中国修复重建外科杂志

中国修复重建外科杂志

椎弓回植与椎板切除治疗轻中度峡部裂性腰椎滑脱症疗效比较

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目的 比较椎弓回植与椎板切除治疗单节段峡部裂性腰椎滑脱的临床疗效。 方法 回顾分析 2014 年 3 月—2016 年 7 月采用椎弓回植或椎板切除治疗的 66 例单节段峡部裂性腰椎滑脱患者临床资料,根据手术方式不同分为试验组(34 例,采用椎弓完整回植固定椎间融合内固定术)和对照组(32 例,采用椎板切除并椎间融合内固定术)。两组患者性别、年龄、病程、病变节段、Meyerding 分度及术前疼痛视觉模拟评分(VAS)、Oswestry 功能障碍指数(ODI)、日本骨科协会(JOA)评分等一般资料比较差异,均无统计学意义(P>0.05),具有可比性。记录并比较两组患者手术时间、术中出血量、并发症情况、术后实验组回植椎弓融合情况及两组硬膜外瘢痕形成情况。术前及术后 3、6、12 个月和末次随访时行腰痛 VAS 评分、JOA 评分及 ODI 评分,并参照侯树勋等提出的标准进行临床疗效评价。 结果 所有患者均顺利完成手术,无神经损伤加重、硬脊膜撕裂、感染等发生。试验组手术时间与对照组比较差异无统计学意义(t=0.583,P=0.562),但术中出血量显著低于对照组(t=2.134,P=0.037)。66 例患者均获随访,随访时间 13~18 个月,平均 16.2 个月。所有患者术后临床症状明显改善。对照组 7 例于术后 3 个月发现体位变动时椎管狭窄症状,5 例于术后 18 个月出现轻度双下肢麻木症状;其余患者未发生感染、神经损伤等并发症。试验组 34 例硬膜外瘢痕组织均被完全阻滞于回植椎弓以外,对照组有 11 例硬膜外瘢痕组织侵入椎管内。末次随访时试验组椎间植骨及椎弓回植融合率均为 100%,对照组椎间植骨融合率亦为 100%。两组术后各时间点 VAS 评分、ODI 评分、JOA 评分均较术前显著改善(P<0.01);试验组术后 3 个月和末次随访时 ODI 评分、JOA 评分显著优于对照组(P<0.05),其余时间点两组间各评分比较差异无统计学意义(P>0.05)。参照侯树勋等提出的标准进行临床疗效评价,试验组优良率为 91.2%,与对照组优良率 84.4%比较差异无统计学意义(χ2=1.092,P=0.573)。 结论 与椎板切除相比,椎弓回植能更好地改善术后神经症状,最大程度重建了骨性椎管,恢复了椎管内环境稳定性,对于峡部裂性腰椎滑脱是一种较好的手术方式。

Objective To compare the effectiveness of vertebral arch replantation and laminectomy in the treatment of mild to moderate isthmic spondylolisthesis. Methods The clinical data of 66 patients with isthmic spondylolisthesis treated with vertebral arch replantation or laminectomy between March 2014 and July 2016 were retrospectively analyzed. They were divided into trial group (34 cases, treated with complete replantation of vertebral arch, intervertebral fusion, and internal fixation) and control group (32 cases, treated with laminectomy with intervertebral fusion and internal fixation) according to different surgical methods. There was no significant difference in general data of gender, age, disease duration, lesion segment, Meyerding grade, and preoperative visual analogue scale (VAS) score, Oswestry disability index (ODI) score, Japanese Orthopaedic Association (JOA) score between the two groups (P>0.05). The operation time, intraoperative blood loss, complications, vertebral arch fusion of trial group, and epidural scar formation of the two groups were recorded. The VAS score, JOA score, and ODI score were evaluated at preoperation, 3, 6, 12 months after operation, and at last follow-up. The effectiveness was evaluated according to HOU Shuxun’s criteria. Results All the patients successfully completed the surgery, without any aggravation of nerve injury, dural tear, infection, etc. There was no significant difference in the operation time between the two groups (t=0.583, P=0.562), but the intraoperative blood loss was significantly lower in the trial group than that in the control group (t=2.134, P=0.037). All the 66 patients were followed up 13-18 months (mean, 16.2 months). Postoperative clinical symptoms of all patients were significantly improved. In the control group, 7 cases were found to have symptoms of spinal canal stenosis with postoperative posture changes at 3 months after operation, and 5 cases showed mild lower limb numbness at 18 months after operation. No complication such as infection and nerve injury occurred in other patients. In the trial group, 34 cases of epidural scar tissue were completely blocked outside the replantation vertebral arch, while in the control group, 11 cases of epidural scar tissue invaded the spinal canal. At last follow-up, the fusion rate of intervertebral bone grafting and vertebral arch replantation in the trial group was 100%, and the fusion rate of intervertebral bone grafting of the control group was also 100%. The VAS score, ODI score, and JOA score were significantly improved at each time point after operation (P<0.01). The ODI score and JOA score of the trial group were significantly better than those of the control group at 3 months after operation and at last follow-up (P<0.05), and there was no significant difference in scores between the two groups at other time points (P>0.05). According to HOU Shuxun’s criteria, the excellent and good rate was 91.2% in the trial group and 84.4% in the control group, showing no significant difference (χ2=1.092, P=0.573). Conclusion Compared with laminectomy, vertebral arch replantation can better improve postoperative neurological symptoms, maximize the reconstruction of the bone spinal canal, restore the stability of the intraspinal environment, and is a better surgical method for lumbar isthmic spondylolisthesis.

关键词: 椎弓回植; 椎板切除; 峡部裂性腰椎滑脱症

Key words: Vertebral arch replantation; laminectomy; lumbar isthmic spondylolisthesis

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