臺灣博碩士論文加值系統

　　研究背景與目的：神經根長期受到壓迫除了會造成腰脊髓腔狹窄病人背部與下肢的症狀外，也常使得病人的神經功能下降以及功能狀態受限。根據過去的文獻報告減壓手術能夠有效的改善病人的症狀和功能狀態 (成功率為64%~91%不等)，然而也有文獻指出病人術後功能狀態的進步和解剖構造上壓迫的解除沒有顯著的相關，此外也發現目前對於病人在手術後神經功能的恢復方面仍很缺乏，因此對於病人術後功能狀態的改善與神經功能恢復之間的關係也仍存在著疑問。所以本研究的目的是要探討腰脊髓腔狹窄病人在接受減壓手術後神經功能恢復的情形以及神經功能恢復與功能狀態改善之間的關係。
　
　　研究材料與方法：本實驗共收集19位經過醫師臨床檢查以及放射學影像確定診斷為退化性腰脊髓腔狹窄且需要接受手術的病人，病人分別會在手術前1個月、1天接受評估而這兩次的評估是作為手術後比較的基準；另外在手術後3星期、7星期與3個月病人也會再次接受評估來看手術立即與短期的效果。手術效果的評估主要包含了三大部分：病人對於臨床症狀的主觀描述、神經功能效果以及功能性效果；在病人對於臨床症狀主觀描述部分會使用visual analog scale來評估病人症狀的嚴重程度；在神經功能效果的評估項目方面則包括了下肢深肌腱反射、振動覺閾值以及神經傳導速度；而在功能性效果方面則包括了使用Oswestry low back pain disability questionnaire評估病人主觀殘疾程度，使用手握式測力器量測病人下肢肌肉力量，以及分別使用力板評估病人靜態平衡能力、前伸測試評估動態平衡能力、計時起身走路測試評估病人功能性平衡的能力。

結果：手術前的兩次評估發現各項參數都沒有顯著的變化。手術後的評估和手術前1天的評估相比則發現病人症狀的嚴重程度在手術後3星期開始就有顯著的下降而這樣的現象一直持續到手術後3個月；而功能性預後的方面則發現病人的主觀殘疾程度在手術後7星期和3個月時和手術前1天相比有顯著的改善。在神經功能方面則發現代表神經功能的參數在手術後不管是3星期、7星期或3個月和手術前1天相比都沒有顯著的變化。

　　結論：減壓手術能夠有效的減輕病人的症狀以及增加病人的功能狀態，而症狀的減輕要比功能狀態的改善來的迅速，此外神經功能在手術前後沒有明顯的變化，這樣的結果也顯示了症狀的減輕、功能狀態的改善與神經功能的完整性之間並沒有直接的因果關係。此外在手術後病人症狀減輕的時間比功能狀態改善的時間要來的快也顯示病人在接受減壓手術後物理治療師可以儘早介入來幫助病人加速功能狀態的恢復。

　　Background and Purpose：In addition to the symptoms on back and leg, chronic compression of the spinal nerve root can lead to neurological deficits and functional disability in patients with lumbar spinal stenosis. Previous studies have reported that decompressive surgery could alleviate the symptoms effectively (successful rate of decompressive surgery ranged from 64~91%). However, it has been reported that there was no significant relationship between the degree of the decompression and functional recovery, and also the investigation on the neurological recovery after decompressive surgery was still lacking. Thus, neurological recovery and its relationship with the functional recovery after decompressive surgery are still questioned. The purpose of this study was to investigate the neurological and functional outcome after decompressive surgery in patients with lumbar spinal stenosis.

　　Materials and Methods：19 patients diagnosed as degenerative lumbar spinal stenosis confirmed by clinical and radiological findings, were evaluated 1 month and 1 day (PRE-1D) before surgery for baseline comparisons, and re-evaluated 3 weeks (POST-3W), 7 weeks (POST-7W), and 3 months (POST-3M) after surgery. Surgical outcome consisted of subjective descriptions of clinical features, and neurological and functional outcome. Symptom intensity was evaluated by visual analog scale. Neurological outcome included deep tendon reflex, vibration sense, and nerve conduction velocity. Functional outcome included subjective disability measured by Oswestry low back pain disability questionnaire, lower extremity strength tested with hand-held dynamometer. Static balance was tested with a force plate in both quite stand and Romberg stand with eyes open and closed, dynamic balance was tested with forward reaching test, and functional balance was tested with timed get up and go test.
　　
　　Results：None of the variables changed significantly between the two baseline measurements. After surgery, symptom intensity decreased at POST-3W, POST-7W and POST-3M, compared with PRE-1D. In functional outcome, comparing PRE-1D, subjective disability significantly improved at POST-7W and POST-3M. Variables representing neurological outcome didn’t change significantly in POST-3W, 7W or 3M.

　　Conclusion：Decompressive surgery alleviated the symptoms and improved functional status effectively, with symptom alleviation occurring sooner than functional recovery. These changes, however, were not accompanied by neurological recovery. It seemed that there was no direct cause-effect relationship between neurological function recovery and symptom and functional recovery. The finding that symptoms alleviation came sooner than functional recovery suggest that physical therapy intervention should begin soon after decompressive surgery to facilitate the functional recovery in patients with lumbar spinal stenosis.

中文摘要 -------------------------------------------------------------------4
英文摘要 -------------------------------------------------------------------6
誌謝 -----------------------------------------------------------------------9
目錄 -----------------------------------------------------------------------10
表目錄 ---------------------------------------------------------------------14
圖目錄 ---------------------------------------------------------------------15

第一章 導論與文獻回顧 -----------------------------------------------------17
1.1 腰脊髓腔狹窄的定義與分類 -----------------------------------17
1.2 腰脊髓腔狹窄的病理解剖構造 --------------------------------21
1.3 腰脊髓腔狹窄的臨床症狀 --------------------------------------24
1.4 腰脊髓腔狹窄的治療方式與效果 -----------------------------27
1.4.1 手術治療的種類與效果 ----------------------------------------28
1.4.1.1 不同手術方式對手術效果的影響 -----------------------30
1.4.1.2 術後追蹤時間長短對手術效果的影響 -----------------32
1.4.1.3 重複手術對手術效果的影響 ----------------------------35
1.4.2 保守性治療的種類與效果 -------------------------------------36
1.4.2.1 藥物治療 ------------------------------------------------38
1.4.2.2 背架治療 ------------------------------------------------40
1.4.2.3 物理治療 ------------------------------------------------41
1.4.2.4 保守治療的效果 -----------------------------------------42
1.4.3 保守性治療與手術治療效果的比較 ---------------------------44
1.5 腰脊髓腔狹窄治療效果的評估面向 --------------------------47
1.5.1 病理解剖構造的評估 ------------------------------------------47
1.5.2 生理功能的缺失 -----------------------------------------------48
1.5.3 病人為中心的效果 ---------------------------------------------50
1.5.4 評估手術效果不同面向間的差異 ------------------------------52
1.6 手術治療腰脊髓腔狹窄效果的知識鴻溝 --------------------54
1.7 目的與動機 --------------------------------------------------------56

第二章 材料與方法 ------------------------------------------------------57
2.1 受試者 --------------------------------------------------------------57
2.2 施測時間 -----------------------------------------------------------58
2.3 評估項目 -----------------------------------------------------------59
2.3.1 病人主觀描述與病史 --------------------------------------------59
2.3.2 神經功能效果 ---------------------------------------------------61
2.3.3 功能性效果 ------------------------------------------------------65
2.3.4 手術滿意程度 ----------------------------------------------------69
2.4 手術方式 -----------------------------------------------------------70
2.5 實驗流程 -----------------------------------------------------------71
2.6 實驗儀器 -----------------------------------------------------------74
2.7 資料處理與分析 --------------------------------------------------77
2.8 統計分析 ----------------------------------------------------------78

第三章 結果 ---------------------------------------------------------------79
3.1 病人基本資料與臨床特徵 --------------------------------------79
3.2 手術前比較 --------------------------------------------------------81
3.3 手術後效果 --------------------------------------------------------87
3.3.1 症狀嚴重程度 ---------------------------------------------------87
3.3.2 神經功能效果 ---------------------------------------------------88
3.3.3 功能性效果 ------------------------------------------------------91
3.3.4 手術滿意程度 ---------------------------------------------------97

第四章討論 ----------------------------------------------------------------99
4.1 腰脊髓腔狹窄病人的臨床症狀表現 --------------------------99
4.2 手術前1個月的腰脊髓腔狹窄疾病病程 ---------------------101
4.3 減壓手術對於症狀改善的效果 --------------------------------103
4.4 減壓手術對於改善神經功能的效果 --------------------------106
4.5 減壓手術對於功能狀態的效果 --------------------------------109
4.6 手術後病人對手術的滿意程度 --------------------------------112
4.7 手術效果不同面向之間的關係 --------------------------------113

第五章 結論 ---------------------------------------------------------------116
5.1 臨床應用 -----------------------------------------------------------117
5.2 研究限制 -----------------------------------------------------------118

參考文獻 -------------------------------------------------------------------120

附錄 -----------------------------------------------------------------------136

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