MED椎间盘镜与开放手术治疗腰椎间盘突出症的比较

2001年5月～2003年5月,我科收治120例单间隙腰椎间盘突出症患者,分别采用MED和开放手术,笔者对疗效进行回顾性分析,比较两种治疗方法的优缺点,评价MED的临床价值。     

Lumbar diskectomy without or with spondylodesis? Revival of an old dilemma

Indications for spine fusion in combination with removal of a lumbar intervertebral disc are not as well defined or as widely accepted. Extreme opinions have been expressed on both side of this issue, but it seems unreasonable that every segment should be fused after removal of a disc or that none should be. The indication for fusion or for no fusion is often based on the specialist to whom the patient is referred. Orthopedists perform often fusion, neurosurgeons rarely. The problem is not the superiority of combined operation or simple disc excision, but the right indication for one or other procedure. It is clear that for the patient with acute disc displacement with leg-pain as the predominant symptom, simple laminectomy and disc excision will yield good results in most cases. Basically the are two indications for combined operation: the first of this is a strong history of instability troubles prior to the disc prolapse; second indication is the bilateral hemilaminectomy and discectomy, which can lead the spine quite instable. Indication for secondary spinal fusion are: 1) the presence after disc excision of complain of pain in the back with relatively little sciatic radiation, sometimes as intermittent claudication; 2) the overproduction of scar tissue is seen very often in instable segment after disc excision and partial or complete facetectomy. Decompression of the nerve root and fusion may result in a great benefit. Finally we recall the possibility to perform simple fusion in flexion without excision of the disc and without laminectomy in cases with median protrusion of the disc, seen in CT in patients with chronic low back pain and inconstant radicular pain radiation. We describe our own technic of combined operation.     

腰椎间盘摘除术硬脊膜损伤的防治对策

腰椎间盘摘除术是骨科的常施手术之一。尽管技术掌握普遍，但仍可因椎管内解剖变化、显露不清、操作不当，在手术过程中造成硬脊膜损伤，发生脑脊液漏。如果处理不当可造成严重的后果。我们总结1987—2005年手术造成硬脊膜损伤22例（含手术后发现脑脊液漏3例）患者的处理经验，取得了较好的治疗效果，现将防治对策报告如下。     

Incongruous pain in patients with spinal osteochondrosis

The article is devoted to the investigation of actual at present problem of incongruent pain in patients with spine osteochondrosis. 26 patients with congruent and 24 patients with incongruent pain, intensity and localization of which did not correspond to organic disturbances, have been examined. The results of comparison of two groups demonstrated involvement of central mechanisms, namely physiologic, in the pain syndrome formation in patients with incongruent pain. They demonstrate the necessity of differentiated approach in the treatment of the patients of the mentioned group, including psychotherapeutic measures.     

The development of discopathy in lumbar discs adjacent to a lumbar anterior interbody spondylodesis. A retrospective matched-pair study with a postoperative follow-up of 16 years.

Of 46 patients who underwent a lumbar or lumbo-sacral anterior interbody fusion at one or two levels, 16 were available for a follow-up of 16-20 years. The indications for operation were instability, degenerative disc disease, pseudarthrosis of a posterior fusion, and spondylolisthesis. Preoperative roentgenograms were compared with those made at follow-up 16 years (or more) later. In only a minority of patients was discopathy or instability found. The roentgenographic findings of the operated patients at a follow-up of at least 16 years were compared with those of a group of age- and sex-matched controls not previously treated for backache. We found that most degenerative changes of the adjacent discs occurred at a rate nearly similar to that in the corresponding levels of the controls. These results may suggest that lumbar anterior interbody spondylodesis does not accelerate the development of degenerative changes in adjacent discs.     

Anterior spinal fixation after lumbar corpectomy. A study in dogs

An animal model was developed to simulate an unstable lumbar burst fracture that had been treated with corpectomy. A fifth lumbar laminectomy, partial facetectomy, and corpectomy was performed in twenty-one dogs. In seven dogs (the control group), a biodegradable polymer spacer was used to create a definite failure of fusion (Group I). Seven dogs were treated with a traditional anterior arthrodesis with an autogenous ulnar strut and without instrumentation (Group II). The remaining seven dogs were treated with an ulnar strut and anterior Kaneda instrumentation that was of an appropriate size for the dog (Group III). At twenty-four weeks, the results were analyzed in terms of the rate of fusion, biomechanical rigidity, neuropathological findings, and histomorphometric data on the vertebral response. The rate of fusion was significantly higher in Group III, in which the Kaneda device had been used, than it was in either Group I or Group II, in which instrumentation had not been used. Biomechanically, the spines in Group III were stiffer in torsion than those in Group I or II. There was no difference between groups in terms of the number of neuropathological changes in the spinal cord. Histomorphometric analysis showed that no meaningful device-related osteopenia occurred in the vertebrae that were spanned by the fixation device. Trabecular density was increased in the vertebrae in which the instrumentation was anchored.     

改良直视下小切口微创手术与椎间盘镜及传统手术治疗腰椎间盘突出症的疗效比较

背景：近年来微创手术用于的腰椎间盘突出症手术治疗已得到了较广泛的发展,但目前采用的多数微创手术方法由于其设备昂贵、学习周期长,基层医院难以开展。本研究采用改良的直视下小切口微创髓核摘除术,为单纯腰椎间盘突出症的患者提供了新的治疗方法。 目的：比较改良的直视下小切口微创手术、椎间盘镜下及传统椎板切除手术治疗腰椎间盘突出的临床效果。 方法：回顾分析我院2002年1月至2010年7月收治的单节段腰椎间盘突出症患者143例,分为3组,分别接受改良的直视下小切口微创髓核摘除术（47例）、椎间盘镜下髓核摘除术（44例）及传统椎板切除髓核摘除术（52例）,并对各组的治疗情况和近期疗效进行比较研究。 结果：平均随访时间为：直视下小切口微创手术组425d,椎间盘镜手术组533d,传统手术组797d,采用日本骨科学会（JOA）关于下腰痛的评分标准进行疗效评定,3组患者治疗后优良率分别为：97．9％、95．5％、96．2％,治疗后平均改善率分别为：92．2％、87．6％、90．1％,组间比较无显著性差异（P〉0．05）,但在切口长度、术中出血量、术后卧床时间等方面,直视下小切口微创手术较传统手术显现了明显的优势,手术时间也较椎间盘镜组明显缩短,其差异有统计学意义（P〈0．05）。 结论：改良的直视下小切口髓核摘除术治疗腰椎间盘突出症的疗效肯定,创伤小,对脊柱正常结构的破坏轻微,患者恢复快,满意度高,而且学习曲线短、无需借助专用通道及光源等特殊手术器械,是一种值得推广的术式。     

Neurological deterioration in a patient with a spinal arteriovenous malformation following lumbar puncture. Case report

The mechanism of nonhemorrhagic neurological deterioration from spinal arteriovenous malformation (AVM) and the role of acute surgical intervention in this setting are not well understood. The case is described of a 65-year-old man who presented with a 2-year history of mild gait spasticity and vague sensory complaints affecting both lower extremities. Following a diagnostic lumbar puncture, these symptoms progressed painlessly over a 4-day period to total motor paraplegia, urinary retention, and hypesthesia in all modalities with a midthoracic sensory level. Magnetic resonance imaging showed a probable spinal AVM but no evidence of hemorrhage or cord compression. Spinal angiography confirmed the diagnosis of spinal AVM fed by radicular branches of left T-7 and T-8 segmental intercostal arteries. Drainage was via long dorsal veins caudally. Emergency laminectomy with intradural exploration was performed. There was no evidence of prior hemorrhage or focal mass effect, although the cerebrospinal fluid pressure was elevated. The dural component of the spinal AVM was excised, and its communications with the spinal cord were disconnected intradurally. Neurological function started improving within 6 hours of the patient awakening from anesthesia. He had achieved antigravity strength in every muscle group of the lower extremities by the time of discharge to a rehabilitation center 10 days after surgery. Three months postoperatively, he was ambulating with a walker and was continent of urine and stool. Possible pathophysiological mechanisms are discussed in light of the favorable response to timely surgical intervention.