后路减压植骨融合内固定术治疗胸椎管狭窄症的疗效及安全性

Effect and safety of decompression and discectomy combined with interbody fusion and pedicle screw internal fixation via posterior approach for thoracic spinal stenosis

目的探讨经后入路减压植骨融合内固定术治疗胸椎管狭窄症的疗效及安全性。方法回顾分析2010年1月至2018年5月重庆医科大学附属第一医院骨科行后入路减压植骨融合内固定术治疗的14例胸椎管狭窄症患者的病历资料。其中男7例,女7例,年龄为(55.14±9.87)岁(38~73岁)。患者出现自觉症状至确诊的时间为(35.25±45.79)个月,症状加重至确诊的时间为(10.67±14.69)个月。导致胸椎管狭窄症的因素:黄韧带骨化10例,椎间盘突出3例,椎间盘突出合并黄韧带骨化1例。观察并记录手术时间、术中减压和固定节段、术中出血量和输血量、术后引流量和引流时间,以及术中和术后并发症。采用美国脊髓损伤协会(ASIA)脊髓损伤分级(简称ASIA分级)和日本骨科协会(JOA)脊髓功能评分表(简称JOA评分)评估患者的神经功能。结果所有手术均在神经电生理监护下完成,手术时间为(216.21±60.40)min(110~322 min),术中出血量为(471.43±358.80)ml(50~1 200 ml),术中输血量为(378.29±622.81)ml(0~2 000 ml),术后引流液量为(440.93±396.44)ml(33~1 430 ml),术后引流时间为(3.93±1.59)d(1~7 d)。术后出现神经系统并发症3例,其中脑脊液漏2例,颅内积气和低颅压综合征1例,经对症处理后均痊愈。术前脊髓损伤ASIA B级1例,末次随访时改善为ASIA D级;ASIA C级4例,末次随访时3例改善为ASIA D级,1例改善为ASIA E级;ASIA D级9例,末次随访时4例改善为ASIA D级,5例改善为ASIA E级。术前及末次随访时JOA评分分别为(6.43±2.10)分和(9.14±0.95)分,二者差异有统计学意义(P<0.05),其中JOA评分改善率优3例,良6例,可4例,差1例。末次随访时未发现内固定失效病例。结论经后入路减压植骨融合内固定术治疗胸椎椎管狭窄安全有效,术后并发症少。术中脊髓的神经电生理监护和审慎的操作有助于提高手术的安全性。

Objective To investigate the effect and safety of the posterior approach decompression and discectomy combined with interbody fusion and pedicle screw internal fixation for thoracic spinal stenosis.Methods From January 2010 to May 2018,a total of 14 patients with thoracic spinal stenosis underwent decompression and discectomy combined with interbody fusion and pedicle screw internal fixation via posterior approach in the First Affliated Hospital of Chongqing Medical University were retrospectively analyzed.There were 7 males and 7 females with an average age of（55.14±9.87）years（ranged from 38 to 73 years）.The time from the patient＇s symptoms appearing to diagnosis was（35.25±45.79）months,and the time from symptom exacerbation to condition worsened was（10.67±14.69）months.Causes of thoracic spinal stenosis included ossification of the ligamentum flavum in 10 cases,thoracic disc herniation in 3 cases,and ossification of the ligamentum flavum combined with thoracic disc herniation in one case.The operation time,intraoperative decompression and fixation segment,volumes of intraoperative blood loss and blood transfusion,postoperative drainage volume and drainage time,as well as intraoperative and postoperative complications were observed and recorded.The neurological function of the patients was evaluated by the American Spinal Injury Association（ASIA）spinal cord injury classification（ASIA classification）and the Japan Orthopaedic Association（JOA）spinal function scale（JOA score）.ResultsAll operations were performed under electrophysiological monitoring.The operation time was（216.21±60.40）min（110-322 min）.The blood loss was（471.43±358.80）ml（50-1 200 ml）.The blood transfusion was（378.29±622.81）ml（0-2 000 ml）.The drainage volume was（440.93±396.44）ml（33-1 430 ml）.The drainage time was（3.93±1.59）d（1-7 d）after surgery.Postoperative neurological complications occurred in 3 cases,included cerebrospinal fluid leakage in2 cases and intracranial gas and low intracranial pressure syndrome in one case.The 3 patients recovered after appropriate treatments.At the last follow-up,one case with ASIA grade B improved to ASIA grade D,among4 cases with ASIA grade C,3 cases improved to ASIA grade D and one case improved to ASIA grade E,among9 cases with ASIA grade D,4 cases improved to ASIA grade D and 5 cases improved to ASIA grade E.The JOA score changed from（6.43±2.10）at preoperation to（9.14±0.95）at last follow-up,and there were excellent in 3 cases,good in 6 cases,fair in 4 cases and poor in one case.All cases reached bony fusion without instrument failure at the last follow-up.ConclusionDecompression and discectomy combined with interbody fusion by posterior approach is a safe and effective procedure for the thoracic spinal stenosis,and with less postoperative complications.Intraoperative electrophysiological monitoring of spinal cord and careful operation can help to improve the safety of the surgery.