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椎板成形在内镜下椎板间入路治疗椎间盘突出中的应用


  黄灿阳 王振强 黄杰聪 曾志远
  [摘要] 目的 研究椎板成形在局部麻醉下脊柱內镜椎板间入路治疗腰椎间盘突出中的应用。 方法 收集我院2016年1月~2018年12月行椎板间入路治疗腰椎间盘突出症患者63例,研究椎板间入路时椎板成形的应用,根据术中是否行椎板成形分为成形组和非成形组,对比了解两组椎板成形与突出节段、突出位置、突出游离情况及原始椎板间隙大小等的关系。 结果 全部病例均成功在局部浸润复合右美托咪定基础麻醉下完成椎间盘突出髓核摘除手术。术后患者的VAS评分及术后ODI评分均较手术前明显好转,差异有统计学意义(P<0.01)。成形组术前椎板间隙高度平均(7.93±1.64)mm小于非成形组的(10.91±1.72)mm,差异有统计学意义(P<0.01);成形组突出位置肩上18例(81.82%)、腋下4例(18.18%),非成形组肩上11例(26.83%)、腋下30例(73.17%),成形组肩上型比例高于非成形组,差异有统计学意义(P<0.01);成形组突出节段L4~5 10例(45.45%)、L5~S1 12例(54.55%),非成形组L4~5 2例(4.88%)、L5~S1 39例(95.12%),成形组L4~5节段比率明显高于非成形组,差异有统计学意义(P<0.01)。但是成形组手术时间平均(108.07±5.61) min明显长于非成形组[(62.12±3.74) min],差异有统计学意义(P<0.01)。 结论 椎板成形在局麻内镜椎板间入路治疗腰椎间盘突出中有时候必不可少,尤其L4~5节段、术前椎板间隙较小及肩上型突出时,能有效扩大内镜通道、减少鞘管对神经根牵拉等,镜下的椎板成形在将来脊柱内镜手术中将大有作为。
  [关键词] 腰椎间盘突出;内镜;椎板间入路;椎板成形
  [中图分类号] R687.3          [文献标识码] B          [文章编号] 1673-9701(2019)32-0059-04
  Application of laminoplasty by endoscopic interlaminar approach for the treatment of intervertebral disc herniation
  HUANG Canyang WANG Zhenqiang HUANG Jiecong ZENG Zhiyuan
  Department of Orthopaedics, Quanzhou First Hospital Affiliated to Fujian Medical University, Quanzhou   362000,China
  [Abstract] Objective To study the application of laminoplasty by endoscopic interlaminar approach for the treatment of intervertebral disc herniation. Methods 63 cases of lumbar disc herniation treated by interlaminar approach from January 2016 to December 2018 in our hospital were collected. The application of laminoplasty by endoscopic interlaminar approach was studied. According to whether or not laminoplasty was performed during operation, they were divided into laminoplasty group and non-laminoplasty group. The relationship between the laminoplasty and protruding segment, the protruding position, the protruding free condition, and the size of the original lamina gap were compared. Results All cases successfully completed the removal of herniated nucleus pulposus of lumbar disc herniation under anesthesia with local infiltration combined with dexmedetomidine. The VAS score and postoperative ODI score of the patients after operation were significantly better than those before surgery, and the difference was statistically significant(P<0.01). The average height of the lamina before operation was(7.93±1.64) mm in the laminoplasty group, less than(10.91±1.72)mm in the non-laminoplasty group, and the difference was statistically significant(P<0.01). There were 18 cases(81.82%) of protruding position above the shoulder and 4 cases(4.18%) of protruding position below the shoulder in the laminoplasty group. There were 11 cases(26.83%) of protruding position above the shoulder and 30 cases (73.17%) of protruding position below the shoulder in the laminoplasty group. The proportion of above-shoulder herniation in the laminoplasty group was higher than that in the non-laminoplasty group, and the difference was statistically significant(P<0.01). There were 10 cases(45.45%) of L4-5 protruding and 12 cases(54.55%) of L5-S1 protruding in the laminoplasty group. There were 2 cases(4.88%) of L4-5 protruding and 39 cases(95.12%) of L5-S1 protruding in the non-laminoplasty group. The ratio of L4-5 protruding in the laminoplasty group was higher than that in the non-laminoplasty group, and the difference was statistically significant(P<0.01). However, the average operation time of the laminoplasty group was(108.07±5.61)min, and that of the non-forming group was(62.12±3.74)min. The difference was statistically significant(P<0.01). Conclusion Laminoplasty is sometimes necessary in the treatment of lumbar disc herniation with local anesthesia and interlaminar approach, especially in the L4-5 segment and when the preoperative lamina is small and protruding position is above the shoulder. It can effectively enlarge the endoscopic channel and reduce the pulling of sheath to the nerve root. Laminoplasty under the microscope will be useful in future endoscopic surgery.
  [Key words] Lumbar disc herniation; Endoscopy; interlaminar approach; Laminoplasty
  腰椎间盘突出症是脊柱骨科最为常见的疾病。除了保守治疗,内镜治疗逐渐成为手术治疗的热门选择,因为其微创、高效、恢复快,受到脊柱外科医生及患者青睐。内镜治疗中入路选择很多但总体上可分为经椎间孔入路及椎板间入路两种方式[1-3]。在这两种方式中均可能需要对椎间孔及椎板间隙进行骨性成形以扩大入路通道。对于椎间孔通道的骨性成形有较多报道,但对于椎板成形在椎板间入路中的报道则较少[4]。本文旨在收集2016年1月~2018年12月我院行局部麻醉下椎板间入路治疗腰椎间盘突出症患者63例,研究椎板间入路时椎板成形的应用,了解椎板成形与突出节段、突出位置、突出游离情况及原始椎板间隙大小等关系。现报道如下。
  1 资料与方法
  1.1 一般资料
  选取2016年1月~2018年12月在我院行局麻下椎板间入路脊柱内镜治疗的腰椎间盘突出症患者63例,根据术中是否行椎板成形分为成形组(22例)和非成形组(41例)。成形组:男12例,女10例;年龄23~70岁,平均(47.73±6.75)岁;病变位置L4~5 10例,L5~S1 12例。非成形组:男22例,女19例;年龄28~76岁,平均(50.11±7.35)岁;病变位置L4~5 2例,L5~S1 39例。患者临床症状、体征及影像资料诊断为腰椎间盘突出,经保守治疗6周无缓解。两组患者一般资料比较,差异无统计学意义(P>0.05),具有可比性。见表1。
  表1   两组一般资料比较
  1.2 方法
  1.2.1 手术方法  所有患者俯卧于专用腰椎后弓垫上,减少腰椎前凸,增加腰椎板间隙面积;腹部悬空减少腹压所致术中出血。手术器械采用德国SPINENDOS脊柱内窥镜手术系统(外鞘套管直径8 mm),该系统包括内窥镜监视系统和髓核摘除的手术器械。术前C臂定位责任节段手术侧椎板间隙。常规用3%碘酒及75%酒精消毒、铺巾。旁开后正中线约在小关节突处插入定位针,深达骨表面。局部5%利多卡因10 mL稀释1倍局部浸润麻醉,尤其注意椎板间隙外侧缘关节突关节内侧与黄韧带交界处的浸润麻醉,复合静脉右美托咪定麻醉下手术。在距棘突旁0.5 cm处做一约0.8 cm的纵行切口,依次切开皮肤、皮下、深筋膜。采用铅笔头状扩张管钝性扩张,深至黄韧带外侧近关节突关节内侧缘表面,逐层扩张并置入外工作通道,再次透视确定手術椎间隙。取出扩张管,置入短内窥镜(外鞘直径8 mm),清理黄韧带及小关节突内侧缘骨表面的脂肪肌肉等软组织,显露小关节内侧缘交界处黄韧带(封三图1A)。等离子烧灼、蓝钳咬开逐层破开关节突内侧缘黄韧带,可见硬膜外脂肪。术中根据椎板间隙大小、突出位置及工作套管牵开神经根时患者的耐受程度选择是否行椎板成形及成形大小,术中通过磨钻及椎板咬骨钳行椎板成形,有时候需成形椎板下缘甚至下位椎体上关节突内侧部(封三图1B),松解神经根。神经剥离子探查突出髓核组织,剥离子牵开保护神经根并旋转放入外工作套,摘除游离及松动的间盘髓核组织,直至硬膜囊及神经根充分减压,双极射频电极消融絮状髓核并行纤维环成形。
  1.2.2 影像采集方法  CT三维重建:取患者平卧位,双手自然放置躯干两边,采用GE64排lightVCT,电压120 kV、电流300 mA,层厚5 mm,拆薄0.625,GE adw4.6工作站,采用VR、MPR重建系列,扫描椎板减压及上下共3个椎体。MRI检查:取患者平卧位,双手自然放置躯干两边,采用GE3.0T,矢状位T2、T1、T2压脂序列,横断位T2序列。矢状位扫描方位平行于脊柱,范围包含双侧椎弓根,横断位T2扫描平行于椎间盘走形。T2参数:TR3000 ms,TE80 ms,激励次数为2;T1参数:TR800 ms,TE20 ms,激励次数为2。矢状位层厚4 mm,层间隔1 mm,fov240×240 mm,相位编码方向A/P;横断位层厚4 mm,层间隔0.5 mm,fov180×180 mm,相位编码方向A/P。扫描包括手术椎间盘间隙的整个腰椎。
  1.3 观察指标
  术前椎板间隙高度:术前通过CT三维测量椎板间隙高度,以矢状位下板间距离最大值为术前椎板间隙高度值(封三图2);突出位置:术前通过MRI(封三图3)及CT三维影像判断行走神经根与突出物之间的关系将突出位置分为肩上、腋下两型,主要通过磁共振水平位影像判断突出髓核与神经根关系;术前腰腿痛视觉模拟评分VAS评分;术前Oswestry功能障碍指数ODI评分。
  术后复查三维CT测量椎板成形情况(封三图2);复查MRI(封三图4)察看椎间盘残留情况;术后3个月VAS评分;术后3个月ODI评分。
  1.4 统计学方法
  采用SPSS25.0统计学软件处理数据,计量资料以均数±标准差(x±s)表示,两组间比较采用成组t检验或多变量方差分析;计数资料采用χ2检验,P<0.05为差异有统计学意义。
  2 结果
  所有患者皆顺利完成手术,未见神经根损伤、硬脊膜撕裂、椎管内血肿等并发症,复查MRI皆未见明显突出髓核残留。
  2.1 两组手术前后VAS评分、ODI评分、手术时间比较
  两组手术前后VAS评分比较,差异无统计学意义(P>0.05);两组手术后均较手术前明显好转(P<0.01)。两组手术前后ODI评分比较,差异无统计学意义(P>0.05);两组手术后均较手术前明显好转(P<0.01)。成形组手术时间(108.07±5.61)min,明显大于非成形组(62.12±3.74)min,(P<0.01)。见表2。
  2.2 两组突出节段、突出位置、术前椎板间隙高度比较
  从突出节段上看L4~5节段间隙成形机会较大(P<0.01);从突出位置上看肩上型突出椎板成形机会较大(P<0.01)。术前椎板间隙高度比较,成形组(7.93±1.64)mm、非成形组(10.91±1.72)mm。成形组术前椎板间隙高度明显小于非成形组,差异有统计学意义(P<0.01)。见表3。
  3 讨论
  椎间盘突出的脊柱内镜治疗主要分为椎间孔入路和椎板间入路两种[5]。椎间孔入路具有对神经牵拉较少、良好的局麻耐受性等优点,是腰椎间盘突出内镜治疗的理想通道。由于下腰段的解剖特点如高髂脊、横突粗大、椎间孔变小等,经椎间孔入路内镜并不容易到达突出椎间盘。相反下腰段的椎板间隙越往下越大,有利脊柱内镜的操作[6],这时椎板间入路更具优势。但椎板间入路术中需通过鞘管牵拉神经根增加了神经损伤可能,特别是全身麻醉情况下。
  局麻下的脊柱内镜手术可以更好保证手术安全性。脊柱内镜手术中麻醉的选择主要是考虑手术安全性与手术舒适性的平衡[7-8]。全麻手术患者具有最好的舒适性,但在没有神经监护下术中神经损伤机会亦增加,带来更多安全性担忧。目前为了手术安全性经椎间孔入路皆采用局部麻醉下手术。而经椎板间入路因为和传统开放手术类似采用全麻下手术。全麻下椎板间入路内镜手术虽然带来最好的手术舒适性及耐受性,但亦有马尾损伤等安全问题报告[9]。所以为了安全性本研究尝试在局麻下行椎板间入路内镜手术。我们可能需要椎板成形来保证手术的耐受性。
  椎板的扩大成形是局部麻醉椎板间入路腰椎髓核摘除手术成功实施的有力保证。正如在椎间孔入路手术中椎间孔扩大成形是成功的重要环节。椎板成形在开放椎间盘突出手术中已经应用广泛,也是手术中主要的操作步骤[10]。同样在椎板间入路内镜手术时我们也可以行椎板成形。
  而在局部麻醉下内镜手术中椎板成形有着特殊几个目的:①扩大操作通道有利内镜的进入,一般来说椎板间隙高度小于8 mm时无法满足后路内镜鞘管置入的基本要求,因此必须成形椎板扩大椎板间隙;②减少神经牵拉,后路椎板间隙入路局麻手术中如果神经牵拉厉害往往患者无法耐受并且术后神经损伤亦增加。在肩上型突出尤其是小关节突内聚的患者为了减少鞘管转动牵拉对神经根干扰,在椎板间入路手术时需要行椎板成形将外侧椎板甚至下位椎体的上关节突内侧缘成形,有利手术操作无需牵拉神经根而直面突出的髓核[11-12];③扩大骨性侧隐窝间隙,椎板成形扩大后侧隐窝骨性间隙能有效的减少症状性椎间盘突出复发[13];④高游离靶点通道的需要,对于高度游离的椎间盘突出椎板间隙后入路是一种相对无盲区的选择,除了极外侧突出[14-16]。但是这时需要对内镜套管进行大成角放置,甚至需要在椎板上特殊制道,需要对椎板进行成形来满足手术要求。
  然而局麻下椎板間入路的椎间盘髓核摘除手术何时需要行椎板成形?通过本研究发现是否需要行椎板成形与患者术前椎板间隙高度、手术椎间盘的节段及突出位置密切相关。需要成形的手术组术前椎板间隙高度较低,为了容纳操作器械及操作空间需要一定的椎板间隙。L4~5节段更需要行椎板成形,因为L4~5本来椎板间隙高度就小,所以更有机会需要成形椎板扩大空间。肩上型突出更需要成形,应该是肩上型突出的椎间盘更多的覆盖在椎板下,而腋下型突出更多覆盖于黄韧带下的缘故。
  椎板成形契合了目前脊柱内镜高速发展、内镜的手术适应证扩大的需要。越来越多的开放手术都是内镜手术指征,如镜下椎管狭窄椎管扩大减压、镜下融合技术等。适应证的扩大均是建立在镜下椎板扩大成形,甚至扩大到小关节突关节成形的基础上,所以椎板成形在后路椎板间隙入路的脊柱内镜手术中大有可为。
  [参考文献]
  [1] Wang B.,Guo HL,Liu W,et al. Full-endoscopic interlaminar approach for the surgical treatment of lumbar disc herniation:The causes and prophylaxis of conversion to open[J]. Arch Orthop Trauma Surg,2012,132(11):1531-1538.
  [2] Hoogland T,Schubert M,Miklitz B,et al. Transforaminal posterolateral endoscopic discectomy with or without the combination of a low-dose chymopapain:A prospective randomized study in 280 consecutive cases[J]. Spine,2006, 31(24):890-897.
  [3] Ruetten S,Komp M,Merk H,et al. Use of newly developed instruments and endoscopes:Full-endoscopic resection of lumbar disc herniations via the interlaminar and lateral transforaminal approach[J]. Journal of Neurosurgery Spine,2007,6(6):521-530.
  [4] Xinyu L,Yanping Z,Jianmin L,et al. Hemilaminoplasty for the treatment of lumbar disc herniation[J]. International Orthopaedics,2009,33(5):1323-1327.
  [5] Jha RT,Syed HR,Catalino M,et al. Contralateral approach for minimally invasive treatment of upper lumbar intervertebral disc herniation:Technical note and case series[J]. World Neurosurg,2017,100:583-589.
  [6] Tonosu J,Oshima Y,Shiboi R,et al. Consideration of proper operative route for interlaminar approach for percutaneous endoscopic lumbar discectomy[J]. Journal of Spine Surgery,2016,2(4):281-288.
  [7] Yeung AT,Tsou PM. Posterolateral endoscopic excision for lumbar disc herniation[J]. Spine,2002,27(7):722-731.
  [8] 王冰,呂国华,刘伟东. 完全内窥镜下经椎板间入路手术治疗腰椎间盘突出症术中转为开放手术的原因分析[J]. 中国脊柱脊髓杂志,2011,21(3):185-188.
  [9] Wang, H.,Zhou Y,Li C,et al. Risk factors for failure of single-level percutaneous endoscopic lumbar discectomy[J].J Neurosurg Spine,2015,23(3):320-325.
  [10] 李亢. 小切口椎板开窗术与显微内镜下髓核摘除术治疗腰椎间盘突出症的疗效比较[J]. 医学综述,2013,19(12):2290-2292.
  [11] 刘元彬,张智,郑佳状,等. 经椎板间入路椎间孔镜治疗巨大游离型腰椎间盘突出症[J]. 中国微创外科杂志,2018,18(7):616-618.
  [12] 孔翔飞,吴小涛,齐新生,等. 经椎板间隙入路椎间盘镜手术治疗合并小关节内聚的腰椎间盘突出症[J]. 中国微创外科杂志,2001,1(6):352-353.
  [13] Li Z,Yang H,Liu M,et al. Clinical characteristics and risk factors of recurrent lumbar disk herniation:A retrospective analysis of three hundred twenty-one cases[J]. Spine,2018,43(21):1463-1469.
  [14] Choi G,Lee SH,Raiturker PP,et al. Percutaneous endoscopic interlaminar discectomy for intracanalicular disc herniations at L5-S1 using a rigid working channel endoscope[J]. Neurosurgery,2006,58(1 Suppl):59-68.
  [15] Hirano Y,Mizuno J,Takeda M,et al. Percutaneous endoscopic lumbar discectomy-early clinical experience[J]. Neurologia Medico-Chirurgica,2012,52(9):625-630.
  [16] Yasushi I,Yasushi O,Hirokazu I,et al. Percutaneous endoscopic lumbar discectomy via adjacent interlaminar space for highly down-migrated lumbar disc herniation:A technical report[J]. J Spine Surg,2018,4(2):483-489.
 
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