床资料。其中63例应用可视骨凿精准成形技术（骨凿组），男37例，女26例，年龄19~68岁（45.3±15.1岁），体重指数（body mass index，BMI）19.2~25.6kg/m2（22.3±1.8kg/m2）；L2/3 8例，L3/4 15例，L4/5 25例，L5/S1 15例；膨隆型20例，突出型22例，脱出型12例，游离型9例；中央型10例，旁中央型21例，椎间孔型24例，极外侧型8例。80例应用环锯切除部分上关节突成形技术（环锯组），男46例，女34例，年龄19~68岁（43.8±14.1岁），BMI 19.2~24.1kg/m2（21.5±1.6kg/m2）；L2/3 9例，L3/4 17例，L4/5 30例，L5/S1 24例；膨隆型23例，突出型31例，脱出型19例，游离型7例；中央型13例，旁中央型27例，椎间孔型29例，极外侧型11例。记录并比较两组患者手术时间、术中总出血量、透视次数、住院时间，测量术前、术后3d及末次随访时手术节段椎间孔面积，术前、术后3d、术后1个月、术后6个月及末次随访时行腰腿痛视觉模拟评分（visual analogue scale，VAS）、Oswestry功能障碍指数（Oswestry disability index，ODI）评定及日本骨科协会（Japanese Orthopedic Association，JOA）评分，末次随访时采用MacNab标准评估疗效。结果：骨凿组手术时间、术中总出血量与透视次数分别为84.6±14.3min、23.1±8.3mL与2.9±1.6次，环锯组分别为86.6±15.1min、32.2±6.4mL与5.6±1.0次，骨凿组总出血量及透视次数均较环锯组少（P＜0.05），两组手术时间无显著性差异（P＞0.05）。143例患者均获得随访，随访时间9~20个月，两组术后3d及末次随访时的椎间孔面积均较术前变大（P＜0.05），环锯组术后3d及末次随访时的椎间孔面积变化率均大于骨凿组（P＜0.05）。两组术后3d、1个月、6个月与末次随访时的VAS评分、JOA评分和ODI与术前比较均有显著性改善（P＜0.05），两组同时间点比较均无统计学差异（P＞0.05）。末次随访时MacNab标准疗效评定，骨凿组优43例，良18例，中2例，差0例，优良率96.8%；环锯组优57例，良20例，中3例，差0例，优良率96.3%，两组优良率无显著性差异（P＞0.05）。结论：FVSE下应用骨凿精准成形技术治疗单节段腰椎间盘突出症与应用环锯成形技术的临床效果相近，但应用可视骨凿精准成形术中透视次数少、出血少。

英文摘要:

  【Abstract】 Objectives: To explore the clinical efficacy of applying the accurate foraminoplasty technique with visualized chisel under full-visualized spinal endoscopy(FVSE) in the treatment of lumbar disc herniation(LDH). Methods: The clinical data of 143 patients with single-segment LDH undergone operative treatment under FVSE in our hospital between July 2020 and December 2022 were retrospectively analyzed. 63 cases were treated with the accurate framinoplasty technique with visualized chisel(Chisel group), consisting of 37 males and 26 females, aged 45.3±15.1 years(range, 19-68 years), and body mass index(BMI) was 22.3±1.8kg/m2(range, 19.2-25.6kg/m2); Operative segment: L2/3 in 8 cases, L3/4 in 15 cases, L4/5 in 25 cases, L5/S1 in 15 cases; LDH anatomical classification: 20 cases of bulging type, 22 cases of protruding type, 12 cases of prolapsing type, and 9 cases of free type; LDH location classification: 10 cases of central type, 21 cases of paracentral type, 24 cases of foraminal type, and 8 cases of extreme lateral type. The other 80 cases were treated with trepan technique(Trephine group), consisting of 46 males and 34 females, aged 43.8±14.1 years(range, 19-68 years), BMI was 21.5±1.6kg/m2(range, 19.2-24.1kg/m2); Operative segment: L2/3 in 9 cases, L3/4 in 17 cases, L4/5 in 30 cases, and L5/S1 in 24 cases; LDH anatomical classification: 23 cases of bulging type, 31 cases of protruding type, 19 cases of prolapsing type, 7 cases of free type; LDH location classification: 13 cases of central type, 27 cases of paracentral type, 29 cases of foraminal type, and 11 cases of extreme lateral type. The operative time, total intraoperative bleeding, number of fluoroscopies, and hospitalization time were recorded and compared between the two groups. The intervertebral foraminal area before operation, at 3d after operation and final follow-up, visual analogue scale(VAS) score, Oswestry disability index(ODI), and Japanese Orthopedic Association(JOA) score before operation, at postoperative 3d, 1 month, 6 months, and final follow-up were recorded and compared between the two groups. The clinical efficacy was assessed by MacNab criteria at the final follow-up. Results: The operative time, total intraoperative bleeding and number of fluoroscopies were 84.6±14.3min, 23.1±8.3mL and 2.9±1.6 times in the chisel group and 86.6±15.1min, 32.2±6.4mL and 5.6±1.0 times in the trephine group, and the intraoperative bleeding and number of fluoroscopies in the chisel group were less than those in the trephine group(P＜0.05), while no significant difference was there in the operative time between the two groups(P>0.05). 143 patients were followed up for 9-20 months. The VAS scores, JOA scores and ODI at 3d, 1 month, 6 months and the final follow-up of both groups showed significant improvements compared with the preoperative data, respectively(P<0.05), and there was no statistical difference between the two groups at the same time points(P>0.05). The intervertebral foramina area at 3d postoperatively and at the final follow-up in both groups increased than that before surgery(P<0.05), and the rate of change in the intervertebral foramina area at 3d postoperatively and at the final follow-up in the trephine group was greater than that in the chisel group(P<0.05). At the final follow-up, according to the MacNab standard, chisel group was excellent in 43 cases, good in 18 cases, moderate in 2 cases, and poor in 0 case, with an excellence and good rate of 96.8%, while the trephine group was excellent in 57 cases, good in 20 cases, moderate in 3 cases, and poor in 0 case, with an excellence and good rate of 96.3%. There was no statistical difference between the two groups in terms of excellent and good rate according to MacNab criteria(P>0.05). Conclusions: The clinical efficacy of accurate foraminoplasty technique with visualized chisel is similar to foraminalplasty with trephine under FVSE, but foraminoplasty technique with visualized chisel reduces the number of fluoroscopies and bleeding volume.