探讨解剖组织部位不同、刺激方式不同与腰椎经皮内镜间盘切除术(percutaneous endoscopic lumbar discectomy, PELD)中患者疼痛的关系及影响疼痛的程度，分析术中疼痛应答对PELD手术安全的影响。

从解放军总医院2015年10月至2016年2月采取PELD治疗腰椎间盘突出症和(或)腰椎管狭窄症的患者中，选取获得完整术中即时随访的74例(其中男性52例、女性22例，年龄14～67岁、平均40.14岁，其中40例为L4～5、34例为L5至S1)。前瞻设计当术中常规接触(钳夹、电凝)每例患者需处理的解剖组织部位(退变髓核、纤维环、后纵韧带、黄韧带)，术中即时随访记录平均的视觉模拟评分(visual analog score, VAS)，分析解剖组织部位不同、刺激方式不同与PELD术中患者疼痛的联系。设A因素为不同解剖组织部位、B因素为不同刺激方式，4种解剖组织部位、2种刺激方式间疼痛评分比较用方差分析，各因素的两两比较用SNK检验。

A因素、B因素的P值均< 0.05，A因素与B因素的交互P值> 0.05；A因素的两两比较，P值< 0.05。即术中接触不同的解剖组织部位对患者的疼痛有影响，且不同解剖组织部位间疼痛应答的表现差异显著，表现为后纵韧带的疼痛应答最剧烈[钳夹VAS＝(7.05±1.41)分、电凝VAS ＝( 7.35 ± 1.53)分]，纤维环表现其次[钳夹VAS＝(4.05 ± 1.43)分、电凝VAS＝(5.35 ± 1.72)分]，黄韧带表现再次[钳夹VAS ＝( 3.76 ± 1.42)分、电凝VAS＝(4.49 ± 1.59)分]，退变髓核的疼痛应答较轻微[钳夹VAS＝(1.38 ± 1.40)分、电凝VAS＝(2.08 ± 1.69)分]；术中采用不同的刺激方式接触患者对术中的疼痛应答也有影响，表现为电凝刺激比钳夹刺激的接触方式患者的疼痛应答更严重(所有部位的电凝VAS均大于钳夹VAS)；不同解剖组织部位与不同刺激方式对疼痛应答评分无交互作用。

PELD术中需要即时有效地监护患者的疼痛应答，可以避免过伤组织、提高手术操作的安全性。

To evaluate the interaction between different anatomic sites, different contact methods and intraoperative pain in PELD, and analyze its value.

From Oct. 2015 to Feb. 2016, 74 patients with lumbar disc herniation and/or lumbar spinal stenosis, who were treated by using percutaneous endoscopic lumbar discectomy (PELD) in General Hospital of PLA and received complete intraoperative follow-up, were reviewed. There were 52 males and 22 females, ranging in age from 14 to 67 years, mean age was 40.14 years. The patients were operated by single levels, of which site in L4-5 was 40 cases and L5 to S1 was 34 cases. When surgeons contacted the tissues by endoscopic clamp and electrocoagulation normally, such as degenerate intervertebral disc, annulus fibrosus, the posterior longitudinal ligament and ligamentum flavum, patients′ visual analog score (VAS) were collected immediately. Factor A was anatomic site, factor B was contact methods. Analysis of variance was uesd to resolve the VAS of four different anatomic sites and two different contact methods. SNK q test was uesd to resolve multiple comparison in factor A and B.

There were statistical significances separately in A and B (P< 0.05), but correlation between A and B was insignificant. Besides, multiple comparison in A was significant (P< 0.05). Different anatomic sites, contacted normally during PELD, reacted patients′ pain response. And the difference of pain response between different anatomic sites was significant. The pain response of the posterior longitudinal ligament was the most dramatic (VAS with endoscopic clamp was 7.05 ± 1.41, with electrocoagulation was 7.35 ± 1.53), annulus fibrosus was secondary (VAS with endoscopic clamp was 4.05 ± 1.43, with electrocoagulation was 5.35 ± 1.72), ligamentum flavum thirdly (VAS with endoscopic clamp was 3.76 ± 1.42, with electrocoagulation was 4.49 ± 1.59), degenerate intervertebral disc lastly (VAS with endoscopic clamp was 1.38 ± 1.40, with electrocoagulation was 2.08 ± 1.69). Different contact methods during PELD also reacted patients’ intraoperative pain response. The pain response of contact method by electrocoagulation was more severe than endoscopic clamp (VAS with electrocoagulation was more severe than endoscopic clamp in all anatomic sites). Correlation between different anatomic sites and different contact methods was insignificant.

We need to monitor patients’ pain responses immediately and effectively during PELD, it could help to avoid hurting tissue and raise the safety of operation.