腰椎间盘突出症疗效不佳的临床观察

Causes of unsatisfactory curative outcomes of lumbar disc herniation

目的 分析腰椎间盘突出症手术疗效不佳的原因，探讨提高疗效的方法。方法 随访本院1993-2003年腰椎间盘突出症行后路髓核摘除术病例236例，对术后腰腿痛症状未缓解或症状消失后再复发者复查X片、CT或MRI了解病因。结果手术疗效不佳者25例。疗效不佳的主要原因为残留髓核再突出、术后脊柱不稳倾向增加、对侧隐窝狭窄认识不足、神经根损伤、极外侧型椎问盘突出漏切、感染、术后椎管内瘢痕黏连等。全椎板切除术较椎板问开窗术更易发生椎管内瘢痕黏连（P＜0．01）。结论首次手术时应尽可能取净髓核组织，对动力位摄片发现有椎问不稳倾向者行后外侧植骨或椎体问植骨融合，常规探查并妥善处理侧隐窝，牵拉神经根时间不应过长且用力轻柔。行腰椎间盘CT和MRI扫描时，应注意包括椎间盘相邻上下椎体的1／3部，以防止遗漏极外侧型椎问盘突出，尽量采用椎板间开窗术式以减少脊柱创伤，术中间断冲洗，术毕持续负压引流，以减少术后黏连，术中应严格无菌操作。

Objective To analyse the causes of unsatisfactory curative outcomes of lumbar disc herniation, and to improve the treatment. Methods A follow-up of 236 cases was carried out,all of whom had undergone lumbar discectomy for lumbar disc herniation in our hospital during the year of 1993 - 2003. X-ray,CT and MRI were retaken in the cases with sustained pain in lumbar region and leg after operation,so as to find the etiological factors. Results Unsatisfactory curative results were found in 25 cases, the main cause of which is re-herniationn of residual nucleus pulposus, increasing tendency of postoperative intervertebral instability, neglecting the problem of lateral recess stenosis, injury of nerve root , omission of resection of far-lateral lumbar disc herniation, discitis, postoperational scar adherence in vertebral canal,et al. There is a greater possibility for total laminectomy to lead to scar adherence compared to fenestration. Conclusion Some methods are effective for improving treatment outcome, such as excision of nucleus pulposus as much as possible in the primary surgical management,performing bone grafting in patients with intervertebral instability, routinely exploring lateral recess, pulling nerve root gently, paying attention to scanning the one thirds section of consecutive vertebrae during CT scan and MRI to avoid omission of far-lateral lumbar disc herniation, performing fenestration more often and undertaking continuous negative pressure drainage to reduce scar adherence,and obeying the intra-operative sterile rule strictly to eliminate infection,et al.