椎管内扩大成形术治疗腰椎管狭窄症的临床疗效

Efficiency of expansive intra-canal plasty in treatment of lumbar spinal stenosis

目的：探讨椎管内扩大成形术（ EICP）治疗老年性中央型腰椎管狭窄的早期疗效及优势。方法回顾性地分析空军总医院2015年1月至2015年7月采用EICP治疗以间歇性跛行为主要表现的退行性中央型椎管狭窄患者23例。观察手术时间、术中出血量、术中神经脊髓监测情况、术后引流量、手术并发症情况，术后影像学观察腰椎管横截面积和腰椎融合情况，采用日本骨科联合会（ JOA）评分、Oswestry失能指数（ ODI）评分、间歇性跛行的改善情况评价临床效果。结果本组所有病例均获得随访，随访时间12～16（13．8±1．5）个月，单节段术中出血量（257．5±47．1）ml，手术时间（114．5±16．8）min，术后引流量（150．0±37．6）ml。双节段术中出血量（344．5±55．6）ml，手术时间（161．8±24．4）min，术后引流量（225．4±40．1）ml，术中脊髓神经监测均未见持续异常。3例患者发生并发症，1例术中出现硬膜囊撕裂，对症处理后术后5 d脑脊液停止，2例术后出现切口延期愈合，积极给予换药，术后3周愈合良好。术前、术后1周CT扫描手术目标狭窄节段水平椎管横截面积，术前L3－4（73．32±2．67） mm^2、L4－5（116．24±2．17） mm^2，术后L3－4（213．33±3．26） mm^2、L4－5（260．16±3．67）mm^2，术前术后差异均有统计学意义（ P＜0．05）。术后1年随访时JOA评分、ODI评分及间歇性跛行的情况较术前明显改善，差异有统计学意义（P＜0．05）。根据JOA 评分，术后平均改善率90．05％。术后3个月、6个月、1年融合率分别为78．2％、86．9％、95．6％。结论 EICP是对传统中央型腰椎管狭窄症的全椎板切除减压手术的革新，体现了精准外科和微创外科的现代外科理念，既能对狭窄的椎管行有效减压，又能保护腰椎后方的原生结构不受到破坏，维持腰椎稳定性，增大植骨面积、提高融合率，手术疗效确切，并发症发生率低，是一种治疗腰椎管狭窄症的有效方法。

Objective To investigate the early efficacy and advantages of expansive intra-canal plasty （EICP） in the treatment of central lumbar spinal stenosis in the elderly .Methods A retrospective analysis was performed on 23 elderly patients with central lumbar spinal stenosis due to degeneration and with main manifestation of intermittent claudication admitted in our hospital from January to July 2015.They were all treated with EICP .The operation time, blood loss, intraoperative monitoring of spinal nerve , postoperative drainage , postoperative complications , postoperative images of lumbar spinal fusion of the lumbar spine and the cross -sectional area during follow-up, Japanese Orthopaedic Association （JOA） score, Oswestry disability index （ODI）, improvement of intermittent claudication were observed and recorded to evaluate clinical outcomes .Results All cases were followed up for 12 to 16（13.8 ±1.5） months.The average bleeding amount of single segment was （257.5 ±47.1）ml, the operation time （114.5 ±16.8）min, and postoperative drainage amount （150.0 ±37.6） ml.For double segments, the intraoperative blood loss was （344.5 ±55.6） ml, the operation time was （161.8 ±161.8）min, the postoperative drainage amount was （225.4 ±40.1） ml, and no abnormality was found in intraoperative spinal cord monitoring.There were 3 patients having postoperative complications .One case had dural sac tear , and the postoperative cerebrospinal fluid was stopped in 5 d after symptomatic treatment .Two cases had postoperative delayed healing of incision , and the incisions were healed well after 3 weeks ’ active treatment .CT scanning showed that the cross-sectional area of narrowed space was significantly increased from preoperative （73.32 ±2.67）mm^2 to （213.33 ±3.26）mm^2 in 1 week postoperatively in L3-4 segments,and from （116.24 ±2.17） to （260.16 ±3.67）mm^2 in L4 -5 segments （P 〈0.05）.In 1 year after operation, the JOA score, ODIscore and intermittent claudication were obviously improved （P 〈0.05）.According to JOA score, the postoperative improvement ratewas 90.05%.The fusion rate was 78.2%, 86.9% and 95.6%, respectively in 3 and 6 months, and 1 year postoperatively. Conclusion EICP is an innovation for the traditional resection of whole lamina and decompression in the treatment of central lumbarspinal stenosis, reflecting the concept of modern surgery, precise surgery and minimally invasive surgery.It can not only exert effectivedecompression in the narrow canal, but also protect the native structure behind the lumbar spine , maintain the stability of lumbarspine, increase the bone graft area, and elevate the rate of fusion.It exerts effective surgical efficiency and causes low incidence ofcomplications, and is an effective approach for lumbar spinal stenosis .