椎间盘镜和小切口开窗髓核摘除手术疗效比
较
作者：艾建国，赵枫，曹杰，陈超，吕宏升
【摘要】目的比较椎间盘镜(MED)与小切口开窗髓核摘除术治疗腰椎间盘突出症的临床疗效，探讨各自的手术适应证。
方法 200例腰椎间盘突出症患者分为两组，行MED和小切口开窗髓核摘除术各100例。
结果按Nakai疗效评价标准，MED组优72例，良21例，可5例，差2例；小切口开窗手术组优70例，良20例，可6例，差4例。
两组并发症主要为术后复发MED组2例，小切口开窗组3例；椎间盘炎各1例。
无神经根及脊髓损伤。
结论两种手术方式疗效均较为肯定，术后疗效大体一致，MED术中出血少，平均住院时间短，但对于多节段椎间盘突出、巨大型、游离型、中央型以及合并椎间盘钙化的手术，小切口开窗疗效较为显著。
【关键词】椎间盘镜；髓核摘除术；腰椎间盘突出症；小切口开窗Comparison of Therapeutic Effects between Microendoscopic Dissectomy and Removal of Nucleus Pulposus by Small incision Fenestration
Abstract： Objective To compare the therapeutic effects between microendoscopic dissectomy (MED) and removal of nucleus pulposus by small incision fenestration, and to discuss their indications.Methods All the 200 patients with lumbar intervertebral disc herniation were averagely divided into two
groups which accepted MED and removal of nucleus pulposus by small incision fenestratio respectively.Results In the MED group, there were 72 patients whose therapeutic effects based on Nakai's Criterion were excellent, 21 ones good, 5 ones so so, and 2 ones not good. In the other group, the counterparts were 70, 20, 6 and 4 respectively. In respect of complication, there were two patients with recurrence in the MED group and three ones with recurrence in the other group. There was one patient with intervertebral disc inflammation in each group. There was no damage in nerve root or spinal cord.Conclusion Both the two operative means have definite and similar therapeutic effects. Furthermore, operative bleeding is little and mean hospitalization is short when MED is performed. With regard to nucleus pulposus removal by small incision fenestration, it is apt for those with multiple intervertebral disc herniation which is large, free, central or calcified.
Key words： microendoscopic dissectomy; nucleus pulposus removal; small incision fenestration; lumbar intervertebral disc herniation
腰椎间盘突出症根据患者的具体情况可采取不同的治疗方法。
对于病程短、症状轻、影像学检查无严重突出者，通过卧床休息、牵引、推拿、按摩和硬膜外腔注入少量激素与麻醉药80%~90%的病人可以治愈。
但对于病史长、症状重、椎间盘突出严重者，则需要手术。
手术方法有髓核化学溶解疗法、经皮穿刺腰椎间盘切吸术、内镜手术、显微外科椎间盘切除术等，各种方法各有优缺点，本研究旨在比较椎间盘镜（microendoscopic discectomy，MED）与小切口开窗髓核摘除术的临床疗效。
1 资料与方法
1 1 一般资料
本组200例，均系本院住院病人，其中男125例，女75例，年龄22~73岁，平均38岁，病史最短2个月，最长11年，所有病人术前经体格检查、X线摄片、CT或MRI检查明确诊断，椎间盘突出间隙：L4~595例，L5S183例，两个间隙均有突出者22例。
全部病例分成A （MED）组和B（小切口开窗）组两组，每组100例。
1 2 手术方法
12 1 MED组
术前透视下定位手术的椎间隙，硬膜外阻滞麻醉，俯卧位，腹部悬空，用定位针插至定位的椎间隙，C臂X线正侧位透视术中再次定位确定，在病变椎间隙棘突靠病侧1 cm 纵向切开长约1.5 cm 切口，深及腰背筋膜，依次沿定位针插入扩张管，最后放入工作套管，固定杆固定。
用髓核钳咬除椎板上方软组织，双极电凝充分止血，枪状咬骨钳从椎板下缘开始，逐步咬除椎板及黄韧带，显露神经根及硬膜囊，神经根拉钩将硬膜囊拉至一侧，暴露突出的椎间盘，切开后纵韧带及纤维环，髓核钳摘除髓核，再用神经根剥离子探查髓核摘除及神经根。