腰椎间盘突出合并侧隐窝狭窄的治疗体会：附23例报告

采用半椎板和切除和椎板间开窗，治疗腰椎间盘突出合并侧隐窝狭窄２３例，对１７例随访６月－４年３月，优良率８８．２％，本病为狭窄的侧隐窝与突出的椎间盘共同压迫神经根引起的一组混合性症状，仔细阅读腰椎平片及ＣＴ扫描有助于诊断，术中撞除椎间盘后需扩大狭窄的侧隐窝，才能获得满意的效果。     

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。     

数字化设计经椎板间隙交叉入路内镜下腰椎侧隐窝减压术

目的探讨影像学联合数字化技术经椎板间隙交叉入路内镜下腰椎侧隐窝减压术治疗腰椎侧隐窝狭窄的可行性。方法选择1名健康志愿者(男,28岁,体重64 kg,身高172 cm)行腰椎CT平扫及Mimics三维重建,观察腰椎骨性组织、硬膜囊及神经根的解剖结构。在Mimics软件中模拟手术操作置入最佳工作通道,切除黄韧带、关节突关节内侧缘及上关节突前上缘骨赘,对腰椎侧隐窝进行减压。结果穿刺路径上的解剖结构由浅入深依次为皮肤、腰背筋膜浅层、竖脊肌、椎板间隙、黄韧带、椎管和侧隐窝。通过该穿刺通道,可以充分显露侧隐窝,适当调整管道方向,可以实现对黄韧带、关节突关节内侧缘、上关节突前上缘骨赘以及突向侧隐窝的椎间盘组织的切除。结论影像学联合数字化技术经椎板间隙交叉入路内镜下腰椎侧隐窝减压术治疗腰椎侧隐窝狭窄是可行的,为内镜下微创治疗腰椎侧隐窝狭窄症提供了新的思路,其临床可操作性有待进一步验证。     

腰椎间盘突出合并侧隐窝狭窄的诊断和治疗

在腰椎间盘突出合并侧隐窝狭窄中,术前明确诊断,选择手术方案,是提高疗效的关键。为此,我们复习了部分ＣＴ片,并进行回顾性分析：１　临床资料１１　一般资料　本组２３例,男１４例,占６０８％,女９例,占３９２％,年龄最大６６岁,最小２４岁,平均４３岁。１２　ＣＴ表现　２３例ＣＴ片均显示有椎间盘突出（术中证实２１例存在椎间突出,２例无突出,仅为单纯性狭窄）。其中５例关节突内聚,黄韧带厚４～１０ｍｍ,侧隐窝矢状径２５～７ｍｍ,病变节段多为Ｌ４－５,Ｌ５～Ｓ１节段少。１３　手术所见　术中见椎间盘…     

腰椎间盘突出合并侧隐窝狭窄症33例报告

本文报告了手术治疗腰间盘突出合并侧隐窝狭窄３３例。其中单侧２８例，双侧５例。４例合并中央管狭窄，２例合并马尾综合征，１例合并椎体滑脱。根据各自的病理特点分别行全椎板、半椎板或开窗减压。手术处理包括摘除突出的椎间盘，切除增生的黄韧带、小关节突和椎体后缘骨赘，从而扩大狭窄的侧隐窝，使神经根充分减压。经１２月～４年６个月（平均２８年）随访，优２２例，良８例，无改善３例。作者认为手术摘除突出髓核后，必须探查神经根的其他致压因素，以防遗漏。手术既要减压充分，又要兼顾腰椎的稳定性     

下腰椎疾患的腰椎小关节角变化规律及其临床意义

目的 对１１６例下要椎小关节角进行研究,以确定该角度与下腰椎疾患之间的关系。方法 将１１６例患者分成四组：对照组２０例,腰椎间盘突出症组６１例,腰椎管狭窄症组２８例,退行性腰椎滑移组７例。分别以Ｌ３,４,Ｌ４,５,Ｌ５Ｓ１做ＣＴ扫描,并将扫描图像输入计算机,分别对小关节角进行测定。结果（１）根据小关节角的大小可将小关节分成三种类型：矢状型,中间型和冠状型;（２）退行性腰椎滑移和腰椎管狭窄症患者的腰     

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。     

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。     

经皮内窥镜技术治疗老年单节段退行性腰椎椎管狭窄症

腰椎椎管狭窄症（LSS）是骨科常见病之一。随着我国老龄化的加速,老年退行性腰椎椎管狭窄症（DLSS）的发生率逐年增加,腰腿痛和间歇性跛行严重影响患者的生活质量^[1]。DLSS往往由椎间盘突出或合并钙化、小关节骨赘增生及黄韧带肥厚等原因引起,部分患者合并发育性椎管狭窄^[2-3]。临床上根据解剖部位将LSS分为中央管狭窄（椎管中央型狭窄）、关节下管狭窄（神经根管的关节下段,包括侧隐窝）和椎间管狭窄（椎弓根及椎间孔段）^[4-5]。老年DLSS患者一般病史较长,影像学资料提示多节段的椎间盘膨出或突出、黄韧带肥厚、小关节增生、侧隐窝狭窄,有时神经根病变的定位诊断也不明确,是否需要将所有狭窄的间隙部位减压,是否需要广泛的融合固定一直是临床争论的问题^[6]。传统腰椎减压融合术治疗DLSS效果明显,但手术创伤较大,术后感染、切口愈合不良、植骨区不融合、内固定松动断裂、邻椎病等手术并发症使得此类技术的应用受到限制^[7]。近年来,经皮内窥镜技术在治疗DLSS方面优势明显,通过术前病史询问、体格检查及相关影像学资料的反复研究,并根据病情需要可结合椎间盘造影,最终精准定位责任椎间隙及椎管狭窄部位行靶向穿刺,达到定点精准减压。2014年5月-2017年8月,本院采用经皮内窥镜下减压术并射频消融术治疗老年单节段DLSS患者40例,现将诊疗过程报告如下。     

坐俯卧位显微椎间盘镜治疗腰椎间盘突出症及腰椎侧隐窝狭窄症

目的探讨后路显微椎间盘镜治疗腰椎间盘突出症及腰椎侧隐窝狭窄症的临床效果：方法手术均取坐俯卧位,经椎板间隙只切除黄韧带不切除椎板及其它结构,应用椎间盘镜及显微外科的技术摘除突出之髓核和／或神经根减压术：临床应用649例。结果术后所有病例均获随访,随访最长时间24个月,最短6个月,平均12个月,按Nakai标准评定,其中优594例,良45例。结论侧卧位经椎板间隙入路行椎间盘镜治疗腰椎间盘突出症及腰椎侧隐窝狭窄症的手术损伤小、出血少,术后不影响脊柱稳定性,临床疗效可靠。     

下腰椎形态与椎管退行性狭窄的关系及其临床意义

目的:探讨腰椎形态与退行性椎管狭窄的关系。方法:测量男、女各100例体检人员L3/4以下椎间小关节角,椎体冠状径、矢状径,椎管中央和侧隐窝的前后径,了解椎体参数、椎间小关节角与椎管狭窄的相关关系,并进行统计学分析。结果:相关和偏相关分析显示椎间小关节角与椎管前后径为负相关关系,且与中央矢状径负相关程度更大;椎体矢状径、冠状径和椎管前后径均为正相关关系。偏相关分析显示椎体冠状径和侧隐窝正相关系数最大。P值均小于0.05。结论:腰椎小关节角增大会改变应力分布,加重不稳定倾向,加速腰椎退变;椎体矢状径、冠状径的增大有助于减轻退行性椎管狭窄。提示临床手术中应注意腰椎前、后路的重建、固定,特别是椎间小关节角已增大时。     

Facet joint asymmetry and protrusion of the intervertebral disc

In a study of 47 cases of lumbar disc protrusion, the hypothesis that asymmetry of the facet joints is correlated with the presence of a disc protrusion, was tested. Seventeen cases of protrusion of the L4-L5 disc and 30 cases of protrusion of the L5-S1 disc were measured on coronal computed tomography (CT) scans. The nonprotruded discs of each level were used as controls of the protruded discs of the same level. The transverse interfacet angle, the inclination and curvature of the facet joints, and the frequency of asymmetric facet joints showed no significant differences, whether there was a disc protrusion or not. The magnitude of the asymmetry was significantly greater only at the L4-L5 interspace in cases of disc protrusion. However, taking into consideration the error of measurement, the difference becomes highly questionable. These results do not indicate any relation between facet joint asymmetry and protrusion of the intervertebral disc.     

The role and incidence of facet tropism in lumbar spine degenerative disc disease.

The correlation of posterior intervertebral (facet) joint tropism (asymmetry), degenerative facet disease, and intervertebral disc disease was reviewed in a retrospective study of magnetic resonance images of the lumbar spine from 100 patients with complaints of low back pain and sciatica. Of the 27 of 100 (27%) of patients discovered to have disc disease (either herniation of nuclear material or bulge) at the L4-5 level, an approximately equal number had facet tropism (14 of 27) as did not (13 of 27). Of the 27 of 100 (27%) patients noted to have disc disease at the L5-S1 level, slightly more (16 of 21) had facet tropism than did not (11 of 27). Of the 65 of 100 (65%) of patients who had facet degenerative disease at the L4-5 level, an approximately equal number had facet tropism (33 of 65) as did not (32 of 100). At the L5-S1 level there was slightly more of a difference, with 25 of 41 having facet degenerative joint disease and tropism and 16 of 41 without it. This study raises questions as to the significance of facet joint tropism in intervertebral disc disease and degenerative facet joint disease but did show that asymmetry of the posterior intervertebral joint is far more common than previously thought: 50% of patients were found to have asymmetric facets at the L5-S1 level and 42% at the L4-5 level.     

退变性腰椎间盘突出症的手术治疗

作者通过１００例退变性腰椎间盘突出症的手术治疗，结合影像学检查和手术所见，将退变性腰椎间盘突出部分：（１）单纯性腰椎间盘突出或膨出；（２）登工节段性椎管狭窄；（３）合并侧隐窝狭窄；（４）合并椎管、侧隐窝狭窄。术中讨论了退变性椎间盘突出的病理特点。手术治疗可获得较好的疗效。本组经术后半年－３．５年的随访，优良率为８９％。     

Microsurgical anatomy and operative technique for extreme lateral lumbar disc herniations

Summary The anatomy of the lateral aspect of the lumbar spine and our lateral microsurgical technique for extreme lateral lumbar disc herniations (ELLDH) is described. This study was based on the microdissection of 4 cadavers, on the morphometric evaluation of these as well as 6 dried cadaver spines and 8 lumbar CT scans, and on the use of this technique on over 200 cases.Level dependent changes in the posterior arch cause a shift of the disc space distally relative to the facet joint, an increasing amount of bone to overlie the intervertebral foramen, and a decreasing amount of working space within the exposure in the caudal direction. Therefore, more bone removal from the lateral aspect of the pars interarticularis and supero-lateral aspect of the facet joint is required in the lower lumbar spine. When the exposed ligamentum flavum is resected, the dorsal root ganglion is seen and access to the herniation and disc space is achieved. Level dependent changes in the pedicles and transverse processes lead to an alteration in the course and relationships of the nerves, thereby influencing the pathophysiology of and surgical technique for the ELLDH. The operative target is the lateral aspect of the pars interarticularis and not the intertransverse space as has been previously described.Our techniques allows for the early identification of the nerve with minimal risks of injury to it, to the adjacent vessels and to the structural integrity of the facet joint and pars interarticularis.Abbreviations DRG dorsal root ganglion - ELLDH extreme lateral lumbar disc herniation - ESA erector spinae aponeurosis - ITL intertransverse ligament - L lumbar - LA lumbar artery - LF ligamentum flavum - LIPC lateral interpedicular compartment - m. muscle - S sacral - TP(s) TP(s) transverse process(es)     

腰椎关节突关节不对称与青少年腰椎间盘突出症

目的:探讨青少年腰椎间盘突出症发生与病变间隙关节突关节不对称性的关系。方法:在CT片上观察并测量24例青少年腰椎间盘突出症患者(年龄13~20岁)26个病变间隙的关节突关节形态及关节突关节角度,并与50例成年患者(年龄30~49岁)60个病变间隙比较。两侧关节突关节形态不同和(或)两侧关节突关节角度之差≥10°定义为关节突关节不对称,比较两组间关节突关节不对称发生率及其与椎间盘突出位置、病理类型的关系。结果:青少年组关节突关节不对称总发生率为57.7%,成年组为10%,两组间比较差异有显著性(P<0.05),关节突关节不对称与椎间盘突出位置、病理类型无关。结论:腰椎关节突关节不对称在青少年腰椎间盘突出症的发生率较高,可能是青少年腰椎间盘突出症发生的原因之一。     

Lumbar facet joint asymmetry. Intervertebral disc herniation.

A study of 136 patients with lumbar intervertebral disc herniation was undertaken to test the hypothesis that asymmetry of the facet joints is associated with the level, type, and side of herniation. Fifty cases of central herniation and 86 cases of lateral herniation, all at the L4-5 or L5-S1 levels, were studied by computed tomographic scans. Adjacent (nonherniated) levels were used as controls. The facet joint angles were measured at the L4-5 and L5-S1 levels of the control, central, and lateral herniated levels. The results showed a similar degree of facet joint asymmetry at all levels. In cases of lateral herniation, there was a significant difference in the facet angle between the herniated and nonherniated side at the L5-S1 level, but not the L4-5 level. The mean difference, however, was less than 3 degrees and not considered to be clinically relevant. There was no difference in the distribution of the more coronally or sagittally facing facet joints with respect to the side of lateral herniation. These results do not support the hypothesis that facet asymmetry is associated with lumbar intervertebral disc herniation.     

经皮激光腰椎间盘减压术后腰椎关节突关节和椎间高度的变化

目的：观察经皮激光椎间盘减压术（percutaneous laser disc decompression，PLDD）治疗腰椎间盘突出症术后腰椎关节突关节和椎间高度的变化。方法：应用半导体激光系统对32例腰椎间盘突出症患者进行PLDD治疗。29例患者为单节段突出，其中L3/4 3例，L4／5 18例，L5/S1 8例；3例患者同时合并IA／5和L5/S1节段突出。利用Macnab标准评价随访患者的疗效，并观察术前、术后椎间盘突出节段关节突关节角的形态，测量L3，4、L4/5和L5／S1椎间高度指数和椎间盘突出节段关节突关节角的角度。结果：所有患者无术中和术后并发症。随访14～22个月，平均17个月，按Macnab标准评价：优14例（43．75％），良13例（40．63％）；可3例（9．37％），差2例（6．25％），优良率84．38％。术后L5/S1椎间高度指数与术前相比显著性下降（P〈0．05），但L3/4和L4／5椎间高度指数无显著性改变；关节突关节无明显退变；L4／5和L5／S1椎间盘突出侧的关节突关节角角度显著性下降（P〈0．05），但L3/4椎间盘突出侧的关节突关节角度无显著性改变。结论：经皮激光腰椎间盘减压术后患者的L5／S1椎间高度和腰椎间盘突出侧关节突关节角角度下降．有可能增加腰椎滑脱的风险。     

Radiographic and myeloscintigraphic evaluation of normal aging changes in the lumbar spine and the relationship with lumbar spinal canal stenosis

In 250 subjects with normal lumbar spine and 39 patients with lumbar spinal canal stenosis (LSCS), radiographic measurement such as canal-to-body ratio (CBR), intervertebral space, inclination and thickness of the facet were performed to statistically evaluate normal degenerative changes in lumbar spine and the difference between normal degenerative changes and those of LSCS. Results were as follows: in normal subjects, 1) intervertebral space became narrower with aging (below L3-4), 2) the inclination of the facet increased in all lumbar spines, 3) the thickness of facet showed no relationship with aging but correlated with inclination (below L3-4). In LSCS, on the other hand, 1) almost no abnormal CBR values were found, 2) canal stenosis was most common at the level of L4-5 and and L3-4, 3) no factor was independently related to the degree of narrowing. Finally, normal subjects patients with LSCS had significant differences in almost all measurement parameters.     

退变性脊柱侧凸椎间盘-终板退变与骨性结构参数的相关性研究及意义

目的 分析退变性脊柱侧凸椎间盘-终板退变与骨性结构参数的关系,探讨其在退变性脊柱侧凸发病机制中的作用及意义.方法 回顾分析2005年3月至2010年3月诊治的79例退变性脊柱侧凸患者(病例组)的影像学资料,选取41例诊断为特发性脊柱侧凸患者(对照组)的影像学资料做为对照.所有患者以主弯内的椎体及附件为观测对象,分别测量椎体和椎间两侧高度及两侧关节突关节面矢状角角度,分别计算椎体和椎间两侧平均高度及两侧关节突关节面平均矢状角作为骨性结构参数.采用分级评分法对各个椎间盘及邻近终板退变程度进行量化,其分值代表椎间盘-终板退变的程度.组内比较各骨性结构参数,分析骨性结构参数的特点及其与椎间盘-终板退变和侧凸Cobb角的关系.结果 经配对t检验比较,病例组的椎间高度、椎体高度及关节面矢状角凸凹侧差异有统计学意义(t=3.411,2.623和2.085,P＜0.05);对照组的椎间高度凸凹侧差异有统计学意义(t =3.276,P＜0.01),椎体高度及关节面矢状角差异无统计学意义(t=1.572和1.493,P＞0.05).直线相关和多元回归分析显示,各骨性结构参数不对称度与椎间盘-终板退变有显著相关性(-1 ＜r＜1,P ＜0.05),与腰椎侧凸Cobb角呈正相关(0＜r＜1,P＜0.05),且存在直线回归关系(F=427.342,P＜0.01),其回归方程为Cobb角=-8.904+8.136×椎间不对称度+3.274×椎体不对称度-0.713×关节突不对称度.结论 退变性脊柱侧凸两侧骨性结构呈不对称改变,其不对称性与椎间盘-终板退变和脊柱侧凸相互关联;不对称骨性结构改变可能是侧凸渐进性发展的生物力学动力因素,而椎间盘-终板不对称退变可能有病因学意义.