Analysis of Clinical and Radiological Outcomes between UBE Procedure and Conventional Open Surgery in the Treatment of Lumbar Disc Herniation
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摘要:
目的 对比单边双通道脊柱内镜(unilateral biportal endoscopy,UBE)与传统开放手术治疗腰椎间盘突出症的临床疗效及影像学结果。 方法 回顾分析2022年1月至2023年3月在昆明医科大学第一附属医院收治的84例单节段腰椎间盘突出患者,其中44例接受单边双通道脊柱内镜手术(UBE组),40例接受传统开放手术。记录患者的年龄、性别、椎间盘突出部位、手术节段、手术时间、术中出血量、住院天数等信息。术前、术后2d和术后1月进行视觉模拟量表(VAS)评分及术后1月采用改良的Macnab评价指标评估疗效。比较2组术前和术后关节突保留率以及椎间盘高度变化。 结果 2组患者在年龄、性别、手术节段及椎间盘突出类型上的差异无统计学意义(P > 0.05)。所有患者均顺利完成手术,相对于开放组,UBE组手术耗时较短,出血量更少,术后住院时间缩短(P < 0.05),同时UBE组围术期并发症发生率显著低于开放组(P < 0.05)。2组患者术前、术后2d时VAS评分明显下降(P < 0.05),但术后1月时2组差异无统计学意义(P > 0.05);且组内术前、术后2d及术后1月时VAS评分差异有统计学意义(P < 0.05)。末次随访患者时改良 Macnab 疗效评定标准结果中UBE组优、良、可、差依次为 40、2、2 与 0 例,总体优良率高达 95.4%。在开放手术组中,优良可差分别为29、7、4与 0例,整体优良率达到90%。术前和术后2组患者的椎间盘高度进行比较,差异有统计学意义(P < 0.05)。在UBE组中,术前和术后椎间盘高度之间比较,差异无统计学意义(P > 0.05),而开放组术后椎间盘高度明显增加(P < 0.05)。UBE组的关节突保留率为63.6%,而开放手术组的关节突保留率仅为10%。 结论 UBE可以直达靶点解除神经压迫,是一种微创、灵活、创伤小、学习曲线平缓、对脊柱活动度影响小、有利于术后康复的新技术,可彻底摘除突出髓核,临床治疗效果理想。 Abstract:Objective To compare the clinical efficacy and imaging results of unilateral biportal endoscopic discectomy (UBE) with traditional open surgery for the treatment of lumbar disc herniation. Methods We retrospectively analyzed 84 patients with single-segment lumbar disc herniation admitted to the First Affiliated Hospital of Kunming Medical University from January 2022 to March 2023, 44 cases in the UBE group and 40 cases in the open surgery group, and recorded the patients' age, gender, disc herniation site, operation segment, operation time, intraoperative bleeding, and hospitalization days, respectively. Visual analog scale (VAS) scores were performed preoperatively, 2 days postoperatively, and at follow-up at 1 month postoperatively. Efficacy was evaluated using the modified Macnab Treatment Effectiveness Evaluation Index at 1 month of surgery. The preoperative and postoperative articular process preservation rate and disc height changes were compared between the two groups. Results There were no statistically significant differences between the two groups of patients in terms of age, gender, operative segment and type of disc herniation (P > 0.05). All patients completed the surgery. Compared with the open group, the UBE group had a shorter operation time, less bleeding, and a shorter postoperative hospitalization (P < 0.05), and the perioperative complication rate was lower in the UBE group than in the open group (P < 0.05). The VAS scores of patients in the two groups decreased significantly at preoperation and 2 days postoperation (P < 0.05), but the difference between the two groups was not significant at 1 month postoperation (P > 0.05); and the difference in VAS scores at preoperation, 2 days postoperation and 1 month postoperation within the groups was statistically significant (P < 0.05). The results of the modified Macnab efficacy evaluation criteria in the UBE group were 40, 2, 2 and 0 cases in order of excellent, good, acceptable and poor at the last follow-up, and the overall excellent rate was as high as 95.4%. In the open surgery group, there were 29, 7, 4 and 0 cases of excellent, good, feasible and poor, with an overall excellent rate of 90%. The difference in disc height between the two groups was statistically significant when comparing preoperative and postoperative disc heights (P < 0.05). For the UBE group, there was no statistically significant difference between the preoperative and postoperative disc heights within the group (P > 0.05), while the postoperative disc height in the open group was significantly increased compared with that of the preoperative period, with a statistically significant difference (P < 0.05).The preservation rate of the articular eminence in the UBE group was 63.6%, while the preservation rate of the articular eminence in the open surgery group was 10%. Conclusion UBE can directly reach the target point to release nerve compression, and is a new technique that is minimally invasive, flexible, less traumatic, has a gentle learning curve, has little effect on spinal mobility, and is conducive to postoperative rehabilitation, which can completely remove the protruding nucleus pulposus, and has an ideal clinical therapeutic effect. -
疼痛是生理、心理、感觉、情感、认知、行为和社会等综合因素相互作用的体验,主要分为急性疼痛和慢性疼痛[1]。慢性疼痛持续时间长且不易根治,患者常伴有抑郁和焦虑等消极情绪,严重影响生活质量。文献报道[2-3],失眠在慢性疼痛患者中高发,而睡眠质量较差又会导致患者心境忧郁、紧张、易激惹和精力不足,易产生或加重患者心身症状,使睡眠质量更差,导致恶性循环[4]。同时,与原发性失眠症相比,继发于慢性疼痛的失眠在临床表现及程度也较为相似,疼痛的严重程度与睡眠障碍之间也存在相关性[5]。调查2019年1至6月玉溪市某综合医院疼痛科慢性疼痛者中失眠情况及影响因素,为相关工作策略的制定提供参考。
1. 对象与方法
1.1 研究对象
选取2019年1月至6月于玉溪市人民医院疼痛科就诊患者。纳入标准:(1)首次因慢性疼痛到本科就诊者;(2)符合国际疼痛学会的慢性疼痛诊断标准[6],即疼痛时间 > 3月,视觉模拟评分(visual analog scale,VAS)≥ 3分或日本尼普洛知觉痛觉定量分析装置NIPRO Painvision判定为疼痛,每天或几乎每天疼痛者;(3)年龄 ≥ 18岁;(4)能够理解所填调查量表者;(5)知情并同意参与。排除标准:(1)急性疼痛者;(2)年龄 < 18岁;(3)无法阅读、理解调查量表内容者;(4)拒绝参与本研究者。
1.2 研究工具及方法
采用自设问卷调查病人的基本人口学特征、疼痛持续时间、疼痛类型等。分别采用日本尼普洛知觉痛觉定量分析装置NIPRO Painvision(PS-2100)和VAS评价患者的疼痛程度。VAS为一条10 cm长的直线,两端分别表示无痛(0分)和剧痛(10分),由患者划出自己的疼痛程度,测量所画线长度即VAS得分,其中0分为无疼痛,1~3分为轻度疼痛,4~6分为中度疼痛,7~10分为重度疼痛。使用Painvision的“疼痛度”评价是根据最小感知电流值以及疼痛对应电流值这2种电流测量、评价疼痛程度的方法,与传统疼痛评价使用的VAS相比,有望导出更为客观的指标,有报告称疼痛度的许多结果与VAS明显相关。综合两种疼痛程度评价方法,得出最终疼痛程度评分,相对单一评价方法更为科学合理。
贝克抑郁自评问卷(beck depression inventory,BDI)[7]评价患者的目前或近1周抑郁状况,BDI共21个项目,以0~3分计分,统计总分:0~13分为无抑郁,14~19分为轻度抑郁,20~28分为中度抑郁,≥29分为重度抑郁。贝克焦虑自评问卷(beck anxiety inventory,BAI)[7]评价患者的目前或近1周焦虑状况,BAI 共21个项目,以0~3分计分,统计总分:0~14分为无焦虑,15~25分为轻度焦虑,26~35为中度焦虑,≥36分为重度焦虑。阿森斯失眠量表(athens insomnia scale,AIS)[8]评价患者的目前或近1周睡眠质量,AIS共8个项目,每个项目分数0~3分,AIS评分≥6分为失眠。三种问卷中文版均具有良好的信度和效度。
1.3 质量控制
调查开始前对调查员进行培训,根据纳入标准确定研究对象并按照知情同意的原则获取同意,所有入选对象均在统一指导语下填写调查问卷,尽可能地保证资料收集的准确性与完整性。在规定时间内完成问卷,视力不佳者由调查人员协助完成调查问卷,问卷当场收回,检查调查表格的质量,发现漏项时,重新询问并补充。在资料分析前,对数据的编码与录入工作进行了查错、补漏及逻辑检查,对有明显逻辑错误以及超过20%漏项的问卷予以剔除。剔除后,共计431例患者问卷纳入研究。
1.4 统计学处理
所有的调查问卷数据,用Epidata 3.1 软件建立数据库,双录入并进行一致性检验,SPSS 24.0完成统计分析。偏态分布资料用中位数M(P25~P75)。分类资料采用频数(百分比)描述。采用Logistic回归模型分析慢性疼痛者中失眠的影响因素,变量筛选法为逐步向前法(LR),入选标准α = 0.05,剔除标准为β = 0.10。P < 0.05为差异有统计学意义。
2. 结果
2.1 基本情况
431例研究对象中,男女比约为1.95∶1;年龄最小18岁,最大99岁,年龄中位数为65(53~73)岁。以汉族、文化程度为初中及以上、已婚、非农、轻度焦虑、轻度抑郁、中度疼痛、> 1个疼痛部位、慢性肌肉骨骼疼痛和疼痛病程为1~2.9 a为主,占比分别为:79.12%、54.75%、51.04%、53.13%、61.95%、65.66%、58.24%、56.15%、30.86%和69.14%,见表1。
表 1 431例慢性疼痛患者的基本情况及失眠的单因素分析Table 1. The basic characteristics and univariate analysis contributing to insomnia among 431 patients with chronic pain因素 n 失眠人数 单因素 P n 率(%) OR(95% CI) 性别 男 279 130 46.59 1.000 女 152 96 63.16 1.965(1.311~2.946) 0.001 年龄(岁) 18~ 71 27 38.03 1.000 30~ 85 28 32.94 0.801(0.414~1.547) 0.508 40~ 44 13 29.55 0.683(0.305~1.529) 0.354 50~ 142 84 59.15 2.360(1.316~4.324) 0.004 ≥60 89 74 83.15 8.040(3.862~16.736) < 0.001 民族 其他民族 90 36 40.00 1.000 汉族 341 190 55.72 1.887(1.176~3.028) 0.008 文化程度 小学及以下 195 88 45.13 1.000 初中及以上 236 138 58.47 1.712(1.168~2.511) 0.006 婚姻状况 未婚 103 41 39.81 1.000 已婚 220 109 49.55 1.485(0.924~2.388) 0.103 离异或丧偶 108 76 70.37 3.591(2.029~6.358) < 0.001 职业 农民 202 121 59.90 1.000 非农 229 105 45.85 0.567(0.386~0.831) 0.004 焦虑程度 无 51 12 23.53 1.000 轻度 267 124 46.44 2.818(1.413~5.620) 0.003 中度 86 69 80.23 13.191(5.713~30.458) < 0.001 重度 27 21 77.78 11.375(3.732~34.667) < 0.001 抑郁程度 无 51 12 23.53 1.000 轻度 283 129 45.58 2.722(1.368~5.417) 0.004 中度 86 76 88.37 24.700(9.807~62.212) < 0.001 重度 11 9 81.82 14.625(2.772~77.163) 0.002 疼痛程度 轻度 11 2 18.18 1.000 中度 251 99 39.44 2.931(0.620~13.850) 0.175 重度 169 125 73.96 12.784(2.659~61.462) 0.001 疼痛部位数(个) 1 189 58 30.69 1.000 > 1 242 168 69.42 5.128(3.394~7.749) < 0.001 疼痛类型 慢性创伤和术后疼痛 95 27 28.42 1.000 慢性肌肉骨骼疼痛 133 50 37.59 1.517(0.860~2.676) 0.150 慢性内脏/头/面部神经疼痛 104 60 57.69 3.434(1.901~6.206) < 0.001 慢性神经病理性疼痛 70 63 90.00 22.667(9.223~55.705) < 0.001 癌性相关疼痛 29 26 89.66 21.827(6.096~78.155) < 0.001 疼痛病程(a) < 1 38 17 44.74 1.000 1~ 298 148 49.66 1.219(0.618~2.402) 0.568 3~ 34 19 55.88 1.565(0.617~3.971) 0.346 ≥5 61 42 68.85 2.731(1.181~6.314) 0.019 2.2 不同特征慢性疼痛患者的失眠率
431例慢性疼痛病人中,226例最近1周失眠,失眠率为52.44%(95%CI 47.72%~57.15%),女性、年龄 ≥ 60岁、汉族、文化程度为初中及以上、离异或丧偶、农民、中度焦虑、中度抑郁、重度疼痛、> 1个疼痛部位、慢性神经病理性疼痛类型和疼痛病程 ≥ 5 a的慢性疼痛病人失眠率最高,见表1。
2.3 慢性疼痛患者失眠的多因素分析
将单因素分析P < 0.05的因素纳入多因素Logistic回归模型,结果显示:女性失眠风险较男性的高;≥60岁的患者失眠风险较60岁以下者高,特别是18~30岁者(6.821倍);轻度、中度和重度抑郁患者较无抑郁病人者高;重度疼痛病人失眠风险较轻度疼痛患者高;疼痛部位>1个的病人失眠风险较仅有1个疼痛部位病人者高;慢性肌肉骨骼疼痛、慢性内脏/头/面部神经疼痛、慢性神经病理性疼痛和癌性相关疼痛病人的失眠风险较慢性创伤和术后疼痛者高;相较于疼痛病程 < 1a的患者,疼痛病程为1 a~和3 a~的患者失眠风险低,见 表2。
表 2 慢性疼痛病人失眠的多因素分析Table 2. The multivariate analysis contributing to insomnia among patients with chronic pain因素 β SE Wald χ2 OR(95% CI) P 性别 男 1.000 女 0.605 0.289 4.398 1.832(1.04~3.225) 0.036 年龄(岁) 18~ 1.000 30~ −0.120 0.433 0.076 0.887(0.379~2.075) 0.782 40~ −0.125 0.496 0.063 0.883(0.334~2.336) 0.802 50~ 0.359 0.410 0.764 1.432(0.640~3.201) 0.382 ≥60 1.920 0.539 12.676 6.821(2.37~19.627) < 0.001 抑郁程度 无 1.000 轻度 1.431 0.533 7.206 4.181(1.471~11.882) 0.007 中度 2.964 0.664 19.955 19.381(5.279~71.155) < 0.001 重度 3.077 1.047 8.634 21.688(2.786~168.85) 0.003 疼痛程度 轻度 1.000 中度 2.401 1.279 3.525 11.034(0.900~135.303) 0.060 重度 2.636 1.273 4.289 13.954(1.152~169.067) 0.038 疼痛部位数(个) 1 1.000 > 1 1.325 0.310 18.275 3.762(2.049~6.907) < 0.001 疼痛类型 慢性创伤和术后疼痛 1.000 慢性肌肉骨骼疼痛 0.766 0.369 4.301 2.150(1.043~4.433) 0.038 慢性内脏/头/面部神经疼痛 0.982 0.383 6.575 2.670(1.260~5.658) 0.010 慢性神经病理性疼痛 3.222 0.616 27.345 25.067(7.494~83.848) < 0.001 癌性相关疼痛 3.639 0.821 19.650 38.052(7.614~190.17) < 0.001 疼痛病程(a) < 1 1.000 1~ −1.110 0.455 5.949 0.330(0.135~0.804) 0.015 3~ −1.194 0.677 3.110 0.303(0.080~1.142) 0.078 ≥5 0.126 0.575 0.048 1.135(0.368~3.499) 0.826 3. 讨论
慢性疼痛患者所经历的睡眠障碍作为一种影响生活质量的重要因素,正引起研究人员越来越多的关注[5]。本次调查发现431例慢性疼痛病人的失眠率为52.44%,目前国内慢性疼痛病人的失眠率的相关调查较少,国外部分研究显示65%~89%的慢性疼痛患者在都存在着失眠问题[9-10],本次调查失眠率低于国外的该两项研究,不过一项在伦敦开展的调查显示慢性疼痛者失眠率为53%[11],与本调查研究结果相近。慢性疼痛及其引起的较高的失眠率问题不容忽视。
本次调查发现女性失眠风险是男性的1.832倍,可能原因为:女性对疼痛的敏感性较高、痛阈较低、耐受性较差;慢性疼痛诱发的负性情绪反应在女性病人表现得更为强烈,如女性患者在遭受到疼痛影响时,往往更容易情绪化,对疼痛的反应更加敏感[12]。此外,≥60岁的患者失眠风险是18~30岁的6.821倍,相较于普通人群,老年慢性疼痛者疼痛程度更重,生活行为受限等症状更明显,会严重的影响老年人的生活质量,且相关调查显示老年慢性疼痛患者较非慢性疼痛患者更易出现激惹、抑郁、焦虑等不良的心理状态,导致生活质量更低[13]。因此,老年人慢性疼痛问题及其相关联的焦虑、抑郁状态须加以关注。失眠风险随病人抑郁严重程度而增加,轻度、中度和重度抑郁病人分别是无抑郁病人的4.181、19.381和21.688倍,有研究表明,慢性疼痛与失眠以及焦虑、抑郁等有着紧密的联系,三者为循环因果关系;同时,睡眠障碍也是抑郁症状的一个外在表现,研究也发现最近一个月未发生睡眠障者较少出现抑郁状态[14]。提示通过改善睡眠也可以有效的降低抑郁状态发生率的可能性,对伴有睡眠障碍患者开展心理干预乃至药物的使用可能能够缓解睡眠障碍及减轻抑郁状态。
本研究发现疼痛部位 > 1个的患者失眠风险较高,中度疼痛和重度疼痛病人的失眠风险较轻度疼痛高,再次佐证了疼痛越严重,也就更易发生失眠情况,说明缓解疼痛引起的失眠,最有效的措施还是缓解、控制疼痛。相较于疼痛病程 < 1 a的病人,疼痛病程为1 a~和3 a~的患者失眠风险分别降低,疼痛史大于1 a者则表明患者已经饱受疼痛折磨,可能已经适应的疼痛,故对睡眠影响较小,因此,临床医生诊疗时必须详细询问其病史,了解其疼痛持续时间。
综上所述,本研究的调查发现慢性疼痛患者常常伴发焦虑、抑郁与失眠,且疼痛与焦虑、抑郁、失眠之间关系密切,不同人群失眠的发生率也不同,对易于出现失眠的人群,需特别加以关注和心理疏导,对出现失眠症状的慢性疼痛患者,应该同时进行抗失眠治疗,适当提供抗抑郁、抗焦虑治疗,以提高慢性疼痛治疗疗效。
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表 1 2组患者基线数据比较[($\bar x \pm s $)/n(%)]
Table 1. Comparison of baseline data between the two groups of patients [($\bar x \pm s $)/n(%)]
指标 UBE组 开放手术组 t/χ2 P 平均年龄(岁) 48.75±7.95 51.80±6.37 −1.931 0.061 性别 男 21(47.73) 21(52.50) 0.191 0.658 女 23(52.27) 19(47.50) 手术节段 L4/5 19(43.18) 29(72.50) 1.912 0.830 L5/S1 25(58.62) 11(27.50) 椎间盘突出位置 中央型 15(34.10) 16(40.00) 0.473 0.642 旁中央型 17(38.60) 14(35.00) 外侧型 12(27.30) 10(25.00) 表 2 2组患者围手术期相关指标比较[($\bar x \pm s $)/n(%)]
Table 2. Comparison of perioperative related indicators between the two groups of patients [($\bar x \pm s $)/n(%)]
指标 UBE组 开放手术组 t/χ2 P 手术时间(min) 172.32±50.03 202.07±45.18 −2.851 0.006* 术中出血量(mL) 72.84±52.94 274.77±70.43 −14.732 <0.001* 术后住院时间(d) 3.95±1.92 6.75±2.11 −5.937 <0.001* 围术期并发症 4(9.1%) 12(30%) −2.362 0.022* *P < 0.05。 表 3 组患者围术期并发症比较[n(%)]
Table 3. Perioperative complications comparison between two groups of patients[n(%)]
组别 硬脊膜撕裂 神经根刺激症状 并发症率 t P UBE组(n=44) 1(2.3) 3(6.8) 4(9.100) −2.430 0.017* 开放手术组(n=40) 6(15) 5(12.5) 11(27.500) *P < 0.05。 表 4 2组患者腰腿痛VAS评分比较($\bar x \pm s $)
Table 4. Comparison of VAS scores for lower back and leg pain between two groups of patients ($\bar x \pm s $)
指标 UBE组 开放手术组 t P VAS 术前 5.79±1.02 6.60±1.08 −3.501 <0.001* 术后2 d 1.97±0.92 3.07±0.83 −5.686 <0.001* 术后1月 0.77±0.83 1.30±1.04 −2.541 0.131 F 692.730 352.311 P <0.001* <0.001* 组内效应 F=950.791 ,P < 0.001* 组间效应 F=27.120 ,P < 0.001* 组内×组间 F=2.740,P=0.069* *P < 0.05。 表 5 2组患者改进后的MacNab量表评分比较[n(%)]
Table 5. Comparison of Improved MacNab Scale Scores between Two Groups of Patients [n(%)]
组别 优 良 可 差 优良率 χ2 P UBE组(n = 44) 40(90.9) 2(4.5) 2(4.5) 0(0) 95.4 5.019 0.081 开放手术组(n = 40) 29(72.5) 7(17.5) 4(10.0) 0(0) 90 表 6 2组患者影像学结果比较($\bar x \pm s $,mm)
Table 6. Comparison of imaging results between the two groups of patients ($\bar x \pm s $,mm)
指标 UBE组 开放手术组 t P 椎间盘高度 术前 8.58±2.06 9.79±3.02 −2.121 0.038* 术后 8.46±2.18 10.24±2.68 −3.340 0.001* t 0.472 7.171 P 0.487 0.010* *P < 0.05。 -
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