Abstract
SUMMARY A 58-year-old male patient diagnosed with thromboangiitis obliterans (Fontaine stage Ⅳ) was recently treated with microendoscope discectomy system-assisted spinal cord stimulation electrode implantation and cured by department of vascular surgery combined with department of spinal surgery at Peking University People's Hospital. The patient suffered from cold injury to the right foot 14 years ago, which was cold, painful, numb, and then the toe was ulcerated and gangrene. Only the right foot small toe was left. The right foot skin was swollen from the toe to the proximal segment 1 year ago, accompanied by resting pain. Both pain and autologous bone marrow stem cell transplantation were ineffective. The above symptoms were aggravated three months ago, and the pain was severe. The visual analogue score was 10 points. A high amputation of the left lower extremity was performed 30 years ago due to trauma. Physical examination: the bilateral femoral artery was weak, and the right radial artery, posterior tibial artery, and dorsal artery were not touched. Buerger sign (+). Auxiliary examination: angiography of both lower extremities showed complete occlusion of the bilateral external iliac artery and its distal end. The percutaneous oxygen partial pressure was measured to be 30 mmHg on the right side of the iliac crest. The operation was performed under the local anesthesia. After X-ray positioning, the body projection of the lumbar vertebrae 1-2 lamina gap was marked. The skin had a 1.8 cm incision on the caudal side 2 cm from the mark. Then the dilators were used, and the working sleeve was tilted to the lumbar vertebrae 1-2 lamina gap. The microendoscope discectomy system was installed, the electrode was directly placed into the epidural space from the interlamina space under the microendoscope, the vascular surgeon adjusted the position of the electrode in the spinal canal under fluoroscopy, then connected the stimulator, adjusted the current until the patient had the lower limb fever, fixed electrode position, removed the microendoscope discectomy system after hemostasis under the microendoscope, used the guide needle to lead the electrode through the lumbar subcutaneous and then sutured the incision. After the operation, the electrode was connected to the temporary stimulator to stimulate for several minutes, the patient felt numbness in his lower limbs. In less than one hour, the skin temperature of the affected limb increased, and the painkiller could be stopped while sleeping. After 1 week, the skin temperature of the affected limb increased, and the percutaneous oxygen partial pressure of the foot and ankle was 36 mmHg, and the pain improved, and the score was reduced to 2 points. One month after surgery, the patient underwent permanent stimulator implantation. The pain disappeared after 3 months and half year of follow-up, and the score was reduced to 1 point. Microendoscope discectomy system-assisted spinal cord stimulation electrode implantation can complete the operation quickly, safely and effectively, and greatly reduce the number of intraoperative fluoroscopy and reduce the occurrence of complications.
Keywords: Microendoscopic discectomy, Spinal cord stimulation, Thromboangiitis obliterans
(本文编辑;刘淑萍)
椎间盘镜下椎间盘摘除术(microendoscopic discectomy, MED)是脊柱外科目前比较成熟的微创手术,该技术通过经皮小切口置入通道,利用光源和影像采集放大系统提供清晰的手术视野[1].脊髓电刺激(spinal cord stimulation, SCS)治疗是将脊髓刺激器的电极置于硬膜外腔,通过不同的电流脉冲刺激脊髓不同部位,实现调节神经功能以及疼痛治疗.对于不适合开放手术或血管介入的慢性肢体缺血疼痛患者,脊髓电刺激治疗也是非常合适的选择[2,3].传统的刺激电极植入方法是在透视下经皮用导针直接植入,并发症发生率高,容易造成硬膜损伤或硬膜外血肿,并且电极位置调整困难,透视次数较多,植入多个电极时难度极大[4];如果通过内镜辅助在直视下植入电极将有助于改善上述缺点,椎间盘镜辅助脊髓刺激电极植入技术国内未见报道,北京大学人民医院成功实施1例椎间盘镜辅助下脊髓刺激电极植入治疗下肢缺血的病例,现报道如下.
1. 病例资料
患者男,58岁,主因"右足疼痛麻木14年,溃烂1年,右手指溃烂3个月"于2017年5月8日入院.患者14年前因右足冻伤,出现怕冷,疼痛,麻木,继而脚趾溃烂坏疽,仅存右足小 
趾,当地医院诊断为"血栓性静脉炎",1年前右脚皮肤从脚趾进行性向近段溃烂,皮肤坏疽加重,伴有静息痛,口服止痛药及自体骨髓干细胞移植均无效,3个月前上述症状加重,同时右手食指出现皮肤溃烂,疼痛剧烈,视觉模拟评分(visual analogue scale, VAS)为10分.既往30年前因外伤行左下肢高位截肢,术后愈合及活动可.查体:右足Ⅰ~Ⅴ足趾缺如,残端愈合良好,足背部约有10 cm×12 cm皮肤破溃,形态略不规则,创面基底暗红,表面覆盖少许黄白色坏死组织,触痛明显.周围皮肤色暗红,无明显水肿.双侧股动脉搏动弱,右侧腘动脉,胫后动脉,足背动脉未触及.Buerger征(+).右手食指皮肤暗红,指端可见约2 mm×4 mm大小皮肤坏疽,触痛明显.左下肢高位截肢术后,断端皮肤愈合良好,肌肉萎缩.辅助检查:双下肢血管造影成像(computerized tomography angiography,CTA)显示双侧髂外动脉及其远端完全闭塞(图1), 双上肢CTA示右侧肱动脉下段局限性狭窄.经皮氧分压测定右侧踝上为30 mmHg.入院诊断:血栓闭塞性脉管炎(Fontaine Ⅳ期),一期手术拟血管外科联合脊柱外科行椎间盘镜辅助下脊髓刺激电极植入术.
1.
下肢动脉血管造影成像
Lower limb artery computer tomography angiography
手术采用第二代椎间盘镜手术系统,局麻下建立通道.患者俯卧位,用5 mL注射器针头X线透视下定位,确认腰椎1~2椎板间隙体表位置并标记,切口位置位于标记点尾侧2 cm,1%(体积分数)利多卡因局部浸润麻醉,切口1.8 cm,逐层切开皮肤,皮下以及腰背筋膜,用扩张器逐级扩张,向头侧倾斜,指向腰椎1~2椎板间隙,置入工作套筒,固定后安装椎间盘镜,连接光源和影像系统(图2),显露腰椎1~2椎板间隙和黄韧带,用椎板钳咬除部分椎板,扩大腰椎1~2椎板间隙,切除部分黄韧带,显露硬膜囊;椎间盘镜下直接将电极自椎板间隙置入硬膜外腔(图3), 注意保护硬膜囊,调整电极,使电极紧贴硬膜囊背侧,将电极缓慢向头侧推送,血管外科医生在X线透视下监测植入电极在椎管内位置(图4), 同时在椎间盘镜下监测电极位置,待电极到达预期位置后,将电极连接刺激器,调整电流,同时X线透视下微调电极位置,直至患者下肢有明显发热感,固定电极位置,椎间盘镜下彻底止血,然后拆除椎间盘镜系统,用导针将电极送至腰部右下方并将连接端引出体外,逐层缝合,关闭切口.
2.
建立通道,安装椎间盘镜
Place the working sleeve and connect the microendoscope discectomy system
3.
椎间盘镜下植入电极
Put in the electrode by monitoring in the microendoscope
4.
X线透视下监测植入硬膜外电极
Put in the electrode by monitoring with X-ray
术后将电极连接临时电刺激仪数分钟,患者即感患肢自腰,臀至小腿右足有酥麻感觉,疼痛消失,不到1 h即出现明显患肢皮温升高,手术当晚停用所有止痛药并安静入睡.1周后患肢皮温升高基本稳定,足踝部皮肤血氧测定为36 mmHg,较术前提高20%,疼痛缓解明显(VAS评分2分,较术前降低80%);2周后可偶尔关闭机器1~2 d而不出现静息痛,术后一直未服用止痛药,症状缓解满意,术后患者继续治疗肢端感染,1个月后行脊髓永久刺激器置入术,局麻下将刺激器植入右髂后部皮下,与之前放置的脊髓电极在体内连接.术后3个月及半年随访患者主诉疼痛症状基本消失,VAS评分1分.
2. 讨论
血管闭塞性脉管炎主要累及中小动脉,其病理基础为受累血管的非化脓性炎症,血栓形成与机化,常常病变广泛.目前对Fontaine Ⅰ期及Ⅱ期的患者大多采用药物治疗,而少数Ⅱ期,Ⅲ期及Ⅳ期患者选用手术,介入,干细胞移植等治疗[5,6].该患者CTA提示腰椎水平以下双侧髂总动脉,髂外动静脉以及股动脉完全闭塞,远端无通畅血管,供血几乎消失,无法实施搭桥,另外该患者从髂部至足底血管闭塞长度极长,实施介入手术风险较大,根据欧洲心血管协会2011发布的《外周动脉疾病诊治指南》,SCS治疗成为该患者的最佳选择[7,8].
SCS系统由电脉冲发生器,硬膜外刺激电极和导线组成.当电极植入硬膜外腔后,通过脉冲发生器发生电流,经电极刺激脊髓神经,达到治疗效果[9].已有研究表明,在治疗缺血性疼痛时SCS可以降低交感神经的活性,抑制血管的收缩,实现继发性血管扩张,改善肢体血供,减轻下肢缺血性疼痛[10,11,12].Kemler等[13]研究结果表明,SCS治疗后能明显减轻疼痛的强度,提高患者的生活质量.一项长达10年的随访系列研究[14]报道显示,62%接受脊髓刺激治疗的患者可获得超过50%的疼痛缓解率,53%的患者可不再使用镇痛药,机体功能和生活质量评分都有很大的改善.
SCS治疗成功的关键是将刺激电极准确地植入到疼痛相应的脊髓节段.如果疼痛范围较大,有时需要同时放置多个电极.植入电极的传统方式为X线透视下自目标椎间隙尾侧向头侧放置穿刺导针,用阻力消失法确认穿刺针进入硬膜外腔,之后用导丝导入临时测试电极,并在X线透视下确认位置[15],这种方式需要反复X线透视,常见的并发症为穿刺部位血肿,硬膜损伤以及刺激电极进入椎间孔压迫神经根引起神经根刺激痛等[16].
MED是脊柱外科中较成熟,应用较广的微创手术技术之一,可为术者提供清晰的解剖结构,切口仅1.8 cm,在椎间盘镜下可以顺利完成椎管减压,神经根松解,椎间盘髓核摘除,手术创伤小,疗效确切,患者满意度高.这一技术的核心在于通道的建立和清晰影像的提供,通常通道建立5~10 min内即可完成,通道可以调整不同角度,可以覆盖上,中,下各1个椎间隙,椎间盘镜下图像放大后在显示屏上可以清晰显示椎板,椎板间隙,黄韧带等结构,对于视野内出血用双极电凝可以很好地止血.本病例通过向头侧倾斜调整工作通道,很容易直达拟定腰椎1~2椎板间隙,椎间盘镜下清理黄韧带,显露硬膜,由于工作通道倾斜约45°,直视下很容易植入带导丝内芯的硬膜外刺激电极,植入过程未出现电极旋转打扭等情况,随后仅需通过少量透视以及试验电刺激即可完成电极的放置,直视下确认未出现硬膜损伤以及硬膜外出血,神经损伤等并发症,术中出血极少.
椎间盘镜下电极植入和传统经皮植入方法相比的优点在于准确性高,并发症少,术中X线辐射少;传统方法为X线透视下经皮穿刺,反复透视辐射明显增加,并可能出现硬膜损伤,硬膜外血肿形成和神经损伤等并发症;由于椎间盘镜工作通道可以调整角度,使电极接近水平角度无阻力植入,避免电极以及导丝出现折弯打扭等情况,降低硬膜损伤,出血等并发症的发生,椎间盘镜下视野清晰,一旦电极位置不满意,可随时退出更换植入角度,调整方向非常容易,而传统方法则需要调整导针位置,再次反复透视确认导针位置,增加并发症的风险.若切开直视下植入电极,切口至少在4 cm以上,创伤较大,且常常因为硬膜外静脉丛渗血导致视野不清,易损伤硬膜囊,由于电极靠内芯导丝引入,进入硬膜外腔需要导丝带电极同步适当折弯才能顺利进入,因为折弯角度不宜过大,所以切口需要达到1~2个椎板宽度,肥胖的患者切口可能需要更大,从而加大手术创伤,因此,对于背部软组织越厚的患者,椎间盘镜辅助下手术较有优势.椎间盘镜手术的并发症为偶有术后血肿形成,所以关闭伤口前应严密止血,必要时可放置引流管,另外在通道放置时有可能造成直接硬膜损伤,熟练操作后即可避免.
椎间盘镜辅助下SCS植入手术国内还处于起步阶段,该技术术中出血少,视野清晰,手术时间短,并发症少,电极位置准确度高,辐射大大降低,优势明显,临床上可逐步开展.
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