Objective To evaluate the effectiveness and safety of different injection sites for collagenase chemonucleolysis for lumbar intervertebral disc protrusion (LIDP). Methods We searched for randomized controlled trials (RCTs) and quasi-RCTs in the following electronic databases: Pubmed (1966 to May 2006), EMBASE(1966 to May 2006), The Cochrane library (Issue 2, 2006), CRD(Center for Reviews and Dissemination),York University, CBM (1978 to May 2006 ), CNKI(1994-2006)and VIP(1989-2006). Quality assessment and data extraction were conducted by two reviewers independently. Disagreement was resolved through discussion. Results Eight studies involving a total of 1035 participants met the inclusion criteria. Meta-analysis was not carried out because of apparent heterogeneity. Four studies made comparisons among intradisc, extradisc, and combined intra- and extra-disc injection. One study (62 participants) showed that intradisc injection was superior to extradisc injection (RR 3.71, 95% CI 1.19 to 11.58, Plt;0.05). Another study (240 participants) showed that intradisc injection was superior to combined intra- and extra-disc injection after 3 months and 6 months of follow-up (RR 0.88, 95% CI 0.80 to 0.98, Plt;0.05). The other two studies showed no significant difference among intradisc, extradisc, and combined intra- and extra-disc injection. Four studies (436 participants in total) showed that amongst three extradisc injections, both anterior epidural space injection and lateral epidural space injection were superior to posterior epidural space injection (Plt;0.05). Although one study indicated that anterior epidural space injection was superior to lateral epidural space injection (RR 1.24, 95% CI 1.03 to 1.51, Plt;0.05), no statistical significance was found between anterior epidural space injection and lateral epidural space injection in two other studies (Pgt;0.05). Conclusions There is insufficient evidence to identify which injection site for collagenase is the most effective for lumbar intervertebral disc protrusion. The included studies showed that both anterior and lateral epidural space injection were superior to posterior epidural space injection. However, these studies are too small and poor quality, and have different diagnostic criteria, follow-up time points, outcome measures and efficacy parameters. Thus, more high quality and large-scale RCTs are needed.
目的 分析腰椎间盘突出症手术后复发的原因，探索有效的手术治疗方法。 方法 对2004年8月－2011年7月收治的32例腰椎间盘突出症术后复发再手术的患者，根据其病因采用3种不同手术方法治疗，其中椎间盘摘除术14例，椎间盘摘除联合腰椎后外侧融合内固定术7例，椎间盘摘除联合腰椎后路椎体间融合内固定术11例，术后应用改良Macnab疗效评定标准、Oswestry功能障碍指数（ODI）和影像学检查对手术治疗的临床疗效进行评价。 结果 3种手术治疗方法均取得了满意的优良率；术后3个月及末次随访ODI评分术后较术前明显降低，差异有统计学意义（P＜0.05）。 结论 腰椎间盘突出症术后复发与多种原因有关；根据复发患者的情况合理选择手术治疗方法均能取得较好的临床疗效。
目的:观察手法复位配合针刺治疗腰椎间盘突出症的疗效。方法:将239例确诊为腰椎间盘突出症的患者随机分为治疗组和对照组，其中治疗组120例，采用手法复位配合针刺治疗，对照组119例，采用针刺治疗。并分别观察两组患者症状评分变化和疗程。结果:治疗组总显效率85.83%，对照组72.27%（Plt;0.05）。治疗组痊愈率53.33%，对照组36.13%（Plt;0.05）。治疗组显效病例，达到显效时所需的治疗时间为12.60±3.39天，对照组为16.85±4.15天（Plt;0.05）。结论:手法复位配合针刺治疗腰椎间盘突出症优于针刺治疗。
目的：探讨在CT引导下经小关节内侧缘穿刺，应用造影剂观察药物分布，准确行靶位注射胶原酶［1］治疗术后复发的腰椎间盘突出症的疗效。方法:10例经临床确诊为腰椎间盘突出症术后复发的患者,在CT引导下经小关节内侧缘入路将穿刺针直接刺入突出物内,注射欧乃派0.5 ml，观察药物分布情况后，注入胶原酶600 u。临床观察患者术后6～12个月的治疗效果，用改良的Macnab方法评价疗效。结果:10例患者穿刺针均顺利准确刺入突出物，造影剂均匀分布在突出物及盘内。治疗优、良率为100%，无严重并发症。结论: CT引导下穿刺造影，观察造影剂的扩散后，再行靶位注射胶原酶对于术后复发的腰椎间盘突出症，可以进一步提高治疗效果，减少并发症的发生。
To evaluate the effectiveness of interrupt percutaneous endoscopy lumbar discectomy (PELD) through interlaminar approach for L5, S1 disc protrusion. Methods Between November 2006 and August 2010, 115 patients with L5, S1 disc protrusion were treated, including 79 males and 36 females with an average age of 38 years (range, 14-79 years). All patients showed the dominated symptom of the S1 nerve root. The working channel was establ ished by puncturing through interlaminar approach under the local anesthesia. After the needle was used to make sure no nerve root or dural sac on working face, the disc tissue was excised directly by bl ind sight. Then the nerve root decompression was observed through the endoscope. In patients with free type, fragment compression was observed through the endoscope, and the disc tissue around the nerve roots was removed, then the free disc tissue around intervertebral space was excised. Results One patient who failed to puncture changed to miniopen discectomy; 3 patients who failed changed to post lateral approach; and the others underwent interrupt PELD through interlaminar approach. Eighty patients were followed up 18 months on average (range, 12-36 months). The average Oswestry Disabil ity Index (ODI) was reduced to 13% ± 5% at 12 months after operation and to 12% ± 8% at last follow- up from 73% ± 12% at preoperation, showing significant differences (P lt; 0.01). According to modified Macnab ,s criterion, the results were excellent in 59 cases, good in 15 cases, fair in 3 cases, and poor in 3 cases at last follow-up, and the excellent and good rate was 92.5%. Conclusion For the treatment of disc protrusion at the L5, S1 level, interrupt PELD through interlaminar approach should be ideal with short operation time, small trauma, and quick recovery.
Objective To evaluate the short-term results of discectomy combined with Isobar non-fusion internal fixation. Methods Between May 2006 and May 2008, 65 cases of single segment lumbar disc protrusion were random surgically treated by discectomy combined with Isobar non-fusion internal fixation (34 cases, group A) and single discectomy (31 cases, group B), respectively. In group A, there were 18 males and 16 females with an average age of 38.8 years (range, 23-51 years); the involved segments were L2,3 (1 case), L3,4 (4 cases), L4,5 (20 cases), and L5, S1 (9 cases), including 11 cases of protrusion type, 16 cases of prolapsed-type, and 7 cases of sequestered type; and the mean disease duration was 7.2 months (range, 1-66 months). In group B, there were 19 males and 12 females with an average age of 39.2 years (range, 21-49 years); the involved segments were L3,4 (2 cases), L4,5 (24 cases), and L5, S1 (5 cases), including 13 cases of protrusion type, 15 cases of prolapsed-type, and 3 cases of sequestered type; and the mean disease duration was 6.5 months (range, 3 weeks to 72 months). There was no significant difference in the general data between 2 groups (P gt; 0.05). The surgical results were assessed by visual analogue scale (VAS) for back/leg pain and the Oswestry disabil ity index (ODI). The height of involved intervertebral space was measured dynamically after operation. Results The patients of two groups were followed up 32 months on average (range, 24-49 months). All cl inical symptoms of the patients were notably improved in 2 groups. One patient in group B experienced postoperative cerebral fluid leakage, and was cured after extubation, changing posture, and other measures. There was no implant failure, such as pedicle fracture, screw loosening, or screw malposition during the follow-up. The ODI and VAS were significantlyimproved after operation. The back and leg pain VAS scores at each time point were decreased significantly when compared with
Objective To investigate the effectiveness of Quadrant retractor for the treatment of recurrent lumbar disc protrusion. Methods Between July 2008 and March 2010, 18 cases of recurrent lumbar disc protrusion were treated with Quadrant. There were 13 males and 5 females with an average age of 43 years (range, 35-67 years). Involved segments includedL4, 5 in 6 cases and L5, S1 in 12 cases. The time between first operation and recurrence was 12-120 months (mean, 42.8 months). Before operation, radiological evaluation including X-ray, CT, and MRI were performed. Visual analogue scale (VAS) score and modified MacNab criteria were used to evaluate the effectiveness. Results The operation time was 40-80 minutes (mean, 60 minutes), and the amount of blood loss was 80-120 mL (mean, 100 mL). All operations were performed successfully, and no compl ication of infection and nerve injury occurred. Incisions healed by first intention. Cerebrospinal fluid leakage occurred in 2 cases and was cured at 3 days after operation by removal of drainage. Eighteen patients were followed up 12-30 months (mean, 22 months). The VAS score of leg pain was decreased from 7.3 ± 2.2 preoperatively to 2.0 ± 1.3 at the final follow-up, showing significant difference (t=11.08, P=0.00). According to modified MacNab criteria, the results were excellent in 12 patients and good in 6 patients. No recurrence was found during follow-up. Conclusion Discectomy via Quadrant retractor is a safe and effective minimally invasive surgical technique in treating recurrent lumbar disc protrusion.
To compare the effectiveness of microdiscectomy and macrodiscectomy on the single-level lumbar disc protrusion (LDP). Methods Between November 2002 and October 2005, 241 patients with LDP underwent 2 surgical procedures: microdiscectomy (group A, 93 cases) and macrodiscectomy (group B, 148 cases). All patients had singlelevel LDP. In group A, there were 51 males and 42 females with an average age of 32.3 yeares (range, 18-47 years); there were 23cases of protrusion, 52 cases of prolapse, and 18 cases of sequestration with an average disease duration of 8.5 months (range, 1-18 months), including 8 cases at L2,3 level, 11 cases at L3,4 level, 35 cases at L4,5 level, and 39 cases at L5, S1 level. In group B, there were 81 males and 67 females with an average age of 31.8 years (range, 16-50 years); there were 37 cases of protrusion, 85 cases of prolapse, and 26 cases of sequestration with an average disease duration of 9.3 months (range, 1-20 months), including 9 cases at L2,3 level, 15 cases at L3,4 level, 63 cases at L4,5 level, and 61 cases at L5, S1 level. There was no significant difference in age, sex, segment level, type, or disease duration between 2 groups (P gt; 0.05). Results Immediate back and sciatic pain rel ief was achieved in 225 (93.4%) patients after operation. The satisfactory rates were 91.4% in group A and 87.8% in group B at 1 week after operation, showing no significant difference (P gt; 0.05). The length of incision, amount of bleeding, amount of drainage, and hospital ization time in group A were significantly fewer than those in group B (P lt; 0.05); while the operative time in group A was longer than that in group B, but showing no significant difference (P gt; 0.05). Dural laceration occurred in 4 cases of groupA and 5 cases of group B, superficial infections of incision occurred in 5 cases of group B and intervertebral space nfections occurred in 4 cases of group B, and epidural hematoma occurred in 1 case of group A. The perioperative compl ication rate (5.4%, 5/93) in group A was significantly lower (P lt; 0.05) than that in group B (9.5%, 14/148). LDP recurred in 4 cases (4.3%) of group A and in 9 cases (6.1%) of group B postoperatively, showing no significant difference (P gt; 0.05); of them, 11 cases received second operation and 2 cases were treated conservatively. All cases were followed up 36-77 months (mean, 51.4 months). There were significant differences in visual analog scale (VAS) and Oswestry disabil ity index (ODI) between 2 groups at the last follow-up and preoperation (P gt; 0.05), but there was significant difference in VAS at 1 week postoperatively between 2 groups (P lt; 0.05). VAS and ODI were obviously improved at 1 week and last follow-up when compared with preoperation (P lt; 0.05). There was no significant difference in the improvement rates of VAS and ODI between 2 groups at last follow-up (P gt; 0.05). According to cl inical evaluation of Modified Macnab criteria, the excellent and good rate was 90.3% in group A and 86.5% in group B at final follow-up (P gt; 0.05). Conclusion Both macrodiscectomy and microdiscectomy are effective for LDP, furthermore microdiscectomy is less invasive than macrodiscectomy. Microdiscectomy is recommended to treat single-level LDP.
Objective To compare microsurgery lumbar discectomy (MSLD) via posterior approach with traditional open discectomy by fenestration for single-level lumbar disc protrusion in terms of methodology and therapeutic effect. Methods From January 2001 to January 2008, 230 patients with single-level lumbar disc protrusion were randomized into two groups. In group A, 114 patients underwent MSLD, including 77 males and 37 females aged 15-76 years old (average 41 years old); the duration of the disease ranged from 6 months to 28 years (average 51 months); the lumbar disc protrusion involved L4,5 level in 52 cases, and L5 - S1 level in 62 cases; there were 50 cases of lumbar disc protrusion on the left side, 54 onthe right side, and 10 of the central type; preoperative JOA score was 6-18 points (average 11.8 points). In group B, 116 patients underwent traditional posterior open discectomy by fenestration, including 78 males and 38 females aged 14-78 years old (average 42 years old); the duration of the disease ranged from 8 months to 26 years (average 52 months); the lumbar disc protrusion involved L4,5 level in 56 cases, and L5 - S1 level in 60 cases; there were 53 cases of lumbar disc protrusion on the left side, 52 on the right side, and 11 of the central type; preoperative JOA score was 5-19 points (average 12.3 points). No significant difference was evident between two groups in terms of general information (P gt; 0.01). Parameters of operative time, volume of blood loss during operation, length of operative incision, length of hospital stay after operation, and total medical cost of single disease were analyzed. Therapeutic effect was assessed by postoperative JOA score during follow-up period. Results The operative time was (40 ± 9) minutes in group A and (47 ± 11) minutes in group B. The volume of blood loss during operation was (26 ± 5) mL in group A and (60 ± 6) mL in group B. The length of operative incision was (2.6 ± 0.8) cm in group A and (5.6 ± 0.5) cm in group B. The length of hospital stay after operation was (4.0 ± 2.6) days in group A and (8.0 ± 2.9) days in group B. The total medical cost of single disease was (5 500 ± 1 800) ￥ in group A and (6 300 ± 1 500) ￥ in group B. Significant difference was evident between two groups in terms of the above parameters (P lt; 0.01). The incisions in two groups all healed by first intention.No compl ications such as wrong orientation, nerve root injury, cauda equina injury, and infection occurred. The follow-upperiod was 12-37 months (average 26 months) for 102 patients of group A and 12-35 months (average 24 months) for 98 patients of group B. The JOA score 12 months after operation was 21-28 points (average 24.8 points) in group A and 22-27 points (average 25.2 points) in group B, showing a significant difference when compared with preoperative score (P lt; 0.01), and no significant difference between two groups (P gt; 0.01). Conclusion Two methods have similar cl inical outcomes, but MSLD has merits of minimal invasion, less blood loss, shorter operative time, shorter length of hospital stay, and lower medical cost. It is one of ideal minimally invasive operations for single-level lumbar disc protrusion．