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Article(id=1199335054196441198, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1199335049175859209, articleNumber=null, orderNo=null, doi=10.11855/j.issn.0577-7402.1975.2023.0221, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=research-article, receivedDate=1662739200000, receivedDateStr=2022-09-10, revisedDate=null, revisedDateStr=null, acceptedDate=1668355200000, acceptedDateStr=2022-11-14, onlineDate=1763873359487, onlineDateStr=2025-11-23, pubDate=1711555200000, pubDateStr=2024-03-28, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1763873359487, onlineIssueDateStr=2025-11-23, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1763873359487, creator=13701087609, updateTime=1763873359487, updator=13701087609, issue=Issue{id=1199335049175859209, tenantId=1146029695717560320, journalId=1189873630562394117, year='2024', volume='49', issue='3', pageStart='245', pageEnd='366', issueExtLink='null', onlineDate='null', pubDate='null', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=0, createTime=1763873358291, creator=13701087609, updateTime=1763874044185, updator=13701087609, preIssue=null, nextIssue=null, ext={EN=IssueExt(id=1199337926086721596, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1199335049175859209, language=EN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1199337926086721597, tenantId=1146029695717560320, journalId=1189873630562394117, issueId=1199335049175859209, language=CN, specialIssueTitle=, coverIllustrator=null, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null}, startPage=349, endPage=354, ext={EN=ArticleExt(id=1199335054502625417, articleId=1199335054196441198, tenantId=1146029695717560320, journalId=1189873630562394117, language=EN, title=Clinical application and perspectives of unilateral biportal endoscopic technique, columnId=1190243275882729994, journalTitle=Medical Journal of Chinese People’s Liberation Army, columnName=Review, runingTitle=null, highlight=null, articleAbstract=

Unilateral biportal endoscopic (UBE) technique is a minimally invasive spinal technique developed rapidly in recent years. Compared with traditional spinal endoscopy, the prominent feature of UBE is that it can open two channels on the same side of the spine, which can be used to provide visual field and insert operating instruments respectively, greatly expanding the operating space and reducing the difficulty of surgery. It has the advantages of less bleeding, little injury, quick recovery and mild pain, and has unique advantages in the treatment of lumbar spinal stenosis, lumbar disc herniation and other lumbar degenerative diseases. With the continuous in-depth exploration and development of the UBE technique, the field of diseases that can be treated by this technology has gradually expanded. It is not only limited to lumbar diseases, but also has made great progress in cervical and thoracic diseases, which has attracted the attention of many spinal surgeons. UBE technique has become one of the promising surgical methods for spinal-related diseases, but there are also complications such as incomplete decompression, nerve root and dural injury, epidural hematoma, relatively prolonged operation time, operation fatigue and other deficiencies. This paper summarizes the progress of the UBE technique, discusses its complications and deficiencies, proposes relevant solutions and possible future directions for its development, so as to provide reference for the clinical practice of UBE technique.

, correspAuthors=Lin Liu, authorNote=null, correspAuthorsNote=
E-mail:
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单侧双通道内镜(UBE)技术是近年来快速发展的一项脊柱微创技术。相较传统脊柱内镜技术，UBE突出的特点为可在脊柱同侧开两个通道，分别用于提供视野与置入操作器械，显著扩大了操作空间、降低了手术难度，具有出血少、创伤小、患者术后恢复快、疼痛轻等优点，且治疗腰椎管狭窄症、腰椎间盘突出症等腰椎退行性疾病具有独特优势。随着对UBE技术的不断深入探索与发展，该技术可治疗的疾病领域逐渐扩大，不再局限于腰椎疾病，在治疗颈椎及胸椎疾病方面也取得了较大进展，引起诸多脊柱外科学者的重视。UBE已经成为脊柱相关疾病具有前景的手术方式之一，但存在减压不全、神经根和硬脊膜损伤、硬膜外血肿等并发症，以及手术时间相对延长、操作疲劳等不足。本文总结UBE技术的临床应用进展，对其并发症和不足展开讨论，提出相关解决方案并展望未来可能的发展方向，以期为该技术的临床实践提供参考。

, correspAuthors=刘林, authorNote=null, correspAuthorsNote=
刘林，E-mail：
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胡震，硕士研究生，主要从事脊柱相关疾病方面的研究

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胡震，硕士研究生，主要从事脊柱相关疾病方面的研究

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胡震，硕士研究生，主要从事脊柱相关疾病方面的研究

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单侧双通道内镜技术的临床应用与展望
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胡震 1 , 杨阳 2 , 赵树雄 1 , 张群立 2 , 张同同 2 , 刘林 2, *
解放军医学杂志 | 综述 2024,49(3): 349-354
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解放军医学杂志 | 综述 2024, 49(3): 349-354
单侧双通道内镜技术的临床应用与展望
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胡震1, 杨阳2, 赵树雄1, 张群立2, 张同同2, 刘林2, *
作者信息
  • 1甘肃中医药大学第一临床医学院，甘肃兰州 730000
  • 2甘肃省人民医院骨二科，甘肃兰州 730000

    • 胡震，硕士研究生，主要从事脊柱相关疾病方面的研究

通讯作者:

刘林，E-mail：
Clinical application and perspectives of unilateral biportal endoscopic technique
Zhen Hu1, Yang Yang2, Shu-Xiong Zhao1, Qun-Li Zhang2, Tong-Tong Zhang2, Lin Liu2, *
Affiliations
  • 1The First Clinical School of Gansu University of Chinese Medicine, Lanzhou, Gansu 730000, China
  • 2The Second Department of Orthopaedics, Gansu Provincial People's Hospital, Lanzhou, Gansu 730000, China
出版时间: 2024-03-28 doi: 10.11855/j.issn.0577-7402.1975.2023.0221
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摘要
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单侧双通道内镜(UBE)技术是近年来快速发展的一项脊柱微创技术。相较传统脊柱内镜技术，UBE突出的特点为可在脊柱同侧开两个通道，分别用于提供视野与置入操作器械，显著扩大了操作空间、降低了手术难度，具有出血少、创伤小、患者术后恢复快、疼痛轻等优点，且治疗腰椎管狭窄症、腰椎间盘突出症等腰椎退行性疾病具有独特优势。随着对UBE技术的不断深入探索与发展，该技术可治疗的疾病领域逐渐扩大，不再局限于腰椎疾病，在治疗颈椎及胸椎疾病方面也取得了较大进展，引起诸多脊柱外科学者的重视。UBE已经成为脊柱相关疾病具有前景的手术方式之一，但存在减压不全、神经根和硬脊膜损伤、硬膜外血肿等并发症，以及手术时间相对延长、操作疲劳等不足。本文总结UBE技术的临床应用进展，对其并发症和不足展开讨论，提出相关解决方案并展望未来可能的发展方向，以期为该技术的临床实践提供参考。

单侧双通道内镜技术  /  脊柱微创技术  /  腰椎管狭窄症  /  腰椎间盘突出症  /  腰椎滑脱症

Unilateral biportal endoscopic (UBE) technique is a minimally invasive spinal technique developed rapidly in recent years. Compared with traditional spinal endoscopy, the prominent feature of UBE is that it can open two channels on the same side of the spine, which can be used to provide visual field and insert operating instruments respectively, greatly expanding the operating space and reducing the difficulty of surgery. It has the advantages of less bleeding, little injury, quick recovery and mild pain, and has unique advantages in the treatment of lumbar spinal stenosis, lumbar disc herniation and other lumbar degenerative diseases. With the continuous in-depth exploration and development of the UBE technique, the field of diseases that can be treated by this technology has gradually expanded. It is not only limited to lumbar diseases, but also has made great progress in cervical and thoracic diseases, which has attracted the attention of many spinal surgeons. UBE technique has become one of the promising surgical methods for spinal-related diseases, but there are also complications such as incomplete decompression, nerve root and dural injury, epidural hematoma, relatively prolonged operation time, operation fatigue and other deficiencies. This paper summarizes the progress of the UBE technique, discusses its complications and deficiencies, proposes relevant solutions and possible future directions for its development, so as to provide reference for the clinical practice of UBE technique.

unilateral biportal endoscopic technique  /  minimally invasive spine technology  /  lumbar spinal stenosis  /  lumbar disc herniation  /  lumbar spondylolisthesis
胡震, 杨阳, 赵树雄, 张群立, 张同同, 刘林. 单侧双通道内镜技术的临床应用与展望. 解放军医学杂志, 2024 , 49 (3) : 349 -354 . DOI: 10.11855/j.issn.0577-7402.1975.2023.0221
Zhen Hu, Yang Yang, Shu-Xiong Zhao, Qun-Li Zhang, Tong-Tong Zhang, Lin Liu. Clinical application and perspectives of unilateral biportal endoscopic technique[J]. Medical Journal of Chinese People’s Liberation Army, 2024 , 49 (3) : 349 -354 . DOI: 10.11855/j.issn.0577-7402.1975.2023.0221
正文
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近年来，脊柱相关疾病的患病率和发病率持续增高，据美国国立卫生研究院(National Institutes of Health，NIH)统计显示，全球约5.7%的人患有脊柱退行性疾病，严重威胁人们的生活质量，而疾病进展到后期往往需要手术介入[1]。传统开放手术虽可以取得良好效果，但由于创伤性较大，椎旁肌肉损伤、过度出血及伤口感染等并发症发生率较高[2]，因此患者更倾向于选择软组织损伤小、失血量少、手术部位感染率低的微创手术进行治疗。目前已经开展了多种治疗脊柱相关疾病的微创脊柱手术，包括颈椎后路椎间孔切开术(posterior cervical formininotomy，PCF)、经皮椎间孔镜椎间盘切除术(percutaneous transforaminal endoscopic discectomy，PTED)、微创经椎间孔入路腰椎椎体间融合术(minimally invasive surgery transforaminal lumbar interbody fusion，MIS-TLIF)等[3-4]，但一般内镜手术都是单通道，即将光源、器械等集中在一个厘米级孔径中，致使操作空间狭窄、视野模糊、学习曲线陡峭[5]。为了改进手术方式，脊柱外科医师开始探索新的术式，其中单侧双通道内镜(unilateral biportal endoscopic，UBE)技术是在不断探索和改进中发展起来的一项微创技术，国内关于该技术的前沿报道相对短缺。本文回顾总结UBE技术目前的应用领域及未来可能的发展方向，并讨论其并发症及不足。
1 UBE技术的发展历程
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De Antoni等[6]于1996年首次对关节镜下椎间盘切除术式进行改良，将双通道置于同侧，使用独立的仪器通道，使器械的活动不受限制，该术式被认为是UBE技术的雏形。此后，该项技术并未有长足的进展，原因在于手术中始终存在出血无法及时清除、视野不清晰等缺点，且术后易发生椎管内粘连，对外科医师的操作要求较高。2013年Soliman[7]进行改良，提出手术时使用高压生理盐水灌洗，在水介质环境中进行椎间盘摘除，可营造更清晰的视野范围。由于UBE使用期间的水压受到入口与出口面积、高度差和注入压力影响，为了得到最合适的水压，Hong等[8]经过相关实验确定了水压的最佳范围为4.41~31.00 cmH2O(2.41~22.83 mmHg)，有效避免了出血并且营造了清晰的视野。2017年韩国学者Eun等[5]进行改良，提出在观察通道内采用关节镜提供视野，在操作通道插入微创椎间盘切除术的器械，并将其成功应用于治疗腰椎疾病。近年来，由于患者选择手术时更倾向于创伤小、疼痛轻及术后并发症少的微创手术，UBE技术引起了脊柱医师的关注并在脊柱相关疾病治疗中被广泛应用。
2 UBE技术的操作要点
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相较一般脊柱内镜技术，UBE技术具有两个通道：一个为观察通道，孔径为5~6 mm，置入内镜及照明设备提供视野，一般采用0°或30° UBE内镜，此外高压生理盐水也可通过此通道流入，营造水介质环境；另一个为操作通道，孔径为8~10 mm，用于常规手术器械的插入及操作，如UBE磨钻、髓核钳、骨刀及骨刮匙等(图1A)。在定位时，患者呈俯卧位，定位针置于椎体上下椎板边缘中心分别建立观察通道与操作通道，分别置入器械后两通道在“C”形臂X透机下呈“V”形，二者器械相交处正好定位于病变椎体，手术操作区域为棘突和上椎骨下椎板边缘连接处，通过视野和器械相互合作，可建立三维直观的操作环境，二者互相独立而不受限制，可任意角度转动，提供全方位、更加清晰的视野(图1B)。
目前使用UBE进行的常见手术类型有双门内镜经椎间孔腰椎融合术(biportal endoscopic transforaminal lumbar interbody fusion，BE-TLIF)、椎间孔外腰椎融合术(biportal endoscopic extraforaminal lumbar interbody fusion，BE-EFLIF)、单侧入路双侧椎管减压术(unilateral laminotomy for bilateral decompression，ULBD)、单侧双通道脊柱内镜下颈椎后路椎间孔切开减压术(unilateral biportal endoscopic posterior cervical formininotomy，UBE-PCF)等。UBE手术的适应证与其他微创或显微镜下手术相似，主要包括各种腰椎间盘突出症(lumbar disc herniation，LDH)、腰椎管狭窄症(lumbar spinal stenosis，LSS)、轻度腰椎滑脱症(Ⅰ°-Ⅱ°)、颈椎病、复发性椎间盘突出症、邻椎病等。禁忌证主要包括重度腰椎滑脱症、严重脊柱畸形、手术区域皮肤或深部组织感染及肿瘤等。
3 UBE技术的应用领域
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3.1 LDH
腰椎间盘退行性改变是引起LDH的主要原因，大多数患者通过非手术治疗可缓解或治愈[9]，但对于非手术治疗无效、临床症状明显、影像学提示严重病变的患者则需行手术治疗[10]。近年来UBE手术治疗LDH取得了良好效果。一项研究比较了采用UBE和显微镜下髓核摘除术治疗LDH的安全性和有效性，发现采用UBE手术治疗的患者手术时间明显缩短、术中出血量明显减少，且临床疗效满意度高达92.9%[11]。另一项回顾性研究比较并评估了UBE与开放性腰椎间盘切除术(open lumbar micro-discectomy，OLM)治疗LDH的术后疗效，包括术后恢复、疼痛和生活质量改善、患者满意度及并发症情况，结果显示，UBE可达到与OLM相似的治疗效果，但行UBE的患者术中失血量更少，住院时间更短，且术后背痛程度更轻[12]。此外，Choi等[13]发现，UBE手术治疗LDH患者不仅取得了良好的手术效果，缩短了住院时间，同时显著提高了成本效益，降低了费用成本。由此可见，UBE手术是治疗LDH的一种有效的术式选择。
值得注意的是，辐射暴露是所有内镜手术无法避免的缺点。一项前瞻性多中心研究(包含75例LDH患者)中，研究者从手术时间、辐射暴露时间以及透视时间等方面比较UBE与其他两种内镜技术的辐射暴露情况，发现术中辐射暴露程度与手术侵入水平呈负相关，而UBE手术的辐射伤害处于中位水平，因此在行UBE过程中应采取相应的保护措施，以尽量减少术者和患者暴露于辐射[14]。C反应蛋白(C-reactive protein，CRP)和肌酸磷酸激酶(creatine phosphokinase，CPK)水平可在一定程度上反映术中肌肉组织的损伤程度。一项前瞻性研究(包括80例LDH患者)比较了4种不同显微内镜治疗LDH时对椎旁肌肉的损伤程度，发现UBE组的CPK、CRP水平较高[15]，表明UBE并不是侵入性最小的脊柱手术技术，因此，在选择治疗LDH的微创术式时，宜谨慎权衡利弊，选择最佳术式。此外，患者术后结局与疾病严重程度、操作者熟练程度有关，因此需要更大样本量的前瞻性队列研究深入比较多种微创术式的优缺点。
总之，UBE手术治疗LDH能达到良好的手术效果，且具有创伤小、恢复快、操作灵活等优势，值得临床推广。
3.2 LSS
LSS是导致腰腿疼痛的常见病因之一。研究表明，接受UBE手术治疗的LSS患者，术后背部和腿部疼痛视觉模拟(VSA-B、VSA-L)评分与Oswestry功能障碍指数(ODI)均较术前降低[5]，提示UBE术后患者的临床症状缓解明显，UBE手术治疗LSS具有独特优势。也有研究发现，UBE手术患者术后硬膜囊横截面积、硬脊膜狭窄区均较术前显著扩大，早期疼痛评分明显低于行显微外科手术的患者，相关椎旁肌肉损伤发生率较低，提示UBE手术具有良好的减压效果，或可成为常规显微外科减压术的替代方法[16]。显微内镜下椎板切除术(microendoscopic laminectomy，MEL)也是治疗LSS的一种主流术式。Ito等[17]评估了139例接受MEL和42例接受UBE的LSS患者的术后临床结局，发现UBE手术的减压效果不逊于MEL，行UBE手术的患者骨切除区面积更小、小关节保存率更高且并发症更少，进一步明确了UBE手术治疗LSS的效果。此外，经UBE手术治疗的患者术后短时间内症状得到明显缓解，大部分患者对手术效果满意[18]。
近年来，UBE手术治疗LSS受到了国内众多脊柱外科专家的重视。毕经纬等[19]的研究发现，虽然UBE和PTED都是治疗LSS的安全、有效的微创术式，但UBE手术时间明显短于PTED，且术后硬膜囊面积大于PTED。同时多项研究表明，UBE手术治疗单节段腰椎中央管狭窄合并椎间孔狭窄和远端综合征时对肌肉与韧带的创伤较小，术中出血量少，减压更充分[20-21]。
总之，UBE治疗LSS可有效提高手术效率，缩短手术时间，对患者的创伤小、出血量少、术后疼痛症状缓解明显，造成腰椎失稳的可能性较低[22-23]。值得注意的是，现有关于手术疗效的研究多基于患者术后短期临床症状是否缓解，而对于术后并发症和长期效果的研究较少，因此，未来应关注术后长期并发症的情况。
3.3 腰椎滑脱症
腰椎滑脱症的手术适应证与滑脱分度密切相关。目前腰椎滑脱症治疗术式较多，其中腰椎后路减压融合术是大多数外科医师的优先选择。传统开放手术对椎旁肌肉和神经损伤较大，可能导致术后背部疼痛与椎旁肌萎缩，而肌肉损伤和再生与肌肉牵引受到的压力负荷密切相关[24]。为了克服这项缺点，Foley等[25]开展了MIS-TLIF，可以很好地保留背部肌肉，但在操作空间有限的深层操作领域仍然难以广泛应用，而使用UBE技术完成腰椎融合手术可有效降低操作难度、减少相关并发症。Gatam等[26]对使用UBE进行腰椎椎间融合术的69例患者进行随访，随访时间为13.5个月，术后影像学显示融合减压效果明显、ODI评分显著改善且无神经系统恶化。另一项研究比较了UBE与后路腰椎体间融合术的临床疗效和放射学结果，发现两种微创术式均能达到满意的临床疗效[27]，但采用UBE的患者腰痛VAS评分在术后1周即得到改善，术后疼痛减轻速度较快，表明使用UBE进行腰椎融合可达到与传统术式相同的手术效果，且在术后恢复中具有优势。值得注意的是，采用UBE的手术时间相对较长，可能与有限的工作空间、复杂的操作准备有关。
3.4 颈椎相关疾病
随着UBE技术在腰椎疾病中应用增多，脊柱外科医师提出各种原创性技术及理论，尝试用于其他脊柱领域，并取得了良好成效。Park等[28]报道了使用UBE技术进行颈椎间孔成形和椎间盘摘除以治疗颈椎间盘突出症患者，术中在持续内镜盐水冲洗情况下提供了清晰的手术区域，术后患者仅需短期住院治疗和术后康复治疗。
脊髓型颈椎病是一种严重的颈椎病，手术风险高，术后并发症多。2022年Zhu等[29]提出在UBE手术中应用第3切口(Zhang's portal)可以更好地实现对侧减压，而无需从棘突中去除过多的骨，是脊髓型颈椎病患者对侧减压的替代方法。此外，他们对多节段颈椎管狭窄症患者采用UBE进行颈椎管扩大成形术治疗，显示出良好的临床结局和影像学效果，提示UBE是治疗颈椎狭窄的一种安全有效的技术[30]。
临床中多节段混合型颈椎病较为常见，而单一术式并不适用于此种病变类型。付豪等[31]报道了采用UBE技术后方减压联合颈椎前路椎间盘切除融合术治疗2例多节段混合型颈椎病患者，术后VAS评分、颈椎ODI均明显下降，影像学结果提示治疗节段神经减压彻底。以上结果表明，UBE应用前景良好，但目前其治疗颈椎相关疾病的报道较少，临床样本量缺乏且随访时间短，后续应进一步行大规模前瞻性研究验证疗效。
3.5 其他脊柱疾病
目前关于UBE在其他脊柱疾病中的应用仍处于探索阶段，但对于椎管内外的疾病，UBE提供了一种新型简便的微创方式。2019年Walker等[32]使用UBE治疗症状性脊髓硬膜外脂肪瘤，采用部分椎板切开与黄韧带切除进行间接减压结合去除增生脂肪进行直接减压的手术方法，有效性和安全性均符合术者和患者的期望，这也是UBE在退行性疾病之外的首次应用。近期，有研究报道利用UBE治疗1例硬膜外脊柱肿瘤患者，在使用UBE技术减压后进行肿瘤切除及活检，术后患者疼痛及功能障碍程度明显减轻[33]。此外，UBE被用于脊髓硬膜外脓肿患者的清创引流，术后患者生命体征恢复正常，腰痛症状好转，影像学提示脓肿完全消失，术后6个月未见脓肿复发[34]。
近年来，关于UBE的扩展应用成为研究热点，其手术适应证不断扩大。UBE开发之初是作为一项针对腰椎的侵入技术，但其优势较多，应用不再限制于腰椎。
4 UBE的优势及局限性
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作为一项近年来快速发展的脊柱微创技术，UBE的治疗领域、操作过程具有独特优势：(1)双通道使得操作过程中器械互不制约，可在稳定光源下进行更精细的操作，提升了手术安全性；(2)单独视野通道及高清显微影像扩大了狭窄空间的可视范围，使得盲区操作减少，减少了并发症的发生；(3)良好的视野及更精细的操作可获得与开放手术相近的疗效，具有创伤小、术后恢复快的优势，其有效性在多项研究中被证实。尽管UBE具有诸多优势，但仍存在一些局限性：(1)对于初学者，UBE较传统开放手术难掌握，学习曲线较长。一项关于技术学习曲线的研究发现，UBE手术在第89例后达到稳定点，达到稳定点后手术失败率从10.11%下降至2.78%[35]，手术时间明显缩短，因此要熟练掌握该技术需要至少经过89例的手术训练。然而韩国一项研究发现，UBE用于单纯椎间盘摘除术时，完成14例手术后手术时间基本接近平均值[36]，操作者手法的熟练程度、理论知识储备、临床经验等均是影响学习曲线的因素，因此个体特征差异性较大。(2)与经皮内镜下腰椎间盘摘除术(percutaneous endoscopy lumbar discectomy，PELD)相比，UBE手术切口数量增加，且由于操作通道反复进出手术器械，其邻近结构的损伤可能超过PELD。(3)与传统术式相比，UBE手术时间相对较长，主要考虑与有限的工作空间、复杂的操作准备有关。(4)目前尚不适用于重度腰椎滑脱、椎体骨折及脊柱畸形等疾病的治疗。UBE存在的局限性需要临床医师进行大量的手术训练以及技术、器械的革新来不断改善。
5 UBE的并发症及防治
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5.1 并发症
硬膜外血肿、神经根或硬脊膜损伤、减压不全、复发及软组织损伤是UBE术后的主要并发症。一项研究分析了797例行UBE手术的患者，其中10.3%出现了术后并发症，而硬膜外血肿和减压不彻底发生率较高[37]。相较传统微创手术，UBE需在手术区域开两个通道，加之盐水的不断冲击导致两个通道的软组织均受到不同程度的破坏，且破坏程度与手术时间、盐水压力密切相关[38]，因此术中合理控制盐水的流速与压力值得探讨，需在充分保证视野的情况下，达到损伤最小的目的。此外，硬脊膜和神经损伤也是UBE的常见并发症，一项回顾性研究纳入了643例行UBE手术的患者，其硬膜囊损伤发生率为4.5%，主要为术中使用磨钻和咬钳所致[39]，损伤发生后及时妥善处理基本可避免严重的神经后遗症。
5.2 并发症防治
术中水压过高掩盖出血点是硬膜外血肿发生的可能原因之一，因此，将灌洗液压力控制在25~30 mmHg可有效避免水压过高掩盖出血点而使患者颅内压升高，缓解患者术后头痛。此外，术中使用明胶海绵止血对预防术后硬膜外血肿具有一定作用[38]。清晰的视野对UBE手术至关重要，即使有少量出血，内镜下视野也会模糊，增加了神经根和硬脊膜损伤的风险。因此建议术中彻底止血，对于术中偶发的硬膜破裂可通过缝线缝合加以明胶海绵覆盖或非穿透性钛夹直接修复，并留置引流管进一步预防硬膜外血肿[40]。对于病程较长的患者或复杂病例，往往伴随着韧带增厚与钙化粘连，剥离过程中建议使用弯角刮刀去除黄韧带和硬脑膜之间的粗细、薄厚不一的网状脊膜韧带[41]，特殊情况下可切除足够多的椎板，保证充分分离韧带，减少损伤。
总之，UBE并发症的发生与操作者的熟练程度密切相关，初学者需要不断总结、加强训练，提高手术操作技巧，并将手术时间控制在合理范围内，以减少并发症的发生。
6 UBE的挑战与设想
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6.1 软组织通道建立
UBE手术成功与否与软组织通道的建立密切相关，整个过程存在一定的难度，可在一定程度上损伤椎旁软组织。此外，该通道的维持需要良好的肌肉松弛条件，对于椎旁肌发达的患者，实行小通道(即撑开肌肉建立操作空间)治疗具有挑战。因此，未来可针对椎旁肌肉松弛展开研究，以便于通道的建立与更小程度的软组织损伤。
6.2 UBE操作疲劳
UBE术中双手操作使得术者很快感受到疲劳，相应的视野布置与手术操作均受到影响，建立“内镜扶手”解放术者双手或是一种有效的解决方案。周跃[42]提出了“数字微创脊柱外科技术”，即3D技术、导航技术、虚拟现实技术以及手术机器人技术，都逐渐应用于微创脊柱外科领域。这类技术能够帮助外科医师提高手术的精准性和安全性，并可利用机器人提供视野辅助完成手术。因此，未来可开展更有前景的“人机配合”完成UBE手术，通过机器人强大的算力与影像学配合，提供切实可靠的三维视野，在虚拟视野中完成手术。
7 总结与展望
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UBE作为一项新发展的内镜技术，是微创手术的一种新的选择，其手术创伤小、术中出血少、椎旁肌肉与神经损伤轻、术后临床症状缓解明显、恢复快的优点显著提高了外科医师的工作效率，且由于具有充分的视野，内镜操作难度有所下降，器械使用更加符合外科医师的习惯；也存在硬脊膜损伤、硬膜外血肿、减压不全或复发、神经根刺激症状、术后感染等并发症，以及手术时间相对延长、操作疲劳等不足，但均可通过大量的临床练习来减少其发生。目前UBE主要用于脊柱退行性疾病的手术治疗，对于其他脊柱疾病的应用正在探索中，并且可以预见会有更多新的突破。与此同时，对于UBE未来的发展，可着眼于采用更便捷的方式建立通道，提供支架维持内镜视野，或可使用机器人参与手术，改变其使用现状。
基金
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  • 甘肃省青年科技基金计划(21JR11RA199)
文献
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doi: 10.11855/j.issn.0577-7402.1975.2023.0221
  • 接收时间：2022-09-10
  • 首发时间：2025-11-23
  • 出版时间：2024-03-28
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  • 收稿日期：2022-09-10
  • 录用日期：2022-11-14
基金
Gansu Provincial Youth Science and Technology Fund Program(21JR11RA199)
甘肃省青年科技基金计划(21JR11RA199)
作者信息
    1甘肃中医药大学第一临床医学院，甘肃兰州 730000
    2甘肃省人民医院骨二科，甘肃兰州 730000

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鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
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红菇科 Russulaceae 3 23 11.00 小皮伞属 Marasmius 6 2.87
小菇属 Mycena 11 5.26
光柄菇属 Pluteus 5 2.39
红菇属 Russula 17 8.13
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