局麻单通道全脊柱内镜单侧入路双侧减压技术临床应用

doi:10.3877/cma.j.issn.1674-6899.2023.03.008

目的

评价局麻单通道全脊柱内镜下单侧入路椎板切开双侧减压技术(Uniportal full-endoscopic unilateral laminotomy for bilateral decompression，UFE-ULBD)治疗腰椎管狭窄症(Lumbar spinal stenosis，LSS)的标准化手术技术要点、临床疗效及影像学变化。

方法

回顾性分析2021年8月至2023年2月期间单中心临床确诊为LSS，且接受局部麻醉UFE-ULBD手术的患者。收集患者一般人口学资料、腰腿痛视觉模拟评分(visual analog scale，VAS)、Oswestry功能障碍指数(Oswestry Disability Index，ODI)以及改良Macnab分级。测量术前术后关节突关节切除角度、盘黄间隙减压率、骨性侧隐窝减压率以及硬膜囊横截面积等影像学参数。在术后1月、3月及末次随访时对上述指标进行随访。

结果

共纳入53例患者(男31例，女22例)，其中单节段狭窄者49例，双节段狭窄者4例，共计57个手术节段。所有患者平均手术时间(77.5±18.7)min，平均术后住院时间(1.5±0.7)d，平均随访10.5个月。至末次随访时，腿痛VAS评分(1.2±2.1 vs. 6.0±0.8，P<0.001)、腰痛VAS评分(1.3±1.9 vs. 6.0±0.8，P<0.001)以及ODI评分(24.0±22.4% vs. 71.2±6.2%，P<0.001)均较术前改善显著。术后硬膜囊横截面积较术前显著扩大(148.4±40.6 mm² vs. 56.0±21.1 mm²，P<0.001)，平均扩大率为(190.4±101.4)%。所有患者在随访期间均未出现手术并发症。

结论

局部麻醉下UFE-ULBD技术治疗LSS可获得满意的临床和影像学效果。

关键词: 单通道全脊柱内镜, 单侧入路椎板切开双侧减压技术, 腰椎管狭窄症, 椎板间入路, 麻醉，局部

Objective

To investigate the standard surgical technique, clinical and radiological outcomes of uniportal full-endoscopic unilateral laminotomy for bilateral decompression (UFE-ULBD) under local anesthesia for patients with lumbar spinal stenosis (LSS).

Methods

Patients with LSS who underwent UFE-ULBD under local anesthesia from a single spine center were retrospectively analyzed between August 2021 and February 2023. Patient demographics, visual analog scale (VAS) scores for leg pain and back pain, Oswestry Disability Index (ODI) scores, modified Macnab grade, angle of facetectomy, decompression ratio of disc-flava ligament space, decompression ratio of osseous lateral recess, and dural sac cross-sectional area were systematically collected. The above measurements were evaluated at 1 month, 3 months after surgery, and at the last follow-up.

Results

Fifty-three patients (31 males and 22 females) were retrospectively enrolled in this study, including 49 patients with single-level stenosis and 4 patients with double-level stenosis, with a total of 57 surgical levels. The mean operation time was (77.5±18.7) minutes, the mean postoperative hospital stay was (1.5±0.7) days, and the mean follow-up was 10.5 months. At the last follow-up, the VAS score for leg pain (1.2±2.1 vs. 6.0±0.8, P<0.001), the VAS score for back pain (1.3±1.9 vs. 6.0±0.8, P<0.001), and the ODI score (24.0±22.4% vs. 71.2±6.2%, P<0.001) improved significantly. The postoperative dural sac cross-sectional area obviously enlarged (148.4±40.6 mm² vs. 56.0±21.1 mm², P<0.001) with compared to preoperative, with an enlargement ratio of 190.4±101.4%. No complication was detected during the follow-up.

Conclusion

The UFE-ULBD under local anesthesia could provide satisfactory clinical and radiological outcomes for patients with LSS.

Key words: Uniportal full-endoscopy, Unilateral laminotomy for bilateral decompression, Lumbar spinal stenosis, Interlaminar approach, Anesthesia, local

图1 单通道全内镜单侧入路椎板切开双侧减压手术(UFE-ULBD)核心手术工具注：A.内镜工作套管；B. 7.5 mm外径镜下环锯。

图2 女性，71岁，L4-5椎管狭窄，接受单通道全内镜单侧入路椎板切开双侧减压手术(UFE-ULBD)注：A-B.术前腰椎CT示L4-5中央椎管及双侧侧隐窝狭窄明显，压迫硬膜囊及双侧神经根；C-D.术后复查腰椎CT示椎管及双侧骨性侧隐窝扩大，硬膜囊面积较术前明显增加；E-F.UFE-ULBD靶点及工作外套管术中定位透视；G.UFE-ULBD术中镜下环锯行骨性减压；H-J.术中内镜视野示硬膜囊与双侧神经根减压充分。^*硬膜囊，^△神经根。

图3 单通道全内镜单侧入路椎板切开双侧减压手术(UFE-ULBD)镜下环锯骨性减压顺序注：A.骨性减压范围；B-D.依次锯除同侧上位椎板下缘及下关节突内侧缘，上位棘突基底部，对侧椎板下缘及下关节突内侧缘；E-G.然后绕回同侧切除上关节突内侧缘及下位椎板上缘，下位棘突基底部，对侧上关节突内侧缘及对侧下位椎板上缘；H.切除黄韧带，显露硬膜囊与双侧神经根。

表1 LSS患者一般资料与UFE-ULBD手术信息

项目	数值
年龄(岁)	69.3±10.1
男性[n(%)]	31 (58.5)
内科合并症[n(%)]	43 (81.1)
狭窄节段[n(%)]
L3~4	12 (21.0)
L4~5	43 (75.4)
L5~S1	2 (3.6)
椎管狭窄Schizas分型[n(%)]
B	4 (7.0)
C	17 (29.8)
D	36 (63.2)
椎间盘髓核摘除[n(%)]	4 (7.5)
手术时间(min)	77.5±18.7
术中失血(ml)	37.6±21.6
术后住院时长(d)	1.5±0.7
随访时间(月)	10.5±4.8

表1 LSS患者一般资料与UFE-ULBD手术信息

项目	数值
年龄(岁)	69.3±10.1
男性[n(%)]	31 (58.5)
内科合并症[n(%)]	43 (81.1)
狭窄节段[n(%)]
L3~4	12 (21.0)
L4~5	43 (75.4)
L5~S1	2 (3.6)
椎管狭窄Schizas分型[n(%)]
B	4 (7.0)
C	17 (29.8)
D	36 (63.2)
椎间盘髓核摘除[n(%)]	4 (7.5)
手术时间(min)	77.5±18.7
术中失血(ml)	37.6±21.6
术后住院时长(d)	1.5±0.7
随访时间(月)	10.5±4.8

表2 UFE-ULBD手术腰腿疼痛与腰椎功能结果

项目	数值	P值
腿痛VAS评分
术前	6.0±0.8
术后1个月	1.2±1.6	<0.001^a
末次随访	1.2±2.1	<0.001^a
腰痛VAS评分
术前	6.0±0.8
术后1个月	2.7±1.2	<0.001^a
末次随访	1.3±1.9	<0.001^a
ODI评分(%)
术前	71.2±6.2
末次随访	24.0±22.4	<0.001^a
改良Macnab分级[n(%)]
优	37 (69.8)
良	9 (17.0)
一般	5 (9.4)
差	2 (3.8)

表2 UFE-ULBD手术腰腿疼痛与腰椎功能结果

项目	数值	P值
腿痛VAS评分
术前	6.0±0.8
术后1个月	1.2±1.6	<0.001^a
末次随访	1.2±2.1	<0.001^a
腰痛VAS评分
术前	6.0±0.8
术后1个月	2.7±1.2	<0.001^a
末次随访	1.3±1.9	<0.001^a
ODI评分(%)
术前	71.2±6.2
末次随访	24.0±22.4	<0.001^a
改良Macnab分级[n(%)]
优	37 (69.8)
良	9 (17.0)
一般	5 (9.4)
差	2 (3.8)

表3 UFE-ULBD手术影像学结果

项目	数值	P值
关节突关节切除角度(°)
同侧	94.6±7.1
对侧	64.1±8.9
盘黄间隙减压率(%)
同侧	20.3±10.4
对侧	5.6±6.5
骨性侧隐窝减压率(%)
同侧	29.3±25.5
对侧	7.9±8.4
硬膜囊横截面积(mm²)
术前	56.0±21.1
术后	148.4±40.6	<0.001^a
扩大率(%)	190.4±101.4

表3 UFE-ULBD手术影像学结果

项目	数值	P值
关节突关节切除角度(°)
同侧	94.6±7.1
对侧	64.1±8.9
盘黄间隙减压率(%)
同侧	20.3±10.4
对侧	5.6±6.5
骨性侧隐窝减压率(%)
同侧	29.3±25.5
对侧	7.9±8.4
硬膜囊横截面积(mm²)
术前	56.0±21.1
术后	148.4±40.6	<0.001^a
扩大率(%)	190.4±101.4

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Clinical application of uniportal full-endoscopic unilateral laminotomy for bilateral decompression under local anesthesia

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Clinical application of uniportal full-endoscopic unilateral laminotomy for bilateral decompression under local anesthesia