腰椎侧隐窝狭窄症诊治体会(附23例报告)

随着CT扫描及MRI技术的应用,人们对腰椎管狭窄症的认识更加深入,并按解剖部位进一步将其分为中央椎管狭窄和侧椎管狭窄（侧隐窝狭窄）。侧隐窝狭窄临床上较常见,自1989年1月-2003年12月我科收治腰椎侧隐窝狭窄症23例,报道如下。     

经皮椎板间隙入路270°椎管减压治疗腰椎管狭窄症

[目的]探讨经皮椎板间隙入路的椎管减压技术治疗伴有双侧侧隐窝狭窄的腰椎管狭窄症临床疗效。[方法]本组单节段双侧侧隐窝腰椎管狭窄症患者20例,采取单侧经皮椎板间隙入路,通过改变内镜的倾斜角度并利用角度椎板钳和镜下磨钻行双侧侧隐窝和中央椎管270°减压,随访时间超过24个月,分析术后疗效参数如VAS评分、ODI评分、Macnab分级评分、单次连续行走距离和手术并发症。[结果]术后影像学证实所有患者进行了有效的中央椎管和双侧侧隐窝的减压。术后ODI评分和VAS评分较术前显著降低,差异有统计学意义;Macnab评分,80%的患者取得了满意或良好的疗效;单次连续行走距离较术前明显增加。[结论]单侧经皮椎板间隙入路双侧侧隐窝和中央椎管270°减压术,具有良好的中央椎管和双侧侧隐窝手术视野显示,可有效减压,是微创治疗退变性椎管狭窄症特别是合并双侧侧隐窝狭窄的有效安全的手术方式。     

退行性腰椎管狭窄的螺旋CT诊断及临床意义

目的探讨退行性腰椎管狭窄的螺旋CT表现及其临床意义。方法对有临床症状且符合退行性腰椎管狭窄诊断的190例患者的临床及CT资料进行回顾性分析。结果退行性椎管狭窄主要发生在L4~5椎间隙,本组病例有133处;根据王永奇等椎管狭窄分型标准,以Ⅱ型和Ⅲ型狭窄为主,本组病例Ⅱ型97例,Ⅲ型74例。CT表现为椎间盘膨出/突出、椎体后缘骨质增生、椎体滑脱及椎小关节肥大、黄韧带肥厚及后纵韧带骨化等,以及中央椎管矢状前后径及横径变小,侧隐窝、椎间孔变窄。以侧隐窝狭窄导致神经根受压患者症状最为明显,而中央椎管狭窄患者症状相对较轻。结论运用螺旋CT进行完整的腰椎间隙扫描,客观评价CT征象与患者临床症状及体征的关系,对退行性腰椎管狭窄临床治疗计划的制定有重要的临床意义。     

腰椎管狭窄症合并腰椎间盘突出的手术治疗：（附66例报告）

腰椎管狭窄症合并腰椎间盘突出在临床上不少见[1,2]赵敦炎等报道腰椎间盘突出合并侧隐窝狭窄占65%[3]。我科1983年5月～1991年3月手术治疗腰椎管狭窄症合并腰椎间盘突出66例,占同期手术治疗腰椎管狭窄症的50%,其中侧隐窝狭窄44例(66.7%),中央椎管狭窄22例(33.3%)。现将我们对此病的一些新的认识和治疗经验总结如下。 临床资料 男性44例,女性22例。年龄18～74岁,平均41.6岁。病史最短者2周,最长20年,平均6.1年。 临床表现:有腰腿痛症状者66例,间歇性跛行52例,下腰椎旁有局限性压痛者59例,鞍区感觉减退者5例,66例直腿抬高试验均<60“阳性。 辅…     

腰椎侧隐窝狭窄症的临床定位与手术方式选择（附32例报告）

目的：探讨椎侧隐窝狭窄症患者的症状、体征与狭窄部位的对应关系,为手术方式的选择提供依据。方法：对32例腰椎侧隐窝狭窄患者的临床症状、体征、影像学检查及手术结果进行分析。结果：腰椎侧隐窝狭窄症绝大多数是由单一间隙引起的,针对引起症状,体征相应的狭窄区进行手术,疗效优良率可达93％,结论：临床症状和体征是确定狭窄区域最重要的指标,单侧或双侧开窗手术入路最为适宜。     

脉冲电治疗腰椎管侧隐窝狭窄症

脉冲电治疗腰椎管侧隐窝狭窄症姚长海，侯树勋，李佳力，孙彦，李庆梅人体腰椎管包括中央椎管和侧隐窝。侧隐窝狭窄症的主要症状是间歇性跛行和根性神经痛。其区别于腰椎间盘脱出之处是临床体征相对轻微，很少有脊柱侧弯，常规Ｘ线片和碘油造影检查无阳性发现［１］。ＣＴ...     

选择性椎管减压术治疗退行性腰椎管狭窄症

采用选择性椎管减压治疗行性腰椎管狭窄症６８例，经术后平均２７个月的随访、优良率９４．１％。文中将退行性腰椎管狭窄症分为中央性腰椎管狭窄，侧隐窝狭窄，混合性狭窄。分别采用中央开窗、潜行扩大减压、一侧或双侧扩大开窗、侧隐窝扩大，蝶形扩大减压术。文中还对选择性腰椎管减压术的理论依据及减压范围进行了讨论。     

CT测量诊断腰椎管狭窄症的相关指标探讨

目的:探讨能够客观反映腰椎管狭窄程度的CT测量指标。方法:对2002年3月~2005年6月间收治的108例退变性腰椎管狭窄症患者(A组)及44例无腰椎管狭窄症患者(B组)的CT片进行测量,包括L4~L5椎体、椎管、硬膜囊的横截面积,侧隐窝角度,侧隐窝矢径,椎体横、矢径,椎管横、矢径。对两组患者的测量结果进行统计学分析,同时对A组测量结果与JOA评分的相关性进行统计学分析,筛选出最能客观反映腰椎管狭窄程度的CT测量指标,并计算其单侧90%可信区间,作为腰椎管狭窄症的诊断标准。应用此标准对2001年3月~2003年2月间在本院手术治疗的66例退变性腰椎管狭窄症患者术前CT片进行回顾性测量分析,评价测量结果相对于拟定标准的符合率。结果:A组的侧隐窝角(L4为18.02°±7.94°,L5为16.88°±4.97°)明显小于B组(L4为40.78°±9.59°,L5为33.76°±9.21°)(P<0.05);A组的椎管面积/椎体面积(L4为0.11±0.03,L5为0.13±0.03)明显小于B组(L4为0.15±0.02,L5为0.15±0.03)(P<0.05);A组的硬膜囊面积/椎管面积(L4为0.82±0.04,L5为0.83±0.06)明显大于B组(L4为0.71±0.04,L5为0.70±0.12)(P<0.05)。此三项指标与JOA评分相关性较强,其90%可信区间为:侧隐窝角L4小于25°、L5小于23°,椎管面积/椎体面积L4小于0.10、L5小于0.09,硬膜囊面积/椎管面积L4大于0.85、L5大于0.86。回顾性测量结果示60例患者通过术前CT测量可确诊为腰椎管狭窄症,符合率为91%。结论:椎管面积/椎体面积、硬膜囊面积/椎管面积、侧隐窝角度与JOA评分有较高相关性;其单侧90%可信区间可作为腰椎管狭窄症CT测量的诊断指标。     

影响老年性腰椎管狭窄症外科治疗效果的因素分析

目的探讨影响老年性腰椎管狭窄症外科手术治疗效果的因素。方法通过回顾性分析我院从2001年6月至2008年3月间对45例老年性腰椎管狭窄病人的手术治疗效果并总结。结果侧隐窝及椎间孔部位的减压不充分是神经根压迫症状不能解除的重要原因。结论老年性腰椎管狭窄症在手术治疗时宜采取中央椎管和神经根管的彻底减压,部分或全部切除1/3~1/2椎小关节,对神经根进行彻底松解,对可能引起的医源性不稳要施以植骨融合椎弓根内固定,保持脊柱的稳定性对完全解除腰椎管狭窄症状有确切的疗效。     

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。     

老年腰椎间盘突出症合并腰椎管狭窄症特点与治疗

目的：研究老年腰椎间盘突出症合并椎管狭窄症的临床表现、影像学表现、病理解剖特点及外科治疗方法。方法：回顾分析了147例(男89例，女58例)老年腰椎间盘突出症合并椎管狭窄症患者临床表现、CT、MRI特点及病理解剖特点，病程2周～15年。病变阶段：L4.5 53例，L5S1 42例，L2,4 5例，L2,3 3例，L4,5和L5S1并存44例。全部病例采用椎板减压髓核摘除术，并对治疗方法进行分析。结果：本组92例获得随访，随访时间3个月～3年，平均8个月。术后功能按我们自己制定方法进行评定，优63例，良17例，可10例，差2例，优良率为87％。结论：老年腰椎间盘突出症合并椎管狭窄症具有临床表现不典型、症状与体征不完全一致的特点，并有其特殊的影像学表现。在治疗上应行全椎板减压，髓核摘除，扩大椎管及侧隐窝，使患者获得良好的功能恢复。     

腰椎间盘手术失败原因分析和治疗

目的：对腰椎间盘手术失败的原因进行分析。方法：对129例腰椎间盘初次术后疗效不满意患者分析其原因，结果：在129列术后疗效不满意的患者中，需要再手术治疗的有98例（75．9％），初次手术失败的常见原因有椎间盘摘除不彻底或复发，保并有腰椎管狭窄（侧隐窝）狭窄的患者失能同时进行彻底地椎管减压、远期继发腰椎不稳以及选择了一些不恰当的手术病例等有关。结论：腰椎间盘术后症状复发原因较多，应充分结合患者的临床表现及影像学检查，严格掌握手术适应证。再手术目的的是解除疼痛，恢复功能，包括彻底减压和腰椎稳定性手术。     

腰椎管狭窄的手术治疗(附68例报告)

自1990年以来,对68例腰椎管狭窄进行手术治疗,其中中央管狭窄9例、侧隐窝狭窄39例、纤维管腔狭窄22例。合并椎间盘突出53例（78％）。全部病例行全椎板切除与神经通道松解,优良率达87.2％。无手术感染、出血等合并症。手术成功的关键是解决椎管狭窄与神经通道狭窄。     

A less invasive surgical approach in the lumbar lateral recess stenosis: direct approach to the medial wall of the pedicle

The lateral recess is one of the main compression sites in lumbar spinal canal stenosis. Lumbar nerve root is mainly entrapped by bony tissue in compression syndrome. The patient has a long history of back pain in conjunction with claudication symptoms. Besides laminotomy and facetectomy techniques, several specific surgical approaches to treat the lateral recess stenosis have been described. The surgical technique of bilateral lateral recess decompression via subarticular fenestrations used in this study is a less invasive technique, which enables to decompress the neural structures while preserving as much of the bony structures and ligamentum flavum as preferred. In 16 patients, we measured lateral recess heights with computerized tomography. The number of involved lumbar segments was one in 11 patients and two in 5 patients. The visual analogue scale (VAS) results were maintained before, 3 and 12 months after the operation. All patients benefited from the operations. Mean VAS scores were 7.0, 5.5, and 4.0, respectively. There were not any surgery-related complications. Mean follow-up period is 22.6 months. The surgical technique described and used in this study provides easy access to every zone of lateral recess and is safe and effective in treating the lumbar lateral recess stenosis syndrome.     

腰椎侧隐窝扩大成形术

本文报道了７６例腰椎侧隐窝狭窄症。其中孤立型２９例，侧隐窝狭窄合并椎间盘突出３４例．侧隐窝狭窄伴中央型椎管狭窄症１３例。采用小切口开窗侧隐窝扩大成形术＋椎间盘切除治疗侧隐窝狭窄，随访１０个月～３６个月６９例术前症状消失；６例根性痛消失．但偶感腰痛；１例症状元明显改善．     

腰椎间盘突出症术后迟发性下肢痛的原因及对策

本文旨在探讨腰椎间盘突出症术后迟发性下肢痛这一现象的原因。我们对764例腰椎间盘突出症手术治疗患者进行回顾性分析,探讨与产生这一现象有关的可能因素。结果发现,共有81例腰椎间盘突出症手术患者术后出现迟发性下肢痛,81例中合并有腰椎管狭窄或侧隐窝狭窄52例。认为,术中对神经根、神经节的再次损伤是导致腰椎间盘突出症患者术后发生迟发性下肢痛的可能原因。     

Morphometry of the lower lumbar vertebrae in patients with and without low back pain

The authors made several measurements in the lower lumbar vertebrae of patients with and without low back pain. Our objective was to determine the allometric relationships between different dimensions of the lumbar canal, the effects on these from degenerative disease, and differences between the symptomatic and asymptomatic populations. We compared 119 patients suffering from low back and sciatic pain and 39 subjects without lumbar symptoms as determined by computed tomography (CT). The following measurements were made: sagittal diameter of the canal, interpedicular distance, interarticular distance, and anteroposterior diameter of lateral recess and foramen. With respect to the patients with lumbar pain, the asymptomatic group proved to have wider foramina from L3 to L5 and wider sagittal diameters in S1. The patients with canal stenosis revealed lower figures for all diameters of the central canal, lateral recess of L4, and foramina of L4 and L5. Patients with lumbarization showed smaller diameters of the central canal. CONCLUSION: There is an allometric relationship between the dimensions of the central canals. This relationship is less evident with lateral canals. The patients without lumbar symptoms had wider foramina and sagittal diameters in S1 than those with lumbar symptoms. Of these, patients who developed symptoms of canal stenosis demonstrated smaller diameters in central and lateral canals. Of the developmental anomalies, lumbarization proved to be associated with canal stenosis due to smaller diameters of the central canals.     

神经根管减压术治疗腰椎神经根管狭窄症

目的 探讨神经根管减压术治疗腰椎神经根管狭窄症的临床疗效.方法 对25例确诊为腰椎神经根管狭窄症患者行神经根减压术治疗,分别进行术前及术后3、12、24个月VAS和JOA评分,同时进行影像学评价.结果 术后VAS逐渐降低,与术前比较差异有统计学意义(P<0.05),随时间延长VAS降低明显;术后各时段间差异比较亦有统计学意义(P<0.05).术后JOA评分明显增高,与术前比较差异有统计学意义(P<0.05);但术后各时段间比较差异无统计学意义(P>0.05).术后24个月临床症状改善优良率为84%(22/25).结论神经根管减压术是建立在熟练掌握神经根解剖特点基础上行椎板有限开窗、对狭窄的神经根管充分减压、椎弓根钉棒系统植骨内固定治疗神经根管狭窄症疗效满意.     

椎管内扩大术治疗腰椎椎管狭窄症

目的：探讨腰椎椎管狭窄的治疗方法。方法：采用作者设计的“半椎板切除行椎管内扩大术”治疗腰椎管狭窄３５例。其中侧隐窝型２例，马尾神经型１１例，混合型２２例。经３９～９６个月的长期随访。结果：疗效优２７例（７７．１％），良８例（２２．９％），优良率１００％，结论：认为采用文中介绍的手术能最大限度地保持脊柱的稳定性，同时椎管减压彻底，神经组织粘连较少，近远期疗效满意     

Clinical study of lumbar spinal canal stenosis on 70 operated cases --clinical symptoms, pathogenesis, operative method, postoperative results

In surgical treatment of lumbar spinal canal stenosis, the stenotic area related to the clinical symptoms was determined and the stenotic form and stenotic factors in this stenotic area were estimated before operation. The most appropriate decompression of the stenotic area was performed taking the stenotic form into consideration and retaining the spinous process and interspinous ligament. In cases of stenosis of the spinal canal, posterolateral decompression of the dural sheath was performed by means of resection of the medial edge of the bilateral inferior articular processes and the yellow ligaments. In cases of stenosis of the spinal canal associated with stenosis of the lateral recess, the root was decompressed by unroofing the lateral recess in addition to posterolateral decompression of the dural sheath. And in cases with stenosis of the lateral recess, the root in an affected area was decompressed. Neither operation on the intervertebral disc nor incision of the dural sheath was performed. After operation as described above, symptoms, operative findings and postoperative results were investigated in 70 cases which could be directly examined. In this paper we discuss the relationship between the symptoms and the stenotic area, stenotic forms and stenotic factors. When our postoperative results were compared with those of cases with extensive laminectomy, it was seen that none of the patients we treated had low back pain nor recurrence of intermittent claudication and that lessening of paralysis was sufficient.