经椎间孔入路全内镜下椎体间融合术治疗胸腰段硬性椎间盘突出症的技术要点及临床疗效

Technical notes and clinical outcomes of full-endoscopic interbody fusion via transforaminal approach for hard disc herniations in thoracolumbar junction

中文关键词:  椎间盘突出症  全内镜下椎体间融合术  椎间盘切除术  经椎间孔入路

英文关键词:Intervertebral disc herniation  Full-endoscopic interbody fusion  Discectomy  Transforaminal approach

中文摘要:

  【摘要】目的：探讨经椎间孔入路全内镜下椎体间融合术治疗胸腰段硬性椎间盘突出症的技术要点及临床疗效。方法：纳入2018年1月~2021年9月期间我科采用经椎间孔入路全内镜下椎体间融合术治疗的14例（20个节段）胸腰段硬性椎间盘突出症患者，其中男11例，女3例，平均年龄43.3±12.6岁；2例三节段病变，2例双节段病变，10例单节段病变。硬性致压物分类包括：钙化性椎间盘突出3例、骨赘性椎间盘突出6例、不典型休门氏病合并椎间盘突出3例，椎体后缘离断症2例。术前所有患者均表现脊髓或马尾神经症状，其中6例合并神经根性症状。手术先采用局部麻醉下经椎间孔入路全内镜下椎体间融合、突出椎间盘切除减压，继而行全麻下经皮椎弓根螺钉系统置入术。观察术后第2天、3个月、6个月及1年的影像学变化，术后1周、3个月、6个月及术后1年时疼痛症状及功能恢复状况。背痛及神经根性疼痛采用视觉模拟评分（visual analogue scale，VAS）评估，神经学功能评估采用Nurick评分及改良日本骨科学会（mJOA）评分，胸椎功能评价采用Oswestry功能障碍指数（Oswestry disability index，ODI）。结果：所有手术均顺利完成，无术中更换手术方式发生。所有患者术后胸腰段MRI及CT检查均显示脊髓或马尾神经减压充分，无致压物残留；术后1年随访时，所有手术节段均获得骨性融合。所有患者术后背痛、神经根性疼痛均明显缓解，脊髓功能明显恢复。术后Nurick评分、mJOA评分及ODI较术前均有显著改善（P<0.01），且术后1年较术后1周、3个月及6个月均有显著性改善（P<0.01）。mJOA平均恢复率72.5%，优7例、良5例、可2例。有2例术中出现硬脊膜撕裂，未予特殊处理，但随访未见脑脊液漏及假性脊膜膨出发生；无其他手术并发症发生。结论：局部麻醉下经椎间孔入路全内镜下椎体间融合、突出椎间盘切除结合全麻下经皮椎弓根螺钉系统固定术是治疗位于胸腰段脊髓或马尾神经腹侧的硬性椎间盘突出症的安全、有效的微创脊柱外科技术。

英文摘要:

  【Abstract】 Objectives: To study the technical notes and clinical outcomes of full-endoscopic interbody fusion via transforaminal approach for hard disc herniations in thoracolumbar junction. Methods: 14 patients with disc herniations involving 20 segments of hard disc herniations in thoracolumbar junction treated with full-endoscopic interbody fusion via transforaminal approach between January 2018 and September 2021 were included in the study. There were 11 males and 3 females with an average age of 43.3±12.6 years; 3-segment disease in 2 cases, 2-segment disease in 2 cases, and single segment disease in 10 cases. The hard compression were classified as: 3 cases of calcified disc herniation, 6 cases of osteophyte protrusion of the posterior edge of the adjacent vertebral body of the diseased disc, 3 cases of disc herniations with atypical Scheuermann disease and 2 cases of disc herniation with epiphyseal separation. All patients had symptoms of myelopathy or cauda equina compromise before operation, and 6 of them had radiculopathy. Via transforaminal approach under local anesthesia, full-endoscopic interbody fusion and discectomy were performed firstly, followed with percutaneous pedicle screw system placement and fixation under general anesthesia. Postoperative imaging changes, pain symptoms and recovery of neurological function at 1 week, 3 months, 6 months and 1 year after operation were observed. Back pain and radicular pain were scored with visual analogue scale(VAS), neurological function was assessed with Nurick score and modified Japanese Orthopaedic Association(mJOA) score, and thoracic spine function was assessed with Oswestry disability index(ODI). Results: All operations were successfully completed, and no intraoperative conversion of surgical methods occurred. Postoperative thoracolumbar junction MRI and CT examinations of all patients showed that the spinal cord or cauda equina was sufficiently decompressed without any residual compression. At 1 year follow-up, all surgical segments were fused. Back pain and radicular pain were all relieved significantly in all the patients, and neurological function was significantly restored. The Nurick score, mJOA score and ODI all improved compared with the preoperative values(P<0.01), and the postoperative 1 year values all improved significantly compared with the values at postoperative 1 week, 3 months and 6 months(P<0.01). The average recovery rate of mJOA was 72.5%, with 7 cases excellent, 5 cases good and 2 cases fair. Dural tear occurred in 2 cases during operation, but no cerebrospinal fluid leakage and pseudomeningocele occurred during follow-up. No other surgical complications occurred. Conclusions: Full-endoscopic interbody fusion and resection of herniated hard disc via transforaminal approach under local anesthesia followed with percutaneous pedicle screw system fixation under general anesthesia are safe and effective minimally invasive spine surgery for the treatment of hard disc herniation located in the thoracolumbar junction.