不同入路脊柱内镜手术治疗L4/5节段脱垂型腰椎间盘突出症的疗效比较

Comparison of the therapeutic effects of different approaches of spinal endoscopy in the treatment of L4/5 segment prolapse type lumbar disc herniation

摘要:

目的 观察经椎间孔入路内镜下腰椎间盘切除术（TELD）和经椎板间入路内镜下腰椎间盘摘除术（IELD）治疗L_4/5节段脱垂型腰椎间盘突出症（LDH）的临床疗效。方法 回顾性分析2020年11月－2022年11月该院采用脊柱内镜手术治疗的75例L_4/5节段脱垂型LDH患者的临床资料。根据手术入路的不同，将患者分为TELD组（53例）和IELD组（22例）。比较两组患者的手术情况和术后疗效。结果 与TELD组比较，IELD组的手术时间明显缩短，术中透视次数明显减少，差异均有统计学意义（P < 0.05）；两组患者住院时间和并发症发生率比较，差异均无统计学意义（P > 0.05）。所有患者术后均获得12～19个月的随访。两组患者末次随访时的视觉模拟评分法（VAS）评分和Oswestry功能障碍指数（ODI）明显低于术前，且IELD组明显低于TELD组，差异均有统计学意义（P < 0.05）。按照突出物和神经根的不同位置进一步分析，两组肩上型患者（TELD组10例，IELD组6例）末次随访时的VAS评分和ODI明显低于术前，且IELD组末次随访时的VAS评分明显低于TELD组，差异均有统计学意义（P < 0.05）；两组腋下型患者（TELD组8例，IELD组16例）末次随访时的VAS评分和ODI明显低于术前，且IELD组明显低于TELD组，差异均有统计学意义（P < 0.05）；35例肩前型患者经TELD术后，末次随访时的VAS评分和ODI明显低于术前，差异有统计学意义（P < 0.05）。按照突出物的不同Lee分区进一步分析，两组Lee Ⅲ区患者（TELD组44例，IELD组10例）末次随访时的VAS评分和ODI明显低于术前，且IELD组的ODI明显低于TELD组，差异均有统计学意义（P < 0.05）；两组Lee Ⅳ区患者（TELD组9例，IELD组12例）末次随访时的VAS评分和ODI明显低于术前，且IELD组明显低于TELD组，差异均有统计学意义（P < 0.05）。结论 采用TELD和IELD治疗L_4/5节段脱垂型LDH，均可获得较满意的减压效果，但IELD的手术时间相对较短，X线透视次数较少，且对肩上型、腋下型、Lee Ⅲ区和Lee Ⅳ区的减压效果更有优势。

Abstract:

Objective To observe the surgical outcomes and complications of transforaminal endoscopic lumbar discectomy (TELD) and interlaminar endoscopic lumbar discectomy (IELD) in the treatment of lumbar disc herniation (LDH) with prolapse type at the L_4/5 segment using full-endoscopic spine surgery.Methods A retrospective analysis was conducted on the clinical data of 75 patients with L_4/5 segmental prolapse type LDH who underwent spinal endoscopic surgery from November 2020 to November 2022. Among them, 53 patients underwent TELD (TELD group) and 22 patients underwent IELD (IELD group). The surgical outcomes and postoperative therapeutic effect of the two groups were compared.Results Compared with the TELD group, the IELD group had significantly shorter operation time and fewer intraoperative fluoroscopy times, the differences were statistically significant (P < 0.05); There were no statistically significant in the length of hospital stay and the incidence of complications between the two groups (P > 0.05). All patients were followed up for 12 to 19 months after surgery. The visual analogue scale (VAS) score and Oswestry disability index (ODI) at the last follow-up in both groups were significantly lower than those before surgery, and the IELD group was significantly lower than the TELD group, the differences were statistically significant (P < 0.05). Further analysis based on the location of the herniation and nerve roots revealed that, compared with preoperative values, the VAS scores and ODI at the last follow-up were significantly reduced in both groups of patients with shoulder-upper type herniation (10 cases in the TELD group and 6 cases in the IELD group), and the VAS score in the IELD group at the last follow-up was significantly lower than that in the TELD group, the differences were statistically significant (P < 0.05). Similarly, both groups of patients with axillary type herniation (8 cases in the TELD group and 16 cases in the IELD group) exhibited significantly reduced VAS score and ODI at the last follow-up than those before operation, with significantly lower in the IELD group compared to the TELD group, the differences were statistically significant (P < 0.05). Among the 35 patients with anterior-shoulder type herniation who underwent TELD, the VAS score and ODI at the last follow-up were also significantly lower than those before surgery, the difference was statistically significant (P < 0.05). Further analysis based on the Lee classification of herniations revealed that, compared with preoperative values, the VAS score and ODI at the last follow-up were significantly reduced in both groups of patients with herniations in Lee zone Ⅲ (44 cases in the TELD group and 10 cases in the IELD group), and the ODI in the IELD group was significantly lower than that in the TELD group, the differences were statistically significant (P < 0.05). Similarly, both groups of patients with LDH in Lee zone Ⅳ (9 cases in the TELD group and 12 cases in the IELD group) exhibited significantly reduced VAS score and ODI at the last follow-up, with significantly lower in the IELD group compared to the TELD group (P < 0.05).Conclusion Both TELD and IELD can achieve satisfactory decompression effects in the treatment of LDH with prolapse type at the L_4/5 segment. However, IELD offers a relatively shorter operative time, requires fewer X-ray fluoroscopies, and demonstrates superior decompression effects for shoulder-type, axillary-type, Lee III and Lee IV.