坐骨神经痛腰椎间盘切除术后的临床结果:碎片类型和环形能力的影响

E. Carragee, Michael Han, Patrick W. Suen, David Kim
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引用次数: 501

摘要

背景:坐骨神经痛的手术治疗与椎间盘切除术在相当大比例的患者中是无效的,并且在5%至15%的此类手术后发生再突出。本研究的目的是确定椎间盘环的能力和突出的类型是否可以用来预测腰椎间盘切除术后的临床结果。方法:对187例连续行单节段腰椎间盘切除术的患者进行前瞻性观察研究。一名外科医生完成了所有的手术,一名独立的审查员在手术后至少2年至中位6年的时间里对180名患者进行了临床评估。确定环状缺损的程度和椎间盘碎片的存在。根据这些术中发现,将椎间盘突出分为四类:(1)碎片-裂隙突出(89例),(2)碎片-缺陷突出(33例),(3)碎片-包含突出(42例),(4)无碎片-包含突出(16例)。连续变量采用Student t检验,分类变量采用卡方分析,确定椎间盘突出形态和术前变量对后续临床结果的影响。结果:有椎间盘碎片和小环缺损的碎裂-裂组患者总体预后最好,再疝率(1%)和再手术率(1%)最低。包含碎片组的患者再疝率为10%,再手术率为5%。碎片-缺损组患者有挤压碎片和大量后环丢失,再疝率为27%,再手术率为21%。无碎片组患者表现较差:38%的患者有复发性或持续性坐骨神经痛,与其他组相比,标准结局评分改善较少(p < 0.001)。结论:术中发现,如本研究所述,与人口统计学、社会经济或临床变量相比,更清楚地与结果相关。椎间盘切除术后的环状能力程度和突出类型似乎对预测坐骨神经痛复发、再手术和腰椎间盘切除术后的临床结果有价值。证据等级:预后研究,I-1级(前瞻性研究)。关于证据等级的完整描述见第2页。
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Clinical Outcomes After Lumbar Discectomy for Sciatica: The Effects of Fragment Type and Anular Competence
Background: The surgical treatment of sciatica with discectomy is ineffective in a sizable percentage of patients, and reherniation occurs after 5% to 15% of such procedures. The purpose of the present study was to determine if competence of the disc anulus and the type of herniation could be used to predict postoperative clinical outcomes following lumbar discectomy.Methods: A prospective observational study of 187 consecutive patients undergoing single-level primary lumbar discectomy was conducted. A single surgeon performed all of the procedures, and an independent examiner evaluated 180 of the patients clinically at a minimum of two and a median of six years after surgery. The extent of anular deficiency and the presence of disc fragments were determined. On the basis of these intraoperative findings, disc herniations were classified into four categories: (1) Fragment-Fissure herniations (eighty-nine patients), (2) Fragment-Defect herniations (thirty-three patients), (3) Fragment-Contained herniations (forty-two patients), and (4) No Fragment-Contained herniations (sixteen patients). The effects of disc herniation morphology and preoperative variables on subsequent clinical outcome were determined with the Student t test for continuous variables and chi-square analysis for categorical variables.Results: Patients in the Fragment-Fissure group, who had disc fragments and a small anular defect, had the best overall outcomes and the lowest rates of reherniation (1%) and reoperation (1%). Patients in the Fragment-Contained group had a 10% rate of reherniation and a 5% rate of reoperation. Patients in the Fragment-Defect group, who had extruded fragments and massive posterior anular loss, had a 27% rate of reherniation and a 21% rate of reoperation. Patients in the No Fragment-Contained group did poorly: 38% had recurrent or persistent sciatica, and the standard outcomes scores were less improved compared with those in the other groups (p < 0.001).Conclusion: Intraoperative findings, as described in the present study, were more clearly associated with outcomes than were demographic, socioeconomic, or clinical variables. The degree of anular competence after discectomy and the type of herniation appear to have value for the prediction of the recurrence of sciatica, reoperation, and clinical outcome following lumbar discectomy.Level of Evidence: Prognostic study, Level I-1 (prospective study). See p. 2 for complete description of levels of evidence.
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