腰椎间盘突出症术后复发原因探讨及处理对策

Recurrent causes and treatment of lumbar disc herniation

目的探讨腰椎间盘突出症术后复发的成因及其处理措施.方法对1995～2002年间本科收治的37例腰椎间盘突出症术后复发患者的病例资料进行回顾性分析.结果 37例中,男24例,女13例,年龄22～63岁,平均37岁.包括侧隐窝狭窄12例,术后复发4例,术中定位错误7例,神经根粘连6例,下腰椎手术后失稳10例.初次手术后症状未缓解或加重者17例,症状有暂时性缓解而后复发者20例.二次手术间隔时间7天～15年,平均2.4年.再次手术前临床表现为腰痛伴下肢放射性疼痛者14例,下肢放射性疼痛者10例,腰背部疼痛者7例,间歇性跛行者6例,会阴部麻木4例,全部患者患侧小腿外侧后侧皮肤感觉减退.再次手术方式为,扩大开窗及神经根管扩大减压术19例,半椎板切除术8例,椎间植骨融合及椎弓根内固定术10例.随访6月～6年2月,平均随访3年10月,再次手术术后优良率97.2%.结论术前周全的检查、准切的定位及术式的合理选择是防范椎间盘突出症术后复发的关键;术中应正确处理神经根管及椎管狭窄与椎体稳定性间的关系,既要避免椎管狭窄减压不足导致术后效果不佳,又要防止过分减压导致术后脊柱不稳;CT及MRI对于引起腰椎手术失败的多数病因有较好的诊断价值;二次手术除摘除突出的髓核和解除椎管狭窄外,一定要注意重建脊柱的稳定性.

Objective To study recurrent causes and treatment of postoperation on lumbar disc herniation.Methods Thirty-seven cases of postoperative information form 1995 to 2002 on lumbar disc herniation were adopted for retrospective analysis.Results All cases, include 24 males and 13 females,were taken vertebral pulp ectomy of intervertebral disc. The recurrent causes involved latero-kryptostenosis (12cases),recurrent herniation(4cases),false localization(7 cases ), 5 cases false diagnosis and 4 cases failed back surgery syndrome. The time of reoperation was 7d to 15 years after primary operation later, average 2.4 years. Clinic symptom before reoperation showed back pain with /or low limb radioactive pain, intermittent claudication, perineal anaesthesia. Cutaneous sensation of lateral-post sura was paralysis. X-ray performance showed lumbar vertebral degeneration, vertebra space stenosis, hypertrophy of vertebral joint and vertebral slippage. CT & MRI determination showed dura mater capsule compression, nerve root canal stenosis.Styles of reoperation included amplificative laminotomy (19 cases), half-laminectomy(8 cases) and intervertebral fusion(10 cases). Average follow-up period was 46 monthes, 97.2 percent of patients were satisfaction after reoperation.Conclusion The careful determination and reasonable operative procedure are important for treatment of lumbar disc herniation. The cure of nerve root canal and vertebral stenosis should be treated with spinal column instability. The stability of spinal column should be reconstructed at reoperative procedure.