腰椎间盘突出症术后腰椎再手术的疗效及其影响因素分析

Clinical outcome and relative factors of revision surgery for lumbar disc herniation

中文关键词:  腰椎间盘突出症  再手术  疗效  影响因素

英文关键词:Lumbar disc herniation  Revision  Clinical outcome  Relative factors

中文摘要:

  【摘要】　目的：分析腰椎间盘突出症术后腰椎再手术的临床效果及其影响因素。方法：回顾性分析我科2005年1月~2009年11月收治的94例腰椎间盘突出症术后腰椎再手术患者的临床资料。根据病史、症状、体征及影像学检查，腰椎再手术的原因包括腰椎间盘突出复发49例（52.1%），腰椎管狭窄症17例（18.1%），初次手术减压不彻底16例（17.0%），邻近节段病变7例（7.4%），其他节段新发腰椎间盘突出5例（5.3%）。再手术前，腰椎JOA评分为15.5±5.6分，腰痛VAS评分为4.5±1.6分，下肢痛VAS评分为7.1±1.9分。再手术均采用后路减压、椎间盘切除、椎弓根螺钉内固定、横突或椎体间植骨融合术。对再手术患者进行随访，并根据VAS、JOA评分及患者主观满意度评价再次手术效果。采用多因素非条件Logistic回归，分析患者性别、年龄、吸烟、既往手术史、既往手术方式、上次术后症状缓解时间、本次病程、再手术前神经损害、本次手术融合节段等变量对手术效果的影响。结果：再手术时间1.6~4.5h，平均2.4h；术中出血量200~1500ml，平均538ml。术中无神经损伤发生；术后发生脑脊液漏7例，切口感染1例，经对症处理均治愈。再手术后随访2～6.5年，平均4.2年。末次随访时，总体优良率78.7%，JOA评分为24.0±6.2分，腰痛VAS评分为1.3±0.9分，下肢痛VAS评分为0.9±1.8分，与术前比较差异均有显著性（P<0．001)。再手术前神经损害、本次病程对手术效果的影响有统计学意义（P<0．05），性别、年龄、吸烟、手术次数、上次术后症状缓解时间、既往手术方式、本次手术减压融合的节段对手术效果的影响无统计学意义（P＞0．05）。结论：腰椎间盘突出症术后腰椎再手术依然能够获得较好的临床效果。再手术前神经损害、本次病程是影响手术效果的因素。

英文摘要:

  【Abstract】　Objectives:　To investigate the clinical outcome and relative factors of revision surgery for lumbar disc herniation. Methods: From January 2005 to November 2009, 94 patients who underwent revision surgery for lumbar disc herniation were reviewed retrospectively. According to natural history, clinical signs, physical examination and imaging findings, the causes of revision surgery included 49(52.1%) disc recurrence, 17(18.1%) lumbar canal stenosis,　16(17.0%) inadequate decompression at primary surgery, 7(7.4%) adjacent segment disease, 5(5.3%) lumbar disc herniation at new level. Before revision surgery, the lumbar JOA score was 15.5±5.6, the VAS score for back pain and leg pain was 4.5±1.6 and 7.1±1.9 respectively. Posterior decompression, discectomy, pedicle screw fixation, and transverse process or interbody bone graft and fusion were performed in all cases. 94 patients were followed up, and the surgical results were evaluated by VAS,　JOA and patients satisfactory degree. Relative factors including sex,　age, smoking, previous operation times, previous operation methods, period of pain-free interval after the last surgery, disease course of this time, neurologic deficit, number of fusion segments were investigated. Data were analyzed by multivariate nonconditiona1 Logistic regression analysis. Results: The revision surgical time ranged from 1.6h to 4.5h, with a mean of 2.4h, and the blood loss ranged from 200ml to 1500ml, with a mean of 538ml. No case was complicated with nerve injury in revision surgery. 7 cases were complicated with cerebrospinal fluid leakage and 1 case was complicated with wound infection after operation, and all resolved after responsive management. All cases were followed up for 2-6.5 years, with a mean of 4.2 years. At final follow-up, the functional results showed excellent to good rate of 78.7%, the lumbar JOA score was 24.0±6.2, the VAS score for back and leg pain was 1.3±0.9 and 0.9±1.8 respectively, which showed significant differences（P<0．001). Neurologic deficit, disease course of this time were the most relative factors of prognosis（P<0.05）, while gender, age, smoking, previous operation times, previous operation methods, period of pain-free interval after the last surgery, number of fusion segments were not the relative factors（P＞0．05）. Conclusions: Revision surgery for lumbar disc herniation is reliable, and neurologic deficit, disease course of this times are the relative factors of prognosis.