Yue James J, Scott David L, Han Xiao, Yacob Alem
Department of Orthopaedics & Rehabilitation, Yale University School of Medicine, New Haven CT 06520.
Int J Spine Surg. 2014 Dec 1;8. doi: 10.14444/1016. eCollection 2014.
Surgery for same level multi-focal extruded lumbar disc herniations is technically challenging and the optimal method controversial. The subarticular disc herniation may pose the most challenging subtype requiring partial or complete facetectomy with or without fusion. The far-lateral disc herniation, often treated using a Wiltse approach, can also be difficult to access especially in the obese patient. When both the subarticular and far-lateral subtypes are simultaneously present at the same level with or without a paracentral disc herniation, a total facetectomy and interbody fusion (TLIF) or a total disc replacement (TDR) may be necessary. Endoscopic surgical techniques may reduce the need for these more invasive methods.
Fifteen patients (6 male and 9 female) who had same level multi-focal (subarticular as well as far-lateral and/or paracentral) extruded disc herniations underwent single incision unilateral endoscopic disc excision by the same surgeon at a single institution. Patients were prospectively followed for an average of 15.3 months (range 14-18 months) and outcomes were evaluated radiographically and clinically (Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI).
The mean operative time was 52 minutes with minimal blood loss in all cases. Fourteen of the 15 patients were discharged to home on the day of their surgery. The mean ODI and leg VAS scores improved from 22.9 ± 3.2 to 12.9 ± 2.7 (p < 0.005), and from 8.6 ± 1.6 to 2.1 + 0.4 (p < 0.005), respectively.
After an average of 15.3 months of follow-up, the clinical and radiographic results of full endoscopic surgical treatment of single level multi-focal (subarticular as well as far-lateral and/or paracentral) disc herniations are excellent. This study is a case series with mid-term follow-up (Level IV).
Foraminal and extra-foraminal full endoscopic decompression appears to offer a safe minimally invasive solution to a complex pathologic problem.
同一节段多节段腰椎间盘突出症的手术在技术上具有挑战性，最佳手术方法存在争议。关节下型椎间盘突出症可能是最具挑战性的亚型，需要进行部分或完全椎板切除术，可伴有或不伴有融合术。远外侧型椎间盘突出症通常采用Wiltse入路治疗，尤其在肥胖患者中，其手术入路也可能存在困难。当关节下型和远外侧型同时出现在同一节段，伴有或不伴有中央型椎间盘突出症时，可能需要进行全椎板切除术和椎间融合术（TLIF）或全椎间盘置换术（TDR）。内镜手术技术可能会减少对这些更具侵入性方法的需求。
15例（6例男性，9例女性）同一节段多节段（关节下型以及远外侧型和/或中央型）椎间盘突出症患者在单一机构由同一位外科医生进行单切口单侧内镜下椎间盘切除术。对患者进行前瞻性随访，平均随访15.3个月（范围14 - 18个月），并通过影像学和临床评估结果（视觉模拟评分法（VAS）和Oswestry功能障碍指数（ODI））。
平均手术时间为52分钟，所有病例失血极少。15例患者中有14例在手术当天出院回家。平均ODI和腿部VAS评分分别从22.9±3.2改善至12.9±2.7（p < 0.005），以及从8.6±1.6改善至2.1 + 0.4（p < 0.005）。
经过平均15.3个月的随访，单节段多节段（关节下型以及远外侧型和/或中央型）椎间盘突出症全内镜手术治疗的临床和影像学结果极佳。本研究是一项中期随访的病例系列研究（IV级）。
椎间孔型和椎间孔外型全内镜减压似乎为复杂病理问题提供了一种安全的微创解决方案。
