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中华老年骨科与康复电子杂志 ›› 2025, Vol. 11 ›› Issue (02) : 102 -110. doi: 10.3877/cma.j.issn.2096-0263.2025.02.004

脊柱疾患

脊柱内镜下中老年PEID术后复发翻修策略的研究
林安涛1, 王岩1, 张豪1, 祝凯1, 周丹1, 郭建伟1, 赵文灏1, 周传利1, 马学晓1,()   
  1. 1. 266000 青岛大学附属医院脊柱外科
  • 收稿日期:2023-10-26 出版日期:2025-04-05
  • 通信作者: 马学晓
  • 基金资助:
    山东省泰山学者计划(No.tstp20230664)

A study on the percutaneous endoscopic strategy of recurrence revision in middle-aged and elderly patients after PEID

Antao Lin1, Yan Wang1, Hao Zhang1, Kai Zhu1, Dan Zhou1, Jianwei Guo1, Wenhao Zhao1, Chuanli Zhou1, Xuexiao Ma1,()   

  1. 1. Department of Spinal Surgery, The Affiliated Hospital of Qingdao University,Qingdao 266000,China
  • Received:2023-10-26 Published:2025-04-05
  • Corresponding author: Xuexiao Ma
引用本文:

林安涛, 王岩, 张豪, 祝凯, 周丹, 郭建伟, 赵文灏, 周传利, 马学晓. 脊柱内镜下中老年PEID术后复发翻修策略的研究[J/OL]. 中华老年骨科与康复电子杂志, 2025, 11(02): 102-110.

Antao Lin, Yan Wang, Hao Zhang, Kai Zhu, Dan Zhou, Jianwei Guo, Wenhao Zhao, Chuanli Zhou, Xuexiao Ma. A study on the percutaneous endoscopic strategy of recurrence revision in middle-aged and elderly patients after PEID[J/OL]. Chinese Journal of Geriatric Orthopaedics and Rehabilitation(Electronic Edition), 2025, 11(02): 102-110.

目的

探讨脊柱内镜下经椎板间入路椎间盘切除术(PEID)治疗中老年L5/S1椎间盘突出症(LDH)术后复发的内镜翻修策略。

方法

回顾性分析2018年5月至2022年10月因LDH(L5/S1)在我院行PEID,术后复发并再次接受脊柱内镜手术的52例中老年患者临床资料,男性28例,女性24例;平均年龄(58.15±10.63)岁。根据翻修方式的不同,将患者分为脊柱内镜下经椎间孔椎间盘切除(PETD)组(简称PETD组)(22例)和PEID组(30例),比较两组患者的一般资料和手术相关指标,并采用疼痛视觉模拟评分、Oswestry功能障碍指数、日本骨科协会评估治疗评分评估患者术后疗效。

结果

两组患者在一般资料、手术时间和术中失血等方面差异均无统计学意义,PETD 组患者透视时间显著多于PEID组患者(P<0.05)。两组随访数据经重复测量方差分析显示其组间差异无统计学意义,不同时间点间差异有统计学意义(P<0.05),组别与时间点间无交互作用(P>0.05)。患者术后随访周期内无严重并发症发生。

结论

L5/S1节段PEID术后复发性LDH,脊柱内镜翻修可以达到满意的效果。PEID透视时间更短,因此当两种术式都可以很好得处理致压物时仍可优先采用PEID。对于几种特定类型的复发,掌握好两种入路的适用条件可有效减小手术难度。

Objectives

To explore the endoscopic revision and surgical techniques for middle-aged or elderly people with L5/S1 recurrent lumbar disc herniation(rLDH)after percutaneous endoscopic interlaminar discectomy (PEID).

Methods

From May 2018 to October 2022, 52 middle-aged or elderly patients who underwent percutaneous endoscopic lumbar discectomy for L5/S1 rLDH after PEID were enrolled in the present study,including 28 males and 24 females with a mean age of 58.154±10.634 years.Based on strategy of the endoscopic revision, patients were divided into PETD group (n=22) and PEID group (n=30),and their demographic data and surgery-related indicators were compared. The visual analogue scale (VAS) for back and leg pain, oswestry disability index (ODI) and Japanese Orthopaedic Association Score (JOA) were recorded to evaluate the clinical outcomes.

Results

No significant differences were found in the demographic data, operative time, and intraoperative blood loss between the two groups (P>0.05), but the time of intraoperative X-ray fluoroscopy exposures in the PEID group were significantly shorter than that in the PETD group(P<0.05).The follow-up data of the two groups were analyzed by repeated-measures ANOVA,which showed no statistically significant differences between the groups(P>0.05),statistically significant differences between the different time points (P<0.05), and no interaction between the groups and the time points (P>0.05). No serious complication observed during the follow-up.

Conclusions

For recurrent LDH after PEID of L5/S1 segments, percutaneous endoscopic revision can achieve satisfactory results. And since the time of intraoperative X-ray fluoroscopy exposures in the PEID group are shorter, the PEID technique is considered as the preferred revision technique when both procedures can remove the compressive material well.And for several specific types of recurrence,mastering the application of the two procedures can effectively minimize the difficulty of the surgery.

图1 L5/S1 节段PEID 术后复发特殊情况的内镜翻修策略。PETD:脊柱内镜下经椎间孔入路腰椎间盘切除术;PEID:脊柱内镜下经椎板间入路腰椎间盘切除术
图2 ~7 脊柱内镜下经椎间孔入路腰椎间盘切除术。图2~3 术前定位、放置工作管道正侧位片;图4 显露出骨性解剖结构后,用环锯从上关节突尖部开始对椎间孔扩大成形;图5 减压前神经根腹侧受突出椎间盘挤压;图6 减压后神经根松弛;图7 取出的骨质和椎间盘组织
图8 ~14 脊柱内镜下经椎板间入路腰椎间盘切除术。图8,9 放置工作管道;图10 清理软组织,镜下结构识别(图中可见残余椎板上缘);图11 打开背侧黄韧带后进入椎管、显露硬膜囊,图中可见硬膜囊背侧除术后残余黄韧带外,还布满瘢痕组织;图12 分离、显露神经根;图13 剥离神经根,显露突出椎间盘;图14 突出间盘全部切除,神经根松解
图15 ~21 患者,女,51 岁,PEID 术后4年复发。图15 初次PEID 术前MR 示L5/S1 左侧LDH;图16 初次PEID 术后MR;图17 术后4年MR示L5/S1左侧LDH复发;图18 初次PEID术后三维CT示术中未做椎板成型;图19,20 采用PEID技术翻修术后MR,突出椎间盘被完整切除;图21 采用PEID技术翻修术后三维CT示术中椎板成型范围。(PETD:脊柱内镜下经椎间孔入路腰椎间盘切除术;PEID:脊柱内镜下经椎板间入路腰椎间盘切除术) 图22~25 患者,女,55岁,PEID术后6个月复发并伴有椎间孔狭窄。图22 初次PEID术前MR示L5/S1左侧LDH;图23 初次PEID术后MR示椎间盘切除满意;图24 术后6个月MR示L5/S1 LDH复发;图25 采用PETD技术翻修术后MR,可见部分关节突术中被切除,突出椎间盘被完整切除。(PETD:脊柱内镜下经椎间孔腰椎间盘切除术;PEID:脊柱内镜下经椎板间腰椎间盘切除术)
表1 中老年椎间盘突出症患者一般资料对比分析
表2 中老年椎间盘突出症患者术前及术后随访VAS腰痛评分(分,±s
表3 中老年椎间盘突出症患者术前及术后随访VAS腿痛评分(分,±s
表4 中老年椎间盘突出症患者术前及术后随访ODI评分(分,±s
表5 中老年椎间盘突出症患者术前及术后随访JOA评分(分,±s
1
丛志超,许德荣,周传利,等.两种可视化关节突成形技术治疗腰椎间盘突出症的早期临床疗效比较[J].中华骨与关节外科杂志,2021,14(7):592-599,610.
2
Kanno H,Aizawa T, Hahimoto K, et al. Minimally invasive discectomy for lumbar disc herniation: current concepts, surgical techniques,and outcomes[J].Int Orthop,2019,43(4):917-922.
3
Choi KC, Kim JS, Park CK. Percutaneous endoscopic lumbar discectomy as an alternative to open lumbar microdiscectomy for large lumbar disc herniation[J].Pain Physician,2016,19(2):E291-E300.
4
Ruetten S, Komp M, Merk H, et al. Recurrent lumbar disc herniation after conventional discectomy: a prospective, randomized study comparing full-endoscopic interlaminar and transforaminal versus microsurgical revision [J]. J Spinal Disord Tech, 2009, 22(2):122-129.
5
Wang Y, Liu HC, Lin AT, et al. Surgical strategy and outcomes of full endoscopic lumbar discectomy for recurrent lumbar disk herniation following a previous full endoscopic lumbar discectomy [J].Orthop Surg,2023,15(10):2602-2611.
6
Zhao C, Zhang H, Wang Y, et al. Nomograms for predicting recurrent herniation in PETD with preoperative radiological factors [J].Pain Res,2021:2095-2109.
7
谈俊,胡鹏涛,王毅.脊柱内镜下经椎板间入路腰椎间盘切除术的并发症及防治策略分析[J].中国内镜杂志,2020,26(7):83-88.
8
赵俊华,杨政伟,刘阳,等.规范的术后康复训练对PELD术预后的影响[J].中华老年骨科与康复电子杂志,2023,09(2023):0263-2096.
9
Sivakanthan S, Hasan S, Hofstetter C. Full-Endoscopic lumbar discectomy[J].Neurosurg Clin N Am,2020,31(1):1-7.
10
佟智慧,曲景文,葛茂锁,等.经皮内镜椎间孔入路手术治疗老年腰椎间盘突出症的临床分析[J].中华老年骨科与康复电子杂志,2019,05(2019):0263-2096.
11
Giannina L Garcés Ambrossi,Matthew J McGirt,Daniel M Sciubba, et al. Recurrent lumbar disc herniation after single-level lumbar discectomy: incidence and health care cost analysis [J]. Neurosurgery,2009,65(3):574-8.
12
Choi KC,Lee JH,Kim JS,et al.Unsuccessful percutaneous endoscopic lumbar discectomy:a single-center experience of 10,228 cases[J].Neurosurgery,2015,76(4):372-380;discussion 380-1;quiz 381.
13
白一冰谢明玖&简伟,椎间孔镜治疗复发性腰椎间盘突出症的临床分析,颈腰痛杂志35(2014).
14
Choi KC, Kim JS, Ryu KS, et al. Percutaneous endoscopic lumbar discectomy for L5-S1 disc herniation: transforaminal versus interlaminar approach[J].Pain Physician,2013,16(6):547-556.
15
Kim CH, Chung CK, Jahng TA, et al. Surgical outcome of percutaneous endoscopic interlaminar lumbar diskectomy for recurrent disk herniation after open diskectomy [J]. J Spinal Disord Tech,2012,25(5):E125-E133.
16
Shin KH, Chang HG, Rhee NK, et al. Revisional percutaneous full endoscopic disc surgery for recurrent herniation of previous open lumbar discectomy[J].Asian Spine J,2011,5(1):1-9.
17
陶晖,张银顺,董福龙,等.经椎板间入路和经椎间孔入路脊柱内镜下治疗L5-S1 椎间盘突出症的临床疗效比较[J].颈腰痛杂志,2019,40(5):587-589,594.
18
Ruetten S, Komp M, Merk H, et al. Full-endoscopic interlaminar and transforaminal lumbar discectomy versus conventional microsurgical technique: a prospective, randomized, controlled study [J].Spine(Phila Pa 1976),2008,33(9):931-939.
19
虞攀峰,昝鹏飞,张西峰,等.脊柱内镜下经椎板间入路翻修L5~S1开窗术后复发的早期临床报告[J].中国骨与关节杂志,2019,8(7):525-530.
20
C Shi,W Kong,W Liao,[J].The Early Clinical Outcomes of a Percutaneous Full-Endoscopic Interlaminar Approach via a Surrounding Nerve Root Discectomy Operative Route for the Treatment of Ventral-Type Lumbar Disc Herniation [J]. Biomed Res Int, 2018,12,2018:9157089.
21
曾娘华.经椎板间入路椎间孔镜下髓核摘除术治疗巨大腰椎间盘突出症的效果分析[J].颈腰痛杂志,2021,42(6):866-868.
22
Yu Y,Zhou Q,Xie YZ,et al.Effect of percutaneous endoscopic lumbar foraminoplasty of different facet joint portions on lumbar biomechanics: a finite element analysis [J]. Orthop Surg, 2020, 12(4):1277-1284.
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