腰椎间盘突出症手术失败原因和再手术方法的探讨

Analysis of the reasons for failed lumbar disc herniation surgery and the methods of reoperation

目的探讨腰椎间盘突出症手术失败的原因及再手术的时机和方法。方法对腰椎间盘突出症手术失败患者的初次术前诊断、手术方法、再手术前临床表现、影像学检查进行评估。分析初次手术失败原因及再手术治疗的适应证、手术方法、手术入路及疗效。在获得随访的患者中，行开窗、扩大开窗法腰椎间盘摘除术46例，行半椎板切除减压、椎间盘摘除术12例，行全椎板切除减压、椎间盘摘除、神经根管松解术22例，行全椎板切除减压、椎体后缘骨赘及软骨结节切除术16例，行后路经椎弓根螺钉固定、椎管减压、神经通道松解、后外侧植骨或椎间融合术47例。结果143例患者初次手术后获得随访，随访时间24-144个月，平均62个月。再手术后29例出现并发症。采用日本骨科学会（JOA）腰背痛29分评分标准对患者进行评分。患者再手术前JOA评分平均11．3分，术后随访时JOA评分平均24．2分，平均改善率72．9％。结论腰椎间盘突出症再手术的原因包括手术适应证选择不当、多间隙突出遗漏、术中定位错误及髓核摘除不彻底、双侧型或中央型突出只切除一侧、椎体后缘软骨结节未切除、未处理中央椎管狭窄及神经根管狭窄、术后腰椎间盘突出复发、全椎板减压术后腰椎节段性不稳定。正确选择再手术时机及方法仍可以获得较为满意的疗效。

Objective To analyze the reasons for failed lumbar disc herniation surgery, and investigate the methods and opportunities.of reoperation. Methods 143 patients （96 males, 47 females, with the mean age 36.5 years） with failed surgery for lumbar disc herniation involved in this study. The preoperative diagnosis before primary operation, primary operation method choice, clinical manifestation before reoperation, and radiological examinations were evaluated. The reasons of failure of primary operation were discussed, and the indications, surgical methods, surgical approach and treatment efficacy of reoperation were analyzed. Among the followed-up patients, 46 cases underwent fenestration, 12 cases did semi-laminectomy, 22 cases did total laminectomy, 16 cases did total laminectomy and decision of posterior marginal cartilaginous node and osteophyte that protrude into canal, 47 cases did total laminectomy and pedical screw fixation and bone graft. Results Totally 143 cases got complete follow-up with an average 62 months （range, 24- 144 months）. 29 patients had various complications after reoperation. The mean JOA score hefore reoperation was 11.3, while during followed-up period, the mean JOA score got to 24.2. The mean improvement rate was 72.9%. Conclusion The main reasons for the need of reoperation for lumhar disc herniation include： inappropriate indication, wrong intraoperative location, incomplete removal of herniated nucleus pulposus, neglect of multiple intervertehml space, unremoval of posterior marginal cartilaginous node, incomplete decompression of central canal and nerve root canal, recurrent disc herniation, and postoperative lumhar segmental unstahility after total laminectomy. With an optimal time and appropriate method, reoperation can achieve satisfactory result.