UBE治疗腰椎管狭窄技术要点2024（全文）

UBE治疗腰椎管狭窄技术要点2024（全文）腰椎管狭窄是指各种形式引起的中央椎管、侧隐窝以及椎间孔的狭窄，进而引起神经根或马尾神经受压并出现相应神经功能障碍的一类疾病单侧双通道脊柱内镜技术（）技术在治疗腰椎管Unilateral biportalendoscopic,UBE狭窄时有着得天独厚的优势［］可在充分减压的同时最大程度保留后方解剖1,结构，降低术后脊柱不稳的发生率［］技术处理腰椎管狭窄时既2-5UBE拥有微创的优势，又具备操作的高效，在临床上取得了优异的效果，被誉为“为狭窄而生”的技术俗-］7

一、治疗腰椎管狭窄的难点UBE治疗多节段腰椎管狭窄对于多节段的腰椎管狭窄，目前大多采取开放

1.UBE手术进行治疗而技术的出现为多节段腰椎管狭窄的手术治疗提供了新UBE思路但采用技术治疗多节段腰椎管狭窄有以下难点（）手术节段多，手UBE1术时间长，操作难度大；（）多节段操作时（左侧为例），中间的切口既要2作为下位节段的观察通道，也要作为上位节段的操作通道，切口定位难度大；（）多节段腰椎管狭窄，责任节段的定位3建议.国内有医生采用双人双侧同时进行手术来缩短手术时长，为的多1UBE

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613.节段操作提供了新思路要重视椎管减压窗这一概念，中间切口建议定位于相邻减压窗的中心位置，

2.这样可以让操作和观察得以兼顾.应结合患者主诉、查体及影像学资料进行综合性判断，若多节段狭窄而责任3节段为单节段，则可先解决单节段病灶治疗重度腰椎管狭窄对于重度腰椎管狭窄，术前更需仔细进行影像

4.UBE学判读，合理规划减压范围既要保证减压效果，又要避免对关节突关节过多的侵扰，达到缓解症状又不影响脊柱稳定性的效果技术治疗重度腰椎管狭窄有以下难点（）腰椎退变严重，椎板间UBE1隙难以辨认；（）关节突内聚严重，若需彻底减压，关节突关节切除较多;2（）硬膜外粘连，黄韧带和硬膜囊之间无空间，易造成医源性损伤，或3者硬膜菲薄引起迟发性脑脊液漏建议既然没有椎板间隙，便自行造一个间隙，可通过术中透视，通过椎体及周围

1.结构确定开窗位置，用磨钻为退化的椎板开一个间隙（图）再以此为基准完1,成后续操作.可将切口适当内移，通过倾斜角度处理内聚的上、下关节突，避免对关节突2关节切除过多或减压范围不足（图）

2.应操作更加轻柔，仔细剥离黄韧带与硬膜间隙，如果无法剥离保留部分黄韧3带可以接受

二、治疗腰椎管狭窄的技术要点UBE定位应用技术治疗腰椎管狭窄时，目前较常用的通道为

①以

1.UBE[8-9]:上下椎体椎弓根内缘连线和椎间隙水平线交点为基点，分别向远、近端为工作通道和内镜通道

②后正中线与椎间隙水平线交点以外1-

1.5cm1cm为工作通道，再向近端至少建立内镜通道（左侧为例），不宜过近，以3cm免对操作造成干扰建议对于的定位，要重视“减压窗”的概念，一切操作都是为减压服务的UBE建议术前评估好减压范围，并找到“减压窗”上下限和椎弓根内缘的交点我们术中通过线透视找到这个交点的体表投影，以这个点位为切口可更X22好控制减压范围（图）

3.减压对于减压环节，建议按照一定顺序进行已达到简单、有序、高效的效2果以单侧为例，顺序为上位椎板下缘、下位椎板上缘、下关节突、上关节突在此过程中，要特别注意侧隐窝区和区的减压，减压时要找到“椎Comer弓根内缘”这一标志以确定骨性开窗足够同时，可应用神经钩对神经根进行张力检查以确保减压充分.止血在术中操作时，出血往往会影响手术视野以影响手术进度针对出血3问题建议.对于可预料的出血可采用预止血；

1.止血时并非要将视野放在中心，可适当调整视野到出血点“上游”，这样可2以更好地看到出血点；.全身应用氨甲环酸、局部应用止血纱布填塞出血区有助于减少出血3

三、并发症的处理技术的并发症包括硬膜囊撕裂、硬膜外血肿、神经组织损伤、医源性脊UBE柱不稳、减压不彻底、早期复发、感染、术后腰痛、术后头痛、腹膜后积液、贫血等［］其中，硬膜外血肿的发生率最高，其次是硬膜囊撕裂以10-13及减压不彻底］等［］报道，术后可检测到的硬膜外4-15Kim16MRI血肿发生率达但是出现症状的血肿发生率为等［］

23.6%,

1.9%Park17对篇文献共例病例的并发症进行了荟萃分析，发现硬膜外血肿、423673硬膜囊撕裂以及减压不彻底的发生率分别为、、

3.79%

2.23%

1.29%建议针对硬膜外血肿的预防，有以下策略［］18-22:将水压维持在过高会导致患者颅内压升高，可能引L

2.41-

22.84mmHg,发麻醉恢复后的疼痛，而压力过低会影响术野进而导致手术时间延长.术前2详细规划手术方案，进行模拟手术，尽量缩短手术时长.术中尽量彻底止血，酌情使用止血材料，放置引流管引流3硬膜囊撕裂好发于硬膜囊背侧区域，由于生理盐水的灌注，使得硬膜囊在中间形成折叠并隐藏于硬膜外脂肪下，若未考虑到这一解剖关系，则易在黄韧带切除时造成硬膜囊撕裂［］部分患者的硬膜囊极其菲薄，术中应特别23-24关注，硬膜囊越趋于透明则证明硬膜囊越菲薄建议对于硬膜囊撕裂，有以下处理措施［］25-

29.撕裂口较小时无需缝合，引流管放置观察通道多留置数日，通常可自行愈合；

1.撕裂口较大时，若切口较规则，可采用镜下缝合；

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