腰椎间盘突出症克氏针定位经皮内镜内侧椎间孔椎间盘切除

Percutaneous endoscopic medial foramenal discectomy with or without Kirschner wire positioning for lumbar disc herniation

摘要:

[目的] 探讨克氏针锚定定位经皮内镜内侧椎间孔椎间盘切除术（percutaneous endoscopic medial foraminal discecto-my, PEMFD） 治疗腰椎间盘突出症（lumbar disc herniation, LDH) 的临床疗效。[方法] 回顾性分析2019 年6 月—2022 年1 月本院脊柱外科应用可视化环锯行PEMFD 治疗的93 例LDH 患者的临床资料，依据医患沟通结果，48 例采用克氏针锚定定位结合可视化环锯PEMFD，另外45 例行常规可视化环锯PEMFD。比较两组围手术期、随访和影像资料。[结果] 两组患者均顺利完成手术，均未发生严重并发症。锚定组在手术时间[(44.9±3.2) min vs (54.3±3.3) min, P＜0.001] 和透视次数[(3.4±1.1) 次vs (7.0±1.4) 次, P＜0.001] 均显著优于常规组；但两组患者在切口长度、术中失血量、术后下地行走时间、切口愈合等级和住院时间的差异均无统计学意义（P＞0.05）。所有患者均获随访12~18 个月，平均（14.4±5.0） 个月，两组患者恢复完全负重活动的时间差异无统计学意义（P＞0.05）。随时间推移，两组患者VAS 评分、ODI 评分均显著下降（P＜0.05），相应时间点，两组间VAS 和ODI 评分的差异均无统计学意义（P＞0.05）。末次随访时按改良Macnab 分级，两组间临床结果优良率差异无统计学意义（89.6% vs 88.9%, P＞0.05）。影像方面，两组术后椎管面积较术前均显著增大（P＜0.05），而椎间隙高度及腰椎前凸角无显著变化（P＞0.05）；相应时间点，两组患者间上述影像测量指标的差异均无统计学意义（P＞0.05）。与术前相比，末次随访时两组患者手术椎间盘的Pfirrmann 评级无显著变化（P＞0.05），相应时间点两组间Pfirrmann 评级的差异无统计学意义（P＞0.05）。[结论]在后路内镜技术治疗LDH 术中采用克氏针锚定定位椎板间内镜椎间盘切除术可显著提升手术效率。

关键词:克氏针锚定;腰椎间盘突出症;椎板间入路;可视化环锯

Abstract:

[Objective] To explore the clinical efficacy of percutaneous endoscopic medial foraminal discectomy (PEMFD) with or with-out Kirschner wire positioning for the treatment of lumbar disc herniation (LDH). [Methods] A retrospective study was conducted on 93 pa-tients who underwent PEMFD using a visualizing trephine for LDH in our hospital from June 2019 to January 2022. Based on doctor-pa-tient discussion preoperatively, 48 patients received PEMFD with Kirschner wire anchoring positioning, while the remaining 45 patients un-derwent the conventional PEMFD. The perioperative, follow-up, and imaging data were compared between the two groups. [Results] All pa-tients in both groups had operation performed successfully with no serious complications . The positioning group proved significantly superi-or to the conventional group in terms of surgical operation time [(44.9±3.2) min vs (54.3±3.3) min, P＜0.001] and fluoroscopy frequency[(3.4±1.1) times vs (7.0±1.4) times, P＜0.001], whereas there were no statistically significant differences in incision length, intraoperativeblood loss, postoperative walking time, incision healing grade and hospital stay between the two groups (P＞0.05). All patients were followedup for 12~18 months, with an average of (14.4±5.0) months, and there was no statistically significant difference in the time to resume fullweight-bearing activity between the two groups (P＞0.05). The VAS and ODI scores significantly decreased in both cohorts over time (P＜0.05), and there was no statistically significant difference in VAS and ODI scores between the two groups at any time points accordingly (P＞0.05). According to the modified Macnab's criteria, there was no statistically significant difference in the excellent and good rate of clinicalresults between the two groups at the latest follow-up (89.6% vs 88.9%, P＞0.05). Regarding imaging, the spinal canal area significantly increased (P＜0.05), while the intervertebral space height and lumbar lordosis angle remained unchanged in both group at the latest follow-upcompared with those preoperatively (P＞0.05). At the corresponding time points, there was no statistically significant difference in the above-said imaging measurement indicators between the two groups of patients (P＞0.05). In addition, there was no significant change in the Pfir-rmann grade of involved discs in both groups at the last follow-up (P＞0.05), and no statistically significant difference in Pfirrmann grade be-tween the two groups at any corresponding time point (P＞0.05). [Conclusion] The Kirschner wire anchoring positioning in PEMFD for pos-terior endoscopic treatment of LDH can significantly improve surgical efficiency.

Key words:Kirschner wire anchoring; lumbar disc herniation; interlaminar approach; visualizing trephine