Objective: To observe the effectiveness and safety of percutaneous endoscopic transforaminal bilateral decompression for severe central lumbar spinal stenosis.
Methods: A retrospective analysis of 44 patients with single-segment severe central lumbar spinal stenosis with bilateral lower extremity symptoms between October 2015 and December 2017 was performed. Among them, 36 cases underwent bilateral decompression through bilateral transforaminal approach, and 8 cases underwent bilateral decompression through unilateral transforaminal approach. There were 25 males and 19 females, the age ranged from 56 to 89 years with an average of 68.6 years. The disease duration was 5-39 months with an average of 14.5 months. Involved segments: L 3, 4 in 6 cases, L 4, 5 in 33 cases, and L 5, S 1 in 5 cases. The dural sac cross-sectional area (DSCA) of the MRI was (66.36±8.48) mm 2. Morphological grading (MG) classification: 29 cases of grade C, 15 cases of grade D. The visual analogue scale (VAS) score of preoperative low back pain was 2.3±1.0 and the VAS score of lower extremity pain was 7.8±1.2; the Oswestry disability index (ODI) was 77.8±7.3. Postoperative VAS scores, ODI scores, MG classification, and DSCA were recorded and compared with preoperative ones, and clinical outcomes were assessed by using the modified MacNab criteria.
Results: All patients successfully underwent surgery and the wounds healed by first intention. All 44 patients were followed up 13-46 months with an average of 24.8 months. One patient developed postoperative lower extremity paralysis and 1 patient developed a dural tear. There was no infection, recurrence, or revision surgery during the follow-up. Postoperative imaging showed that the central spinal canal was enlarged and the area of the dural sac was significantly increased compared with preoperative one. The VAS score of low back pain was 2.4±0.6 and 2.5±0.8 at 1 month after operation and at last follow-up, showing no significant difference when compared with preoperative scores ( P>0.05). The VAS of lower limb pain was 2.1±0.6 and 2.0±1.1 at 1 month after operation and at last follow-up, which was significantly improved when compared with preoperative scores ( P<0.05); but no significant difference was found between at 1 month after operation and at last follow-up ( P>0.05). At last follow-up, the ODI score was 19.7±6.4, and the DSCA was (104.93±12.56) mm 2, which was significantly improved when compared with preoperative values ( P<0.05). The MG classification was also significantly higher than preoperative one ( Z=-5.789, P=0.000). According to the modified MacNab criteria, the results were excellent in 32 cases, good in 9 cases, and fair in 3 cases, with an excellent and good rate of 93.2%.
Conclusion: Percutaneous endoscopic transforaminal bilateral decompression for treating severe central lumbar spinal stenosis has the advantages of less trauma, adequate decompression, and rapid recovery. The short-term effectiveness is good.
目的: 观察经皮内镜下经椎间孔入路双侧减压治疗重度腰椎中央管狭窄症的临床效果及安全性。.
方法: 回顾性分析 2015 年 10 月—2017 年 12 月收治的具有双下肢症状的单节段重度腰椎中央管狭窄症患者 44 例，其中行双侧椎间孔入路双侧减压术 36 例，单侧椎间孔入路双侧减压术 8 例。男 25 例，女 19 例；年龄 56～89 岁，平均 68.6 岁。病程 5～39 个月，平均 14.5 个月。受累节段：L 3、4 6 例，L 4、5 33 例，L 5、S 1 5 例。MRI 横断位硬膜囊面积（dural sac cross-sectional area，DSCA）为（66.36±8.48）mm 2。形态学分级（morphological grading，MG）：C 级 29 例，D 级 15 例。术前腰痛疼痛视觉模拟评分（VAS）为（2.3±1.0）分，下肢痛 VAS 评分为（7.8±1.2）分，Oswestry 功能障碍指数（ODI）为（77.8±7.3）分。记录术后 VAS 评分、ODI 评分、MG 分级和测量 DSCA 并与术前比较，采用改良 MacNab 标准评估临床效果。.
结果: 患者均顺利完成手术，术后切口均Ⅰ期愈合。44 例患者均获随访，随访时间 13～46 个月，平均 24.8 个月。1 例出现术后下肢麻痹，1 例出现硬膜囊撕裂。患者随访期间均未发生感染、复发或需行翻修手术。术后影像学提示中央椎管扩大，硬膜囊面积较术前明显增加。术后 1 个月和末次随访时腰痛 VAS 评分分别为（2.4±0.6）分和（2.5±0.8）分，与术前比较差异均无统计学意义（ P>0.05）；下肢痛 VAS 评分分别为（2.1±0.6）分和（2.0±1.1）分，较术前显著改善（ P<0.05），术后 1 个月和末次随访间差异无统计学意义（ P>0.05）。末次随访时 ODI 评分为（19.7±6.4）分，DSCA 为（104.93±12.56）mm 2，均较术前显著改善（ P<0.05）。MG 分级也较术前显著提高（ Z=−5.789， P=0.000）。末次随访时采用改良 MacNab 标准评定疗效，获优 32 例、良 9 例、可 3 例，优良率为 93.2%。.
结论: 采用经皮内镜下经单侧或双侧椎间孔入路双侧减压治疗重度腰椎中央管狭窄症具有创伤小、减压精准、恢复快的优点，近期疗效良好。.
Keywords: Lumbar central spinal stenosis; percutaneous endoscopy; spinal decompression; transforaminal approach.