椎间盘退行性疾病生物治疗研究的进展

椎间盘退行性疾病( degenerative disc diseases，DDD )是一类常见的，可引起椎间盘突出、椎管狭窄、退变性滑脱以及退变性脊柱侧弯的疾病，通常伴随慢性下腰痛等症状，严重影响患者的日常工作及生活。目前，对 DDD 的治疗一般包括药物等保守治疗和手术治疗，目的在于缓解症状及提高患者生活质量，但是现有的治疗方案仅缓解了患者的症状，却难以恢复其椎间盘的结构和功能。现在，越来越多的医生认为通过对 DDD 患者进行生物治疗，不仅可以缓解症状，而且生物治疗可以早期阻止甚至逆转椎间盘退变并恢复其生物学功能，这使得生物治疗有望成为DDD 的主要治疗手段。现将近年来椎间盘退行性疾病的生物治疗研究成果综述如下。

经皮椎间孔入路全内镜技术治疗腰椎间盘突出症

一、前言
　　腰椎间盘突出症是一种常见病、多发病，手术治疗方法可以分为传统开放手术和微创手术两大类。近些年来，微创脊柱外科以其创伤小、恢复快等优点，取得了快速的发展进步，在腰椎间盘突出症的治疗中获得了显著疗效。其中经皮内镜椎间盘摘除技术是目前创伤小的镜下椎间盘摘除术式。经皮内镜技术通过带工作通道的硬杆状内窥镜在生理盐水持续灌洗下进行，可在直视下对病变椎间盘进行操作，因其操作全程在内窥镜下完成，故又称为全内镜技术。根据经皮穿刺入路不同，该技术分为经皮椎间孔入路全内镜下腰椎间盘摘除术(transforaminalpercutaneousendoscopiclumberdiscectomy，TF-PELD)和经皮椎板间入路全内镜下腰椎间盘摘除术(interlaminarpercutaneousendoscopiclumberdiscectomy，IL-PELD)。其中TF-PELD技术开展早，近年来随着微创理念和器械革新的不断推动，该技术的适应证和临床需求逐渐扩大，为更好地掌握和推广该项技术，现就其技术操作及相关临床问题综述如下。

经皮完全内镜下脊柱手术技术的发展与现状

现代经皮内镜下脊柱手术技术的发展是建立在Yeung [1]发明的YESS ( yeung endoscopic spine system )脊柱内镜系统及YESS技术基础之上的。Ruetten，Hoogland等[2-3]在YESS脊柱内镜系统基础上进行改进，并提出完全内镜技术( full-endoscopic technique )及TESSYS ( transforaminal endoscopic surgical system )等概念。但这些脊柱内镜系统都是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脊柱手术，只是手术技术上不断改进以适应更复杂的病例，所以都可以称为完全内镜下手术技术。目前主要用于颈、腰椎间盘突出症、颈椎管狭窄症、腰椎管狭窄症及慢性腰痛等疾病的治疗。

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]。