后路减压植骨内固定治疗复发性腰椎间盘突出症

目的探讨后路减压植骨内固定治疗复发性腰椎间盘突出症疗效。方法对20例复发性腰椎间盘突出症患者行经后路椎板切除减压、椎弓根钉固定、自体骨及人工骨后外侧植骨融合手术。结果患者均获随访,时间1~3年。术后1年时X线片复查植骨均牢固融合,无内固定松动、脱落、断裂等,术前原有腰腿疼痛消失。结论后路减压植骨内固定治疗复发性腰椎间盘突出症,减压彻底,效果确切,内固定后植骨愈合良好,可作为复发性腰椎间盘突出症的常用手术方式。     

The results of decompression and anterior lumbar interbody fusion with the use of interbody cages for the treatment of degenerative lumbar spondylolisthesis]

In this paper we reviewed 28 patients who had been treated surgically for lumbar degenerative spondylolisthesis. They were operated between 1998-2003. The decompression and anterior lumbar interbody fusion with the use of interbody cages, was performed in all of them. The outcome was assessed using rating system of Prolo and VAPS. The disc height, degree of slippage and segmental lordosis were measured, on the radiographs, before surgery, after 6 weeks and at the time of final follow-up. In all cases spinal fusion was achieved. The disc height, degree of slipage and segmental lordosis were improved and these results were stable in time. A significant decrease in radicular pain and low back pain were seen but the relation between clinical and radiological autcomes was not observed.     

下腰椎内固定融合手术后复发性腰痛及下肢放射痛23例原因分析

目的分析椎弓根螺钉内固定下腰椎融合手术后腰痛原因。方法随访2001年1月~2003年12月采用椎弓根螺钉内固定下腰椎融合手术103例,男43例,女60例;腰椎滑脱28例,腰椎管狭窄54例,腰椎间盘突出症21例。随访时进行问卷调查及X线、CT或MRI检查,并分析手术后腰痛的可能原因。结果随访时间3~5年,疗效优良80例(77.7%);术后有明显腰痛或腰痛伴下肢放射痛23例(22.3%)。邻近节段疾病11例(2节段融合7例,1节段融合4例;10.7%),内固定使用不当3例,椎弓根螺钉断裂2例,减压不完全2例,高位椎间盘突出1例,不明原因4例。结论邻近节段疾病、内固定使用不当、内固定失败是复发性腰痛主要原因。原有退变基础、减压范围超过融合节段、融合节段的长短都是产生邻近节段疾病的重要的危险因素。     

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.     

腰椎间盘退变性疾病术后短期内再手术原因分析与疗效

目的探讨腰椎间盘退变性疾病手术后短期内再次手术的原因及干预方法。方法 2010年8月至2011年2月手术治疗腰椎管狭窄症、腰椎间盘突出症等腰椎间盘退变性疾病238例,手术方式包括髓核摘除、椎管减压、椎间融合、椎弓根螺钉内固定等。术后7例因腰腿痛及神经根性症状持续存在或加重在短期内进行再次手术,其中男2例,女5例,年龄47～67岁。再手术原因包括神经根管减压不充分伴髓核组织残留2例,椎弓根螺钉误置2例,椎间融合术后相邻节段退变2例,椎板切除减压、髓核摘除术后椎间不稳1例。结果 7例手术均顺利完成,有效随访6～12个月,术后视觉模拟疼痛评分和Oswestry功能障碍指数评分均有改善,腰腿痛及神经根性症状有所缓解,疗效满意。结论游离型腰椎间盘突出症容易发生髓核组织残留致神经根管减压不充分、椎弓根螺钉误置;要重视腰椎融合术后相邻节段退变发生的相关因素,有效预防和延缓相邻节段退变的发生。     

通道下单侧椎体间减压融合内固定结合对侧经皮椎弓根螺钉内固定治疗腰椎退变性疾病

目的探讨采用Quadrant通道下单侧椎体间减压融合内固定结合对侧经皮椎弓根螺钉内固定治疗腰椎退变性疾病的方法及疗效。方法 2009年9月至2012年12月,采用Quadrant通道下单侧PLIF技术结合对侧经皮椎弓根螺钉内固定微创治疗腰椎退变性疾病共20例,男8例,女12例;年龄45~66岁,平均57.5岁。病程1~8年,平均36.5个月。腰椎间盘突出症11例,复发性腰椎间盘突出症4例,腰椎间盘突出合并1°退变性滑脱症3例,腰椎间盘突出合并腰椎不稳症2例。术前患者腰痛视觉模拟疼痛评分(visual analogue scale,VAS)为(6.5±1.1)分。结果患者手术时间(150±20)min,术中出血量(340±90)mL,术后住院时间为(11.0±3.5)d。术后切口均Ⅰ期愈合。患者均获随访,随访时间6~20个月,平均15.2个月。末次随访时VAS评分为(1.4±2.2)分,与术前比较差异有统计学意义(P0.05)。X线片示术后6个月椎体间达骨性融合,未见椎弓根螺钉内固定系统松动、断裂或移位。末次随访时临床疗效按改良Macnab标准评定,获优18例,良2例。结论对于单节段病变,且只需要单侧操作即可完成减压和椎间融合者,Quadrant通道下单侧椎体间融合内固定结合对侧经皮椎弓根螺钉内固定是一种可供临床选择的微创手术方式。     

颈椎间盘与纵韧带损伤的诊断及治疗

目的 探讨颈椎间盘和纵韧带损伤的诊断与治疗方法。方法回顾性分析2001至2005年63例颈椎间盘与纵韧带损伤患者的X线片和MRI表现,根据是否合并脊髓损伤及椎间不稳,早期采取不同治疗方法。早期手术治疗54例,早期颈托和（或）石膏颈围保守治疗9例。结果61例患者获得随访,随访时间6～41个月,平均16个月。8例脊髓完全性损伤患者术后2例神经功能获得改善,39例脊髓不完全性损伤患者术后31例神经功能获得改善。4例保守治疗4～6周后存在颈椎不稳而行颈椎前路椎间盘切除植骨融合术,2例长期颈部疼痛,1例伤后3年出现脊髓压迫症而行前路减压植骨融合术。结论MRI检查是颈椎间盘和纵韧带损伤的最佳诊断手段,早期颈椎前路减压植骨内固定术是治疗颈椎间盘与纵韧带损伤的重要方法。     

The long-term results of decompression and anterior lumbar interbody fusion for the treatment of degenerative lumbar spondylolisthesis]

In this paper we reviewed 31 patients who had been treated surgically for lumbar degenerative spondylolisthesis. They were operated between 1990-1996. The decompression and anterior lumbar interbody fusion with use of autologous bone graft,was performed in all of them. The duration of follow-up ranged from 12 to 6 years. The outcome was assessed using rating system of Prolo and VAPS. The disc high, degree of slippage, segmental lordosis, before surgery, after 6 weeks and at the time of final follow-up were measured on the radiographs. In all cases spinal fusion were achieved. A significant decrease in radicular pain and low back pain was seen but the relation between clinical and radiological outcomes was not observed.     

颈椎前纵韧带损伤的诊断与治疗

目的 探讨颈椎前纵韧带损伤的诊断与治疗.方法 2001年3月至2003年7月经影像学证实为前纵韧带损伤的患者46例.患者均在伤后3 h～3 d内摄颈椎正、侧位X线片并行MRI检查.颈椎椎前阴影增宽35例,椎体不稳征象14例.颈椎MRI T<,1>加权像表现为前纵韧带呈灰色或灰白色信号,部分可见连续性中断、增厚;T<,2>加权像表现为椎体前缘增厚的片状纵行不均匀高信号,边界不清晰,部分可见高信号掀起、连续性中断.19例合并脊髓损伤的患者行早期手术治疗.27例单纯颈部疼痛患者中,早期前路手术治疗6例,颈围石膏固定5例,颈托固定16例. 结果 45例患者获6～41个月(平均16.7个月)随访.5例脊髓完全性损伤患者术后有2例转为不完全性损伤,14例脊髓不完全损伤患者术后有10例获得不同程度的好转.21例单纯颈部疼痛患者中,早期手术的6例无神经症状患者随访时未发生颈椎后凸畸形及颈部慢性疼痛症状;21例早期保守治疗的患者中,7例伤后4～6周因存在颈椎不稳征象而行颈椎前路手术,2例伤后2～3年因损伤节段椎间盘退变突出压迫脊髓而行前路减压植骨内固定术,3例有慢性颈部疼痛不适,余8例患者无特殊不适主诉,另1例失访.结论 MRI检查是诊断颈椎前纵韧带损伤最有价值的方法.合并脊髓受压征象或椎间严重不稳的颈椎前纵韧带损伤,可早期行减压融合术;不伴脊髓损伤的颈椎前纵韧带合并椎间盘损伤,可考虑早期行前路椎间盘切除融合术.     

肌间隙入路单侧钉棒内固定加椎间融合治疗腰椎间盘突出伴不稳

目的：探讨采用手术新入路利用单侧钉棒内固定加椎间融合治疗腰椎间盘突出伴不稳的综合疗效。方法25例腰椎间盘突出伴不稳患者采用肌间隙入路,保护脊柱后方韧带复合体,利用TLIF术式辅助单侧钉棒固定及椎间融合治疗。分别于术前、术后对患者的腰腿痛情况进行VAS评分,同时评价术后腰椎融合率。结果25例患者术后功能明显恢复正常,腰腿痛症状基本消失,1例残留轻度腰痛症状,经对症治疗后缓解,腰椎融合率100%。结论具有单侧神经根症状的腰椎间盘突出伴不稳患者,采用肌间隙入路并进行单侧钉棒固定及融合,术中保留了后方韧带复合体,显露充分,出血少,创伤小,侧隐窝减压彻底,临床效果好,值得临床推广应用。     

经骶骨钛网原位融合与经椎间孔融合治疗成人Ⅱ度腰椎滑脱疗效对比

目的针对13例椎间隙塌陷合并骨质疏松的L5Ⅱ度滑脱患者采取后路减压经骶骨钛网原位融合固定治疗,并与后路减压复位内固定、经椎间孔融合（transforaminal lumbar interbody fusion,TLIF）的21例患者在临床和影像学预后等方面进行了对比研究。方法回顾性分析了共34例患者,其中13例接受后路减压经骶骨钛网原位融合术（A组）,另外21例接受后路减压复位内固定、TLIF术式（B组）。采用Oswestry功能障碍指数（Oswestry disabilityindex,ODI）和腰腿痛视觉模拟量表（visual analog scale,VAS）评分来评价临床疗效。影像学评估参数包括滑移率,全腰椎前凸角和腰骶角。同时记录了术中相关资料,融合率及围术期并发症。结果 A组平均手术时间和出血量显著低于B组,所有患者术后背部和腿部疼痛均显着减轻,2组间比较差异无统计学意义（P〉0.05）。两组患者术后腰骶角、腰椎前凸角、VAS评分和ODI差异无统计学意义（P〉0.05）。2组患者椎体融合率分别为92.3%和95.2%,A组中2例硬膜撕裂,2例一过性的S1感觉异常,踇长伸肌肌力下降1例;B组患者中有2例患者术后出现固定部位疼痛,1例表浅感染,1例螺钉松动。结论对于存在椎间隙塌陷和/或骨质疏松患者,经骶骨钛网原位融合固定术式可成为TLIF术式外的另一选择。经骶骨钛网原位融合固定与TLIF手术相比较,虽然具有相对较高的神经系统并发症发生率,但在短期临床预后和影像学结果方面并无明显差异。     

Cage联合SF在腰椎间盘突出合并椎管狭窄中的应用

目的 探讨Cage联合SF在冶疗腰椎间盘突出合并椎管狭窄中的应用价值。方法 采用全椎板切除减压Cage自体骨植入联合SF内固定治疗腰椎间盘突出合并椎管狭窄22例。结果 随访22例，随访时间平均40个月，脊柱均满意融合。根据Nakai评分，优13例，良7例，可2例。结论 Cage、SF联合应用在冶疗腰椎间盘突出合并椎管狭窄中疗效显著，能提供良好的脊柱稳定性和满意的脊柱融合率，符合腰椎的生物力学。     

单纯减压与减压融合内固定术治疗伴I度退行性滑脱的腰椎管狭窄症的疗效比较

目的:比较单纯减压术与减压融合内固定术治疗伴Ⅰ度退行性滑脱的腰椎管狭窄症的疗效。方法:1993年1月~2007年6月收治的61例伴Ⅰ度退行性滑脱的腰椎管狭窄症患者,按手术方法分为单纯减压组(A组)和减压加融合内固定组(B组),A组28例,B组33例。两组年龄、性别、病程及术前JOA评分、腰腿痛VAS评分、椎体滑脱程度及椎间隙高度无统计学差异(P>0.05)。A组单纯行椎板开窗、椎管潜行扩大术,B组行椎板扩大开窗、后外侧或加椎间融合、椎弓根螺钉内固定术。均获2年以上随访,其中A组25例随访4~12年,平均6.8±4.7年;B组31例随访4~11年,平均6.5±4.1年;两组随访时间无统计学差异(P>0.05)。比较两组术后2年及末次随访时的JOA评分、腰痛及腿痛VAS评分、滑脱节段的椎间隙高度及滑脱程度变化。结果:B组手术时间、术中出血量均明显大于A组(P<0.05)。A组并发症3例,其中术中硬脊膜撕裂2例,神经根损伤1例;B组并发症6例,其中术中硬脊膜撕裂3例,术后根性疼痛1例,术后切口感染1例,全麻术后认知功能障碍1例。A组再手术3例,其中2例因腰痛加重伴影像学滑脱加重至Ⅱ度分别于术后5年和6年行内固定融合术,再手术后腰痛缓解;1例因腰痛改善不满意于术后3年行内固定融合术,再手术后症状缓解;B组无再手术病例。术后2年A、B组JOA评分优良率分别为89.8%和90.9%,末次随访时分别为76%和87.1%,两组比较均无统计学差异(P>0.05)。两组腰痛VAS评分术后2年和末次随访时较术前明显降低(P<0.05),A组末次随访时较术后2年增加(P<0.05),B组末次随访时与术后2年比较无统计学差异(P>0.05),术后2年和末次随访时B组腰痛VAS评分明显低于A组(P<0.05)。两组腿痛VAS评分术后2年及末次随访时较术前明显降低(P<0.05),组间比较无统计学差异(P>0.05)。A组术后滑脱节段椎间高度较术前降低,末次随访时低于术后2年(P<0.05),滑脱程度术后2年时较术前无加重但末次随访时较术后2年时增加(P<0.05);B组术后椎间隙高度维持,滑脱部分复位,术后2年及末次随访时无丢失(P>0.05)。结论:单纯开窗减压与减压融合内固定术治疗伴Ⅰ度退行性滑脱的腰椎管狭窄症早期疗效相当,前者损伤小、并发症少但中远期效果下降,而后者能更好维持中远期疗效。     

改良腹直肌旁入路在下腰椎前路手术中的应用

目的探讨改良腹直肌旁腹膜外人路在腰椎前路手术中的应用价值。方法2000年12月～2003年12月应用改良腹直肌旁腹膜外人路行椎体间植骨结合后路椎弓根螺钉内固定系统治疗腰椎滑脱症36例,结核病灶清除植骨融合术12例,腰椎爆裂性骨折椎体次全切除植骨内固定2例,腰椎体肿瘤切除术4例,腰椎间隙感染病灶清除术2例。结果病椎显露平均时间为15．8min,显露过程平均出血量45．6ml,术后切口愈合良好,切口旁皮肤感觉正常。结论改良腹直肌旁腹膜外人路为下腰椎前路手术提供简单便捷的手术人路,尤其适合于椎体间融合术及病灶清除术。     

显微椎间盘镜下B-Twin椎间融合术治疗腰椎退变失稳型椎间盘突出症

目的探讨后路显微椎间盘镜下可膨胀性椎间融合器B-Twin植入椎间融合术治疗腰椎退变失稳型椎间盘突出症的临床疗效。方法 2005年9月~2008年6月,对32例腰椎退变失稳型椎间盘突出症行后路显微椎间盘镜联合可膨胀性椎间融合器B-Twin植入椎间融合术。手术融合节段：L2/31例,L3/43例,L4/518例,L5/S110例,均为单节段。结果植入2枚B-Twin 23例,单枚9例。术后1周VAS疼痛评分由术前8.7±0.3降至2.3±1.7（t=20.64,P=0.001）。随访时间平均25个月（24~29个月）,植骨融合率采用Suk标准：1年融合率为93.8%（30/32）,2年融合率为96.9%（31/32）,B-Twin椎间融合器无明显下沉。结论后路显微椎间盘镜联合可膨胀性椎间融合器B-Twin植入椎间融合术治疗腰椎退变失稳型椎间盘突出症创伤小,植骨融合率高,临床症状缓解满意。     

腰椎间盘突出症术后腰椎再手术的疗效及其影响因素分析

目的:分析腰椎间盘突出症术后腰椎再手术的临床效果及其影响因素。方法:回顾性分析我科2005年1月～2009年11月收治的94例腰椎间盘突出症术后腰椎再手术患者的临床资料。根据病史、症状、体征及影像学检查,腰椎再手术的原因包括腰椎间盘突出复发49例(52.1%),腰椎管狭窄症17例(18.1%),初次手术减压不彻底16例(17.0%),邻近节段病变7例(7.4%),其他节段新发腰椎间盘突出5例(5.3%)。再手术前,腰椎JOA评分为15.5±5.6分,腰痛VAS评分为4.5±1.6分,下肢痛VAS评分为7.1±1.9分。再手术均采用后路减压、椎间盘切除、椎弓根螺钉内固定、横突或椎体间植骨融合术。对再手术患者进行随访,并根据VAS、JOA评分及患者主观满意度评价再次手术效果。采用多因素非条件Logistic回归,分析患者性别、年龄、吸烟、既往手术史、既往手术方式、上次术后症状缓解时间、本次病程、再手术前神经损害、本次手术融合节段等变量对手术效果的影响。结果:再手术时间1.6～4.5h,平均2.4h;术中出血量200～1500ml,平均538ml。术中无神经损伤发生;术后发生脑脊液漏7例,切口感染1例,经对症处理均治愈。再手术后随访2～6.5年,平均4.2年。末次随访时,总体优良率78.7%,JOA评分为24.0±6.2分,腰痛VAS评分为1.3±0.9分,下肢痛VAS评分为0.9±1.8分,与术前比较差异均有显著性(P<0.001)。再手术前神经损害、本次病程对手术效果的影响有统计学意义(P<0.05),性别、年龄、吸烟、手术次数、上次术后症状缓解时间、既往手术方式、本次手术减压融合的节段对手术效果的影响无统计学意义(P>0.05)。结论:腰椎间盘突出症术后腰椎再手术依然能够获得较好的临床效果。再手术前神经损害、本次病程是影响手术效果的因素。     

Direct pediculo-body fixation in cases of spondylolisthesis with advanced intervertebral disc degeneration

In inveterate cases of grade 2–3 spondylolisthesis (degenerative or spondylolytic), segmental mobility may be reduced by radiologically confirmed disc resorption. Fusion may be indicated in patients with persistent pain. A simple technique for fusion without reduction of the spondylolisthesis is presented. Fixation of the segment is achieved by two cancellous bone screws inserted bilaterally through the pedicles of the lower vertebra into the body of the upper slipped, vertebra. The cases of 16 patients with an average follow-up of 31 months (range 24–77 months) treated with this direct pediculo-body fixation are presented. Clinical evaluation showed significant decrease in pain and, in patients with concomitant spinal stenosis, walking distance without pain improved from between 500 and 1000 m to more than 3000 m. Radiologically, fusion was observed in all cases. The presented technique of internal fixation of a slipped segment in the degenerative lumbar spine represents a simple minimally traumatic procedure with successful clinical and radiological outcome. Additional procedures, such as decompression of the spinal canal, may be performed.     

腰椎滑脱症的再手术治疗

目的探讨腰椎滑脱症手术失败的原因、再手术的术式选择及疗效。方法对20例腰椎滑脱症再手术病例进行回顾性分析。所有20例患者均因首次手术后症状复发或加重而再次入院,症状复发或加重的原因包括,滑脱节段仍不稳定6例,滑脱加重3例,内固定物松动或断裂10例,手术节段错误1例。再入院距首次手术的时间平均24．3个月。所有患者均做了再次手术治疗。结果再次手术后,对所有患者进行了平均34．1个月的随访,手术总优良率85％。18例横突间植骨及2例椎间植骨者均达到骨性融合。8例同时做椎间融合器植入者,其中6例椎间可见骨桥形成。未再见到内固定物松动或断裂。结论单纯椎板切除减压或间盘切除不适合于腰椎滑脱症患者,未植骨或植骨不融合是导致内固定失败或滑脱加重的主要原因。对于首次手术为前路椎间植骨或单纯间盘切除者,再次手术可行椎板切除减压,后外侧植骨及复位内固定;对于首次已行广泛椎板切除术者,可行前路椎体间融合加后路复位融合及内固定术。     

微创经椎间孔腰椎间融合术治疗高位腰椎间盘突出症

目的评价微创经椎间孔入路腰椎间融合术（MIS-TLIF）治疗高位腰椎间盘突出症的中短期临床疗效。方法对自2009-01—2012—12收治的高位腰椎间盘突出症22例行MIS—TLIF术,根据患者症状、体征及影像学资料,切除单侧减压、对侧潜行减压或两侧开窗减压,并行自体及同种异体骨椎间植骨、椎间融合器融合、经皮椎弓根钉内固定。结果所有患者获平均（12±3）个月的随访,出现椎间植骨不融合1例,椎间植骨融合时间为（7．2±1．3）个月。术后下肢放射痛VAS评分及腰背痛ODI评分与术前比较,差异有统计学意义（P〈0．05）。改良MacNab标准评价优良率为86．4％。结论MIS-TLIF治疗高位腰椎间盘突出症是安全、有效的方法。     

Clinical studies of isolated disc resorption in the lumbar spine

Low lumbar pain with radiation into the leg is a common symptom pattern caused by a number of pathological processes. Isolated disc resorption is one such entity which can be readily identified and is amenable to surgical treatment. This study consisted of two groups of patients. Group I were 50 patients suffering from isolated disc resorption at L5--S1 with ill-defined low backache extending into the buttocks and down one or both legs, but not into the feet. Clinical signs of nerve root dysfunction were found in 16 per cent of patients. Radiographic changes with loss of disc height, facet over-riding and intrusion into the nerve root canal and intervertebral foramen were common and frequently associated with sclerosis of the vertebral end-plate. Group II were a series of 45 patients with isolated disc resorption independently reviewed an average of 45 months after surgical decompression of the S1 (98 per cent) or lower lumbar nerve roots. Based on objective grading by the clinician and subjective assessment by the patient complete success was achieved in 62 per cent of the patients and partial success in 24 per cent. Provided there is full appreciation of the pathological anatomy, strict diagnostic criteria and meticulous surgery, decompression of the nerve root canal is a useful surgical procedure in severely disabled patients suffering from isolated disc resorption.