显微镜下精准减压术治疗退变性腰椎管狭窄症

[目的]对比显微镜下精准减压术(microscope- assisted precise decompression,MPD)与传统椎板切除减压术(traditional laminectomy decompression,TLD)治疗单节段退变性腰椎管狭窄症(degenerative lumbar spinal stenosis,DLSS)的临床效果,评估MPD治疗DLSS的可行性.[方法]回顾分析2007年3月～2009年3月本院收治的82例单节段DLSS患者,其中采取TLD治疗43例,采取MPD治疗39例.比较两种手术方法的手术时间、术中出血量、术后引流量、切口长度、术后3d内最高体温以及术后外周血的白细胞和C反应蛋白的动态变化.采用ODI和VAS评价临床治疗效果.[结果]两组的手术时间无显著性差异(P＞0.05).与TLD组相比,MPD组术中出血量和术后引流量更少、切口更小、术后3d内的最高体温较低、以及术后24 h外周血的白细胞和C反应蛋白的平均值较低,差异有显著性(P＜0.01).在VAS和ODI评分方面,两组术后6个月和末次随访时均较术前明显改善(P＜0.01),术后6个月两组间的比较无显著性差异(P＞0.05),而末次随访时MPD组优于TLD组(P＜0.01).末次随访时,TLD组优18例,良15例,可7例,差3例,优良率为76.7％;MPD组优27例,良9例,可3例,差0例,优良率92.3％,MPD组的临床疗效优于TLD组(P＜0.05).末次随访时,11例TLD及3例MPD患者出现手术节段失稳,TLD手术节段失稳发生率高于MPD组(P＜0.05).[结论]短期内,两种方法治疗单节段DLSS均可获得充分的减压及良好的临床效果;与TLD相比,MPD具有术中出血量和术后引流量少、手术切口小、术后全身炎性反应轻、手术对腰椎稳定性负面影响小以及远期的临床疗效更好的优势.     

腰椎管狭窄症伴不稳定性腰椎退变性滑脱的手术治疗

目的　探讨腰椎管狭窄伴不稳定性腰椎退变性滑脱的手术治疗疗效。　方法　回顾性分析 86例腰椎管狭窄伴不稳定性腰椎退变滑脱的手术治疗结果 ,其中男 30例 ,女 5 6例 ,年龄 30～ 77岁 ,平均 5 5 8岁 ,腰痛合并双侧下肢痛 6 3例 ,单侧下肢痛 10例 ;单纯腰痛 13例 ,其中 72例主诉间歇性跛行 ,出现跛行的行走距离 10～ 10 0 0m ,32例合并有足部感觉、运动及反射的改变。本组病例均并存病变节段的腰椎动力性腰椎不稳 ,滑脱Ⅰ° 79例 ,Ⅱ° 7例。术前CT检查 5 6例 ,MRI检查 2 4例 ,MRM检查 6例 ,术前同时行脊髓造影 6 1例 ,CTM检查 12例。狭窄并滑脱的节段 :L4 549例 ,L3 46例 ,L5 S12 5例 ,L3 4、L4 52例 ,L3 S14例。单纯侧隐窝狭窄 10例 ,双侧侧隐窝狭窄 2 2例 ,中央椎管狭窄 5 4例 ;合并椎间盘突出 12例。所有的患者均经手术减压、植骨融合及不同的内固定治疗。　结果　患者均经 8个月～ 13年的随访 ,其中随访 1年以上者 81例 (平均 5 6年 )。本组优 78例 ,良 5例 ,可 3例。滑脱完全复位Ⅰ° 70例 (89 9% ) ,Ⅱ° 6例 (85 7% )。随访过程中无滑脱加重患者 ,3个月内植骨融合者 74例 ,6个月内植骨融合 10例 ,出现假关节 2例。术后发生内固定断裂 1例 ,晚发感染 1例。结论　减压和脊柱固定可改善腰椎管     

椎板开窗潜行减压术治疗腰椎管狭窄症

目的探讨椎板开窗潜行减压术治疗腰椎管狭窄症的疗效。方法采用单节段或多节段椎板间隙开窗潜行减压加神经根管减压治疗腰椎管狭窄症患者50例。结果疗效参照JOA分级标准评定,术后对45例获得随访,平均3.1年,优27例,良13例,可4例,差1例,手术优良率88.8%。结论该术式保留了棘突、棘上韧带、棘间韧带及部分椎板,关节突,最大限度地保留了腰椎稳定性,避免了因手术瘢痕粘连和骨化造成的医源性的椎管狭窄,术后疗效确实可靠。     

椎板间开窗潜行减压治疗退行性腰椎管狭窄症

行椎板间开窗潜行减压治疗退行性腰椎管狭窄症１１５例,年龄５４．２岁,病程平均３年９个月脸部病人都有腰痛和一侧或两侧下肢痛及麻木,无题有间歇性跛行。除Ｘ线平片外,ＣＴ、ＣＴＭ和／或ＭＲＩ检查１０１例,椎管造影２４例。其中伴椎间盘突出７例,狭窄段位于Ｌ４．５４９例,Ｌ５Ｓ１２５例,Ｌ３,４３例,两个节段２６例三个节段（Ｌ３,４,Ｌ４,５,Ｌ５Ｓ１）１２例,术后复查ＣＴ／ＭＲＩ５９。结果８４例获得随访,     

退行性腰椎滑脱伴腰椎管狭症的手术治疗

目的探讨退变性腰椎滑脱伴椎管狭窄症的手术治疗。方法回顾性分析 84例退变性腰椎滑脱伴腰椎管狭窄症的手术治疗结果。其中男性 33例 ,女 5 1例 ;年龄 4 3～ 79岁 ,平均 5 6 .1岁 ;包括Ⅰ°滑脱 5 1例 ,Ⅱ°滑脱 33例。33例接受单侧或双侧椎板开窗减压术 ,5 1例接受全椎板切除减压、植骨融合椎弓根螺钉内固定术。结果 84例经过平均 5年 3个月的随访 ,两种手术方法疗效优良率分别是 90 .90 %、84 .2 7% ,两种疗效无显著性差别 (P >0 .0 5 )。手术并发症发生率为 9.0 9%、17.6 4 % ,亦无显著性差异 (P >0 .0 5 )。结论对于腰椎管狭窄症伴腰椎滑脱症手术适应症和减压范围要掌握恰当 ,二种手术方式减压均可以取得满意疗效。     

腰椎管狭窄症椎板减压后对脊椎稳定影响的临床分析

自１９８８年２月～１９９４年５月采用椎板减压术治疗腰椎管狭窄症４８例，对得到随访的４６例进行回顾性分析。１４例合并退变性脊椎滑脱中的４例术后原有滑脱程度增加，３２例术前无滑脱中２例术后发生滑脱。但术后症状均有改善，手术效果同无滑脱组相比无明显差别。本文讨论了术后腰椎滑脱的原因。认为对腰椎管狭窄症做充分后路减压的同时应尽量保留外侧半小关节，常规的植骨融合术意义不大。     

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。     

经皮椎板间入路内窥镜下减压治疗退变性腰椎管狭窄症的疗效分析

目的 :评估经皮椎板间入路内窥镜下减压治疗退变性腰椎管狭窄症的临床疗效。方法 :2014年1月~2014年12月采用经皮椎板间入路内窥镜下减压治疗退变性腰椎管狭窄症126例,男82例,女44例;年龄46~83岁(65.8±12.4岁)。L4-5节段狭窄73例,L5-S1节段狭窄53例。术前和术后随访时采用疼痛视觉模拟评分(visual analogue scale,VAS)、Oswestry功能障碍指数(Oswestry disability index,ODI)对患者进行评估,改良Mac Nab评价临床疗效。结果 :126例患者手术均顺利完成,手术时间48~75min(61.4±11.4min),术中透视2~4次(2.4±0.3次),手术切口长约7mm,住院时间3~4d(3.2±0.2d)。术中均未发生硬膜囊撕裂、神经根损伤等并发症。随访24~30个月(26.5±2.1个月),术前和术后1d、1个月、3个月、6个月、12个月、24个月时的腰痛VAS评分分别为4.80±1.46分和3.21±0.75分、1.88±1.15分、1.81±1.05分、0.63±0.62分、0.25±0.15分、0.28±0.12分;腿痛VAS评分分别为7.88±0.81分和2.88±1.45分、2.13±1.02分、1.38±0.62分、0.88±0.62分、0.81±0.54分、0.82±0.23分;术前和术后1个月、3个月、6个月、12个月、24个月时的ODI分别为67.63±9.91和38.4±10.46、26.75±6.88、13.81±5.95、9.19±6.04、9.22±4.56。术后腰腿痛VAS评分及ODI评分与术前比较均有统计学差异(P0.05)。术后24个月时改良Mac Nab评价疗效优89例,良25例,可12例,优良率为90.5%。结论:经皮椎板间入路内窥镜下减压治疗退变性腰椎管狭窄症创伤小,术中透视少,减压精准彻底,术后恢复快,近期疗效好。     

减压后原位固定融合治疗退变性腰椎管狭窄症

目的 探讨减压后原位固定融合治疗退变性腰椎管狭窄症的方法及疗效.方法 利用后路椎管狭窄节段减压,椎弓根螺钉系统原位固定,自体髂骨椎间植骨治疗52例退变性腰椎管狭窄症.结果 术后随访48例,下肢症状完全缓解者46例(95.83%),腰痛完全缓解者41例(85.42%).随机抽取10例术后1年以上患者行CT三维重建,示椎间植骨均骨性融合.结论 退变性腰椎管狭窄症,减压后原位固定,椎间植骨融合,既可以解除神经根的压迫,又可解决因关节突关节退变而引发的腰痛.     

单纯椎板减压治疗退变性椎管狭窄症并腰椎侧凸的疗效及其影响因素

目的：探讨单纯椎板减压治疗退变性椎管狭窄症并腰椎侧凸的效果及其影响因素。方法：1996年-2000年我科收治的资料完整的退变性椎管狭窄症合并腰椎侧凸患者57例，均采用单纯腰椎椎板减压术治疗。使用JOA评分标准进行疗效评价，根据JOA评分恢复率（recoverrate，RR）将患者分为效果满意组（RR≥50％）和效果不满意组（RR〈50％），对腰椎前凸角、侧凸角、腰椎活动度以及L4椎体倾斜率和侧向位移等影像学参数与l临床治疗效果的关系进行统计分析。结果：本组随访3～7年，平均5．1年，效果满意者42例，不满意者15例，统计分析显示腰椎前凸、活动度、L4椎体的倾斜率和手术减压节段对手术效果有显著影响（P〈0．05），与效果不满意组相比，疗效满意组患者术前腰椎前凸小，活动度低，L4椎体倾斜率不明显，需要手术减压的节段少。结论：对腰椎前凸较小、活动度低和L4椎体倾斜率较小的椎管狭窄症合并腰椎侧凸的患者使用短节段全椎板减压可以获得满意的疗效。     

Results of surgical treatment for lumbar canal stenosis due to degenerative spondylolisthesis: enlargement of the lumbar spinal canal

The purpose of this retrospective study was to analyze clinical results and radiographic findings in patients who underwent surgical enlargement of the lumbar spinal canal combined with resection of the posterosuperior margin underneath the slipping vertebral body for the treatment of lumbar canal stenosis due to degenerative spondylolisthesis. A series of 64 patients who were observed for 3 years or more after operation were examined. The mean age at the time of operation was 64.2 years. The follow-up period was 3–17 years. The Japanese Orthopaedic Association (JOA) score increased from 14.9 points before operation to 25.4 points at the time of the study on average. The general improvement rate was 75.6%. The height and range of motion of the enlarged intervertebral disc were mildly to moderately decreased, and it was found there was a small effect on the adjacent intervertebral disc. On computed tomography, the total level of the enlarged region of the posterosuperior margin increased from 184.4mm² to 339.1mm² on average, but the area of the resected region was 163.3mm² and accounted for 48% of the postoperative area of the spinal canal in the posterosuperior margin. This enlargement of the spinal canal was maintained along the dural canal, and physiological morphology was established. By surgically enlarging the lumbar spinal canal combined with resecting the posterosuperior margin underneath the slipping vertebral body, concomitant repositioning or spinal fixation was unnecessary.     

后路综合手术治疗腰椎退变性滑脱并椎管狭窄

目的 探讨后路综合手术治疗腰椎退变性滑脱并椎管狭窄(DLSSS)的手术方法和疗效。方法 对47例均采取后路充分减压,植骨融合及经椎弓根复位固定综合性手术治疗。平均随访32个月,进行临床功能和影像学评价。结果 临床功能评价优良率87％(41/47);椎体滑移复位率96％(45/47);退变畸形矫正率91％(43/47);植骨融合率96％(45/47)。内固定松动率4％(2/47),一过性腰腿痛发生率34％(16/47)。结论 应用上述综合手术治疗DLSSS可同时解除神经卡压,矫正畸形和稳定脊柱,从而能够达到多症兼治的治疗目的。     

Union versus nonunion after posterolateral lumbar fusion: a comparison of long-term surgical outcomes in patients with degenerative lumbar spondylolisthesis

It has been reported that in patients undergoing posterolateral lumbar fusion (PLF), the fusion status is not related to the short-term operative results. To determine whether the fusion status influences the long-term operative results of PLF, we retrospectively examined the surgical outcomes of uninstrumented PLF for a minimum of 8 years (average, 9.5 years), by comparing cases exhibiting union with those exhibiting nonunion. Uninstrumented PLF was performed for the treatment of lumbar canal stenosis (LCS) with degenerative spondylolisthesis. Since nine patients were lost to final follow-up, the study included 42 patients, and the follow-up rate was 82.4%. The mean age of the patients was 64.1 years (range 46–77 years). Eight patients exhibited fusion at the L3–4 level and 34 patients, at the L4–5 level. The fusion status was assessed using plain radiographs. The clinical outcomes were evaluated using the Japanese Orthopaedic Association (JOA) scores. Nonunion was noted in 26% (11/42) of the patients. There were no statistically significant differences between the groups exhibiting union and nonunion with respect to age, sex, preoperative JOA score, or preoperative lumbar instability. The union group achieved better operative results than the nonunion group at the 5-year and final follow-up (P = 0.006 and 0.008, respectively) although there was no significant difference in the percent recovery at 1 and 3-year follow-up (P = 0.515 and 0.506, respectively). A stepwise regression analysis revealed that the best combination of predictors for percent recovery at the time of final follow-up included the fusion status and the presence of comorbid disease. The results indicate that the fusion status following PLF is a critical factor influencing the long-term but not short-term operative results in the treatment of LCS with degenerative spondylolisthesis.     

老年退行性腰椎管狭窄症的手术疗效分析

目的:探讨老年退行性腰椎管狭窄症患者减压手术的疗效。方法:1997年1月～2003年12月收治的70岁以上且获得2～6年随访的退行性腰椎管狭窄症患者106例,男49例,女57例;年龄70～82岁,平均76.3岁;病史4～10年,平均6.7年。42例并存1种内科疾病,55例并存两种或以上的内科疾病。均经过正规保守治疗无效。术前联合内科诊治并存的内科疾病。95例行单纯全椎板切除减压术;11例采用椎板减压、椎弓根固定、椎间植骨融合术,对手术疗效进行回顾性分析。结果:无围手术期死亡病例。出现并发症22例次,经对症及内科联合处理后好转。单纯减压组术后3周配戴腰围下床活动;内固定组术后3～5d下床活动。平均随访3年10个月,Oswestry评分从术前59.64±11.07分改善至16.81±7.36分。所有患者连续行走从术前不足15min改善到至少30min。95.2%患者自诉生活质量明显提高。结论:老年退行性腰椎管狭窄症患者在积极控制并存内科疾病的基础上,手术减压治疗对神经功能的恢复有重要作用,可获得较满意的临床疗效。     

High failure rate of the interspinous distraction device (X-Stop) for the treatment of lumbar spinal stenosis caused by degenerative spondylolisthesis

The X-Stop interspinous distraction device has shown to be an attractive alternative to conventional surgical procedures in the treatment of symptomatic degenerative lumbar spinal stenosis. However, the effectiveness of the X-Stop in symptomatic degenerative lumbar spinal stenosis caused by degenerative spondylolisthesis is not known. A cohort of 12 consecutive patients with symptomatic lumbar spinal stenosis caused by degenerative spondylolisthesis were treated with the X-Stop interspinous distraction device. All patients had low back pain, neurogenic claudication and radiculopathy. Pre-operative radiographs revealed an average slip of 19.6%. MRI of the lumbosacral spine showed a severe stenosis. In ten patients, the X-Stop was placed at the L4–5 level, whereas two patients were treated at both, L3–4 and L4–5 level. The mean follow-up was 30.3 months. In eight patients a complete relief of symptoms was observed post-operatively, whereas the remaining 4 patients experienced no relief of symptoms. Recurrence of pain, neurogenic claudication, and worsening of neurological symptoms was observed in three patients within 24 months. Post-operative radiographs and MRI did not show any changes in the percentage of slip or spinal dimensions. Finally, secondary surgical treatment by decompression with posterolateral fusion was performed in seven patients (58%) within 24 months. In conclusion, the X-Stop interspinous distraction device showed an extremely high failure rate, defined as surgical re-intervention, after short term follow-up in patients with spinal stenosis caused by degenerative spondylolisthesis. We do not recommend the X-Stop for the treatment of spinal stenosis complicating degenerative spondylolisthesis.     

腰椎管狭窄症伴退变性腰椎侧凸患者的影像学表现与临床特点

目的观察伴退变性腰椎侧凸的腰椎管狭窄症患者的临床特点和影像学表现.方法将2004年1月至2005年10月我院收治的44例需手术治疗的伴退变性腰椎侧凸的腰椎管狭窄症患者作为侧凸组,同时随机抽取44例单纯腰椎管狭窄症患者作为对照组.两组患者均拍摄包括胸腰段在内的腰椎正侧位X线片,侧凸组患者加拍全脊柱X线片,两组均测量腰椎前凸角和胸腰段后凸角,侧凸组还测量侧凸Cobb角、顶椎偏离度、侧凸范围内椎体最大侧方滑移度等参数;同时对两组患者进行腰痛程度评级、神经功能JOA 29分法评分及骨密度测量.结果侧凸组患者的平均侧凸Cobb角为17.03°,顶椎偏离度平均为0.31,有25例患者出现侧凸范围内椎体侧向滑移.侧凸组患者腰椎前凸角为19.30°±12.49°,胸腰段后凸角为7.73°±5.16°,对照组分别为20.85°±11.73°和8.73°±6.09°,两组之间无显著性差异(P＞0.1).18例侧凸组和23例对照组患者的平均骨密度值分别为-3.22±2.82和-0.03±2.18,差异有显著性(P＜0.05).侧凸组和对照组的JOA评分分别为11.54±3.78分和12.52±3.67分,无显著性差异(P＞0.1).侧凸组患者明显腰痛占81.8%,对照组患者明显腰痛占52.3%,差异有显著性(P＜0.01).结论腰椎退变性侧凸可以加重腰椎管狭窄症患者的腰痛症状,但对神经功能无明显影响.     

退行性多节段腰椎管狭窄症定位诊断

目的 :探讨退行性多节段腰椎管狭窄症术前定位诊断准确方法 ,以减少手术对后柱的创伤。方法 :回顾分析退行性腰椎管狭窄症 68例患者术前定位、术中所见以及术后疗效。结果 :退行性腰椎管狭窄症临床表现复杂 ,定位诊断较易出现错误与遗漏。结论 :病史采集分析、影像检查的选择与临床症状、体征相结合是准确定位诊断的关键。     

椎板复合体回植重建椎管前后融合内固定治疗腰椎滑移伴椎管狭窄

腰椎滑移常见的有峡部裂型及腰椎退变型,虽然大部分可以经过保守治疗获得满意的疗效,但仍有部分患者经保守治疗无效而需手术治疗,目前手术方法主要有前路减压融合、后路椎弓根螺钉内固定加植骨融合术。我院近15年来采用椎板复合体重建椎管、前后融合加内固定治疗56例腰椎滑移伴椎管狭窄患者,疗效满意,现作一回顾分析。