椎间盘造影在腰椎多节段退变性疾病诊治中的应用探讨

目的初步探讨椎间盘造影术在腰椎多节段退变性疾病临床诊疗中的应用价值。方法 2006年9月～2010年4月,行手术治疗的伴有明显腰痛症状的腰椎多节段退变性疾病患者143例,分为2组：椎间盘造影组69例,术前对MRI检查提示椎间盘退变的椎间节段进一步行椎间盘造影检查,根据常规影像学检查以及椎间盘造影检查结果选择手术干预节段;常规诊疗组74例,术前仅根据常规影像学检查结果选择手术干预节段。对所有手术干预节段行改良经椎间孔腰椎椎体间融合术。随访并比较2组患者术前及术后3个月、6个月、12个月Oswestry功能障碍指数（Oswestry disability index,ODI）及疼痛视觉模拟量表（visual analogue scale,VAS）评分。结果椎间盘造影组及常规诊疗组分别有64例、71例患者完成了至少12个月的系统随访。2组患者术后3个月、6个月及12个月的ODI、VAS评分较术前均有好转;但椎间盘造影组术后3个月、6个月及12个月ODI、VAS评分明显优于常规诊疗组,差异有统计学意义（P〈0.05）。结论对伴有明显腰痛症状的腰椎多节段退变性疾病患者,椎间盘造影术具有良好的临床应用价值;在良好掌握临床适用范围及操作技术的基础上,不失为常规影像学检查的一种有益补充。     

椎间盘内破裂症的诊断和经椎间孔腰椎间融合术的手术治疗

[目的]探讨椎间盘造影对诊断椎间盘内破裂症的意义和经椎间孔腰椎间融合治疗盘内破裂症的效果。[方法]对25例下腰痛的患者进行椎间盘造影术，诊断椎间盘内破裂症20例，其中18例接受经椎间孔腰椎间融合术。[结果]18例均得到随访，12-24个月，平均16个月，采用Oswestry功能障碍指数评分，术前平均35分，术后12个月平均为12分，融合率100％。无1例发生严重并发症。[结论]椎间盘造影术是诊断椎间盘内破裂症的一种可靠方法，经椎间孔腰椎间融合术治疗盘内破裂症，具有安全、有效，创伤小并且并发症少的优点。     

间盘造影在近融合椎正常间盘的诊断价值

目的 采取回顾分析的研究方法，探讨椎间盘造影术在腰椎融合邻近正常椎间盘的诊断应用价值。方法 57例因椎间盘源性下腰痛行椎间盘切除和后路椎间融合术的患者。手术前行椎间盘造影时，不包括邻近融合节段的正常椎间盘。所有患者随访35．6个月（24-80个月）。对所有患者的临床疗效和影像学结果进行评价分析。结果 53例患者中49例临床效果优良，随访2年以上，38例患者无任何症状。15例患者在度过21个月的无症状期后出现疼痛复发，采用腰椎MRI和椎间盘造影复查。结果 MRI发现15例患者中的8例出现了邻近节段椎间盘的退变，而此8例中仅有1例（2％）经过MRI和椎间盘造影同时证实该节段为疼痛的原因，从而再次进行融合手术。结论 术前MRI上专现为正常的相邻椎间盘在椎间融合术后不容易变成病变节段，因此没有必要常规在术前为了排除病变节段，而行相邻于拟融合节段的正常椎间盘的造影检查。     

椎间盘造影阴性在椎间盘源性腰痛诊断中的分析评价

[目的]通过对一组有典型椎间盘源性下腰痛症状和影像学表现但椎间盘造影阴性的患者进行前瞻性分析,观察椎间盘造影阴性是否能完全排除椎间盘源性下腰痛的诊断.[方法] 2008年6月～2011年2月连续诊治的具有典型椎间盘源性疼痛症状和影像学表现(Dallas V型)但椎间盘造影阴性的一组患者共59例,其中男16例,女43例;年龄36～ 51岁,平均43.8岁;病史6个月～4年,平均1.8年.将59例患者随机分为两组,实验组(29例)于造影剂注射完后于椎间隙再给予注射利多卡因10 mg和地塞米松2.5 mg的混悬液,对照组(30例)则不注射药物并结束造影.两组患者于椎间盘造影术术前、术中、术后行VAS及ODI评分并观察结果.[结果]实验组术后2周内可见VAS评分下降,与对照组相比有统计学意义(P＜0.01),术后第3周随访时两组间VAS评分无明显差别(P＞0.05).实验组中18例VAS评分下降的患者在术后第1、4、8周时进行VAS评分及ODI评分时均较术前明显改善(P＜0.01),在第12周随访时总体上VAS评分及ODI评分与术前比较无明显差别(P＞0.05),对照组患者VAS评分及ODI评分与术前比较均无明显差别(P＞0.05).[结论]本研究结果表明椎间盘造影阴性,但同时合并典型的症状和影像学表现时,并不能完全排除椎间盘源性疼痛的诊断.     

椎间盘造影压力与椎间盘源性腰痛手术疗效的关系

目的 探讨椎间蕊造影压力与腰椎间盘源件疼痛手术疗效的关系.方法 2004年4月至2006年6月,65例慢性腰痛患者经压力控制性椎间盘造影确诊为椎间盘源性腰痛.其中22例经保守治疗无效者接受前路腰椎椎间融合术,年龄25～67岁,平均43.6岁.L4-5例,L5S112例,L4-5和L5S1双间隙2例.记录椎间盘造影诱发疼痛时的压力,将患者分为椎间盘造影压力≤300 kPa(低压组)10例,300～500 kPa(高压组)12例.椎间cage融合术22例24个椎间盘.术后3～7 d下地活动.腰围固定3个月.根据术前、术后VAS评分和ODI评分比较高压组和低压组手术疗效.结果 所有患者随访6～26个月,平均18个月.手术时间70～120 min,平均90 min;出血量100～400 ml,平均220 ml.低压组与高压组术前VAS评分和ODI评分、椎间隙高度、手术时间、出血量差异无统计学意义.术后腰及下肢痛症状明显缓解,均恢复正常生活或工作.椎间隙高度从术前平均9.5 mm增加至13.5 mm.术后6个月低压组VAS、ODI改善率分别为82.4%、90.1%,高压组为71.7%、80.6%.随访时未发现肠梗阻、逆行射精和假体位置移动.结论 压力控制性椎间盘造影能够提高椎间盘源性腰痛的诊断准确性,低压力椎间盘造影阳性者手术疗效更好.     

终板源性腰痛的诊断和外科治疗分析

目的探讨严重终板源性腰痛的诊断和外科治疗方法。方法所有患者行影像学检查,并用腰椎间盘造影术确定疼痛椎间隙融合节段。用视觉疼痛模拟评分（VAS）和Oswestry功能障碍问卷调查表,对每个患者术前和术后的腰痛症状和腰椎功能障碍指数（ODI）分别评分,评估腰椎融合术疗效。结果本组21例患者,经腰椎间盘造影术诊断为终板源性腰痛,全部行腰椎前路或后路融合术。术后随访2—6年,平均3年5个月。除1例仍有腰痛外,其余20例（95％）腰痛症状明显改善或完全消失,腰椎物理功能明显改善。VAS和ODI评分在术前和术后的比较,差异有统计学意义（P=0．0001）。结论研究表明腰椎间盘造影术是诊断终板源性腰痛的可靠手段,腰椎融合术是治疗终板源性腰痛的有效方法。     

椎间盘源性腰痛的诊断与治疗

目的探讨腰椎间盘源性疼痛的诊断方法及采用前路经腹膜外入路椎间盘切除人工椎间盘置换或椎间cage植骨融合的临床疗效。方法35例经保守治疗无效的椎间盘源性腰痛患者接受手术治疗。椎间盘源性腰痛的诊断标准为：（1）腰部及下肢疼痛的部位与神经根定位不符；（2）症状反复发作，病程在半年以上；（3）MRI病变椎间盘T2加权像低信号；（4）椎间盘造影阳性，相邻节段为阴性对照；（5）关节突关节封闭除外关节突关节退变引起的疼痛。患者年龄25-67岁，平均43．6岁。L4-5 14例，L5S1 16例，L4-5和L5S1双间隙5例。前路经腹膜外入路椎间盘切除后行人工椎间盘置换13例16个椎间盘，椎间cage融合22例24个椎间盘。术后3-7天下地活动。腰围固定3个月。结果所有患者随访6～26个月，平均18个月。术后腰痛及下肢痛症状明显缓解，均恢复正常生活或工作。VAS评分由术前平均72分，降至术后18分，随访6个月时6．5分。ODI评分由术前平均21．5分。降至随访6个月时3分。椎间隙高度从术前平均9．5mm增加至术后13．5mm。手术时间70-120min，出血量100-400ml。随访时未发现肠梗阻、逆行射精和假体位置移动。结论椎间盘源性腰痛由于临床和影像学表现不典型，常被误诊或漏诊，可结合腰椎MRI及椎间盘造影进行诊断。腰椎前路椎间盘切除人工椎间盘置换或椎间cage融合是治疗椎间盘源性腰痛的有效选择。     

腰椎间盘造影在腰椎间盘源性腰痛诊治中的应用

目的：探讨椎间盘造影对腰椎间盘源性腰痛的诊断价值及椎间融合手术的疗效，研究椎间盘造影对椎间融合节段范围选择的意义。方法：2004年1月至2006年2月对35例具有腰椎间盘源性腰痛症状的患者进行了椎间盘造影，共74个椎间盘。所有病例均行MR和CT检查，观察造影图像和MRI表现，记录诱发痛。35例患者中根据椎间盘造影的结果，行腰椎间融合术20例，并随访手术患者的疗效。结果：35例中20例患者22个椎间盘出现了诱发痛（57．1％），20例诱发痛阳性患者的22个节段均行腰椎间盘融合术，并全部随访，随访时间10个月-2年，平均15个月，按改良MacNab评定标准判断：优13例，良4例，可2例，差1例。15例诱发痛阴性的患者予保守治疗，在同期随访中，5例腰痛完全消失，7例疼痛基本消失，3例疼痛没有变化，甚至加重。6例患者腰椎融合节段相邻的9个椎间盘有MRI异常改变，但造影无诱发痛，即无症状椎间盘，未包括在融合范围之内，在同期的随访中，1例因相邻无症状退变间盘退变加重并产生严重症状而接受融合手术。结论：腰椎间盘造影对椎间盘源性腰痛的诊断和选择治疗方法等方面具有独特的价值，对确定为疼痛原因的椎间隙实施腰椎间融合术可以消除患者的疼痛。在选择融合节段时，仅融合有症状的退变椎间盘即可。     

腰椎融合区相邻节段无症状退变椎间盘的转归

目的：观察腰椎融合区相邻节段无症状性退变间盘的转归，探讨腰椎融合节段的选择。方法：71例因椎间盘源性腰痛而接受椎阃盘切除、椎间植骨融合术患者，术前均进行仔细的体格检查、MRI和椎间盘造影，对MRI表现和柞间盘造影阳性的节段进行融合，其中53例相邻椎间盘MRI表现正常（A组），18例相邻20个节段为无症状性退变间盘（B组）比较两组术后的临床疗效、疼痛复发以及二次手术率。结果：所有患者均随访2年以上（平均35个月），临床疗效优良率A组为92.4％，B组为77．8％，无统计学差异（P=0.189）。A组中1例因相邻节段间盘发生退变并产生严重症状而进行了二次融合手术：B组叶14例因相邻的无症状性退变间盘退变加重并产生严重症状而接受一次融合手术。结论：柑邻于融合节段的无症状性退变间盘大多数（77.8％）不产生后期的疼痛症状，临床疗效满息、存初次进行融合时，仅融合有症状的退变间盘即可。     

腰椎椎间盘突出症再手术治疗的临床分析

目的总结腰椎椎间盘突出症再手术治疗的临床疗效。方法回顾总结2002年1月-2009年5月收治的78例采用腰椎单枚斜向融合器椎间融合、椎弓根螺钉内固定术治疗的腰椎椎间盘突出症再手术患者的临床资料,男48例,女30例;年龄为41-78岁,平均为62.4岁。术后应用Oswestry功能障碍指数（Oswestry disability index,ODI）、VAS评分及影像学检查对临床疗效进行评价。结果手术时间平均150min（120-210min）。随访0.5-5年,平均3.9年。术后椎间隙高度得到明显恢复,末次随访高度未见明显丢失。VAS评分由术前的7.3±1.4减至末次随访时的2.2±0.6,ODI由术前的59.6%±9.4%减至末次随访时的28.4%±3.2%。在随访期间VAS评分及ODI均得到明显恢复,与术前相比差异有显著统计学意义（P〈0.01）。结论腰椎椎间盘突出症再手术患者多伴有椎间隙狭窄和节段性失稳,其治疗需要兼顾减压和稳定两个方面,腰椎单枚斜向融合器椎体间融合术不失为一种较为理想的手术方式。     

Imaging evaluation of the candidate for percutaneous lumbar discectomy

Percutaneous lumbar discectomy has been advocated as an alternate means of treating lumbar disc disease. A disc treatable by this method must not be free in the spinal canal and cannot be above or below the disc space. Magnetic resonance imaging, computed tomography, and discography all can be valuable in selecting patients for percutaneous lumbar discectomy.     

Lumbar discography followed by computed tomography. Refining the diagnosis of low-back pain

Two hundred fifty patients with low-back pain who underwent lumbar discography followed by computed tomography (CT) are the subject of this prospective study. In 93% of the patients, these combined imaging techniques provided additional useful diagnostic information that affected patient management and the selection of treatment alternatives. Lumbar discography followed by CT proved valuable in determining the significance of equivocal or multiple level abnormalities, determining the type of disc herniation, defining surgical options, and evaluating the previously operated spine. In 94% of patients who had surgery, CT-discography correctly predicted the type of disc herniation as protruded, extruded, sequestrated, or internally disrupted. Computed tomography-discography may be more sensitive that magnetic resonance imaging (MRI) in the early stages of disc degeneration because 18 of 177 discs with a normal T2-weighted image were discographically abnormal and the CT-discogram revealed annular tears or radial fissuring. The radiographic morphology of the normal herniated and degenerative lumbar discs shown by CT-discography gives unique insight into the pathogenesis of disc degeneration. The complications that followed the 750 discograms were one case of urticaria and one disc space infection. Even with the availability of high resolution CT and MRI, lumbar discography remains the only pain provocation challenge to the lumbar disc.     

Percutaneous discography: comparison of low-dose CT, fluoroscopy and MRI in the diagnosis of lumbar disc disruption

Aim: To compare the diagnostic accuracy of low-dose computed tomography (CT), magnetic resonance imaging (MRI) and fluoroscopy in percutaneous discography in patients scheduled for lumbar spondylodesis. Material and methods: Within a prospective pilot study, 18 disc segments of 11 patients with radicular or pseudoradicular pain prior to anteroposterior spondylodesis were evaluated. After injection of a mixture of non-ionic iodine-containing contrast agent and gadolinium-based contrast medium into the disc spaces, all patients underwent conventional fluoroscopy, as well as low-dose CT and MRI. The occurrence of memory pain during contrast injection was recorded. CT, MRI and fluoroscopic images were analyzed independently by two readers blinded to the clinical findings. Results: There was 100% agreement between CT and MRI discography in the detection, localization and grading of degenerative changes. In contrast, conventional fluoroscopy identified only 9 of the 12 abnormal segments. Memory pain following puncture was identified in 3 of the 12 affected segments. Summary: Low-dose CT and MRI discography have a similar accuracy in the assessment of disc disruption and they are superior to fluoroscopic discography.     

Functional results after anterior lumbar fusion at L5-S1 in patients with normal and abnormal MRI scans.

The debate continues as to which patient responds best to surgical versus nonsurgical intervention for painful degenerative disc syndrome. Discography is often used as the basis for that decision. In a review of 53 cases followed for an average of 20 months after surgery, only 50% of patients with type I (contained) discography and normal magnetic resonance imaging findings were found to be improved. In those patients with types II and III (noncontained) discography and abnormal magnetic resonance imaging scans, a 75% success rate was seen. There was an overall 80% fusion rate for all patients who underwent anterior lumbar fusion at L5-S1. Average age was 34 years, with average length of disability from low-back pain of 11 months. All patients were placed in a similar presurgery and postsurgery rehabilitation protocol and had failed nonsurgical treatment options. In this matched group of patients, those with abnormal magnetic resonance imaging scans and abnormal discography, clearly fared better, with a 75% percent success rate versus 50% success rate in those with normal magnetic resonance imaging findings. This series raises the question as to whether those patients with normal magnetic resonance imaging findings are surgical candidates.     

A cadaveric study comparing discography, magnetic resonance imaging, histology, and mechanical behavior of the human lumbar disc.

The aims of this study were 1) to compare discography and magnetic resonance imaging scanning on cadaver specimens and to correlate these imaging procedures by examining all the discs histologically; and 2) to study the extent to which the amplitude of rotational movement in the neutral and flexed position at a certain level correlates with the morphologic appearance of that disc. Twenty-four human lumbar spines were harvested from cadavers between the ages of 19 and 75 years. Each specimen underwent standard radiography, magnetic resonance imaging scanning, discography, histologic examination, and measurement of axial rotation in a torsion apparatus. For practical reasons, all specimens did not undergo all of the examinations. Not all peripheral anular lesions were detected by discography. Histology showed rim lesions of the anterior anulus in 18% of discs with normal discography. The overall incidence of anterior and posterior anular tears was greater in discs where larger amplitudes of rotation were observed. To which extent the one is a consequence of the other or vice versa is not clear. Magnetic resonance imaging was found to be less specific than discography. However, it must be emphasized that no axial magnetic resonance imaging scans were taken in this study. Discs with significantly decreased amounts of nuclear material (observed at histology) can still produce normal magnetic resonance imaging images. Infolding of the inner layers of the anulus fibrosus (33% anterior, 4% posterior) was a frequently observed feature.     

Lumbar spinal stenosis assessment with computed tomography, magnetic resonance imaging, and myelography

Degenerative spinal stenosis of the lumbar spine is caused by many factors, some of which include: disc herniation, ligamentum flavum and facet hypertrophy, spondylolisthesis, and compression fracture. Most often the stenosis is caused by a combination of these factors. The imaging modalities in routine use to evaluate these conditions are computed tomography, magnetic resonance imaging and computed tomography-myelogram. They each have their advantages and disadvantages although any one of these modalities can adequately diagnose lumbar stenosis. The overall accuracy rate of computed tomography, magnetic resonance imaging, and computed tomography-myelogram has been reported to be similar and even complimentary. It is recommended that the least invasive modality be performed first. Magnetic resonance imaging should be the first choice because it does not require ionizing radiation or contrast injection. The aim of the current study is to present the common causes of lumbar stenosis. Where appropriate, each case is shown with images from each modality so that their similarities and differences can be highlighted.     

Juvenile spondylodiscitis: the value of magnetic resonance imaging: a report of two cases

Two boys presenting with reluctance to sit straight and stand were diagnosed with spondylodiscitis of the lumbar spine. After confirmation of the diagnosis on plain radiographs, computed tomography and magnetic resonance imaging, they were successfully treated with antibiotics and in one case a lumbar orthosis. The use of magnetic resonance imaging is discussed and compared to the other radiological techniques. Magnetic resonance imaging seems to be the most sensitive and specific imaging technique used in the diagnostic process of spondylodiscitis. Computed tomography and technetium bone scan both play a specific part in the process of diagnosis and follow-up.     

Patient attitudes to myelography,computed tomography and magnetic resonance imaging when examined for suspected lumbar disc herniation

Summary In reports of diagnostic methods in disorders of the spine focus is centred on diagnostic resolution, while psychological effects and patients' discomfort are often disregarded. To get a comprehensive picture of the appropriateness of a new technology the latter factors need to be explored and included in an assessment.In a prospective study, eight patients with signs of lumbar disc herniation underwent myelography, computed tomography and magnetic resonance imaging. A structured patient interview on attitudes to these technologies was carried out after all three examinations had been carried out.Myelography was most often reported painful and unpleasant among the three modalities. Discomfort due to magnetic resonance imaging stem from the narrow calibre of the machine and the noise. In computed tomography immobilization was the main reason for discomfort. Altogether most patients preferred computed tomography.In view of the fact that myelography must be considered as diagnostically inferior to the other two examinations, the reported discomfort from myelography indicates that computed tomography and magnetic resonance imaging should be the primary examinations for patients with lumbar disc herniation.This study is supported by the Vigo and Katrine Skovgaard Foundation, and the Danish Hospital Foundation, Region of Copenhagen, Greenland and the Faroe Islands.     

Thoracic discography in healthy individuals. A controlled prospective study of magnetic resonance imaging and discography in asymptomatic and symptomatic individuals.

STUDY DESIGN: A prospective case-control investigation. OBJECTIVES: To determine the responses to thoracic discography of asymptomatic individuals. SUMMARY OF BACKGROUND DATA: Literature regarding lumbar and cervical discography reveals that even morphologically abnormal discs often are not painful, whereas painful discs typically exhibit anular or endplate disruption. METHODS: Ten adult lifelong asymptomatic volunteers, ages 23 to 45 years, underwent magnetic resonance imaging of the thoracic spine, followed by four-level discography. Provocative responses were graded on a scale of 0 (no sensation) to 10 (extreme pain or pressure), and filmed discs were graded using a modified Dallas scheme. Concomitantly, 10 nonlitigious adults (6 men and 4 women, ages 31 to 55 years) experiencing chronic thoracic pain were similarly studied as a control group. RESULTS: The mean pain response in the asymptomatic volunteers was 2.4/10. Three discs were intensely painful (scores of 7/10, 8/10, 10/10), with all three exhibiting prominent endplate irregularities and anular tears typical of thoracolumbar Scheuermann's disease. On discography, 27 of 40 discs were abnormal, with endplate irregularities, anular tears, and/or herniations. Ten discs read as normal on magnetic resonance imaging showed anular pathology on discography. In the group with chronic thoracic pain, the average pain response was 6.3/10 (P < 0.05). Of the 48 discs studied, 24 were concordantly painful, with a pain response of 8.5/10 (P < 0.05); 17 had nonconcordant pain/pressure, with an average pain of 4.8/10 (P < 0.05); and 5 had no response. On magnetic resonance imaging 21 of the 48 discs appeared normal. However, on discography, only 10 were judged as normal. CONCLUSIONS: On discography, thoracic discs with prominent Schmorl's nodes may be intensely painful, even in lifelong asymptomatic individuals, but the pain is unfamiliar or nonconcordant. Thoracic discography may-demonstrate disc pathology not seen on magnetic resonance imaging.     

Lumbar synovial cysts: report of eleven cases

Over the past 18 months we have encountered 11 cases of symptomatic lumbar synovial cysts. This experience occurred during a period during which some 1,800 lumbar computed tomographic scans were done. The apparent increased incidence of these lesions is most likely due to the increased diagnostic ability made possible by the advent of high-resolution computed tomography and magnetic resonance imaging. This is a report and discussion of our 11 cases with a review of the literature. There is nothing distinctive in the physical findings or in the histories of our patients, but we have found, as have others, that high-resolution computed tomographic scanning and magnetic resonance imaging significantly enhance the diagnosis of such lesions.