经皮椎间孔镜TESSYS技术治疗中央型腰椎间盘突出症

发布时间：2018-06-09 17:11

本文选题：中央型腰椎间盘突出症 + 椎间孔镜　；参考：《河北医科大学》2014年硕士论文

【摘要】：目的:腰椎间盘突出症(lumber disc herniation)是引起腰腿痛最常见原因，是指腰椎间盘退变、纤维环破裂后髓核向后方突出或突至椎板内致使相邻组织受刺激或压迫而出现一系列临床症状。根据椎间盘突出的部位可将其分为后外侧突出，椎间孔型突出及中央型突出。中央型腰椎间盘突出症central lumbar disc herniation (CLDH)是指突出或脱出的椎间盘组织位于椎管前方中央处者。由于椎间盘后外侧为其解剖结构薄弱点，因此后外侧突出最常见,但临床上中央型腰椎间盘突出症并不少见，有研究显示其发病率为5.4%-33.4%。经正规保守治疗无效的患者需采取手术治疗，因中央型腰椎间盘突出症的临床表现多样，下肢痛症状可表现为单侧或双侧，部分患者存在马尾神经症状，故常根据患者病情采用单侧或双侧部分椎板切除术即开窗术治疗，对于伴有椎管狭窄的患者需行全椎板切除术，但传统开放手术创伤大、出血多，术后恢复时间漫长，有伴发腰椎不稳的风险。随着科学技术及医疗设备的进步，许多新的脊柱微创技术开始被应用于腰椎间盘突出症的治疗。应用内窥镜经椎间孔入椎管内进行神经根松解及减压技术TESSYS（transforaminal endoscopic spine system）技术是传统的后外侧途径腰椎间盘治疗技术与脊柱内窥镜技术的结合，它的出现又为外科医生解决中央型腰椎间盘突出症提供了一条新的解决方案。本研究通过对比分析患者术后症状改善情况来探讨椎间孔镜TESSYS技术治疗中央型腰椎间盘突出症的临床疗效。方法:自2011年1月-2013年7月69例中央型腰椎间盘突出症患者在我院行腰椎侧后路椎间孔镜下髓核摘除术治疗。术中患者取俯卧位，在C-型臂X线机正位透视下定位并标记腰椎棘突中线及经目标椎间盘上缘的水平线在体表投影，于侧位X线透视下确定目标椎间隙方向，沿此方向在体表做经过下位椎体后上缘的直线，此线与经过目标椎间盘上缘的水平线的交点为穿刺点，再于侧位X线透视下标记关节突上缘连线为安全线。如患者为L5-S1节段突出，穿刺点的标定方法为：在X线正位透视下于体表标出髂嵴的最高点连线以及通过L5椎体下缘的水平线，再于X线侧位透视下在体表标定通过S1上关节突和S1椎体后上缘的侧位线，该侧位线与正位透视下标定的髂嵴最高点连线的交点为穿刺点。突出节段在L2-3和L3-4时，选择旁开中线6-10cm进针，，突出节段在L4-5和L5-S1时，选择旁开中线12-14cm进针。消毒铺单后于穿刺位点用浓度1%利多卡因行局部浸润麻醉。以18号穿刺针经穿刺位点进针并在C-型臂X线机引导下穿刺，针尖穿抵上关节突的前下缘，取出针芯，置入前端弯曲的22号穿刺针，注入造影剂行椎间盘造影。取出22号穿刺针，插入导丝，以穿刺点为中点在皮肤做一长约8mm切口。沿导丝插入导棒及逐级扩张导管扩大手术通道，逐级取出扩张导管后延导棒插入锯齿状绞刀，在透视下切除上关节突外缘部分骨质，扩大椎间孔。取出环锯，沿导棒放入工作套管后放入椎间孔镜。于镜下用专有髓核钳将染色退变的髓核组织取出，至镜下硬膜囊清晰可见并随心跳发出搏动，患支行直腿抬高试验呈阴性，可进一步说明减压彻底有效。最后以射频双极电极对纤维环撕裂口行皱缩成形术，并对术野内出血点行电凝止血。取出椎间盘镜，切口缝合一针，盖敷料，手术完毕。 69例患者中女性35例，男性34例；年龄17~83岁，平均年龄37.52岁。疗效评价采用视觉疼痛模拟评分（VAS）、JOA及MacNab评分法评定。结果:本组69例患者，67例患者手术成功并获得随访，随访时间3-18个月，平均11.6个月，术前下肢VAS评分（7.12±0.70）,术后3个月下肢VAS评分为（2.46±0.68）,差异有统计学意义（P0.05），术后1年下肢VAS评分（2.27±0.74），差异有统计学意义（P0.05）。术前JOA评分（13.7±0.87），术后3个月JOA评分（21.8±1.27），差异有统计学意义（P0.05），术后1年JOA评分（22.1±0.79），差异有统计学意义（P0.05）。本组患者均未出现手术并发症，1例术后患者症状无明显改善，择期行椎板切除联合植骨融合内固定手术治疗，2例L5-S1突出，由于髂嵴过高，阻挡手术入路，术中改行后路椎间盘镜治疗，3例患者术后复发，择期行椎板切除联合植骨融合内固定手术治疗。整体优良率83.5%。结论:应用椎间孔镜TESSYS技术治疗中央型腰椎间盘突出安全、有效，严格掌握手术适应症是手术成功的关键和疗效的保障。
[Abstract]:Objective: lumbar intervertebral disc herniation (lumber disc herniation) is the most common cause of lumbago and leg pain, which refers to the degeneration of the lumbar intervertebral disc. After the rupture of the fibrous ring, the nucleus pulposus protruding to the rear or into the vertebral plate causes a series of clinical symptoms to be stimulated or oppressed by adjacent tissues. The central type of lumbar intervertebral disc herniation central lumbar disc herniation (CLDH) refers to the protrusion or degenerative disc tissue located in the middle of the vertebral canal. The lateral protrusion of the posterior intervertebral disc is the most common, but the clinical central lumbar disc herniation is the most common. It is not uncommon that a study has shown that the patients who have the incidence of 5.4%-33.4%. in the normal conservative treatment need to be operated on, because the clinical manifestations of the central lumbar disc herniation are diverse, the symptoms of the lower extremity pain may be unilateral or bilateral, and the cauda cauda nerve is present in some patients, so the unilateral or bilateral part of the vertebral body is often used according to the patient's condition. Plate excision, or fenestration, requires full laminectomy for patients with stenosis of the vertebral canal, but the traditional open surgery has large trauma, much bleeding, long recovery time and a risk of accompanying lumbar instability. With the advancement of science and technology and medical equipment, many new spinal minimally invasive techniques have been applied to lumbar disc herniation. TESSYS (transforaminal endoscopic spine system) technique is the combination of the traditional posterolateral approach to the lumbar intervertebral disc therapy and the spinal endoscopy, which provides a surgical solution for the surgical treatment of central lumbar intervertebral disc herniation. A new solution. This study examines the clinical efficacy of intervertebral foraminoscopy in the treatment of central lumbar intervertebral disc herniation by comparing and analyzing the improvement of postoperative symptoms in patients with TESSYS.
Methods: from January 2011 to July -2013, 69 patients with central lumbar disc herniation underwent posterior lumbar intervertebral discectomy in our hospital.
During the operation, the patient took the prone position, located and marked the middle line of the spine spinous process and the horizontal line of the upper intervertebral disc on the body surface under the position perspective of the C- arm X ray machine. The direction of the target intervertebral space was determined under the lateral X-ray perspective, and the straight line through the upper edge of the lower vertebral body was made in the direction of the body surface, and the line and the water passing through the target intervertebral disc were water. The intersection point of the flat line is the puncturing point, and then the upper edge of the articular process is marked as the safety line under the lateral X-ray perspective. If the patient is the L5-S1 segment, the method of demarcation is to mark the highest point of the iliac crest on the body surface and through the horizontal line through the lower edge of the L5 vertebral body under the X-ray position perspective, and then to demarcate the body surface under the X-ray side perspective and then demarcate the body surface under the surface of the X-ray side. The lateral line of the upper edge of the S1 and S1 vertebrae on the upper part of the articular process and the vertebral body, the intersection point of the highest point of the iliac crest which is calibrated under the perspective of the positive perspective is the puncturing point. When the prominent segment is at L2-3 and L3-4, the side open middle line 6-10cm needle is selected, and when the segment is in L4-5 and L5-S1, the side open middle line 12-14cm injection needle is selected. The concentration of the sterilizing sheet is 1% after the puncture site. The puncture site was injected with the puncture site of No. 18 puncture needle and guided by the C- arm X-ray machine. The needle tip was put on the anterior and lower edge of the joint process, the needle core was taken out, the 22 puncture needle was inserted into the front end, and the contrast agent was injected into the intervertebral disc. The puncture needle was taken out and the needle was inserted at the center point to make a long skin. About 8mm incision. Insert the guide rod into the guide rod and the progressive dilatation catheter to expand the operation channel, take out the dilated catheter step by step, insert the sawtooth cutter, remove the partial bone of the outer edge of the upper joint under the perspective, expand the intervertebral foramen, remove the circular saw, and put the guide rod into the intervertebral foramen mirror after the guide rod is put into the working sleeve. The special nucleus pulposus forceps will be stained under the mirror. The nucleus pulposus was taken out, the dural sac was clearly visible and pulsated with the heartbeat. The direct leg lift test was negative. It could be further indicated that the decompression was complete and effective. Finally, the RFID was performed with the radiofrequency bipolar electrode for the laceration of the fibrous ring. Cover the dressings, the operation is finished.
Among the 69 patients, 35 were female and 34 were male. The age was 17~83 years and the average age was 37.52 years. The efficacy evaluation was evaluated by visual pain simulation score (VAS), JOA and MacNab score.
Results: 69 patients in this group, 67 cases were successful and followed up for 3-18 months, average 11.6 months, VAS score of lower extremity (7.12 + 0.70), lower limb VAS score (2.46 + 0.68) in 3 months after operation (P0.05), and 1 years' lower limb VAS score (2.27 + 0.74) after operation (P0.05). The preoperative JOA score was statistically significant (P0.05). (13.7 + 0.87), 3 months after operation JOA score (21.8 + 1.27), the difference was statistically significant (P0.05), 1 years after the JOA score (22.1 + 0.79), the difference was statistically significant (P0.05). The patients in this group had no surgical complications, 1 patients had no obvious improvement in postoperative symptoms, selective laminectomy combined with bone graft fusion and internal fixation, 2 cases of L5-S1 protruding, Due to high iliac crest and obstruction of surgical approach, posterior intervertebral discectomy was performed in the operation. 3 patients had recurrence after operation. Laminectomy combined with bone fusion and internal fixation was performed. The overall good rate was 83.5%..
Conclusion: the application of TESSYS in the treatment of central lumbar intervertebral disc herniation is safe, effective, and strict control of surgical indications is the key to the success of the operation and the guarantee of the curative effect.
【学位授予单位】：河北医科大学
【学位级别】：硕士
【学位授予年份】：2014
【分类号】：R687.3

【引证文献】