經皮內視鏡腰椎椎間盤突出切除手術後臨床結果及相關分析

An Analysis of the Prognostic Factors Affecting the Clinical Outcomes of Percutaneous Endoscopic Lumbar Discectomy

陳瑩潔(Ying-Chien Chen)

指導教授 ： 林志立

中山醫學大學/醫學院/醫學研究所/碩士(2015年)

https://doi.org/10.6834/CSMU.2015.00124

摘要

研究目的：本研究為探討病患經由經皮內視鏡脊椎手術後臨床療效及相關分析，而經皮內視鏡脊椎手術自西元1990年末，開始有了較佳的發展，此手術是醫師經由C-arm(X光機)定位下，利用人體構造上的自然孔洞到達手術的部位，透過內視鏡專用的微小手術器械導入，來進行椎間盤突出的切除。和傳統手術比較起來，除了傷口小約0.8公分、傷口較不痛及脊椎內破壞較小，部份病患甚至可以選擇使用局部麻醉完成手術，而病患大部份不需住院或僅需觀察一天，即可立刻回到工作崗位。本研究將探討腰椎椎間盤經核磁共振的影像等級分析及突出的型態統計，評估分析病人疼痛、生活品質的改善程度，了解與手術相關性及什麼型態的椎間盤在此手術治療後容易會有再次復發情形。

研究方法及資料：採回溯性研究，於2006年2月至2014年2月期間，收集200例接受經皮內視鏡脊椎手術患者資料，手術前均接受各項評估量表，分析相關是否造成疾病因素，例如:年齡、性別、職業、吸煙史及身體質量指數、日常工作姿勢型態、疼痛指數、生活品質評估、腰椎核磁共振檢查之分析、術後滿意度調查，術後分別紀錄手術後1、3、6及12個月後之評估。

研究結果：針對經皮內視鏡脊椎手術最終結果臨床結果及相關分析，共有三個論證，首先年齡大於等於65歲以上、術前ODI指數分數較高及椎間盤Prolapse突出類型的患者，為影響術後生活品質之因素；第二、手術部位為影響術後疼痛指數之因素；第三、術前有下背痛情形及椎間盤Prolapse為增加復發之風險。

結論與建議：關於經皮內視鏡脊椎手術的技術，其學習曲線一開始是複雜具挑戰的，但如果在醫師相當經驗累積下，此手術是安全及對椎間盤有良好減壓效果，且病人預後恢復佳，滿意度也高。而腰椎核磁共振之影像檢查，擁有良好的對比辨識度，可以讓我們了解椎間盤軟組織的變化，而在詳細檢查及評估後，告知患者臨床療效的預後因素，培養良好醫病關係，降低醫療糾紛。

關鍵字

腰椎椎間盤突出 ； 經皮內視鏡脊椎手術 ； 臨床結果 ； 預後因素

並列摘要

Objective: This study provides the efficacy and correlation analysis of the impact of Percutaneous endoscopic lumbar disc discectomy. From the end of 1990, the surgery began to have a good development, the surgeon used C-arm (X-ray machine) to position, and used natural holes on the anatomy of humans to reach the site for surgery. Furthermore, they used a special and tiny instruments imported the disc herniation. Compare with traditional spine surgery, the percutaneous endoscopic lumbar disc discectomy makes a small wound about 0.8 cm, and besides the wound makes less pain and less damage in the spine surgery, even some patients can choose to use local anesthesia to complete the surgery. In addition, most patients don’t need hospitalization or just need observation about one day then they can return to work immediately. This study analyses lumbar disc magnetic resonance from lumbar Magnetic Resonance Imaging (MRI), protrusion statistics, assessment of pain, and degree of improvement of quality of life. Moreover, I will figure out the correlation between the surgery and the patterns of the disc to realize the reasons of recurrence of the disease.

Materials and Methods: This is a retrospective study. I collected 200 cases about patients who accepted percutaneous endoscopic lumbar disc discectomy from February 2006 to February 2014. These patients filled in the scales of analysis the factors such as: age, sex, occupation, smoking history and body mass index, daily working posture patterns, pain scores, quality of life, lumbar MRI analysis, which cause the disease before the surgery. After the surgery, the patients would fill in the scales of inspection of postoperative satisfaction, and the assessments at 1, 3, 6 and 12 months after the surgery. These scales are the data source which I analyzed for the study.

Results: Regard to the final results of percutaneous endoscopic lumbar disc discectomy and the analysis, there are three assessments. First, the higher preoperative ODI index and intervertebral disc prolapse types are the risk factors which affect postoperative quality of life on the groups with age of 65 years and above. Second, spine levels affect postoperative pain score. Third, preoperative low back pain and intervertebral disc prolapse increase the risk of recurrence.

Conclusion and Suggestion: Regard to Percutaneous endoscopic lumbar disc discectomy, the learning curve is complex and challenge in the beginning. However, when the surgeons have accumulated considerable experience, the surgery is relatively safe and has a good effect of decompression on the disc. In addition, the prognosis of patients recover and the satisfaction degree are exceptional, and the lumbar MRI has good contrast readability. It allows us to comprehend the changes in the soft tissue of the disc. After detailed inspection and evaluation, we may inform patients about the clinical efficacy of prognostic factors. Hence, we will create the good doctor-patient relationships, which will reduce medical arguments.

並列關鍵字

lumbar disc herniation ； percutaneous endoscopic lumbar disc discectomy ； clinical outcome ； prognostic factor

參考文獻

2. Lee JC, Kim MS, Shin BJ. (2010). An analysis of the prognostic factors affecting the clinical outcomes of conventional lumbar open discectomy : clinical and radiological prognostic factors. Asian Spine J, 4(1), 23-31.

3. Pfirrmann CW, Metzdorf A, Zanetti M, Hodler J, Boos N. (2001) Magnetic resonance classification of lumbar intervertebral disc degeneration. Spine (Phila Pa 1976), 26(17), 1873-1878.

5. Shimia M, Babaei-Ghazani A, Sadat BE, Habibi B, Habibzadeh A. (2013). Risk factors of recurrent lumbar disk herniation. Asian J Neurosurg, 8(2), 93-96.

6. Schumann B, Bolm-Audorff U, Bergmann A, Ellegast R, Elsner G, Grifka J, Haerting J, Jäger M, Michaelis M, Seidler (2010). A. Lifestyle factors and lumbar disc disease: results of a German multi-center case-control study (EPILIFT). Arthritis Res Ther, 12(5), R193.

7. Nachemson, A. L. (1976). The lumbar spine, an orthopaedic challenge. Spine, 1(1).