经皮腰椎间盘切吸术治疗腰椎间盘突出症并腰椎管狭窄

经皮腰椎间盘切吸术(Automated percutaneous lum-bar discectomy,APLD)自从Hijikata首次报道成功以来,以其创伤小、出血少、不造成神经根粘连、不影响脊柱稳定性、病人易接受等优点而被广泛应用于临床,但有关APLD治疗腰椎间盘突出症并椎管狭窄的报道较少,且多数人把此类腰椎间盘症作为APLD的禁忌证.我们通过收治的45例此类腰椎间盘突出症行APLD治疗后,近期疗效满意,报告如下     

腰椎管狭窄伴椎间盘突出症的手术选择

腰椎管狭窄伴腰间盘突出在临床上很常见,其椎管狭窄症多为退行性变引起,约占腰椎管狭窄的60%。而椎间盘退变是最常见的引发脊椎退变的病因,其中的腰间盘突出症与退行性腰椎管狭窄也常有交叉。虽然成年人椎管狭窄伴椎间盘突出而施行的全椎板切除及间盘摘除术后,很少发生明显的脊柱畸形,但其术后可能会破坏脊柱的稳定性,出现活动异常和功能单位的刚度减弱等,使术后的腰腿痛复发,影响远期疗效。因此,现代脊柱手术提出了要求保护脊柱稳定性的要求。     

内固定加植骨融合治疗腰椎间盘突出合并腰椎失稳

目的：探讨腰椎间盘突出症合并腰椎不稳的手术疗效。方法：自2000年6月至2006年6月,采用后路减压、椎间盘摘除、植骨融合、椎弓根系统内固定手术治疗腰椎间盘突出症合并腰椎不稳46例,男33例,女13例;年龄37～68岁,平均48岁。病程4个月～20年,平均3.5年。单节段21例,双节段22例,3节段3例。结果：46例均获得随访,时间12～45个月,平均25个月。植骨全部愈合,临床症状明显改善,按疗效评定标准：优32例,良8例,可6例,优良率86.9%。结论：对明确诊断存在腰椎不稳合并腰椎间盘突出症的患者,施行髓核摘除、内固定加植骨融合、重建脊柱的稳定性,能获得满意的临床疗效。     

Idiopathic spinal cord herniation associated with intervertebral disc extrusion: a case report and review of the literature

STUDY DESIGN: A case of idiopathic spinal cord herniation is reported, and the literature is reviewed. OBJECTIVE: To report a case of thoracic spinal cord herniation with a ventral dural defect, probably caused by thoracic disc extrusion. SUMMARY OF BACKGROUND DATA: Recently, reports of spinal cord herniation have been increasing. This increase can be attributed to the development of magnetic resonance imaging and increased awareness of this entity. However, the cause of the ventral dural defect remains unknown. METHODS: A 54-year-old woman had experienced Brown-Séquard syndrome for 2 years. Magnetic resonance imaging demonstrated an S-shaped anterior kinking of the spinal cord, with dilation of the dorsal subarachnoid space. RESULTS: After incision of the dural sac and gentle retraction of the spinal cord, a dural defect was recognized into which the spinal cord had herniated. An extruded disc was visualized through the defect at T3-T4. The ventral dural defect and the dorsal incision of the dural sac were repaired with a fascial graft from the thigh. CONCLUSIONS: Intraoperative findings suggest that the thoracic disc herniation in the current case was the probable cause of the ventral dural defect. Surgical reconstruction using double fascial graft under careful spinal cord monitoring resulted in a satisfactory neurologic recovery.     

Outcomes in patients admitted for rehabilitation with spinal neurological lesions following intervertebral disc herniation

BACKGROUND: Little information is available about the survival, neurological recovery, and length of stay in hospital for rehabilitation (LOS) of patients with spinal neurological deficit following disc herniation (DH). STUDY DESIGN: Retrospective cohort study. OBJECTIVE: To report on outcomes and factors affecting these. SETTING: The Spinal Research Laboratory, Loewenstein Rehabilitation Hospital, Israel. SUBJECTS: A total of 158 patients with DH spinal neurological lesions (DHSNL). METHOD: Data were collected retrospectively. Survival was assessed using the Kaplan-Meier method; relative mortality risk by the Cox proportional hazard model. Neurological recovery was evaluated by calculating the change in Frankel grades, and factors that affect it were assessed by logistic regression. LOS associations were analyzed with ANOVA. RESULTS: The median age at lesion onset was 48 years, and the median survival 29 years. Age and gender had a significant effect on survival, but not so lesion severity, level, or decade of onset. Of the 69 patients who had Frankel grades A, B, or C on admission, 72% achieved useful recovery to grades D or E. The severity and level of the spinal neurological lesion (SNL) had a significant effect on recovery. The mean LOS was 87 days; it was significantly affected by lesion severity and level and by the decade of admission to rehabilitation, and decreased with time. CONCLUSIONS: Patients with DHSNL who were admitted for rehabilitation have favorable survival and recovery rates compared with previously studied patients with other types of SNL. Their LOS is probably a function of medical requirements, but is decreasing with time.     

腰神经根管狭窄合并椎间盘突出症的手术治疗

目的探讨腰神经根管狭窄合并椎间盘突出症的诊断，手术方法。方法 对８３例腰神经根管狭窄合并椎间盘突出症病例进行椎间盘切除并神经根管扩大术。结果 经１－６年的随访观察，优良率为９２．９％。结论根据类型选择手术方法，减压必须彻底。     

Idiopathic spinal cord herniation associated with calcified thoracic disc extrusion--case report

A 48-year-old man presented with idiopathic spinal cord herniation associated with calcified thoracic disc extrusion at the T7-8 intervertebral level, manifesting as Brown-Sequard syndrome at the thoracic level persisting for 20 years. Preoperative magnetic resonance imaging and computed tomography myelography revealed ventral displacement of the spinal cord and extrusion of a calcified disc at the T7-8 intervertebral level. At surgery, the spinal cord herniation at this level was released from the dura mater and carefully returned to the dural sac. An extruded calcified thoracic disc was found just below the dural defect at the same level. The development of idiopathic spinal cord herniation is associated closely with a defect in the ventral dura mater of unknown etiology. In our case, the etiology of the ventral dural defect was probably associated with the calcified thoracic disc extrusion.     

介入注射胶原酶配合三维牵引治疗腰椎间盘突出症

我院2000年12月-2003年3月，运用介入注射胶原酶配合三维牵引治疗腰椎间盘突出症50例，取得了满意效果，现报告如下。     

腰椎椎间孔镜手术治疗伴神经根管狭窄的腰椎椎间盘突出症

目的退变性腰椎椎间盘突出、黄韧带肥厚、关节突关节增生内聚引起神经根管狭窄,利用椎间孔镜对神经根管进行减压。方法对20例退变性神经根管狭窄症患者行腰椎椎间孔镜下神经根管扩大成形术,记录术前术后腰腿痛疼痛视觉模拟量表(visual analogue scale,VAS)评分,采用Macnab标准评价疗效。结果 20例患者术前平均腰痛VAS评分为5分,术后即刻为1.5分,术后3个月为0.5分。术前平均腿痛VAS评分为7分,术后即刻为0.3分,术后3个月为0.1分。18例患者术后3个月的改良Macnab疗效评定为优,2例患者为良。结论对腰椎退变性神经根管狭窄症,椎间孔镜可对突出的腰椎椎间盘、关节突关节以及黄韧带进行减压,有效地扩大神经根管,可获得很好的疗效。     

矫形鞋辅助手法治疗腰椎间盘突出症的临床研究

目的:探讨矫形鞋在手法治疗腰椎间盘突出症患者中的作用及机制。方法:选取2009年9月至2010年9月收治的腰椎间盘突出症患者44例(男28例,年龄24～58岁;女16例,年龄21～60岁),首先使用表面肌电图(surface electromyogram,sEMG)技术记录患者左右两侧腰段竖脊肌表面肌电图的平均肌电波幅(average EMG,AEMG)和频谱面积(spectrum area,SPA),并比较穿矫形鞋站立1min与不穿矫形鞋站立1min、穿矫形鞋行走1min与不穿矫形鞋行走1min左右两侧竖脊肌AEMG及SPA差值的绝对值larAEMG和larSPA。然后随机分为实验组和对照组,每组22例。实验组患者接受脊柱定点旋转复位法辅助自制矫形鞋治疗,对照组患者只接受脊柱定点旋转复位法治疗。矫形鞋制作:患者着平底鞋,将髂嵴较低侧下肢所穿鞋,鞋底增高,使患者髂嵴连线与地面平行,保持骨盆的正常位置。脊柱定点旋转复位法为治疗医师用拇指将偏歪的棘突拨正,每周2～3次。比较两组患者的临床治愈时间。结果:患者穿矫形鞋站立1min与不穿矫形鞋站立1min两种体位下测定的larSPA分别为0.12±0.73、0.65±0.61,larAEMG分别为3.43±25.56、21.74±20.34;在穿矫形鞋行走1min与不穿矫形鞋行走1min两种体位下测定的larSPA分别为0.15±0.36、0.57±0.24,larAEMG分别为4.65±12.87、25.18±16.58,组间差异均有统计学意义(P<0.01)。实验组和对照组平均治愈时间分别为(20.36±4.92)d和(28.14±7.13)d,前者治愈时间明显少于后者(P<0.01)。结论:矫形鞋可以明显改善两侧腰部竖脊肌不对称收缩,平衡腰肌,为脊柱定点旋转复位法治愈腰椎间盘突出症创造良好条件,缩短临床治愈时间。     

Sagittal spinal alignment in patients with lumbar disc herniation

A retrospective cross-sectional study was designed to evaluate total sagittal spinal alignment in patients with lumbar disc herniation (LDH) and healthy subjects. Abnormal sagittal spinal alignment could cause persistent low back pain in lumbar disease. Previous studies analyzed sciatic scoliotic list in patients with lumbar disc herniation; but there is little or no information on the relationship between sagittal alignment and subjective findings. The study subjects were 61 LDH patients and 60 age-matched healthy subjects. Preoperative and 6-month postoperatively lateral whole-spine standing radiographs were assessed for the distance between C7 plumb line and posterior superior corner on the top margin of S1 sagittal vertical axis (SVA), lumbar lordotic angle between the top margin of the first lumbar vertebra and first sacral vertebra (L1S1), pelvic tilting angle (PA), and pelvic morphologic angle (PRS1). Subjective symptoms were evaluated by the Japanese Orthopedic Association (JOA) score for lower back pain (nine points). The mean SVA value of the LDH group (32.7 ± 46.5 mm, ± SD) was significantly larger than that of the control (2.5 ± 17.1 mm), while L1S1 was smaller (36.7 ± 14.5°) and PA was larger (25.1 ± 9.0°) in LDH than control group (49.0 ± 10.0° and 18.2 ± 6.0°, respectively). At 6 months after surgery, the malalignment recovered to almost the same level as the control group. SVA correlated with the subjective symptoms measured by the JOA score. Sagittal spinal alignment in LDH exhibits more anterior translation of the C7 plumb line, less lumbar lordosis, and a more vertical sacrum. Measurements of these spinal parameters allowed assessment of the pathophysiology of LDH.     

脊柱手法治疗腰椎间盘突出症原则的演变

脊柱手法以纠正脊柱畸形或力学失衡为原则治疗腰椎间盘突出症已经有数千年的历史了。但是,自从70多年前腰椎间盘突出症的病理机制被现代科学揭示以来,人们就开始逐渐忽略或摒弃脊柱力学失衡的手法治疗,转而关注突出髓核组织。但是,随着现代医学的发展,临床一线的医生们又逐渐发现了许多临床证据,证明大部分患者都可以通过保守治疗使症状得到缓解甚至临床治愈,而突出髓核在保守治疗成功之后并未产生显著改变,这不得不让现代医学重新审视突出髓核的,临床意义。同时,根据脊柱手法在保守治疗临床工作的实际效应,临床医生在新的背景下,又开始重新展开对腰椎间盘突出症患者脊柱力学失衡问题的认识。本文从文献回顾的角度,总结了本病的这一认知历程,希望为腰椎间盘突出症病理认识的深入和治疗原则的完善带来一些启示。     

胸腰段与腰椎多节段椎间盘突出症的诊治方法

目的探讨胸腰段与腰椎多节段椎间盘突出症的诊断和治疗方法。方法手术治疗17例胸腰段与腰椎多节段椎间盘突出患者,观察其临床特点及影像学表现,判断责任节段,对不同患者采用不同的个性化手术方式。结果17例均获随访,时间6—48个月。根据Otani标准评价疗效：优8例,良6例,可3例。结论胸腰段与腰椎多节段椎间盘突出症的临床表现较复杂,诊断是关键,需要对临床表现进行全面分析,选择适当的手术方法,才能获得满意疗效。     

青少年腰椎间盘突出症诊断与治疗

目的 分析青少年腰椎间盘突出症特点，提高诊治水平。方法 12例青少年患者中，2例症状较轻者保守治疗后缓解，6例经2～16个月保守治疗失败，4例未行保守治疗。共9例行后路手术治疗。结果 无严重手术并发症。随访时，2例未手术患者腰腿痛常复发。8例手术患者获1年6个月～9年随访，6例无腰腿痛，神经功能恢复，恢复术前活动度；2例劳累后有轻微腰痛，其中1例5年后复发。结论 神经根张力试验阳性是青少年腰椎间盘突出症临床特点，提高对该病的认识是防止漏诊误诊的关键。     

腰椎关节突关节不对称与青少年腰椎间盘突出症

目的:探讨青少年腰椎间盘突出症发生与病变间隙关节突关节不对称性的关系。方法:在CT片上观察并测量24例青少年腰椎间盘突出症患者(年龄13~20岁)26个病变间隙的关节突关节形态及关节突关节角度,并与50例成年患者(年龄30~49岁)60个病变间隙比较。两侧关节突关节形态不同和(或)两侧关节突关节角度之差≥10°定义为关节突关节不对称,比较两组间关节突关节不对称发生率及其与椎间盘突出位置、病理类型的关系。结果:青少年组关节突关节不对称总发生率为57.7%,成年组为10%,两组间比较差异有显著性(P<0.05),关节突关节不对称与椎间盘突出位置、病理类型无关。结论:腰椎关节突关节不对称在青少年腰椎间盘突出症的发生率较高,可能是青少年腰椎间盘突出症发生的原因之一。     

Markers of nerve tissue injury in the cerebrospinal fluid in patients with lumbar disc herniation and sciatica

STUDY DESIGN: The light subunit of neurofilament protein, S-100 protein, neuron-specific enolase, and glial fibrillary acidic protein were determined in the cerebrospinal fluid in patients with lumbar disc herniation and in control patients. OBJECTIVES: To determine whether nerve root injury caused by disc herniation increases the levels of nerve and glial cell injury markers in the cerebrospinal fluid. SUMMARY OF BACKGROUND DATA: Markers of nerve tissue injury can be analyzed in the cerebrospinal fluid, allowing characterization of the cell types involved and the degree of disease in patients with neurologic disorders. METHODS: Cerebrospinal fluid samples were obtained by preoperative lumbar puncture in patients who underwent surgery for lumbar disc herniation and in patients who underwent lower extremity surgery (control group), neurofilament protein (light subunit) and glial fibrillary acidic protein were analyzed by enzyme-linked immunosorbent assay and S-100 protein and neuron-specific enolase by radioimmunoassay and luminescence immunoassay, respectively. In the disc herniation group the concentrations of the four markers were evaluated regarding possible correlation to patient history, computed tomographic findings, and clinical findings. RESULTS: Cerebrospinal fluid concentration of neurofilament protein (light subunit) and S-100 were increased in the disc herniation group compared with that in control subjects (1158 +/- 383 ng/L vs. 152 +/- 14 ng/L, P < 0.01; 1963 +/- 231 ng/L vs. 1003 +/- 152 ng/L, P < 0.05, respectively). No statistical differences in neuron-specific enolase and glial fibrillary acidic protein concentrations were observed between the groups. Disc herniation patients with fewer than 3 months' duration of subjective symptoms had higher neurofilament protein levels than did patients with longer duration. None of the markers was related to preoperative clinical or computed tomographic findings. Patients with persistent neurologic findings at follow-up 2-3 months after surgery had higher levels of neurofilament protein before surgery compared with-those without sequelae. CONCLUSIONS: Patients with disc herniation and sciatica have increased concentrations of neurofilament protein and S-100 in the cerebrospinal fluid, which indicates damage of axons and Schwann cells in the affected nerve root.     

急性脊髓损伤脊髓与脑脊液中炎性因子相关性的实验研究

[目的]了解急性脊髓损伤后脊髓内及脑脊液中IL-6、IL-1β及TNF-α变化的相关性。[方法]随机将152只大鼠分为正常组、假手术组、脊髓损伤组。采用Allen打击法造模,分别于造模后2、4、6、8、12、24、36、48、72 h取大鼠损伤区脊髓及脑脊液,利用ELISA及Real-time PCR检测并比较两者中炎性因子的浓度变化。[结果]大鼠脊髓损伤后IL-6、IL-1β、TNF-α均在脊髓中表达迅速升高,IL-6、IL-1β在4 h即达到高峰,而TNF-α在2 h即达到高峰。IL-6、IL-1β、TNF-α在脑脊液中表达相对较迟,但在6 h也已能检测出,IL-6、IL-1至24 h达到高峰,TNF-α12 h达到高峰,然后逐渐下降。[结论]脊髓损伤后脑脊液中炎性因子出现时间及到达高峰时间较损伤脊髓区稍晚,但趋势基本相仿,脑脊液炎性因子的研究可以基本反映脊髓炎性因子情况。     

切吸联合不同溶核疗法治疗腰椎间盘突出症

目的分析比较3种不同联合疗法治疗突出型L4,5椎间盘突出症的临床疗效,并观察其不良反应。方法本组59例,男36例,女23例;年龄19～69岁,平均(38.18±10.24)岁。将所有病例随机分为3组进行相应治疗切吸+盘内法组(A组)15例,切吸+盘外法组(B组)26例,切吸+盘内外法组(C组)18例。结果59例术后进行了4个月以上的随访,近期总优良率72.88%,总有效率96.61%;远期总优良率72.88%,总有效率86.44%。但各组间近、远期疗效差异均无显著性意义(P>0.05)。结论以上3种不同联合疗法均是临床治疗突出型腰椎间盘突出的有效方法,且不良反应少。