腰椎管狭窄症手术治疗的临床分析
摘要
目的：伴随着人口的老龄化以及影像学诊断技术的发展,退变性腰椎管狭窄症的发病率明显增高,是中老年人腰腿痛的重要原因之一,也是需要手术治疗的常见病之一。治疗上主要包括手术和非手术治疗。本文就退变性腰椎管狭窄症手术治疗的方法,如椎板减压、融合固定的应用加以阐述,探讨后路椎弓根螺钉系统固定、Cage加自体骨椎间融合(PLIF)与传统术式(开窗减压、半椎板切除、全椎板截骨回植)治疗腰椎管狭窄症的疗效差异及手术技术进行分析并评价其临床应用价值。
方法：回顾性分析我院骨科自2006年6月至2008年8月收治的85例腰椎管狭窄症患者的临床资料：年龄在39岁-75岁,平均58岁,病程3个月-40年,平均4年2个月；85例患者获得隧访。对85例腰椎管狭窄症患者行传统术式(开窗减压、半椎板切除、全椎板截骨回植)减压(A组,38例)、后路椎弓根螺钉系统固定、Cage加自体骨椎间融合(PLIF)治疗(B组,47例)。术后随访16-43个月,平均23个月。采用JOA评分评估疗效并行统计学分析。PLIF:对明确诊断为腰椎管狭窄症的47例患者进行后正中入路下的椎间盘切除、椎管狭窄减压,椎弓根螺钉植入并行椎间隙撑开,保留侧方及前方的纤维环,刮除终板的软骨层,植入少许松质骨粒,安放一到两枚合适的融合器,椎弓根螺钉系统加压固定。
结果：通过围手术期疗效观察发现PLIF与传统手术相比,手术时间、出血量、引流量稍多,患者卧床时间短及术后稳定性高。术后早期患者可以佩戴支具下床活动。所有患者术后临床症状改善明显,未发现椎间隙感染及排斥反应。X线片显示椎体间植骨融合良好,无一例发生椎间隙高度明显丢失及内固定松动、断裂。根据JOA评分标准,两种术式术后优良率分别为：78.94%、95.74%。A组有效率78.94%,B组有效率95.74%。取a=0.05检验水准,Xc2=4.22. p<0.05。A组与B组比较,B组疗效优于A组,差异有统计学意义。后路椎弓根螺钉系统固定、Cage加自体骨椎间融合(PLIF)比传统术式(开窗减压、半椎板切除、全椎板截骨回植)治疗腰椎管狭窄症的疗效好。
结论：后路椎弓根螺钉系统固定、Cage加自体骨椎间融合治疗腰椎管狭窄症满足充分减压、椎间隙高度恢复和稳定性重建以及长期可靠融合治疗的基本要素,椎弓根内固定可矫正滑移,恢复脊柱的生理曲度,达到即刻稳定,增加植骨的融合率,提高手术疗效。其疗效优于传统术式(开窗减压、半椎板切除、全椎板截骨回植)。PLIF治疗组,近、中期疗效优于传统术式治疗,但长期疗效还有待于临床观察。
Objective:With the population aging and the rapid development of imaging diagnostic techniques,the morbidity of degenerative lumbar spinal stenosis(LSS) was significantly increased. It is an important cause of skelalgia in aged, and common cause for lumbar spinal surgery. The surgical and non-surgical intervention were the major treatment of LSS. In this article, the application and development of surgical therapies for degenerative LSS were expatiated, such as laminectomy and decompression, fixation with fusion discectomy, and so on. To evaluate the therapetic effect of posterior trans-pedicle internal fixation and lumbar interbody fusion (PLIF) using cage and autogenus bone grafting and traditional decompression operations (vertebral windowing surgery,hemivertebral resection,holovertebral resection and trasplant) for treatment of lumbar spinal canal stenosis and investigate its technique and clinical value.
Methods:From Jun,2006 to Aug,2008,85 patients accepted surgical treatments in our hospital due to lumbar spinal stenosis。Their ages were from 39 to 75, average 58. Their courses of disease were from 3 months to 40 years, average 4 years and 2 months.85 patients were followed up, traditional decompression operation (vertebral windowing surgery,hemivertebral resection,holovertebral resection and trasplant) in 38 cases (group A), posterior trans-pedicle internal fixation and lumbar interbody fusion PLIF in 47 cases (group B).All patients were followed up 16-43 months,with average 23 months.the clinical results of different operations were evaluated according to JO A method. Statistic analysis was done to evaluate the results.PLIF:Among 47 cases with lumbar spinal canal stenosis,decompression for stenosis were performed firstly,pedicle screws were conducted and intervertebral space increased,disc was removed while the anterior and lateral wall of fibrosus annulus were well preserved,the cartilage layer of end plate were gently cureted,some cancellous bone were inserted into the space firstly,then one or tow Cages were inserted.Finally,pedicle screw system with compression and locking was installed.
Result:Through comparison between the above two groups the results confirmed that the PLIF had obvious advantage over traditional methods in achieving instantly stabilitation,increasing the fusion rate of bone implant and duration of recombence,madvantage in blood loss,drainage and medical cost.The patients can mobilize with brace earlier post-operativly.All the patients had excellent results,all segments were confirmed to be solidly fixed by constant X-ray exzamination.there were significant retrieve of disc space height and foraminal height,and the meaningful loss of disc height was not found in following period. there were no break of Cages and pedicle screws breakage there were no infection. According to the JOA score standard, the fineness rate was 78.94% in the patients accepted traditional decompression operations (vertebral windowing surgery,hemivertebral resection,holovertebral resection and trasplant) and 95.74% in the patients accepted posterior trans-pedicle internal fixation and lumbar interbody fusion (PLIF). According to a=0.05, xc2=4.22.P<0.05.the difference between group B and group A was statistically significant. group B higher than group A. the therapeutic effect of posterior trans-pedicle internal fixation and lumbar interbody fusion (PLIF) using cage and autogenus bone grafting is better than traditional decompression operations (vertebral windowing surgery,hemivertebral resection,holovertebral resection and trasplant) for treatment of lumbar spinal canal stenosis.
Conclusion:PLIF technique meets the need of complete decompression,interbody height reconstruction,stability and sound bony fusion in the elderly lumbar disc herniation.Vertebral pedicle internal fixation can correct vertebral slip,restore the spinal physiologic curve,achieve instantly stabilization,increase the fusion rate of bone implant,ang elevate the operative effects.The effect of posterior trans-pedicle internal fixation and lumbar interbody fusion using cage and autogenus bone grafting for treatment of lumbar spinal canal stenosis is better than traditional decompression operations (vertebral windowing surgery,hemivertebral resection,holovertebral resection and trasplant).The effects of the group B were better than the group A recently,but unknown long time later.
方法：回顾性分析我院骨科自2006年6月至2008年8月收治的85例腰椎管狭窄症患者的临床资料：年龄在39岁-75岁,平均58岁,病程3个月-40年,平均4年2个月；85例患者获得隧访。对85例腰椎管狭窄症患者行传统术式(开窗减压、半椎板切除、全椎板截骨回植)减压(A组,38例)、后路椎弓根螺钉系统固定、Cage加自体骨椎间融合(PLIF)治疗(B组,47例)。术后随访16-43个月,平均23个月。采用JOA评分评估疗效并行统计学分析。PLIF:对明确诊断为腰椎管狭窄症的47例患者进行后正中入路下的椎间盘切除、椎管狭窄减压,椎弓根螺钉植入并行椎间隙撑开,保留侧方及前方的纤维环,刮除终板的软骨层,植入少许松质骨粒,安放一到两枚合适的融合器,椎弓根螺钉系统加压固定。
结果：通过围手术期疗效观察发现PLIF与传统手术相比,手术时间、出血量、引流量稍多,患者卧床时间短及术后稳定性高。术后早期患者可以佩戴支具下床活动。所有患者术后临床症状改善明显,未发现椎间隙感染及排斥反应。X线片显示椎体间植骨融合良好,无一例发生椎间隙高度明显丢失及内固定松动、断裂。根据JOA评分标准,两种术式术后优良率分别为：78.94%、95.74%。A组有效率78.94%,B组有效率95.74%。取a=0.05检验水准,Xc2=4.22. p<0.05。A组与B组比较,B组疗效优于A组,差异有统计学意义。后路椎弓根螺钉系统固定、Cage加自体骨椎间融合(PLIF)比传统术式(开窗减压、半椎板切除、全椎板截骨回植)治疗腰椎管狭窄症的疗效好。
结论：后路椎弓根螺钉系统固定、Cage加自体骨椎间融合治疗腰椎管狭窄症满足充分减压、椎间隙高度恢复和稳定性重建以及长期可靠融合治疗的基本要素,椎弓根内固定可矫正滑移,恢复脊柱的生理曲度,达到即刻稳定,增加植骨的融合率,提高手术疗效。其疗效优于传统术式(开窗减压、半椎板切除、全椎板截骨回植)。PLIF治疗组,近、中期疗效优于传统术式治疗,但长期疗效还有待于临床观察。
Objective:With the population aging and the rapid development of imaging diagnostic techniques,the morbidity of degenerative lumbar spinal stenosis(LSS) was significantly increased. It is an important cause of skelalgia in aged, and common cause for lumbar spinal surgery. The surgical and non-surgical intervention were the major treatment of LSS. In this article, the application and development of surgical therapies for degenerative LSS were expatiated, such as laminectomy and decompression, fixation with fusion discectomy, and so on. To evaluate the therapetic effect of posterior trans-pedicle internal fixation and lumbar interbody fusion (PLIF) using cage and autogenus bone grafting and traditional decompression operations (vertebral windowing surgery,hemivertebral resection,holovertebral resection and trasplant) for treatment of lumbar spinal canal stenosis and investigate its technique and clinical value.
Methods:From Jun,2006 to Aug,2008,85 patients accepted surgical treatments in our hospital due to lumbar spinal stenosis。Their ages were from 39 to 75, average 58. Their courses of disease were from 3 months to 40 years, average 4 years and 2 months.85 patients were followed up, traditional decompression operation (vertebral windowing surgery,hemivertebral resection,holovertebral resection and trasplant) in 38 cases (group A), posterior trans-pedicle internal fixation and lumbar interbody fusion PLIF in 47 cases (group B).All patients were followed up 16-43 months,with average 23 months.the clinical results of different operations were evaluated according to JO A method. Statistic analysis was done to evaluate the results.PLIF:Among 47 cases with lumbar spinal canal stenosis,decompression for stenosis were performed firstly,pedicle screws were conducted and intervertebral space increased,disc was removed while the anterior and lateral wall of fibrosus annulus were well preserved,the cartilage layer of end plate were gently cureted,some cancellous bone were inserted into the space firstly,then one or tow Cages were inserted.Finally,pedicle screw system with compression and locking was installed.
Result:Through comparison between the above two groups the results confirmed that the PLIF had obvious advantage over traditional methods in achieving instantly stabilitation,increasing the fusion rate of bone implant and duration of recombence,madvantage in blood loss,drainage and medical cost.The patients can mobilize with brace earlier post-operativly.All the patients had excellent results,all segments were confirmed to be solidly fixed by constant X-ray exzamination.there were significant retrieve of disc space height and foraminal height,and the meaningful loss of disc height was not found in following period. there were no break of Cages and pedicle screws breakage there were no infection. According to the JOA score standard, the fineness rate was 78.94% in the patients accepted traditional decompression operations (vertebral windowing surgery,hemivertebral resection,holovertebral resection and trasplant) and 95.74% in the patients accepted posterior trans-pedicle internal fixation and lumbar interbody fusion (PLIF). According to a=0.05, xc2=4.22.P<0.05.the difference between group B and group A was statistically significant. group B higher than group A. the therapeutic effect of posterior trans-pedicle internal fixation and lumbar interbody fusion (PLIF) using cage and autogenus bone grafting is better than traditional decompression operations (vertebral windowing surgery,hemivertebral resection,holovertebral resection and trasplant) for treatment of lumbar spinal canal stenosis.
Conclusion:PLIF technique meets the need of complete decompression,interbody height reconstruction,stability and sound bony fusion in the elderly lumbar disc herniation.Vertebral pedicle internal fixation can correct vertebral slip,restore the spinal physiologic curve,achieve instantly stabilization,increase the fusion rate of bone implant,ang elevate the operative effects.The effect of posterior trans-pedicle internal fixation and lumbar interbody fusion using cage and autogenus bone grafting for treatment of lumbar spinal canal stenosis is better than traditional decompression operations (vertebral windowing surgery,hemivertebral resection,holovertebral resection and trasplant).The effects of the group B were better than the group A recently,but unknown long time later.
引文
[1].贾连顺,杨立利,退变性腰椎管狭窄症的现代外科学概念(J).中华骨科杂志,2002 22(8)：509-512
[2].Lee CK, Rauschning W, Glenn W. Lateral lumbar spinalⅧ1aIstenosis: classification, pathologic anatomy and surgical decem—pression[J]. Spine, 1988,13(3):313-320.
[3]. Hansraj KK, Cammisa FP Jr, OLeary PF, et al. Deeompressivesurgery for typical lumbar spinal stenosis[J]. Clin Orthop RelatRes,2001, (384):10-17.
[4].赵延胜.腰椎管狭窄症手术治疗进展(J).Chinese Journal Modern Operative Surgery,2009,2:70-74
[5].胥少汀,葛宝丰,徐印坎.实用骨科学.第3版.北京：人民军医出版社,2008.10：1713-1715.
[6]. Postacchini F. Spine,1999:24(10):1043-1047
[7]. Amundsen T, Weber H, Nordal HJ et al. Spine,2000; 25(11):1424-1435
[8]. Atlas SJ, Keller RB, Robson D et al. Spine,2000:25(5):556 - 562
[9]. Postacchini F. Spine,1999:24(10):1043-1047
[10]. Spivak JM. J Bone Joint Surg Am,1998:80(7):1053-1066
[11]. Rosen C, Rothman S, Zigler J, et al. Lumbar facet fracfure as a possible source of painafter lumbar laminectomy. Spine,1991; 16(Suppl):234
[12].李慧友,朱青安,李桂兰等.单侧小关节分级切除对腰椎稳定性影响的三维运动研究.中国脊柱脊髓杂志,1996；6(5)：206
[13]. Postacchini F, Cinotti G, Gumina S. Longterm results of surgery in lumbar spinalstenosis. J Bone Joint Surg(Br),1993; 75:175
[14].Malcolm HP, John WF, Martin HK. Diagnosing instability. Clin orthop,1992; 227:143
[15].陈其听,陈维善.腰椎管后路减压术后的腰椎不稳定及其对手术结果的影响.中华骨科杂志,1997；17(10)：603
[16]. Harry B,Skinner MD,PhD.Current Diagnosis & Treatment in Orthopedics[M].Second Edition.北京：人民卫生出版社,2000.201.
[17].Spetzger U, Bertalanffy H, Reinges MH, et al. Unilateral laminot—omy for bilateral decompression of lumbar spinal stenosis. Pardi:Clinical experiences[J]. Acta Neurochir(Wien),1997,139(5):397-403.
[18].吴叶,李家顺,贾连顺.单椎板切除双侧减压和保守治疗腰椎管狭窄疗效的比较[J].颈腰痛杂志,2003,24(4)：210-213.
[19]. Postaechini F, Cinotti G, Perugia D, et al. The surgical.treatmentof.central lumbar stenosis. Multiple laminotomy compared with tOtallaminectomy[J]. J Bone Joint Surg Br,1993,75(3):386-392.
[20]. Guigui P,Ulivieri JM,Lassale B,et al.Reoperations after surgical treatment of lumbar stenosis [J].Rev Chir Orthop Reparatrice Appar Mot,1995,81 (8):663-671.
[21]. Aota X,Kumano K,Hirabagashi S.Postfusion instability at the adjacent segments after rigid pedicl screw fixation for degenerative lumbar spinal disorders [J].J Spinal Disord,1995,8 (6):464-473.
[22]. Spivak JM. J Bone Joint Surg Am,1998:80(7):1053-1066
[23]. Fischgrund JS. The argument for instrumented deeompressive posterolateralfusion for patients with degenerative spondylolisthesis and spinal stenosis(J). Spine,2004,29(2):173-174
[24]. Eisentein S. Fusion for spinal stenosis:a personaiview(J). J Bone Jiont SurgBr, 2002,84,9-10
[25]. Fraser JF, Huang RC, Giraidi FP, et al Pathogenesis presentation and treatment oflumbar spinal stenosis associated with coronal or sagittal spinal befomities JNeurosurg Focus 2003 14(1):16.
[26]. Hanisraj KK, Cammisa FP J O'Leary PF, et al Decompressive surlumbar spinal stenosis J Clin Orthop Relat Res 2001,384:10-17.
[27]. Smmons ED. Surgical reatment patients with sseoliosis J Clin Orthop Relat Res 2001,384:45-53.
[28].丁文元,张为,申勇,等.经腹腔镜腰椎融合术,中华骨科杂志,2002,22：237.
[29]. Kuslich SD. The scientific Basis for the badge method of spinal intedxMyFusion. ISSLS Annual Meeting. Afimna, USA,1993.23-24.
[30]. Ray CD. Lumbar interbody threaded prothese in his text book'The Artifi-cal Disc". Berlin, Springer Verag. Brock MB,1991.53-57. Disc. Berlin, Springer
[31]. Nibu K, Panjabi MM, Oxland T, et al. Muhidirectional stability potenialof BAK interbody spinal fusion system for anterior suregery. J Spinal Dis-cord,1997, 10:357-362.
[32].Harms JK. Screw—threaded rod system in spinal fusion suregery. Spine,1992, 6:541-575.
[33]. Jassen ME, Cam C, Beckham R, et al. Outcomes of allogenie cages in terior and posterior lumbar fusion. Eur, Spine J,2001,10:158-168.
[34]. Thomas RO, Zohan H, Thomas NO, et al. A comparative biomechanieal investigation of anterior lumbar interbody cage:central and bilateral ap-proaches. J Bone and Joint Surg(Am),2000,82:383-393.
[35]. Ahthony J, Antonios AO, Max A. Biomeehanical stability of five stand alone anterior lumbar interbody fusion constructs. Eur, Spine J,2000,9: 14.22.
[36]. Asano S,Kaneda K,Umehara S,et al.The mechanical properties of the human L4-5 functional spinal unit during cyclic loading.the structural effects of the posteriorelements. Spine,1992,17:1343-1352
[37]. Brantigan JW,McAfee PC,Cunningham BW,et al.Interbody lumbar fusion using a carbon fiber cage implant versus allograft bone:an investingational study in the Spanish goat [J].Spine,1994,19(13):1436-1444.
[38].Bagby GW.Arthrodesis by the distraction-compression method using a stainless steel implant [J].Orthopedics,1988,11(6):931-934.
[39]. Goh JC, Wong HK, Thambyah A, et al.Influence of PLIF cage size on lumbar spine stability [J]. Spine,2000,25 (1):35-39.
[40]. Aota X,Kumano K,Hirabagashi S.Postfusion instability at the adjacent segments after rigid pedicl screw fixation for degenerative lumbar spinal disorders [J].J Spinal Disord,1995,8 (6):464-473.
[41].Garner MD, Wolfe SJ, Kuslich SD. Development and preclinicaltesting of a new tensian-band device for the spine:the Imp sys-tern[J]. Eur Spine J,2002, JI Suppl 2:S186-S191.
[42].Hashimoto T, Oha F. Shigenobu K. el al. Mid-term clinical suits of raf stabilization for lumbar degenerative pathoh,gies. a
[43].sengup DK. Dynamic stabilization devices in the treatment of lowback pain[J]. Neurol India,2005,53(4):466-474.
[44]. Khoo LT, Fessler RG. Micruendoscopic decompressive laminotomy for the treatment of lumbar stenosis[J]. Neurosorgery,2002,51 (5Suppi):S146-S154.
[45].千文军,宋西正,王鹿山等.町膨胀式椎问融合器B-twin在腰椎间盘退行性疾病治疗中的作用[A].第八届全国脊柱脊髓损伤学术会议论文汇编[C],2007.
[46]. sengupDK. Dynamic stabilization devices in the treatment of lowback pain[J]. Neurol India,2005,53(4):466-474.
[47].Sengupta DK。Mulholland RC. Fuk-rum assisted soft stabilization system:a new concept in the surgk'al treatment of degenerative low back pain[J]. Spine,2005,30(9):1019-1029.
[48].周跃,李长青,王键,等.内窥镜(METR)下单侧入路行双侧椎管减压治疗退变性腰椎管狭窄症[A].第三届全国微创脊柱外科学术会议论文汇编.2008.
[49].Herrron LD, Trippi AC. L4-5 degenerative sopndylolithesis:the results oftreatment by decompressive laminectomy without fusion. Spine,1989,14: 534.538
[50]. Fischgrund JS, Mackay M, Herkowitz HN et al. Spine,1997; 22(24):2807-28 12
[51]. Kornblum MB Fischgrund JS, herkowitz HN, et al. Degenerative lumbar spondylolisthesis with spinal stenosis:a prospective long'term study comparingfusion and pseudarthrosis.. Spine.2004,29(7):726-733.
[52].Simmons ED. Surgical treatment of patients with lumbar spinal stenosis withassociated scoliosis. Clin Orthop,2001, (384):45-53
(53]. Blau JN, Logue V. The natural history of intermiltent claudication ofthe cauda equina[J]. Brain,1978,101:211-222.
[54].Tile M, Mcneil SR, Zains RK, et al. Spinal stenosis:results of treatment[J]. Clin Orthop,1976,115:104-108.
[55]. Rosomoff H, Rosomoff R. Nonsurgieal aggressive treatment of lumbar spinal stenosis[J]. Spine,1987,3:383.
[56]. Saal JS, SaM JA, Parthasarathy R, et al. The natural history of lumbar spinal stenosis. The results of nonoperative treatment[R]. Presented atthe Annual Meeting of the International Society for the Study of the Lumbar Spine, Singapore,1997.
[57].Hemo A, Nevalainen S, Saari T, et al. The natural course of 91 nonoperatedpatients with lumbar spinal stenosis[R]. Presented at the Annual Meeting of the International Society for the Study of the Lumbar Spine, Burlington,1996,25-29.
[58].Amundsen T, Weber H, Nordal H, et al. Lumbar spinal stenosis:con—servative or surgical management. A prospective 10 year study[J]. Spine,2000,25: 1424-1435.
[59].刘伟,退变性腰椎管狭窄症的预后研究进展.中国矫形外科杂志,2007.15(3)：203-205
[60].Costanzo G, Cellocco P, Di Francesco D. The role of JO A score as an indication for surgical or conservative treatment of symptomatic degenerative lumbar spinal stenosis[J]. J Orthopaed Traumatol,2005,6:150.153.
[61]. Porter RW, Hibbert C, Evans C. The natural history of root entrapment syndrome[J]. Spine,1984,9:418-421.
[62].Postacchini F. Lumbar spinal stenosis. Long-term results. In:Wiesel SW, Weinstein JN. Herkowitz H. et al. The lumbar spine, Volume 2 [M]. Philadelphia:WB Saunders,1990,766-781.
[63].Johnsson Ke, Rosen I, Uden A. The natural coul. se of lumbar spinal stenosis[J]. Clin Orthop,1992,279:82-86.
[64].Johnsson, KE, Sass M. Cauda equina syndrome in lumbar spinal stenosis: casc report andincidencein Jutland, Denmark[J]. J SpinalDisordTech,2004, 17(4):334-335.
[65].Spetzger U, Bertalanffy H, Rcinges MHT, et al.Unilateral laminotomy for bilateral decompression of lumbar spinal stenosis[J]. Acta Neurochir( Wien),1997,139:397-403.
[66].Gunzburg R, Szpalski M. The conservative treatment of lumbar spinal stenosis in the elderly[J]. Eur Spine,2003,12(Suppl2):81-83.
[67]Amundsen T, Weber H, Nordal H, et al. Lumbar spinal stenosis:con-servative or surgical management. A prospective 10 year study [J]. Spine,2000, 25:1424-1435.
[68]Porter RW, Hibbert C, Evans C. The natural history of root entrapment syndrome[J]. Spine,1984,9:418-421.
[69].Airaksinen O, Hemo A, Tumnen V, et al. Surgical outcome of 438 patients treated surgically for lumbar spinal stenosis[J]. Spine,1997,22:2278-2282.
[70].loannis D, Gelalis, Kosmas S, et al. Decompressive surgery for degenerative lumbar spinal stenosis:long-term results [J]. International Oahopaedics,2005, 10(2).
[71].Costanzo G, Cellocco P, Di Francesco D. The role of JO A score as an indication for surgical or conservative treatment of symptomatic degenerative lumbar spinal stenosis[J]. J Orthopaed Traumatol,2005,6:150.153.
[72].Johnsson Ke, Uden A, Rosen I. The effect ofdecompression on the nat—ural course of spinal stenosis. A comparison of sumcally treated anduntreated patients[J]. Spine,1991,16:615-619.
[73].Atlas SJ, Keller RB, Robson D, et al. Surgical and non surgical man—agement of lumbar spinal stenosis. Four year outcomes from the mainelumbar spine study[J]. Spine,2000,25:556-562.
[74].Zucherman JF, Hsu KY, Hartjen CA, et al. A prospective randomized multi-center study for the treatment of lumbar spinal stenosis with the X-STOP intempinous implant:year results[J]. Eur Spine J,2004,13(1):22-31.
[75].Chang Y, Singer DE, Wu YA. The effect of surgical and nonsurgical treatment on longitudinal outcomes of lumbar spinal stenosis over 10 years[J]. J AmGeriatr Soc,2005,53(5):785-792.
[76].Smorgick Y, Mirevsky Y, Rand N. Degenerative lumbar spinal stenosis: review ofthe current diagnosis andtreatment[J]. Harefuah,2005,144(4): 279-284,302.
[77]. Snyder DL, Doggett D, Turkelson C. Treatment of degenerative lumbar spinal stenosis[J]. Am Fam Physician,2004,70(3):517-520.
[78].Baskov AV, Ogleznev KIa, Sidorov EV, et al. Prognosis of the outcome of the samcal treatment of the acquired lumbar spinal stenosis[J]. Zh-Vopr-Neirokhir-Im N-N-Burdenko,2003, (2):20-26.
[79]Aota X,Kumano K,Hirabagashi S.Postfusion instability at the adjacent segments after rigid pedicl screw fixation for degenerative lumbar spinal disorders [J].J Spinal Disord,1995,8 (6):464-473.
[2].Lee CK, Rauschning W, Glenn W. Lateral lumbar spinalⅧ1aIstenosis: classification, pathologic anatomy and surgical decem—pression[J]. Spine, 1988,13(3):313-320.
[3]. Hansraj KK, Cammisa FP Jr, OLeary PF, et al. Deeompressivesurgery for typical lumbar spinal stenosis[J]. Clin Orthop RelatRes,2001, (384):10-17.
[4].赵延胜.腰椎管狭窄症手术治疗进展(J).Chinese Journal Modern Operative Surgery,2009,2:70-74
[5].胥少汀,葛宝丰,徐印坎.实用骨科学.第3版.北京：人民军医出版社,2008.10：1713-1715.
[6]. Postacchini F. Spine,1999:24(10):1043-1047
[7]. Amundsen T, Weber H, Nordal HJ et al. Spine,2000; 25(11):1424-1435
[8]. Atlas SJ, Keller RB, Robson D et al. Spine,2000:25(5):556 - 562
[9]. Postacchini F. Spine,1999:24(10):1043-1047
[10]. Spivak JM. J Bone Joint Surg Am,1998:80(7):1053-1066
[11]. Rosen C, Rothman S, Zigler J, et al. Lumbar facet fracfure as a possible source of painafter lumbar laminectomy. Spine,1991; 16(Suppl):234
[12].李慧友,朱青安,李桂兰等.单侧小关节分级切除对腰椎稳定性影响的三维运动研究.中国脊柱脊髓杂志,1996；6(5)：206
[13]. Postacchini F, Cinotti G, Gumina S. Longterm results of surgery in lumbar spinalstenosis. J Bone Joint Surg(Br),1993; 75:175
[14].Malcolm HP, John WF, Martin HK. Diagnosing instability. Clin orthop,1992; 227:143
[15].陈其听,陈维善.腰椎管后路减压术后的腰椎不稳定及其对手术结果的影响.中华骨科杂志,1997；17(10)：603
[16]. Harry B,Skinner MD,PhD.Current Diagnosis & Treatment in Orthopedics[M].Second Edition.北京：人民卫生出版社,2000.201.
[17].Spetzger U, Bertalanffy H, Reinges MH, et al. Unilateral laminot—omy for bilateral decompression of lumbar spinal stenosis. Pardi:Clinical experiences[J]. Acta Neurochir(Wien),1997,139(5):397-403.
[18].吴叶,李家顺,贾连顺.单椎板切除双侧减压和保守治疗腰椎管狭窄疗效的比较[J].颈腰痛杂志,2003,24(4)：210-213.
[19]. Postaechini F, Cinotti G, Perugia D, et al. The surgical.treatmentof.central lumbar stenosis. Multiple laminotomy compared with tOtallaminectomy[J]. J Bone Joint Surg Br,1993,75(3):386-392.
[20]. Guigui P,Ulivieri JM,Lassale B,et al.Reoperations after surgical treatment of lumbar stenosis [J].Rev Chir Orthop Reparatrice Appar Mot,1995,81 (8):663-671.
[21]. Aota X,Kumano K,Hirabagashi S.Postfusion instability at the adjacent segments after rigid pedicl screw fixation for degenerative lumbar spinal disorders [J].J Spinal Disord,1995,8 (6):464-473.
[22]. Spivak JM. J Bone Joint Surg Am,1998:80(7):1053-1066
[23]. Fischgrund JS. The argument for instrumented deeompressive posterolateralfusion for patients with degenerative spondylolisthesis and spinal stenosis(J). Spine,2004,29(2):173-174
[24]. Eisentein S. Fusion for spinal stenosis:a personaiview(J). J Bone Jiont SurgBr, 2002,84,9-10
[25]. Fraser JF, Huang RC, Giraidi FP, et al Pathogenesis presentation and treatment oflumbar spinal stenosis associated with coronal or sagittal spinal befomities JNeurosurg Focus 2003 14(1):16.
[26]. Hanisraj KK, Cammisa FP J O'Leary PF, et al Decompressive surlumbar spinal stenosis J Clin Orthop Relat Res 2001,384:10-17.
[27]. Smmons ED. Surgical reatment patients with sseoliosis J Clin Orthop Relat Res 2001,384:45-53.
[28].丁文元,张为,申勇,等.经腹腔镜腰椎融合术,中华骨科杂志,2002,22：237.
[29]. Kuslich SD. The scientific Basis for the badge method of spinal intedxMyFusion. ISSLS Annual Meeting. Afimna, USA,1993.23-24.
[30]. Ray CD. Lumbar interbody threaded prothese in his text book'The Artifi-cal Disc". Berlin, Springer Verag. Brock MB,1991.53-57. Disc. Berlin, Springer
[31]. Nibu K, Panjabi MM, Oxland T, et al. Muhidirectional stability potenialof BAK interbody spinal fusion system for anterior suregery. J Spinal Dis-cord,1997, 10:357-362.
[32].Harms JK. Screw—threaded rod system in spinal fusion suregery. Spine,1992, 6:541-575.
[33]. Jassen ME, Cam C, Beckham R, et al. Outcomes of allogenie cages in terior and posterior lumbar fusion. Eur, Spine J,2001,10:158-168.
[34]. Thomas RO, Zohan H, Thomas NO, et al. A comparative biomechanieal investigation of anterior lumbar interbody cage:central and bilateral ap-proaches. J Bone and Joint Surg(Am),2000,82:383-393.
[35]. Ahthony J, Antonios AO, Max A. Biomeehanical stability of five stand alone anterior lumbar interbody fusion constructs. Eur, Spine J,2000,9: 14.22.
[36]. Asano S,Kaneda K,Umehara S,et al.The mechanical properties of the human L4-5 functional spinal unit during cyclic loading.the structural effects of the posteriorelements. Spine,1992,17:1343-1352
[37]. Brantigan JW,McAfee PC,Cunningham BW,et al.Interbody lumbar fusion using a carbon fiber cage implant versus allograft bone:an investingational study in the Spanish goat [J].Spine,1994,19(13):1436-1444.
[38].Bagby GW.Arthrodesis by the distraction-compression method using a stainless steel implant [J].Orthopedics,1988,11(6):931-934.
[39]. Goh JC, Wong HK, Thambyah A, et al.Influence of PLIF cage size on lumbar spine stability [J]. Spine,2000,25 (1):35-39.
[40]. Aota X,Kumano K,Hirabagashi S.Postfusion instability at the adjacent segments after rigid pedicl screw fixation for degenerative lumbar spinal disorders [J].J Spinal Disord,1995,8 (6):464-473.
[41].Garner MD, Wolfe SJ, Kuslich SD. Development and preclinicaltesting of a new tensian-band device for the spine:the Imp sys-tern[J]. Eur Spine J,2002, JI Suppl 2:S186-S191.
[42].Hashimoto T, Oha F. Shigenobu K. el al. Mid-term clinical suits of raf stabilization for lumbar degenerative pathoh,gies. a
[43].sengup DK. Dynamic stabilization devices in the treatment of lowback pain[J]. Neurol India,2005,53(4):466-474.
[44]. Khoo LT, Fessler RG. Micruendoscopic decompressive laminotomy for the treatment of lumbar stenosis[J]. Neurosorgery,2002,51 (5Suppi):S146-S154.
[45].千文军,宋西正,王鹿山等.町膨胀式椎问融合器B-twin在腰椎间盘退行性疾病治疗中的作用[A].第八届全国脊柱脊髓损伤学术会议论文汇编[C],2007.
[46]. sengupDK. Dynamic stabilization devices in the treatment of lowback pain[J]. Neurol India,2005,53(4):466-474.
[47].Sengupta DK。Mulholland RC. Fuk-rum assisted soft stabilization system:a new concept in the surgk'al treatment of degenerative low back pain[J]. Spine,2005,30(9):1019-1029.
[48].周跃,李长青,王键,等.内窥镜(METR)下单侧入路行双侧椎管减压治疗退变性腰椎管狭窄症[A].第三届全国微创脊柱外科学术会议论文汇编.2008.
[49].Herrron LD, Trippi AC. L4-5 degenerative sopndylolithesis:the results oftreatment by decompressive laminectomy without fusion. Spine,1989,14: 534.538
[50]. Fischgrund JS, Mackay M, Herkowitz HN et al. Spine,1997; 22(24):2807-28 12
[51]. Kornblum MB Fischgrund JS, herkowitz HN, et al. Degenerative lumbar spondylolisthesis with spinal stenosis:a prospective long'term study comparingfusion and pseudarthrosis.. Spine.2004,29(7):726-733.
[52].Simmons ED. Surgical treatment of patients with lumbar spinal stenosis withassociated scoliosis. Clin Orthop,2001, (384):45-53
(53]. Blau JN, Logue V. The natural history of intermiltent claudication ofthe cauda equina[J]. Brain,1978,101:211-222.
[54].Tile M, Mcneil SR, Zains RK, et al. Spinal stenosis:results of treatment[J]. Clin Orthop,1976,115:104-108.
[55]. Rosomoff H, Rosomoff R. Nonsurgieal aggressive treatment of lumbar spinal stenosis[J]. Spine,1987,3:383.
[56]. Saal JS, SaM JA, Parthasarathy R, et al. The natural history of lumbar spinal stenosis. The results of nonoperative treatment[R]. Presented atthe Annual Meeting of the International Society for the Study of the Lumbar Spine, Singapore,1997.
[57].Hemo A, Nevalainen S, Saari T, et al. The natural course of 91 nonoperatedpatients with lumbar spinal stenosis[R]. Presented at the Annual Meeting of the International Society for the Study of the Lumbar Spine, Burlington,1996,25-29.
[58].Amundsen T, Weber H, Nordal H, et al. Lumbar spinal stenosis:con—servative or surgical management. A prospective 10 year study[J]. Spine,2000,25: 1424-1435.
[59].刘伟,退变性腰椎管狭窄症的预后研究进展.中国矫形外科杂志,2007.15(3)：203-205
[60].Costanzo G, Cellocco P, Di Francesco D. The role of JO A score as an indication for surgical or conservative treatment of symptomatic degenerative lumbar spinal stenosis[J]. J Orthopaed Traumatol,2005,6:150.153.
[61]. Porter RW, Hibbert C, Evans C. The natural history of root entrapment syndrome[J]. Spine,1984,9:418-421.
[62].Postacchini F. Lumbar spinal stenosis. Long-term results. In:Wiesel SW, Weinstein JN. Herkowitz H. et al. The lumbar spine, Volume 2 [M]. Philadelphia:WB Saunders,1990,766-781.
[63].Johnsson Ke, Rosen I, Uden A. The natural coul. se of lumbar spinal stenosis[J]. Clin Orthop,1992,279:82-86.
[64].Johnsson, KE, Sass M. Cauda equina syndrome in lumbar spinal stenosis: casc report andincidencein Jutland, Denmark[J]. J SpinalDisordTech,2004, 17(4):334-335.
[65].Spetzger U, Bertalanffy H, Rcinges MHT, et al.Unilateral laminotomy for bilateral decompression of lumbar spinal stenosis[J]. Acta Neurochir( Wien),1997,139:397-403.
[66].Gunzburg R, Szpalski M. The conservative treatment of lumbar spinal stenosis in the elderly[J]. Eur Spine,2003,12(Suppl2):81-83.
[67]Amundsen T, Weber H, Nordal H, et al. Lumbar spinal stenosis:con-servative or surgical management. A prospective 10 year study [J]. Spine,2000, 25:1424-1435.
[68]Porter RW, Hibbert C, Evans C. The natural history of root entrapment syndrome[J]. Spine,1984,9:418-421.
[69].Airaksinen O, Hemo A, Tumnen V, et al. Surgical outcome of 438 patients treated surgically for lumbar spinal stenosis[J]. Spine,1997,22:2278-2282.
[70].loannis D, Gelalis, Kosmas S, et al. Decompressive surgery for degenerative lumbar spinal stenosis:long-term results [J]. International Oahopaedics,2005, 10(2).
[71].Costanzo G, Cellocco P, Di Francesco D. The role of JO A score as an indication for surgical or conservative treatment of symptomatic degenerative lumbar spinal stenosis[J]. J Orthopaed Traumatol,2005,6:150.153.
[72].Johnsson Ke, Uden A, Rosen I. The effect ofdecompression on the nat—ural course of spinal stenosis. A comparison of sumcally treated anduntreated patients[J]. Spine,1991,16:615-619.
[73].Atlas SJ, Keller RB, Robson D, et al. Surgical and non surgical man—agement of lumbar spinal stenosis. Four year outcomes from the mainelumbar spine study[J]. Spine,2000,25:556-562.
[74].Zucherman JF, Hsu KY, Hartjen CA, et al. A prospective randomized multi-center study for the treatment of lumbar spinal stenosis with the X-STOP intempinous implant:year results[J]. Eur Spine J,2004,13(1):22-31.
[75].Chang Y, Singer DE, Wu YA. The effect of surgical and nonsurgical treatment on longitudinal outcomes of lumbar spinal stenosis over 10 years[J]. J AmGeriatr Soc,2005,53(5):785-792.
[76].Smorgick Y, Mirevsky Y, Rand N. Degenerative lumbar spinal stenosis: review ofthe current diagnosis andtreatment[J]. Harefuah,2005,144(4): 279-284,302.
[77]. Snyder DL, Doggett D, Turkelson C. Treatment of degenerative lumbar spinal stenosis[J]. Am Fam Physician,2004,70(3):517-520.
[78].Baskov AV, Ogleznev KIa, Sidorov EV, et al. Prognosis of the outcome of the samcal treatment of the acquired lumbar spinal stenosis[J]. Zh-Vopr-Neirokhir-Im N-N-Burdenko,2003, (2):20-26.
[79]Aota X,Kumano K,Hirabagashi S.Postfusion instability at the adjacent segments after rigid pedicl screw fixation for degenerative lumbar spinal disorders [J].J Spinal Disord,1995,8 (6):464-473.