Ong Damian, Chua Nicholas H L, Vissers Kris
Department of Anaesthesiology, Intensive Care and Pain Medicine, Tan Tock Seng Hospital, Singapore City, Singapore.
Specialist Pain International Clinic, Singapore City, Singapore.
Pain Pract. 2016 Jan;16(1):111-26. doi: 10.1111/papr.12250. Epub 2014 Oct 29.
Open discectomy remains the standard of treatment for patients with lumbar radicular pain secondary to a prolapsed intervertebral disc. Open discectomy performed in patients with small, contained herniations may result in poor outcomes. The various techniques of percutaneous disc decompression (PDD) have been developed to address this population.
A literature search was conducted on articles, which address PDD for lumbar radicular pain. Published techniques include chymopapain chemonucleolysis, percutaneous laser disc decompression (PLDD), automated percutaneous lumbar discectomy (APLD), Dekompressor, nucleoplasty, and targeted disc decompression (TDD). In addition, the rationale of provocative discography, selective nerve root injections, and intra-op discograms before performing PDD is discussed in detail.
Dekompressor and nucleoplasty have the best level of evidence with a score of 2B+. The chymopapain chemonucleolysis has the most publications, but it is also accompanied by the most significant adverse complications and so it is scored as a 2B+/-. The other techniques are supported mainly by observational studies and thus their scores range between 0 and 2B+/-. There is no supporting evidence for provocative discography in patients with lumbar radicular pain. The evidence for a positive selective nerve root injection as an inclusion criteria or the need for an intra-op discogram shows mixed results.
Nucleoplasty and Dekompressor have a weak positive recommendation for the treatment of patients with lumbar radicular pain. There is no role for provocative discography in this group of patients, although the evidence for a selective nerve root injection or an intra-op discogram is inconclusive.
开放性椎间盘切除术仍是因椎间盘突出继发腰椎神经根性疼痛患者的治疗标准。对小型、包容性椎间盘突出患者进行开放性椎间盘切除术可能导致预后不良。已开发出各种经皮椎间盘减压（PDD）技术来治疗这类患者。
对有关PDD治疗腰椎神经根性疼痛的文章进行文献检索。已发表的技术包括木瓜凝乳蛋白酶化学溶解术、经皮激光椎间盘减压术（PLDD）、自动经皮腰椎间盘切除术（APLD）、Dekompressor、髓核成形术和靶向椎间盘减压术（TDD）。此外，还详细讨论了在进行PDD之前进行激发性椎间盘造影、选择性神经根注射和术中椎间盘造影的基本原理。
Dekompressor和髓核成形术的证据水平最佳，评分为2B +。木瓜凝乳蛋白酶化学溶解术的文献最多，但也伴有最严重的不良并发症，因此评分为2B + / -。其他技术主要得到观察性研究的支持，因此其评分在0至2B + / -之间。对于腰椎神经根性疼痛患者，激发性椎间盘造影没有支持证据。将阳性选择性神经根注射作为纳入标准或术中椎间盘造影必要性的证据显示结果不一。
对于腰椎神经根性疼痛患者的治疗，髓核成形术和Dekompressor有弱的阳性推荐。在这类患者中，激发性椎间盘造影没有作用，尽管选择性神经根注射或术中椎间盘造影的证据尚无定论。
