Department of Orthopaedic Surgery, School of Medicine, Keio University, Shinjuku-ku, Tokyo, Japan.
J Neurosurg Spine. 2010 Jan;12(1):72-81. doi: 10.3171/2009.7.SPINE09344.
In this paper, the authors' goal was to elucidate the clinical features and results of decompression surgery for extraforaminal stenosis at the lumbosacral junction.
Twenty-eight patients with severe leg pain caused by extraforaminal stenosis at the lumbosacral junction (18 men and 10 women; mean age 68.2 +/- 8.9 years) were treated by posterior decompression without fusion using a microendoscope in 19 patients and a surgical microscope or loupe in 9 patients. The decompression procedures consisted of partial resection of the sacral ala, the L-5 transverse process, and the L5-S1 facet joint along the L-5 spinal nerve. The following items were investigated: 1) preoperative neurological findings; 2) preoperative radiological findings, including plain radiographs, CT scans, selective radiculography of L-5; 3) surgical outcome as evaluated using the Japanese Orthopaedic Association scale for low-back pain (JOA score); and 4) need for revision surgery.
All patients presented with neurological deficits compatible with a diagnosis of L-5 radiculopathy such as weakness of the extensor hallucis longus muscle and sensory disturbance in the L-5 area together with neurogenic claudication. On plain radiographs, 21 patients (75%) and 17 patients (60.7%) exhibited lumbar scoliosis (>or= 5 degrees) and wedging of the L5-S1 intervertebral space (>or= 3 degrees), respectively. The CT scans demonstrated marked osteophyte formation at the posterolateral margin of the L5-S1 vertebral bodies, and a selective L-5 nerve root block was effective in all patients. All patients reported pain relief immediately after surgery. The mean JOA scores were 11.3 +/- 3.8 before surgery and 24.3 +/- 3.4 at the time of the final follow-up examination; the recovery rate was 68.6 +/- 16.5%. The mean estimated blood loss was 66.6 +/- 98.6 ml, and the mean surgical time was 135.3 +/- 46.5 minutes. No significant difference in the recovery rate of the JOA scores or in the surgical time and blood loss was observed between the 2 surgical approaches. Four patients underwent revision posterior interbody fusion for the recurrence of radicular pain as a result of intraforaminal stenosis in 3 patients and insufficient decompression of the extraforaminal area in the remaining patient at an average of 19.5 months after surgery.
Extraforaminal stenosis at the lumbosacral junction is a rare but distinct pathological condition causing L-5 radiculopathy. Decompression surgery without fusion using a microendoscope or a surgical microscope/loupe is a feasible and less invasive surgical option for elderly patients with extraforaminal stenosis at the lumbosacral junction.
本文旨在阐明腰骶部椎间孔外狭窄症减压手术的临床特点和结果。
采用后路显微镜或手术显微镜下经皮微内镜减压术治疗腰骶部椎间孔外狭窄症（L5-S1）导致严重下肢痛的 28 例患者（男 18 例，女 10 例；平均年龄 68.2±8.9 岁）。减压手术包括骶骨翼、L5 横突和 L5-S1 关节突的部分切除，沿着 L5 脊神经进行。研究项目包括：1）术前神经学表现；2）术前影像学表现，包括平片、CT 扫描、L5 选择性神经根造影；3）采用日本矫形协会腰痛评分（JOA 评分）评估手术结果；4）翻修手术的需求。
所有患者均表现出与 L5 神经根病变相符的神经功能缺损，如伸趾长肌无力和 L5 区域感觉障碍，伴有神经源性跛行。平片显示，21 例（75%）患者存在腰椎侧凸（≥5°），17 例（60.7%）患者 L5-S1 椎间隙楔形变（≥3°）。CT 扫描显示 L5-S1 椎体后外侧缘有明显的骨赘形成，L5 神经根选择性阻滞在所有患者中均有效。所有患者术后即刻疼痛缓解。术前 JOA 评分平均为 11.3±3.8，末次随访时平均为 24.3±3.4；恢复率为 68.6±16.5%。平均估计出血量为 66.6±98.6ml，平均手术时间为 135.3±46.5 分钟。两种手术方法在 JOA 评分恢复率、手术时间和出血量方面无显著差异。4 例患者因神经根痛复发（3 例为椎间孔内狭窄，1 例为椎间孔外减压不充分）行后路椎间融合翻修术，平均术后 19.5 个月。
腰骶部椎间孔外狭窄是一种罕见但独特的病理状态，可导致 L5 神经根病变。对于腰骶部椎间孔外狭窄的老年患者，后路显微镜或手术显微镜下经皮微内镜减压术是一种可行且微创的手术选择。
