经皮椎间孔镜与椎板开窗术治疗腰椎间盘突出症的疗效对比

目的比较经皮内镜和椎板开窗髓核摘除术治疗单节段单侧腰椎间盘出症的临床效果及优缺点。方法回顾性分析自2011-01—2014-01诊治的278例腰椎间盘突出症,采用经皮内镜腰椎间盘切除术治疗142例,采用椎板开窗髓核摘除术治疗136例。结果椎板开窗髓核摘除术出血量多和时间短,并发症多,2组比较差异有统计学意义(P0.05);术后2周、3个月和6个月Macnab标准优良率2组比较,经皮内镜腰椎间盘切除术优于椎板开窗髓核摘除术,差异均有统计学意义(P0.05)。结论 2种术式都能有效缓解腰椎间盘突出症患者的症状,但经皮内镜腰椎间盘切除术后并发症发生率低,是理想的微创治疗腰椎间盘突出症的方法。     

经皮椎间孔镜下髓核摘除术治疗腰椎间盘突出症术中并发症分析

经皮椎间孔镜下髓核摘除术(PELD)被认为是腰椎间盘突出症微创脊柱外科手术技术,其适应证也随着该技术的发展而逐渐扩大。但PELD术中并发症并不少见,其术中并发症主要有硬脊膜撕裂与脑脊液漏、术区出血、神经损伤、类脊髓高压症、术中减压失败及器械断裂等。PELD技术对术者专业知识和操作技能的要求较高且不易学习。该文就PELD术中并发症发生原因及防治方法作一综述。     

经皮脊柱内镜技术与传统开放手术治疗腰椎间盘突出症并发症的系统评价与Meta分析

目的 :系统分析经皮脊柱内镜技术与传统开放手术治疗腰椎间盘突出症的相关的并发症发生率及其特点。方法:两位作者独立对MEDLINE、Cochrane library、Pubmed数据库、Web of Science、中国期刊全文数据库(CNKI)、万方数据库和Embase数据库进行关于经皮脊柱内镜技术和传统开放手术治疗腰椎间盘突出症相关的并发症的随机对照试验(RCT)及队列研究进行搜索。语种不限。两位作者独立评估各研究的质量,且将各研究中的术中和术后各种并发症(术后感觉异常、神经根直接损伤、硬脊膜损伤、术区伤口并发症、椎间盘复发、髓核部分残留、相关并发症的额外手术及其他并发症)等提取整理为电子基线表,并将这些研究的数据通过Revman 5.3软件进行Meta分析与综合,以评估两种手术技术在各种并发症方面的统计学意义。结果:共有24篇研究最终被纳入,共计2797例患者被纳入分析。经皮脊柱内镜技术与传统开放手术比较:两者的术后感觉异常[OR=0.84,95%CI(0.57,1.24)]的发生率相等。前者相关并发症的额外手术[OR=1.15,95%CI(0.79,1.66)]的发生率略高,但无统计学差异(P0.05);后者椎间盘复发[OR=1.03,95%CI(0.67,1.61)]、其他并发症[OR=0.88,95%CI(0.53,1.46)]的发生率高于前者,但亦无统计学差异(P0.05);前者髓核部分残留[OR=2.82,95%CI(1.36,5.85)]的发生率较高,差异有统计学意义(P0.05);后者神经根直接损伤[OR=0.28,95%CI(0.09,0.80)]、硬脊膜损伤[OR=0.34,95%CI(0.17,0.70)]、术区伤口并发症[OR=0.31,95%CI(0.14,0.70)]的发生率较高,差异有统计学意义(P0.05)。结论:相对于传统开放手术治疗腰椎间盘突出症,经皮脊柱内镜技术在减少神经根损伤、硬脊膜损伤及术区伤口并发症方面占有明显优势,但在防止手术部位髓核残留方面受限于经皮内镜技术特点,差于开放手术。     

腰椎间盘摘除术中神经根鞘内注药的疗效观察

目的评价后路小切口椎板间开窗腰椎间盘髓核摘除术中神经根鞘内注射类固醇激素的临床疗效。方法自2013-01—2015-12对70例腰椎间盘髓核摘除术患者进行前瞻性随机分为2组,观察组采用后路小切口椎板间开窗腰椎间盘髓核摘除术中神经根鞘内注射类固醇激素;对照组采用后路小切口椎板间开窗腰椎间盘髓核摘除术后全身短期使用类固醇激素。评价2组术前和术后4 d、7 d、14 d、1个月、3个月的JOA评分及改善率以及不良反应的发生。结果观察组术后4、7、14 d的JOA评分及JOA改善率均明显高于对照组,差异均有统计学意义。2组均未发生神经根、硬脊膜损伤,术后均无切口愈合不良及脑脊液漏等并发症。结论后路小切口椎板间开窗腰椎间盘髓核摘除术中神经根鞘内注射类固醇激素治疗腰椎间盘突出症疗效显著,安全性高,明显优于静脉短期全身使用类固醇激素。     

经皮椎间孔镜技术与小切口椎板开窗髓核摘除术治疗腰椎间盘突出症的疗效比较

目的比较经皮椎间孔镜技术与小切口椎板开窗髓核摘除术治疗腰椎间盘突出症疗效。方法将166例腰椎间盘突出症患者随机分为两组,每组83例,对照组采用小切口椎板开窗髓核摘除术,观察组采用经皮椎间孔镜技术。比较两组手术相关指标、疼痛缓解和功能恢复情况、临床疗效及并发症发生情况。结果患者均获得3个月随访。切口长度、手术时间、术中出血量及住院时间观察组均优于对照组(P 0. 001)。术后3个月,两组VAS评分、JOA评分及临床治疗有效率比较差异均无统计学意义(P 0. 05)。并发症发生率观察组低于对照组(P 0. 05)。结论经皮椎间孔镜技术与小切口椎板开窗髓核摘除术治疗腰椎间盘突出症临床疗效相当,但经皮椎间孔镜技术损伤少,并发症少,住院时间短。     

经皮椎间孔镜与椎板开窗髓核摘除术治疗复发性腰椎间盘突出症的疗效比较

目的比较经皮椎间孔镜和椎板开窗髓核摘除术治疗复发性腰椎间盘突出症的临床疗效。方法回顾性分析自2012-06—2014-02诊治的单节段同侧椎板开窗髓核摘除术后复发性腰椎间盘突出症42例,采用经皮椎间孔镜技术治疗18例(椎间孔镜组),采用椎板开窗髓核摘除术治疗24例(椎板开窗组)。采用VAS评分和ODI指数评价2组手术疗效。结果 2组均获得随访8~12个月,平均10.7个月。2组术后腰痛、腿痛VAS评分及ODI指数较术前明显降低,差异有统计学意义(P0.05)。椎间孔镜组与椎板开窗组术后1 d、1个月、6个月、末次随访时腰痛VAS评分比较差异无统计学意义(P0.05)。椎间孔镜组术后1 d腿痛VAS评分低于椎板开窗组,差异有统计学意义(P0.05);但2组术后1个月、6个月、末次随访时的腿痛VAS评分比较差异无统计学意义(P0.05)。结论经皮椎间孔镜手术是治疗复发性腰椎间盘突出症的有效方法,但手术费用较昂贵,学习曲线长。     

单侧椎弓根内固定椎间融合术治疗复发性腰椎间盘突出症疗效分析

目的比较传统髓核摘除术（A组）及单侧椎弓根内固定椎间融合术（B组）治疗复发性腰椎间盘突出症的临床疗效。方法对自2000一01—2012—02收治的复发性腰椎间盘突出症86例行手术治疗,包括行单纯传统髓核摘除术52例,行单侧椎弓根内固定椎间融合术34例。结果B组末次随访VAS、ODI及JOA评分均优于A组,差异有统计学意义（P〈O．05）;2组间并发症发生率比较,差异无统计学意义（P〉O．05）。结论采用单侧椎弓根内固定椎间融合术治疗复发性腰椎间盘突出症较传统髓核摘除术能取得更好的临床疗效。     

类脊髓高压综合征的发生机制及预防措施

<正>随着对腰椎间盘突出症的科学认识及手术技术的不断改进，后外侧入路椎间孔镜腰椎间盘髓核摘除术及后路椎板间腰椎髓核摘除术已经成为治疗腰椎间盘突出症的主流手术方式^[1]。经历40余年的临床应用，手术器械更新换代，手术技术臻至成熟，为众多腰椎间盘突出症患者解决了疾病的困扰。随着该手术的广泛开展，经皮椎间孔镜腰椎间盘髓核摘除术出现很多原因较为明确的并发症，比如髓核残留、神经根损伤、硬脊膜撕裂(脑脊液漏)、神经根诱发痛觉过敏、手术器械断裂、椎管内血肿     

后路椎间盘镜手术中转传统开窗椎板切除髓核摘除术的原因分析

目的 分析后路椎间盘镜(MED)治疗腰椎间盘突出症术中转传统开窗椎板部分切除髓核摘除术的原因,探讨相应的预防措施.方法 分析应用MED技术治疗300例(342个间隙)患者的临床资料,总结9例中转开窗椎板部分切除髓核摘除术的原因,并提出相应的预防措施.结果 300例患者手术切口均一期愈合.疗效评定:优148例,良130例,中18例,差4例,优良率为92.7%.中转开窗椎板部分切除髓核摘除术9例:3例术中出血多者果断中转而治愈;5例脑脊液漏者经治疗治愈;1例神经根损伤开放探查,为部分马尾损伤,经治疗残留部分感觉减退但无足下垂.结论 硬脊膜损伤、术中出血、神经根损伤是MED治疗腰椎间盘突出症中转传统开窗椎板部分切除髓核摘除术的常见原因;术者丰富的微创经验、合适的病例选择可减少MED治疗腰椎间盘突出症中转开窗椎板部分切除髓核摘除术.     

经皮内镜下腰椎间盘切除术

近年来,经皮内镜下腰椎间盘切除术(PELD)已由非直视下切除椎间盘中央髓核的间接减压术,发展为内镜直视下切除压迫神经根髓核的直接减压术.PELD适应证与腰椎板开窗髓核切除术适应证相似,随着外科技术和设备的发展,也适用于椎间孔狭窄、侧隐窝狭窄和高髂嵴的L5～S1中央型椎间盘突出症患者.PELD设备种类很多,但外科技术基本一致.手术中可能会受到高髂嵴或L5横突的阻挡,但近来报道显示L5～S1经皮入路其实并不十分困难.PELD术后满意率与腰椎板开窗髓核切除术相当,且具有创伤小、并发症少、术后复发率低等优点,是治疗部分腰椎间盘突出症的理想选择.     

腰椎不稳和腰椎滑脱的相关问题

<正>腰椎不稳或腰椎滑脱是导致腰腿痛的常见病因之一。然而在临床上,有关不稳和滑脱的界定、两者之间的关系、影像学诊断、治疗方案的合理选择、滑脱的复位等     

Posterior lumbar interbody fusion and segmental lumbar lordosis

Introduction

The sagittal plane of body produces a convex curve anteriorly referred to as the lordotic curve. Malalignment of lordotic curve leads to low back disorders and lumbar spinal surgery has been known to cause this. This study was a retrospective analysis of the effects of posterior lumbar interbody fusion using cages on segmental lumbar lordosis.

Materials and methods

We conducted a retrospective study involving 27 patients of which 16 were females and 11 were males. All patients underwent single level posterior lumbar interbody fusion with insertion of non-wedged intervertebral cage and pedicle screw fixation. Intraoperatively, all patients had a change from knee chest position to prone to augment their lumbar lordosis. The minimum follow up was 2 years and fusion was achieved in 21 patients.

Results

Segmental lordotic angles increased from 15.2° to 20.6° at L4/5 level and from 17.8° to 24.5° at L5/S1 level, preoperative to postoperative, respectively (P < 0.01 at both levels).

Conclusion

Thus apparently, posterior lumbar interbody fusion with insertion of non-wedged intervertebral cage and pedicle screw fixation results in creation and maintenance of lumbar lordosis.     

Degenerative lumbar spinal stenosis and lumbar spine configuration

As life expectancy increases, degenerative lumbar spinal stenosis (DLSS) becomes a common health problem among the elderly. DLSS is usually caused by degenerative changes in bony and/or soft tissue elements. The poor correlation between radiological manifestations and the clinical picture emphasizes the fact that more studies are required to determine the natural course of this syndrome. Our aim was to reveal the association between lower lumbar spine configuration and DLSS. Two groups were studied: the first included 67 individuals with DLSS (mean age 66 ± 10) and the second 100 individuals (mean age 63.4 ± 13) without DLSS-related symptoms. Both groups underwent CT images (Philips Brilliance 64) and the following measurements were performed: a cross-section area of the dural sac, vertebral body dimensions (height, length and width), AP diameter of the bony spinal canal, lumbar lordosis and sacral slope angles. All measurements were taken at L3 to S1. Vertebral body lengths were significantly greater in the DLSS group at all levels compared to the control, whereas anterior vertebral body heights (L3, L4, L5) and middle vertebral heights (L3, L5) were significantly smaller in the LSS group. Lumbar lordosis, sacral slope and bony spinal canal were significantly smaller in the DLSS compared to the control. We conclude that the size and shape of vertebral bodies and canals significantly differed between the study groups. A tentative model is suggested to explain the association between these characteristics and the development of degenerative spinal stenosis.     

经皮全脊柱内镜技术治疗腰椎间盘突出症

[目的]研究经皮全脊柱内镜技术(percutaneous endoscopic lumbar discectomy,PELD)治疗腰椎间盘突出症的临床疗效及安全性。[方法]回顾性研究2013年1月~2015年1月连续接受手术治疗的153例单节段伴有单侧神经根性症状的腰椎间盘突出症患者,其中68例行经皮全脊柱内镜下腰椎间盘髓核摘除术(内镜组),85例行开放腰椎间盘髓核摘除术(开放组)。采用视觉模拟评分法(VAS评分)、Oswestry功能障碍指数(ODI)、Mac Nab评分评定疗效。[结果]所有患者均完成手术,内镜组有1例出现神经根损伤。其他患者未发生神经、血管损伤等严重并发症。内镜组手术时间大于开放组,术中出血量、切口长度小于开放组,差异均有统计学意义(P0.05)。术后3 d和末次随访时腰痛VAS评分内镜组显著小于开放组,差异有统计学意义(P0.05),术后3 d腿痛VAS评分内镜组小于开放组,差异有统计学意义(P0.05),末次随访时两组腿痛VAS评分差异无统计学意义(P0.05)。内镜组末次随访时ODI指数小于开放组,差异有统计学意义(P0.05),两组疗效优良率差异无统计学意义(P0.05)。两组术后腰痛、腿痛VAS评分显著小于术前,差异有统计学意义(P0.05),内镜组术后3 d和末次随访时腰痛、腿痛VAS评分差异无统计学意义(P0.05)。开放组术后3 d和末次随访时腰痛VAS评分差异无统计学意义(P0.05),末次随访时腿痛VAS评分小于术后3 d,差异有统计学意义(P0.05)。[结论]经皮全脊柱内镜下腰椎间盘髓核摘除术治疗腰椎间盘突出症安全有效,创伤小,恢复快,是开放腰椎间盘髓核摘除术很好的替代技术。     

经椎间孔入路与经后方入路椎间融合术治疗退变性腰椎失稳症的疗效比较

目的回顾性研究经后方入路椎体间融合术（posterior lumbar interbody fusion,PLIF）和切除上、下关节突的经椎间孔入路椎体间融合术（transforaminal lumbar interbody fusion,TLIF）治疗腰椎失稳症的疗效及并发症情况。方法采用PLIF和TLIF治疗2004年1月至2008年1月本院收治的退变性腰椎失稳症患者78例,其中PLIF31例,TLIF47例。比较两组手术时间、术中出血量、平均卧床时间、Nakai评分优良率、融合时间（按Suk标准）及术后并发症发生率。对两组术前及末次随访时的椎间隙高度及椎间孔高度进行对比研究。结果 78例患者均获随访,随访时间1.5～4.5年,平均3.5年。所有患者均获椎间骨性融合。对两组卧床时间、Nakai评分优良率、融合时间、同时间点椎间隙高度和椎间孔高度进行比较,差异无统计学意义（P〉0.05）;而在手术时间、出血量以及术后并发症发生率方面,两组之间的差异有统计学意义（P〈0.05）。两组末次随访时的椎间隙高度和椎间孔高度均较术前有明显改善（P〈0.05）。结论 TLIF和PLIF治疗退变性腰椎失稳症效果良好;与PLIF相比,TLIF操作简单,出血量小,并发症少。     

Percutaneous lumbar discectomy in the treatment of lumbar discitis

Lumbar disc infection, either after surgical discectomy or caused by haematogenous spread from other infection sources, is a severe complication. Specific antibiotic treatment has to be started as soon as possible to obtain satisfactory results in conservative treatment or operative fusion. The aim of this study was to analyse 16 cases of lumbar disc infection, treated with percutaneous lumbar discectomy (PLD) to obtain adequate amounts of tissue for histological examination and microbial culture. Between 1990 and 1994, 26 patients with vertebral osteomyelitis were treated. Sixteen patients, with an average age of 41.4 years (range 14–59 years), underwent a diagnostic PLD. Eight of them showed only moderate changes on computed tomograms (CT scans) and magnetic resonance (MR) images in the initial stages of the disease. The other eight showed more or less extensive osteolytic lesions of one or both vertebral bodies adjacent to the involved disc. The histology results showed non-specific discitis in nine patients and tuberculosis in one. In two patients an open biopsy had been performed, which showed non-specific discitis. Microbiological analysis revealed specific infection in 45% of the patients. These patients received a specific antibiotic treatment after antibiogram for an average of 33 days. Only three patients were treated surgically, with evacuation of the disc space and interbody fusion; the whole group received a spondylitis brace. All patients obtained satisfactory clinical results at the last follow-up regarding pain, mobility and spontaneous fusion of the involved disc space. In conclusion, PLD is a very helpful minimally invasive procedure in conservative treatment of lumbar discitis.     

腰椎滑脱与腰椎不稳的诊疗

<正>腰椎滑脱和腰椎不稳虽然为临床中的常见疾病,但目前对其诊断和治疗仍存在诸多问题需要理清、界定和探讨,当然存在的争议问题也不是本文浅谈片语能够解决的。立足目前许多专家学者对腰椎滑脱和腰椎不稳的观点阐述[1-7],笔者仅对腰椎滑脱和腰椎不稳典型的几个问题梳理如下。1腰椎滑脱和腰椎不稳的诊断脊椎滑脱的英文名称为spondylolysis,其字根来源于希腊语,spondylo(椎体)和listhesis(滑移)。两个     

经椎间孔椎体间植骨治疗下腰椎爆裂性骨折

目的 探讨在下腰椎爆裂性骨折中应用单一后路经椎间孔椎体间植骨融合术重建椎体前中柱的有效性.方法 2009年1月～2011 年6月,采用单一后路切开复位椎弓根内固定经椎间孔椎体间植骨融合术治疗下腰椎爆裂性骨折19例.分别评价术前、术后、末次随访时的影像学指标变化,及术前与术后末次随访时神经功能变化.结果 19例患者平均随访15.6 个月.所有患者术后未发生切口感染、神经功能损伤及内固定器松动断裂等并发症.末次随访时18例患者证实椎间融合,19例患者术前平均伤椎高度为正常椎体高度的（40.62±12.32）%,术后恢复至（96.52±10.62）%,末次随访时为（95.43%9.54）%.腰椎前凸角术前32.2°±5.1°,术后38.4°±5.2°,末次随访时为38.4°±7.2°.末次随访时伴有神经功能障碍的患者均有1级以上的恢复.结论 下腰椎爆裂性骨折行后路椎弓根螺钉内固定经椎间孔椎体间植骨融合术,能完成短节段三柱固定,同时修复了前柱及矫正脊柱后凸,取得满意的骨性融合率.     

后路腰椎椎体间融合术治疗腰椎滑脱的临床疗效

目的：探讨后路腰椎椎体间融合术（posterior lumbar interbody fusion,PLIF）治疗腰椎滑脱的中期疗效,对腰椎滑脱症的临床治疗提供指导意见。方法回顾性分析采用PLIF治疗的腰椎滑脱40例,所有病例随访观察＞3年,对手术前后影像学资料、Oswestry功能障碍指数（Oswestry disability index,ODI）、视觉模拟量表（visual analog scale ,VAS）评分及日本骨科学会（Japanese Orthopaedic Association ,JOA）腰背痛手术治疗评分标准的评分变化情况进行比较分析。结果椎间隙高度、椎间孔高度术后1年、3年与术前比较差异均有统计学意义（P＜0．05）;术后1年与术后3年测量值比较差异不具有统计学意义（P＞0．05）。 ODI、腰痛VAS评分、腿痛VAS评分及JOA评分术前和术后1年、3年比较差异具有统计学意义（P＜0．05）;术后1年与术后3年比较差异不具有统计学意义（P＞0．05）。结论 PLIF手术能够恢复腰椎序列稳定性,改善临床症状,是治疗腰椎滑脱的理想术式,中期随访疗效满意。