1、 第四軍醫大學西京醫院骨科專科醫院第四軍醫大學西京醫院骨科專科醫院Special Hospital for Orthopsedics & TraumotologySpecial Hospital for Orthopsedics & TraumotologyXiJing Hospital , 4th Military Medical UniversityXiJing Hospital , 4th Military Medical University葉正旭 羅卓荊 吳子祥第四軍醫大學西京醫院西京骨科醫院 第四軍醫大學西京醫院骨科專科醫院第四軍醫大學西京醫院骨科專科醫院Special Hospi

2、tal for Orthopsedics & TraumotologySpecial Hospital for Orthopsedics & TraumotologyXiJing Hospital , 4th Military Medical UniversityXiJing Hospital , 4th Military Medical University 第四軍醫大學西京醫院骨科專科醫院第四軍醫大學西京醫院骨科專科醫院Special Hospital for Orthopsedics & TraumotologySpecial Hospital for Orthopsedics & Tr

3、aumotologyXiJing Hospital , 4th Military Medical UniversityXiJing Hospital , 4th Military Medical University 腰椎管狹窄癥腰椎管狹窄癥Lumbar Spinal Stenosis LSS)是指因原發或繼發要是指因原發或繼發要素呵斥椎管構造異常，椎管腔內變窄，出現以間歇性跛行為主要素呵斥椎管構造異常，椎管腔內變窄，出現以間歇性跛行為主要特征的腰腿疼痛特征的腰腿疼痛 第四軍醫大學西京醫院骨科專科醫院第四軍醫大學西京醫院骨科專科醫院Special Hospital for Orthopsedi

4、cs & TraumotologySpecial Hospital for Orthopsedics & TraumotologyXiJing Hospital , 4th Military Medical UniversityXiJing Hospital , 4th Military Medical University脊椎退變所致的狹窄脊椎退變所致的狹窄1復合要素所致的狹窄復合要素所致的狹窄2脊椎滑脫癥與骨溶解病所致狹窄脊椎滑脫癥與骨溶解病所致狹窄3其他其他6損傷性狹窄損傷性狹窄5醫源性狹窄醫源性狹窄4 第四軍醫大學西京醫院骨科專科醫院第四軍醫大學西京醫院骨科專科醫院Special Ho

5、spital for Orthopsedics & TraumotologySpecial Hospital for Orthopsedics & TraumotologyXiJing Hospital , 4th Military Medical UniversityXiJing Hospital , 4th Military Medical University影像學表現體征病癥診斷diagnosis 第四軍醫大學西京醫院骨科專科醫院第四軍醫大學西京醫院骨科專科醫院Special Hospital for Orthopsedics & TraumotologySpecial Hospita

6、l for Orthopsedics & TraumotologyXiJing Hospital , 4th Military Medical UniversityXiJing Hospital , 4th Military Medical Universityl 雙側神經性跛行，間歇性大腿或小腿放射性疼痛，長時間站立、活動或腰過伸時病癥加重，坐、臥或腰屈曲時減輕。普通病癥 第四軍醫大學西京醫院骨科專科醫院第四軍醫大學西京醫院骨科專科醫院Special Hospital for Orthopsedics & TraumotologySpecial Hospital for Orthopsedi

7、cs & TraumotologyXiJing Hospital , 4th Military Medical UniversityXiJing Hospital , 4th Military Medical University體 征 膝踝反射改動多不對稱 病理反射缺如 覺得妨礙 直腿抬高實驗陰性 壓迫馬尾及神經根時影響大、小便 嚴重者下肢不完全性癱瘓 第四軍醫大學西京醫院骨科專科醫院第四軍醫大學西京醫院骨科專科醫院Special Hospital for Orthopsedics & TraumotologySpecial Hospital for Orthopsedics & Traum

8、otologyXiJing Hospital , 4th Military Medical UniversityXiJing Hospital , 4th Military Medical University非手術治療手術治療腰椎管狹窄的治療 第四軍醫大學西京醫院骨科專科醫院第四軍醫大學西京醫院骨科專科醫院Special Hospital for Orthopsedics & TraumotologySpecial Hospital for Orthopsedics & TraumotologyXiJing Hospital , 4th Military Medical University

9、XiJing Hospital , 4th Military Medical University活動后腰及腿疼痛，影響任務、生活，經保守治療不愈者 進展性跛行加重，或站立時間逐漸縮短者 神經機能出現明顯缺損者 腰椎管狹窄手術指征： 第四軍醫大學西京醫院骨科專科醫院第四軍醫大學西京醫院骨科專科醫院Special Hospital for Orthopsedics & TraumotologySpecial Hospital for Orthopsedics & TraumotologyXiJing Hospital , 4th Military Medical UniversityXiJing

10、 Hospital , 4th Military Medical University 減壓是解除病癥的主要手段 減壓范圍： 包括黃韌帶、椎間盤、增生的關節突、側隱窩 盡量保管有用的椎間盤 減壓破壞后柱構造,故通常添加了腰椎失穩的風險常用手術方式為全椎板切除減壓術常用手術方式為全椎板切除減壓術 第四軍醫大學西京醫院骨科專科醫院第四軍醫大學西京醫院骨科專科醫院Special Hospital for Orthopsedics & TraumotologySpecial Hospital for Orthopsedics & TraumotologyXiJing Hospital , 4th Mi

11、litary Medical UniversityXiJing Hospital , 4th Military Medical University1983年Denis提出三柱分類 傳統減壓破壞了c柱的張力帶作用 第四軍醫大學西京醫院骨科專科醫院第四軍醫大學西京醫院骨科專科醫院Special Hospital for Orthopsedics & TraumotologySpecial Hospital for Orthopsedics & TraumotologyXiJing Hospital , 4th Military Medical UniversityXiJing Hospital

12、, 4th Military Medical University峽部仍堅持完好退變性腰椎失穩 小關節磨損 關節突程度前縱韌帶松弛椎間盤退變腰椎退變性滑脫腰椎退變性滑脫 第四軍醫大學西京醫院骨科專科醫院第四軍醫大學西京醫院骨科專科醫院Special Hospital for Orthopsedics & TraumotologySpecial Hospital for Orthopsedics & TraumotologyXiJing Hospital , 4th Military Medical UniversityXiJing Hospital , 4th Military Medical

13、 University 第四軍醫大學西京醫院骨科專科醫院第四軍醫大學西京醫院骨科專科醫院Special Hospital for Orthopsedics & TraumotologySpecial Hospital for Orthopsedics & TraumotologyXiJing Hospital , 4th Military Medical UniversityXiJing Hospital , 4th Military Medical University 全椎板切除減壓手術組 22例 保管后部構造的改良減壓手術組 26例 2003年5月2004年5月 腰椎管狹窄癥患者隨機分組

14、 第四軍醫大學西京醫院骨科專科醫院第四軍醫大學西京醫院骨科專科醫院Special Hospital for Orthopsedics & TraumotologySpecial Hospital for Orthopsedics & TraumotologyXiJing Hospital , 4th Military Medical UniversityXiJing Hospital , 4th Military Medical University臨床表現：均有間歇性跛行伴下肢放散痛病史 下肢有皮區覺得減弱 36例 皮區覺得消逝 12例 小便失禁 6例 影象學檢查 CT、MRI 影像顯示：椎

15、管狹窄節段在L3-S1范圍內，需減壓的節段為23個 x線片顯示：無腰椎失穩的征象實驗組實驗組2626例男例男1212例，女例，女1414例，平均年齡例，平均年齡62622 2歲歲對照組對照組2222例男例男1313例，女例，女 9 9例，平均年齡例，平均年齡63631.51.5歲歲 第四軍醫大學西京醫院骨科專科醫院第四軍醫大學西京醫院骨科專科醫院Special Hospital for Orthopsedics & TraumotologySpecial Hospital for Orthopsedics & TraumotologyXiJing Hospital , 4th Military

16、 Medical UniversityXiJing Hospital , 4th Military Medical University手術采用腹臥位后正中切口 第四軍醫大學西京醫院骨科專科醫院第四軍醫大學西京醫院骨科專科醫院Special Hospital for Orthopsedics & TraumotologySpecial Hospital for Orthopsedics & TraumotologyXiJing Hospital , 4th Military Medical UniversityXiJing Hospital , 4th Military Medical Uni

17、versity椎板骨膜下剝離一側骶棘肌達關節突外側將需求減壓節段的棘突于其基部截骨，骨膜下剝離對側椎板，顯露椎板、黃韌帶全椎板及增厚的黃韌帶切除，行椎管減壓 第四軍醫大學西京醫院骨科專科醫院第四軍醫大學西京醫院骨科專科醫院Special Hospital for Orthopsedics & TraumotologySpecial Hospital for Orthopsedics & TraumotologyXiJing Hospital , 4th Military Medical UniversityXiJing Hospital , 4th Military Medical Unive

18、rsitya 黃韌帶 b 棘突間韌帶 c 棘突上韌帶術中留意保管術中留意保管的后部構造的后部構造 第四軍醫大學西京醫院骨科專科醫院第四軍醫大學西京醫院骨科專科醫院Special Hospital for Orthopsedics & TraumotologySpecial Hospital for Orthopsedics & TraumotologyXiJing Hospital , 4th Military Medical UniversityXiJing Hospital , 4th Military Medical Universityl手術時間平均55min(3068min)l均未輸

19、血l術后第3天開場腰背肌鍛煉，腰圍或支具固定3個月 第四軍醫大學西京醫院骨科專科醫院第四軍醫大學西京醫院骨科專科醫院Special Hospital for Orthopsedics & TraumotologySpecial Hospital for Orthopsedics & TraumotologyXiJing Hospital , 4th Military Medical UniversityXiJing Hospital , 4th Military Medical University兩組病人術后1年，3年拍腰椎過伸、過屈側位X片按Macnab評定規范 評定術后恢復情況參照Han

20、ley法丈量L3、5節段的屈伸活動度 ab 第四軍醫大學西京醫院骨科專科醫院第四軍醫大學西京醫院骨科專科醫院Special Hospital for Orthopsedics & TraumotologySpecial Hospital for Orthopsedics & TraumotologyXiJing Hospital , 4th Military Medical UniversityXiJing Hospital , 4th Military Medical University組別優秀良好差實驗組16100對照組1480兩組間無顯著性差別兩組間無顯著性差別 P0.05P0.05

21、第四軍醫大學西京醫院骨科專科醫院第四軍醫大學西京醫院骨科專科醫院Special Hospital for Orthopsedics & TraumotologySpecial Hospital for Orthopsedics & TraumotologyXiJing Hospital , 4th Military Medical UniversityXiJing Hospital , 4th Military Medical University 兩組術前及術后腰椎活動角度組別術前術后1年術后3年對照組43.764.3841.245.6854.345.36實驗組42.963.5440.146

22、.1245.874.62術前及術后1年腰椎活動度無顯著性差別 P0.05術后3年的實驗組腰椎活動度顯著低于對照組 P0.05 第四軍醫大學西京醫院骨科專科醫院第四軍醫大學西京醫院骨科專科醫院Special Hospital for Orthopsedics & TraumotologySpecial Hospital for Orthopsedics & TraumotologyXiJing Hospital , 4th Military Medical UniversityXiJing Hospital , 4th Military Medical Universityl患者：何某，男，56

23、歲l病癥：間歇性跛行1年伴雙下肢放散痛lMRI、CT示：L3.4，L4.5椎管狹窄 第四軍醫大學西京醫院骨科專科醫院第四軍醫大學西京醫院骨科專科醫院Special Hospital for Orthopsedics & TraumotologySpecial Hospital for Orthopsedics & TraumotologyXiJing Hospital , 4th Military Medical UniversityXiJing Hospital , 4th Military Medical University術前術前MRI術后1年術后3年術前CT 第四軍醫大學西京醫院骨科專科醫院第四軍醫大學西京醫院骨科專科醫院Special Hospital for Orthopsedics & TraumotologySpecial Hospital for Orthopsedics & TraumotologyXiJing Hospital , 4th Military Medical UniversityXiJing Hospital , 4th Military Medical University 第四軍醫大學西京醫院骨科專科醫院第四軍醫大學西京醫院骨科專科醫院Special Hospital for Orthopsedics & Tra