青少年腰椎间盘突出症患者下腰椎关节突关节不对称情况分析

目的 :测量青少年腰椎间盘突出症(lumbar disc herniation,LDH)患者下腰椎关节突关节角度,观察其关节突关节不对称(facet tropism,FT)情况。方法:选取2012年8月～2018年8月在我院就诊的LDH和腹部疾病患者。LDH组共纳入52例,其中男42例,女10例,年龄为17.9±1.4岁(14～20岁);L4/5椎间盘突出33例,L5/S1突出18例,L4/5、L5/S1双节段椎间盘突出1例;中央型椎间盘突出24个节段,左侧突出18个节段,右侧突出11个节段。选择腹部CT扫描的层面经过椎间盘且与上位椎体的下终板平行的腹部疾病患者111例作为对照组,其中男87例,女24例,年龄为17.8±1.7岁(14～20岁)。LDH组在腰椎CT片上测量L3-4、L4-5、L5-S1关节突关节角度(作一直线通过椎间盘中点连接棘突基底部中点作为腰椎矢状轴,通过上关节突内外点作一连线,一侧连线与腰椎矢状轴相交所形成的角度即为一侧关节突关节角度),双侧角度之差10°作为FT的衡量标准。对照组在腹部CT片上测量L3-4、L4-5、L5-S1关节突关节角度。结果:LDH组各节段的关节突关节角度的平均值与对照组比较无明显差异(P0.05)。52例LDH患者中,L3-4节段出现FT的患者19例,L4-5节段出现FT 27例,L5-S1节段出现FT 24例;而对照组111例患者中相对应节段出现FT的患者分别为19例、28例、18例,LDH组各节段FT出现的概率明显高于对照组(P0.05)。在LDH组34例L4/5椎间盘突出的患者中,15例出现FT;19例L5/S1椎间盘突出患者中,13例出现FT;椎间盘突出节段FT出现的概率明显高于对照组相应节段(P0.05)。结论:在青少年LDH患者的下腰椎中FT发生率显著高于普通人群,与青少年LDH的发生存在一定的相关性。     

与后路腰椎椎间融合器融合术相关的解剖学和影像学研究

目的：测量与后路腰椎椎间融合器融合术（PLIF）相关的解剖学和影像学参数，以规范及改进手术方法。方法：（1）L3-L5干燥标本各20个，测量椎体两侧下关节突内、中、外之间的距离及椎体旁矢状径、椎弓根内距离。（2）从210个椎间隙选择MRI检查正常的L3／4-L5／S1间隙，测量下关节突内、中、外距及椎体旁矢状径、椎间隙高度、椎间隙角度。（3）假设采用宽度7mm、9mm、11mm，长度22mm、24mm cage从后侧置入，间距4mm且cage轴线距离小于椎弓根内距、cage陷入椎体后缘3mm。计算符合上述要求的数值并与两种测量结果比较。结果：解剖学与影像学测量的关节突内、中、外距离无显著性差异。当cage宽度为7mm，L3／4-L5／S1各有64．8％、94．8％、100％可保留完整关节突，9mm时则有12．7％、53-4％、96-3％可保留完整关节突，但均可保留1/2关节突；宽度为11mm分别有0、5．2％、18．5％可保留完整关节突，47．9％、84．5％、100％可保留1/2关节突；3个节段均不必切除全关节突，cage轴线距离小于椎弓根内距：椎体旁矢状径大于22mm、24mm长度cage置入要求的分别为91．2％、86．9％；结论：宽度7-11mm，长度22mm、24mm的立方体形cage适宜国人解剖特点，大多数可保留1／2关节突，以维持节段稳定。恢复椎间高度，增加融合面积。     

双侧关节突关节切除致椎间盘退变的影像学观察

[目的]探讨新西兰大白兔腰椎关节突关节破坏能否诱发出椎间盘退变的影像学改变。[方法]45只新西兰大白兔，体重2．25～2．95kg，雄性。随机分为骨性手术组和软组织手术组。软组织手术组骨膜下剥离L3至b的椎旁肌肉：骨性手术组完整切除L4、5，双侧下关节突、L5棘突，保留L5、6上关节突。骨性手术组L4、5、L5、6椎间盘为实验组椎间盘，上下相邻的L3、4、L6、7，为自身对照组椎间盘。软组织手术组L4、5、L5、6。椎间盘为实验对照组椎间盘。术后1、2、4及8个月行X线检查。计数不同组别椎间盘退变的异常X线征象发生频数并进行统计分析。[结果]术后1个月，实验组椎间盘开始出现软骨终板钙化。随着时间推移，椎间隙狭窄、椎体边缘骨赘、软骨终板钙化发生频数逐渐增多，与实验对照组、自身对照组比较具有统计学差异。术后8个月，骨性手术组中大部分动物出现以L4、5、或L5、6为中心的角状后凸畸形。[结论]L4、5、L5、6。关节突关节破坏导致椎间失稳，椎间失稳后可以诱发出椎间盘退变的影像学改变。     

极外型腰椎间盘突出症的治疗

[目的]研究极外型腰椎间盘突出症的治疗，尤其是L5／S1间隙孔外突出的治疗。[方法]单纯椎间孔外突出经后正中旁切口椎板外侧入路，伴有椎管内病变者经后正中切口加行椎板间入路。L5／S1间隙均行骶骨翼，L5横突，椎板外缘部分切除。[结果]经2～5年随访，优19例；良3例；可3例；差0例，优良率88．9％。[结论]极外型腰椎间盘突出症，手术治疗效果可靠，L5／S1间隙必须切除部分骶骨翼，L5横突，椎板外缘（骶上关节突外缘）才能良好显露。     

腰椎椎间孔成形幅度对关节突关节应力变化的有限元分析

目的建立L_(3~5)三维有限元模型,分析椎间盘摘除并不同幅度椎间孔成形前后对L_4/L_5关节突关节应力分布的影响。方法选取1名既往无腰椎疾病史的20岁男性志愿者,获取其腰椎CT数据构建有限元模型并验证其有效性。在L_4/L_5椎间盘中度退变模型(M1)的基础上,模拟经椎间孔入路经皮内窥镜技术,去除椎间盘左后侧约1/4纤维环中部及1/4髓核,模拟腰椎椎间盘摘除术,构建模型M2;以圆柱体代替环锯模拟切除L_5上关节突部分骨质行椎间孔扩大成形,构建一级椎间孔成形模型M3(环锯直径5.0 mm)、二级椎间孔成形模型M4(环锯直径6.5 mm)和三级椎间孔成形模型M5(环锯直径7.5 mm)。给予特定加载条件,比较模型在前屈、后伸、左右侧曲、左右旋转6种工况下L_4/L_5关节突关节应力变化。结果建立的L_(3~5)三维有限元模型有效。M1模型在各种工况下L_4/L_5关节突关节的应力左侧较右侧大。M2模型在前屈工况下左侧L_4/L_5关节突关节应力下降,右侧应力上升;在后伸工况下左侧应力上升,右侧应力下降;在右旋工况下,左侧应力变化不明显,右侧应力稍下降;在左侧屈及左旋工况下两侧应力均上升;在右侧屈工况下左侧应力稍下降,右侧应力变化不明显。除M5模型左旋工况下右侧应力增加明显外,其他各种工况下M3、M4、M5模型应力变化不明显。结论椎间盘摘除后引起病变节段关节突关节面所承载的负荷不对称;在精确穿刺的指引下,环锯直径5.0、6.5、7.5 mm行椎间孔成形对病变节段关节突关节应力变化无显著影响。     

改良经椎板间隙法腰椎间盘髓核摘除术52例报告

1998年7月～2001年7月采用改良经椎板间隙法腰椎间盘髓核摘除术治疗腰椎间盘突症52例，取得良好效果。报告如下。临床资料男38例，女14例，年龄19～67岁，平均36岁。均经临床、CT和/或MRI确诊。腰椎间盘突出部位：L4/524例，L5/S120例，L4/5并L5/S18例。旁侧型突出40例，中央型突出12例。13例合并侧隐窝狭窄。双侧手术8例，余均为单侧手术。从52例腰椎正侧位片上测量椎板间隙与椎间盘后缘的对应关系，椎间盘后缘中点与椎板间隙正相对者：L4/56例，L5/S119例。椎间盘后缘中点与椎板间隙上部相对者：L4/524例，L5/S18例。椎间盘后缘中…     

椎间关节内缘入路行经皮激光椎间盘减压术对L5～S1椎间盘突出症病人的疗效

经皮激光椎间盘减压术(PLDD)具有损伤小、显效快、对脊柱稳定性影响小、易恢复、住院时间短等优点,是微创治疗腰椎间盘突出症的常用方法。行PLDD时,传统的穿刺入路穿刺点远离后正中线8～10 cm,靠近髂嵴,由于髂嵴平面多高于L5～S1椎间隙平面,导致穿刺困难。本院采用椎间小关节内缘入路穿刺行PLDD47例,现总结如下。     

棘突撑开与小关节、椎间孔形态变化关系的初步实验研究

目的 观察棘突撑开程度与小关节移位、椎间孔形态变化的关系.方法 使用6具新鲜腰椎尸体,制作标本,保留关节突周围关节囊韧带及棘间韧带,通过分别撑开L3/4,L4/5棘突,测量相应节段小关节间相对位移、椎间孔高度及宽度改变.结果 棘突撑开2 mm、4 mm后,L3/4、L4/5腰椎间孔高度增大、小关节位移改善均有明显差异,椎间孔宽度的改变在撑开2 mm无明显差异,在撑开4 mm时宽度增大有统计学差异.结论 棘突撑开能有效改善小关节位移、增加椎间孔高度,但对于椎间孔宽度的增加需要撑开足够距离.     

椎板关节突螺钉瞄准器在治疗下腰椎退行性病变的临床应用

[目的]探讨在瞄准器引导卜经皮行椎板关节突螺钉固定并联合椎间融合器置入治疗下腰椎退行性病变的可行性和疗效.[方法]自2007年6月～2008年6月共治疗下腰椎退行性病变26例,其中男性9例,女性17例;年龄29～70岁,平均52.0岁,病史1.5个月～30年,平均47.1个月,均有腰痛病史,伴双下肢放射4例,伴一侧下肢放射20例.疾病类型:腰椎间盘退行性病变19例,腰椎间盘突出症术后原位复发2例,腰椎退行性滑脱(Ⅰ度)3例,腰椎问盘突出伴椎管狭窄2例.病变部位:L4、5节段21例,L5S1节段3例.L3、4L4、51例.L4、5L5S11例.采用全麻,在瞄准器引导下经皮行椎板天节突螺钉固定并小切口完成椎管减压、髓核摘除及椎间融合器置入术.[结果]本组切口长3.8～5.9 cm,平均4.4 cm,手术时间 55～100 min,平均72 min;术中出血量100～380 ml,平均190 ml,均未输血;术后切口引流量50～300 ml,平均162 ml.术后切口无感染、无皮肤坏死,术中、术后未出现马尾神经或神经根损伤以及下肢神经根功能恶化现象.所有病例均获随访,随访时间12～30个月,平均16.8个月,本组病例除1例不能明确外,其余均于术后6个月获得椎间融合,融合率为96.1%.随访过程中未发现螺钉松动、移位、断裂等现象,亦未出现椎间融合器移位现象,但大部分病例出现病变节段椎间隙高度下降,融合器部分陷入终板.最后随访时JOA评分南术前的11～16(平均13.1分)提高到21～27(平均24.6分),改善率为60.6%～89.7%,平均71.6%.[结论]瞄准器引导下经皮行椎板关节突螺钉固定具有简单、准确和安全等优点,其联合椎间融合器置入是治疗下腰椎退行性病变的较好方法.     

经椎间孔椎间融合术治疗腰椎间盘再突出

目的探讨经椎间孔椎间融合术（transforam final lumbar interbody fusion,TLIF）治疗腰椎间盘再突出的临床疗效。方法2002年4月-2006年8月,采用TLIF治疗腰椎间盘再突出患者36例,男25例,女11例;年龄为37～68岁,平均51．2岁。手术节段包括L3／L4 2例,L4／L5 19例,L3／S1 15例。采用日本骨科学会JOA评分系统对患者术前、术后神经功能进行评价。结果随访2年,神经功能JOA评分从术前平均9．5分提高至术后平均24．6分（P〈0．01）,神经功能改善率为45％～100％,平均84％。临床疗效优19例,良11例,中6例。骨性融合率达到100％。结论TLIF治疗腰椎间盘再突出临床效果满意,并发症少。     

下腰椎小关节的方向性与椎间盘突出和侧隐窝狭窄的关系

目的探讨下腰椎小关节的方向性在椎间盘突出的发生和侧隐窝狭窄的形成中的作用和影响。方法通过腰椎ＣＴ片对下腰椎小关节角度进行测量,并分析、研究小关节的对称性、方向性与椎间盘突出和侧隐窝狭窄的关系。共观察１３６例患者３８６个下腰椎间隙的ＣＴ影像,采用横切关节面角度（ＴＩＦＡ）测量法,测量了７７２个下腰椎小关节角度。结果（１）下腰椎椎间盘突出与小关节对称性无关;（２）在Ｌ４～Ｓ１小关节不对称的间隙中,椎间盘易突向矢状小关节侧;（３）小关节角度小于２０度易发生退行性侧隐窝狭窄症;（４）该组测量的国人下腰椎小关节角度明显小于西方学者测量的欧洲人的角度。结论（１）下腰椎高发椎间盘突出症为特殊体位导致的应力集中所致,与椎间小关节方向性无关;（２）在Ｌ４～Ｓ１椎间隙中,如果椎小关节角度不对称将影响椎间盘突出的方向;（３）下腰椎小关节角度太小易导致退行性侧隐窝狭窄的发生。     

经皮激光腰椎间盘减压术治疗腰椎间盘突出症

目的探讨经皮激光椎间盘减压术（PLDD）治疗腰椎间盘突出症效果,研究适宜激光照射量。方法使用ND：YAG激光治疗腰椎间盘突出症40例（L4～5椎间盘突出32例,L5～S1和L4～5同时突出8例）,C臂X线机透视下将激光光纤沿穿刺针插入椎间盘髓核中进行汽化,每节激光总量CT分级Ⅰ级为500J,Ⅱ级为700J能量进行汽化,减轻椎间盘内压力。结果椎间盘内压力减低,神经根受压解除,突出的椎间盘组织回缩,采用Machab标准评定疗效：优26例,良6例,可6例,差2例,优良率为80%。结论PLDD是一种安全、简单、有效的治疗椎间盘突出症的微创方法。     

Facet joint asymmetry and protrusion of the intervertebral disc

In a study of 47 cases of lumbar disc protrusion, the hypothesis that asymmetry of the facet joints is correlated with the presence of a disc protrusion, was tested. Seventeen cases of protrusion of the L4-L5 disc and 30 cases of protrusion of the L5-S1 disc were measured on coronal computed tomography (CT) scans. The nonprotruded discs of each level were used as controls of the protruded discs of the same level. The transverse interfacet angle, the inclination and curvature of the facet joints, and the frequency of asymmetric facet joints showed no significant differences, whether there was a disc protrusion or not. The magnitude of the asymmetry was significantly greater only at the L4-L5 interspace in cases of disc protrusion. However, taking into consideration the error of measurement, the difference becomes highly questionable. These results do not indicate any relation between facet joint asymmetry and protrusion of the intervertebral disc.     

The role and incidence of facet tropism in lumbar spine degenerative disc disease.

The correlation of posterior intervertebral (facet) joint tropism (asymmetry), degenerative facet disease, and intervertebral disc disease was reviewed in a retrospective study of magnetic resonance images of the lumbar spine from 100 patients with complaints of low back pain and sciatica. Of the 27 of 100 (27%) of patients discovered to have disc disease (either herniation of nuclear material or bulge) at the L4-5 level, an approximately equal number had facet tropism (14 of 27) as did not (13 of 27). Of the 27 of 100 (27%) patients noted to have disc disease at the L5-S1 level, slightly more (16 of 21) had facet tropism than did not (11 of 27). Of the 65 of 100 (65%) of patients who had facet degenerative disease at the L4-5 level, an approximately equal number had facet tropism (33 of 65) as did not (32 of 100). At the L5-S1 level there was slightly more of a difference, with 25 of 41 having facet degenerative joint disease and tropism and 16 of 41 without it. This study raises questions as to the significance of facet joint tropism in intervertebral disc disease and degenerative facet joint disease but did show that asymmetry of the posterior intervertebral joint is far more common than previously thought: 50% of patients were found to have asymmetric facets at the L5-S1 level and 42% at the L4-5 level.     

Paired cylindrical interbody cage fit and facetectomy in posterior lumbar interbody fusion in an Asian population

STUDY DESIGN: The intervertebral disc heights and interfacetal distances of normal lower lumbar segments were measured from MRI scans of 150 male subjects. OBJECTIVES: To investigate the probabilities of paired cylindrical interbody cage placement across the facet joints of the lower lumbar spine in an Asian population with respect to the spinal segmental level, facetectomy, and the restoration of normal intervertebral height. SUMMARY OF BACKGROUND DATA: Cylindrical interbody cage devices often require extensive facetectomy for insertion through a posterior approach in a posterior lumbar interbody fusion (PLIF) procedure. This is because the transverse dimension of a pair of cages could far exceed the interfacetal interval of the lumbar segment. METHODS: One hundred and fifty MRI scans of the lumbosacral spine of male patients between the ages of 18 and 55 years undergoing investigation for low back pain were collected for this study. The interfacetal distances and intervertebral disc heights were measured from transverse and sagittal images, respectively, at L3/L4, L4/L5 and L5/S1. Degenerated discs were not measured. The inner, mid, and outer interfacetal distances were compared with the dimensions of paired cages of 13, 15, and 17 mm in diameter to obtain the proportion of lumbar segments at a particular spinal level that would accommodate paired cages of different diameters and under conditions of varying degrees of facetectomy. RESULTS: Without facetectomy, there was no lumbar segment that could accommodate paired cages as well as restore intervertebral height. With hemi-facetectomy, very few segments at L3/L4 and L4/L5 could fit paired cages. At L5/S1, fewer than 9% of segments could fit paired cages and restore intervertebral heights. The proportion of segments that could accommodate paired cages increased with near-total facetectomy: 25% of L5/S1 segments could accommodate 15-mm cages with restoration of intervertebral heights. CONCLUSIONS: Paired cylindrical cage installation in the majority of patients is likely to require near-total or total facetectomy, with implications for potential segmental instability. Among the three lumbar segments studied, L5/S1 had the highest proportion of segments that could accommodate paired cages and at the same time restore intervertebral height.     

Lumbar facet joint asymmetry. Intervertebral disc herniation.

A study of 136 patients with lumbar intervertebral disc herniation was undertaken to test the hypothesis that asymmetry of the facet joints is associated with the level, type, and side of herniation. Fifty cases of central herniation and 86 cases of lateral herniation, all at the L4-5 or L5-S1 levels, were studied by computed tomographic scans. Adjacent (nonherniated) levels were used as controls. The facet joint angles were measured at the L4-5 and L5-S1 levels of the control, central, and lateral herniated levels. The results showed a similar degree of facet joint asymmetry at all levels. In cases of lateral herniation, there was a significant difference in the facet angle between the herniated and nonherniated side at the L5-S1 level, but not the L4-5 level. The mean difference, however, was less than 3 degrees and not considered to be clinically relevant. There was no difference in the distribution of the more coronally or sagittally facing facet joints with respect to the side of lateral herniation. These results do not support the hypothesis that facet asymmetry is associated with lumbar intervertebral disc herniation.     

Modic改变与下腰椎三关节复合体退变相关性的回顾性分析

目的探讨Modic改变(modic changes,MCs)与下腰椎三关节复合体退变的相关性。方法选择2016年3月~2020年6月在本院住院治疗的231例腰椎间盘突出症(lumbar disc herniation,LDH)患者进行分析,观察MCs的发生率、椎间盘的Pfirmann分级和小关节退变分级(Weishaupt分级)的关系。结果MCs总发生率为45.31%(296/693),L_3-4、L_4-5、L₅-S₁节段MCs发生率分别为25.11%(58/231)、54.11%(125/231)和48.92%(113/231),组间差异存在统计学意义(P<0.05)。L_3-4、L_4-5和L₅-S₁节段MCsⅠ型、Ⅱ型和Ⅲ型病变节段的椎间盘退变程度均高于无MCs病变节段(P<0.05)。L_3-4节段MCsⅢ型与无MCs患者的小关节退变差异存在统计学意义(P<0.05)。L_4-5和L₅-S₁节段MCsⅡ型患者与无MCs患者的小关节退变差异存在统计学意义(P<0.05)。结论MCs与三关节复合体退变存在相关性,主要表现在MCs不同类型均与腰椎间盘退变分级相关,MCsⅡ型与腰椎小关节退行性病变相关。     

盘外与盘内外胶原酶注射治疗腰椎间盘突出症的临床效果

目的 观察和分析盘外与盘内外胶原酶注射治疗腰椎间盘突出症的临床效果及其与突出物缩小率的关系.方法 对分别行盘外注射(A组)与盘内外联合注射(B组)的腰椎间盘突出症患者各150例作回顾性分析.根据Macnab标准评定近、远期疗效;复查CT影像,测量手术前后椎间盘突出指数(IDH),计算出椎间盘突出物缩小率;对Macnab评定结果与突出物缩小率行相关性分析.结果 A组与B组的近期疗效差异无统计学意义,但B组的远期疗效优于A组(P＜0.05),B组的突出物缩小率明显高于A组(P＜0.05),远期疗效与突出物缩小率呈正相关.结论 盘外与盘内外胶原酶注射均为治疗腰椎间盘突出症的有效方法,盘内外注射的远期疗效及突出物缩小率较单纯盘外注射更显著.     

经皮激光椎间盘减压术后影像学变化的中期随访

目的 观察经皮激光椎间盘减压术(PLDD)后中期随访影像学变化,评价该手术的安全性和有效性.方法 回顾性分析经PLDD治疗的22例颈腰椎病患者的临床资料,其中男性10例,女性12例;年龄44～73岁,平均58岁;随访时间36～54个月,平均41.5个月.椎间盘分布:颈椎12例27个,腰椎10例22个;其中C_(3～4)3个,C_(4～5)8个,C_(5～6)10个,C_(6～7)个,L_(2～3)2个,L_(3～4)2个,L_(4～5)9个,L_5S_1 9个.在侧位x线片应用手术椎间隙高度与椎体高度比值观察手术前后病变椎间隙高度变化;在MRI横断面上,应用椎间盘突出指数观察手术间盘突出情况的变化,并对结果进行统计学分析.结果 术后末次随访病变椎间盘椎间隙前缘高度、中心高度及后缘高度较术前无明显变化(P>0.05).颈椎间盘病变节段突出指数术前为0.10～0.54,术后末次随访为0.06～0.39,差异有统计学意义(P<0.05);腰椎间盘病变节段突出指数术前为0～0.71,末次随访为0～0.48,差异有统计学意义(P<0.01).结论 PLDD术后对椎间隙高度没有明显影响,该手术能有效促进椎间盘突出物的缩小.从影像学上分析,PLDD是治疗颈腰椎病的一种安全有效的微创手术.     

经L5/S1小关节内侧缘双针法行上腹下丛神经化学毁损治疗慢性盆腔痛的临床研究

目的 探讨一种新的穿刺方法行上腹下丛神经毁损治疗慢性盆腔痛的疗效及安全性.方法 15例确诊为子宫内膜异位症的慢性盆腔痛患者,经止痛药物保守治疗失效.患者取俯卧位,在腰椎正位X光下确定L5/S1双侧小关节内侧缘与L5/S1椎间盘,穿刺针经L5/S1双侧小关节内侧缘穿刺,在腰椎侧位X光引导下突破椎间盘,确认针的位置正确无误后双侧总共给予10%酚甘油20 ml.分别就手术耗时及治疗后第1天、1月、2月、3月的VAS评分、每日止痛药的需要量、生活质量改善情况及安全性进行评估.结果 手术耗时短,平均为(26.3±4.6)min,治疗后患者的疼痛评分较治疗前有明显降低(P<0.05),止痛药的日需要量较术前明显下降(P<0.01),生活质量也有显著改善,治疗总有效率与术前单纯药物治疗相比有统计学差异(P<0.05),有1例患者术后出现便秘,未发现有椎间盘炎、椎间盘破裂及血管、神经损伤等其他严重并发症.结论 经小关节内侧缘双针法是一项操作简便、安全,疗效确切、可靠的微创介入治疗方法.