腰5神经根孔外卡压症的诊断与手术治疗

目的:分析腰5神经根孔外卡压症的病理解剖、诊断特点和手术治疗.方法:对24例腰5神经根孔外卡压症病人的临床手术资进行了回顾性研究.结果:术后对其中的18例病人进行了0.5年-5 年,平均3.5年的随访观察,手术优良率达94.5%.结论:孔外区腰5神经根卡压症的致病因素为孔外型椎间盘突出,椎间隙退变狭窄,腰骶椎滑脱,腰5 椎体侧方骨质增生,腰5横突及骶骨翼肥大等.其诊断依赖于腰5根性卡压症、CT扫描或 MRI.手术减压是其有效的治疗方法,它包括经椎管入路、椎管旁入路或椎管内、外联合入路,术中应注意神经结构的识别和保护.     

腰_5神经根孔外卡压症的诊断与手术治疗

目的 :分析腰 5 神经根孔外卡压症的病理解剖、诊断特点和手术治疗。方法 :对 2 4例腰 5 神经根孔外卡压症病人的临床手术资进行了回顾性研究。结果 :术后对其中的 18例病人进行了 0 .5年 -5年 ,平均 3.5年的随访观察 ,手术优良率达 94.5 %。结论 :孔外区腰 5 神经根卡压症的致病因素为孔外型椎间盘突出 ,椎间隙退变狭窄 ,腰骶椎滑脱 ,腰 5 椎体侧方骨质增生 ,腰 5 横突及骶骨翼肥大等。其诊断依赖于腰 5 根性卡压症、CT扫描或 MRI。手术减压是其有效的治疗方法 ,它包括经椎管入路、椎管旁入路或椎管内、外联合入路 ,术中应注意神经结构的识别和保护     

钙化型腰椎间盘突出症及其经皮内镜治疗进展

钙化型腰椎间盘突出症(calcified lumbar disc herniation,CLDH)是比较特殊的椎间盘突出症,钙化的椎间盘组织质地坚硬,钙化病变常黏附在神经根或硬膜囊上,且椎间盘钙化程度随着退变严重程度的增加而显著增加[1~3]。儿童椎间盘内钙化可自发消退,而成人椎间盘钙化可持续存在[4,5]。一般以中老年多见,因钙化椎间盘组织质地坚硬且活动度差,常合并椎管狭窄或神经根管狭窄,易损伤神经根或硬膜囊,保守治疗效果不佳,且随时间推移,神经根或硬膜囊的损伤加重,故一旦诊断CLDH,应尽早手术。以往多以传统开放手术为主,术中需切除部分骨性结构,反复牵拉神经,才能充分显露钙化椎间盘组织,术后可能出现腰背部疼痛及腰椎不稳,存在出血多、损伤大、恢复慢等缺点。随着脊柱微创技术的发展,微创器械也取得了突破性的改进,尤其是脊柱内镜技术的发展,CLDH不再是微创治疗的禁忌证。脊柱内镜技术包括经皮内镜经椎间孔椎间盘切除术(percutaneous endoscopic transforaminal discectomy,PETD)和经皮内镜经椎板间椎间盘切除术(percutaneous endoscopic interlaminar discectomy,PEID)。与传统开放手术相比,经皮内镜手术具有切口小、出血少、损伤小等优势,为CLDH的治疗提供了新的方法。本文对CLDH及其经皮内镜治疗进展进行综述。     

腰骶神经节椎管内异位畸形的诊断与手术治疗

目的：再认识腰骶神经节椎管内异位的应用解剖和探讨腰骶神经节椎管内异位畸形的诊断与手术治疗。方法：１９９１～１９９６年对２７例腰骶神经节椎管内异位畸形的病人进行了诊断与手术治疗。结果：术后对所有病人进行了４月～４年的随访，平均２５年，手术优良率为９２６％。结论：该类病人主要表现为下腰痛和根性腿痛，其诊断依赖于临床表现、腰椎管造影术、ＣＴ或ＭＲＩ及手术探查，该类病人的腰骶神经节异位于神经根管或侧隐窝内，并因组织退变或间盘突出而遭受卡压。手术治疗包括神经根管的探查、矫形、减压，并注意异位神经节与神经根肿瘤的鉴别，以免发生腰骶神经节误伤或误切     

腰骶神经根管非骨性段狭窄的动态影像学与临床研究

对临床具腰腿痛并脊髓造影显示单或双侧腰骶神经根影中断者，做了椎管斜位伸屈造影（３５例）和动态ＣＴＭ扫描（１３例），观察了根影动态变化。其中１７例术中加用伸屈腰椎拱桥探查了椎管前外侧角与神经根间关系。上述研究结果结合临床症状、体征发现：Ｌ５、Ｓ１神经根受椎管非骨性段挤压机会显著高于Ｌ４神经根。分析认为：常遇的腰骶神经根中断多发生在非骨性段的椎管前外侧角，椎间盘与黄韧带退变是神经根受压的主要病理因素，症状可随体位变动减轻或加重。斜位椎管造影和动态ＣＴＭ对判断不同狭窄节段与指导手术有重要参考价值。     

后路椎间盘镜手术治疗退变性腰椎管狭窄症

目的 探讨后路椎间盘镜系统(MED)在腰椎管狭窄症中的应用.方法 对40例退变性腰椎管狭窄症行MED下椎管减压术.结果 责任间隙神经根及硬膜囊充分减压松解,疗效按Macnab标准,优良率92.15%,无并发症.结论 退变性腰椎管狭窄症采用MED手术治疗,效果较好.     

椎管动态造影对非骨性腰椎管狭窄的诊断意义

１９８５年～１９９２年２月，对２００例临床拟诊为腰椎管狭窄症者进行了腰椎管仲屈动态造影，发现２４例患者共３９个椎间平面在某一特定体应下硬膜囊下腔呈３种不同表现的完全性阻塞，手术证实为椎管内非骨性组织所致。分析结果认为：非骨性腰椎管狭窄症是继椎间盘组织退变而逐渐形成的，椎间盘突出／膨出和黄韧带增厚皱褶为椎管狭窄的形成因素，最终可导致粘连性蛛网膜炎，而椎管动态造影对判断其病变的范围、性质及指导治疗具有重要的作用。     

后路椎间盘镜治疗腰椎管狭窄症临床体会

目的 探讨后路椎间盘镜治疗椎管狭窄症的临床应用、手术适应证和临床效果.方法 采用后路椎间盘镜进行单侧或双侧"开窗"彻底解除硬脊膜及神经根的压迫.术中通过"C"臂机或拍摄侧位X线片定位.在局麻或浅硬外麻醉下于腰后部正中做大约1.5 cm的切口,逐级扩张后置人工作通道管,钻除部分椎板,置入内窥镜于电视监视下显露清除椎板、增生内聚的关节突、肥厚的黄韧带及突出的椎间盘髓核组织,减压神经根管,彻底解除其对硬膜、神经根的压迫.结果 本组共治疗183例,随访5个月至3年,按Nakai标准评定,优168例,良9例,可6例,优良率为96.7%.结论 本方式创伤小、出血少、恢复快,在保证神经根充分减压的前提下,能尽可能保持脊柱的稳定性.本方法适用于单节段或多节段椎管狭窄症及合并椎间盘突出的患者.     

退变性腰椎椎管狭窄症的病理变化及诊断治疗

本文报告１４６例退变性腰椎椎管狭窄症，其目的在于：探讨腰椎退变与椎管狭窄的关系，退变性椎管狭窄的临床特点及其治疗方法问题。本组全部经手术治疗，椎管扩大减压包括侧隐窝扩大，充分暴露受压神经根和硬膜囊是提高治疗效果重要措施，维持腰椎稳定是外科治疗重要内容。１３２例随访，平均３８个月，优良者１１２例（８４．８％）。研究表明，退变性腰椎管狭窄症，除中央椎管狭窄外，神经根管（包括侧隐窝）狭窄更多见。在外科治疗时必须注意这种病理变化特点，避免遗漏，影响手术效果。     

腰骶神经根变异

腰骶神经根变异30年前已有报导(Zagnani1949),发生率为0.34—2.7％。怀疑椎间盘手术失败者,可能是神经根的变异所致。美国每年做椎间盘手术20万例,失败率为33％。熟习神经根变异的发生与类型,有利于脊柱手术的成功率及诊断的改善。 以往文献中,有关此症的诊断是困难的,故多数于手术时发现。神经根的详细探查,有一定的限度。也有报告采用椎管造影方法诊断者。还有的作者提出用体表感觉反应方法诊断者(Scarff1981)。 本文对100具尸体的腰骶椎进行了解剖。     

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。     

The spinal cord and its membranes

The spinal cord is 45 cm long in the adult. In the early fetus, it extends the length of the vertebral canal; differential growth results in its termination at L3 in the newborn. In the adult it terminates, as the conus medullaris, at the disc between L1 and L2, although there is a range from T12 to L3. Inferiorly, the nerve roots form the cauda equina, while the lower end of the cord is attached by the filum terminale, of pia mater, to the coccyx. The dural sac terminates usually at the second segment of the sacrum. The cord receives its arterial supply from the anterior and posterior spinal arteries, which descend from the foramen magnum. They are reinforced serially via the intervertebral foramina from segmental vessels, especially the arteria magna. The three layers of the meninges are the dura mater, arachnoid mater and pia mater. The cerebrospinal fluid is contained within the subarachnoid space. The epidural space contains fat, blood vessels, lymphatics and the nerve roots.     

腰骶神经根异常

本文报告了６例腰骶神经根异常并腰椎间盘突出或腰椎椎管狭窄。结合文献复习讨论了神经根变异的分型。Ⅰ型联合神经根畸形；Ⅱ型两神经根自同一椎间孔穿出；Ⅲ型神经根起点异常；Ⅳ型相邻神经根之间有交通支相连。单纯腰骶神经根异常一般无症状，诊断困难。但脊髓造影可提高诊断率。手术治疗关键在于切除椎弓根内侧部，以达到充分减压     

1990 AcroMed Award in basic science. Cauda equina anatomy. II: Extrathecal nerve roots and dorsal root ganglia

Inconsistent data exist regarding the anatomy of the spinal nerve roots lateral to the thecal sac. A newly developed in situ technique was used to precisely define anatomic parameters on 20 fresh human cadavers. The take-off angle of the nerve roots from the thecal sac decreases from a mean of approximately 40 degrees from L1-L5 to 22 degrees at S1. The motor bundles are directly ventral to the sensory fibers within individual roots extrathecally. Dorsal root ganglia size varies with vertebral level. The majority of ganglia lie directly beneath the vertebral pedicles and one third overlie a portion of the lateral intervertebral disc. These previously undescribed relationships may aid in the understanding of lumbosacral neurocompressive disorders and are important to note during pedicle screw insertion, posterolateral decompression for spinal trauma, and paravertebral approaches for lateral disc herniations.     

The anatomy of lumbar spondylosis

To identify the major osseous, ligamentous, and neural relations of the lumbar spine pertinent to understanding the pathogenesis, diagnostic imaging, and therapy of lumbar spondylosis, 25 bony lumbar spines and 25 intact cadaver spines were studied both qualitatively and quantitatively. Pedicle anteroposterior dimension and obliquity and the relative interarticular process-interpedicle dimensions were found to be important osteologic determinants of the presence and size of lateral recesses at different vertebral levels and of the increasing size of each lateral recess as it descends. The varying length and relations of the osteoligamentous nerve root canals at different lumbar levels are a function of a progressively earlier exit from the dural sac by the lower lumbar nerve roots. Both the osteoligamentous nerve root canals and their terminal intervertebral canals showed significant normal narrowing at the level of the opposed intervertebral discs and facet joint capsules. This caused the normal nerve root canals to have a beaded appearance and the osteoligamentous intervertebral canals to have the appearance of long-necked gourds. These normally narrow areas correlate well with the spondylotic neural entrapment points. Narrowing of the disc interval is an important cause of many of the interdependent degenerative changes in the lumbar spine. Hence, its reconstitution should be a major goal of spondylotic surgery.     

Location of the first and second sacral nerve roots in relation to pedicle screw placement

Dissection and measurements of the first 2 sacral nerve roots with regard to the commonly used entrance points for S1 and S2 pedicle screw placement were performed to determine the location of the first 2 sacral nerve roots in relation to the pedicle screw entrance points in the upper 2 sacral vertebrae. The sacral nerve roots, dural sac, and pedicles were exposed after laminectomy. The mean distance from the reference point to the adjacent nerve roots superiorly and inferiorly at the S2 pedicle level was smaller than those at the S1 pedicle level. The medial angle of the sacral nerve roots progressively decreased from L5 to S3. The nerve root passing through the next foramen formed an immediate medial relation to the sacral pedicle rather than the dural sac. Pedicle screw placement in the first 2 sacral vertebral pedicles has been recommended for lumbosacral fusion and internal fixation of sacral fractures. No anatomic study is available regarding the location of the sacral nerve roots relative to the entrance points of sacral pedicle screw placement. Violation of the sacral canal and foramina by a sacral pedicle screw may injure the sacral nerve roots, especially at the level of the S2 pedicle.     

The anatomic relation among the nerve roots, intervertebral foramina, and intervertebral discs of the cervical spine

STUDY DESIGN: An anatomic study of the cervical intervertebral foramina, nerve roots, and intradural rootlets performed using a surgical microscope. OBJECTIVES: To investigate the anatomy of cervical root compression, and to obtain the anatomic findings related to cervical foraminotomy for the treatment of cervical radiculopathy. SUMMARY OF BACKGROUND DATA: Cervical foraminotomy is a procedure performed frequently for the management of cervical radiculopathy. However, anatomic studies of cervical foraminotomy have not been fully elucidated. METHODS: In this study, 18 cadavers were obtained for the study of the cervical spine. All the soft tissues were dissected from the cervical spine. Thereafter, laminectomy and facetectomy were performed on C4 through T1 using a surgical microscope. The nerve roots and surrounding anatomic structures, including intervertebral discs and foramina, were exposed. In addition, the intradural rootlets and their intersegmental connections were observed. RESULTS: The shape of the intervertebral foramina approximated a funnel, the entrance zone being the most narrow part and the root sleeves conical, with their takeoff points from the central dural sac being the largest part. Therefore, compression of the nerve roots occurred at the entrance zone of the intervertebral foramina. Anteriorly, compression of the nerve roots was caused by protruding discs and osteophytes of the uncovertebral region, whereas the superior articular process, the ligamentum flavum, and the periradicular fibrous tissues affected the nerve posteriorly. The C5 nerve roots were found to exit over the middle aspect of the intervertebral disc, whereas the C6 and C7 nerve roots were found to traverse the proximal part of the disc. The C8 nerve roots had little overlap with the C7-T1 disc in the intervertebral foramen. The C6 and C7 rootlets passed two disc levels in the dural sac. Also, a high incidence of the intradural connections between the dorsal rootlets of C5, C6, and C7 segments was found. CONCLUSIONS: This study demonstrated the anatomy of the nerve roots, rootlets, and intervertebral foramina, and may aid in understanding the pathology of cervical radiculopathy. The presence of intradural connections between dorsal nerve roots and the relation between the course of the nerve root and the intervertebral disc may explain the clinical variation of symptoms resulting from-nerve root compression in the cervical spine. To perform cervical foraminotomy for cervical radiculopathy, it is necessary to understand the detailed anatomy of the intervertebral foramina thoroughly.     

人工椎间盘置换术后下腰椎椎管及神经根管改变的初步临床研究

目的探讨人工椎间盘(artificialdiscreplacement,ADR)植入后,下腰椎神经根管、椎管的径线及容积改变,以其为合理的ADR植入提供临床依据。方法7例腰椎间盘突出症分别行ADR置换,观察术后JOA与ODI评分、椎间隙活动度、椎间孔径线改变以及椎间孔、椎管的容积变化。结果ADR术后JOA与ODI评分明显改善,椎间隙与椎管径线与容积显著增加,腰椎节段的稳定性与功能恢复。结论人工椎间盘植入后不仅能改善患者的临床症状,而且能有效地恢复椎管及神经根管径线与容积。目的探讨人工椎间盘(artificialdiscreplacement,ADR)植入后,下腰椎神经根管、椎管的径线及容积改变,以其为合理的ADR植入提供临床依据。方法7例腰椎间盘突出症分别行ADR置换,观察术后JOA与ODI评分、椎间隙活动度、椎间孔径线改变以及椎间孔、椎管的容积变化。结果ADR术后JOA与ODI评分明显改善,椎间隙与椎管径线与容积显著增加,腰椎节段的稳定性与功能恢复。结论人工椎间盘植入后不仅能改善患者的临床症状,而且能有效地恢复椎管及神经根管径线与容积。     

Radicular compression by lumbar intraspinal epidural gas pseudocyst in association with lateral disc herniation. Role of the posterior longitudinal ligament

Among unusual abnormalities of the lumbar spine reported since the introduction of Computed Tomography (CT), the presence of gas lucency in the spinal canal, known as vacuum phenomenon, is often demonstrated. On the contrary, epidural gas pseudocyst compressing a nerve root in patients with a lateral disc herniation has rarely been reported. We report a case of a 44-year-old man who experienced violent low back pain and monolateral sciatica, exacerbated by orthostatic position, one week before admission. A lumbosacral spine CT showed the presence of vacuum phenomenon associated with a degenerated disc material and a capsulated epidural gas collection with evidence of root compression. A microsurgical interlaminar approach was carried out and, before the posterior longitudinal ligament was entered, a spherical "bubble" compressing the nerve roots was observed. The capsulated pseudocyst was dissected out, peeled off and excised en bloc. A large part of the posterior longitudinal ligament and the lateral disc herniation were removed. Postoperatively the patient was completely free of symptoms. The mechanism of exacerbation of pain was probably due to the increased radicular compression in the upright posture and, besides the presence of a lateral disc herniation, could be related to a pneumatic squeezing of gas from the intervertebral space into the well capsulated sac by the solicitated L4-L5 motion segment. Histological study of the wall of the pseudocyst showed the presence of fibrous tissue identical to the ligament. We conclude that, in case of a lumbar disc herniation, it is recommended to perform a complete microdiscectomy and an accurate removal of the involved portion of posterior longitudinal ligament in order to prevent pseudocystic formations.     

Mechanical effects of leg position on vertebral structures examined by magnetic resonance imaging

BACKGROUND AND OBJECTIVES: Leg manipulation has been postulated to affect spinal curvature and position of the cauda equina within the dural sac. However, no evidence of such mechanical effects has been shown in living subjects. We used magnetic resonance imaging to evaluate the mechanical effects of leg position on these 2 parameters. METHODS: Sagittal and axial magnetic resonance images of the lumbosacral vertebral canal were obtained in 5 healthy, female volunteers with the subject in the supine position with knees straight, knees slightly flexed, and knees fully flexed. RESULTS: In the straight leg position, physiologic lumbar lordosis was evident in all subjects on midline sagittal slices, whereas lumbar lordosis disappeared in the fully flexed leg position. On the axial slices the cauda equina moved ventrally within the dural sac in all subjects in the fully flexed leg position. In 1 of the 5 subjects the cauda equina moved ventrally and also separated completely into right and left parts. CONCLUSIONS: Our findings indicate that 2 potential factors, flattening of the lumbar lordosis and some added tension on the lumbosacral nerve roots, may contribute to postoperative back and leg aching after spinal anesthesia in the lithotomy position.