椎板间隙入路椎间盘镜治疗腰椎管狭窄症

目的：探讨在椎板间隙入路椎间盘镜下有限化手术治疗退行性腰椎管狭窄症。方法：选取退行性腰椎管狭窄症病例，在椎板间隙入路椎间盘镜下行椎管有限减压。咬除病变间隙上位椎板下缘、肥厚的黄韧带和下位椎板上缘，摘除突出椎间盘髓核，松解神经根粘连，侧隐窝减压，必要时切除部分关节突。结果：应用椎板间隙入路椎间盘镜治疗迟行性腰椎管狭窄症，行椎管有限减压87例，减压彻底。82例得到随访，优良串92．7％，手术效果满意。结论：单纯腰椎间盘膨出或突出、黄韧带肥厚和小关节增生引起的退行性腰椎管狭窄症是椎板间隙入路椎间盘镜下椎管有限减压的适应证。满意的手术效果取决于：病人选择适当，术中操作精细，减压彻底。     

有限椎板切除减压治疗退行性腰椎管狭窄症

退行性腰椎管狭窄症(LSS)的治疗一般采用传统的全椎板切除减压，切除范围较大，包括棘突、双侧椎板及部分关节突等，术后易引起脊柱不稳、硬膜外广泛瘢痕粘连继发医源性椎管狭窄等腰椎术后失败综合征。自1995年9月～2001年3月应用有限的椎板切除(保留棘突、棘上韧带、棘间韧带)椎管减压治疗退行性腰椎管狭窄症61例，其中9例同时行后路内固定植骨融合术，取得了满意效果。     

腰椎管环形减压术治疗腰椎管狭窄症

目的 探讨腰椎管环形减压治疗腰椎管狭窄症的方法及疗效。方法 自病变间隙切除棘间韧带、咬除部分上、下棘突和椎板（１／４￣１／３）,切除黄韧带,两侧小关节突内缘有限切除（〈１／３）。前方凿除骨性凸起及摘除突出髓核。结果 ２０例经１年￣１年５个月随访,疗效均为优。结论 腰椎管环形减压即可对腰椎管狭窄进行减压,又可减少对腰椎稳定性的影响。     

后路椎间盘镜在治疗腰椎管狭窄症中的应用

目的：探讨后路椎间盘镜在治疗腰椎管狭窄症中的应用。方法：2000年2月--2001年12月退行性腰椎管狭窄症142例行后路椎间盘镜下椎管有限减压、全椎板或半椎板切除减压、开窗减压术。结果：应用后路椎间盘镜行椎管有限减压87例，减压松解充分。82例随访平均18月，优良率92．7％(优58例，良18例)。无并发症。结论：单纯腰椎间盘膨出或突出、黄韧带肥厚和小关节增生引起的退行性腰椎管狭窄症是后路椎间盘镜下椎管有限减压的适应证。满意的手术效果取决于：病人选择适当，术中操作精细，减压彻底。     

有限椎板切除减压治疗退行性腰椎管狭窄症

退行性腰椎管狭窄症 (LSS)的治疗一般采用传统的全椎板切除减压 ,切除范围较大 ,包括棘突、双侧椎板及部分关节突等 ,术后易引起脊柱不稳、硬膜外广泛瘢痕粘连继发医源性椎管狭窄等腰椎术后失败综合征。自 1 995年 9月～2 0 0 1年 3月应用有限的椎板切除 (保留棘突、棘上韧带、棘间韧带 )椎管减压治疗退行性腰椎管狭窄症 6 1例 ,其中 9例同时行后路内固定植骨融合术 ,取得了满意效果。1　临床资料1 1　一般资料　本组 6 1例 ,男 2 8例 ,女 33例。年龄 4 1～70岁 ,平均 5 6岁。有腰痛及单侧或双侧下肢神经性间歇性跛行者 32例 ,单纯间歇性…     

老年性腰椎管狭窄症的外科治疗

目的：探讨６０岁以上老年性腰椎管狭窄症外科治疗的方法及疗效。方法：自病变间隙切除棘间韧带,咬除部分上、下棘突和椎板（１／４～１／３）,切除黄韧带,两侧小关节突内缘有限切除（＜１／３）,前方凿除骨性凸起及摘除突出髓核,伴腰椎不稳者,行保留的上、下棘突劈开自体髂骨植入植骨。结果：２０例经１２～１８个月随访,疗效均达优。结论：腰椎管环形减压术治疗老年性腰椎管狭窄,目的性强,减压较彻底,对腰椎稳定性影响小。     

椎板部分切除和椎管扩大治疗腰椎管狭窄症

作者采用椎板部分切除、黄韧带切除和椎管扩大术治疗３８例腰椎椎管狭窄症。本法根据腰椎管狭窄症的病变特点，施行病变节段有限外科手术，直接切除导致狭窄的病理因素，既可获得减压作用又能保持腰椎的稳定。平均随访１４个月，优良率为８９．５％（３４／３８）。     

关节突旁节段性开窗治疗退行性腰椎管狭窄症

目的 为使脊柱后部结构得到较大程度保留,又达到减压目的,作者用关节突旁节段性开窗治疗退行性腰椎管狭窄症患者２６例。方法 于确定的狭窄节段一侧或二侧,切除关节突的内侧半。肥厚的黄韧带及邻近部分椎板。清除所有导致神经受压的因素。但保留棘突,棘间韧带、大部分关节突及椎板。结果 ２３例获得６月至６年９个月随访（平均２年３个月）。手术优良率达９１．３％。无一例加重和发生椎体滑脱。结论 对于治疗以侧隐窝狭窄为     

后路椎间盘镜显微治疗腰椎椎管狭窄症

目的 报道显微后路椎间盘镜治疗退行性腰椎椎管狭窄症的临床效果。方法 选取退行性腰椎管狭窄症病例，椎板间隙入路椎间盘镜下行椎管减压，单侧单节段开窗减压23例，双侧单节段开窗减压12例，单侧双节段开窗减压9例，单侧双节段半椎板切除减压4例。结果 除1例术中硬膜破裂改常规手术外，其余病例均在手术显微镜下完成腰椎管减压术。所有病例获得5～18个月随访，平均8．3个月，优良率92％。结论 显微后路椎间盘镜治疗退行性腰椎管狭窄症具有手术创伤小、神经根减压彻底、术后恢复快的特点；单纯腰椎间盘膨出或突出、黄韧带肥厚和小关节增生引起的退行性腰椎管狭窄症是其适应证。     

胸椎黄韧带骨化症的诊断与治疗

目的总结胸椎黄韧带骨化症（TOLF）的临床特点，手术方法及疗效，提高治疗效果。方法回顾性分析37例经过手术治疗的胸椎黄韧带骨化症患者的临床资料，其中30例行后路半关节突全椎板切除减压术，7例行后路半关节突全椎板切除加前路经胸腔侧前方椎管减压椎间盘切除及植骨融合内固定术。结果37例患者全部获得随访，随访时间6～78个月，平均38个月，疗效参照Epstein标准，优21例、良10例、改善5例、差1例。优良率83．78％。结论胸椎黄韧带骨化症一旦确诊，尽快手术治疗是唯一选择，手术可获得满意的疗效，手术疗效与脊髓损伤程度和病程长短有关。     

Surgical management of lumbar spinal stenosis

Eighty consecutive patients with lumbar spinal stenosis surgically treated during a 5-year period by the author were reviewed. Patients were placed in the following categories: lateral spinal stenosis (10), central-mixed stenosis (29), spinal stenosis after laminectomy and/or fusion (32), and spinal stenosis with degenerative scoliosis (9). Contrast-enhanced computed tomographic (CT) scans were helpful in determining the levels requiring decompression. However, in the multiply operated patient, contrast-enhanced CT scans were misleading in six patients. Patients with lateral spinal stenosis were treated with unilateral laminectomy and partial facetectomy. The 29 patients with central-mixed stenosis underwent decompressive laminectomy and bilateral facetectomies. Six fusions were done. In the nine patients with spinal stenosis and scoliosis, concaveside partial facetectomies and laminectomies were done as well as spinal fusions. The 32 patients with spinal stenosis after previous laminectomy and spinal fusions were the most difficult group to analyze, and their treatment was the least standardized. There were 19 good, eight fair, and five poor results in those who had undergone previous surgery. Fifty-seven of the 80 patients (71%) experienced a good result from their surgical treatment.     

A pilot safety and efficacy study of OP-1 putty (rhBMP-7) as an adjunct to iliac crest autograft in posterolateral lumbar fusions

The ability of bone morphogenetic proteins (BMPs) to induce bone formation has led to an increasing interest in the potential for their use in fusion surgery. The purpose of this multi-center clinical pilot study was to evaluate the safety of one such BMP—osteogenic protein 1, in the form of OP-1 putty—combined with autograft for intertransverse process fusion of the lumbar spine in patients with symptomatic spinal stenosis and degenerative spondylolisthesis following spinal decompression. Twelve patients with spinal stenosis and degenerative lumbar spondylolisthesis underwent laminectomy and partial or complete medial facetectomy as required for decompression of the neural elements followed by intertransverse process fusion by placing iliac crest autograft and OP-1 putty between the decorticated transverse processes. No instrumentation was used. Patients were followed clinically using the Oswestry scale and radiographically using static and dynamic radiographs to assess their fusion status. Independent and blinded radiologists assessed the films for the presence of bridging bone between the transverse processes and measured translation and angulation on dynamic films using digital calipers. In addition to bridging bone, less than or equal to 5° of angular motion and less than or equal to 2 mm of translation were required to classify the patients as successfully fused, as per the definition of successful fusion provided by the FDA for use in clinical trials involving investigational devices to attain spinal fusion. Radiographic outcome was compared to a historical control (autograft alone fusion without instrumentation for the treatment of degenerative spondylolisthesis). All adverse events were recorded prospectively. The results showed 9 of the 12 patients (75%) obtained at least a 20% improvement in their preoperative Oswestry score, while 6 of 11 patients (55%) with radiographic follow-up achieved a solid fusion by the criteria used in this study. Bridging bone on the anteroposterior film was observed in 10 of the 11 patients (91%). No systemic toxicity, ectopic bone formation, recurrent stenosis or other adverse events related to the OP-1 putty implant were observed. A successful fusion was observed in slightly over half the patients in this study, using stringent criteria without adjunctive spinal instrumentation. This study did not demonstrate the superiority of OP-1 combined with autograft over an autograft alone historical control, in which the fusion rate was approximately 45%. The lack of adverse events related to the OP-1 putty implant in this study is in agreement with other studies supporting the safety of bone morphogenetic proteins in spinal surgery.     

Anterior shear strength of the porcine lumbar spine after laminectomy and partial facetectomy

Degenerative lumbar spinal stenosis is the most common reason for lumbar surgery in patients in the age of 65 years and older. The standard surgical management is decompression of the spinal canal by laminectomy and partial facetectomy. The effect of this procedure on the shear strength of the spine has not yet been investigated in vitro. In the present study we determined the ultimate shear force to failure, the displacement and the shear stiffness after performing a laminectomy and a partial facetectomy. Eight lumbar spines of domestic pigs (7 months old) were sectioned to obtain eight L2–L3 and eight L4–L5 motion segments. All segments were loaded with a compression force of 1,600 N. In half of the 16 motion segments a laminectomy and a 50% partial facetectomy were applied. The median ultimate shear force to failure with laminectomy and partial facetectomy was 1,645 N (range 1,066–1,985) which was significantly smaller (p = 0.012) than the ultimate shear force to failure of the control segments (median 2,113, range 1,338–2,659). The median shear stiffness was 197.4 N/mm (range 119.2–216.7) with laminectomy and partial facetectomy which was significantly (p = 0.036) smaller than the stiffness of the control specimens (median 216.5, 188.1–250.2). It was concluded that laminectomy and partial facetectomy resulted in 22% reduction in ultimate shear force to failure and 9% reduction in shear stiffness. Although relatively small, these effects may explain why patients have an increased risk of sustaining shear force related vertebral fractures after spinal decompression surgery.     

A 2-year follow-up pilot study evaluating the safety and efficacy of op-1 putty (rhbmp-7) as an adjunct to iliac crest autograft in posterolateral lumbar fusions

The ability of bone morphogenetic proteins (BMPs) to induce bone formation has led to a multitude of investigations into their use as bone graft substitutes in spinal surgery. The purpose of this multi-center clinical pilot study was to evaluate the safety and efficacy of BMP-7 (osteogenic protein 1, OP-1), in the form of a putty, combined with autograft for intertransverse process fusion of the lumbar spine in patients with symptomatic spinal stenosis and degenerative spondylolisthesis following spinal decompression. Twelve patients with spinal stenosis and degenerative lumbar spondylolisthesis underwent a laminectomy and partial or complete medial facetectomy as required for decompression of the neural elements, followed by an intertransverse process fusion by placing iliac crest autograft and OP-1 putty between the decorticated transverse processes. No instrumentation was used. Patients were followed clinically using the Oswestry scale and SF-36 outcome forms, and radiographically using static and dynamic radiographs to assess their fusion status over a 2-year period. Independent and blinded radiologists assessed the films for the presence of bridging bone between the transverse processes and measured translation and angulation on dynamic films using digital calipers. Radiographic outcome was compared to a historical control (autograft alone fusion without instrumentation for the treatment of degenerative spondylolisthesis). All adverse events were recorded prospectively. The results showed eight of the nine evaluable patients (89%) obtained at least a 20% improvement in their preoperative Oswestry score, while five of ten patients (50%) with radiographic follow-up achieved a solid fusion by the criteria used in this study. Bridging bone on the anteroposterior film was observed in seven of the ten patients (70%). No systemic toxicity, ectopic bone formation, recurrent stenosis or other adverse events related to the OP-1 putty implant were observed. A successful fusion was observed in slightly over half the patients in this study, using stringent criteria without adjunctive spinal instrumentation. This study did not demonstrate the statistical superiority of OP-1 combined with autograft over an autograft alone historical control, in which the fusion rate was 45%. There were no adverse events related to the OP-1 putty implant in this study, which supports findings in other studies suggesting the safety of bone morphogenetic proteins in spinal surgery.     

Extensive postoperative epidural hematoma after full anticoagulation: case report and review of the literature

BACKGROUND/OBJECTIVE: A 67-year-old man with degenerative lumbar spinal stenosis and a medical history significant for coronary artery disease underwent routine lumbar surgical decompression. The objective of this study was to report a case of postoperative epidural hematoma associated with the use of emergent anticoagulation, including the dangers associated with spinal decompression and early postoperative anticoagulation. METHODS: Case report. FINDINGS: After anticoagulation therapy for postoperative myocardial ischemia, the patient developed paresis with ascending abdominal paraesthesias. Immediate decompression of the surgical wound was carried out at the bedside. Magnetic resonance imaging revealed a massive spinal epidural hematoma extending from the middle of the cervical spine to the sacrum. Emergent cervical, thoracic, and revision lumbar laminectomy without fusion was performed to decompress the spinal canal and evacuate the hematoma. RESULTS: Motor and sensory function returned to normal by 14 days postoperatively, but bowel and bladder function continued to be impaired. Postoperative radiographs showed that coronal and sagittal spinal alignment did not change significantly after extensive laminectomy. CONCLUSIONS: Full anticoagulation should be avoided in the early postoperative period. In cases requiring early vigorous anticoagulation, patients should be closely monitored for changes in neurologic status. Combined cervical, thoracic, and lumbar laminectomy, without instrumentation or fusion, is an acceptable treatment option.     

伴有侧凸畸形的腰椎管狭窄症的外科治疗

目的总结后路一期减压、内固定、融合手术治疗伴有腰椎侧凸畸形的腰椎管狭窄症患者的效果。方法自1998年1月-2005年10月,治疗伴有腰椎侧凸畸形的腰椎管狭窄症患者38例,腰椎侧凸畸形角度平均31°,术前 JOA评分平均11分,均采用腰椎后路一期减压、矫形、内固定、融合治疗。结果 32例得到随访,随访时间1-4年,平均2．5年,矫正角度平均13°。矫正角度丧失1°-5°,平均3°。截骨融合率100％。随访时JOA评分平均23分,患者对手术效果满意。结论后路一期减压、内固定、融合手术是治疗伴有腰椎侧凸畸形的腰椎管狭窄症的有效手段。     

Surgical management of lumbar degenerative spinal stenosis with spondylolisthesis via posterior reduction with minimal laminectomy

Degenerative lumbar spondylolisthesis with spinal stenosis is commonly treated with laminectomy. Recent reports have consistently supported the incremental clinical benefit of associated in situ arthrodesis with or without instrumentation. Resection of the lamina may result in intraoperative dural tear or epidural scar formation. Fifty-six consecutive patients with back pain, neuroclaudication, or both, in addition to degenerative spondylolisthesis with spinal stenosis, underwent a surgical procedure that incorporated fusion after reduction of the spondylolisthesis deformity with preservation of the lamina and the balance of the posterior elements. Clinical records were reviewed and patients interviewed at a mean of 33 months after surgery. Oswestry Disability Index scores were obtained independently at baseline and at a late review. Late imaging was available a mean of 28 months after operation. Clinical and imaging analyses and Oswestry scoring confirmed results comparable to the published outcomes of in situ fusion after formal laminectomy. Resection of the lamina may not be necessary in the treatment of degenerative lumbar spinal stenosis with spondylolisthesis.     

Usefulness of Posner's definition of spinal instability for selection of surgical treatment for lumbar spinal stenosis

The aim of this study was to determine the usefulness of Posner's definition of spinal instability for selection of surgical therapy for lumbar spinal stenosis. Sixty patients with lumbar spinal stenosis were studied. Thirty-three patients were found to have instability, as defined using Posner's method. Nineteen of the 33 patients with instability underwent decompression and instrumented fusion. The 14 remaining patients with instability underwent decompression alone. Twenty-seven patients without instability were treated by decompression alone. Patients treated by decompression and fusion obtained the best results. Good results also could be obtained by decompression alone only if patients did not have instability. However, patients treated by decompression alone in the presence of instability had the worst results. The Posner's definition of instability proved useful for selecting patients with instability for fusion treatment.     

Technique for lumbar decompression of spinal stenosis

This article presents a technique for lumbar laminectomy and decompression in patients suffering from acquiredlumbar spinal stenosis. The technique is discussed in detail and illustrated accordingly. The discussion reviewed a “typical” L3 to S1 (ie, L3-4, L4-5, and L5-S1) lumbar laminectomy without fusion.     

Rationale for spinal fusion in lumbar spinal stenosis

In order to define the indications for spinal fusion in patients undergoing decompression for lumbar spinal stenosis, 114 patients surgically treated were reviewed. Follow-up was 24 to 108 months. Patients were grouped into four categories: 15 with lateral recess stenosis, 45 with central-mixed stenosis, 43 with stenosis following prior lumbar surgery(s), and 11 with scoliosis and spinal stenosis. Only two patients with lateral recess stenosis underwent fusion with fair results. Approximately one-third of those with central-mixed stenosis required a fusion. Results were good in 70%. In those with stenosis following prior lumbar surgeries, although not statistically significant, those who had concomitant decompression and arthrodesis had a better outcome than those in whom decompression only was done. Patients with scoliosis and stenosis had decompression for significant motor and reflex deficits and fusion over the length of their major curves. Patients having decompression for lumbar stenosis with degenerative spondylolisthesis, isolated disc resorption with degenerative facet joints, intervertebral disc disease with instability, and those with scoliosis with multidirectional instabilities benefit from concomitant spinal fusion.