Neurological Surgery 脳神経外科42巻12号

2014年12月発行

研究

変性すべり症を伴った腰部脊柱管狭窄症に対する減圧術の長期予後

著者： 佐々木修¹ 中村公彦¹ 梨本岳雄¹ 山下慎也¹ 矢島直樹¹ 鈴木健司¹ 斎藤明彦¹

所属機関： ¹新潟市民病院脳神経外科

ページ範囲：P.1109 - P.1117

Ⅰ．はじめに
　腰部脊柱管狭窄症には変性すべり症を合併することがあり，このような症例を手術するにあたっては，固定術を併用するか否かが問題となってくる．椎弓切除単独だと術後すべりが増強し，不安定性が発生，症状が悪化する可能性があるからである^{3,6,7,9,12,13,22,26)}．一方，すべり症があっても椎弓切除術単独で十分良好な成績が得られ，固定術は必要ないとする報告もあり^5,8,20)，意見の一致をみていない．椎弓切除術後にすべりが増強するのか，すべりが増強したとすると症候性となるのかといった疑問に明確な回答が与えられてないのが一因と言えよう．
　近年，椎弓切除の変法として，構造を極力温存したまま減圧を図るいわゆるless invasive surgeryが導入され，良好な成績が報告されるようになってきた^1,2,4,27,29)．このような低侵襲の減圧術を行えば固定術を併用せずともすべり症の悪化が減少し，良好な手術成績が得られる可能性が想定される．そこで今回変性すべり症を合併する腰部脊柱管狭窄症に対し，固定術を併用しない従来行ってきた椎弓切除術単独で手術した例と，less invasive surgeryを行った例の2群で，術後のすべり症と臨床症状の継時的変化をretrospectiveに比較検討した．

参考文献

1) Adams MA, Hutton WC：The mechanical function of the lumbar appophyseal joints. Spine（Phila Pa 1976）8：327-330, 1983

2) Aryanpur J, Ducker T：Multilevel lumbar laminotomies：an alternative to laminectomy in the treatment of lumbar stenosis. Neurosurgery 26：429-432；discussion 433, 1990

3) Caputy AJ, Luessenhop AJ：Long-term evaluation of decompressive surgery for degenerative lumbar stenosis. J Neurosurg 77：669-676, 1992

4) Costa F, Sassi M, Cardia A, Ortolina A, De Santis A, Luccarell G, Fornari M：Degenerative lumbar spinal stenosis：analysis of results in a series of 374 patients treated with unilateral laminotomy for bilateral microdecompression. J Neurosurg Spine 7：579-586, 2007

5) Epstein NE：Decompression in the surgical management of degenerative spondylolisthesis：advantages of a conservative approach in 290 patients. Spinal Disord 11：116-122；discussion 123, 1998

6) Fox MW, Onofrio BM, Hanssen AD：Clinical outcomes and radiological instability following decompressive lumbar laminectomy for degenerative spinal stenosis：a comparison of patients undergoing concomitant arthrodesis versus decompression alone. J Neurosurg 85：793-802, 1996

7) Herkowitz HN, Kurz LT：Degenerative lumbar spondylolisthesis with spinal stenosis. A prospective study comparing decompression with decompression and intertransverse process arthrodesis. J Bone Joint Surg Am 73：802-808, 1991

8) Herron LD, Trippi AC：L4-5 degenerative spondylolisthesis. The results of treatment by decompressive laminectomy without fusion. Spine（Phila Pa 1976）14：534-538, 1989

9) Johnsson KE, Redlund-Johnell I, Udén A, Willner S：Preoperative and postoperative instability in lumbar spinal stenosis. Spine（Phila Pa 1976）14：591-593, 1989

10) Kirkaldy-Willis WH, Farfan HF：Instability of the lumbar spine. Clin Orthop Relat Res 165：110-123, 1982

11) Kleeman TJ, Hiscoe AC, Berg EE：Patient outcomes after minimally destabilizing lumbar stenosis decompression：the “Port-Hole” technique. Spine（Phila Pa 1976）25：865-870, 2000

12) Martin BI, Mirza SK, Comstock BA, Gray DT, Kreuter W, Deyo RA：Reoperation rates following lumbar spine surgery and the influence of spinal fusion procedures. Spine（Phila Pa 1976）32：382-387, 2007

13) Martin CR, Gruszczynski AT, Braunsfurth HA, Fallatah SM, O'Neil J, Wai EK：The surgical management of degenerative lumbar spondylolisthesis. Spine 32：1791-1798, 2007

14) Matsunaga S, Sakou T, Morizono Y, Masuda A, Demirtas M：Natural history of degenerative spondylolisthesis. Pathogenesis and natural course of the slippage. Spine 15：1204-1210, 1990

15) Matsunaga S, Ijiri K, Hayashi K：Nonsurgically managed patients with degenerative spondylolisthesis：a 10-to 18-years follow-up study. J Neurosurg（2 Suppl）93：194-198, 2000

16) McCulloch L：Results in McCulloch J（ed）Principles of microsurgery for lumbar disc disease, New York, Raven Press, 1989, p278

17) Nakai O, Ookawa A, Yamaura I：Long-term roentgenographic and functional changes in patients who were treated with wide fenestration for central lumbar stenosis. J Bone Joint Surg Am 73：1184-1191, 1991

18) Postacchini F, Cinotti G, Perugia D, Gumina S：The surgical treatment of central lumbar stenosis. Multiple laminotomy compared with total laminectomy. J Bone Joint Surg Br 75：386-392, 1993

19) Shenkin HA, Hash CJ：Spondylolisthesis after multiple bilateral laminectomies and facetectomies for lumbar spondylosis. Follow-up review. J Neurosurg 50：45-47, 1979

20) Silvers HR, Lewis PJ, Asch HL：Decompressive lumbar laminectomy for spinal stenosis. J Neurosurg 78：695-701, 1993

21) Thomas NW, Rea GL, Pikul BK, Mervis LJ, Irsik R, McGregor JM：Quantitative outcome and radiographic comparisons between laminectomy and laminotomy in the treatment of acquired lumbar stenosis. Neurosurgery 41：567-574；discussion 574-575, 1997

22) Thomé C, Zevgaridis D, Leheta O, Bäzner H, Pöckler-Schöniger C, Wöhrle J, Schmiedek P：Outcome after less-invasive decompression of lumbar spinal stenosis：a randomized comparison of unilateral laminotomy, bilateral laminotomy, and laminectomy. J Neurosurg Spine 3：129-141, 2005

23) Tuite GF, Stern JD, Doran SE, Papadopoulos SM, McGillicuddy JE, Oyedijo DI, Grube SV, Lundquist C, Gilmer HS, Schork MA, Swanson SE, Hoff JT：Outcome after laminectomy for lumbar spinal stenosis. PartⅠ：Clinical correlations. J Neurosurg 81：699-706, 1994

24) Tuite GF, Doran SE, Stern JD, McGillicuddy JE, Papadopoulos MP, Lundquist CA, Oyedijo DI, Grube SV, Gilmer HS, Schork MA, Swanson SE, Hoff JT：Outcome after laminectomy for lumbar spinal stenosis. PartⅡ：Radiographic changes and clinical correlations. J Neurosurg 81：707-715, 1994

25) Turner JA, Ersek M, Herron L, Deyo R：Surgery for lumbar spinal stenosis. Attempted meta-analysis of the literature. Spine（Phila Pa 1976）17：1-8, 1992

26) Watters WC 3rd, Bono CM, Gilbert TJ, Kreiner DS, Mazanec DJ, Shaffer WO, Baisden J, Easa JE, Fernand R, Ghiselli G, Heggeness MH, Mendel RC, O'Neill C, Reitman CA, Resnick DK, Summers JT, Timmons RB, Toton JF；North American Spine Society：An evidence-based clinical guideline for the diagnosis and treatment of degenerative lumbar spondylolisthesis. Spine J 9：609-614, 2009

27) Weiner BK, Walker M, Brower RS, McCulloch JA：Microdecompression for lumbar spinal canal stenosis. Spine（Phila Pa 1976）24：2268-2272, 1999

28) Wiltse LL, Winter RB：Terminology and measurement of spondylolisthesis. J Bone Joint Surg Am 65：768-772, 1983

29) Young S, Veerapen R, O'Laoire SA：Relief of lumbar canal stenosis using multilevel subarticular fenestrations as an alternative to wide laminectomy：preliminary report. Neurosurgery 23：628-633, 1988