Guigui P, Delecourt C, Delhoume J, Lassale B, Deburge A
Service de Chirurgie Orthopédique-Hôpital Beaujon, Clichy.
Rev Chir Orthop Reparatrice Appar Mot. 1997;83(7):622-8.
Severe motor weakness is a rather infrequent symptom in the course of lumbar stenosis. The objectives of this study are three fold: describe the motor deficit, evaluate the prognosis factors and determine the type of stenosis the most likely to be complicated by motor loss.
61 consecutive patients with a mean age of 63 years, operated on for a lumbar stenosis and with a severe motor deficit have been retrospectively studied. The mean follow-up was 38 months. The overall functional result was evaluated according to a rating scale, specially developed in our unit for the follow-up of lumbar stenosis. The motor capacity was rated from 0 (complete paralysis) to 5 (normal strength). According to that scale the motor weakness was rated as 0, 11 times as 1, 11 times, as 2, 11 times and as 3, 28 times. The deficit was unilateral in 79 per cent of cases and multiradicular in 58 per cent of patients. Sphincter abnormalities were also present in 9 cases. In 9 out of 10 patients the motor deficit was in the L5 territory. Stenosis was extended to 3 levels in 30 cases and was focal in the remaining cases. Degenerative spondylolishthesis was disclosed in 20 patients. In 3 out of 4 cases decompression was performed after 3 weeks of motor weakness and within 3 weeks in the remaining cases.
According to our rating scale the overall results were considered excellent in 29 cases, good in 21 cases and fair in the 11 remaining cases. There was no complication, and no postoperative worsening of the deficit was observed. Regression of motor weakness was complete 22 times, partial 29 times and null 10 times. In the eleven complete deficits with a 0 cotation one receded completely, 7 receded partially and no improvement was noted in the 3 remaining cases. 6 out of the 9 patients with sphincter abnormalities recovered completely. In this study favourable prognosis parameters were as follows: age under 62 years, monoradicular deficit, stenosis at one level and association with a discal herniation. In contrast, severity of the initial motor weakness, association with sphincter abnormalities, presence or not of degenerative spondylolisthesis, or of a complete block on the myelogram were not influential variables. Chances of recovery were statistically diminished when decompression was performed after 6 weeks.
No study dealing specifically with the postoperative outcome of motor deficit caused by lumbar stenosis has been published. However the rate of motor recovery (complete or partial) disclosed in our series is comparable with that found in other series dealing more generally with the overall post-surgery outcome. At our last follow-up, 82 per cent of our patients were considered as having an excellent or good result. It can be concluded that the existence of a motor deficit is not a major pejorative factor of the overall final functional result. Motor weakness is more frequently observed in elderly patients, in cases with degenerative spondylolisthesis, or when a discal herniation is associated with a bony compression. Chances of recovery are better, when the deficit is monoradicular, when the stenosis is focal, or associated with a discal herniation and when the patient is relatively young.
严重运动无力是腰椎管狭窄症病程中较为少见的症状。本研究的目的有三个：描述运动功能缺损情况，评估预后因素，并确定最易并发运动功能丧失的狭窄类型。
对61例平均年龄63岁、因腰椎管狭窄症接受手术且存在严重运动功能缺损的连续患者进行回顾性研究。平均随访时间为38个月。根据我们科室专门制定的用于腰椎管狭窄症随访的评分量表评估总体功能结果。运动能力从0（完全瘫痪）到5（肌力正常）进行评分。根据该量表，运动无力评分为0的有11例，评分为1的有11例，评分为2的有11例，评分为3的有28例。79%的病例为单侧缺损，58%的患者为多节段神经根受累。9例患者还存在括约肌异常。10例患者中有9例运动功能缺损位于L5区域。30例患者的狭窄累及3个节段，其余病例为局限性狭窄。20例患者发现有退行性椎体滑脱。4例患者中有3例在运动无力3周后进行减压，其余病例在3周内进行减压。
根据我们的评分量表，29例患者的总体结果被评为优秀，21例为良好，其余11例为中等。无并发症发生，且未观察到术后缺损情况恶化。运动无力完全恢复的有22例，部分恢复的有29例，无恢复的有10例。在11例评分为0的完全缺损病例中，1例完全恢复，7例部分恢复，其余3例无改善。9例有括约肌异常的患者中有6例完全恢复。本研究中预后良好的参数如下：年龄在62岁以下、单节段神经根缺损、单节段狭窄以及合并椎间盘突出。相比之下，初始运动无力的严重程度、合并括约肌异常、是否存在退行性椎体滑脱或脊髓造影显示完全梗阻等因素并非有影响的变量。在运动无力6周后进行减压，恢复的几率在统计学上降低。
尚未有专门针对腰椎管狭窄症所致运动功能缺损术后结果的研究发表。然而，我们系列研究中显示的运动恢复率（完全或部分恢复）与其他更普遍涉及手术总体结果的系列研究中发现的恢复率相当。在我们的最后一次随访中，82%的患者被认为结果优秀或良好。可以得出结论，运动功能缺损的存在并非总体最终功能结果的主要不良因素。运动无力在老年患者、存在退行性椎体滑脱的病例或合并椎间盘突出与骨质压迫的情况下更为常见。当缺损为单节段神经根受累、狭窄为局限性、合并椎间盘突出且患者相对年轻的时候，恢复的几率更高。
