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[腰椎管狭窄症治疗中的扩大减压]

[Enlargement in managment of lumbar spinal stenosis].

作者信息

Steib J P, Averous C, Brinckert D, Lang G

机构信息

Service d'Orthopédie 'Stéphanie', Pavillon Chirurgical B, Hôpitaux Universitaires, 1, place de l'Hôpital, BP 426, F-67091, Strasbourg Cedex.

出版信息

Eur J Orthop Surg Traumatol. 1996 May;6(2):129-34. doi: 10.1007/BF00568331.

Abstract

Lumbar stenosis has been well discussed recently, especially at the 64th French Orthopaedic Society (SOFCOT: July 1989). The results of different surgical treatments were considered as good, but the indications for surgical treatment were not clear cut. Laminectomy is not the only treatment of spinal stenosis. Laminectomy is an approach with its own rate of complications (dural tear, fibrosis, instability... ).Eight years ago, J. Sénégas described what he called the "recalibrage" (enlargement). His feeling was that, in the spinal canal, we can find two different AP diameters. The first one is a fixed constitutional AP diameter (FCAPD) at the cephalic part of the lamina. The second one is a mobile constitutional AP diameter (MCAPD) marked by the disc and the ligamentum flavum. This diameter is maximal in flexion, minimal in extension. The nerve root proceeds through the lateral part of the canal: first above, between the disc and the superior articular process, then below, in the lateral recess bordered by the pedicle, the vertebral body and the posterior articulation. With the degenerative change the disc space becomes shorter, the superior articular process is worn out with osteophytes. These degenerative events are complicated by inter vertebral instability increasing the stenosis. The idea of the "recalibrage" is to remove only the upper part of the lamina with the ligamentum flavum and to cut the hypertrophied anterior part of the articular process from inside. If needed the disc and other osteophytes are removed. The surgery is finished with a ligamentoplasty reducing the flexion and preventing the extension by a posterior wedge.Our experience in spine surgery especially in scoliosis surgery, showed us that it was possible to cure a radicular compression without opening the canal. The compression is then lifted by the 3D reduction and restoration of an anatomy as normal as possible. Lumbar stenosis is the consequence of a degenerative process. Indeed, hip flexion, obesity or quite simply overuse, involve an increase in the lumbar lordosis. The posterior articulations are worn out and the disc gets damaged by shear forces. The disc space becomes shorter with a bulging disc, and the inferior articular process of the superior vertebra goes down. This is responsible of a loss of lordosis. For restoring the sagittal balance the patient needs more extension of the spine. Above and below the considered level the degenerative disease carries on extending to the whole spine. At the level considered, because of local extension, the inferior facet moves forward, the disc bulges, the ligamentum flavum is shortened and the stenosis is increased. This situation is improved by local kyphosis: the inferior facet moves backward, the disc and the ligamentum flavum are stretched with a quite normal posterior disc height and most often there is no more stenosis. Myelograms show this very well with a quite normal appearance lying, clear compression standing, worse in extension and improved, indeed disappeared in flexion. CT scan and MRI don't show that because they are done lying. The expression of the clinical situation is the same, mute lying and maximum standing with restriction of walking. For us lumbar stenosis is operated with lumbar reconstruction without opening the canal. The patient is in moderate kyphosis on the operating table. Pedicle screws rotated to match a bent rod allow reduction of the spine. The posterior disc height is respected and not distracted, and the anterior part of the disc is stretched in lordosis. The inferior facet is cut for the arthrodesis and no longer compresses the dura. The canal is well enlarged and the lumbar segment in lordosis is the best protection of the adjacent levels at follow-up. This behaviour responds to the same analysis as the ≪recalibrage≫ (enlargement). The mobile segment is damaged by the degenerative disease, the stenosis is a consequence of this damage. It's logical to treat the instability and to restore the normal static anatomy; thus bone resection is not necessary. At the present time all the lumbar stenoses with reduction in flexion are instrumented with spinal reduction and arthrodesis without opening the canal. The laminoarthrectomy and the enlargement are done when there is a fixed arthrosis which is rare in our practice and found in an older population. The follow-up shows a loss of reduction in some cases after reduction-instrumentation-arthrodesis and poses the question of an interbody fusion. We don't open the canal only for fusion (PLIF) if this is not necessary for the treatment of the stenosis. We think that, in such a situation, the future is ALIF with endoscopical approach. The problem is to determine which disc demanding this anterior fusion, is able to regenerate or not.

摘要

腰椎管狭窄症最近已得到充分讨论,尤其是在第64届法国骨科协会会议(法国骨科协会:1989年7月)上。不同手术治疗的结果被认为是良好的,但手术治疗的适应症并不明确。椎板切除术并非椎管狭窄的唯一治疗方法。椎板切除术是一种有其自身并发症发生率的手术方式(硬脊膜撕裂、纤维化、不稳定……)。八年前,J. 塞内加斯描述了他所谓的“重新校准”(扩大)手术。他认为,在椎管内,我们可以发现两种不同的前后径。第一种是在椎板头部的固定结构前后径(FCAPD)。第二种是由椎间盘和黄韧带所界定的可移动结构前后径(MCAPD)。这个直径在屈曲时最大,在伸展时最小。神经根通过椎管的外侧部分:首先在上方,位于椎间盘和上关节突之间,然后在下方,处于由椎弓根、椎体和后关节所界定的侧隐窝内。随着退行性改变,椎间隙变窄,上关节突因骨赘而磨损。这些退行性病变因椎间不稳定而变得复杂,进而加重椎管狭窄。“重新校准”手术的理念是仅切除带有黄韧带的椎板上部,并从内部切除关节突肥大的前部。如有必要,切除椎间盘和其他骨赘。手术最后进行韧带成形术,通过后楔形结构减少屈曲并防止伸展。我们在脊柱手术尤其是脊柱侧弯手术方面的经验表明,不打开椎管也有可能治愈神经根受压。然后通过三维复位和尽可能恢复正常解剖结构来解除压迫。腰椎管狭窄症是一种退行性过程的结果。实际上,髋关节屈曲、肥胖或者仅仅是过度使用,都会导致腰椎前凸增加。后关节磨损且椎间盘因剪切力而受损。椎间盘间隙变窄且椎间盘膨出,上位椎体的下关节突下移。这导致了前凸丧失。为恢复矢状面平衡,患者需要脊柱更多地伸展。在所考虑节段的上方和下方,退行性疾病继续向整个脊柱发展。在该节段,由于局部进展,下关节突向前移动,椎间盘膨出,黄韧带缩短,椎管狭窄加重。通过局部后凸可改善这种情况:下关节突向后移动,椎间盘和黄韧带被拉伸,椎间盘后高度相当正常,而且大多数情况下不再有椎管狭窄。脊髓造影很好地显示了这一点,平躺时外观相当正常,但站立时明显受压,伸展时更糟,而在屈曲时改善,甚至消失。CT扫描和MRI无法显示这一点,因为它们是在平躺时进行的。临床症状表现相同,平躺时无症状,站立时症状最严重,行走受限。对我们来说,腰椎管狭窄症通过腰椎重建手术治疗,而不打开椎管。患者在手术台上处于中度后凸位。通过旋转椎弓根螺钉以匹配弯曲的棒来实现脊柱复位。尊重椎间盘后高度且不使其牵张,并且使椎间盘前部在脊柱前凸位被拉伸。切除下关节突以进行椎间融合,这样它就不再压迫硬脊膜。椎管得到充分扩大,处于脊柱前凸位的腰椎节段在随访中是对相邻节段的最佳保护。这种做法与“重新校准”(扩大)手术的分析原理相同。可移动节段因退行性疾病而受损,椎管狭窄是这种损伤的结果。治疗不稳定并恢复正常静态解剖结构是合理的;因此无需进行骨质切除。目前,所有在屈曲时出现狭窄的腰椎管狭窄症患者均采用脊柱复位和椎间融合手术治疗,不打开椎管。当存在固定性关节病时才进行椎板关节突切除术和扩大手术,这种情况在我们的实践中很少见,多见于老年人群。随访显示,在进行复位 - 内固定 - 椎间融合手术后,有些病例会出现复位丢失的情况,这就引发了椎间融合的问题。如果治疗椎管狭窄没有必要,我们不会仅为了融合(后路腰椎椎间融合术)而打开椎管。我们认为,在这种情况下,未来的发展方向是采用内镜入路的前路腰椎椎间融合术。问题在于确定哪些需要进行前路融合的椎间盘能够再生。

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