高龄腰椎管狭窄症患者的手术方式选择及疗效

Surgical options and outcomes of degenerative lumbar spinal stenosis in octogenarian

中文关键词:  腰椎管狭窄症  高龄患者  椎板开窗减压术  经椎间孔入路椎间融合术

英文关键词:Degenerative lumbar spinal stenosis  Senile patients  Selective interlaminar fenestration decompression  Transforaminal lumbar interbody fusion

中文摘要:

  【摘要】 目的：探讨高龄腰椎管狭窄症患者的手术方式选择及其疗效。方法：回顾分析2012年3月~2015年3月在我院行手术治疗并获得至少1年随访的39例80岁以上腰椎管狭窄症患者的临床资料，男21例，女18例；年龄80~90岁（82.4±3.1岁）。术前13例伴有一种合并症，12例伴有两种或两种以上合并症。按相关科室会诊意见处理合并疾病，应用美国麻醉医师协会（ASA）体格状态分级评估患者可耐受全麻下手术。12例根性疼痛和间歇性跛行症状为主、无明显腰椎不稳者，采用椎板开窗减压术（单纯减压组）；27例明确存在腰椎不稳/腰椎滑脱或术中需要手术切除小关节突、椎板范围较大发生继发性不稳者采用经椎间孔入路椎间融合内固定术（TLIF）（融合内固定组）。采用日本骨科协会（JOA）评分和疼痛视觉模拟评分法（VAS评分）评估手术的临床疗效。结果：39例患者均完成手术。12例患者发生围手术期并发症，单纯减压组3例（肺炎1例，尿路感染1例，肺炎合并术后贫血1例），融合内固定组9例（肺炎3例，硬膜撕裂、尿潴留、心律失常、术后贫血、术后认知功能障碍各1例，尿路感染合并认知功能障碍1例），均经保守治疗后好转；无围手术期死亡病例。单纯减压组JOA评分由术前的10.8±2.3分改善至末次随访时的19.0±4.8分，融合内固定组JOA评分由术前的11.8±2.2分改善至末次随访时的21.8±3.4分，两组患者末次随访时与术前比较均有统计学差异（P＜0.05）。两组患者末次随访时的腰痛和腿痛VAS评分（单纯减压组3.2±1.7分和3.5±2.1分，融合内固定组3.0±1.2分和2.9±1.2分）与术前（单纯减压组7.4±0.9分和7.8±1.0分，融合内固定组7.4±1.7分和7.7±1.1分）比较均有统计学差异（P＜0.05）。结论：对于高龄退行性腰椎管狭窄症患者，术前充分评估患者全身状况，积极处理合并疾病后，根据临床症状、体征及影像学资料，确定责任节段及致病因素，合理选择手术方式，可获得满意的疗效。

英文摘要:

  【Abstract】 Objectives: To investigate the surgical options and clinical outcomes of degenerative lumbar spinal stenosis in octogenarian patients. Methods: From March 2012 to March 2015, 39 cases who were eighty years or older with degenerative lumbar spinal stenosis and surgically treated in our hospital were reviewed. The follow-up time was at least 1 year. In the series, there were 21 males and 18 females aging from 80-90 years(average age, 82.4±3.1 years). All patients had severe low back pain and lower extremity radiculopathy or neurogenic claudication. All cases experienced conservative treatment, and the symptoms did not alleviate. Thirteen cases suffered from one type of comorbidity, twelve cases suffered from at least 2 types of comorbidities. All the patients could tolerate surgery under general anesthesia according to American Society of Anesthesiologists(ASA) physical status. Twelve patients with primary symptoms of root pain and neurogenic claudication, with no obvious lumbar instability, were treated with selective interlaminar fenestration decompression(decompression group). Twenty-seven patients with lumbar instability or lumbar spondylolisthesis, complex causes of spinal stenosis and a variety of pressure-causing factors, who could withstand major surgery, were treated with transforaminal lumbar interbody fusion(TLIF)(fusion group). Japanese Orthopaedic Association(JOA) score system and visual analogue scale(VAS) scores system were used to evaluate the surgical outcomes. Results: All operations were successfully performed. Twelve cases experienced perioperative complications which improved by conservative treatment. There were three cases in the decompression group(1 case of pneumonia, 1 case of urinary tract infection, 1 case of pneumonia combined with postoperative anemia) and nine cases in the fusion group(3 cases of pneumonia, 1 case of dural tear, 1 case of urinary retention, 1 case of arrhythmia, 1 case of postoperative anemia, 1 case of postoperative cognitive dysfunction, 1 case of urinary tract infection combined with postoperative cognitive dysfunction). No one died in the perioperative period. JOA score in decompression group improved from preoperative 10.8±2.3 to 19±4.8 after surgery. JOA score in fusion group improved from preoperative 11.8±2.2 to 21.8±3.4 after surgery. The differences of JOA scores before and after surgery were statistically significant(P＜0.05) in both groups. The VAS scores of lower back pain and leg pain in both groups at the last follow-up(3.2±1.7 and 3.5±2.1 in decompression group, 3.0±1.2 and 2.9±1.2 in fusion group) were significantly different from those before operation(7.4±0.9 and 7.8±1.0 in decompression group, 7.4±1.7 and 7.7±1.1 in fusion group)(P<0.05). Conclusions: Satisfactory results can be achieved in octogenarian with degenerative lumbar spinal stenosis, by adequately assessing the general condition, properly handling the comorbidity, and selecting reasonable surgical options, which according to clinical symptoms and signs, imaging data, responsible lesion and pathogenic factors.