目的: 比较单侧双通道内镜技术(unilateral biportal endoscopic discectomy, UBE)与显微内镜椎间盘切除系统(microendoscopic discectomy, MED)两种术式辅助下治疗退行性腰椎管狭窄症(degenerative lumbar spinal stenosis, DLSS)的中远期疗效。方法: 回顾性分析2018年9月至2019年9月云南中医药大学第三附属医院骨伤科与云南中医药大学第一附属医院骨伤科收治的DLSS患者共137例,按照手术方式分为UBE组(n=66例)和MED组(n=71例),比较两组患者术前、术后、随访时的临床资料及影像学资料。结果: 术前、术中、术后两组患者均无严重并发症发生,且两组患者顺利出院。UBE组手术切口总长度长于MED组,差异具有统计学意义(P＜0.05)。两组患者住院时间、下地时间比较,差异无统计学意义(P＞0.05);两组患者术后随着时间递进,腰痛VAS评分、腿痛VAS评分、ODI评分均明显降低(P＜0.05),术后7 d UBE组腰痛VAS评分明显高于MED组(P＜0.05),但两组上述指标在术后3、24、36个月比较差异无统计学意义(P＞0.05)。术后24、30个月随访时两组腰椎椎管面积比较差异无统计学意义(P＞0.05),但在椎旁肌截面积、椎旁肌萎缩程度MED组明显优于UBE组(P＜0.05)。在术后随访时两组患者并发症的发生率比较差异无统计学意义(P＞0.05)。结论: UBE与MED均具有创伤小、出血少等优势,但在早期腰痛缓解、中远期椎旁肌截面积、椎旁肌萎缩程度等方面,UBE相对于MED并不具有优势,同时两种术式减压效果相当;由于UBE技术仍处于发展探索阶段,因此在退行性腰椎管狭窄症患者手术方式选择时,MED技术值得优先推荐。
Objective: To compare the mid-long term efficacy of unilateral biportal endoscopic discectomy (UBE) and microendoscopic discectomy (MED) in the treatment of degenerative spinal stenosis (DLSS). Methods: A total of 137 patients with DLSS admitted to the Department of Orthopedics and Traumatology of the Third Affiliated Hospital of Yunnan University of Chinese Medicine and the First Affiliated Hospital of Yunnan University of Chinese Medicine from September 2018 to September 2019 were retrospectively analyzed. They were divided into the UBE group (n=66) and MED group (n=71) based on different surgical methods. The clinical and imaging data of the two groups were compared before, after operation and during follow-up. Results: There were no serious complications in the two groups before, during and after operation, and the patients in the two groups were discharged smoothly. The total length of surgical incision in the UBE group was longer than that in the MED group, and the difference was statistically significant (P＜0.05). There was no significant difference in length of stay and ambulation time between the two groups (P＞0.05). VAS scores of low back pain and leg pain and ODI scores of the two groups decreased significantly with time after operation (P＜0.05). VAS scores of low back pain in the UBE group were significantly higher than those in the MED group 7 days after operation, and the difference was statistically significant (P＜0.05). However, there was no significant difference in the above indicators between the two groups 3 months, 24 months and 36 months after operation (P＞0.05). There was no significant difference in the area of lumbar spinal canal between the two groups 24 months and 30 months after operation (P＞0.05), but the cross-sectional area of paraspinal muscle and the degree of paraspinal muscle atrophy in the MED group were significantly better than those in the UBE group, and the difference was statistically significant (P＜0.05). There was no significant difference in the incidence of complications between the two groups (P＞0.05). Conclusion: Both UBE and MED have the advantages of smaller incision and less bleeding, but UBE is not superior to MED in the early relief of low back pain, the cross-sectional area of paraspinal muscle in the medium and long term, and the degree of paraspinal muscle atrophy. Meanwhile, the decompression effect of the two surgical methods is similar. Therefore, MED technique is worthy of priority recommendation in the selection of surgical methods for patients with DLSS.
[1] Hennemann S, de Abreu MR. Degenerative lumbar spinal stenosis[J]. Rev Bras Ortop (Sao Paulo), 2021, 56(1): 9-17.
[2] Lurie J, Tomkins-Lane C. Management of lumbar spinal stenosis[J]. BMJ, 2016, 352: h6234.
[3] Otani K, Kikuchi S, Yabuki S, et al. Lumbar spinal stenosis has a negative impact on quality of life compared with other comorbidities: an epidemiological cross-sectional study of 1862 community-dwelling individuals[J]. Scientific World J, 2013, 2013(11): 1653-1656.
[4] Kitab S, Lee BS, Benzel EC. Redefining lumbar spinal stenosis as a developmental syndrome: an MRI-based multivariate analysis of findings in 709 patients throughout the 16-to 82-year age spectrum[J]. Neurosurg Spine, 2018, 29(6): 654-660.
[5] 庹伟, 周霖, 刘德森, 等. 单侧双通道内镜技术治疗腰椎管狭窄的初步研究[J]. 中国微创外科杂志, 2021, 21(1): 56-60.
[6] 赵晓东, 邓立明, 王建波, 等. 椎间孔镜与椎间盘镜治疗腰椎间盘突出症5年疗效比较[J]. 中国微创外科杂志, 2019, 19(8): 684-687, 701.
[7] 林上进, 杨丰建, 范永前. 老年退行性腰椎管狭窄症微创手术治疗进展[J]. 国际骨科学杂志, 2022, 43(4): 231-235.
[8] 余可谊. 单侧入路双通道脊柱内镜的发展简史、全球现状与中国使命[J/OL]. 中国修复重建外科杂志: 1-5[2022-09-29]. http://kns--cnki--net--https.cnki.ynzyy.shuyaoshu.com:2222/kcms/detail/51.1372.R.20220819.1652.010.html.
[9] 肖亚杰, 申杨勇, 陈京峰, 等. 单侧双通道内镜手术治疗腰椎管狭窄症安全性的Meta分析[J]. 中国临床神经外科杂志, 2022, 27(2): 85-89.
[10] 陈涛, 程子官, 张弛. 单侧双通道脊柱内镜技术在治疗腰椎管狭窄症中的应用进展及思考[J]. 按摩与康复医学, 2022, 13(11): 70-73.
[11] 沈天宇, 柏刚, 陈瑞, 等. 单侧双通道内镜技术与显微内镜技术治疗退变性腰椎管狭窄症的Meta分析[J]. 临床荟萃, 2022, 37(8): 691-698.
[12] Lee HG, Kang MS, Kim SY, et al. Dural injury in unilateral biportal endoscopic spinal surgery[J]. Global Spine, 2021, 11(6): 845-851.
[13] 吴永超. 大力开展双通道脊柱内镜手术[J]. 临床外科杂志, 2022, 30(4): 301-302.
[14] 贺少杰, 查丁胜, 黄嘉文, 等. 单侧双通道脊柱内镜与显微内镜下减压术治疗腰椎管狭窄症疗效的Meta分析[J]. 中华创伤骨科杂志, 2022, 24(7): 634-639.
[15] Kim JE, Choi DJ. Unilateral biportal endoscopic decompression by 30 endoscopy in lumbar spinal stenosis: Technical note and preliminary report[J]. J Orthop, 2018, 15(2): 366-371.
[16] Kim W, Kim SK, Kang SS, et al. Pooled analysis of unsuccessful percutaneous biportal endoscopic surgery outcomes from a multi-institutional retrospective cohort of 797 cases[J]. Acta Neurochir (Wien), 2020, 162(2): 279-287.
[17] Kim JE, Yoo HS, Choi DJ, et al. Comparison of minimal invasive versus biportal endoscopic transforaminal lumbar interbody fusion for single-level lumbar disease[J]. Clin Spine Surg, 2020, 34(2): E64-E71.
[18] Ahn DK, Lee JS, Shin WS, et al. Postoperative spinal epidural hematoma in a biportal endoscopic spine surgery[J]. Medicine, 2021, 100(6): e24685-e24685.
[19] Choi CM, Chung JT, Lee SJ, et al. How I do it? Biportal endoscopic spinal surgery (BESS) for treatment of lumbar spinal stenosis[J]. Acta Neurochir (Wien), 2016, 158(3): 459-463.
