CT横断面测量分析腰椎管狭窄症与黄韧带肥厚的关系

背景:CT检查能够对椎管诸径线进行测量,对狭窄类型、形态、程度及其与周围组织关系进行分析,对腰椎管狭窄症具有明确诊断的作用.目的:采用一种自行设计的CT图像测量方法,分析腰椎黄韧带变性、肥厚与腰椎管狭窄症的关系.方法:黄韧带组织取材于3组病例:腰椎管狭窄症患者、腰椎问盘突出症患者及腰椎外伤骨折患者.通过切片苏木精-伊红染色观察3组病例黄韧带组织的病理学特点,以腰椎骨折组作为对照.腰椎管狭窄症与腰椎间盘突出症患者均常规进行了CT扫描,通过测量腰椎不同间隙在椎间盘平面以及椎弓上切迹平面关节囊部黄韧带的厚度,以及椎管左右侧的前后斜径,计算二者的比值,分析黄韧带的厚度与腰椎管狭窄症的关系.结果与结论:在腰椎管狭窄症组、腰椎间盘突出症组及腰椎骨折组的CT图像测量中,腰椎管狭窄症组黄韧带厚度平均〉(4.79±1.07)mm,黄韧带厚度与椎管前后斜径的比值≥0.41±0.08;腰椎间盘突出症组黄韧带厚度平均〉(3.18±0.71)m,黄韧带厚度与椎管前后斜径的比值≥0.26:±0.07,两组差异具有显著性意义(P〈0.01).腰椎管狭窄症组黄韧带厚度与椎管前后斜径的比值明显大于腰椎间盘突出症组及腰椎骨折组.提示在腰椎CT横断面上计测黄韧带厚度〉4 mm,黄韧带厚度与椎管前后斜径的比值≥0.41可能可以作为选择椎管狭窄症手术适应证的指标之一.     

胸椎获得性椎管狭窄致臀肌萎缩

【病例】女，32岁。因左侧臀肌萎缩3年人院。查体：左臀中、上神经支配区肌肉萎缩，痛觉减退，左侧足背侧痛觉减退。行CT检查示胸10、11黄韧带增厚并钙化，黄韧带厚度〉5mm，呈不规则突向椎管内而压迫硬膜囊和神经根。诊断：胸椎椎管狭窄。     

MRI影像测量腰椎黄韧带厚度与退变性椎间盘的关系

背景：腰椎间盘退变和黄韧带增厚都被认为是与老化的变化相关。然而,却很少见用MRI评价黄韧带肥厚自然病程的报道。目的：用MRI评价黄韧带厚度与年龄、椎间隙水平及椎间盘退行性变的关系。方法：MRI测量178例患有腰腿痛的患者的L2/3、L3/4、L4/5、L5S1水平712条黄韧带的厚度。并检验黄韧带厚度与年龄和椎间隙水平及椎间盘退行性变的关系。结果与结论：黄韧带的厚度随着年龄的增加而增加。然而,L4/5、L5S1水平黄韧带厚度的增加要比L2/3、L3/4水平明显。在L4/5水平,在20～29岁年龄段的患者黄韧带厚度已超过3mm。所有的患者如果L2/3水平黄韧带肥厚（〉3.0mm）,那么其余个水平的黄韧带均肥厚。在老年患者中,黄韧带的厚度和椎间盘的退行性变没有相关性。提示在20～29年龄段的患者黄韧带已经开始变厚,而黄韧带的增厚不是随着椎间盘的退变屈曲凸入椎管内的。L2/3水平黄韧带的厚度可以作为一个多水平腰椎管狭窄的指示剂。     

屈曲旋转牵引对人腰神经通道影响的断面解剖学研究

目的：探讨腰椎前屈旋转牵引对人腰神经通道的影响。方法：青壮年男尸10具．取腰骶段置入-20℃水柜中冰硬，用电动断层带锯制戚脊柱区腰骶段断层标本。矢状断层标本每具切成6片．分别经两侧的推间管外孔、两侧的关节突关节和正中矢状面。冠状断层标本每具切成4片，分别经关节突关节、椎间管和椎弓根。将制作好的断层标本常温下复温，固定于自制牵引器上．使L4～5间隙对准牵引间隙。先进行牵引、再成角，然后骶骨旋转。牵引距离0～50mm，成角度数0～18°．左右旋转角度0～10°。摄片观察矢状面L4～5、L6～S1矢状面关节突关节，椎间孔．冠状面关节突关节、黄韧带、神经根在上述动作下的变化。结果：矢状面断层水平牵引时，椎间隙增宽，椎间管(孔)增大，关节突关节面上下滑动，关节间隙增宽。牵引的同时腰椎前屈椎间隙后部增宽．椎间盘后突、黄韧带拉紧．椎间孔上2／3(神经根所在位置)增大．而下1／3由于椎间盘后突相对变小．此时若再加骶，向同侧旋转．椎间孔相对变小．关节突关节间隙进一步加大；骶，向对侧旋转．椎间孔变大．关节突关节受挤压。冠状面断层牵引时关节突关节增宽．前屈时关节间隙进一步增宽．黄韧带拉紧．神经根在神经通道内牵伸向上滑动，此时骶，向同侧旋转，关节间隙由于上下关节突的旋转运动使间隙变大，黄韧带牵伸．对侧旋转时也出现上述情况．但不如同侧明显。结论：屈曲旋转牵引可通过纠正关节突关节紊乱、松解神经根粘连．解除神经根在腰神经通道内的卡压达到治疗目的。     

MRI影像测量腰椎黄韧带厚度与退变性椎间盘的关系

背景:腰椎间盘退变和黄韧带增厚都被认为是与老化的变化相关。然而,却很少见用MRI评价黄韧带肥厚自然病程的报道。目的:用MRI评价黄韧带厚度与年龄、椎间隙水平及椎间盘退行性变的关系。方法:MRI测量178例患有腰腿痛的患者的L2/3、L3/4、L4/5、L5S1水平712条黄韧带的厚度。并检验黄韧带厚度与年龄和椎间隙水平及椎间盘退行性变的关系。结果与结论:黄韧带的厚度随着年龄的增加而增加。然而,L4/5、L5S1水平黄韧带厚度的增加要比L2/3、L3/4水平明显。在L4/5水平,在20～29岁年龄段的患者黄韧带厚度已超过3mm。所有的患者如果L2/3水平黄韧带肥厚(>3.0mm),那么其余个水平的黄韧带均肥厚。在老年患者中,黄韧带的厚度和椎间盘的退行性变没有相关性。提示在20～29年龄段的患者黄韧带已经开始变厚,而黄韧带的增厚不是随着椎间盘的退变屈曲凸入椎管内的。L2/3水平黄韧带的厚度可以作为一个多水平腰椎管狭窄的指示剂。     

微创经椎间孔腰椎椎体间融合术对邻近节段侵扰情况及术后影像学退变的影响

【目的】探讨微创经椎间孔腰椎椎体间融合术(MIS-TLIIF)对邻近节段侵扰情况及术后影像学退变(ASDed)的影响。【方法】本院收治的185例行MIS-TLIIF治疗的单节段退行性腰椎病变患者为研究对象。术后3个月,统计患者邻近节段关节突关节侵扰的发生情况,根据患者关节是否侵扰分为侵扰组与非侵扰组。探讨影响MIS-TLIIF术后邻近节段关节突关节侵扰的相关因素;随访3年,比较侵扰组与非侵扰组术后3年内ASDed的发生情况。【结果】术后3个月,邻近节段关节突关节发生侵扰64例,发生率为34.59%;未侵扰组121例。侵扰组体重指数(BMI)≥30 kg/m^(2),顶椎节段为L5,术前关节突关节角≥40°例数占比,关节突关节轴径、冠状径、矢状径高于非侵扰组(P<0.05);侵扰组术前螺钉内倾角、螺帽-上关节突间距低于非侵扰组(P<0.05)。Logistic多因素回归分析结果显示,顶椎节段为L5、BMI≥30 kg/m^(2)、术前关节突关节角≥40°均为MIS-TLIIF术后关节侵扰的影响因素(P<0.05)。随访3年,侵扰组失访2例,非侵扰组失访4例,随访率为96.76%,侵扰组术后3年内ASDed的发生率(56.45%)高于非侵扰组(39.32%)(P<0.05)。【结论】顶椎节段为L5、BMI≥30 kg/m^(2)、术前关节突关节角≥40°均为MIS-TLIIF术后邻近节段关节突关节侵扰的影响因素,且术后邻近节段关节突关节侵扰的患者术后3年内ASDed的发生风险较高。     

腰椎滑脱伴邻近节段变化的CT分析及临床意义

目的：探讨腰椎滑脱伴邻近节段结构变化的CT表现及临床意义。方法：回顾分析了244例腰椎滑脱及邻近节段结构变化的CT表现。结果：腰椎滑脱282个,最多见于第4腰椎;邻近椎间隙狭窄174个;椎体骨质增生328个;邻近椎间盘变化472个;邻近椎管狭窄46个、黄韧带肥厚26个、侧隐窝狭窄68个;邻近椎小关节退变619对。结论：越靠近滑椎的邻近节段变化越明显;滑椎以下节段的变化较以上节段的多。变化突出的首先是椎小关节和椎间盘,其次是椎间隙和骨质增生。全面认识腰椎滑脱及邻近节段的变化,对临床治疗具有重要的指导意义。     

无骨折脱位型颈脊髓损伤程度的影响因素研究

目的探讨无骨折脱位型颈脊髓损伤程度的影响因素。方法回顾性分析44例无骨折脱位的颈脊髓损伤病例的MRI资料。从矢状位和轴位图像观察记录：脊髓损伤的长度，脊髓损伤处椎间盘突出最大径，椎间盘突出类型，脊髓损伤处椎管前后径、黄韧带厚度、椎体后缘骨赘有无和脊髓损伤节段，同时记录患者的年龄和性别。以脊髓损伤长度为应变量，以性别、年龄、椎间盘突出最大径、椎管前后径、椎间盘突出类型、黄韧带厚度、椎体后缘骨赘有无、脊髓损伤节段为自变量，进行多因素相关性分析。结果①44例中，脊髓损伤的长度为3～22mm，椎间盘突出的最大径为4～8mm，椎管前后径为4～9mm，黄韧带厚度为2—7mm，脊髓损伤平面位于C。～C，水平。②颈脊髓损伤的程度与颈椎间盘突出程度、颈椎管径前后径、颈椎黄韧带的厚度、颈脊髓损伤节段相关，差异有显著性意义（P〈0、01）。结论无骨折脱位的颈脊髓损伤的程度与颈椎间盘突出程度正相关，与颈椎管径前后径负相关，与颈椎黄韧带的厚度、颈脊髓损伤节段相关，与椎间盘突出的类型、椎体后缘有无骨赘、性别和年龄无关。     

正常腰椎椎间小关节角度的CT测量研究

目的　为了研究正常人群腰椎间关节与矢、冠状面角度。方法　采用CT扫描 ,测量 10 0例正常人腰椎小关节与冠状面的角度 ,每 10岁为一年龄组 ,男女性别各区分 5组。结果　①相同腰椎节段不同年龄组之间椎间小关节与冠状面所成角度差异无显著性 (P >0 .0 5 ) ;②相同腰椎节段椎间小关节与冠状面所成角度 ,男女两性之间差别无显著性 (P >0 .0 5 ) ;③椎间小关节与冠状面的角度大小与腰椎的节段呈负相关 ,从L1,2 至L5S1水平 ,椎间小关节与冠状面角度有逐渐减小或与矢状面的角度有逐渐增大的趋势 ;④L1,2 ～L3 ,4椎间小关节与冠状面所成的角度为 62 .1°～ 5 3 .1° ,L4,5～L5S1为 44 .5～ 3 7.7°。结论　CT是观察腰椎小关节结构较准确的方法。L1,2 ～L3 ,4椎间小关节角度偏矢状面 ,L4,5～L5S1椎间小关节角度更偏冠状面。     

腰椎小关节方向性与腰椎间盘突出症

背景：腰椎小关节及其对称性与腰椎间盘突出之间是否存在关系,文献报道争议很大。目的：测量分析腰椎小关节方向性与腰椎间盘突出的关系。方法：收集因腰腿痛行CT检查的169例患者,L4/5腰椎间盘突出35例,L5/S1腰椎间盘突出67例,无间盘突出对照组67例。在CT终端机上选取L3～S1椎间隙的远侧椎体上终板层面,测量3个节段的腰椎小关节角。结果与结论：①L4/5和L5/S1腰椎间盘突出组L3/4、L4/5、L5/S1每个节段腰椎小关节角左侧均大于右侧（P〈0.05）;各组小关节前内侧角和后外侧角两侧相比差异均无显著性意义（P〉0.05）。②各节段腰椎小关节角、前内侧角、后外侧角3组之间比较没有显著性差异（P〉0.05）。③各组腰椎小关节角、后外侧角自L3/4至L5/S1节段均逐渐增大（P〈0.05）;而前内侧角L4/5节段最大,L3/4节段最小（P〈0.05）。提示腰椎间盘突出与腰椎小关节角左右侧不相等有关;腰椎小关节角和后外侧角自L3/4至L5/S1逐渐更偏向冠状位,而内侧角在L4/5节段更偏冠状位,可能与腰椎管狭窄的发病有关。     

黄韧带退变与腰椎管狭窄症椎管形态的变化

背景：目前研究发现Ⅰ型及Ⅱ型胶原在结缔组织的增殖与分化、软骨的形成和吸收等过程中起十分重要的作用。目的：探讨腰椎黄韧带退变与腰椎管狭窄症椎管形态变化的相关性。方法：收集中央型腰椎管狭窄症36例和外伤性腰椎骨折20例患者的黄韧带标本分别为实验组和对照组,采用酶联免疫吸附法测定Ⅰ型和Ⅱ型胶原;CT测量腰椎硬膜横截面积;黄韧带行苏木精-伊红和Masson染色,观察组织病理学变化。结果与结论：实验组黄韧带厚度、Ⅰ型及Ⅱ型胶原含量高于对照组,腰椎硬膜横截面积和Ⅰ型/Ⅱ型比值低于对照组（P〈0.05）;病理学显示实验组黄韧带弹性纤维排列紊乱,数量减少,胶原纤维增生。提示腰椎黄韧带Ⅰ型、Ⅱ型胶原含量及Ⅰ型/Ⅱ型比值发生改变,可能引起黄韧带厚度增加,导致椎管横截面积减小,参与腰椎管狭窄症的发生。     

经椎板间隙内窥镜下分开黄韧带切除椎间盘

背景：经椎板间隙途径内窥镜下间盘切除需游离黄韧带,后者如果辅助连续扩张器及工作通道进行操作,无论切口多小（甚至3—5mm）,均可完整保留黄韧带。目的：介绍经椎板间隙内窥镜下分开黄韧带切除椎间盘的应用。方法：采用经椎板间隙内窥镜下分开黄韧带椎间盘切除治疗16例男性患者和14例女性患者,平均年龄（48±15）岁,主诉单下肢根性疼痛,病变位于L3-4间隙1例,L45间隙13例,L5-S1间隙16例,其中间盘向上脱出游离者4例,向下脱出游离者7例,所有患者术中电生理监测,在工作通道中分开黄韧带,间盘切除撤出工作通道后,黄韧带可自行复位。结果与结论：操作时间20-40min,治疗后随访时间（149±108）d。治疗中电生理监测无异常,椎间盘切除症状均得以改善。经核磁随访显示：脱出间盘组织已完全摘除,黄韧带保留完整,所有患者无相关并发症。结果可见经椎板间隙内窥镜下分开黄韧带切除脱出的间盘组织,是一种可行的操作方式。     

胸椎黄韧带骨化症的手术治疗

目的 :探讨胸椎黄韧带骨化症的手术治疗方法与技巧 ,以提高胸椎黄韧带骨化症的诊疗水平。方法 :胸椎黄韧带骨化症 2 1例 ,均行胸椎后路节段全椎板切除椎管扩大脊髓减压术。结果 :本组术后平均随访 1 5a ,优 16例 ( 76 2 %) ,良 5例 ( 2 3 8%)。疗效满意。结论 :早期诊断并尽早手术是治疗胸椎黄韧带骨化症的关键。     

Chronic subdural hematoma coexisting with ligamentum flavum hematoma in the lumbar spine: a case report

We present a case of a chronic spinal subdural hematoma combined with a ligamentum flavum hematoma in the lumbar spine treated surgically. An 83-year-old woman receiving antiplatelet medicine due to an angina suffered from pain in her lower extremity and gait disturbance after a backward fall. Radiological findings including magnetic resonance imaging (MRI) revealed hematoma in the ligamentum flavum at the level of L2 - L3 and a chronic subdural hematoma at the level from L3 to L5. Laminectomy through L2 to L5 was performed and a hematoma existing in the ligamentum flavum and cystic mass was removed. A chronic subdural hematoma was spontaneously evacuated after splitting of the dura mater and an intact arachnoid membrane was observed with no leakage of cerebrospinal fluid. Her clinical symptoms completely disappeared after surgery. To the best of our knowledge, this is the first case of combination of chronic subdural hematoma and ligamentum flavum hematoma in the lumbar spine treated by surgery. Chronic spinal subdural hematoma and hematoma in the ligamentum flavum should be considered as a cause of progressive nerve root compression in patients with anticoagulant therapy, and an appropriate pre-operative diagnosis would be needed to achieve complete decompression of subdural and epidural hematoma.     

The use of ultrasound to identify pertinent landmarks for lumbar puncture

Objective

This study was conducted to assess the ultrasound's (US's) ability to identify pertinent landmarks for lumbar puncture (LP) in patients of various body mass indices (BMIs) and establish spatial relationships of pertinent LP landmarks across BMIs.

Methods

In this institutional review board–approved cross-sectional study, we calculated the BMIs of eligible patients and then categorized them as normal (BMI ≤24.9), overweight (BMI 24.9-30), or obese (BMI ≥30). We recorded the difficulty in palpating traditional LP landmarks. Identification and measurement of the spatial relationships of the sacrum; spinous processes of lumbar vertebrae L3, L4, and L5; ligamentum flavum; and the spinal canal by US was attempted.

Results

Successful identification of pertinent structures (L4-L5 spinous processes and the spinal canal) occurred in 100% of patients with normal BMI, 95% of those who were overweight, and 74% of those who were obese (P = .011). Difficulty in palpating landmarks was noted in 5% of patients with normal BMI, 33% of those who were overweight, and 68% of those who were obese (P < .0001). In subjects with difficult-to-palpate landmarks, US identified pertinent structures in 16 of 21 (76%; 95% confidence interval, 53-92). The average distance from skin to ligamentum flavum was 44 mm in those with normal BMI, 51 mm in those who were overweight, and 64 mm in those who were obese (P < .00001); measurements between spinous processes did not vary by BMI. Overall, there was a moderate correlation (0.62) between BMI and the distance from skin to ligamentum flavum.

Conclusion

The usefulness of US in identifying structures for LP is inversely related to BMI. Even with this limitation, US is still able to identify obese patients' pertinent landmarks almost 75% of the time. In addition, US may be helpful in identifying pertinent structures for LP in those patients with difficult-to-palpate landmarks. In patients who were obese with structures not palpable by hand or identifiable by US, other modalities should be considered.     

Numerical investigation of the relative effect of disc bulging and ligamentum flavum hypertrophy on the mechanism of central cord syndrome

BackgroundThe pathogenesis of the central cord syndrome is still unclear. While there is a consensus on hyperextension as the main traumatic mechanism leading to this condition, there is yet to be consensus in studies regarding the pathological features of the spine (intervertebral disc bulging or ligamentum flavum hypertrophy) that could contribute to clinical manifestations.MethodsA comprehensive finite element model of the cervical spine segment and spinal cord was used to simulate high-speed hyperextension. Four stenotic cases were modelled to study the effect of ligamentum flavum hypertrophy and intervertebral disc bulging on the von Mises stress and strain.FindingsDuring hyperextension, the downward displacement of the ligamentum flavum and a reduction of the spinal canal diameter (up to 17%) led to a dynamic compression of the cord. Ligamentum flavum hypertrophy was associated with stress and strain (peak of 0.011 Mpa and 0.24, respectively) in the lateral corticospinal tracts, which is consistent with the histologic pattern of the central cord syndrome. Linear intervertebral disc bulging alone led to a higher stress in the anterior and posterior funiculi (peak 0.029 Mpa). Combined with hypertrophic ligamentum flavum, it further increased the stress and strain in the corticospinal tracts and in the posterior horn (peak of 0.023 Mpa and 0.35, respectively).InterpretationThe stenotic typology and geometry greatly influence stress and strain distribution resulting from hyperextension. Ligamentum flavum hypertrophy is a main feature leading to central cord syndrome.     

Upper thoracic myelopathy caused by delayed neck extensor weakness in myotonic dystrophy

Myotonic dystrophy is the most common autosomal dominant myopathy in adults. Our patient, a 41 year-old female suffering from myotonic muscular dystrophy, developed upper thoracic myelopathy due to hypertrophy of the ligamentum flavum and the posterior longitudinal ligament. She had a typical hatchet face and ptosis with "head hanging forward" appearance caused by neck weakness. Motor weakness, sensory changes and severe pain below T4 level, along with urinary incontinence began 3 months ago. Genetic and electrodiagnostic studies revealed myotonic dystrophy type 1. Magnetic resonance imaging of the spine showed loss of cervical lordosis and spinal cord compression due to hypertrophied ligamentum flavum and posterior longitudinal ligament at T1 to T3 level. We concluded that her upper thoracic myelopathy was likely related to the thickness of the ligamentum flavum and posterior longitudinal ligament due to repetitive mechanical stress on her neck caused by neck muscle weakness with myotonic dystrophy.