后路椎间盘镜与传统开放手术治疗腰椎间盘突出症的临床疗效分析
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摘要
目的：观察分析后路椎间盘镜(Microendoscopic discectomy,MED)与传统开放手术(Open discectomy, OD)治疗腰椎间盘突出症(Lumbar disc herniation,LDH)的临床疗效分析,比较两组术式对患者的创伤程度、主观满意度以及其治疗效果。通过本研究的开展,为微创手术治疗腰椎间盘突出症的进一步应用,提供临床和实验依据。
方法：选取2011年5月至2012年3月明确诊断为单节段腰椎间盘突出症患者46例,其中20例行后路椎间盘镜下髓核摘除术,为MED组,另外26例行传统开放单纯髓核摘除术,为OD组。分别比较两组手术时间长度,切口长短,术中出血量及术后住院日,围手术期两组患者的切口疼痛口测类比评分(Visual Analog Scale, VAS),术前及术后3月Oswestry功能障碍指数(Oswestry Disability Index, ODI)评估改善程度,记录住院后术前及术后1天,2天,一周外周血血清肌酸激酶(CK)、血沉、C-反应蛋白(CRP)。
结果：MED组与OD组相比,其手术时间短,切口小,术中出血量少,术后住院时间短,术后切口疼痛轻,但ODI近期改善程度相近,两组患者术前血清CK,血沉及CRP相似,术后两组均较术前升高,但OD组在术后1天、2天及一周血清CK、血沉、CRP较MED组升高明显。
结论：后路椎间盘镜下髓核摘除术与传统开放手术治疗腰椎间盘突出症相比,其具有手术时间短,切口小,出血量少,恢复快,疼痛轻等明显优势,且对患者腰背肌的损伤较轻,对全身机体创伤反应明显低于开放手术,具有微创性特点。
Objective:To observe and analyze the difference of microendoscopic discectomy(MED) with the traditional open discectomy (OD) of the treatment of lumbar disc herniation (LDH) in the analysis of clinical efficacy between the two groups of surgical patients with traumathe degree of subjective satisfaction, as well as its therapeutic effect. Through this study, carried out for the further application of minimally invasive surgery for lumbar disc herniation, the clinical and experimental evidence.
Methods:from May2011to March2012to confirm the diagnosis of a single lumbar disc herniation in46patients,20of which routine posterior disc endoscopic discectomy for the MED group, another26patients with traditional open discectomy for the OD group. Two groups were compared to the length of operation time, incision length, blood loss and postoperative hospital stay, perioperative incisional pain Visual Analog Scale (VAS) scores of two groups of patients, preoperative and postoperative March Oswestry Disability Index (ODI) assess the degree of improvement, record the hospital before surgery and1day, after two days a week in peripheral blood serum creatine kinase (CK), erythrocyte sedimentation rate, the C-reactive protein (CRP).
Results:The MED group compared with the OD group, the operative time is short, small incision, less blood loss, shorter postoperative hospital stay, postoperative wound pain, but the recent ODI to improve to a similar level of two groups of patients with preoperative serum CK, ESR and CRP is similar to the two groups after operation compared with preoperative elevated, but the OD group one day after two days and one week in serum CK, ESR, CRP increased significantly over the MED group.
Conclusion:The posterior disc microscope, the nucleus pulposus removal surgery and traditional open surgery for lumbar disc herniation, compared with shorter operative time, a small incision, less bleeding, faster recovery, less pain and other obvious advantages, and the patient back the less muscle damage and trauma on the body the body was significantly lower than open surgery, minimally invasive characteristics.
方法：选取2011年5月至2012年3月明确诊断为单节段腰椎间盘突出症患者46例,其中20例行后路椎间盘镜下髓核摘除术,为MED组,另外26例行传统开放单纯髓核摘除术,为OD组。分别比较两组手术时间长度,切口长短,术中出血量及术后住院日,围手术期两组患者的切口疼痛口测类比评分(Visual Analog Scale, VAS),术前及术后3月Oswestry功能障碍指数(Oswestry Disability Index, ODI)评估改善程度,记录住院后术前及术后1天,2天,一周外周血血清肌酸激酶(CK)、血沉、C-反应蛋白(CRP)。
结果：MED组与OD组相比,其手术时间短,切口小,术中出血量少,术后住院时间短,术后切口疼痛轻,但ODI近期改善程度相近,两组患者术前血清CK,血沉及CRP相似,术后两组均较术前升高,但OD组在术后1天、2天及一周血清CK、血沉、CRP较MED组升高明显。
结论：后路椎间盘镜下髓核摘除术与传统开放手术治疗腰椎间盘突出症相比,其具有手术时间短,切口小,出血量少,恢复快,疼痛轻等明显优势,且对患者腰背肌的损伤较轻,对全身机体创伤反应明显低于开放手术,具有微创性特点。
Objective:To observe and analyze the difference of microendoscopic discectomy(MED) with the traditional open discectomy (OD) of the treatment of lumbar disc herniation (LDH) in the analysis of clinical efficacy between the two groups of surgical patients with traumathe degree of subjective satisfaction, as well as its therapeutic effect. Through this study, carried out for the further application of minimally invasive surgery for lumbar disc herniation, the clinical and experimental evidence.
Methods:from May2011to March2012to confirm the diagnosis of a single lumbar disc herniation in46patients,20of which routine posterior disc endoscopic discectomy for the MED group, another26patients with traditional open discectomy for the OD group. Two groups were compared to the length of operation time, incision length, blood loss and postoperative hospital stay, perioperative incisional pain Visual Analog Scale (VAS) scores of two groups of patients, preoperative and postoperative March Oswestry Disability Index (ODI) assess the degree of improvement, record the hospital before surgery and1day, after two days a week in peripheral blood serum creatine kinase (CK), erythrocyte sedimentation rate, the C-reactive protein (CRP).
Results:The MED group compared with the OD group, the operative time is short, small incision, less blood loss, shorter postoperative hospital stay, postoperative wound pain, but the recent ODI to improve to a similar level of two groups of patients with preoperative serum CK, ESR and CRP is similar to the two groups after operation compared with preoperative elevated, but the OD group one day after two days and one week in serum CK, ESR, CRP increased significantly over the MED group.
Conclusion:The posterior disc microscope, the nucleus pulposus removal surgery and traditional open surgery for lumbar disc herniation, compared with shorter operative time, a small incision, less bleeding, faster recovery, less pain and other obvious advantages, and the patient back the less muscle damage and trauma on the body the body was significantly lower than open surgery, minimally invasive characteristics.
引文
[1]何京,于法景,李振东.平衡补泻治疗腰椎间盘突出症60例[J).中国针灸,1998,18：456-458.
[2]周永红,刘敏勇.针刺配合走罐治疗腰椎间盘突出症60例[J].中国针灸,1998.18：424-426.
[3]庄建光,王强,张祖煌.手法推拿配合中药熏蒸治疗腰椎间盘突出症150例分析[J].山东医药,2007,47(22)：77-77.
[4]赵强.腑卧牵拉斜扳法治疗腰椎间盘突出症的临床研究[J].中华中医药杂志,2007,22(1)：15-17.
[5]Gille O, Jolivet E, Dousset V, et al. Erector spinae muscle changes on magnetic resonance imaging following lumbar surgery through a posterior approach[J]. Spine (Phila Pa 1976).2007,32:1236-41.
[6]Marras WS, Davis KG, Granata KP. Trunk muscle activities during asymmetric twisting motions[J].J Electromyogr Kinesiol.1998,8:247-56.
[7]Boelderl A ,Daniaux H,Kathrein A,et al. Danger of damaging the medial branches of the posterior rami of spinal nerves during a dorsomedian approach to the spine[J]. Clinical Anatomy.2002,15(2):77-81.
[8]Kawaguchi Y, Matsui H, Gejo R, et al. Preventive measures of back muscle injury after posterior lumbar spine surgery in rats[J]. Spine (Phila Pa 1976).1998,23:2282-8.
[9]Taylor H, McGregor AH, Medhi-Zadeh S, et al.The impact of selfretaining retractors on the paraspinal muscles during posterior spinal surgery[J]. Spine (Phila Pa 1976).2002,27:2758-62.
[10]Kawaguchi Y, Matsui H, T suji H, et al. Back muscle injury after posterior lumbar spine surgery-A histologic and enzymatic analysis[J].Spine,1996,21:941.
[11]Mixter WJ, Barr JS. Rupture of the intervertebral disc with involvement of the spinal canal.N Englj,1934;211:201-5
[12]王宵光,孙树坤.腰椎间盘突出症几种手术方法的疗效评价[J].中国解剖与临床,2005,5(9)：161-162.
[13]Asano, Kancda k, Umehara S,et al.The mechnical properties of the human L4-5 Function spinal unit during cyclic loading,the structural effect of the posterior elements,1992,11:1343
[14]WANG XG, SUN SK. Operative approaches to lumbar intervertebral disc protrusion [J]. Anatomy and Clinics,2005,5 (9):161-162.
[15]Foley KT, Smith MM. Microendoscopic discectomy[J].Tech Neurosurg. 1997,3:301-7.
[16]Foley KT, Smith MM, Rampersaud YR. Microendoscopic approach to far-lateral lumbar disc herniation[J].Neurosurg Focus. 1999,7:e5.
[17]Perez-Cruet MJ, Foley KT, Isaacs RE, et al. Microendoscopic lumbar discectomy:technical note[J]. Neurosurgery.2002,51 (5 Suppl):S 129-36.
[18]FONTANELLA A. Endoscopic microsurgery in herniated disc[J].Neurol Research,1999(21):3- 38.
[19]BRAYDA M, CINNELLA P. Posterior endoscopic discectomy and other procedure[J]. Eur Spine J, 2000, 9(Suppll):S24-S29.
[20]镇万新,王育才,马乐群,等.脊柱后路显微内窥镜治疗腰椎间盘突出症[J].中华骨科杂志,1999,9(8)：460-462.
[21]WU X, ZHANG SZ, CHEN H. Microendospic discectomy for lumbar disc herniation:Surgical and outcome in 873 consecutive cases[J]. Spine, 2006, 31(23):2689.
[22]RIGHESS. Comparison of open discectomy with microendoscopic discectomy in lumbar disc herniations:results of a randomized controlled trial[J]. Neurosurgery, 2007,61(3):545- 549.
[23]Kawaguchi Y, Matsui H, T suji H, et al. Back muscle injury after posterior lumbar spine surgery-A histologic and enzymatic analysis[J].Spine, 1996,21:941.
[24]Kim KT, Lee SH, Suk KS, et al.The quantitative analysis of tissue injury markers after mini-open lumbar fusion[J]. Spine (Phila Pa 1976). 2006,31:712-6.
[25]Huang TJ, Hsu RW, Li YY, et al. Less systemic cytokine response in patients following microendoscopic versus open lumbar discectomy. J Orthop Res. 2005 Mar;23(2):406-11.
[26]Lehninger A L. Bioenergetics, 2nd.. Benjamin, Menlo Park. 1977. 67-77
[27]Seraydrarian M W and Abbot B C. The role of the creatine phosphokinase system in muscle. J. Mol. Cell. Cardiol.1976,8:741~746.
[28]汤新之,崔乃杰.临床生物化学.第1版.天津科学技术出版社,1995.109-111.
[29]Malinoski DJ, Slater MS, Mullins RJ. Crush injury and rhabdomyolysis. Crit Care Clin.2004,20(1): 171-92.
[30]Buunen M; Gholghesaei M; Veldkamp R. Stress response to laparoscopic surgery:a review. Surg Endosc.2004, Jul,18(7):1022-8.
[31]Haque Z, Rahman M, Siddique MA, et al.Metabolic and stress responses of the body to trauma: produced by the laparoscopic and open cholecystectomy. Mymensingh-Med-J.2004, Jan, 13(1): 48-52.27.
[32]Ruzic B,Tomaskovic I,Trnski D et al. Systemic stress responses in patients undergoing surgery for benign prostatic hyperplasia.. BJU Int. 2005 Jan; 95(1):77-80.
[33]张喜平,解恩义.创伤后外周血TNF-α,IL-6的变化.陕西医学杂志.2002,31(3),236-238.
[34]Ooshiro M, Sugishita Y1, Tanaka H, et al. Regulation of perioperative immunological changes following laparotomy:effects of biological response modifier (BRM) on surgical stress. Immunol Lett,2004,93(1):33 - 38.
[35]Janicki K,Bicki J,et al.C-reactive protein(CRP) as a response to postopetative stress in laparoscopic cholecystectomy using the abdominal wall lift,with performed pneumoperitoneum(CO2),and in open cholecystectomy.Ann Univ Mariae Curie Sklodowska.2001,56:397-402.
[1]Ng J K, Richardson C A, Parnianpour M, et al. EMG activity of trunk muscles and torque output during isometric axial rolation exertion:a comparison between back pain patient and matched controls[J]. J Orthop Res,2002,20(1):112-121.
[2]0'Sullivan P B, Grahamalaw K M, Kendell M, et al. The effect of different standing and sitting postures on trunk muscle activity in a pain-free population[J]. Spine,2002,27 (11):1238-1244.
[3]邵诗泽,张恩忠,付松,等.腰骶段多裂肌的形态特点及功能意义[J].中国临床解剖学杂志,2010,28(1)：17-19.
[4]Gille 0, Jolivet E, Dousset V, et al. Erector spinae muscle changes on magnetic resonance imaging following lumbar surgery through a posterior approach[J]. Spine (Phila Pa 1976), 2007,32 (11):1236-1241.
[5]Kim K T, Lee S H, Suk K S, et al. The quantitative analysis of tissue injury markers after mini-open lumbar fusion[J]. Spine (Phila Pa 1976),2006, 31 (6):712-716.
[6]Boelderl A, Daniaux H, Kathrein A, et al. Danger of damaging the medial branches of the posterior rami of spinal nerves during a dorsomedian approach to the spine [J]. Clinical Anatomy,2002,15(2):77-81.
[7]Kim D Y, Lee S H, Chung S K, et al. Comparison of multifidus muscle atrophy and trunk extension muscle strength:percutaneous versus open pedicle screw fixation[J]. Spine (Phila Pa 1976),2005,30 (1):123-129.
[8]Tsutsumimoto T, Shimogata M, Ohta H, et al. Mini-open versus conventional open posterior lumbar interbody fusion for the treatment of lumbar degenerative spondylolisthesis:comparison of paraspinal muscle damage and slip reduction[J]. Spine (Phila Pa 1976),2009,34 (18):1923-1928.
[9]Macintosh J E, Bogduk N. The morphology of the lumbar erector spinae[J]. Spine (Phila Pa 1976),1987,12 (7):658-668.
[10]刘相军,郭伟.骶管封闭加综合疗法治疗腰椎间盘突出症[J].中华实用诊断与治疗杂志,2007,21(9)：681-682.
[11]王胜利,赵秀芝.两种入路注射胶原酶治疗腰椎间盘突出症的疗效比较[J].中华实用诊断与治疗杂志,2006,20(3)：228-229.
[12]Boelderl A, Daniaux H, Kathrein A, et al. Danger of damaging the medial branches of the posterior rami of spinal nerves during a dorsomedian approach to the spine [J]. Clinical Anatomy,2002,15(2):77-81.
[13]Sihvonen T, Herno A, Palj"arvi L, et al. Local denervation atrophy of paraspinal muscles in postoperative failed back syndrome[J]. Spine (Phila Pa 1976),1993, 18 (5):575-581.
[14]Castro-Men'endez M, Bravo-Ricoy J A, Casal-Moro R, et al. Midterm outcome after microendoscopic decompressive laminotomy for lumbar spinal stenosis:4-year prospective study[J]. Neurosurgery,2009,65 (1):100-10, A12.
[15]沈合群,张叶松,蒋清,等.MED与开放手术治疗腰椎间盘突出症的疗效比较[J].中国现代医学杂志,2004,14(12)：140-141.
[16]张闻生,张劫,李庆富,等.经皮激光椎间盘减压术治疗椎间盘源性腰痛临床观察[J].中华实用诊断与治疗杂志,2010,24(1)：78-79.
[17]Yagi M, Okada E, Ninomiya K, et al. Postoperative outcome after modified unilateral-approach microendoscopic midline decompression for degenerative spinal stenosis[J]. J Neurosurg Spine,2009,10 (4):293-299.
[18]Kleeman T J, Hiscoe A C, Berg E E. Patient outcomes after minimally destabilizing lumbar stenosis decompression:the''Port-Hole''technique[J]. Spine(Phila Pa 1976), 2000,25 (7):865-870.
[19]罗亚平,王勤业,冯夏莺,等.微创经皮AF内固定治疗胸腰椎骨折[J].中国骨与关节损伤杂志,2009,8(24)：678-680.
[20]Arts M, Brand R, van der Kallen B, et al. Does minimally invasive lumbar disc surgery result in less muscle injury than conventional surgery? A randomized controlled trial[J]. Eur Spine J, 2011,20 (1):51-57.
[2]周永红,刘敏勇.针刺配合走罐治疗腰椎间盘突出症60例[J].中国针灸,1998.18：424-426.
[3]庄建光,王强,张祖煌.手法推拿配合中药熏蒸治疗腰椎间盘突出症150例分析[J].山东医药,2007,47(22)：77-77.
[4]赵强.腑卧牵拉斜扳法治疗腰椎间盘突出症的临床研究[J].中华中医药杂志,2007,22(1)：15-17.
[5]Gille O, Jolivet E, Dousset V, et al. Erector spinae muscle changes on magnetic resonance imaging following lumbar surgery through a posterior approach[J]. Spine (Phila Pa 1976).2007,32:1236-41.
[6]Marras WS, Davis KG, Granata KP. Trunk muscle activities during asymmetric twisting motions[J].J Electromyogr Kinesiol.1998,8:247-56.
[7]Boelderl A ,Daniaux H,Kathrein A,et al. Danger of damaging the medial branches of the posterior rami of spinal nerves during a dorsomedian approach to the spine[J]. Clinical Anatomy.2002,15(2):77-81.
[8]Kawaguchi Y, Matsui H, Gejo R, et al. Preventive measures of back muscle injury after posterior lumbar spine surgery in rats[J]. Spine (Phila Pa 1976).1998,23:2282-8.
[9]Taylor H, McGregor AH, Medhi-Zadeh S, et al.The impact of selfretaining retractors on the paraspinal muscles during posterior spinal surgery[J]. Spine (Phila Pa 1976).2002,27:2758-62.
[10]Kawaguchi Y, Matsui H, T suji H, et al. Back muscle injury after posterior lumbar spine surgery-A histologic and enzymatic analysis[J].Spine,1996,21:941.
[11]Mixter WJ, Barr JS. Rupture of the intervertebral disc with involvement of the spinal canal.N Englj,1934;211:201-5
[12]王宵光,孙树坤.腰椎间盘突出症几种手术方法的疗效评价[J].中国解剖与临床,2005,5(9)：161-162.
[13]Asano, Kancda k, Umehara S,et al.The mechnical properties of the human L4-5 Function spinal unit during cyclic loading,the structural effect of the posterior elements,1992,11:1343
[14]WANG XG, SUN SK. Operative approaches to lumbar intervertebral disc protrusion [J]. Anatomy and Clinics,2005,5 (9):161-162.
[15]Foley KT, Smith MM. Microendoscopic discectomy[J].Tech Neurosurg. 1997,3:301-7.
[16]Foley KT, Smith MM, Rampersaud YR. Microendoscopic approach to far-lateral lumbar disc herniation[J].Neurosurg Focus. 1999,7:e5.
[17]Perez-Cruet MJ, Foley KT, Isaacs RE, et al. Microendoscopic lumbar discectomy:technical note[J]. Neurosurgery.2002,51 (5 Suppl):S 129-36.
[18]FONTANELLA A. Endoscopic microsurgery in herniated disc[J].Neurol Research,1999(21):3- 38.
[19]BRAYDA M, CINNELLA P. Posterior endoscopic discectomy and other procedure[J]. Eur Spine J, 2000, 9(Suppll):S24-S29.
[20]镇万新,王育才,马乐群,等.脊柱后路显微内窥镜治疗腰椎间盘突出症[J].中华骨科杂志,1999,9(8)：460-462.
[21]WU X, ZHANG SZ, CHEN H. Microendospic discectomy for lumbar disc herniation:Surgical and outcome in 873 consecutive cases[J]. Spine, 2006, 31(23):2689.
[22]RIGHESS. Comparison of open discectomy with microendoscopic discectomy in lumbar disc herniations:results of a randomized controlled trial[J]. Neurosurgery, 2007,61(3):545- 549.
[23]Kawaguchi Y, Matsui H, T suji H, et al. Back muscle injury after posterior lumbar spine surgery-A histologic and enzymatic analysis[J].Spine, 1996,21:941.
[24]Kim KT, Lee SH, Suk KS, et al.The quantitative analysis of tissue injury markers after mini-open lumbar fusion[J]. Spine (Phila Pa 1976). 2006,31:712-6.
[25]Huang TJ, Hsu RW, Li YY, et al. Less systemic cytokine response in patients following microendoscopic versus open lumbar discectomy. J Orthop Res. 2005 Mar;23(2):406-11.
[26]Lehninger A L. Bioenergetics, 2nd.. Benjamin, Menlo Park. 1977. 67-77
[27]Seraydrarian M W and Abbot B C. The role of the creatine phosphokinase system in muscle. J. Mol. Cell. Cardiol.1976,8:741~746.
[28]汤新之,崔乃杰.临床生物化学.第1版.天津科学技术出版社,1995.109-111.
[29]Malinoski DJ, Slater MS, Mullins RJ. Crush injury and rhabdomyolysis. Crit Care Clin.2004,20(1): 171-92.
[30]Buunen M; Gholghesaei M; Veldkamp R. Stress response to laparoscopic surgery:a review. Surg Endosc.2004, Jul,18(7):1022-8.
[31]Haque Z, Rahman M, Siddique MA, et al.Metabolic and stress responses of the body to trauma: produced by the laparoscopic and open cholecystectomy. Mymensingh-Med-J.2004, Jan, 13(1): 48-52.27.
[32]Ruzic B,Tomaskovic I,Trnski D et al. Systemic stress responses in patients undergoing surgery for benign prostatic hyperplasia.. BJU Int. 2005 Jan; 95(1):77-80.
[33]张喜平,解恩义.创伤后外周血TNF-α,IL-6的变化.陕西医学杂志.2002,31(3),236-238.
[34]Ooshiro M, Sugishita Y1, Tanaka H, et al. Regulation of perioperative immunological changes following laparotomy:effects of biological response modifier (BRM) on surgical stress. Immunol Lett,2004,93(1):33 - 38.
[35]Janicki K,Bicki J,et al.C-reactive protein(CRP) as a response to postopetative stress in laparoscopic cholecystectomy using the abdominal wall lift,with performed pneumoperitoneum(CO2),and in open cholecystectomy.Ann Univ Mariae Curie Sklodowska.2001,56:397-402.
[1]Ng J K, Richardson C A, Parnianpour M, et al. EMG activity of trunk muscles and torque output during isometric axial rolation exertion:a comparison between back pain patient and matched controls[J]. J Orthop Res,2002,20(1):112-121.
[2]0'Sullivan P B, Grahamalaw K M, Kendell M, et al. The effect of different standing and sitting postures on trunk muscle activity in a pain-free population[J]. Spine,2002,27 (11):1238-1244.
[3]邵诗泽,张恩忠,付松,等.腰骶段多裂肌的形态特点及功能意义[J].中国临床解剖学杂志,2010,28(1)：17-19.
[4]Gille 0, Jolivet E, Dousset V, et al. Erector spinae muscle changes on magnetic resonance imaging following lumbar surgery through a posterior approach[J]. Spine (Phila Pa 1976), 2007,32 (11):1236-1241.
[5]Kim K T, Lee S H, Suk K S, et al. The quantitative analysis of tissue injury markers after mini-open lumbar fusion[J]. Spine (Phila Pa 1976),2006, 31 (6):712-716.
[6]Boelderl A, Daniaux H, Kathrein A, et al. Danger of damaging the medial branches of the posterior rami of spinal nerves during a dorsomedian approach to the spine [J]. Clinical Anatomy,2002,15(2):77-81.
[7]Kim D Y, Lee S H, Chung S K, et al. Comparison of multifidus muscle atrophy and trunk extension muscle strength:percutaneous versus open pedicle screw fixation[J]. Spine (Phila Pa 1976),2005,30 (1):123-129.
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