腰椎间盘突出症再手术原因分析和手术方式探讨

目的:探讨腰椎间盘突出症再手术的原因及手术方式。方法:对39例腰椎间盘突出症术后症状无改善或缓解一段时间后复发需再手术的患者进行分析和总结。再手术方式:椎板间开窗或经原椎板间扩大开窗、椎间盘切除8例;半椎板切除减压、椎间盘切除3例;全椎板切除减压、椎间盘切除27例(其中23例行后路椎弓根内固定加横突间植骨融合,2例同时行椎间cage置入融合);经左前外侧入路腹膜外椎间盘切除、椎间植骨融合1例。结果:再手术原因包括复发性腰椎间盘突出20例、相邻节段腰椎间盘突出7例、腰椎节段性不稳定8例和腰椎间盘未彻底去除4例,其中合并继发性腰椎管狭窄8例,硬膜外瘢痕形成4例。术中发生脑脊液漏4例,均行硬膜修补,术后恢复良好。随访1年6个月～5年7个月,其中31例患者症状明显改善,7例症状部分改善,1例无改善,优良率为79.5%。再手术前JOA评分平均11.8分,再手术后末次随访时平均25.6分,有显著性差异(P<0.05),恢复率为80.2%。23例行椎弓根内固定加横突间植骨融合患者末次随访时植骨融合率为70%,1例行椎间植骨融合患者末次随访时植骨融合。结论:腰椎间盘突出症再手术的主要原因为复发性腰椎间盘突出、相邻节段腰椎间盘突出、腰椎节段性不稳定和腰椎间盘未彻底去除等,正确分析再手术原因并选择合理的手术方式,仍可以取得较为满意的疗效。

Causes and investigation of the types of reoperation for the treatment of lumbar disc herniation

Objective:To analyze the causes and investigate the types of revisional surgery for treatment of lumbar disc herniation.Method:39 patients with symptoms not improved or partial improved for a short time and recurring after lumbar discectomy were studied.The types of revisional surgery were as follows:spinal fenestration or enlarged laminectomy at the initially operative sites(8 cases),hemilaminectomy and decompressive discectomy(3 cases),the total laminectomy and decompressive discectomy(27 cases)(including internal fixation and diapophysis fusion for 23 cases,spinal fusion with cage for 2 cases),the discectomy and spinal fusion for 1 case.Result:The causes of reoperation included:recurrent lumbar disc herniation(20 cases),adjacent lumbar disc herniation(7 cases),postoperative segmental instability(8 cases),incomplete lumbar discectomy(4 cases).Among them,there were coexisting secondary spinal canal stenosis(8 cases),epidural scar formation(4 cases).4 patients with cerebrospinal fluid leakage during surgery recovered better after epidural remedy.All patients have been followed up from 18 months to 67 months.The clinical symptoms of 31 patients improved significantly,7 patients improved incompletely,only 1 patient had no improvment,the clinical improvement rate was 79.5%.The JOA score averaged 11.8 points before reoperation,the latest follow-up JOA increased to 25.6 points after reoperation(P<0.05),with the recovery rate of 80.2%.23 patients underwent internal fixation and interdiapophysis fusion with the latest follow-up fusion rate of 70%,1 patient undergoing intervertebral disc bone graft had the fusion rate of 100%.Conclusion:Recurrent lumbar disc herniation,adjacent lumbar disc herniation,postoperative segmental instability,incomplete lumbar discectomy,coexisting secondary stenosis of spinal canal and epidural scar are the main causes of reoperation.If the causes of reoperation are analyzed correctly,and selection of reasonable types of surgery,satisfied effect could be obtained.