Lumbar spinal stenosis and degenerative spondylolisthesis

Lumbar spinal stenosis and degenerative spondylolisthesis are common spinal conditions resulting in pain and functional disability. The prevalence of these conditions will increase as the population ages. Multiple nonsurgical treatment options have been reported including physical therapy, medications, and injections but with only limited data and marginal effect. Large, multicenter studies have compared surgical to nonsurgical treatment and have consistently demonstrated greater success in the surgical treatment of both lumbar spinal stenosis and of degenerative spondylolisthesis. This positive treatment effect has been seen at both short-term and long-term follow-up with good durability over time. This suggests that surgical treatment of lumbar spinal stenosis and degenerative spondylolisthesis significantly improves the patient's pain and functional status.     

Decompressive surgery for degenerative lumbar spinal stenosis: long-term results

We report the outcome of 50 patients with degenerative lumbar spinal stenosis who were treated surgically by spinal decompression between 1984 and 1995. Their mean age at the time of surgery was 59.9 (45-77) years and the mean follow-up was 11.6 (6.1-17.2) years. Five patients had a concomitant spinal fusion. The preoperative data were collected retrospectively from the patients' charts. The follow-up data were obtained from a clinical examination and questionnaire including overall pain, ability to work, walking ability, use of analgesics and satisfaction with surgery. The outcome was rated as excellent in 23 patients, good in 13 patients, fair in 9 patients and poor in 5 patients. Patients with concomitant fusion had good to excellent results and were more satisfied, whereas patients with long-standing preoperative symptoms had poor to fair result and were less satisfied.     

Predictors of surgical outcome in degenerative lumbar spinal stenosis

STUDY DESIGN: A prospective, observational study. OBJECTIVES: To identify outcome predictors of surgery for degenerative lumbar spinal stenosis. SUMMARY OF BACKGROUND DATA: Degenerative lumbar spinal stenosis is the most frequent indication for spine surgery in the elderly. More than 25% of surgical patients have a poor outcome, yet little is known about factors that predict the outcome of surgery. METHODS: Surgery was performed on 199 patients with degenerative lumbar spinal stenosis, and they were observed for 2 years after surgery in four referral centers. Surgery consisted of decompressive laminectomy with or without arthrodesis. Outcomes included validated measures of symptom severity, walking capacity, and satisfaction with the results of surgery. Potential predictors of outcome included sociodemographic factors and physical examination, as well as radiographic, psychological, social, and clinical history variables. RESULTS: The proportion of patients with severe pain decreased from 81% before surgery to 31% by 2 years afterward. The most powerful preoperation predictor of greater walking capacity, milder symptoms, and greater satisfaction was the patient's report of good or excellent health before surgery. Low cardiovascular comorbidity also predicted a favorable outcome. CONCLUSIONS: Patient's assessments of their own health and comorbidity are the most cogent outcome predictors of surgery for spinal stenosis.     

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。     

显微镜下手术治疗退变性腰椎管狭窄症

目的评价显微镜下手术减压治疗退变性腰椎管狭窄症的临床效果.方法2006年1月～2006年12月在显微镜下行手术减压治疗退变性腰椎管狭窄症患者36例,单节段13例,双节段23例.术前及术后8个月时应用ODI(Oswestry disability index)评分法对患者进行评定,并进行综合满意度评估.结果均顺利完成手术,单节段手术时间60～180min,平均85min,出血50～130ml,平均73ml;双节段手术时间70～180min,平均95min,出血50～150ml,平均80ml.术中4例患者发生硬膜破裂,予以相应处理后痊愈,术后无神经根损伤、感染及腰椎失稳等并发症发生,所有病例均获得8个月以上随访,术前ODI评分平均78.22±17.62分,术后8个月时平均30.17±15.26分,Wilcoxon秩和榆验手术前后ODI评分差异显著(P＜0.05).手术综合满意程度评估,优28例,良5例,可3例,优良率92%.结论显微镜下手术减压治疗退变性腰椎管狭窄症可以获得良好的疗效.     

退行性腰椎管狭窄症的治疗进展

腰椎管狭窄症（lumbar spinal stenosis,LSS）是指各种原因引起的腰椎骨与软组织（椎体、小关节、椎板、黄韧带、椎间盘等）发生形态与组织结构的变化,导致中央椎管、侧隐窝、神经孔狭窄,使神经根和/或马尾神经受到刺激或压迫,引起一系列临床症状的疾病。常见原因包括退行性、先天性、医源性、外伤性、峡部裂滑脱、代谢及内分泌疾病、感染性疾病、肿瘤、软骨疾病等[1],临床上以退行性腰椎管狭窄为主,50岁以上人群常见。退变多始于椎间盘,椎间盘退变、突出,压迫神经根、硬膜囊、马尾等;椎间盘退变又会导致椎间隙变窄,使侧隐窝、椎间孔狭窄;椎间隙变窄导致椎间不稳、小关节负荷增大,使小关节增生肥大;加之黄韧带褶皱、肥厚,多因素作用导致椎管狭窄,引起一系列临床症状[2]。随着人口老龄化,退行性腰椎管狭窄症的发生率呈上升趋势,影响中老年人的日常生活,甚至导致生活不能自理,亟须治疗。在治疗上,包括保守治疗及手术治疗。现就退行性腰椎管狭窄症的治疗及其疗效简要综述如下。     

显微内窥镜下手术治疗退变性腰椎管狭窄症

目的 :评价显微内窥镜下手术治疗退变性腰椎管狭窄症的临床效果。方法 :用METRX手术系统对 2 3例退变性腰椎管狭窄症患者在显微内窥镜下行手术减压 ,以ODI(oswestrydisabilityindex)(Version 2 0 )评分法对患者术前及术后 9个月评分 ,并综合满意度评估。结果 :术前ODI评分平均71 32± 18 6 2 ,术后平均 39 84± 17 38,Wilcoxon秩和检验手术前后ODI评分差异显著 ,手术综合满意程度 :优 11例 ,良 6例 ,可 3例 ,差 0例 ,优良率 85 %。结论 :显微内窥镜下手术减压可以治疗退变性腰椎管狭窄症 ,但应注意适应证的选择 ,微创下难以处理时应中转为常规开放手术。     

Operative treatment for degenerative lumbar spinal canal stenosis

The authors have made a retrospective study of a cohort of patients who underwent surgery for spinal stenosis. A total of 85 patients were surgically treated for spinal stenosis between 1993 and 1997, and 79 patients were available for re-evaluation. The average time of follow-up was 79 months. Twenty patients with monosegmental stenosis underwent fenestration and undercutting, 16 patients had a hemilaminectomy or laminectomy and 43 patients had an instrumented fusion after decompression. The severity of the clinical complaints, the degree of stenosis and the extent of the instability determined the method of operation used. Results were more variable when extensive decompression (hemilaminectomy or more) was needed and segmental stability was reduced by resection of large portions of the facet joints. Instability clearly worsened the results. The overall results clearly show that limited decompression is an ideal operative method, provided the indication is correct. Fusion cannot be avoided if segmental instability is present. This retrospective study shows that satisfactory long-term results can be achieved in lumbar spinal stenosis with surgery adapted to the degree of instability and the degree of stenosis.     

个体化手术治疗退变性腰椎管狭窄症

目的回顾性分析选择性减压和减压融合治疗退变性腰椎管狭窄症的临床疗效。方法对我科2008年10月-2010年10月81例行手术治疗的退变性腰椎管狭窄症的临床资料进行总结：其中男37例,女44例,年龄39~72岁,平均（59.4±6.3）岁;单节段狭窄48例,双节段狭窄25例,三个及其以上节段狭窄8例;7例伴L4椎体I°滑脱,5例伴腰椎退变性侧弯,26例存在节段性不稳。根据无或有不稳行减压（A组）或减压融合（B组）。A组43例,行经后路常规椎板开窗减压或后路椎间盘椎管探查减压;B组38例,行后路减压椎体间或横突间植骨融合及椎弓根钉棒内固定术。采用JOA评分、ODI量表评价临床疗效,比较两组的疗效。结果平均随访1.8年,总体临床优良率82.1%,A组82.1%,B组82.2%。结论在仔细分析病情的基础上,选择个体化手术方案治疗退变性腰椎管狭窄症可取得满意的临床疗效,提高生活质量。     

The natural history of lumbar degenerative spinal stenosis

The purpose of this review is to present current information on the natural course of lumbar spinal stenosis. As the population becomes older this condition is encountered more frequently. The diagnosis accuracy has improved and the number of cases detected is increasing intemationally. Because of the relative unpredictability of surgical treatment, good knowledge of natural evolution and of the predictive factors influencing the course of the disease is crucial. Unfortunately, and in contrast with numerous surgical series few studies have dealt with natural evolution. In addition to anecdotal reports, a few non randomized studies will be reviewed. Only one randomized study has compared shortand long term results of medical versus surgical treatment. Most of these studies are retrospective, with methodological flaws and are difficult to compare. At the present time no scientifically based recommandations can be made to LSS. patients at diagnosis. Similarly predictors of success of medical and surgical treatment still need to be identified. However results of the studies analyzed in this review suggest that a substantial proportion of patients do not automatically deteriorate and will remain unchanged or even improved by medical means. They also suggest that patients with severe baseline symptoms, block stenosis and degenerative spondylolisthesis tend to require surgical decompression. Randomized studies with the necessary ethical precautions are needed to obtain clear-cut conclusions.     

腰椎椎管狭窄症融合方式的选择

目的探讨不同融合方式治疗退行性腰椎椎管狭窄症(degenerative lumbar spinal stenosis,DLSS)的疗效差异。方法回顾分析38例DLSS患者资料,所有患者均行腰后路蝶形减压,椎弓根钉内固定。依据有无椎间融合分为A、B组。A组21例行椎间融合及后外侧融合;B组17例未行椎间融合仅行后外侧融合。术后平均随访2年,应用健康状况调查简表(MOS item short form health survey,SF-36),Oswestry功能障碍指数(Oswestry disability index,ODI),疼痛视觉模拟量表(visual analogue scale,VAS)量表评估2种不同融合方式的疗效差异。结果 SF-36评分显示38例腰椎手术疗效显著(P0.01),且2种融合方式疗效差异无统计学意义(P0.05)。结论 2种融合方式治疗腰椎椎管狭窄症疗效无明显差异。     

退行性腰椎滑脱与退行性腰椎椎管狭窄症患者脊柱-骨盆矢状面参数的差异

目的应用骨盆半径(PR)技术分析退行性腰椎滑脱(DLS)与退行性腰椎椎管狭窄症(DSS)患者脊柱-骨盆参数的特点,并探讨其代偿机制。方法回顾性分析2015年9月—2017年8月宁夏医科大学总医院收治的36例DLS和35例DSS患者的影像学资料。在站立位全脊柱侧位X线片上测量脊柱矢状面平衡(SVA)、总腰椎骨盆前凸角(PR-T_(12))、骨盆形态(PR-S_1)、骨盆角(PA)、腰椎前凸(LL)和胸椎后凸(TK)。将2组所测参数分别与健康国人脊柱-骨盆参数进行比较,同时采用Pearson相关分析研究各脊柱骨盆-参数之间的相关性。结果 DLS组与DSS组中SVA、PA均明显大于正常参考值,差异有统计学意义(P0.05)。DSS组PR-T_(12)明显小于正常参考值,DLS组PR-S_1明显小于正常参考值,差异均有统计学意义(P0.05)。DLS组PR-T_(12)与PA的相关性强于与LL、TK的相关性,DSS组PR-T_(12)与LL、TK的相关性强于与PA的相关性。DLS组PR-S_1与PA呈负相关,DSS组PR-S_1与PA无相关性。结论 DLS患者可能主要通过骨盆后倾维持脊柱矢状位平衡,DSS患者可能主要通过改变胸腰椎曲度维持脊柱矢状位平衡。     

Aperius interspinous device for degenerative lumbar spinal stenosis: a review

With an aging population, degenerative lumbar spinal stenosis (DLSS) leading to neurogenic intermittent claudication (NIC) is a growing problem. For patients suffering from this condition, interspinous process distraction devices (IPDs) offer an effective and cheap alternative to conservative or decompressive surgery. Aperius is one such device that has been gaining popularity for its percutaneous insertion under local anesthetic, short operative time, and low risk of complications. The main objective of this review was to carry out a comprehensive search of the literature to evaluate the effectiveness and potential complications of Aperius. A database search, including PubMed, Clinical trials.gov, Cochrane (CENTRAL), MEDLINE, CINAHL, EMBASE, and Scopus, was carried out to identify relevant articles written in English reporting on complications with a minimum 12-month follow-up. The literature search resulted in six eligible studies; two nonrandomized comparative and four prospective case series were available. The analysis revealed that in total, 433 patients underwent treatment with Aperius, with all studies demonstrating an improvement in outcome measures. The average follow-up was 17 months with an overall complication rate of 10.62 %. Overall, the quality of evidence is low, suggesting that currently, the evidence is not compelling and further prospective randomized trials including cost-effectiveness studies are required.     

老年人退行性腰椎管狭窄症的手术治疗

腰椎管狭窄症是老年人腰腿痛的重要原因之一。随着内固定技术的发展,临床上融合手术应用日益广泛。由于老年患者多合并各种内科疾病,使手术风险上升,如何针对各个患者的具体情况选择合适的治疗方式,以达到减轻症状、降低并发症发生率的目的,是骨科医师面对的一个重要课题。     

责任节段融合术治疗高龄多节段腰椎管狭窄症

[目的]探讨责任节段腰椎融合术治疗高龄多节段腰椎管狭窄症的应用价值。[方法]回顾性分析2014年1月～2017年12月收治的160例高龄多节段退行性腰椎管狭窄症患者。其中,82例减压术后仅行责任节段融合,78例减压术后行常规长节段融合术。比较两组围手术期、随访和影像资料。[结果]两组患者均顺利完成手术。责任节段融合组手术时间、出血量、住院时间均少于多节段融合组,差异有统计学意义(P<0.05)。多节段融合组并发症发生率略高于责任节段融合组,差异无统计学差异(P>0.05)。两组患者术后平均随访(24.59±3.25)个月,随术后时间推移,两组患者的VAS评分、ODI指数均显著下降,而JOA评分明显增加,不同时间点间差异有统计学意义(P<0.05);相同时间点,两组间VAS、 ODI和JOA评分的差异均无统计学意义(P>0.05)。至末次随访时,两组患者疼痛、行走、弯腰活动、劳动能力较术前均得到明显改善,生活质量明显提高。影像检查显示随访过程中均未发生螺钉松动、断裂等现象,笼架未出现明显移位及下沉,所有患者均获得骨性融合。[结论]责任节段融合术治疗高龄多节段腰椎管狭窄症能有效地缩短手术时间,减少出血量,缩短住院时间,且能达到预期临床疗效,改善患者生活质量。