经皮椎间孔内镜下椎间盘切除术与显微镜辅助管状椎间盘切除术治疗腰椎间盘突出症的比较。

OBJECTIVE: The aim of the present study was to compare the clinical outcomes and quality of life following percutaneous transforaminal endoscopic discectomy (PTED) and microscope-assisted tubular discectomy (MTD) for lumbar disc herniation (LDH). METHODS: This study had a retrospective design. From June 2017 to June 2018, the clinical data of 120 patients with LDH treated with PTED (60 cases, PTED group) and MTD (60 cases, MTD group) were analyzed and followed up for at least 20 months. There were 59 men and 61 women. Patients were aged between 22 and 80 years. The operation time, intraoperative blood loss, incision length, frequency of intraoperative fluoroscopy, cost, hospital stay, types of herniated discs, complications, and clinical outcomes were evaluated. Clinical outcomes were assessed using the visual analog scale (VAS), the Oswestry disability index (ODI), and the modified Macnab criteria. Short-Form 36 (SF-36) and the EQ-5D-5L were used to evaluate the quality of life of patients. The data between the two groups were compared by independent sample t-tests. Multiple comparisons between samples were analyzed by analysis of variance. RESULTS: Compared with the MTD group, the PTED group had shorter incision length (9.20 ± 1.19 mm vs 26.38 ± 1.82 mm), less intraoperative blood loss (18.00 ± 4.97 mL vs 39.83 ± 6.51 mL), and shorter hospital stay (5.42 ± 5.08 days vs 10.58 ± 3.69 days) (P = 0.00). PTED was much more appropriate for foraminal and extraforaminal disc herniation. The incidence of paresthesia was lower in the PTED group (6.67% vs 16.67%). At each follow up, the VAS and ODI scores of all patients were significantly improved compared with those before surgery (P = 0.00). At 3 days postoperatively, the lumbar VAS score of the PTED group was significantly lower (1.58 ± 1.00 vs 2.37 ± 1.10, P = 0.00). The excellent rate of the PTED group reached 91.67%, and that of the MTD group reached 93.33%. Compared with the preoperative SF-36 scores for physiological function, mental health, and social function, the postoperative scores were significantly improved in both groups (P = 0.00). The EQ-5D-5L in the PTED group increased from 0.30 ± 0.17 before the operation to 0.69 ± 0.13 after 6 months of follow up (P = 0.00) and 0.73 ± 0.14 after 20 months of follow up. The EQ-5D-5L in the MTD group increased from 0.28 ± 0.17 before the operation to 0.68 ± 0.13 after a 6-month follow up (P = 0.00), and 0.73 ± 0.12 after a 20-month follow up. CONCLUSION: Although both PTED and MTD are effective for LDH, PTED is much more appropriate for various types of LDH and has the advantages of the low incidence of low back pain, fewer complications, and early recovery.

目的：本研究旨在比较经皮椎间孔内窥镜椎间盘切除术（PTED）和显微镜辅助管状椎间盘切除术（MTD）治疗腰椎间盘突出症（LDH）的临床疗效和生活质量。

方法：本研究为回顾性设计。2017 年 6 月至 2018 年 6 月，对 120 例接受 PTED（60 例，PTED 组）和 MTD（60 例，MTD 组）治疗的 LDH 患者的临床资料进行分析，并进行至少 20 个月的随访。其中男 59 例，女 61 例；年龄 22~80 岁。评估手术时间、术中出血量、切口长度、术中透视次数、费用、住院时间、椎间盘突出类型、并发症及临床疗效。采用视觉模拟评分（VAS）、Oswestry 功能障碍指数（ODI）和改良 Macnab 标准评估临床疗效。采用 Short-Form 36（SF-36）和 EuroQol-5 Dimensions 5 Levels（EQ-5D-5L）量表评估患者的生活质量。采用独立样本 t 检验比较两组间数据。多组样本间比较采用方差分析。

结果：与 MTD 组相比，PTED 组切口长度更短（9.20±1.19mm 比 26.38±1.82mm）、术中出血量更少（18.00±4.97mL 比 39.83±6.51mL）、住院时间更短（5.42±5.08d 比 10.58±3.69d）（P=0.00），且更适合治疗椎间孔和椎间孔外型椎间盘突出症。PTED 组感觉异常发生率更低（6.67%比 16.67%）。所有患者术后各随访时间的 VAS 和 ODI 评分均较术前显著改善（P=0.00）。术后 3d，PTED 组腰椎 VAS 评分明显低于 MTD 组（1.58±1.00 比 2.37±1.10，P=0.00）。PTED 组的优良率达 91.67%，MTD 组的优良率达 93.33%。与术前生理功能、心理健康和社会功能的 SF-36 评分相比，两组术后各评分均明显提高（P=0.00）。PTED 组的 EQ-5D-5L 评分从术前的 0.30±0.17 增加到术后 6 个月的 0.69±0.13（P=0.00）和术后 20 个月的 0.73±0.14。MTD 组的 EQ-5D-5L 评分从术前的 0.28±0.17 增加到术后 6 个月的 0.68±0.13（P=0.00）和术后 20 个月的 0.73±0.12。

结论：虽然 PTED 和 MTD 治疗 LDH 均有效，但 PTED 更适用于各种类型的 LDH，具有腰痛发生率低、并发症少、恢复早等优点。