腰椎不稳和腰椎滑脱的相关问题

<正>腰椎不稳或腰椎滑脱是导致腰腿痛的常见病因之一。然而在临床上,有关不稳和滑脱的界定、两者之间的关系、影像学诊断、治疗方案的合理选择、滑脱的复位等     

Posterior lumbar interbody fusion and segmental lumbar lordosis

Introduction

The sagittal plane of body produces a convex curve anteriorly referred to as the lordotic curve. Malalignment of lordotic curve leads to low back disorders and lumbar spinal surgery has been known to cause this. This study was a retrospective analysis of the effects of posterior lumbar interbody fusion using cages on segmental lumbar lordosis.

Materials and methods

We conducted a retrospective study involving 27 patients of which 16 were females and 11 were males. All patients underwent single level posterior lumbar interbody fusion with insertion of non-wedged intervertebral cage and pedicle screw fixation. Intraoperatively, all patients had a change from knee chest position to prone to augment their lumbar lordosis. The minimum follow up was 2 years and fusion was achieved in 21 patients.

Results

Segmental lordotic angles increased from 15.2° to 20.6° at L4/5 level and from 17.8° to 24.5° at L5/S1 level, preoperative to postoperative, respectively (P < 0.01 at both levels).

Conclusion

Thus apparently, posterior lumbar interbody fusion with insertion of non-wedged intervertebral cage and pedicle screw fixation results in creation and maintenance of lumbar lordosis.     

经皮全脊柱内镜技术治疗腰椎间盘突出症

[目的]研究经皮全脊柱内镜技术(percutaneous endoscopic lumbar discectomy,PELD)治疗腰椎间盘突出症的临床疗效及安全性。[方法]回顾性研究2013年1月~2015年1月连续接受手术治疗的153例单节段伴有单侧神经根性症状的腰椎间盘突出症患者,其中68例行经皮全脊柱内镜下腰椎间盘髓核摘除术(内镜组),85例行开放腰椎间盘髓核摘除术(开放组)。采用视觉模拟评分法(VAS评分)、Oswestry功能障碍指数(ODI)、Mac Nab评分评定疗效。[结果]所有患者均完成手术,内镜组有1例出现神经根损伤。其他患者未发生神经、血管损伤等严重并发症。内镜组手术时间大于开放组,术中出血量、切口长度小于开放组,差异均有统计学意义(P0.05)。术后3 d和末次随访时腰痛VAS评分内镜组显著小于开放组,差异有统计学意义(P0.05),术后3 d腿痛VAS评分内镜组小于开放组,差异有统计学意义(P0.05),末次随访时两组腿痛VAS评分差异无统计学意义(P0.05)。内镜组末次随访时ODI指数小于开放组,差异有统计学意义(P0.05),两组疗效优良率差异无统计学意义(P0.05)。两组术后腰痛、腿痛VAS评分显著小于术前,差异有统计学意义(P0.05),内镜组术后3 d和末次随访时腰痛、腿痛VAS评分差异无统计学意义(P0.05)。开放组术后3 d和末次随访时腰痛VAS评分差异无统计学意义(P0.05),末次随访时腿痛VAS评分小于术后3 d,差异有统计学意义(P0.05)。[结论]经皮全脊柱内镜下腰椎间盘髓核摘除术治疗腰椎间盘突出症安全有效,创伤小,恢复快,是开放腰椎间盘髓核摘除术很好的替代技术。     

Degenerative lumbar spinal stenosis and lumbar spine configuration

As life expectancy increases, degenerative lumbar spinal stenosis (DLSS) becomes a common health problem among the elderly. DLSS is usually caused by degenerative changes in bony and/or soft tissue elements. The poor correlation between radiological manifestations and the clinical picture emphasizes the fact that more studies are required to determine the natural course of this syndrome. Our aim was to reveal the association between lower lumbar spine configuration and DLSS. Two groups were studied: the first included 67 individuals with DLSS (mean age 66 ± 10) and the second 100 individuals (mean age 63.4 ± 13) without DLSS-related symptoms. Both groups underwent CT images (Philips Brilliance 64) and the following measurements were performed: a cross-section area of the dural sac, vertebral body dimensions (height, length and width), AP diameter of the bony spinal canal, lumbar lordosis and sacral slope angles. All measurements were taken at L3 to S1. Vertebral body lengths were significantly greater in the DLSS group at all levels compared to the control, whereas anterior vertebral body heights (L3, L4, L5) and middle vertebral heights (L3, L5) were significantly smaller in the LSS group. Lumbar lordosis, sacral slope and bony spinal canal were significantly smaller in the DLSS compared to the control. We conclude that the size and shape of vertebral bodies and canals significantly differed between the study groups. A tentative model is suggested to explain the association between these characteristics and the development of degenerative spinal stenosis.     

经椎间孔入路与经后方入路椎间融合术治疗退变性腰椎失稳症的疗效比较

目的回顾性研究经后方入路椎体间融合术（posterior lumbar interbody fusion,PLIF）和切除上、下关节突的经椎间孔入路椎体间融合术（transforaminal lumbar interbody fusion,TLIF）治疗腰椎失稳症的疗效及并发症情况。方法采用PLIF和TLIF治疗2004年1月至2008年1月本院收治的退变性腰椎失稳症患者78例,其中PLIF31例,TLIF47例。比较两组手术时间、术中出血量、平均卧床时间、Nakai评分优良率、融合时间（按Suk标准）及术后并发症发生率。对两组术前及末次随访时的椎间隙高度及椎间孔高度进行对比研究。结果 78例患者均获随访,随访时间1.5～4.5年,平均3.5年。所有患者均获椎间骨性融合。对两组卧床时间、Nakai评分优良率、融合时间、同时间点椎间隙高度和椎间孔高度进行比较,差异无统计学意义（P〉0.05）;而在手术时间、出血量以及术后并发症发生率方面,两组之间的差异有统计学意义（P〈0.05）。两组末次随访时的椎间隙高度和椎间孔高度均较术前有明显改善（P〈0.05）。结论 TLIF和PLIF治疗退变性腰椎失稳症效果良好;与PLIF相比,TLIF操作简单,出血量小,并发症少。     

腰椎滑脱和腰椎不稳的诊断和治疗

<正>腰椎滑脱症和腰椎不稳是目前临床上最为常见的腰椎疾患。在同一个病例中,两种病变经常同时存在,但两种病变的概念是有区别的,腰椎滑脱应是一种静态概     

双侧经皮穿刺椎间盘切吸术治疗腰椎间盘突出症

自１９９６年１月到１９９７年３月,我们将１０４例腰椎间盘突出症患者随机分为单侧经皮穿刺切吸组（Ａ组）、双侧经皮穿刺切吸组（Ｂ组）。随访６～１８个月,结果显示,双侧经皮穿刺椎间盘切吸术治疗腰椎间盘突出症的疗效优于单侧穿刺切吸术。１资料与方法１１临床资...     

腰椎后路减压术后预后及稳定性的相关因素分析

[目的]探讨腰椎后路手术不同程度地切除后部结构与术后脊柱稳定性的关系,以及在腰椎后部结构切除后的机体反应和机械稳定性改变,分析机体对自身稳定性损伤修复的能力及机制.[方法]对腰椎术后稳定性表现进行临床回顾分析.[结果]对临床病例的总结显示腰椎板切除减压手术对退行性腰椎管狭窄症效果满意,通过对手术改善率低者的影像学检查,未见手术节段椎间不稳定发生;腰椎板切除减压手术临床结果与术前JOA评分、年龄、手术涉及的小关节数、椎板减压节段数没有相关性;术后功能恢复率与术后时间长短及病史长短有统计学负相关性.[结论]在术前无失稳存在时不同范围和程度的腰椎后部结构切除均可获得满意的临床效果,并未造成随访时限内的腰椎不稳定的发生,提示机体对损伤具有修复代偿的能力.     

经椎间孔椎间融合术治疗高位腰椎间盘突出症

<正>2008年1月~2012年6月,我们采用经椎间孔椎间融合术治疗12例高位腰椎间盘突出症患者,疗效满意。1材料与方法1.1病例资料本组12例,男8例,女4例,年龄30~65岁。突出节段:L1~24例,L2~33例,L3~45例。患者术前均有不同程度的腰痛,同时伴或不伴一侧或双侧下肢放射痛和皮肤麻木等症状;经系统保守治疗无效,症状持续均≥6个     

腰椎滑脱与腰椎不稳的诊疗

<正>腰椎滑脱和腰椎不稳虽然为临床中的常见疾病,但目前对其诊断和治疗仍存在诸多问题需要理清、界定和探讨,当然存在的争议问题也不是本文浅谈片语能够解决的。立足目前许多专家学者对腰椎滑脱和腰椎不稳的观点阐述[1-7],笔者仅对腰椎滑脱和腰椎不稳典型的几个问题梳理如下。1腰椎滑脱和腰椎不稳的诊断脊椎滑脱的英文名称为spondylolysis,其字根来源于希腊语,spondylo(椎体)和listhesis(滑移)。两个     

经椎间孔椎体间植骨治疗下腰椎爆裂性骨折

目的 探讨在下腰椎爆裂性骨折中应用单一后路经椎间孔椎体间植骨融合术重建椎体前中柱的有效性.方法 2009年1月～2011 年6月,采用单一后路切开复位椎弓根内固定经椎间孔椎体间植骨融合术治疗下腰椎爆裂性骨折19例.分别评价术前、术后、末次随访时的影像学指标变化,及术前与术后末次随访时神经功能变化.结果 19例患者平均随访15.6 个月.所有患者术后未发生切口感染、神经功能损伤及内固定器松动断裂等并发症.末次随访时18例患者证实椎间融合,19例患者术前平均伤椎高度为正常椎体高度的（40.62±12.32）%,术后恢复至（96.52±10.62）%,末次随访时为（95.43%9.54）%.腰椎前凸角术前32.2°±5.1°,术后38.4°±5.2°,末次随访时为38.4°±7.2°.末次随访时伴有神经功能障碍的患者均有1级以上的恢复.结论 下腰椎爆裂性骨折行后路椎弓根螺钉内固定经椎间孔椎体间植骨融合术,能完成短节段三柱固定,同时修复了前柱及矫正脊柱后凸,取得满意的骨性融合率.     

后路腰椎椎体间融合术治疗腰椎滑脱的临床疗效

目的：探讨后路腰椎椎体间融合术（posterior lumbar interbody fusion,PLIF）治疗腰椎滑脱的中期疗效,对腰椎滑脱症的临床治疗提供指导意见。方法回顾性分析采用PLIF治疗的腰椎滑脱40例,所有病例随访观察＞3年,对手术前后影像学资料、Oswestry功能障碍指数（Oswestry disability index,ODI）、视觉模拟量表（visual analog scale ,VAS）评分及日本骨科学会（Japanese Orthopaedic Association ,JOA）腰背痛手术治疗评分标准的评分变化情况进行比较分析。结果椎间隙高度、椎间孔高度术后1年、3年与术前比较差异均有统计学意义（P＜0．05）;术后1年与术后3年测量值比较差异不具有统计学意义（P＞0．05）。 ODI、腰痛VAS评分、腿痛VAS评分及JOA评分术前和术后1年、3年比较差异具有统计学意义（P＜0．05）;术后1年与术后3年比较差异不具有统计学意义（P＞0．05）。结论 PLIF手术能够恢复腰椎序列稳定性,改善临床症状,是治疗腰椎滑脱的理想术式,中期随访疗效满意。     

Percutaneous lumbar discectomy in the treatment of lumbar discitis

Lumbar disc infection, either after surgical discectomy or caused by haematogenous spread from other infection sources, is a severe complication. Specific antibiotic treatment has to be started as soon as possible to obtain satisfactory results in conservative treatment or operative fusion. The aim of this study was to analyse 16 cases of lumbar disc infection, treated with percutaneous lumbar discectomy (PLD) to obtain adequate amounts of tissue for histological examination and microbial culture. Between 1990 and 1994, 26 patients with vertebral osteomyelitis were treated. Sixteen patients, with an average age of 41.4 years (range 14–59 years), underwent a diagnostic PLD. Eight of them showed only moderate changes on computed tomograms (CT scans) and magnetic resonance (MR) images in the initial stages of the disease. The other eight showed more or less extensive osteolytic lesions of one or both vertebral bodies adjacent to the involved disc. The histology results showed non-specific discitis in nine patients and tuberculosis in one. In two patients an open biopsy had been performed, which showed non-specific discitis. Microbiological analysis revealed specific infection in 45% of the patients. These patients received a specific antibiotic treatment after antibiogram for an average of 33 days. Only three patients were treated surgically, with evacuation of the disc space and interbody fusion; the whole group received a spondylitis brace. All patients obtained satisfactory clinical results at the last follow-up regarding pain, mobility and spontaneous fusion of the involved disc space. In conclusion, PLD is a very helpful minimally invasive procedure in conservative treatment of lumbar discitis.     

经皮穿刺腰椎间盘切吸术治疗合并腰椎管狭窄的腰椎间盘突出症

目的：总结采用经皮穿刺腰椎间盘切吸术（APLD）治疗合并腰椎管狭窄的腰椎间盘突出症的经验。方法：对12例经CT扫描确诊为腰椎间盘突出症合并有腰椎管狭窄患者，术前行轴位牵引下直腿抬高试验检查。对属可逆性腰椎间突出患者，使用APLD治疗。结果：经3个月以上随访，优7例，良4例，可1例。近期优良率91．7％，未出现并发症。结论：合并腰椎管狭窄的腰椎间盘突出症不应列为APLD治疗的禁忌证。对术前行轴位牵引下直腿抬高试验检查属可逆性腰椎间盘突出的患者，仍可行APLD治疗。     

经皮腰椎间盘切吸术治疗腰椎间盘突出症并腰椎管狭窄

经皮腰椎间盘切吸术(Automated percutaneous lum-bar discectomy,APLD)自从Hijikata首次报道成功以来,以其创伤小、出血少、不造成神经根粘连、不影响脊柱稳定性、病人易接受等优点而被广泛应用于临床,但有关APLD治疗腰椎间盘突出症并椎管狭窄的报道较少,且多数人把此类腰椎间盘症作为APLD的禁忌证.我们通过收治的45例此类腰椎间盘突出症行APLD治疗后,近期疗效满意,报告如下     

经皮椎间孔入路内镜下治疗腰椎融合术后邻椎腰椎间盘突出症

目的:探讨经皮椎间孔入路内镜下治疗腰椎融合术后邻椎腰椎间盘突出症的临床疗效。方法:对2010年2月至2018年6月收治的64例腰椎融合术后邻椎腰椎间盘突出症患者进行回顾性分析,分为观察组与对照组。观察组33例中男23例,女10例;年龄55~83(65.7±7.4)岁;单节段融合27例,双节段融合6例;运用经皮椎间孔入路内镜下手术治疗。对照组31例中男22例,女9例;年龄51~78(64.8±7.8)岁;单节段融合25例,双节段融合6例;运用开放融合翻修手术治疗。比较两组患者的手术时间、术中出血量、透视次数、术后下床活动时间和住院时间。采用疼痛视觉模拟评分(visual analgue scale,VAS),Oswestry功能障碍指数 (Oswestry Disability Index,ODI)评估临床疗效。观察两组并发症发生情况。结果:64例患者均获得至少2年随访,观察组随访时间(2.4±0.5)年,对照组随访时间(2.6±0.7)年。观察组的手术时间、术中出血量、术后下床活动时间、住院时间较对照组明显减少(P<0.05),观察组的透视次数较对照组明显增加(P<0.05)。两组患者腰痛、下肢痛VAS和ODI在末次随访时和术前比较均有明显改善(P<0.05);观察组术后各时间点腰痛VAS,术后1、3个月ODI均较对照组有优势(P<0.05),而两组间下肢痛VAS比较差异无统计学意义(P>0.05)。观察组并发症发生率明显低于对照组(P<0.05)。结论:与传统再次开放融合翻修术相比,经皮椎间孔入路内镜下微创手术治疗腰椎融合术后邻椎腰椎间盘突出症具有减少手术时间和术中出血量,缩短下床活动时间和住院时间,促进疼痛和功能改善的优点,且可降低并发症发生率。但其中远期的临床疗效有待进一步研究。     

后路减压内固定融合治疗退变性腰椎侧凸

目的探讨后路减压内固定植骨融合治疗退变性腰椎侧凸的临床疗效。方法后路减压内固定植骨融合治疗19例退变性腰椎侧凸患者。手术前后进行JOA、VAS评分评估临床疗效,影像学测量比较手术前后的Cobb角、骨盆倾斜角(PT)、腰椎前凸角(LL)。结果所有患者均获得随访,时间11~23(15.7±2.2)个月。JOA评分:术前为12.2分±1.7分,术后3个月为22.7分±3.1分,末次随访为24.0分±2.8分。VAS评分:术前为8.4分±0.5分,术后3个月为1.9分±0.8分,末次随访为1.8分±0.6分。Cobb角:术前为23.9°±4.2°,术后3个月为3.1°±1.4°,末次随访为3.3°±1.1°。LL:术前为31.6°±5.9°,术后3个月为42.5°±6.6°,末次随访为44.3°±6.0°。PT:术前为21.5°±7.3°,术后3个月为18.9°±9.4°,末次随访为18.5°±7.8°。以上各项指标术后3个月与术前比较差异均有统计学意义(P0.05),末次随访与术后3个月比较差异均无统计学意义(P0.05)。结论后路减压内固定植骨融合治疗退变性腰椎侧凸可充分减压,缓解症状,重建腰椎矢状面和冠状面的序列并维持脊柱稳定。