认识颈腰椎间盘病

目的　探讨颈腰椎间盘病的特点和诊断。方法　对近 6年中的颈腰椎盘突出症伴退变性椎管狭窄症和颈椎病并施行手术的 5 6例进行分析。结果　发现颈腰椎间盘突出症是本病的重要原因。结论　根据临床症状、体征和影像学检查 ,颈椎MRI和腰椎CT检查 ,是防范混淆和误诊的必要条件     

Pyogenic infections of the adult spine.

A retrospective analysis of 61 patients forms the basis for this paper's comment on three major types of pyogenic spinal disease. The first group consists of 22 patients with vertebral osteomyelitis and intervertebral discitis. The second group comprises 22 patients in whom the diagnosis of pyogenic spinal disease was made only after failure of discectomy. In retrospect they were shown to have atypical degenerative disc disease and were similar to the first group. The third group of 17 patients, while demonstrating some similarities to the second group, represents true postdiscectomy wound infection. An understanding of the clinical presentation and pathophysiology of pyogenic disease of the spine allows it to be distinguished preoperatively from degenerative disc disease which superficially it resembles. Further, true postdiscectomy wound infection can be distinguished from pyogenic spinal disease misdiagnosed preoperatively. The differences in the results of treatment of these three groups warrant such distinctions.     

A study of the relationship between type of lumbar disc herniation,straight leg raising test and peripheral T lymphocytes

Objective: To observe changes in peripheral T lymphocytes of patients with lumbar disc herniation, and investigate the relationship between the type of herniation, signs and T lymphocyte subsets. Methods: Blood samples from 20 healthy blood donors (control group), and 49 patients (27 male and 22 female) with single‐level lumbar intervertebral disc herniation were collected, the latter preoperatively. T lymphocytes subsets were detected by flow cytometer. According to the position of the intervertebral disc observed during surgery, the patients were divided into ruptured disc herniation (RDH) and degenerative disc herniation (DDH) groups. Straight leg raising (SLR) was assessed preoperatively. Results: Percentages of CD3+, CD4+, and ratio of CD4+/CD8+ in the RDH group were significantly higher, and of percentage of CD8+ significantly lower, than were those in the control group. Percentages of CD4+ and ratio of CD4+/CD8+ were significantly higher, and percentage of CD8+ significantly lower, in the positive SLR test group than were those in the negative SLR test group. The positive rate of SLR testing was significantly higher in the RDH than in the DDH group. Conclusion: Our results suggest that changes in T lymphocyte subsets in peripheral blood take place after herniation of the lumbar intervertebral disc. T lymphocyte mediated immune responses may play an important role in the occurrence and development of signs in patients with herniated lumbar intervertebral discs. The SLR test may help to confirm that disc herniation has caused nerve root impairment by mechanical loading or inflammatory stimulus and provide guidance on the choice of treatment.     

颈腰椎间盘病

目的： 探讨颈腰椎间盘病的特点和诊断。方法： 对近４ 年中的颈腰椎间盘突出症、退变性椎管狭窄和颈椎病并施行手术的１９ 例进行了分析。结果： 发现颈腰椎间盘突出症是本病的重要原因。结论： 根据临床症状、体征和影像学检查, 颈椎 Ｍ Ｒ Ｉ和腰椎 Ｃ Ｔ 检查, 是防范混淆和误诊的必要条件。     

Comparative analysis of lumbar spine degeneration documented by x-rays versus large specimen cryomicrotome sections

AIM OF THE STUDY: The extent of degenerative changes in the lumbar spine as seen on conventional radiographs is interpreted on the basis of visualized osseus structures and indirect signs such as diminution of disc height. In order to analyze the accuracy of these interpretations we compared and correlated different stages of degeneration in conventional radiographs with cuts of large-specimen cryomicrotome sections (LSCS), offering a direct macroscopic vision of the degenerative anatomic features. METHOD: A total of 50 human cadaver lumbar spines with 251 spine segments (Th 12 - S1) was investigated by plain radiograms and LSCS. The degenerative changes were differentiated into 5 stages for both diagnostic measures. Criteria for radiological degeneration were: diminution of disc space, presence of osteophytes and sclerosis of the endplates. Degenerative changes as seen by LSCS were evaluated by the following features: cracks in the endplate, bleeding into the intervertebral disc, alignment of the annulus fibrosus fibres and osseous alterations in the spine segment. RESULTS: Complete matches of the evaluated radiological and macroscopic stages of degeneration were observed in 206 cases. A difference of 1 degree on the degeneration scale was registered in 42 segments, whereas a difference of 2 degrees was seen in 3 cases. The correlation coefficient between the degeneration stages of the two diagnostic measures scored rho = 0.883. CONCLUSION: The comparison of the different degrees of degeneration in the lumbar spine as evaluated by both plain radiographs and LSCS revealed a good correlation.     

Experimental instability in the rabbit lumbar spine

The authors performed mechanical, biochemical, and histologic analyses of changes in the rabbit lumbar spine occurring after instability had been induced by facet removal to find whether this intervention produced an experimental model for intervertebral disc degeneration. Sham operated animals and an unoperated control group were used for comparison. Half of the operated animals were housed under conditions to promote higher physical activity than the other animals housed individually in small cages. Acutely, the removal of facet joints increased the flexibility of intervertebral joints. Over the following year, this increase in flexibility was reduced to close to control levels in all groups of animals. Within the intervertebral discs, there was no significant change in proportions or solubility of collagen or proteoglycans after surgery, nor was there microscopic or macroscopic evidence of disc degeneration. The surgical procedure produced hypermobility of the spine, but there was a subsequent restabilization, and the intended disc degeneration was not produced. These findings indicate that some as yet unidentified soft tissue repair process, facilitated by activity, overcame the hypermobility created at surgery, so degenerative changes in the intervertebral discs did not result. We suggest that other animal models of disc degeneration may represent a failure of reparative response to acute injury.     

1980 Volvo award in clinical sciences. Assessment of patients with low-back pain by biplanar radiographic measurement of intervertebral motion

Abnormalities of intervertebral joint motion including hypermobility, reduced mobility, torsional abnormality, and displacement of the center of rotation have been associated with degenerative change. However, measurement of these signs in plane X-ray films is handicapped by the three-dimensional motion and geometry of the spine. This study aimed to relate three-dimensional motion of the joints to their pathological state. We have used biplanar radiography to measure intervertebral motion during voluntary movements by patients with low back pain. Primary (or intentional) and coupled motions were measured by a refined technique, along with disc shear and facet joint motion. Abnormalities were found, especially in the "coupled" motions which were related to narrowed disc space, and to proximity to previous fusions. There was asymmetry of motion specific to joints with herniated nucleus pulposus.     

认识颈腰椎间盘病

目的：探讨颈腰椎间盘病的特点和诊断。方法：对近6年中的颈腰椎间盘突出症、迟变性椎管狭窄症和颈椎病并施行手术的56例进行了分析。结果：发现颈腰椎间盘突出症是本病的重要原因。结论：根据临床症状、体征和影像学检查，颈椎MRI和腰椎CT检查，是防范混淆和误诊的必要条件。     

Surgical Results after Soft System Stabilization of the Lumbar Spine in Degenerative Disc Disease – Long Term Results

Summary  After having reported preliminary results of soft system stabilization according to Graf in a series of 27 patients with degenerative disc disease of the lumbar spine in early 1995 the authors report long term clinical and radiological results of this patient series (n=25). At a mean period of postoperative observation of 50 months excellent, good, satisfactory, moderate and poor results were obtained in 62,9%, 11,1% and 11,1%, 7,4% and 7,4 % of the patients, respectively. The well-known phenomenon of loss of disc height at the level of posterolateral fusion and instrumentation as well as overcharge of adjacent segments were not observed after soft system stabilization. Regional as well as global lumbar lordosis were maintained and, although statistically not significant, an increase of intervertebral distance was observed in adjacent segments in flexion of the lumbar spine. These phenomena might represent pressurization of instrumented as well as adjacent discs after the insertion of ligament prostheses. It is the impression of the authors, that the Graf technique leads to good surgical results in degenerative disc disease with destabilization of lumbar motion segment(s) if the following criteria are strictly respected: 1.*No or only mild arthrotic changes of the facet joints 2.*Preferably minor disc degeneration/only mild loss of intervertebral distance 3.*Well trained low back muscles and 4.*A clear-cut, repeatedly demonstrated pain-relief on trial anaesthesia of the corresponding articular nerves and while wearing a probatory jacket.     

临床症状体征与影像学检查分离的腰椎间盘突出症的发生机制研究进展

临床会出现少数症状体征与影像学检查结果不相符的腰椎间盘突出症患者,而单纯用传统的突出髓核直接机械压迫刺激神经根的理论不能解释这种反常的腰椎间盘突出症。腰椎间盘髓核的突出与患者临床症状体征的出现受多因素、多环节的影响,脊神经根的间接性机械压迫与神经根牵张效应为主要因素,而反常症状体征的产生往往与突出的髓核自身位置的迁移、神经系统对信息的传递以及髓核与硬膜囊或神经根的相互作用密切相关。此外,突出的髓核组织所继发的局部微循环、炎症改变,相应节段的骨质增生退变和腰椎应力姿势改变诱发此类反常腰椎间盘突出症患者出现多样性的症状体征。同时,一些患者还存在神经或椎体的先天性发育异常,并可能出现影像学检查上的误诊或漏诊。突出髓核对硬膜囊以及周围神经根之间的确切相互作用机制及其继发的局部病理生理、生物力学改变,病变责任节段的确定以及如何克服影像学检查的局限性需进一步研究。     

Quantitative ultrasound measurements of the calcaneus in the prediction of lumbar spine degeneration

A cross-sectional study was conducted to evaluate the possible use of a low-cost radiation-free technique in the prediction of degenerative changes in the lumbar spine. Although an inverse correlation between osteoporosis and degenerative changes in the lumbar spine has been reported, no previous studies have asked whether there is a correlation between calcaneal quantitative ultrasound results and degenerative findings in the lumbar spine. In 117 patients with low back pain or pain in the lower limb, ultrasonographic parameters (speed of sound, broadband ultrasound attenuation, stiffness) of the calcaneus were correlated with evidence of degenerative changes and stenosis on magnetic resonance scans of the lumbar spine. Linear and logistic regression, as well as receiver operator characteristic curve analyses, were used to evaluate the correlation. Lumbar spine stenosis was associated with elevated calcaneal ultrasonographic parameters, particularly speed of sound. For the identification of a narrowing of the lumbar spinal canal below 100 mm² of dural sac cross-sectional area, speed of sound showed 89% sensitivity and 75% specificity in males older than 60 years. In male patients, we also found a significant positive correlation between ultrasonographic parameters and scores on a degenerative scale that primarily reflects intervertebral disc degeneration (P=0.019 for speed of sound; P=0.039 for stiffness). In conclusion, calcaneal quantitative ultrasound is frequently used in elderly patients with low back pain as a diagnostic test for osteoporosis. The incidental finding of high values on ultrasonographic parameters in these subjects, particularly in males, is highly correlated with lumbar spine degeneration and stenosis, and can help to identify those symptomatic patients needing more extensive diagnostic testing.     

Adenomyosis — an unusual cause of sciatic pain

Summary We report the case of a female patient who presented with a 5-month history of sciatic pain. She was referred to us for investigation and eventual surgical treatment of a suspected herniated lumbar intervertebral disc. Because of an ill-defined clinical picture at admission, she was treated conservatively. After 2 weeks without any improvement, imaging of the spine by MR was performed. No signs of a herniated disc or intraspinal, space-occupying lesion were apparent, but a right paramedian pelvic mass was seen. Ultrasonography confirmed an enlarged, irregular uterus. Hysterectomy abolished the symptoms.     

Tandem age-related lumbar and cervical intervertebral disc changes in asymptomatic subjects

Purpose

To investigate the frequency of tandem lumbar and cervical intervertebral disc degeneration in asymptomatic subjects.

Methods

We evaluated magnetic resonance imaging (MRI) results from 94 volunteers (48 men and 46 women; mean age 48 years) for age-related intervertebral disc degeneration in the lumbar and cervical spine.

Results

MRI indicated degenerative changes in the lumbar spine in 79 subjects (84 %), with decreased disc signal intensity in 74.5 %, posterior disc protrusion in 78.7 %, anterior compression of the dura in 81.9 %, disc space narrowing in 21.3 %, and spinal canal stenosis in 12.8 %. These findings were more common in older subjects at caudal levels. MRI showed degenerative changes in both the lumbar and cervical spine in 78.7 % of the volunteers.

Conclusions

Degenerative findings in both the lumbar and cervical spine, suggesting tandem disc degeneration, was common in asymptomatic subjects. These results provide normative data for evaluating patients with degenerative lumbar and cervical disc diseases.     

Kyphotic malalignment after anterior cervical fusion is one of the factors promoting the degenerative process in adjacent intervertebral levels

The aim of this study was to determine whether postoperative malalignment of the cervical spine after anterior interbody fusion surgery promotes degenerative changes in the neighboring intervertebral discs. Forty-two patients who underwent anterior interbody fusion surgery for cervical spondylosis and disc herniation (34 men, 8 women) were followed for an average of 9.8 years. The average age at surgery was 50.2 years. Twenty-three patients underwent a single-level fusion, 17 underwent two-level fusion, and 2 had three levels fused. The Japanese Orthopaedic Association cervical myelopathy score, with a normal score 17 points, was 11.7 before surgery and 14.9 at follow-up. Neurological status was significantly improved postoperatively, and the improvement was preserved thereafter in most cases (paired t-test, P<0.001). Degenerative changes were evident on radiological examination in the levels adjacent to the fused segment in 21 of the 42 (50%) patients. Eight of these 21 patients demonstrated neurological deterioration caused by an adjacent disc lesion. A total of 43% of the patients with adjacent-level degeneration had malalignment of the cervical spine, such as kyphosis or sigmoid curvature. In addition, degenerative change in adjacent intervertebral levels was observed in 77% of kyphoses of the fused segment. These were statistically significant (Fisher exact method, P<0.05, P<0.04, respectively). Our findings suggest that one of the factors promoting degenerative change in adjacent intervertebral levels after anterior cervical fusion for degenerative disorders is postoperative kyphotic change in the cervical spine and the fused segment.     

Structure and function of the lumbar intervertebral disk in health, aging, and pathologic conditions.

This report is a comprehensive review of the basic and clinical science relating to the morphology and function of the intervertebral disc of the lumbar spine. The purpose is to review the anatomy, physiology, and biomechanics of the intervertebral disc of the lumbar spine in health, with aging, and in pathologic conditions. The complex morphology and ultrastructure of the intervertebral disc of the lumbar spine in the human provide the critical elements that permit normal mobility and transmission of force through the vertebral column. Alterations in this structure are manifest in a variety of clinical conditions routinely encountered in orthopaedic physical therapy practice. These structural and biomechanical changes are related to degenerative changes that occur in association with aging and trauma. Knowledge of the gross morphology and ultrastructure of the intervertebral disc and pathobiologic processes underlying associated conditions is essential to orthopaedic practice.     

Pyogenic vertebral osteomyelitis.

Pyogenic vertebral osteomyelitis is defined as a primary infection in the osseous elements of the spine by pyogenic organisms with secondary involvement of the intervertebral disc and adjacent soft tissue or epidural space. Epidemiology and pathogenesis, clinical presentation, diagnosis, treatment and prognosis are briefly reviewed in this article.     

Cauda equina lesions as a complication of spinal surgery

Although the most common aetiology of cauda equina lesions is lumbar intervertebral disc herniation, iatrogenic lesions may also be the cause. The aim of this study was to identify and present patients in whom cauda equina lesions occurred after spinal surgery. From the author’s series of patients with cauda equina lesions, those with the appearance of sacral symptoms after spinal surgery were identified. To demonstrate lesions more objectively, electrodiagnostic studies were performed in addition to history and clinical examination. Imaging studies were also reviewed. Of 69 patients from the series, 11 patients in whom a cauda equina lesion developed after spinal surgery were identified. The aetiology comprised surgery for herniated intervertebral disc in 5 (4 performed by a single surgeon), spinal stenosis surgery in 4, and postoperative lumbar epidural haematoma in 2 patients (each performed by a different surgeon). Proportion of spinal surgeries with this complication varied from 0 to 6.6‰ in different centres. Patients with iatrogenic cauda equina lesion were significantly older (p < 0.001), and reported more severe urinary, but similar bowel and sexual symptoms compared to other patients in the series. In conclusion the study identified spinal surgery as the cause of approximately 15% of cauda equina lesions. More than a third of lesions developed after procedures performed by a single surgeon. Most of the remaining lesions could probably be avoided by better surgical technique (e.g. the use of a high-speed drill instead of a Kerrison rongeur in patients with severe spinal stenosis), or prevented by closer postoperative monitoring (e.g. in patients with postoperative lumbar epidural haematoma).     

以腰臀部疼痛为主的腰椎间盘突出症

目的探讨对于临床表现主要为腰臀部疼痛的腰椎间盘突出症患者的有效治疗方法。方法回顾性分析了87例主要表现为腰臀部疼痛的腰椎间盘突出症患者,入院后直接手术者32例,先行牵引等保守治疗1月左右无效而改行手术者23例,一直行保守治疗者32例。结果所有患者均获得随访,时间:5月～7年,平均3年5月。手术患者根据中华骨科学会脊柱学组腰背痛手术评定标准评定:优良率89.1%。保守治疗患者根据Tauffer和Coventry腰椎间盘突出症疗效标准评定:良好率84.3%。结论对于初次发作或病史少于3个月者,应采用保守治疗;而对于反复发作,病史超过半年,腰臀部疼痛严重,经保守治疗无效者应果断采取手术治疗。     

Lumbar spinal surgery for sciatica due to intervertebral disc disease in the elderly

This report reviews 36 patients aged 71 to 93 years who had lumbar spinal surgey for sciatica pain some with motor and or sensory disturbances and with no motor and sensory disturbances. Even though we found soft disc herniations, these patients should have a thorough circumferential decompression because of bony osteophytes and facet hypertrophy. Special attention is drawn to the removal of herniated discs associated with massive spondylotic degenerative changes.     

Pyogenic Vertebral Osteomyelitis after Acute Bacterial Prostatitis: A Case Report

A case of pyogenic vertebral osteomyelitis after acute bacterial prostatitis in a 78-year-old man is reported. The rarity and subtle clinical presentation of this condition, and the delayed appearance of radiologic signs of progression to destructive osteomyelitis, contributed to a significant delay in diagnosis. An arterial blood culture positive for bacterial growth during the episode of acute prostatitis suggested that bacteremia might result from hematogenous spread of the infection to the vertebral column via the venous system. Since intensive antimicrobial therapy proved ineffective, debridement of the first and second lumbar vertebral bodies, and anterior spinal fusion from the twelfth thoracic to the third lumbar vertebrae were performed. The patient's high fever and severe lumbago subsided immediately after the surgery. The possibility of development to pyogenic vertebral osteomyelitis should be kept in mind when treating a serious genitourinary tract infection.