42例腰椎融合术后难治性下腰痛的治疗体会

目的探讨腰椎融合术后骶髂关节病变的特点及治疗方法与疗效。方法回顾性分析42例因腰椎退变性滑脱、腰椎椎间盘突出、腰椎椎管狭窄曾行后路减压、后外侧或椎体间植骨融合及椎弓根内固定术,术后随访12～72个月(平均42.6个月)出现新的难治性持续性下腰痛症状的病例。本研究运用骶髂关节内封闭进行诊断性治疗。阳性标准:疼痛缓解≥75%,采用疼痛视觉模拟量表(visual analogue scale,VAS)进行定量分析。结果阳性12例(28.57%),是否融合L5/S1、术后疼痛缓解期是否≥3个月与诊断阳性率相关,有统计学意义(P<0.05)。结论腰椎融合术后下腰痛部分可能是由骶髂关节病变引起的,L5/S1融合可能促进骶髂关节发生退变。症状以下腰痛症状为主者,手术应慎重。     

腰椎/腰骶融合术后骶髂关节痛的诊断与治疗

大约90%的人在其一生中会经历下腰痛,骶髂关节是产生慢性下腰痛的重要来源之一,据报道由骶髂关节病变所致下腰痛者占所有下腰痛者的15%～30%[1].近年来,腰椎/腰骶融合术得到了广泛的普及,它在解决下腰/腰骶关节病变的同时,也带来了新的问题,常有患者抱怨术后出现持续性的下腰痛,一些学者认为骶髂关节继发性病变可能是造成这种持续性疼痛的原因.     

终板源性腰痛的诊断和外科治疗分析

目的探讨严重终板源性腰痛的诊断和外科治疗方法。方法所有患者行影像学检查,并用腰椎间盘造影术确定疼痛椎间隙融合节段。用视觉疼痛模拟评分（VAS）和Oswestry功能障碍问卷调查表,对每个患者术前和术后的腰痛症状和腰椎功能障碍指数（ODI）分别评分,评估腰椎融合术疗效。结果本组21例患者,经腰椎间盘造影术诊断为终板源性腰痛,全部行腰椎前路或后路融合术。术后随访2—6年,平均3年5个月。除1例仍有腰痛外,其余20例（95％）腰痛症状明显改善或完全消失,腰椎物理功能明显改善。VAS和ODI评分在术前和术后的比较,差异有统计学意义（P=0．0001）。结论研究表明腰椎间盘造影术是诊断终板源性腰痛的可靠手段,腰椎融合术是治疗终板源性腰痛的有效方法。     

PLIF加椎弓根内固定治疗腰椎间盘源性腰痛

[目的]研究后路椎体间融合加椎弓根固定治疗腰椎间盘源性腰痛的手术疗效。[方法]36例腰椎间盘源性下腰痛，选择后路椎体间植骨融合（posterior lumbar interbody fusion，PLIF）加椎弓根螺钉系统内固定术。分别于术前、术后对病人的腰痛情况进行视觉疼痛自我评定（visual analogue scale，VAS）评分，同时评估术后腰椎融合率。[结果]术后随访时间8—28个月，平均16个月。36例行PLIF治疗者，33例术后腰腿痛症状基本消失，3例仍有轻度腰痛，术前、术后VAS腰痛评分，差异有统计学意义（P〈0．01）。行PLIF患者，融合率为90％。[结论]严格掌握手术适应证，后路腰椎椎体间融合术（PLIF）加椎弓根内固定是治疗腰椎间盘源性下腰痛的有效方法。     

妊娠后骶髂关节半脱位诊治体会

目的：探讨骶髂关节半脱位的诊断与治疗方法。方法：对45例骶髂关节半脱位病人的临床特点进行分析,并用理疗、封闭、骨盆带固定、手术融合等方面进行治疗。结果：明确诊断后46例患者经治疗均获满意效果。结论：本病与妊娠关系密切,根据临床特点多可明确诊断,经保守治疗无效,可行骶髂关节融合术。     

后路融合治疗腰椎滑脱与不稳症的临床疗效分析

目的探讨后路融合术治疗腰椎滑脱与不稳症的疗效。方法2000年1月至2010年1月应用后路椎弓根钉系统融合治疗腰椎滑脱症与不稳症122例,为单节段融合术,其中腰椎滑脱症75例,腰椎退变性不稳症47例。术后应用X线评价植骨融合情况,视觉疼痛评分（visualanaloguescale,VAS）、侯树勋等疗效标准评价腰腿痛程度及社会、生活功能情况。结果本组122例随访22～64个月,平均（33．2±6．4）个月,122例中109例获骨性融合,骨融合率89．34％。下腰痛VAS术前为（6．85±1．35）分,术后为（3．15±1．02）分;腿痛VAS术前为（8．21±1．82）分,术后为（4．35±1．12）分。Oswestry功能障碍指数术前为（68．5±14．5）％,术后为（13．5±1．5）％。按侯树勋等的疗效评价标准评定,优50例,良53例,可14例,差5例,优良率84．43％。结论后路融合术治疗腰椎滑脱症和不稳症的疗效令人满意。     

骶髂关节骨折脱位的手术治疗

目的报告骶髂关节骨折脱位切开复位内固定的方法和治疗效果.方法采用骶髂关节前部切口,显露骶髋关节前面,复位后应用骨盆钢板内固定并植骨融合.结果45例骶髂关节骨折脱位均施行切开复位内固定融合术,随访8～20个月,骶髂关节完全融合,骨盆稳定.结论骶髂关节的完整对骨盆环的稳定性起着重要作用,当发生骨折脱位时应及时手术治疗,恢复其稳定性.     

椎间盘源性腰痛的诊断与治疗

目的探讨腰椎间盘源性疼痛的诊断方法及采用前路经腹膜外入路椎间盘切除人工椎间盘置换或椎间cage植骨融合的临床疗效。方法35例经保守治疗无效的椎间盘源性腰痛患者接受手术治疗。椎间盘源性腰痛的诊断标准为：（1）腰部及下肢疼痛的部位与神经根定位不符；（2）症状反复发作，病程在半年以上；（3）MRI病变椎间盘T2加权像低信号；（4）椎间盘造影阳性，相邻节段为阴性对照；（5）关节突关节封闭除外关节突关节退变引起的疼痛。患者年龄25-67岁，平均43．6岁。L4-5 14例，L5S1 16例，L4-5和L5S1双间隙5例。前路经腹膜外入路椎间盘切除后行人工椎间盘置换13例16个椎间盘，椎间cage融合22例24个椎间盘。术后3-7天下地活动。腰围固定3个月。结果所有患者随访6～26个月，平均18个月。术后腰痛及下肢痛症状明显缓解，均恢复正常生活或工作。VAS评分由术前平均72分，降至术后18分，随访6个月时6．5分。ODI评分由术前平均21．5分。降至随访6个月时3分。椎间隙高度从术前平均9．5mm增加至术后13．5mm。手术时间70-120min，出血量100-400ml。随访时未发现肠梗阻、逆行射精和假体位置移动。结论椎间盘源性腰痛由于临床和影像学表现不典型，常被误诊或漏诊，可结合腰椎MRI及椎间盘造影进行诊断。腰椎前路椎间盘切除人工椎间盘置换或椎间cage融合是治疗椎间盘源性腰痛的有效选择。     

椎弓根钉系统治疗骶髂关节脱位合并下腰椎疾患

目的探讨椎弓根钉系统治疗骶髂关节脱位合并下腰椎疾患的疗效和安全性。方法8例骶髂关节脱位合并下腰椎疾患采用手术切开复位骶髂关节脱位,同时腰椎行后路椎管减压,而后椎弓根钉系统同时固定腰椎和骶髂关节。结果8例术后均获得随访,术后X线片示骶髂关节脱位复位满意,骶髂关节均获融合,功能评价采用Pohlemann骨盆骨折评分:优6例,良2例。结论本手术方法是治疗骶髂关节脱位合并下腰椎疾患的一种简单、有效的新方法。     

骶髂关节骨折脱位的手术治疗

目的：报告骶髂关节骨折脱位切开复位内固定的方法和治疗效果。方法：采用骶髂关节前部切口,显露骶髋关节前面,复位后应用骨盆钢板内固定并植骨融合。结果：45例骶髂关节骨折脱位均施行切开复位内固定融合术,随访8－20个月,骶髂关节完全融合,骨盆稳定。结论：骶髂关节的完整对骨盆环的稳定性起着重要作用,当发生骨折脱位时应及时手术治疗,恢复其稳定性。     

Sacroiliac joint pain after lumbar fusion. A study with anesthetic blocks

Low back pain persisting or appearing after a technically successful lumbar fusion challenges clinicians. In this context, the sacroiliac joint could be a possible source of pain, but the frequency of its responsibility is not really known. We used sacroiliac anesthetic blocks, the gold standard for diagnosis, to determine this frequency. Our second goal was to search predictive factors for a positive block. Our prospective series consisted of 40 patients with persistent low back pain after a technically successful fusion who received a sacroiliac anesthetic block under fluoroscopic control. The diagnostic criterion was a relief of more than 75% of the pain on a visual analog scale. We found a 35% rate of positive blocks. The only criterion that characterized these patients was a postoperative pain different from the preoperative pain in its distribution ( p =0.017). A free interval of more than 3 months between surgery and appearance of the pain had an indicative value ( p =0.17). An increased uptake in the sacroiliac on bone scintigraphy or a past history of posterior iliac bone-graft harvesting had no significant value ( p =0.74 and p =1.0, respectively). The sacroiliac joint is a possible source of pain after lumbar fusion. The anesthetic block under fluoroscopic control remains the gold standard.     

腰椎融合术后邻近节段退变的诊断与治疗

目的：探讨腰椎融合术后邻近节段退变的特点及再手术治疗的术式与疗效.方法：回顾性分析2002年1月至2004年12月间收治的10例因腰椎管狭窄症或腰椎滑脱症曾行后路减压、植骨及椎弓根内固定术,术后12～132个月（平均41.6个月）出现新的腰腿痛症状的病例.对所有患者进行影像学检查,与术前资料比较,并行手术治疗.结果：X线片显示融合的上方（1个节段7例,2个节段1例）或下方（1个节段2例）邻近节段出现了退变,首次术前及术后上述邻近节段均未见退变征象.8例MRI显示邻近节段出现了新的椎管狭窄,且有明显的神经压迫.采用后路术式,将减压及固定融合范围向邻近退变节段延伸.经7～36个月平均12.1个月的随访,优良率80%.结论：腰椎融合术后邻近节段退变是术后症状复发的原因之一,应仔细鉴别症状复发的原因.对于有明显神经压迫者,再手术治疗仍可取得较好的疗效.     

Poor outcome following bilateral sacroiliac joint fusion for degenerative sacroiliac joint syndrome

The purpose of this retrospective study was to evaluate the clinical and radiological outcome of bilateral sacroiliac joint (SIJ) fusion, using a new technique, in patients with a chronic SIJ syndrome. Seventeen patients with chronic low back pain, with a positive response to specific diagnostic tests for the SIJ, were considered candidates for bilateral sacroiliac fusion. The surgical indication was based on the results of local anaesthetic joint infiltration, temporary external fixation or bone scan. Ten patients had had previous surgery on the lumbar spine. Bilateral posterior SIJ fusion was performed with internal fixation and decortication of the sacroiliac joint, using a separate approach to each joint. Local bone grafting was performed. At the time of follow-up (on average 39 months after surgery), 3 patients reported moderate or absent pain, 8 marked pain and 6 severe pain. Seven patients showed a symptomatic non-union; union occurred in only 6 cases. Eighteen percent of the patients were satisfied, but in the other 82% the results were not acceptable. Reoperation was performed in 65% of the patients. Our results with bilateral posterior SIJ fusion were disappointing, which may be related with difficulties in patient selection, as well as with surgical technique. Better diagnostic procedures and possibly other surgical techniques might provide more predictable results, but this remains to be demonstrated.     

Absence de fiabilité des tests cliniques et des blocs pour le diagnostic positif de l’origine sacro-iliaque d’une douleur

Mapping studies of pain elicited by injections into the sacroiliac joints (SIJs) suggest that sacroiliac joint syndrome (SIJS) may manifest as low back pain, sciatica, or trochanteric pain. Neither patient-reported symptoms nor provocative SIJ maneuvers are sensitive or specific for SIJS when SIJ block is used as the diagnostic gold standard. This has led to increasing diagnostic use of SIJ block, a procedure in which an anesthetic is injected into the joint under arthrographic guidance. However, several arguments cast doubt on the validity of SIJ block as a diagnostic gold standard. Thus, the effects of two consecutive blocks are identical in only 60% of cases, and the anesthetic diffuses out of the joint in 61% of cases, often coming into contact with the sheaths of the adjacent nerve trunks or roots, including the lumbosacral trunk (which may contribute to pain in the groin or thigh) and the L5 and S1 nerve roots. These data partly explain the limited specificity of SIJ block for the diagnosis of SIJS and the discordance between the pain elicited by the arthrography injection and the response to the block. The limitations of provocative maneuvers and SIJ blocks may stem in part from a contribution of extraarticular ligaments to the genesis of pain believed to originate within the SIJs. These ligaments include the expansion of the iliolumbar ligaments, the dorsal and ventral sacroiliac ligaments, the sacrospinous ligaments, and the sacrotuberous ligaments (sacroiliac joint lato-sensu). They play a role in locking or in allowing motion of the SIJs. Glucocorticoids may diffuse better than anesthetics within these ligaments. Furthermore, joint fusion may result in ligament unloading.     

Provocative sacroiliac joint maneuvers and sacroiliac joint block are unreliable for diagnosing sacroiliac joint pain

Mapping studies of pain elicited by injections into the sacroiliac joints (SIJs) suggest that sacroiliac joint syndrome (SIJS) may manifest as low back pain, sciatica, or trochanteric pain. Neither patient-reported symptoms nor provocative SIJ maneuvers are sensitive or specific for SIJS when SIJ block is used as the diagnostic gold standard. This has led to increasing diagnostic use of SIJ block, a procedure in which an anesthetic is injected into the joint under arthrographic guidance. However, several arguments cast doubt on the validity of SIJ block as a diagnostic gold standard. Thus, the effects of two consecutive blocks are identical in only 60% of cases, and the anesthetic diffuses out of the joint in 61% of cases, often coming into contact with the sheaths of the adjacent nerve trunks or roots, including the lumbosacral trunk (which may contribute to pain in the groin or thigh) and the L5 and S1 nerve roots. These data partly explain the limited specificity of SIJ block for the diagnosis of SIJS and the discordance between the pain elicited by the arthrography injection and the response to the block. The limitations of provocative maneuvers and SIJ blocks may stem in part from a contribution of extraarticular ligaments to the genesis of pain believed to originate within the SIJs. These ligaments include the expansion of the iliolumbar ligaments, the dorsal and ventral sacroiliac ligaments, the sacrospinous ligaments, and the sacrotuberous ligaments (sacroiliac joint lato-sensu). They play a role in locking or in allowing motion of the SIJs. Glucocorticoids may diffuse better than anesthetics within these ligaments. Furthermore, joint fusion may result in ligament unloading.     

The facet syndrome. Myth or reality?

The lumbar facet joint has long been considered a significant source of low back pain (LBP). Facet blocks with anesthetic and cortisone, and even facet denervation procedures, have been recommended as treatment for patients with LBP. The literature, however, fails to conclusively document the role of the facet in the production of LBP. Based on a review of the literature and the author's clinical studies, the following statements appear to be appropriate and defensible: (1) The lumbar facet joints are very important biomechanically. (2) The facet is not a common or clear source of significant pain. (3) The facet syndrome is not a reliable clinical diagnosis. (4) Injection of intraarticular saline into the facets in control cases is as effective as local anesthetic and steroids in relieving the patient's pain temporarily. (5) Response to facet joint injection in patients with LBP does not correlate with or predict their clinical results after solid posterior lumbar fusion, and it should not be used preoperatively as a clinical criterion in selection of patients for fusion. (6) More prospective, controlled and randomized clinical studies are recommended.     

Sacroiliac joint pain after lumbar/lumbosacral fusion: current knowledge

Recently, the sacroiliac joint (SIJ) has gained increased attention as a source of persistent or new pain after lumbar/lumbosacral fusion. The underlying pathophysiology of SIJ pain may be increased mechanical load, iliac crest bone grafting, or a misdiagnosis of SIJ syndrome. Imaging studies show more frequent degeneration of the SIJ in patients with lumbar/lumbosacral fusion than in patients without such fusion. Using injection tests, it has been shown that SIJ pain is the cause of persistent symptoms in a considerable number of patients after fusion surgery. Recent articles reporting on surgical outcomes of SIJ fusion include a high percentage of patients who had lumbar/lumbosacral fusion or surgery before, although well-controlled clinical studies are necessary to assess the efficacy of surgical treatment. Taking these findings into consideration, the possibility that the SIJ is the source of pain should be considered in patients with failed back surgery syndrome after lumbar/lumbosacral fusion.     

Results of surgery for spinal stenosis adjacent to previous lumbar fusion

The literature provides little data to guide surgical management of spinal stenosis adjacent to previous lumbar fusion. Thirty-three consecutive patients who had surgical decompression for spinal stenosis at the lumbar segments adjacent to a previous lumbar fusion were studied. The mean interval between fusion and the adjacent segment surgery was 94 months. Of the 33 patients, 26 were followed for 3-14 years (mean: 5 years) after adjacent segment surgery and were clinically evaluated and independently completed an outcome questionnaire. Of the 26 patients, 15 rated their outcome as completely satisfactory, 6 were neutral toward the surgery, and 5 considered their surgery a failure. The surgery was generally effective at improving or relieving lower extremity neurogenic claudication. The strongest independent predictive factor of patient dissatisfaction was ongoing postoperative low back pain (r = 0.7, p = 0.001). A higher back pain score at follow-up was associated with continued narcotic use (p = 0.001) and decreased ability to perform activities of daily living (p = 0.05). Six patients required further lumbar surgery during the follow-up period. This study provides the longest published follow-up data of surgical results for symptomatic spinal stenosis adjacent to a previously asymptomatic lumbar fusion.     

Facet joint degeneration as a cause of low back pain

Recognizing that not all patients with low back pain have lumbar disc disease, the authors began to inject facet joints in June 1982 and have experience now with 21 patients, each injected under fluoroscopic control with a mixture of local anesthetic and steroid. One technical problem occurred when large osteophytes blocked access to the facet joints. Otherwise, there were no complications and minimal morbidity. Most patients (15 of 20; 75%) had an initial response, but a much smaller number (six of 18 followed more than three months; 33%) had a lasting response. Repeat injections, when done, always led to temporary improvement but rarely to lasting relief (one of five; 20%). Three factors characterized the patients: a negative screening examination for other causes of back pain or sciatica; back pain with tenderness localized over one or more facet joints; and radiologic changes of degenerative joint disease within the facet joints. Facet joint disease may be a significant cause of low back pain. The above three criteria are useful in clinical identification of patients with this problem. Facet joint injections play an important role in the diagnosis and treatment of low back pain.