NGOAI KHOA SO D^C BIET 1,2,3/2012
NGHIEN Cini UNG DUNG DUNG CU CO DINH DONG COT SONG LIEN GAI SAU TRONG H 6 TR0 DIEU TRj P H A U THUAT JVIOT c k SO XUVNG
DIEU TRI BENH LY HEP ONG SONG THAT LUNG
Nguyin Van Thach, Dinh Nggc Son, Nguyen Le Bao Tien, Nguy6n Hoang Long, D6 Manh Hung, Dinh Manh Hai, Tran Qudc Khanh(*)
TOM TAT
Bat van de: Danh gia hieu qua cung nhu kha nang ifng dung ciia dung cu Silicon lien gai sau (Devide for Interspinous Assisted Motion_DIAM) trong ho t r d dieu trj benh ly hep ong song that lUng.
Boi t&&ng va phu'dng phap nghien cii'u:
30 BN du'dc chan doan va dieu tri phau thuat hep ong song that lu'ng dng dung dung cu cd djnh dpng lien gai sau Silicon tai khoa Phau thuat cot song Benh vien Viet Oiic trong thdi gian t d thang 2/2011 - thang 7/2011. Nghien ciru tien ciiu, md ta cat ngang.
Ket qua va ban luan: Oanh gia ket qua dieu tn sau 6 thang kham lai. Cai thien miic dp dau luhg va chan theo thang diem VAS: VAS lutig cai thien tif 5,7 ± 1,24 xudng 1,1 ± 0,69 , VAS chan cai thien tiS 6,2 ± 1,70 xuong 1,0 ± 0,74 sau 6 thang (p< 0.001). Cai thien chiic nang CSTL tir 48,3 ± 15,39 (%) xudng 22,4 ± 7,60 (%) (p<0.0Dl). Dp hai Idng cua BN theo Macnab; Rat tdt va tdt dat 86.7%. Trung binh chieu cao dTa dem cai thien tir 16,6 ± 1,19 Ien 17,5 ± 1,21 (mm), trung binh chieu cao io hen hdp cai thien t d 20,9 ± l , 5 0 J e n 23,1 ± 1,42 (mm). Thdi gian phau thuat: X ± SD : 54,0 ± 13,11 (phut). Min - Max: 30 - 80 (phiit). Lu'dng mau mat: Tat ca cac BN deu khdng phai truyen mau trong va sau md. Tai bien bien chiTng: 2 BN (6.7%) rach mang cirng. Khdng ghi nhan tru'dng hdp nao cd bien chirng nang.
Kit tuan: ij'ng dung dung cu DIAM trong ho trd dieu trj benh ly hep dng sdng that lu'ng an toan, de ap dung va bu'dc dau cho hieu qua dieu trj cao.
(*) Benh vien Viet D&c
S U M M A R Y
RESEARCHING ON APLLYING DEVICE INTERSPINOUS ASSISTED MOTION ( D I A M )
I N T O L A M I N O T O M I TO TREAT LUMBAR STENOSIS DISEASE Introduction: Evaluating the effectiveness as well the feasibility of applying DIAM into treating Lumbar Spinal Stenosis
i^ateriai and method: 30 patients have been diagnosed and received surgical treatment of lumbar spinal stenosis with DIAM in Viet Due hospital from February, 2011 to July, 2011.
Prospective cohort, cross - sectional study Results: Assessing treatment results after 6 months. Reliving back and leg pain via VAS:
back: from 5,7 ± 1,24 to 1,1 ± 0,69 ; leg: from 6,2 ± 1,70 to 1,0 ± 0,74 ( p < 0,001). ODI: from 48,3 ± 15,39 (%) to 22,4 ± 7,60 (%) (p<0.001).
Macnab: very good and good ( 86,7%). Disc mean height: from 16, 6 ± 1, 19 to 17, 5 ± 1,21 (mm), foraminal mean height: from 20,9 ± 1,50 to 23,1 ± 1,42 (mm). Operation time: 54,0 ± 13,11 mins, no blood transfusion within and after the operation. Complication: Dura! tear 2 cases.
No other severe complication
Conclusion: Applying DIAM In treating Lumbar Spinal Stenosis is safe, feasible, and has initially proven its high effectiveness.
I. OATVANOE
Hep dng sdng that Imig la mpt benh ly thu'dng gap, vdi ban chat la sir giam chu vi qua gidi han binh thudng cua dng sdng hay lo lien hop.
Vd diSu tri phau thuat, trudc day chu yeu 351
DAI HOI HOI NGOAI KHOA VN LAN T H Q Xll VA HOl NGH! KHOA HOC NGOAI KHOA TOAN QUOC LAN XIV
la md cung sau lam rdng dng sdng (Laminectomy), tuy nhien phircmg phap nay gay nhieu bien chimg nhu mat vimg, dau Imig keo dai va trugt ddt sdng sau md.
De han che nhiing van de tren, nam 1980, lan dau tien dung cu cd dinh ddng cdt sdng phia sau (Posterior Dynamic Stabilization-PDS ) duac dua vao img dung.
Tai Viet Nam, dung cu cd dinh ddng lien gai sau Silicon (DIAM) da dugc benh vien Viet Due dua vao umg dung hd trg dieu tri phau thuat benh ly hep dng sdng that lung tu nam 2008 va budc dau cho ket qua tdt, viec tim hieu danh gia hieu qua dieu tri cua dung cu la rat cSn thiet. Vi vay chung tdi tien hanh nghien cuu de tai nham hai muc tieu:
Ung dung ky thudt dgt dung cu co dinh dpng cot song lien gai sau bdng DIAM.
Buac ddu ddnh gid ket qud dieu tri benh nhan hep ong song that lung duac phdu thudt
ket hap dgt dung cu hd trg van dong cot song hen gai sau DIAM.
IL OOI TaONG VA PHUONG PHAP NGHIEN COU
2.1. DSi tircmg nghien cmi: 30 benh nhan dugc chan doan va dieu trj phSu thuat hep dng sdng that lung irng dung dung cu c6 dinh ddng lien gai sau Silicon (DIAM) tai khoa Phau thuat cdt sdng Benh vien Viet Due trong thdi gian tir thang 2/2011 - thang 7/2011
2.2. Phuong phap nghien eihi Sir dung phuong phap nghien cuu md ta Danh gia tinh trang benh nhan trudc mo va sau md, khi ra vien, kham lai sau 3 thang, 6 thang, 1 nam.
Xu" ly sd lieu
So sanh su thay ddi cac trieu chung truoc va sau md vdi test X^, khac biet cd y nghia khi p< 0,05. Sir dung ph5n mhm SPSS 13.0
III. KET Q U A
3.1. Dac diem chung Tudi: X ± S D : 42.3 ±11.31, Gidi: Nam/Ni5: 2/1
Min - Max: 2 1 - 5 9 (Tudi). N = 30.
Trieu chirng Idm sdng Trieu chu'ng Dau lirtiq
Oau kieu re Bau each hoi than Icinh Roi loan cam qiac Yeucd Roi loan cd tron Hoi chu'nq duoi nqu'a Tonq
N 30 28 18 13 2 0 0 30
»/o 100,0
93,3 60,0 13,3 6,7 0,0 0,0 100,0
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NGOAI KHOA s o B A C BIET 1,2,3/2012
Hinh dnh cdng hir&ng tir Hinh anh tren phim CHT I^lLTc do hep
Vi tri hep
Hinh anh ong tuy
DTa dem
Tuyet doi TUPnq doi Toan bo Trunq tam Nqach ben, LLH Tam qiac Oval Tron Thoat vi Thoai hoa
N 22 8 22
3 5 22
7 1 10 26
»/o 73,3 26,7 73,3 10,0 16,7 73,3 23,3 3,4 33,3 86,7 Mpt so thong so chung lien quan den phdu thuat
Thoi gian phau thuat:
X ± SD : 54,0 ± 13,11 (phut). Min - Max: 30 - 80 (phut) Luong mau mat:
Tkt ca cac benh nhan trong va sau md deu khdng phai truyen mau, xet nghiem cdng thirc mau sau md khdng trudng hgp nao bieu hien thieu mau.
Thoi gian nam vien:
X ± SD : 6,9 ± 1,62 (ngay). Min - Max: 5 - 10 (ngay) Tai bien - bien chung:
Trong 30 BN chung tdi ghi nhan 2 trudng hgp rach mang cung trong qua trinh giai ep thkn kinh, khdng ghi nhan trudng hgrp nao gay mdm gai, nham mirc thoat vi, hay nhiem triing sau md.
Ket qua phau thuat
Trong 30 benh nhan nghien cim, tai thdi didm ra vien chung tdi danh gia lam sang va chup XQ dugc 100% cac BN, tai thdi diim kham lai (trung binh 6 thang sau md) chung tdi goi dien va kham lai dugc 22 BN (ty le kham lai 73,3%)
Lam sang Thong so danh gia VAS (diem)
ODI (%)
Macnab
Lu'ng Chan 1. Rat tot 2. Tot 3.TB 4. Kem
Tru'dc mo 5,7 ± 1,24 6,2 ± 1,70 48,3 ± 15,39
Khi ra vien 1,8 ± 0,68 1,6 ± 0,72 22,4 ± 7,60
3 (10,0%) 21 (70,0%) 6 (20,0%) 0 (0,0%)
Sau mo 6 thang 1,1 ± 0,69 1,0 ± 0,74 20,3 ± 6,65
6 (20%) 20 (66,7%)
4 (13,3%) 0 (0,0%)
P
< 0,001
< 0,001
< 0,001
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BAI HOI HOI NGOAI KHOA VN LAN THLT XII VA HOI NGHI KHOA HOC NGOAI KHOA TOAN QUOC LAN XIV
C a i thien kha n a n g d i lai Kha nang di lai
Binh thudnq 100 - 500 (m)
< 100 (m)
Tru'dc mo 12 (40%) 13 (43,3%)
5 (16,7%)
Ra vien 12 (40%) 17 (56,7%)
1 (3,3%)
Sau 6 thang 18 (69,2%)
8 (30,8%) 0 (0,0%)
P
< 0,001
C a n lam s a n g :
——-___
TB chieu cao dTa dem (mm) TB chieu cao io lien
hdp (mm)
Tru'dc mo
16,6 ± 1,19
20,9 ± 1,50
Luc ra vien
17,6 ± 1,25
23,1 ± 1,42
Thdi diem kham lai
17,5 ± 1,21
23,0 ± 1,46 P
< 0,001
< 0,001
IV. BAN LUAN
4.1. Thoi gian phau thuat:
Trung binh thdi gian phSu thuat la 54,0
± 13,11 (phiit), ngan nhat 30 phut, lau nhat 80 (phiit).
Trong nghien ciru ve DIAM cua Zhao Yu, trung binh thdi gian phau thuat la 60 (phiit). Qua nghien cuu chiing tdi nhan thay thdi gian cho phau thuat chii yeu tap trung cho giai ep than kinh, lam rdng dng sdng va Id tiep hgp (trung binh 45 phut), cdn thdi gian chuan bi vi tri va dat dung cu khdng mat nhieu thdi gian (trung binh 10 phut).
4.2. Tai bien trong md va bien chirng:
Chung tdi ghi nhan cd 2 trudng hgp rach mang cung trong luc giai ep, ngoai ra chiing tdi chua ghi nhan trudng hgp tai bien nao khac.
L.HrabaIek khi nghien cim iing dung DIAM ho trg didu trj cho 68 BN cd benh ly hep dng sdng that lung do thoai hda ghi nhan cd mdt trudng hgp bi nhilm trung nhung khdng phai thao bd dung cu, J Buric vdi 52 BN ciing khdng ghi nhan trudng hgp nao cd bien chimg. Trong 152 BN Jean Taylor ung dung DIAM dng ghi nhan mot trudng hgp bi gay dinh mdm gai nhung khdng can trd viec dat dung cu, mdt trudng hgp nhiem trimg
phai thao dung cu nhung khdng cd tinh trang viem dia dem.
Ddi vdi nhdm BN dieu tri hep dng song cd sir dung dung cu hd trg DIAM, hai tai bien thudng gap nhat dd la rach mang cimg khi giai ep than kinh va gay mdm gai, khdng dat dugc dung cu trong md, dac biet d nhihig BN cao tudi cd kem loang xucmg. Theo Zhao Yu de han che nhirng tai bien tren, viec lua chpn benh nhan trudc md, chpn kich cd dung cu phii hgp (to qua de gay mdm gai, nhd qua khdng phat huy dugc hieu qua dieu tri) va nam vung ky thuat khi dat dung cu vao la nhirng yeu td rat quan.
4.3. Cai thien trieu chu-ng lam sang Cdi thien m&c dp dau theo chisS VAS:
Sau phau thuat cd su cai thien rd ret trieu chung dau cua cac BN, ca dau lung va dau chan. Dau lung cai thien tir 5,7d xudng cdn 1,8 d liic ra vien (cai thien 68.5%) va 1,1 d sau 6 thang theo ddi ( cai thien 79.3%). Dau chan cai thien tic 6,2d xudng cdn 1,6d liic ra vien (cai thien 74.2%) va 1,0 d sau 6 thang theo ddi (83.9%). Su cai thien nay cd y nghTa thdng ke vdi p< 0,001.
Ket qua nghien cim ve DIAM cua cac tac gia tren the gidi cung cho ket qua kha quan ve muc dp cai thien dau lung va dau
NGOAI KHOA SO OAC BIET 1,2,3/2012
chan sau md, theo J Taylor sau md tinh trang dau lung va dau chan giam cd y nghia thdng ke d 88.5% cac trudng hgp, theo L Hrabaiek muc dp trieu chiing dau lung va dau re cai thien 71% .
Mac du cac tac gia thudng sir dung VAS trong danh gia dau cap tinh hem la dau man tinh, tuy nhien VAS dugc cho la thang didm dem gian, dugc sii dung rdng rSi va cho do tin cay cao trong danh gia miic dp dau ciia benh nhan.
Cdi iliiin chiic ndng CSTL theo cliisd ODI:
Chuc nang cdt sdng that lung giam tir 48,3% xudng cdn 22,4% liic ra vien (cai thien 53.6%) va 20.3% liic kham lai (cai thien 57.9%), su cai thien nay cd y nghia thong ke vdi p< 0,001.
Cai thiSn kha nang di lai:
Hep dng sdng that lung chinh la nguyen nhan chinh gay khd khan trong di lai, sau md CO sir cai thien dang ke kha nang di lai ciia BN, sau md ca 5 BN cd CHTK < 100m trudc md deu cai thien va cd the di lai > 100m va CO den 69.2% cac BN di lai binh thudng sau 6 thang theo doi.
Do hai Idng ciia benh nhan sau mo theo IMacnab:
Vdi muc dich danh gia khach quan hieu qua dieu tn, chiing tdi sir dung thang diem Macnab de danh gia dp hai long ciia BN, ket qua nghien cuu cho thay 80% BN cho danh gia rat tdt va tdt liic ra vien va tang Ien 86,7%
liic kham lai. 20% cac BN cho ket qua trung binh liic ra vien va giam cdn 13,3% sau 6 thang theo ddi. Kiidng cd trudng hgp nao cho kk qua kem.
S Palmer khi sir dung DIAM ho trg dieu tri cho 65 BN bj hep dng sdng va thoat vi dia d?m, sau 4 nam theo ddi cho ket qua rat tdt va tdt dat 85%, cdn theo ket qua nghien ciin ciia J Buric tdt dat 88% va 4% cho k8l qua khong cai thien.
Chiing tdi da tien hanh danh gia su cai thien trieu chiing lam sang cua benh nhan d hai gidi (Nam, nir), d cac t^ng hep dng sdng khac nhau (L34, L45, L345), d ky thuat md cua sd xuong (mdt ben hoac hai ben) va d cac nhdm BN sic dung dung cu DIAM vdi cac kich cd khac nhau. KSt qua thu dugc cho thay khdng cd su khac biet vh hieu qua didu tri d cac nhdm BN nay.
4.4. Cai thien tren chan doan hinh anh Cdi thien trung binh chiiu cao dia dim:
Sau md cd su cai thien ro ret trung binh chidu cao dia dem, tir 16,6 ± 1,19 (mm) Ien 17,6 ± 1,25 (mm) liic ra vien va 17,5 ± 1,21 (mm) luc kham lai. Su cai thien nay cd y nghia thdng ke vdi p < 0,001.
Su cai thien chieu cao dTa dem se cd tac dung lam cang he thdng cac day chSng quanh dng sdng dac biet la day chang vang, tranh tinh trang day chang vang phi dai chiing xudng, dilu dd keo theo dng sdng dugc md rdng.
Theo nghien ciiu cua mdt sd tac gia tren the gidi, khi chieu cao dia dem dugc cai thien se keo theo ap luc ddn Ien dia dugc giam xudng, dieu do giiip tranh dugc nguy co gay thoat vi tai phat va lam giam qua trinh thoai hda mat nude cua dia dem, dac biet cd y nghTa vdi nhimg BN tre tudi.
Cai thien trung binh chieu cao Id lien hop:
Chieu cao Id lien hgp cua cac BN sau md ciing dugc cai thien dang ke, dieu dd da tao dieu kien rdng rai cho sir di ra ciia cac re than kinh, dieu nay dac biet cd y nghia vdi nhung trudng hgp hep dng sdng ngach ben va hep Id lien hgp.
Ket qua nghien ciin cho thay sau md chieu cao Id lien hgp cai thien tir 20,9 ± 1,50 (mm) Ien 23,1 ± l,42(mm) liic ra vien va 23,0 ± 1,46 (mm) liic kham lai, su cai thien nay cd y nghia thdng ke vdi p<0,001.
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DAI HOI HOI NGOAI KHOA VN LAN THLT Xll VA HOI NGHj KHOA HOC NGOAI KHOA TOAN QUOC LAN XW
Mdt sd tac gia khi nghien cuu ve DIAM ciing uu tien su dung DIAM cho nhimg BN cd hep dng sdng ngach ben va Id lien hgp, dieu nay cang ciing cd gia tri nang chieu cao lo lien hgp khi sir dung dung cu DIAM.
V. KET LUAN
1. Danh gia kha nang u n g dung dung cu ho trff van dong cot song lien gai sau (DIAIM) trong dieu tri benh ly hep ong song that lung
Thdi gian phau thuat trung binh ngan:
54,0 ± 13,11 (phut), thdi gian nam vien trung binh: 6,9 ± 1,62 (ngay),lugng mau mat khdng dang ke.
Ky thuat dem gian, de ap dung.
An toan, it tai bien va bien chiing.
Sau 6 thang kham lai khdng ghi nhan trudng hgp nao di lech, bien d^ng dung cu.
2. Ket qua dieu tri khi sir dung dung cu ho trgr van dong cot song lien' gai sau (DIAM) trong dieu trj benh ly hep ong song that limg
Lam sang cho ket qua dieu tri tdt vdi:
Cai thien miic do dau theo thang diem VAS cd y nghia thdng ke.
Chiirc nang cdt sdng that lung (ODI) dugc cai thien 53.6% liic ra vien va tang Ien 57.9% sau 6 thang kham lai.
Kha nang di lai cua BN sau md dugc cai thien cd y nghia thdng ke.
80% BN liic ra vien va 86,7% BN sau 6 thang kham lai hai long vdi ket qua dieu trj (Macnab rat tdt hoac tdt).
Can Iam sang cho kdt qua:
Cai thien chieu cao trung binh dia dem tir 16,6 ± 1,19 (mm) Ien 17,6 ± 1,25 (mm) liic ra vien va 17,5 ± 1,21 (mm) liic kham lai.
Cai thien chieu cao Id lien hgp tir 20,9 ± 1,50 (mm) Ien 23,1 ± 1,42 (mm) luc ra vien va 23,0 ± 1,46 (mm) liic kham lai.
TAI LIEU THAM KHAO
1 Le Van Ngoc Cu-ffng, Hoang Minh Loi, Nguyen Trirffng An. "£>ac diem lam sangva hinh dnh hep dng song a benh nhan tnt0 36l sdng thai lung". Tap chi y hpc Viet Nam.
2009; Chuyen de hdi nghi dien quang va y hoc hat nhan thang 9: 168-173.
2. Vu Hiing Lien , Cong Su. "Cdi tienkythuqt giO- day chdng lien gai. Pen gai trong phdu thuat cat cung sau cot song". T^p chi Y - Dugc hoc quan su. 2004; 4: 93-95.
3. Hd Hull LiroTig. "Dau that lung vd thoat vi dia dem". Nha xuat ban y hgc 2008.
4. Trinh Van Minh. "Gidi phdu nguai". Nha XuatBanYhoc.2001:tr3-]l.
5. Frank A. Netter. (Nguyin Quang Quy6n dich). "Atlas gidi phdu ngu&r. Nha xuat ban y hoc 2009. Mary Webb, Hugo Van Woeden. "Interspinous devices for lumbar stenosis- a review of the literature". The Internet Joumal of Surgery. 2004 Volume 5 Number 2.
6. Sung Joo Ryu, In- Soc Kim MD.
"Interspinous implant With unilateral Laminotomy For Bilateral Decompression of Degenerative Lumbar spinal Sterosis in elderly patient", J Korean Neurosur Soc 2010,
7. S.Palmer. "Posterior Dynamic Stabilization Implant (DIAM) for the treatment Lumbar Degenerative Disease ".
8. Jean Taylor MD. "Posterior Dynamic Stabilization Using the DIAM\ 2003.
9. Jean Taylor M.D, Patrick Pupin, M.D. S.
Delajoux, M.D. and S. Palmer, M.D.
"Devices for intervertebral Assisted Motion- DIAM: Teachnique and Unitial Result", Neurosurg Focus 22 (1): E6, 2007.
