腰椎间盘突出症椎间孔镜下分型对腰椎间盘突出症治疗的临床意义
发布时间：2018-01-20 20:12
本文关键词： 经皮椎间孔镜技术 腰椎间盘突出症 椎间孔镜下分型 手术疗效 临床意义 出处：《承德医学院》2017年硕士论文 论文类型：学位论文
【摘要】：众所周知腰椎间盘突出症是临床上的十分容易见到的骨科退行性变化的病种,患者常常表现为腰背部疼痛,单侧或双侧下肢麻痛,因其病情常反复发作,且有不断加重的趋势,令大多数病人难以忍受,造成病人及其亲属较大的负担。随着现今社会老龄化的日趋显著,罹患该病的病例越来越多,因此众多医生都在找寻一种可以安全有效的医治该病的办法。椎间孔镜技术作为一种微创的外科术式,取得了很好的手术结果,又因其创伤小、出血少,适应症范围也比较大的优势,成为越来越多的医师和患者的首选。伴随该项技术的大量普及,手术医师对该种疾病有了全新理解,部分学者提出依据镜下分析椎间盘的变化和它与神经根的位置划分椎间孔镜下分型,并依据此分型指导医师进行椎间孔镜下操作,取得了良好的手术疗效。目的:通过经皮椎间孔镜对腰椎间盘突出症进行椎间孔镜下分型,并按照此种分型指导镜下操作,观察治疗结果并与传统未分型的椎间孔镜病例进行比较,探讨椎间孔镜下分型对治疗腰椎间盘突出症的临床意义。方法:对武警北京市总队第三医院骨科收治128例患者行经皮椎间孔镜手术,通过在镜下观察纤维环、髓核的退变程度及神经根的状态改变,将这种疾病划分成以下4种:髓核突出巨大,压迫到邻近的神经根的压迫型;神经根表面有大量纤维束增生包裹的瘢痕型;伴有椎间盘钙化及后方骨赘形成的钙化型;合并关节增生、周围软组织增厚等共同致使患者根性症状明显的侧隐窝狭窄型。并根据镜下分型指导手术治疗。选取早期相同纳入标准与排除标准的未进行椎间孔镜下分型的病例128例。采用视觉模拟评分法(visual analog scale,VAS)、日本骨科协会评估治疗分数(Japanese Orthopaedic Association Scores,JOA)、Oswestry功能障碍指数(Oswestry disability index,ODI)及Mac Nab标准评估手术疗效。记录手术时间、出血量和并发症发生率。并对两组VAS、JOA、ODI、Mac Nab标准和手术时间、出血量和并发症发生率进行统计学分析。结果:全部128例病例均顺利完成手术及随访。其中镜下分型128例病例中中压迫型的病例有60例,比例为46.9%,瘢痕型的病例有31例,比例为24.2%,钙化型的病例有23例,比例为18.0%,侧隐窝狭窄型的病例有14例,比例为10.9%。经过平均(10.5±3.7)个月的随访,术前VAS评分为7.6±0.7,术后VAS评分为2.5±0.6;JOA术前评分为7.8±1.6,术后评分为20.4±1.0;术前ODI为(62.9±5.3)%,术后ODI为(25.1±2.2)%;术后按照改良的Mac Nab标准评定疗效,优75例,良47例,可6例,总体优良率为95.3%。分型组和未分型组的所有病例的病情均有显著的减轻,椎间孔镜下分型与未进行椎间孔镜下分型组的术前VAS评分、JOA评分、ODI评分比较无统计学意义(P0.05),椎间孔镜下分型组术后VAS评分较未分型组显著偏低(P0.05),椎间孔镜下分型组术后JOA评分较未分型组显著偏高(P0.05),椎间孔镜下分型组术后ODI评分较未分型组显著偏低(P0.05),Mac Nab标准优良率为95.3%显著高于未分型组的Mac Nab标准优良率87.5%。椎间孔镜下分型组和未分型组的手术时长及出血量比较差异未见明显的统计学意义(P0.05),椎间孔镜下分型组术中、术后的并发症发生率较未分型组显著下降(P0.05)。结论:根据椎间孔镜下的不同表现进行分型可以增加医师对该疾病的理解,可以解释一些临床表现与影像学分型并不符合的病例,因此这种分型方法更加够能反映腰椎间盘突出症的本质,是对传统的影像学分型的一种补充。术中可以依据椎间孔镜下分型指导手术,压迫型主要处理突出压迫的髓核组织;瘢痕型主要去除神经根表面大量的的纤维等;钙化型主要取出钙化的间盘及增生的骨赘;侧隐窝狭窄型主要去掉增生的韧带组织,打开侧隐窝,对神经根走行全程进行松解。通过一系类针对性操作可以获比传统未分型手术更加优良的手术疗效。因此椎间孔镜下分型是一种科学的、有临床意义的分型方法,合理利用该分型可以使这项手术最大程度地缓解病人的病情,有效地提高手术疗效,显著减少术后复发率。
[Abstract]:As everyone knows of lumbar disc herniation is clinically very easy to see the Department of orthopedics of degenerative changes in the disease, patients often manifested as back pain, unilateral or bilateral leg pain, because the disease is often recurrent, and gradually, so that the majority of patients to bear, causing a greater burden on the patients and their relatives. With the aging of society is more and more obvious, more and more patients with the disease, so many doctors are looking for a safe and effective way to cure the disease. Transforaminal endoscopic surgery is a minimally invasive surgery, has achieved good results, but also because of its small trauma, less bleeding the indications, scope of comparative advantage, become more and more doctors and patients preferred. Accompanied by a large number of popularization of this technique, the surgeon has a new understanding of the disease, some scholars put forward the basis for Microscopic analysis of the changes of intervertebral disc and nerve root and its location transforaminal endoscopic classification, and according to this type of guide physicians transforaminal endoscopic operation has good operation effect. Objective: through percutaneous transforaminal endoscopic discectomy for transforaminal endoscopic discectomy for lumbar disc herniation type this type of guidance, and in accordance with the endoscopic operation, observation and treatment results were compared with the traditional foraminal mirror case and not typing, discuss the clinical significance of transforaminal endoscopic classification for the treatment of lumbar disc herniation. Methods: admitted to the Department of orthopedics, Third Hospital of Beijing Armed Police Corps of 128 patients underwent percutaneous lumbar endoscopic surgery through the observation hole, a fiber ring under the microscope, the degeneration and nerve root nucleus state changes, the disease will be divided into the following 4 types: the nucleus pulposus is huge, compression of the nerve root compression type adjacent nerve root surface; a large amount of fiber bundles. Wrapped with scar type; intervertebral disc calcification and posterior osteophyte formation calcification type; with joint hyperplasia, thickening of the soft tissue around the common root resulting in patients with obvious symptoms of lateral recess stenosis. According to endoscopic classification guidance for selecting early surgical treatment. The same inclusion criteria were not transforaminal endoscopic classification and the exclusion criteria of the 128 cases. The visual analogue score (visual analog, scale, VAS), Japan Association for Department of orthopedics (Japanese Orthopaedic Association evaluation scores of Scores, JOA), Oswestry disability index (Oswestry disability index, ODI) and Mac Nab standard to assess the efficacy of surgery. Operation time, bleeding volume and the incidence of complications. And two groups of VAS, JOA, ODI, Mac, Nab standard and the operation time, bleeding volume and postoperative complications were analyzed. Results: the incidence of all 128 cases were successfully completed surgery and follow-up .鍏朵腑闀滀笅鍒嗗瀷128渚嬬梾渚嬩腑涓帇杩瀷鐨勭梾渚嬫湁60渚，
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