夏可周，郭衛(wèi)春

(武漢大學(xué)人民醫(yī)院，武漢430060)

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退變性腰椎管狹窄癥手術(shù)治療中不同術(shù)式的應(yīng)用進展

夏可周，郭衛(wèi)春

(武漢大學(xué)人民醫(yī)院，武漢430060)

目的 治療退變性腰椎管狹窄癥(DLSS)的手術(shù)主要分為腰椎板切除減壓、椎弓根螺釘內(nèi)固定及植骨融合術(shù)。減壓手術(shù)是治療DLSS最根本的術(shù)式，主要分為椎板切除術(shù)(全椎板切除術(shù)和半椎板切除術(shù))、椎板間開窗術(shù)、微創(chuàng)椎管減壓術(shù)；植骨融合大致分為后外側(cè)植骨融合和椎間融合，其中椎間融合術(shù)的融合率最高，但對于DLSS患者在行椎管減壓的同時是否需植骨融合至今仍存在較大爭議；非融合性內(nèi)固定的植入體可增加局部的脊柱前突，減輕椎管狹窄，增加腰椎椎間隙高度及穩(wěn)定性，減少鄰近節(jié)段退變。臨床工作中，應(yīng)正確處理好減壓與脊椎穩(wěn)定二者間的關(guān)系，充分評估是否同時采取相應(yīng)植骨融合及內(nèi)固定等治療措施，對于不同患者選擇適宜的手術(shù)方式。

退變性腰椎管狹窄癥；外科手術(shù)；椎管減壓術(shù)；植骨融合術(shù)；椎弓根內(nèi)固定術(shù)

退變性腰椎管狹窄癥(DLSS)是指腰椎間盤、韌帶、小關(guān)節(jié)及椎板等骨性或纖維結(jié)構(gòu)隨著年齡增長發(fā)生退變，導(dǎo)致椎管、神經(jīng)根管、側(cè)隱窩或椎間孔管腔內(nèi)徑狹窄，刺激或壓迫相應(yīng)節(jié)段神經(jīng)或血管而引起的相應(yīng)臨床癥狀[1]。隨著社會老齡化的加劇，DLSS的發(fā)病率日益增高[2，3]。在DLSS癥狀未嚴重影響生活質(zhì)量的前提下盡量采取保守治療原則[4]，但當保守治療無效時往往需行手術(shù)治療。DLSS手術(shù)治療的目的并不是治愈，而是緩解間歇性跛行、腰腿痛及神經(jīng)功能缺失等臨床癥狀，提高患者生活質(zhì)量。多數(shù)學(xué)者認為手術(shù)治療DLSS的適應(yīng)證主要包括：①有中重度神經(jīng)根放射痛或神經(jīng)根功能損害，伴或不伴腰背痛者；②有間歇性跛行，行走距離短于100～200 m或進行性加重者；③進行性的側(cè)凸、滑脫伴相應(yīng)臨床癥狀和體征加重，影響生活活動功能者；④出現(xiàn)馬尾神經(jīng)損傷癥狀者；⑤經(jīng)保守治療3～6個月無明顯緩解者，在全身情況可耐受手術(shù)情況下應(yīng)行手術(shù)治療。近年來，DLSS已成為脊柱外科手術(shù)中常見的手術(shù)指征[5,6]。治療DLSS手術(shù)主要分為腰椎板切除減壓、椎弓根螺釘內(nèi)固定及植骨融合術(shù)。關(guān)于手術(shù)治療DLSS的研究較多，然而至今尚未形成統(tǒng)一的手術(shù)治療標準[7～12]?，F(xiàn)就退行性腰椎管狹窄癥手術(shù)治療中不同術(shù)式的應(yīng)用進展綜述如下。

1 腰椎板切除減壓術(shù)

減壓手術(shù)是治療DLSS最根本的術(shù)式，主要分為椎板切除術(shù)(全椎板切除術(shù)和半椎板切除術(shù))、椎板間開窗術(shù)、微創(chuàng)椎管減壓術(shù)，關(guān)于各術(shù)式之間的比較研究較少[13]。

1.1 全椎板減壓術(shù) 以往認為全椎板切除術(shù)是DLSS的經(jīng)典手術(shù)方式，對于多種因素造成單一平面出現(xiàn)嚴重椎管狹窄情況或出現(xiàn)多節(jié)段、多平面嚴重椎管狹窄者主要采用全椎板切除為主的后路減壓術(shù)[14，15]。Jakola等[16]研究表明，全椎板切除術(shù)雖然減壓徹底，但切除范圍較大，術(shù)后并發(fā)癥發(fā)生率高，影響脊柱穩(wěn)定性，術(shù)后易導(dǎo)致醫(yī)源性腰椎不穩(wěn)和腰椎管再次狹窄，遠期療效欠佳[17]。

1.2 半椎板切除術(shù) 切除范圍包括一側(cè)椎板、肥厚的黃韌帶、突出的椎間盤及增生的小關(guān)節(jié)等，適用于單側(cè)神經(jīng)根管和側(cè)隱窩狹窄、關(guān)節(jié)突肥大及中央型狹窄但對側(cè)無癥狀者。Overdevest等[18]對比分析了半椎板切除全椎管減壓術(shù)與全椎板切除減壓術(shù)治療DLSS的療效，認為半椎板切除全椎管減壓術(shù)同樣能達到全椎管減壓的目的，術(shù)后療效明顯，同時對椎管破壞少，避免對脊柱中線結(jié)構(gòu)(如棘突、椎弓和棘間、棘上韌帶等)的切除，在一定程度上保留脊柱后部結(jié)構(gòu)的完整性，對脊柱穩(wěn)定性影響較小，可避免因全椎板切除引發(fā)的術(shù)后并發(fā)癥。

1.3 椎板間開窗術(shù) 椎板間開窗減壓術(shù)適用于輕、中度DLSS伴脊椎無滑脫者，椎管狹窄不嚴重伴椎間盤突出者。該術(shù)式可保留脊柱后部的骨韌帶結(jié)構(gòu)，避免醫(yī)源性腰椎管狹窄和脊柱滑脫，促進術(shù)后腰背肌功能恢復(fù)，防止肌肉失神經(jīng)萎縮，大大降低術(shù)后脊柱失穩(wěn)的發(fā)生率。Fu等[19]研究認為開窗減壓術(shù)與椎板切除術(shù)相比遠期療效更好，并發(fā)癥更少。

1.4 微創(chuàng)椎管減壓術(shù)[20]脊柱微創(chuàng)手術(shù)已成為最新研究熱點，包括顯微鏡下減壓術(shù)和內(nèi)窺鏡下減壓術(shù)。①顯微鏡下減壓術(shù)：經(jīng)暴露椎板間隙后由顯微鏡進入行椎管減壓術(shù)，顯微鏡下能直觀地顯示并放大病變部位；Mayer等[21]報道顯微內(nèi)窺鏡下單側(cè)入路雙側(cè)椎管減壓術(shù)療效滿意，隨訪6年優(yōu)良率為64.9%；但Toyoda等[22]認為此術(shù)式短期療效較好，遠期療效尚不明確。②內(nèi)窺鏡下減壓術(shù)：原理是應(yīng)用攝像系統(tǒng)將手術(shù)視野清晰顯示在熒幕上并通過可多角度調(diào)節(jié)的工作通道進行手術(shù)操作，該術(shù)式切口小、創(chuàng)傷小、出血少，可有效保留脊柱后方韌帶復(fù)合結(jié)構(gòu)的完整性，術(shù)后恢復(fù)快；在內(nèi)窺鏡下減壓減少了對肌肉組織的剝離及牽拉，降低術(shù)后腰骶部疼痛的發(fā)生率，借助顯微影像放大技術(shù)可對被壓迫的硬膜囊及神經(jīng)根徹底松解減壓，緩解臨床癥狀。Wu等[23]認為椎間盤鏡作為一種微創(chuàng)技術(shù)在脊柱外科手術(shù)具有明顯的優(yōu)勢和良好的應(yīng)用前景，值得進一步研究和推廣。Wu等[24]采用微創(chuàng)經(jīng)椎間孔聯(lián)合腰椎椎間融合術(shù)(MIS-TLIF)治療65歲以上老年患者1或2個節(jié)段腰椎退變性疾病，療效滿意。

2 腰椎植骨融合術(shù)

植骨融合大致分為后外側(cè)植骨融合(PLF)和椎間融合，根據(jù)融合入路不同，椎間融合術(shù)又分為后路椎間融合術(shù)(PLIF)、前路椎間融合術(shù)(ALIF)、椎間孔入路椎間融合術(shù)(TLIF)、極外側(cè)椎間融合術(shù)(XLIF)。椎間融合因接觸面積大及縱向應(yīng)力的作用，融合率最高。但是，對于DLSS患者在行椎管減壓的同時是否需植骨融合至今仍存在較大爭議。近年來許多學(xué)者主張在徹底減壓時輔以腰椎融合術(shù)，尤其是術(shù)前腰椎動力位片顯示有腰椎不穩(wěn)者或術(shù)中減壓范圍過大、術(shù)后可能出現(xiàn)腰椎不穩(wěn)者，應(yīng)考慮行植骨融合術(shù)；對于術(shù)前腰椎穩(wěn)定者，純椎板切除同時行植骨融合術(shù)并不能提高臨床療效。對于DLSS患者，因組織已經(jīng)存在退變，而在手術(shù)過程中為了充分減壓，往往需要切除部分關(guān)節(jié)突關(guān)節(jié)，導(dǎo)致術(shù)后可能出現(xiàn)退變加速發(fā)展，癥狀復(fù)發(fā)。Molina等[25]研究表明雙側(cè)小關(guān)節(jié)切除范圍超過1/2時將導(dǎo)致脊柱失穩(wěn)。Andreisek等[26]認為減壓治療后行植骨融合可改善原有腰椎不穩(wěn)，但減壓后可能出現(xiàn)的腰椎失穩(wěn)。Bai等[27]研究表明，在一些情況下徹底減壓后導(dǎo)致腰椎不穩(wěn)時應(yīng)輔以內(nèi)固定和植骨來維持脊柱穩(wěn)定性。Liang等[28]認為減壓融合術(shù)相比單純減壓可獲得更好的臨床療效，但再手術(shù)率也較高。

然而，最近多篇文獻報道椎管減壓聯(lián)合植骨融合術(shù)與單純減壓術(shù)相比療效并無顯著優(yōu)越性。Modhia等[29]發(fā)現(xiàn)行減壓聯(lián)合植骨融合術(shù)的DLSS患者再手術(shù)率高于行單純減壓術(shù)者。Forsth等[30]將50～80歲的單節(jié)段或雙節(jié)段腰椎管狹窄患者隨機分為減壓聯(lián)合融合組和單純減壓組，兩組術(shù)后2、5年療效無統(tǒng)計學(xué)差異，但減壓聯(lián)合融合組患者住院時間長、出血量大、花費高。Ghogawala等[31]的研究結(jié)果顯示，減壓聯(lián)合植骨融合在住院時間、出血量及再手術(shù)率方面較單純減壓術(shù)者均無優(yōu)勢。Peul等[32]認為植骨融合已不再是DLSS的最佳治療方案，行植骨融合預(yù)防性治療DLSS并無積極意義。目前認為對于DLSS患者應(yīng)針對導(dǎo)致狹窄的原因采用個體化手術(shù)方案治療，根據(jù)患者病情及術(shù)中減壓具體情況決定是否行植骨融合術(shù)。

3 椎弓根螺釘內(nèi)固定術(shù)

內(nèi)固定術(shù)的目的包括：①重建腰椎穩(wěn)定性，糾正脊柱畸形，復(fù)位滑脫的椎體，恢復(fù)脊柱的生理彎曲，使脊柱生物力學(xué)和生理功能恢復(fù)正常；②縮短術(shù)后恢復(fù)時間，利于術(shù)后腰背肌功能鍛煉。常規(guī)的植骨融合+椎弓根螺釘內(nèi)固定術(shù)是目前國內(nèi)臨床廣泛應(yīng)用的治療脊柱退行性疾病的手術(shù)方式之一，療效顯著。但近年來臨床發(fā)現(xiàn)椎間融合內(nèi)固定的效果并不十分滿意，該術(shù)式出血較多、耗時較長，術(shù)后并發(fā)癥較多，且有再次手術(shù)的可能(與多節(jié)段融合、高齡、退變性疾病和性別男有關(guān))[33]。隨著對脊柱生理功能的研究不斷深入，保留脊柱運動功能的非融合動態(tài)固定得到充分發(fā)展。非融合性內(nèi)固定的植入體可增加局部的脊柱前突，限制腰椎后伸及不穩(wěn)定節(jié)段的運動范圍，減輕椎管狹窄，增加腰椎椎間隙高度及穩(wěn)定性，最大可能地保留運動功能，減少鄰近節(jié)段退變。近年來臨床較多應(yīng)用的非融合技術(shù)包括棘突間內(nèi)固定裝置、椎弓根彈性固定裝置、關(guān)節(jié)突關(guān)節(jié)置換術(shù)等，其中以棘突間內(nèi)固定裝置技術(shù)應(yīng)用最為廣泛。Zhang等[34]發(fā)現(xiàn)，與PLIF相比，Dynesys固定裝置可更好的限制上位節(jié)段的過度活動，防止鄰近階段退變發(fā)生，認為Dynesys動態(tài)固定器可替代PLIF治腰椎退變性疾病。Kim等[35]采用X-stop動態(tài)固定裝置治療14例DLSS患者，結(jié)果顯示X-stop動態(tài)固定器可增加腰椎椎間孔高度和面積，短期臨床療效較好。但是，有學(xué)者[36～38]研究認為棘突間植入術(shù)雖然術(shù)后并發(fā)癥較低，但再手術(shù)率為25%～29%，高于椎管減壓組。最近Hong等[39]和Wu等[40]也認為，在行棘突間植入術(shù)前應(yīng)仔細考慮手術(shù)適應(yīng)證、手術(shù)風(fēng)險，評估手術(shù)所帶來的收益[41]。

總之，退變性椎管狹窄癥發(fā)病緩慢，是中老年人的常見病與多發(fā)病，由于該病具有復(fù)雜性、多樣性等特點，且老年患者常合并多種器官和系統(tǒng)疾病、手術(shù)風(fēng)險相對較大，醫(yī)生應(yīng)在圍手術(shù)期全面客觀地分析患者的癥狀、體征及影像學(xué)資料，積極控制其他疾病，嚴格掌握手術(shù)指征，采用合適的手術(shù)方式。DLSS手術(shù)治療的核心是神經(jīng)減壓與維持脊柱穩(wěn)定。醫(yī)師應(yīng)正確處理好減壓與脊椎穩(wěn)定二者間的關(guān)系，充分評估是否同時采取相應(yīng)植骨融合及內(nèi)固定等治療措施，對于不同患者選擇適宜的手術(shù)方式。

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郭衛(wèi)春(E-mail: guoweichun@aliyun.com)

10.3969/j.issn.1002-266X.2016.39.035

R681.5

A

1002-266X(2016)39-0103-04

2016-06-09)