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微创PELD手术与传统手术治疗 腰椎间盘突出 症,哪个更好?仁者见仁,智者见智。我的观点,当然是微创PELD手术优于传统手术一方面是多年的经历,第二个理由是为什么越来越多的人选择了微创手术,而不选择传统的开放手术的方法。 厦门大学附属成功医院骨科黄 哲元

荟萃分析研究的结果对医生和患者的临床选择都非常重要。什么是荟萃分析?大家可以参见百度百科

https://baike.baidu.com/view/981518.htm#1_1

2014-6-4《丁香园骨科时间》翻译了一篇荟萃分析文章《微创手术治疗腰突症并不优于传统手术》。该研究结果表明,椎板间入路微创手术治疗 腰椎间盘突出 症在临床结果和围手术期成本方面,与传统手术并无差异。而椎间孔入路微创手术和传统手术的临床差异因研究样本的局限性,尚不能做结论。


而同时我们注意到到了另外一篇Rasouli MR的荟萃分析的文章《微创手术与显微/开放手术治疗症状性 腰椎间盘突出 症》的文章。文章将微创手术的方法涵盖到了经皮内窥镜下经椎间孔腰椎间盘摘除手术、经皮内窥镜下经椎板间孔腰椎间盘摘除手术、经通道下显微腰椎间盘手术、经皮腰椎间盘切吸手术。结论是微创手术在腿痛、腰痛、再住院率上没有明显优势。潜在的优点包括:手术部分相关的风险低、 感染 率低。住院时间短的证据不统一,就是不是所有的研究都显示住院时间短。针对这些优势的研究,需要制定微创手术和显微手术/开放手术的最佳适应症来进行研究。

临床体会: 腰椎间盘突出 症手术标准化的重要性,不同的医院不同的医生做同样的手术,尽量获得相同的或者相似的治疗结果。优点:便于教学、便于控制不良事件的发生。缺点:有的病例治疗方法可能不当,过大或者过小。 腰间盘突出 症手术差异的优点:不同的医院不同的医生做不同的手术,获得了有差异的结果。这样的临床过程更符合实际情况,标准化是相对的差异是绝对的。这就是外科手术的挑战性。优点:方法不断改进,疗效不断提高,与手术相关的事件不断改善。比如住院时间不断缩短,伤口疼痛不断降低,回归工作时间更加缩短。缺点:技术的推广时间更长,不良事件不便于控制。

回归本话题的核心:脊柱内窥镜腰椎间盘摘除手术(PELD percutaneous endoscopic lumbar discectomy)与显微手术(MED microdiscectomy)/开放手术(open discectomy)治疗有症状的 腰椎间盘突出 症哪个更好?

从我们数十年的经验看脊柱内窥镜手术PELD比常规手术(显微手术/开放手术)有更大的优势。

一、与围手术相关的事件

1、手术部位的创伤小,相关并发症也少。病房护理责任和压力低。

2、护理简单,术后即可下地活动,家属护理的负担轻。

3、恢复工作时间短。

二、与手术相关的事件

1、手术目标性强,微创手术按照责任间隙实施治疗。如果开放手术可能需要2-3个间隙融合,微创可以选择1个责任间隙进行治疗,其他间隙可以根据后期是否责任症状,再决定是否进行针对治疗。

2、PELD手术不融合间隙,理论上相邻节段并发症低。PELD手术单纯摘除突出的椎间盘,不进行间隙融合,相当于脊柱非融合手术。理论上不增加相邻间隙的负荷,发生继发性不稳的可能性降低。

3、手术部位相关的并发症发生率低、严重性低。PELD手术在局部麻醉下实施,患者是最好的即刻的全能神经监护仪。保证了手术的顺利和安全。比如硬膜囊破裂,PELD的破裂不需要修补,增加卧床时间即可。而开发手术导致的硬膜囊破裂可能需要再次手术或者穿刺治疗,并且显著增加了住院的时间。

三、任何事情都是两方面的:PELD有优点当然就有缺陷。

1、PELD手术不做腰椎固定融合,对于腰痛(lower back pain LBK)无法控制。相关高级别研究也显示,微创手术与开放手术相比,腿痛、腰痛的缓解无明显差异。

2、再手术率与开放手术无差异。即使再手术率没有差异,但是PELD手术的创伤非常小,再次手术处理就非常简单了。我们的数据库中因为各种原因再次内窥镜或者手术治疗的患者共45例,占同期病例的2.5%。与国外的报告5-12%相比,已经低了许多。究其原因与我们学科分科细,医生执业范围窄,适应症掌握严格有密切的关系。

3、学习曲线长。


从一个既做开放手术也擅长微创手术的医生角度出发,我喜欢PELD微创手术,并推荐给适合的患者。愿所有的患者都找到适合自己的治疗方法。

参考文献:

微创手术治疗腰突症也许并不优于传统手术

2014-06-04 丁香园骨科时间

坐骨神经痛通常被定义为腰骶神经压迫或刺激引起的下肢疼痛。当保守治疗无效或患者症状加重的情况下,可通过手术切除压迫的椎间盘,解除神经根受压。当前微创手术(椎板间入路和椎间孔镜入路)的应用越来越普及。然而,微创手术的安全性由于其小的工作通道及欠佳的可视性受到质疑。

不过,传统手术又有其自身的缺点,如长切口和大幅度的肌肉创伤。为了明确微创手术和传统手术临床意义及手术成本花费差异,澳大利亚学者Kamper SJ等进行了一项Meta分析,对2013年1月前的研究进行了归纳总结,该研究结果已在近期的Eur Spine杂志上发表。

按既定的检索方案,搜索MEDLINE, EMBASE,和 Cochrane 图书馆,并按照既定的纳入与排除标准,最终纳入相关研究29项(16项随机对照试验,4项前瞻性队列研究,9项回顾性队列研究),纳入的样本是4472人。并且,作者对研究结果进行了治疗评价(GRADE 方法)。

该研究结果显示,微创手术和传统手术治疗 腰椎间盘突出 临床结果并无明显的差异。不过,椎板间入路手术时间长11分钟,出血量少52ml,住院日短1.5天。

在并发症及在手术率上,微创椎板间入路手术与传统手术无差异。然而,椎间孔镜手术与传统手术相比较的研究存在如下缺点,如高偏倚风险、纳入研究小和样本少。

本研究的缺点如下:1.纳入的随机对照研究多为小样本,尤其是缺乏高质量,精确临床结果的椎间孔镜手术与传统手术相比较的研究,这就导致研究结论的力度不足。

2.微创手术住院日缩短,患者可以早期返回工作岗位,相关的社会效益研究也是缺乏的。

该研究结果表明,椎板间入路微创手术治疗 腰椎间盘突出 症在临床结果和围手术期成本方面,与传统手术并无差异。而椎间孔入路微创手术和传统手术的临床差异因研究样本的局限性,尚不能做结论。

本文来自丁香园骨科频道

参考文献:

Cochrane Database Syst Rev. 2014 Sep 4;9:CD010328. [Epub ahead of print]

Minimally invasive discectomy versus microdiscectomy/open discectomy for symptomatic lumbar disc herniation.

Rasouli MR1, Rahimi-Movaghar V, Shokraneh F, Moradi-Lakeh M, Chou R.

Author information

Abstract

BACKGROUND:

Microdiscectomy or open discectomy (MD/OD) are the standard procedures for symptomatic lumbar disc herniation and they involve removal of the portion of the intervertebral disc compressing the nerve root or spinal cord (or both) with or without the aid of a headlight loupe or microscope magnification. Potential advantages of newer minimally invasive discectomy (MID) procedures over standard MD/OD include less blood loss, less postoperative pain, shorter hospitalisation and earlier return to work.

OBJECTIVES:

To compare the benefits and harms of MID versus MD/OD for management of lumbar intervertebral discopathy.

SEARCH METHODS:

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (November 2013), MEDLINE (1946 to November 2013) and EMBASE (1974 to November 2013) and applied no language restrictions. We also contacted experts in the field for additional studies and reviewed reference lists of relevant studies.

SELECTION CRITERIA:

We selected randomised controlled trials (RCTs) and quasi-randomised controlled trials (QRCTs) that compared MD/OD with a MID (percutaneous endoscopic interlaminar or transforaminal lumbar discectomy, transmuscular tubular microdiscectomy and automated percutaneous lumbar discectomy) for treatment of adults with lumbar radiculopathy secondary to discopathy. We evaluated the following primary outcomes: pain related to sciatica or low back pain (LBP) as measured by a visual analogue scale, sciatic specific outcomes such as neurological deficit of lower extremity or bowel/urinary incontinence and functional outcomes (including daily activity or return to work). We also evaluated the following secondary outcomes: complications of surgery, duration of hospital stay, postoperative opioid use, quality of life and overall participant satisfaction. Two authors checked data abstractions and articles for inclusion. We resolved discrepancies by consensus.

DATA COLLECTION AND ANALYSIS:

We used standard methodological procedures expected by The Cochrane Collaboration. We used pre-developed forms to extract data and two authors independently assessed risk of bias. For statistical analysis, we used risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes with 95% confidence intervals (CI) for each outcome.

MAIN RESULTS:

We identified 11 studies (1172 participants). We assessed seven out of 11 studies as having high overall risk of bias. There was low-quality evidence that MID was associated with worse leg pain than MD/OD at follow-up ranging from six months to two years (e.g. at one year: MD 0.13, 95% CI 0.09 to 0.16), but differences were small (less than 0.5 points on a 0 to 10 scale) and did not meet standard thresholds for clinically meaningful differences. There was low-quality evidence that MID was associated with worse LBP than MD/OD at six-month follow-up (MD 0.35, 95% CI 0.19 to 0.51) and at two years (MD 0.54, 95% CI 0.29 to 0.79). There was no significant difference at one year (0 to 10 scale: MD 0.19, 95% CI -0.22 to 0.59). Statistical heterogeneity was small to high (I2 statistic = 35% at six months, 90% at one year and 65% at two years). There were no clear differences between MID techniques and MD/OD on other primary outcomes related to functional disability (Oswestry Disability Index greater than six months postoperatively) and persistence of motor and sensory neurological deficits, though evidence on neurological deficits was limited by the small numbers of participants in the trials with neurological deficits at baseline. There was just one study for each of the sciatica-specific outcomes including the Sciatica Bothersomeness Index and the Sciatica Frequency Index, which did not need further analysis. For secondary outcomes, MID was associated with lower risk of surgical site and other infections, but higher risk of re-hospitalisation due to recurrent disc herniation. In addition, MID was associated with slightly lower quality of life (less than 5 points on a 100-point scale) on some measures of quality of life, such as some physical subclasses of the 36-item Short Form. Some trials found MID to be associated with shorter duration of hospitalisation than MD/OD, but results were inconsistent.

AUTHORS' CONCLUSIONS:

MID may be inferior in terms of relief of leg pain, LBP and re-hospitalisation; however, differences in pain relief appeared to be small and may not be clinically important. Potential advantages of MID are lower risk of surgical site and other infections. MID may be associated with shorter hospital stay but the evidence was inconsistent. Given these potential advantages, more research is needed to define appropriate indications for MID as an alternative to standard MD/OD.


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