颈椎间盘突出症介入治疗的现状和进展

【摘要】 颈椎间盘突出症（CDH）临床上较为常见, 多发于中老年人,表现为头、颈、肩及上肢的疼痛或麻木感,可伴有下肢的行走无力及步态不稳,随着病情的进展,可导致患者大小便功能障碍,使患者的生活质量降低。近年来随着介入技术的发展,其已成为治疗CDH的趋势,介入治疗因其具有损伤小、恢复快、疗效好等优点,易被多数医患接受。现阶段常用的微创介入治疗措施主要有经皮激光椎间盘减压术（PLDD）、髓核化学溶解术、臭氧（O3）髓核溶解术、射频热凝靶点消融术、低温等离子射频消融术、经皮内镜颈椎间盘切除术（PECD）以及经皮穿刺颈椎间盘髓核切除术（PCD）,可根据患者的病情以及需求选择相应的微创介入方式,本文就这7种介入治疗方式的临床应用及研究现状加以综述,为临床工作提供参考。     

腰椎关节突关节基础研究新进展

腰椎关节突关节是脊柱连接的重要关节。临床上往往仅注重椎间盘突出症,而忽略腰椎关节突关节炎引起的症状。近年来,随着医学影像学的飞速发展,人们越来越重视对腰椎关节突关节的研究,在解剖学、生物力学以及病因学上都取得了一些新的进展。     

腰椎SPECT显像对关节突关节源性下腰痛的诊断价值

目的 探讨腰椎SPECT显像对关节突关节源性下腰痛的诊断价值.方法 2006年7月至2007年3月共35例下腰痛患者被纳入该研究,根据腰椎SPECT显像结果分为腰椎关节突关节阳性组和阴性组.阳性组行关节突关节注射治疗,阴性组行保守治疗或手术治疗.记录治疗前腰痛情况和显像阳性组随访治疗后1,3及6个月的腰痛情况,并比较分析,阴性组记录相关治疗和治疗后6个月的腰痛情况.采用SPSS 10.0软件,2组患者治疗前相应参数比较用完全随机设计的成组比较t检验,显像阳性组患者治疗前后视觉模拟比例尺(VAS)评分比较采用配对t检验.结果 腰椎SPECT显像检出关节突关节病变15例,随访行关节突关节注射治疗的14例患者(另1例因治疗后在外院又行手术治疗,排除在外),治疗后1,3和6个月疼痛缓解人数比例分别为12/14(85.7%),11/14(78.6%)和7/14(50.0%).治疗后1,3和6个月疼痛评分[VAS分别为(31.33±7.69),(38.21±10.67),(44.64±12.63)mm]与治疗前[VAS为(69.67±5.81)mm]相比差异有统计学意义(t值分别为12.55,8.36,5.54,P均<0.01).显像阴性20例,其中手术治疗3例,保守治疗17例,随访6个月14例(70.0%)患者治疗有效.结论 腰椎SPECT显像有助于检出关节突关节源性下腰痛,筛选适合行关节突关节治疗的患者,以减轻疾病症状,提高患者生活质量.     

腰椎关节突关节功能紊乱的X线诊断研究

通过关节突关节位,对53例经CT证实无椎间盘脱出及椎管狭窄病人进行了研究,发现了11种不同的X线征象,其中,以关节错位、关节面硬化、关节间隙变窄及椎弓峡部骨质硬化最常见。为腰椎关节突关节功能紊乱引起腰腿痛病人的诊断和治疗提供了可靠的X线征象。     

腰椎关节突关节直面小角度的CT特征与临床意义

目的: 探讨腰椎关节突关节直面小角度的CT特征及其临床意义.材料和方法: 收集86例腰腿痛的CT片,排除椎体、椎间盘等病变,以关节突关节角大小分为小关节角组和大关节角组,对照分析其关节突关节形态、退变程度、附属软组织病变、局部治疗效果.结果: 小关节角组(46例)比大关节角组(40例)退变程度轻、软组织病变不明显、局部保守治疗疗效良好.结论: 关节突关节角度的大小和形态是引起腰腿痛的重要解剖基础之一.     

腰椎关节突关节退变的影像学表现及意义

具有统计学意义（P＜0．01）;此外,腰椎间盘的退变同小关节的骨关节炎同样呈现出正相关的关系（r=0．937,P＜0．05）。结论通过影像学对患者的腰椎关节突关节退变情况进行观察发现其腰椎关节突关节退变同患者的年龄以及小关节骨关节炎存在一定的关联性。     

椎弓根螺钉对腰椎关节突关节破坏率的研究

目的回顾性分析腰椎经椎弓根螺钉固定后对邻近的关节突关节破坏的发生率，从而提出选择较佳置钉的方法和减少钉杆结合部体积的设想。方法对1995—2003年行腰椎经椎弓根螺钉固定手术的143例患者，利用X线、CT扫描等影像学检查，评价经椎弓根螺钉对上关节突破坏的发生率。结果26．0％(157／604)的螺钉和31．5％(46／143)的患者存在固定节段椎体的上关节突不同程度的破坏。上关节突破坏的发生率主要与患者的关节突关节角有关。结论术前可借助CT等影像学检查，确定腰椎上关节突的关节角指导术中进钉，同时设计器械时尽量减少钉杆结合部的体积，可减少椎弓根螺钉对腰椎关节突关节的破坏，有助于提高患者的远期疗效。     

介入治疗食管瘘合并纵隔脓肿

【摘要】 目的 探讨介入放射学技术治疗食管瘘合并纵隔脓肿的疗效。方法 回顾性分析采取介入技术治疗食管瘘合并纵隔脓肿患者的相关临床资料,包括病历记录、影像资料、手术操作记录和随访结果。结果 本组30例食管瘘合并纵隔脓肿患者均成功置入经鼻空肠营养管和食管减压管,技术成功率100%,10例DynaCT下经皮穿刺置入纵隔脓腔引流管、15例经鼻食管瘘口置入纵隔脓腔引流管、5例纵隔脓腔小无需置入纵隔脓腔引流管。1例糖尿病患者术后5 d死于脓毒血症、糖尿病酮症酸中毒。29例患者,顺利拔出脓腔引流管预后良好,临床成功率96.7%。结论 介入技术治疗食管瘘合并纵隔脓肿是一种操作简单、安全、有效的微创性治疗措施,临床上值得推广应用。     

X线透视引导穿刺大鼠腰椎间盘建立椎间盘源性腰痛模型的实验研究

【摘要】 目的 探讨X线透视引导下穿刺大鼠腰椎间盘建立椎间盘源性腰痛（DLBP）动物模型的可行性。方法 将60只Sprague-Dawley大鼠随机分为DLBP组（X线透视引导下穿刺L4～5和L5～6,n=24）、假手术组（穿刺同层面椎旁肌,n=15）、正常组（不做任何处理,n=21）;根据建模时间,再将每组大鼠平均分为30 d组、90 d组、180 d组。分别在建模后1、7、14、30、90、180 d进行行为学实验,评估大鼠步态功能、痛温觉阈值、轴性腰痛的改变;建模后30、90、180 d进行腰椎MR矢状位T2加权成像扫描,扫描完成后处死大鼠截取L4～5和L5～6椎间盘,行苏木精-伊红（HE）染色和番红O-固绿染色观察椎间盘退变程度。结果 DLBP组建模后大鼠步态障碍评分呈先增高后恢复再增高改变,至90、180 d与正常组和假手术组相比大鼠行为学表现为痛温觉阈值显著减低（均P＜0.01）、轴性腰痛诱发的弯腰时间增加及挣扎时间减少（均P＜0.05）。腰椎MR矢状位T2加权成像显示,建模后30、90、180 d正常组和假手术组大鼠腰椎间盘T2信号均无降低,而 DLBP组腰椎间盘T2信号均降低,Pfirrmann分级以Ⅲ～Ⅳ级为主,呈中-重度退变。组织学结果显示,DLBP组大鼠椎间盘退变Masuda评分显著高于正常组和假手术组（均P＜0.05）。结论 X线透视引导下腰椎间盘穿刺技术便捷、高效、微创,成功建立了DLBP大鼠模型。     

腰椎关节突不对称与椎间盘突出的关系

目的：探讨腰椎关节突关节的不对称性对腰椎间盘突出症的病因学意义。材料和方法：通过７６例正常人与１５８例腰椎间盘突出症患者的ＣＴ资料研究，测量关节突关节角度。结果：７６例正常人中有１９例存在关节突关节不对称，占２５％，而１５８例腰椎间盘突出症患者中则有９６例，占６０．７％；旁侧型椎间盘突出方向多偏向于关节突关节面近冠状位侧，二者具有显著性差异。结论：腰椎关节突关节的不对称与腰椎间盘突出有明显关联性     

The prevalence of lumbar facet joint edema in patients with low back pain

Objective The objective was to assess the prevalence of lumbar facet joint edema in patients with low back pain. Materials and methods Lumbar spine MR examinations (1.5 T) of 145 consecutive patients (87 women, 58 men; mean age 52.8, range 17–94 years) were retrospectively evaluated with regard to the presence of facet joint edema. The MR protocol included sagittal short-tau inversion recovery (STIR), T1- and T2-weighted as well as transverse T2-weighted images. In 9 patients follow-up MR examinations were performed and results were compared with pain. The agreement between the change in intensity of facet joint edema and the change in intensity of pain was assessed using kappa statistics and Kendall’s tau coefficient. Results In 21 of the 145 patients (14%) edema was found at the facet joints: in 52.4% at L4/5, in 19.0% at L5/S1, in 14.3% at L4/5 and L5/S1, in 9.5% at L3/4 and L4/5, and in 4.8% at L3/4. The agreement between the change in pain score and intensity of edema within the follow-up group was “almost perfect” (kappa = 0.81). Kendall’s tau coefficient was 0.91, indicating high agreement. Conclusion Sagittal STIR images detect facet joint edema in 14% of patients with low back pain. This fact may be useful for planning treatment including facet joint injections.     

Appropriate use of lumbar imaging for evaluation of low back pain

Use of lumbar spine imaging, particularly advanced imaging, continues to grow rapidly in the United States. Many lumbar spine imaging tests are obtained in patients who have no clinical symptoms or risk factors suggesting a serious underlying condition, yet evidence shows that this routine imaging is not associated with benefits, exposes patients to unnecessary harms, and increases costs. This article reviews current trends and practice patterns in lumbar spine imaging, direct and downstream costs, benefits and harms, current recommendations, and potential strategies for reducing imaging overuse.     

Lumbar facet joint injection in low back pain and sciatica: preliminary results

Fluoroscopically controlled intra-articular facet joint block is a reliable method of diagnosing low back pain and sciatica caused by lumbar facet arthropathy. Of 20 patients studied, 13 had complete and immediate relief of pain, confirming the diagnosis, Six patients have been free of pain for more than six months following a single facet joint block with injection of a local anesthetic and corticosteroid suspension. Preliminary findings suggest that computed tomography has an important role in diagnosing symptomatic facet arthropathy.     

Evidence against the use of lumbar spine radiography for low back pain

AIM: To review abnormalities reported on plain radiographic examination of the lumbar spine in patients referred with low back pain by general practitioners. Additionally, we evaluated and stratified the prevalence of these abnormalities by age. Finally, the diagnostic impact of lumbar spine radiography for the diagnosis of degenerative change, fracture, infection and possible tumour, was modelled. MATERIALS AND METHODS: A retrospective review of 2007 radiographic reports of patients referred with low back pain for lumbar spine radiography to a large radiology department was performed. The reports were classified into different diagnostic groups and subsequently stratified according to age. The potential diagnostic impact of lumbar spine radiography was modelled by using the prevalence of conditions studied as pre-test probabilities of disease. RESULTS: The prevalence of reported lumbar spine degeneration increased with age to 71% in patients aged 65-74 years. The overall prevalence of fracture, possible infection, possible tumour was low in our study population: 4, 0.8 and 0.7%, respectively. Fracture and possible infection showed no association with age. Possible tumour was only reported in patients older than 55 years of age. CONCLUSION: Although the prevalence of degenerative changes was high in older patients, the therapeutic consequences of diagnosing this abnormality are minor. The prevalence of possible serious conditions was very low in all age categories, which implies radiation exposure in many patients with no significant lesions.     

Lumbar facet joint injection in low back pain and sciatica: description of technique

Lumbar facet arthropathy is an important cause of low back pain and sciatica. Intra-articular facet block can confirm symptomatic facet joint disease. Good understanding of the anatomy of the joint and fluoroscopic control are essential for intra-articular placement of anesthetics and steroids.     

Real-time fusion-imaging in low back pain: a new navigation system for facet joint injections

Aims and Objectives

The aim of the current study is to present our experience in lumbar spine interventional procedures performed with a newly developed multimodal echo-navigator (EcoNav) and to evaluate short-term clinical outcomes of a series of patients affected by facet joint disease (FJD) treated with steroid and anaesthetic injection under fusion-imaging guidance, compared to a cohort of patients that received the same treatment under computed tomography (CT) guidance.

Methods

Sixty-five consecutive patients (34 females; mean age 68.3?±?12.8 years) with a clinical diagnosis of non-radicular low back pain lasting for more than 6-weeks and magnetic resonance (MR) or CT confirmed FJD were enrolled for image-guided FJI. Twenty-eight patients underwent FJI with fusion-guided technique, while CT-guided procedures were performed in the other cases. Clinical and procedural data were recorded and compared at a mean follow-up of 6.1?±?2.0 months.

Results

A significant improvement in clinical parameters was observed for both fusion-guided and CT-guided group. Comparing both groups, no statistically significant difference could be detected neither at baseline conditions nor during the follow-up period. No significant periprocedural complication occurred in both groups. A satisfaction rate of 92.3 and 81.1% was reported for fusion-guided and CT-guided group, respectively.

Conclusion

EcoNav fusion-imaging system represents a safe, feasible, effective and reproducible guidance option in FJD infiltration procedures, also avoiding use of ionising radiations.

     

Assessment of a single lumbar spine radiograph in low back pain

The lumbosacral spine radiographs of 200 patients with unexplained low back pain and without neurological signs were reviewed. The purpose of the study was to determine whether significant diagnostic information would be lost by replacing the standard three film series with a single radiograph, either in the lateral or antero-posterior projection. The contribution of the coned lumbosacral junction view was also assessed. The results show that a single lateral radiograph is diagnostically satisfactory and would have the added advantages of reducing patient radiation dose and radiographic workload.     

经皮穿刺腰椎间盘摘除术治疗慢性椎间盘源性下腰痛

目的评价应用经皮穿刺腰椎间盘摘除术对慢性椎间盘源性下腰痛的治疗效果。方法应用经皮穿刺腰椎间盘摘除术治疗慢性椎间盘源性下腰痛26例。所有病例均在X线电视导向下进行。结果随访3个月～4年,无严重并发症。根据MacNab腰腿痛手术评价标准,术后3～6个月随访组,26例中优15例(57．7％),良7例(26．9％),可3例,差1例,优良率84．6％。7个月～1年随访组22例,优11例(50．0％),良6(27．2％),可3例,差2例,优良率77．2％。术后1年以上随访组14例,优7例(50,0％),良4例(28．5％),可1例,差2例,优良率78．5％。结论经皮穿刺腰椎间盘摘除术对慢性椎间盘源性下腰痛疗效确切。