腰椎间盘退变性疾病术后短期内再手术原因分析与疗效

目的探讨腰椎间盘退变性疾病手术后短期内再次手术的原因及干预方法。方法 2010年8月至2011年2月手术治疗腰椎管狭窄症、腰椎间盘突出症等腰椎间盘退变性疾病238例,手术方式包括髓核摘除、椎管减压、椎间融合、椎弓根螺钉内固定等。术后7例因腰腿痛及神经根性症状持续存在或加重在短期内进行再次手术,其中男2例,女5例,年龄47～67岁。再手术原因包括神经根管减压不充分伴髓核组织残留2例,椎弓根螺钉误置2例,椎间融合术后相邻节段退变2例,椎板切除减压、髓核摘除术后椎间不稳1例。结果 7例手术均顺利完成,有效随访6～12个月,术后视觉模拟疼痛评分和Oswestry功能障碍指数评分均有改善,腰腿痛及神经根性症状有所缓解,疗效满意。结论游离型腰椎间盘突出症容易发生髓核组织残留致神经根管减压不充分、椎弓根螺钉误置;要重视腰椎融合术后相邻节段退变发生的相关因素,有效预防和延缓相邻节段退变的发生。     

显微内窥镜下治疗腰椎间盘突出伴椎管狭窄

目的研究后路显微内窥镜(MED)治疗腰椎间盘突出合并椎管狭窄的临床应用价值。方法显微内窥镜下髓核摘除,同时扩大侧隐窝,部分患者需要同时扩大神经根管,对受压神经根充分减压。结果本组经后路显微内窥镜下治疗腰椎间盘突出合并椎管狭窄452例,术后随访305例,优263例,良31例。差11例,优良率达96.3％。结论MED在神经根充分减压的基础上,具有损伤小,恢复快,脊柱稳定性好,适用于治疗单侧1个间隙或同侧2个间隙椎间盘突出合并椎管狭窄。     

30例胶原酶治疗腰椎间盘突出症无效原因分析

目的进一步探讨胶原酶治疗腰椎间盘突出症的适应证.方法在2年中对30例用胶原酶治疗腰椎间盘突出症的患者因治疗无效,症状未改善,予以手术摘除术.术中进行探察.结果 30例患者手术后症状均改善.但术中发现,髓核及后纵韧带钙化者18例,突出物较大者10例,髓核粘连4例,椎管狭窄者8例,神经根管狭窄者8例,脊柱退变不稳者3例.结论对于一些椎间盘突出后明显钙化,椎管狭窄,或神经根管明显狭窄者,或椎板及黄韧带增厚者而又同时伴有椎间盘突出者,或巨大型突出者,或个别腰椎不稳定者,均不宜行胶原酶治疗.     

选择性神经根封闭术在腰椎退变性疾病中的应用

目的探讨选择性神经根封闭术在腰椎退变性疾病中的定位诊断作用。方法 2008年1月～2010年12月共收治多节段腰椎退变患者58例。多节段腰椎椎管狭窄症患者共32例,其中男20例,女12例;年龄55～75岁,平均64岁;病程1～11年。多节段腰椎椎间盘突出患者26例,其中男15例,女11例;年龄38～63岁,平均45岁;病程1～8年。以上患者均有下肢疼痛不适症状。所有患者均采用选择性神经根封闭术明确责任节段。结果 32例多节段腰椎椎管狭窄症患者中25例行>2个节段的减压术;26例多节段腰椎椎间盘突出患者,12例行单节段髓核切除,另14例行双节段髓核切除。责任间隙准确,患者疗效良好。结论在腰椎退变性疾病的定位诊断中,选择性神经根封闭是一种准确而有效的确认责任间隙的方法。     

基因芯片表达谱在椎间盘退变领域应用的研究进展

正椎间盘退变是指椎间盘自然老化、退化的生理病理过程,它是一系列脊柱退行性疾病的病理基础,可引起椎管狭窄、脊柱节段不稳、骨赘形成,导致腰腿痛、椎间盘突出及神经根或脊髓压迫。对椎间盘退变引起的脊柱疾患可采用保守或手术治疗。脊柱融合术是目前治疗椎间盘退变引起的椎间盘突出、椎管狭窄等相关疾病的"金标准",但     

常规及改良式椎间盘镜治疗腰椎间盘退变性疾病的疗效分析

目的观察常规椎间盘镜及改良式椎间盘镜手术治疗腰椎间盘退变性疾病的疗效。方法2006年10月至2010年6月用显微椎间盘镜髓核摘除术共治疗136例腰椎间盘突出症,154个间隙腰椎间盘突出。单节段突出者118例,双节段者18例,合并神经根管狭窄者41例,合并椎管狭窄症者15例,合并突出物钙化11例,合并软骨板撕脱者6例。合并腰椎失稳4例,中央型巨大突出25例,脱垂游离型16例。其中男性87例,女性49例,发病年龄16-73岁,平均42．1岁。突出间隙：L3-412例,L。-s52例,LsS1,54例。L3-4加L4-53例,L4-5加LsS1 15例。结果所有患者均获得6-24个月的随访,平均12个月。优良率94．1％。结论常规椎间盘镜及改良式椎间盘镜下手术治疗腰椎间盘退变性疾病,具有创伤小、恢复快、神经根减压彻底、维护脊柱稳定性优点。术前诊断明确、适应证选择合适并及时手术、手术方式选择正确、术前与术中相吻合及术中耐心细致的操作是手术成功的关键。而改良术式作为常规椎间盘镜术的补充,可以扩大椎间盘镜在临床的应用范围,减少术中中转开放的概率,最大程度用微创术服务于患者。     

经皮内窥镜下腰椎间盘切除术治疗腰椎间盘突出症的并发症

【摘要】 目的：回顾性分析经皮内窥镜下腰椎间盘切除术（percutaneous endoscopic lumbar discectomy,PELD）治疗腰椎间盘突出症的并发症及其相关因素。方法：自2006年3月~2010年10月共行经皮内窥镜下腰椎间盘切除术治疗162例腰椎间盘突出症患者,男82例,女80例;年龄21~71岁,平均36.5岁。统计术中、术后早期及术后长期并发症的发生情况。结果：162例患者均获得3~60个月的随访,平均随访30个月。本组患者出现手术并发症共12例,发生率为7.2%。术中发生并发症4例,其中节段定位错误1例,术中活动出血1例,硬膜囊损伤1例,钬激光器械金属头部断裂1例;术后早期发生并发症5例,其中髓核遗漏2例,椎间隙感染1例,神经感觉异常2例;术后中长期并发症3例,2例为同节段椎间盘突出复发,术后遗留活动后明显慢性腰部疼痛1例。结论：经皮内窥镜下腰椎间盘切除术治疗腰椎间盘突出症有一定的并发症,术者的手术经验及技巧、术前准备与术后处理、手术适应证的选择与手术并发症有关。     

显微内窥镜下治疗腰椎间盘突出伴椎管狭窄

目的 研究后路显微内窥镜(MED)治疗腰椎间盘突出合并椎管狭窄的临床应用价值。方法 显微内窥镜下髓核摘除，同时扩大侧隐窝，部分病人需要同时扩大神经根管，对受压神经根充分减压。结果 本组经后路显微内窥镜下治疗腰椎间盘突合并椎管狭窄452例，术后随访305例，优263例，良31例，差11例，优良率达96．3％。结论 MED在神经根充分减压的基础上，具有损伤小，恢复快，脊柱稳定性好，适用于单侧1个间隙或同侧2个间隙椎间盘突出合并椎管狭窄的治疗。     

微创经椎间孔腰椎体间融合术的围手术期并发症

目的:分析微创经椎间孔腰椎体间融合术(minimally invasive transforaminal lumbar interbody fusion,MIS-TLIF)的围手术期并发症发生情况。方法 :对2007年6月~2013年7月接受MIS-TLIF治疗的523例腰椎退变性疾病患者的临床资料进行回顾性分析。男231例,女292例,年龄53.1±8.4岁(31~83岁)。其中腰椎滑脱症194例,腰椎管狭窄症128例,腰椎不稳症62例,巨大腰椎间盘脱出症59例,腰椎术后复发52例(开放腰椎间盘切除术后复发26例,显微内窥镜下椎间盘切除术后复发17例,经皮内窥镜下椎间盘切除术后复发9例),退变性椎间盘病(degenerative disc disease,DDD)28例。围手术期并发症定义为手术后1个月内发生的与手术直接相关的并发症。持久并发症指手术导致新的损害术后持续大于30d无改善,短暂并发症指手术导致新的损害在术后30d内获得改善。统计分析并发症发生情况及原因。结果:本组523例平均随访47.5±8.2个月(24~81个月)。92例患者共计发生围手术期并发症96例次,其中持久并发症2例次,分别为1例因为椎弓根解剖结构畸形在螺钉置入时造成神经根损伤和1例操作失误导致出行神经根损伤,神经功能部分恢复。90例发生短暂性并发症94例次,其中最常见为下肢麻木不适,发生率为10.71%(56/523),发生硬膜撕裂21例,表浅感染9例,局部血肿4例,神经卡压2例,深部感染1例,植骨移位1例。88例患者发生单项并发症,4例发生2项并发症,围手术期并发症发生率为17.59%(92/523)。不同疾病并发症率分别为:腰椎滑脱症17.53%,腰椎管狭窄症17.19%,腰椎不稳14.52%,巨大腰椎间盘脱出13.56%,腰椎术后翻修30.77%,退变性椎间盘病10.71%。单节段融合并发症率(17.53%)和双节段融合并发症发生率(18.42%)统计学差异不显著(χ~2=0.02,P0.05)。结论 :MIS-TLIF围手术期并发症包括神经根损伤、硬膜撕裂、切口感染和短暂性下肢麻木等,短暂性下肢麻木是最常见并发症。     

121例腰椎间盘突出症并椎管狭窄症的手术治疗分析

目的探讨腰椎间盘突出症并椎管狭窄症的手术治疗。方法对121例腰椎间盘突出症合并椎管狭窄患者临床资料进行回顾总结。结果 121例均顺利完成手术,术中无脊髓、神经及无重要血管损伤。优84例,良30例,差7例,优良率达94.21%。结论腰椎间盘突出症并椎管狭窄症的手术治疗中应全面探查骨性和软组织,认真探查并切除退变的椎间盘组织,椎管狭窄手术减压一定要彻底,可以达到良好的临床效果。     

Minimally invasive strategies and options for far-lateral Iumbar disc herniation

Objective: To investigate the surgical procedlures,options and surgical indications for far-lateral lumbar disc herniation between three different minimally invasive procedures.Methods: From January 2000 to October 2006, 52 patients with far-lateral lumbar disc herniation (29 males and 23 females, with the average age of 41.5 years) were treated with minimally invasive procedures. All the patients were assessed by X-ray and CT. Some were given additional myeography, discography, Computerized tomography myelography (CTM) and MRI examination. Yeung Endoscopy Spine System (YESS), METRx and X-tube procedures were performed in 25, 13 and 14 cases, respectively. All patients were followed up for a mean period of 13.5 months. Clinical outcomes were assessed by visual analog score (VAS) and Nakai criteria. Results: The results indicated that the three procedures could significantly improve the radiating leg symptoms (P<0.05). The postoperative overall excellent and good rates of YESS, METRx and X-tube procedures were 84.0%,84.6% and 92.8% respectively, with no statistical difference among three groups (P>O.05). The YESS procedure had several advantages including shortest operation time, simplest anesthesia and least trauma as compared with the other two procedures, especially for simple type I far-lateral lumbar disc herniation. METRx procedure was specially suitable for simple type II. And the procedure of posterior endoscopic facetectomy, posterior lumbar interbody fusion and unilateral pedicle screw instrumentation with X-tube was designed for far-lateral disc herniation combined with degenerative lumbar instability. Conclusion: Minimally invasive strategies and options should be determined by different types of far-lateral lumbar disc herniation.     

Minimally invasive strategies and options for far-lateral lumbar disc herniation

Objective： To investigate the surgical procedures, options and surgical indications for far-lateral lumbar disc herniation between three different minimally invasive procedures.
Methods： From January 2000 to October 2006, 52 patients with far-lateral lumbar disc herniation （29 males and 23 females, with the average age of 41.5 years） were treated with minimally invasive procedures. All the patients were assessed by X-ray and CT. Some were given additional myeography, discography, Computerized tomography myelography （CTM） and MRI examination. Yeung Endoscopy Spine System （YESS）, METRx and X-tube procedures were performed in 25, 13 and 14 cases, respectively. All patients were followed up for a mean period of 13.5 months. Clinical outcomes were assessed by visual analog score （VAS） and Nakai criteria.
Results： The results indicated that the three procedures could significantly improve the radiating leg symptoms （P〈0.05）. The postoperative overall excellent and goodrates of YESS, METRx and X-tube procedures were 84.0%, 84.6% and 92.8% respectively, with no statistical difference among three groups （P〉0.05）. The YESS procedure had several advantages including shortest operation time, simplest anesthesia and least trauma as compared with the other two procedures, especially for simple type I far-lateral lum- bar disc herniation. METRx procedure was specially suitable for simple type II. And the procedure of posterior endoscopic facetectomy, posterior lumbar interbody fusion and unilateral pedicle screw instrumentation with X-tube was designed for far-lateral disc herniation combined with degenerative lumbar instability.
Conclusion： Minimally invasive strategies and options should be determined by different types of far-lateral lumbar disc herniation.     

椎间盘镜辅助 X-Tube下椎体间融合术治疗退变性腰椎间盘疾病

 目的 探讨椎间盘镜辅助 X-Tube下腰椎后路椎体间融合术(posterior lumbar interbody fusion, PLIF)和经椎间孔腰椎椎体间融合术(transforaminal lumbar interbody fusion, TLIF)治疗退变性椎间盘疾病的临床疗效。方法 2007年 11月至 2008年 4月, 采用椎间盘镜辅助 X-Tube下 TLIF和 PLIF治疗退变性椎间盘疾病 32例: PLIF 13例, TLIF 19例。单节段腰椎间盘突出症伴相应节段腰椎不稳定 21例, 腰椎滑脱症 11例(玉度 6例, 域度 5例)。病变节段: L3-4 2例, L4-5 18例, L5S1 12例。年龄 38~72岁, 平均 51.2岁;男 19例, 女 13例。术后进行定期随访和影像学检查, 并进行 Oswestry功能障碍指数评定以评价术后康复情况。结果手术时间 90~180 min, 平均 120 min;手术出血量 100~400 ml, 平均 190 ml。切口均为甲级愈合, 未见切口及椎管、椎间隙感染、内固定失败等并发症发生。所以患者均获随访, 随访时间 13~41个月, 平均 21个月。 Oswestry功能障碍指数由术前 40.1%±4.1%下降到术后 3个月的 9.5%±3.7%。疗效评价: 优 19例, 良 10例, 可 3例;优良率为 90.6豫。骨融合均取得成功。结论椎间盘镜辅助 X-Tube下 TLIF和 PLIF治疗退变性椎间盘疾病具有切口小, 创伤小, 术后恢复快等优点。     

Perioperative complications in transforaminal lumbar interbody fusion versus anterior-posterior reconstruction for lumbar disc degeneration and instability

OBJECTIVES: Multiple different approaches are used to treat lumbar degenerative disc disease and spinal instability. Both anterior-posterior (AP) reconstructive surgery and transforaminal lumbar interbody fusion (TLIF) provide a circumferential fusion and are considered reasonable surgical options. The purpose of this study was to quantitatively assess clinical parameters such as surgical blood loss, duration of the procedure, length of hospitalization, and complications for TLIF and AP reconstructive surgery for lumbar fusion. METHODS: A retrospective analysis was completed on 167 consecutive cases performed between January 2002 and March 2004. TLIF surgical procedure was performed on 124 patients, including 73 minimally invasive and 51 open cases. AP surgery was performed on 43 patients. Patients were treated for painful degenerative disc disease, facet arthropathy, degenerative instability, and spinal stenosis. RESULTS: The mean operative time for AP reconstruction was 455 minutes, for minimally invasive TLIF 255 minutes, and open TLIF 222 minutes. The mean blood loss for AP fusion surgery was 550 mL, for minimally invasive TLIF 231 mL, and open TLIF 424 mL. The mean hospitalization time for AP reconstruction was 7.2 days, for minimally invasive TLIF 3.1 days, and open TLIF 4.1 days. The total rate of complications was 76.7% for AP reconstruction, including 62.8% major and 13.9% minor complications. The minimally invasive TLIF patients group had the total 30.1% rate of complications, 21.9% of which were minor and 8.2% major complications. There were no major complications in the open TLIF patients group, with 35.3% minor complications. CONCLUSIONS: AP lumbar interbody fusion surgery is associated with a more than two times higher complication rate, significantly increased blood loss, and longer operative and hospitalization times than both percutaneous and open TLIF for lumbar disc degeneration and instability.     

显微内窥镜下髓核摘除治疗腰椎间盘突出症术中并发症原因分析及防治措施

目的:分析显微内窥镜下髓核摘除术(MED)治疗腰椎间盘突出症术中并发症的发生原因,总结预防及处理办法。方法:回顾性分析2001年10月至2012年1月,采用显微内窥镜下髓核摘除治疗腰椎间盘突出症的患者851例,男469例,女382例;年龄16～75岁,平均42.5岁;病程1～18个月,平均3个月。突出间隙:L3,424例,L4,5418例,L5S1409例。主要症状为腰痛伴下肢放射性疼痛、麻木,其中单侧下肢症状者729例,双侧下肢症状者122例,相应神经支配区感觉、肌力、反射异常及肌肉萎缩4项检查至少2项出现异常,神经牵拉试验阳性,CT或MRI表现与临床症状、体征相吻合。851例患者未同时合并腰椎失稳、椎管狭窄患者,未包括高位腰椎间盘突出症及合并马尾神经综合征患者。记录术中并发症的发生情况。结果:依据Macnab标准,总体优良率为87.5%(745/851),与开放手术相似。1例因设备故障中转为切开手术,1例术后11d因突发心肌梗塞死亡,2例于术后1h内出现急性硬膜外血肿。发生硬脊膜损伤28例,发生率3.29%(28/851)。神经根牵拉伤38例,发生率4.46%(38/851);腹膜后血肿1例,不完全性马尾损伤2例,不完全性神经根断裂2例。结论:熟练的镜下止血技巧、精细的操作是预防MED术中并发症的重要因素,及时发现及时处理是防治显微内窥镜下髓核摘除术术中并发症的有效措施。     

巨大型腰椎椎间盘突出症的微创外科治疗

目的探讨巨大型腰椎椎间盘突出症微创手术策略。方法 2007年1月～2010年10月,对86例巨大型腰椎椎间盘突出症患者采用微创外科手术治疗。其中,椎间孔内镜椎间盘切除术(percutaneous endoscopic lumbar discectomy,PELD)28例,显微内镜椎间盘切除术(microendoscopic discectomy,MED)35例,微创经椎间孔腰椎椎间融合术(minimally invasive transforaminal lumbar interbody fusion,miTLIF)23例。术前与术后疼痛视觉模拟量表(visual analog scale,VAS)评分和改良Macnab标准评价临床疗效。结果 3种微创术式均能显著改善患肢放射性疼痛VAS评分。术后优良率都在85%以上。PELD术适于年轻人巨大型腰椎椎间盘突出症;MED术适于巨大型腰椎椎间盘突出症伴椎管狭窄;miTLIF术适于伴有腰椎退行性失稳或伴有马尾综合征或术后复发的巨大型腰椎椎间盘突出症。结论临床上应依据巨大型腰椎椎间盘突出症的不同类型,选择不同微创外科术式。     

中后路显微椎间盘镜(METRx)手术治疗腰椎间盘突出症(附290例报告)

目的：探讨中后路显微椎间盘镜(METRx)治疗腰椎间盘突出症的疗效。方法：应用METRx椎间盘镜治疗腰椎间盘突出症290例，随访3月～33月。结果：按Nakai分级，优81．O％(235例)，良13．4％(39例)，可4．8％(14例)，差0．7％(2例)。2例术后发生椎间隙感染。结论：应用METRx治疗腰椎间盘突出症近期疗效满意。     

可动式椎间盘镜技术治疗腰椎间盘突出症和椎管狭窄症

目的 探讨可动式椎间盘镜技术治疗腰椎间盘突出症和腰椎管狭窄症的疗效.方法 应用可动式椎间盘镜技术治疗腰椎间盘突出症130例、退变性椎管狭窄症60例、椎间盘突出合并椎管狭窄122例.26例有同一节段手术史.法国Bagatelle医院212例,均为单处开窗减压,双侧狭窄者潜行减压至对侧;天津医院100例,单处开窗82例、两处开窗14例、三处开窗3例、四处开窗l例,其中4例伴失稳者行镜下B-Twin椎体间融合术.根据Macnab评分标准评定疗效.结果 术后随访1～24个月,平均12个月.法国Bagatelle医院单侧手术时间平均35 min,双侧减压平均45 min;术中出血量平均35ml;术中硬膜囊撕裂1例;术后当天下床活动,平均住院1.2 d.疗效优191例,良15例,可6例;200例于术后3周内恢复原工作或牛活.天津医院单处手术平均50 min;术中出血量平均100 ml;术中转开放手术2例,定位错误4例,神经根部分损伤2例,硬膜囊撕裂4例,切口浅表感染2例;术后1～3 d下床活动,平均住院5d.疗效优80例,良15例,可5例.71例术后3周内恢复原工作或牛活.结论 可动式椎间盘镜手术器械可随意倾斜或摆动,使椎间盘切除手术操作更方便,减压彻底,效果优良.     

退变性腰椎间盘突出症的手术治疗

作者通过１００例退变性腰椎间盘突出症的手术治疗，结合影像学检查和手术所见，将退变性腰椎间盘突出部分：（１）单纯性腰椎间盘突出或膨出；（２）登工节段性椎管狭窄；（３）合并侧隐窝狭窄；（４）合并椎管、侧隐窝狭窄。术中讨论了退变性椎间盘突出的病理特点。手术治疗可获得较好的疗效。本组经术后半年－３．５年的随访，优良率为８９％。     

显微内窥镜腰椎间盘切除系统治疗腰椎间盘突出症

目的分析显微内窥镜腰椎间盘切除系统(MED)治疗腰椎间盘突出症的技术特点和疗效。方法54例腰椎间盘突出症行MED治疗,手术采用后路椎间盘镜手术进行“开窗”减压,髓核摘除术及神经根减压。结果随访6~12个月,按照Macnab标准:优40例,良6例,可4例,优良率92.6%。结论该方法适用于腰椎间盘突出症或伴轻度侧隐窝、神经根管狭窄的患者,近期疗效好且具有创伤小、出血少、术后恢复快等优点。