OBJECTIVE:To compare the clinical effects and safety of ultrasound (US)-guided selective cervical nerve root injection (SCNI) and computed tomography (CT)-guided SCNI for patients with cervical radicular pain (CRP).METHODS:Forty-two CT-guided SCNI procedures (26 eligible patients) and forty-two US-guided SCNI procedures (25 eligible patients) performed to treat CRP were identified from the medical record system between October 2017 and July 2021 and enrolled in the study. The numeric rating scale was used to assess pre- and postprocedural pain levels, and the neck disability index was used to assess the level of function. All immediate and delayed clinical complications were also recorded. The cost of each procedure and the radiation dose of the CT procedure were documented. The follow-up data were obtained by telephone calls or outpatient visits.RESULTS:Five patients in the CT group and one patient in the US group were lost to follow-up at 1 year. No procedure-related complications were observed in either group. Significant pain relief and cervical function improvement were achieved after treatment in both the CT-guided SCNI and US-guided SCNI groups; however, there were no significant differences between the two groups. The average cost per CT-guided SCNI procedure was 133.2 USD, which was higher than the cost per US-guided SCNI procedure (42.2 USD). Meanwhile, the necessary radiation dose per patient in the CT group was 0.36 ± 0.08 mGy.CONCLUSIONS:US-guided SCNI and CT-guided SCNI have similar efficacy in treating CRP, but US-guided SCNI is radiation free and less costly than the CT-guided procedure.

极外侧型腰椎间盘突出 (extreme lateral lumbar disc herniation, ELLDH) 特指腰椎间盘突出髓核位于椎间孔内和(或)椎间孔外,是腰椎间盘突出的一种特殊类型 [1].经典ELLDH分型包括:陈仲强等 [2]依据髓核移位位置提出的Ⅰa-Ⅱb型和周跃等 [3]依据髓核在孔内、孔外位置提出的Ⅰ-Ⅲ型,以上两种分型对指导手术和解释症状具有重要意义.蒲俊刚等[4]发现部分ELLDH病人突出物不仅位于椎间孔内或(和)外,同时位于椎管内,并将合并椎管内突出的ELLDH归为IV型,丰富了ELLDH分型,对临床治疗ELLDH具有一定意义.

极外侧型腰椎间盘突出 (extreme lateral lumbardisc herniation, ELLDH) 为腰椎间盘突出的一种特殊类型,由Abdullah 等 [1] 于1974 年首次提出.ELLDH病人腰椎间盘突出或脱出于侧隐窝外侧、椎间孔内或椎间孔外,直接压迫相应节段背根神经节或神经根,引起神经分布区剧烈放射性疼痛、麻木、无力和浅感觉下降等[2].虽然ELLDH 发病率相对较低,占所有腰椎间盘突出症病人的0.7％～11.7％ [3,4],但其导致的神经卡压损伤较重,症状明显,非手术治疗效果较差,常需手术治疗.

目的:评估CT引导经皮脊柱内镜(Percutaneous endoscopic lumbar discectomy,PELD)治疗高度脱垂型腰椎间盘突出症的疗效与安全性.方法:选取2016年8月至2019年12月因腰腿痛就诊于我院疼痛科或脊柱外科门诊,且最终诊断为高度脱垂型腰椎间盘突出症患者88例,分别行CT引导经皮脊柱内镜手术(CT-PELD组)和后路开放椎间盘摘除术(OD组).应用数字模拟评分(Numerical rating scale,NRS)评估两组患者术前、术后1周、术后3月、术后6月、术后12月和末次随访疼痛变化,应用改良MacNab疗效评定标准评估两组患者术后优良率,记录术中及围手术期并发症及复发情况.结果:与术前相比,两组手术患者术后各时间段NRS评分明显降低,差异有统计学意义(P<0.01);组间比较,除术后1周OD组患者疼痛NRS评分高于CT-PELD组(P<0.01),两组术前及术后各时间点NRS评分差异无统计学意义(P>0.05);术后12月OD组和CT-PELD组的疗效优良率分别为87.8％、91.5％,差异无统计学意义(P>0.05);OD组住院费用较CT-PELD组更低,手术时间更短,但住院天数更长,差异均有统计学意义(P<0.05).结论:依据个体化选择手术方案,CT-PELD可有效治疗高度脱垂型腰椎间盘突出症,且安全性较好.

经皮脊柱内镜下腰椎间盘切除术 (percutaneous endoscopic lumbar discectomy, PELD) 已成为治疗腰椎间盘突出症的首选微创术式,椎板间入路 (percu-taneous endoscopic interlaminar discectomy, PEID) [1]作为成熟术式之一被推广应用.其中按是否保留黄韧带可以分为两类技术,一是全内镜下腰椎间盘切除术,在切除部分黄韧带后进入椎管去除突出物,该方法安全性较高,适应证广;另一类是C形臂引导下,引导针、扩张管、工作套管直接挤开黄韧带进入椎管内,术后黄韧带可再次闭合,但存在较大安全隐患 [2].针对C形臂引导下保留黄韧带技术的不足,本研究团队充分发挥CT引导优势,采取保留黄韧带PEID技术治疗L5/S1椎间盘突出症,获得了良好的安全性和有效性 [3].目前对PEID是否能保留黄韧带同时,安全有效治疗L4-5椎间盘突出症,临床尚有争议.本研究拟在一定解剖条件下,探索CT引导下PEID保留黄韧带治疗L4-5节段椎间盘突出症的疗效及安全性.

极外侧型腰椎间盘突出症 (extreme lateral lum-bar disc herniation, ELLDH) 是因椎间盘组织脱出于椎间孔内、外,压迫同节段出口神经根,从而引起相应神经分布区放射性疼痛麻木等下肢神经损伤症状的腰椎疾病 [1～4].依据 ELLDH 具体突出部位可分为椎间孔内型(I 型)、椎间孔外型(Ⅱ型)与混合型(Ⅲ型)[1].该病发病率约占腰椎间盘突出症的 2.6％～11.7％ [5],此类病人症状一般较重,常需手术治疗 [6～9].近年来,国内外探索脊柱内镜下治疗极外侧型腰椎间盘突出症,取得一定的效果 [3,4,10].然而因腰椎间盘极外侧突出与出口神经根的压迫关系复杂、常合并多处卡压、神经受压范围广及在突出物压迫下神经、血管位置异常,使得其手术难度较常规类型腰椎间盘突出增大.如何提高脊柱内镜手术治疗 ELLDH 疗效,降低并发症目前仍是挑战.本研究首次提出 CT 三维重建导航经皮脊柱内镜手术治疗极外侧型腰椎间盘突出症,分析其治疗ELLDH 可能的优越性,为临床治疗提供参考.

OBJECTIVE The purpose of this study is to evaluate the effectiveness and safety of percutaneous radiofrequency thermocoagulation (PRT) via the foramen rotundum (FR) for the treatment of isolated maxillary (V2) idiopathic trigeminal neuralgia (ITN) and assess the appropriate puncture angle through the anterior coronoid process to reach the FR. METHODS Between January 2011 and October 2016, 87 patients with V2 ITN refractory to conservative treatment were treated by computed tomography (CT)-guided PRT via the FR at our institution. The outcome of pain relief was assessed by the visual analog scale (VAS) and Barrow Neurological Institute (BNI) pain grade and grouped as complete pain relief (BNI grades I-III) or unsuccessful pain relief (BNI grades IV-V). Recurrence and complications were also monitored and recorded. The puncture angle for this novel approach was assessed based on intraoperative CT images. RESULTS Of the 87 treated patients, 85 (97.7%) achieved complete pain relief, and two patients (2.3%) experienced unsuccessful pain relief immediately after operation. During the mean follow-up period of 44.3 months, 15 patients (17.2%) experienced recurring pain. No severe complications occurred, except for hypoesthesia restricted to the V2 distribution in all patients (100%) and facial hematoma in 10 patients (11.5%). The mean puncture angle to reach the FR was 33.6° ± 5.7° toward the sagittal plane. DISCUSSION CT-guided PRT via the FR for refractory isolated V2 ITN is effective and safe and could be a rational therapy for patients with V2 ITN.

经皮脊柱内镜下腰椎间盘摘除技术 (percuta-neous endoscopic lumbar discectomy, PELD) 已发展为治疗腰椎间盘突出症的标准术式之一,目前有椎间孔入路 (percutaneous endoscopic transforaminal discectomy PETD) 和椎板间入路 (percutaneous endo-scopic interlaminar discectomy PEID) 两类技术.因髂嵴的原因导致"kambin"三角区过小及穿刺角度受限,在大部分L5/S1椎间盘突出病人中行PETD会出现置管困难,且大多需行小关节部分去除,因而对于L5/S1椎间盘突出 [1~3]仍存在很大局限性.PEID成功地弥补了PETD在这方面的缺陷,但多数学者在C臂下完成,需切除黄韧带暴露神经根.CT引导下PEID开展较少,是否有其自身优势研究较少,术中保留黄韧带,保存椎管及脊柱后纵韧带复合体的完整性和功能价值仍需进一步探讨.本研究在CT引导下行保留黄韧带PEID手术,通过观察其临床疗效及并发症的发生情况评估该技术的有效性和安全性,为进一步优化、推广脊柱内镜技术提供依据.