腰椎间盘突出症术后同间隙再突出与不稳的防治

Prevention and Treatment of Re-protrusion and Unstability of PLD at the Same Level

目的 了解腰椎间盘突出症再手术原因 ,分析传统腰间盘手术对腰椎运动节段稳定性的影响 ,为某些腰椎间盘突出症手术方法的改进 ,提供临床及试验室依据。方法 分临床及试验室两部分。临床部分回顾分析了我院近十年开展腰椎间盘手术6 2 0例 ,对手术疗效进行了随访及评定。试验室部分选用新鲜尸体 4个腰椎运动节段 ,分别对腰椎间盘进行不同程度的破坏 ,包括未破坏、用环钻破坏纤维环、刮除部分髓核、彻底刮除间盘组织。通过夹具将相邻椎体固定于试验机上 ,通过百分表测量腰椎椎体在矢状面上的水平位移 ,比较在不同负荷下水平位移位的变化。结果 临床上 6 2 0例腰间盘手术后随访超过半年 ,按改良Macnab疗效评定标准 ,优良率 84% ,2 2例进行了两次以上的手术 ,再手术率 3 6 %。再手术的主要原因是 :同间隙复发及病变节段不稳定。这类患者具有术前年龄偏大 ,X线平片存在腰椎退行性改变等特点。试验结果 ,髓核刮除困难 ,传统间盘手术只摘除 1/ 3～ 1/ 4的髓核。手术破坏了纤维环张力及髓核的完整性 ,造成该运动节段的潜在不稳 ,是引起同间隙病变的主要原因。结论 腰椎间盘突出症的手术治疗 ,在尽量摘除髓核的同时要考虑腰椎节段稳定性的问题。对年龄偏大的腰椎间盘突出症患者 ,若存在椎间隙狭窄。

Objective To understand the reasons for re-operation of lumbar disc herniation,to analyze stability of the lumbar spinal segment affect by classical discectomy,to offer some clinical and laboratory warrant which improve some operative methods of lumbar disc herniation Methods The study includes clinical part and laboratory part In clinical part,we analyze and evaluate the operative effect by follow-up of 620 cases of lumbar disc operation in recent 10 years In the laboratory part we selected four lumbar spinal motive segment of fresh cadaver Then we reset the lumbar disc in different degrees respectively,which include normal disc,the fibrosis by circle drill,scraping the nucleus partly and entirely Then we measured the horizontal displacement and compared the variety of that under different load Results The follow-up of 620 cases over one half of a year The excellent and good rate is 84% estimated by modified Macnab's standard 22 cases preformed operation more then two times and re-operative rate was 3 6% The reason of re-operation was recurrence and instability at the same level The trait of the group is that they are older and obvious degenerate change in lumbar vertebrae The result of the study showed that it is difficult to scrape the normal nucleus only 1/3～1/4 of nucleus could be scraped in general discectomy The operation destroyed the tension of the annulus and integrates of the nucleus,which cause the potential instability of the segment This is the main pathogenicity of the same level Conclusions We should pay attention for the stability of the lumbar spine when we performed the lumbar disc-operation and discectomy entirely To the elder patients with degeneration such as disc space narrowing and osteophytosis,we suggest TFC is necessary to fuse the segment