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本次文献选自Kim JS, Choi G, Lee SH. Percutaneous endoscopic lumbar discectomy via contralateral approach: a technical case report. Spine. 2011;36(17):E1173-8.本次学习由赵学军主任医师主讲。
Abstract
Study Design. Technical case report.
Objective. The authors report a new percutaneous endoscopic lumbar discectomy (PELD) technique for the treatment of lumbar disc herniation via a contralateral approach.
Summary of Background Data. When there are highly down-migrated lumbar disc herniation along just medial to pedicle and narrow ipsilateral intervertebral foramen, the conventional PELD is not easily accessible via ipsilateral transforaminal route.
Methods. Five patients manifested gluteal and leg pain because of a soft disc herniation at the L4–L5 level. Transforaminal PELD via a contralateral approach was performed to remove the herniated fragment, achieving complete decompression of the nerve root.
Results. The symptom was relieved and the patient was discharged the next day.
Conclusion. When a conventional transforaminal PELD is diffifi cult because of some anatomical reasons, PELD via a contralateral route could be a good alternative option in selected cases.
Key words: contralateral, disc herniation, lumbar, percutaneous endoscopic lumbar discectomy (PELD), transforaminal.
摘要
研究设计：技术案例报告。
目的：作者报道了一种新的经对侧入路经皮内镜下腰椎间盘切除术治疗腰椎间盘突出症的方法。
背景：当突出的髓核组织沿着椎弓根内侧向下大幅度移位或同侧椎间孔狭窄时，常规的经同侧椎间孔入路PELD不容易到达突出髓核。
方法：五名患者因L4–L5间盘的非骨性突出症导致下肢疼痛。采用经对侧椎间孔入路PELD切除突出物使神经根完全减压。
结果：症状缓解，患者第二天出院。
结论：由于某些解剖学原因，当传统的经同侧椎间孔入路PELD很难到达靶点时，经对侧椎间孔入路进行PELD可能是一个不错的选择。
关键词：对侧，椎间盘突出，腰椎，经皮经内镜下腰椎间盘切除术（PELD）。
Since Kambin reported the posterolateral percutaneous approach for lumbar disc herniation, minimally invasive techniques, including percutaneous procedures using rigid endoscopes, have rapidly evolved and are increasingly gaining attention. The posterolateral percutaneous approach has been accomplished with the aid of specialized instruments such as endoscopes with video equipment and lasers. This has led to success rates comparable to those for open discectomy. Percutaneous endoscopic lumbar discectomy (PELD) may be an attractive technique because of its minimal invasiveness, swift recovery, and fast return to daily activities. However, the effifi cacy of the procedure is still in doubt for patients in whom the conventional transforaminal approach is hindered by anatomic barriers such as a pedicle or highly migrated disc fragments. In this report, we introduce and describe in detail our new surgical technique to overcome these barriers in selected cases.
自从Kambin报道经皮后外侧入路治疗腰椎间盘突出症以来，微创技术，包括使用经皮刚性内窥镜手术，已迅速发展并日益受到重视。经皮后外侧入路是在专用设备和器械的帮助下完成的，如带有视频设备和激光的内窥镜。这导致成功率与开放式椎间盘切除术相当。经皮内镜下腰椎间盘切除术（PELD）因其创伤小、恢复快，并且很快重返日常生活，是一种很有吸引力的技术。然而，当因为椎弓根阻挡或突出物大幅度移位等解剖因素使传统的经椎间孔入路难以达到靶点时，该手术方式的有效性就受到了质疑。本文中，我们详细介绍了在某些特殊病例中克服这些障碍的新手术技术。
CASE REPORT
Case 1
A 43-year-old woman presented the severe radicular pain in the left leg along the L5 dermatome. Physical examination demonstrated a positive straight leg raising sign at 20 ° on the left side. There was an objective weakness of dorsiflfl exion of the great toe graded at 4. The patient had no fasciculation, muscle atrophy, or upper motor neuron signs. Magnetic resonance imaging (MRI) showed an inferior migrated disc fragment from L4–L5 level (Figure 1A). The patient’s symptoms did not improve after conservative treatments, including medication and physiotherapy for 5 week. After the proper insertion of a working cannula (Figure 1B), we performed a transforaminal PELD via the contralateral route. The thecal sac and L5 nerve root were successfully decompressed in the endoscopic view and the result was confifi rmed on postoperative MRIs (Figure 1A). Visual analogue scale (VAS) score for leg pain and Oswestry disability index (ODI) were improved from 8% and 64.4% preoperatively to 2% and 14%, respectively at the 6-month follow-up.
病例报告
案例1
一位43岁的女性出现了沿着L5脊神经分布区的左腿严重的神经根性疼痛。体格检查显示左侧直腿抬高征20°阳性。拇趾背伸肌力4级。患者没有出现肌痉挛、肌肉萎缩或上运动神经元体征。磁共振成像（MRI）显示L4–L5水平的向下移位的间盘突出（图1A）。保守治疗（包括药物和物理治疗）5周后，患者的症状没有改善。在正确插入工作套管（图1B）后，我们通过对侧路径进行经椎间孔PELD。在内窥镜下，硬膜囊和L5神经根成功减压，结果在术后MRI上得到证实（图1A）。随访6个月，下肢疼痛视觉模拟评分（VAS）和Oswestry残疾指数（ODI）分别从术前的8%和64.4%提高到2%和14%。
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