椎间孔入路经皮脊柱内镜治疗无脱垂型腰椎间盘突出症的穿刺点位置选择研究  

A retropective study of percutaneous endoscopic lumbar discectomy for no prolapsed lumbar disc herniation:selection of entry point region

作　　者：刘印[1] 孔清泉[1] 徐练[1] 李晓龙[1] 蔡鹏[1] 宋跃明[1] 

机构地区：[1]四川大学华西医院骨科,成都610041

出　　处：《中国骨与关节杂志》2016年第5期360-366,共7页Chinese Journal of Bone and Joint

摘　　要：目的应用全腹三维重建CT测定内镜下经椎间孔入路Half-Half技术治疗无脱垂型腰椎间盘突出症的穿刺位点距离和穿刺水平角度范围,为经皮内镜腰椎间盘髓核摘除（percutaneous endoscopic lumbar discectomy,PELD）技术提供更全面精确的临床参考数据;通过术前测定的数据研究椎间孔入路PELD（transforaminal percutaneous endoscopic lumbar discectomy,PETD）临床实践的有效性和安全性。方法回顾性分析2014年8月至2015年10月,我院应用PETD治疗的65例腰椎间盘突出症患者的影像学资料（包括全腹三维重建CT、腰椎三维重建CT和腰椎MRI）,其中男38例,女27例;年龄25-73岁,平均（37.58±7.14）岁。术前通过全腹三维重建CT测定和明确以下影像学指标：椎间盘突出节段、穿刺入针点距离棘突的体表水平距离（D1）、关节突腹侧缘水平连线与皮肤交点距离棘突中点距离（D2）、横断面上入针最大水平角度α、横断面上入针最小水平角度β（穿刺时既不受小关节突阻挡,也不损伤内脏）。应用术前测定的数值指导PETD临床实践,结合术中穿刺位置情况,来判定测定的数值是否能够达到预期目的,并计算安全性和有效性的比率大小。结果术前全腹CT测量D1距离在L（1-2）至L5-S1水平分别为8.4-10.9 cm、9.6-12.7 cm、11.1-14.3 cm、12.4-15.7 cm、13.6-15.9 cm,随目标节段的下降,旁开距离逐渐增大,且受患者体重指数的影响（P〈0.05）。D2距离同样受患者体重指数的影响（P〈0.05）,在L1-2至L5-S1水平分别为12.2-15.9 cm、12.7-16.3 cm、13.4-17.6 cm、14.9-18.4 cm、15.1-18.5 cm。入针最大水平角度在L（1-2）至L5-S1水平分别为17°-29°、14°-25°、11°-22°、6°-18°、6°-13°,不同体重指数患者入针角度差异无统计学意义（P〉0.05）。左、右侧入针最小水平角度在L（1-2）至L（3-4）水平分别为13°-16°、7°-13°、2°-5°,在下腰椎L（4-5）和L5-S1节段则分别为2°-4°�Objective To discuss Lthe xole of preoperative abdominal 3 D-CT assessment in the selection of entry point region and the range of puncture horizontal angle for nonprolapsed lumbar disc herniation treated with endoscopic trans;foraminal approach and Half-Half technique to provide more comprehensive and precise clinical reference data for percutaneous endoscopic transforaminal lumbar discectomy （ PETD ） technology and to study the effectiveness and safety of imaging parameters measured preoperatively for guiding the clinical practice of PETD. Methods The imaging data of 65 patients,with,lumbar disc herniation treated with endoscopic transforaminal approach were analyzed from August 2014 to October 2015 retrospectively. Preoperative abdominal 3 D-CT, lumbar 3 D-CT, and lumbar MR/were included. Preoperative,radiographic evaluation via abdominal 3 D-CT included the diseased disc segments, distance from the entry point to the spinous process （ D1 ）, distance from the spinous to the ventral margin of the facet level connection with skin （ D2 ）, angle between the puncture path in the axial plane of the body and horizontal line （ α ）, the least puncture angle which would avoid injury to any abdominal organ, and would not be obstructed by the facet joints （ β ）. The imaging parameters measured were used for guiding the clinical practice of PETD, and were judged whether able to achieve the desired objectives combined with intraoperative puncture position. The ratio of the safety and efficacy was also calculated. Results Measurement of distances from the entry point to the spinous process in preoperative abdominal CT （ D1 ） was 8.4 - 10.9 cm, 9.6 - 12.7 cm, 11.1 - 14.3 cm, 12.4 - 15.7 cm and 13.6 - 15.9 em at L1-2 - L5 - S1 respectively. They increased when target segments decreased. There were statistically significant differences in D1 and D2 between different BMI （ P 〈 0.05 ）. And at Li.2 - L5 - S1 the mean D2 were 12.2 - 15.9 cm, 12.7 - 16.3 era, 13.4 - 17.6 era, 14.9 - 18.4 cm and 15.1 -

关 键 词：外科手术 微创性 内窥镜 腰椎 椎间盘移位 影像学评估 

分 类 号：R687.3[医药卫生—骨科学]