椎间盘退变过程中碱性成纤维细胞生长因子和转移生长因子-β1的表达及其意义

目的：研究椎间盘退变过程中碱性成纤维细胞生长因子(bFGF)和转移生长因子-β1(TGF-β1)的表达及其意义。方法：收集腰椎后路手术切除的15例椎间盘源性下腰痛患者的21个通过腰椎间盘造影术证实的疼痛椎间盘，同时收集16个在MRIT2加权像上信号强度明显减弱的无腰痛症状的生理老化椎间盘和10个正常对照椎间盘，行组织学检查并用免疫组化方法检测bFGF、TGF-β1及其受体在不同椎间盘组织中的表达，观察增殖细胞核抗原在不同椎间盘的表达。结果：免疫组化染色显示bFGF、TGF-β1及其受体在疼痛椎间盘大量表达，生理老化椎间盘有少量表达，正常对照椎间盘没有表达。增殖细胞核抗原在疼痛椎间盘的肉芽组织区大量表达，在非肉芽组织区有少量表达；生理老化椎间盘有少量表达，正常对照椎间盘组织没有表达。结论：椎间盘退变和椎间盘源性下腰痛起源于椎间盘纤维环的损伤修复过程，bFGF、TGF-β1在纤维环外层的损伤修复和随之的椎间盘退变过程中可能起关键作用。     

椎间盘源性下腰痛的发病机制

目的探讨椎间盘源性下腰痛的发病机制。方法收集腰椎后路切除的17例椎间盘源性下腰痛患者的19个经腰椎间盘造影术证实的疼痛腰椎间盘;同时收集12个在MRI T2加权像上信号强度明显减弱、无腰痛症状的生理老化椎间盘和10个正常对照椎间盘,行组织学检查和P物质、神经丝蛋白和血管活性肠肽的免疫组织化学染色检查。结果椎间盘源性下腰痛患者的疼痛椎间盘在组织学上的显著特征表现为,一条从髓核至纤维环外层的血管化肉芽组织条带区,其间伴有1个或多个裂隙;肉芽组织条带区与椎间盘造影术后CT上显示的纤维环裂隙一致,肉芽组织之外的纤维环结构基本正常。生理老化椎间盘和正常对照椎间盘表现为与年龄相关的改变。免疫组织化学染色显示,疼痛椎间盘中P物质、神经丝蛋白和血管活性肠肽3种神经肽阳性神经纤维分布数量和比例,较正常对照椎间盘和生理老化椎间盘明显增多;神经纤维主要沿伴有裂隙的肉芽组织条带区分布;疼痛椎间盘髓核中可见P物质和神经丝蛋白的阳性神经纤维分布。结论椎间盘后方神经分布广泛的肉芽组织条带区是椎间盘造影术疼痛和椎间盘源性下腰痛的起源部位。肉芽组织条带可能起源于椎间盘的创伤修复过程。生理老化椎间盘和疼痛椎间盘的差异是后者形成组织学上的肉芽组织条带区。     

结缔组织生长因子在椎间盘纤维化和退变中的表达和作用

目的研究疼痛椎间盘组织中结缔组织生长因子（connective tissue growth factor, CTGF）的表达及其在椎间盘纤维化和退变中的作用。方法收集腰椎后路融合过程中切除的43个疼痛的病理椎间盘，来自于28例行腰椎后路椎体间融合手术的严重椎间盘源性下腰痛患者；同时收集16个在MRIT2加权像信号强度明显减弱的无腰痛症状的退变椎间盘，取自于6例腰椎管狭窄症和8例多节段腰椎后路融合的患者（年龄44～75岁，平均53．5岁，男女比例为8：6）和8个正常对照椎间盘，来自于4具新鲜尸体标本（22～39岁，平均28岁）的L。和蛉．椎间盘。均行组织学检查并用免疫组化方法检测CTGF在不同椎间盘组织的表达。结果组织学检查发现，疼痛椎间盘组织显示不同程度的慢性血管化炎症反应。纤维环组织失去正常的胶原纤维板层结构，板层结构断裂、紊乱或相互交叉融合，正常的成纤维细胞被软骨细胞替代。髓核显示明显纤维化、血管浸润或形成炎性肉芽组织，软骨细胞被成纤维细胞所替代。免疫组化染色显示CTGF在疼痛椎间盘大量表达，无腰痛症状的退变椎间盘有少量表达，正常对照椎间盘没有表达。结论疼痛的退变椎间盘在组织学上明显不同于无腰痛症状的退变椎间盘。CTGF在疼痛椎间盘的大量表达可能与椎间盘纤维化和退变过程密切相关。     

P物质阳性神经纤维在退变腰椎间盘的分布及意义

目的研究P物质（substance P,SP）阳性神经纤维在腰椎间盘中的出现及分布,以探讨其在椎间盘退变中的潜在作用。方法收集16例患者的21个病变腰椎间盘和来自于新鲜尸体的12个正常对照椎间盘,行组织学检查和SP免疫组织化学染色检查。结果SP阳性神经纤维偶见于正常椎间盘,在病变椎间盘内可见较多的SP免疫反应阳性神经纤维分布,阳性神经纤维数量与腰椎间盘退变程度呈正相关。结论腰椎间盘退变程度和SP阳性神经纤维数量有明显的相关性,SP可能作为神经炎性介质加速了腰椎间盘的退变。     

腰椎终板、椎间盘退变及椎间盘造影疼痛激发试验的相关性研究

目的探讨下腰痛患者腰椎终板Modic退变、椎间盘退变及CT引导下腰椎间盘造影疼痛激发试验的相关性.方法对45例下腰痛患者常规行腰椎X线和MR检查,分别按Modic终板退变标准（0～3级）与Pearce椎间盘退变标准（Ⅰ～Ⅴ级）对终板和椎间盘进行评估.在CT引导下对45例患者中的40例（120个椎间盘）进行造影和疼痛激发试验,并按Dallas椎间盘造影分级系统（DDD）测评椎间盘退变程度.采用SPSS 11.5统计学软件分析腰椎终板Modic退变、椎间盘退变与腰椎间盘造影疼痛激发试验之间的相关性.结果40例下腰痛患者的腰椎终板Modic分级与椎间盘退变Pearce分级存在较强的相关性（Pearson x^2=43.326,P=0.000）,与椎间盘造影疼痛激发试验有显著相关性（Pearson x^2=27.858,P=0.000）;椎间盘退变Pearce分级与CT椎间盘造影椎间盘退变Dallas分级也呈较强的相关性.结论腰椎终板Modic退变分级与椎间盘退变Pearce分级密切相关,而与椎间盘疼痛激发试验有显著相关性,提示终板Modic退变可能是下腰痛的原因之一.     

腰椎间盘MRI高信号区的组织病理学特点和临床意义

目的研究椎间盘源性下腰痛患者腰椎间盘纤维环后方MRI高信号区的组织病理学特征及其临床意义。方法对52例经保守治疗无效、CT片显示无腰椎间盘突出的下腰痛患者行腰椎MR检查及腰椎间盘造影术。男39例,女13例;平均年龄38.8岁。选择纤维环后方出现高信号区的部分病例行腰椎后路椎间盘切除、椎体间融合、椎弓根螺钉内固定术,术中收集包括高信号区部位的椎间盘。对标本行矢状面连续组织学切片,光镜下观察高信号区椎间盘组织的组织病理学结构,并分析其临床意义。结果在行腰椎间盘造影的52例142个椎间盘中,17例17个椎间盘显示高信号区,且在椎间盘造影过程中全部呈现2或3级的纤维环破裂和疼痛复制反应。敏感性和特异性均为100%。高信号区与纤维环破裂程度分级呈正相关,说明纤维环破裂程度分级越高,越易出现高信号区(R=0.462,P<0.01)。共收集11例患者11个椎间盘,组织学研究发现对应高信号区的椎间盘组织表现为沿纤维环裂隙形成的不同程度的血管化肉芽组织,有成熟的瘢痕化胶原组织。结论症状性下腰痛患者的腰椎MRI上有椎间盘高信号区,可以作为椎间盘源性下腰痛诊断的重要征象。     

应用椎间盘造影判断腰椎间盘突出症腰痛的来源

[目的]应用椎间盘造影术探讨腰椎间盘突出症患者临床腰痛来源.[方法]137例椎间盘突出症患者根据造影术前MRI表现将椎间盘分为:正常、突出和退变.患者腰痛和腿痛的严重程度应用疼痛视觉模拟评分(VAS评分)判定,分为三组:(1)腰痛为主组;(2)腿痛为主组;(3)腰腿痛并重组.对所有退变的腰椎间盘及至少1个作对照的正常椎间盘进行椎间盘造影检查,如造影过程中诱发一致性腰痛,即认为椎间盘造影阳性.[结果]137例患者总共427个椎间盘行造影检查,其中104个造影阳性.椎间盘造影阳性患者腰痛与腿痛VAS评分无明显差异(P＞0.05),而阴性者腿痛评分高于腰痛评分(P＜0.05).腰痛为主组,腿痛为主组,腰腿痛并重组其造影阳性率分别为79.2%,18.6%,71. 7%.MRI表现为正常、突出和退变的椎间盘其造影阳性率分别是1.4%、48.3%、21.6%(P＜0.05).[结论]盘源性腰痛可能是腰痛明显的椎间盘突出症患者腰痛的主要原因,这种腰痛主要来源于椎间盘突出节段和或邻近退变节段.     

腰椎间盘造影术

虽然椎间盘造影术在诊断方面仍有争议,它仍是目前诊断椎间盘源性下腰痛的最重要手段,它能明确决定哪一个椎间盘是疼痛的椎间盘,它是目前对椎间盘源性下腰痛病人行腰椎融合手术前的必须检查。50以上人群中椎间盘退变是普遍的,MRI不能区分在T2加权上信号减弱的腰椎间盘是正常老化的椎间盘还是疼痛的病理椎间盘。诱发的腰椎间盘造影术能够呈现疼痛反应与椎间盘异常形态学的相关性。椎间盘造影后的CT扫描能够准确地研究纤维环撕裂解剖学。     

椎间盘源性腰痛动态摄片及其临床意义

目的：探讨椎间盘源性腰痛动态摄片的临床意义。方法：对30例椎间盘源性腰痛患者组进行牵引／负重动态摄片，观察病变椎间盘纵向位移范围，并与椎间盘退变无腰痛组和正常组比较。结果：椎间盘退变无腰痛组和正常组间无明显性差异；椎间盘源性腰痛组与椎间盘退变无腰痛组间有明显性差异。结论：椎间盘源性腰痛患者常规X线检查未能显示的椎间隙节段纵向不稳定，通过牵引／负重动态摄片可显示。     

椎间盘退变和颈腰痛及其治疗的新动向

椎间盘退变和颈腰痛及其治疗的新动向（续完）徐印坎（上期连载文章刊登于本刊１９９５年第２卷第２期１２３页）４椎间盘退变后出现的症状个别椎间盘超年龄退变后，此部位应力分布不正常，相应的周围组织会出现各种症状。４．１椎旁肌肉的症状脊柱周围肌肉对脊柱起到协助...     

The pathogenesis of discogenic low back pain

Discogenic low back pain is a common cause of disability, but its pathogenesis is poorly understood. We collected 19 specimens of lumbar intervertebral discs from 17 patients with discogenic low back pain during posterior lumbar interbody fusion, 12 from physiologically ageing discs and ten from normal control discs. We investigated the histological features and assessed the immunoreactive activity of neurofilament (NF200) and neuropeptides such as substance P (SP) and vasoactive-intestinal peptide (VIP) in the nerve fibres. The distinct histological characteristic of the painful disc was the formation of a zone of vascularised granulation tissue from the nucleus pulposus to the outer part of the annulus fibrosus along the edges of the fissures. SP-, NF- and VIP-immunoreactive nerve fibres in the painful discs were more extensive than in the control discs. Growth of nerves deep into the annulus fibrosus and nucleus pulposus was observed mainly along the zone of granulation tissue in the painful discs. This suggests that the zone of granulation tissue with extensive innervation along the tears in the posterior part of the painful disc may be responsible for causing the pain of discography and of discogenic low back pain.     

Pathophysiology,diagnosis, and treatment of discogenic low back pain

Discogenic low back pain is a serious medical and social problem, and accounts for 26%-42% of the patients with chronic low back pain. Recent studies found that the pathologic features of discs obtained from the patients with discogenic low back pain were the formation of the zones of vascularized granulation tissue, with extensive innervation in fissures extending from the outer part of the annulus into the nucleus pulposus. Studies suggested that the degeneration of the painful disc might originate from the injury and subsequent repair of annulus fibrosus. Growth factors such as basic fibroblast growth factor, transforming growth factor β1, and connective tissue growth factor, macrophages and mast cells might play a key role in the repair of the injured annulus fibrosus and subsequent disc degeneration. Although there exist controversies about the role of discography as a diagnostic test, provocation discography still is the only available means by which to identify a painful disc. A recent study has classified discogenic low back pain into two types that were annular disruption-induced low back pain and internal endplate disruption-induced low back pain, which have been fully supported by clinical and theoretical bases. Current treatment options for discogenic back pain range from medicinal anti-inflammation strategy to invasive procedures including spine fusion and recently spinal arthroplasty. However, these treatments are limited to relieving symptoms, with no attempt to restore the disc’s structure. Recently, there has been a growing interest in developing strategies that aim to repair or regenerate the degenerated disc biologically.     

The pathogenesis and clinical significance of a high-intensity zone (HIZ) of lumbar intervertebral disc on MR imaging in the patient with discogenic low back pain

Recently, the presence of a high-intensity zone (HIZ) within the posterior annulus seen on T2-weighted MRI has aroused great interest and even controversy among many investigators, particularly on whether the HIZ was closely associated with a concordant pain response on awake discography. The study attempted to interpret the correlation between the presence of the HIZ on MRI and awake discography, as well as its characteristic pathology. Fifty two patients with low back pain without disc herniation underwent MRI and discography successively. Each disc with HIZ was correlated for an association between the presence of a HIZ and the grading of annular disruption and a concordant pain response. Eleven specimens of lumbar intervertebral discs which contain HIZ in the posterior annulus from 11 patients with discogenic low back pain were harvested for histologic examination to interpret the histologic basis of a nociceptive response during posterior lumbar interbody fusion (PLIF). The study found that in all of 142 discograms in 52 patients, 17 presented HIZ. All 17 discs with HIZ showed painful reproduction and abnormal morphology with annular tears extending either well into or through the outer third of the annulus fibrosus. The consecutive sagittal slices through the HIZ lesion showed that a notable histologic feature of the formation of vascularized granulation tissue in the outer region of the annulus fibrosus. The current study suggests that the HIZ of the lumbar disc on MRI in the patient with low back pain could be considered as a reliable marker of painful outer anular disruption.     

The role of mast cells in disc herniation inflammation.

STUDY DESIGN: A study of herniated lumbar disc tissue samples and control disc material to determine the presence of mast cells in disc herniations. OBJECTIVES: To analyze whether mast cells have any involvement in disc herniation pathophysiology and lumbar pain, because mast cells may have an important role in acute and chronic inflammatory responses. SUMMARY OF BACKGROUND DATA: Studies of inflammatory cells, biochemical mediators of inflammation, and tissue degrading enzymes have suggested that these factors may be involved--and perhaps play an important role--in the pathophysiology of lumbar pain and radiculopathy. Mast cells are known to play an important role in acute and chronic inflammatory responses. It was therefore of interest to clarify their possible role in intervertebral disc herniation inflammation. METHODS: Fifty herniated lumbar discs from 50 patients who had undergone disc surgery and three normal control discs were obtained. Sections from every disc then were examined histologically and immunocytochemically for mast cells by using monoclonal antibodies to either of two types of specific proteases of mast cells, tryptase and chymase. RESULTS: By none of the methods could any mast cells be observed in any of the control disc samples. With toluidine blue staining, mast cells were observed in 9 of 50 (18%) of discs. Mast cells immunoreactive to either tryptase or chymase were observed in 10 of 50 disc samples (20%) and immunoreactive for tryptase and chymase simultaneously in 4 of 50 disc samples (8%). However, the majority of the samples studied (80%) demonstrated immunoreactivity to neither tryptase nor chymase. Among the samples studied were five disc protrusions that totally lacked mast cells. CONCLUSIONS: A minority of disc herniations exhibited mast cells, as verified by toluidine blue staining and immunocytochemistry. The results may suggest a role of mast cells in intervertebral disc herniation inflammation, but only in a subset of these cases. Massive infiltration by mast cells never was observed.     

MRI高信号区与椎间盘造影在椎间盘源性腰痛诊断中的相关性研究

目的 研究腰椎间盘MRI高信号区(HIZ)与椎间盘造影诱发疼痛反应之间的关系,为椎间盘源性下腰痛诊断和治疗提供参考.方法 对37例长期慢性下腰痛、无典型的神经根性症状和体征,且CT证实无椎间盘突出的患者行MRI检查和腰椎间盘造影.分析造影后的X线片和CT片,并结合造影时诱发的疼痛反应,比较其与腰椎间盘MRI高信号区之间的关系.结果 37例患者共行98个腰椎间盘造影,21个椎间盘疼痛反应阳性,其中有HIZ的间盘10个,占47.6%.77个疼痛反应阴性的椎间盘中,有HIZ的间盘29个,占37.6%.纤维环破裂程度分级越高,MRI出现高信号区的比例也越高,说明有高信号区的纤维环破裂程度高,无高信号区的纤维环破裂程度低(P＜0.01);而高信号区与造影疼痛反应阳性之间并无明显一致性(P＞0.05).结论 MRI高信号区在诊断椎间盘源性腰痛中仅为提示性和筛选性的影像学征象,不能替代椎间盘造影的金标准.     

腰椎间盘MRI高信号区在诊断椎间盘源性下腰痛中的意义

目的:探讨腰椎间盘MRI高信号区(HIZ)在诊断椎间盘源性下腰痛中的作用。方法:对52例经保守治疗无效、CT影像上无腰椎间盘突出的下腰痛患者行腰椎MRI检查和腰椎间盘造影术,分析腰椎间盘MRI高信号区与腰椎间盘造影诱发的下腰痛之间的关系。结果:在行腰椎间盘造影的142个椎间盘中,共有38个椎间盘呈现疼痛复制反应,其中17个椎间盘显示高信号区。这17个有高信号区的椎间盘在椎间盘造影过程中全部呈现2～3级的纤维环破裂和疼痛复制反应。结论:无椎间盘突出的下腰痛患者在腰椎MRI上存在椎间盘内高信号区,可表明该椎间盘是产生腰痛的破裂椎间盘。     

2000 Volvo Award winner in clinical studies: Lumbar high-intensity zone and discography in subjects without low back problems

STUDY DESIGN: A prospective observational study of patients with low back pain and those without was performed. OBJECTIVE: To investigate the prevalence and significance of a high-intensity zone in a group of patients asymptomatic for low back pain, but who had known risk factors for lumbar disc degeneration. This asymptomatic group was compared with a symptomatic group of patients with respect to the presence of anular high-intensity zone and the pain response with discography. SUMMARY OF BACKGROUND DATA: Some authors have estimated the prevalence of a high-intensity zone in a group of symptomatic patients to be 86%. They have reported a strong correlation between a high-intensity zone and positive discography in patients with low back pain. Other investigators have reported evidence either supporting or discounting these findings. METHODS: Patients with low back pain and those without underwent physical examination, psychometric testing, plain radiograph, magnetic resonance imaging, and discography. The presence of a high-intensity zone, anular disruption, and positive discographic pain then were compared between the two groups. There were strict inclusion criteria for both groups. A total of 109 discs in 42 patients were evaluated in the symptomatic group and compared with 143 discs in 54 patients in the asymptomatic group. The presence of a high-intensity zone was determined by a standardized criteria on T2-weighted magnetic resonance images. Psychometric testing also was administered to each patient before discography. Standard discography was performed on all the patients, and the pain response was recorded using a visual analog scale according to the Walsh et al criteria. RESULTS: The prevalence of a high-intensity zone in the patient populations was 59% in the symptomatic group and 24% in the asymptomatic group. In the symptomatic group, 33 (30.2%) of 109 discs were found to have a high-intensity zone. In the asymptomatic group, 13 of 143 discs were found to have a high-intensity zone. In the symptomatic group, 72.7% of the discs with a high-intensity zone were positive on discography, whereas 38.2% of the discs without a high-intensity zone were positive. In the asymptomatic group, 69.2% of the discs with a high-intensity zone were positive on discography, whereas 10% of the discs without a high-intensity zone were positive. In the patients with normal psychometric testing, 50% of the discs with a high-intensity zone were positive on discography, as compared with 100% positive discography results in patients with abnormal psychometric testing or chronic pain. CONCLUSIONS: The presence of a high-intensity zone does not reliably indicate the presence of symptomatic internal disc disruption. Although higher in symptomatic patients, the prevalence of a high-intensity zone in asymptomatic individuals with degenerative disc disease (25%) is too high for meaningful clinical use. When injected during discography, the same percentage of asymptomatic and symptomatic discs with a high-intensity zone were shown to be painful.     

Changes of low back pain after vascular reconstruction for abdominal aortic aneurysm and high aortic occlusion: a retrospective study

BACKGROUND: The purpose of the present study is to clarify the influence of acute and chronic interruption of blood flow from lumbar arteries as well as the influence of vascular reconstruction on low back pain, back muscles, and lumbar discs. METHODS: Subjects were 34 patients with AAA in whom vascular reconstruction was performed. A second group was comprised of 9 patients with HAO. The presence of low back pain before surgery and at follow-up examination was retrospectively examined in the AAA group and the HAO group to investigate postoperative changes. The CSA and degeneration of the multifidus muscle and the lumbar discs on magnetic resonance imaging were assessed in the AAA group and control group. RESULTS: Low back pain, significant atrophy, or degeneration of the multifidus muscle or degeneration of the lumbar disc did not newly develop after surgery in the AAA group. These results indicated that acute interruption of lumbar arteries did not induce the development or deterioration of low back pain and organic changes in the back muscles or lumbar discs. The frequency of low back pain before surgery was significantly higher in the HAO group than that in the AAA group. However, the frequency of low back pain after surgery did not differ significantly between the 2 groups because low back pain in the HAO group was improved after surgery. CONCLUSION: The finding that low back pain was improved by merely performing treatment for the vascular system might provide support for the presence of vascular backache.