孙凤龙; 梁庆晨; 王宏庆; 刘祖耀; 李富; 董婕; 刁文博; 闫明; 胡永成

doi:10.3760/cma.j.issn.0253-2352.2019.12.005

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• 临床论著 •

经皮内镜下椎板减压术与开放半椎板减压术治疗腰椎管狭窄症的疗效比较

中华骨科杂志, 2019,39(12) : 755-765. DOI: 10.3760/cma.j.issn.0253-2352.2019.12.005

摘要

目的

比较经皮内镜下椎板减压术与开放半椎板减压术治疗腰椎管狭窄症患者的疗效。

方法

2016年1月至2017年4月共32例腰椎椎管狭窄症患者纳入研究，采用经皮内镜下椎板减压术32例（微创组），男13例，女19例；年龄38~76岁，平均（58.47±7.51）岁。选取同期匹配的采用开放半椎板减压手术29例作为对照（开放组），男11例，女18例；年龄38~75岁，平均（57.17±9.99）岁。记录两组患者的手术时间、术中出血量、切口长度、卧床时间、住院时间。疗效评价采用疼痛视觉模拟评分（visual analogue scale，VAS）、Oswestry功能障碍指数（oswestry disability index，ODI）、硬膜囊横断面积(dural sac cross-sectional area，DSCA)、椎间隙腹侧高度（ventral intervertebral space height，VH)、椎间隙背侧高度（dorsal in-tervertebral space height，DH）和腰椎活动度(range of motion，ROM)，并进行统计分析。

结果

61例患者均获得随访，随访时间14~27个月，平均（19.2±2.95）个月。微创组手术时间平均（60.88±6.49）min，开放组为（52.07±9.45）min（t=4.277，P=0.000）；微创组术中出血量平均（55.63±10.14）ml，开放组为（78.79±12.58）ml（t=7.952，P=0.000）；微创组切口长度平均（23.31±4.56）mm，开放组为（82.59±7.66）mm（t=12.047，P=0.000）；微创组卧床时间平均（21.97±6.42）h，开放组为（78.79±12.58）h（t=12.047，P=0.000）；微创组住院时间平均（8.53±2.75）d，开放组为（11.34±3.12）d（t=3.745，P=0.000）；；两组间比较差异均有统计学意义。末次随访时微创组VAS评分平均（1.06±0.56）分，开放组为（1.14±0.74）分（t=0.469，P=0.634）；微创组ROM平均5.66°±1.12°，开放组为5.56°±1.13°（t=0.140，P=0.710）；微创组VH平均（14.75±2.81）mm，开放组为（14.44±2.89）mm（t=0.181，P=0.672）；微创组DH平均（6.30±0.83）mm，开放组为（6.19±0.90）mm（t=0.282，P=0.597）；两组间比较差异均无统计学意义。末次随访时微创组ODI平均为13.25%±1.08%，开放组为14.28%±2.10%（t=5.911，P=0.018）；微创组DSCA平均为（108.56±8.69）mm²，开放组为（117.28±11.09）mm²（t=11.774，P=0.001）；两组间比较差异均有统计学意义。

结论

腰椎管狭窄症患者采用经皮内镜下及开放手术行椎板减压术均可获得优良的临床疗效，经皮内镜下手术具有局部创伤小，对腰椎稳定性破坏较少，术后恢复快等优点，但对术者有较高的手术技术要求。

引用本文: 孙凤龙, 梁庆晨, 王宏庆, 等. 经皮内镜下椎板减压术与开放半椎板减压术治疗腰椎管狭窄症的疗效比较 [J] . 中华骨科杂志, 2019, 39(12) : 755-765. DOI: 10.3760/cma.j.issn.0253-2352.2019.12.005.

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腰椎管狭窄症（lumbar spinal stenosis，LSS）发病率为1.7%~10.0%^[1,2]，是常见的腰椎退行性疾病，好发生于40岁以上的中老年人^[3]。临床表现为臀部及下肢疼痛、神经源性跛行以及伴或不伴有腰痛症状^[4,5]。经保守治疗后症状改善率为15%~43%^[6,7]，但随着病程进展，手术治疗在缓解症状方面比保守治疗有更好的效果^[8]。传统的开放减压手术历史悠久，治疗效果得到充分的验证，为标准手术方法和标准培训术式^[9]。不过由于开放手术广泛剥离软组织，会导致术后腰部慢性疼痛等并发症发生。

贡献者信息

孙凤龙

北京，首都医科大学附属北京康复医院骨二科　100144

梁庆晨

北京，首都医科大学附属北京康复医院骨二科　100144

王宏庆

北京，首都医科大学附属北京康复医院骨二科　100144

刘祖耀

北京，首都医科大学附属北京康复医院骨二科　100144

李富

北京，首都医科大学附属北京康复医院骨二科　100144

董婕

北京，首都医科大学附属北京康复医院骨二科　100144

刁文博

周口协和骨科医院骨科　466000

闫明

长春，吉林大学白求恩第一医院脊柱外科　130021

胡永成

天津医院骨肿瘤科　300210

通信作者

闫明

长春，吉林大学白求恩第一医院脊柱外科　130021

Email：bjsylqc@163.com

胡永成

天津医院骨肿瘤科　300210

Email：yongchenghu@126.com

关键词

腰椎; 椎管狭窄; 椎板切除术; 电视辅助外科手术; 外科手术，微创性;

作者声明

【证据等级】治疗性研究Ⅲ级

历史

出版日期：2019-06-16

收稿日期：2018-12-01

本文编辑

马宏庆

Clinical Original Article

Early efficacy of endoscopic laminectomy and traditional hemilaminectomy for lumbar spinal stenosis

Fenglong Sun, Qingchen Liang, Hongqing Wang, Zuyao Liu, Fu Li, Jie Dong, Wenbo Diao, Ming Yan, Yongcheng Hu

Published 2019-06-16

Cite as Chin J Orthop, 2019, 39(12): 755-765. DOI: 10.3760/cma.j.issn.0253-2352.2019.12.005

Abstract

Objective

To compare the clinical effects of endoscopic laminectomy with traditional hemilaminectomy for lumbar spinal stenosis.

Methods

From January 2016 to April 2017, 61 patients with lumbar spinal stenosis were treated surgi-cally. Percutaneous endoscopic laminectomy was performed in 32 patients (minimally invasive group), including 13 males and 19 females, aged 38-76 years, with an average age of 58.47±7.51 years. Twenty-nine patients (open group) underwent hemilaminecto-my, including 11 males and 18 females, aged 38-75 years, with an average age of 57.17±9.99 years. The operation time, bleeding, incision length, bedridden time and hospitalization time were recorded. Visual analogue scale(VAS), Oswestry disability index (ODI), dural sac cross-sectional area (DSCA), ventral intervertebral space height (VH), dorsal intervertebral space height (DH) and lumbar mobility (range of motion, ROM) were compared between the two groups.

Results

All of 61 patients were followed up for 14 to 27 months, with an average of 19.2±2.95 months. The operation time was 60.88±6.49 min in the minimally invasive group, and 52.07±9.45 min in the open group (t=4.277, P=0.000). The blood loss of minimally invasive group was 55.63±10.14 ml, and that of open group was 78.79±12.58 ml (t=7.952, P=0.000). The incision length of minimally invasive group was 23.31±4.56 mm, and open group 82.59±7.66 mm (t=12.047, P=0.000). Bed rest time was 21.97±6.42 h in minimally invasive group and 78.79±12.58 h in open group (t=12.047, P=0.000). The hospitalization time of the minimally invasive group was 8.53±2.75 d and the open group 11.34±3.12 d (t=3.745, P=0.000). All these parameters had statistical significance (P<0.05). At the last follow-up, the VAS score of minimally invasive group was 1.06±0.56, and the open group was 1.14±0.74 (t=0.469, P=0.634). ROM of open group was 5.66±1.12 degree, and ROM of minimally invasive group was 5.56±1.13 degree (t=0.140, P=0.710), VH of minimally invasive group was 14.75±2.81 mm, and open group was 14.44±2.89 mm (t=0.181, P=0.672). There was no significant difference between the two groups for these parameters. At the last follow-up, ODI score was 13.25%±1.08% in the minimally invasive group and 14.28%±2.10% in open group (t=5.911, P=0.018). DSCA score was 108.56±8.69 mm² in the minimally invasive group, and 117.28±11.09 mm² in open group (t=11.774, P=0.001). There were significant differences between the two groups for ODI and DS-CA.

Conclusion

Both endoscopic and open laminectomy have excellent clinical effects on lumbar spinal stenosis. Endoscop-ic laminectomy has the advantages of less local trauma, less damage to the stability of the lumbar spine and faster recovery. However, there's a higher technical requirement for endoscopic spine surgery.

Key words:

Lumbar vertebrae; Spinal stenosis; Laminectomy; Video-assisted surgery; Surgical procedures, minimally in-vasive

Contributor Information

Fenglong Sun