Dynesys动态稳定系统在腰椎退变性疾病治疗中的应用

目的探讨Dynesys动态稳定系统在腰椎退变性疾病治疗中的临床疗效。方法回顾分析2008年7月～2012年5月采用Dynesys动态固定系统治疗的腰椎椎管狭窄症和椎间盘突出症患者120例,随访〉2年的共52例,其中腰椎椎管狭窄症40例,椎间盘突出症12例。术前腰椎疼痛视觉模拟量表（visual analogue scale,VAS）评分为5.5分（3.0～9.0分）,腿痛VAS评分5.36分（2.6～9.0分）,Oswestry功能障碍指数（Oswestry disability index,ODI）为61.4%。测量术后末次随访时患者腰痛、腿痛的VAS评分及ODI。测量手术前后手术节段椎间盘的高度,置入节段的活动度,固定节段头侧邻近节段的椎间活动度。结果 52例患者平均随访29个月。手术时间95 min±16 min,术中出血量183 mL±32 mL。脑脊液漏1例,经改变体位及换药局部处理后愈合;1例切口脂肪液化,经换药对症处理后愈合。围手术期无死亡病例,术后症状无加重,神经功能无恶化。患者腰痛VAS评分在末次随访时较术前有明显的降低,腿痛VAS评分也较术前有明显的降低,ODI较术前也有明显的降低。手术后椎间隙高度有所降低,但与术前相比差异无统计学意义（P〉0.05）;固定节段椎间活动度明显减小,与术前相比差异有统计学意义（P〈0.05）;手术固定节段头侧邻近节段活动度有所增加,但与术前相比差异无统计学意义（P〉0.05）。结论 Dynesys动态固定系统手术操作简单、易掌握,可避免融合术相关并发症,效果满意。Dynesys系统固定上端的邻近节段活动度较术前略有增加（P〉0.05）,其长期临床疗效以及能否减少术后相邻节段退变的发生率等还需长时间、大宗病例的临床观察。     

Dynesys系统治疗腰椎退变性疾病的早期疗效

目的：探讨Dynesys用于治疗腰椎退变性疾病的早期临床疗效,并观察邻近节段的退变趋势。方法：选取2013年1月至2013年12月于我院行腰椎后路减压+Dynesys植入手术病例21例,成功随访病例 21例（男性16名 76.2%。女性5名 23.8%）,平均随访时间17.4±3.5个月（范围12-24个月）,平均年龄为42.1±9.4岁。分别于术前、术后各时间点（术后3,6,12月）及末次随访时,完成腰痛及腿痛VAS评分、腰部功能障碍ODI评分、JOA日本骨科协会腰痛治疗评估量表评分、SF-36生活质量问卷调查评分,并统计各种并发症事件的发生率。对比术前及术后末次随访时腰椎活动度的变化及腰椎间盘MRI改良Pfirrmann分级改变。结果：末次随访时腰痛及腿痛VAS评分,ODI指数均较术前明显下降（P＜0.05）,JOA评分及SF-36生活质量评分均较术前明显增加（P＜0.05）。随访期间共发生2例并发症事件：1例螺钉松动,1例切口下积液导致切口愈合延迟。末次随访时手术节段上一相邻节段活动度及椎间盘改良Pfirrmann分级均较术前增加（P＜0.05）。结论：Dynesys用于治疗腰椎退变性疾病获得了良好的早期临床疗效,本研究随访期内手术节段上一相邻节段观察到更为明显的退变趋势。     

Dynesys系统治疗腰椎疾病的长期临床疗效观察

目的评估Dynesys系统治疗腰椎退变性疾病的长期临床安全性和有效性。方法回顾自2006年1月至2010年6月于本院实施Dynesys系统植入术患者共43例,男18例,女25例,年龄35～70岁,平均52．2岁,其中单纯退行性腰椎管狭窄者21例,腰椎管狭窄并椎间盘突出者15例,腰椎管狭窄伴退行性腰椎滑脱（I度滑脱）者5例,复发性腰椎间盘突出者2例,均经非手术治疗无效,于我院植入Dynesys系统。以疼痛视觉模拟评分（visual analoguescale,VAS）、Oswestry功能障碍指数评分（oswestry disability index,ODI）、椎间隙高度、椎间活动度（rangeofmotion,ROM）进行疗效评估;采用NASS指数评估患者满意度;观察患者行走距离、术后固定及邻近节段退变、并发症发生情况等。结果本组病例全部获得随访,时间27～54个月,平均39．5个月。术后3个月患者的腰痛VAS评分、腿痛VAS评分、ODI评分分别由术前的7．67分、6．77分、60．58分下降到2．93分、2．32分、26．02分（P〈0．01）;椎间隙高度由术前的9．73mm升高到12．50mm（P〈0．01）;步行距离由术前的10～1000m升高到均大于1000m;ROM值由术前的7．80。下降到5．26。（P〈0．01）。术后随访期间各时间点之间腰痛VAS评分、腿痛VAS评分、ODI评分、椎间隙高度、ROM值均无显著性差异（P〉0．05）,而与术前相比差异均有统计学意义（P〈0．01）。UCLA系统评价显示术后及随访期间固定节段及相邻节段未出现进一步退变。术中、术后及随访期间均未出现严重并发症。结论Dynesys系统对腰椎退变性患者具有良好的长期临床疗效,安全性高,值得进一步推广。     

Dynesys系统治疗腰椎退变性疾病的临床观察

目的探讨Dynesys系统治疗腰椎退变性疾病的效果和安全性。方法对16例腰椎退变性疾病患者采用Dynesys系统治疗。观察腰痛VAS评分、ODI及并发症发生情况,并按照Nakai标准评价疗效。结果本组手术时间150~290 min,术中出血350~700 m L。所有患者均获18~24个月随访,腰痛缓解,腰椎功能明显改善。腰痛VAS评分0~3分。ODI指数11%~38%。无螺钉松动、装置移位、组件磨损断裂及感染等并发症发生。按照Nakai标准评定疗效,优8例、良8例。结论应用Dynesys系统治疗腰椎退变性疾病,可将腰椎控制在正常或接近正常的稳定范围,最大限度保留脊柱功能,有效缓解腰痛,腰椎功能恢复好,并发症少。     

退变性腰椎滑脱症的手术治疗

目的探讨采用后路腰椎椎管减压、钉棒内固定并椎间植骨融合术和后路腰椎减压并Dynesys系统内固定手术治疗退变性腰椎滑脱的效果。方法应用后路腰椎椎间融合（posterior lumbar interbody fusion,PLIF）术进行椎管减压、钉棒系统固定并椎体间植骨融合手术治疗退变性腰椎滑脱37例;应用后路腰椎管减压并Dynesys内固定手术治疗退变性腰椎滑脱5例。结果随访9～39个月,平均26个月,腰痛疼痛视觉模拟量表（visual analogue scale,VAS）评分术前为8.7分,随访时为2.1分;腿痛VAS评分术前为7.6分,随访时为2.3分。术前Oswestry功能障碍指数（Oswestry disability index,ODI）为58.2%,随访时为21.2%。无严重手术并发症发生。术后X线片复查显示椎间高度均得到不同程度的恢复,滑脱椎体完全复位或者基本复位,椎间植骨融合。无融合器移位或螺钉松动、断裂。结论后路腰椎椎管减压、钉棒内固定并椎间植骨融合术和后路腰椎减压并Dynesys内固定手术治疗退变性腰椎滑脱效果满意,安全彻底的神经根管减压是取得满意临床效果的关键。     

腰椎棘突间动态固定对相邻节段退变影响的临床研究

目的:通过临床随访和影像学分析研究腰椎棘突间动态固定对相邻节段退变的影响.方法:2007年9月～2009年9月应用后路减压结合腰椎棘突间动态固定治疗L4/5单节段退变性疾患病例76例,其中应用静态Wallis固定系统45例,动态Coflex固定系统31例.主要适应证包括腰椎间盘突出症和轻度腰椎管狭窄症.采用腰痛VAS评分、下肢痛VAS评分、腰椎JOA评分(29分法)评定临床症状情况,采用Prolo腰椎功能评定标准和ODI评分评定功能情况,术前和末次随访各评价1次;在术前和末次随访腰椎正侧位X线片上测量手术节段(L4/5)前凸角和上、下位相邻节段(L3/4和L5/S1)的前凸角以及腰椎整体前凸角(L1～S1);在术前和末次随访腰椎过伸过屈位X线片上测量L3/4、L4/5、L5/S1活动度及腰椎整体活动度.术前和末次随访分别对L3/4和L5/S1进行UCLA(University of California at Los Angeles)分级评定.结果:66例患者获得完整随访,Wallis组41例,Coflex组25例,随访时间57～81个月,平均64.6个月.末次随访时,两组患者的腰痛VAS评分、下肢痛VAS评分、腰椎JOA评分、Prolo腰椎功能评定标准和ODI评分较术前均有显著性改善(P＜0.01);L4/5的前凸角和腰椎整体前凸角较术前均有明显下降(P＜0.01),L4/5活动度和腰椎整体活动度较术前均明显下降(P＜0.01);L3/4和L5/S1的前凸角较术前无显著性变化(P＞0.05),L3/4的活动度较术前下降有统计学差异(P＜0.05),而L5/S1的活动度较术前无显著性变化(P＞0.05).Wallis组末次随访时同术前相比,L3/4节段有2例由UCLA Ⅰ级变为UCLA Ⅱ级;L5/S1节段有4例由UCLA Ⅰ级变为UCLA Ⅱ级,1例由UCLA Ⅱ级变为UCLAⅢ级.Coflex组末次随访时同术前相比,L3/4节段只有1例由UCLA Ⅰ级变为UCLAⅡ级;L5/S1节段有2例由UCLA Ⅰ级变为UCLA Ⅱ级,1例由UCLA Ⅱ级变为UCLA Ⅲ级.结论:后路减压结合腰椎棘突间动态固定治疗腰椎单节段退变性疾病临床效果满意,未发现症状性相邻节段退变,但其对相邻节段退变的影响有待进一步对照研究的结果和更长时间的临床随访.     

Dynesys内固定系统治疗腰椎退变性疾病

目的评估Dynesys系统治疗腰椎退变性疾病的安全性和效果。方法自2008年1月至2010年6月收治8例退行性腰椎疾患患者,男3例,女5例,年龄51~72岁,平均58岁,其中退变性椎管狭窄5例,复发性腰椎间盘突出3例,均行后路减压加Dynesys系统固定。以疼痛视觉模拟评分（visual analogue scale,VAS）和Oswestry功能障碍指数（oswestry disability index,ODI）进行疗效评估,所有患者进行随防,平均随防时间为1~2年,应用X线分析患者椎间隙高度及椎间活动度。结果所有患者VAS评分从术前的（8.2±1.1）分降至随访时的（2.3±0.5）分（P〈0.01）,ODI从术前的（76.46±17.12）分降到随访时的（19.20±8.54）分（P〈0.01）,固定节段椎间隙高度由术前的6.72 mm恢复为术后的8.34 mm（P〈0.05）,邻近节段椎间隙高度没有明显变化,手术节段活动度（4.3±0.26）°。结论 Dynesys系统治疗腰椎退变性疾病安全有效,可以保留固定节段的活动度并提供稳定,同时也可能降低相邻节段退变的发生。     

经皮腰椎间孔成形内窥镜下椎间盘切除术治疗腰椎间盘突出症的疗效观察

目的:观察经皮腰椎间孔成形、经椎间孔内窥镜下椎间盘切除术治疗非包含型腰椎间盘突出症的近期疗效.方法:2007年4月～2007年7月收治非包含型腰椎间盘突出症患者26例,其中L3/4 4例,L4/5 12例,L5/S1 10例.应用自制椎间孔成形器械行经皮腰椎间孔扩大成形、经椎间孔内窥镜下椎间盘切除术,分析治疗前及治疗后9个月时腰痛及腿痛视觉模拟评分(VAS)的变化情况,术后9个月时采用MacNab功能评分判断疗效.结果:手术均顺利完成,手术时间45～120min,平均75min;术中出血量20～50ml,平均35ml.2例患者术后1周出现下肢"日光烧灼综合征",均为L5/S1椎间盘突出,经过脉冲电刺激治疗1周后缓解;无其他手术并发症发生.随访9个月,腰痛VAS评分术前6.3±2.5分,术后1d 2.1±1.3分,术后3个月1.8±1.6分,术后9个月1.5±1.1分:腿痛VAS评分术前8.6±2.1分,术后1d 1.1±0.7分,术后3个月0.5±0.6分,术后9个月03±0.1分;术后腰痛和腿痛的VAS评分较术前均明显降低(P<0.01).按照MacNab评分标准,术后9个,月随访时优18例,良8例,优良率为100％.结论:经皮腰椎间孔成形、经椎间孔内窥镜下椎间盘切除术治疗非包含型腰椎间盘突出症患者创伤小、近期疗效好.     

腰椎椎间孔镜手术治疗伴神经根管狭窄的腰椎椎间盘突出症

目的退变性腰椎椎间盘突出、黄韧带肥厚、关节突关节增生内聚引起神经根管狭窄,利用椎间孔镜对神经根管进行减压。方法对20例退变性神经根管狭窄症患者行腰椎椎间孔镜下神经根管扩大成形术,记录术前术后腰腿痛疼痛视觉模拟量表(visual analogue scale,VAS)评分,采用Macnab标准评价疗效。结果 20例患者术前平均腰痛VAS评分为5分,术后即刻为1.5分,术后3个月为0.5分。术前平均腿痛VAS评分为7分,术后即刻为0.3分,术后3个月为0.1分。18例患者术后3个月的改良Macnab疗效评定为优,2例患者为良。结论对腰椎退变性神经根管狭窄症,椎间孔镜可对突出的腰椎椎间盘、关节突关节以及黄韧带进行减压,有效地扩大神经根管,可获得很好的疗效。     

椎间盘造影在腰椎多节段退变性疾病诊治中的应用探讨

目的初步探讨椎间盘造影术在腰椎多节段退变性疾病临床诊疗中的应用价值。方法 2006年9月～2010年4月,行手术治疗的伴有明显腰痛症状的腰椎多节段退变性疾病患者143例,分为2组：椎间盘造影组69例,术前对MRI检查提示椎间盘退变的椎间节段进一步行椎间盘造影检查,根据常规影像学检查以及椎间盘造影检查结果选择手术干预节段;常规诊疗组74例,术前仅根据常规影像学检查结果选择手术干预节段。对所有手术干预节段行改良经椎间孔腰椎椎体间融合术。随访并比较2组患者术前及术后3个月、6个月、12个月Oswestry功能障碍指数（Oswestry disability index,ODI）及疼痛视觉模拟量表（visual analogue scale,VAS）评分。结果椎间盘造影组及常规诊疗组分别有64例、71例患者完成了至少12个月的系统随访。2组患者术后3个月、6个月及12个月的ODI、VAS评分较术前均有好转;但椎间盘造影组术后3个月、6个月及12个月ODI、VAS评分明显优于常规诊疗组,差异有统计学意义（P〈0.05）。结论对伴有明显腰痛症状的腰椎多节段退变性疾病患者,椎间盘造影术具有良好的临床应用价值;在良好掌握临床适用范围及操作技术的基础上,不失为常规影像学检查的一种有益补充。     

Short‐term clinical observation of the Dynesys neutralization system for the treatment of degenerative disease of the lumbar vertebrae

Objective: To explore the safety and short‐term efficacy of the posterior approach of the Dynesys dynamic neutralization system for degenerative disease of the lumbar vertebrae. Methods: From March 2008 to March 2010, 32 cases of degenerative lumbar vertebral disease, 19 men and 13 women, (mean age 58 ± 5.2, range, 43–78 years), were treated with posterior laminectomy and Dynesys internal fixation. All patients had a history of over 3 months waist or leg pain that had not been relieved by conservative treatment. There were 10 cases of single lumbar intervertebral disc protrusion, 14 of degenerative lumbar spinal stenosis, 5 of degenerative lumbar isthmic spondylolisthesis, and 3 of recurrent lumbar disc protrusion after surgery. A visual analogue score (VAS) was used for pain assessment, and the Oswestry disability index (ODI) for functional evaluation of clinical outcomes. Results: All patients were followed up for 6–23 months (mean, 16.4 ± 5.5 months). Forty‐one segments in 32 patients were stabilized; 23 cases (71.9%) underwent single‐segmental stabilization, and 9 (28.1%) two‐segmental stabilization. VAS of leg pain, root and low back pain was significantly improved postoperatively. The ODI improved from preoperative 69% ± 12.6% to postoperative 28% ± 15.7% (P < 0.001). On the stabilized segment and adjacent segments above and below, the range of movement showed no statistical difference; no loosening of screws, cord and polyester spacer occurred. Conclusion: The Dynesys dynamic neutralization system combined with decompression can achieve satisfactory short‐term clinical results in lumbar degenerative disease. This procedure system not only reduces back and leg pain, but also preserves the mobility of fixed segments, minimizes tissue injury and avoids taking bone for spinal fusion.     

Dynesys动态稳定系统治疗多节段腰椎退变性疾病的中远期临床疗效观察

目的:探讨Dynesys动态中和内固定系统治疗多节段腰椎退变性疾病的中远期临床疗效。方法:对2008年12月至2011年5月采用Dynesys系统治疗的多节段腰椎间盘突出症和多节段腰椎管狭窄症28例患者进行回顾性分析。其中男16例,女12例;年龄27～75岁,平均49.1岁。多节段腰椎间盘突出症13例,L₃-L₅ 7例,L₂-L₄ 1例,L₄-S₁ 5例;多节段腰椎管狭窄症15例,L₃-L₅ 10例,L₂-L₅ 4例,L₂-S₁ 1例。所有患者腰腿痛和(或)间歇性跛行症状经正规保守治疗6个月以上无效。记录手术前后患者的腰腿部疼痛视觉模拟评分(Visual analogue scale,VAS),通过影像学资料观察固定节段及头侧邻近节段的椎间隙高度和椎间活动度,采用Oswestry功能障碍指数(Oswestry Disability Index,ODI)对疗效进行评定。结果:28例患者均顺利完成手术,且均获得随访,随访时间38～65个月,平均50.6个月。末次随访时腰腿痛VAS评分分别为1.25±0.70和1.29±0.89,ODI为(25.10±6.52)%,腰腿痛VAS评分及ODI较术前有明显下降(p<0.05).术后随访固定节段椎间隙高度较术前有所升高,椎间活动度下降,与术前比较差异有统计学意义(p<0.05).术前及术后各随访时间点头侧邻近节段活动度、椎间隙高度差异无统计学意义(p>0.05).结论:Dynesys治疗多节段腰椎退变性疾病中远期临床疗效满意,能保留部分椎间活动度,对邻近节段影响小。Dynesys远期临床疗效还有待更长时间的随访观察。     

Predictors of outcome after decompressive lumbar surgery and instrumented posterolateral fusion

There has been no agreement among different authors on guidelines to specify the situations in which arthrodesis is justified in terms of results, risks and complications. The aim of this study was to identify preoperative predictors of outcome after decompressive lumbar surgery and instrumented posterolateral fusion. A prospective observational study design was performed on 203 consecutive patients. Potential preoperative predictors of outcome included sociodemographic factors as well as variables pertaining to the preoperative clinical situation, diagnosis, expectations and surgery. Separate multiple linear regression models were used to assess the association between selected predictors and outcome variables, defined as the improvement after 1 year on the visual analog scale (VAS) for back pain, VAS for leg pain, physical component scores (PCS) of SF-36 and Oswestry disability index (ODI). Follow-up was available for 184 patients (90.6%). Patients with higher educational level and optimistic preoperative expectations had a more favourable postoperative leg pain (VAS) and ODI. Smokers had less leg pain relief. Patients with better mental component score (emotional health) had greater ODI improvement. Less preoperative walking capacity predicted more leg pain relief. Patients with disc herniation had greater relief from back pain and more PCS and ODI improvement. More severe lumbar pain was predictive of less improvement on ODI and PCS. Age, sex, body mass index, analgesic use, surgeon, self-rated health, the number of decompressed levels and the length of fusion had no association with outcome. This study concludes that a higher educational level, optimistic expectations for improvement, the diagnosis of “disc herniation”, less walking capacity and good emotional health may significantly improve clinical outcome. Smoking and more severe lumbar pain are predictors of worse results.     

小切口肌间隙入路Dynesys动态内固定在治疗腰椎间盘突出症中的应用

目的:分析后正中小切口经双侧肌间隙入路Dynesys置入、开窗髓核摘除术治疗腰椎间盘突出症的可行性和临床疗效。方法:回顾性分析2014年4月~2016年4月间,我院采用后正中小切口经双侧肌间隙入路Dynesys置入、开窗髓核摘除治疗腰椎间盘突出症25例患者的临床及影像学资料,并选取相同时间段内行常规显露Dynesys置入、开窗髓核摘除术治疗的腰椎间盘突出症患者25例做对比。记录切口长度、手术时间、术中出血量、并发症;评估术前、术后3d、术后3个月及末次随访时腰痛及下肢放射痛VAS评分、ODI评分;测量围手术期血清C反应蛋白(CRP)结果;测量手术节段椎间隙高度、活动度、邻近节段活动度;测量术后1年时多裂肌残存率。结果:两组患者均获得完整随访,术后随访时间30~54个月。小切口组平均随访时间35.5±7.3个月,常规显露组平均随访时间34.8±5.1个月。两组患者术前VAS评分和ODI评分组间差异无统计学意义,末次随访时均较术前明显改善(P<0.05),两组间差异无统计学意义(P<0.05)。小切口组在手术时间、术中出血量、切口长度、术后引流量优于常规显露组(P<0.05)。两组患者术后腰痛VAS、腿痛VAS、ODI均较术前明显缓解(P<0.05),小切口组术后3d腰痛VAS评分优于常规显露组(P<0.05)。小切口组患者术后3d和5d的CRP水平低于常规显露组(P<0.05)。手术节段在末次随访时仍存在4.1°±1.5°的活动度,所有患者末次随访时均未发现断钉及螺钉松动病例,小切口组减压侧多裂肌残留率高于常规显露组(P<0.05)。手术椎间隙高度在术后3个月时有所增高,但在末次随访是恢复到术前水平(P<0.05)。小切口组2例切口延迟愈合,常规显露组1例切口延迟愈合。结论:后正中小切口经双侧肌间隙入路Dynesys置入、开窗髓核摘除术治疗腰椎间盘突出症,较常规显露方法手术时间短,出血量、引流量、切口长度较常规显露小,对肌肉组织损伤小,是手术治疗腰椎间盘突出症的选择之一。     

Outcome analysis of lumbar endoscopic unilateral laminotomy for bilateral decompression in patients with degenerative lumbar central canal stenosis

Background ContextLumbar endoscopic unilateral laminotomy for bilateral decompression (LE-ULBD) has been reported as an alternative treatment for degenerative lumbar central canal stenosis (DLCS).PurposeTo investigate the outcomes of LE-ULBD for different types of DLCS, including simple DLCS, DLCS with degenerative spondylolisthesis (DSL), and DLCS with degenerative scoliosis (DSC).Study Design/SettingProspective cohort study.Patient SampleOne-hundred sixteen patients with DLCS who underwent LE-ULBD at a spine center from April 2015 to June 2017 were enrolled in this study.Outcome MeasuresOperative time, postoperative duration of hospitalization, and clinical outcomes (Oswestry disability index [ODI], visual analog scale [VAS], and modified Macnab outcome scale), and adverse events.MethodsA comparative analysis was performed evaluating medical records, radiological studies, and patient reported outcomes including ODI score, VAS scores and modified Macnab outcome scales in patients who underwent LE-ULBD. Data were prospectively collected at preoperative, postoperative 3-, 6-, 12-, 24-month to assess clinical and radiological outcomes and complications.ResultsThe study analyzed 106 patients (45 men and 61 women, with a mean age of 69.5 years); 40 (37.8%) had simple DLCS, 41 (38.7%) had DLCS with DSL, and 25 (23.5%) had DLCS with DSC. The mean follow-up period was 33.3 months. The mean preoperative and postoperative follow-up ODI score and VAS scores for leg and back pain showed significant improvement in all time points. No significant difference was found among different pathologies in terms of VAS scores for back and leg pain, ODI scores and modified Macnab outcome scales at all follow-up periods.ConclusionsLE-ULBD is a feasible treatment method for DLCS. It did not result in worse outcomes in cases with DLCS with DSL or DLCS with DSC as compared with cases with simple DLCS.     

棘突间 CoflexTM 非融合固定的临床应用及疗效分析简

目的评价棘突间Coflex非融合固定治疗腰椎管狭窄症的临床效果及应用前景。方法对腰椎管狭窄症121例采用后路双侧椎板开窗减压,棘突间Coflex非融合固定手术。其中119例行单节段棘突间Coflex固定,2例行双节段棘突间Coflex固定。结果121例术后症状均得到明显改善,平均手术时间40．24min,平均失血量51．43ml;术前下腰椎JOA评分平均为13．62分,术后为25．06分;术前ODI评分平均为67．36％,术后为14．33％;术前腰痛VAS评分为7．89分,术后为2．01分：术前腿痛VAS疼痛评分平均为8．44分,术后为1．22分。结论应用双侧椎板开窗减压,棘突问Coflex非融合固定治疗腰椎管狭窄症具有良好的近期临床疗效。     

A novel lumbar total joint replacement may be an improvement over fusion for degenerative lumbar conditions: a comparative analysis of patient-reported outcomes at one year

Background contextEffective alternatives to lumbar fusion for degenerative conditions have remained elusive. Anterior total disc replacement does not address facet pathology or central/recess stenosis, resulting in limited indications. A posterior-based motion-preserving option that allows for neural decompression, facetectomy, and reconstruction of the disc and facets may have a role.PurposeThe purpose was to compare one-year patient-reported outcomes for a novel, all-posterior, lumbar total joint replacement (LTJR – replacing both the disc and facet joints) against transforaminal lumbar interbody fusion (TLIF) for degenerative lumbar conditions warranting fusion (degenerative spondylolisthesis, recurrent disc herniation, severe foraminal stenosis requiring facet removal, and adjacent segment degeneration).Study design/settingA retrospective analysis of prospectively collected data comparing outcomes for LTJR patients to TLIF patients at an academic teaching hospital.Patient sampleAnalysis was conducted on 156 adult TLIF patients who were propensity matched to the 52 LTJR patients for a total sample of 208.Outcome measuresSelf-reported Oswestry Disability Index (ODI) and Numeric Rating Scale (NRS) for back and leg pain were compared preoperatively, 3 months and 1 year after surgery.MethodsThe implant is a motion-preserving lumbar reconstruction that replaces the function of both the disc and facets and is implanted using a bilateral transforaminal approach with complete facetectomies. Adult patients with degenerative lumbar pathology undergoing either LTJR or open TLIF were analyzed. These degenerative conditions included: grade 1 degenerative spondylolisthesis, recurrent disc herniation, adjacent segment disease, disc degeneration with severe foraminal stenosis). Trauma, tumor, grade 2 or higher spondylolisthesis, spinal deformity, and infection cases were excluded. Propensity score matching was performed to ensure parity between the cohorts. Multivariable regression analyses were done to compare the 1-year results as measured by 3 different standards to assess procedure success.ResultsAt 3 months, both the LTJR and TLIF cohorts showed significant and similar improvements in ODI and NRS back and leg pain. At 1 year, the LTJR cohort showed continued improvement in ODI and NRS back pain, while the TLIF group showed a plateau for ODI, back and leg pain. In a series of three multivariable logistic regressions, LTJR was shown to provide 3.3 times greater odds of achieving the minimal clinical symptom state in disability and pain (ODI <20%, NRS back and leg pain <2) and 2.4 and 4.1 times greater odds of achieving substantial clinical benefit (18% reduction in ODI) and minimal clinically important difference (30% reduction in ODI) as compared to TLIF.ConclusionsHere we present a comparative analysis for the first 52 patients undergoing a novel, posterior-based LTJR for the lumbar spine versus TLIF for degenerative pathology. The approach for the LTJR allows for wide neural decompression, facetectomy, and complete discectomy, with the implant working to replace the function of the disc and facets to preserve motion. At 1 year, the LTJR cohort showed significant improvement in ODI and NRS back and leg pain as compared to TLIF. These results suggest that wide neural decompression combined with motion preservation using this novel LTJR may represent a viable alternative to TLIF for treating certain degenerative conditions. A prospective controlled trial is under development to further evaluate the efficacy, safety, and durability of this procedure.     

后路椎体间融合治疗退变性腰间盘疾病、腰椎滑脱和腰椎手术失败综合征的疗效比较

目的探讨后路椎体间融合(PLIF)治疗退变性腰间盘疾病、腰椎滑脱和腰椎手术失败综合征的疗效比较。方法126例应用PLIF手术治疗患者,其中退变性腰间盘疾病(degenerative lumber disc diseases,DDD)52例、腰椎滑脱(spondylolisthesis,SL)43例、腰椎手术失败综合征(failed back surgery syndrome,FBSS)31例,术前和术后行Oswestry功能障碍评分(the Oswestry disability index,ODI)、腰痛及腿痛视觉疼痛评分(visual analog scales,VAS),评价治疗效果。结果随访12~26个月,平均18个月。ODI评分:DDD组减少22.5分,SL组减少28.2分,FBSS组减少22.2分,各组手术前后有统计学差异(配对t检验,P<0.05),各组间无统计学差异(方差分析,P>0.05)。腰痛VAS评分:DDD组减少4.1分,SL组减少3.8分,FBSS组减少3.2分,各组手术前后有统计学差异(配对t检验,P<0.05)各组间无统计学差异(方差分析,P>0.05)。腿痛VAS评分:DDD组减少3.8分,SL组减少3.5分,FBSS组减少2.2分,各组手术前后有统计学差异(配对t检验,P<0.05),各组间无统计学差异(方差分析,P>0.05)。结论PLIF治疗能够明显减轻DDD、SL和FBSS 3组患者的腰腿痛及改善相关功能障碍,但3组治疗结果间无统计学差异。     

Dynesys动态内固定与融合术治疗腰椎退变疾病的对比研究

目的 比较Dynesys动态内固定与腰椎后路椎间融合术（posterior lumbar interbody fusion,PLIF）治疗腰椎退变疾病的临床疗效和影像学结果.方法回顾分析2008年7月-2011年3月采用Dynesys 动态固定治疗且随访时间＞2年的腰椎退变患者46例（Dynesys组）,以同期行PLIF的50例患者作为对照（PLIF组）.记录2组手术前后Oswestry 功能障碍指数（Oswestry disability index,ODI）和疼痛视觉模拟量表（visual analogue scale,VAS） 评分,摄腰椎正侧位和前屈后伸位X线片,测量手术节段椎间高度、活动度（range of motion,ROM）以及近侧邻近节段的椎间ROM,评估2组影像学和症状学邻近节段退变的发生情况.结果 2组患者术前资料差异无统计学意义,末次随访时的ODI及VAS评分均较术前明显改善（P＜0.05）,组间差异无统计学意义（P＞0.05）.末次随访时Dynesys组手术节段椎间高度较术前轻度升高（P＞0.05）,而PLIF组显著升高（P＜0.05）且大于Dynesys组,组间差异有统计学意义（P＜0.05）.Dynesys组手术节段ROM由术前的7.1°降至末次随访时的4.9°（P＜0.05）,而PLIF组手术节段ROM由术前的7.3°降至末次随访时的0°（P＜0.05）.2组近侧邻近节段椎间高度变化差异无统计学意义（P＞0.05）,ROM在末次随访时均较术前有所增加（P＜0.05）,且PLIF组大于Dynesys组（P＜0.05）.Dynesys组有6例患者出现影像学邻近节段退变,PLIF组患者有15例出现影像学邻近节段退变,差异有统计学意义（P＜0.05）,仅PLIF组有1例出现症状学邻近节段退变,行二次手术治疗.结论 Dynesys动态内固定与融合术均获得良好临床疗效.与融合术相比,Dynesys动态内固定能够保留手术节段部分ROM,邻近节段椎间ROM的增幅及邻近节段退变发生数均较低.