本文關(guān)鍵詞： 經(jīng)皮椎間孔鏡技術(shù) 腰椎間盤突出癥 椎間孔鏡下分型 手術(shù)療效 臨床意義　出處：《承德醫(yī)學(xué)院》2017年碩士論文　論文類型：學(xué)位論文

【摘要】：眾所周知腰椎間盤突出癥是臨床上的十分容易見到的骨科退行性變化的病種,患者常常表現(xiàn)為腰背部疼痛,單側(cè)或雙側(cè)下肢麻痛,因其病情常反復(fù)發(fā)作,且有不斷加重的趨勢(shì),令大多數(shù)病人難以忍受,造成病人及其親屬較大的負(fù)擔(dān)。隨著現(xiàn)今社會(huì)老齡化的日趨顯著,罹患該病的病例越來越多,因此眾多醫(yī)生都在找尋一種可以安全有效的醫(yī)治該病的辦法。椎間孔鏡技術(shù)作為一種微創(chuàng)的外科術(shù)式,取得了很好的手術(shù)結(jié)果,又因其創(chuàng)傷小、出血少,適應(yīng)癥范圍也比較大的優(yōu)勢(shì),成為越來越多的醫(yī)師和患者的首選。伴隨該項(xiàng)技術(shù)的大量普及,手術(shù)醫(yī)師對(duì)該種疾病有了全新理解,部分學(xué)者提出依據(jù)鏡下分析椎間盤的變化和它與神經(jīng)根的位置劃分椎間孔鏡下分型,并依據(jù)此分型指導(dǎo)醫(yī)師進(jìn)行椎間孔鏡下操作,取得了良好的手術(shù)療效。目的:通過經(jīng)皮椎間孔鏡對(duì)腰椎間盤突出癥進(jìn)行椎間孔鏡下分型,并按照此種分型指導(dǎo)鏡下操作,觀察治療結(jié)果并與傳統(tǒng)未分型的椎間孔鏡病例進(jìn)行比較,探討椎間孔鏡下分型對(duì)治療腰椎間盤突出癥的臨床意義。方法:對(duì)武警北京市總隊(duì)第三醫(yī)院骨科收治128例患者行經(jīng)皮椎間孔鏡手術(shù),通過在鏡下觀察纖維環(huán)、髓核的退變程度及神經(jīng)根的狀態(tài)改變,將這種疾病劃分成以下4種:髓核突出巨大,壓迫到鄰近的神經(jīng)根的壓迫型;神經(jīng)根表面有大量纖維束增生包裹的瘢痕型;伴有椎間盤鈣化及后方骨贅形成的鈣化型;合并關(guān)節(jié)增生、周圍軟組織增厚等共同致使患者根性癥狀明顯的側(cè)隱窩狹窄型。并根據(jù)鏡下分型指導(dǎo)手術(shù)治療。選取早期相同納入標(biāo)準(zhǔn)與排除標(biāo)準(zhǔn)的未進(jìn)行椎間孔鏡下分型的病例128例。采用視覺模擬評(píng)分法(visual analog scale,VAS)、日本骨科協(xié)會(huì)評(píng)估治療分?jǐn)?shù)(Japanese Orthopaedic Association Scores,JOA)、Oswestry功能障礙指數(shù)(Oswestry disability index,ODI)及Mac Nab標(biāo)準(zhǔn)評(píng)估手術(shù)療效。記錄手術(shù)時(shí)間、出血量和并發(fā)癥發(fā)生率。并對(duì)兩組VAS、JOA、ODI、Mac Nab標(biāo)準(zhǔn)和手術(shù)時(shí)間、出血量和并發(fā)癥發(fā)生率進(jìn)行統(tǒng)計(jì)學(xué)分析。結(jié)果:全部128例病例均順利完成手術(shù)及隨訪。其中鏡下分型128例病例中中壓迫型的病例有60例,比例為46.9%,瘢痕型的病例有31例,比例為24.2%,鈣化型的病例有23例,比例為18.0%,側(cè)隱窩狹窄型的病例有14例,比例為10.9%。經(jīng)過平均(10.5±3.7)個(gè)月的隨訪,術(shù)前VAS評(píng)分為7.6±0.7,術(shù)后VAS評(píng)分為2.5±0.6;JOA術(shù)前評(píng)分為7.8±1.6,術(shù)后評(píng)分為20.4±1.0;術(shù)前ODI為(62.9±5.3)%,術(shù)后ODI為(25.1±2.2)%;術(shù)后按照改良的Mac Nab標(biāo)準(zhǔn)評(píng)定療效,優(yōu)75例,良47例,可6例,總體優(yōu)良率為95.3%。分型組和未分型組的所有病例的病情均有顯著的減輕,椎間孔鏡下分型與未進(jìn)行椎間孔鏡下分型組的術(shù)前VAS評(píng)分、JOA評(píng)分、ODI評(píng)分比較無統(tǒng)計(jì)學(xué)意義(P0.05),椎間孔鏡下分型組術(shù)后VAS評(píng)分較未分型組顯著偏低(P0.05),椎間孔鏡下分型組術(shù)后JOA評(píng)分較未分型組顯著偏高(P0.05),椎間孔鏡下分型組術(shù)后ODI評(píng)分較未分型組顯著偏低(P0.05),Mac Nab標(biāo)準(zhǔn)優(yōu)良率為95.3%顯著高于未分型組的Mac Nab標(biāo)準(zhǔn)優(yōu)良率87.5%。椎間孔鏡下分型組和未分型組的手術(shù)時(shí)長(zhǎng)及出血量比較差異未見明顯的統(tǒng)計(jì)學(xué)意義(P0.05),椎間孔鏡下分型組術(shù)中、術(shù)后的并發(fā)癥發(fā)生率較未分型組顯著下降(P0.05)。結(jié)論:根據(jù)椎間孔鏡下的不同表現(xiàn)進(jìn)行分型可以增加醫(yī)師對(duì)該疾病的理解,可以解釋一些臨床表現(xiàn)與影像學(xué)分型并不符合的病例,因此這種分型方法更加夠能反映腰椎間盤突出癥的本質(zhì),是對(duì)傳統(tǒng)的影像學(xué)分型的一種補(bǔ)充。術(shù)中可以依據(jù)椎間孔鏡下分型指導(dǎo)手術(shù),壓迫型主要處理突出壓迫的髓核組織;瘢痕型主要去除神經(jīng)根表面大量的的纖維等;鈣化型主要取出鈣化的間盤及增生的骨贅;側(cè)隱窩狹窄型主要去掉增生的韌帶組織,打開側(cè)隱窩,對(duì)神經(jīng)根走行全程進(jìn)行松解。通過一系類針對(duì)性操作可以獲比傳統(tǒng)未分型手術(shù)更加優(yōu)良的手術(shù)療效。因此椎間孔鏡下分型是一種科學(xué)的、有臨床意義的分型方法,合理利用該分型可以使這項(xiàng)手術(shù)最大程度地緩解病人的病情,有效地提高手術(shù)療效,顯著減少術(shù)后復(fù)發(fā)率。
[Abstract]:As everyone knows of lumbar disc herniation is clinically very easy to see the Department of orthopedics of degenerative changes in the disease, patients often manifested as back pain, unilateral or bilateral leg pain, because the disease is often recurrent, and gradually, so that the majority of patients to bear, causing a greater burden on the patients and their relatives. With the aging of society is more and more obvious, more and more patients with the disease, so many doctors are looking for a safe and effective way to cure the disease. Transforaminal endoscopic surgery is a minimally invasive surgery, has achieved good results, but also because of its small trauma, less bleeding the indications, scope of comparative advantage, become more and more doctors and patients preferred. Accompanied by a large number of popularization of this technique, the surgeon has a new understanding of the disease, some scholars put forward the basis for Microscopic analysis of the changes of intervertebral disc and nerve root and its location transforaminal endoscopic classification, and according to this type of guide physicians transforaminal endoscopic operation has good operation effect. Objective: through percutaneous transforaminal endoscopic discectomy for transforaminal endoscopic discectomy for lumbar disc herniation type this type of guidance, and in accordance with the endoscopic operation, observation and treatment results were compared with the traditional foraminal mirror case and not typing, discuss the clinical significance of transforaminal endoscopic classification for the treatment of lumbar disc herniation. Methods: admitted to the Department of orthopedics, Third Hospital of Beijing Armed Police Corps of 128 patients underwent percutaneous lumbar endoscopic surgery through the observation hole, a fiber ring under the microscope, the degeneration and nerve root nucleus state changes, the disease will be divided into the following 4 types: the nucleus pulposus is huge, compression of the nerve root compression type adjacent nerve root surface; a large amount of fiber bundles. Wrapped with scar type; intervertebral disc calcification and posterior osteophyte formation calcification type; with joint hyperplasia, thickening of the soft tissue around the common root resulting in patients with obvious symptoms of lateral recess stenosis. According to endoscopic classification guidance for selecting early surgical treatment. The same inclusion criteria were not transforaminal endoscopic classification and the exclusion criteria of the 128 cases. The visual analogue score (visual analog, scale, VAS), Japan Association for Department of orthopedics (Japanese Orthopaedic Association evaluation scores of Scores, JOA), Oswestry disability index (Oswestry disability index, ODI) and Mac Nab standard to assess the efficacy of surgery. Operation time, bleeding volume and the incidence of complications. And two groups of VAS, JOA, ODI, Mac, Nab standard and the operation time, bleeding volume and postoperative complications were analyzed. Results: the incidence of all 128 cases were successfully completed surgery and follow-up .鍏朵腑闀滀笅鍒嗗瀷128渚嬬梾渚嬩腑涓帇榪瀷鐨勭梾渚嬫湁60渚，

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