腰椎管扩大减压术中保留棘突韧带复合体的优势与问题
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摘要
背景:棘突韧带复合体对维持脊柱稳定性及保护椎管后方结构具有重要作用。传统的腰椎管扩大减压术需将后方组织完全切除,术后常导致出血多、脑脊液漏、感染、椎体滑脱、顽固性腰腿痛、僵硬等并发症。随着对传统术式的不断改进和改良,越来越多的学者青睐于在腰椎管扩大减压术中保留棘突韧带复合体,并在此基础上形成多种改良术式。目的:总结腰椎管扩大减压术中保留棘突韧带复合体不同术式的特点及相关手术问题。方法:应用计算机检索PubMed、万方、知网数据库中从1983年1月至2018年6月关于在腰椎管扩大减压术保留棘突韧带复合体的文章。英文检索词为"Laminectomy,Spinous process ligament complex,lumbar expandeddecompression",中文检索词"腰椎保留棘突韧带复合体,腰椎管扩大减压",排除与研究内容无关和内容重复的文章,保留32篇文章进行综述。结果与结论:(1)随着对传统腰椎后路术式的不断改进,腰椎管扩大减压术中保留棘突韧带复合体的术式逐渐受到推崇;(2)目前其术式主要包括保留棘突韧带复合体的腰椎管扩大减压术、保留一侧肌肉韧带复合体的腰椎管扩大减压术及椎板棘突韧带复合体回植的腰椎管扩大减压术3大类,每一大类又衍生出几种特殊术式,每种术式均具有其自身特点与相关手术问题;(3)对不同的患者,应严格把握其手术指征,选择最适合的术式进行手术治疗,对改善其疗效及预后至关重要。
BACKGROUND: Spinous process ligament complex plays an important role in maintaining the stability of the spine and protecting the posterior structure of the spinal canal. Traditional expanded decompression of lumbar spinal canal requires complete resection of the posterior bone and soft tissue, which often leads to complications such as hemorrhage, cerebrospinal fluid leakage, infection, vertebral spondylolisthesis, intractable low back pain and stiffness. With the improvement and development of traditional procedures, scholars prefer to the preservation of the spinous process ligament complex in lumbar decompression, and then develop various advanced surgical techniques.OBJECTIVE: To summarize the features and problems of different improved techniques about the spinous process ligament complex in expanded decompression of lumbar spinal canal. METHODS: A computer-based online search was conducted in PubMed,WanFang and CNKI databases from January 1983 to June 2018 to screen the relevant articles regarding the preservation of the spinous process ligament complex in the posterior lumbar spinal canal enlargement using the keywords of "laminectomy, spinous process ligament complex, lumbar expanded decompressionl" in English and Chinese, respectively. The irrelevant and duplicate articles were excluded, and finally 32 eligible articles were reviewed. RESULTS AND CONCLUSION:(1) With the continuous improvement and development of traditional surgery, retaining the spinous process ligament complex in expanded decompression of lumbar spinal canal is more and more advocated.(2) The advanced techniques mainly have three major categories, including expanded decompression of lumbar spinal canal with preserved spinous process ligament complex, expanded decompression of lumbar spinal canal with retaining one side of the muscle ligament complex, and the expanded decompression of lumbar spinal canal with replantation after spinous process resection. Some characteristic techniques are derived, and each technique has its features and related surgical problems.(3) We should strictly grasp the indications and select the optimal surgical methods for different patients, which is essential to improve the efficacy and prognosis.
BACKGROUND: Spinous process ligament complex plays an important role in maintaining the stability of the spine and protecting the posterior structure of the spinal canal. Traditional expanded decompression of lumbar spinal canal requires complete resection of the posterior bone and soft tissue, which often leads to complications such as hemorrhage, cerebrospinal fluid leakage, infection, vertebral spondylolisthesis, intractable low back pain and stiffness. With the improvement and development of traditional procedures, scholars prefer to the preservation of the spinous process ligament complex in lumbar decompression, and then develop various advanced surgical techniques.OBJECTIVE: To summarize the features and problems of different improved techniques about the spinous process ligament complex in expanded decompression of lumbar spinal canal. METHODS: A computer-based online search was conducted in PubMed,WanFang and CNKI databases from January 1983 to June 2018 to screen the relevant articles regarding the preservation of the spinous process ligament complex in the posterior lumbar spinal canal enlargement using the keywords of "laminectomy, spinous process ligament complex, lumbar expanded decompressionl" in English and Chinese, respectively. The irrelevant and duplicate articles were excluded, and finally 32 eligible articles were reviewed. RESULTS AND CONCLUSION:(1) With the continuous improvement and development of traditional surgery, retaining the spinous process ligament complex in expanded decompression of lumbar spinal canal is more and more advocated.(2) The advanced techniques mainly have three major categories, including expanded decompression of lumbar spinal canal with preserved spinous process ligament complex, expanded decompression of lumbar spinal canal with retaining one side of the muscle ligament complex, and the expanded decompression of lumbar spinal canal with replantation after spinous process resection. Some characteristic techniques are derived, and each technique has its features and related surgical problems.(3) We should strictly grasp the indications and select the optimal surgical methods for different patients, which is essential to improve the efficacy and prognosis.
引文
[1]Healy AT,Lubelski D,West JL,et al.Biomechanics of open-door laminoplasty with and without preservation of posterior structures.J Neurosurg Spine.2016;24(5):746-751.
[2]孙宇.关于轴性症状[J].中国脊柱脊髓杂志,2008,18(4):289.
[3]Hosono N,Yonenobu K,Ono K, et al.Neck and shoulder pain after laminoplasty:A noticeable complication. Spine(Phila Pa 1976).1996;21(17):1969-1973.
[4]Miyamoto S, Yonenobu K, One K, et al.Experimental cervical spondylosis in the mouse.Spine(Phila Pa 1976).1991;16(10):S495-500.
[5]Denis F.The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine(Phila Pa 1976).1983;8(8):817-831.
[6]Nakai O,Ookawa A,Yamaura I, et al.Long-term roentgenographic and functional changes in patients who were treated with wide fenestration for central lumbar stenosis.J Bone Joint Sur Am.1991;73(8):1184-1191.
[7]Chen CS, Feng CK, Cheng CK, et al.Biomechanical analysis of the disc adjacent to posterolateral fusion with laminectomy in lumbar spine.Spinal Disord Tech.2005;18(1):58-65.
[8]孙志刚,敖强,姜长明,等.保留腰椎后方韧带复合体腰椎管扩大的生物力学评价[J].中国组织工程研究与临床康复, 2007,11(49):9894-9897.
[9]McGirt MJ,Ambrossi GL,Parker SL,et al. Short-term progressivespinal deformity following laminoplasty versus laminectomy for resectionof intradural spinal tumors:analysis of 238 patients.Neurosurgery.2010;66(5):1005-1012.
[10]Cusick JF, Yoqanandan N, Pintar F,et al. Biomechanics of cervical spine facetectomy and fixation techniques.Spine(Phila Pa 1976). 1988;13(7):808-812.
[11]大岛义彦,佐藤浩,林雅弘,等.脊柱管扩大术-片侧侵入有茎棘突起形成片开展法[J].脊椎脊髓, 1991,4(7):577-583.
[12]Sihvonen T,Herno A,Paljarvi L,et al.Local denervation atrophy of paraspinal muscles in postoperative failed back syndrome. Spine(Phila Pa 1976).1993;18(5):575-581.
[13]孙保安,王予治,刘其明,等.保留棘突韧带复合体的双侧椎板开窗联合椎间融合治疗腰椎滑脱症[J].蚌埠医学院学报, 2017,42(7):885-887.
[14]甘霖,陈鹏,施克勤,等.有限减压保留后方韧带复合体结构在腰椎减压融合手术中的意义[J].颈腰痛杂志, 2017,38(6):555-557.
[15]焦勇,赵子义,俞兴,等.腰椎板切除内固定术后骶棘肌疝的发生和治疗[J].中华疝与腹壁外科杂志,2016,10(6):441-443.
[16]施建东,卢一生,黄波,等.保留棘突韧带复合体椎管隧道式减压治疗腰椎管狭窄症[J].中国骨与关节损伤杂志, 2013,8(11):1059-1060.
[17]牛晓健,杨永林,聂润华,等.棘突间“V”型截骨显露在巨大腰椎间盘突出症手术中的应用[J].临床军医杂志, 2014,42(12):1259-1262.
[18]胡伟,赵杰,巩陈,等.单侧椎板入路双侧减压治疗单侧症状为主腰椎管狭窄的疗效分析[J].中华医学杂志, 2016,96(21):1673-1676.
[19]Kanbara S,Yukawa Y,Lto M, et al.Surgical outcomes of modified lumbar spinous process-splitting laminectomy for lumbar spinal stenosis.J Neurosurg.2015;22(4):353-355.
[20]Chatani K.A novel surgical approach to the lumbar spine involving hemilateral split-off of the spinous process to preserve the multifidus muscle:technical note. J Neurosurg.2016;24(5):694-699.
[21]敖强,姜长明.保留棘突韧带复合体的腰椎管扩大术[J].中国脊柱脊髓杂志, 2001,11(2):99.
[22]Usman M, Ali M, Khanzada K, et al. Unilateral approach for bilateral decompression of lumbar spinal stenosis:a minimal invasive surgery. J Coll Physicians Surg Pak.2013;23(12):852-856.
[23]王云清,李华,魏东,等.保留棘突韧带复合体改良椎管减压术治疗老年腰椎管狭窄症的疗效分析[J].中国骨与关节损伤杂志,2017,32(5):510-512.
[24]罗杰多,罗雨桥,黎伟文,等.保留棘突韧带复合体治疗腰椎退变性疾病的临床效果[J].中国当代医药,2018,25(4):93-96.
[25]Alimi M,Hofstetter CP,Pyo SY, et al.Minimally invasive laminectomy for lumbar spinal stenosis in patients with and without preoperative spondylolisthesis:clinical outcome and reoperation rates. J Neurosurgery.2015;22(4):339-352.
[26]胡景阳,翁润民,王芝英,等.椎板复合体后移椎管扩大成形术治疗腰椎管狭窄症[J].颈腰痛杂志,2010,31(4):272-274.
[27]王颖博,朱军,柳峰,等.椎管内肿瘤切除术中脊柱稳定性重建方式的选择:单中心5年经验[J].第三军医大学学报, 2014,36(6):537-540.
[28]杨大志,王敏,王尔天,等.椎管成形术治疗原发性胸腰椎椎管内肿瘤临床分析[J].临床外科杂志,2016,24(6):467-469.
[29]贺建新,林雪英.卷帘式腰椎管成形术治疗老年退变性腰椎管狭窄症[J].实用骨科杂志,2011,17(6):498-501.
[30]Johnsson KE,Redlund-Johnell I,Udén A,et al.Preoperative and postoperative instability in lumbar spinal stenosis.Spine(Phila Pa 1976).1989;14(6):591-593.
[31]柯荣军,许福生,陈建民,等.改良棘突椎板复合体回植治疗原发性腰椎管内肿瘤[J].中国骨与关节杂志,2015,4(7):561-563.
[32]刘国强,谢垒,等.改良棘突椎板复合体回植在治疗原发性椎管内肿瘤中的应用[J].临床骨科杂志,2017,20(2):145-146.
[2]孙宇.关于轴性症状[J].中国脊柱脊髓杂志,2008,18(4):289.
[3]Hosono N,Yonenobu K,Ono K, et al.Neck and shoulder pain after laminoplasty:A noticeable complication. Spine(Phila Pa 1976).1996;21(17):1969-1973.
[4]Miyamoto S, Yonenobu K, One K, et al.Experimental cervical spondylosis in the mouse.Spine(Phila Pa 1976).1991;16(10):S495-500.
[5]Denis F.The three column spine and its significance in the classification of acute thoracolumbar spinal injuries. Spine(Phila Pa 1976).1983;8(8):817-831.
[6]Nakai O,Ookawa A,Yamaura I, et al.Long-term roentgenographic and functional changes in patients who were treated with wide fenestration for central lumbar stenosis.J Bone Joint Sur Am.1991;73(8):1184-1191.
[7]Chen CS, Feng CK, Cheng CK, et al.Biomechanical analysis of the disc adjacent to posterolateral fusion with laminectomy in lumbar spine.Spinal Disord Tech.2005;18(1):58-65.
[8]孙志刚,敖强,姜长明,等.保留腰椎后方韧带复合体腰椎管扩大的生物力学评价[J].中国组织工程研究与临床康复, 2007,11(49):9894-9897.
[9]McGirt MJ,Ambrossi GL,Parker SL,et al. Short-term progressivespinal deformity following laminoplasty versus laminectomy for resectionof intradural spinal tumors:analysis of 238 patients.Neurosurgery.2010;66(5):1005-1012.
[10]Cusick JF, Yoqanandan N, Pintar F,et al. Biomechanics of cervical spine facetectomy and fixation techniques.Spine(Phila Pa 1976). 1988;13(7):808-812.
[11]大岛义彦,佐藤浩,林雅弘,等.脊柱管扩大术-片侧侵入有茎棘突起形成片开展法[J].脊椎脊髓, 1991,4(7):577-583.
[12]Sihvonen T,Herno A,Paljarvi L,et al.Local denervation atrophy of paraspinal muscles in postoperative failed back syndrome. Spine(Phila Pa 1976).1993;18(5):575-581.
[13]孙保安,王予治,刘其明,等.保留棘突韧带复合体的双侧椎板开窗联合椎间融合治疗腰椎滑脱症[J].蚌埠医学院学报, 2017,42(7):885-887.
[14]甘霖,陈鹏,施克勤,等.有限减压保留后方韧带复合体结构在腰椎减压融合手术中的意义[J].颈腰痛杂志, 2017,38(6):555-557.
[15]焦勇,赵子义,俞兴,等.腰椎板切除内固定术后骶棘肌疝的发生和治疗[J].中华疝与腹壁外科杂志,2016,10(6):441-443.
[16]施建东,卢一生,黄波,等.保留棘突韧带复合体椎管隧道式减压治疗腰椎管狭窄症[J].中国骨与关节损伤杂志, 2013,8(11):1059-1060.
[17]牛晓健,杨永林,聂润华,等.棘突间“V”型截骨显露在巨大腰椎间盘突出症手术中的应用[J].临床军医杂志, 2014,42(12):1259-1262.
[18]胡伟,赵杰,巩陈,等.单侧椎板入路双侧减压治疗单侧症状为主腰椎管狭窄的疗效分析[J].中华医学杂志, 2016,96(21):1673-1676.
[19]Kanbara S,Yukawa Y,Lto M, et al.Surgical outcomes of modified lumbar spinous process-splitting laminectomy for lumbar spinal stenosis.J Neurosurg.2015;22(4):353-355.
[20]Chatani K.A novel surgical approach to the lumbar spine involving hemilateral split-off of the spinous process to preserve the multifidus muscle:technical note. J Neurosurg.2016;24(5):694-699.
[21]敖强,姜长明.保留棘突韧带复合体的腰椎管扩大术[J].中国脊柱脊髓杂志, 2001,11(2):99.
[22]Usman M, Ali M, Khanzada K, et al. Unilateral approach for bilateral decompression of lumbar spinal stenosis:a minimal invasive surgery. J Coll Physicians Surg Pak.2013;23(12):852-856.
[23]王云清,李华,魏东,等.保留棘突韧带复合体改良椎管减压术治疗老年腰椎管狭窄症的疗效分析[J].中国骨与关节损伤杂志,2017,32(5):510-512.
[24]罗杰多,罗雨桥,黎伟文,等.保留棘突韧带复合体治疗腰椎退变性疾病的临床效果[J].中国当代医药,2018,25(4):93-96.
[25]Alimi M,Hofstetter CP,Pyo SY, et al.Minimally invasive laminectomy for lumbar spinal stenosis in patients with and without preoperative spondylolisthesis:clinical outcome and reoperation rates. J Neurosurgery.2015;22(4):339-352.
[26]胡景阳,翁润民,王芝英,等.椎板复合体后移椎管扩大成形术治疗腰椎管狭窄症[J].颈腰痛杂志,2010,31(4):272-274.
[27]王颖博,朱军,柳峰,等.椎管内肿瘤切除术中脊柱稳定性重建方式的选择:单中心5年经验[J].第三军医大学学报, 2014,36(6):537-540.
[28]杨大志,王敏,王尔天,等.椎管成形术治疗原发性胸腰椎椎管内肿瘤临床分析[J].临床外科杂志,2016,24(6):467-469.
[29]贺建新,林雪英.卷帘式腰椎管成形术治疗老年退变性腰椎管狭窄症[J].实用骨科杂志,2011,17(6):498-501.
[30]Johnsson KE,Redlund-Johnell I,Udén A,et al.Preoperative and postoperative instability in lumbar spinal stenosis.Spine(Phila Pa 1976).1989;14(6):591-593.
[31]柯荣军,许福生,陈建民,等.改良棘突椎板复合体回植治疗原发性腰椎管内肿瘤[J].中国骨与关节杂志,2015,4(7):561-563.
[32]刘国强,谢垒,等.改良棘突椎板复合体回植在治疗原发性椎管内肿瘤中的应用[J].临床骨科杂志,2017,20(2):145-146.