Epstein Nancy E
Professor of Clinical Neurosurgery, School of Medicine, University of State of New York at Stony Brook, Mineola, New York, USA.
Chief of Neurosurgical Spine/Education, NYU Winthrop Hospital, Mineola, New York, USA.
Surg Neurol Int. 2018 Mar 7;9:56. doi: 10.4103/sni.sni_27_18. eCollection 2018.
In this new section, Case of the Month with Short Perspective from Surgical Neurology International, we want to see how various spine surgeons would approach different spinal pathologies. In this first case, an elderly male presented with 3 years of lower back pain and progressive neurogenic claudication with bilateral radiculopathy that had exacerbated over the prior 6 months. An outside physician performed a magnetic resonance (MR) study of the lumbar spine that showed a massive synovial cyst filling the spinal canal (e.g., large bilateral cysts) at the L3-L4 level with grade I spondylolisthesis. The MR and CT studies also both demonstrated moderate L2-L3, and severe L3-L4 stenosis.
Despite the massive synovial cyst filling the spinal canal at the L3-L4 level, pain management (anesthesia training) spent 3 months performing three successive epidural steroid injections accompanied by attempts at percutaneous synovial cyst aspiration/rupture.
By the time the patient presented to neurosurgery, he had developed severe neurogenic claudication, radiculopathy, myelopathy, and a cauda equina syndrome. Dynamic X-rays revealed a mild grade I degenerative spondylolisthesis at the L3-L4 level without active motion, while both computed tomography (CT) and MR studies confirmed moderate stenosis stenosis/ossification of the yellow ligament at the L2-L3 level, severe stenosis at L3-L4 level with spondylolisthesis, and massive bilateral synovial cysts at the L3-L4 level filling the spinal canal.
Following an L2-L4 decompressive laminectomy without fusion (note the absence of motion intraoperatively at the L3-L4 level), the patient's symptoms resolved, and he regained normal function. How would you have managed this patient?
在这个新板块“《国际外科神经学》月度病例短评”中，我们想看看不同的脊柱外科医生会如何处理各种脊柱疾病。在这第一个病例中，一位老年男性出现了3年的下背部疼痛以及进行性神经源性间歇性跛行并伴有双侧神经根病，且在过去6个月中病情加重。一位外院医生对腰椎进行了磁共振（MR）检查，结果显示在L3 - L4水平有一个巨大的滑膜囊肿充满椎管（如双侧大囊肿），同时伴有I度椎体滑脱。MR和CT检查还均显示L2 - L3有中度狭窄，L3 - L4有重度狭窄。
尽管在L3 - L4水平有巨大的滑膜囊肿充满椎管，但疼痛管理（麻醉培训）仍花了3个月时间连续进行了三次硬膜外类固醇注射，并尝试经皮穿刺抽吸/破裂滑膜囊肿。
当患者就诊于神经外科时，他已出现严重的神经源性间歇性跛行、神经根病、脊髓病和马尾综合征。动态X线显示L3 - L4水平有轻度I度退变性椎体滑脱，无活动，而计算机断层扫描（CT）和MR检查均证实L2 - L3水平有中度狭窄/黄韧带骨化，L3 - L4水平有重度狭窄伴椎体滑脱，以及L3 - L4水平有巨大的双侧滑膜囊肿充满椎管。
在进行了L2 - L4减压性椎板切除术且未行融合术（注意术中L3 - L4水平无活动）后，患者的症状得到缓解，并恢复了正常功能。你会如何处理这个患者呢？
