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Effectiveness of discectomy combined with IsobarPg 229 34[PMIDX21427858]

髓核摘除联合Isobar非融合内固定治疗

腰椎间盘突出症

刘明1勘武生1李鹏1何大为2

【摘 要】目的评价髓核摘除联合Isobar非融合内固定治疗腰椎间盘突出症的近期疗效。 方法 2006年5月-2008年5月,对65例单间隙腰椎间盘突出症患者分别采用髓核摘除联合Isobar非融合内固定(A组,34例)和单独髓核摘除(B组,31例)治疗。A组男18例,女16例;年龄23~51岁,平均38.8岁。责任节段:L2、3 1例,L3、4 4例,L4、5 20例,L5、S1 9例。分型:突出型11例,脱出型16例,游离型7例。病程1~66个月,平均7.2个月。B组男19例,女12例;年龄21~49岁,平均39.2岁。责任节段:L3、4 2例,L4、5 24例,L5、S1 5例。分型:突出型13例,脱出型15例,游离型3例。病程3周~72个月,平均6.5个月。两组患者一般资料比较差异无统计学意义(P > 0.05),有可比性。手术前后采用疼痛视觉模拟评分(V AS)及Oswestry功能障碍指数(ODI)进行比较评价,并动态观察术后责任椎间隙高度变化情况。 结果两组患者均获随访,随访时间24~49个月,平均32个月。术后A、B组患者腰、腿痛症状均明显改善,B组1例发生术后脑脊液漏,经处理后治愈。随访期间两组均无内固定物松动、断裂等并发症发生。A、B组术后3周、3、6个月和1、2年腰、腿痛V AS均较术前显著改善(P < 0.05);术后1、2年,A、B组间腰痛V AS比较差异有统计学意义(P < 0.05),其余各时间点腰痛V AS及手术前后各时间点腿痛V AS A、B组间比较差异均无统计学意义(P > 0.05)。术后2年两组ODI与术前比较差异均有统计学意义(P < 0.05),但A、B组间比较差异无统计学意义(P > 0.05)。术后各时间点A 组责任椎间隙高度均较术前增加(P < 0.05);B组较术前下降,术后3周及3个月与术前比较差异无统计学意义(P > 0.05),术后6个月、1年及2年与术前比较差异有统计学意义(P < 0.05)。A、B组间术后各时间点责任椎间隙高度比较差异均有统计学意义(P < 0.05)。 结论髓核摘除联合Isobar非融合内固定治疗节段隙腰椎间盘突出症的近期疗效满意,患者术后腰痛缓解程度较单独髓核摘除术更明显,可能与其能维持术后责任椎间隙高度有关。

【关键词】腰椎间盘突出症髓核摘除非融合内固定

EFFECTIVENESS OF DISCECTOMY COMBINED WITH Isobar NON-FUSION INTERNAL FIXATION IN TREATING LUMBAR DISC PROTRUSION/LIU Ming1, KAN Wusheng1, LI Peng1, HE Dawei2. 1Department of Spine Surgery, Af? liated Puai Hospital of Tongji Medical College, Huazhong University of Science and Technology, Wuhan Hubei, 430033, P.R.China; 2Department of Orthopaedics, Shanghai Changhai Hospital. Corresponding author: HE Dawei, E-mail: hedawei2000@http://www.doczj.com/doc/723cb7e719e8b8f67c1cb9c3.html 【Abstract】Objective To evaluate the short-term results of discectomy combined with Isobar non-fusion internal fixation. Methods Between May 2006 and May 2008, 65 cases of single segment lumbar disc protrusion were random surgically treated by discectomy combined with Isobar non-fusion internal ? xation (34 cases, group A) and single discectomy (31 cases, group B), respectively. In group A, there were 18 males and 16 females with an average age of 38.8 years (range, 23-51 years); the involved segments were L2,3 (1 case), L3,4 (4 cases), L4,5 (20 cases), and L5, S1 (9 cases), including 11 cases of protrusion type, 16 cases of prolapsed-type, and 7 cases of sequestered type; and the mean disease duration was 7.2 months (range, 1-66 months). In group B, there were 19 males and 12 females with an average age of 39.2 years (range, 21-49 years); the involved segments were L3,4 (2 cases), L4,5 (24 cases), and L5, S1 (5 cases), including 13 cases of protrusion type, 15 cases of prolapsed-type, and 3 cases of sequestered type; and the mean disease duration was 6.5 months (range, 3 weeks to 72 months). There was no signi? cant difference in the general data between 2 groups (P > 0.05). The surgical results were assessed by visual analogue scale (V AS) for back/leg pain and the Oswestry disability index (ODI). The height of involved intervertebral space was measured dynamically after operation. Results The patients of two groups were followed up 32 months on average (range, 24-49 months). All clinical symptoms of the patients were notably improved in 2 groups. One patient in group B experienced postoperative cerebral ? uid leakage, and was cured after extubation, changing posture, and other measures. There was no implant failure, such as pedicle fracture, screw loosening, or screw malposition during the follow-up. The ODI and V AS were signi? cantly improved after operation. The back and leg pain V AS scores at each time point were decreased signi? cantly when compared with

作者单位:1 华中科技大学同济医学院附属普爱医院脊柱外科(武汉,430033);2 上海长海医院骨科

通讯作者:何大为,副主任医师,硕士生导师,研究方向:脊柱外科,E-mail: hedawei2000@http://www.doczj.com/doc/723cb7e719e8b8f67c1cb9c3.html

网络出版时间:2011-1-6 16:22:41;网络出版地址:http://www.doczj.com/doc/723cb7e719e8b8f67c1cb9c3.html/kcms/detail/51.1372.R.20110106.1622.201102.92_020.html

those before operation (P < 0.05) in 2 groups. There were signi? cant differences in back pain V AS (P < 0.05) between groups A and B at 1 and 2 years after operation. There was signi? cant difference in the ODI score (P < 0.05) at 2 years when compared with that before operation in 2 groups, but there was no signi? cant difference between 2 groups (P > 0.05). After operation, the mean height of involved intervertebral space was increased signi? cantly (P < 0.05) when compared with preoperative value in group A, while the height had a gradual decline at 3 weeks and 3 months (P > 0.05), and had a signi? cant decline at 6 months, 1 year, and 2 years (P < 0.05) when compared with preoperative value in group B. There were signi? cant differences in the height of involved intervertebral space between groups A and B at each time point after operation (P < 0.05). Conclusion Discectomy combined with Isobar non-fusion internal ? xation presents with satisfactory short-term results; moreover, it can better relieve back pain in comparison with single discectomy, which possibly related to the preservation of responsible intervertebral spaces.

【Key words】Lumbar disc protrusion Discectomy Non-fusion internal ? xation

椎板间开窗减压髓核摘除术是治疗单纯腰椎间盘突出症的经典手术方法之一,但术后由于椎间隙变窄,可能发生椎体间不稳、小关节退变和复发椎间盘突出等,导致腰腿痛症状复发或加重[1-4]。因而有学者主张椎间盘摘除术后应同时行椎间融合术[5],但椎间融合后易引起邻近节段椎间盘及小关节承受负荷增加及负荷传导方式改变,导致邻近节段出现椎间滑移、椎间盘突出、小关节增生和椎管狭窄等一系列问题[6-8]。非融合内固定(或称动力内固定)由此应运而生,其不作椎体间融合,在稳定腰椎的同时保留一定腰椎活动度。国外目前已有数种非融合内固定系统应用于临床,并取得了满意疗效[9-12]。而国内采用髓核摘除联合非融合内固定治疗腰椎间盘突出症的相关报道尚不多见。Isobar非融合内固定系统是一种基于椎弓根螺钉的半坚强内固定装置,它能承担固定节段不同方向及运动平面的载荷,并能维持椎间隙高度。2006年5月-2008年5月,我们分别采用髓核摘除联合Isobar非融合内固定和单独髓核摘除法治疗单间隙腰椎间盘突出症患者,现对比分析其近期疗效。报告如下。

1临床资料

1.1 患者纳入标准

①临床记录完整并获2年以上随访的腰椎间盘突出症患者;②均为单间隙腰椎间盘突出,无严重小关节退变、发育性或退行性椎管狭窄,无腰部手术史,腰椎动力位X线片显示无椎间不稳;③患者术前均经3个月以上正规保守治疗无效,或临床症状严重强烈要求手术治疗。共65例患者纳入研究,根据手术方法不同分为髓核摘除联合Isobar非融合内固定组(A组,34例)和单独髓核摘除组(B组,31例)。

1.2 一般资料

A组:男18例,女16例;年龄23~51岁,平均38.8岁。责任节段:L2、3 1例,L3、4 4例,L4、5 20例,L5、S1 9例。按髓核突出病理形态分型[13]:突出型11例,脱出型16例,游离型7例。病程1~66个月,平均7.2个月。伴二便功能障碍2例。B组:男19例,女12例;年龄21~49岁,平均39.2岁。责任节段:L3、4 2例,L4、5 24例,L5、S1 5例。按髓核突出病理形态分型:突出型13例,脱出型15例,游离型3例。病程3周~72个月,平均6.5个月。伴二便功能障碍者3例。两组患者性别、年龄、病程、责任节段及分型等一般资料比较差异均无统计学意义(P > 0.05),有可比性。

1.3手术方法

A组:全麻下,患者取俯卧位,作腰正中切口。完整保留棘间、棘上韧带,骨膜下剥离至关节突外缘,于责任椎间隙上、下植入椎弓根螺钉,保留椎间小关节完整。本组27例采用椎板间开窗法摘除髓核;7例髓核脱出或游离于椎间隙较远处,不易经开窗法顺利取出,采用半椎板切除法摘除髓核,神经减压。S1椎弓根螺钉进钉点尽量偏下,使螺钉方向与S1上终板呈20~30°,否则上、下螺钉将过于靠近而影响动力棒安装。因责任椎间隙已有狭窄,适当撑开后再锁紧动力棒可恢复责任椎间隙高度。放置负压引流后分层关闭切口。

B组:全麻下取俯卧位,以突出间隙为中心作正中小切口。由椎间盘突出较大的一侧进入,中央型突出者由症状较重侧进入,骨膜下剥离至关节突外缘,椎板拉钩拉开肌组织,保留椎间小关节完整,采用椎板间开窗(17例)或扩大开窗法(14例)行髓核摘除,神经减压。放置负压引流后分层关闭切口。

1.4 术后处理

A组患者术后卧床2周,B组术后卧床3~5 d,拔除引流管后即开始床上腰背肌功能锻炼,之后腰带保护下床活动,避免弯腰、扭腰等活动。A组术后3个月、B组术后1个月去除腰带,逐渐恢复正常活动。

1.5 观察指标

术前及术后3周,3、6个月,1、2年门诊定期复查,摄腰椎正侧位及动力位X线片检查,按疼痛视觉模

拟评分(V AS)行腰、腿痛评分,并测量责任椎间隙高度(椎间隙前、后缘高度之和的一半)评估腰椎稳定性。术前及术后2年根据Oswestry功能障碍指数(ODI)问卷表计算ODI[14]。

1.6统计学方法

采用SPSS11.5统计软件包进行分析。数据以均数±标准差表示,两组间患者手术前后腰、腿痛V AS、ODI及责任椎间隙高度比较采用成组t检验;对各组患者手术前后腰、腿痛V AS、ODI及责任椎间隙高度比较采用重复测量的方差分析;检验水准α=0.05。

2结果

两组患者术后均获随访,随访时间24~49个月,平均32个月。

A组:手术时间70~120 min,平均95 min;术中出血量50~300 mL,平均100 mL。2例术中出现硬膜囊撕裂,给予修补。术后切口Ⅰ期愈合。住院时间7~14 d,平均10 d;住院期间无切口感染、脑脊液漏等并发症发生。术后患者腰、腿痛症状明显改善,未出现复发或加重。术后2年15例腰、腿痛症状完全消失,余患者腰、腿痛大部分解除,5例偶需服用止痛药缓解疼痛;2例伴二便功能障碍者恢复正常。随访期间无内固定松动、断裂,动力位X线片显示无椎间不稳。见图1。

B组:手术时间40~100 min,平均50 min;术中出血量30~100 mL,平均50 mL。1例术中出现硬膜囊撕裂,给予修补。住院时间5~8 d,平均5 d;住院期间1例出现脑脊液漏,给予拔管、改变体位等措施后伤口顺利愈合,未出现其他术后早期并发症。术后3周,患者腰、腿痛症状明显缓解;术后3个月~2年,7例患者再次出现腰痛症状,无下肢放射痛,其中2例自觉腰痛较术前加重,给予小关节封闭可缓解;术后2年13例腰、腿痛症状完全消失,余患者腰、腿痛大部分解除,8例偶需服用止痛药缓解疼痛。3例伴二便功能障碍者恢复正常。见图2。

A、B组术后各时间点腰、腿痛V AS均较术前显著改善,差异有统计学意义(P < 0.05);术后各时间点间差异无统计学意义(P > 0.05)。术后1、2年,A、B组间腰痛V AS比较差异有统计学意义(P < 0.05),其余各时间点组间腰痛V AS及手术前后各时间点组间腿痛V AS 比较差异均无统计学意义(P > 0.05),见表1、2。两组术后2年ODI与术前比较差异均有统计学意义(P < 0.05),A、B组间比较差异均无统计学意义(P > 0.05),见表3。术后各时间点A组责任椎间隙高度均较术前增加,差异有统计学意义(P < 0.05);B组较术前呈进行性下降,术后3周及3个月与术前比较差异无统计学意义(P > 0.05),术后6个月、1年及2年与术前比较差异有统计学意义(P < 0.05)。A、B组间术前责任椎间隙高度比较差异无统计学意义(P > 0.05),术后各时间点组间比较差异均有统计学意义(P < 0.05)。见表4。

表1两组患者手术前后腰痛V AS变化(x ± s)

Tab.1 Comparison of pre- and post-operative V AS for back pain in 2 groups(x ± s)

组别Group 例数

n

术前

Preoperatively

术后3周

Three weeks

postoperatively

术后3个月

Three months

postoperatively

术后6个月

Six months

postoperatively

术后1年

One year

postoperatively

术后2年

Two years

postoperatively

统计值

Statistic

A34 5.45 ± 1.70 2.12 ± 1.58* 1.97 ± 1.65* 2.04 ± 1.49* 1.94 ± 1.52* 1.90 ± 1.62*F=3.774,P=0.010 B31 5.48 ± 1.83 2.16 ± 1.68* 2.78 ± 1.74* 2.61 ± 1.62* 2.94 ± 1.48* 2.98 ± 1.50*F=2.199,P=0.000

统计值Statistic t=0.064

P=0.949

t=0.093

P=0.926

t=1.811

P=0.075

t=1.387

P=0.171

t=2.535

P=0.014

t=2.635

P=0.014

*与术前比较P < 0.05

* Compared with preoperative value, P < 0.05

表2两组患者手术前后腿痛V AS变化(x ± s)

Tab.2 Comparison of pre- and post-operative V AS for leg pain in 2 groups(x ± s)

组别Group 例数

n

术前

Preoperatively

术后3周

Three weeks

postoperatively

术后3个月

Three months

postoperatively

术后6个月

Six months

postoperatively

术后1年

One year

postoperatively

术后2年

Two years

postoperatively

统计值

Statistic

A348.85 ± 1.12 2.21 ± 1.78* 2.13 ± 1.72* 2.12 ± 1.68* 2.08 ± 1.76* 2.04 ± 1.70*F=13.472,P=0.000 B318.87 ± 1.09 2.14 ± 1.80* 2.09 ± 1.77* 2.15 ± 1.82* 2.06 ± 1.84* 2.16 ± 1.64*F=11.577,P=0.000

统计值Statistic t=0.069

P=0.945

t=0.148

P=0.883

t=0.087

P=0.931

t=0.065

P=0.948

t=0.042

P=0.967

t=0.273

P=0.787

*与术前比较P < 0.05

* Compared with preoperative value, P < 0.05

表3两组患者术前及术后2年ODI比较(%,x ± s)

Tab.3 Comparison of pre- and post-operative ODI in 2 groups(%,x ± s)

组别Group 例数

n

术前

Preoperatively

术后2年

Two years postoperatively

统计值

Statistic

A3476.50 ± 17.5121.13 ± 15.23t=17.500,P=0.000 B3175.80 ± 15.9522.30 ± 14.42t=16.300,P=0.000

统计值Statistic t=0.159

P=0.875

t=0.300

P=0.766

3 讨论

3.1 非融合内固定技术产生背景、机制及主要优点

上世纪90年代,基于坚强内固定的椎间融合技术被广泛应用于治疗腰椎退行性疾病,以缓解腰痛并稳定脊柱。但临床实践表明,高的融合率并未带来满意临床效果[15]。由于腰椎融合在消除融合节段椎间盘及小关节负荷的同时也改变了邻近节段椎间盘及小关节的负荷传导方式,容易导致邻近脊柱节段出现椎间滑移、椎间盘突出、小关节增生和椎管狭窄等一系列问题[6-8]。因此,有必要设计一种有助于限制异常负荷而不是单纯消除异常负荷的技术。非融合内固定即动力性内固定,是一种改变腰椎运动节段活动范围及负荷而不进行融合的固定方式,它将运动节段的活动限制

表4两组患者手术前后责任椎间隙高度变化(mm,x ± s)

Tab.4 Comparison of pre- and post-operative intervertebral spaces in 2 groups(mm,x ± s)

组别Group 例数

n

术前

Preoperatively

术后3周

Three weeks

postoperatively

术后3个月

Three months

postoperatively

术后6个月

Six months

postoperatively

术后1年

One year

postoperatively

术后2年

Two years

postoperatively

统计值

Statistic

A349.6 ± 3.412.3 ± 2.8*12.2 ± 3.2*12.4 ± 2.9*12.2 ± 3.4*12.2 ± 3.5*F=0.553,P=0.735 B319.8 ± 3.09.7 ± 3.28.9 ± 4.07.3 ± 3.8* 6.2 ± 4.2* 5.8 ± 4.0*F=0.961,P=0.460

统计值Statistic

t=0.248

P=0.806

t=3.464

P=0.002

t=3.657

P=0.000

t=6.062

P=0.000

t=6.299

P=0.000

t=7.370

P=0.000

*与术前比较P < 0.05

* Compared with preoperative value, P < 0.05

图1A组患者,男,42岁,L4、5椎间盘突出

Effectiveness of discectomy combined with IsobarPg 229 34[PMIDX21427858]

术前

Effectiveness of discectomy combined with IsobarPg 229 34[PMIDX21427858]

MRI 术后3

Effectiveness of discectomy combined with IsobarPg 229 34[PMIDX21427858]

Effectiveness of discectomy combined with IsobarPg 229 34[PMIDX21427858]

Effectiveness of discectomy combined with IsobarPg 229 34[PMIDX21427858]

Effectiveness of discectomy combined with IsobarPg 229 34[PMIDX21427858]

X线片术后2年腰椎动力位X线片

Effectiveness of discectomy combined with IsobarPg 229 34[PMIDX21427858]

图2

Effectiveness of discectomy combined with IsobarPg 229 34[PMIDX21427858]

B组患者,女,34岁,L5

Effectiveness of discectomy combined with IsobarPg 229 34[PMIDX21427858]

、S1椎间盘突出术前MRI

Effectiveness of discectomy combined with IsobarPg 229 34[PMIDX21427858]

术后3周腰椎正侧位

Effectiveness of discectomy combined with IsobarPg 229 34[PMIDX21427858]

X术后

Effectiveness of discectomy combined with IsobarPg 229 34[PMIDX21427858]

2年腰椎动力位X线片

Fig.1

Effectiveness of discectomy combined with IsobarPg 229 34[PMIDX21427858]

A 42-year-old male patient with L4,5

Effectiveness of discectomy combined with IsobarPg 229 34[PMIDX21427858]

Effectiveness of discectomy combined with IsobarPg 229 34[PMIDX21427858]

Effectiveness of discectomy combined with IsobarPg 229 34[PMIDX21427858]

disc protrusion in group A

Effectiveness of discectomy combined with IsobarPg 229 34[PMIDX21427858]

Effectiveness of discectomy combined with IsobarPg 229 34[PMIDX21427858]

Effectiveness of discectomy combined with IsobarPg 229 34[PMIDX21427858]

Effectiveness of discectomy combined with IsobarPg 229 34[PMIDX21427858]

Effectiveness of discectomy combined with IsobarPg 229 34[PMIDX21427858]

Effectiveness of discectomy combined with IsobarPg 229 34[PMIDX21427858]

MRI AP and lateral X-ray ? lms at 3 weeks after operation X-ray ? lms at 2 years after operation Fig.2 A 34-year-old female patient with L5, S1 disc protrusion in group B MRI AP and lateral X-ray ? lms at 3 weeks after operation X-ray ? lms at 2 years after operation

在正常或接近正常范围内,承担椎间盘及椎间小关节部分载荷,避免异常载荷的产生,从而解除疼痛。非融合内固定系统尽可能保留了责任节段的生物力学特性,不仅可以缓解或预防与不稳定有关的下腰痛症状,而且还能减缓该节段椎间盘退变的速度,甚至使轻度退变的椎间盘获得修复。同时,该系统能够保留责任节段的运动功能,从而避免椎间融合后相邻节段退变加速的问题。近年来,国内外已进行了大量非融合内固定技术的基础和临床研究,普遍认为通过节段融合来缓解腰痛并不可取,通过重建正常的力学传导模式达到“动态稳定”的效果将更合理[16]。Isobar非融合内固定系统是一种基于椎弓根螺钉的半坚强内固定装置。它将普通的刚性棒更换为动态棒,动态棒包含1个受控微动关节,具有± 0.2 mm的纵向位移、± 2°的伸屈及侧屈(多向)三维活动度,起到震荡吸收器的作用,从而达到动态固定的目的。

3.2椎间隙狭窄与小关节源性腰痛的关系

腰椎间盘和椎间小关节是构成腰椎运动节段的主要结构,腰椎的正常运动要求椎间盘和椎间小关节之间应力分布均衡。正常椎间盘髓核由胶原和蛋白多糖组成,可将不同姿势或体位的负荷进行均匀传导。椎间盘退变改变了其均匀一致的化学成分及物理特性,从而使负荷的传导方式发生改变,导致局部应力集中,椎间盘损伤,出现椎间盘源性腰痛;如纤维环破裂、髓核突出、神经根受压将导致腰、腿痛。同时随着椎间盘退变,腰椎椎间小关节承受的负荷显著增加,产生异常应力和异常活动,随之而来的是腰椎椎间小关节骨质增生,韧带代偿性增生肥厚,而这些又是椎间小关节源性腰痛产生的重要病理基础[17]。

通常当腰椎屈曲活动时,椎间小关节约承受30%载荷,椎间盘约承受70%载荷,但椎间盘存在蠕变和负荷松弛效应,因此椎间小关节承受的剪切负荷逐渐增大,加上附着在椎板肌肉的收缩,椎间小关节之间产生很高的作用力[18]。当椎间隙狭窄时上述变化更明显。van Schaik[19]研究发现,随着椎间隙高度的递减,椎间小关节承受的压力显著递增,关节软骨载荷增加一方面引起软骨胶原纤维网架破坏,另一方面影响软骨组织中代谢物质的交换,使软骨细胞失去营养而出现退变。Niosi等[20]报道在不同姿势下腰椎椎间小关节承受0~35%的压缩负荷。在腰椎间盘退变引起椎间隙变窄情况下,椎间小关节和椎板甚至承担高达70%的轴向压缩负荷。由此可见,椎间隙高度下降,将导致椎间小关节退变加速,从而诱发小关节源性腰痛。既便是退变不明显的年轻患者,由于椎间盘突出,椎间隙高度明显下降,小关节半脱位、关节囊受过度牵张、小关节滑膜炎、滑膜皱壁嵌顿等也可导致小关节源性腰痛。3.3 髓核摘除联合Isobar非融合内固定治疗腰椎间盘突出症的近期疗效

本研究发现,术后3周两组患者腰、腿痛均明显缓解。术后3个月,B组7例患者出现腰痛症状缓解后又加重或消失后又复发;X线片复查显示患者责任椎间隙高度较术前出现不同程度下降,且椎间隙狭窄的程度随时间延长呈不断加剧的趋势。而A组无这种情况。由此可见,单独髓核摘除术后腰痛症状加重或复发可能与术后椎间隙进一步狭窄有关,其本质即是小关节源性腰痛。导致腰椎术后腰痛的原因很多,如后方稳定结构破坏过多所致的医源性腰椎不稳定,肌肉组织的失神经支配及纤维化等。但这些都不是B组腰痛加重或复发的原因,因为采用椎板开窗、髓核摘除的方法,理论上对后方稳定结构的破坏较小,肌肉剥离有限,相比而言A组暴露更广泛。综上述,与单独髓核摘除术治疗腰椎间盘突出症相比,髓核摘除联合Isobar 非融合内固定能取得良好的近期治疗效果,患者术后2年ODI均显著提高;但在缓解腰痛方面,A组更有优势,可能与术后能维持责任椎间隙高度有关。

3.4髓核摘除联合Isobar非融合内固定治疗腰椎间盘突出症的适应证及不足

禁忌证:①伴有椎管狭窄需要广泛减压的患者,由于后方稳定结构破坏,必然导致内固定系统承受应力增加,提高了内固定物松动、失效的风险;②已有明显椎间不稳的患者;③由于Isobar非融合内固定系统是一种基于椎弓根螺钉的内固定系统,因而骨质疏松患者禁用。适应证:①年轻患者,髓核突出或脱出较大,预计单纯髓核摘除术后椎间隙可能会明显狭窄者。此类患者腰椎退变往往不严重,采用Isobar非融合内固定能有效维持椎间隙高度,并保留一定的活动度,从而避免因椎间隙狭窄带来的一系列退变。②邻近节段椎间盘已有变性,但尚无明显突出的患者。通过保留责任节段一定的活动度,减缓邻近节段的退变。③高位腰椎间盘突出患者。因责任节段紧邻胸腰段,承受应力较大,如应用融合技术,邻近节段更易退变。

我们采用髓核摘除联合Isobar非融合内固定治疗腰椎间盘突出症的主要目的是避免单纯髓核摘除术后椎间隙狭窄及腰椎融合术后邻近节段退变加速,虽然近期疗效满意,但由于Isobar非融合内固定系统长期处于应力作用之下,随着时间延长,极有可能出现内固定物松动[21],甚至疲劳断裂等,因此远期疗效仍有待临床观察。另外,其费用偏高,相对于单纯髓核摘除术,创伤也较大,是其不足之处。

4参考文献

1 Findlay GF, Hall BI, Musa BS, et al. A 10-year follow-up of the out-

come of lumbar microdiscectomy. Spine (Phila Pa 1976), 1998, 23(10): 1168-1171.

2 Moore AJ, Chilton JD, Uttley D. Long-term results of microlumbar

discectomy. Br J Neurosurg, 1994, 8(3): 319-326.

3 Pappas CT, Harrington T, Sonntag VK. Outcome analysis in 65

4 sur-

gically treated lumbar disc herniations. Neurosurgery, 1992, 30(6): 862-866.

4 Yorimitsu E, Chiba K, Toyama Y, et al. Long-term outcomes of stan-

dard discectomy for lumbar disc herniation: a follow-up study of more than 10 years. Spine (Phila Pa 1976), 2001, 26(6): 652-657.

5 Bridwell KH, Sedgewick TA, O’Brien MF, et al. The role of fusion and

instrumentation in the treatment of degenerative spondylolisthesis with spinal stenosis. J Spinal Disord, 1993, 6(6): 461-472.

6 Bono CM, Lee CK. Critical analysis of trends in fusion for degenerative

disc disease over the past 20 years: in? uence of technique on fusion rate and clinical outcome. Spine (Phila Pa 1976), 2004, 29(4): 455-463.

7 Zencica P, Chaloupka R, Hladíková J, et al. Adjacent segment degen-

eration after lumbosacral fusion in spondylolisthesis: a retrospective radiological and clinical analysis. Acta Chir Orthop Traumatol Cech, 2010, 77(2): 124-130.

8 李淳德, 于峥嵘, 刘宪义, 等. 腰椎内固定融合术后邻近节段退变的

影响因素. 中华外科杂志, 2006, 44(4): 246-248.

9 Cienciala J, Chaloupka R, Repko M, et al. Dynamic neutralization

using the Dynesys system for treatment of degenerative disc disease of the lumbar spine. Acta Chir Orthop Traumatol Cech, 2010, 77(3): 203-208.

10 Kim YS, Zhang HY, Moon BJ, et al. Nitinol spring rod dynamic sta-

bilization system and Nitinol memory loops in surgical treatment for lumbar disc disorders: short-term follow up. Neurosurgical Focus, 2007, 22(1): E10. 11 Di Silvestre M, Lolli F, Bakaloudis G, et al. Dynamic stabilization

for degenerative lumbar scoliosis in elderly patients. Spine (Phila Pa 1976), 2010, 35(2): 227-234.

12 Ozer AF, Crawford NR, Sasani M, et al. Dynamic lumbar pedicle

screw-rod stabilization: two-year follow-up and comparison with fu-sion. Open Orthop J, 2010, 4: 137-141.

13 贾连顺. 现代脊柱外科学. 北京: 人民军医出版社, 2007: 815.

14 郑光新, 赵晓鸥, 刘广林, 等. Oswestry 功能障碍指数评定腰痛患者

的可信性. 中国脊柱脊髓杂志, 2002, 12(1): 13-15.

15 Boos N, Webb JK. Pedicle screw ? xation in spinal disorders: a Euro-

pean view. Eur Spine J, 1997, 6(1): 2-18.

16 Korovessis P, Papazisis Z, Koureas G, et al. Rigid, semirigid versus dy-

namic instrumentation for degenerative lumbar spinal stenosis: a cor-relative radiological and clinical analysis of short-term results. Spine (Phila Pa 1976), 2004, 29(7): 735-742.

17 Tischer T, Aktas T, Milz S, et al, Detailed pathological changes of

human lumbar facet joints L1-L5 in elderly individuals. Eur Spine J, 2006,15(3):308-315.

18 Krismer M, Haid C, Behensky H, et al. Motion in lumbar functional

spine units during side bending axial rotation moments depending on the degree of degeneration. Spine (Phila Pa 1976), 2000, 25(16): 2020-2027.

19 van Schaik JP. Lumbar facet joint morphology. J Spinal Disord, 2000,

13(1): 88-89.

20 Niosi CA, Oxland TR. Degenerative mechanics of the lumbar spine.

Spine J, 2004, 4(6 Suppl): 202S-208S.

21 Ko CC, Tsai HW, Huang WC, et al. Screw loosening in the Dynesys

stabilization system: radiographic evidence and effect on outcomes.

Neurosurgical Focus, 2010, 28(6): E10.

(收稿:2010-09-19 修回:2010-11-08)

(本文编辑:王雁)

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