Abstract:

Objective　To explore the clinical efficacies of percutaneous endoscopic lumbar discectomy (PTED) versus decompressive fenestration and discectomy under x-tube operation system for the treatment of adjacent segment degeneration (ASD) after lumbar fusion surgery. Methods　The data of the patients with ASD who underwent operation at Luohe Central Hospital from January of 2019 to January 2021 were analyzed retrospectively. According to the inclusion criteria, we collected the data of 37 patients with unilateral protrusion. There were 18 patients in the endoscopic group treated with PTED and 19 patients in the fenestration group treated with decompressive fenestration and discectomy under x-tube operation system. There were 8 males and 10 females in the endoscopic group; they were (48.50±9.49) years old. There were 9 males and 10 females in the fenestration group; they were (48.15±9.75) years old. All the cases were diagnosed by lumbar anterior-posterior X-ray, lateral X-ray, lumbar dynamic X-ray, and MRI. The imaging showed that adjacent segments of degenerative intervertebral discs protruded or extruded towards the inner side of the spinal canal, with compression of the dural sac and ipsilateral nerve roots. The operation times, intraoperative bleeding volumes, numbers of fluoroscopy, and hospitalization times were compared between the two groups. The clinical efficacies were evaluated by Japanese Orthopaedic Association Scores (JOA) of 29 points for low back pain. The improvement of limb pain was evaluated by the Visual Analogue Scale (VAS). t and χ² tests were used. Results　The operation time, intraoperative bleeding volume, hospitalization time, and number of intraoperative fluoroscopy in the endoscopic group were (49.44±10.65) min, (7.44±1.97) ml, (4.61±1.03) d, and (13.83±2.03) times; those in the fenestration group were (50.89±9.63) min, (117.00±54.48) ml, (12.31±1.79) d, and (1.15±0.37) times; there was no statistical difference in the operation time between the two groups (P=0.666) and were in the intraoperative bleeding volume, hospitalization time, and number of intraoperative fluoroscopy (all P<0.05). The intraoperative bleeding volume and hospitalization time in the fenestration group were higher than those in the endoscopic group. The fluoroscopy times in the endoscopic group was higher than that in fenestration group. There were no statistical differences in the scores of JOA and VAS before and 3 months after the surgery and at the last follow-up (all P>0.05). There were 2 cases in the endoscopic group and no case in the fenestration group complicated with cerebrospinal fluid leakage. There was no case complicated with infection and nerve root injury in both groups. At the last follow-up, spinal instability was well in both groups through postoperative X-ray examination. Conclusion　For the lumbar disc herniation caused by adjacent segment degeneration after lumbar fusion, PTED can achieve the same clinical effect as fenestration decompression surgery and avoid the scar of the original surgical approach. It has the advantages of less trauma and quick postoperative recovery and can be used as an effective surgical method to treat symptomatic ASD after lumbar fusion.

Key words:

Protrusion of lumbar intervertebral disc, Degeneration of intervertebral disc, Transforaminal endoscope, Intervertebral fusion,  , Adjacent segment degeneration, Minimally invasive

摘要：

目的　对比经皮椎间孔镜腰椎间盘切除术（percutaneous endoscopic lumbar discectomy，PTED）和通道下椎板间开窗髓核摘除术治疗腰椎融合术后症状性相邻节段病变（adjacent segment degeneration，ASD）所致的腰椎间盘突出症的临床疗效。方法　回顾性分析2019年1月至2021年1月期间漯河市中心医院收治的腰椎融合术后症状性相邻节段病变患者，根据纳入标准纳入单侧突出患者共37例，18例采用PTED治疗（孔镜组），19例采用通道下椎板间开窗髓核摘除术治疗（开窗组）。孔镜组，男8例，女10例，年龄（48.50±9.49）岁；开窗组，男9例，女10例，年龄（48.15±9.75）岁。所有病例均行腰椎正侧位片、腰椎过伸过屈侧位片及MRI检查确诊，影像学显示相邻节段退变的椎间盘向椎管内偏一侧突出或脱出，硬膜囊及同侧神经根受压。比较两组的手术时间、术中出血量、透视次数、住院时间，临床疗效采用日本矫形外科协会下腰痛29分法标准（JOA）评分评定，患肢疼痛的改善情况采用视觉模拟量表（VAS）评价。采用t检验、χ²检验进行统计分析。结果　孔镜组的手术时间（49.44±10.65）min、术中出血量（7.44±1.97）ml、住院时间（4.61±1.03）d、术中透视次数（13.83±2.03）次，开窗组分别为（50.89±9.63）min、（117.00±54.48）ml、（12.31±1.79）d、（1.15±0.37）次，两组间手术时间比较差异无统计学意义（P=0.666），两组术中出血量、住院天数、术中透视次数比较，差异均有统计学意义（均P<0.001）。在术中出血量、住院天数方面，开窗组高于孔镜组，但在透视次数方面孔镜组高于开窗组。两组术前、术后3个月、末次随访时JOA评分与VAS评分比较，差异均无统计学意义（均P>0.05）。开窗组出现2例脑脊液漏，孔镜组未出现脑脊液漏病例，两组均未出现感染及神经根损伤病例。末次随访时，术后X线片检查两组均未见脊柱失稳。结论　对腰椎融合术后相邻节段退变引起的腰椎间盘突出症，PTED可以取得和开窗减压手术一样的临床疗效，同时避开原手术入路的瘢痕组织，具有创伤小、术后恢复快的优势，可作为治疗腰椎融合术后症状性相邻节段病变的有效术式。

关键词:

腰椎间盘突出症, 椎间盘退行性变, 椎间孔镜, 椎间融合术, 相邻节段退变, 微创