腰椎小关节方向性与腰椎间盘突出症

背景：腰椎小关节及其对称性与腰椎间盘突出之间是否存在关系,文献报道争议很大。 目的：测量分析腰椎小关节方向性与腰椎间盘突出的关系。 方法：收集因腰腿痛行CT检查的169例患者,L4/5 腰椎间盘突出35例,L5/S1腰椎间盘突出67例,无间盘突出对照组67例。在CT终端机上选取L3~S1椎间隙的远侧椎体上终板层面,测量3个节段的腰椎小关节角。 结果与结论：① L4/5和L5/S1腰椎间盘突出组L3/4、L4/5、L5/S1每个节段腰椎小关节角左侧均大于右侧(P < 0.05);各组小关节前内侧角和后外侧角两侧相比差异均无显著性意义(P > 0.05)。②各节段腰椎小关节角、前内侧角、后外侧角3组之间比较没有显著性差异(P > 0.05)。③各组腰椎小关节角、后外侧角自L3/4至L5/S1节段均逐渐增大(P < 0.05);而前内侧角L4/5节段最大,L3/4节段最小(P < 0.05)。提示腰椎间盘突出与腰椎小关节角左右侧不相等有关;腰椎小关节角和后外侧角自L3/4至L5/S1逐渐更偏向冠状位,而内侧角在L4/5节段更偏冠状位,可能与腰椎管狭窄的发病有关。     

Adolescent lumbar disc herniation: Experience from a large minimally invasive treatment centre for lumbar degenerative disease in Chongqing,China

Purpose

This article discusses the aetiology, medical history, physical examination, imaging characteristics and treatment modalities relevant to this entity aiming to increase awareness among paediatricians regarding LDH (lumbar disc herniation) in young children.

Methods

We retrospectively reviewed the medical records of 120 adolescent patients (aged 13–20 years old) with LDH at the orthopaedics department of a teaching hospital in Chongqing, China, between 2001 and 2011.

Results

The present retrospective analysis was performed on 121 adolescent patients (2.6%, 121/4695 cases with LDH operations) with LDH. One hundred and thirteen patients (93.4%) presented with low back pain with or without radiculopathy, and 12 patients (9.9%) presented with leg pain as the first symptom. Only 60 patients (49.6%) were diagnosed with LDH as their first outpatient diagnosis. Thirty-eight patients (31.4%) had a history of trauma before the onset of their symptoms. The most common segments were L4/5 (61, 50.4%), L5/S1 (42, 34.7%) and L4/5 + L5/S1 (13, 10.7%). Disc herniation was centrolateral in 77.7% (n = 94) and central in 35.5% (n = 43). Eighty patients were treated by MED (microendoscopy discectomy), 25 by PELD (percutaneous endoscopic lumbar discectomy) and 16 by OLD (open lumbar discectomy). The rate of operative complications was 3.8%, 4.0% and 6.3% in MED, PELD and OLD, respectively. Through the ordinal regression analysis, we found that the patients with central disc herniation had much better outcomes than the patients with centrolateral disc herniation (P = 0.046).

Conclusions

Diagnosis of LDH in young children is usually delayed, but there were no risk factors for the delayed outpatient diagnosis of LDH. Awareness of LDH will help the paediatrician extract a relevant medical history, perform a directed physical examination and order appropriate imaging studies.     

高龄腰椎间盘突出症的临床特点和术式选择

目的 研究高龄（70岁以上）腰椎间盘突出症的临床特点和手术术式选择。方法1992年至2003年对39例高龄腰椎间盘突出症患者采用扩大开窗髓核摘除部分椎管减压、半椎板切除椎管扩大减压髓核摘除或全椎板切除椎管扩大减压髓核摘除。结果 34例获得随访，平均3．3年，优良率为88.2％（30／34）。结论 高龄腰椎间盘突出症病史长，症状复杂，体征广泛，伴随疾病多。在控制伴随疾病的基础上选择适当的麻醉，行扩大开窗、半椎板切除、全椎板切除椎管扩大髓核摘除手     

Enhanced Fos expression in rat lumbar spinal cord cultured with cerebrospinal fluid from patients with amyotrophic lateral sclerosis

Abstract

School, Okayama, Japan The etiology of amyotrophic lateral sclerosis (ALS) remains unknown although an existence of neurotoxic substances in cerebrospinal fluid (CSF) from ALS patients have been postulated. In order to investigate a possible effect of CSF from ALS patients on cellular signaling in spinal neurons, we compared Fos-like immunoreactivity (Fos-LI) in organotypic cultures of rat lumbar spinal cord after addition of CSF from ALS patients or another neurologic disease. Fos-LI was normally present predominantly in dorsal horn neurons, whereas only a few ventral horn neurons were positive for Fos-LI. The number of Fos-LI positive neurons significantly increased in dorsal horn with addition of CSF from ALS patients as well as glutamate at 100 μM. However, the increase was not observed with addition of CSF from other neurologic diseases. The increase in Fos-LI positive neurons in dorsal horn was reversed by a further supplement of MK801, an N-methyl-D-aspartate (NMDA) receptor antagonist, but not of CNQX, an a-amino-3-hydroxy-5-methyl-4- isoxazole propionic acid (AMPA)/kainate antagonist. These results indicate that there may be substances in CSF from ALS patients that stimulate Fos expression in certain populations of spinal neurons via the NMDA receptors. [Neurol Res 1999; 21: 309-312]     

Neuro-urological sequelae of lumbar spinal stenosis

Purpose: Lumbar spinal stenosis is characterized by the narrowing of the spinal canal, which subsequently induces impingement of neural elements in the lumbar spine. Thus, symptoms of lumbar spinal stenosis are typically associated with damage to those neural elements. Herewith, we target the genitourinary symptoms of lumbar spinal stenosis and the importance of differentiating these symptoms from other genitourinary pathologies, namely benign prostatic hyperplasia.

Materials and methods: MeSH and keywords relevant to lumbar spinal stenosis and the organs of the urinary tract were used to a guide a literature search on MEDLINE.

Results: Bladder dysfunction, lower urinary tract symptoms (e.g. urinary incontinence, detrusor overactivity and underactivity, as well as frequent urinary tract infections), renal osteodystrophy and sexual dysfunction (e.g. erectile dysfunction and priapism) are implicated in lumbar spinal stenosis.

Conclusions: It is imperative for urologists to conduct a thorough history and physical examination so that they will not misdiagnose secondary genitourinary manifestations of lumbar spinal stenosis as primary problems or misunderstand secondary problems. Urological consultations are also integral to prioritizing patients with the highest risk of bladder damage for corrective spinal surgery.     

经皮髓核钳夹术联合臭氧治疗腰椎间盘突出症的应用研究

目的 探讨经皮髓核钳夹术(PLD)联合医用臭氧(O3)注射治疗腰椎间盘突出症后O3在椎间盘内外弥散、突出物回缩情况以及临床效果、不良反应、并发症等.方法 选择通过影像检查(CT或MR)结合临床确诊为腰椎间盘突出症的120例患者,按随机数字表法分为3组(PLD组、O3注射组、PLD+O3注射组),每组各40例,分别按方案实施治疗.结果 PLD+O3注射组腰痛发生率最低,O3在椎间盘内外弥散最好;突出物回缩率3组间无明显差异;PLD+O3注射组术后立即有效率为86%,PLD组为83%,O3注射组为35%;随访6～18个月,PLD+O3注射组总有效率为92.5%,PLD组为87.5%,O3注射组为77.5%;3组均未发生并发症.结论 PLD联合O3注射治疗腰椎间盘突出症是一种较好的综合治疗方案,安全、有效,可提高治疗效果,减少不良反应.     

经皮微通道显微手术治疗腰椎间盘突出症的效果分析

目的 探讨经皮微通道显微手术治疗单节段腰椎间盘突出症的效果.方法 回顾性分析2018年12月至2020年2月经皮微通道显微手术治疗的16例单节段腰椎间盘突出症的临床资料.结果 16例均顺利完成手术,手术时间平均(105.00±18.07)min,术中失血量平均(43.75±11.03)ml,术后无感染、神经根损伤、硬脊...     

射频热凝和臭氧注射对腰椎间盘突出患者的疗效及其电生理评估意义

目的评估射频热凝联合臭氧注射（RFTC—OI）,对腰椎间盘突出（LDH）患者的疗效及其电生理检测的意义。方法收集2011年9月-2013年1月就诊的LDH患者,符合纳入标准者50例,随机分为2组,试验组25例,采用CT下靶椎间盘RFTC—OI治疗;对照组25例,采用椎旁注射镇痛液治疗。在治疗后第1、7、30d比较2组间视觉模拟评分法（VAs）评分、总有效率以及电生理检测的变化。结果患侧下肢运动和感觉神经传导速度均无异常,2组胫神经F波和H反射潜伏期均延长（P〈0．05）,治疗后30d与治疗前无明显差异;与治疗前比较,治疗后2组VAS评分均减低（P〈0．05）,治疗后30d,试验组低于对照组（P〈0．05）;治疗后30d,试验组总有效率高于对照组（P〈0．05）。结论射频热凝联合臭氧注射是治疗LDH所致疼痛的有效方法,其疗效优于椎旁注射镇痛剂;电生理检测应用于监测疗效的意义不大。     

经皮椎间盘摘出联合医用臭氧治疗腰椎间盘突出症

目的探讨经皮髓核摘除术(PLD)联合医用臭氧注射治疗腰椎间盘突出症的临床效果及可行性。方法临床与影像检查确诊为腰椎间盘突出25例,先行PLD,后行椎间盘内及椎旁注射臭氧。结果25例病人治疗后经一年随访,治愈21例,有效24例,无效1例,无一例并发症。结论PLD联合医用臭氧治疗腰椎间盘突出症,安全可靠,可改善治疗效果,减少不良反应,值得推广应用。     

Cyclic nucleotides in cerebrospinal fluid of patients with intracranial and spinal tumors

Since the cyclic nucleotides (CN) adenosine 3',5'-monophosphate (cAMP) and guanoside 3',5'-monophosphate (cGMP) are involved in the regulation of cell proliferation and tumor growth in vitro, a study was made of the levels of these compounds in the lumbar cerebrospinal fluid (CSF) of 20 patients with intracranial and spinal tumors. In the presence of benign or malignant intracranial tumors there was a slight and not significant decrease of cAMP as well as cGMP levels in the CSF, as compared to control patients. While there was no significant correlation between the levels of the two CN in controls, there was a positive correlation in tumor patients. Total protein content and cAMP were negatively correlated in malignant intracranial tumors. Possible influences of tumor growth and intracranial pressure increases on CN levels are discussed. In spinal tumor patients normal CN levels were observed. However, in a patient with meningeal sarcoma an extremely marked elevation of cAMP occurred in parallel with the extension of the tumor to the spinal meningeal space, suggesting massive secretion of cAMP from the tumor cells.     

Surgical management of recurrent lumbar disc herniation and the role of fusion

This systematic review was performed to evaluate the various operative management strategies for recurrent lumbar disc herniation (RLDH), including the efficacy of instrumented spinal fusion (ISF) at repeat discectomy, and whether the operative approach for repeat discectomy, minimally invasive (MID) or conventional open discectomy (CD), affected the outcomes. RLDH is one of the most common complications of lumbar discectomies. Whilst repeat discectomy is the standard procedure performed, the routine addition of ISF has been advocated to improve outcomes and prevent reherniation. A comprehensive search of the MEDLINE, EMBASE, CINAHL and Cochrane databases was performed. The measured outcomes included the rate of satisfactory clinical outcome, improvement in leg and back pain, Japanese Orthopaedic Association (JOA) recovery score, and complication rates. In total, 37 studies met our inclusion criteria, with 1483 patients. The rate of satisfactory outcomes was found to be statistically similar between the patients undergoing a discectomy with or without fusion (77.8% with ISF versus 79.5% without ISF; p = 0.665). Back pain and JOA scores showed greater improvements in the patients undergoing discectomy and fusion, compared to discectomy alone. The rate of satisfactory outcomes was marginally higher in the patients undergoing MID compared to CD (MID 81.2% versus CD 77.5%; p = 0.248). However, the leg pain improvement was similar. The postoperative back pain improvement was greater in the MID group (52.5% MID versus 36.3% CD), but with lower complication rates, specifically durotomies (MID 5.2% versus CD 15.3%; p < 0.001). There is no evidence to recommend the routine addition of ISF in the management of RLDH. The data suggest that MID has lower complication rates than CD in the setting of RLDH, yet unequivocal evidence is lacking.     

活血止痛膏外敷配合骨康胶囊治疗老年腰椎间盘突出症的疗效观察

目的 观察活血止痛膏配合骨康胶囊治疗老年腰椎间盘突出症的临床疗效.方法 选取2014-01-2015-12本院收治的老年腰椎间盘突出症患者60例为研究对象,按照随机数字表法分为观察组和对照组各30例,2组均予以骨康胶囊口服,观察组给予活血止痛膏外敷,对照组给予吲哚美辛巴布膏外敷,4周为1个疗程,观察2组不同时间点的VAS评分、JOA评分,治疗结束后统计治疗有效率及Oswestry功能障碍评分.结果 治疗第1、2周,观察组与对照组VAS评分、JOA评分接近,差异均无统计学意义(P＞0.05),而治疗第3、4周,观察组VAS评分、JOA评分均显著低于对照组(P＜0.05);治疗结束后,观察组Oswestry功能障碍评分显著低于对照组(t=-10.251,P＜0.05);观察组有效率为93.33％,显著高于对照组的73.33％ (P＜0.05).结论 活血止痛膏配合骨康胶囊治疗老年腰椎间盘突出症,可以短期、有效减轻患者的临床症状,且安全性较高,值得推广.     

老年性腰椎管狭窄症61例诊治体会

目的探讨老年性腰椎管狭窄症的临床特点、诊断及治疗效果。方法回顾性分析我科收治的61例老年性腰椎管狭窄症患者,多采用外科治疗,术式分别采用椎板切除、开窗减压以及内固定等手术方法。结果绝大多数患者术后取得满意疗效。61例获随访,平均31个月,优良者57例。结论老年性腰椎管狭窄症多由退行性变引起。合理的外科治疗一般可以获得满意疗效,但术前应明确指征,根据不同病变特点选用相应的术式。     

Percutaneous bipolar radiofrequency thermocoagulation for the treatment of lumbar disc herniation

Lumbar disc herniation is usually managed with conservative treatment or surgery. However, conservative therapy seldom yields good results, and surgery is associated with multiple complications. This study aimed to assess bipolar radiofrequency thermocoagulation for the treatment of lumbar disc herniation. A total of 168 patients with lumbar disc herniation suitable for radiofrequency thermocoagulation were enrolled and randomized to monopolar radiofrequency thermocoagulation (control group, n = 84) or bipolar radiofrequency thermocoagulation (experimental group, n = 84) treatment groups. Ablation sites were targeted under CT scan guidance, and consecutive radiofrequency therapy was used. One and two probes were used for monopolar and bipolar thermocoagulation, respectively. Thermocoagulation was achieved at 50°C, 60°C, and 70°C for 60 s each, 80°C for 90 s, and 92°C for 100 s. Symptoms and complications were evaluated using the modified Macnab criteria and Visual Analog Scale at 7, 30, and 180 days postoperatively. At 180 days, a significantly higher efficacy rate was obtained in the experimental group compared with control patients (91.6% versus 79.7%, P < 0.05). No severe complications were occurred in either group. Targeted ablation via bipolar radiofrequency thermocoagulation is efficient for lumbar disc herniation treatment, and should be further explored for broad clinical application.     

鼠神经生长因子联合甲钴胺治疗合并足下垂的腰椎间盘突出症

目的 探讨鼠神经生长因子(mNGF)在合并足下垂的腰椎间盘突出症患者中的应用价值. 方法 对复旦大学附属中山医院骨科自2008年1月至2011年6月进行手术治疗的76例合并足下垂的腰椎间盘突出症患者的临床资料进行回顾性分析,其按照术后处理方法不同分为2组:联合组36例(应用mNGF联合甲钴胺治疗)、单纯组40例(单纯应用甲钴胺治疗).分析患者治疗后一般情况,比较2组治疗后1周、4周、12周、12个月时视觉模拟评分(VAS)和神经功能(感觉功能和肌力)恢复情况. 结果 患者获得12～54个月(平均24.8个月)随访,无一例死亡,均无创口感染,平均8个月时植骨融合.治疗后1周、4周、12周及12个月时2组VAS评分均明显低于治疗前,且各时间点联合组VAS评分亦明显低于单纯组,差异有统计学意义(P＜0.05).治疗后1周、4周、12周及12个月时联合组感觉功能改善有效率均明显优于单纯组,差异有统计学意义(P＜0.05);除1周外其余时间点联合组肌力改善有效率均明显优于单纯组,差异有统计学意义(P＜0.05). 结论 mNGF与甲钴胺联合使用能促进合并足下垂的腰椎间盘突出症患者的神经功能恢复.     

A 6.5-year follow-up of 14 patients who underwent ProDisc total disc arthroplasty for combined long-standing degenerative lumbar disc disease and recent disc herniation

A highly selected cohort of nine women and five men (mean age±standard error of the mean, 39.6±10.2 years) with discogenic low-back pain (duration: 75.4±97.5 months) and radiculopathy due to disc herniation (duration: 9.4±11.8 months) underwent anterior microdiscectomy and ProDisc-L II arthroplasty (Synthes, Oberdorf, Switzerland) (L5/S1 in 13 patients, L4/5 in one). As reported earlier, initial results were excellent in 11 and good in three patients at 17.8±4.7 months. At an average of 6.5 years after surgery, all were reassessed using the SWISSDISC-questionnaire, which involves the EuroQol-5D and North American Spine Society evaluations (general health, low-back and lower limb status), and a telephone call. Patients reporting an unsatisfactory outcome were re-examined clinically and radiologically. Results were excellent for 10, good for two, satisfactory for one, and poor for one patient. Visual analog scores for back and leg pain at 6.5 years had improved significantly relative to preoperative values (p<0.01), and were only slightly higher than at 1.48 years (p=0.3). This study confirms the initial favorable results.     

Characteristic protein fractions of cerebrospinal fluid disc electrophoretic analysis

The present work was undertaken to determine characteristic proteins of normal cerebrospinal fluid (CSF) by disc electrophoresis in polyacrylamide gel, and to evaluate their usefulness as indicators of blood-brain-CSF barrier disturbance. The technique has been applied to 1280 samples of unconcentrated CSF obtained from 27 reference subjects and 847 neurological patients, with a simultaneous analysis of 361 sera.The pre-albumin content (mean ± S.D. as a percentage of total protein, 11.0 ± 2.3%) was higher than formerly reported. One reason for this is that preliminary concentration was not necessary, and the second is related to the principle of protein resolution. The no. 5 protein band of the post-albumin group (3.9 ± 1.1% was characteristic, though it has not yet been identified. The no. 3 protein band of the post-transferrin group (5.2 ± 1.7%)was highly specific to CSF; it was found to be closely related to transferrin, and may correspond to τ fraction obtained by other methods. Barrier dysfunction was easily recognizable by the appearance of polymers of haptoglobin 2-1 or 2-2, because only haptoglobin 1-1 was detected in normal CSF. The percentage of the main region of the G-zone (13.7 ± 2.6%) was postulated as normal content of CSF immunoglobulins.     

Surgery for lumbar disc herniation: Analysis of 500 consecutive patients treated in an interdisciplinary spine centre

Surgical removal of a symptomatic herniated lumbar disc is performed either with or without the support of a microscope. Up to the time of writing, the literature has reported similar clinical outcomes for the two procedures. Five hundred consecutive patients, operated upon for primary single-level lumbar disc herniation in our University Spine Center between 2003–2011, with (n = 275), or without (n = 225), the aid of a microscope were included. Data were retrospectively analyzed, comparing the primary endpoint of clinical outcome and the secondary endpoints of complications, surgical time and length of hospitalization. Clinical outcomes and reoperation rates were comparable in both groups. Surgical time was significantly shorter with a mean time of 47 minutes without use of the microscope compared to the mean time of 87 minutes (p < 0.001) with the use of the microscope. Mean length of hospitalization was shorter in those operated with the microscope (5.3 days) compared to those without (6.1 days, p = 0.004). There was no difference in rates of complications. Microdiscectomy versus open sequestrectomy and discectomy for surgical treatment of lumbar disc herniation is associated with similar clinical outcomes and reoperation rates. Open sequestrectomy is associated with shorter operation times. Microdiscectomy is associated with shorter hospitalization stays.     

Efficacy of surgery and type of fusion in patients with degenerative lumbar spinal stenosis

Degenerative lumbar spinal stenosis (DLSS) can be treated by several surgical procedures. However, the choice of procedure and use of instrumentation remain controversial. In this retrospective study of 81 patients with DLSS, 43 patients received decompression and posterolateral fusion without instrumentation, and the surgery for 38 patients was supplemented with posterior transpedicular screw fixation. Both surgeon-based (Fischgrund criteria) and patient-based (Medical Outcome Trust Short-Form 36 [SF-36] questionnaire) standards were used to assess the clinical outcomes. An excellent to good result was achieved in 71.6% of patients and there was no significant difference 6.2 years later between groups with or without instrumentation (Z = 0.0358, p > 0.05). SF-36 data revealed significant postoperative improvement (p < 0.01), and there was no significant difference between the two groups (t = 1.67, p > 0.05). Successful fusion occurred in 87% of patients with instrumentation versus 67% of the patients without instrumentation (χ² = 4.23, p < 0.05). Thus, surgical treatment of DLSS generally results in satisfactory outcomes. Transpedicular screw fixation may not improve clinical outcomes and the use of posterior instrumentation should be adopted cautiously.     

Evidence for shoulder girdle dystonia in selected patients with cervical disc prolapse.

Some patients with cervical disc herniation suffer from persistent nuchal pain and muscle spasms after decompressive surgery despite the lack of clinical and radiological signs for actual spinal root compression. Sonographic examination of the brain in some of these patients showed increased echogenicity of the lentiform nuclei as described in patients with idiopathic dystonia. This has been linked to an altered Menkes protein level and copper metabolism. We suggest a relationship between persistent nuchal pain after adequate cervical disc surgery and dystonic movement disorders. Thirteen patients with persistent nonradicular nuchal pain after at least one cervical disc surgery and without evidence of continuing spinal root compression and 13 age-matched controls were included. All patients had a complete neurological examination, ultrasound, and MRI scan of the brain. In addition, Menkes protein mRNA levels of leucocytes were analyzed in patients and controls. All patients with persistent nuchal pain exhibited a constant tonic unilateral shoulder elevation associated with an ipsilateral hypertrophy of the trapezius muscle. Ultrasound examination showed an increased echogenicity of the lentiform nucleus in one patient unilaterally and in 10 patients bilaterally but in none of the controls. On MRI the T2-values of the lentiform nuclei were found to be higher in patients exhibiting a hyperechogenicity of the lentiform nuclei compared to controls (P = 0.01). In addition, Menkes protein mRNA levels were decreased in patients with cervical disc herniation (P = 0.03). Clinical, neuroimaging, and biochemical findings of this selected patient sample with chronic nuchal pain and muscle spasms after cervical disc surgery resemble alterations in patients with idiopathic cervical dystonia. This suggests a link between both disorders. A peripheral trauma to the nerve roots may precipitate dystonic movements in susceptible patients and chronic dystonic muscle contraction would account for the persistent nuchal pain.