Epstein N E
Department of Surgery (Neurosurgery), North Shore University Hospital, Manhasset, New York, USA.
J Neurosurg. 1995 Oct;83(4):648-56. doi: 10.3171/jns.1995.83.4.0648.
This study was undertaken to determine and compare indications and relative benefits of various surgical approaches in 170 patients (average age 55 years) with far-lateral herniated lumbar discs, identified by magnetic resonance (MR) imaging and computerized tomography (CT) and operated on between 1984 and 1994. Essentially three surgical procedures were performed: complete facetectomy in 73 patients, laminotomy with medial facetectomy in 39 patients, and intertransverse discectomy (also known as ITT) in 58 patients. Follow-up periods averaged 5 years (range 0.5-10 years). Outcomes were scored as excellent (no deficit), good (mild radiculopathy), fair (moderate radiculopathy), and poor (unchanged or worse). Overall, excellent and good results were achieved in 73 and 51 patients, respectively, and fair and poor results in 26 and 20, respectively. There was little difference among the results encountered for the three major surgical groups: 79% of the intertransverse (ITT) group had good-to-excellent outcomes, as compared with 70% of the facetectomy group, and 68% of the group who underwent at minimum laminotomy, and additional hemilaminectomy or laminectomy with medial facetectomy. Results were the same for the 121 patients followed for more than 2 years and for the 49 patients studied for under 2 years. In the management of far-lateral discs, total facetectomy provides the best exposure, but increases the risk of instability. Laminotomy and medial facetectomy uncover the lateral and subarticular recess and preserve stability, but visualization of the far-lateral compartment is often inadequate. The intertransverse approach offers extensive far-lateral but not medial intraforaminal exposure, while also preserving stability. Full facetectomy, laminotomy with medial facetectomy, and the intertransverse approaches yielded nearly comparable outcomes in far-lateral disc surgery. Only the full facetectomy exposes the entire course of the nerve root both medially and laterally, whereas the intertransverse procedure provides direct exposure of the fat-lateral compartment alone. It is important to select the correct approach or combination of approaches to address attendant complicating factors such as spinal stenosis, spondyloarthrosis, and degenerative spondylolisthesis identified on CT and MR studies.
本研究旨在确定并比较170例（平均年龄55岁）经磁共振成像（MR）和计算机断层扫描（CT）确诊为极外侧腰椎间盘突出症且于1984年至1994年间接受手术治疗的患者，采用不同手术入路的适应证及相对获益情况。基本上实施了三种手术方式：73例患者行全椎板切除术，39例患者行椎板切开术加内侧椎板切除术，58例患者行横突间椎间盘切除术（也称为ITT）。随访期平均为5年（范围0.5 - 10年）。结果分为优（无神经功能缺损）、良（轻度神经根病）、可（中度神经根病）和差（无改善或加重）。总体而言，分别有73例和51例患者取得了优和良的结果，26例和20例患者的结果为可和差。三个主要手术组的结果差异不大：横突间（ITT）组79%的患者取得了良至优的结果，全椎板切除术组为70%，至少接受椎板切开术、附加半椎板切除术或椎板切除术加内侧椎板切除术的组为68%。随访超过2年的121例患者和随访不足2年的49例患者结果相同。在极外侧椎间盘的处理中，全椎板切除术提供了最佳的显露，但增加了不稳定的风险。椎板切开术加内侧椎板切除术可显露外侧和关节下隐窝并保持稳定性，但对极外侧间隙的显露往往不足。横突间入路可广泛显露极外侧但不能显露椎间孔内侧部分，同时也保持了稳定性。在极外侧椎间盘手术中，全椎板切除术、椎板切开术加内侧椎板切除术和横突间入路产生的结果几乎相当。只有全椎板切除术能从内侧和外侧显露神经根的全程，而横突间手术仅能直接显露极外侧间隙。根据CT和MR研究中发现的伴随复杂因素（如椎管狭窄、脊椎关节病和退行性腰椎滑脱）选择正确的入路或入路组合非常重要。
