神经根封闭术在退行性腰椎侧凸合并多节段腰椎管狭窄症长节段固定矫形选择性减压中的意义

Nerve root block in selective decompression of long segment fixation for degenerative lumbar scoliosis with multi-segmental lumbar spinal stenosis

目的探讨神经根封闭术在退行性腰椎侧凸合并多节段腰椎管狭窄症长节段固定矫形选择性减压中的意义。方法回顾性分析2015年6月至2017年6月在西安交通大学医学院附属红会医院治疗的40例退行性腰椎侧凸合并多节段腰椎管狭窄症病人的临床资料,根据术前是否采用神经根封闭术明确责任节段分为神经封闭组和非神经封闭组。神经封闭组共20例病人,术前采用神经根封闭术明确责任节段后对相应节段进行减压融合,并行长节段固定矫形;非神经封闭组共20例病人,术前未行神经根封闭术,由于责任节段不明确,故行预防性减压后固定矫形。分别记录并比较两组术前、术后第3天、术后6个月、末次随访的疼痛视觉模拟量表(visual analogue scale, VAS)评分、日本骨科协会(Japanese Orthopaedic Association, JOA)评分、Cobb角和腰椎前凸角的变化等。结果神经封闭组病人术前封闭过程无神经损伤,神经根封闭术准确率为100%,手术时间为(147.55±17.56)min,出血量为(703.75±129.74)ml,并发症2例,发生率为10%。非神经封闭组手术时间为(180.45±25.32)min,出血量为(945.65±175.30)ml,并发症4例,发生率为20%。所有病人获得(12.73±2.27)个月的随访,两组病人术后第3天、术后6个月、末次随访的VAS评分、JOA评分、Cobb角及腰椎前凸角较术前均明显改善,差异均有统计学意义(P均<0.05)。神经封闭组术后第3天、术后6个月、末次随访的VAS评分、JOA评分优于非神经封闭组,差异均有统计学意义(P均<0.05),神经封闭组术中出血量、手术时间及并发症发生率均优于非神经封闭组,差异均有统计学意义(P均<0.05)。两组术后均未发现内固定松动、断裂及融合器移位,植骨愈合良好。结论神经根封闭术简单、准确、有效,对于定位不明确的退行性腰椎侧凸合并多节段腰椎管狭窄症的病人,术前通过神经根封闭术明确责任节段,进行针对性减压,可避免预防性减压带来的手术创伤和风险,使病人获得较为满意的术后疗效。因此,可作为一种有效的术前定位诊断方法。

Objective To investigate the significance of nerve root block in the selective decompression of long segment fixation for degenerative lumbar scoliosis with multi-segmental lumbar spinal stenosis. Methods From June 2015 to June 2017, the clinical data of 40 patients with degenerative lumbar scoliosis with multi-segmental lumbar spinal stenosis were retrospectively analyzed in our hospital. According to whether the nerve root block was used to identify the responsible segments, the patients were divided into nerve root block group and non-nerve root block group, 20 cases in each group. In nerve root block-group,preoperative nerve root block was used to identify the responsible segments. Decompression and fusion were performed on the corresponding segments, and long-segment fixation was performed. In non-nerve root block group, a total of 20 patients were not treated with nerve root block before surgery. Due to unclear responsibility segment, they received preventive decompression and fixed orthodontic treatment. The visual analogue scale(VAS) score, Japanese Orthopaedic Association(JOA) score, Cobb angle and lumbar lordosis before and 3 days and 6 months after operation and the last follow-up were compared, and the changes of each index between the two groups were recorded and compared. Results In the nerve root block group, there was no nerve injury in the process of preoperative nerve root block, and the accuracy rate of nerve root closure was 100%. The operative time was(147.55±17.56) min, and the bleeding volume was(703.75±129.74) ml. Complications occurred in 2 cases(10%). In the non-nerve root block group, the operative time was(180.45±25.32) min, and the bleeding volume was(945.65±175.30) ml. Complications occurred in 4 cases(20%). All patients were followed up for(12.73±2.27) months. The VAS score, JOA score, Cobb angle and lumbar lordosis at 3 rd day,6 th month and the last follow-up postoperatively in both groups were significantly improved than preoperation,with statistically significant differences(P<0.05). The VAS score and JOA score in nerve root block group were superior to those in non-nerve root block group at 3 rd day and 6 th month after surgery and the last follow-up(P<0.05). The amount of bleeding, operation time and complication rate in nerve root block group were significantly reduced as compared with those in non-nerve root block group(P<0.05). There was no loosening or fracture of internal fixation or displacement of fusion device in the two groups postoperatively, and the bonegrafting was healed. Conclusion Nerve root block is simple, accurate and effective. For patients with degenerative lumbar scoliosis with multi-segmental lumbar spinal stenosis whose location is not clear, the preoperative nerve root block is used to define the responsible segment, and then targeted decompression was performed, which can avoid the surgical trauma and risk caused by preventive decompression, and make the patients obtain satisfactory results after operation. Therefore, the nerve root block can be used as an effective preoperative localization diagnosis method.