单纯减压与减压融合内固定术治疗伴I度退行性滑脱的腰椎管狭窄症的疗效比较

Clinical result comparision of simple decompression versus decompression and fusion for lumbar stenosis combined with Ⅰ degree degenerative spondylolisthesis

中文关键词:  腰椎管狭窄症  腰椎滑脱  退行性  减压  融合  内固定

英文关键词:Lumbar stenosis  Lumbar spondylolisthesis  Degenerative  Decompression  Fusion  Internal fixation

中文摘要:

  【摘要】　目的：比较单纯减压术与减压融合内固定术治疗伴Ⅰ度退行性滑脱的腰椎管狭窄症的疗效。方法：1993年1月~2007年6月收治的61例伴Ⅰ度退行性滑脱的腰椎管狭窄症患者，按手术方法分为单纯减压组（A组）和减压加融合内固定组（B组），A组28例，B组33例。两组年龄、性别、病程及术前JOA评分、腰腿痛VAS评分、椎体滑脱程度及椎间隙高度无统计学差异（P>0.05）。A组单纯行椎板开窗、椎管潜行扩大术，B组行椎板扩大开窗、后外侧或加椎间融合、椎弓根螺钉内固定术。均获2年以上随访，其中A组25例随访4~12年，平均6.8±4.7年；B组31例随访4~11年，平均6.5±4.1年；两组随访时间无统计学差异（P>0.05）。比较两组术后2年及末次随访时的JOA评分、腰痛及腿痛VAS评分、滑脱节段的椎间隙高度及滑脱程度变化。结果：B组手术时间、术中出血量均明显大于A组（P＜0.05）。A组并发症3例，其中术中硬脊膜撕裂2例，神经根损伤1例；B组并发症6例，其中术中硬脊膜撕裂3例，术后根性疼痛1例，术后切口感染1例，全麻术后认知功能障碍1例。A组再手术3例，其中2例因腰痛加重伴影像学滑脱加重至Ⅱ度分别于术后5年和6年行内固定融合术，再手术后腰痛缓解；1例因腰痛改善不满意于术后3年行内固定融合术，再手术后症状缓解；B组无再手术病例。术后2年A、B组JOA评分优良率分别为89.8%和90.9%，末次随访时分别为76%和87.1%，两组比较均无统计学差异（P>0.05）。两组腰痛VAS评分术后2年和末次随访时较术前明显降低（P＜0.05），A组末次随访时较术后2年增加（P＜0.05），B组末次随访时与术后2年比较无统计学差异（P>0.05），术后2年和末次随访时B组腰痛VAS评分明显低于A组（P＜0.05）。两组腿痛VAS评分术后2年及末次随访时较术前明显降低（P＜0.05），组间比较无统计学差异（P>0.05）。A组术后滑脱节段椎间高度较术前降低，末次随访时低于术后2年（P＜0.05），滑脱程度术后2年时较术前无加重但末次随访时较术后2年时增加（P＜0.05）；B组术后椎间隙高度维持，滑脱部分复位，术后2年及末次随访时无丢失(P＞0.05)。结论：单纯开窗减压与减压融合内固定术治疗伴Ⅰ度退行性滑脱的腰椎管狭窄症早期疗效相当，前者损伤小、并发症少但中远期效果下降，而后者能更好维持中远期疗效。

英文摘要:

  【Abstract】 Objectives: To compare the clinical results of simple decompression versus decompression and fusion for lumbar stenosis with Ⅰ degree degenerative spondylolisthesis. Methods: 61 consecutive cases suffering from lumbar stenosis with Ⅰ degree degenerative spondylolisthesis between January 1993 and June 2007 were classified into simple decompression group(group A) and decompression and fusion group(group B). There were 28 cases in group A and 33 cases in group B with no statistic difference with respect to age, gender, course of disease, severity of low back or leg pain, slippage extent or disc height between two groups(P＞0.05). Cases in group A received window laminectomy, while cases in group B received extensive laminoplasty, transpedicular internal fixation and posterolateral fusion or interbody fusion. All cases were followed up for at least 2 years, while 25 cases in group A and 31 cases in group B were followed up for 4 to 12 years(average, 6.8±4.7 years) and 4 to 11 years(average, 6.5±4.1 years) respectively(P＞0.05). JOA scores, VAS scores for low back pain and leg pain, disc height and slippage at two year′s and final follow-up were compared. Results: Group B had more operation time and more intraoperative blood loss(P＜0.05). Complications were noted in 3 cases of group A(including tearing of dura sac in 2 and nerve root impingement in 1) and 6 cases in groups B(including tearing of dura sac in 3, radiculalgia in 1, wound infection in 1, and cognitive disorder in 1). 3 cases in group A received revision surgery of decompression and fusion, including 2 cases due to aggravated low back pain and Ⅱ degree spondylolisthesis respectively 5 and 6 years later, and 1 case due to unalleviated low back pain three years later. No case in group B received revision surgery. Good to excellent rate of JOA score in group A and group B was 89.8% and 90.9% at two year′s follow-up, and 78% and 87.1% at the final follow-up respectively, which showed no intergroup statistic difference(P>0.05). VAS score for low back pain decreased statistically, both at two year′s and final follow-up in each group(P<0.05). In group A, the score at final follow-up increased statistically compared with two year′s counterpart(P<0.05), while in group B, the score remained unchanged(P＞0.05). The score in group B was statistically smaller than that in group A at each follow-up(P<0.05). Postoperative VAS scores for leg pain both at two year′s follow-up and final follow-up were better than preoperative ones in each group(P<0.05), with no significant inter-group difference(P＞0.05). In group A, disc height significantly decreased more at final follow-up, and significant difference existed between two year′s and final follow-up(P＜0.05). Slippage remained unchanged at two year′s follow-up, but final follow-up had lower disc height than two-year′s follow-up(P<0.05). In group B, the disc height remained unchanged(P>0.05), slippage progressed significantly(P<0.05), while the reduction was maintained at final follow-up(P>0.05). Conclusions: Both simple decompression and decompression combined with fusion can alleviate low back pain and leg pain effectively for lumbar stenosis with Ⅰ degree degenerative spondylolisthesis at postoperative early stage; simple decompression is relatively minimal invasive with lower incidence of complication, but for long time, the clinical outcome declines, while the latter one has better long time results.