压迫及非压迫因素在实验性神经根性疼痛中的作用

目的：探讨压迫及非压迫因素在实验性椎间盘源性神经根性疼痛中的作用。方法：取大鼠白体脊椎关节突修剪后放置在L5神经根下．造成对L5神经根的直接压迫（压迫组）；取大鼠白体尾椎椎间盘组织无压迫下放置在L5神经根表面（非压迫组）：同时设立对照组。术后不同时间点测定各组大鼠后足底机械刺激疼痛阈值的变化。结果：压迫组与非压迫组大鼠后足底均产生了一个长时程机械刺激疼痛阈值的降低；与压迫组相比．非压迫组大鼠术后1天就开始出现了疼痛阈值降低（P〈0．05），明显早于压迫组大鼠，并且疼痛阈值降低更加显著：而压迫组大鼠术后1周时才出现明显的疼痛阈值降低（P〈0．05）。对照组大鼠疼痛阈值没有发生明显的改变。结论：尽管压迫和非压迫因素都参与椎间盘源性神经根性疼痛的发生．但二者作用的时间不同＋在椎间盘突出的早期阶段非压迫因素可能在疼痛中起着重要的作用：随后压迫因素可能逐渐成为致痛的主因。     

椎管内修复臂丛神经损伤的解剖及临床应用研究

目的观察通过打开椎管找到残存的臂丛神经根并进行神经修复的可行性。方法甲醛溶液固定的成人尸体标本15具30侧，测量C5-T1，神经前根椎间孔段的直径、长度和有髓神经纤维计数。选择5例臂丛神经损伤患者，2例为椎孔处刀刺伤，3例为闭合性创伤。自受伤到椎管内探查的时间为3-6个月，平均4个月。CTM显示部分已损伤的神经根其椎管内神经前后根仍存在，而锁骨上臂丛神经探查在椎间孔外找不到相应的具有正常结构的神经根近端，通过打开椎管将椎管内残存的神经根用腓肠神经桥接进行神经修复。结果C5-T1，神经前根的有髓神经纤维数目为4000-6000根，椎间孔段的长度为11～14mm，外径为1．2～1．5mm。5例患者的椎管内均找到了具有正常结构的神经根近端，其中C5神经根3例，C5、C6神经根1例，C7神经根1例。C5修复肩胛上神经和C5神经远端各1例，C5修复正中神经内侧头1例，C7修复内侧束1例，C5、C6分别修复上干后股、肌皮神经1例。术后随访38--46个月，平均42个月。5例患者其修复神经所支配肌肉的肌力分别达3-4级。结论对于神经根在椎间孔处断裂的臂丛神经损伤，可通过打开椎管找到损伤神经根的近端，为臂丛神经根性损伤的修复提供理想的动力神经源，有利于臂丛神经治疗效果的提高。     

Quantitative evaluation for cervical foraminal bony stenosis based on angled sagittal slices along a nerve root on computed tomography

Cervical foraminal canal stenosis is a common disease, but any relationships between the measurement values of cervical foraminal canals and clinical symptoms have yet to be explored. We aim to determine a numerical cutoff point of cervical foraminal bony canal size that does not lead to radiculopathy so as to establish criteria for the surgical indication. We reconstructed angled sagittal slices along a nerve root on computed tomography (CT) on a workstation from pre-operative CT data and measured 1152 cervical foraminal canals (144 patients) from Cervical (C) 4/5 to C7/Thoracic (Th) 1. We evaluated the relationship between the size of foraminal canals and clinical manifestations. Receiver operating characteristic (ROC) analysis was used to calculate cutoff points of each foraminal canal size with positive neurologic manifestations. Of the 144 patients’ 1152 nerve roots, 286 nerve roots (24.8%) were diagnosed as radiculopathy by neurological examinations. The mean measured value of all foraminal canals on angled sagittal CT imagery was 3.39 ± 1.37 mm. The cutoff point of foraminal canal sizes without radiculopathy was 2.7 mm (sensitivity 0.680, specificity 0.591) overall. A cutoff point ascertained by quantitative evaluation of cervical foraminal canal size is useful for making diagnosis of cervical foraminal canal bony stenosis.     

Spinal Manipulation for Subacute and Chronic Lumbar Radiculopathy: A Randomized Controlled Trial

ObjectiveWe evaluated the efficacy of spinal manipulation for the management of nonacute lumbar radiculopathy.MethodsIn a university hospital we performed a randomized controlled trial with 2 parallel arms. Patients (n = 44) with unilateral radicular low back pain lasting more than 4 weeks were randomly allocated to manipulation and control groups. The primary outcome was the intensity of the low back pain on a visual analog scale. The secondary outcome was the Oswestry Disability Questionnaire score. We also measured spinal ranges of motion. The assessments were carried out at the baseline, immediately after intervention, and at 3 months’ follow-up. All patients underwent physiotherapy. The manipulation group received three sessions of manipulation therapy 1 week apart. For manipulation, we used Robert Maigne's technique.ResultsBoth groups experienced a decrease in back and leg pain significantly (all P ≤ 0.003). However, only the manipulation group showed significantly favorable results in the Oswestry scores (P < 0.001), and the straight leg raise test (P = 0.001). All ranges of motion increased significantly with manipulation (all P < 0.001), but the control group showed favorable results only in right and left rotations and in extension (all P < 0.001). Between-group analyses showed significantly better outcomes for manipulation in all measurements (all P ≤ 0.009) with large effect sizes.ConclusionSpinal manipulation improves the results of physiotherapy over a period of 3 months for patients with subacute or chronic lumbar radiculopathy.     

Complete recovery of herpes zoster radiculopathy based on electrodiagnostic study: A case report

BACKGROUNDHerpes zoster is a painful infectious disease caused by the varicella zoster virus. Herpes zoster radiculopathy, which is a type of segmental zoster paresis, can complicate the disease and cause motor weakness. This complication should be considered when a patient with a rash complains of acute-onset motor weakness, and the diagnosis can be verified via electrodiagnostic study. CASE SUMMARYA 64-year-old female with a history of asthma presented to the emergency department with stabbing pain, an itching sensation, and a rash on the right anterior shoulder that had begun 5 d prior. Physical examination revealed multiple erythematous grouped vesicles in the right C4-5 and T1 dermatome regions. Because herpes zoster was suspected, the patient immediately received intravenous acyclovir. On the third hospital day, she complained of motor weakness in the right upper extremity. Magnetic resonance imaging of the cervical spine revealed mild intervertebral disc herniation at C4-C5 without evidence of nerve root compression. On the 12^th hospital day, electrodiagnostic study revealed right cervical radiculopathy, mainly in the C5/6 roots. Six months later, monoparesis resolved, and follow-up electrodiagnostic study was normal. CONCLUSIONThis case emphasizes that clinicians should consider the possibility of post-herpetic paresis, such as herpes zoster radiculopathy, and that electrodiagnostic study is useful for diagnosis and follow-up.     

直视下选择性神经根管减压术治疗腰骶神经根病的疗效评价

目的 探讨直视下选择性神经根管减压术治疗腰骶神经根病的临床疗效.方法 回顾性分析2002年3月至2008年11月应用直视下选择性神经根管减压术治疗且随访超过3年的178例腰骶神经根病患者资料,男95例,女83例;年龄22～73岁,平均48.2岁.狭窄部位:L2,34例,L3,4 17例,L4,5 49例,L5S1 55例,双节段37例,三节段及以上病变16例.依据神经根走行及神经根管解剖特点,结合Lee等对神经根管的入口区、中间区及出口区三分区理论,对神经根的受压部位行直视下选择性神经根管减压术.术后以Oswestry功能障碍指数(Oswestry disability index,ODI)、疼痛视觉模拟评分(visual analogue scale,VAS)及Macnab标准评定功能.结果 手术时间30～60 min,平均(45±10) min;术中出血量10～150 ml,平均(50±20) ml.术前、术后2周、6、12、36个月ODI分别为62.33％±8.70％、26.40％±10.30％、23.80％±10.30％、27.10％±9.90％、33.00％±8.90％,VAS分别为(7.20±1.23)分、(1.56±1.17)分、(1.19±1.43)分、(1.16±1.32)分、(1.26±1.17)分.Macnab评价优良率,术后2周为91.0％(162/178),术后6个月为88.2％(157/178),术后12个月为84.8％(151/178),术后36个月为83.7％ (149/178).结论 直视下选择性神经根管减压术治疗腰骶神经根病手术时间短、术中出血少,术后症状改善明显.     

Ultrasound-guided versus computed tomography-controlled periradicular injections in the middle and lower cervical spine: a prospective randomized clinical trial

Purpose

We conducted this study to evaluate accuracy, time saving, radiation doses, safety, and pain relief of ultrasound (US)-guided periradicular injections versus computed tomography (CT)-controlled interventions in the cervical spine in a prospective randomized clinical trial.

Methods

Forty adult patients were consecutively enrolled and randomly assigned to either a US or a CT group. US-guided periradicular injections were performed on a standard ultrasound device using a broadband linear array transducer. By basically following the osseous landmarks for level definition in “in-plane techniques”, a spinal needle was advanced as near as possible to the intended, US-depicted nerve root. The respective needle tip positioning was then verified by CT. The control group underwent CT-guided injections, which were performed under standardized procedures using the CT-positioning laser function.

Results

The accuracy of US-guided interventions was 100 %. The mean time to final needle placement in the US group was 02:21 ± 01:43 min:s versus 10:33 ± 02:30 min:s in the CT group. The mean dose-length product radiation dose, including CT confirmation for study purposes only, was 25.1 ± 16.8 mGy cm for the US group and 132.5 ± 78.4 mGy cm for the CT group. Both groups showed the same significant visual analog scale decay (p < 0.05) without “inter-methodic” differences of pain relief (p > 0.05).

Conclusions

US-guided periradicular injections are accurate, result in a significant reduction of procedure expenditure under the avoidance of radiation and show the same therapeutic effect as CT-guided periradicular injections.     

Transvertebral anterior cervical foraminotomy: midterm outcomes of clinical and radiological assessments including the finite element method

Purpose

The aim of this study was to compare the clinical features, radiological changes, biomechanical effects, and efficacy in patients treated by transvertebral anterior foraminotomy. Preservation of segmental motion and avoidance of adjacent segment degeneration are theoretical advantages of transvertebral anterior foraminotomy. In practice, this procedure is minimally invasive and has shown good clinical results, especially in patients with unilateral cervical radiculopathy.

Method

We conducted a retrospective minimum 2-year follow-up study of the cervical spine of patients treated by transvertebral anterior foraminotomy at our institution. Radiological outcomes, which were estimated by measuring disc and functional spinal unit heights, and the angle and range of motion (ROM) from C2 to C7 of the functional spinal unit and adjacent segments were evaluated. Furthermore, a three-dimensional finite element method was used to biomechanically analyze the strength of the postoperative vertebral body.

Results

Between 2004 and 2009, 34 patients underwent surgery. The improvement rate was 94.2 %. The average flexion–extension ROM from C2 to C7 was 36.6 ± 16.6°. On plain radiographs, the disc height and ROM and height of the functional spinal unit in the operated segment were not significantly decreased relative to the preoperative levels. The finite element method also revealed that there was no difference in strength between the pre- and postvertebral bodies.

Conclusions

These results demonstrate that biomechanical stability was achieved. Transvertebral anterior cervical foraminotomy did not limit motion in the operated and adjacent segments and did not cause a significant decrease in disc and vertebral heights after surgery.     

Anterior cervical decompression and fusion on neck range of motion,pain, and function: a prospective analysis

Background contextIntractable cervical radiculopathy secondary to stenosis or herniated nucleus pulposus is commonly treated with an anterior cervical decompression and fusion (ACDF) procedure. However, there is little evidence in the literature that demonstrates the impact such surgery has on long-term range of motion (ROM) outcomes.PurposeThe objective of this study was to compare cervical ROM and patient-reported outcomes in patients before and after a 1, 2, or 3 level ACDF.Study designProspective, nonexperimental.Patient sampleForty-six patients.Outcome measuresThe following were measured preoperatively and also at 3 and 6 months after ACDF: active ROM (full and painfree) in three planes (ie, sagittal, coronal, and horizontal), pain visual analog scale, Neck Disability Index, and headache frequency.MethodsPatients undergoing an ACDF for cervical radiculopathy had their cervical ROM measured preoperatively and also at 3 and 6 months after the procedure. Neck Disability Index and pain visual analog scale values were also recorded at the same time.ResultsBoth painfree and full active ROM did not change significantly from the preoperative measurement to the 3-month postoperative measurement (ps>.05); however, painfree and full active ROM did increase significantly in all three planes of motion from the preoperative measurement to the 6-month postoperative measurement regardless of the number of levels fused (ps≤.023). Visual analog scale, Neck Disability Index, and headache frequency all improved significantly over time (ps≤.017).ConclusionsOur results suggest that patients who have had an ACDF for cervical radiculopathy will experience improved ROM 6 months postoperatively. In addition, patients can expect a decrease in pain, an improvement in neck function, and a decrease in headache frequency.