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2014년 11월 3일 월요일

우리들병원 최경철부장님 논문 게재 Percutaneous endoscopic lumbar discectomy for L5-S1 disc herniation: transforaminal versus interlaminar approach

우리들병원 최경철 부장님의 논문이 Pain Physician에 게재되었습니다.

요추5번-천골1번에 디스크 탈출증이 있는 환자들을 대상으로 추간공경유 내시경요추절제술과 추궁간판 경유 내시경 요추절제술을 비교하여 시행한 연구 입니다.

수술한 환자 30명을 대상으로 2년 후의 VAS, ODI, 업무 복귀 소요시간 등의 임상결과와 디스크 종류, 사이즈, 위치, 높이, 추간공 높이 등을 조사하였습니다.

임상결과는 두 군 모두 수술전에 비해 수술 후 결과가 향상되었고, 디스크 종류, 크기, 높이 및 추간공 높이 등은 두 군간의 유의한 차이가 있었습니다.

연구자는 요추5번-천골1번 디스크를 수술하는데 있어 이 추간공 경유 내시경수술과 추궁간판 경유 내시경수술의 접근법은 현재 집도의의 선호도와 장골뼈와 디스크 공간 사이의 해부학적인 연관성에만 의존해서 수술하고 있고, 아직 참고문헌이 없어 연구를 시작하게 되었다고 합니다.


*Title: Percutaneous endoscopic lumbar discectomy for L5-S1 disc herniation: transforaminal versus interlaminar approach
*Authors: Choi KC, Kim JS, Ryu KS, Kang BU, Ahn Y, Lee SH
*Bibliography: Pain Physician. 2013 Nov-Dec;16(6):547-56.


BACKGROUND
Percutaneous endoscopic lumbar discectomy (PELD) is a minimally invasive spinal technique.
The unique anatomic features of the L5-S1 space include a large facet joint, narrow foramen, small disc space, and a wide interlaminar space. 
PELD can be performed via 2 routes, transforaminal (TF-PELD) or interlaminar (IL-PELD).
However, it is questionable that the decision of the endoscopic route for L5-S1 discs only depends on the surgeon's preference and anatomic relation between iliac bone and disc space.


OBJECTIVE
-To compare the radiologic features and results of TF-PELD and IL-PELD.
We have clarified the patient selection for the PELD route for L5-S1 disc herniation.


STUDY DESIGN
Retrospective evaluation.



METHODS
Subjects: 30 patients (treated with TF-PELD and IL-PELD for L5-S1 disc herniation)
Radiological assessments: pre&postoperatively
Assessments parameters: The disc type, disc size, location, migration, disc height, foraminal height, iliolumbar angle, iliac height, and interlaminar space
Clinical outcomes: visual analog scale(VAS: back, leg pain), Oswestry Disability Index(ODI), time to return to work (2-year F/U)


RESULTS
































-Mean VAS(back, leg) and ODI: significantly improved in the 2 groups.
-Mean time to return to work: 4.9wks(TF-PELD) and 4.4wks(IL-PELD)
Incomplete removal, resulting in the need for subsequent open surgery: 1 case(3.3%) of TF-PELD /  2 cases(6.6%) of IL-PELD
Postoperative dysesthesia: 2patients(6.7%) after IL-PELD / 0 patients after TF-PELD
Recurrence: 3.3% with TF-PELD / 6.7% with IL-PELD (2yr F/U)
Disc type, location, and migration: significant difference between groups

The prevalence of axillary disc herniation (20 cases, 66.7%) was higher than that of shoulder disc herniation (10 cases, 33.3%) in the IL-PELD group. On the other hand, in the TF-PELD group, shoulder disc herniation (20 cases, 66.7%) was more prevalent than the axillary type (10 cases, 33.3%; P = 0.01). A higher number of patients in the TF-PELD group had central disc herniation (10 cases, 33.3%) compared with that in the IL-PELD group (2 cases, 6.7%; P = 0.01). Eleven cases (36.7%) of high grade migration were removed using IL-PELD and one case (6.7%) was removed using TF-PELD (P = 0.01). TF-PELD was used to remov only 3 cases of recurrent disc herniation. There were no significant differences of radiologic parameters between the iliac bone and L5-S1 disc space between the 2 groups.


LIMITATIONS
-Relatively small sample size and a short follow-up period.
                

CONCLUSION

-Demonstrated that TF-PELD is preferred for shoulder type, centrally located, and recurrent disc herniation, while IL-PELD is preferred for axillary type and migrated discs, especially those of a high grade.