腰椎椎管狭窄症 PPT课件.ppt

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1、 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical University保留脊柱后部结构的椎板切除减压术保留脊柱后部结构的椎板切除减压术治疗腰椎管狭窄的研究治疗腰椎管狭窄的研究A study of the treating lumba

2、r stenosis with laminectomy reserving spinal posterior structure叶正旭 罗卓荆 吴子祥第四军医大学西京医院西京骨科医院 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical

3、University研研 究究 背背 景景 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical University 腰椎管狭窄的定义腰椎管狭窄的定义腰椎管狭窄症（腰椎管狭窄症（Lumbar Spinal Stenosis LSS)是指

4、因原发或继发因素造成椎管结构异常，椎管腔内变窄，出现以间歇性跛行为主要特征的腰腿疼痛“步行不到几十米，骑车可行几十里步行不到几十米，骑车可行几十里步行不到几十米，骑车可行几十里步行不到几十米，骑车可行几十里”第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Milit

5、ary Medical University腰椎管狭窄的分类腰椎管狭窄的分类脊椎退变所致的狭窄脊椎退变所致的狭窄1复合因素所致的狭窄复合因素所致的狭窄2脊椎滑脱症与骨溶解病所致狭窄脊椎滑脱症与骨溶解病所致狭窄3其他其他6损伤性狭窄损伤性狭窄5医源性狭窄医源性狭窄4 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical Univer

6、sityXiJing Hospital,4th Military Medical University影像学表现体征症状诊断（diagnosis）腰椎管狭窄的诊断腰椎管狭窄的诊断 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical Un

7、iversityl双侧神经性跛行，间歇性大腿或小腿放射性疼痛，长时间站立、活动或腰过伸时症状加重，坐、卧或腰屈曲时减轻。一般症状 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical University体 征膝踝反射改变多不对称病理反射

8、缺如感觉障碍直腿抬高试验阴性压迫马尾及神经根时影响大、小便 严重者下肢不完全性瘫痪 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical University非手术治疗手术治疗腰椎管狭窄的治疗腰椎管狭窄的治疗腰椎管狭窄的治疗 第四军医大学

9、西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical University活动后腰及腿疼痛，影响工作、生活，经保守治疗不愈者 进行性跛行加重，或站立时间逐渐缩短者 神经机能出现明显缺损者 腰椎管狭窄手术指征：第四军医大学西京医院骨科专科医院第四军医大

10、学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical University减压是解除症状的主要手段减压范围：l包括黄韧带、椎间盘、增生的关节突、侧隐窝l尽量保留有用的椎间盘减压破坏后柱结构,故通常增加了腰椎失稳的风险腰椎失稳的风险腰椎失稳的风险腰椎失稳的风险常用手术方式为全椎板切

11、除减压术常用手术方式为全椎板切除减压术 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical University1983年Denis提出三柱分类 传统减压破坏了c柱的张力带作用 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专

12、科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical University退变性失稳因素退变性失稳因素后部张力结构后部张力结构后部张力结构后部张力结构破坏破坏破坏破坏峡部仍保持完整退变性腰椎失稳 小关节磨损 关节突水平前纵韧带松弛椎间盘退变腰椎退变性滑脱腰椎退变性滑脱 第四军医大学西京医院骨科专

13、科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical University保留脊柱后部结构的椎板切除减保留脊柱后部结构的椎板切除减压术治疗腰椎管狭窄的对照研究压术治疗腰椎管狭窄的对照研究临床研究临床研究临床研究临床研究 第四军医大学西京医院骨科专科医院第四军医大学

14、西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical University全椎板切除减压手术组 22例保留后部结构的改良减压手术组 26例 2003年5月2004年5月 腰椎管狭窄症患者随机分组 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hos

15、pital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical University临床表现：均有间歇性跛行伴下肢放散痛病史 下肢有皮区感觉减弱 36例 皮区感觉消失 12例 小便失禁 6例 影象学检查 CT、MRI 影像显示：椎管狭窄节段在L3-S1范围内，需减压的节段为23个 x线片显示：无腰椎失稳的征象入选标准入选标准:实验组

16、实验组2626例（男例（男1212例，女例，女1414例），平均年龄例），平均年龄62622 2岁岁对照组对照组2222例（男例（男1313例，女例，女 9 9例），平均年龄例），平均年龄63631.51.5岁岁 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Mi

17、litary Medical University手术方法手术方法 l l对照组对照组对照组对照组采用传统全椎板切除减压手术采用腹卧位后正中切口 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical University实验组：实验组：实

18、验组：实验组：保留脊柱后部结构的椎板切除减压术保留脊柱后部结构的椎板切除减压术保留脊柱后部结构的椎板切除减压术保留脊柱后部结构的椎板切除减压术A.椎板骨膜下剥离一侧骶棘肌达关节突外侧B.将需要减压节段的棘突于其基部截骨，骨膜下剥离对侧椎板，显露椎板、黄韧带C.全椎板及增厚的黄韧带切除，行椎管减压A AB BC C 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4t

19、h Military Medical UniversityXiJing Hospital,4th Military Medical Universitya 黄韧带 b 棘突间韧带 c 棘突上韧带术中注意保留术中注意保留的后部结构的后部结构 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Ho

20、spital,4th Military Medical University手术基本情况手术基本情况l手术时间平均55min(3068min)l均未输血l术后第3天开始腰背肌锻炼，腰围或支具固定3个月 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military

21、 Medical University结果分析结果分析两组病人术后1年，3年拍腰椎过伸、过屈侧位X片按Macnab评定标准 评定术后恢复情况参照Hanley法测量L3、5节段的屈伸活动度 ab 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Med

22、ical University术后术后1年随访年随访Macnab评定结果评定结果组别优秀良好差实验组16100对照组1480两组间无显著性差异两组间无显著性差异 （P0.05P0.05）第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical

23、 University 两组术前及术后腰椎活动角度两组术前及术后腰椎活动角度组别术前术后1年术后3年对照组43.764.3841.245.6854.345.36实验组42.963.5440.146.1245.874.62术前及术后1年腰椎活动度无显著性差异 （P0.05）术后3年的实验组腰椎活动度显著低于对照组 （P0.05）第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospi

24、tal,4th Military Medical UniversityXiJing Hospital,4th Military Medical University病例介绍病例介绍l患者：何某，男，56岁l症状：间歇性跛行1年伴双下肢放散痛lMRI、CT示：L3.4，L4.5椎管狭窄 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medi

25、cal UniversityXiJing Hospital,4th Military Medical University术前术前MRI术后1年术后3年术前CT 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical University术

26、后术后3 3年腰椎活动情况年腰椎活动情况 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical University讨讨 论论椎管后路减压治疗时，尽可能维持小关节的完整性 除小关节以外，脊柱的后部韧带结构对前屈载荷有重要的抵抗作用后部韧带

27、结构对腰椎的旋转稳定性有一定的作用腰椎管狭窄症手术应遵循充分减压和有限化的手术原则 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical University保留后部结构改良减压手术的优点保留后部结构改良减压手术的优点l保留了棘上韧带、棘间韧带及棘突，对维持脊柱的稳定性起到积极作用l术中仅剥离一侧骶棘肌，损伤小，出血少，利于患者术后康复l术中显露充分，减压彻底，与传统方法的显露范围无显著差别 第四军医大学西京医院骨科专科医院第四军医大学西京医院骨科专科医院Special Hospital for Orthopsedics&TraumotologySpecial Hospital for Orthopsedics&TraumotologyXiJing Hospital,4th Military Medical UniversityXiJing Hospital,4th Military Medical University