规范的术后康复训练对PELD术预后的影响

doi:10.3877/cma.j.issn.2096-0263.2023.03.005

目的

探讨规范的术后康复训练对经皮内镜下腰椎间盘切除术（PELD）预后的影响。

方法

分析我院近年来153例行PELD术的腰椎间盘突出症（LDH）者，其中98例行经椎间孔入路，55例经板间入路。出院时给每位患者一份康复手册，嘱其严格按照手册内容进行康复训练。经随访调查，坚持按康复手册训练，每周训练次数≥4 d的患者82例，列为观察组；每周训练次数≥2 d，<4 d的患者50例，列为对照组a；每周训练次数<2 d的患者21例，列为对照组b。术后2、4、8、12周、6月、12月定期随访，比较三组术前术后的视觉模拟评分（VAS）、Oswestry功能障碍指数评分（ODI）及腰椎日本骨科学会（JOA）腰椎功能评分。

结果

随访128例，平均随访时间（364.34±3.27）d，男性76例，女性52例，平均年龄（54.75±9.86）岁。三组术后VAS、ODI、JOA评分结果经重复测量设计资料的方差分析显示：三组组间差异有统计学意义（P<0.05）；组别与时间点间存在交互作用，各时间点除术前与术后2周外，术后4、8、12周三组的VAS、ODI、JOA评分结果差别均有统计学意义（P<0.05）；术后6、12月，观察组与对照组a的VAS、ODI、JOA评分结果差异均无统计学意义，观察组与对照组b的VAS、ODI、JOA评分结果差异均有统计学意义（P<0.05）。观察组在各时间点间差异均有统计学意义（P<0.05）。

结论

PELD术后应尽早进行规范的康复训练，能改善患者预后，尤其对术后3月内患者腰椎功能改善明显，促进患者更早地恢复术前生活状态。

关键词: 康复训练, 脊柱内镜, 髓核摘除术, 腰椎间盘突出症

Objective

To analyze effect of standardized postoperative rehabilitation training on the prognosis of Percutaneous Endoscopic Lumbar Discectomy (PELD).

Methods

In recent years, 153 cases of lumbar disc herniation (LDH) underwent PELD in our hospital were analyzed. Among them, 98 cases underwent transforaminal approach and 55 cases underwent interlaminar approach. At the time of discharge, each patient was given a rehabilitation manual and instructed to carry out rehabilitation training in strict accordance with the manual. After followup investigation, 82 patients who insisted on training according to the rehabilitation manual and had training times ≥4 days a week were included in the observation group; 50 patients with weekly training times ≥2 days and <4 days were classified as control group a; 21 patients with training times less than 2 days per week were classified as control group b.The patients were followed up regularly at 2, 4, 8, 12 weeks, 6 months and 12 months after operation. The preoperative and postoperative visual analog scale (VAS), Oswestry disability index (ODI) and lumbar function score of Japanese Orthopaedic Association (JOA) were compared among the three groups.

Results

128 cases were followed up, with an average follow-up time of (364.34±3.27) days. There were 76 males and 52 females, with an average age of (54.75±9.86) years. The results of postoperative VAS, ODI, and JOA scores in the three groups were analyzed using repeated measurement design data. The difference between the three groups was statistically significant (P<0.05); There is an interaction between groups and time points. Except for preoperative and postoperative 2 weeks, the VAS, ODI, and JOA scores of the groups at 4, 8, and 12 weeks after surgery showed statistically significant differences (P<0.05); At 6 and 12 months after surgery, there was no statistically significant difference in VAS, ODI, and JOA scores between observation group and control group a (P>0.05), while there was a statistically significant difference in VAS, ODI, and JOA scores between observation group and control group b (P<0.05). The difference between the observation group at each time point was statistically significant (P<0.05).

Conclusions

Standardized rehabilitation training should be carried out as soon as possible after the operation of PELD, which can improve the prognosis of patients, especially the lumbar function of patients within 3 months after the operation, and promote the patients to recover their preoperative life state earlier.

Key words: Rehabilitation training, Spinal endoscopy, Enucleation of nucleus pulposus, Lumbar disc herniation

表1 观察组与对照组腰椎间盘突出症患者一般资料（±s）

组别	例数	男/女（例数）	年龄（岁）	男/女（例数）	身高（m）	体重（kg）	病程（年）
观察组	82	49/33	54.77±10.26	49/33	1.65±0.08	65.35±9.35	4.88±1.29
对照组a	50	26/24	52.46±6.24	26/24	1.63±0.09	64.97±11.16	3.95±1.16
对照组b	50	9/12	55.35±7.18	9/12	1.62±0.12	66.43±10.63	4.57±2.28
统计值		χ²=1.017	F=0.964	χ²=1.017	F=0.248	F=0.569	F=0.377
P值		>0.05	>0.05	>0.05	>0.05	>0.05	>0.05

表1 观察组与对照组腰椎间盘突出症患者一般资料（±s）

组别	例数	男/女（例数）	年龄（岁）	男/女（例数）	身高（m）	体重（kg）	病程（年）
观察组	82	49/33	54.77±10.26	49/33	1.65±0.08	65.35±9.35	4.88±1.29
对照组a	50	26/24	52.46±6.24	26/24	1.63±0.09	64.97±11.16	3.95±1.16
对照组b	50	9/12	55.35±7.18	9/12	1.62±0.12	66.43±10.63	4.57±2.28
统计值		χ²=1.017	F=0.964	χ²=1.017	F=0.248	F=0.569	F=0.377
P值		>0.05	>0.05	>0.05	>0.05	>0.05	>0.05

图1~17 术后各阶段康复训练动作。图1　仰卧拉伸躺；图2　侧卧；图3　仰卧团身抱运动；图4　被动直腿抬高；图5　主动直腿抬高；图6~7　飞燕运动；图8~9　起床；图10　臀桥式；图10　平板支撑；图11~12　猫伸展式；图13~14　旋转稳定训练；图15~16　利用体内束腰弯腰拾物

表2 三组术前与术后各观察时间点的腰腿疼痛VAS评分比较（±s）

组别	术前	2周	4周	8周	12周	6月	12月	F值	P值
观察组	8.4±1.5	2.7±1.8^a	2.4±1.1^ab	1.6±0.8^abc	1.5±0.7^abcd	1.0±1.4^abcde	0.9±1.8^abcdef	34.518	0.007
对照组a	8.5±1.4	2.8±1.2^a	^*2.7±1.1^ab	^*2.2±0.8^abc	^*1.8±0.6^abcd	1.1±0.4^abcde	1.0±1.6^abcdef	56.267	0.003
对照组b	8.6±1.5	2.7±2.0^a	^*#3.7±1.7^ab	^*#3.1±0.7^abc	^*#2.4±1.0^abcd	^*1.2±0.3^abcde	^*1.0±1.7^abcdef	48.359	0.005
F值	0.114	0.175	3.572	5.994	4.325	3.165	3.087
P值	>0.05	>0.05	<0.05	<0.05	<0.05	<0.05	<0.05

表2 三组术前与术后各观察时间点的腰腿疼痛VAS评分比较（±s）

组别	术前	2周	4周	8周	12周	6月	12月	F值	P值
观察组	8.4±1.5	2.7±1.8^a	2.4±1.1^ab	1.6±0.8^abc	1.5±0.7^abcd	1.0±1.4^abcde	0.9±1.8^abcdef	34.518	0.007
对照组a	8.5±1.4	2.8±1.2^a	^*2.7±1.1^ab	^*2.2±0.8^abc	^*1.8±0.6^abcd	1.1±0.4^abcde	1.0±1.6^abcdef	56.267	0.003
对照组b	8.6±1.5	2.7±2.0^a	^*#3.7±1.7^ab	^*#3.1±0.7^abc	^*#2.4±1.0^abcd	^*1.2±0.3^abcde	^*1.0±1.7^abcdef	48.359	0.005
F值	0.114	0.175	3.572	5.994	4.325	3.165	3.087
P值	>0.05	>0.05	<0.05	<0.05	<0.05	<0.05	<0.05

表3 三组术前与术后各观察时间点的ODI（%）评分比较（±s）

组别	术前	2周	4周	8周	12周	6月	12月	F值	P值
观察组	74.5±14.0	22.8±3.6^a	15.6±3.5^ab	9.3±2.7^abc	8.2±2.5^abcd	6.4±2.6^abcdef	3.8±2.6^abcdef	61.253	0.002
对照组a	72.8±15.3	23.2±5.0^a	16.8±4.2^ab	^*12.4±2.3^abc	^*11.2±2.2^abcd	7.1±1.9^abcde	4.4±1.6^abcdef	57.334	0.003
对照组b	75.4±12.6	^*25.0±5.7^a	^*#20.6±3.5^ab	^*#15.3±3.1^abc	^*#13.8±3.3^abcd	^*#9.4±3.1^abcde	^*#6.2±1.6^abcdef	49.548	0.004
F值	0.168	0.177	6.451	7.297	6.355	4.196	5.793
P值	>0.05	>0.05	<0.05	<0.05	<0.05	<0.05	<0.05

表3 三组术前与术后各观察时间点的ODI（%）评分比较（±s）

组别	术前	2周	4周	8周	12周	6月	12月	F值	P值
观察组	74.5±14.0	22.8±3.6^a	15.6±3.5^ab	9.3±2.7^abc	8.2±2.5^abcd	6.4±2.6^abcdef	3.8±2.6^abcdef	61.253	0.002
对照组a	72.8±15.3	23.2±5.0^a	16.8±4.2^ab	^*12.4±2.3^abc	^*11.2±2.2^abcd	7.1±1.9^abcde	4.4±1.6^abcdef	57.334	0.003
对照组b	75.4±12.6	^*25.0±5.7^a	^*#20.6±3.5^ab	^*#15.3±3.1^abc	^*#13.8±3.3^abcd	^*#9.4±3.1^abcde	^*#6.2±1.6^abcdef	49.548	0.004
F值	0.168	0.177	6.451	7.297	6.355	4.196	5.793
P值	>0.05	>0.05	<0.05	<0.05	<0.05	<0.05	<0.05

图18~25 患者女性，52岁，因腰痛伴右下肢疼痛3月入院。查体：腰部轻微叩痛，右下肢直腿抬高试验阳性，右小腿外侧及足背皮肤痛触觉减退，右踇趾背伸肌力3级，肢端血运正常。经椎间孔入路行单通道内镜下髓核摘除术。图18~19　术前影像；图20　术后1周：直腿抬高；图21　术后4周：臀桥式；图22　术后8周：猫伸展式；图23　术后12周：臀桥式运动；图24　术后6月：旋转稳定训练；图25　术后12月：平板支撑

图26~33 患者男性，66岁，腰痛伴左下肢疼痛、麻木1年，加重1月。查体：腰部轻微叩痛，左下肢直腿抬高试验阳性，左小腿后侧及足背外侧及足底皮肤痛触觉减退，左踝跖屈肌力下降。经后侧板间入路行单通道内镜下髓核摘除术。图26~27　术前影像：图28　术后1~2周：直腿抬高；图29　术后2~4周：仰卧团身抱；图30　术后4~8周：臀桥式；图31　术后8~12周：猫伸展式；图32　术后12周~6月：旋转稳定训练；图33　术后6~12月：平板支撑

图34~41 患者女性，29岁，因腰痛伴左下肢疼痛1月入院。查体：腰部轻微叩痛，左下肢直腿抬高试验阳性，左小腿后外侧及足底部皮肤痛触觉减退，右踝跖屈肌力4级，肢端血运正常。经后侧板间入路行单通道内镜下髓核摘除术。图34~35　术前影像；图36　术后1~2周：直腿抬高；图37　术后2~4周：仰卧团身抱；图38　术后4~8周：臀桥式；图39　术后8~12周：猫伸展式；图40　术后12周~6月：旋转稳定训练；图41　术后6~12月：平板支撑

表4 三组术前与术后各观察时间点的JOA评分比较（±s）

组别	术前	2周	4周	8周	12周	6月	12月	F值	P值
观察组	6.7±2.5	15.4±2.4^a	18.3±2.2^ab	20.5±2.8^abc	22.7±2.5^abcd	24.6±1.7^abcde	25.6±2.3^abcdef	38.369	0.006
对照组a	7.1±3.2	15.8±3.3^a	17.8±2.5^ab	^*#19.5±3.5^abc	^*#21.5±1.8^abcd	23.9±3.2^abcde	25.4±2.6^abcdef	42.025	0.005
对照组b	6.8±2.7	14.7±2.9^a	^*16.6±2.4^ab	^*#18.7±3.7^abc	^*#19.8±2.3^abcd	^*#21.7±2.5^abcde	^*#23.45±2.7^abcdef	34.756	0.007
F值	0.108	0.134	3.153	4.026	3.114	4.157	3.243
P值	>0.05	>0.05	<0.05	<0.05	<0.05	<0.05	<0.05

表4 三组术前与术后各观察时间点的JOA评分比较（±s）

组别	术前	2周	4周	8周	12周	6月	12月	F值	P值
观察组	6.7±2.5	15.4±2.4^a	18.3±2.2^ab	20.5±2.8^abc	22.7±2.5^abcd	24.6±1.7^abcde	25.6±2.3^abcdef	38.369	0.006
对照组a	7.1±3.2	15.8±3.3^a	17.8±2.5^ab	^*#19.5±3.5^abc	^*#21.5±1.8^abcd	23.9±3.2^abcde	25.4±2.6^abcdef	42.025	0.005
对照组b	6.8±2.7	14.7±2.9^a	^*16.6±2.4^ab	^*#18.7±3.7^abc	^*#19.8±2.3^abcd	^*#21.7±2.5^abcde	^*#23.45±2.7^abcdef	34.756	0.007
F值	0.108	0.134	3.153	4.026	3.114	4.157	3.243
P值	>0.05	>0.05	<0.05	<0.05	<0.05	<0.05	<0.05

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Effect of standardized postoperative rehabilitation training on the prognosis of PELD

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Effect of standardized postoperative rehabilitation training on the prognosis of PELD