规范手法治疗腰椎间盘突出症的CT三维重建观察

目的：通过对规范手法治疗前后腰椎间盘突出症三维重建CT突出物形态学的定性定量观测,探讨手法的生物力学效应。方法：自2009年12月至2010年5月,采用规范的手法操作技术治疗偏侧型腰椎间盘突出症患者24例（32个突出椎间盘）,隔日治疗1次,每次20min,3周为1个疗程。其中男10例,女14例;年龄25～54岁,平均36.2岁;病程2d～10年,平均6.9年;突出部位：L4,512个,L5S120个。突出髓核和关节突关节及椎板（黄韧带）间距：Ⅰ型5例、Ⅱ型13例、Ⅲ型6例。制订观测CT重建图像的操作规程,3周治疗后通过对治疗前后同一层面神经根鞘膜间距（TD）重构神经根鞘膜侧轮廓图、突出髓核和关节突关节及椎板间距、突出物偏向角（AN值）、矢状径指数（SI值）的观测,进行突出物形态学的分析评价。结果：神经根鞘膜间距（TD）重构神经根鞘膜侧轮廓图的观察中,可以确定19例患者（79.2%）治疗前后神经根走行形态发生变化;突出髓核和关节突关节及椎板间距Ⅱ型患者中有7例治疗后变为Ⅰ型,Ⅲ型患者中有2例治疗后变为Ⅱ型;AN值治疗后比治疗前增大（P〈0.05）,说明突出物朝偏离椎间孔的方向形变;SI值治疗前后无差别（P〉0.05）。结论：规范手法可以使偏侧型的突出髓核或膨出物发生形变,突出物与神经根之间发生松解,相互位置改善,为研究手法的生物力学效应提供了影像学依据。     

椎间隙突出髓核内压力与相邻神经根受压程度的临床研究

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制。方法：选取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阳性组、阴性组，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；同时选取收治的手法治疗腰椎间盘突出症患者30例，观察手法治疗后直腿抬高高度的变化。结果：①手术患者中直腿抬高阳性组患者突出髓核内压力明显高于阴性组患者，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)。②手法治疗患者中手法治疗后直腿抬高高度明显增加(P＜0．01)，手法治疗前后CT或MRI显示突出髓核大小无改变(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，可能不是仅依靠改变突出髓核空间占位达到治疗目的。     

椎板开窗减压髓核摘除术治疗腰椎间盘突出症

目的：探讨应用腰椎后路椎板开窗减压髓核摘除术治疗腰椎间盘突出症的方法及疗效。方法：回顾以往应用该方法治疗的32例腰椎间盘突出症病例。术中咬除椎间盘髓核突出部位相应的上椎板部分下缘及下椎板上缘，呈开窗状，切除增厚的黄韧带、增生的椎体后缘和关节突内侧皮质骨、钙化的后纵韧带及突出的纤维环和髓核，术后观察其疗效。结果：术后全部随访6—36个月，优良率达92％。结论：腰椎后路椎板开窗减压髓核摘除术治疗椎间盘突出症具有创伤小，对腰椎功能影响小，疗效好。     

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。     

腰椎间盘突出合并侧隐窝狭窄症33例报告

本文报告了手术治疗腰间盘突出合并侧隐窝狭窄３３例。其中单侧２８例，双侧５例。４例合并中央管狭窄，２例合并马尾综合征，１例合并椎体滑脱。根据各自的病理特点分别行全椎板、半椎板或开窗减压。手术处理包括摘除突出的椎间盘，切除增生的黄韧带、小关节突和椎体后缘骨赘，从而扩大狭窄的侧隐窝，使神经根充分减压。经１２月～４年６个月（平均２８年）随访，优２２例，良８例，无改善３例。作者认为手术摘除突出髓核后，必须探查神经根的其他致压因素，以防遗漏。手术既要减压充分，又要兼顾腰椎的稳定性     

经显微内窥镜手术治疗腰椎间盘突出症

目的：研究显微内窥镜椎间盘切除术（microendoscopic discectomy,MED）治疗腰椎间盘突出症的特点及易出现的情况和并发症,以提高手术疗效。方法：通道管经棘突旁小切口进入,在显微内窥镜下半环切除椎板下部,黄韧带、关节突内侧。保护器保护神经根,切除突出的髓核组织,必要时扩大神经根管。本组共56例,其中52例经术后随访24～32个月,平均27．2个月。结果：术后住院5～18天,平均8．4天。术后平均16天生活自理,5周恢复工作。术后改善率优良率92．8％。患者满意率为85．7％。初期手术可能出现：①定位错误;②进入椎管困难;③止血困难;④损伤硬膜;⑤损伤关节突关节。结论：MED可直视下切除髓核,创伤小,视野照明好等特点,但其工作通道末端不易与椎板表面固定。其在镜下操作,有一定难度的学习曲线。     

通道下单侧椎板入路双侧减压治疗腰椎间盘突出并对侧下肢症状

目的 探讨通道下单侧椎板入路双侧减压治疗腰椎间盘突出并对侧下肢症状的疗效.方法 回顾性分析2010年1月～2020年12月11例以一侧腰椎间盘突出并对侧下肢为主要症状者的手术疗效,均为单间隙旁中央型髓核突出.均由髓核突出侧行单侧椎板开窗髓核切除术,5例行对侧神经根减压,6例椎间盘摘除后仍有明显后纵韧带隆起,硬膜囊挤压,...     

显微内窥镜下椎间盘切除术治疗腰椎间盘突出症的疗效分析

目的：总结经后路显微内窥镜下椎间盘切除术（MED）治疗腰椎间盘突出症的疗效，探索其操作要点。方法：2001年5月～2003年7月对132例腰椎间盘突Ⅲ症患者采用MED治疗．术中用C型臂X线定位相应节段，建立工作通道，在显微内窥镜下切除部分椎板、黄韧带和少量关节突内缘，牵开硬膜和神经根，显露突出的纤维环和髓核，切除髓核，减压神经根管。采用MacNab腰椎评价标准评价疗效。结果：患者术后平均3d下地活动，平均住院时间8.4d。平均16d生活自理，5周恢复工作。平均随访时间30．5个月，优8l例（61.4％）．良47例（35．6％）。优良率97．0％。硬膜破裂3例，无神经根损伤。结论：后路MED手术创伤小，患者术后卧床时间短，恢复快，可以取得与开窗手术柏近的效果。但需要学习过程，掌握一些要点才能熟练操作。     

腰椎间盘镜下手术治疗腰椎间盘突出症

目的：研究腰椎间盘镜（METPX）髓核摘除术治疗腰椎间盘突出症的特点及适应证，以提高手术疗效。方法：通道管经棘突旁小切口进入，在显微内窥镜下半环切除椎板下部、外侧黄韧带、关节突内侧。保留硬膜囊后方黄韧带，用棉片、保护器保护神经，环切突出的纤维环和髓核组织，扩大根管。结果：本组共治疗148例腰椎间盘突出症。随访8-14个月。平均11个月。按Nakai标准评定：优110例，良29例，可8例，差1例。无复发，无神经根损伤或硬膜囊撕裂，无1例术中转开放手术。结论：后路椎间盘镜手术在保证神经根通道充分减压的基础上，具有手术创伤轻，组织剥离少，保持脊椎中后柱完整性，不破坏脊柱的生物力学结构、出血少、卧床时间短及恢复快的特点。适用于单侧1个间隙、同侧2个间隙或中央型单间隙的腰椎间突出症。     

腰椎间盘突出症合并椎管狭窄23 例治疗分析

目的探讨经后路椎间盘镜手术治疗合并腰椎管狭窄症的椎间盘突出症的临床应用。方法采用后路椎间盘镜进行单侧开窗减压术。通过术前标记腰椎正侧位片定位，于定位棘突间隙后正中偏患侧作长约1.5 cm小切口，逐级扩张后置入工作通道管，钻除部分椎板，置入内窥镜，于电视监视器下显露椎板、增生内聚的关节突、肥厚的黄韧带及突出的椎间盘髓核组织，彻底解除其对硬脊膜、神经根的压迫。结果本组共治疗合并腰椎管狭窄症的腰椎间盘突出症23例，平均随访7个月，按Prolo标准评定，治愈20例，有效2例，无效1例。结论本术式在严格掌握适应证前提下对合并腰椎管狭窄症的腰椎间盘突出症患者效果明显。     

腰椎椎间孔镜手术治疗伴神经根管狭窄的腰椎椎间盘突出症

目的退变性腰椎椎间盘突出、黄韧带肥厚、关节突关节增生内聚引起神经根管狭窄,利用椎间孔镜对神经根管进行减压。方法对20例退变性神经根管狭窄症患者行腰椎椎间孔镜下神经根管扩大成形术,记录术前术后腰腿痛疼痛视觉模拟量表(visual analogue scale,VAS)评分,采用Macnab标准评价疗效。结果 20例患者术前平均腰痛VAS评分为5分,术后即刻为1.5分,术后3个月为0.5分。术前平均腿痛VAS评分为7分,术后即刻为0.3分,术后3个月为0.1分。18例患者术后3个月的改良Macnab疗效评定为优,2例患者为良。结论对腰椎退变性神经根管狭窄症,椎间孔镜可对突出的腰椎椎间盘、关节突关节以及黄韧带进行减压,有效地扩大神经根管,可获得很好的疗效。     

Biomechanical effects of sequential resection of the posterior ligamentous complex on intradiscal pressure and resistance to compression forces

ObjectiveThe aim of this biomechanical experimental study was to evaluate the resistance of each posterior ligamentous complex structure of the thoracic and lumbar spine to compression forces and to measure the shifting load to the intervertebral disc when each PLC structure was interrupted.MethodThe study was conducted on 4 groups for thoracic and lumbar region as intact, supraspinous ligament interrupted, interspinous ligament/ligamentum flavum combination interrupted and facet joint capsule interrupted. Pre and post anterior vertebral body height, the highest compression force and pressure changes in the intervertebral disc during 40 N loading were measured.ResultsA significantly different degree of resistance to compression force was determined in each posterior ligamentous complex structure in the thoracic and lumbar spine samples. The combination of interspinous ligament and ligamentum flavum was found to be the most effective structure to resist compression forces (p = 0.001 in both groups). The effect of the supraspinous ligament in thoracic and lumbar segments was found to be similar to that of the interspinous ligament and ligamentum flavum combination (p = 0.008 and p = 0.006, respectively). The least effective structure was observed to be the facet joint capsule. Compression forces were significantly increased in the intervertebral disc as a result of the disruption of supraspinous ligament (p = 0.0032 and p = 0.0029, respectively in thoracic and lumbar segments) and combination of interspinous ligament/ligamentum flavum (p = 0.0019 and p = 0.0021, respectively in thoracic and lumbar segments).ConclusionThe interspinous ligament/ligamentum flavum combination and supraspinous ligament are the largest contributor to resisting applied compression moments in the sheep thoracic and lumbar spine. As a result of the loss of resistance to compression forces, there will be a shift of a great proportion of this force onto the intervertebral disc.Level of evidenceLevel V.     

Infolding of the ligamentum flavum: a cause of spinal cord compression after reduction of cervical facet injuries

Controversy exists regarding management of cervical facet injuries. Previous literature has focused on associated disc herniations reported to cause neurologic injury upon reduction. Although rupture of the ligamentum flavum has been noted with these injuries, its clinical significance has not been examined. In this case report, we present two patients in whom neurologic deterioration occurred due to infolding of the torn ligamentum flavum with spinal cord compression after reduction of cervical facet subluxations. Both had large flaps of ligamentum flavum arising from the caudal lamina which infolded upon reduction and became trapped between the spinal cord and cephalad lamina. Both patients regained normal motor function after removal of the pathologically infolded ligamentum. Neither patient had a disc herniation, hypotensive/anemic/hypoxic event, or epidural hematoma that could have otherwise been causative of the neurologic deficit. Pathologic infolding of ligamentum flavum, in addition to extruded disc herniations, should be recognized as another potential cause for spinal cord compression with reduction of cervical facet injuries. In particular, if there is a long flap of flavum arising from the caudal lamina poised to become entrapped in the spinal canal with reduction and the patient has a congenitally narrow canal, the surgeon should consider removal of the ligamentum flavum prior to reduction.     

腰椎间孔狭窄症的诊断与手术治疗

目的：讨论腰椎间孔狭窄症的病理解剖、临床特征、诊断和手术治疗。方法：对１９９１年至１９９８年间４２例腰椎间孔狭窄症病人的诊断与手术治疗进行了回顾性研究。结果：术后对其中的３８例病人进行了０．５～５．５年,平均３．５年的随访,手术优良率达９２．７％。结论：引起腰椎间孔狭窄并导致根本性卡压征的原因有腰椎间盘退变狭窄,小关节增生内聚,黄韧带肥厚内陷,椎间孔内间盘突出和腰椎滑脱等。诊断依赖于根性损害表现和可靠的腰椎ＣＴ扫描或ＭＲＩ检查。手术包括腰椎间孔的探查和减压,术中注意保护和重建脊柱稳定性,并防止神经结构误伤。     

Quantitative analysis of transforming growth factor-beta 1 in ligamentum flavum of lumbar spinal stenosis and disc herniation.

STUDY DESIGN: The concentration of transforming growth factor-beta 1 (TGF-beta1) was examined in the ligamentum flavum of lumbar spinal stenosis and disc herniation. OBJECTIVE: To investigate the role of TGF-beta1 on hypertrophy of the ligamentum flavum in lumbar spinal stenosis compared with that of lumbar disc herniation. SUMMARY OF BACKGROUND DATA: The hypertrophy of the ligamentum flavum is known to be related to degenerative changes that are secondary to the aging process or mechanical instability. However, there has been no study to investigate the effect of biochemical factors, such as growth factors, associated with hypertrophy of the ligamentum flavum. METHODS: The concentrations of TGF-beta1 were analyzed in the surgically obtained ligamentum flavum specimens from lumbar spinal stenosis (n = 10; mean age 62.8 years) and disc herniation (n = 10; mean age 35.6 years) by enzyme-linked immunosorbent assay. The localization of TGF-beta1 within the ligamentum flavum was determined using immunohistochemical study. The thickness of the ligamentum flavum was measured with axial T1-weighted magnetic resonance imaging. The biochemical and radiologic results were compared for these two conditions. RESULTS: The mean concentration of TGF-beta1 was 123.78 pg/100 microg protein (range 11-374 pg/100 microg protein) in lumbar spinal stenosis and 38.56 pg/100 microg protein (range 0-155 pg/100 microg protein) in lumbar disc herniation; the difference between lumbar spinal stenosis and disc herniation was statistically significant (P = 0.029). The mean thickness of the ligamentum flavum was 4.44 mm (range 3.4-5.4 mm) in lumbar spinal stenosis and 2.44 mm (range 1.8-4.0 mm) in lumbar disc herniation; the difference between lumbar spinal stenosis and disc herniation was statistically significant (P = 0.001). On immunohistochemical study TGF-beta1 was positively stained on the fibroblasts within the ligamentum flavum specimens. CONCLUSION: The current results suggest that higher expression of TGF-beta1 by fibroblasts might be related to the development of hypertrophy of the ligamentum flavum in lumbar spinal stenosis.     

腰椎管狭窄症的影像学诊断

目的：探讨腰椎管狭窄症的X线、CT及MRI诊断价值。方法：分析130例临床诊断和影像学检查征象典型的腰椎管狭窄症的病例资料。男83例,女47例;年龄27～75岁,平均43.5岁。所有病例均行CT检查,其中23例行X线检查,57例行MRI扫描。结果：腰椎管狭窄位于L3,4水平25例,L4,5水平48例,L5S1水平57例。CT显示椎体后缘、椎板、下关节突骨质增生46例,椎板上下关节突肥大7例,黄韧带钙化、骨化13例,椎体向前滑脱5例,侧隐窝狭窄24例,椎间孔狭窄35例。MRI显示椎间盘突出伴黄韧带肥厚23例,黄韧带对称性肥厚18例,广泛多节段增生肥厚9例,局限性黄韧带肥厚7例。结论：继发性腰椎管狭窄症的最常见原因是退变。传统X线检查有很大的局限性,CT和MRI具有多方位成像和分辨率高的优点,但在韧带骨化上MRI难于显示,而CT能很好的显示韧带钙化与骨化及骨质改变,腰椎管狭窄症检查应该首选CT。     

Myxomatous degeneration of the ligamentum flavum of the lumbar spine

STUDY DESIGN: Report of two cases of acute lumbar nerve root compression caused by myxomatous degeneration of the ligamentum flavum. OBJECTIVE: To report a rare cause of acute lumbar nerve root compression. SETTING: Orthopaedic department, Osaka, Japan. SUMMARY OF BACKGROUND DATA: Two patients, both 50-year-old men presenting with signs and symptoms suggestive of acute lumbar nerve root compression were found to have a ligamentum flavum mass. The masses were removed and the patients regained normal function postoperatively. METHODS: To reveal the nature of the mass, histopathological studies were made. Continuous sections were prepared from the removed mass lesions. The sections were stained with hematoxylin and eosin, van Gieson's stain, azan stain, periodic acid Schiff reaction, Alcian blue stain and von Kossa's stain. RESULTS: Histological examination revealed myxomatous degeneration of the ligamentum flavum. No elastic fibers were found at the degeneration site. Diffuse mucopolysaccharide deposition was found at the degeneration site, however, no cyst was found. Collagen fibers were not increased. Hypertrophy or ossification of the ligamentum flavum was not recognized in the sections. At a follow-up examination over 2 years later, the patients were free of symptoms and the findings of a neurological examination were normal. CONCLUSION: Two cases of myxomatous degeneration of the ligamentum flavum of the lumbar spine were reported, which have seldom been described as the cause of acute lumbar nerve root compression.     

Hypertrophy of ligamentum flavum in lumbar spinal stenosis associated with increased proteinase inhibitor concentration

BACKGROUND: It is well known that age-related fibrosis, or decreases in the elastin-to-collagen ratio of the ligamentum flavum, along with hypertrophy of the ligamentum flavum, are associated with lumbar spinal stenosis. However, the molecular mechanism by which this fibrosis and hypertrophy develop is unknown. Tissue inhibitors of matrix metalloproteinase (TIMPs) are proteinase inhibitors that suppress extracellular matrix degradation. Elevated TIMP-1 and TIMP-2 expression has been implicated in various fibrotic diseases of the liver, kidney, lung, and heart. These TIMPs can also induce cellular proliferation and inhibit apoptosis in a wide range of cell types. These findings led us to postulate that TIMP-1 and TIMP-2 might also be associated with hypertrophy and fibrosis of the ligamentum flavum in lumbar spinal stenosis. METHODS: We quantified and localized TIMP expression in ligamentum flavum tissues that had been obtained during surgery from thirty patients with spinal stenosis and from thirty gender-matched control patients with disc herniation. The thickness of the ligamentum flavum at the level of the facet joint was measured on axial T1-weighted magnetic resonance images. In addition, we examined ligamentum flavum tissues for the expression of markers of cellular proliferation and apoptosis. RESULTS: The ligamentum flavum was significantly thicker in the patients with spinal stenosis (mean, 5.68 mm) than in the patients with disc herniation (mean, 2.70 mm) (p < 0.001). The concentration of TIMP-2 in the ligamentum flavum was significantly higher in the patients with spinal stenosis (mean, 12.62 ng/mL) than in those with disc herniation (mean, 8.85 ng/mL) (p = 0.028). TIMP-1 and TIMP-2 were detected in the cytoplasm of ligamentum flavum fibroblasts. TIMP-1 and TIMP-2 concentrations were associated with hypertrophy of the ligamentum flavum (p = 0.015 and p = 0.003, respectively). None of the samples from the patients with stenosis had evidence of proliferation of ligamentum flavum fibroblasts. The expression of markers for apoptosis was significantly higher in the patients with spinal stenosis (58.8%) than in those with disc herniation (26.6%) (p < 0.001). CONCLUSIONS: Increased TIMP expression has been implicated in fibrosis and hypertrophy of the extracellular matrix of several organs. Our results suggest that increased expression of TIMP-2 in ligamentum flavum fibroblasts is associated with fibrosis and hypertrophy of the ligamentum flavum in patients with spinal stenosis.     

腰椎间盘突出症手术并发症的防治

探讨腰椎间盘突出症手术并发症的防治,方法分析近８年我科腰椎间盘突出症手术并发症的原因。讨论其防治和治疗措施。结果术中保留棘上韧带能避兔术后腰酸乏力,采用环锯去除椎板黄韧带省时,安全。Ｌ５和Ｓ１的术中确定可依据其形态,活动度,叩击音区别。     

Microsurgical anatomy and operative technique for extreme lateral lumbar disc herniations

Summary The anatomy of the lateral aspect of the lumbar spine and our lateral microsurgical technique for extreme lateral lumbar disc herniations (ELLDH) is described. This study was based on the microdissection of 4 cadavers, on the morphometric evaluation of these as well as 6 dried cadaver spines and 8 lumbar CT scans, and on the use of this technique on over 200 cases.Level dependent changes in the posterior arch cause a shift of the disc space distally relative to the facet joint, an increasing amount of bone to overlie the intervertebral foramen, and a decreasing amount of working space within the exposure in the caudal direction. Therefore, more bone removal from the lateral aspect of the pars interarticularis and supero-lateral aspect of the facet joint is required in the lower lumbar spine. When the exposed ligamentum flavum is resected, the dorsal root ganglion is seen and access to the herniation and disc space is achieved. Level dependent changes in the pedicles and transverse processes lead to an alteration in the course and relationships of the nerves, thereby influencing the pathophysiology of and surgical technique for the ELLDH. The operative target is the lateral aspect of the pars interarticularis and not the intertransverse space as has been previously described.Our techniques allows for the early identification of the nerve with minimal risks of injury to it, to the adjacent vessels and to the structural integrity of the facet joint and pars interarticularis.Abbreviations DRG dorsal root ganglion - ELLDH extreme lateral lumbar disc herniation - ESA erector spinae aponeurosis - ITL intertransverse ligament - L lumbar - LA lumbar artery - LF ligamentum flavum - LIPC lateral interpedicular compartment - m. muscle - S sacral - TP(s) TP(s) transverse process(es)