椎间盘源性腰痛的诊断与治疗

目的探讨腰椎间盘源性疼痛的诊断方法及采用前路经腹膜外入路椎间盘切除人工椎间盘置换或椎间cage植骨融合的临床疗效。方法35例经保守治疗无效的椎间盘源性腰痛患者接受手术治疗。椎间盘源性腰痛的诊断标准为：（1）腰部及下肢疼痛的部位与神经根定位不符；（2）症状反复发作，病程在半年以上；（3）MRI病变椎间盘T2加权像低信号；（4）椎间盘造影阳性，相邻节段为阴性对照；（5）关节突关节封闭除外关节突关节退变引起的疼痛。患者年龄25-67岁，平均43．6岁。L4-5 14例，L5S1 16例，L4-5和L5S1双间隙5例。前路经腹膜外入路椎间盘切除后行人工椎间盘置换13例16个椎间盘，椎间cage融合22例24个椎间盘。术后3-7天下地活动。腰围固定3个月。结果所有患者随访6～26个月，平均18个月。术后腰痛及下肢痛症状明显缓解，均恢复正常生活或工作。VAS评分由术前平均72分，降至术后18分，随访6个月时6．5分。ODI评分由术前平均21．5分。降至随访6个月时3分。椎间隙高度从术前平均9．5mm增加至术后13．5mm。手术时间70-120min，出血量100-400ml。随访时未发现肠梗阻、逆行射精和假体位置移动。结论椎间盘源性腰痛由于临床和影像学表现不典型，常被误诊或漏诊，可结合腰椎MRI及椎间盘造影进行诊断。腰椎前路椎间盘切除人工椎间盘置换或椎间cage融合是治疗椎间盘源性腰痛的有效选择。

Diagnosis and treatment of discogenic low back pain

Objective To explore diagnostic method to discogenic low back pain and evaluate the effect of discectomy and artificial disc replacement or anterior lumbar interbody fusion (ALIF) via retroperitoneal approach. Methods From April 2004 to June 2006, 35 patients who underwent a failed conservative treatment for at least 6 months received surgery. The diagnostic criteria for discogenic low back pain were: 1) location of low back and leg pain not concordant to nerve roots innervations; 2) symptoms lasting for at least 6 months; 3) low disc intensity on T2 weight MRI; 4) positive discography with negative control on adjacent level; 5) articular process block to exclude pain derived from degenerative articular processes. The surgically treated patients aged 43.6 years on the average (ranging form 25 to 67). The treated discs located: 14 in L4-5, 16 in L5S1, 5 in both L4-5 and L5S1. After total discectomy 13 cases (16 discs) received artifical disc replacement and 22 cases (24 discs) received ALIF via retroperitoneal approach. 3 days postoperative the patients were allowed to leave bed with a brace, and the brace should be used for 3 months. Results All the cases were followed up for 18 months on the average (6-26 months), at the end of follow-up all the patients recovered normal social life and work without any symptoms. VAS decreased from 72 preoperatively to 18 postoperatively, and averaged 6.5 at 6 months after operation. ODI decreased from 21.5 preoperatively to averaged 3 at 6 months postoperatively. Disc height increased from 9.5 mm preoperatively to 13.5 mm postoperatively. Surgery time averaged 90 min (70-120 min), blood loss averaged 220 ml (100-400 ml). No ileus, retrograde ejaculation nor artificial disc translation was noticed during follow-up. Conclusion With atypical symptom discogenic low back pain which is easily misdiagnosed should always be kept in mind when atypical back and leg pain is encountered. Discography provides good differential diagnosis. Surgical treatment including artifical disc replacement and ALIF provides satisfactory outcome.