内镜治疗中青年双节段腰椎间盘突出症患者的手术策略

doi:10.19723/j.issn.1671-167X.2021.04.019

摘要/Abstract

摘要：

目的: 比较针对中青年双节段腰椎间盘突出症患者分别采用经皮内镜下腰椎间盘单节段责任病灶切除与双节段病灶全部切除的临床疗效与安全性。方法: 选择北京大学第一医院2015年1月至2018年10月应用经皮内镜下腰椎间盘切除术治疗中青年双节段腰椎间盘突出症患者32例进行回顾性分析,其中单节段责任病灶治疗组(单节段组)18例,双节段病灶治疗组(双节段组)14例。临床评价采用腰腿痛视觉模拟量表评分(visual analogue score,VAS)和 oswestry功能障碍指数(oswestry disability index,ODI),分别于术前、术后3个月、末次随访时比较两组患者的临床症状转归,同时采用Macnab标准评价患者术后总体满意度;影像学参数包括X线片的腰椎前凸角、病灶节段椎间高度、病灶节段终板角,以及磁共振成像(magnetic resonance imaging, MRI)的腰椎间盘突出程度密歇根州立大学(Michigan State University,MSU)分级和T2序列上椎间盘退变程度的Pfirrmann分级;围手术期参数包括手术医师、麻醉方式、手术时间、术后住院天数、术后支具佩戴时间及围手术期并发症。结果: 最终纳入患者平均随访(26.78±10.64)个月,两组之间随访时间和基线信息差异无统计学意义(P>0.05)。临床症状评估方面,双节段组在术后3个月和末次随访的ODI相比于单节段组明显更低(P<0.05),同时双节段组末次随访ODI相较于术前缓解强于单节段组(P<0.05);影像学方面,术前两组X线和MRI影像学参数在主要病灶和次要病灶上均无明显差异。两组主要病灶的MSU突出分级在术后分别较术前均明显降低(P<0.05)。次要病灶的MSU突出分级双节段组术后较术前明显降低(P<0.05), 而单节段组次要病灶MSU突出分级术后较术前差异并无统计学意义(P>0.05);围术期参数方面,单节段组手术时间明显短于双节段组(P<0.001),两组均未发现围手术期并发症,但单节段组术后随访期间内3例患者接受了二次腰椎手术治疗。结论: 对于中青年双节段腰椎间盘突出症患者,双节段病灶同期切除在中长期可能有更好的功能改善而不增加相关手术并发症的风险。

关键词: 微创, 经皮内镜腰椎间盘切除术, 双节段, 腰椎间盘突出症

Abstract:

Objective: To investigate clinical efficacy and safety of single and double segmental percutaneous lumbar discectomy for young and middle-aged patients with double-segment disc herniation. Methods: Retrospective analysis was undertaken for 32 young and middle-aged patients with percutaneous endoscopic lumbar discectomy (PELD) in the treatment of double-segment lumbar disc herniation from January 2015 to October 2018 in Peking University First Hospital. In the study, 18 cases were treated with single-segment treatment and 14 cases with double-segment treatment. Visual analogue score (VAS) and oswestry disability index (ODI) assessment were used to compare clinical symptom outcomes before surgery, 3 months after surgery and at the last follow-up. Macnab criteria were used to assess the patients’ overall satisfaction after surgery. Imaging parameters included lumbar lordosis, intervertebral height at each segment and endplate angle of lesion segment on the X-ray. And Michigan State University(MSU) rating and Pfirrmann scoring system were used to evaluate the grade of disc herniation and disc degeneration respectively on magnetic resonance imaging (MRI). The perioperative parameters included the surgeon, anesthesia method, operation time, postoperative hospital stay, postoperative bracing time and perioperative complications. Results: The mean follow-up time was (26.78±10.64) months. There was no significant difference in the follow-up time and baseline information between the two groups(P>0.05). ODI scores 3 months post-operatively and at the last follow-up were lower in the double segment (P<0.05). The ODI improvement was also more significant in the double-segment group at the last follow-up (P<0.05). There was no significant difference in radiographic parameters at baseline (P>0.05). MSU scale for the primary segment was significantly lowered after both operations (P<0.05). MSU scale for secondary segment was significantly lowered in double segment group but not in single segment group. Other imaging parameters were similar between the two groups (P>0.05). The operation time of the single-segment group was significantly shorter than that of the double-segment group(P<0.001). No perioperative complications were found in either group, but three patients underwent secondary lumbar surgery during the postoperative follow-up period in the single-segment group. Conclusion: For young and middle-aged patients with double-segment disc herniation, this study suggests double-segment PELD may be more advantageous than single-segment PELD in terms of asuring clinical efficacy without increasing perioperative risks.

Key words: Minimally invasive surgery, Discectomy, Double segment, Lumbar disc herniation

中图分类号:

R681.5

越雷,王月田,白纯碧,陈浩,付豪永,于峥嵘,李淳德,孙浩林. 内镜治疗中青年双节段腰椎间盘突出症患者的手术策略[J]. 北京大学学报（医学版）, 2021, 53(4): 734-739.

YUE Lei,WANG Yue-tian,BAI Chun-bi,CHEN Hao,FU Hao-yong,YU Zheng-rong,LI Chun-de,SUN Hao-lin. Analysis of surgical strategy of percutaneous endoscopic lumbar discectomy in young and middle-aged double-segment patients with lumbar disc herniation[J]. Journal of Peking University (Health Sciences), 2021, 53(4): 734-739.

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Items	Single segment group (n=18)	Double segment group (n=14)	P
Baseline parameter
Age/years, M(Q1, Q3)	39.50 (30.00, 46.25)	30.50 (28.00, 37.50)	0.077
Gender, male/female	12/6	9/5	1.000
Follow-up time/days, M(Q1, Q3)	26.00 (18.50, 35.75)	27.00 (21.00, 34.25)	0.955
BMI /(kg/m²), M(Q1, Q3)	24.33 (22.08, 24.90)	24.28 (22.39, 29.00)	0.587
ASA score, M(Q1, Q3)	1.00 (1.00, 2.00)	1.00 (1.00, 2.00)	0.667
Drinking, yes/no	7/11	4/10	0.712
Smoking, yes/no	6/12	3/11	0.694
Perioperative parameter
Surgeon, yes/no	11/7	9/5	1.000
Anesthesia method, intraspinal anesthesia/local anesthesia	15/3	12/2	1.000
Operation time/min, M(Q1, Q3)	102.50 (78.50, 126.50)	150.00 (133.25, 167.00)	<0.001^*
Postoperative time in hospital/d, M(Q1, Q3)	1.00 (1.00, 2.00)	1.00 (1.00, 1.25)	0.808
Postoperative bracing time/months, M(Q1, Q3)	2.00 (1.00, 3.00)	2.00 (1.75, 3.00)	0.837

Items
Single segment group, M (Q1, Q3)	VAS	6.00 (4.00, 6.00)	2.00 (2.00, 2.50)	2.00 (0.00, 2.00)	-0.67 (-0.69, -0.46)	-0.71 (-1.00, -0.63)	<0.001^*	<0.001	0.020^*
Single segment group, M (Q1, Q3)	ODI	0.38 (0.18, 0.76)	0.11 (0.04, 0.23)	0.06 (0.02, 0.15)	-0.68 (-0.89, -0.44)	-0.86 (-0.93, -0.53)	<0.001^*	<0.001	0.007^*
Double segment group, M (Q1, Q3)	VAS	6.00 (4.00, 6.50)	2.00 (0.00, 2.00)	0.00 (0.00, 0.25)	-0.67 (-1.00, -0.63)	-1.00 (-1.00, -0.97)	0.001^*	0.001^*	0.014^*
Double segment group, M (Q1, Q3)	ODI	0.52 (0.33, 0.79)	0.09 (0.02, 0.19)	0.00 (0.00, 0.05)	-0.86 (-0.96, -0.54)	-1.00 (-1.00, -0.89)	0.001^*	0.001^*	0.013^*
P	VAS	0.722	0.071	0.059	0.091	0.099
P	ODI	0.338	0.398	0.041^*	0.267	0.025^*

Items		Single segment group (preoperative)	Double segment group (preoperative)	Single segment group (postoperative)	Double segment group (postoperative)	P1	P2	P3	P4
Lumbar lordosis		30.47 (24.14, 39.35)	31.90 (24.38,34.95)	30.04 (24.19, 39.35)	32.82 (26.05,44.05)	1.000	0.488	0.983	0.158
Lumbar lordosis changes^☆				4.18 (-2.31, 6.47)	2.75 (-2.43, 8.32)		0.925
Lesion segment endplate angle	Major	7.55 (4.06, 10.85)	4.51 (3.38, 5.96)	7.54 (4.82, 9.40)	6.16 (1.59, 7.87)	0.116	0.125	0.679	0.875
Lesion segment endplate angle	Minor	9.27 (6.80, 14.08)	6.18 (4.23, 11.51)	10.93 (9.22, 12.03)	8.31 (5.39, 12.41)	0.145	0.235	0.711	0.300
Lesion segment endplate angle changes^☆	Major			0.16 (-2.50, 2.23)	0.61 (-2.50, 2.23)		0.866
Lesion segment endplate angle changes^☆	Minor			2.35 (0.11, 4.73)	1.74 (-2.18, 5.28)		0.837
Intervertebral height of lesion segment	Major	1.50 (1.00, 2.00)	2.00 (1.00, 2.00)	1.00 (1.00, 1.00)	1.00 (1.00, 1.00)	0.319	0.896	0.008^*	0.021^*
Intervertebral height of lesion segment	Minor	1.50 (1.00, 2.00)	2.00 (1.00, 2.00)	1.00 (1.00, 1.00)	1.00 (1.00, 1.00)	0.512	0.613	0.014^*	0.005^*
Intervertebral height changes^☆	Major			0.05 (-1.29, 0.67)	0.04 (-1.34, 0.67)		0.896
Intervertebral height changes^☆	Minor			-0.37 (-1.12, 0.50)	-0.64 (-1.19, -.0.06)		0.639
Pfirrman grading	Major	4.00 (3.75, 4.00)	3.50 (3.00, 4.25)			0.837
Pfirrman grading	Minor	4.00 (3.00, 4.00)	3.50 (3.00, 4.00)			0.357
MSU grading	Major	2.00 (2.00, 3.00)	2.00 (2.00, 3.00)	1.50 (1.00, 2.00)	1.00 (1.00, 2.00)	0.955	0.319	0.003^*	0.012^*
MSU grading	Minor	1.00 (1.00, 2.00)	2.00 (1.00, 2.00)	1.00 (1.00, 1.00)	1.00 (1.00, 2.00)	0.319	0.587	0.102	0.025^*
MSU grading changes^☆	Major			-1.00 (-1.00, 0.00)	-1.00 (-2.00, 0.00)		0.512
MSU grading changes^☆	Minor			0.00 (-1.00, 0.00)	0.00 (-1.00, 0.00)		0.587