退行性腰椎侧弯合并椎管狭窄的手术治疗

Surgical treatment of the lumbar degenerative de novo scoliosis combined with vertebral stenosis

[目的]探讨退行性腰椎侧弯合并椎管狭窄的手术方案及疗效。[方法]自2003年6月～2007年1月本院手术治疗退行性腰椎侧弯合并椎管狭窄患者32例,术前均行X线、CT、MRI检查,10例另行脊髓造影,图像输入计算机并采用IPP软件计算Cobb’s角、椎体旋转度、侧方移位程度;32例患者均行后路减压植骨融合椎弓根内固定手术。记录手术时间、出血量、透视时间;随访观察腰椎融合、畸形矫正、疼痛缓解情况,同时采用VAS、LBOS评分对患者手术前后进行疗效分析。[结果]32例平均手术时间为(4±0.5)h,出血(400±30)ml,透视时间(30±5)min。32例患者均获随访,期限8个月～4年(平均20个月),术后8个月、16个月进行X线复查,24例患者获骨性融合(75%),末次随访时平均侧弯Cobb’s角从37.2°减少至18.4°,纠正率23.7%;平均前突角度从术前13.1°增加到16.4°,增长率25.1%;平均顶椎旋转度从14.2°减少至9.8°,纠正率31.0%;手术前后腰椎侧弯、前突角度均具有显著性差异(t检验,P<0.05)。术前平均VAS和LBOS平均为5.8±2.1、21.8±11.6,末次随访时分别增加为3.1±1.9、44.8±15.1,32例患者手术满意程度:优18例,良8例,可4例,差2例,优良率为81.2%。并发症情况:融合失败8例,内固定断裂1例,症状不缓解2例,神经根损伤2例,脑脊液漏2例,融合节段以外邻近节段退变3例需二次手术延长固定。[结论]退行性腰椎侧弯合并椎管狭窄后路减压植骨融合内固定手术创伤大,风险高,只有严格神经组织微创操作、椎体内固定个体化设计才能获得满意效果。

[Objective]To explore the surgical plan of lumbar degenerative de novo scoliosis combined with vertebral stenosis（LDDS） and evaluate the surgical efficiency.[Method]From July 2003 to Jan.2007,32 LDDS patients were diagnosed and operated in the author’s hospital.The X-ray,computed tomography and MRI radiological data were measured carefully preoperately which included the Cobb’s angle,vertebral rotational and lateral subluxation degree.All the patients were treated by posterior decompression and pedicle screw internal fixation,and the surgery,fluoroscopic time and bleeding amount were recorded.Patients were administered pre- and postoperatively with clinical outcome surveys of Visual Analogue Pain Score（VAS）,Low Back Outcome Score（LBOS）.Pre- and postoperative measurements of the Cobb＇s angle and lumbar lordosis of the involved segments were analyzed.[Result]The surgery time was 4±0.5 hours,the average bleeding amount was 400±30 ml,the fluoroscopic time was 30±5 min.All the patients were followed from 8 months to 4 years,and radiography was proceeded on 8 and 16 months respectively post surgery.Twenty-four cases got good bone fusion,and mean Cobb＇s angle decreased from 37.2 to 18.4 degrees,mean focal lordosis increased from 13.1 to 16.4 degrees,mean vertebral rotation angle decreased from 14.2 to 9.8 degrees,mean preoperative measures of VAS and LBOS improved from 5.3±2.2 and 24.8±15.6,respectively to 2.2±2.1 and 44.8±18.0 at last follow-up,the Cobb’s angle,lumbar lordosis and the degree of vertebral rotation had significantly difference pre and post surgery（t test,P〈0.05）.Twenty-six of 32 patients considered their outcome to be good or excellent.One patient required extension of his fusion at 12 months for adjacent segment stenosis.[Conclusion]This series suggests that surgery for degenerative lumbar scoliosis using posterior decompression and pedicle screw internal fixation is effective,but it is dangerous and traumatical.Only by the mini-invasive surgery and individualized internal fixation design can we get a better operative effect.