Bärlocher C, Benini A
Neurochirurgische Klinik, Kantonsspital, St. Gallen.
Schweiz Arch Neurol Psychiatr (1985). 1994;145(5):14-24.
The indication for spine fusion in combination with diskectomy it neither clearly defined nor widely accepted. It largely depends on the specialist to whom the patient is referred. While orthopedists often perform primary fusions, neurosurgeons hardly ever do so, no matter what the nature of the complaint is. Therefore, the selection of the procedure seems to be a rather random choice. The question is not whether the combined operation or the simple disc excision is superior in itself, but which of the two should be chosen in a given case. For patients with disc displacement and radicular pain as the predominant symptom, undercutting hemilaminectomy and disc excision will generally yield satisfying results. The main indication for a combined operation is a history of instability complaints long before radicular pain caused by the disc displacement appears. Since the number of patients (of all age groups) that require a disc operation is ever increasing, the selection of patients suited for a combined operation is becoming more and more important, so as to bring down the number of secondary fusions for the treatment of invalidating low back pain after disc excision. The aim of our clinical research is to test the criteria for the selection of patients for the combined operation by taking into account both patients who underwent a combined operation and others whose postoperative condition was such as to require a secondary fusion within one year after diskectomy. In the majority of these cases, one can presume that the fusion should have been carried out on the occasion of the first operation. 26 (90%) out of 29 patients showed a good result three months after the combined operation; 25 (86%) were still satisfied four years later. This confirms that patients with a long history of low back pain as a symptom of instability--in addition to the recent symptoms of the herniation--and those with a significant dislocation of one vertebral body (retrolisthesis, spondylolisthesis and pseudospondylolisthesis), too, should be examined in view of a possible combined operation. However, the combined operation is needed in no more than about three to four per cent of all diskectomies.
脊柱融合术联合椎间盘切除术的适应症既未明确界定，也未被广泛接受。这在很大程度上取决于患者所转诊的专科医生。骨科医生经常进行一期融合术，而神经外科医生几乎从不这样做，无论病情如何。因此，手术方式的选择似乎是相当随意的。问题不在于联合手术或单纯椎间盘切除术本身哪种更优越，而在于在特定病例中应选择哪一种。对于以椎间盘移位和神经根性疼痛为主要症状的患者，潜行半椎板切除术和椎间盘切除术通常会产生令人满意的结果。联合手术的主要适应症是在由椎间盘移位引起的神经根性疼痛出现之前很久就有不稳定症状的病史。由于（所有年龄组中）需要进行椎间盘手术的患者数量不断增加，选择适合联合手术的患者变得越来越重要，以便减少因椎间盘切除术后无效性腰痛而进行二次融合术的数量。我们临床研究的目的是通过考虑接受联合手术的患者以及那些术后情况需要在椎间盘切除术后一年内进行二次融合术的患者，来测试联合手术患者选择标准。在大多数这些病例中，可以推测融合术应该在首次手术时进行。29例患者中有26例（90%）在联合手术后三个月显示出良好的效果；四年后仍有25例（86%）感到满意。这证实，除了近期的椎间盘突出症状外，有长期腰痛作为不稳定症状病史的患者，以及椎体有明显移位（椎体后移、脊椎滑脱和假性脊椎滑脱）的患者，也应考虑是否可能进行联合手术。然而，在所有椎间盘切除术中，需要联合手术的病例不超过约3%至4%。
