Modified Full-Endoscopic Interlaminar Discectomy via an Inferior Endplate Approach for Lumbar Disc Herniation: Retrospective 3-Year Results from 321 Patients
Modified Full-Endoscopic Interlaminar Discectomy via an Inferior Endplate Approach for Lumbar Disc Herniation: Retrospective 3-Year Results from 321 Patients
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DOI：
10.1016/j.wneu.2020.05.234
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发表时间：
2020-09-01
影响因子：
2
通讯作者：
Li, Qingchu
中科院分区：
文献类型：
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作者：
Cheng, Liang;Cai, Heguo;Li, Qingchu
背景：经皮内窥镜椎间盘切除术（PEID）是一种广泛应用的微创手术，治疗L5-S1甚至L4-5椎间盘突出症效果满意。根据工作通道的确定方法，PEID可分为直接法和间接法。直接入路主要采用穿刺针在间接视觉下直接穿过椎间隙进入椎间盘，导丝插入穿刺针引导扩张器进入工作通道，牵拉黄韧带、硬膜囊、神经根。考虑到神经根和硬脑膜囊损伤的高风险，这种方法需要熟练的穿刺技术。因此，我们改进了这种椎板间通路程序，将穿刺靶置于下终板，并在穿刺针穿过黄韧带后进行术前硬膜外造影以暴露脊神经根和硬膜囊。然后我们将穿刺针放在上椎体的后边缘。最后，我们插入工作套管进行手术。该方法方便、有效地减少了学习曲线和术中并发症。在这里，我们介绍手术过程，并报告经下终板入路的全内窥镜椎间盘间切除术治疗腰椎间盘突出症的安全性和有效性。方法：我们在2014年5月至2017年5月期间对符合纳入标准的321例患者进行了经下终板入路的全内窥镜椎间盘切除术。所有手术均在局麻下完成。在透视引导下，我们进行了硬膜外造影以暴露脊神经根和硬膜囊。然后将工作套管和内窥镜置入上椎体的下终板。在清晰的内镜下，用镊子和激光去除突出的椎间盘材料。我们回顾性评估了321例随访超过30个月（12-48个月）的患者。采用视觉模拟量表（VAS）评分、Oswestry残疾指数（ODI）评分、Macnab标准评分和红外热成像评分评估治疗效果。结果：根性疼痛VAS评分由术前的6.3 +/- 1.01分改善至终期随访时的1.01 +/- 0.35分（P < 0.01）。平均ODI评分由术前的85.5 +/- 12分改善至最终随访时的12.4 +/- 3.7分（P < 0.01）。按照MacNab标准，优良率为96.5%。红外热成像评分显示，术后1周双下肢皮肤温度较术前明显改善（P < 0.01）。结论：经皮下终板入路是治疗腰椎间盘突出症的一种安全有效的方法。
BACKGROUND: Percutaneous endoscopic interlaminar discectomy (PEID) is a widely used minimally invasive procedure that shows satisfying outcomes for the treatment of L5-S1 and even L4-5 disc herniation. PEID can be divided into direct and indirect approaches according to the established method of the working channel. The direct approach mainly uses the puncture needle directly through the intervertebral space into the intervertebral disc under indirect vision and insertion of the guidewire into the puncture needle to guide the dilator and into the working channel to retract the ligamentum flavum, dural sac, and nerve roots. This approach requires a skilled puncture technique, given the high risk of damage to the nerve roots and dural sac. Therefore, we improved this interlaminar access procedure, placing the puncture target at the inferior endplate and performing preoperative epidurography to expose the spinal nerve roots and dural sac after the puncture needle was passed through the ligamentum flavum. We then positioned the puncture needle at the posterior edge of the superior centrum. Finally, we inserted the working sleeve for the operation. This approach is convenient and effectively reduces the learning curve and intraoperative complications. Here we introduce the procedure and report the safety and efficacy of full-endoscopic interlaminar discectomy via an inferior endplate approach for the treatment of lumbar disc herniation.METHODS: We performed full-endoscopic interlaminar discectomy via the inferior endplate approach in 321 patients who met our inclusion criteria between May 2014 and May 2017. All operations were completed under local anesthesia. Under fluoroscopic guidance, we performed epidurography to expose the spinal nerve roots and dural sac. The working sleeve and endoscope were then introduced into the inferior endplate of the superior centrum. Herniated disc material was removed using forceps and a laser under clear endoscopic visualization. We retrospectively evaluated the 321 patients with more than 30 months (range, 12-48 months) of follow-up. The therapeutic effects were assessed using scores of the visual analog scale (VAS), Oswestry disability index (ODI), Macnab standard, and infrared thermal imaging.RESULTS: The mean VAS score for radicular pain improved from 6.3 +/- 1.01 preoperatively to 1.01 +/- 0.35 at the final follow-up (P < 0.01). The mean ODI score improved from 85.5 +/- 12 preoperatively to 12.4 +/- 3.7 at the final follow-up (P < 0.01). According to the MacNab standard, the excellent and good outcome scores were 96.5%. The infrared thermal imaging scores indicated significantly improved skin temperature of both lower extremities at 1 week after surgery compared with the preoperation temperature (P < 0.01).CONCLUSIONS: The inferior endplate approach for percutaneous endoscopic interlaminar discectomy provides a safe and effective alternative for the treatment of lumbar disc herniation.