椎间孔外入路单侧双通道内镜技术在治疗椎管外腰骶神经根卡压症中的应用  

The application of unilateral biportal endoscopy through extraforaminal approach in the treatment of extra canal lumbosacral nerve root entrapment

作　　者：徐宝山[1] 张凯辉 田和顺 黎宁[1] 许海委[1] Xu Baoshan;Zhang Kaihui;Tian Heshun;Li Ning;Xu Haiwei(Departemnt of Minimally Invasive Spinal Surgery,Tianjin Hospital,Tianjin 300211,China)

机构地区：[1]天津市天津医院微创脊柱外科,天津300211

出　　处：《中华骨科杂志》2023年第2期81-88,共8页Chinese Journal of Orthopaedics

基　　金：国家自然科学基金资助项目(82072491);天津市自然科学基金(20JCYBJC00820);天津市卫生健康委员会科技项目(KJ20211)。

摘　　要：目的探讨椎间孔外入路单侧双通道内镜(unilateral biportal endoscopy,UBE)在治疗椎管外腰骶神经根卡压症中的应用。方法回顾性收集2020年1月至2022年3月在天津医院采用椎间孔外入路UBE治疗椎管外腰骶神经根卡压症17例,男9例、女8例,平均年龄为59.2岁(范围45~71岁)。17例患者均有下肢放射性疼痛、麻木、无力,伴或不伴间歇性跛行。MRI示L4,5椎间孔狭窄伴椎间盘极外侧突出2例,L_(5)S_(1)椎间孔狭窄伴椎间盘极外侧突出15例;7例诊断为远外侧综合征,12例合并腰骶移行椎;17例椎间隙高度均降低,相应节段出口神经根和神经节卡压。切口在相邻椎弓根投影外侧2 cm处,S1因髂骨遮挡在髂骨内缘设计切口,以椎间孔外口峡部外缘为靶点,自峡部和上关节突外缘逐步磨除上关节突腹侧和尖部,必要时磨除遮挡的骶骨翼和横突下缘,去除增生的韧带显露出口神经根,在神经根腹侧显露并摘除突出的椎间盘,远外侧综合征沿出口神经根向外侧减压直至完全松解。术后及随访采用疼痛视觉模拟评分(visual analogue scale,VAS)、Oswestry功能障碍指数(Oswestry disability index,ODI)、Macnab评分和腰椎过屈过伸位X线片评估疗效及稳定性。结果17例均顺利完成手术,手术时间平均为60 min(范围45~85 min)。术中磨除上关节突尖端、扩大椎间孔后均能充分显露出口神经根和突出的椎间盘,对远外侧综合征可沿出口神经根向外侧充分减压直至完全松弛无卡压,神经减压彻底。术后症状均明显缓解,CT示关节突关节大部保留。随访时疼痛和功能进一步改善,末次随访时VAS平均改善率为85.2%,ODI平均改善率为86.2%,根据Macnab评分优15例、良2例,腰椎过屈过伸位X线片均无腰椎失稳表现。结论椎间孔外入路UBE治疗椎管外腰骶神经卡压症显露充分、减压彻底,并可较好地保留腰椎稳定性。Objective To investigate the effect of unilateral biportal endoscopy(UBE)through extraforaminal approach in the treatment of extra canal lumbosacral nerve entrapment.Methods Seventeen patients with extra canal lumbosacral nerve root entrapment were treated by UBE through extraforaminal approach in Tianjin Hospital from January 2020 to March 2022,including 9 males and 8 females with an average age of 59.2 years(range 45-71 years).All 17 patients had lower limb radiation pain,numbness,and weakness with or without intermittent claudication.MRI imaging examination showed L4,5 foramen stenosis with far lateral disc herniation in 2 case,and L_(5)S_(1) foramen stenosis with far lateral disc herniation in 15 cases,and the height of intervertebral space decreased,resulting in the compression of exiting nerve root and ganglion.Among them,far-out syndrome was diagnosed in 7 cases and transitional lumbarsacral vertebrae was found in 12 cases.The incisions were designed 2 cm away form the projection of adjacent pedicles,while incision at S1 was designed at the inner edge of the iliac bone due to the shielding of the ilium,taking the outer edge of the isthmus at the outer opening of the intervertebral foramen as the target of channels.The ventral and apical part of superior articular process(SAP)was gradually removed with high-speed burr from its outer edge and isthmus,and the occluded sacral ala and the lower edge of transverse process were removed when necessary.The hyperplastic ligament was removed to expose the exiting nerve root.The protruding intervertebral disc was removed at the ventral side of the nerve root.The far-out syndrome was decompressed laterally along the exiting nerve root until it is completely released.The results and stability were evaluated with visual analogue scale(VAS),Oswestry disability index(ODI),Macnab scores and dynamic X-ray film during follow-up.Results The operation time was 45-85 min,with an average of 60 min.After remove of the SAP tip and enlarge of the intervertebral foramen,the exiting n

关 键 词：腰椎 椎间盘移位 内窥镜检查 最小侵入性外科手术 

分 类 号：R687.3[医药卫生—骨科学]