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椎间孔镜通道导向模块在椎间孔镜治疗腰椎间盘突出症中的应用
Clinical application of transforaminal endoscope-guided module in treatment of lumbar disc herniation by transforaminal endoscopic
目的 探讨椎间孔镜通道导向模块在椎间孔镜治疗腰椎间盘突出症中的应用价值。方法 选取60例L5/S1腰椎间盘突出症患者，将其随机分为模块组和对照组各30例。模块组采用一种自创的椎间孔镜通道导向模块辅助穿刺，对照组采用传统徒手穿刺放置工作管道。比较2组的一次穿刺成功率、定位穿刺时间和术中X线透视次数，观察并发症发生情况，比较2组术后3个月的视觉模拟评分法（VAS）评分、臀部和下肢功能障碍指数（ODI）评分，并采用改良Mac Nab评分评估2组疗效。结果 2组患者术程均顺利。与对照组比较，模块组一次穿刺成功率更高、穿刺时间更短、术中X线透视次数更少（P均< 0.05）。2组患者术中并发症发生率比较差异无统计学意义（P > 0.05），术后均无出现严重并发症。2组患者术后3个月的VAS评分与ODI评分均较术前降低（P均< 0.01），模块组与对照组术后3个月的VAS、ODI评分比较差异均无统计学意义（P均> 0.05），但2组VAS术前术后评分差值比较差异有统计学意义（P < 0.05）。模块组改良Mac Nab评分优良率为83.3%（25/30），对照组优良率为80.0%（24/30），2组比较差异无统计学意义（P > 0.05）。结论 在椎间孔镜治疗腰椎间盘突出症中，椎间孔镜通道导向模块操作简便且安全，可以缩短穿刺时间、提高穿刺效率、减少医源性损伤，值得在临床进一步推广应用。
Objective To evaluate the clinical application value of transforaminal endoscope-guided module in the treatment of lumbar disc herniation by transforaminal endoscopic. Methods Sixty patients with L5 / S1 lumbar disc herniation were randomly divided into the module group and control group， with 30 cases in each group. In the module group， self-designed transforaminal endoscope-guided module was utilized to assist puncture， and conventional manual puncture was adopted to place the working channel in control group. The success rate of one-time puncture， positioning puncture time and intraoperative X-ray fluoroscopy times were compared between two groups， and the incidence of complications was observed. The Visual Analogue Scale （VAS） score and Oswestry Disability Index （ODI） score of the hip and lower limbs at postoperative 3 months were compared between two groups. Postoperative modified Mac Nab score was employed to evaluate clinical efficacy between two groups. Results All patients successfully completed the operation. Compared with the control group， the success rate of one-time puncture was higher， positioning puncture time was shorter and the times of intraoperative X-ray fluoroscopy was less in the module group （all P <0.05）. There was no statistical significance in the incidence of intraoperative complications between two groups （P >0.05）， and no severe postoperative complications were noted in two groups. In two groups， the VAS score and ODI score at postoperative 3 months were less compared with preoperative levels （both P <0.05）， and there was no statistical significance between two groups （both P >0.05），however， the difference of VAS between preoperative and postoperative values was statistically significant（P <0.05）. There was no statistical significance in the excellent rate of modified Mac Nab score between the module （83.3% （25/30））and control groups （80.0% （24/30）， P >0.05）. Conclusions Transforaminal endoscope-guided module is safe and convenient. This module can effectively shorten puncture time， enhance puncture efficiency and minimize iatrogenic injuries， which is worthy of clinical application.
椎间孔镜通道导向模块 / 经皮椎间孔镜椎间盘切除术 / 辅助穿刺装置 / 腰椎间盘突出症 / 经椎间孔入路 {{custom_keyword}} /
Transforaminal endoscope-guided module / Percutaneous transforaminal endoscopic discectomy / Auxiliary puncture device / Lumbar disc herniation / Transforaminal route {{custom_keyword}} /
表1 模块组与对照组LDH患者一般资料比较Table 1 Comparison of general data of LDH patients in the module group and the control group |
| 分 组 | n | 男/女 | 年龄/岁 | 病程/月 |
|---|---|---|---|---|
| 模块组 | 30 | 13/17 | 44.0（35.5，52.3） | 15.5（10.8，20.3） |
| 对照组 | 30 | 16/14 | 39.0（24.5，47.5） | 16.0（12.8，22.0） |
| Z值 | 0.601 | 1.902 | 0.681 | |
| P值 | 0.438 | 0.086 | 0.498 |
图2 应用椎间孔镜通道导向模块的操作图例注：A~D为腰椎X线片，A中红线为穿刺基线Ⅰ（由上关节突尖部到后正中线距离）;B中红线为穿刺基线Ⅱ（由上关节突尖部到下位椎体后上角）;C为外展角α;D为头倾角β;E为MRI片上确定穿刺定位针穿刺深度（a点到b点距离）;F为根据术前预设方位摆放椎间孔镜通道导向模块;G~J为C型臂机X线片，G、H为确定放置克氏针方位;I为选择最佳穿刺方向后进针到位;J为靶向穿刺置管到位。Figure 2 Illustrates the operation of the foraminal mirror channel guide module |
表2 模块组与对照组穿刺情况比较Table 2 Comparison of puncture conditions between the module group and the control group |
| 组 别 | 一次穿刺成功/n（%） | 穿刺时间/min | 术中C型臂机X线透视次数 |
|---|---|---|---|
| 模块组（n=30） | 17（68.0） | 5.0（4.0，6.0） | 11.0（10.0，12.0） |
| 对照组（n=30） | 8（32.0） | 6.0（6.0，7.0） | 13.0（11.8，14.0） |
| Z值 | — | 3.646 | 4.185 |
| P值 | 0.004 | 0.001 | <0.001 |
表3 模块组与对照组术中并发症发生情况比较Table 3 Comparison of intraoperative complications between the module group and the control group |
| 组 别 | 例数 | 并发症/n | 无/n | 发生率/% | ||||
|---|---|---|---|---|---|---|---|---|
| 一过性神经损伤 | 硬膜撕裂 | 血管损伤 | 脏器损伤 | 其他 | ||||
| 模块组 | 30 | 1 | 0 | 0 | 0 | 0 | 29 | 3.3 |
| 对照组 | 30 | 2 | 1 | 0 | 0 | 0 | 27 | 10.0 |
| P值 | 0.605a | |||||||
| 注：aFisher确切概率法。 |
表4 模块组与对照组术康复情况比较Table 4 Comparison of operative rehabilitation between the module group and the control group M（P25 , P75） |
| 组 别 | 模块组 | 对照组 | Z值 | P值 |
|---|---|---|---|---|
| VAS评分/分 | ||||
| 术前 | 7.0（7.0，8.0） | 7.0（6.0，7.2） | 1.052 | 0.293 |
| 术后3个月 | 1.5（1.0，2.2）a | 2.0（1.0，2.0）a | 0.211 | 0.833 |
| 术前术后评分差值 | 5.0（4.8，6.2） | 5.0（3.0，5.0） | 3.106 | 0.002 |
| ODI评分/分 | ||||
| 术前 | 43.5（41.0，45.0） | 43.5（41.8，45.0） | 0.060 | 0.952 |
| 术后3个月 | 11.0（10.0，12.0）a | 12.0（11.0，12.2）a | 1.749 | 0.080 |
| 术前术后评分差值 | 32.5（30.0，33.2） | 32.0（31.0，33.0） | 0.924 | 0.355 |
| 注： 与术前相比， aP < 0.01。 |
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