对中央型腰椎间盘突出症诊治中一些问题的认识

对中央型腰椎间盘突出症诊治中一些问题的认识张明，赵敦炎，侍德中央型腰椎间盘突出临床上不多见。突出的椎间盘组织可压迫同平面单侧、双侧神经根，或压迫其下位的神经根，使临床症状复杂多变，常诊断困难，甚至误诊。本文收集我院近１０年来经手术证实的５６例中央型腰...     

腰椎间盘突出症重手法按摩后神经根水肿粘连（附5例报告）

腰椎间盘突出症重手法按摩后神经根水肿粘连（附５例报告）吴国平，武长林，张乃仁，顾言行，张庆民，任德新自１９９０年以来，我科手术治疗腰椎间盘突出症９２例，其中发现有５例受累神经根异常水肿，突出间盘与硬膜囊及神经根广泛粘连，约占５．４％，５位患者均有反复...     

极外侧型腰椎间盘突出症的诊断与治疗

极外侧型腰椎间盘突出症的诊断与治疗翁文杰陈亮朱丽华椎间孔与椎间孔外腰椎间盘突出症，亦称为极外侧型腰椎间盘突出症，是指椎间盘突出或脱出位于椎弓根内、外缘之间或椎弓根外缘以外，压迫相应的神经根而引起的一系列症状和体征。１９４４年Ｌｉｎｄｂｌｏｍ及１９５４...     

腰椎间盘突出症炎症机理研究概述

腰椎间盘退变或突出后引起疼痛的机理尚不清楚。传统的观点认为，突出的腰椎间盘的机械性压迫是引起神经根性疼痛的原因，但机械性压迫并不能满意地解释所有的临床和病理现象。例如一些小的局部的椎间盘膨出在临床表现方面可能比大的椎间盘突出更严重。近年来，大量的研究...     

腰椎间盘突出症脑脊液和血清免疫球蛋白升高机理的初步探讨

本研究有助于进一步了解腰椎间盘突出症所致坐骨神经痛的免疫发病机理。方法：采取３６例腰椎间盘突出症和２０例对照组病人的脑脊液和血清，用放射免疫分析法测定样本的ＩｇＡ、ＩｇＧ、ＩｇＭ、ＡＬｂ含量。结果和结论：我们的研究结果显示ＩｇＧｃｓｆ／ＩｇＧｓ×１０￣３、ＩｇＭｃｓｆ／ＩｇＭｓ×１０￣３较对照组增高，尤其是破裂型和游离型腰椎间盘突出症患者增高更显著。表明神经根与突出的髓核接触可引起炎症反应，腰椎间盘突出症坐骨神经痛可能与这种神经根炎症反应有关，本实验还证实了腰椎间盘突出症体液免疫异常。     

腰椎间盘突出与有无临床症状的影像对照研究

目的：探讨应用区域定位评分法研究腰椎间盘突出（膨出、突出、脱出）有临床症状与无临床症状的相关性及原因分析。方法：将符合要求的CT病理分型为膨出、突出、脱出的体检或住院或门诊患者120例,按有临床症状与无临床症状分为2组,每组按CT病理分型分3组,年龄20-59岁,平均38．5岁,有临床症状与无临床症状两组间在性别、年龄、病程及椎间盘分布节段差异均无统计学意义;应用区域定位评分法对各组评分;用游标卡尺分别测量矢状径指数（SI）、盘黄韧带前间隙、侧隐窝上口宽度、硬膜囊前后径。CT值由X线断层扫描测定,分别测量3次,取平均值。结果：④腰椎间盘突出有临床症状与无临床症状两组在SI、CT值、CT评分、硬膜囊前后径之间差异无统计学意义（P〉0．05）;在侧隐窝上口宽度、盘黄韧带前间隙之间差异有统计学意义（P〈0．05）。②腰椎间盘突出有临床症状与无临床症状两组突出类型比较,差异有统计学意义（P〈0．05）;腰椎间盘脱出有临床症状与无临床症状两组突出节段比较,差异有统计学意义（P〈0．05）。结论：①腰椎间盘突出大小、部位、类型不一定与临床症状存在必然关系,腰椎间盘突出症与压迫程度无正比关系;②椎管内突出髓核是否导致相应的临床症状存在着诸多或必然因素,可能与椎间盘突出物可代偿的椎管储备容量、受累神经根对机械压迫的逃逸避让与弹性延长功能,以及受累神经根低氧消耗与抗缺血性损伤代偿作用等因素有关。     

突出髓核内压力在神经根受压机制中的作用

目的观察腰椎间盘突出症患者突出髓核内压力与神经根受压程度的关系。探讨突出髓核组织的临床意义及手法治疗的机理。方法选取空军总医院收治的腰椎间盘突出症手术患者30例,根据直腿抬高试验分为直腿抬高(+)性组、(-)性组,术中测量患者突出髓核内压力大小、观察突出髓核内压力与直腿抬高高度的关系。结果直腿抬高(+)性组患者突出髓核内压力明显高于(—)性组患者,具有显著意义(P<0.01)。两组患者突出髓核大小无明显差异(P>0.05)。结论1、突出髓核对神经根的压迫与突出髓核内压力有关,突出髓核内压力较大时患者直腿抬高受限,突出髓核内压力较小时直腿抬高不受限。突出髓核对神经根的压迫与突出髓核大小尚未见明显关系。2、椎管对突出髓核组织的容纳的极限与突出髓核内的压力相关,推测手法治疗可以通过降低突出髓核内压力减轻甚至解除神经根受压,达到治疗目的。     

腰椎间盘突出致马尾损伤的因素与治疗

腰椎间盘突出症是骨科的常见病，经保守或手术治疗效果较好。但一旦发生马尾神经损伤会造成病人下肢肌肉不同程度瘫痪或／和大小便功能障碍，治疗效果远不如仅有神经很受累者。作者认为，对反复发作的腰椎间盘突出症，特别是复发后症状加重者宜手术治疗，若伴有马尾神经损伤，应尽早手术减压，对于病人的预后至关重要’“。本文依据对14例腰椎间盘突出致马尾损伤的因素作了分析，并强调了发生马尾神经损伤早期手术治疗的重要性。1临床资料1．1一般资料本组病例的马尾损伤系指有排尿功能即括约肌功能障碍和／或有2个神经根以上支配之肌肉瘫痪…     

青少年型腰椎间盘突出症：（附6例报告）

青少年型腰椎间盘突出症少见，本组发病率为１．８％，主要由外伤引起，神经根受累征状明显，Ｘ线片可见椎体后缘钙化后突，椎间隙后半变窄，边缘不整，为骺软骨与椎体后缘分离和髓核向椎管内移位，压迫脊髓和神经根，治疗宜早期手术治疗。     

骶管注射治疗腰椎间盘突出症及腰椎骨质增生症50例

骶管注射治疗腰椎间盘突出症及腰椎骨质增生症５０例山东省沂南县中医院（２７６３００）高玉兰，王俊娥腰椎间盘突出症、腰椎骨质增生症，均可表现为突出部位、增生部位压迫神经根，引起神经根发生水肿、无菌性炎症、周围组织增生和粘连，使该神经支配区出现放射性疼痛。...     

对腰椎间盘突出症传统机械压迫刺激观的质疑与反思

脊神经根的机械性压迫被认为与疼痛和特定节段神经功能障碍有关,然而不是在所有情况下突出髓核都导致相应的临床症状,解除突出的髓核也并不皆意味着腰腿痛的立即消失。该文通过系统的文献研究,认为椎管内突出髓核是否导致相应的临床症状存在着诸多或然因素,并因此提出腰椎间盘突出症多因素动态致压观。     

Pathoanatomy and pathophysiology of nerve root compression

The anatomy and physiology of the nerve root complex in the lumbar spine are reviewed, with special reference to the effects of mechanical deformation of nerve roots in association with intervertebral disc herniation and spinal stenosis. Biomechanical aspects of nerve root deformation induced by compression are discussed. The functional changes induced by compression can be caused by mechanical nerve fiber deformation but also may be a consequence of changes in nerve root microcirculation, leading to ischemia and formation of intraneural edema. Nerve root compression can, by different neurophysiologic mechanisms, induce motor weakness and altered sensibility or pain. Intraneural edema and demyelination seem to be critical factors for the production of pain in association with nerve root compression.     

临床症状体征与影像学检查分离的腰椎间盘突出症的发生机制研究进展

临床会出现少数症状体征与影像学检查结果不相符的腰椎间盘突出症患者,而单纯用传统的突出髓核直接机械压迫刺激神经根的理论不能解释这种反常的腰椎间盘突出症。腰椎间盘髓核的突出与患者临床症状体征的出现受多因素、多环节的影响,脊神经根的间接性机械压迫与神经根牵张效应为主要因素,而反常症状体征的产生往往与突出的髓核自身位置的迁移、神经系统对信息的传递以及髓核与硬膜囊或神经根的相互作用密切相关。此外,突出的髓核组织所继发的局部微循环、炎症改变,相应节段的骨质增生退变和腰椎应力姿势改变诱发此类反常腰椎间盘突出症患者出现多样性的症状体征。同时,一些患者还存在神经或椎体的先天性发育异常,并可能出现影像学检查上的误诊或漏诊。突出髓核对硬膜囊以及周围神经根之间的确切相互作用机制及其继发的局部病理生理、生物力学改变,病变责任节段的确定以及如何克服影像学检查的局限性需进一步研究。     

Theory of Bowstring Disease: Diagnosis and Treatment Bowstring Disease

Bowstring disease (BSD) is a new classification of spine disease caused by axial stretched lesion on nerve roots and the spinal cord, which is differentiated from disc herniation and canal stenosis in that it is caused by nerve compression lesions. BSD could be caused by mismatched growth rates between the spine and nerve roots (the juvenile type), or by imbalanced degenerative rates between the spine column and nerve roots (degenerative type). Here, we propose that there are several self‐adjust mechanisms to relieve axial nerve tension: (i) nerve growth; (ii) posture adjustment and low back pain; (iii) autogenous degeneration of intervertebral disc; and (iv) idiopathic and degenerative scoliosis. Iatrogenic lesions could also result in BSD, which could be presented as adjacent segment degeneration, leading to adding‐on effects and other neurological symptoms. The diagnosis criteria are proposed based on symptoms, physical examination, and radiological presentations. To remove axial tension on nerve roots, lumbar surgery should aim to restore the coordination of spine and cord units. Capsule surgery, shortening the spine column, could decompress cord and nerve roots 3‐dimensionally.     

Nitric oxide as a mediator of nucleus pulposus-induced effects on spinal nerve roots.

Nerve root dysfunction and sciatic pain in disc herniation are considered to be caused by mechanical compression and related to the presence of nucleus pulposus in the epidural space. Autologous nucleus pulposus has been shown to induce endoneural edema and to decrease nerve-conduction velocity in spinal nerve roots in experimental disc herniation models, and inflammatory mediators have been suggested to be involved in these mechanisms. Nitric oxide, a potent inflammatory mediator, is implicated in vasoregulation, neurotransmission, and neuropathic pain. Nitric oxide synthesis can be induced by different cytokines, e.g., tumor necrosis factor-alpha, which recently was shown to be of pathophysiological importance in experimental disc herniation. The enzyme nitric oxide synthase mediates the production of nitric oxide. Three series of experiments were performed in rat and pig disc herniation models to (a) investigate nitric oxide synthase activity in spinal nerve roots after exposure to autologous nucleus pulposus and (b) evaluate the effects of systemic treatment with aminoguanidine, a nitric oxide synthase inhibitor, on vascular permeability and nerve-conduction velocity. In a disc herniation model in the rat, calcium-independent nitric oxide synthase activity was measured in nerve roots exposed to nucleus pulposus; however, no nitric oxide synthase activity was detected in nerve roots from animals that underwent a sham operation, reflecting increased inducible nitric oxide synthase activity. In nucleus pulposus-exposed spinal nerve roots in the pig, the edema was less severe after systemic aminoguanidine administration than without aminoguanidine treatment. Aminoguanidine treatment also significantly reduced the negative effect of nucleus pulposus on nerve-conduction velocity in spinal nerve roots in the pig. These results demonstrate that nucleus pulposus increases inducible nitric oxide synthase activity in spinal nerve roots and that nitric oxide synthase inhibition reduces nucleus pulposus-induced edema and prevents reduction of nerve-conduction velocity. Furthermore, the results suggest that nitric oxide is involved in the pathophysiological effects of nucleus pulposus in disc herniation.     

神经根性症状的多变性与腰椎间盘突出症的定位诊断

大量的证据表明,临床症状体征对腰椎间盘突出症的定位诊断具有较高的特异度,但在不同患者间存在着较大的多变性,其灵敏度并不高。定位诊断的失误是导致临床治疗尤其是手术或介入治疗失败的重要原因。该文系统探讨了神经根性症状的多变性及其与腰椎间盘突出症定位诊断的相关问题,提出多方法联合运用是提高腰椎间盘突出症临床定位准确性的可行途径。     

Radicular compression by lumbar intraspinal epidural gas pseudocyst in association with lateral disc herniation. Role of the posterior longitudinal ligament

Among unusual abnormalities of the lumbar spine reported since the introduction of Computed Tomography (CT), the presence of gas lucency in the spinal canal, known as vacuum phenomenon, is often demonstrated. On the contrary, epidural gas pseudocyst compressing a nerve root in patients with a lateral disc herniation has rarely been reported. We report a case of a 44-year-old man who experienced violent low back pain and monolateral sciatica, exacerbated by orthostatic position, one week before admission. A lumbosacral spine CT showed the presence of vacuum phenomenon associated with a degenerated disc material and a capsulated epidural gas collection with evidence of root compression. A microsurgical interlaminar approach was carried out and, before the posterior longitudinal ligament was entered, a spherical "bubble" compressing the nerve roots was observed. The capsulated pseudocyst was dissected out, peeled off and excised en bloc. A large part of the posterior longitudinal ligament and the lateral disc herniation were removed. Postoperatively the patient was completely free of symptoms. The mechanism of exacerbation of pain was probably due to the increased radicular compression in the upright posture and, besides the presence of a lateral disc herniation, could be related to a pneumatic squeezing of gas from the intervertebral space into the well capsulated sac by the solicitated L4-L5 motion segment. Histological study of the wall of the pseudocyst showed the presence of fibrous tissue identical to the ligament. We conclude that, in case of a lumbar disc herniation, it is recommended to perform a complete microdiscectomy and an accurate removal of the involved portion of posterior longitudinal ligament in order to prevent pseudocystic formations.     

开放手术观察腰椎间盘突出症溶核失败45例分析

目的 通过开放手术观察分析椎间盘髓核化学溶解术治疗腰椎间盘突出症失败原因。方法 收集溶核失败的腰椎间盘突出症45例行开放手术治疗。结果 术中见45例硬膜外脂肪完全消失，43例髓核未见溶解，2例髓核溶解呈糊状但未被吸收，21例伴有侧隐窝狭窄，15例突出物与神经根粘连，20例黄韧带增厚，2例椎管骨性狭窄，14例突出物钙化。结论 腰椎间盘突出症病变间隙合并有侧隐窝狭窄、神经根粘连、椎管狭窄、突出物钙化等，不是溶核治疗的适应证。     

经皮内窥镜治疗腰椎间盘突出症的并发症及其处理

目的 总结经皮内窥镜腰椎间盘切除术( PELD)治疗腰椎间盘突出症中出现的并发症,探讨其处理对策.方法 2002年7月至2010年10月采用PELD治疗腰椎间盘突出症患者689例,男性448例,女性241例;年龄13 ～84岁,平均39.8岁.单间隙椎间盘突出669例,双间隙椎间盘突出19例,三间隙椎间盘突出l例.中央型突出66例,旁中央型365例,外侧型242例,极外侧型10例,游离型6例.观察术中和术后并发症及其处理.结果 术中髓核部分残留压迫神经根5例,2例术中改行开窗髓核切除术,2例二期行开窗髓核切除术,1例二期行经椎间孔腰椎体间融合术(TLIF);神经根纤维束部分损伤2例,术后3～6个月内完全恢复;硬脊膜破裂2例,给予缝合皮肤伤口后痊愈.689例患者随访6～96个月,平均33个月.出现椎间隙感染7例,1例保守治疗,4例给予经皮穿刺置管冲洗引流持续局部应用抗生素,2例行后路开窗感染腰椎间盘清除术,均痊愈;术后复发6例,4例患者再次行PELD术,2例患者采用TLIF治疗,术后症状缓解;术后神经根性痛觉过敏和灼样神经根痛19例,经过止痛药物、神经营养药及物理治疗后好转;腰椎管狭窄症行单个节段的PELD术,效果不佳,二期行多节段TLIF治疗10例.结论 术中主要并发症有髓核部分残留压迫神经根、神经根纤维束部分损伤、硬脊膜破裂;术后主要并发症有椎间隙感染、复发、神经根性痛觉过敏和灼样神经根痛等.严格的适应证选择、无菌、熟练操作及术后康复锻炼可以减少并发症的发生.     

臭氧髓核消融术联合高渗盐水盘内注射治疗腰椎间盘突出症

目的评价臭氧髓核消融术联合10%高渗盐水盘内注射治疗腰椎间盘突出症（LIDH）的疗效。方法选取356例LIDH患者,采用CT定位,以60μg/ml浓度的臭氧8～20ml注射后加注10%高渗盐水1.5～2.5ml于椎间盘内（臭氧联合高渗盐水组）。另选取279例LIDH患者进行单纯臭氧髓核消融术（单纯臭氧治疗组）。根据改良MacNab标准分级对比评价两组疗效。结果臭氧联合高渗盐水组显效213例（213/356,59.83%）,改善126例（126/356,35.39%）,无效17例（17/356,4.78%）;其总有效率为95.22%（339/356）,高于单纯臭氧治疗组（253/279,90.68%,P=0.024）。注射后无并发症发生。结论臭氧髓核消融术联合高渗盐水椎间盘内注射治疗LIDH有效、微创、安全。