英語晨讀 ·
山東省立醫院疼痛科英語晨讀已經堅持10余年的時間了，每天交班前15分鐘都會精選一篇英文文獻進行閱讀和翻譯。一是可以保持工作后的英語閱讀習慣，二是可以學習前沿的疼痛相關知識。我們會將晨讀內容與大家分享，助力疼痛學習。
本次文獻選自Pan M , Li Q , Li S , et al. Percutaneous Endoscopic Lumbar Discectomy: Indications and Complications[J]. Pain physician, 2020, 23(1):49-56.本次學習由趙學軍主任醫師主講。
Since Kambin experimentally induced arthroscopy to treat lumbar disc herniation (LDH), percutaneous endoscopic lumbar discectomy (PELD) has undergone great development in the past decade. In 1997 and 2003, Yeung et al and Hoogland et al developed the Yeung endoscopic spine system (YESS) and transforaminal endoscopic spine system (TESSYS) techniques, respectively, and the techniques are collectively named percutaneous endoscopic transforaminal discectomy (PETD). Afterwards, Ruetten introduced percutaneous endoscopic interlaminar discectomy (PEID) in 2006. Both PETD and PEID have been proven to be equivalent to open spine surgery or other minimally invasive surgery in terms of efficacy and safety.
自Kambin實驗性地將關節鏡引入腰椎間盤突出癥（LDH）的治療以來，經皮內鏡下腰椎間盤切除術（PELD）在過去的十年中得到了長足的發展。1997年和2003年，Yeung等人和Hoogland等人分別開發了Yeung內窺鏡脊柱系統（YESS）和經椎間孔內窺鏡脊柱系統（TESSYS）技術，這兩種技術統稱為經皮內鏡下經椎間孔椎間盤切除術（PETD）。后來，Ruetten在2006年提出了經皮內鏡下椎板間入路椎間盤切除術（PEID）。PETD和PEID在療效和安全性上與開放性脊柱手術或其他微創手術相當。
Indications of PELD ought to be taken into consideration for surgical efficacy and safety. With the development of surgical techniques, navigation techniques, and optical systems, indications of PELD have expanded from single LDH to lumbar spinal stenosis, lumbar metastatic tumor, lumbar discal cyst, and revision of recurrent LDH. On the other hand, surgery-related complications have become more common and inevitable due to the wide spread of PELD . The most prevalent among them include dural tear, intervertebral infection, postoperative hypoesthesia, guidewire breakage, and recurrence of lumbar disc herniation. By the use of PubMed database and key words such as “percutaneous endoscopic lumbar discectomy”, “percutaneous endoscopic transforaminal discectomy”, “percutaneous endoscopic interlaminar discectomy”, “PELD”, “PETD”, “PEID”, “YESS” and “TESSYS”, this study aims to summarize the indications of PELD, describe the complications, and explore their solutions.
為了保證手術的有效性和安全性，應考慮PELD的適應證。隨著手術技術、導航技術和光學系統的發展，PELD的適應癥已從單純的腰椎間盤突出癥擴展到腰椎管狹窄癥、腰椎轉移瘤、腰椎間盤囊腫和復發性腰椎間盤突出癥的治療。另一方面，由于PELD的廣泛傳播，與手術相關的并發癥變得越來越常見和不可避免。其中最常見的包括硬腦膜撕裂、椎間盤感染、術后感覺減退、導絲斷裂和腰椎間盤突出癥復發。本研究利用PubMed數據庫檢索了“經皮內窺鏡下腰椎間盤切除術”、“經皮內窺鏡下經椎間孔椎間盤切除術”、“經皮內鏡下經椎板間椎間盤切除術”、“PELD”、“PEID”、“YESS”和“TESSYS”等關鍵詞，總結PELD的適應癥、描述并發癥并探索解決方法。
Percutaneous endoscopic transforaminal d iscectomy
In the YESS technique, the disc is accessed through the Kambin triangle approach, which consists of the exiting nerve root (hypotenuse), superior endplate of the caudal vertebra (base), and superior articular process of the caudal segment (height). The YESS procedure removes the nuclear pulposus with rongeur inside the annulus fibrosus, so TESS is an “inside-out” technology making it difficult to address migrated disc herniation. While using the TESSYS technique, a foraminoplasty is conducted by serial trephine and the endoscope is inserted into the spinal canal to deal with herniated disc materials. Therefore, TESSYS is an “outside-in” technology and has great advantage in treating highly migrated disc herniation and lumbar spinal stenosis. When it comes to the L5/S1 segment, puncture through the foramen can be technically difficult due to the high iliac crest, the large transverse process of L5, and hidden disc materials, and in these cases an interlaminar approach may be a better choice .
經皮內窺鏡下經椎間孔椎間盤切除術
在YESS技術中，經皮內鏡下經椎間孔椎間盤切除術是通過Kambin三角入路進行的，該三角由神經根（斜邊）、尾端椎體上終板（底部）和尾段上關節突（高度）組成。YESS手術是在纖維環內用髓核鉗切除髓核，因此YESS是一種“由內而外”的技術，該技術難以解決移位的椎間盤突出癥。而TESSYS技術是通過一系列的環鉆進行椎間孔成形術，并將內窺鏡插入椎管內以處理突出的髓核。因此，TESSYS是一種“由外而內”的技術，在治療高度移位的椎間盤突出癥和腰椎管狹窄癥方面具有很大的優勢。在L5/S1節段，由于髂骨嵴高、L5橫突較大、突出椎間盤隱蔽，在這些病例中，經椎間孔的穿刺技術難度很大，經椎板間入路可能是更好的選擇。
Percutaneous endoscopic interlaminar discectomy
Unlike PETD, PEID employs a posterior approach, passing through the lamina and ligamentum flavum to the disc, which is more familiar to spinal surgeons. Owing to the wide intervertebral space, PEID has advantages over PETD in treating disc herniation of L5/S1. Besides, PEID can resect the ligamentum flavum and hypertrophy of the facet joint to resolve central stenosis and foraminal stenosis. As a significant complement to PETD, PEID is also suitable for highly migrated or calcified disc herniation because of the large operating space in the spinal canal. However, PEID requirestraction of the thecal sac to deal with disc fragments, which may consequently cause dura laceration and other complications.
經皮內窺鏡下經椎板間椎間盤切除術
與PETD不同，PEID采用后路，通過椎板和黃韌帶到達椎間盤，這是脊柱外科醫生更熟悉的入路。由于椎間隙較寬，PEID在治療L5/S1椎間盤突出癥方面優于PETD。除此之外，PEID還可以切除黃韌帶和小關節肥大以解決中央椎管狹窄和椎間孔狹窄。作為PETD的重要補充，PEID也適用于高度移位或鈣化的椎間盤突出癥，因為椎管內手術空間大。然而，PEID需要牽引鞘囊來處理椎間盤碎片，這可能導致硬腦膜撕裂和其他并發癥。
