静脉增强CT扫描检查术后腰痛患者的初步报告

腰痛疾患术后效果欠佳的常见原因为硬膜外瘢痕粘连、复发椎间盘突出、摘除突出的椎间盘时对合并椎管狭窄减压不够,以及术后发生椎管狭窄。椎管的骨性改变,用平扫CT检查即可明确诊断,但对术后硬膜外瘢痕和复发椎间盘突出尚很难区分。而临床实际工作中,再手术切除硬膜外瘢痕常导致更多瘢痕形成,术后效果反差;摘除复发突     

腰椎手术后硬膜外腔瘢痕预防的实验研究

目的比较腰椎手术后硬膜外放置明胶海绵、几丁糖和高分子量的透明质酸钠 (sodium hyaluronate,HA)对术后硬膜外瘢痕形成的预防作用。方法 96只 Wistar大鼠被随机分成四组,每组 24只。一组为对照组,其它三组分别于单侧半椎板切除术和椎间盘破坏术关闭切口前在硬膜外腔放置明胶海绵、几丁糖和高分子量 HA。分别在术后第 2、 4、 8、 12周时,每组各取 6只大鼠进行大体标本、组织切片 (HE、 VG和免疫组化染色 )和透射电镜观察。对术后硬膜外瘢痕的多少和椎管的大小进行计算机图像分析和统计学处理。检测对照组和高分子量 HA组大鼠脑脊液中的 HA浓度。结果几丁糖和高分子量 HA组的硬膜外瘢痕比其它各组显著减少 (P< 0.05);椎管的大小在各组各时段差异没有显著性意义;在各组各时段均可见到纤维环的环状纤维未能修复椎间盘手术带来的连续性中断。所有脑脊液标本中 HA浓度最高的 2例在 2周时的 HA组。结论几丁糖和高分子量 HA能减少后路腰椎间盘术后的硬膜外瘢痕的形成;评价材料对硬膜外瘢痕影响的同时,也要考虑到其对椎间盘破口愈合的影响;在硬膜外腔放置各种材料时应考虑到其对中枢神经系统的潜在影响。     

腰椎手术后硬膜外—蛛网膜炎

手术后的腰部硬膜外一蛛网膜炎是椎间盘切除术的常见併发症,也是椎间盘切除后根性症状仍持续或复发的主要原因之一。其诊断困难,疗效也不佳。作者报告了在Beaujon医院骨科经再次手术证实为术后硬膜外一蛛网膜炎的38例病人,均有因椎间盘突出症而手术的病史,其中12人做过2～4次腰椎手术。主要症状是坐骨神经痛38(单侧31、双侧7),下腰痛28,还有其它神经症状。单侧坐骨神经     

腰椎手术失败综合征的影像学评价和手术处理

目的对经一次髓核摘除手术的FBSS患者进行临床及影像学评价，分析FBSS的影像学特点及其临床预防与治疗。方法回顾性分析2000～2003年连续收治的32例FBSS患者的临床资料，根据临床及影像学评价，第二次诊断分别为：椎间盘再突出9例（28．1％）；邻近节段椎间盘突出3例（9．4％）；腰椎管及神经根管狭窄6例（18．8％）；腰椎不稳5例（15．6％）；椎管内肿瘤1例（3．1％）；神经根损伤1例（3．1％）；硬膜外瘢痕7例（21．9％）。对其中24例进行再次手术治疗。术后22例获得随访，随访时间1年以上（1～4年，平均2．3年）。结果第二次术后随访2例硬膜外疤痕形成，4例仍残留下肢麻木症状。5例不同程度伴有腰部的酸胀不适，未见内固定失败病例。结论硬膜外疤痕和椎间盘再突出是FBSS最常见的原因。术前全面评价和术中仔细操作是预防FBSS的有效方式。MRI扫描对鉴别硬膜外疤痕和椎间盘再突出价值最大。     

腰椎板切除术后硬膜外粘连预防方法的研究进展

腰椎板切除术后硬膜外瘢痕粘连是下腰椎手术失败综合征(failed back surgery syndrome,FBSS)的病因之一,可引起腰腿疼痛或神经损伤症状。预防和减少腰椎板切除术后硬膜外瘢痕形成,对提高腰椎手术疗效具有重要意义。椎板切除后骶棘肌粗糙面和椎间盘损伤纤维环是硬膜外纤维化和瘢痕形成的主要来源,目前硬膜外粘连的主要预防方法包括植入物阻隔、药物抑制和低剂量放射线照射等,但大多还处于动物实验阶段,其临床应用仍不确定。临床研究如自体游离脂肪移植、ADCON-L和丝裂霉素C(MMC)的结果仍有争议,未得到医学界共识和和广泛应用。理想植入物材料应具有良好的生物相容性、无不良反应、可降解吸收、在体内维持一定时间,药物的选择应抗粘连作用好、不良作用小、半衰期长。此外,药物联合生物可降解医用膜,两种或多种医用膜联合也是预防硬膜外粘连及瘢痕形成的研究方向,需要进一步研究探索新的组织材料及药物,以稳定有效地预防硬膜外瘢痕粘连。     

腰椎手术失败综合征病因分析

腰椎术后失败综合征（FBSS）发生率约为10％～40％，严重困扰临床医师。其常见原因有以下几种：椎间盘切除术后再突出，椎管内硬膜外瘢痕增生致硬脊膜和神经根牵拉、挤压，椎间盘切除术后椎管狭窄，椎间盘切除术后腰椎不稳，诊断错误和遗漏，手术节段的定位错误，骨质疏松，自身免疫反应，化学因素等。     

应用腰椎管成形术治疗腰椎管狭窄

由于腰椎管狭窄,压迫脊髓、马尾或神经根而引起腰腿痛,在临床上十分常见[1～2]。症状轻者可采用保守治疗,保守治疗无效或症状严重者应进行手术治疗。而手术治疗,通常都是采用椎板减压或神经根管扩大术。 传统的椎管减压,把椎板切除后,虽然能达到减压的目的,但由于切除了全椎板和部分小关节,造成了脊柱节段性不稳[4],再加上硬膜外瘢痕粘连,因而不少病人术后仍章有一定症状。自1988年我们开始应用腰椎管成形术,来治疗腰椎管狭窄,以减少创伤,增加稳定性及防止瘢痕粘连。经过临床的初步观察,取得了满意效果。 手　术　方　法 麻醉:硬膜外麻醉,或…     

骶管硬膜外腔注药治疗椎间盘突出症术后残留症状

骶管硬膜外腔注药治疗椎间盘突出症术后残留症状青岛工人温泉医院（２６６２０７）莫静波，张文义我们对腰椎间盘突出症术后残留症状的病人选用骶管硬膜外腔注药治疗３７例，收到满意效果，现报告如下。临床资料３７例患者均经ＣＴ、核磁共振或腰椎管造影诊断为腰椎间盘突...     

预防腰椎术后硬膜外纤维化的研究进展

腰椎术后硬膜外纤维化可以压迫、束缚硬膜囊和神经根,被认为是术后再发腰腿痛的因素之一。国内外很多学者就如何预防术后硬膜外瘢痕的形成和粘连进行了大量的实验和临床研究,取得了一定的成果,综述如下。     

圆利针配合灸法治疗腰椎术后综合征86例临床观察

腰椎术后综合征是指在行腰椎椎板切除术或椎间盘摘除、神经根减压术后仍残留相应的症状和体征,如腰部、臀部或下肢的顽固性疼痛或其它不适症状,或虽有暂时缓解而后又出现症状甚至加重,或术前无症状的部位出现了新症状,是一种难治性疾病。我科从2006-01-2010-01采用圆利针配合灸法治疗腰椎术后综合征86例,疗效较     

腰椎间盘突出症再手术原因分析和手术方式探讨

目的:探讨腰椎间盘突出症再手术的原因及手术方式。方法:对39例腰椎间盘突出症术后症状无改善或缓解一段时间后复发需再手术的患者进行分析和总结。再手术方式:椎板间开窗或经原椎板间扩大开窗、椎间盘切除8例;半椎板切除减压、椎间盘切除3例;全椎板切除减压、椎间盘切除27例(其中23例行后路椎弓根内固定加横突间植骨融合,2例同时行椎间cage置入融合);经左前外侧入路腹膜外椎间盘切除、椎间植骨融合1例。结果:再手术原因包括复发性腰椎间盘突出20例、相邻节段腰椎间盘突出7例、腰椎节段性不稳定8例和腰椎间盘未彻底去除4例,其中合并继发性腰椎管狭窄8例,硬膜外瘢痕形成4例。术中发生脑脊液漏4例,均行硬膜修补,术后恢复良好。随访1年6个月～5年7个月,其中31例患者症状明显改善,7例症状部分改善,1例无改善,优良率为79.5%。再手术前JOA评分平均11.8分,再手术后末次随访时平均25.6分,有显著性差异(P<0.05),恢复率为80.2%。23例行椎弓根内固定加横突间植骨融合患者末次随访时植骨融合率为70%,1例行椎间植骨融合患者末次随访时植骨融合。结论:腰椎间盘突出症再手术的主要原因为复发性腰椎间盘突出、相邻节段腰椎间盘突出、腰椎节段性不稳定和腰椎间盘未彻底去除等,正确分析再手术原因并选择合理的手术方式,仍可以取得较为满意的疗效。     

Lumbar micro disc surgery with and without autologous fat graft. A prospective randomized trial evaluated with reference to clinical and social factors

Epidural scarring is one of the possible complications after lumbar disc surgery. Perineural scar tissue has been considered responsible for recurrent neurological symptoms in patients operated on for disc herniation and leads to a high rate of unsatisfactory results. In addition, postoperative scars may increase the technical difficulty and risk of subsequent procedures. Various materials have been used in animal studies to try to affect the degree of epidural scar tissue with controversial results. In particular, free fat transplantation has been described to reduce the degree of intraspinal scar tissue. We therefore performed a prospective, double-blind, randomized study comparing clinical and social factors of patients being operated on for the first time for lumbar disc herniation. A total of 92 patients received an implantation of autologous fat graft, 94 did not. After a median of 24.2 months after their surgery, an objective examinator compared various clinical parameters and the social situation of patients in both groups without knowing the operation method used. We found no significant differences between the fat-graft group and the control group regarding either the clinical outcome or the social aspects. Received: 24 November 2000     

MRI诊断腰椎间盘术后粘连和突出复发

失败的下腰椎手术是个复杂的问题，由于其症状和体征不典型，单靠临床检查很难明确诊断，而脊髓造影和常规ＣＴ等检查也很难区别突出复发和硬膜外粘连。本文分析了３２例再手术患者ＭＲＩ图象，并与第二次手术所见对比，发现２７例ＭＲＩ诊断准确，３例假阳性，２例因信号缺失不能明确诊断。     

Lumbar disc herniation regression after successful epidural steroid injection

In some lumbar disc herniation patients, noninvasive measures fail, necessitating more aggressive treatment, such as epidural steroid injections or surgery. This study sought to determine whether improvement in patients who receive epidural steroid injections is related to regression of herniated nucleus pulposus or whether such patients' symptoms decrease because of the steroid effect in the presence of continued herniated nucleus pulposus. Two nonoperatively treated patient cohorts were followed who had follow-up MRI. Specifically, 38 other patients who improved without invasive treatment within 6 weeks after the onset of their symptoms were compared with 20 patients who improved with epidural steroid injections. Results found that both groups had similar initial and follow-up herniated nucleus pulposus size and outcomes. The epidural steroid injection group had fewer sequestered or extruded herniations that resorbed, and most were of lower hydration. In conclusion, epidural steroid injections do not alter ultimate herniated nucleus pulposus regression. Patients in whom the disc herniation has less hydration may have prolonged symptoms, but many improve with epidural steroid injections.     

Prevention of scar tissue formation in spinal surgery: state of the art and review of the literature

Recurrent radicular pain after lumbar micro-discectomy may lead to reduced quality of life of the patient. Lumbar epidural fibrosis is believed to be one of the mechanisms involved in the genesis of the pain. The use of absorbable gel temporarily separating disc remnants, muscle or bone structures from the nerve roots could reduce the amount of scar tissue surrounding the nerve, reduce tethering and therefore pain, improve outcomes and facilitate revision surgery. The author reviews the literature on prevention techniques for lumbar epidural fibrosis. The most recent studies on new compounds are encouraging in terms of safety and clinical efficacy.     

聚乳酸薄膜预防腰椎间盘突出症术后硬膜外粘连的临床研究

目的观察聚乳酸薄膜预防硬膜外粘连的临床效果. 方法将1998年7月～2000年4月入院的62例腰椎间盘突出症患者,随机分成实验组32例,对照组30例,行椎板间开窗或椎板切除、腰椎间盘切除术.实验组在椎板间缺损区域置入0.1 mm厚度的聚乳酸薄膜,对照组缺损区域未置入聚乳酸薄膜.术后2周对局部及全身不良反应进行观察,6个月对患者随访并作手术节段CT复查. 结果术后2周,实验组与对照组无局部及全身不良反应;体温在正常范围内,伤口均Ⅰ期愈合;复查血常规及肝肾功能均在正常值范围.术后6个月实验组27例痊愈,4例显效,1例有效;对照组24例痊愈,4例显效,1例有效,1例无效.两组间差异无统计学意义(P＞0.05).CT复查显示:实验组无硬膜外瘢痕粘连;对照组有不同程度的硬膜外瘢痕粘连. 结论聚乳酸薄膜组织相容性好,无毒,能有效预防硬膜外瘢痕粘连,具有临床应用价值.     

Cervical epidural steroid injections for symptomatic disc herniations

OBJECTIVES: Cervical disc herniations are a common cause of radicular pain from nerve root impingement and may necessitate surgical decompression to alleviate symptoms. The use of cervical epidural injections has not been studied in detail. The objective of this retrospective study was to examine the efficacy of cervical epidural steroid injections for the treatment of symptomatic herniated cervical discs. METHODS: Patients with herniated cervical discs without myelopathy that had failed conservative management and were otherwise surgical candidates were offered a trial of cervical epidural injections. The results and benefits of the injections were examined as well as the incidence of proceeding to surgical intervention. RESULTS: Of the 70 treated patients, 44 (63%) had significant relief of their symptoms and did not wish to proceed with surgical treatment. Of the 26 patients who underwent surgical decompression, 92% had successful resolution of their symptoms. The nonsurgical and surgical groups were similar in terms of gender, preinjection symptoms, or number of injections. However, significant differences between the two groups were found with regard to age (P<0.05) and time from initial consultation to initial injection (P<0.05). With an average of 13-month follow-up, 45 (65.3%) patients reported a good/excellent result per Odom criteria. In addition, 53 (75%) would attempt cervical epidural steroid injections again in the future. No complications were noted in our series. CONCLUSIONS: Cervical epidural injections are a reasonable part of the nonoperative treatment of patients with symptomatic cervical disc herniations. The success rates appear to be very similar to prior studies of lumbar epidural injections for symptomatic lumbar disc herniations. It appears that a large percentage of the patients may obtain relief from radicular symptoms and avoid surgery for the follow-up period up to 1 year. In addition, patients older than 50 years and those who received the injections earlier, less than 100 days from diagnosis, seemed to have a more favorable outcome.     

Caudal epidural injection for L4-5 versus L5-S1 disc prolapse: is there any difference in the outcome?

One hundred seventy-seven patients with radicular pain due to disc prolapse treated with caudal epidural injection were included in our study. All the injections were carried out between January 2000 and December 2004. Inclusion criteria include symptomatic disc prolapse diagnosed with magnetic resonance imaging scan, disc prolapse of 1 level only either L4-5 or L5-S1, leg pain for more than 4 wk and age more than 18. Exclusion criteria include multiple disc levels, spondylolithesis, spinal stenosis, cauda equina, and progressive neurologic deficits. Outcome Measures include Oswestry score and patient satisfaction and final outcome patient satisfaction either excellent (complete pain relief), good (minimal symptoms), moderate (some symptoms), no relief (symptoms unchanged), and worse (symptoms deteriorated). The final outcome is excellent (more than 6 mo pain relief), very good (3 to 6 mo pain relief), good (6 wk to 3 mo pain relief), fair (4 to 6 wk pain relief), brief (less than 4 wk pain relief), and no relief postal questionnaire sent and telephone interview done with the nonresponders. Ninety-six answered the postal questionnaire and this number increased to 136 after telephone interview. Forty-nine percent females and 51% males. Eighty-nine with L5-S1 disc prolapse and 47 with L4-5 disc prolapse. Caudal epidural not only relieve leg pain but also relieve back pain. There is no significant difference in the Oswestry disability index nor in the patient satisfaction nor the final outcome after caudal epidural injections for patients with disc prolapse L5-S1 and L4-5 ones. The number of patients who required surgery were much less than the literature figures 3.05%. There is no significant difference in the response after caudal epidural injection considering the sex only. The longest the back pain before injection is associated with the worst Oswestry disability index.     

Magnetic resonance image changes and clinical outcome after microdiscectomy or nucleotomy for ruptured disc

Preoperative and postoperative magnetic resonance imaging (MRI) of the lumbar spine was performed on 41 patients treated either microsurgically or with percutaneous nucleotomy for lumbar disc herniation. On the first postoperative day, MRI revealed an edematous mass effect at the level of surgery in 25 (61%) patients. The mass effect caused compression of the anterior dural sac mimicking preoperative disc herniation. After the follow-up of 6 months, the mass effect had disappeared in all patients, and the MRI finding in the operated disc space was that of a prolapse in six (15%) patients and that of a protrusion in 16 (39%) patients. Postoperative scarring was detected in 23 (56%) patients. The amount of the epidural scar tissue was significantly (p = 0.0002) associated with the extent of the early postoperative hemorrhagic changes detected in these patients with MRI. No association was observed between these MRI findings (mass effect, disc herniation, epidural scarring) and the clinical outcome of the patients.     

Epidural injections for the treatment of symptomatic lumbar herniated discs

Epidural steroid injections are widely used as part of the conservative care for symptomatic herniated lumbar discs. There are studies showing their effectiveness, and some studies demonstrating no clinical benefits. The purpose of this study was to evaluate the effectiveness of epidural steroid injections for patients with symptomatic lumbar disc herniations who were surgical candidates. Sixty-nine patients were diagnosed with a herniated disc in the lumbar spine and remained symptomatic despite conservative care, and were treated with an epidural injection in an attempt to avoid surgical discectomy. Of the total group of 69 patients (average age = 44.8 years, range 19-77 years, average follow-up = 1.5 years), 53 (77%) had successful resolution or significant decrease of their symptoms and were able to avoid surgery. Only 16 (23%) patients failed to have significant relief of their symptoms and required surgical treatment of their herniated disc. Epidural steroid injections have a reasonable success rate for the alleviation of radicular symptoms from lumbar herniated discs for up to twelve to twenty-seven months. Patients treated with injections may be able to avoid surgical treatment up to this period and perhaps even longer.