目的 对比分析经皮椎间孔镜技术(percutaneous transforaminal endoscopic discectomy,PTED)与单纯开放髓核摘除治疗腰椎间盘突出症患者术前和术后的影像学改善情况,评价椎间孔镜的临床应用价值。方法 选取2017-07至2018-12 L_4/5椎间盘突出症患者60例。随机分成PTED组(n=30例)和髓核摘除组(n=30例)。行术前,术后1 d,术后3、6、12个月的影像学评估。结果 X线片与术前相比, PTED组L_3-4椎间隙高度升高明显,差异有统计学意义(P<0.05)。磁共振与术前相比,髓核摘除组与PTED组的相对信号强度(RSI)在术后1 d及术后3个月无明显变化;PTED组在术后6个月和术后12个月也无明显变化,但是髓核摘除组在术后6个月开始显著降低,且呈进行性下降趋势(P<0.05);在术后1 d、术后3个月,PTED组患者RSI值比较差异无统计学意义,但术后6个月及术后12个月时,PTED组患者RSI值比髓核摘除组显著增大,差异有统计学意义(P<0.05),提示从术后6个月开始,髓核摘除组患者邻近的L_3-4节段逐渐地开始出现退行性改变。结论 利用椎间孔镜技术治疗腰椎间盘突出症安全有效,与单纯开放髓核摘除比较,在术后对邻近椎间隙的解剖结构、病理改变,退行变的影响更小,优势明显,是一种值得推广应用的的微创方法。

Objective To evaluate the clinical applicability of percutaneous transforaminal endoscopic discectomy (PTED) by comparing imaging diagnosis improvements before and after respective treatment with PTED and with discectomy in patients with lumbar intervertebral disc protrusion. Methods Sixty patients with L4/5 disc protrusion treated between July 2017 and December 2018 were randomly divided into two groups: PTED group and discectomy group, with 30 cases in each. Imaging data collected one day before operation, one day after operation, three months after operation, six months after operation and one year after operation was analyzed. Results On the X-ray film, the lumbar lordosis angle and the sacral inclination angle of patients in both groups began to increase one day after operation, P<0.05, but there was no significant difference between the two groups. There was no significant change in the lumbosacral angle postoperatively.No significant difference was seen in the intervertebral space (L_3-4) height one day after operation. However, three months after operation, the height decreased gradually, suggesting that degeneration had occurred in patients in the discectomy group (P<0.05),but there were no obvious changes in the PTED group. At the same time point, there was no significant difference in the lumbar lordosis angle or sacral inclination angle between the two groups, but the L_3-4 intervertebral space height of the PTED group was significantly higher, P<0.05. On the magnetic resonance imaging, the relative signal intensity (RSI) of either group did not change significantly one day and three months after operation. The RSI hardly changed in the PTED group six months and one year after operation, but it significantly decreased in the discectomy group six months after operation and trended down, P<0.05. There was no significant difference in the RSI between the two groups before operation, one day and three months after operation, but six months and one year after operation, the RSI in the PTED group increased more significantly than in the discectomy group (P<0.05). Six months after operation, gradual degeneration occurred in the adjacent L_3-4 segments of the disc in the discectomy group. Conclusions PTED is an efficient and safe approach to lumbar intervertebral disc protrusion. PTED has advantages over discectomy in the anatomical structure of the adjacent intervertebral disc, pathological changes and in the incidence of degeneration.