侯樹勛

. 述評 Editorial .

經(jīng)皮完全內(nèi)鏡下脊柱手術(shù)技術(shù)的發(fā)展與現(xiàn)狀

侯樹勛

現(xiàn)代經(jīng)皮內(nèi)鏡下脊柱手術(shù)技術(shù)的發(fā)展是建立在 Yeung[1]發(fā)明的 YESS ( yeung endoscopic spine system ) 脊柱內(nèi)鏡系統(tǒng)及 YESS 技術(shù)基礎(chǔ)之上的。Ruetten，Hoogland 等[2-3]在 YESS 脊柱內(nèi)鏡系統(tǒng)基礎(chǔ)上進行改進，并提出完全內(nèi)鏡技術(shù) ( full-endoscopic technique ) 及 TESSYS ( transforaminal endoscopic surgical system ) 等概念。但這些脊柱內(nèi)鏡系統(tǒng)都是使用帶工作通道的硬桿狀內(nèi)鏡在持續(xù)生理鹽水灌洗下進行的微創(chuàng)脊柱手術(shù)，只是手術(shù)技術(shù)上不斷改進以適應更復雜的病例，所以都可以稱為完全內(nèi)鏡下手術(shù)技術(shù)。目前主要用于頸、腰椎間盤突出癥、頸椎管狹窄癥、腰椎管狹窄癥及慢性腰痛等疾病的治療。

目前，經(jīng)皮完全內(nèi)鏡下腰椎手術(shù)技術(shù)漸趨成熟。完全內(nèi)鏡下腰椎間盤摘除術(shù)分為經(jīng)椎間孔入路和經(jīng)椎板間入路兩類技術(shù)[4]。最早的完全內(nèi)鏡下腰椎間盤摘除術(shù)是使用 YESS 系統(tǒng)經(jīng)后外側(cè)椎間孔入路進行的由盤內(nèi)至盤外的操作技術(shù)，適用于椎間孔型及極外側(cè)型椎間盤突出，對椎管內(nèi)包含型突出及韌帶下型椎間盤脫出也可以有效處理，但對椎管內(nèi)脫出及游離髓核無法有效切除[5]。Ruetten 等[6]采用側(cè)方入路技術(shù)可以將內(nèi)鏡經(jīng)椎間孔置入椎管內(nèi)，摘除脫出及游離髓核組織，使經(jīng)椎間孔完全內(nèi)鏡下腰椎間盤摘除術(shù)適應證進一步擴大，但 L5～S1節(jié)段解剖與上位腰椎有諸多不同，使該技術(shù)運用困難。腰椎間孔擴大成形術(shù)的出現(xiàn)使這一難題的解決出現(xiàn)轉(zhuǎn)機，Knight 等[7-8]在治療腰痛時使用激光對腰椎間孔進行擴大以達到椎間孔減壓的效果，Hoogland等[3]在此基礎(chǔ)上發(fā)明的逐級環(huán)鋸系統(tǒng)，對腰椎間孔進行逐級擴大，使工作套管及內(nèi)鏡直接進入椎管內(nèi)進行脫出物的靶向切除，即由椎間盤外向內(nèi)的 TESSYS 技術(shù)。

隨著腰椎間孔成形技術(shù)的出現(xiàn)及完善，可對大多數(shù)腰椎間盤突出癥進行有效治療[9-10]。但用于治療椎管內(nèi)巨大型脫出及高度移位型椎間盤突出癥時，失敗率仍高達 15.7%[11]。

經(jīng)椎板間入路完全內(nèi)鏡下腰椎間盤摘除術(shù)可以作為技術(shù)補充治療各種復雜的椎管內(nèi)腰椎間盤突出癥，如巨大型或高度移位型椎間盤脫出。經(jīng)皮經(jīng)椎板間隙入路內(nèi)鏡下腰椎間盤摘除術(shù)最早由 Choi 等[12]報道，盡管提出根據(jù)術(shù)前影像學資料確定穿刺路徑及工作區(qū)域 ( 腋路或肩路 ) 等理念，但由于工作套管進入椎管內(nèi)的過程完全依賴 X 線透視引導及患者的反饋，無法確保工作套管置入過程中對椎管內(nèi)神經(jīng)組織的保護，所以出現(xiàn)術(shù)中轉(zhuǎn)開放手術(shù)、硬膜撕裂、神經(jīng)根損傷、脫出物殘留等并發(fā)癥，總并發(fā)癥發(fā)生率高達 20.9%。而 Ruetten等[2]采用經(jīng)皮完全內(nèi)鏡監(jiān)視下逐層進入、切開黃韌帶、經(jīng)走行神經(jīng)根外側(cè) ( 肩路 ) 進入椎管內(nèi)摘除脫出椎間盤組織的手術(shù)技術(shù)明顯提高了手術(shù)的安全性，優(yōu)良率達 92%，但復發(fā)率高達 5.7%，可能與術(shù)中只摘除椎管內(nèi)脫出、游離椎間盤，而沒有處理椎間盤內(nèi)松動的髓核有關(guān)，因此，該技術(shù)術(shù)后仍可出現(xiàn)神經(jīng)支配區(qū)感覺異常、硬膜撕裂等并發(fā)癥。李振宙等[13-14]結(jié)合 Choi 和 Ruetten 的技術(shù)優(yōu)點，提出根據(jù)椎間盤突出部位選擇合適椎管內(nèi)工作區(qū)域的手術(shù)策略，大大增強了該手術(shù)的合理性及安全性。對于 L5～S1腋部 ( S1神經(jīng)根與硬膜囊之間 ) 脫出型，由于突出椎間盤組織相對固定，S1神經(jīng)根被擠向側(cè)隱窩，如果仍采用肩路 ( S1神經(jīng)根外側(cè) ) 手術(shù)，神經(jīng)根可能嵌夾于脫出物和工作套管之間，造成神經(jīng)根損傷，而且 S1神經(jīng)根神經(jīng)節(jié)大多位于椎管內(nèi)，擠壓神經(jīng)節(jié)會引起 S1皮節(jié)感覺異常；而對于腋部游離型，由于脫出物處于游離狀態(tài)，從肩路手術(shù)，可能將神經(jīng)根和游離脫出物一并推擠至對側(cè)，導致脫出物殘留，甚至引起對側(cè)神經(jīng)根受壓。解剖學研究發(fā)現(xiàn) S1神經(jīng)根從硬膜囊的發(fā)出角平均 22°，這個角度允許工作套管進入腋部進行手術(shù)操作[15-16]，而且 L5～S1腋型椎間盤脫出往往把 S1神經(jīng)根推向外側(cè)，增加神經(jīng)根硬膜囊之間的角度及空間，使腋路手術(shù)更加安全、容易。當然，對于腹型或肩型 L5～S1椎間盤突出，神經(jīng)根向內(nèi)下移位，從神經(jīng)根肩部手術(shù)更為合理。對于 L2～5椎間盤突出癥，運用經(jīng)皮經(jīng)椎板間隙入路完全內(nèi)鏡下腰椎間盤摘除術(shù)的手術(shù)策略更須小心謹慎：對肩型及腹型椎間盤突出，采用肩路手術(shù)；對腋型椎間盤突出，首先按 Suh 等[17]的方法確定走行神經(jīng)根發(fā)出點的位置，如果走行神經(jīng)根在硬膜囊的發(fā)出點位于椎間盤平面或椎間盤平面以上，單純采用腋路，將內(nèi)鏡及工作套管直接置入走行神經(jīng)根腋部進行脫出物及椎間盤內(nèi)松動髓核的摘除；如果走行神經(jīng)根在硬膜囊上的發(fā)出點位于椎間盤平面以下，先采用腋路，摘除腋部脫出或游離椎間盤組織，然后將工作區(qū)域移至走行神經(jīng)根肩部，摘除椎間盤內(nèi)松動髓核組織 ( 腋路 - 肩路 )。

隨著經(jīng)皮內(nèi)鏡下手術(shù)器械的改進與完善，經(jīng)皮經(jīng)椎板間隙入路完全內(nèi)鏡下腰椎管減壓技術(shù)也獲得良好的臨床療效。經(jīng)皮經(jīng)椎板間隙完全內(nèi)鏡下可以充分切除腰椎側(cè)隱窩骨性、肥厚韌帶、關(guān)節(jié)突關(guān)節(jié)囊腫及椎間盤來源的壓迫，Ruetten 等[18-19]比較經(jīng)椎板間隙完全內(nèi)鏡下及顯微鏡下腰椎側(cè)隱窩減壓技術(shù)，兩者療效相近，但完全內(nèi)鏡下手術(shù)并發(fā)癥明顯低于顯微鏡下腰椎管減壓技術(shù)。Komp 等[20]采用經(jīng)皮經(jīng)椎板間隙入路、單通道雙側(cè)減壓技術(shù)治療中央椎管狹窄也獲得 93% 的優(yōu)良率，與傳統(tǒng)手術(shù)結(jié)果相近，但并發(fā)癥發(fā)生率明顯降低。

經(jīng)皮腰椎內(nèi)鏡技術(shù)在慢性腰痛的治療方面也取得優(yōu)異療效。采用側(cè)后路經(jīng)椎間孔下選擇性摘除、射頻熱凝纖維環(huán)成形術(shù)治療椎間盤源性腰痛[21-22]；采用內(nèi)窺鏡下腰脊神經(jīng)背內(nèi)側(cè)支切斷術(shù)治療腰椎小關(guān)節(jié)源性腰痛均獲得良好療效[23-24]。使大部分慢性腰痛的治療微創(chuàng)化、可視化、靶向化。

經(jīng)皮完全內(nèi)鏡下胸椎手術(shù)技術(shù)運用較少[25]。Choi 等[26]采用局麻下完全內(nèi)鏡下手術(shù)技術(shù)治療 14 例軟性胸椎間盤突出癥獲得良好的臨床療效，術(shù)中對上關(guān)節(jié)突外、下部分切除做椎間孔成形手術(shù)，創(chuàng)造內(nèi)鏡進入胸椎管的通道，從而達到脫出物靶向切除的目的。

經(jīng)皮完全內(nèi)鏡下頸椎手術(shù)技術(shù)目前有長足的發(fā)展。頸椎前路完全內(nèi)鏡下椎間盤摘除、椎間孔成形、纖維環(huán)成形、椎管減壓等技術(shù)具有切口小、非融合、保留頸椎運動節(jié)段、費用低、恢復快、并發(fā)癥少、術(shù)后止痛藥使用少等優(yōu)點，無器械失敗風險、無假關(guān)節(jié)、術(shù)后吞咽不適、無融合手術(shù)后相鄰節(jié)段病變等并發(fā)癥，可以作為門診手術(shù)實施[27]。Ruetten 等[28]比較完全內(nèi)鏡下頸椎前路椎間盤摘除術(shù)和傳統(tǒng)頸椎前路融合手術(shù)療效、兩者無明顯差異，完全內(nèi)鏡下手術(shù)組優(yōu)良率高達 96%。完全內(nèi)鏡下頸椎前路椎間盤摘除、椎間融合術(shù)也獲得至少 5 年的隨訪，臨床優(yōu)良率達 86.6%，椎間融合率高達 100%[29]。當然，頸椎前路完全內(nèi)鏡技術(shù)也可能發(fā)生嚴重并發(fā)癥如頸部大血管、食道、脊髓等重要結(jié)構(gòu)的損傷[30-31]。所以嚴格適應證選擇、完善手術(shù)技術(shù)對促進該技術(shù)的推廣至關(guān)重要[32]，Liu 等[33]采用經(jīng)椎間盤及硬膜外造影技術(shù)勾勒出頸脊髓前方壓迫形態(tài)，術(shù)中X 線監(jiān)視及內(nèi)鏡監(jiān)視下減壓，可以減少頸脊髓損傷的幾率。Ruetten 等[34]運用頸椎后路完全內(nèi)鏡下頸椎間孔切開、椎間盤摘除術(shù)治療側(cè)后方型頸椎間盤突出癥也獲得 96.6% 的優(yōu)良率，未發(fā)生明顯并發(fā)癥。

在中國微創(chuàng)脊柱外科醫(yī)生的努力下，國內(nèi)的經(jīng)皮完全內(nèi)鏡下手術(shù)技術(shù)也獲得可喜的發(fā)展。本期內(nèi)容涵蓋經(jīng)椎間孔入路、經(jīng)椎板間隙入路完全內(nèi)鏡下腰椎間盤摘除技術(shù)、腰椎管減壓技術(shù)、頸椎管減壓及頸椎間盤摘除技術(shù)等內(nèi)容，客觀反映了國內(nèi)、外運用經(jīng)皮完全內(nèi)鏡下脊柱手術(shù)技術(shù)治療脊柱疾病的現(xiàn)狀和水平。衛(wèi)生部建立的脊柱內(nèi)鏡手術(shù)技術(shù)的逐級培訓及準入制度，一定會促進該技術(shù)在國內(nèi)的健康發(fā)展。希望經(jīng)皮完全內(nèi)鏡下脊柱手術(shù)技術(shù)能得到科學、合理地運用及推廣，惠及廣大患者。

[1]Yeung AT. Minimally invasive disc surgery with the Yeung Endoscopic Spine System (YESS). Surg Technol Int, 1999, 8:267-277.

[2]Ruetten S, Komp M, Godolias G. A new full-endoscopic technique for the interlaminar operation of lumbar disc herniations using 6-mm endoscopes: prospective 2-year results of 331 patients. Minim Invasive Neurosurg, 2006, 49(2):80-87.

[3]Hoogland T, Schubert M, Miklitz B, et al. Transforaminal posterolateral endoscopic discectomy with or without the combination of a lowdose chymopapain: a prospective randomized study in 280 consecutive cases. Spine, 2006, 31(24):E890-897.

[4]Ruetten S, Komp M, Merk H, et al. Use of newly developed instruments and endoscopes: full-endoscopic resection of lumbar disc herniations via the interlaminar and lateral transforaminal approach. J Neurosurg Spine, 2007, 6(6):521-530.

[5]Yeung AT, Tsou PM. Posterolateral endoscopic excision for lumbar disc herniation: Surgical technique, outcome, and complications in 307 consecutive cases. Spine, 2002, 27(7):722-731.

[6]Ruetten S, Komp M, Godolias G. An extreme lateral access for the surgery of lumbar disc herniations inside the spinal canal using the fullendoscopic uniportal transforaminal approach-technique and prospective results of 463 patients. Spine, 2005, 30(22):2570-2578.

[7]Knight MT, Ellison DR, Goswami A, et al. Review of safety in endoscopic laser foraminoplasty for the management of back pain. J Clin Laser Med Surg, 2001, 19(3):147-157.

[8]Knight MT, Goswami A, Patko JT, et al. Endoscopic foraminoplasty: a prospective study on 250 consecutive patients with independent evaluation. J Clin Laser Med Surg, 2001, 19(2):73-81.

[9]李振宙, 吳聞文, 侯樹勛, 等. 經(jīng)皮腰椎間孔成型內(nèi)窺鏡下椎間盤切除術(shù)治療腰椎間盤突出癥的療效觀察. 中國脊柱脊髓雜志, 2008, 18(10):752-756.

[10]李振宙, 侯樹勛, 商衛(wèi)林, 等. 經(jīng)皮腰椎間孔擴大成型器械的設計及臨床運用. 中華骨科雜志, 2011, 31(10):1026-1032.

[11]Lee SH, Kang BU, Ahn Y, et al. Operative failure of percutaneous endoscopic lumbar discectomy: a radiologic analysis of 55 cases. Spine, 2006, 31(10):E285-290.

[12]Choi G, Lee SH, Raiturker PP, et al. Percutaneous endoscopic interlaminar discectomy for intracanalicular disc herniations at L5-S1 using a rigid working channel endoscope. Neurosurgery, 2006, 58(1 Suppl):ONS59-68.

[13]李振宙, 侯樹勛, 宋科冉, 等. 經(jīng)椎板間隙入路完全內(nèi)窺鏡下椎間盤摘除術(shù)治療L5～S1非包含型椎間盤突出癥. 中國脊柱脊髓雜志, 2013, 23(9):771-777.

[14]李振宙, 侯樹勛, 宋科冉, 等. 經(jīng)椎板間完全內(nèi)鏡下L2～5椎間盤摘除術(shù)的手術(shù)策略. 中國矯形外科雜志, 2014, 22(3):201-207.

[15]Hasegawa T, Mikawa Y, Watanabe R, et al. Morphometric analysis of the lumbosacral nerve roots and dorsal root ganglia by magnetic resonance imaging. Spine, 1996, 21(9):1005-1009.

[16]Ebraheim NA, Miller RM, Xu R, et al. The location of the intervertebral lumbar disc on the posterior aspect of the spine. Surg Neurol, 1997, 48(3):232-236.

[17]Suh SW, Shingade VU, Lee SH, et al. Origin of lumbar spinal roots and their relationship to intervertebral discs: a cadaver and radiological study. J Bone Joint Surg Br, 2005, 87(4):518-522.

[18]Ruetten S, Komp M, Hahn P, et al. Decompression of lumbar lateral spinal stenosis: full-endoscopic, interlaminar technique. Oper Orthop Traumatol, 2013, 25(1):31-46.

[19]Ruetten S, Komp M, Merk H, et al. Surgical treatment for lumbar lateral recess stenosis with the full-endoscopic interlaminar approach versus conventional microsurgical technique: a prospective, randomized, controlled study. J Neurosurg Spine, 2009, 10(5):476-485.

[20]Komp M, Hahn P, Merk H, et al. Bilateral operation of lumbar degenerative central spinal stenosis in full-endoscopic interlaminar technique with unilateral approach: prospective 2-year results of 74 patients. J Spinal Disord Tech, 2011, 24(5):281-287.

[21]Tsou PM, Alan Yeung C, Yeung AT. Posterolateral transforaminal selective endoscopic discectomy and thermal annuloplasty for chronic lumbar discogenic pain: a minimal access visualized intradiscal surgical procedure. Spine J, 2004, 4(5):564-573.

[22]李振宙, 吳聞文, 侯樹勛, 等. 側(cè)后路經(jīng)皮椎間孔鏡下髓核摘除, 射頻熱凝纖維環(huán)成型術(shù)治療椎間盤源性腰痛. 中國微創(chuàng)外科雜志, 2009, 9(4):332-335.

[23]李振宙, 侯樹勛, 商衛(wèi)林, 等. 內(nèi)窺鏡下腰脊神經(jīng)背內(nèi)側(cè)支解剖變異及其臨床意義. 中國骨與關(guān)節(jié)雜志, 2013, 2(4):188-193.

[24]李振宙, 侯樹勛, 商衛(wèi)林, 等. 內(nèi)窺鏡下脊神經(jīng)背內(nèi)側(cè)支切斷術(shù)治療腰椎關(guān)節(jié)突關(guān)節(jié)源性慢性腰痛. 中國脊柱脊髓雜志, 2013, 23(3): 215-221.

[25]Chiu JC, Clifford TJ, Sison R, et al. Percutaneous microdecompressive endoscopic thoracic discectomy for herniated thoracic discs. Surg Technol Int, 2002, 10:266-269.

[26]Choi KY, Eun SS, Lee SH, et al. Percutaneous endoscopic thoracic discectomy; transforaminal approach. Minim Invasive Neurosurg, 2010,53(1):25-28.

[27]Deukmedjian AJ, Cianciabella A, Cutright J, et al. Cervical Deuk Laser Disc Repair (?): A novel, full-endoscopic surgical technique for the treatment of symptomatic cervical disc disease. Surg Neurol Int, 2012, 3:142.

[28]Ruetten S, Komp M, Merk H, et al. Full-endoscopic anterior decompression versus conventional anterior decompression and fusion in cervical disc herniations. Int Orthop, 2009, 33(6):1677-1682.

[29]Yao N, Wang C, Wang W, et al. Full-endoscopic technique for anterior cervical discectomy and interbody fusion: 5-year follow-up results of 67 cases. Eur Spine J, 2011, 20(6):899-904.

[30]Tzaan WC. Anterior percutaneous endoscopic cervical discectomy for cervical intervertebral disc herniation: outcome, complications, and technique. J Spinal Disord Tech, 2011, 24(7):421-431.

[31]Haufe SM, Mork AR. Complications associated with cervical endoscopic discectomy with the holmium laser. J Clin Laser Med Surg, 2004, 22(1):57-58.

[32]Ahn Y, Lee SH, Lee SC, et al. Factors predicting excellent outcome of percutaneous cervical discectomy: analysis of 111 consecutive cases. Neuroradiology, 2004, 46(5):378-384.

[33]Liu KX, Massoud B. Endoscopic anterior cervical discectomy under epidurogram guidance. Surg Technol Int, 2010, 20:373-378.

[34]Ruetten S, Komp M, Merk H, et al. A new full-endoscopic technique for cervical posterior foraminotomy in the treatment of lateral disc herniations using 6.9-mm endoscopes: prospective 2-year results of 87 patients. Minim Invasive Neurosurg, 2007, 50(4):219-226.

( 本文編輯：李貴存 )

Development and present status of percutaneous full-endoscopic spine surgery

HOU Shu-xun. Orthopedic Institute of CPLA, the frst Affliated Hospital of the General Hospital of CPLA, Beijing, 100048, PRC

With the improvement of the instrument and development of the technique, the same curative effects can be achieved in modern percutaneous endoscopic spine surgery as in traditional open surgery in the treatment of lumbar disc herniation. And the occurrence rate of complications is obviously reduced. The percutaneous endoscopic technique can be performed via the interlaminar approach and the transforaminal approach. Lumbar spinal stenosis and joint bone cyst are effectively treated with percutaneous endoscopic spinal canal decompression. Good curative results will be obtained in percutaneous endoscopic cervical discectomy and cervical intervertebral foramen dissection via anterior and posterior approaches for cervical disc herniation, cervical foraminal stenosis and so on. With unique advantages and higher treatment effectiveness, the percutaneous endoscopic technique is also effective in the treatment of chronic cervical and lumbar pain.

Intervertebral disc displacement; Diskectomy, percutaneous; Nal diseases; Surgical procedures; Minimally invasive

10.3969/j.issn.2095-252X.2014.08.002

Th776.1, R687.3

100048 北京，解放軍總醫(yī)院第一附屬醫(yī)院骨科

2014-06-13 )