HOI NGHI KHOA HOC BENH VIEN H Q U NGHI VI^T TI^P H A I PHONG LAN THLf 37
DANH GIA KET QUA DIEU TRj PHAU THUAT TRl/OTT DOT SONG VUNG TH&T LUNG CUNG
B A N GCO DINH QUA CUONG KEM HAN XlTONG
TAI BENH VIEN VIET TIEP
Pham Thanh Tuan, Do Manh Th^ng Nguyen Ngyc Hiing, Nguyen Diic Thiet(*
TOM T A T
Muc dich: danh gia ket qua phau thuat trUdt dot song that lu'ng ciing bSng co dinh cgt song qua cuong kem ban xUdng tai khoa PTTK benh vien Viet Tiep Hai Phong tii* 6/2004 den 6/2011. Phifc/ng phipr. mo ta hoi ciiu 29 benh nhan dugc phau thuat tai khoa PTTK benh vien Viet Tiep. Ket qua: co 29 benh nhan. Ty le nam/nu' la 0,45. Tuoi trung binh la 47,8, gap nhieu nhat la 40-49 tuoi. Thu'dng gap 6 ngUdi lao dgng nang (58%), th6i gian ii benh trung binh la 18 thang (5- 36 thang ).V| trf tru'dt hay gap nhat la L4L5 (79,3%), chii yeu la tru-gt do 2-3 (75,8%). Trieu chu'ng thu'dng gap la dau that lu'ng, dau kieu re va dau each hoi. Can lam sang du'dc sir dung chii yeu la XQ quy u'dc (100%), cgng hu'dng tir (100%). Phu'dng phap mo du'dc chung toi ap dung la co djnh cgt song qua cuong, md cung sau giai ep kem ban xu'dng lien than dot. Thdi gian mo trung binh la 150 phiit (120-
180 phiit). Oanh gia ket qua dUa vao Prolo va JOA cho thay cac trieu chirng du'dc cai thien dan sau mo. JOA tru'dc mo 9,25±1,25 (7-12), JOA sau mo 16,75 (13-19). Ket qua sau mo theo Prolo: ty le tot 62,07%, ty le trung binh 37,93%.
Cac benh nhan khong con bleu hien ciia dau that lu'ng, khong tru'dng hdp nao bi gay vit. Kit luarr. phu'dng phap dieu tri tru'dt dot song viing that lu'ng cung bang phu'dng phap co dinh qua cuong kem ban xu'dng cho ket qua phuc hoi tot, mire do can xu'dng chac, giam trieu chiing dau lu'ng sau mo. Tuy vay phu'dng phap nay ddi hoi ky thuat tot va co nguy cd ton thu'dng re than kinh.
SUMMARY
DURING THE PERIOD OF 7 YEARS (6-2004 TO 6-2011),
29 patients with isthmic spondyolisthesi:
were operated at Department of Neurosurgefy, Viet Tiep Hospital. Surgical method;
decompression of nerve roots and osteosynthesis by pedicle screw technique. Allmost of the patients were females (69%), common ages ranged from 40 - 49 (56%). The result: good 62,07% and normal 37,93%. In our opinion;
large decompression and interbody fusion is one of the key works in this operation
* Key words: Neurosurgery; Isthmic spondyollsthesis.
I.
OAT V A No f
Trugt dot s6ng la su di chuyen bat thuong ra phia truoc cua than d6t song ciing
\ai cuong, m6m ngang \a dien khop phia tren. Trugl d6t song la mgt trong nhung nguyen nhan hang dau gay dau viing that lung do sir mat \ img cua cgt s6ng vimg that lung ciing. Trugt dot song dugc phat hien lan dau tien vao nSm 1782 do ong Herbinaux, mgt bac sy san khoa nguoi Bi.
Theo th6ng ke co khoang 2-3% dan so mSc benh trugt d6t s6ng. Vi benh co anh huong rat Ion den doi song, lao dgng cua benh nhan nen la ganh nang cho xa hgi.
Khuylt eo d6t s6ng la mgt trong nhiing
YHOC VIET NAM T H A N G 10 - SO D A C BIET/2011 guyen nhan cua trugt d6t s6ng. Chdn doan
ua vao cac bi6u hien lam sang nhu dau that mg, dau hieu chen ep re, di lai kh6 khan kht ap voi cac phuong tien chk\ doan hinh anh gay cang phat triln.
Ve dieu tn, chi dinh phau thuat dugc dat I khi cac phuong phap dieu tri n6i khoa bao )n that bai. C6 nhieu ky thuat m6 dugc ap ung nhu c6 dinh cgt s6ng qua cuong kem an xuong sau ben, ban xuong lien than dot.
Ihim danh gia kht qua phau thuat benh ly ugt d6t s6ng tai benh \ ien Viet Tiep. chung M tien hanh nghien cim dh tai:
" Ddnh gid ket qud phdu thudt trugt ddt ong viing that lung ciing tgi benh vien Viet lip bdng phuang phdp c6 dinh cgt s6ng kem dn xuang''
. OOI TUpNG VA PHUONG P H A P NGHIEN CCfU
2.1. Doi turang nghien ciru: 29 benh ban dugc chan doan, phau thuat trong thoi ian 6/2004 dhn 6/2011 tai khoa PTTK benh ien Viet Tiep Hai Phong
2.2. PhuoTig phap nghien ciiu: nghien cuu m6 ta h6i cuu
Cac th6ng tin nghien ciru can thu thap Cac th6ng tin chung ciia benh nhan Tinh trang benh tat
Irieu chung lam sang truoc mo I lgi chung cgt s6ng
Hgi chirng chen cp re Hinh anh can lam sang
Xquang quy uoc: tu th6 tbSng, tu thh nghieng \a XQuang dgng. Xac dinh dugc muc do trugt d6t s6ng theo phan loai cua Mc>crding. hinh anh khuyet eo d6t s6ng,...
Chup cgng huomg tir: tinh trang thoai h6a dTa dem, xo tir khe ho eo cua cgt s6ng, hinh anh chen ep 6ng tiiy, tinh trang ciia lo ghep
Phuong phap phau thuat, ky thuat mo Danh gia lam sang, hinh anh Xquang sau m6
Cac bien chung trong va sau mo
Danh gia lam sang, hinh anh Xquang khi tai kham
Danh gia ciia chung toi dura vao hai bang sau Thang diem Prolo
Diem Mu'c do van dong
Khong tii van dgng du'dc
Khong lam viec du'dc ke ca viec ngi trd, nghi ngdi hoan toan Lim viec du'dc nhu'ng khong bang tru'dc khi bj benh
Lim viec du'dc nhu'trUdc khi bj benh(cd ban che) Hoi phuc hoan toan
Mu'c do dau Oau khong chju du'dc
Dau hang ngay mu'c dp trung binh den nang Dau hang ngay mire do nhe
Dau thanh cdn hoac thinh thoang dau Khong dau
Benh nhan dugc danh gia: tot (>8), kha (6-7), trung binh (<5).
HOI NGHI KHOA HOC BENH VI^N HLfU NGHj VIET TIER H A I PHONG LAN THL/37
Bdng JOA
Trieu chu'ng chu quan A: Oau that IUng
Kh6ng dau
Thinh thoang dau nhe
Thudng xuyen dau nhe hoac thinh liioanq dau nhieu Thu'dng xuyen hoac lien tuc dau nhieu
B: Oau va/hoac nhoi chan Khdng dau
Thinh thoang cd bieu hien nay nhu'ng nhe
Thu'dng xuyen nhUng nhe hoac thinh thoang nSng Thudng xuyen hoac lien tuc
C: Van dgng Binh thudng
Oi bg >500 cd bj dau hoac yeu cd
Kh6ng the di bg >500m vi dau hoac yeu cd Kh6ng the di bo >100m vi dau hoac yeu cd Trieu chu'ng khach quan
A: Lassegue 70-90' 30-70"
<3(f
B: Roi loan cam giac Kh6ng
Roi loan nhe Roi loan nang
C: Roi loan van dgng Binh thu'dng
Yeu cd nhe Yeu cd ro rang
D: Han che cugc song hang ngay Khong ban che
Han che vira phai Han che rat nhieu
E: Chirc nang bang quang Binh thu'dng
Kho tieu
Bl tieu hoan toan
Diem
3 2 1 0
3 2 1 0
3 2 1 0
2 1 0
2 1 0
2 1 0 14
2 1 0
0 -3 - 6 _
Y HOC VIET NAM T H A N G 10 - SO D A C BIET/2011
Ty 1? binh phuc = (Di6m kham lai-di6m uoc m6)/(29-di6m truoc m6)xl00%. K6t m: Kht t6t (>75%), T6t (50-75%), Trung
nh (25-50%), xau (<25%).
Xu: ly kit qud-. Cac s6 lieu dugc tinh ra
\xm tram, trung binh, phuong sai theo tirng ac diem. So sanh kiem dinh dugc su dung leo bang X^ va test t-Student. Sir dung phdn iem EPl INPO 6.0 \6i cac thuat toan th6ng e y hgc th6ng thuong.
I. KET QUA VA BAN LUAN
3.1. Tuoi vd gi&i tinh
Nghien cuu cua chung t6i t> lc nam/nO la ,45. Trong cac nghien cim 6 trong \ a ngoai uoc deu cho thay ty le nil nhieu hon nam heo Schnee CL. Phan Trgng Hau) boi ngoai ong viec hang nga\ thi phu nil con bi anh uong bod yeu t6 sinh de. loang xuong, man inh,... anh huoTig rat nhieu den cgt s6ng dac iet la vimg that lung ciing.
Nghien cuu cua chung t6i gap nhieu 6 hom tuoi 40-49 (56%) voi do tu6i trung binh I 47,8. Trong nghien cuu ciia Schnee c6 do loi trung binh cao hon: 53,4 nhung tat ca eu tap trung 6 do tu6i lao dgng. Dieu nay ho thay muc do, cuong do lao dgng va muc 6 thoai hoa cgt s6ng co m6i lien quan true
ep den bieu hien benh.
3.2. Nghe nghiep
Trong nghien curu nay chung t6i thay c6 8% benh nhan la nguoi co lao dgng nang hoc anh huong xhu den cgt s6ng va tu the 5t sdng. Nhung van dgng cgt s6ng sai tu the a van dgng cgt song qua muc lam tang qua inh trugt ciia cgt song.
Da so benh nhan co bieu hien dau that mg lap di lap lai chung to cgt s6ng da mat )ng tir truoc.
3.3. Vi tri trirat dot sdng
Tk ca cac benh nhan cua chiing t6i d6u
trugt d6t s6ng mgt tang, cbii y6u la trugt L4 (79,3%). Cac tiic gia trong nuoc khac cung cho thay chu yeu la trugt 1.4 nhung theo Schnee lai chii yeu trugt L5 (63,5%). Giai thich cho \ ice trugt ciia L4 la do L5 c6 gai ngang to khoe va la diem bam ciia nhieu day chang that lung chau va cac co tang cuong cho sir lien kcl ciia no voi xuong ciing. D6t L4 c6 gai ngang nho va yeu hon, it day chang hon nen nguy co trugt ciia L4 Ion hon L5.
Hon nira L4L5 co bien do van dgng va chiu lire Idn hon nhieu so voi L5S1.
3.4. Bieu hien lam sdng
Irugt d6t s6ng chii yeu do vi chan thuong la nliinig sang chan nh6 lap di lap lai nhieu lan do th6i quen sinli boat, lao dgng anh huong den xau tdi tu the sinli ly ciia cgt s6ng.
Trieu chimg khdi phat cua benh la dau cgt s6ng that lung (100%)), dau kieu re 1 hoac 2 ben (79,3%), r6i loan van dgng va co trdn hiem gap.
C6 the do thdi gian dau mdi trien khai nen s6 lugng benh nhan ciia chung t6i chua dii Idn nen kh6ng gap r6i loan van dgng.
Tir khi c6 trieu chung khdi phat den khi vao vien trong nghien cuu ciia chung t6i la 18 thang, sdm nhat la 5 thang va mugn nhat la 36 thang. Chinh vi benh nhan den vien mugn nen cac trieu chimg thudng bieu hien rat ro ret, dien hinh la dau hieu chen ep re, r6i loan cam giac gap d 100%) s6 benh nhan la chu yhu la dj cam, 86,2%o dau each h6i, kh6ng c6 benh nhan nao co r6i loan co tron.
3.5. Bieu hien lam sdng
Lam sang ciia benh la bieu hien ciia hai hgi chung: hgi chung cgt s6ng va hgi chung chen ep re. Kh6ng co dau hieu nao dac trung cho benh ly trugt cgt s6ng nen de nham vdi cac benh ly thoat vi dia dem hoac ep 6ng s6ng.
3.6. Can lam sdng
Chup Xquang quy udc thang, nghieng dugc ap dung cho tat ca cac benh nhan, day la
HOI NGHI KHOA HOC BENH VIEN HUfU NGHI VIET TIEP HAI PHONG LAN THCr37
phuong phiip dcrn gian nhimg cho ki't qua rat cao, giiip danh giii mire do trugt, tig miit vung ciia cgt song tixMi phim chup dgng. Trong nghien ciru ciui cluing loi hinh anh Xquang
cho tha\ trirgl do 2 chicni 2(),7'Ki, trugl do 3 la 5.^.1" o. I()()"o benh nhan dugc chyp cgng hudng tir di- danh gia mire do thoai hda dia dem. mire do chcn cp ong sdng ciia cac td chirc phan mem: da\ chang \ang, ila\ chang dgc sau \a danh giei mire dg chcn cp \o Id tiep hgp. Trong nghien cim na>' chiing tdi thay 86,2%) benh nhan cd bieu hien hep ong sdng. 62% cd chen ep 16 tiep hgp 1 hoac 2 ben
3.7. Ki't qud dieu tri
Chung t6i ap dung ky thuat c6 dinh cgt s6ng qua cu6ng, md cung sau giai ep. md rgng dudng ra ciia re, han xuong lien than ddt (xuong chau) hoac ban xuong sau ben.
Sau md trudc khi benh nhan ra vien chiing tdi danh gia sir cai thien ciia cac trieu chung trudc md: dau kieu re, dau each hoi.
r6i loan van dgng. Chup Xquang dh danh gia muc do nan chinh, k6t qua cho thhy hhu hht deu giam 1 do. Theo cac tac gia trong va ngoai nude deu cho rang muc tieu quan trgng trong md la giai phdng chen ep than kinh sau dd mdi den nan chinh cdt sdng va k6t hgp xuong de lam vung cdt sdng.
Sau md 3 thang chiing tdi kham lai dugc 86,2%) s6 benh nhan va dua vao thang diem JOA cho thdy ket qua trudc m6 9,25±1.25 (7-
12), JOA sau mo 16,75 (13-19). Ti le h6i phuc trung binh la 31,52 (14,2-43.1)%). Dua vao ban JOA thi kh6ng c6 benh nhan nao dat ket qua t6t va kha, 82,3%) dat trung binh. K^t qua thip nhu vay boi JOA danh gia cac boat dgng binh thudng ciia ngudi benh ma sau 3 thang thi chua cd benh nhan nao dam lam cac dgng tac sinh boat nhu binh thudng va mgt s6 benh nhan van mac ao nep cgt song. Tuy vay nhimg trieu chimg co nang: dau lung, di cam
da (V chan, dau chan,... dugc cai thien rore Dieu nay giiip lam tang chat lugng s6ngct hcnh nhan.
IV. KET LUAN
BC'nh ly trugt cgt s6ng chii yeu gap 6d luoi lao dgng (47,6) va gap nhieu ban 6 n;
gidi. Phim Idn cac benh nhan thudng hi da krng keo dai, dau hieu chen ep re va d^n via khi da mugn (18 thang) ca biet cd nhiini Inrirng hgp den 36 thang.
Chan doan xac dinh dua vao Xquang (d(
2-3 chiem 75,8%)) va cgng hudng tir giu[
danh mire do chen ep than kinh dac biet laic tiep hcrp.
Kcl qua sau md cac trieu chirng dau kiei re. dau each h6i dirge cai thien rd ret. Miicdc nan chinh trong mo t6t.
TAI UEU THAM
KHAO1. V6 Van Thanh (2000), "Dieu tn phau thual CO dinh bang dung cu \a han xircmg loi sau cho benh nhan trugt dot song that limg do thoai hda" , >' hoc thanh pho Ho Chi Minh, 4(4), tr 38-45
2. Phan Trong Hau (2002), "Nghien curu chan doan \ a dieu tri benh ly trugt dot song that lung do thd co d ngudi trudng thanh" luan an ticMi s\ \ khoa. Hoc \ ien quan Y
3. Vo Pham Tryng Nhan (2007): Dieu trj tnrot dot song L4-L5 va L5-S1 hkng nep vit qua cuong ket hgp vdi ban xuong loi sau ben, Lu^n \ an cao hgc
4. Schnee CL et al (1997) "Outcome analysis for adults with spondylolisthesis treated with posterolateral fusion and transpecdicular screw fixation" , J Neurosurg 86:56-63.
5. Serena S.Hu, Cliff B.T, Mohammad D, Alexander J.G (2008), "Spondylolisthesis and spondylosis", JBJS, 90, p 656-671
