【作者】 张劲松；

【导师】 杨述华；

【作者基本信息】 华中科技大学 ， 外科学， 2010， 博士

【摘要】 第一部分减压结合Dynesys动态稳定系统治疗退行性腰椎管狭窄症早期疗效观察目的探讨减压结合Dynesys动态稳定系统治疗退行性腰椎管狭窄症的疗效和安全性。方法2007年1月至2008年6月,对23例退行性腰椎管狭窄症患者在后路减压后行Dynesys内固定术。男10例,女13例：年龄56.38±11.63岁(38-68岁)。结果随访时间26.23±7.34个月(17～34个月),疼痛VAS评分：术前8.16±0.98(6-10),术后2.24±1.32(0-5) (P=0.001)；Oswestry功能障碍指数：术前72.42±17.01分(45～89分)：术后22.43±14.67(0-43分)(P=0.002)。无椎弓根螺钉松动、断裂。临床疗效按Macnab评定标准评价：优17例,良4例,可2例,症状改善优良率达91.3%。结论减压结合Dynesys治疗退行性腰椎管狭窄症取得良好的早期临床效果,防止固定及邻近节段的退变,是治疗腰椎退行性疾病的一种有效的非融合性、动态稳定方法。第二部分减压后Dynesys动态稳定和植骨融合内固定治疗退行性腰椎管狭窄症早期临床疗效比较目的用减压结合Dynesys动态稳定系统和减压结合植骨融合、内固定两种不同方法治疗退行性腰椎腰椎管狭窄症,比较其早期临床疗效差异。方法2007年1月～2009年1月两种不同方法治疗退行性腰椎管狭窄症87例,A组：减压结合Dynesys动态稳定系统治疗退行性腰椎管狭窄症；B组：减压结合植骨融合、椎弓根钉棒系统内固定。A组28例,B组59例,分别观察2组病例的手术时间、术中出血量、疼痛VAS评分、Oswestry功能障碍指数、手术效果优良率。结果两组所有患者均获得随访,随访13-37个月,平均随访26个月,以最后1次随访资料作为最终评价依据。两组手术时间、术中出血量B组高于A组(P<0.05), VAS评分、Oswestry功能障碍指数、手术效果优良率均无显著性差异(P>0.05),两组术后疼痛VAS评分、Oswestry功能障碍指数均较术前明显改善,差异有显著性(P<0.05)。结论Dynesys动态稳定系统治疗退行性腰椎管狭窄症,相比传统的植骨融合、内固定具有创伤小、出血少、手术时间短,早期临床效果相当,提供足够的脊柱稳定性,防止手术及相邻节段的退变。第三部分髓核摘除结合Dynesys动态稳定和显微镜下髓核摘除治疗腰椎间盘突出症早期临床疗效比较目的用髓核摘除结合Dynesys动态稳定和单纯髓核摘除两种不同方法治疗腰椎间盘突出症,比较其早期临床疗效差异。方法2007年1月～2009年1月两种不同方法治疗腰椎间盘突出症,A组：髓核摘除结合Dynesys动态稳定,26例；B组：显微镜下髓核摘除,556例。分别观察2组病例的手术时间、术中出血量、疼痛VAS评分、Oswestry功能障碍指数、手术效果优良率。结果A组26例全部获得随访,B组378例获得随访。随访13-37个月,平均随访28个月,以最后1次随访资料作为最终评价依据。两组手术时间、术中出血量A组高于B组(P<0.05);VAS评分Oswestry功能障碍指数、手术效果优良率均无显著性差异(P>0.05)；两组术后疼痛VAS评分、Oswestry功能障碍指数均较术前明显改善,差异有显著性(P<0.05)。A组无椎间盘突出复发,无腰椎不稳；B组有2例椎间盘突出复发,有2例出现腰椎不稳。结论髓核摘除结合Dynesys动态稳定系统与显微镜下单纯髓核摘除术治疗腰椎间盘突出症,都能取得良好的短期临床疗效；单纯髓核摘除术手术时间短、出血少、创伤小、费用低,而髓核摘除结合Dynesys动态稳定防止突出及邻近节段的退变、复发、不稳效果更佳。更多还原

【Abstract】 PartⅠThe Dynamic Stabilization System in Addition to Decomprssion for the Degenrative Lumar Spinal Stenosis.Objective:To investigate the efficacy and safety of the dynamic stabilization system in addition to decompression for degenerative lumbar spinal stenosis.Methods From January 2007 to June 2008,23 consecutive patients (10 males and 13 females) with lumbar spinal stenosis underwent decompression and Dynesys dynamic stabilization. The age was 56.38±11.63 years (range 38-68 years). Results The follow-up period was 26.23±7.34 months (range 17-34 months). The VAS decreased from preoperative score of 8.16±0.98 (6-10) to postoperative score of 2.24±1.32 (0 to 5) (P =0.001), and the patients’Oswestry disability index was improved from preoperative score of 72.42±17.01 (45 to 89) to postoperative score of 22.43±14.67 (0to48) (P= 0.002). No patient had screw loosensing and screw breakage. According to clinical outcome judgement criterion of Macnab, excellent in 17cases, good 4 cases, fair 2 cases, the excellent and good rate was 91.3%. Conclusions It is concluded that early outcome were excellent when we used the Dynesys dynamic stabilization system in addition to decompression for degenerative lumbar spinal stenosis. It prevent the degeneration of the instrumented level and the adjacent segments. It is a nofusion and semirigid fixation for the lumbar degenarative diseases. Part IITO compare the early clinical results of the treatment of degenerative lumbar spinal stenosis with two different methods.Objective To compare the early clinical results of the treatment of degenerative lumbar spinal stenosis with the dynamic stabilization system in addition to decompression and fusion, fixation in addition to decompression. Methods We treated 87 patients with degenerative lumbar spinal stenosis, from January 2007 to January 2009. Patients with degenerative lumbar spinal stenosis were randomly assigned to be treated with dynamic stabilization system in addition to decompression (group A) and fusion, fixation in addition to decompression (group B). The group A consisted of twenty-eight patients, and the group B consisted of fifty-nine patients. The factors considered included the operative time, amount of intraoperative bleeding,pre and post operative assessment based on pain visual analog scales(VAS) and the Oswestry disability index(ODI), the total excellent and good ratio of outcome. Results All the patients were followed up for a mean of 26 months(range,13～37 months). The final valuation was based on the documents of the last fellow up. The two groups had significant differences on operative time, amount of intraoperative bleeding, the group B is higher than the group A(P<0.05). There were no significant differences in the pain visual analog scales(VAS) and the Oswestry disability index(ODI), the total excellent and good ratio of outcome(P>0.05). In the two group, VAS and the Oswestry disability index(ODI), improved from preoperative to postoperative(P<0.05). Conclusion Compared to the segment fusion and fixation, transpedicular dynamic stabilization for the treatment of degenerative lumbar spinal stenosis, have the merit of minimally invasive, shorter surgical time, little hemorrhage.But their early clinical effect were comparable, maintain the stabilization of the spine, prevent the degeneration of the instrumented segments and adjacent segments.Part IIITo compare the clinical results of the treatment of lumbar disc prolapse with the transpedicular dynamic stabilization in addition to nucleotomy and nucleotomy alone.Objective To compare the clinical results of the treatment of lumbar disc prolapse with the transpedicular dynamic stabilization in addition to nucleotomy and nucleotomy alone. Methods We treated lumbar disc prolapse with two different methods, from January 2007 to January 2009. Group A:the transpedicular dynamic stabilization in addition to nucleotomy. Group B:microsurgical nucleotomy alone. The group A consisted of twenty-six patients, all of them were followed up.The group B consisted of five hundreds and fifty-six patients, only 378 patients were followed up. The factors considered included the operative time, amount of intraoperative bleeding,pre and post operative assessment based on pain visual analog scales(VAS) and the Oswestry disability index(ODI), the total excellent and good ratio of outcome. Results All the patients were followed up for a mean of 28 months(range,13～37 months). The final valuation was based on the documents of the last fellow up. The two groups had significant differences on operative time, amount of intraoperative bleeding, the group A is higher than the group B(P<0.05). There were no significant differences in the pain visual analog scales(VAS) and the Oswestry disability index(ODI), the total excellent and good ratio of outcome(P>0.05). In the two group, VAS and the Oswestry disability index(ODI) improved from preoperative to postoperative(P<0.05). The were no reprolapse and instability in group A. Two reprolapse and two instability of spine were seen in group B. Conclusion Both the clinical effects of the two methods are satisfactory. Microsurgical nucleotomy alone have the merit of minimally invasive, shorter surgical time, little hemorrhage.However, the transpedicular dynamic stabilization in addition to nucleotomy maintain the stabilization of the spine, prevent the degeneration, reprolapse and instability of the instrumented and adjacent segments.更多还原