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腰椎管狭窄症手术治疗的临床分析

Surgicaltreatmentof Complicated Lumbar Spinal Stenosis

作者: 专业:外科学 导师:聂林 年度:2010 学位:硕士  院校: 山东大学

Keywords

lumbar spinal canal stenosis, decompression, fusion

        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.
        

腰椎管狭窄症手术治疗的临床分析

中文摘要6-8
ABSTRACT8-10
符号说明11-12
前言12-14
资料与方法14-16
结果16-17
讨论17-31
结论31-32
附图表32-37
参考文献37-44
致谢44-45
攻读学位期间发表的学术论文目录45-46
学位论文评阅及答辩情况表46
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