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Article(id=1149774732784001316, tenantId=1146029695717560320, journalId=1146123166801305609, issueId=1149774724923880044, articleNumber=null, orderNo=null, doi=10.12404/j.issn.1671-1815.2308559, pmid=null, cstr=null, oa=null, hot=null, price=null, onlineType=0, articleFormat=0, articleType=null, articleTypeStr=null, receivedDate=1698854400000, receivedDateStr=2023-11-02, revisedDate=1737388800000, revisedDateStr=2025-01-21, acceptedDate=null, acceptedDateStr=null, onlineDate=1752057258077, onlineDateStr=2025-07-09, pubDate=1745769600000, pubDateStr=2025-04-28, doiRegisterDate=null, doiRegisterDateStr=null, onlineIssueDate=1752057258077, onlineIssueDateStr=2025-07-09, onlineJustAcceptDate=null, onlineJustAcceptDateStr=null, onlineFirstDate=null, onlineFirstDateStr=null, sourceXml=null, magXml=null, createTime=1752057258077, creator=13701087609, updateTime=1752057258077, updator=13701087609, issue=Issue{id=1149774724923880044, tenantId=1146029695717560320, journalId=1146123166801305609, year='2025', volume='25', issue='12', pageStart='4827', pageEnd='5272', issueExtLink='null', onlineDate='null', pubDate='null', beforeIssueId=null, nextIssueId=null, price=null, status=1, issueComplete=1, articleOrder=1, issueType=-1, specialIssue=0, createTime=1752057256203, creator=13701087609, updateTime=1768456746933, updator=13701087609, preIssue=null, nextIssue=null, ext={EN=IssueExt(id=1218559174552764785, tenantId=1146029695717560320, journalId=1146123166801305609, issueId=1149774724923880044, language=EN, specialIssueTitle=, coverIllustrator=, specialIssueEditor=, specialIssueAbout=), CN=IssueExt(id=1218559174552764786, tenantId=1146029695717560320, journalId=1146123166801305609, issueId=1149774724923880044, language=CN, specialIssueTitle=, coverIllustrator=, specialIssueEditor=, specialIssueAbout=)}, issueFiles=null}, startPage=4926, endPage=4931, ext={EN=ArticleExt(id=1149774733014688041, articleId=1149774732784001316, tenantId=1146029695717560320, journalId=1146123166801305609, language=EN, title=A Clinical Study on the Surgical Technique of Ligamentum Flavum in Percutaneous Endoscopic Interlaminar Lumbar Discectomy, columnId=1156262732384031076, journalTitle=Science Technology and Engineering, columnName=Papers·Medicine, runingTitle=null, highlight=null, articleAbstract=

In order to compare the clinical effect of different surgical technique of ligamentum flavum in percutaneous endoscopic interlaminar lumbar discectomy. From March 2015 to March 2019, 86 cases of L5-S1 lumbar disc herniation (LDH) were analyzed retrospectively. According to the different treatment of ligamentum flavum during operation, the patients were divided into control group (n=55) and modified group (n=31). The age, gender, course of disease, duration of surgery, intraoperative bleeding, hospital stay, and surgical related complications between the two groups of patients were analyzed and compared. One month, three months and six months after the operation, the routine outpatient reexamination and follow-up were carried out. Numerical rating scale(NRS) and modified macnab were used to evaluate the effect of operation. SPSS 19.0 was used to process the data. Mean±SD was used for measurement data. Comparison between groups using independent sample t-test, and analysis of variance of repeated measurement data was used for the NRS score comparison before and after operation. The counting data were expressed in percentage, Fisher exact test or χ2 test were used for comparison between groups, and Mann Whitney rank sum test was used for comparison of follow-up time and grade grouping data between groups. The results show that the postoperative pain score of both groups decrease significantly(overall variance within the group Fwithin=197.477, P=0.001). There is no difference between the two groups (inter group overall variance value Finterg=1.701, P=0.203).The time factor has no effect on the results of the two groups(Interaction effect value Finter=2.231, P=0.108). The NRS score of the modified group is significantly lower than that of the control group (t=2.086, P=0.046). According to modified Macnab criteria, there is no significant difference between the two groups (distribution of postoperative outcomes U=782.000, P=0.308). It is concluded that the modifiedsurgical technique of ligamentum flavum in the PEILD will not prolong the operation time or increase the amount of bleeding. While removing the herniated intervertebral disc, it can preserve the integrity of the relevant tissue structure, achieve satisfied clinical effect, and conforms to the core concept of minimally invasive surgery.

, correspAuthors=Yu-bao HE, authorNote=null, correspAuthorsNote=null, copyrightStatement=null, copyrightOwner=null, extLink=null, articleAbsUrl=null, sourceXml=null, magXml=null, pdfUrl=null, pdf=null, pdfFileSize=null, pdfExtLink=null, richHtmlUrl=null, mobilePdfUrl=null, reviewReport=null, pdfFirstPage=null, abstractGraph=null, abstractGraphContent=null, abstractVideo=null, citation=null, cebUrl=null, magXmlContent=null, mapNumber=null, authorCompany=null, fund=null, authors=null, authorsList=Yun-hua ZHAO, Yu-bao HE), CN=ArticleExt(id=1149774752262349452, articleId=1149774732784001316, tenantId=1146029695717560320, journalId=1146123166801305609, language=CN, title=经皮内镜下腰椎椎板间入路黄韧带处理方法的临床研究, columnId=1156262732526637414, journalTitle=科学技术与工程, columnName=论文·医药、卫生, runingTitle=null, highlight=null, articleAbstract=

为比较经皮内镜下椎板间入路腰椎间盘切除术中不同黄韧带处理方法的临床效果。通过回顾性分析自2015年3月—2019年3月,行经皮内镜下椎板间入路腰椎间盘切除术的86 例L5-S1节段腰椎间盘突出症(LDH)患者。根据术中黄韧带的不同处理方法,分为对照组(n=55)和改良组(n=31)。分析对比两组患者之间的年龄构成、性别差异、病程、手术的时程、术中的出血、住院的时间和并发症。术后1、3、6个月常规门诊复查随访。手术结果的评价采用数字评定法(numeric rating scale, NRS)和改良Macnab标准。数据的处理采用统计学分析软件SPSS 19.0,mean±SD表示计量资料,独立样本t检验用于组间的对比,比较手术前后多次测量NRS评分采用数据方差分析。计数资料采用百分率的形式描述,组间对比应用精确概率法或χ2检验;Mann-Whitney秩和检验用于比较各组间的随访时间和等级分组资料。结果表明:疼痛评分:两组患者术后均明显下降(组内总体方差值Fwithin=197.477,P=0.001),两组之间术后疼痛评分比较没有明显差别(组间总体方差值Finterg=1.701, P=0.203),时间因素对于两组结果的影响并没有不同(交互效应值Finter=2.231, P=0.108)。术后6 个月,改良组NRS评分明显低于对照组(t=2.086,P=0.046)。两组患者术后改良Macnab标准比较并没有明显不同(术后结果的分布情况U=782.000, P=0.308)。可见经椎板间入路腰椎间盘切除术中采用改良的黄韧带处理技术与传统方法相比不会延长手术时间或者增加手术出血量,在去除突出椎间盘的同时,能够保留相关组织结构的完整性,具有良好的临床效果,符合微创的核心理念。

, correspAuthors=何玉宝, authorNote=null, correspAuthorsNote=
* 何玉宝(1980—),男,汉族,内蒙古乌兰浩特人,博士,主任医师。研究方向:脊柱外科。E-mail:。
, copyrightStatement=null, copyrightOwner=null, extLink=null, articleAbsUrl=null, sourceXml=4B+L04rmZ/8lMvQkWScw2w==, magXml=xVEFj4BiEhor8KeHgGlZWw==, pdfUrl=null, pdf=KzEybS7FqeSJXZkJBMboLg==, pdfFileSize=null, pdfExtLink=null, richHtmlUrl=null, mobilePdfUrl=null, reviewReport=null, pdfFirstPage=null, abstractGraph=null, abstractGraphContent=null, abstractVideo=null, citation=null, cebUrl=null, magXmlContent=VrDtZ4/l9CmyBtAFpncSzQ==, mapNumber=null, authorCompany=null, fund=null, authors=

赵云华(1983—),女,汉族,北京人,硕士,主治医师。研究方向:急诊急救、危重症、创伤。E-mail:。

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赵云华(1983—),女,汉族,北京人,硕士,主治医师。研究方向:急诊急救、危重症、创伤。E-mail:。

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赵云华(1983—),女,汉族,北京人,硕士,主治医师。研究方向:急诊急救、危重症、创伤。E-mail:。

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Pain Physician, 2018, 21(4): 337-350., articleTitle=Prevalence of recurrent herniation following percutaneous endoscopic lumbar discectomy: a Meta-analysis, refAbstract=null)], funds=null, companyList=[AuthorCompany(id=1180089296590615030, tenantId=1146029695717560320, journalId=1146123166801305609, articleId=1149774732784001316, xref=1, ext=[AuthorCompanyExt(id=1180089296599003639, tenantId=1146029695717560320, journalId=1146123166801305609, articleId=1149774732784001316, companyId=1180089296590615030, language=EN, country=null, province=null, city=null, postcode=null, companyName=null, departmentName=null, remark=1 Department of Emergency, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China), AuthorCompanyExt(id=1180089296607392248, tenantId=1146029695717560320, journalId=1146123166801305609, articleId=1149774732784001316, companyId=1180089296590615030, language=CN, country=null, province=null, city=null, postcode=null, companyName=null, 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language=EN, label=Fig.6, caption=Surgical removal of nucleus pulposus tissue, figureFileSmall=x3+5MaoHw1OUtbIiyFFXpw==, figureFileBig=ovN4RkfPM4q6r/xtKtoNLQ==, tableContent=null), ArticleFig(id=1180089298322862616, tenantId=1146029695717560320, journalId=1146123166801305609, articleId=1149774732784001316, language=CN, label=图6, caption=取出的髓核组织, figureFileSmall=x3+5MaoHw1OUtbIiyFFXpw==, figureFileBig=ovN4RkfPM4q6r/xtKtoNLQ==, tableContent=null), ArticleFig(id=1180089298389971481, tenantId=1146029695717560320, journalId=1146123166801305609, articleId=1149774732784001316, language=EN, label=Table 1, caption=

Comparison of routine data between two groups of LDH patients(mean±SD)

, figureFileSmall=null, figureFileBig=null, tableContent=
组别 例数 性别 平均年龄/岁 病程/月 住院时间/d 随访时间/月
男性例数/例 男性占比/% 女性例数/例 女性占比/%
对照组 55 31 56.4 24 43.6 44.6±16.7 11.3±10.1 10.1±5.9 12.8±8.1
改良组 31 18 58.1 13 41.9 40.7±13.2 13.9±15.6 11.8±6.5 12.6±9.9
χ2/t 0.023 0.642 0.563 0.738 —
P 0.878 0.526 0.573 0.466 0.650
), ArticleFig(id=1180089298448691738, tenantId=1146029695717560320, journalId=1146123166801305609, articleId=1149774732784001316, language=CN, label=表1, caption=

两组LDH患者常规资料对比(mean±SD)

, figureFileSmall=null, figureFileBig=null, tableContent=
组别 例数 性别 平均年龄/岁 病程/月 住院时间/d 随访时间/月
男性例数/例 男性占比/% 女性例数/例 女性占比/%
对照组 55 31 56.4 24 43.6 44.6±16.7 11.3±10.1 10.1±5.9 12.8±8.1
改良组 31 18 58.1 13 41.9 40.7±13.2 13.9±15.6 11.8±6.5 12.6±9.9
χ2/t 0.023 0.642 0.563 0.738 —
P 0.878 0.526 0.573 0.466 0.650
), ArticleFig(id=1180089298503217691, tenantId=1146029695717560320, journalId=1146123166801305609, articleId=1149774732784001316, language=EN, label=Table 2, caption=

Comparison of surgical outcomes between two groups of LDH patients(mean±SD)

, figureFileSmall=null, figureFileBig=null, tableContent=
组别 例数 手术时间/min 出血量/mL 并发症 复发
椎间盘炎 脑脊液漏 例数/例 占比/%
例数/例 占比/% 例数/例 占比/%
对照组 55 62.8±25.1 18.0±12.9 1 1.8 1 1.8 1 1.8
改良组 31 66.0±24.1 21.0±13.1 0 0 1 3.2 0 0
χ2/t 0.338 0.597 0.010 0.570
P 0.738 0.555 0.921 0.450
), ArticleFig(id=1180089298566132252, tenantId=1146029695717560320, journalId=1146123166801305609, articleId=1149774732784001316, language=CN, label=表2, caption=

两组LDH患者的手术情况对比(mean±SD)

, figureFileSmall=null, figureFileBig=null, tableContent=
组别 例数 手术时间/min 出血量/mL 并发症 复发
椎间盘炎 脑脊液漏 例数/例 占比/%
例数/例 占比/% 例数/例 占比/%
对照组 55 62.8±25.1 18.0±12.9 1 1.8 1 1.8 1 1.8
改良组 31 66.0±24.1 21.0±13.1 0 0 1 3.2 0 0
χ2/t 0.338 0.597 0.010 0.570
P 0.738 0.555 0.921 0.450
), ArticleFig(id=1180089298624852509, tenantId=1146029695717560320, journalId=1146123166801305609, articleId=1149774732784001316, language=EN, label=Table 3, caption=

Comparison of NRS scores after lumbar discectomy via percutaneous endoscopic lumbar interlaminar approach in LDH patients(mean±SD)

, figureFileSmall=null, figureFileBig=null, tableContent=
组别 例数 NRS评分/分
术前 术后1个月 术后3个月 术后6个月
对照组 55 8.6±1.0 2.4±1.7 2.1±1.9 2.0±2.1
改良组 31 8.8±1.0 1.9±1.4 1.1±1.1 0.5±1.3a
t 0.532 0.738 1.471 2.086
P 0.599 0.467 0.152 0.046
), ArticleFig(id=1180089298691961374, tenantId=1146029695717560320, journalId=1146123166801305609, articleId=1149774732784001316, language=CN, label=表3, caption=

LDH患者经皮内镜椎板间入路腰椎间盘切除术后NRS评分的对比(mean±SD)

, figureFileSmall=null, figureFileBig=null, tableContent=
组别 例数 NRS评分/分
术前 术后1个月 术后3个月 术后6个月
对照组 55 8.6±1.0 2.4±1.7 2.1±1.9 2.0±2.1
改良组 31 8.8±1.0 1.9±1.4 1.1±1.1 0.5±1.3a
t 0.532 0.738 1.471 2.086
P 0.599 0.467 0.152 0.046
), ArticleFig(id=1180089298763264543, tenantId=1146029695717560320, journalId=1146123166801305609, articleId=1149774732784001316, language=EN, label=Table 4, caption=

Comparison of modified Macnab evaluation criteria for lumbar discectomy via percutaneous endoscopic lumbar interlaminar approach in LDH patients 6 months after surgery

, figureFileSmall=null, figureFileBig=null, tableContent=
组别 例数 改良MacNab评价标准
优 良 可 差
例数/例 占比/% 例数/例 占比/% 例数/例 占比/% 例数/例 占比/%
对照组 55 45 81.8 8 14.5 2 3.6 0 0
改良组 31 28 90.3 2 6.5 1 3.2 0 0
U 782.000
P 0.308
), ArticleFig(id=1180089298826179104, tenantId=1146029695717560320, journalId=1146123166801305609, articleId=1149774732784001316, language=CN, label=表4, caption=

LDH患者经皮内镜下腰椎椎板间入路腰椎盘切除术后6个月改良Macnab评价标准比较

, figureFileSmall=null, figureFileBig=null, tableContent=
组别 例数 改良MacNab评价标准
优 良 可 差
例数/例 占比/% 例数/例 占比/% 例数/例 占比/% 例数/例 占比/%
对照组 55 45 81.8 8 14.5 2 3.6 0 0
改良组 31 28 90.3 2 6.5 1 3.2 0 0
U 782.000
P 0.308
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经皮内镜下腰椎椎板间入路黄韧带处理方法的临床研究
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赵云华 1 , 何玉宝 2, *
科学技术与工程 | 论文·医药、卫生 2025,25(12): 4926-4931
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科学技术与工程 | 论文·医药、卫生 2025, 25(12): 4926-4931
经皮内镜下腰椎椎板间入路黄韧带处理方法的临床研究
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赵云华1 , 何玉宝2, *
作者信息
  • 1 首都医科大学附属北京友谊医院急诊科, 北京 100050
  • 2 北京市垂杨柳医院骨科, 北京 100022

    • 赵云华(1983—),女,汉族,北京人,硕士,主治医师。研究方向:急诊急救、危重症、创伤。E-mail:。

通讯作者:

* 何玉宝(1980—),男,汉族,内蒙古乌兰浩特人,博士,主任医师。研究方向:脊柱外科。E-mail:。
A Clinical Study on the Surgical Technique of Ligamentum Flavum in Percutaneous Endoscopic Interlaminar Lumbar Discectomy
Yun-hua ZHAO1 , Yu-bao HE2, *
Affiliations
  • 1 Department of Emergency, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
  • 2 Department of Orthopedics, Beijing Chuiyangliu Hospital, Beijing 100022, China
出版时间: 2025-04-28 doi: 10.12404/j.issn.1671-1815.2308559
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摘要
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为比较经皮内镜下椎板间入路腰椎间盘切除术中不同黄韧带处理方法的临床效果。通过回顾性分析自2015年3月—2019年3月,行经皮内镜下椎板间入路腰椎间盘切除术的86 例L5-S1节段腰椎间盘突出症(LDH)患者。根据术中黄韧带的不同处理方法,分为对照组(n=55)和改良组(n=31)。分析对比两组患者之间的年龄构成、性别差异、病程、手术的时程、术中的出血、住院的时间和并发症。术后1、3、6个月常规门诊复查随访。手术结果的评价采用数字评定法(numeric rating scale, NRS)和改良Macnab标准。数据的处理采用统计学分析软件SPSS 19.0,mean±SD表示计量资料,独立样本t检验用于组间的对比,比较手术前后多次测量NRS评分采用数据方差分析。计数资料采用百分率的形式描述,组间对比应用精确概率法或χ2检验;Mann-Whitney秩和检验用于比较各组间的随访时间和等级分组资料。结果表明:疼痛评分:两组患者术后均明显下降(组内总体方差值Fwithin=197.477,P=0.001),两组之间术后疼痛评分比较没有明显差别(组间总体方差值Finterg=1.701, P=0.203),时间因素对于两组结果的影响并没有不同(交互效应值Finter=2.231, P=0.108)。术后6 个月,改良组NRS评分明显低于对照组(t=2.086,P=0.046)。两组患者术后改良Macnab标准比较并没有明显不同(术后结果的分布情况U=782.000, P=0.308)。可见经椎板间入路腰椎间盘切除术中采用改良的黄韧带处理技术与传统方法相比不会延长手术时间或者增加手术出血量,在去除突出椎间盘的同时,能够保留相关组织结构的完整性,具有良好的临床效果,符合微创的核心理念。

椎间盘退化  /  微创性外科手术  /  电视辅助外科手术

In order to compare the clinical effect of different surgical technique of ligamentum flavum in percutaneous endoscopic interlaminar lumbar discectomy. From March 2015 to March 2019, 86 cases of L5-S1 lumbar disc herniation (LDH) were analyzed retrospectively. According to the different treatment of ligamentum flavum during operation, the patients were divided into control group (n=55) and modified group (n=31). The age, gender, course of disease, duration of surgery, intraoperative bleeding, hospital stay, and surgical related complications between the two groups of patients were analyzed and compared. One month, three months and six months after the operation, the routine outpatient reexamination and follow-up were carried out. Numerical rating scale(NRS) and modified macnab were used to evaluate the effect of operation. SPSS 19.0 was used to process the data. Mean±SD was used for measurement data. Comparison between groups using independent sample t-test, and analysis of variance of repeated measurement data was used for the NRS score comparison before and after operation. The counting data were expressed in percentage, Fisher exact test or χ2 test were used for comparison between groups, and Mann Whitney rank sum test was used for comparison of follow-up time and grade grouping data between groups. The results show that the postoperative pain score of both groups decrease significantly(overall variance within the group Fwithin=197.477, P=0.001). There is no difference between the two groups (inter group overall variance value Finterg=1.701, P=0.203).The time factor has no effect on the results of the two groups(Interaction effect value Finter=2.231, P=0.108). The NRS score of the modified group is significantly lower than that of the control group (t=2.086, P=0.046). According to modified Macnab criteria, there is no significant difference between the two groups (distribution of postoperative outcomes U=782.000, P=0.308). It is concluded that the modifiedsurgical technique of ligamentum flavum in the PEILD will not prolong the operation time or increase the amount of bleeding. While removing the herniated intervertebral disc, it can preserve the integrity of the relevant tissue structure, achieve satisfied clinical effect, and conforms to the core concept of minimally invasive surgery.

disc degeneration  /  minimally invasive surgery  /  video-assisted surgery
赵云华, 何玉宝. 经皮内镜下腰椎椎板间入路黄韧带处理方法的临床研究. 科学技术与工程, 2025 , 25 (12) : 4926 -4931 . DOI: 10.12404/j.issn.1671-1815.2308559
Yun-hua ZHAO, Yu-bao HE. A Clinical Study on the Surgical Technique of Ligamentum Flavum in Percutaneous Endoscopic Interlaminar Lumbar Discectomy[J]. Science Technology and Engineering, 2025 , 25 (12) : 4926 -4931 . DOI: 10.12404/j.issn.1671-1815.2308559
正文
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内窥镜下腰椎间盘手术(percutaneous endoscopic lumbar discectomy, PELD)[1]发展迅速,其重要的核心理念是采用微创方法切除突出的椎间盘组织。PELD主要采用经椎间孔和经椎板间入路[2]。经椎间孔入路对神经根减压术有良好的效果,手术并发症发生率低,因此被认为是PELD的标准手术入路[3]。然而,在L5-S1节段,髂嵴常常阻挡经椎间孔入路的穿刺路线,L5横突和肥大的小关节突也常影响经椎间孔入路手术。2006年,Priola等[4]首次报道了L5-S1节段的经椎板间入路,此后被许多外科医生广泛采用,该技术也逐渐完善。
在L5-S1的经椎板间入路中,黄韧带的处理很棘手,而黄韧带在术后瘢痕形成中起着重要作用[5],会影响手术疗效。鉴于此,改良术中黄韧带的处理方法,以期对黄韧带的损伤更小,以期获得更好的临床疗效。
1 材料和方法
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1.1 常规资料
分析北京市垂杨柳医院2015 年3 月—2019 年3 月期间骨科住院并接受经椎板间入路的86 例有症状的L5-S1节段腰椎间盘突出症(lumbar disc herniation, LDH)患者,性别(男∶女=49∶29)。年龄(43.3±15.2) 岁,年龄范围16~81 岁;病程(12.1±12.0) 月(界限1~48 月),住院时间(10.6±6.1) d(界限3~28 d),随访(12.7±8.5)月(界限6~36 月)。所有患者均采用椎板间入路,根据术中黄韧带的处理方式不同分组,对照组(样本数n= 55)采用传统的黄韧带切除法,改良组(样本数n= 31)采用黄韧带撕裂法。对两组患者之间的性别构成比、年龄范围、病程、住院时间和随访时间进行比较,发现无统计学差异,如表1所示。手术指征为经计算机断层扫描成像或核磁共振成像明确为L5-S1椎间盘后外侧突出,保守治疗无效,单侧下肢放射痛,直腿抬高试验阳性。排除标准:①因椎管狭窄或椎间盘钙化而需要进行广泛减压切除的患者;②L5-S1复发病例;③腰椎不稳定或者腰椎滑脱;④合并其他病理改变,如感染、肿瘤和骨折;⑤失访病例。
手术均由1名经过脊柱外科培训的副主任医师完成,术中使用的器械为德国Joimax公司提供的经椎间孔脊柱内镜手术器械系统。出院后,通过预约定期门诊复查随访。
1.2 手术方法
根据术前计算机断层扫描或者核磁共振观察到椎间盘突出的具体位置,设计穿刺路线。手术在安定镇痛麻醉下进行,术中监测患者生命体征,包括心电、血氧饱和度、血压和呼吸。麻醉深度控制在随时可以唤醒的水平。手术体位采用半跪体位。术前C臂透视确定穿刺路线入点(图1),局部消毒,铺无菌巾单。局部麻醉后,在C臂透视引导下将穿刺针尖置于L5-S1椎板间隙(图2),拔除穿针的针芯,置入导丝(图3)。将穿刺针拔除,以导丝为中心,纵形切开皮肤、皮下组织及深筋膜,切口长约1 cm。沿导丝逐级置入扩张套筒(图4),选择置入斜面工作通道,斜面尖端位于下方(图5)。将导丝及扩张套筒取出,连接内窥镜光源及入水管,调节白平衡及焦距。对照组在镜下用45°抓钳在黄韧带上开一个小孔,切除部分黄韧带,约3 mm×5 mm,进入硬膜外间隙;改良组的技术是在镜下使用无创解剖器在黄韧带上撕开一个小裂隙,将斜面工作通道尖端插入小裂隙并旋转扩大黄韧带裂口,进入硬膜外间隙。确认硬膜外脂肪、硬膜囊和S1神经根,旋转工作通道,将硬膜囊和神经根推开后,显露突出的椎间盘。用2 mg/mL亚甲蓝染色突出的椎间盘组织,使用抓钳和髓核钳取出突出的髓核组织(图6)。
使用双极射频进行纤维环消融修复。确认硬膜囊和神经根松弛后,探查无残留椎间盘组织后,去除工作通道。留置负压引流管1 枚,切口缝合1 针后,返回病房。
1.3 观察指标
(1)观察指标。手术时间、出血量、并发症和复发率。并发症有常见的切口感染、脑脊液漏、神经损伤、椎间盘炎等。复发定义为在随访期间内,经过一段疼痛减轻或者消失的时间后,再次出现同一部位的下肢放射痛,且经过辅助检查证实为前次手术同一节段同一侧突出。
(2)临床结果的评估。疼痛缓解情况的评估采用数字评定法(numeric rating scale, NRS)[6]:疼痛的严重程度分为10分,无痛:0分;轻度疼痛:1~3分;中度疼痛:4~6分;严重疼痛:7~10。术后恢复情况的评估采用改良Macnab标准[7]:优:疼痛完全消失,活动不受限制,恢复到正常的工作和生活水平;良:偶有非放射性、非持续性疼痛,能够参加其他的工作;可:生活能力有一些改善,仍然有功能障碍和/或不能工作;差:持续存在明显的神经根受累症状,在任何随访期间都有明确的再次手术指征。
1.4 统计学方法
数据的处理采用统计学分析软件SPSS 19.0,用平均值±标准差(mean±SD)表示计量资料,独立样本t检验用于组间的比较,比较手术前后多次测量NRS评分采用数据方差分析。计数资料采用百分率的形式描述,组间的比较应用精确概率法或χ2检验;Mann-Whitney秩和检验用于比较各组间的随访时间和等级分组资料。P<0.05为研究结果有统计学意义。
2 结果
收起
2.1 手术情况
手术节段为L5-S1,均采用椎板间入路,手术时间(63.8±24.4) min (范围25~120 min),出血量(19.0±12.8) mL (范围5~50 mL),两组比较没有统计学差异(t=0.338, 0.597, P=0.738, 0.555)。对照组出现1例椎间盘炎,术后下肢疼痛缓解,但是出现持续加重的腰痛,经过核磁共振检查,确诊为椎间盘炎,给予制动、止痛、抗炎对症治疗后,症状缓解。脑脊液漏出现2 例,对照组和改良组各1 例,术后出现头痛、恶心、呕吐的症状,给予补液、止吐、抗生素预防感染等治疗后,症状均得到缓解。拔除引流管前将引流管间断夹闭,拔除引流管后,局部缝合1 针后,垫厚沙垫,嘱患者平卧4 h,切口均一期愈合。对照组出现1 例病例复发,该患者出院后,术前疼痛症状已得到明显缓解,但是并未嘱医嘱佩戴腰围,弯腰搬重物后再次出现下肢放射痛,位于小腿后方,经腰椎核磁共振检查证实为L5-S1椎间盘突出。再次住院行经椎板间入路,术后症状得到缓解。如表2所示。
2.2 手术结果评价
临床结果显示下肢疼痛的平均NRS评分从术前的(8.7±1.0) 分(范围7~10 分)降至术后1 个月的(2.2±1.6) 分(范围0~6 分)、术后3 个月(1.7±1.7)分(范围0~7 分)、术后6 个月(1.5±2.0) 分(范围0~8 分)。两组患者术后疼痛评分均明显下降(组内总体方差值Fwithin=197.477, P=0.001),两组之间比较无明显差异(组间总体方差值Finterg=1.701, P=0.203),时间因素对于两组结果的影响并无差异(交互效应值Finter=2.231, P=0.108)。但是在术后6 个月时,改良组NRS评分明显低于对照组(t=2.086, P=0.046),显示出更好的临床结果。如表3所示。
根据改良Macnab的标准,83例患者(96.5%, 83/86)获得了良好的结果(优或良),3例患者(3.5%, 3/86)结果为可。两组患者术后临床结果比较并没有明显不同(U=782.000, P=0.308),如表4所示。
3 讨论
收起
在腰椎间盘突出症的外科治疗中,传统的开放手术被认为是金标准手术,但自从微创手术出现以来,PELD的应用越来越多[8]。随着内窥镜技术和器械的进步,PELD的发展也很快。内窥镜手术的优点包括术中视野清晰,对周围肌肉、韧带或小关节的损伤小,术后腰椎稳定性好,住院时间短,可以快速恢复正常生活[9]。研究发现与传统开放椎间盘切除术相比具有优越性[10-11]。
PELD常采用经椎间孔入路,但是对于L5-S1节段,由于高髂嵴、L5横突及肥大增生的关节突等解剖因素的遮挡,很难采用经椎间孔入路[12]。同时,L5-S1椎板间隙最大,为经椎板间入路提供了重要的解剖基础。
经椎板间入路的关键是黄韧带的处理。经椎间孔入路并不存在这个问题,因为它不通过黄韧带。然而,经椎板间入路与传统椎间盘切除术的入路相同,必须处理黄韧带。常见的黄韧带的处理方法[13-14]有:一是在到达硬膜外间隙的入路上制作3 mm×5 mm的孔;二是在透视引导下,观察病人反应的同时,在椎间盘间隙插入一根金属导丝,然后依次插入一系列扩张套管,到达硬膜外间隙。第一种方法更安全,直视下检查黄韧带表面后进行切除和手术。但是对黄韧带的损伤也是不可避免的。第二种方法由于手术过程不在直视下进行,有损伤神经根和硬膜囊的可能。由于盲视下手术还是存在一定的风险[15],因此,第二种方法在临床中应用越来越少。
为了尽可能保持周围正常组织结构,仅切除突出的椎间盘。对第一种方法进行改良,使用无创解剖器垂直、线性切开黄韧带,然后利用工作通道的斜面到达硬膜外间隙。这样黄韧带损伤较小,而且因为手术是在直视下进行的,神经根或硬膜囊损伤的可能性较小。
黄韧带的损伤会形成瘢痕,而硬膜外瘢痕又会导致术后疼痛[16]。即使在传统的开放手术中,为了减少瘢痕,通常更倾向于保留黄韧带的完整性;其他减少瘢痕的措施包括保留硬膜外脂肪或应用防粘连剂[17]。结果表明,改良组NRS评分呈下降趋势,尤其是术后6个月疼痛评分明显低于对照组,而术后3~6个月正是瘢痕形成期,这也证实了通过改良方法处理黄韧带能够有效地减少术后瘢痕形成,改善临床疗效。
黄韧带撕裂技术符合微创的理念和趋势,事实上,当移除工作通道时,这个裂缝可以很好地闭合,而且改良的处理方法不会增加手术时间和出血量,结合快速康复理念效果会好[18-19]。同时,根据改良MacNab评价标准,术后临床效果相同。该改良方法的优点是,切开黄韧带后不会形成一个洞,避免对周围组织结构的破坏。在安定镇痛麻醉下将工作通道推进至黄韧带,内窥镜置入后,切除阻塞的肌肉和脂肪,观察黄韧带。然后用无创解剖器进行垂直劈开,将工作通道的斜面插入劈开的黄韧带并旋转以扩大开口,同时进入硬膜外间隙。这时,要注意在进入硬膜外间隙时,工作通道的斜面尖端一定要朝向尾侧,然后进行旋转。因为如果尖端朝向头侧可能会损伤硬膜囊发出的神经根起始部,导致硬脊膜漏甚至神经损伤。一旦进入硬膜外腔,可以看到并确认硬膜外脂肪组织和S1神经根,有时也可以看到突出的椎间盘。
受限于L5-S1椎间盘间隙和经椎板间入路并不在同一延长线上,因此,L5-S1节段椎间盘髓核的切除量有限,不能进行彻底的椎间盘切除。有限的突出椎间盘切除并不影响临床效果[20],而且有限的椎间盘切除手术时间短,术中并发症少,术后退行性改变较少。因此,有限的椎间盘切除已经足够了。
此外,椎间盘纤维环的完整性对于组织结构的保留和预防复发也很重要。射频消融修复纤维环的效果已经在先前内镜手术的相关研究得到证实,使用双极射频减少纤维环裂隙可以有效地降低复发率[21]。由于热能的作用,组织收缩,减少了裂缝,收紧了周围疏松的纤维环组织。椎间盘切除术,包括传统的开放手术和内窥镜椎间盘切除术,主要担心的就是椎间盘突出复发。尽可能减小纤维环的裂隙很重要,因为纤维环裂隙与椎间盘突出复发密切相关[22]。为了减少纤维环的裂隙,传统开放手术中采用了一些器械或缝合的手术方法,据报道这些方法有效减少了椎间盘再次突出[23]。
目前复发标准不同,因此,有时很难明确是否为复发。经皮内镜腰椎间盘切除术后复发通常定义为术后6个月内[24]。因此,在本研究中,将复发定义为术后经过一段时间疼痛消失后相同节段再次出现椎间盘突出。在经皮内镜腰椎间盘切除术中,早期复发是一个很重要的问题。本次研究的复发率约为1.2%(1/86),比以往经皮内镜下椎板间髓核摘除术复发率(3.6%)[24]更好一点,考虑与重视术中射频修复椎间盘纤维环有关。
4 结论
收起
内镜下L5-S1腰间盘切除术中采用改良的黄韧带处理技术具有良好的临床效果。在去除突出椎间盘的同时,能够保留相关组织结构的完整性。黄韧带改良的处理方法容易掌握,也不会延长手术时间或者增加手术出血量。
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2025年第25卷第12期
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doi: 10.12404/j.issn.1671-1815.2308559
  • 接收时间：2023-11-02
  • 首发时间：2025-07-09
  • 出版时间：2025-04-28
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  • 收稿日期：2023-11-02
  • 修回日期：2025-01-21
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    1 首都医科大学附属北京友谊医院急诊科, 北京 100050
    2 北京市垂杨柳医院骨科, 北京 100022

通讯作者:

* 何玉宝(1980—),男,汉族,内蒙古乌兰浩特人,博士,主任医师。研究方向:脊柱外科。E-mail:。
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2种不同金属材料的力学参数
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Family		 属数
Number of
genus		 种数
Number of
species		 占总种数比例
Percentage of
total species (%)		 属
Genus		 种数
Number of
species		 占总种数比例
Percentage of total
species (%)
鹅膏菌科Amanitaceae 2 11 5.26 鹅膏菌属 Amanita 10 4.78
小菇科 Mycenaceae 2 12 5.74 丝盖伞属 Inocybe 5 2.39
多孔菌科 Polyporaceae 8 14 6.70 蜡蘑属 Laccaria 5 2.39
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
栓菌属 Trametes 5 2.39
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