本文選題：中央型腰椎間盤突出癥 + 椎間孔鏡��； 參考：《河北醫(yī)科大學》2014年碩士論文

【摘要】：目的:腰椎間盤突出癥(lumber disc herniation)是引起腰腿痛最常見原因，是指腰椎間盤退變、纖維環(huán)破裂后髓核向后方突出或突至椎板內(nèi)致使相鄰組織受刺激或壓迫而出現(xiàn)一系列臨床癥狀。根據(jù)椎間盤突出的部位可將其分為后外側突出，椎間孔型突出及中央型突出。中央型腰椎間盤突出癥central lumbar disc herniation (CLDH)是指突出或脫出的椎間盤組織位于椎管前方中央處者。由于椎間盤后外側為其解剖結構薄弱點，因此后外側突出最常見,但臨床上中央型腰椎間盤突出癥并不少見，有研究顯示其發(fā)病率為5.4%-33.4%。經(jīng)正規(guī)保守治療無效的患者需采取手術治療，因中央型腰椎間盤突出癥的臨床表現(xiàn)多樣，下肢痛癥狀可表現(xiàn)為單側或雙側，部分患者存在馬尾神經(jīng)癥狀，故常根據(jù)患者病情采用單側或雙側部分椎板切除術即開窗術治療，對于伴有椎管狹窄的患者需行全椎板切除術，但傳統(tǒng)開放手術創(chuàng)傷大、出血多，術后恢復時間漫長，有伴發(fā)腰椎不穩(wěn)的風險。隨著科學技術及醫(yī)療設備的進步，許多新的脊柱微創(chuàng)技術開始被應用于腰椎間盤突出癥的治療。應用內(nèi)窺鏡經(jīng)椎間孔入椎管內(nèi)進行神經(jīng)根松解及減壓技術TESSYS（transforaminal endoscopic spine system）技術是傳統(tǒng)的后外側途徑腰椎間盤治療技術與脊柱內(nèi)窺鏡技術的結合，它的出現(xiàn)又為外科醫(yī)生解決中央型腰椎間盤突出癥提供了一條新的解決方案。本研究通過對比分析患者術后癥狀改善情況來探討椎間孔鏡TESSYS技術治療中央型腰椎間盤突出癥的臨床療效。 方法:自2011年1月-2013年7月69例中央型腰椎間盤突出癥患者在我院行腰椎側后路椎間孔鏡下髓核摘除術治療。 術中患者取俯臥位，在C-型臂X線機正位透視下定位并標記腰椎棘突中線及經(jīng)目標椎間盤上緣的水平線在體表投影，于側位X線透視下確定目標椎間隙方向，沿此方向在體表做經(jīng)過下位椎體后上緣的直線，此線與經(jīng)過目標椎間盤上緣的水平線的交點為穿刺點，再于側位X線透視下標記關節(jié)突上緣連線為安全線。如患者為L5-S1節(jié)段突出，穿刺點的標定方法為：在X線正位透視下于體表標出髂嵴的最高點連線以及通過L5椎體下緣的水平線，再于X線側位透視下在體表標定通過S1上關節(jié)突和S1椎體后上緣的側位線，該側位線與正位透視下標定的髂嵴最高點連線的交點為穿刺點。突出節(jié)段在L2-3和L3-4時，選擇旁開中線6-10cm進針，，突出節(jié)段在L4-5和L5-S1時，選擇旁開中線12-14cm進針。消毒鋪單后于穿刺位點用濃度1%利多卡因行局部浸潤麻醉。以18號穿刺針經(jīng)穿刺位點進針并在C-型臂X線機引導下穿刺，針尖穿抵上關節(jié)突的前下緣，取出針芯，置入前端彎曲的22號穿刺針，注入造影劑行椎間盤造影。取出22號穿刺針，插入導絲，以穿刺點為中點在皮膚做一長約8mm切口。沿導絲插入導棒及逐級擴張導管擴大手術通道，逐級取出擴張導管后延導棒插入鋸齒狀絞刀，在透視下切除上關節(jié)突外緣部分骨質，擴大椎間孔。取出環(huán)鋸，沿導棒放入工作套管后放入椎間孔鏡。于鏡下用專有髓核鉗將染色退變的髓核組織取出，至鏡下硬膜囊清晰可見并隨心跳發(fā)出搏動，患支行直腿抬高試驗呈陰性，可進一步說明減壓徹底有效。最后以射頻雙極電極對纖維環(huán)撕裂口行皺縮成形術，并對術野內(nèi)出血點行電凝止血。取出椎間盤鏡，切口縫合一針，蓋敷料，手術完畢。 69例患者中女性35例，男性34例；年齡17~83歲，平均年齡37.52歲。療效評價采用視覺疼痛模擬評分（VAS）、JOA及MacNab評分法評定。 結果:本組69例患者，67例患者手術成功并獲得隨訪，隨訪時間3-18個月，平均11.6個月，術前下肢VAS評分（7.12±0.70）,術后3個月下肢VAS評分為（2.46±0.68）,差異有統(tǒng)計學意義（P0.05），術后1年下肢VAS評分（2.27±0.74），差異有統(tǒng)計學意義（P0.05）。術前JOA評分（13.7±0.87），術后3個月JOA評分（21.8±1.27），差異有統(tǒng)計學意義（P0.05），術后1年JOA評分（22.1±0.79），差異有統(tǒng)計學意義（P0.05）。本組患者均未出現(xiàn)手術并發(fā)癥，1例術后患者癥狀無明顯改善，擇期行椎板切除聯(lián)合植骨融合內(nèi)固定手術治療，2例L5-S1突出，由于髂嵴過高，阻擋手術入路，術中改行后路椎間盤鏡治療，3例患者術后復發(fā)，擇期行椎板切除聯(lián)合植骨融合內(nèi)固定手術治療。整體優(yōu)良率83.5%。 結論:應用椎間孔鏡TESSYS技術治療中央型腰椎間盤突出安全、有效，嚴格掌握手術適應癥是手術成功的關鍵和療效的保障。
[Abstract]:Objective: lumbar intervertebral disc herniation (lumber disc herniation) is the most common cause of lumbago and leg pain, which refers to the degeneration of the lumbar intervertebral disc. After the rupture of the fibrous ring, the nucleus pulposus protruding to the rear or into the vertebral plate causes a series of clinical symptoms to be stimulated or oppressed by adjacent tissues. The central type of lumbar intervertebral disc herniation central lumbar disc herniation (CLDH) refers to the protrusion or degenerative disc tissue located in the middle of the vertebral canal. The lateral protrusion of the posterior intervertebral disc is the most common, but the clinical central lumbar disc herniation is the most common. It is not uncommon that a study has shown that the patients who have the incidence of 5.4%-33.4%. in the normal conservative treatment need to be operated on, because the clinical manifestations of the central lumbar disc herniation are diverse, the symptoms of the lower extremity pain may be unilateral or bilateral, and the cauda cauda nerve is present in some patients, so the unilateral or bilateral part of the vertebral body is often used according to the patient's condition. Plate excision, or fenestration, requires full laminectomy for patients with stenosis of the vertebral canal, but the traditional open surgery has large trauma, much bleeding, long recovery time and a risk of accompanying lumbar instability. With the advancement of science and technology and medical equipment, many new spinal minimally invasive techniques have been applied to lumbar disc herniation. TESSYS (transforaminal endoscopic spine system) technique is the combination of the traditional posterolateral approach to the lumbar intervertebral disc therapy and the spinal endoscopy, which provides a surgical solution for the surgical treatment of central lumbar intervertebral disc herniation. A new solution. This study examines the clinical efficacy of intervertebral foraminoscopy in the treatment of central lumbar intervertebral disc herniation by comparing and analyzing the improvement of postoperative symptoms in patients with TESSYS.
Methods: from January 2011 to July -2013, 69 patients with central lumbar disc herniation underwent posterior lumbar intervertebral discectomy in our hospital.
During the operation, the patient took the prone position, located and marked the middle line of the spine spinous process and the horizontal line of the upper intervertebral disc on the body surface under the position perspective of the C- arm X ray machine. The direction of the target intervertebral space was determined under the lateral X-ray perspective, and the straight line through the upper edge of the lower vertebral body was made in the direction of the body surface, and the line and the water passing through the target intervertebral disc were water. The intersection point of the flat line is the puncturing point, and then the upper edge of the articular process is marked as the safety line under the lateral X-ray perspective. If the patient is the L5-S1 segment, the method of demarcation is to mark the highest point of the iliac crest on the body surface and through the horizontal line through the lower edge of the L5 vertebral body under the X-ray position perspective, and then to demarcate the body surface under the X-ray side perspective and then demarcate the body surface under the surface of the X-ray side. The lateral line of the upper edge of the S1 and S1 vertebrae on the upper part of the articular process and the vertebral body, the intersection point of the highest point of the iliac crest which is calibrated under the perspective of the positive perspective is the puncturing point. When the prominent segment is at L2-3 and L3-4, the side open middle line 6-10cm needle is selected, and when the segment is in L4-5 and L5-S1, the side open middle line 12-14cm injection needle is selected. The concentration of the sterilizing sheet is 1% after the puncture site. The puncture site was injected with the puncture site of No. 18 puncture needle and guided by the C- arm X-ray machine. The needle tip was put on the anterior and lower edge of the joint process, the needle core was taken out, the 22 puncture needle was inserted into the front end, and the contrast agent was injected into the intervertebral disc. The puncture needle was taken out and the needle was inserted at the center point to make a long skin. About 8mm incision. Insert the guide rod into the guide rod and the progressive dilatation catheter to expand the operation channel, take out the dilated catheter step by step, insert the sawtooth cutter, remove the partial bone of the outer edge of the upper joint under the perspective, expand the intervertebral foramen, remove the circular saw, and put the guide rod into the intervertebral foramen mirror after the guide rod is put into the working sleeve. The special nucleus pulposus forceps will be stained under the mirror. The nucleus pulposus was taken out, the dural sac was clearly visible and pulsated with the heartbeat. The direct leg lift test was negative. It could be further indicated that the decompression was complete and effective. Finally, the RFID was performed with the radiofrequency bipolar electrode for the laceration of the fibrous ring. Cover the dressings, the operation is finished.
Among the 69 patients, 35 were female and 34 were male. The age was 17~83 years and the average age was 37.52 years. The efficacy evaluation was evaluated by visual pain simulation score (VAS), JOA and MacNab score.
Results: 69 patients in this group, 67 cases were successful and followed up for 3-18 months, average 11.6 months, VAS score of lower extremity (7.12 + 0.70), lower limb VAS score (2.46 + 0.68) in 3 months after operation (P0.05), and 1 years' lower limb VAS score (2.27 + 0.74) after operation (P0.05). The preoperative JOA score was statistically significant (P0.05). (13.7 + 0.87), 3 months after operation JOA score (21.8 + 1.27), the difference was statistically significant (P0.05), 1 years after the JOA score (22.1 + 0.79), the difference was statistically significant (P0.05). The patients in this group had no surgical complications, 1 patients had no obvious improvement in postoperative symptoms, selective laminectomy combined with bone graft fusion and internal fixation, 2 cases of L5-S1 protruding, Due to high iliac crest and obstruction of surgical approach, posterior intervertebral discectomy was performed in the operation. 3 patients had recurrence after operation. Laminectomy combined with bone fusion and internal fixation was performed. The overall good rate was 83.5%..
Conclusion: the application of TESSYS in the treatment of central lumbar intervertebral disc herniation is safe, effective, and strict control of surgical indications is the key to the success of the operation and the guarantee of the curative effect.
【學位授予單位】：河北醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2014
【分類號】：R687.3

【引證文獻】

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2 趙顯;宋濤;孫新宏;;椎間孔鏡技術與椎板間開窗治療雙節(jié)段腰椎間盤突出癥的療效觀察[J];臨床骨科雜志;2015年06期

3 唐剛;;棘突間撐開器Rocker治療腰椎間盤突出[J];當代醫(yī)學;2015年31期

本文編號：2000498