腰椎后路全椎板切除减压椎体间植骨融合内固定术治疗退行性腰椎管狭窄症临床疗效观察
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摘要
目的：观察腰椎后路全椎板切除减压椎体间植骨融合内固定术在治疗退行性腰椎管狭窄症中的临床疗效。方法：选择2007年3月-2009年10月在山东中医药大学附属医院因退行性腰椎管狭窄症行手术治疗的患者45例,男性16例,女性29例,年龄44—84岁,平均62岁,两个节段狭窄者36例,其中L3-L5节段16例,L4-S1节段20例。个节段狭窄者9例,均为1,3-S1节段。术前常规行临床神经功能检查,影像学检查包括标准的腰椎正侧位及前屈、后伸动力位X线片,腰椎CT及MRI检查。手术方式均采用腰椎后路全椎板切除减压椎体间植骨融合椎弓根钉系统内固定术,应用JOA下腰痛和ODI评分对所有患者腰椎术前术后功能进行主客观评估,以观察其临床疗效。结果：45例患者术前JOA评分由11.73±1.45分改善为术后24.71±2.29分,优良率为88.89%,具有显著统计学意义(P<0.01)；术前ODI评分由35.84±3.24分改善为术后16.24±3.16分,改善率为86.67%,具有显著统计学意义(P<0.01)；术前行走距离由153.3±47.38m改善为术后534±105.25m,具有显著统计学意义(P<0.01)；术前椎间隙高度由11.22±0.83mm改善为12.81±0.77mm,并维持良好,具有显著统计学意义(P<0.01)；术前腰椎前凸角由28.91±2.6°改善为术后34.14±1.36°,具有显著统计学意义(P<0.01)。结论：腰椎后路全椎板切除减压椎体间植骨融合内固定术在治疗退行性腰椎管狭窄症上具有明显的疗效,能有效的改善JOA、ODI术后评分,维持术后椎间隙高度,改善腰椎前凸角,增加术后行走距离,说明此手术方式能够有效治疗退行性腰椎管狭窄症。
Objective:To investigate the clinical efficacy of degenerative lumbar spinal stenosis with lumbar laminectomy interbody fusion and internal fixation. Methods:According to inclusion criteria and exclusion criteria,45 patients (16males and 29 females,age of 44-84 years.mean 62 years)with degenerative lumbar spinal stenosis who underwent operative treatment between March 2007 and October 2009 in Affilated Hospital of Shan dong University of Triditional Chinese Medicine were included in this study. Two segments of 36 patients with stenosis, in which L3-L5 segment in 16 cases,L4-S1 segment in 20 cases.and three narrow segments of 9 patients were L3-S1 segment.All the patients were received the routine neurological examination preoperative,inculding the standard lateral lumbar spine and flexion,extension X-ray,lumbar CT and MRI in photogrammetry. According to Japanese Orthopedics Association score method for low back pain and Oswestry Disability Index.all patients who were received lumbar laminectomy with interbody fusion and pedicle screw fixation with lumbar function of subjective and objective preoperative and postoperative were applied to assess the clinical efficacy. Results:The JOA score and Oswestry Disability Index improved significantly after surgery, and the differences were significant(P<0.01). The mean JOA score before surgery was 11.73±1.45 points,and the mean preoperative Oswestry Disability Index was 35.84±3.24.The mean postoperative JOA score was 24.71±2.29 points,and the mean postoperative Oswestry Disability Index wasl6.24±3.16.The good JOA recovery rate among the total patients was 88.89%,and the improvement of Oswestry Disability Index was 86.67%;There was a significant difference in traveleddistance, disc height and lumbar lordosis angle(P<0.01),the traveleddistance was from preoperative 153.3±47.38m to postoperative 534±105.25m,the height of the disc was from preoperative 11.22±0.83mm to postoperative 12.81±0.77mm,and the lumbar lordosis angle was from preoperative 28.91±2.6°to postoperative 34.14±1.36°.Conclusion:Laminectomy lumbar interbody fusion and internal fixation has a significant effect on degenerative lumbar spinal stenosis.which can effectively improve the JOA,ODI score after surgery,and maintain the postoperative disc height.improve the lumbar lordosis angle to increase the efficacy of postoperative walking distance.It can be confirmed that this method is an effective treatment on degenerative lumbar spinal stenosis
Objective:To investigate the clinical efficacy of degenerative lumbar spinal stenosis with lumbar laminectomy interbody fusion and internal fixation. Methods:According to inclusion criteria and exclusion criteria,45 patients (16males and 29 females,age of 44-84 years.mean 62 years)with degenerative lumbar spinal stenosis who underwent operative treatment between March 2007 and October 2009 in Affilated Hospital of Shan dong University of Triditional Chinese Medicine were included in this study. Two segments of 36 patients with stenosis, in which L3-L5 segment in 16 cases,L4-S1 segment in 20 cases.and three narrow segments of 9 patients were L3-S1 segment.All the patients were received the routine neurological examination preoperative,inculding the standard lateral lumbar spine and flexion,extension X-ray,lumbar CT and MRI in photogrammetry. According to Japanese Orthopedics Association score method for low back pain and Oswestry Disability Index.all patients who were received lumbar laminectomy with interbody fusion and pedicle screw fixation with lumbar function of subjective and objective preoperative and postoperative were applied to assess the clinical efficacy. Results:The JOA score and Oswestry Disability Index improved significantly after surgery, and the differences were significant(P<0.01). The mean JOA score before surgery was 11.73±1.45 points,and the mean preoperative Oswestry Disability Index was 35.84±3.24.The mean postoperative JOA score was 24.71±2.29 points,and the mean postoperative Oswestry Disability Index wasl6.24±3.16.The good JOA recovery rate among the total patients was 88.89%,and the improvement of Oswestry Disability Index was 86.67%;There was a significant difference in traveleddistance, disc height and lumbar lordosis angle(P<0.01),the traveleddistance was from preoperative 153.3±47.38m to postoperative 534±105.25m,the height of the disc was from preoperative 11.22±0.83mm to postoperative 12.81±0.77mm,and the lumbar lordosis angle was from preoperative 28.91±2.6°to postoperative 34.14±1.36°.Conclusion:Laminectomy lumbar interbody fusion and internal fixation has a significant effect on degenerative lumbar spinal stenosis.which can effectively improve the JOA,ODI score after surgery,and maintain the postoperative disc height.improve the lumbar lordosis angle to increase the efficacy of postoperative walking distance.It can be confirmed that this method is an effective treatment on degenerative lumbar spinal stenosis
引文
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[16]朱建平,于小华,刘云鹏,等.退变性腰椎管狭窄椎板切除术后远期随访分析[J].中国脊柱脊髓杂志,2002；12(1)：55-57.
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[24]Ivelfegn.Dalttoy,Fossel,et al.A prognositic importance of prent preoperative exp-ectations of surgery for lumbar spinal stenosis[J].Patient E due Courts 1998;34: 160-178.
[25]Guiglli P,Benoist M,Delecourt C,Delhoume J.Dcburge A.Motor deficit in lumba-r spinal stenosis:A retrospective study of a series of 50 patients[J].J Spinal Di sord 1998;11:283-288.
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[28]Brown C A,Eismont F J.Complications in spinal fusion[J].Orthop Clin North A-m,1998;29:679-699.
[29]Khoueir P, Kim KA, Wang MY.Classificatin of posterior dynamic stabilization devices. Neurosurg Focus.2007,22:E3
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[2]郝定均,温世明,窦榆生.椎间融合器与椎弓根系统复位固定治疗腰椎滑脱症[J].中国脊柱脊髓杂志,2003；13(7)：409.
[3]McAfee PC,Boden SD,Brantigan JW,et al. Symposium:a critical discrepan-cy criteria of successful arthrodesis following interbody spinal fusions[J].Spine,2 001;26 (3):320.
[4]Yone K,Sakou T,Kawauchi Y,et al. Indication of fusion for lumbar spinal ste-nosis in elderly patients and its significance [J].Spine,1996;21 (2).
[5]李德平,鹿均先,熊传芝.退行性腰椎管狭窄症的手术治疗进展[J].现代医学,2007；35(1)：613.
[6]贾连顺,杨立利.退行性腰椎管狭窄症的现代外科学概念[J].中华骨科杂志2002；2(8)：509-510.
[7]俞伟,费俊,严建武,等.退行性腰椎管狭窄症术后疗效不佳的原因分析[J].骨与关节损伤杂志,2002；17(4)：239-240.
[8]吴玉杰,贾连顺,沈康平,等.伴腰椎不稳退变性腰椎管狭窄症内固定材料植入并椎体间植骨融合181例资料回顾分析[J].中国组织工程研究与临床康复,2008,12(22)：429
[9]赵定麟等.腰椎管狭窄症[M],脊柱外科学,上海科技文献出版社,1997：493,
[10]李宝俊,韩建军,丁文元,等.全节段椎弓根螺钉矫形术治疗退变性腰椎侧凸[J]. 中国矫形外科杂志,2008,，16；385-388.
[11]Kawaguchi Y, KanamoriM, Ishihara H, et allClinical and radiographic results of expansive lumbar laminop lasty in patientswith spinal stenosis[J].J Bone Join t Surg(Am),2004,86:1698-17031
[12]Fischgrund JS.The argument for instrumented decompressive posterolateral fusio-n for patients with degenerative spondylolisthesis and spinal stenosis[J].Spine, 2004;29(2):173-174.
[13]O'Leary PF Mc Cance SE. Distraction laminoplasty for decompression of lumb -ar spinal stenosis[J].Clin Orthop,2001;384:26-34.
[14]Khoo LT,Fessler RGMicroendoscopic. Decompressive laminotomy for the treat-ment of lumbar stenosis[J].Neuosurgery,2002;51(5):146-154.
[15]丁宇,阮狄克.下腰椎不同融合方法的即刻与疲劳后稳定性[11].中国脊柱脊髓杂志,2002；12(5)：348-351.
[16]朱建平,于小华,刘云鹏,等.退变性腰椎管狭窄椎板切除术后远期随访分析[J].中国脊柱脊髓杂志,2002；12(1)：55-57.
[17]Zdeblick TA.A prospective,randomized study of lumbar fusion:preliminary resu-Its [J].spine,1993;18:983-991.
[18]Fischgrund JS,Mackay M,Herkowitz HN.et al.Degenerative lumbar spondylo list-hesis with spinal stenosis:A prospective,randomized study comparing decompres-sive laminectomy and arthrodesis with and without spinal instrumentation [J]. Spine,.1997,22:2807-2812.
[19]Komblum MB,Fischgrund JS,Herkowitz HN.et al. Degenerative lumbar spondyl-olisthesis with spinal stenosis:a prospective long term study comparing fusion and pseudarthrosis[J].Spine,2004;29(7):726-733.
[20]顾勇,陈亮,陈晓庆,等.退变性腰椎管狭窄症的手治疗及其疗效[J].中国矫形外科杂志,2009，2：106-109
[21]Deyo RA,Nachemson A,Mirza AK. Spinal fusion surgery:the case for restrain-t [J].New England J Med,2004; 12:722-726.
[22]Timo J.Aalto,Antti Malmivama Francisco Kovacs,et al.Preoperative predictors f-or postoperative clinical outcome in lumbar spinal stenosis[J].Spine 2006;31:648-663.
[23]Massimo Maticonda,Giovanni Zanforlino.Ginseppe A.et al.Factors influencing th-e outcome of degenerative lumbar spinal stenosis[J].Journal of spine.Disorders 2000;13:131-137.
[24]Ivelfegn.Dalttoy,Fossel,et al.A prognositic importance of prent preoperative exp-ectations of surgery for lumbar spinal stenosis[J].Patient E due Courts 1998;34: 160-178.
[25]Guiglli P,Benoist M,Delecourt C,Delhoume J.Dcburge A.Motor deficit in lumba-r spinal stenosis:A retrospective study of a series of 50 patients[J].J Spinal Di sord 1998;11:283-288.
[26]Wang J C,Bohlman HH,Riew K D.Dural tears secondary to operations on the lumbar spine.Management and results after a two years minimum follow up of-eighty eight patients[J].J Bone Joint Surg Am,1998;80:1728-1732.
[27]Kawaguchi Y, Kanamori M, Ishihara H, et al Clinical and radio graphic results of expansive lumbar laminop lasty in patients with spinal stenosis surgical technique [J]J Bone Joint Surg (Am),2005,87:292-2991.
[28]Brown C A,Eismont F J.Complications in spinal fusion[J].Orthop Clin North A-m,1998;29:679-699.
[29]Khoueir P, Kim KA, Wang MY.Classificatin of posterior dynamic stabilization devices. Neurosurg Focus.2007,22:E3
[1]赵定麟.脊柱外科学[M].上海：上海科学技术文献出版社,1996；554-555.
[2]邱平,杨树宣.腰椎管狭窄症[J].国外医学物理医学与康复学分册,2004，24(1)：34-36.
[3]Botwin KP, Gruber RD. Lumbar spinal stenosis:anatomy and pathogenesis[J]. Phys Med Rehabil Clin N Am,2003;14 (1):12-15.
[4]Thomas SA.Spinal stenosis:history and physical examination [J].Phys Med Reha-bil Clin N Am,2003;14(1):29-39.
[5]Ideler C, Zucherman JF, Yerby S, et al. A novel technique of intra spinous process infection of PM MA to augment the strength of an inter-spinous proce-ss device such as the X-STOP. Spine,2008;33(4):452-456
[6]Verhoof OJ, Bron JL, Wapstra FH, et al. High failure rate of the interspinou-s distraction device(X-Stop)for the treatment of lumbar spinal stenosis caused by degenerative spondylolistbesis. Eur Spine J,2008;17(2):188-192
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