神经根造影加封闭的精确诊断在脊柱内镜镜下融合治疗多节段腰椎管狭窄合并腰椎失稳症中的应用

doi:10.3969/j.issn.1006-5725.2023.21.023

摘要/Abstract

摘要：

目的探讨神经根造影加封闭（neurography and nerve root sealing， NNRS）的精确诊断在脊柱内镜镜下融合（Endo-P/TLIF）治疗多节段腰椎管狭窄合并腰椎失稳症中的应用。方法收集从2022年1月1日至6月21日广西中医药大学第一附属医院住院的多节段腰椎管狭窄合并腰椎失稳的患者共60例，所有患者术前均行神经根封闭造影确认责任节段并对其行Endo-P/TLIF治疗，随访6个月。记录患者的年龄、性别、病程、手术时间、术中出血、住院时间、下床时间；术前、术后、术后3个月和术后6个月的VAS评分、ODI评分、JOA评分、腰椎前凸角、椎间高度、硬膜横断面积、骶骨倾斜角、骨盆投射角、骨盆倾斜角；MRI提示、神经根封闭造影确认的责任节段和最终减压时的单节段、双节段、3节段及以上的例数，并进行统计学分析。结果所有患者均顺利完成手术，随访6个月过程中1例患者未按时复诊，1例患者失联，最终58例患者随访资料完整纳入统计。术后6个月改善率优55例，良2例，好转1例，总有效率100%。通过NNRS的责任节段得出单侧单节段、双侧单节段的责任神经节段明显多于腰椎MRI显示节段数，得出单侧、双侧双节段和3节段及以上的责任神经节段明显少于腰椎MRI显示节段数差异有统计学意义（P < 0.05）；术后VAS评分、ODI评分、JOA评分，VAS评分、ODI评分、JOA评分、腰椎前凸角、椎间高度、硬膜横断面积、骶骨倾斜角、骨盆倾斜角与术前相比差异均有统计学意义（P < 0.05）；骨盆投射角与术前比较差异无统计学意义（P > 0.05），但仍有明显的改善。结论选择性NNRS的精确诊断的方法，能够在术前确认责任神经节段，在精确诊断的基础上运用Endo-P/TLIF手术方式治疗多节段腰椎管狭窄合并腰椎失稳症，责任节段精细减压，明显减小创伤和出血，缩短了住院时间，良好地恢复脊柱生理曲度，提高临床疗效，值得临床中广泛运用。

关键词: 多节段腰椎管狭窄, 神经根造影加封闭, 脊柱内镜镜下融合, 经皮脊柱内镜

Abstract:

Objective To explore the clinical value of neurography and nerve root sealing in treatment of multilevel lumbar spinal stenosis with lumbar instability using Endo?P/TLIF. Methods A total of 60 patients with multi?segment lumbar spinal stenosis and lumbar instability hospitalized in our hospital were included in this study From January 1， 2022 to June 21， 2022. All patients underwent nerve root closure angiography before surgery to confirm the responsible segments， and then the responsible segments were treated with Endo?P/TLIF. The patients were followed up for 6 months. The basic information on the age， gender， course of disease， surgical time， intraoperative bleeding， hospitalization time， and off?bed ambulation time was collected. Then the data on VAS score， ODI score， JOA score， lumbar lordosis angle， intervertebral height， dural cross?sectional area， sacral inclination angle， pelvic projection angle， and pelvic inclination angle before， right after， 3 months and 6 months after the operation were calculated. The number of responsible segments indicated by MRI and confirmed by nerve root closure angiography and the number of the single segment， double segments， 3 segments， and above finally decompressed were statistically analyzed. Results All patients went through the surgery safely. During the 6?month follow?up， one patient did not return to the hospital for consultation on time， and one patient was out of contact. Finally， the follow?up data of 58 patients were completely collected for statistical analysis. Fifty?five cases were remarkably improved， 2 better， and 1 moderately， 6 months after the operation， with a total effectiveness rate of 100%. The number of unilateral and bilateral single responsible segments confirmed by nerve root angiography and sealing was significantly larger than by MRI （P < 0.05）， but the number of unilateral and unilateral double， or multiple responsible segments was significantly smaller （P < 0.05）. There were statistically significant differences in terms of postoperative VAS score， ODI score， JOA score， VAS score， ODI score， JOA score， lumbar lordosis angle， intervertebral height， dural cross?sectional area， sacral inclination angle， pelvic inclination angle as compared to the preoperative data （P ? 0.05）. The pelvic projection angle was insignificantly improved as compared to the preoperative condition （P ? 0.05）. Conclusion The accurate diagnosis with selective neurography and nerve root sealing improves the confirmation of responsible nerve segments before operation. Base on the accurate diagnosis， multi?segment lumbar spinal canal stenosis with lumbar instability can be effectively treated with Endo?P/TLIF， the responsible segment decompressed， trauma and bleeding reduced， hospital stay shortened， spinal physiological curvature well recovered， and clinical efficacy improved. Therefore， the method is worthy of extensive application in clinical practice.

Key words: multi?segment lumbar spinal stenosis, nerve root sealing, Endo?P/TLIF, percutaneous spinal endoscopy

中图分类号:

R605.97

张翼升,孙亚如,唐福波,李智斐,莫怡,钟远鸣. 神经根造影加封闭的精确诊断在脊柱内镜镜下融合治疗多节段腰椎管狭窄合并腰椎失稳症中的应用[J]. 实用医学杂志, 2023, 39(21): 2827-2833.

Yisheng ZHANG,Yaru SUN,Fubo TANG,Zhifei LI,Yi MO,Yuanming ZHONG. Accurate diagnosis of neurography and nerve root sealing in treating multi⁃segment lumbar spinal stenosis with lumbar instability using Endo⁃P/TLIF[J]. The Journal of Practical Medicine, 2023, 39(21): 2827-2833.

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指标	数值
手术时间（min）	129.34 ± 14.58
术中出血（mL）	115.85 ± 17.80
住院时间（d）	6.32 ± 1.10
下床时间（h）	12.21 ± 2.78
性别（男/女，例）	33/25
年龄（岁）	57.40 ± 5.92
病程（个月）	16.72 ± 5.56

指标	术前^?	术后^■	术后3个月^▲	术后半年^●	t值	P值
VAS评分	6.98 ± 0.99	4.24 ± 0.80	2.06 ± 0.58	1.07 ± 0.65	14.691^?/■	0.001^?/■
					10.328^■/▲	0.001^■/▲
					9.292^▲/●	0.001^▲/●
ODI评分	41.05 ± 3.65	11.27 ± 1.84	6.86 ± 1.89	4.74 ± 0.73	55.082^?/■	0.001^?/■
					12.266^■/▲	0.001^■/▲
					8.371^▲/●	0.001^▲/●
JOA评分	13.05 ± 0.21	18.37 ± 1.86	20.71 ± 1.94	24.33 ± 1.30	-16.979^?/■	0.001^?/■
					-6.482^■/▲	0.001^■/▲
					-13.176^▲/●	0.001^▲/●

项目	术前^α	术后^β	术后3个月^γ	术后半年^ε	F值	P值
腰椎前凸角	（38.05 ± 3.97）°	（49.21 ± 2.06）°	（49.08 ± 2.17）°	（49.25 ± 2.13）°	-19.272 0.315^β -0.405	0.001 0.754^β/γ 0.687^γ/β
椎间高度（mm）	4.07 ± 0.62	5.03 ± 0.67	4.95 ± 0.69	5.08 ± 0.68	-7.423 0.692 -1.070^γ/β	0.001^α/β 0.489^β/γ 0.289^γ/β
硬膜横断面积（mm²）	81.12 ± 3.88	103.46 ± 5.68	103.08 ± 6.30	103.27 ± 7.10	-23.539 0.345 -1.174	0.001^α/β 0.731^β/γ 0.862^γ/β
骶骨倾斜角∠DOB	（29.17 ± 1.13）°	（26.81 ± 0.84）°	（26.71 ± 0.83）°	（26.74 ± 0.82）°	13.764 0.704 0.145	0.001^α/β 0.484^β/γ 0.818^γ/β
骨盆投射角∠FOG	（49.38 ± 3.14）°	（50.43 ± 2.87）°	（50.27 ± 2.67）°	（50.29 ± 2.47）°	-1.878 0.316 0.145	0.065^α/β 0.753^β/γ 0.885^γ/β
骨盆倾斜角∠HGO	（18.62 ± 1.99）°	（21.75 ± 2.22）°	（21.74 ± 2.08）°	（21.51 ± 2.05）°	-8.228 0.198 0.565	0.001^α/β 0.843^β/γ 0.574^γ/β