对腰椎Schmorl结节形成的探讨

目的：探讨腰椎Schmorl结节的形成及其与下腰痛和椎间盘变的关系。方法：12个腰椎Schmorl结节来自10例严重下腰痛伴或不伴坐骨神经痛患者。均行腰椎X线摄片和CT扫描，并将术中完整切除的12个Schmorl结节病灶标本组织学检查，结果：CT扫描发现Schmorl结节形成区软骨终板下有一类圆形、多囊状骨密度不规则区，边缘通常硬化，呈骨坏死改变。组织学检查发现，在CT片上显示的骨密度不规则区实际上是骨坏死区，骨坏死区表面的软骨终板通常完整，软骨下髓腔内脂肪细胞消失，大量纤维组织增生和缺血性纤维软骨形成，小梁骨内骨细胞消失或死亡，形成空骨陷窝，结论：X线片显示的经典Schmorl结节实际上是椎体软骨终板下的片状骨坏死,灶软骨终板通常是完整的，有无髓核突出与Schmorl结节形成无关。     

腰椎椎体终板后缘骨坏死病理演变过程的观察

目的：研究腰椎椎体终板后缘骨坏死的病理演变过程和Schmorl结节的形成机制。方法：对13例腰椎椎体终板后缘骨坏死症患者腰椎后路减压术中切除的完整病灶标本行组织病理学检查，观察不同年龄和不同阶段病变的组织学变化。结果：1例儿童和6例成人患者发病时间较短，其病灶的组织学特征表现为软骨终板明显增厚、变性，软骨终板下的骨组织坏死，部分坏死区为纤维组织替代，局部出现修复性新生骨。另6例成人患者发病时间较长，其病灶的组织学特征表现为软骨终板下的成熟骨组织。结论：腰椎椎体终板后缘先发生软骨终板下的骨组织坏死，然后出现修复性新生骨，新生的骨组织由于硬度较低，在压力的作用下发生塌陷，随着爬行替代的完成及骨骼的成熟，逐渐形成凸向椎管内的骨块，表明病变已发展至晚期，处于相对静止状态。腰椎椎体终板后缘骨坏死的病理演变过程实际上也是发生于腰椎椎体终板后缘Schmorl结节的形成过程。     

Schmorl结节与椎间盘退变和腰痛相关性的研究进展

1927年,德国医生Schmorl第一次描述了Schmorl结节及其形成理论:由椎间盘的髓核组织经软骨终板的薄弱区疝入椎体内所形成的椎间盘改变.长期以来,经典的Schmorl结节定义至少包含两个部分:一是椎体软骨终板的破裂;二是髓核通过破裂的软骨终板突向软骨下松质骨内.但至今为止,Schmorl结节的发生因素、分布规律以及与椎间盘退变、腰痛的关系尚不明确.现将当前国内外关于Schmorl结节与椎间盘退变及腰痛相关性的研究进展综述如下.     

非典型Scheuermann病和颈椎脊髓病

目的:对非典型Scheuermann病所致的颈椎脊髓病的病理、影像和临床特点,与颈椎间盘突出的关系进行比较,以便评价和指导治疗.方法:颈椎脊髓病84例中有12例MRI所见确切符合非典型Scheuermann病征.行后路椎板切除减压术10例;2例移位椎间盘后方原有片状高信号影者行前路一个节段减压植骨融合术.结果:非典型Scheuermann病组和对照组年龄差异有显著意义.X线可显示终板不平整或硬化,椎体形状不规则.MRI可见单一或多个椎间隙的软骨结节,或终板不平整,相应椎体缘显示不规则高信号.结论:软骨结节为特征的非典型Scheuermann病是椎骨常见的发育异常,累及椎体的次发骨骺,多合并椎间盘向后移位、突出,是颈椎脊髓病常见的病理类型.     

腰椎椎体后缘终板骨坏死症

目的：探讨腰椎椎体后缘终板骨坏死症的发病机制和诊断治疗。方法：21例病人,以腰腿痛症状为主,少数伴有间隙性跛行和马尾压迫症状,平均发病时间4．5年。X线检查发现下腰椎管内有一与椎体后缘相连的小骨块,CT扫描清晰显示椎体后缘有类圆形或多囊状骨质缺损,周边形成硬化带,后方骨质凸入椎管内,或压迫硬膜囊或压迫神经根。MRI显示对应椎间盘大都呈严重退变状态。本组病人全部行手术治疗,将凸入椎管内骨质凿除和对应突入的椎间盘摘除,部分病人行手术节段的植骨融合和内固定。结果：术中肉眼所见,切除的凸入骨质都与纤维环边缘相连在一起,骨缺损区为纤维软骨组织和骨性组织所充填。术后21例病人均获随访,时间6个月－3年,平均18个月。18例腰腿痛症状消失,3例有轻度腰痛,3例大小便功能基本恢复正常。结论：腰椎受异常应力或过度活动或其它一些尚不明的原因引起椎体终板缺血性变性、坏死,终板内形成骨软骨性坏死缺损区（Schmorl结节）,终板缺损区四周骨软骨组织在压力作用下增生、硬化。向后增生的骨质凸入椎管压迫硬脊膜囊内马尾神经或腰神经根,导致了本病的发生。因此将本病命名为“腰椎椎体后缘终板骨坏死症”能比较准确地反映它的病理本质。     

实验性椎间盘退变的放射影像学与病理学观察

目的 研究椎间盘退变过程中，椎间盘退变的放射影像学与病理学改变。方法 选用40只新西兰大白兔随机分为2组，实验组切除兔腰椎间棘间、棘上韧带及棘突、关节突，造成力学失稳状态诱导形成椎间盘退变模型。术后一周、3个月、8个月时摄腰椎正、侧位X线片，观察腰椎影像学变化。第3个月、8个月时取腰椎间盘，进行组织检查，评定椎间盘退变的病理改变情况。结果 模型建立后，3个月、8个月的X线片显现对照组无明显改变，实验组腰椎后突畸形，椎间隙狭窄，随着时间延长椎体软骨终板钙化更加明显。组织学观察发现，实验组随术后时间延长，髓核由椎间盘内脱出，并伴有椎间盘两侧软骨终板的纤维化即软骨终板发生退变。结论 椎体软骨终板的退变是椎间退变早期的主要表现方式。     

腰椎椎体后缘终板骨坏死症42例报告

目的探讨腰椎椎体后缘终板骨坏死症的发病机制和诊断治疗方法。方法42例患者，以腰腿痛症状为主，少数伴有间歇性跛行和马尾压迫症状，平均发病时间7．6年。X线检查发现下腰椎管内有一与椎体后缘相连的小骨块，CT扫描清晰显示椎体后缘有类圆形或多囊状骨质稀疏区，周边形成硬化带，后方骨质凸入椎管内，或压迫硬膜囊或压迫神经根。MRI显示对应椎间盘大都呈严重退变状态。本组全部行手术治疗，将凸入椎管内骨质切除和对应间隙的退变髓核摘除，短节段椎弓根螺钉系统内固定、椎体间植骨融合。术中完整切除的11例标本作组织病理学检查。结果术中肉眼所见，切除的凸入骨质为松质骨组织，周围硬化带为骨皮质。组织学所见病灶区为小梁骨和髓腔，表现为不同程度的骨坏死，无髓核组织成分充填于骨坏死区。术后所有患者均获随访，时间3月-7年，平均3.8年。38例腰腿痛症状消失，4例仍有轻度腰痛，2例伴有马尾功能障碍者大小便功能基本恢复正常。结论腰椎受异常应力或过度活动或其它一些尚不明的原因引起椎体终板后缘缺血性变性、坏死，引起腰痛。向后塌陷、增生的骨质凸入椎管压迫硬脊膜囊内马尾神经或腰神经根，导致神经根性症状。因此将本病命名为“腰椎椎体后缘终板骨坏死症”能比较准确地反映它的病理本质。     

腰椎后缘骨内软骨结节：附11例报告

作者分析了１１例腰椎后缘骨内软骨结节的临床，Ｘ线及ＣＴ表现，多为青壮年，主要症状为腰腿痛，均为单处发病。典型的Ｘ线表现为发病椎体后下缘有一骨质缺损，其后有一骨块突入椎管。ＣＴ扫描均见椎体后缘类圆型或多囊状骨质缺损，为典型的软骨结节（许莫氏结节）结节的骨性后壁凸入椎管构成侧位Ｘ线片上的骨块，作者认为腰椎后骨内软骨结节多形成于青少年时期，是由椎间盘组织经破裂的软骨终板突入椎体后缘的松质骨内所致。当症状     

实验性椎间盘退变的放射影像学与病理学观察

目的　研究椎间盘退变过程中 ,椎间盘退变的放射影像学与病理学改变。方法　选用 4 0只新西兰大白兔随机分为 2组 ,实验组切除兔腰椎间棘间、棘上韧带及棘突、关节突 ,造成力学失稳状态诱导形成椎间盘退变模型。术后一周、 3个月、 8个月时摄腰椎正、侧位X线片 ,观察腰椎影像学变化。第 3个月、 8个月时取腰椎间盘 ,进行组织检查 ,评定椎间盘退变的病理改变情况。结果　模型建立后 ,3个月、 8个月的X线片显现对照组无明显改变 ,实验组腰椎后突畸形 ,椎间隙狭窄 ,随着时间延长椎体软骨终板钙化更加明显。组织学观察发现 ,实验组随术后时间延长 ,髓核由椎间盘内脱出 ,并伴有椎间盘两侧软骨终板的纤维化即软骨终板发生退变。结论　椎体软骨终板的退变是椎间退变早期的主要表现方式。     

腰椎侧凸软骨终板退变的X线表现及临床意义

目的探讨腰椎侧凸软骨终板退变的X线表现及其临床意义。方法收治的退变性腰椎侧凸43例,均行X线平片检查,观察其影像学特点。分别测定凹侧和凸侧每个椎体头、尾侧关节软骨的钙化层厚度,均数行t检验。结果 X线片显示椎间隙楔形样变、椎间隙狭窄、终板钙化和骨赘形成。退变的软骨终板潮标明显前移,钙化和骨化层增厚,形成突向外侧的椎体边缘的骨赘。凹侧和凸侧椎间盘关节软骨钙化层厚度分别为(35±8)μm和(72±12)μm,差异有统计学意义(P0.01)。结论软骨终板退变较其他椎间盘退变的X线征象出现早,详细研究其X线特点,对于诊断退变性腰椎侧凸和设计合理的手术方式具有重要的指导作用。     

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。     

髓核成形术治疗腰腿痛患者的选择(附45例临床初步报告)

目的:探讨髓核成形术治疗腰腿痛患者的最佳适应证。方法:应用髓核成形术治疗45例腰腿痛患者,男26例,女19例,平均年龄32岁(18~46岁),病程平均2年(5个月~4年),其中腰痛伴有下肢放射痛40例。手术前先进行椎间盘造影,然后行髓核成形术治疗,比较手术前后疼痛症状并进行疗效评定。结果:术后随访3~20个月,平均12个月。优良率为80%(36例);腰痛伴有下肢放射痛者有效率为85%;椎间盘造影阳性者有效率为92%。无效8例,术后加重1例。结论:在下列情况下应用髓核成形术治疗腰腿痛患者将提高临床的有效率:(1)腰痛伴有下肢放射痛症状的患者;(2)影像学上表现为侧方小的椎间盘突出,以神经根刺激症状为主要症状者;(3)椎间盘造影阳性的患者。     

腰椎间盘造影在椎间盘源性腰痛诊治中的应用

[目的]探讨椎间盘造影对椎间盘源性腰痛的诊断价值及椎间融合手术的疗效。[方法]2003年10月～2004年6月间对45例具有椎间盘源性腰痛症状的病人进行了椎间盘造影,共101个椎间盘,45例中依据椎间盘造影的结果行椎间360°融合手术18例,保守治疗27例。所有病例全部进行了MRI和CT检查。观察造影图像和MRI表现,记录诱发痛,随访手术组和保守组的疗效。[结果]45例中2l例出现了诱发痛(47%),101个造影椎间盘中有21个椎间盘出现诱发痛(21%);21例诱发痛阳性的病人中18例接受了360°融合手术,随访时间平均6个月(3～10个月),术后1l例病人腰痛完全消失(11/18,优:61%),4例疼痛基本消失(4/18,良:22%),3例腰痛无变化(3/18,差:17%);3例诱发痛阳性的病人和24例诱发痛阴性的病人行保守治疗,在同期随访中,1例腰痛完全消失(1/27,优:4%),10例疼痛基本消失(10/27,良:37%),16例疼痛没有变化甚至加重(16/27,差:59%)。[结论]腰椎间盘造影对椎间盘源性腰痛的诊断具有一定的敏感性,对确定为疼痛原因的椎间隙实施椎间360°融合手术可以消除病人的疼痛,近期效果比保守治疗好。     

腰椎间盘造影在椎间盘源性腰痛诊治中的应用

目的应用椎间盘造影对椎间盘源性腰痛进行诊断并评价椎间融合手术的疗效。方法2003年10月—2004年6月间对45例具有椎间盘源性腰痛症状的患者进行了椎间盘造影,共101个椎间盘。所有病例全部进行了MRI和CT检查。观察造影图像和MRI表现,记录诱发痛、手术和保守治疗的疗效。结果45例患者中21例出现了诱发痛（47％）,101个造影椎间盘中有21个椎间盘出现诱发痛（21％）;21例诱发痛阳性患者中18例接受了360。融合手术,随访时间平均16个月（15～23个月）,术后11例患者腰痛完全消失（11／18,优：61％）,4例疼痛基本消失（4／18,良：22％）,3例腰痛无变化（3／18,差：17％）;3例诱发痛阳性患者和24例诱发痛阴性患者行保守治疗,在同期随访中,1例腰痛完全消失（1／27,优：4％）,10例疼痛基本消失（10／27,良：37％）,16例疼痛无变化甚至加重（16／27,差：59％）。结论腰椎间盘造影对椎间盘源性腰痛的诊断具有一定的敏感性,但不是一个特异性诊断方法;对确定为疼痛原因的椎间隙实施椎间360。融合手术可以消除患者的疼痛,中期效果好。     

术后重症腰椎间盘炎治疗方法的比较

目的探讨重症腰椎间盘炎的有效、省时、经济的治疗方法。方法回顾分析1992年10月～2000年10月诊治的15例重症腰椎间盘炎患者的治疗过程,比较前路经腹膜后入路病变间隙残余椎间盘切除术和传统的保守治疗方法在疗效、住院时间、治疗费用方面的差异。结果经保守治疗组症状持续时间平均3.8个月(3～5个月),住院时间平均1.5个月(1～3个月),住院费用平均3.25万元(2～6万元);手术治疗组在术后3～5d严重腰痛明显缓解,不需再使用止痛剂,住院时间平均16.5d(14～23d),住院费用平均0.8万元(0.6～1.5万元)。两者比较差异有显著性意义(P<0.01)。结论对重症腰椎间盘炎患者采用传统的保守治疗方法疗效差、费用高、住院时间长;而采用前路经腹膜后病变间隙残余椎间盘切除术则能迅速解除症状、缩短住院时间、降低费用,是治疗重症腰椎间盘炎最为有效的手段。     

腰椎棘突间稳定器(Wallis)早期疗效分析

目的评价棘突间动力稳定器(Wallis)治疗腰椎退行性疾病的即时(出院前)和短期效果,探讨其适应证选择和手术技巧。方法2008年7月～2009年7月,36例腰椎退行性疾病患者共植入Wallis38套(L2/31套,L3/44套,L4/533套)。其中腰椎间盘脱出症(中央型)8例,腰椎盘脱出伴突出2例,腰椎间盘突出症伴黄韧带增厚10例,腰椎间盘突出症伴侧隐窝狭窄8例,单节退变性椎管狭窄症4例,Topping off4例。采用北美脊柱学会(North American Spine Society,NASS)问卷评价出院前患者及随访患者对手术的满意度,同时测量手术前后椎间盘终板间高度。结果手术时间30～90min,平均60min;术中出血量10～100ml,平均50ml。出院前NASS问卷显示,32例患者(88.9%)认为腰部坚实有力,术前酸乏症状消失或明显减轻。术前终板间高度降低的37个椎间盘中有31个(84%)获得1～3mm的改善。36例患者均获随访,随访时间1～12个月,平均7个月。随访期间NASS问卷总满意度为92.5%,未出现Wallis引起的并发症。结论Wallis的即时和近期疗效满意,是治疗腰椎退变性疾病的有效方法。     

Video-assisted ALIF with cage and anterior plate fixation for L5-S1 spondylolisthesis

INTRODUCTION: Spondylolysis and spondylolisthesis grade 0, 1, and 2 are mainly asymptomatic but with aging process and different factors some back pain can occur and lead to chronic low back pain. The conservative treatment with physiotherapy and steroid injection is the gold standard but in some cases is not efficient enough and a surgical treatment is proposed. OBJECTIVES: The goal of this study is to propose a new technique to treat grade 0, 1, and 2 spondylolisthesis with an anterior video-assisted fusion and stabilization. METHODS: Twenty patients with chronic low back pain since more than 2 years and resistant to conservative therapy were included in this protocol. Clinical signs and radicular pain were noted. They were evaluated preoperatively and postoperatively until the last follow up using Oswestry score and visual analog score (VAS) for leg and back pain. X-rays showed grade 0 (8 cases), 1 (10 cases), and 2 (2 cases) spondylolisthesis according to Meyerding classification with disc collapse (bulging disc). MRI showed in all cases a disc degeneration with at least black disc and/or endplates changes with Modic I or II. All patients were operated using an anterior video-assisted retroperitoneal approach, with discectomy and fusion using an anterior impacted cage filled with autologous cancellous bone from the iliac crest and an anterior fixation with a triangular plate (Pyramid, Medtronic, Memphis). The follow up at 3, 6, 12, and 24 months was done with clinical and radiologic evaluation. In case of problem a computed tomography scan was performed. RESULTS: There were 11 women and 9 men, with and average age of 39 years old and a BMI of 25.6. All spondylolistheses occurred at level L5. The average slippage was 19%. All L5S1 discs were black, 8 had a Modic I changes in the endplates and 2 had Modic II. The shape of L5 vertebra was abnormal (trapezoidal) in 7 cases. All anterior approaches were performed without vascular, urologic, or digestive complication. Blood loss was inferior to 100 mL. All patients had a soft brace for 8 weeks postoperatively. There was no retrograde ejaculation for the 9 men and no sexual dysfunction reported by the women. One patient had no pain relief and was reoperated for posterior pedicular screw fixation. It was obvious that there was a pseudarthrosis even after the posterior fixation and an anterior transperitoneal revision was performed with the removal of the interbody device and iliac crest bone graft packing alone. A propioni bacterium acnes germ was found responsible for the anterior nonunion. This revision surgery with antibiotics treatment was successful. One of the patients with grade 2 had an additional posterior screw fixation with a minimally invasive pedicle screw system (Sextant, Medtronic, Memphis). Nineteen patients had a good fusion at 2 years follow-up (95%), mean Oswestry score improved from 74% preoperative to 21% postoperative at the last follow-up. Visual analog score (VAS) for back pain improved from 6.5 to 2.7 and VAS for leg pain improved from 6.2 to 3.4. Satisfaction rate was 90%. All active patients except two, were back to work at an average of 5.5 months (6 wk to 1 y). The 2 patients still not working were the nonunion and a work compensation. CONCLUSIONS: The results of this technique compare favorably with posterior stabilization and fusion (posterior lumbar interbody fusion and postero-lateral fusion) reported in the literature. Unlike posterior lumbar interbody fusion, however, it seems that the complication rate due to the approach is much lower, the fusion rate is similar. Grade 2 SPL is the limitation of the technique. The main advantage of the technique is to avoid posterior muscle damage and a quick recovery with no blood loss. Preservation of adjacent level disease can be assessed only after long-term follow-up.     

Diagnostic modalities for the evaluation of pediatric back pain: a prospective study

The commonly taught premise that pediatric back pain frequently has an underlying diagnosis has been recently challenged. Previous studies have suggested that up to 84% of children with low back pain have associated serious diagnoses. Children with back pain, therefore, have frequently undergone exhaustive diagnostic testing. There have been few prospective studies, however, about the diagnosis rate and appropriate diagnostic methods for back pain in children. This study prospectively examines the rate of diagnosis for pediatric back pain and the value of various diagnostic studies for this problem. METHODS: All patients presenting to our institution with a chief complaint of back pain were evaluated for the study. Inclusion criteria consisted of age younger than 18 years, no previous back surgery, no previous diagnosis given, and duration of pain longer than 3 months. Seventy-three patients were enrolled in the study, and an algorithm was created for diagnostic evaluation. The algorithm incorporated commonly used diagnostic techniques including radiographs, magnetic resonance imaging, computed tomography, bone scan, and laboratory studies. The end point was considered to be either (1) a definitive diagnosis or (2) no diagnosis and no symptomatic or clinical changes during a 2-year period. RESULTS: Fifty-seven patients (78.1%) ended with no diagnosis. Of the remaining 16, 9 were diagnosed with spondylolysis with or without spondylolisthesis. Three other patients had abnormal laboratory values but no definitive diagnosis. Other diagnoses included Scheuermann disease (n = 2), osteoid osteoma (n = 1), and a herniated disk (n = 1). CONCLUSIONS: This investigation is the largest prospective study of diagnostic modalities in pediatric back pain to date. Contrary to most of the previously published data, most of our patients ended the study with no definitive diagnosis. In addition, the most of the diagnoses were made at initial physical examination or via initial plain radiographs. No diagnoses were missed using our algorithm. These results suggest that pediatric back pain frequently does not carry a definitive diagnosis and that exhaustive diagnostic protocols may not be necessary for this problem. LEVEL OF EVIDENCE: Prospective study; Level 2 clinical evidence.