脊柱内镜技术治疗腰椎椎体后缘离断症临床疗效与影像学改变的相关性研究

Correlation between the clinical efficacy and imaging changes of spinal endoscopy in the treatment of lumbar posterior ring apophysis fracture

摘要:

目的： 探讨脊柱内镜技术治疗腰椎椎体后缘离断症的临床疗效。分析手术前后临床症状的改善与椎管影像学改变的相关性，为临床充分减压提供理论依据。方法： 收集2015年12月至2019年12月符合入选和排除标准的腰4~5节段椎体后缘离断症患者42例，均采用脊柱内镜技术进行治疗，经椎间孔入路内镜下行部分椎间盘组织切除以及离断骨块完全切除。所有患者术前和术后3个月进行疼痛视觉模拟（visual analogue scale，VAS）评分、Oswestry功能障碍指数（Oswestry disability index，ODI）评分、日本骨科协会（Japanese Orthopaedic Association，JOA）评估治疗分数，并在术后进行改良版MacNab疗效评估；同时在术前及术后进行影像学检查，记录数据变化，并进行统计学数据分析。结果： 手术顺利，无中转开放、硬膜囊撕裂、神经根损伤等情况。手术时间35～80 min，术中透视3～17次，术中出血量10～20 mL。手术后影像学提示硬膜囊及神经减压彻底，完全切除离断的骨块42例。患者术后获得随访，根据MacNab疗效评定标准，优良率达95.24%。术后3个月随访获得的VAS评分由术前的（7.19±0.40）分下降至（2.58±0.83）分（P<0.01），ODI评分由术前的（56.52±3.55）%降至（19.83±5.00）%（P<0.01），JOA评分由术前的（8.48±2.42）分上升至（21.71±2.86）分（P<0.01）。分析手术前后CT中椎管横径、椎管正中矢状径、椎管横截面积及MRI中椎管矢状径，关节间径、椎管横截面积、硬膜囊横截面积变化差异均有统计学意义（P<0.01）。结论： 脊柱内镜技术采用安全有效的微创入路治疗腰4~5节段的腰椎椎体后缘离断症，可达到满意的临床疗效。手术前后椎管正中矢状径、关节间径、椎管横截面积的改善与临床疗效均具有较强的相关性，影像学数据的改善可作为判断临床疗效的静态方法，同时精准的靶向穿刺及彻底的神经减压也是手术疗效的保证。

Abstract:

Objective: To explore the clinical efficacy of spinal endoscopy in the treatment of lumbar posterior ring apophysis fracture, and analyze the correlation between the improvement of clinical symptoms before and after surgery and the imaging changes of the spinal canal for providing a theoretical basis for clinical full decompression. Methods: A total of 42 patients with posterior ring apophysis fracture of lumbar 4-5 segments meeting the inclusion and exclusion criteria from December 2015 to December 2019 were collected in the study. All patients were treated with spinal endoscopy, partial discectomy and complete resection of separated and broken bones under the transforaminal endoscope. All patients received visual analogue scale (VAS), Oswestry disability index (ODI), and Japanese Orthopaedic Association (JOA) scores 3 months before and after operation, and the therapeutic effect of modified MacNab was evaluated after operation. At the same time, preoperative and postoperative imaging examinations were performed to record the changes in data, and statistical data analysis was made. Results: The operation was smooth, with no open transition, dural sac tear, or nerve root injury. The operation time was 35 min to 80 min, with 3 to 17 times of intraoperative fluoroscopy, and the amount of bleeding during the operation was about 10 mL to 20 mL. Postoperative imaging showed that the dural sac and nerves were completely decompressed and 42 cases of severed bone masses were completely removed. The patients were followed up after operation, and the excellent and good rate was 95.24% according to the MacNab efficacy evaluation standard. After 3 months of follow-up after operation, the VAS score decreased from (7.19±0.40) points before surgery to (2.58±0.83) points (P<0.01), the ODI score decreased from (56.52±3.55) % before surgery to (19.83±5.00) % (P<0.01), and the JOA score increased from (8.48±2.42) points before surgery to (21.71±2.86) points (P<0.01) . There were significant differences in spinal canal transverse diameter, spinal canal median sagittal diameter, and spinal canal cross-sectional area in CT before and after surgery, as well as in inter-articular diameter, spinal canal cross-sectional area, and dural sac cross-sectional area in MRI before and after operation (P<0.01) . Conclusion: Firstly, spinal endoscopy can be used to treat posterior ring apophysis fracture of the 4-5 segments of the lumbar vertebrae through a safe and effective minimally invasive approach, which can achieve satisfactory clinical results. Secondly, improvement of the median sagittal diameter of the spinal canal, the inter-articular diameter, and the cross-sectional area of the spinal canal have a strong correlation with clinical efficacy before and after surgery. The improvement of imaging data can be used as a static method for judging clinical efficacy, meanwhile, accurate targeted puncture and thorough nerve decompression are also guarantees of good surgical efficacy.