经皮全内镜下颈后路椎间盘切除术在颈椎融合术后邻近节段退变病的应用初探

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摘要目的探讨经皮全内镜下颈后路椎间盘切除技术(posterior percutaneous endoscopic cervical discectomy，PPECD)在颈椎融合术后邻近节段退变病中的临床应用价值。方法收集2015年4月至2017年6月，我院脊柱科收治颈椎前路融合术后邻近节段退变病患者8例，其中男性6例，女性2例，年龄49~77岁，平均60.9岁。邻近节段退变发生在融合术后48~162个月，平均94.3个月，表现为神经根型颈椎病4例，脊髓型颈椎病3例，混合型颈椎病(脊髓型+神经根型)1例。应用PPECD方式治疗，记录手术时间、住院天数和手术相关并发症。采用日本矫形外科协会(Japanese orthopedic association，JOA)评分及颈部残障功能指数(neck disability index，NDI)评价神经功能，疼痛视觉模拟评分法(visual analogue scale，VAS)评价颈部、上肢疼痛，末次随访时根据Odom标准与JOA改善优良率评定临床疗效。颈椎侧位X线片测量手术节段椎间高度，过伸过屈位X线片测量手术节段活动度(range of motion，ROM)，对术前及随访时的数据进行比较。结果所有病例均在内镜下顺利完成手术，无病例更改手术方式。手术节段共9节，其中单节段7例，双节段1例。C_3～4节段1例，C_4～5节段4例，C_6～7节段2例，C_5～6、C_6～7双节段1例。手术时间为62～140 min，平均94.8 min，平均住院天数为4.8 d。8例患者均获得随访，术后随访8~33个月，平均(15.9±6.7)个月，术后1周的VAS、NDI及JOA较术前显著改善(P＜0.05)，末次随访时的VAS、NDI及JOA较术后1周进一步改善，差异有统计学意义(P＜0.05)。术前手术节段ROM为(5.27±1.26)°，术后1周时为(5.63±1.48)°，末次随访时为(5.44±1.56)°，手术前后相比差异无统计学意义(P＞0.05)。手术节段椎间隙高度术前及末次随访时相比差异无统计学意义(P＞0.05)。本组病例术中未出现脊髓神经和重要血管损伤，术后无伤口感染、血肿等并发症。根据Odom标准末次随访时的优良率为87.5%(优5例，良2例，中1例，差0例)，JOA评分改善率78.14%。结论 PPECD技术作为一种崭新的脊柱微创技术，为颈椎融合术后邻近节段退变提供了一种安全、有效的治疗方式，并获得良好的近期临床结果。

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	杨立进 1
	陈博来 2*
	林涌鹏 2
	李永津 2

关键词 ：经皮内窥镜, 椎间盘切除术, 脊柱融合术, 邻近节段退变, 临床疗效

Abstract：Objective To investigate the clinical value of percutaneous endoscopic posterior cervical discectomy in patients with adjacent segment disease after cervical fusion.Methods From April 2015 to June 2017，8 cases of adjacent segment disease after anterior cervical fusion were treated in our department，including 6 males and 2 females，aged 49~77 years (average 60.9 years).The adjacent segment disease occurred in 48~162 months after fusion (average 94.3 months)，there were 4 cases of cervical spondylotic radiculopathy，3 cases of cervical spondylotic myelopathy and 1 case of mixed cervical spondylosis.PPECD therapy was used and record the operation time，the days of hospitalization and the complications.The Japanese Orthopedic Association (JOA) score and cervical disability function index (Neck Disability Index，NDI) were used to evaluate neurological function，visual analogue scale(VAS) was used to evaluate neck and upper limb pain，in the last follow-up，the clinical efficacy was evaluated according to the Odom standard and the JOA improvement rate.The lateral X-ray of the cervical spine was used to measure the intervertebral height of the surgical segment.The ROM of the surgical segment was measured by the dynamic X-ray and the data were compared before and after the follow-up.Results All cases were successfully performed under the complete percutaneous endoscopy，no cases needed to be changed.There were 9 sections of the operative segment，7 cases of single segment，1 cases of double segment，1 cases of C_3～4segment，4 cases of C_4～5 segment，1 cases of C_5～6，C_6～7 double segment and 2 cases of C_6～7 segment，the operation time was 62~140 min (average 94.8 min)，and the average number of hospitalization days was 4.8 days.8 cases were followed up，the follow-up of 8~33 months (average 15.9±6.7 months)，VAS，NDI and JOA were significantly improved at 1 weeks after operation (P＜0.05)，and VAS，NDI and JOA at the last time were further improved than those at 1 weeks after operation.The difference was statistically significant (P＜0.05).The preoperative surgical segment ROM was (5.27±1.26)°，(5.63±1.48)° at 1 week，and (5.44±1.56)° at the last follow-up.There was no statistical difference before and after surgery (P＞0.05).There was no significant difference in the height of intervertebral space between preoperative and final follow-up (P＞0.05).There were no injuries of the spinal nerve and important vessels during the operation，and no complications such as wound infection and hematoma were found after operation.According to the Odom standard，the excellent rate at the last follow-up was 87.5% (excellent 5 cases，good 2 cases，middle 1 cases，0 poor cases)，and the improvement rate of JOA score was 78.14%.Conclusion As a newly minimally invasive technique，PPECD technology provides a safe and effective way in the treatment of adjacent segment disease after cervical fusion and achieves good recent clinical results.

Key words： percutaneous endoscopic endoscopy discectomy spinal fusion adjacent segment disease clinical outcome

通讯作者: 陈博来

作者简介: 杨立进(1992－ )，男，研究生在读，广州中医药大学，510405。

引用本文:

杨立进 1，陈博来 2*，林涌鹏 2，李永津 2. 经皮全内镜下颈后路椎间盘切除术在颈椎融合术后邻近节段退变病的应用初探[J]. 实用骨科杂志, 2018, 24(11): 961-966.
Yang Lijin 1，Chen Bolai 2，Lin Yongpeng 2，et al. Clinical Application of Percutaneous Endoscopic Posterior Cervical Discectomy in Patients with Adjacent Segment Disease after Cervical Fusion. sygkzz, 2018, 24(11): 961-966.

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http://www.sygkzz.com/CN/ 或 http://www.sygkzz.com/CN/Y2018/V24/I11/961

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