1、 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical UniversityA study of the treating lumbar stenosis with laminectomy reserving spinal posteri
2、or structure叶正旭 罗卓荆 吴子祥第四军医大学西京医院西京骨科医院 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical University 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special H
3、ospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical University 腰椎管狭窄症（腰椎管狭窄症（Lumbar Spinal Stenosis LSS)是指因原发或继发因素造成椎管结构异常，椎管腔内变窄，出现以间歇性跛行为主要特征的腰腿疼痛 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Spec
4、ial Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical University脊椎退变所致的狭窄脊椎退变所致的狭窄1复合因素所致的狭窄复合因素所致的狭窄2脊椎滑脱症与骨溶解病所致狭窄脊椎滑脱症与骨溶解病所致狭窄3其他其他6损伤性狭窄损伤性狭窄5医源性狭窄医源性狭窄4 第四军医大学西京医院骨科专科医院第四军医大学西
5、京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical University影像学表现体征症状诊断（diagnosis）第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpeci
6、al Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical Universityl 双侧神经性跛行，间歇性大腿或小腿放射性疼痛，长时间站立、活动或腰过伸时症状加重，坐、卧或腰屈曲时减轻。一般症状 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopse
7、dics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical University体 征 膝踝反射改变多不对称 病理反射缺如 感觉障碍 直腿抬高试验阴性 压迫马尾及神经根时影响大、小便 严重者下肢不完全性瘫痪 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyX
8、iJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical University非手术治疗手术治疗腰椎管狭窄的治疗 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4t
9、h Military Medical University活动后腰及腿疼痛，影响工作、生活，经保守治疗不愈者 进行性跛行加重，或站立时间逐渐缩短者 神经机能出现明显缺损者 腰椎管狭窄手术指征：第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medi
10、cal University减压是解除症状的主要手段减压范围：l包括黄韧带、椎间盘、增生的关节突、侧隐窝l尽量保留有用的椎间盘减压破坏后柱结构,故通常增加了常用手术方式为全椎板切除减压术常用手术方式为全椎板切除减压术 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th
11、Military Medical University1983年Denis提出三柱分类 传统减压破坏了c柱的张力带作用 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical University峡部仍保持完整退变性腰椎失稳 小关节磨损 关
12、节突水平前纵韧带松弛椎间盘退变腰椎退变性滑脱腰椎退变性滑脱 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical University 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital fo
13、r Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical University 全椎板切除减压手术组 22例 保留后部结构的改良减压手术组 26例 2003年5月2004年5月 腰椎管狭窄症患者随机分组 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&Trau
14、motologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical University临床表现：均有间歇性跛行伴下肢放散痛病史 下肢有皮区感觉减弱 36例 皮区感觉消失 12例 小便失禁 6例 影象学检查 CT、MRI 影像显示：椎管狭窄节段在L3-S1范围内，需减压的节段为23个 x线片显示：无腰椎失稳的征象实验组实验组2626例（男例（男1212例，女例，女1414例），平均年龄例）
15、，平均年龄62622 2岁岁对照组对照组2222例（男例（男1313例，女例，女 9 9例），平均年龄例），平均年龄63631.51.5岁岁 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical University 采用传统全椎板切除减
16、压手术采用腹卧位后正中切口 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical UniversityA.椎板骨膜下剥离一侧骶棘肌达关节突外侧B.将需要减压节段的棘突于其基部截骨，骨膜下剥离对侧椎板，显露椎板、黄韧带C.全椎板及增厚的黄韧
17、带切除，行椎管减压 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical Universitya 黄韧带 b 棘突间韧带 c 棘突上韧带术中注意保留术中注意保留的后部结构的后部结构 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科
18、专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical Universityl手术时间平均55min(3068min)l均未输血l术后第3天开始腰背肌锻炼，腰围或支具固定3个月 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthop
19、sedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical University两组病人术后1年，3年拍腰椎过伸、过屈侧位X片按Macnab评定标准 评定术后恢复情况参照Hanley法测量L3、5节段的屈伸活动度 ab 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&Traum
20、otologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical University组别优秀良好差实验组16100对照组1480两组间无显著性差异两组间无显著性差异 （P0.05P0.05）第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for O
21、rthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical University 组别术前术后1年术后3年对照组43.764.3841.245.6854.345.36实验组42.963.5440.146.1245.874.62术前及术后1年腰椎活动度无显著性差异 （P0.05）术后3年的实验组腰椎活动度显著低于对照组 （P0.05）第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Or
22、thopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical Universityl患者：何某，男，56岁l症状：间歇性跛行1年伴双下肢放散痛lMRI、CT示：L3.4，L4.5椎管狭窄 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecia
23、l Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical University术前术前MRI术后1年术后3年术前CT 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Mi
24、litary Medical UniversityXiJing Hospital,4th Military Medical University 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical University 椎管后路减压治疗
25、时，尽可能维持小关节的完整性 除小关节以外，脊柱的后部韧带结构对前屈载荷有重要的抵抗作用 后部韧带结构对腰椎的旋转稳定性有一定的作用 腰椎管狭窄症手术应遵循充分减压和有限化的手术原则 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical
26、Universityl保留了棘上韧带、棘间韧带及棘突，对维持脊柱的稳定性起到积极作用l术中仅剥离一侧骶棘肌，损伤小，出血少，利于患者术后康复l术中显露充分，减压彻底，与传统方法的显露范围无显著差别 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical University
