退变性腰椎管狭窄症的微创手术治疗策略.doc

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1、退变性腰椎管狭窄症的微创手术治疗策略StrategiesofMinimallyInvasiveSurgeryforTreatmentofDegenerativeLumbarSpinalStenosis根据患者临床及影像学表现采用以下几种手术方式。Accordingtotheclinicalandimagingmanifestations,thefollowingsurgeryprogramsmaybeapplied.a).可扩张通道下单侧椎旁肌间隙或肌束间隙入路潜行双侧减压：对于临床表现为I型、II型且影像学表现为A型及部分

2、B型的患者可以采用此方法进行治疗。患者麻醉成功后采用自行设计的微创手术定位器(图2)准确定位出手术椎间隙，以椎间隙水平线为屮心，椎旁开2〜3cm,在患者症状严重侧或影像学狭窄严重侧，垂直做2〜3cm长纵行切口，切开皮肤、皮下组织，用扩张器逐级扩张分离软组织(对于部分多裂肌和最长肌之间的肌间隙比较靠近外侧，且需要对椎管进行充分减压的患者，经过多裂肌肌束间隙进入)；然后在可扩张通道辅助下切除部分椎板，扩大同侧侧隐窝及神经根管。如果患者还有屮央椎管狭窄，则再将手术床适当倾斜，进行对侧减压，扩大椎管。a).Bilateralsnea

3、kdecompressionapproachedthroughunilateralparaspinalmusclegapunderexpandablechannelorthroughtheintermuscularspacebetweenmusclebundle:ForpatientswithsubtypeIandsubtypeIIclinicalmanifestationsandsubtypeAandsubtypeBimagingmanifestations,thisprogramcouldbeappliedfortrea

4、tment-Afterthepatientwasanesthetized,theintervertebralspacetobeoperatedonwasaccuratelylocatedwithself-designedminimallyinvasivesurgerylocator(Fig.2).Centeredonthehorizontalintervertebralline,and2-3cmbesidesthevertebrate,averticallongitudinalincisionabout2-3cmwasmad

5、eonthesidewithmoreseveresymptomorwithmoreseveredegreeofstenosis.Theskinandsubcutaneoustissuewereincisedopenandexpanderwasappliedforprogressiveexpansionandseparationofsofttissues(forpatientswiththeintermuscularspacebetweenmultifidusandlongissimusmuscleneartheoutersi

6、deandpatientsforwhomanampledecompressionofspinalcanalwasessential,theincisionwasapproachedthroughintermuscularspacebetweenmultifidusmusclebundles).Thenremovepartofthevertebralplateandexpandipsilaterallateralrecessandnerverootcanal.Ifthepatientalsopresentcentralspin

7、alcanalstenosis,thecontralateraldecompressionshouldbeperformedtoexpandspinalcanalthroughtitlingthebedtotheproperextent.b).可扩张通道下双侧入路开窗减压加潜行屮央椎管扩大：对于临床表现为I型、III型且影像学表现为B型的患者可采用此方法进行治疗。具体方法同上，在完成一侧减压后再同法进行另一侧减压。b).Decompressionthroughbilateralapproachunderexpandablec

8、hannelsplussneakcentralspinalcanalexpansion:ForpatientswithsubtypeIandsubtypeIIIclinicalmanifestationandsubtypeBofimagingmanifestation,thisprogra