椎间孔镜侧入路和后入路的适应症及其对比研究

发布时间：2018-03-07 11:16

  本文选题：腰间盘突出症　切入点：椎间孔镜　出处：《大连医科大学》2017年硕士论文　论文类型：学位论文

【摘要】：背景:随着社会的进步、医学科学的快速发展,缩小创伤、加快术后康复、减短术后患者卧床时间等越来越受到人们的关注。随着目前脊柱外科领域腰椎病和颈椎病患病率的逐年增加,单纯的保守治疗已经很难达到治疗目的。自开放手术开创以来,经过约半个世纪的不断发展,已经非常成熟,但是传统开放性手术手术并发症(创伤大、出血多、术后疼痛严重、术中腰背部的肌肉、软组织广泛剥离等)也越来越受到各方面的广泛关注,这些并发症造成的软组织损伤导致的患者术后慢性腰痛常常影响治疗效果。随着其他外科微创手术的出现,微创手术因其创伤小、术中出血少、对椎旁软组织损伤小、术后疼痛轻、恢复快等特点得到大家的青睐,脊柱外科的大夫也想利用脊柱微创技术解决脊柱问题。早期,医生在开放手术的基础上发明了小开窗,其优势较开放手术已经非常明显,但是随着其他外科显微技术的快速发展,小开窗逐渐满足不了要求。随着内镜系统在其他外科的普及,脊柱内镜手术也开始慢慢出现。后路显微内镜下行腰椎间盘切除术(MED)的出现,为脊柱内镜作出了巨大贡献,可以说具有划时代的意义,它的临床疗效在一段时间内得到了人们的认可。随着相关显微技术技术及显微器械的进一步高速发展,更为"微创"的椎间孔镜技术(将工作套管直接植入椎管内,在内镜直视下行髓核摘除及神经根减压,PELD)逐渐进入我们的视野。我们发现通过椎间孔镜直视下行髓核摘除、神经根减压(椎间孔镜技术),具有创伤更小、更安全、恢复更快等特点,较间盘镜手术,椎间孔镜手术的认可度更高。目前随着椎间孔镜技术的快速发展,逐渐出现多种手术入路,其中大家较为常用的是后路椎板间入路及侧后方椎间孔入路,这两种手术入路逐渐成熟并逐渐在各大小医院得到普及,目前国内并不缺乏这两种手术入路的研究报道,但是却无系统及完整的比较,包括这两种术式的优缺点及这两种手术入路的最佳适应症。本文将研究、比较这两种手术入路,得出这两种术式的最佳适应症及在L5-S1节段时两种术式的优缺点。目的:研究椎间孔镜经椎间孔入路(transforaminal,TF)和椎板间入路(interlaminar,IL),得出这两种手术入路的最佳适应症,同时比较在L5-S1节段行这两种术式的患者,得出在L5-S1节段行两种术式的优缺点。方法:收集大连市中心医院自2015年至2016年间行椎间孔镜手术包括经椎板间(interlaminar,IL)入路及椎间孔(transforaminal,TF)入路的患者,统计这两种手术入路的基本手术数据包括穿刺次数、手术时间、透视次数、出血量、患者术后卧床时间、手术至出院时间、并发症、术前术后改善情况(术后当日、出院时VAS评分及术后六月Oswestry功能障碍指数)、术后6月MacNab评分等等,得出这两种术式的最佳适应症。比较2015年至2016年间大连市中心医院所有L5-S1节段行PETD和PEID手术的患者的手术基本资料,得出在L5-S1节段时,这两种术式的优劣。结果:行PETD手术组的患者和行PEID组手术的患者的性别构成、年龄构成、椎间盘髓核突出类型均无明显统计学差异(p0.05)。在L5-S1阶段行两种手术术式的患者,PEID组的手术时间为80±14.8min,术中C型臂透视次数平均为5.0±2次,术后卧床时间平均为为12±2h,手术至出院时间为3.0±1.8d,术中出血量约为16.8±7.1m 1;PETD组分别131±16.2min,15±6 次,12.0±1.1h,4.0±1.2d,25.6±2ml。PEID组的手术时间、术中C型臂透视次数、出血量等均明显低于PETD组(p0.01),两组间术后卧床时间、住院时间无统计学差异(p0.05)。PEID组术后3例并发神经根痛,无复发,PETD组术后并发神经根痛4例,术后三月复发1例,行切开手术后症状缓解,随访6月无新发阳性症状;两组间术后并发症发生率无统计学差异(p0.05)。PEID组术前VAS、ODI分别为8±1.6分、(60.9±15.3)%,术后当日、出院时、末次随访V AS 分别为 5.3±2.6、2.8±1.6、1.2±0.9 分;末次随访 ODI评分为(30.6±16.3%);PETD组术前VAS、ODI分别为7±2.5分、(60.8±20.5)%,术后当日、出院时、末次随访VAS评分分别为5±2、2±1、1.3±0.8分、(32±7.6)%。两组末次随访时的VAS评分和ODI均较术前明显改善(p0.05),两组间术前、末次随访时的VAS评分和ODI均无统计学差异(p0.05)。按照Macnab疗效评定标准评定术后6月患者情况,无论行PETD术式还是在L5S1节段行PETD和PEID术式的患者,其6月后优良率均大于90%.结论:经皮内镜,无论是PEID术式还是PETD术式,其疗效较开放手术无明显差异,但是出血少、切口小、术后恢复快、对人体损伤小等都是开放手术不具备的优势,经皮内镜经过一段时间的发展,将会成为以后脊柱外科手术治疗的首选手术方案。就L5S1节段的腰椎间盘突出而言,需要我们结合患者自身情况、影像学资料等选择合适的治疗方案,才能取得良好的术后疗效。
[Abstract]:Background: with the social progress and the rapid development of medical science, reduce trauma, accelerate the rehabilitation after operation, shorten the postoperative bed time has attracted more and more attention. With the current field of lumbar and cervical spine disease prevalence rate increased year by year, conservative treatment alone has been difficult to achieve the goal of treatment. Since the open surgery to create, through the continuous development of about half a century, has been very mature, but the traditional open surgery complications (bleeding, severe trauma, postoperative pain, waist and back muscles during operation, extensive soft tissue stripping) has attracted more and more attention in all aspects, often chronic low back pain the effect of lead to soft tissue injury caused by these complications of patients after operation. With the emergence of other minimally invasive surgery, minimally invasive surgery for its small trauma, less bleeding, injury of paraspinal soft tissue small, Postoperative pain, rapid recovery and so on by people of all ages, spinal surgery doctor wants to use the technology to solve the problem of minimally invasive spinal spine. The early invention of the small window based on open surgery doctor, it has very obvious advantages compared with open surgery, but with the rapid development of the he microsurgery technology, small window gradually can not meet the requirements. With the popularization of endoscope system in other spinal surgery, endoscopic surgery also started to appear. Descending posterior microendoscopic lumbar discectomy (MED) has made a great contribution to the spine endoscope, can be said to have epoch-making significance, its clinical effect has been recognized by the people in a time. With the further rapid development of related technology and micro micro instruments, more "transforaminal endoscopic minimally invasive" (the working cannula implanted directly into the spinal canal, in endoscopy Underwent discectomy and nerve root decompression, PELD) into our vision. We found that by transforaminal endoscopic euthyphoria discectomy and nerve root decompression (foraminal mirror), with less trauma, more safety, faster recovery etc., the operation is disc mirror, intervertebral foramen surgery recognition a higher degree. At present, with the rapid development of foraminal mirror technology, the gradual emergence of a variety of surgical approach, in which everyone is commonly used is the posterior approach and posterolateral transforaminal approach, the two gradually mature and gradually get the size of the hospital popularity at home is not the lack of research reports the two approach, but no system and complete comparison, including the advantages and disadvantages of these two kinds of operation and the two approach the best adaptation. This paper will study and compare these two approaches, the two methods of optimal Should be in and the advantages and disadvantages of two kinds of operation in the L5-S1 segment. Objective: To study the transforaminal endoscopic transforaminal (transforaminal, TF) and interlaminar approach (interlaminar, IL), obtained the best indications of these two surgical approaches, and comparison in L5-S1 segment for the two surgical patients, the advantages and disadvantages of the L5-S1 segment for two kinds of operation. Methods: We collected the Central Hospital of Dalian from 2015 to 2016 for transforaminal endoscopic surgery including interlaminar (interlaminar, IL) approach and foramen (transforaminal, TF) in patients with basic surgery statistics these two surgical approaches including the number of puncture, operation time, fluoroscopy times, bleeding volume, postoperative bed time, time to discharge, surgical complications, preoperative and postoperative improvement (postoperative day, June at discharge VAS score and postoperative Oswestry dysfunction index), postoperative June MacNab score 绛，

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