局部麻醉下单侧双通道内镜辅助单侧椎板入路双侧椎管减压治疗腰椎椎管狭窄症的疗效分析

Clinical outcomes of unilateral biportal endoscopy assisted unilateral laminotomy for bilateral decompression in the treatment of lumbar spinal stenosis under local anesthesia

中文关键词:  腰椎椎管狭窄症  局部麻醉  单侧双通道内镜  单侧椎板入路双侧椎管减压

英文关键词:Lumbar spinal stenosis  Local anesthesia  Unilateral biportal endoscopy  Unilateral laminotomy for bilateral decompression

中文摘要:

  【摘要】 目的：探讨局部麻醉下应用单侧双通道内镜技术辅助单侧椎板入路双侧椎管减压（unilateral laminotomy for bilateral decompression，ULBD）治疗腰椎椎管狭窄症的临床疗效，比较单次和两阶段局部麻醉的麻醉效果。方法：回顾性分析2022年1月~2023年6月在我院接受局部麻醉下单侧双通道内镜辅助ULBD治疗的106例腰椎椎管狭窄症患者的临床资料，其中男性51例，女性55例；年龄55~83岁（66.7±14.5岁）。病变节段：L3-4 17例，L4-5 36例，L5-S1 53例。Schizas分级：B级25例，C级36例，D级45例。其中52例患者采用单次局部麻醉，纳入单次麻醉组（A组）；54例采用两阶段局部麻醉，纳入分次麻醉组（B组）。两组患者年龄、性别比、体重指数、手术节段、Schizas分级、美国麻醉师协会分级（American Society of Anesthesiologists，ASA）分级均无统计学差异，具有可比性。记录两组患者围手术期并发症、手术时间，术前（T1）、术中暴露时（T2）、术中牵拉神经根时（T3）及手术结束即刻时（T4）的疼痛视觉模拟量表（visual analogue scale，VAS）评分、氧饱和度、平均动脉压及心率，比较两组患者术前与术后随访时的腰痛VAS评分、腿痛VAS评分、Oswestry功能障碍指数（Oswestry disability index，ODI）；末次随访时使用MacNab评定标准评价患者临床疗效。结果：所有患者均顺利完成手术，2例出现硬脊膜撕裂，未行硬脊膜修补；5例出现轻微头疼，对症处理后症状消失；4例出现下肢疼痛、麻木较术前加重情况，给予对症处理，术后3~5d症状缓解或消失。所有患者切口均Ⅰ期愈合。手术过程中生命体征均平稳，未出现意外事件。A组手术时间101.9±17.3min，B组103.6±15.9min，两组无统计学差异（P>0.05）。两组患者在T1和T2时的VAS评分、平均动脉压及心率无统计学差异（P>0.05），T3和T4时A组患者的VAS评分、平均动脉压及心率均显著性高于B组（P<0.05）。两组术后各时间点的腰腿痛VAS评分、ODI与术前比较均显著性改善（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A组优31例，良14例，可7例，优良率86.5%；B组优36例，良13例，可5例，优良率90.7%，两组优良率无统计学差异（P>0.05）。结论：局部麻醉下应用单侧双通道内镜技术辅助ULBD治疗腰椎椎管狭窄症可取得良好的临床疗效，两阶段局部麻醉较单次局部麻醉镇痛效果更好，对于伴有复杂基础疾病、全身麻醉风险高的腰椎椎管狭窄症患者具有临床应用价值。

英文摘要:

  【Abstract】 Objectives: To investigate the clinical outcomes of unilateral biportal endoscopy assisted unilateral laminotomy for bilateral decompression(ULBD) in the treatment of lumbar spinal stenosis under local anesthesia, and to compare the anesthetic effects of single-stage and two-stage local anesthesia. Methods: A retrospective analysis was conducted on the data of 106 patients with lumbar spinal stenosis who underwent unilateral biportal endoscopy assisted ULBD treatment under local anesthesia in our hospital from January 2022 to June 2023. There were 51 males and 55 females, aged 55-83(66.7±14.5) years old, with the following lesion segments: 17 cases at L3-4, 36 cases at L4-5, and 53 cases at L5-S1. Schizas classification: 25 cases of grade B, 36 cases of grade C, and 45 cases of grade D. Among them, 52 patients underwent single-stage local anesthesia and were included in the single anesthesia group(Group A), while 54 patients received two-stage local anesthesia and were included in the two-stage local anesthesia group(Group B). There were no statistically significant differences in age, gender ratio, body mass index(BMI), surgical segments, Schizas classification and American Society of Anesthesiologists(ASA) classification between the two groups of patients. The perioperative complications, operative time, as well as the visual analogue scale(VAS) score, oxygen saturation, mean arterial pressure, heart rate in both groups before surgery(T1), during exposure(T2), during traction of the nerve root(T3), and immediately after surgery(T4) were recorded; The VAS scores for low back pain and leg pain, as well as the Oswestry disability index(ODI), were compared between the two groups before and after surgery. The MacNab assessment criteria were used to evaluate the overall postoperative efficacy of the patients at the final follow-up. Results: All patients successfully completed the operation. Two cases had dural tear, but no dural repair was performed; Five cases had mild headache, which disappeared after symptomatic treatment; Four cases had increased lower limb pain and numbness compared to pre-operative conditions, which were treated with symptomatic treatment for swelling reduction, and the symptoms alleviated or disappeared 3-5d after surgery; All incisions healed in stage I. During the operation, the vital signs remained stable throughout and no unexpected incidents occurred. There was no statistical difference between group A and group B in operative time(101.9±17.3min vs. 103.6±15.9min, P>0.05). No statistically significant difference was observed in VAS scores, mean arterial pressure and heart rate between the two groups at T1 and T2(P>0.05). At T3 and T4, the VAS scores, mean arterial pressure and heart rate of group A were significantly higher than those of group B(P<0.05). At each time point after surgery, the VAS scores and ODI of the two groups improved significantly compared with those before surgery(P<0.05), but there was no statistically significant difference between the two groups at the same time point(P>0.05). At the final follow-up, 31 cases in group A were excellent, 14 cases were good, and 7 cases were fair, with an excellent and good rate of 86.5%; 36 cases in group B were excellent, 13 cases were good, and 5 cases were fair, with an excellent and good rate of 90.7%. There was no statistically significant difference in the excellent and good rate between the two groups(P>0.05). Conclusions: The unilateral biportal endoscopy technique under local anesthesia for ULBD in the treatment of lumbar spinal canal stenosis can achieve good clinical efficacy, and two-stage local anesthesia provides a superior analgesic effect compared to single-stage local anesthesia. This method holds significant clinical application value, particularly for patients with lumbar spinal canal stenosis accompanied by complex comorbidities and at high risk for general anesthesia.