后路腰椎间盘镜治疗单节段腰椎间盘突出症的MRI改变

目的为证实MED治疗腰椎间盘突出是否属微创手术提供影像学依据。方法对接受椎间盘突出髓核摘除手术的54例单节段腰椎间盘突出症患者进行随访(其中MED组32例,Love组22例),行MRI扫描,部分患者做了增强扫描。在MRI上观察测量手术前后硬膜外压痕大小、椎间隙高度率、软骨终板退变及信号改变情况并观察硬膜外压痕的强化情况。结果54例患者术后硬膜外压痕较术前明显缩小,但术后1年和3年随访时比较差异无显著性(P>0.05)。椎间隙高度有随时间下降趋势;软骨终板继续退变;MED组14例强化,Love组9例强化。以上观察指标两组间比较差异均无显著性(P>0.05)。结论术后MRI检查未能提供MED术微创的影像学依据。     

Transdural cauda equina incarceration after microsurgical lumbar discectomy: case report

OBJECTIVE AND IMPORTANCE: Complications usually occur when they are least expected. We present an unusual case of nerve entrapment after microsurgical discectomy. CLINICAL PRESENTATION: A patient undergoing uneventful first lumbar microsurgical discectomy developed severe back and leg pain and a progressive neurological deficit during the first postoperative night. Herniation of cauda equina nerve roots had occurred through an unnoticed minimal defect in the dura, which had not caused cerebrospinal fluid leakage. The roots were incarcerated and swollen, and they filled the space of the resected nucleus pulposus. It was presumed that elevation of intra-abdominal pressure and consequent increased intraspinal pressure during extubation led to the herniation of arachnoid and cauda equina roots. The nerve roots were then trapped and incarcerated in the manner of bowel loops in an abdominal wall hernia. INTERVENTION: During reoperation, the nerve roots were repositioned into the dural sac. The patient recovered without further complications and without long-term sequelae. CONCLUSION: All dural tears that occur during intraspinal surgery, even if they are small and the arachnoid is intact, should be closed with stitches or at a minimum with a patch of muscle or gelatin sponge with fibrin glue. Care should be taken to avoid increased intra-abdominal pressure during extubation. Excessive pain and progressive neurological dysfunction occurring shortly after microsurgical lumbar discectomy or any intraspinal procedure is indicative of possible hemorrhage with subsequent compression of nerve roots. The case reported here provides anecdotal evidence that this situation can also be caused by a herniation of cauda equina nerve roots through a small dural defect that was not evident during the initial operation.     

后路椎间盘镜手术中转传统开窗椎板切除髓核摘除术的原因分析

目的 分析后路椎间盘镜(MED)治疗腰椎间盘突出症术中转传统开窗椎板部分切除髓核摘除术的原因,探讨相应的预防措施.方法 分析应用MED技术治疗300例(342个间隙)患者的临床资料,总结9例中转开窗椎板部分切除髓核摘除术的原因,并提出相应的预防措施.结果 300例患者手术切口均一期愈合.疗效评定:优148例,良130例,中18例,差4例,优良率为92.7%.中转开窗椎板部分切除髓核摘除术9例:3例术中出血多者果断中转而治愈;5例脑脊液漏者经治疗治愈;1例神经根损伤开放探查,为部分马尾损伤,经治疗残留部分感觉减退但无足下垂.结论 硬脊膜损伤、术中出血、神经根损伤是MED治疗腰椎间盘突出症中转传统开窗椎板部分切除髓核摘除术的常见原因;术者丰富的微创经验、合适的病例选择可减少MED治疗腰椎间盘突出症中转开窗椎板部分切除髓核摘除术.     

脊柱后路显微内窥镜下手术治疗腰椎间盘突出症的临床应用

目的 探讨脊柱后路显微内窥镜下椎间盘切除术(MED)治疗腰椎间盘突出症的临床效果和应用价值。方法 自1999年9月～2002年10月，对腰椎间盘突出症152例患者采用椎板间隙入路显微内窥镜下椎间盘切除术治疗，随访观察临床疗效。结果 113例获得3～19个月随访，按Macnab疗效评定标准，优86例，良21例，可4例，差2例，手术优良率94．6％。结论 只要掌握好适应证，应用椎板间隙入路显微内窥镜下椎间盘切除术治疗腰椎间盘突出症具有创伤小、术后恢复快、手术安全性好等优点，疗效可靠。     

Cauda equina syndrome as a postoperative complication in five patients operated for lumbar disc herniation

STUDY DESIGN: A retrospective analysis of records and radiographs in five patients who developed acute cauda equina syndrome after surgery for lumbar disc herniation. OBJECTIVES: To postulate as a possible pathophysiologic mechanism the venous congestion caused by preexisting spinal stenosis and to present a management plan: extended decompression within 48 hours. SUMMARY OF BACKGROUND DATA: Cauda equina syndrome is reported as a sequela in 0.2%-1% of the surgeries for lumbar disc herniation. There is, however, no consensus on the possible pathophysiologic mechanism to the complication or to its management. METHODS: Preoperative investigations consisted of magnetic resonance imaging, or myelography and computed tomography. There was a good correlation between clinical appearance and radiographic findings in all patients. When the complication became apparent in four of the patients, they were investigated with magnetic resonance imaging and reoperated on within 48 hours with wide decompressions. RESULTS: The index operation was reported uneventful in all patients. Postoperative magnetic resonance imaging did not show the cause of the cauda equina syndrome, nor could this be established at the reoperation. Before surgery, all five patients had preexisting narrowing of the spinal canal. In no case was the lumbosacral disc the index level. Two patients recovered fully, whereas the other three experienced varying degrees of residual symptoms. There was no correlation between the end result and the delay until secondary decompression. CONCLUSION: Relative spinal stenosis may contribute to the development of cauda equina syndrome after surgery for lumbar disc herniation. A venous congestion can be triggered by postoperative edema, leading to nerve root ischemia. The treatment of choice seems to be extended decompression within 48 hours.     

经椎板间隙入路内窥镜下髓核摘除术并发症的预防与处理

目的 分析经椎板间隙入路内窥镜下髓核摘除术治疗腰椎间盘突出症的手术并发症、预防及处理方法。方法 回顾性总结487例行经椎板间隙入路内窥镜下髓核摘除术的并发症。结果 术中并发症大多发生在早期开展的50例中。并发症包括：术中硬脊膜撕裂8例(占1．64％);马尾神经损伤l例(占0．2l％);脊神经根损伤l例(占0．2l％);镜下止血困难改开放手术3例(占0．62％);椎间盘炎l例(占0．2l％)。结论 经椎板间隙入路内窥镜下髓核摘除术治疗腰椎间盘突出症的并发症与术者经验有直接关系,早期并发症明显高于开放手术,而后期并发症少见。     

显微椎间盘镜治疗腰椎间盘突出症疗效分析

目的通过后路显微内窥镜椎间盘摘除术的临床应用，探讨其技术要点和临床效果。方法对116例(143个间隙)腰椎间盘突出症患者施行后路显微内窥镜椎间盘摘除术。对其疗效进行回顾性分析。结果本组病人均在术后7d内出院。全组病人均获得随访，平均随访时间5．5个月，术后按Macnnab标准评级：优68例，良39例，可9例，优良率92．2％。结论后路显微内窥镜椎间盘摘除术手术创伤小，基本不影响脊柱稳定性，术后恢复快且疗效肯定。     

复发性腰椎间盘翻修术的微创术式选择与临床应用

目的 评价内镜辅助下微创腰椎间盘翻修术的临床效果,并比较单纯减压与椎间融合、椎弓根螺钉内固定的临床结果 .方法 共32例微创腰椎间盘翻修术患者,男22例,女10例,平均45.7岁.其中27例患者获得随访(随访率84.4%),平均随访25.5个月.临床患者被分为二组:内镜下单纯减压组(14例)和内镜下减压、椎间植骨融合、椎弓根螺钉内固定组(13例).疗效评定按照目测视觉类比评分法(VAS评分)和Nakai分级评定.结果 二组患者术后平均腰腿痛VAS指数显著降低,手术前后差异有显著(P<0.05)和极显著(P<0.01)统计学意义.根据Nakai分级;单纯减压组优良率92.8%,减压内固定组优良率85.5%.虽然二组优良率间比较无统计学意义(P=0.793),但单纯减压组的手术时间、术中出血量、术后下床时间和治疗费用都显著低于减压内固定组(P<0.05).结论 内镜下微创腰椎间盘翻修术非常有效和安全,内镜下单纯纤维瘢痕组织松解和椎间盘摘除减压是腰椎间盘翻修术的首选术式.     

椎间盘镜与传统开放术治疗腰椎间盘突出症疗效和安全性比较的Meta分析

目的:比较椎间盘镜与传统开放椎间盘摘除术治疗腰椎间盘突出症的疗效与安全性。方法:在中国生物医药数据库,CNKI数据库,重庆VIP数据库和万方数据库进行系统文献检索。Meta统计分析使用RevMan4.2软件完成。对两种手术方法的优良率、手术时间、术中失血量、术后卧床休息时间、恢复日常活动时间、住院或手术后住院天数,以及并发症进行比较。结果:总共纳入了20篇文献,其中2957例患者行椎间盘镜术,而2130例患者行传统开放椎间盘摘除术。有12篇报道比较了两种治疗方法的手术时间,11篇比较了术中失血量,7篇比较了术后卧床休息时间,5篇进行了术后恢复日常活动所需时间的比较,另外分别有4篇比较了住院日及术后住院天数。其中有10篇文献提到了手术并发症。与开放手术比较,椎间盘镜治疗的患者有较高的优良率[OR=1.29,95%CI(1.03,1.62)],术中出血量少[OR=-63.67,95%CI(-86.78,-40.55)],更少的卧床休息时间[OR=-15.33,95%CI(-17.76,-12.90)],恢复日常活动所需时间更短[OR=-24.41,95%CI(-36.86,-11.96)],更少住院日[OR=-5.00,95%CI(-6.94,-3.06)]或手术后住院天数[OR=-7.47,95%CI(-9.17,-5.77)]。但是在手术并发症发生率和手术时间方面,两者之间差异无统计学意义。结论:椎间盘镜与传统开放术治疗腰椎间盘突出症均是安全有效的,手术并发症发生率相当。与传统手术比较,椎间盘镜治疗出血量少,术后卧床休息天数及住院日短,并且能更快地恢复日常生活。选择哪种手术方式主要根据患者的适应证,在相同适应证的情况下椎间盘镜手术应该被推荐。     

The role of Gd-enhanced three-dimensional MRI fast low-angle shot (FLASH) in the evaluation of symptomatic lumbosacral nerve roots

In the field of lumbar spine disorders, three-dimensional (3-D) magnetic resonance imaging (MRI) can clearly depict a lumbar nerve root from the distal region to the dorsal root ganglion. In this study, we used a gadolinium-diethylenetriaminepentaacetic acid (Gd-DTPA) enhanced-three-dimensional (3-D) fast low-angle shot (FLASH) se-quence when examining lumbosacral disorders. The subjects were 33 patients (14 men and 19 women) in whom lumbosacral neural compression had been diagnosed clinically. Twenty-one patients had lumbar disc herniation, 11 had lumbar spinal stenosis, and 1 had lumbar radiculopathy caused by rheumatoid arthritis. Five subjects with low back pain were also studied as a control group. In all patients and in all 5 of the controls, the dorsal root ganglion of every root was enhanced clearly. There was no root enhancement in the 5 controls. Enhancement of the symptomatic nerve roots, caused by compression, was found in 11 of the 33 patients. All 11 patients had radiculopathy, and muscle weakness was more frequent in patients with enhanced nerve roots than in those without enhancement. There was no enhancement of the cauda equina, even in the patients with cauda syndrome. The enhancement effect may reflect some pathological condition of the compressed nerve root and needs to be studied further. Received: March 6, 2000 / Accepted: October 20, 2000     

椎间盘镜手术治疗腰椎间盘突出症

目的：评价椎间盘镜手术治疗腰椎间盘突出症的临床疗效。方法：腰椎间盘突出症患者15例，男11例，女4例；平均年龄39．8岁。在椎间盘镜下行腰椎间盘髓核切除、椎板减压及神经根管扩大术。术前在X线机下，分别于病变节段上位棘突下缘、上位椎板下缘中点定位，置人内窥镜头。在椎间盘镜配套的监视器下咬除部分椎板下缘及黄韧带，扩大椎板间隙，清除椎间盘髓核组织，扩大神经根管。结果：本组除1例患者因术中硬膜囊破裂改为开放手术，其余14例平均手术出血量60ml，平均手术时问86min。本组平均随访时间13．2个月，按照Nakai评级，优11例，良3例，可1例。结论：椎间盘镜手术治疗腰椎间盘突出症比常规手术方法视野清晰、创伤小、恢复快，基本保持了脊柱后柱完整。     

腰椎间盘镜手术并发症的分析

目的：探讨腰椎间盘镜手术并发症的原因及治疗。方法：2000年8月-2004年5月用SOFAMOR DANEK公司METRX椎间盘镜治疗腰椎间盘突出症162例，对其临床结果进行回顾性分析。结果：出现并发症10例：硬脊膜撕裂6例，神经根断裂1例，马尾神经损伤1例，椎间隙感染1例，腰背骶脊肌抽搐1例。治疗后1例神经断裂随访23个月未见明显好转，1例马尾神经损伤随访9个月有所好转，但大小便仍不能控制。结论：椎间盘镜治疗腰椎间盘突出具有切口小、创伤小、恢复快等优点；手术操作必须规范、熟悉解剖，避免神经损伤等并发症发生。     

Plexiform neurofibroma of the cauda equina: case report

BACKGROUND: Plexiform neurofibromas are rarely found in the cauda equina. The most recent report of a plexiform neurofibroma of the cauda equina noted only 2 previously described cases. CASE DESCRIPTION: To these we add the current case, as well as 2 additional previously published cases. We report the case of a 44-year-old man with a sudden exacerbation of his long-standing lower-back and bilateral leg pain. An intradural lesion was seen on magnetic resonance imaging and he underwent surgery. Intraoperatively, there were swollen nerve roots and tumor insinuating itself between the roots. A biopsy was performed, and pathology findings were consistent with plexiform neurofibroma. CONCLUSIONS: Plexiform neurofibroma of the cauda equina is a rare tumor, with variable manifestations. These tumors are not amenable to complete resection. Surgical treatment consists of either partial resection or biopsy, possibly with dural grafting for decompression.     

Partial cauda equina syndrome after an uneventful minimally invasive microdiscectomy in a patient with Crohn's disease

Cauda equina syndrome is a serious condition resulting from dysfunction of the lumbosacral nerve roots and characterized by impairment of bladder, bowel, sexual and lower limb functions. We report the case of a 48-year-old woman who had Crohn's disease for more than twenty years. The patient was undergoing immunotherapy with infliximab and developed a partial cauda equina syndrome after an uneventful minimally invasive microdiscectomy (L₅–S₁) that completely cured her sciatica. A postoperative magnetic resonance imaging examination showed root clumping but no compressive lesion. We discuss a possible relationship between the cauda equina syndrome and the patient's active Crohn's disease, treatment and surgery.     

Dorsal compression of the epidural cord due to free sequestral lumbar prolapse

Due to the anatomical situation, intervertebral disc herniation usually results in compression of the anterior epidural space, with lateral or medial irritation of nerve root or cauda equina. Rare locations are an intra- or extraforaminal position or dislocation dorsally. Three patients with dorsal cauda equina compression caused by a sequestered herniated nucleus pulposus (HNP) are reported. The patients complained mainly of severe back pain. In two patients nondermatome-related leg pain was observed; one patient suffered additionally from incomplete cauda equina syndrome. In all cases magnetic resonance imaging and computed tomography diagnosed neoplastic tissue.     

Surgery for lumbar disc herniation during pregnancy

STUDY DESIGN: The case reports of three pregnant patients with lumbar disc herniation causing cauda equina syndrome or severe neurologic deficits are presented to illustrate that disc surgery during gestation is a safe method of management. OBJECTIVE: To emphasize the importance of recognizing and definitively treating lumbar disc displacement causing neurologic deficits during pregnancy. SUMMARY OF BACKGROUND DATA: The advent of magnetic resonance imaging and modern surgical techniques for treatment of lumbar disc displacement allows safe management of this condition at any stage of gestation. A review of the literature on the risks of nonobstetric surgery and the risks of delaying disc surgery until delivery shows that operating at any stage during gestation for severe neurologic deficit secondary to lumbar disc displacement is justified. METHODS: A review of the literature on the use of magnetic resonance imaging scan and nonobstetric surgery during pregnancy was performed. Three case reports of the authors' patients who had lumbar disc displacement with cauda equina syndrome or severe neurologic deficit are presented. Patients were placed prone on a four-poster frame, and an epidural anesthetic agent was administered. A one-level hemilaminectomy, partial facetectomy, and disc excision were performed in all three cases. RESULTS: The methods used for diagnosis and surgical treatment of three patients with disc herniation during pregnancy resulted in a satisfactory outcome for both mother and child. The medical literature supports surgical intervention in pregnant patients with cauda equina syndrome and severe and/or progressive neurologic deficit(s) from lumbar disc displacement at any state of gestation. CONCLUSION: Although extremely rare, cauda equina syndrome and severe and/or progressive neurologic deficit caused by lumbar disc displacement can occur during pregnancy. The prevalence of symptomatic lumbar disc herniation during pregnancy may be on the increase because of the increasing age of patients who are becoming pregnant. These cases showed, and the literature confirms, that pregnancy at any stage is no contraindication to magnetic resonance imaging scan, epidural and/or general anesthesia, and surgical disc excision.     

显微内镜治疗腰椎间盘突出症远期效果评价

目的探讨显微内镜治疗腰椎间盘突出症远期效果. 方法回顾性分析218例经显微内镜治疗腰椎间盘突出症远期疗效,术后随访3年以上,采用日本骨科学会下腰痛评分标准(JOA)进行疗效评定. 结果本组病例术后随访3年以上,优121例,良80例,可16例,差1例,优良率92.2%(201/218).结论显微内镜治疗腰椎间盘突出症远期疗效确切,娴熟的操作技巧和术后正确指导患者康复训练是确保手术效果的关键.     

手术显微镜下与椎间盘镜下治疗腰椎间盘突出症的比较研究

 目的 对比研究手术显微镜下腰椎间盘切除术(microsurgical lumbar discectomy, MSLD)与椎间盘镜下腰椎间盘切除术(microendoscopic discectomy, MED)治疗单节段腰椎间盘突出症的方法、特点与疗效。方法 2006年 1月至 2009年 12月, 900例单节段腰椎间盘突出症患者被随机分为两组, MSLD组与 MED组各 450例, 术后分别平均随访 36个月和 38个月。比较两组手术病例的平均切口长度、手术时间、出血量、并发症、住: 天数及恢复情况。结果 MSLD组及 MED组的切口长度分别为(3.8±1.1) cm和(2.4±0.7) cm, 手术时间分别为(51.0±14.2) min和(62.0±16.3) min, 术中出血量分别为(60±35) ml和(106±43) ml, 以上指标两组间差异均有统计学意义(P 0.05)。末次随访时, MSLD组及 MED组的疼痛视觉模拟评分(visual analogue scales, VAS)改善率和 Oswestry功能障碍指数(Oswestry disability index, ODI)改善率差异均无统计学意义(P >0.05)。 MSLD组硬脊膜撕裂、急性竖脊肌血肿、神经根及马尾损伤等并发症及术后复发的发生率均明显少于 MED组(P< 0.01)。两组均未出现定位错误、大血管损伤和术后感染。结论 MSLD与 MED治疗单节段腰椎间盘突出症均可获得满意的远期疗效, 但 MSLD操作简单、并发症少、学习曲线短。     

Cauda Equina Intradural Extramedullary Cavernous Haemangioma: Case Report and Review of the Literature

Cavernous haemangioma (cavernoma) is a benign vascular lesion, exceptionally located in cauda equina. We report a case, diagnosed and operated in the Department of Neurosurgery from Pitesti County Emergency Hospital, of a 60-year-old woman with history of lumbar region distress, who presented with low back pain, paravertebral muscle contracture, and bilateral lumbar radiculopathy, with sudden onset after lifting effort. The preoperative diagnosis was done using computed tomography (CT) and magnetic resonance imaging (MRI), and the patient underwent surgery—two level laminectomy, dural incision, and tumor dissection from the cauda equina nerve roots under operatory microscope. Histopathological examination confirmed the positive diagnosis of cavernoma of cauda equina. The patient''s outcome was favorable, without postoperative neurological deficits.     

大鼠非压迫性髓核突出模型的建立

目的:设计一种新的非压迫性腰椎间盘髓核突出动物模型。方法:16只SD雄性大鼠随机分对照组和实验组,分别将生理盐水和大鼠自身尾椎髓核混悬液注射到腰椎硬膜外腔,对其马尾神经传导速度和神经根组织形态学进行观察。结果:无明显机械压迫情况下,大鼠硬膜外移植自体髓核能使马尾神经根传导速度和组织形态产生明显改变。结论:本动物模型简单、可靠、费用低廉,为进一步研究腰椎间盘突出症提供了一种动物模型。