胸椎管狭窄症的治疗现状及研究进展

胸椎管狭窄症(thoracicspinalstenosis，TSS)是指由于先天、退变或内分泌及全身系统性疾病等因素导致胸椎管容积变小，胸脊髓、神经根受压，从而引起相应临床症状和体征的疾病，可分为原发性胸椎管狭窄症(primarythoracicstenosis)和继发性胸椎管狭窄症(secondarythoracicstenosis)。原发性胸椎管狭窄症指先天性的椎管矢状径＜10mm，加之后天退变等因素造成胸脊髓、神经根受压，出现临床症状的疾病。继发性胸椎管狭窄症与内分泌或全身系统性疾病有关，典型表现为全脊柱的环形狭窄[1]。TSS多发生于中老年人，以下胸椎为主，上胸椎次之。与熟知的颈椎病、腰椎管狭窄症等疾病相比，TSS发生率相对较低[2-6]，许多TSS的患者同时合并颈椎病或腰椎疾病，往往容易误诊和漏诊[7-10]。随着CT与MRI技术逐步应用于临床及手术技术的发展，TSS进一步为人们所认识[11]，但由于其特殊的生理及解剖结构，其手术高致瘫率仍是一大难题，笔者就其近年来的治疗现状及进展作一简要综述。

Degenerative constrictions of the spinal canal with compression of neural elements arise as a result of bony, disk, capsular or ligament structures. The most frequent causes are disk herniations and spinal stenoses. The lumbar and cervical spine is the most prominent cause. After conservative treatments have been exhausted, surgical intervention may be necessary. Today, microsurgical or microscopically-assisted decompression is regarded as the standard procedure for disk herniation and spinal stenosis in the lumbar region, while in the cervical spine, microsurgical or microscopically-assisted anterior decompression and fusion are standard. Both procedures demonstrate good clinical results but present problems associated with the operation. Decompressions in the area of the spine must be carried out under continuous visualization and must entail the possibility of adequate bone resection. Taking this into account, completely new endoscopes and instrument sets has been developed for full-endoscopic operations in tandem with the development of the lateral transforaminal and interlaminar approaches for the lumbar spine and the posterior, contralateral and anterior approaches for the cervical spine. The possibilities and results of comparable and established standard procedures have been used as a benchmark in the course of clinical validation. The development of surgically created approaches and the new rod lens endoscopes combined with appropriate instrument sets have laid the technical foundations for full-endoscopic operation in the lumbar spine on all primary and recurrent disk herniations inside and outside the spinal canal and on spinal stenoses. This development has also permitted resection of soft disk herniations in the cervical spine. The use of the relevant approaches depends on anatomical and pathological inclusion and exclusion criteria. The clinical results of standard procedures are achieved, which must be regarded as a minimum criterion for the introduction of new technologies. On the basis of evidence-based medicine ( EBM ) criteria, it can be established that using the full-endoscopic techniques developed, adequate decompression is achieved in the deifned indications with reduced traumatization, improved visibility conditions and positive cost beneifts. Today, full-endoscopic operations may be regarded as an expansion and alternative within the overall concept of spinal surgery.

经皮侧后路腰椎间孔成形与经椎间孔完全内镜下腰椎间盘摘除术

一、背景
　　1992年，报道经侧后路内窥镜下进行腰椎间盘摘除术以来，许多学者报告了经椎间孔内窥镜下腰椎间盘摘除术的技术及疗效[1-3]。完全内镜下腰椎间盘摘除术是指使用带工作通道的硬杆状内镜在持续生理盐水灌洗下进行的微创腰椎间盘摘除手术，分为经椎间孔入路和经椎板间入路两类技术[4]。Yeung等[5-7]发明的YESS(yeungendoscopicspinesystem)系统是早的完全内镜手术系统，早的完全内镜下腰椎间盘摘除术是使用YESS系统经后外侧椎间孔入路进行的由盘内至盘外的操作技术，适用于椎间孔型及极外侧型椎间盘突出，对椎管内包含型突出及韧带下型椎间盘脱出也可以有效处理，但对椎管内脱出及游离髓核无法有效切除。Ruetten等[8]采用侧方入路技术可以将内镜经椎间孔置入椎管内，摘除脱出及游离髓核组织，使经椎间孔完全内镜下腰椎间盘摘除术适应证进一步扩大，但L5～S1节段由于侧方髂骨的阻挡，使该技术无法实施；对于高位腰椎间盘突出症使用该技术有损伤腹腔脏器的风险。随着腰椎间孔成型技术的出现及内窥镜手术系统的改进，可以对腰椎间孔有效扩大，使内镜可以经椎间孔进入椎管内，对合并腰椎侧隐窝或椎间孔狭窄者也可一起处理，对L5～S1椎间盘突出症亦可适用，大大扩展经皮经椎间孔完全内镜下腰椎间盘摘除术的适应证，提高疗效及安全性[9-11]。但我们也要记住：尽管经椎间孔入路完全内镜技术经过上述技术改进，用于椎管内巨大型脱出及高度移位型椎间盘突出症时，仍然有高达15.7%的失败率，所以经椎板间入路完全内镜下腰椎间盘摘除术是必要的补充，尤其适用于L5～S1节段及其他节段椎间盘突出并高度移位者[12-14]。