腰椎椎间盘突出症再手术因素及治疗策略

Reoperation factors and treatment strategies for posterior lumbar intervertebral disc herniation

目的探讨腰椎椎间盘突出症再手术的因素,以及手术治疗的方法和疗效。方法回顾分析2007年1月～2010年6月收治的腰椎椎间盘突出症再手术病例共计73例,再手术方式为单侧椎板开窗椎间盘切除术14例,半椎板切除减压椎间盘切除术11例,全椎板切除减压椎间盘切除术6例,后路腰椎椎间盘切除联合椎体间植骨融合术40例,内固定翻修2例。结果本组出现并发症14例,经治疗后好转。获得6～44个月随访,平均21个月。Oswestry功能障碍指数(Oswestry disability index,ODI):术前(63.26±5.36)%,术后3个月(19.68±8.42)%。视觉模拟量表(visual analog scale,VAS)评分:术前7.26±2.06分,术后3个月3.68±1.22分。ODI及VAS评分均有明显改善,与术前相比差异有统计学意义(P<0.05)。结论腰椎椎间盘突出症再手术主要因素为术中突出节段定位错误,游离髓核摘除不彻底,遗漏突出间隙的椎间盘,邻近节段退变突出,椎管狭窄减压不充分,腰椎不稳,内固定失败等;再手术时正确选择手术时机和方法仍可以获得较满意的疗效。

Objective To discuss the reoperation factors,surgical treatment strategies,and the treatment outcomes of patients with posterior lumbar intervertebral disc herniation.Methods A total of 73 patients with posterior lumbar intervertebral disc herniation who underwent reoperation during January 2007 to June 2010 after primary lumbar discectomy with or without instrument fixation were retrospectively studied.Reoperation was performed by discectomy with unilateral laminactomy in 14 cases,hemilaminactomy decompression in 11 cases,discectomy with total laminactomy in 6 cases,posterior lumbar interbody fusion（PLIF） in 40 cases,and revision surgery with failed instrument in 2 cases.Results After a follow-up of 21 months（ranging 6-44 months）,complications were found in 14 cases;the Oswestry disability index（ODI）and visual analog scale（VAS） scores were both significantly improved after operation（P〈0.05）.ODI was decreased from（63.26±5.36）% before operation to（19.68±8.42） % 3 months after operation.VAS score was decreased from 7.26±2.06 before operation to 3.68 ± 1.22 3 months after operation.Conclusion The major reoperation factors for posterior lumbar intervertebral disc surgery include intraoperative segment malpositioning,residual nucleus pulposus,sequestered intervertebral disc,adjacent segment degeneration,inadequate decompression,lumbar instability and instrumentation failure.Satisfactory effectiveness of reoperation can be obtained by proper operation time and surgery strategies.