超声骨刀辅助通道下单侧开窗减压治疗腰椎管狭窄症的安全性及有效性分析

2020-09-14 12:01:57 中国现代医生 2020年19期

谭同军 何强 姚年伟 尹宏 刘易昕 张大鹏 严坤 钱卫庆

[摘要] 目的 研究超聲骨刀辅助通道下单侧开窗减压治疗退行性腰椎管狭窄症的安全性及临床疗效。 方法 纳入2018年6月~2019年6月本院诊治的32例腰椎管狭窄症患者,分为采用超声骨刀辅助通道下单侧开窗减压治疗的超声骨刀组16例,采用电动磨钻辅助通道下单侧开窗减压治疗的传统减压组16例。统计有关手术观察指标:椎板减压时间、术中出血量等,根据VAS(Visual analogue scale)和ODI(The Oswestry disability index)评定手术效果,应用t检验进行统计学分析。 结果 32例均获随访,两组患者椎板减压时间、术中出血量比较,差异有统计学意义(P<0.05)。两组手术患者均未出现神经根损伤、硬脊膜撕裂等相关并发症。两组术后各时间点VAS评分比较,差异均有统计学意义(P<0.05)。超声骨刀组:术前与术后3 d VAS评分比较,差异有统计学意义(t=22.213,P=0.001);术前与术后3个月VAS评分比较,差异有统计学意义(t=21.742,P=0.002);术后3 d与术后3月VAS评分比较,差异无统计学意义(t=-0.382,P=0.452)。传统减压组:术前与术后3 d VAS评分比较,差异有统计学意义(t=24.693,P=0.046);术前与术后3个月VAS评分比较,差异有统计学意义(t=25.607,P=0.020);术后3 d与术后3个月VAS评分比较,差异无统计学意义(t=0.713,P=0.200)。两组术后ODI评分比较,差异均有统计学意义(P<0.05)。超声骨刀组:术前与术后3 d ODI评分比较,差异有统计学意义(t=24.536,P=0.044);传统减压组:术前与术后3 d ODI评分比较,差异有统计学意义(t=32.183,P=0.009)。 结论 超声骨刀辅助通道下单侧开窗减压术作为微创手术,创伤小、减压充分,对脊柱稳定性影响小,无需内固定,大大缩短手术时间,并且术中出血较少、术后疼痛轻、恢复快,具有明显的临床优势,值得临床推广。

[关键词] 腰椎管狭窄;外科微创性手术;椎板减压;脊柱融合术;超声骨刀

[中图分类号] R454.3          [文献标识码] B          [文章编号] 1673-9701(2020)19-0084-05

Efficacy analysis of the safety and effectiveness of unilateral fenestration decompression under ultrasound osteotome-assisted channel against lumbar spinal stenosis

TAN Tongjun   HE Qiang   YAO Nianwei   YIN Hong   LIU Yixin   ZHANG Dapeng   YAN Kun   QIAN Weiqing

Department of Orthopedics and Traumatology, Nanjing Hospital of Chinese Medicine Affiliated to Nanjing University of Chinese Medicine, Nanjing   210022, China

[Abstract] Objective To study the safety and clinical efficacy of unilateral fenestration decompression under ultrasound osteotome-assisted channel against degenerative lumbar spinal stenosis. Methods 32 cases of lumbar spinal stenosis(LSS) diagnosed and treated from June 2018 to June 2019 were included, with 16 cases being treated with unilateral fenestration decompression under ultrasound osteotome-assisted channel, and another 16 cases being treated with unilateral fenestration decompression under electric drill bit sharpener-assisted channel. The changes of the operative observation indexes such as laminectomy decompression time and intraoperative blood loss, etc. were counted, the operative effect was assessed according to visual analogy scale (VAS) and the oswestry disability index(ODI), and t test was used for statistical analysis. Results 32 cases of patients were all followed up, and the difference in laminectomy decompression time and in intraoperative blood loss between the two groups was significant(P<0.05). No nerve root injury, dural laceration and other related complications occurred to the two groups of operative patients. There were statistically significant differences in VAS scores of the two groups at different time points after operation(P<0.05). In the ultrasound osteotome group: there was statistically significant difference in the VAS scores before and 3 d after operation(t=22.213, P=0.001); there was statistically significant difference in VAS scores before and 3 m after operation(t=21.742, P=0.002); there was no statistically significant difference in VAS scores 3 d and 3 m after operation(t=-0.382, P=0.452). In the traditional decompression group: there was statistically significant difference in the VAS scores before and 3 d after operation(t=24.693, P=0.046); there was statistically significant difference in VAS scores before and 3 m after operation(t=25.607, P=0.020); there was no statistically(t=0.713, P=0.200). There were statistically significant differences in the ODI scores of the two groups after operation(P<0.05). In the ultrasound osteotome group: there was statistically significant difference in the ODI scores before and 3 d after operation(t=24.536, P=0.044). In the traditional decompression group: there was statistically significant difference in the ODI scores before and 3 d after operation(t=32.183, P=0.009). Conclusion As a minimally invasive surgery(MIS), unilateral fenestration decompression under ultrasound osteotome-assisted channel incurs less trauma, has sufficient decompression, exerting little influence on spinal stability. With no need for internal fixation, operation time is greatly shortened. There is less intraoperative hemorrhage, less postoperative pain, and faster recovery. With obvious clinical advantages, it is worthy of clinical promotion.

[Key words] Lumbar spinal stenosis; Minimally invasive surgery; Laminectomy decompression; Spinal fusion; Ultrasound osteotome

腰椎管狭窄症(Lumbar spinal stenosis,LSS)是一种与自然老化过程有关的疾病,它导致腰椎管和椎间孔变窄,是一种退行性病变。当狭窄与临床相关时,它会导致一种被称为神经源性跛行的综合征[1]。患者通常会经历与活动相关的腰腿痛,这种疼痛随着长时间站立或走动而加重,限制了他们的步行距离,影响他们的生活能力[2]。目前有效的治疗方法即手术,但伴随着较高的并发症,在手术操作过程中易损伤神经根、脊髓、硬脊膜等结构[3]。传统电动磨钻在手术过程中虽然减轻了手术医师的工作强度,但在其工作过程中钻头高速旋转的情况下惯性高、产热高,且手术过程创伤大、术中出血量多,术后椎旁肌脂肪化和纤维化,均提高术后腰背部顽固性疼痛发生概率[4-5]。随着骨科医疗技术的发展,对手术安全性及精确性均提出了更高要求。超声骨刀目前属于新型的切骨工具,因其具有良好的止血性能、组织选择性能且在口腔科及外科的广泛安全应用而被选择[4,6-8]。本文现回顾性分析2018年6月~2019年6月于我院采用超声骨刀辅助通道下单侧开窗减压治疗退行性腰椎管狭窄症患者的临床资料,并与同期采用电动磨钻辅助通道下单侧开窗减压治疗的患者进行比较,评价超声骨刀在退行性腰椎管狭窄症单侧开窗减压过程中的安全性与有效性。

1 资料与方法

1.1 纳入标准、排除标准

纳入标准:①术前影像学检查提示单节段退变性腰椎管狭窄症,狭窄程度为中度及以上[8];②持续反复的腰腿部疼痛伴有间歇性跛行,经过半年及以上保守治疗无明显好转;③患者病历信息完整。

排除标准:①有腰椎相关既往手术史;②伴有腰椎峡部裂、腰椎滑脱症(Meyerding分度≥Ⅱ度)等相关疾病;③单纯诊断为腰椎椎间盘突出症。

2018年6月~2019年6月共32例患者符合选择标准纳入研究,根据手术方式的不同分为超声骨刀组16例和传统减压组16例。

1.2 一般资料

将符合标准的患者按照随机数字表法分为超声骨刀组与传统减压组,每组16例,共32例。其中超声骨刀组:男10例,女6例;年龄45~82岁,平均58.9岁;病程6~32个月,平均14.1个月。传统减压组:男9例,女7例;年龄42~79岁,平均60.7岁。病程6~32个月,平均13.5个月。两组患者在性别、年龄、病程方面比较,差异无统计学意义(P>0.05),具有可比性。

1.3手术方法

两组手术均由同一组医师进行。依据术前讨论计划,患者采取俯卧位于脊柱手术台,定位相应节段,常规消毒铺单处理后,于相應间隙症状较重侧旁开1.5~2 cm处斜向内侧置入克氏针导针至相应节段椎板表面,逐级插入扩增套管至放入工作通道,自由臂固定工作通道。根据病情,可经椎板连接处、棘突基底部,进入对侧椎管内进行对侧椎管及侧隐窝减压。(1)超声骨刀组:利用超声骨刀(厂家:Silfradent;型号:SURGYBONE)及椎板咬骨钳切除椎板、增生的关节突关节及黄韧带;(2)传统减压组:利用磨钻及椎板咬骨钳切除椎板、增生的关节突关节及黄韧带。

1.4 术后处理

手术切口内常规不放置引流管。术中出现脑脊液漏患者1例,放置引流后连接引流袋引流,术后48 h拔除,患者佩戴支具下地活动,佩戴腰围1个月。

1.5疗效评价指标

记录并比较两组患者椎板减压时间、术中出血量。术前、术后3 d及术后3个月采用疼痛视觉模拟评分(VAS)评估患者腰背部疼痛情况[9]:以得分结果进行分度,分为无痛(0~10分)、轻微疼痛(11~25分)、疼痛(26~40分)、剧痛(41~50分)。术前及术后3 d采用Oswestry功能障碍指数(ODI)评分评估患者腰背部功能改善情况[10]。

1.6 统计学方法

应用SPSS22.0统计学软件进行分析,通过配对t检验比较患者术前、术后及末次随访的VAS评分、ODI指数,计数资料以[n(%)]表示,采用χ2检验,以P<0.05为差异有统计学意义。

2 结果

2.1 两组患者椎板减压时间及术中出血量比较

两组患者椎板减压时间比较,差异有统计学意义(P<0.05)。两组患者术中出血量比较,差异有统计学意义(P<0.05)。见表1。

2.2 两组患者手术前后各时间点VAS评分比较

两组手术患者均未出现神经根损伤、硬脊膜撕裂等相关并发症。VAS评分术前、术后3 d、术后3个月组间比较,差异无统计学意义(P>0.05)。两组术后各时间点间VAS评分比较,差异有统计学意义(P<0.05)。超声骨刀组:术前与术后3 d VAS评分比较,差异有统计学意义(t=22.213,P=0.001);术前与术后3个月VAS评分比较,差异有统计学意义(t=21.742,P=0.002);术后3 d与术后3个月VAS评分比较,差异无统计学意义(t=-0.382,P=0.452)。传统减压组:术前与术后3 d VAS评分比较,差异有统计学意义(t=24.693,P=0.046);术前与术后3个月VAS评分比较,差异有统计学意义(t=25.607,P=0.020);术后3 d与术后3个月VAS评分比较,差异无统计学意义(t=0.713,P=0.200)。见表2。

2.3 两组患者手术前后ODI评分比较

两组患者术后ODI评分比较,差异有统计学意义(P<0.05)。超声骨刀组:术前与术后3 d ODI评分比较,差异有统计学意义(t=24.536,P=0.044);传统减压组:术前与术后3 d ODI评分比较,差异有统计学意义(t=32.183,P=0.009)。见表3。

3讨论

腰椎管狭窄症(LSS)是一种退行性疾病,是由与衰老相关的硬脊膜囊和脊神经根受压导致的椎管狭窄和压迫引起的。建议对保守治疗无反应的症状性LSS患者进行手术治疗。LSS的标准手术是单独减压,以及使用椎弓根螺钉和杆系统结合骨移植材料和腰椎椎间融合术进行减压加脊柱融合术[11]。尽管LSS的金标准治疗是减压,但去除过多的后路骨和过度的小平面切除术可能会导致手术水平的脊柱不稳定[12]。要解决此并发症,可考虑采用微创减压手术治疗[12-13]。微创通道下开窗减压术较开放减压手术具有手术时间短、术中出血少、术后腰椎滑脱退变小及术后感染率低等优点[14],是微创治疗腰椎管狭窄症的有效手段之一。微创通道减压手术最大限度地保留脊柱后部复合体的完整性,减少相邻脊柱节段退变和软组织损伤,减少对脊柱稳定性的影响[15]。目前传统电动磨钻是开展该手术公认的必备工具[16],但其在使用过程中有手柄不易把控、丢失骨量多、损伤周围软组织、术后并发症多等缺点[17]。本院应用超声骨刀与传统电动磨钻进行多方面对比,以求为患者提供更经济、安全的手术选择。

3.1 超声骨刀辅助微创通道下单侧开窗减压的安全性及有效性

超声骨刀的原理是将电能转化为机械能,应用其刀头的高频率振动对相应的骨组织进行切割[18],能轻松、安全、精确、有效地切割坚硬的密质骨而不损伤软组织,有研究表明使用超声骨刀可以将脑脊液漏的发生率控制在10%以内,且降低硬脊膜及神经根的损伤风险[19]。与传统电动磨钻相比,超声骨刀能够更有效地避免神经根的机械性损伤和热损伤[20]。近年来,超声骨刀相继应用于单侧椎板成形术、腰椎椎间孔减压术等骨科手术中,其良好的安全性能为更广泛应用于骨科手术提供支持[21]。同时有研究表明,超声骨刀减压治疗腰椎管狭窄症与传统电动磨钻相比所取得的临床疗效相似[22]。本次临床研究过程中,超声骨刀组在椎板减压时间及術中出血量较传统减压组均有明显优势。

3.2 超声骨刀辅助微创通道下单侧开窗减压治疗腰椎管狭窄症的优势

有研究表明,超声骨刀在缩短手术时间与减少术中出血量方面均优于传统电动磨钻[23]。

超声骨刀较传统电动磨钻能明显缩短手术时间[23]。临床研究中,Mehmet RO[20]将46例患者分为两组,结果提示超声骨刀手术较传统电动磨钻节约3倍时间。基础研究中有学者等[25]将羊作为研究对象,结果表明超声骨刀手术较传统电动磨钻节约2倍时间。本次研究中同样发现超声骨刀较传统电动磨钻明显缩短手术时间,减短患者麻醉时间,降低手术风险。

在进行脊柱手术过程中,术中出血一直是增加手术风险的原因之一。腰椎手术常见出血原因有3种:①腰动脉及其相应的背侧分支动脉损伤;②椎管内外静脉丛损伤;③截骨面骨性出血[26]。超声骨刀因其遇到硬度较小组织时的低损伤,减少了术中出血的可能。有学者等[23]在307例使用超声骨刀的手术病例中发现超声骨刀的出血量明显少于传统电动磨钻。本次研究中同样发现超声骨刀较传统电动磨钻明显减少术中出血量,与既往报道一致。

术后并发症是影响患者手术选择的因素之一。腰椎管狭窄症的术后并发症主要有切口部位感染、术后神经功能损伤及硬膜撕裂[23-25]。有研究表明,超声骨刀与传统电动磨钻相比可以降低术后并发症。

综上所述,超声骨刀辅助通道下单侧开窗减压作为微创手术,创伤小,减压充分,对脊柱稳定性影响小,无需内固定,手术时间短,术中出血少,术后疼痛轻、恢复快,具有明显的临床优势,值得临床推广。超声骨刀减压技术治疗腰椎管狭窄症临床可行、安全,与传统减压技术相比,具有肌肉创伤小、术后背痛小、患者恢复快等优点[26]。对侧椎管鞘膜减压是手术的潜在危险环节,硬膜损伤和脑脊液泄漏的风险最高,因此,需在同侧创造足够的空间,使器械能够安全地进入椎管进行对侧减压;减少椎旁肌剥离,尽可能减少医源性肌肉损伤和失血;骨清除渗出物可通过骨蜡或多种止血剂控制。

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(收稿日期:2020-01-08)