重建椎管后部结构治疗腰椎管狭窄症

目的 介绍一种应用劈开截骨，以黄韧带为轴保留棘突、椎板和外层黄韧带行椎板回植，重建完整椎管后部结构和硬膜外腔的椎管重建术治疗腰椎管狭窄症的后路手术技术，并评价效果。方法 2001年10月～2003年4月，应用椎管重建术治疗腰椎管狭窄症39例，男19例，女20例。年龄36～77岁，平均49．6岁。病变椎体为L3、4～L5S15例，L4、5～L5S418例，L4、511例，L5S15例；病程3个月～16年，平均40．3个月。术中纵行劈开棘突，将上位椎板的下1／2梯形截断后，连同黄韧带浅层向尾侧翻开，切除深层黄韧带、两侧侧隐窝椎板的内层和增生的关节突，椎管扩大后，原位缝合截开的椎板。术后1周、3个月及1年行CT检查，并于术后1年进行疗效评定。结果 39例术后均获18～36个月随访。术后1周CT示椎管及神经根管扩大满意，术后3个月复查CT示87．2％（34／39）椎板和棘突已达骨性融合，术后1年CT示所有患者椎板原位固定融合，黄韧带愈合，无再狭窄。按标准量化评分，术后疗效评定优良率为92.3％（36／39）。结论 此术式保留了棘突、棘间韧带、椎板和黄韧带的连续性，重建完整的硬膜外腔和椎管的后部结构，阻挡了肌肉与神经组织的瘢痕粘连。截骨范围小、保留血液供给、固定方法简便、术后骨愈合时间短及腰椎稳定。

TREATMENT OF LUMBAR SPINAL STENOSIS BY RECONSTRUCTION OF POSTERIOR CANAL STRUCTURES

Objective To evaluate the clinical outcomes of a surgical approach for decompression of lumbar spinal stenosis,which was featured with reconstruction of posterior spinal structures and epidural space by spinous process-splitting,less osteotomy,laminar flap and keeping spinal process,lamina,outer ligmentum flavum intact.Methods From October 2001 to April 2003,39 patients(19 males and 20 females,aging 36 to 77 years with a mean age of 49.6 years with lumbar stenosis underwent the surgical decompression procedure with reconstruction of posterior canal structures and epidural space.The involved locations were L_(3,4) to L_5S_1(5 cases),L_(4,5) to L_5S_1(18 cases),L_(4,5)(11 cases) and L_5S_1(5 cases).The course of disease was 3 months to 16 years(40.4 months on average).The clinical outcomes after 1 year of operation.Results All patients were followed up from 18 to 36 months.No intraoperative and postoperative complications were observed and all patients were satisfactory with the surgery.Computerized tomography showed that spinal and nerve root canal were satisfactorily enlarged 1 week postoperatively in all cases.Fusion of lamina and spinous process were detected on CT in 87.2% patients(34/39) 3 months after operation.No patients presented re-stenosis of lumbar spine and all patients presented bony fusion 1 year after surgery.Conclusion The approach of the current study was a reliable and effective method in the management of lumbar stenosis,it preserved the continuity of spinal process,interspinous ligaments,lamina and ligmentumn flavum and integrality of posterior spinal structures and epidural space.The integrity of the psoterior spinal structures can prevent the scar formation and improve the stability of lmbar spine postoperatively.