开窗腰椎间盘切除再手术的远期疗效

目的探讨开窗腰椎间盘切除再手术治疗初次开窗髓核摘除术失败患者的远期疗效和影响因素。方法回顾性研究51例行第二次开窗腰椎间盘切除术的患者临床资料,随访时间120~203个月,平均随访146.8个月。按MacNab分类和JOA评分标准评价满意度和远期功能。对放射学资料完整的患者进行手术前后椎间隙高度对比研究。结果51例患者中,结果优良率70.6%,失败率15.7%,患者总体满意率78.4%。除了8例失败患者,远期随访的43例患者JOA评分平均提高(64.6±18.2)%,术后行走能力明显改善。对手术节段椎间隙高度测量发现术后椎间隙高度明显下降,但不影响远期功能结果。吸烟、是否有外伤等发病诱因、合并纤维化和初次术后症状未缓解期对远期结果有影响。心理社会因素与预后可能存在一定关系。结论开窗腰椎间盘切除再手术治疗初次开窗髓核摘除术失败患者疗效满意,但手术复杂性高,明确术前诊断和严格手术指征非常重要。JOA评分被证明为易于患者和医师实施,量化主观数据的评估法。

Long-term outcomes of the revision open lumbar discectomy by fenestration: a follow-up study of more than 10 years

OBJECTIVE: To evaluate the long-term clinical results and the factors that influences the outcomes of the revision open lumbar discectomy by fenestration. METHODS: Fifty-one patients, who underwent the second open discectomy by fenestration from January 1 1988 to December 31 1994, were followed for an average of 146.8 months (range, 120 to 203 months). The long-term follow-up results were evaluated by using the MacNab classification and the Japanese Orthopaedic Association (JOA) scoring system through direct examinations and questionnaires. Radiography was also used in patients who agreed to visit the hospital, and findings were compared with those on preoperative radiographs. RESULTS: At the final follow-up, with the MacNab classification an excellent and good outcome was achieved in 70.6% of the cases, 78.4% were satisfied with their results. The failure rate was 15.7% (8 patients). Excluding those 8 failed cases who needed another reoperation, the average improvement calculated by JOA scores was (64.6 +/- 18.2)%. The disc height of the operation site significantly decreased after surgery, nevertheless, this did not affect the long-term clinical outcome. Factors that were associated with a fair and bad outcome included smoking, isolated trauma or injury, fibrosis and the length of the remaining or recurrent primary postoperative symptoms history. Psychosociological signs were probably known as negative predictors of lumbar disc surgery outcome. CONCLUSION: The long-term outcome of the revision open lumbar discectomy by fenestration in this series was favorable. Because the revision operation is typically associated with a higher complexity, selection of suitable surgical candidates and determination of valid indications for operative treatment are very important. JOA scores have proved to be easy to perform for patients and clinicians and standardize subjective data.