退行性腰椎滑脱症

本文从病因，病机，症状，体症及诊断治疗等方面详细阐述了退行性腰椎滑脱症。认为椎间盘退变所致腰椎失稳和关节突骨性关节炎是导致本病的主要原因。对本症的病理机制做了认真论述，提供了目前常用的治疗方法，供诊断时参考。     

退行性腰椎滑脱外科治疗中的相关问题

退行性滑脱也称“假性滑脱”,是由于腰椎椎间盘和腰椎关节退变引起的存在完整神经弓的椎体滑移.多数行保守治疗有效,大约30%的滑脱患者需行手术治疗.手术治疗的适应证包括：持续性或反复的腰骶部疼痛或神经性间歇性跛行,最少3个月的保守治疗无效,影响生活、休息、睡眠或学习等;神经症状进行性加重;有膀胱和直肠症状等.现就其手术治疗的相关问题做一综述,供同道参考.     

BacFuse固定融合术治疗老年腰椎退行性滑脱

[目的]探讨BacFuse固定融合术治疗老年腰椎退行性滑脱的中短期临床疗效。[方法]回顾性分析2014年1月~2015年6月应用BacFuse固定融合术治疗的老年腰椎退行性滑脱症患者临床资料。共32例患者纳入研究,平均年龄(67.3±5.1)岁,平均随访(15.6±5.0)个月。Ⅰ度滑脱29个节段,Ⅱ度滑脱11个节段。临床疗效评估包括视觉模拟量表(VAS)评估疼痛情况,功能障碍指数(ODI)和日本骨科协会评分(JOA)评估功能情况;在X线片中测量椎间盘后缘高度(PDH)、椎间孔高度(FH)、手术节段活动范围(ROM)和上下椎体间的相对位移。[结果]本组平均手术时间(55.0±12.4)min。VAS评分由术前的(6.75±1.39)分降至末次随访的(2.41±1.78)分、ODI评分由术前的(35.47±11.15)分降至(13.22±7.66)分,JOA评分从(12.25±1.52)分增至(24.16±3.46)分;PDH由(6.75±2.43)mm增至末次随访的(8.44±2.56)mm、FH由(19.98±3.34)mm增至末次随访的(21.72±2.74)mm、手术节段活动范围(ROM)由(15.95±4.31)°降至末次随访的(3.75±1.36)°、上下椎体间的相对位移由(5.02±0.93)mm降至末次随访的(0.35±0.27)mm。[结论]BacFuse棘突间固定融合术治疗老年腰椎退行性滑脱症,具有手术时间短、出血少、疗效好、并发症少等优点,对高龄患者是一个安全有效的手术方式。     

退行性腰椎滑脱的发病机理及其手术治疗

早在1782年比利时的产科医生就发现了由于L5椎体前滑脱导致难产的现象，而脊柱滑脱的概念最早是由德国人Killan于1854年提出来的。1930年，Jumghamns报道60例滑脱尸检中有14例没有椎弓峡部缺损，因而提出了假性脊椎滑脱一词：Macnab对22例病人的解剖、临床表现和手术治疗后进行分析，提出应称为“椎弓完整的脊柱滑脱症”。1955年Newmall发现Macnab所称的“椎弓完整的脊柱滑脱症”不是唯一类型的伴有神经弓完整的滑脱。所以，他将这种滑脱结合其病理变化称之为“退变性脊柱滑脱（degenaralive spondylolisthesis．DS）”，并将其定为Ⅲ型腰椎滑脱。近年来，对退行性腰椎滑脱的发病机理及其治疗的研究愈来愈多，在许多相关问题上的看法不一，本文就此方面的研究进展作一综述。     

退行性腰椎滑脱症的Ⅹ线形态学观察

对６３套退行性腰椎滑脱（ＤＳ）的Ⅹ线正侧位和两对照组．ＣＩ（５０例同龄因腰腿痛拍片而非滑脱者）、Ｃ Ⅱ（５０例无腰腿痛的大学生志愿者的Ⅹ线片）作了形态学的对比分析，发现ＤＳ组椎间小关节间隙更近矢状位，下关节突靠拢（Ｐ＜０．０００５），下关节突长度短（Ｐ＜０．０００５），小关节椎弓根角大（Ｐ＜０．０００５）。以上特征使得ＤＳ组椎小关节对抗椎骨的前滑分力作用小，可能是引起退变滑脱的局部重要因素。     

腰椎滑脱治疗进展

脊椎滑脱(spondylolisthesis)一词是由希腊文的脊柱(spondylo)与滑脱(1isthesis)2个字组合而成。其是指脊椎椎体间因各种原因造成骨性连接异常而发生的上位椎体与下位椎体部分或全部滑移。最常发生腰椎,尤其是L5、S1节段前滑脱,颈椎或胸椎滑脱也有个别报道。现将近几年腰椎滑脱     

SOCON内固定器在治疗腰椎退行性滑脱中的应用

目的 观察腰椎管减压、横空间植骨和ＳＯＣＯＮ内固定手术治疗不稳定型退行性腰椎滑肿合并腰椎管狭窄患者的早期临床疗效。方法 从１９９７年１２月～１９９９年１月,２１例腰椎退行性滑脱合并腰椎管狭窄的患者,经长期（６～１２个月）严格保守治疗失败后,入院接受腰椎管减压、横空间植骨和ＳＯＣＯＮ内固定手术。２１例中表现为下腰痛、间歇性跛行者１９例,下肢疼痛者８例。经术前Ｘ线检查证实ＭｅｙｅｒｄｉｎｇⅠ度滑脱１８     

旋转牵压手法治疗退行性腰椎滑脱41例临床观察

<正>腰椎退行性滑脱属于中医"腰腿痛"范畴。本病的治疗要分清滑脱的程度,对腰椎假性滑脱Ⅰ°及Ⅱ°而且不伴有峡部裂的患者我们运用保守治疗为主,对真性滑脱以外科手术治疗为主,     

Degenerative lumbar spinal stenosis: an evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis.

BACKGROUND CONTEXT: The objective of the North American Spine Society (NASS) evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spinal stenosis (DLSS) is to provide evidence-based recommendations to address key clinical questions surrounding the diagnosis and treatment of DLSS. The guideline is intended to reflect contemporary treatment concepts for symptomatic DLSS as reflected in the highest quality clinical literature available on this subject as of April 2006. The goals of the guideline recommendations are to assist in delivering optimum, efficacious treatment, and functional recovery from this spinal disorder. PURPOSE: To provide an evidence-based tool that assists practitioners in improving the quality and efficiency of care delivered to patients with DLSS. STUDY DESIGN/SETTING: Evidence-based clinical guideline. METHODS: This report is from the Spinal Stenosis Work Group of the NASS Clinical Guidelines Committee. The work group comprised medical, diagnostic, interventional, and surgical spinal care specialists, all of whom were trained in the principles of evidence-based analysis. In the development of this guideline, the work group arrived at a consensus definition of a working diagnosis of lumbar spinal stenosis by use of a modification of the nominal group technique. Each member of the group formatted a series of clinical questions to be addressed by the group and the final list of questions agreed on by the group is the subject of this report. A literature search addressing each question and using a specific literature search protocol was performed on English language references found in MEDLINE, EMBASE (Drugs and Pharmacology), and four additional, evidence-based, databases. The relevant literature to answer each clinical question was then independently rated by at least two reviewers using the NASS-adopted standardized levels of evidence. An evidentiary table was created for each of the questions. Any discrepancies in evidence levels among the initial raters were resolved by at least two additional members' review of the reference and independent rating. Final grades of recommendation for the answer to each clinical question were arrived at in face-to-face meetings among members of the work group using the NASS-adopted standardized grades of recommendation. When Levels I to IV evidence was insufficient to support a recommendation to answer a specific clinical question, expert consensus was arrived at by the work group through the modified nominal group technique and is clearly identified as such in the guideline. RESULTS: Eighteen clinical questions were asked, addressing issues of prognosis, diagnosis, and treatment of DLSS. The answers to these 18 clinical questions are summarized in this document along with their respective levels of evidence and grades of recommendation in support of these answers. CONCLUSIONS: A clinical guideline for DLSS has been created using the techniques of evidence-based medicine and using the best available evidence as a tool to aid both practitioners and patients involved with the care of this disease. The entire guideline document including the evidentiary tables, suggestions for future research, and all references is available electronically at the NASS Web site (www.spine.org) and will remain updated on a timely schedule.     

腰椎退变性侧凸的治疗策略

目的探讨非手术治疗或腰椎后路减压、矫形固定、融合手术治疗由于椎间盘退变后继发小关节退变、椎管和神经根管容积变化以及脊柱失稳、畸形等病理改变导致的腰椎退变性侧凸患者的效果。方法2001年7月-2007年6月,治疗退变性腰椎侧凸患者56例,其中行非手术治疗5例。手术治疗51例。手术组患者平均年龄为63岁,腰椎侧凸Cobb角平均30°,采用腰椎后路减压,或辅助椎弓根螺钉矫形固定、后外侧融合或椎间融合治疗。结果56例均得到随访,平均随访时间为20个月,非手术治疗和手术患者均对治疗效果满意,生活质量提高,手术组矫正角度平均为15°,骨融合率达到95％,无神经损伤及翻修病例。结论腰椎退变性侧凸首选非手术治疗,如失败应根据患者情况遵循尽量采用有限内固定和融合的原则行手术治疗。     

Degenerative lumbar scoliosis: features and surgical treatment

Degenerative lumbar scoliosis is a de novo deformity of the spine occurring after the fourth or fifth decade of life in patients with no history of scoliosis in the growing age. We evaluated complications and functional and radiographic outcomes of twelve patients with degenerative lumbar scoliosis, treated by spinal decompression associated with posterolateral and/or interbody fusion. Mean lumbar scoliosis angle was 18° (SD=4°) and mean age at surgery was 57 years (SD=6 years). Average follow–up was 3.5 years. Surgical treatment consisted in decompression of one or more roots, associated with stabilization with pedicle screws and posterolateral fusion. To correct the deformity, the collapse of the disc was corrected by implanting a cage in the anterior interbody cage. Clinical symptoms and functional tolerance for daily activities improved after surgery. Radiographic evaluation showed a reduction in the deformity on the frontal and sagittal planes. There were no infections, evidence of pseudoarthrosis, instrumentrelated failures or re–operations in this series. In patients with persisting pain caused by degenerative scoliosis associated with spinal stenosis, in whom conservative treatment has failed, spinal decompression and segmented fusion with instrumentation represents a valid treatment option.     

Degenerative lumbar scoliosis

In adults, symptomatic scoliosis is usually a de novo primary degenerative deformity that develops in the fifth or sixth decade or an unrecognized or untreated idiopathic deformity with superimposed degeneration. The evaluation and treatment of adult scoliosis must focus on addressing patient symptoms while limiting the consequences of the treatment. The presence of neurological deficits, the flexibility of the deformity, the coronal and sagittal balance, and status of spinal segments outside of the main deformity are all important considerations when planning surgery. The complication rate of deformity surgery in adults is potentially high; but excellent functional outcome and patient satisfaction can occur with thorough preoperative patient education and meticulous surgical technique.     

Degenerative lumbar scoliosis

Recent work on degenerative lumbar curves has focused on stable deformities with entrapment syndrome secondary to spondylotic compression. A review of our local experience with degenerative lumbar curves shows that approximately half of the 14 cases have had a less typical radiographic presentation of short reciprocating lumbar curves thought to be on the basis of asymmetric intervertebral osteochondrosis. In these latter cases, marked spondylotic ridging and intervertebral buttressing were absent; therefore, major decompressive surgery on the residual posterior elements may increase instability and hasten further collapse. Although most patients have had good relief of radicular leg complaints with decompressive procedures, several patients had persistent low-back pain that appeared to have a mechanical basis. In those instances of potentially increased postoperative instability or persistent mechanical back complaints, consideration should be given to augmenting decompressive procedures with Harrington instrumentation and fusion for these painful collapsing lumbar spines.     

Degenerative lumbar instability

The degenerative process typically results in a stiff but stable lumbar spine; however, occasionally instability may result. The primary forms of degenerative lumbar instability are spondylolisthesis, which is a translation of a single vertebra over another or a more global degenerative scoliosis. All forms of lumbar instability can result in back pain and neural compression. Most forms of degeneration that result in instability are self-limited and can be treated through non-operative means; however, some forms may be progressive and significantly symptomatic so that patients will require surgery.     

Degenerative lumbar spinal stenosis: results of operative treatment

The results of decompressive laminectomy in 22 patients with degenerative lumbar spinal stenosis are reported. The average follow-up period was 29 months. Twelve of the 15 patients with marked stenosis (a minimum anteroposterior (a.p.) diameter of the spinal canal in extension of 10 mm or less) and all 7 patients with moderate stenosis (a minimum a.p. diameter between 11--14 mm) obtained relief from leg pain. A pseudovascular syndrome was observed in 12 of the 15 patients with marked and in 2 of the 7 patients with moderate spinal stenosis. Of these patients, 10 obtained increased (7 patients unlimited) walking distance postoperative. Vertebral fusion was not performed in any of the patients. Slight vertebral slip (2--5 mm) occurred postoperatively in 4 out of 20 patients whose follow-up examination included dynamic roentgenogram of the spine. Five of the 15 patients with marked spinal stenosis also suffered from severe osteoarthritis of the hip. Total hip replacement subsequent to laminectomy was performed in 4 patients and excellent results were achieved for both the spinal and the hip operations.     

Degenerative lumbar spinal stenosis

The aim of the study was to evaluate the long-term outcome of various surgical procedures for lumbar spinal stenosis. Operations were performed on 117 consecutive patients for lumbar spinal stenosis between 1987 and 1992. Pre- and intraoperative data were recorded in a standardized manner. Three treatment groups were distinguished: group I consisting of 39 patients submitted to undercutting decompression; group II, 51 patients, submitted to laminectomy and foraminal decompression alone; and group III, 27 patients, who underwent foraminal decompression and laminectomy with instrumented fusion. Eight years (5–10 years) after surgery a questionnaire was mailed to the patients containing the outcome scales according to Greenough and Fraser [6] and Turner et al. [22] together with questions about residual pain, necessity of treatment and satisfaction with the operative outcome. A total of 72 questionnaires (61.6%) gave enough information for analysis. After a mean follow-up of 8 years, walking capacity had increased significantly in all groups (P<0.001). Compared to preoperative values, pain had decreased significantly in all groups (P<0.01). In group I 36% had good-to-excellent outcomes, and 30.8% and 23.8% in groups II and III (P>0.05). Forty percent of group I patients were unsatisfied with the result, compared to 38.4% and 33.3% in the other groups (P>0.05). Overall, 25 of 72 patients (34.7%) had severe constant back and/or leg pain requiring daily administration of analgesics. We conclude that the long-term outcome of decompressive surgery of the lumbar spinal canal, without and with instrumented fusion, is less favourable than was previously reported. Received: 26 June 1998 / Accepted: 19 August 1998     

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.