单侧双通道内窥镜技术治疗单节段腰椎椎间盘突出症.pdf

254王辉，等.单侧双通道内窥镜技术治疗单节段腰椎椎间盘突出症临床研究单侧双通道内窥镜技术治疗单节段腰椎椎间盘突出症王辉，陈雄生2*，潘敏，余建丰11.宜兴市第四人民医院骨科，宜兴2 142 0 02.海军军医大学长征医院骨科，上海2 0 0 0 0 3【摘要】目的探讨单侧双通道内窥镜（UBE）技术治疗单节段腰椎椎间盘突出症(LDH）的疗效。方法回顾性分析2 0 2 0 年1月一2 0 2 2 年9 月在宜兴市第四人民医院接受手术治疗的6 0 例单节段LDH患者临床资料，其中30 例采用UBE技术治疗（UBE组），其余30 例采用传统椎板开窗椎间盘切除术（FD）治疗（FD组）。记录2 组手术时间、术中出血量、住院时间、下床活动时间及并发症发生情况。术前及术后1、3个月和末次随访时采用疼痛视觉模拟量表（VAS）评分评估腰腿痛程度，采用Oswestry功能障碍指数（ODI)评估腰椎功能。末次随访时采用改良MacNab标准评价临床疗效。结果所有手术顺利完成。所有患者随访（5.0 1.4）个月。UBE组手术时间、术中出血量、住院时间及下床活动时间明显低于FD组，差异均有统计学意义（P0.05）。2 组术后各时间点VAS评分、ODI较术前明显改善，且UBE组术后1个月VAS评分、ODI优于FD组，差异均有统计学意义（P0.05）。末次随访时，按照改良MacNab标准评价疗效，UBE组疗效优良率为96.7%，FD 组为9 3.3%，差异无统计学意义（P0.05）。U BE组发生硬膜囊撕裂1例，并发症发生率为3.33%；FD组发生硬膜囊撕裂2 例，感染1例，椎间不稳1例，并发症发生率为13.33%；2 组并发症发生率差异有统计学意义（P0.05）结论与传统FD相比，UBE技术治疗LDH可有效减少手术时间及术中出血量，术后早期腰腿痛程度更低，腰椎功能改善更明显。【关键词】腰椎；椎间盘移位；内窥镜检查；椎间盘切除术，经皮；外科手术，微创性【中图分类号】R681.533.1【D 0 1】10.39 6 9/j i s s n.16 7 2-2 9 57.2 0 2 3.0 4.0 0 8Unilateral biportal endoscopic technique for single-segment lumbar disc herniationWang Hui,Chen Xiongsheng*,Pan Min,She Jianfeng!1.Department ofOrthopaedics,Fourth Peoples Hospital of Yixing,Yixing 214200,Jiangsu,China2.Department of Orthopaedics,Changzheng Hospital,Naval Medical University,Shanghai 200003,ChinaAbstract Objective To investigate the efficacy of unilateral biportal endoscopic(UBE)technique in the treatment ofsingle-segment lumbar disc herniation(LDH).Methods From January 2020 to September 2022,the clinical data of 60patients with single-segment LDH who received surgical treatment in the Fourth Peoples Hospital of Yixing were retrospectivelyanalyzed,30 of whom were treated with UBE technique(UBE group)and the remaining 30 were treated with traditionalfenestrated discectomy(FD group).The operation time,intraoperative blood loss,hospital stay,time to get out of bed and theoccurrence of complications of the 2 groups were recorded.The pain visual analog scale(VAS)score and Oswestry Disability Index(ODI)were used to evaluate the intensity of low back and leg pain and lumbar function at pre-operation,postoperative 1,3 monthsand the final follow-up.The modified MacNab criteria were used to evaluate the clinical efficacy at the final follow-up.ResultsAll the operations were successfully completed.All the patients were followed up for(5.0 1.4)months.The operation time,intraoperative blood loss,hospital stay and time to get out of bed were significantly lower in the UBE group than in the FD groupand the differences were statistically significant(P0.05).The VAS score and ODI of the 2 groups were improved significantlyat each postoperative time point compared with those before surgery,and the VAS score and ODIof the UBE group were betterthan those of the FD group at postoperative 1 month,and the differences were statistically significant(P0.05).At the final follow-up,according to the modified MacNab criteria,the rate of excellent and good efficacy was 96.7%*通信作者（Corresponding author）作者简介王辉（19 7 9），硕士，副主任医师；430 8 347 30 通信作者陈雄生【文献标志码】A【文章编号】16 7 2-2 9 57（2 0 2 3）0 4-0 2 54-0 5脊柱外科杂志，2 0 2 3年8 月，第2 1卷第4期JSpinalSurg，A u g u s t 2 0 2 3，Vo l.2 1，No.4in the UBE group and 93.3%in the FD group,and there was no statistical significance between the 2 groups(P0.05).In theUBE group,dural sac tear occurred in 1 case,with a complication rate of 3.33%;in the FD group,dural sac tear occurred in 2cases,infection in 1 and intervertebral instability in 1,with a complication rate of 13.33%;the difference in complication ratesbetween the 2 groups was statistically significant(P0.05，表1），具有可比性。表12 组患者一般资料Tab.1 General information of patients in 2 groups性别Gendern男Male30183020责任节段年龄/岁病程/周女AgelyearFemale1210Responsible segmentCourseof disease/weekLA/Ls54.20 15.6128.63 2.4755.33 15.2829.33 2.77织，显露上椎板下缘、下关节突、下椎板上缘以及椎板间隙，采用4.0 金刚砂磨钻将上椎板下缘骨质磨薄，使用椎板咬骨钳进一步处理椎板下缘直至黄韧带近端止点，使用神经剥离子从下椎板上缘剥离黄韧带止点，使用反向咬骨钳咬除部分椎板上缘，使用黄韧带剥离器自近端向远端剥离黄韧带，使用椎板咬骨钳切除黄韧带。然后采用磨钻及椎板咬骨钳处理侧隐窝骨质，切除侧隐窝残留黄韧带直至走行根肩端，使用神经剥离子剥离松解走行根，使用神经拉钩将神经根牵拉向中线方向，显露突出椎间盘，采用UBE301刀头清理表面血管，切开纤维环，摘除突出的髓核组织，椎间隙插人UBE冲洗器，将Ls/Si16141713256残留碎屑冲出，使用UBE405刀头皱缩纤维环破口及止血，术毕冲洗后全层缝合伤口。FD组患者气管插管全身麻醉后取俯卧位，将腹部垫空，扩大病变椎间隙。C形臂X线机透视确定病变椎间隙，常规消毒、铺巾，以病变椎间隙为中心做腰椎后路正中切口，逐层切开皮肤、皮下组织、腰背筋膜，采用电刀、骨剥离器分离至椎板及关节突，暴露责任节段，使用椎板钳咬除上位椎板部分下缘3 4mm，开窗后暴露硬膜囊、神经根，牵拉神经根，暴露突出椎间盘，摘除突出髓核组织及破裂纤维环，处理椎间松动的髓核组织，之后探查硬膜囊、神经根松解度，确认神经根四周无残留髓核、椎间盘组织。最后用生理盐水冲洗手术区域，止血、缝合、包敷手术创口。2组患者围手术期均未使用抗生素，术后未放置引流管。术后酌情佩戴腰围下床适度活动，3周内以卧床休息为主。1.3观察指标记录2 组手术时间、术中出血量、住院时间、下床活动时间及并发症发生情况。术后1、3个月时采用疼痛视觉模拟量表（VAS)评分 51评估腰腿痛程度，采用Oswestry功能障碍指数（ODI)6评估腰椎功能，末次随访时采用改良MacNab标准 7 评价临手术时间/min术中出血量/mL住院时间/d组别GroupnOperationtime/minUBE3073.80 4.50*FD30102.60 5.62组别GroupPre-operationUBE35.87 1.36FD35.97 1.47注：*与FD组相比，P0.05；与术前相比，P0.05。Note:*P0.05,compared with FD group;P 0.0 5,c o mp a r e d w i t h p r e-o p e r a t i o n.3讨 论LDH是骨科常见病，各年龄层均有分布，临床王辉，等.单侧双通道内窥镜技术治疗单节段腰椎椎间盘突出症床疗效。1.4统计学处理采用SPSS22.0软件对数据进行统计分析，符合正态分布的计量资料以xS表示，组间比较采用t检验，计数资料以率或百分比（%）表示，采用x检验；以P0.05为差异有统计学意义。2结果所有手术顺利完成。所有患者随访（5.0 1.4）个月。UBE组手术时间、术中出血量、住院时间及下床活动时间明显低于FD组，差异均有统计学意义（P0.05，表2)。2 组术后各时间点VAS评分、ODI较术前明显改善，且UBE组术后1个月VAS评分、ODI优于FD组，差异均有统计学意义（P0.05，表2）。末次随访时按照改良MacNab标准评价疗效，UBE组疗效优良率为9 6.7%，FD组为9 3.3%，组间差异无统计学意义（P0.05，表2)。UBE组发生硬膜囊撕裂1例，并发症发生率为3.33%（1/30）；FD组发生硬膜囊撕裂2 例，感染1例，椎间不稳1例，并发症发生率为13.33%（4/30）；2 组并发症发生率差异有统计学意义（P0.05)。表2 2 组临床疗效指标Tab.2Clinical efficacy indexes of 2 groups下床活动时间/dIntraoperativeHospital stay/ldblood loss/mL42.47 13.35*96.63 13.61ODI(%)术后1个月术后3个月术前Postoperative1month13.67 5.74*415.43 5.594腰腿痛VAS评分VAS score of lowbackand leg painTime to get术后1个月术后3个月out of bed/dPre-operation术前PostoperativePostoperative1 month4.96 1.24*1.53 0.86*10.13 2.063.16 0.98末次随访PostoperativeFinal follow-up3months9.93 5.17410.67 5.96 4Final follow-up末次随访3months8.47 0.512.83 1.88*1.93 1.61 48.500.513.43 1.6142.13 1.794改良MacNab标准Modified MacNabcriteria优良ExcellentGood7.47 5.704238.17 6.34422表现以腰腿痛为主，该症状主要为脱出或突出的髓核组织刺激或压迫神经根所致。传统开放手术能较好地去除病变组织，解除炎性刺激，减轻神经根压1.23 1.73 41.53 1.994优良率（%）可差Excellent andgoodFairPooroutcomerate(%)42511296.793.3脊柱外科杂志，2 0 2 3年8 月，第2 1卷第4期JSpinalSurg，A u g u s t 2 0 2 3，Vo l.2 1，No.4迫，但存在创伤大、出血多、视野差、恢复慢等缺点，操作不当更易引起神经根损伤，影响脊柱稳定性。为减少或避免上述弊端，脊柱微创技术应运而生，并在近年蓬勃发展。UBE技术由De Antoni8于1996年在关节镜下切除腰椎椎间盘的基础上首次提出。但Yeung脊柱内窥镜系统（YESS）9 和经椎间孔脊柱内窥镜系统（TESSYS）10 1技术的出现和快速发展，对UBE技术造成巨大冲击，使其渐渐淡出骨科医师的视野。后来，在大批韩国医师 1-12 的摸索及改良下，该技术得以复兴，并成功运用到各类脊椎疾病的治疗中，并取得了良好的临床效果。本研究结果也显示，UBE组患者术后疗效优良率达96.7%。同时，本研究结果还显示，UBE组术中出血量低，手术时间、住院时间、下床活动时间均优于FD组，提示UBE技术能改善围手术期情况，分析原因如下。UBE技术术中镜下视野放大且清晰，可最小范围剥离软组织及骨质结构，避免术区广泛显露造成的术中出血量增加。UBE技术术中运用磨钻行椎板减压，采用常规手术器械处理椎间隙，工作效率高，缩短了手术时间；此外，手术时间还与术者内窥镜下操作熟练程度有关。UBE技术术中软组织及骨创面较小，内窥镜监视下可安全处理硬膜及血管等重要器官及组织，故患者术后疼痛缓解较快，住院时间和下床活动时间减少。UBE技术采用2 个独立通道，一个为观察通道，切口约0.5cm；一个为经过多裂肌与棘突间潜在腔隙建立的操作通道13，切口约1.0 cm；避免了传统手术的软组织广泛剥离，减少了术后腰痛的发生。UBE技术采用4.0 mmUBE内窥镜，术中可轻易置入椎管内并放大视野。因此，可更仔细地观察病变组织；该内窥镜也可经过棘突基底部到达对侧，术中可清晰观察对侧椎间盘、神经根等结构 14，且不压迫神经，手术视野较传统开放手术更广泛、清晰，操作更安全。操作通道较观察通道稍大，能兼用常规的椎板咬骨钳、髓核钳等器械，处理病变组织效率明显高于TESSYS技术，且不用购买TESSYS技术特有的操作器械，节约了成本 15。另外，UBE技术均采用改良腰后方人路，无论是术前透视定位、术中解剖标志都和传统开放手术类似，与TESSYS技术相比，大大降低了学习难度 16-17 。UBE技术镜下操作需医师熟练掌握关节镜的三角成像操作技术，即内窥镜和操作器械成“V”形相交时才能进行操作，否则无法在镜下找到操作器械。这与单轴内窥镜有很大不同，需要一定的学257习周期，有关节镜手术基础的医师可更快掌握该技术，并做到同质化操作。对于退行性变较重的老年患者，镜下有发生“迷路”的可能。此时，可用1.5克氏针穿刺骨面后采用C形臂X线机重新透视定位手术节段。整个手术在持续的水介质下完成，要保持清晰的视野，首先要维持合适的灌注压，本研究选择离手术床9 0 cm高度，能维持较好的通畅出水，不但可以压迫小的出血点，而且有助于分离硬膜囊和黄韧带潜在腔隙，降低术中损伤硬膜囊的概率。有研究 18 报道，即使出现了硬膜囊损伤，UBE技术术中修补也更具优势。本研究中UBE组发生硬膜囊撕裂1例，术中应用明胶海绵压迫，术后患者并未出现头晕、头痛等脑脊液漏症状。UBE技术并发症较传统开放手术少，其硬膜囊撕裂、硬膜外血肿、神经根损伤、远期椎间不稳等并发症发生率为0 24.7%19。本研究结果也提示UBE技术并发症发生率低于FD。原因考虑：UBE技术术中大量生理盐水持续冲洗，大大降低了感染的概率。术中止血技术至关重要。UBE技术术中减压时造成的骨面渗血既可利用骨屑填压止血，也可用骨蜡压迫或低温等离子刀头（UBE405）止血，对于神经表面出血可采用低功率低温等离子刀头（UBE301）止血，电凝时间更短，否则有损伤硬膜囊及神经根的可能。合理控制血压也尤为关键。本研究发现，将收缩压控制在9 0 10 0 mmHg(1 mmHg=0.133kPa）时,可有效控制创面渗血。有研究 2 0 1报道，UBE技术治疗LDH术后引流量较少，本研究中所有患者均未置入引流管，均未发生不良反应。为进一步探究UBE技术的临床疗效，本研究于术后1个月评估患者的康复情况，结果显示，2 组腰腿痛VAS评分及ODI均较术前明显改善，且UBE组优于FD组，证实UBE技术微创、安全，可最小范围暴露术区，彻底椎管减压；且UBE技术可在内窥镜直视下处理椎间盘髓核组织，充分松解神经根，可最大程度地保留纤维环完整度，保障脊柱生物力学稳定性，更有利于术后早期腰椎功能恢复。随着康复时间的延长，术后3个月及末次随访时2 组腰腿痛VAS评分及ODI差异无统计学意义。综上所述，UBE作为新兴的脊柱内窥镜技术，不仅保留了TESSYS技术的优势 2 1，还兼顾了传统手术的人路和器械，为治疗LDH提供了全新思路，术后近期快速康复效果较传统手术更好，但中远期疗效仍需要进行大样本的前瞻性随机研究及长期随访来综合评估。2581Hu ZJ,Fang XQ,Zhou ZJ,et al.Effect and possiblemechanism of muscle-spliting approach on multifidusmuscle injury and atrophy after posterior lumbar spinesurgeryJ.J Bone Joint Surg Am,2013,95(24):1921-1929.2Mobbs RJ,Li J,Sivabalan P,et al.Outcomes afterdecompressive laminectomy for lumbar spinal stenosis:comparison between minimally invasive unilateral laminectomyfor bilateral decompression and open laminectomy:clinical article J.J Neurosurg Spine,2014,21(2):179-186.3Miller LE,Bhattacharyya S,Pracyk J.Minimallyinvasive versus open transforaminal lumbar interbodyfusion for single-level degenerative 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