TAP CHi Y HOC VIET MAM TAP 451 • THAHG 2 • S01 • 2017
DANH GIA KET QUA DIEU TRI THOAT VI DIA D£M COT SONG
THAT LUNG L4 L5 BANG PHAU THUAT NOI SOI QUA L5 LIEN HOP TAI B|NH VIEN VIET DI^C NAM 2015
Dinh Ngoc Sffn**, Nguyin Le Bao Tiln*, Binh Trong Tuyen**
study lias not encountered any complications and complications. Meet 1 case of recurrence after 7 mffliths of surgery and patients are blocking selective nerve root by steroid anti-Inflammatory drugs.
Condusion: The endoscopic tlirougii conjugated iioles giving good results, should be applied in practice.
Keywords: Surgery herniated disc of tiie lumbar spine, endoscopy through conjugated holes TOMTAT
Muc tieu; Oanh gia ket qua dieu trj thoat v| dTa dem CSTL L4L5 bSng phau thu$t ngl sol qua lo lien hdp. Phu'dng phSp: Nghien cu^ tien CIJIJ md ta ISm sang. Ket qua: Diem VAS trung binh txdtc va sau phlu thuSt 24h, 1, 3, 6 thang co si/ cai thien ro ret.
Diem ODI trung binh tru'dc phlu thuSt Id 66±9,67, sau phau thuat chii'c nang CSTL co sy" cai thi|n ro ret thong qua diem ODI sau 1 thang la 11±9,48 sau 3 tiiang 10,7±10,56 sau 6 thang 11,6±14,24. Theo thang diem Maenad cai tien,sau phau thuSt 3,6 th^ng b' le tot va rat to la 90%, ti I? xau d 3 thaiig la 0%, ti lejrung binh d 3 thang la 10%. Ti \% trung binh 6 6
^ i g la 7,5%, ti le xau d 5 thang la 2,5%. Trong nghien cu\] Ichdng g^p tru'dng hdp ndo c6 tai bi€h va blen chulig. G^p 1 tru'dng hdp tai phat sau 7 thang t^tiau thult va tienh nhan du'^c phong be chpn Ipc re Wl<fbang thuoc chong viim corticoid. K ^ lu^n:
Phu'dng phap npi soi qua l5 lien hdp diiu til thoat vj dia d?m CSTL L4L5 dem lai ket qua dilu trj tSt cho benh nhan, (^n du'dc ap dung.
Tdkhoa: Phau thuat thoat vf dia dim edt sdng thatiutig, npi soi gua ioiien hop.
SUMMARY
THE RESULTS OF THE TREATMENT HERNIATED DISC OF THE LUMBAR SPINE
BY ENDOSCOP THROUGH CONJUGATED HOLES AT THE VIETNAMESE GERMAN
HOSPITAL I N 2 0 1 5
Objective: To evaluate the results of treatment herniated disk of lumbar spine L4L5 by endoscopy through conjugated holes. Method: A prospective study of the dinicai description. Results: The average VAS before and after surgery 24 hours, 1, 3, 6 montiis Improved markedly. Point average preoperative ODI was 66 ± 9.67, post-surgical spinal function markedly improved through ODI score after 1 month 11±9.48, after 3 months 10.7±10.56, after 6 months 11.6±14.24. According Maenad scale improvement of 3, 6 months after surgery well and very factor ratio is 90%, bad in 3 month rate was 0%, rate on 3-month average is 10%. The average rate at 6 montiis was 7.5%, the rate at 6 montiis w/as negative 2.5%. In the
*Benh vi$n HuV Nghj Yi?t Dui:
**D§ihge YHa Npi
Chju tradi nhi?m chi'nh: Nguy§n L§ Bao Tien Email: [email protected] Ngay nhan bai: 22.11.2016 Ngay phan bien khoa hpc: 4.01.2017 Ngay duyet b4i: 13.01.2017
\. OAT VAN o l
Thoat vi dia dem la sd dicli chuyen to chu'e dia dem vu'dt qua gidi lian giai phau sinh ly cua vong xd. Khoi thoat vi co the la: nhan nhay, sun, ban xu'dng sun tham chf ca vong xd dTa dem.
Benh thu'dng gap d tuoi 30 - 50 gay anh hu'dng tdi ngu'di lao dong.
Oieu tri thoat vj dia dem CSTL td tru'dc den nay chii yeu la dteu trj npi va dieu trj phau thuat.
Dieu trj phiu thuat du'dc dat ra khi thoat vj da v3 chen ep vao re than kinh gay trieu chihig dau Wdng litig va nhutig tru'dng hdp co thoat vj dieu trj noi khoa sau 3 thang khong co ket qua. Trong diiu trj phau thuat, mo md co be day lich sd va dddc ap dung nliieu hhat,tuy nhien mo md co nhieu han che nhu* du'cfng md dai, ton thu'dng phan mem Idn, mat mau nhieu, oS the gay mat vijtig cot song, vi v$y ma t?i cac nu'dc phat trien phau ttiuat mo md chi con ap dung trong nhChig tru'dng hdp thoat vj da vd, the thoat vj d vj tri Wid hoac thoat vj kem theo mat vutig cot song, hep ong song, hoi chu'ng duoi ngu^. Trong khi do phau thuat npi so! qua iS lien hdp lay nhan thoat vj trong thoat vj dTa dem du'dng vao la du'dng ben qua lo liSn hdp, hau nhu* khong lam thu'dng ton den giai phiu ci!ia cot song, va seo sd dinh rat ft vi du'dng mo nhd khoang 0,7 cm, benh nhan chl can te tai cho, trang qua trinh piiau thuat benh nhan tinh iioan toan do do phau thuat vien co the danh gia ngay du'dc hieu qua CLia phiu thuat, ngu'di benh chi phai nam vien 1-2 ngay va co the tiiam gia cac hoat dgng xa hpi trong vong 4 tuan. Tren the giiS pliau thuat npi soi qua lo lien hdp lay nhan thoat vj du'dc titig dung rong rai tai cac nu'dc phat trieri nhu" l^y, NhSt, Bdc... Tai Viet Nam phau thuat npi soi qua lo lien hdp lay nhan thoat vj du'dc ufng dung dau tien tai thanh pho Ho Chf iwiiiih nam 2007, va dau nam 2008 tai benh vien Viet
VIETNAW MEDICAL JOURNAL N'l - FEBRUARY - 2017
eifc da trien khai thu'cing quy. TCr nam 2007 den nay cung co nhieu cong trinh nghien ctfu iien quan den thoat vj dia dem CSTL nhufig chu'a co nghlSn ciJu nao danh gia rieng ve k& qua dieu tri thoat vi dia dem CSTL L4L5 bang npi soi qua iS iien hdp (LLH). Vi vay chung toi tien lianh nghien ciJu nay nham muc tieu: "Danh gia ket qua dieu trf thoat vi dia dem CSTL L4L5 bang phau thuat ngi sol qua lo iien hdp ".
n. OOI nroNG VA pHirowe PHAP NGHIIN CUU 2.1 Boi tu'dng nghien cuti: Gom 40 tienh nhan duHc chan doan thoat v| dia dem L4L5 co chi dinh phau thuat va duHc phau thuat tiang phuHng phap NS qua LLH tiJ' 3/2014 den 1/4/2015
2.2 Phu'dng phap nghien cihi: Nghien ciilJ tien cull mo ta iam sang.
Bing 1. Binh gii han che vin dgng CSTL qua cic thed diem theo bing diem OSWeSTRYjODI)
2.3 Thu thap so iieu: So iieu du'dc tiiu thap vao benh an da dutfc xay dutig san. Benii nhan du'dc theo doi va danh gia i<et qua trong qua trinh dieu tri tai benh viSn Vift Du'c. Kham -iai benh nhan sau Vn\ icet thuc nghien cull.
Xu' iy va phan b'ch so lieu: Cac so iieu diTdt nhap va phan tfch theo phan mem SPSS 16.0.
iii. KET QUA
Sau phlu thuat 24h, trung binh diem VAS la 2,15±0,77, sau 1,3,6 thang la l,52±i,32, 1,2±1,3, 1,28±1,58. Trong do sau phau thuat 24h, 1,3,6 thang khong co benh nhan nao co VAS tren 7 diem, tuy nhien sau phau thuat 6 thang CO 1 benh nhan co VAS kieu re 7 diem chiem ti 1^
2,5%. khac biet c6 y nghla v6i p < 0,001.
eiem OSWESTRY
<20 diem 20-40 diem 42-60 diem 62-80 diem
> 80 diem Trung binh
Sau phau thuat 1 thang SL 39 0 1 0 0
Tyie 97.5%
0%
2.5%
0%
0%
11±9,48
Sau phiu thu|t 3 thang SL 1 Ty le 37 92,5%
1 2.5%
2 5%
0 0%
0 1 0%
ia.7:tl0,56
Sau phau thuat 6 1 thang I SL
36 0 3 1 0
Tyie 1 90%
0%
7.5%
2.5%
0%
11.6±14.24 Biem ODI trung binh sau phau thuat 1,3,6 thang la 11±9,48,10,7±10,55,11,6±14,24.
Sau phau thuat 1,3,6 thang khong co benh nhan nao co ODI tren 80%, sau 6 thang co 01 benti nhan co ODI trong khoang 62 -80 diem chiem 2,5%. Su" khac biet_c6 y nghia vdi p < 0,001.
Bang 2. MU'C do hai long cda benh nhan theo tiiang diem Maenad cai tiin Diem Maenad
Rat tot Tot Trunq binh
Xau Tong
Sau phau thuat 3 thang SL
15 21 4 0 40
Tyle 37.5%
52.5%
10%
0%
100%
Sau phiu thuit 6 thing SL
16 20 3 1 40
Tyle 40%
50%
7.5%
2.5%
100%
Tong so benh nhan du'dc danh gia theo thang diem Maenad rat tot va tot sau 3 va 6 thang phau thuat la 36 benh nhan (90%), trung binh va xau co 4 benh nhan (10%), trong do co 1 benh nhan tu" thang diem trung binh sau 3 thang phau thuat xuong thang diem xau sau 6 thang phau thuat.
-Hinh anh MRI sau phau thuat: Sau phau thuat 24 h 100% benh nhan du'dc chup lai I^RI CSTL de danh gia tinh trang thoat vi dia dem, trong do khong thay tru'dng hdp nao cdn thoat vL
-Cx tai bi&ivalH&tchdiig sau phau thiiit Trong^ qua trinh theo doi benh nhan khdng benh nhin nao bong nhom nghien cuV ed tai
bien va bien chutig.
- Thoat vj tai phcit: Trong nhom nghien cull cd 1 benh nhan thoat vj tai phat sau 7 thang phau thuat chiem 2,5%. Do la tru'dng hdp benii nhan Nam 47 tuoi (so thii" tu" 20) vao vien vdi h6i chiiTig that lutig va hpi chutig chen ep re TK ro, benh nhan dau chan phai Vas chan khi vao 7 diem ODI 90, MFU CSTL hinh anh TVDD L4L5 thg' trung tam, benh nhan dudc phau thuat lay tiioat vj qua npi soi LI>I L4L5 phai. Sau do benh nhSn du'dc phong be than kinh re L5 phai, sau tlii thuat lam sang dd dau chan khoang 60%. Hien tai benh nhan van du'dc theo doi.
TAP CHi Y HOC VIET NAM TAP 451 - THAHG 2 - SO 1 - 2017
- Cac y€u t6i anh [iu'dng den phau thuat ^ _
Bang 3. Tu'dng quan giO'a k& qua dieu tii va cac yeu to lien quan thong qua hi so tdng quan va gia tilp <^Sp nhan he sotxtdng quanOPIoethang I Macnab06thang Ket qua VAS 06 thaiig
Yeu to
0.369 0.19 0.1
0.388
0.013Gidi The thoat vj
Mu'c dp thoai hoa dTa 0.296
Mu'c do thoat vj
-0.81 0.621-0.109 0.502 0.24 0.881 VAS tru'dc phau thuat
0.168 0.301"0.109 0.502 0.058 0.720 Theo bang tren cho thay mut dp thoai hoa dia co tu'dng quan vdi ODI sau mo 6 thang, he so r = ,274 va CO "/ nghTa thong ke vcfi p = 0,037 < 0,05. Vide dp thoai hda dia lien quan chat che vdi lacnad sau nro 6 thang, he so r = 0,861 va co y nghia thong ke vdi p = 0,022 < 0,05.
/. BAN LUAN
4.1 fianh gia chu'e nang cot song that Aig theo thang di€m ODI
Dau CSTL la trieu chu'ng ma 87,5% benh Mp trong nhom nghien culi gap phai, de danh
^mu'c dp dau anh hu'dng den chii'c nang CSTL i^the nao chung toi danh gia theo thang diem IDI (Owestry).
Dion ODI trung binh tru'dc phau thuat ta 6±9,67 sau phau thuat 1 thang la 11 ± 9,48 au 3 thang 10,7±10,56 sau 6 thang 11,5 ± .4^24. Nhu" vay su" khac biet giu^ ODI tru'dc
>hau thuat va sau phau thuat 1,3,6 thang la ro et vdi p< 0,001. ODI sau phau thuat 6 thang ab ifdng quan v6i mu'c dp thoai hoa dTa dem, he so udng quan r = 0,274 vdi p < 0,05. Theo nghien :ihj cua Dino [2] cho thciy dau CSTL co lien quan :hat che vdi mu'c dd thoai hoa dia, dieu nay giai hich tai sao sau phau thuat nhulig benh nhan co nut do thoai hoa dTa dp 4 dp 5 tinh chat dau ulig van ton tai, nhulig ti le dau lUhg sau phau huat c^i thien ro ret so vdi tru'dc phau thuat.
4.2 Sanh giac mu'c do hai long cua b|nh than theo thang di€m Maenad cai tien
Nghien oiu cho thay sau phau tiiu$t 3 thang i le ^ va rat tot la 90% va trung binh la 10%,
^a ti le nay van giu' nguyen sau 6 thang phau huat, tuy nhien co 1 tru'dng hdp (2,5%) tiJ" mu'c To tmng binh xuong mu'c dp xau la do benh liian bj thoat vi tai phat. Theo bang 2 cho thay 'laaiad sau phau thuat 6 thang co b/dng quan :hat che vdi mu'c dp tiioai hda dia , he so tu'dng iuan r = 0,861 vdi p < 0,05.
4.3 Cae yeu to anh hu'dng den Icet qua ihau thuat
Chung toi thay rang, ulj diem cua phau thuat lpi soi qua Io lien hdp trong nhuHg tru'&ng hdp no cu, \^\ di phfa sau la kha \d: thOr nhat duSng no cDa npi soi la du'dng mo khac, vi vay khong
sd seo cu, khong sd dinh, giam thieu du'dc cac nguy cd rach mang culig, bao re trong klii mo.
TnDng nghien cdu Idiong cd tru'dng hdp nao bj rach mang cuTng, ton thu'dng re trong mo, Idiong CO bien chulig nao khac nu^. ThiJ hai, day la phu'dng phap mo can thiep ft xam lan, Idiong iam anh hu'i^ng them phia sau cot song, va vi vay nguy cd mat vulig sau mo la giam thieu.
Mpt nghien CUIJ gan day cua Lee D.Y. [3] so
sanh giij^ 02 phu'dng phap mo md siT dung vi phau va mo n6i soi qua lo tien hdp.Tac gia thay, mo md vi phau cd 02 tru'dng hdp rach mang culig (6.9%), trong khi do mo npi soi khong cd tru'dng hdp nao
Trong nghien CLTU cd moi tu'dng quan chat che giij^ mu'c dp thoai hoa dTa va Maenad sau mo 6 thang vdi h | so tu'dng quan r = 0,861 va p= 0,022, va cd sir tu'dng quan giffa mu'c dp thoai hda dia v&\ ODI sau mo 6 thang v^ he so r=
0,274 va p = 0,037. Do yeu to npi sinh va ngoai sinh ma da dem thoai hda gay hpi chlilig cot song that lulig lam co ngudi benh dau mdi CSTL
4.4 Bi€n chu^g va tai bien
Trong nghien cuU chiing toi khong gap trui&ng hdp nao cd tai bien va bien chiilig trang qua trinh phau thuat va sau qua trinh dieu tri.
Trong khi dd nam 2011 Yong Ahn thong bao co 9 trudng htfp rach mang ciilig trong tong so 826 benh nhan chiem 1,1%, trong so 9 bn nay cd 3 bnjjhat hien npay trong khi phau thuat va du'dc phau thuat mo md de va mang culig, 6 tru'dng hdp con l^i phat hien sau phau thuat khi benh nhan cd^do dich nao tuy sau phau tfiuat va cOng du'dc phau thuat mo md de va mang ciilig.
4.5 Thoat vj tai phat: Thoat vj tai phat
du'dc dinh nghTa kinh ^en la hien tutfng trieu
chjng dau lan theo re TK het lioan toan sau
phau thuat va xuat hien lai cd the sau vai tuan
hoac vai nam, trieu chiilig cd the cijng ben hoac
VIETHAM MEDJCAL JOURNAL N°1 - FEBRUARY - 2017 )en doi dien. Trong nghien cii'u cd 1 benh nhan
hoat vj tai phat sau 7 thang phau thuat chi^m U5%. Do la trudng hdp benh nhan Nam 47 tuSi ma so 36) vao vien vdi tioi chiilig that lulig va ioi chii'ng chen ep re TK ro, benh nhan dau chan iliai Vas chan khi vao 7 diem, ODI 9 0 % , MRI I S R hinh anh TYDD L4L5 the trung tam, bSnh ihan du'dc phau thuSt lay thoat vj qua npi soi I H L4L5 phai, benh nhan du'dc phong be r l han kinh bang corticoid hien tai benh nhan dd Iau kieu re VAS 6 diem va con dau CSTL nhieu Ianh gia ODI khoang 8 0 % , benh nhan van du'dc :hung toi theo doi, neu trong tiidi gian tdi trieu rhiilig dau ciia benh nhan khdng cai thien chiing :di se phau thuat mo m d lay thoat vj tai phat.
Ttioat vi dia dem tai phat khac nhau tuy ulig tac gia. Theo l^uetten S theo doi 463 benh ihan sau mo ndi soi qua lo lien hdp sau 01 nam, hay ty le tai phat gSp 32 b^rih nhan ( 7 % ) . Trong khi do Peng C W . [4] theo doi 55 benh ih3n trong 02 nam thay ty 1$ tai phat la 5%. Con .ee S.H. [5] theo doi 116 benh nhan mo npi s o l , hdi gian theo doi trung binh la 14.5 thang(9-20 hangj, Idiong tiiay trudng hc^ nao tai phat Mot bao 30 iang hc^ aia Kim DH[6] va cong sir qua 6522 ca )hau thuat r o soi qua lo lien htfp vd! thcfi gian theo Joi tij" 01-06 nam, thi ty le tai p h ^ la 4,7%.
/ . K^'T LUAN
Diem VAS trung binh tru'dc va sau phau
;huat 24h, 1, 3, 6 thang cd su" cai thien ro ret.
Diem ODI trunc| binh tru'dc phau thuat la )6±9,67, sau phau tiiuat c h u t nang CSTL co sd a i thl$n ro ret thong qua diem ODI sau 1 thang a 11±9,48 sau 3 thang 10,7± 10,56 sau 6 thang Ll,6±14,24. Theo thang diem Maenad cai tien
sau phau thuat 3,6 thang ti le t o t va rat ^ i 9 0 % , ti le xHu d 3 thang la 0 % t i le trung bin'i 3 tiiang la 10%. T l le trung binh d 6 tJiangi 7,5%, ti le xau d 6 thang la 2,5%. Trong n g h i ciiu khong gap tru'cfng hdp nao cd tai bien i bien chiilig. Gap 1 tru'dng hdp tai phat s a u ; thang phau thuat va benh nhan du'dc phong W chpn Ipc re TK bang thuoc chong viem corticoldj
T A I LIEU THAIVI KHAO ^ 1 . Nguyen Van Thach, N g u y i n Van C h i ^
Nguyen Thj Ng9c Lan & Va Cong S u ' ( i w , Bao cao tong hap ket qua ichoa hge eong fig^i l3i:" Nghien edU thu'c bang, cac yiu tdng0!s va cac phu'dng phap dieu bi thoat vi dia 0mM song-De tai doe iap cap nha nddc". Ha n o j . ' . M 2. Dino S a m a r t z i s / J a r o Karppinen,^J3so]^m
Yin Cheung,^ and Jeffrey Lotz^ * ^ Degeneration and Low Back Pain: Are T h e y »
Related Conditions?" ^ J . D. Y. Lee, C. S. Shim, Y. Ahn, Y. G. Choi, H. J.
Kim & S. H. Lee (2009), "Comparison ot percutaneous endoscopic lumbar discectomy anti open lumbar mierodiscedomy for reeunent disc hemiation", Joumai of Korean Neurosurgical Society, 46(6): p. 515-21.
4. C. W. Peng, W. Yeo & S. B. Tan (2009};;
"P&ojisneous endoscopic lumbar dix&imfi dini(3l and quality of life outcomes wiO) a minimum 2 year foilow-up", Joumai of orthopaedic surgery and research, 4: p. 20.
5. S. L e e , S . K . Kim, S. H.Lee, W . J . Kim, W.C Choi, G. Choi & S. W. Shin (2007),
"Percutaneous endosajpic iumbar discednmyior migrated disc herniation: dassifieabon of disc migiation and surgical approadies", EuropeSi;
spine joumai 16(3): p. 431-7. m 6. D. H. Kim , G. Choi & S. H. Lee, ComplicaVM
in pereutsneous Eruioseopic iumbar DiscecSJtm in Endoscopic Spine Proeedute. 2011, Thiem^
New York, Stuttgart, p. 253 - 268. "
KgT QUA PHAU THUAT THAY KHOT HANG T O A N PHAN KHONG XI MANG CO LOT P H O HYDROXYAPATITE
roM
TAT>3l van de: khdp hang nhan tao co ldp phu lydroxyapatite da duWc sOf dung tr§n fam sang trong
B0mdnlpoaiO?ihgcYHiNdi,
khoa Phau thu$t khdp BV TWQuan doi 108
"hiu tr^ch nhi^m chfnh: DSo Xu3n Thhnh imail: [email protected]}m Igay nh^n bai: 5.11.2016 Igay phan bien khoa hoc: 9.01.2017 Igay duyet bai: 16.01.2017
Dao Xuan Thanh^, Nguyin Qu^c Dung^
hdn hai th§p ky. Tranh cSi van con ton tgi trong vi|c siy^dung hydroxyapatite trong thay khdp hang toan phan lin ^ u . Myc dfch oia nghien culi nay la danli gia kgt qua thay khdp hang to^n phan khong a mSng, CO Idp phij hydroxyapatite. Phu'dng phap: nghiSn oiu hoi ddu tren 80 khdp hang nhan t^o khong xi mSng cd Idp phti hydroxyapatite. Danh gl^ ket qua ciia chiing tdi diJ^ tren thang dllm Harris hip score (HHS). Cac dau hieu x-quang cung dUdc nghien dht.
K@t qua: tiidi gian theo doi tmng binh I^ 26,5 thang:
Tuoi trung binh tai tiidi C^em phlu thuat la 53,4 nSm:
lOidp hang phd Hydroxyapatite cai thien dang ke di^in
32
