Liu Chao, Chu Lei, Yong Hao-Chuan, Chen Liang, Deng Zhong-Liang
The Second Affiliated Hospital of Chongqing Medical University, Chong Qing, China.
Pain Physician. 2017 Jan-Feb;20(1):E75-E84.
Percutaneous endoscopic lumbar discectomy (PELD) has been growing in popularity for the treatment of lumbar disc herniation (LDH) due to its irreplaceable advantages over conventional open surgery. Compared with common lumbar disc herniations, discectomy of highly migrated LDH by PELD is known to be very difficult. Highly migrated lumbar disc herniation has long been a challenge for its specific characteristics. Three approaches for PELD have been applied to access a highly migrated LDH, including an interlaminar approach (IL), transforaminal approach (TF), and contralateral transforaminal approach (CTF). However, none of the existing research has systematically described the selection of the most appropriate procedure from the 3 approaches or the individualization of an operative procedure in different cases.
The purpose of this study was to present a detailed surgical approach selection and individualization of procedure in the treatment of highly migrated LDH with PELD. We also mean to compare the outcomes of patients with highly migrated LDH treated with PELD by the 3 approaches.
Single-center retrospective observational study.
An interventional pain management practice, a medical center, major metropolitan city, China.
In our retrospective analysis between March 2011 and March 2013, 73 patients with single level highly migrated LDH received PELD. Clinical outcomes were assessed with the visual analogue scale (VAS) score, the modified MacNab criteria, and the Oswestry disability index (ODI). Relevant data such as operation duration and fluoroscopy frequency of the 3 operative approaches were recorded.
The mean operating time of IL was 56 minutes, compared with 64 minutes for TF and 112 minutes for CTF. The mean intraoperative fluoroscopy times were 5.5 for IL, 9.7 for TF, and 14.6 for CTF. In each group, the mean VAS and ODI after surgery and 3 months after surgery improved dramatically compared with preoperative counterparts. However, the difference between postoperative results and the results 3 months after surgery was not significant (P > 0.05). The overall excellent rate was 90.4% according to the modified MacNab criteria; there was no significant statistical difference between the 3 operative routes. Operative complications occurred in 3 patients (2 after IL and one after CTF, 3 of 73, 4.1%).
This study is limited by its sample size.
In our research, PELD with all 3 approaches was similarly effective to highly migrated disc herniation. The CTF approach required the longest operation duration and the most intraoperative times. On the contrary, the least operation time and radiographfrequency was required with the IL approach. In addition, we came to a conclusion of surgery approach selection when it comes to varied HM-LDH. Key words: Highly migrated, lumbar disc herniation, percutaneous endoscopic lumbar discectomy, minimally invasive treatment.
经皮内镜下腰椎间盘切除术（PELD）因相较于传统开放手术具有不可替代的优势，在治疗腰椎间盘突出症（LDH）方面越来越受欢迎。与常见的腰椎间盘突出症相比，经皮内镜下高度移位型腰椎间盘突出症的椎间盘切除术非常困难。高度移位型腰椎间盘突出症因其特殊的特点长期以来一直是一个挑战。经皮内镜下腰椎间盘切除术的三种入路已被应用于治疗高度移位型腰椎间盘突出症，包括椎板间入路（IL）、椎间孔入路（TF）和对侧椎间孔入路（CTF）。然而，现有的研究均未系统描述从这三种入路中选择最合适的手术方式或针对不同病例进行手术方式个体化。
本研究旨在详细介绍经皮内镜下腰椎间盘切除术治疗高度移位型腰椎间盘突出症时手术入路的选择及手术方式个体化。我们还旨在比较经三种入路行PELD治疗的高度移位型腰椎间盘突出症患者的疗效。
单中心回顾性观察研究。
中国某大都市的一家医疗中心的介入性疼痛管理诊所。
在我们对2011年3月至2013年3月期间的回顾性分析中，73例单节段高度移位型腰椎间盘突出症患者接受了PELD治疗。采用视觉模拟量表（VAS）评分、改良MacNab标准和Oswestry功能障碍指数（ODI）评估临床疗效。记录三种手术入路的相关数据，如手术时间和透视次数。
椎板间入路的平均手术时间为56分钟，椎间孔入路为64分钟，对侧椎间孔入路为112分钟。椎板间入路的平均术中透视次数为5.5次，椎间孔入路为9.7次，对侧椎间孔入路为14.6次。每组患者术后及术后3个月的平均VAS和ODI与术前相比均有显著改善。然而，术后结果与术后3个月的结果之间差异无统计学意义（P>0.05）。根据改良MacNab标准，总体优良率为90.4%；三种手术路径之间无显著统计学差异。3例患者发生手术并发症（椎板间入路2例，对侧椎间孔入路1例，73例中的3例，4.1%）。
本研究受样本量限制。
在我们的研究中，三种入路的PELD对高度移位型椎间盘突出症同样有效。对侧椎间孔入路所需手术时间最长，术中透视次数最多。相反，椎板间入路所需手术时间最短，透视次数最少。此外，我们得出了针对不同类型高度移位型腰椎间盘突出症手术入路选择的结论。关键词：高度移位；腰椎间盘突出症；经皮内镜下腰椎间盘切除术；微创治疗
