顕微内視鏡下椎間板切除術システムを用いた刺激電極埋込術で治癒した下肢虚血．症例報告

[Lower limb ischemia cured by stimulation electrode implantation assisted with microendoscopic discectomy system: A case report].

• Y L Qian
• S Xu
• H Y Liu

抄録

閉塞性血栓性血管炎（Fontaine stage IV）と診断された58歳の男性患者がこのほど、北京大学人民病院の血管外科と脊椎外科を組み合わせた血管外科で、マイクロ内視鏡椎間板切除術システム補助脊髄刺激電極植え込み治療を受け、治癒した。この患者は14年前に右足小指を冷やして痛くてしびれ、その後、足の指が潰瘍化して壊疽を起こしていました。右足小指だけが残っていました。右足の皮膚は1年前に足指から近位分節まで腫れており、安静時の痛みを伴っていた。疼痛、自己骨髄幹細胞移植ともに効果はなかった。3ヶ月前に上記の症状が悪化し、激痛を伴っていた。視覚アナログスコアは10点であった。30年前に外傷により左下肢の高位切断を行った。身体所見：両側大腿動脈は弱く、右橈骨動脈、後脛骨動脈、背骨動脈は触診していない。Buerger sign（＋）。補助検査：両下肢の血管造影で両側外腸骨動脈とその遠位端の完全閉塞を認めた。経皮的酸素分圧は腸骨クレスト右側で30mmHgであった。手術は局所麻酔下で行った。レントゲンポジショニング後、腰椎1-2ラミナギャップの体幹突起をマークした。皮膚はマークから2cmの尾側に1.8cmの切開を行った。その後、拡張器を使用し、作業スリーブを腰椎1-2ラミナギャップに傾斜させた。マイクロ内視鏡ディスセクトミーシステムを設置し、マイクロ内視鏡下のlamina間隙から硬膜外空間に電極を直接入れ、血管外科医が透視下の脊柱管内の電極の位置を調整し、刺激装置を接続し、患者が下肢発熱、電極位置を固定し、マイクロ内視鏡下で止血した後、マイクロ内視鏡ディスセクトミーシステムを取り外し、ガイド針を使用して腰椎皮下を通して電極を誘導し、切開部を縫合した。手術後、電極を一時的な刺激装置に接続して数分間刺激を与えたところ、患者は下肢のしびれを感じた。1時間以内に患肢の皮膚温度が上昇し、睡眠中に鎮痛剤を中止することができた。1週間後、患肢の皮膚温度が上昇し、足・足首の経皮的酸素分圧が36mmHgとなり、痛みが改善し、点数は2点となった。術後1ヶ月後に永久刺激装置埋込術を行った。3ヶ月半年後の経過観察で痛みは消失し、スコアは1点となった。マイクロ内視鏡椎間板切除術システムを用いた脊髄刺激電極埋込術は、安全かつ効果的に迅速に手術を完了させることができ、術中透視の回数を大幅に減らすことができ、合併症の発生を抑えることができます。

A 58-year-old male patient diagnosed with thromboangiitis obliterans (Fontaine stage IV) was recently treated with microendoscope discectomy system-assisted spinal cord stimulation electrode implantation and cured by department of vascular surgery combined with department of spinal surgery at Peking University People's Hospital. The patient suffered from cold injury to the right foot 14 years ago, which was cold, painful, numb, and then the toe was ulcerated and gangrene. Only the right foot small toe was left. The right foot skin was swollen from the toe to the proximal segment 1 year ago, accompanied by resting pain. Both pain and autologous bone marrow stem cell transplantation were ineffective. The above symptoms were aggravated three months ago, and the pain was severe. The visual analogue score was 10 points. A high amputation of the left lower extremity was performed 30 years ago due to trauma. Physical examination: the bilateral femoral artery was weak, and the right radial artery, posterior tibial artery, and dorsal artery were not touched. Buerger sign (+). Auxiliary examination: angiography of both lower extremities showed complete occlusion of the bilateral external iliac artery and its distal end. The percutaneous oxygen partial pressure was measured to be 30 mmHg on the right side of the iliac crest. The operation was performed under the local anesthesia. After X-ray positioning, the body projection of the lumbar vertebrae 1-2 lamina gap was marked. The skin had a 1.8 cm incision on the caudal side 2 cm from the mark. Then the dilators were used, and the working sleeve was tilted to the lumbar vertebrae 1-2 lamina gap. The microendoscope discectomy system was installed, the electrode was directly placed into the epidural space from the interlamina space under the microendoscope, the vascular surgeon adjusted the position of the electrode in the spinal canal under fluoroscopy, then connected the stimulator, adjusted the current until the patient had the lower limb fever, fixed electrode position, removed the microendoscope discectomy system after hemostasis under the microendoscope, used the guide needle to lead the electrode through the lumbar subcutaneous and then sutured the incision. After the operation, the electrode was connected to the temporary stimulator to stimulate for several minutes, the patient felt numbness in his lower limbs. In less than one hour, the skin temperature of the affected limb increased, and the painkiller could be stopped while sleeping. After 1 week, the skin temperature of the affected limb increased, and the percutaneous oxygen partial pressure of the foot and ankle was 36 mmHg, and the pain improved, and the score was reduced to 2 points. One month after surgery, the patient underwent permanent stimulator implantation. The pain disappeared after 3 months and half year of follow-up, and the score was reduced to 1 point. Microendoscope discectomy system-assisted spinal cord stimulation electrode implantation can complete the operation quickly, safely and effectively, and greatly reduce the number of intraoperative fluoroscopy and reduce the occurrence of complications.