Knaub Mark A, Won Douglas S, McGuire Robert, Herkowitz Harry N
Department of Orthopaedic Surgery, William Beaumont Hospital, Royal Oak, Michigan, USA.
Instr Course Lect. 2005;54:313-9.
Surgical indications for simple decompression in patients with lumbar spinal stenosis are well established. Following these guidelines, surgeons can expect good and excellent outcomes in 75% to 90% of patients. Despite the publication of many studies pertaining to the addition of arthrodesis and instrumentation, the indications for adding these procedures to a decompression are much less clear. Preoperative and intraoperative factors must be carefully considered when contemplating the addition of arthrodesis in the setting of spinal stenosis. In patients with preoperative degenerative spondylolisthesis, scoliosis, or kyphosis, and those in whom stenosis develops at a previously decompressed segment, serious consideration should be givenfor inclusion of an arthrodesis. Fusion should also be considered for those patients with stenosis adjacent to a previously fused lumbar segment. Excision of a significant portion of the facet joints or radical excision of the intervertebral disk during the course of the decompression predispose the patient to postoperative instability. The addition of an arthrodesis will likely benefit these patients. Relative indications for the use of spinal instrumentation in the setting of spinal stenosis include correction of deformity, recurrent spinal stenosis with instability, degenerative spondylolisthesis, adjacent segment stenosis with instability, and multiple level fusions.
腰椎管狭窄症患者单纯减压的手术指征已明确确立。遵循这些指南，外科医生预计75%至90%的患者会有良好和优异的结果。尽管发表了许多关于增加关节融合术和内固定术的研究，但在减压手术中增加这些手术的指征仍不太明确。在考虑在椎管狭窄情况下增加关节融合术时，必须仔细考虑术前和术中因素。对于术前有退行性椎体滑脱、脊柱侧凸或后凸的患者，以及在先前减压节段出现狭窄的患者，应认真考虑纳入关节融合术。对于狭窄位于先前融合的腰椎节段附近的患者，也应考虑融合术。在减压过程中切除大部分小关节或彻底切除椎间盘会使患者术后易发生不稳定。增加关节融合术可能会使这些患者受益。在椎管狭窄情况下使用脊柱内固定的相对指征包括畸形矫正、伴有不稳定的复发性椎管狭窄、退行性椎体滑脱、伴有不稳定的相邻节段狭窄以及多节段融合。
