自体椎间植骨融合椎弓根钉棒内固定治疗椎间盘源性腰痛

目的探讨和总结腰椎间盘源性腰痛的诊断方法和手术疗效。方法对20例反复发作的腰痛患者进行MRI及椎间盘造影检查,并对确诊的12例患者行腰椎后路全椎板切除,切除病变椎间盘,自体椎体间植骨融合,相邻椎弓根螺钉内固定。结果12例患者术后获得随访,11例腰痛消失,活动自如。有一例术后2月,滑倒摔伤后,再次引起腰痛,卧床休息2周后好转。结论MRI对椎间盘源性腰痛的诊断提供了确切的影像学依据;椎间盘造影,复制腰痛症状,是确诊的重要临床依据。后路病变椎间盘切除,椎间融合,椎弓根内固定治疗腰椎间盘源性腰痛疗效确切。     

椎间盘源性下腰痛的组织病理学变化

背景：椎间盘源性下腰痛是一种椎间盘外周部基本保持完整,而内部各种病理(退变、终板损伤、炎症等)刺激椎间盘内疼痛感受器引起的功能丧失性下腰痛,并且不伴有根性症状,无神经或节段过度活动的放射学证据。 目的：综述了椎间盘源性下腰痛病理变化、临床诊断的特异性、敏感性和安全性以及各种诊断方法存在的争议观点。 方法：应用计算机检索中国期刊全文数据库、PubMed 数据库、EMBASE数据库1970/2010 有关椎间盘源性下腰痛诊断的文献,排除重复性研究。 结果与结论：共保留42篇文献归纳总结。目前临床上根据椎间盘源性下腰痛的病理变化有多种诊断方法,包括物理检查的中心化趋势和骨震动测试,MRI上的黑间盘、高密度区、Modic 改变,椎间盘超声检查,血清学中的高敏感性C-反应蛋白和椎间盘造影。其中腰椎间盘造影有较高的敏感性和特异性,是目前首选的诊断方法。     

椎间盘退变的机制及修复

背景：目前为止,椎间盘退变源性腰痛的发病机制研究并不十分清楚明了,对于其治疗的手段也多种多样,但效果不一。目的：综述近年国内外椎间盘退变机制及修复的研究进展。方法：由第一作者检索至2014年11月为止 PubMed数据(http://www.ncbi.nlm.nih.gov/PubMed)及CNKI中国期刊全文数据库(http://www.cnki.net/),以“椎间盘退变因素,椎间盘源性腰痛,椎间盘退变治疗”等为检索词,共检索到78篇相关文献,排除重复研究,共30篇文献符合纳入标准。结果与结论：综合大量国内外科研人员对椎间盘退变的研究,目前比较推崇的退变因素包括形态学上的改变、炎性递质和细胞外基质的变化、生长因子的作用等,治疗上仍处于对其形态学的修复方面,其中经皮穿刺椎间盘减压、椎体融合、人工椎间盘置换、动态稳定系统等手术治疗方法对椎间盘退变引起的症状有确切的疗效。 中国组织工程研究杂志出版内容重点：组织构建;骨细胞;软骨细胞;细胞培养;成纤维细胞;血管内皮细胞;骨质疏松;组织工程全文链接：     

椎间盘突出临近退变节段是否导致腰痛

背景：椎间盘突出症患者腰痛原因很难判断,一直以来,认为突出的椎间盘是椎间盘突出症患者腰痛及腿痛重要原因,椎间盘突出临近退变节段是否导致腰痛需进一步研究证实。 目的：通过椎间盘造影判断突出临近退变节段是否是椎间盘突出症患者腰痛原因,并报告经椎间盘镜摘除椎间盘后残留腰痛在临近退变疼痛椎间盘经亚甲蓝注射治疗的效果。 方法：20例同时具有腰痛和腿痛椎间盘突出症患者行椎间盘造影检查,这些患者腰椎MRI表现为有1个突出椎间盘外至少合并1个或1个以上的临近退变的椎间盘,全部患者均经椎间盘镜摘除椎间盘切除突出的椎间盘,5例临近退变椎间盘造影阳性患者在椎间盘镜切除后经椎间盘内注射亚甲蓝治疗。腰痛、腿痛采用目测类比评分评定。 结果与结论：20例患者总共64个椎间盘行椎间盘造影,共11个椎间盘造影阳性,其中6个位于椎间盘突出临近退变节段,5个位于引起神经根性痛的椎间盘突出节段。全部病例腿痛行椎间盘镜切除突出椎间盘后明显缓解,腰痛有部分缓解,6例临近椎间盘造影阳性患者经椎间盘镜摘除椎间盘后腰痛明显,影响日常生活,其中5例行临近疼痛椎间盘亚甲蓝注射后腰痛缓解,1例患者拒绝亚甲蓝注射治疗仍有明显腰痛。结果显示椎间盘突出症患者腰痛可能来源于突出临近退变节段。     

下腰痛磁共振弥散加权成像诊断价值的研究进展

下腰痛是临床常见病,此病约累及全部人群的70％～85％,约有10％发展成慢性腰痛[1].下腰痛临床症状的产生主要是由于椎间盘退变,周围疼痛感受器受刺激所致,约有39％的慢性腰痛的患者是椎间盘源性的.部分患者丧失劳动能力,影响了正常的社会生活. 1 腰椎间盘正常解剖及病理过程 1.1 腰椎间盘生理特征 正常腰椎间盘主要由中央髓核、纤维软骨环、终板软骨和Sharpey纤维4部分组成,构成一个完整的结构单元.椎间盘髓核主要成分为蛋白多糖,由Ⅱ型胶原纤维和弹性蛋白构成网状结构,位于椎间盘的中央.纤维软骨环位于椎间盘的外围,主要由Ⅰ型胶原纤维组成,位于相邻椎体间.     

椎间盘再生与修复的组织工程支架材料研究进展

椎间盘退变性疾病是导致下腰痛的主要原因之一,传统保守治疗或手术治疗均存在明显局限性。椎间盘组织工程学的发展为椎间盘退变性疾病的治疗提供了新的治疗方案。支架材料作为构建组织工程椎间盘的关键环节,是目前研究的热点和难点。目前常用的支架材料有天然材料、合成材料及复合材料。本文就构建纤维环、髓核和全椎间盘3个方面支架材料的研究现状进行简要综述。虽然组织工程椎间盘还面临着诸多问题,但未来会为椎间盘退变性疾病的治疗带来美好前景。     

椎间盘退变动物模型的研究现状与进展

椎间盘退行性疾病（intervertebral disc degenerative diseases, IDDDs）是跟衰老相关的典型脊柱疾病，是造成下腰痛的主要原因，严重影响着患者的劳动能力和生活质量。关于IDDDs的发病机制目前尚不完全清楚，因而建立椎间盘退变的实验动物模型对于IDDDs的发生机制和临床前研究具有不可替代的作用。利用实验动物从不同方法诱发其椎间盘退变，可以部分模拟人类的椎间盘退变这一复杂的生理、病理过程，并以此探究椎间盘退行性疾病的病理发展过程和药物治疗手段。本文总结了当前常用的椎间盘退行性疾病的实验动物模型，并且对比不同动物模型的优缺点、适用性及局限性，建议实验者可以根据实验对象、实验时间、病理要求等条件，选定最适合其研究的椎间盘退变的动物模型。     

非手术脊柱减压系统DRX9000治疗椎间盘源性腰痛的临床初步报告

目的观察非手术脊柱减压系统DRX9000治疗椎间盘源性腰痛的疗效。方法对50例椎间盘源性腰痛患者进行非手术脊柱减压系统DRX9000治疗,在治疗开始时、治疗1周后、治疗2周后、治疗4周后、整个疗程结束时都对患者进行腰椎活动度、压痛点、双下肢运动感觉、肌力、神经反射的检查并记录,填写《汉化Oswestry功能障碍评分表》,根据分值的变化对疗效进行评估。50例患者均完成了20次治疗。结果 50例患者汉化Oswestry功能障碍评分平均分从治疗前的24.64分,变为治疗1周后13.12分,治疗2周后11.74分,治疗4周后9.70分,治疗结束后9.22分。治疗有效率为86%。将汉化Oswestry功能障碍评分的分值换算为功能障碍指数（CODI）后,发现随着治疗时间的增加,CODI降低的人数逐渐增多。随访50例患者,得到其中36人完整资料,平均随访时间6.2个月,汉化Oswestry功能障碍评分平均分为5.75分。结论非手术脊柱减压系统DRX9000治疗椎间盘源性腰痛,患者恢复良好,效果优。     

干细胞在椎间盘退变生物学治疗中的研究进展

腰痛是一种常见的肌肉骨骼症状,与椎间盘退变密切相关。常规保守或传统手术疗法仅针对临床症状,并未从根本上解决椎间盘退变问题。以干细胞为基础的生物学治疗基于椎间盘退变的始发因素可以为椎间盘退变性疾病提供一种新的治疗思路。目前常用的干细胞类型有间充质干细胞、诱导多能干细胞、造血干细胞及胚胎干细胞等。体内外研究报道提示干细胞疗法具有促进退变椎间盘恢复的作用,将干细胞应用于椎间盘退变性疾病的治疗具有光明前途,但长期疗效有待于进一步研究。     

软骨终板形态与椎间盘退变的相关性

背景：以往研究证明多种内环境因素共同作用引发椎间盘退变,最重要的机制为椎间盘软骨终板的退变。 目的：分析椎间盘退变与终板形态的关系。 方法：回顾性分析62例因椎间盘源性慢性下腰痛和79例因髓核脱出致神经根性症状患者的腰椎MRI正中矢状位图像资料。根据腰椎MRI正中矢状位T1W1图像确定终板形态,T2W1图像确定椎间盘退变程度分级。 结果与结论：平坦型和不规则型终板最常见于椎间盘退变人群下腰椎,L5/S1平坦型最多见。髓核脱出组与椎间盘源性慢性下腰痛组中凹陷型终板椎间盘退变程度均较平坦型、不规则型低,平坦型终板椎间盘退变程度较不规则型低(P < 0.01)。两组间凹陷型与不规则型终板椎间盘退变程度差异无显著性意义,髓核脱出组平坦型椎间盘退变程度较椎间盘源性慢性下腰痛组高(P < 0.05)。提示随着椎间盘退变程度的加重,软骨终板形态有由凹陷型向平坦型、不规则型依次转变的趋势。     

Mast cells in the pathogenesis of chronic back pain: a hypothesis

The pathophysiology of chronic low back pain is poorly understood, mainly because it is difficult to study experimentally or objectively. Recently it has been found that there is a relationship between neovascularization and innervation of the usually avascular and aneural intervertebral disc at the sites of discogenic pain. These data, together with the recognized involvement of mast cells in tissue repair, in the induction of angiogenesis, and in the production of and response to neurotrophic stimuli such as nerve growth factor, has suggested the hypothesis that mast cells may have a causative role in chronic low back pain. If so, the mast cell may represent an attractive therapeutic target.     

Injection of Bupivacaine into Disc Space to Detect Painful Nonunion after Anterior Lumbar Interbody Fusion (ALIF) Surgery in Patients with Discogenic Low Back Pain

Purpose

Bupivacaine is commonly used for the treatment of back pain and the diagnosis of its origin. Nonunion is sometimes observed after spinal fusion surgery; however, whether the nonunion causes pain is controversial. In the current study, we aimed to detect painful nonunion by injecting bupivacaine into the disc space of patients with nonunion after anterior lumbar interbody fusion (ALIF) surgery for discogenic low back pain.

Materials and Methods

From 52 patients with low back pain, we selected 42 who showed disc degeneration at only one level (L4-L5 or L5-S1) on magnetic resonance imaging and were diagnosed by pain provocation on discography and pain relief by discoblock (the injection of bupivacaine). They underwent ALIF surgery. If the patients showed low back pain and nonunion 2 years after surgery, we injected bupivacaine into the nonunion disc space. Patients showing pain relief after injection of bupivacaine underwent additional posterior fixation using pedicle screws. These patients were followed up 2 years after the revision surgery.

Results

Of the 42 patient subjects, 7 showed nonunion. Four of them did not show low back pain; whereas 3 showed moderate or severe low back pain. These 3 patients showed pain reduction after injection of bupivacaine into their nonunion disc space and underwent additional posterior fixation. They showed bony union and pain relief 2 years after the revision surgery.

Conclusion

Injection of bupivacaine into the nonunion disc space after ALIF surgery for discogenic low back pain is useful for diagnosis of the origin of pain.     

Analysis of Efficacy Differences between Caudal and Lumbar Interlaminar Epidural Injections in Chronic Lumbar Axial Discogenic Pain: Local Anesthetic Alone vs. Local Combined with Steroids

Study Design: Comparative assessment of randomized controlled trials of caudal and lumbar interlaminar epidural injections in chronic lumbar discogenic pain.Objective: To assess the comparative efficacy of caudal and lumbar interlaminar approaches of epidural injections in managing axial or discogenic low back pain.Summary of Background Data: Epidural injections are commonly performed utilizing either a caudal or lumbar interlaminar approach to treat chronic lumbar axial or discogenic pain, which is pain exclusive of that associated with a herniated intervertebral disc, or that is due to degeneration of the zygapophyseal joints, or due to dysfunction of the sacroiliac joints, respectively. The literature on the efficacy of epidural injections in managing chronic axial lumbar pain of presumed discogenic origin is limited.Methods: The present analysis is based on 2 randomized controlled trials of chronic axial low back pain not caused by disc herniation, radiculitis, or facet joint pain, utilizing either a caudal or lumbar interlaminar approach, with a total of 240 patients studied, and a 24-month follow-up. Patients were assigned to receive either local anesthetic only or local anesthetic with a steroid in each 60 patient group.Results: The primary outcome measure was significant improvement, defined as pain relief and functional status improvement of at least 50% from baseline, which was reported at 24-month follow-ups in 72% who received local anesthetic only with a lumbar interlaminar approach and 54% who received local anesthetic only with a caudal approach. In patients receiving local anesthetic with a steroid, the response rate was 67% for those who had a lumbar interlaminar approach and 68% for those who had a caudal approach at 12 months. The response was significantly better in the lumbar interlaminar group who received local anesthetic only, 77% versus 56% at 12 months and 72% versus 54% at 24 months.Conclusion: This assessment shows that in patients with axial or discogenic pain in the lumbar spine after excluding facet joint and SI Joint pain, epidural injections of local anesthetic by the caudal or lumbar interlaminar approach may be effective in managing chronic low back pain with a potential superiority for a lumbar interlaminar approach over a caudal approach.     

Clarifying the nomenclature of intervertebral disc degeneration and displacement: from bench to bedside

As a significant determinant of low back pain, intervertebral disc degeneration (IDD) has attracted more and more attention of both investigators and physicians. Disc herniation, termed as intervertebral disc displacement, is amongst the most prevalent spinal diseases closely linked with IDD. Due to the same origins and similar pathophysiology, the ambiguity regarding the similarity and difference of IDD and intervertebral disc displacement thus remains. The aim of this study was to clarify the nomenclature of IDD and disc herniation in terms of molecular etiology, pathophysiology, nature history and clinical outcomes. Collectively, IDD is a type of multifaceted, progressive spinal disease with or without clinical symptoms as back pain, characterized by extracellular matrix and the integrity of NP and AF lost, fissures formation. Disc herniation (termed as intervertebral disc displacement) is a type of spinal disease based on IDD or not, with local pain and/or sciatica due to mechanical compression and autoimmune cascades upon the corresponding nerve roots. Clarifying the nomenclature of intervertebral disc degeneration and displacement has important implications both for investigators and for physicians.     

腰椎间盘退变MRI：与Modic改变相关的影像学分析

背景：部分椎间盘源性下腰痛患者MRI可出现Modic改变,但Modic改变的相关因素及Modic改变与椎间盘退变之间因果关系目前尚不十分清楚。 目的：分析存在腰椎间盘Modic改变的下腰痛患者性别、年龄分布特点及腰椎间盘发生Modic改变的相关因素。 方法：回顾性分析634例(2 536个椎间盘)存在腰椎间盘Modic改变患者的性别、年龄分布特点,并分析腰椎间盘Modic改变与椎间盘突出或膨出、Schmorl结节、椎体滑脱、椎间盘解剖水平及椎间盘退行性改变程度的相关性。 结果与结论：634例患者中,女性患者ModicⅡ、Ⅲ型出现率均较男性高,而ModicⅠ型出现率小于男性患者(P < 0.001);40岁以上患者较40岁以下患者Modic各型改变的出现率均高(P < 0.001)。2 536个腰椎间盘中,有椎体滑脱、出现Schmorl结节、有椎间盘突出或膨出者Modic各型改变的出现率均比无此类表现者高(P < 0.001);L4/5、L5/S1水平(低位)Modic各型改变的出现率均比L2/3、L3/4水平(高位)高(P < 0.001);椎间盘退行性改变越严重,Modic各型改变的出现率越高(P < 0.001)。椎间盘退行性改变分级、Schmorl结节与Modic改变有显著相关性。结果说明,腰椎间盘Modic改变与患者性别、年龄、椎间盘有无突出或膨出、有无Schmorl结节、椎体有无滑脱、椎间盘解剖水平及椎间盘退行性改变分级均有相关性。其中,椎间盘退行性改变分级、Schmorl结节与腰椎间盘Modic改变间的相关性最高,且椎间盘退行性改变分级较Schmorl结节与之相关性更高。     

6-Month Results of Transdiscal Biacuplasty on Patients with Discogenic Low Back Pain: Preliminary Findings

Study Design: Prospective observational study.Objective: Our aim is to investigate the efficacy and safety of TransDiscal Biacuplasty.Summary of Background Data: Chronic discogenic pain is one of the leading causes of low back pain; however, the condition is not helped by most non-invasive methods. The results of major surgical operations for these patients are unsatisfactory. Recently, attention has shifted to disk heating methods for treatment. TransDiscal Biacuplasty is one of the minimally invasive treatment methods. The method was developed as an alternative to spinal surgical practices and Intradiscal Electrothermal Therapy for treatment of patients with chronic discogenic pain.Methods: The candidates for this study were patients with chronic discogenic pain that did not respond to conservative treatment. The main criteria for inclusion were: the existence of axial low back pain present for 6 months; disc degeneration or internal disc disruption at a minimum of one level, and maximum of two levels, in MR imaging; and positive discography. Physical function was assessed using the Oswestry Disability Index when measuring the pain with VAS. Patient satisfaction was evaluated using a 4-grade scale. Follow-ups were made 1, 3, and 6 months after treatment.Results: 15 patients were treated at one or two levels. The mean patient age was 43.1±9.2 years. We found the mean symptom duration to be 40.5±45.7 months. At the sixth month, 57.1% of patients reported a 50% or more reduction in pain, while 78.6% of patients reported a reduction of at least two points in their VAS values. In the final check, 78.6% of patients reported a 10-point improvement in their Oswestry Disability scores compared to the initial values. No complications were observed in any of the patients.Conclusions: TransDiscal Biacuplasty is an effective and safe method.