腰椎间盘突出融合术后症状性邻近节段退变再次手术方式选择研究

Reoperation of adjacent segment degeneration postoperation of lumbar disc herniation fusion

目的:探讨腰椎间盘突出融合术后邻近间隙椎间盘突出再次手术方式选择及其决定因素。方法:回顾性分析因腰椎间盘突出融合术后症状性邻近节段突出19例首次和再手术术前病例资料。首次患者行腰椎后路融合术(PLF)13例,腰椎经椎间孔入路椎体间融合术(TLIF)6例,再次手术时选择行椎间孔镜下髓核摘除5例,腰椎后路椎间融合术(TLIF)14例,其中包括手术前动态位失稳4例,伴腰椎管狭窄10例,应用改良Macnab法、术前及再手术后及末次随访时ODI功能评价、VAS评分对手术疗效进行评价。结果:19例患者均获得随访,平均随访时间16个月(15~38个月);再次术前腰椎ODI功能评价(56.21±2.74)%,术后下降为(19.65±2.48)%;VAS评分术前为(7.46±0.37)分,术后下降为(2.58±0.72)分(P<0.01);术中粘连较重出现硬脊膜破裂4例,术后发生脑脊液漏1例,无神经损伤发生,优10例,良6例,可3例,优良率84.21%。结论:腰椎间盘突出融合术后症状性邻近节段突出,若未合并椎管狭窄和失稳时,可以考虑行椎间孔镜下髓核摘除术,短期疗效确切,选择再次固定融合时要慎重。

Objective：To explore the reoperation and determinants of adjacent segment intervertebral disc herniation post-operation of lumbar fusion.Methods：In the study,19 cases of symptomatic adjacent segment intervertebral disc herniation post-operation of lumbar fusion were retrospectively reviewed,with an average age of（58.6 ±7.3）years.Including the male 11 cases and female 8 cases,lesions segment distribution located in L_（3/4） in 5 cases,in L_（4/5） in 11 cases,in L_5/S_1 in 13 cases,and the mean recurrence time was 4.7（3.9~6.4）years.To review the preoperative clinical data of the first time surgery and the reoperation in patients,the Posterior lumbar fusion（PLF）were 13 cases and there were 14 cases by intervertebral foramen approach between vertebral fusion（TLIF）for the first time surgery.In the reoperation,the intervertebral foramen microscopically removal of nucleus pulposus were 5 cases,the lumbar posterior intervertebral fusion（TLIF）were 14 cases,including preoperative dynamic instability in 4 cases and lumbar spinal stenosis in 10 cases.The modified Macnab method、ODI functional evaluation and VAS score were used to evaluate the efficacy of the operation before surgery and after reoperation and at the end of follow-up.Results：All 19 patients were followed up with an average time of 16 months（15~38 months）;The ODI functional evaluation of lumbar spine was evaluated again（56.21±2.74）%,and the postoperative decrease was（19.652.48）%;The VAS score after operation was decreased from （7.46±0.37） to （2.58±0.72）（P〈0.01）.There were 4 cases appearing dural rupture during the operation because of the severe adhesion,1 case occurred cerebrospinal fluid leakage after the operation,no nerve damage occurred.Excellent in 10 cases,good in 6 cases,fair in 3 cases,the excellent rate was 84.21%.Conclusions：The intervertebral foramen microscopically removal of nucleus pulposus is prominent efficient in the adjacent segment intervertebral disc herniation post-operation of lumbar fusion,if the spinal canal is not combined with spinal stenosis and instability.It should be cautious to choose fixed fusion again.