退变性腰椎侧凸合并腰椎管狭窄症患者的个体化手术治疗

Individualized surgical therapy for degenerative lumbar scoliosis with stenosis

目的：观察选择性椎管减压及融合术治疗退变性腰椎侧凸合并椎管狭窄（degenerative lumbar scoliosis with stenosis，DLSS）患者的临床疗效。方法2007年2月至2011年1月，我院经后路治疗DLSS患者28例。男11例，女17例；年龄54～73岁，平均67.3岁。病程4～8年。术前Cobb’s角15°～49°，平均31°；腰椎前凸角（T12～S1）-30.6°～3.3°，平均-10.5°。对Cobb’s角＜20°的5例行选择性椎管或神经根管减压，经后路椎体间融合，短节段椎弓根钉棒系统固定；对Cobb’s角＞20°的23例行椎管减压，长节段固定侧凸矫正，后路椎体间融合及后外侧自体骨植骨融合。采用视觉模拟评分（visual analogue scale，VAS）、日本骨科协会（Japanese orthopedic association，JOA）评分评估临床疗效，应用SF-36调查问卷对患者治疗前和末次随访时生活质量变化情况进行评价。结果28例行减压手术节段113个，平均减压4.0个节段；共融合90个节段，平均融合3.2个节段。术后随访24～70个月，平均32个月，平均手术时间为（3.5±0.5）h，出血（600±30）ml，末次随访时腰痛及腿痛VAS评分较治疗前明显降低（P＜0.05），侧凸由术前平均31°矫正至术后平均15.2°，改善率平均为51.0%。腰椎前凸角矫正为5.4°～28.2°，平均18.4°。腰椎前凸角及侧凸Cobb’s角均明显改善（P＜0.05）。术前JOA评分平均13.6分，末次随访时平均27.5分（P＜0.05）。所有患者生活质量明显提高，SF-36调查问卷表中的8个维度分值均较术前明显提高（P＜0.05）。结论 DLSS的治疗应个体化地选择治疗方案。手术治疗以减压为主、矫形为辅，应准确判断责任节段，临床疗效满意，患者的生活质量明显提高。

Objective To investigate the therapeutic outcomes of selective decompression and fusion for degenerative lumbar scoliosis with stenosis （ DLSS ）. Methods From February 2007 to January 2011, 28 patients with DLSS underwent posterior surgery. There were 11 males and 17 females, whose average age was 67.3 years old （ range：54-73 years ）. The course of disease lasted from 4 to 8 years. Preoperatively the mean Cobb’s angle was 31° （ range：15°-49° ）, and the mean lordosis angle （ T12-S1 ） was-10.5° （ range：-30.6°-3.3° ）. Selective spinal canal or nerve root canal decompression was performed on 5 patients with the Cobb’s angle20° underwent spinal canal decompression, long-segment pedicle instrumentation, scoliosis correction, posterior lumbar interbody fusion and posterolateral autograft bone fusion. The clinical outcomes were evaluated by Visual Analogue Scale （ VAS ） scores and Japanese Orthopedic Association （ JOA ） scores. The Medical Outcomes Study 36-item short-form health survey （ SF-36 ） was used to assess the patients’ quality of life before the operation and in the latest follow-up. Results Decompression was performed on 113 segments and fusion on 90 segments in 28 patients. The average number of decompressed segments was 4.0 and the average number of fused segments was 3.2. The mean follow-up period was 32 months （ range：24-70 months ）. The mean surgery time was （ 3.5±0.5 ） h, and the mean blood loss was （ 600±30 ） ml. In the latest follow-up, the VAS scores of low back and leg pain were obviously decreased when compared with the preoperative VAS scores （ P〈0.05 ）. The preoperative Cobb’s angle was 31° on average, which was corrected to 15.2° postoperatively, and the mean correction rate was 51.0%. The lordosis angle was corrected to 18.4° on average （ range：5.4°-28.2° ）. Both the lordosis angle and Cobb’s angle were obviously improved （ P〈0.05 ）. The average JOA score was 13.6 points preoperatively and 27.5 points in the latest follow-up （ P〈0.05 ）. All the patients’ quality of life was significantly improved. The scores of all the 8 SF-36 domains were significantly improved postoperatively （ P〈0.05 ）. Conclusions An individualized surgical therapy should be chosen for DLSS. Decompression is given priority and fusion is complementary, when the surgical plan is designed. The responsible segment should be judged accurately. The clinical outcomes are satisfactory, and the patients’ quality of life is signiifcantly improved.