脊柱腰段的神经支配与下腰背痛

脊柱腰段的神经分布与下腰背痛的关系颇为密切。下腰背痛的原因很多,主要由于压迫和激惹支配脊柱腰段的敏感结构—椎管内容物、椎间盘、椎间关节、椎间韧带、椎体以及腰段周围软组织等的神经所引起。但对这些结构的神经来源、支配范围与神经性质等,尚未完全阐明。据最近文献,作此综述,提供临床工作者参考。关于脊柱腰段的神经支配有:窦椎神经、腰神经后支以及来自交感神经的分支。因此,在叙述脊柱腰段各结构的神经支配以     

腰椎小关节骨关节炎与椎间高度及年龄的相关性研究

目的探讨腰椎小关节骨关节炎和椎间盘高度、年龄的相关性．方法收集120例腰椎间盘退患者下腰段（L3-L5）的腰椎CT和MRI影像学资料,对腰椎小关节骨骨关节炎、椎间高度降低程度进行分级,采用SSPS17．0统计软件包,采用有序Logistic回归分析（Ordinal或Regression）腰椎小关节骨骨关节炎和椎间高度降低、年龄的相关性．结果（1）年龄因素：年龄与腰椎小关节骨关节炎呈正相关（P〈0．001）,有统计学意义．（2）椎体间高度降低因素：相对于椎体间高度正常者（GE=5）,只有Ⅱ度椎体间高度降低者（GL=3）的腰椎小关节骨关节炎病情程度明显加重（P=0．037）,有统计学意义．而Ⅰ度、Ⅲ度和Ⅳ度椎体间高度降低者（GL=4、GL=2、GL=1）的腰椎小关节骨关节炎病情程度无明显加重,与正常者基本一致（P≥0．183）,无统计学意义．结论自然老化是腰椎小关节骨关节炎主要因素,多数腰椎椎小关节骨关节炎与椎间盘高度减低的相关性无统计学意义．     

胸段脊柱侧凸矫形术对腰段脊柱应力影响的有限元分析

目的采用有限元方法,分析胸段脊柱侧凸矫形术后对腰椎应力的影响。方法采用脊柱三维有限元模型模拟计算矫治特发性脊柱侧凸。在患者施行脊柱侧凸矫形术之前对胸段及腰段脊柱进行CT平扫,提取脊椎各节段椎体（胸2-腰5）的结构信息,删除肋骨等非脊柱结构并编辑分离脊柱节段,分别对脊柱侧凸矫形的主要步骤进行模拟并计算其腰段脊柱应力的分布。结果模拟计算结果显示脊柱腰段各椎体之间小关节周围的应力相对均大于模型中其他节段,最大值应力为68.62MPa,位于腰2与腰3之间凹侧椎小关节处。结论通过应力分布分析,腰椎应力较大,在矫形过程中,应充分考虑胸段脊柱侧凸矫形对腰椎的影响。     

经前路腰骶椎椎间融合后内固定技术的研究进展

经前路腰椎椎间融合术（ALIF）是由O＇brien首先提出并应用于临床,现已发展成为一种成熟的腰椎融合技术［1］,广泛应用于腰椎滑脱、脊柱失稳、椎间盘源性疼痛以及椎体肿瘤或结核等疾病的治疗。但是相关研究证明,单独的融合不能使脊柱获得初始的稳定性［2］,那么在ALIF后如何进行内固定获得脊柱即时稳定性就显得非常重要。上腰椎（L1～L3）局部解剖结构简单,易于行内固定进行重建,而腰骶段脊柱（L4～S1）局部毗邻血管神经等,相对复杂多变,独特的生物力学特性以及骶椎较疏松的骨质都导致腰骶段脊柱内固定较困难,特别是 L5切除后,因腰骶角的存在,钛板难以固定到S1椎体上,这一直是一个富有挑战性的研究领域。本文就目前经前路腰骶椎椎间融合内固定方式的应用与进展作一概述,具体如下。     

腰椎椎体终板的特征与临床意义的研究进展

随着社会老龄化群体的日趋增多,慢性下腰痛是最常见的影响人类生存质量的骨骼肌疾病。近年来脊柱椎间融合术广泛应用于椎间盘性腰痛患者的治疗,但在手术中是否保留要腰椎椎体终板成为近些年脊柱外科研究的热点。该文详细介绍了腰椎椎体终板的解剖结构、营养环境、生物力学特性以及椎体间界面融合技术在临床中的应用以及优缺点。     

腰椎不同节段固定对腰椎活动度及椎间压力的影响

目的研究不同节段腰椎内固定后对下位相邻节段退变加速发生过程的影响。方法 60具绵羊腰段脊柱标本:取腰1椎体-骶5,以椎弓根螺钉固定,依据固定节段的不同分为完整对照组(未固定)、L6~L7单节段固定组、L5~L7短节段固定组、L3~L7长节段固定组。本实验为自身对照实验,在6N·m(牛顿·米)力矩加载下进行生物力学测定,比较各组在椎弓根螺钉进行不同节段固定下腰7骶1节段的变化。结果施加内固定后,下方相邻节段在屈伸方向上的活动度、椎间盘压力都明显增加,增加幅度随着固定范围的增大而增大,各组间差异有统计学意义(P<0.05)。结论固定节段越长,椎弓根钉内固定对下方邻近节段退变的影响越大。     

“腰椎间盘突出症”摄影的体会

腰椎间盘突出症常发腰段脊柱的下部,是椎间盘的髓核突出压迫神经根造成腰痛或坐骨神经痛的一种常见病。腰椎间盘突出症使病人脊柱内外平衡失调,髓核突出后使下腰段脊柱失稳相继出现腰椎生理曲度变平,腰骶上移,旋盆翘臀、旋腰挺胸四步规律性的“腰型”变化及腰区局部“四大体征”。患椎棘突位置偏歪,患椎上、下棘间隙一宽一     

椎间融合器治疗退行性腰椎失稳症

椎间融合器是近年来出现的一种新型内固定器 ,我院自 2 0 0 0～ 2 0 0 2年采用多孔螺纹钛合金椎间融合器治疗下腰段退行性腰椎失稳症患 1 2例 ,平均随访 2 0个月 ,疗效满意 ,现报告如下。1　临床资料1 .1　本组共 1 2例 ,其中男性 3例 ,女性 9例 ,年龄 30～ 60岁 ,平均 45岁 ,病程 1个月～ 2年 ,平均7个月。单纯腰部疼痛 2例 ,腰痛伴单侧下肢麻痛 7例 ,腰痛伴双下肢麻痛 3例 ,腰椎 CT显示腰 5骶 1椎间盘突出 3例 ,腰 4、 5椎间盘突出 6例 ,腰 4、 5并腰 5骶 1椎间盘突出 3例 ,其中合并椎体 1度前滑脱 2例 ,合并椎管狭窄 4例 ,1 2例 X片上…     

经皮穿刺椎体成形术治疗老年骨质疏松椎体压缩性骨折的早期疗效分析

目的采用经皮穿刺椎体成形术(Percutaneous Vertebroplasty,PVP)治疗胸腰段及下腰段老年骨质疏松椎体压缩性骨折的疗效分析。方法对2010年3月至2015年10月我院脊柱外科收治的98例老年骨质疏松椎体压缩性骨折的患者行骨水泥注射。其中A组胸腰段组(T11、T12及L1)53例,推注骨水泥3-4mL,B组下腰段组(L4及L5)45例,推注骨水泥5-6mL,记录两组患者的手术时间、术中出血量、平均住院天数、平均骨水泥注入量;椎体高度压缩比。结果两组患者手术时间、术中出血量、平均住院天数均无明显差异(P0.05),B组平均骨水泥注入量大于A组,差异有统计学意义(P0.05)。A组与B组患椎压缩比比较,差异有统计学意义(P0.05)。结论 PVP是治疗老年骨质疏松压缩性骨折微创、经济、安全、有效的方法,但对椎体高度的恢复欠佳,胸腰段骨折疼痛改善情况优于下腰段骨折。     

探讨经椎弓根植骨加椎弓根螺钉治疗脊柱胸腰段单节段爆裂性骨折的临床疗效

目的:探讨经椎弓根植骨加椎弓根螺钉治疗脊柱胸腰段单节段爆裂性骨折的临床疗效。方法:回顾性分析2011年1月-2012年5月收治脊柱胸腰段单节段爆裂性骨折患者临床资料,观察和分析手术前后均神经功能情况、Cobb’s角、受伤部位椎体高度情况、椎管占位情况比和腰背部疼痛情况。结果:所有患者平均随访2.4年,未出现断钉和内固定物松动的现象,椎体高度和后凸角未发现再丢失,神经功能和腰背疼痛情况改善明显。结论:经椎弓根植骨加椎弓根钉治疗胸腰椎单节段爆裂性骨折是目前重要的治疗脊柱胸腰段爆裂性骨折的手术方法之一,它不但能够重建脊柱前中柱的稳定性,以及纠正应力集中于后柱的现象,而且避免再次引发晚期矫正角度和椎体高度丢失的情况。     

CTGF和TIMP1双基因体外联合转染恒河猴腰椎间盘细胞对II型胶原和蛋白多糖的影响

目的 建立恒河猴腰椎间盘细胞体外培养模型,研究腺相关病毒（adeno-associated virus,AAV）介导的结缔组织生长因子（connective tissue growth factor,CTGF）和基质金属蛋白酶组织抑制因子1(tissue inhibitor of metalloproteinases 1,TIMP1) 双基因体外联合转染恒河猴椎间盘细胞较单基因对II型胶原和蛋白多糖合成的影响的变化,以探讨体外延缓椎间盘细胞退变的方法。方法 应用酶消化法培养恒河猴腰椎间盘髓核细胞,以感染复数（MOI） 为106的rAAV2-CTGF-IRES-TIMP1及rAAV2-CTGF、rAAV2-TIMP1分别感染髓核细胞,应用Western blot鉴定和RT-PCR检测II型胶原及蛋白多糖mRNA的表达,35S整合法性行蛋白多糖合成率的测定,SP-ABC免疫组化法检测Ⅱ型胶原含量。结果 rAAV2-CTGF-IRES-TIMP1双基因及rAAV-CTGF、rAAV-TIMP1单基因能够转染恒河猴椎间盘髓核细胞并在其内表达细胞因子。与对照组相比,CTGF可以促进II型胶原及蛋白多糖的合成,TIMP1可以促进蛋白多糖的合成,对II型胶原的合成未见到明显作用;双基因联合感染可以显著促进髓核细胞蛋白多糖和II型胶原的合成。结论 CTGF和TIMP1 单基因转染均可以促进蛋白多糖的合成,CTGF 对 II型胶原的合成亦有促进作用;双基因联合感染可以明显促进蛋白多糖和II型胶原的合成,其效果优于单基因,为多基因治疗椎间盘退变奠定了良好的基础。     

Intervertebral disc degeneration and bone density in degenerative lumbar scoliosis: a comparative study between patients with degenerative lumbar scoliosis and patients with lumbar stenosis

Background  Degenerative lumbar scoliosis is common in older patients. Decreased bone density and the degeneration of intervertebral discs are considered to be correlated with degenerative lumbar scoliosis. A means of quantifying the relative signal intensity for degenerative disc disease has not been previously discussed. The purpose of this study was to compare bone mineral density and intervertebral disc degeneration between degenerative lumbar scoliosis and lumbar spinal stenosis patients in a nine-year retrospective study.

Methods  From January 2001 to August 2010, 96 patients with degenerative lumbar scoliosis were retrospectively enrolled and 96 patients with lumbar spinal stenosis were selected as controls. Cobb angle, height of the apical disc and the contiguous disc superiorly and inferiorly on convex and concave sides, the height of the convex and concave side of the apical and the contiguous vertebral body superiorly and inferiorly were measured in the scoliosis group. The height of L2/L3, L3/L4, L4/L5 discs and the height of L2/L4 vertebral body was measured in the control group. The grade of intervertebral disc degeneration was evaluated using T2WI sagittal images in both groups. The bone density of lumbar vertebrae was measured with dual-energy X-ray.

Results  In scoliosis group, the intervertebral disc height on the convex side was greater than the height on the concave side (P <0.001). The vertebral body height on the convex side was greater than the height on the concave side (P=0.016). There was a significant difference between the scoliosis group and the control group (P=0.003), and between T-value and the rate of osteoporosis between the two groups (both P <0.001). Results were verified using multiple linear regression analysis.

Conclusions  Degenerative lumbar scoliosis is accompanied by height asymmetry between the intervertebral disc and vertebral body regarding the convex and concave surfaces. There is a positive correlation between the angle of scoliosis and the disc index, the degree of degeneration of the intervertebral disc, and a negative correlation between the angle of scoliosis and bone density.

     

Combined expression of CTGF and tissue inhibitor of metalloprotease-1 promotes synthesis of proteoglycan and collagen type II in rhesus monkey lumbar intervertebral disc cells in vitro

Background Low back pain has emerged as a widespread disease often caused by intervertebral disc degeneration.This study aimed to establish an in vitro cell culture model of rhesus monkey lumbar intervertebral discs and to investigate the effect of combined connective tissue growth factor （CTGF） and tissue inhibitor of metalloprotease-1（TIMP-1） expression mediated by adeno-associated virus （AAV） on collagen type Ⅱ and proteoglycan levels.The purpose of these investigations was to explore potential methods for relieving the degeneration of lumbar intervertebral disc cells.Methods Rhesus monkey lumbar intervertebral disc nucleus pulposus cells （NPCs） were isolated by enzyme digestion,cultured, and transduced with rAAV2-CTGF-IRES-TIMP-1, rAAV2-CTGF, or rAAV2-TIMP-1 at a multiplicity of infection （MOl） of 106.The expression of collagen type Ⅱ and proteoglycan was measured using RT-PCR and Western blotting.The synthetic rate of proteoglycan was measured using 35S incorporation.Results Rhesus monkey lumbar intervertebral disc NPCs were transduced with rAAV2-CTGF-IRES-TIMP-1,rAAV2-CTGF, and rAAV2-TIMP-1 and the transduced genes were expressed and detected.Compared to the control,CTGF promoted the synthesis of collagen type Ⅱ and proteoglycan.TIMP-1 showed an enhancing effect on the expression of proteoglycan but no effect on collagen type Ⅱ.Expression of both genes in rhesus monkey lumbar intervertebral disc NPCs significantly enhances the synthesis of proteoglycan and collagen type Ⅱ.Conclusions Single gene transduction of CTGF or TIMP-1 can enhanced synthesis of proteoglycan.CTGF expression can also enhance collagen type Ⅱ protein synthesis.Combined transduction of both CTGF and TIMP1 can significantly promote the expression of proteoglycan and collagen type Ⅱ to levels greater than transduction of a single gene alone.Our study provides a good basis for multi-gene therapy to treat lumbar intervertebral disc degeneration.     

退变腰椎间盘髓核中PDCD5的表达

目的测定程序化死亡基因5(PDCD5)在退变椎间盘髓核中的表达,研究PDCD5表达与腰椎间盘退变的相关性。方法通过免疫组织化学方法检测26例腰椎间盘突出症患者及10例腰椎骨折患者髓核标本中PD-CD5的表达,并进行比较分析。结果椎间盘突出组髓核中PDCD5表达阳性率达73.1%,与对照组(30%)相比差异有统计学意义(P<0.05)。PDCD5表达的高低与椎间盘退变程度有一定相关性(r=0.365)。结论 PDCD5在不同椎间盘髓核中均有表达,提示PDCD5参与了椎间盘退变过程,在椎间盘退变过程中发挥了一定的作用。     

An animal model to create intervertebral disc degeneration characterized by radiography and molecular biology

Objectives:To develop a rabbit model of intervertebral disc degeneration that more exactly simulates the pathological changes of human intervertebral disc degeneration.Methods:Twelve New Zealand white rabbits were utilized to establish three different disc injury models according to the following protocol;group A:anulus punctures were done with a 18-gauge needle at L2-L3 and L5-L6; Group B:intradiscal injection of interleukin-1 IL-1βwith a 23-gauge needle at L3-L4;and Group C:intradiscal injection of phosphate buffer saline(PBS)with a 23-gauge needle at L4-L5.The L1-L2 level was used as a control.Rabbits were killed after 24 weeks.The intervertebral disc height was measured by lateral plain radiographs.After the radiographic measurements were obtained,the interver- tebral discs were removed and analyzed for DNA,sulfated glycosaminoglycan(s-GAG)and water contents of nucleus pulposus.Results: The intervertebral disc height,s-GAG,and water contents in anulus needle punctures were significantly decreased in Group A,but the DNA content in the nucleus pulposus was significantly increased when compared to the control.The significant decrease of disc height and water contents were demonstrated,only the s-GAG and DNA contents did not show a significant difference in Group B when compared to the control.The significant decrease of disc height,s-GAG,water,and DNA contents did not show in Group C when compared to the control.Conclusion:The 18-gauge puncture models produced the most consistent disc degeneration in the rabbit lumbar spine.     

小鼠腰椎间盘退变与OPG基因的关系研究

目的：比较骨保护素（OPG）基因敲除（OPG-／-）小鼠与正常（WT）小鼠腰椎间盘退变的关系。方法：分别取出生后4、8、12W的OPG-／-小鼠及正常对照组小鼠的L4,5椎间盘,运用番红O-固绿染色法观察L。／5椎间盘形态学变化,测量椎间盘及软骨终板高度。应用免疫组化染色观察椎间盘聚集蛋白聚糖（aggrecan）基因表达量的变化。结果：①小鼠腰椎间盘番红。-固绿染色结果：OPG_／-小鼠的椎间盘软骨终板在第8W及第12W时可观察到退化改变,软骨终板排列不规则,并有骨髓腔组织进入软骨终板及外层纤维环。②免疫组化染色结果显示：各年龄点OPG-／-组小鼠椎间盘aggrecan的蛋白表达均低于同龄WT组小鼠。③OPG-／-小鼠软骨终板及椎间盘高度在4周时较对照组无明显变化,随着年龄的增长,第8周时较对照组降低,第12周时高度下降最明显（P〈0．01）。结论：OPG基因缺失后可导致椎间盘退变,椎间盘正常的结构和功能的维持有赖于OPG基因。     

PDCD5在退变椎间盘组织中的表达及临床意义

目的测定PDCD5在椎间盘髓核和纤维环中的表达,深入研究腰椎间盘退变的发生机制,为临床进一步预防及治疗腰椎间盘突出症提供实验依据。方法通过免疫组织化学以及RT-PCR方法检测26例腰椎间盘突出症患者及10例腰椎骨折患者髓核和纤维环标本中PDCD5的表达,进行比较分析。结果椎间盘突出组髓核和纤维环中PDCD5表达阳性率分别达73.1%、80.8%与对照组(30%、40.0%)比较差异有统计学意义(P<0.05)。PDCD5 mRNA在椎间盘突出组髓核和纤维环中的表达分别为0.5609±0.0495和0.5740±0.0447,与对照组(0.4895±0.0259和0.5065±0.0129)比较差异有统计学意义(P<0.05)。结论 PDCD5在不同椎间盘髓核和纤维环中均有表达,椎间盘突出组髓核和纤维环中PDCD5表达高于对照组,提示PDCD5参与了椎间盘退变过程,在椎间盘退变的过程中发挥了一定的作用。     

新型解剖型纳米椎间融合器在腹腔镜下腰椎前路椎间盘切除椎间植骨融合术的初步临床应用

探讨新型解剖型纳米羟基磷灰石/聚酰胺66椎间融合器在腹腔镜下腰椎前路L5/S1椎间盘切除椎间融合术中应用的初步临床疗效。在本院脊柱外科进行的21例腹腔镜下前路椎间盘切除椎间融合术中应用该新型椎间融合器,于术前、术后1周、术后3个月及术后6个月进行VAS评分及骨性融合和椎间隙高度变化情况分析。结果显示VAS评分在术后持续改善,椎间隙高度在术后变化无统计学差异,在术后6个月时均达到骨性融合。该研究验证了该新型椎间融合器应用于腹腔镜下腰椎前路 L5/S1椎间盘切除椎间植骨融合术的初步临床应用效果良好。     

腰椎间盘组织的超微结构观察

对4例胎儿,1例正常成人和14例腰椎间盘突出症患者以及5例Wistar大鼠,2例家兔的腰椎间盘做了透射电镜观察,结果发现胎儿不同年龄的脊索细胞的演变,显示脊索细胞在形成髓核,尤其是在髓核的基质中发挥重要作用。不同物种、不同时期的腰椎间盘在早期即有髓核组织的退行性改变,并随年龄增长日趋明显,但四肢动物退变程度不如人类明显。腰椎间盘突出症组织的超微结构变化主要为细胞及基质的退行性改变,但其程度和某些变化有别于正常生理退变。     

腰椎间盘突出症翻修术中单、双枚椎间融合器的应用效果

目的:比较腰椎间盘突出症翻修术中椎弓根螺钉内固定并单枚椎间融合器(Cage)加周围松质骨植入与双枚Cage植入椎间融合术的应用效果。方法:15例接受腰椎间盘突出症翻修术的患者根据病变节段椎体横径大小,分别采用单枚Cage加周围松质骨植入(A组,n=7)和双枚Cage植入(B组,n=8)。术后随访6个月～2a,评估术前、术后3d及24周时患者的腰椎椎间隙高度、腰椎融合率,并进行下腰疼JOA评分。结果:2组L4/L5、L5/S1腰椎间隙高度和下腰疼JOA评分差异均无统计学意义(F组间分别为1.615、3.040和3.059,P均>0.05),但均较术前明显改善(F时间=7.567、5.639和255.498,P均<0.05),2组融合率均为100%。结论:腰椎间盘突出症翻修术中椎弓根螺钉内固定并单枚Cage加周围松质骨植入与双枚Cage植入的效果无显著差异。