儿童及青少年腰椎峡部裂的诊治进展

腰椎峡部裂（1umbar spondylolysis）为腰椎一侧或两侧椎弓上下关节突之间的峡部骨质缺损不连续,亦称椎弓峡部裂或峡部不连。该疾病是一种常见的脊柱疾患^[1],一般无症状。随着青少年参与高强度、高难度体育运动的人数逐渐增多,腰椎峡部裂的发生率有所上升,青少年的发病率为3％～7％^[2]。在一些青少年患者当中,峡部裂可引起剧烈的下腰痛,其也是导致脊柱滑脱的主要原因。对于峡部裂的治疗有保守和手术治疗方式,手术也分很多术式。本文就儿童及青少年腰椎峡部裂的诊治进展做一综述。     

腰椎峡部裂CT诊断进展

腰椎峡部裂的病因主要有先天性发育缺陷、重复性损伤及应力造成的疲劳性骨折及先天发育性因素与后天损伤共同作用.对腰椎峡部裂的诊断CT常规轴位检查较普通X线摄片有较大优势,但也常发生漏诊、误诊.反角度CT扫描能清晰显示环裂征及双关节征等特征性表现,CT常规轴位扫描结合反角度CT扫描可避免对腰椎峡部裂的误诊和漏诊.多层螺旋CT多平面重组、曲面重组、最大密度投影、容积再现或表面遮盖成像等图像重组,可以不同角度、不同方位、不同观察窗条件真实全面地反映腰椎峡部裂的结构特征,确诊率达100%,是目前诊断腰椎峡部裂理想的成像方法.     

犬腰椎峡部裂模型的建立与评价

目的：设计一个可靠的腰椎峡部裂动物模型，同时评价腰椎峡部裂非手术治疗的疗效。 方法：实验于2005—02／08在南方医科大学珠江医院和南方医院动物实验中心完成。选取健康成年杂种犬12只，雌雄不限，均采取手术方法造成L6双侧峡部裂的动物模型。术后随机分为治疗组和对照组，每组6只。治疗组给予支具外固定，对照组未给予任何治疗措施。分别于术后1，3，6个月行X射线、CT检查，6个月后处死所有实验动物取峡部组织。结果：12只动物全部进入结果分析。①实验动物术后当天X射线拍片均可见L6峡部裂。②6个月后，对照组有3只犬峡部裂椎体出现Ⅰ度滑脱，而治疗组未出现椎体滑脱。③术后6个月行X射线、CT检查未见峡部缺损处骨性融合，组织学切片两组电镜下均可见大量纤维组织及少量软骨组织。 结论：这种动物模型可以作为可靠的峡部裂动物模型。峡部裂可导致椎体滑脱，通过非手术治疗可预防椎体滑脱发生，但不能使峡部缺损处骨性融合。     

腰椎峡部裂CT诊断进展

腰椎峡部裂的病因主要有先天性发育缺陷、重复性损伤及应力造成的疲劳性骨折及先天发育性因素与后天损伤共同作用。对腰椎峡部裂的诊断CT常规轴位检查较普通X线摄片有较大优势,但也常发生漏诊、误诊。反角度CT扫描能清晰显示环裂征及双关节征等特征性表现,CT常规轴位扫描结合反角度CT扫描可避免对腰椎峡部裂的误诊和漏诊。多层螺旋CT多平面重组、曲面重组、最大密度投影、容积再现或表面遮盖成像等图像重组,可从不同角度、不同方位、不同观察窗条件真实全面地反映腰椎峡部裂的结构特征,确诊率达100%,是目前诊断腰椎峡部裂理想的成像方法。     

腰椎峡部裂性滑脱合并下位椎峡部裂的治疗

目的探讨腰椎峡部裂性滑脱合并下位椎峡部裂患者的治疗。方法回顾性分析2006年8月至2010年8月收治的腰椎峡部裂性滑脱合并下位椎峡部裂的15例患者,行脊柱后路滑脱椎体复位、椎板切开减压、椎体间植骨融合、椎弓根螺钉系统内固定术治疗。结果 15例滑脱椎体获得良好复位,术后13例患者得到6～25个月随访,全部患者腰背疼痛及神经根性症状改善,无神经功能障碍存在。结论腰椎峡部裂性滑脱合并下位椎峡部裂病例少见,临床上易遗漏下位峡部裂的诊断及治疗,手术治疗需同时固定融合下位峡部断裂的椎体,防止术后再次滑脱。     

腰椎峡部裂患者37例手术疗效分析

目的观察椎弓根钉-椎板钩系统治疗腰椎弓峡部裂的临床疗效。方法对37例腰椎峡部裂的患者应用椎弓根钉-椎板钩系统行峡部断端间植骨内固定。结果全部病例均获随访,平均随访时间9个月,术前日本整形外科学会(JOA)评分平均为(19.08±2.54)分,末次随访时平均(27.05±1.73)分。所有患者术后峡部裂植骨均骨性融合,内固定无松动、脱落。结论椎弓根钉-椎板钩系统是一种节段性内固定治疗腰椎峡部裂的有效方法,简单易行,尤其适用于年轻且无明显椎体滑脱和椎间盘突出的峡部裂患者。     

腰椎峡部裂滑脱前期MRI的诊断价值

目的探讨磁共振成像（MRI）对滑脱前期腰椎弓峡部裂（SPLS）的诊断价值。方法收集SPLS患者69例,对照组69例,由3名资深的影像科医师盲法阅读每个患者的MRI图像。结果 SPLS组中在MRI旁矢状面图像均可见椎弓峡部骨质连续性中断,63例显示断端间可见不同程度分离、错位、成角,与上位腰椎椎弓峡部对照可见失去叠瓦状走行规律,60例显示远侧断端向后下移。SPLS组中显示L5间盘退变60例,两组间差异有统计学意义（χ2=17.03,P〈0.05）。SPLS组可见脊柱发育畸形39例,两组间差异有统计学意义（χ2=26.61,P〈0.05）。结论 MRI对SPLS具有重要的诊断价值,SPLS有特征性的MRI表现,椎弓后部的移位,与上下位椎弓峡部对照失去叠瓦状走行,为诊断椎弓峡部裂的重要的间接征象,当峡部裂直接征象未能显示时,看到此征象应想到本病可能。可为临床评价提供正确、全面的影像学证据。     

腰椎峡部裂合并椎体滑脱的CT误诊分析

腰椎峡部裂合并椎体滑脱的ＣＴ误诊分析中山医科大学康复教研室赖在文ＣＴ扫描诊断腰椎间盘突出症虽可探查体内某些应用其他技术难以探明的部位，也能更好地反映被探测物的形态和性质［１～７］，也还有某些不足之处［３，１０］，同样可导致谬误的结论。现将笔者近年收治...     

张力带内固定在治疗腰椎峡部裂中的应用

作者根据腰椎峡部的生物力学特点,自1995年使用峡部清理、植骨、张力带内固定方法,治疗腰椎峡部裂伴滑脱16例,取得满意效果。报告如下: 1 临床资料 1.1 一般资料:本组16例,男7例,女9例,年龄30～46岁。平均年龄37.6岁。均为体力劳动者,病程经过6个月保守治疗无效。腰痛剧烈,影响生活,L_5～S_1,峡部裂14例,L_4～L_5峡部裂2例,Ⅰ度滑脱6例,Ⅱ度滑脱10例。有神经根压迫症状3     

椎弓根钉-椎板钩系统治疗腰椎峡部裂

目的:观察椎弓根钉-椎板钩系统治疗腰椎弓峡部裂的临床疗效.方法:对37例腰椎峡部裂的患者应用椎弓根钉-椎板钩系统行峡部断端间植骨内固定.结果:37例均获随访,时间6～24个月,平均9个月,术前JOA评分平均(19.08±2.54)分,末次随访时平均(27.05±1.73)分.CT显示所有患者术峡部裂植骨均骨性融合,内固定无松动、脱落.结论:椎弓根钉-椎板钩系统是一种节段性内固定治疗腰椎峡部裂的有效方法,简单易行,尤其适用于年轻且无明显椎体滑脱和椎间盘突出的峡部裂患者.     

Surgical treatment of four segment lumbar spondylolysis: A case report

BACKGROUNDFour-level lumbar spondylolysis is extremely rare. So far, only 1 case has been reported in the literature. CASE SUMMARYA 19-year-old man presented with severe back pain irresponsive to conservative therapies for 2 years. Lumbar radiographs and two-dimensional computed tomography scan showed four segment lumbar spondylolysis on both sides of L2-L5. Lumbar magnetic resonance imaging showed normal signal in all lumbar discs. Because daily activities were severely limited, surgery was recommended for the case. The patient underwent four-level bilateral isthmic repair at L2-L5. During surgery, L2-L5 isthmi were curetted bilaterally, freshened, and then grafted with autologous iliac bone that was bridged and compressed with a pedicular screw connected to a sub-laminar hook by a short rod. The symptoms of back pain almost disappeared. He has been followed-up for 96 mo, and his symptoms have never recurred. Fusion was found in all repaired isthmi 14 mo after surgery according to evaluation of lumbar radiography and computed tomography scan.CONCLUSIONWe report here 1 case of four-level lumbar spondylolysis that was treated successfully with direct isthmic repair.     

Application of a new anatomic hook-rod-pedicle screw system in young patients with lumbar spondylolysis: A pilot study

BACKGROUNDThe pedicle screw-laminar hook system has strong fixation and is conducive to bone graft fusion for lumbar spondylolysis. However, the current pedicle screw-laminar hook fixation system is not specifically designed for lumbar spondylolysis.AIMTo investigate the clinical effects of a new anatomical hook-rod-pedicle screw system in the treatment of lumbar spondylolysis in young adults.METHODSWe designed a new anatomic hook-rod-pedicle screw system for young patients with lumbar spondylolysis. The isthmus and the corresponding pedicle screw entry point were exposed through the intermuscular approach. Autogenous iliac bone graft was obtained to bridge the isthmus defect, and then the anatomic hook-rod-pedicle screw system was used to fix the isthmus in 15 young patients.RESULTSAt 24 mo follow-up, the visual analogue scale score of low back pain decreased from 6.73 ± 0.88 to 0.73 ± 0.59, and the Oswestry disability index score decreased from 58.20 ± 8.99 to 7.87 ± 4.97. Computed tomography showed bilateral isthmic bone healing in 14 cases and unilateral isthmic bone healing in 1 case. Magnetic resonance imaging showed that the lumbar disc signal of diseased segment and adjacent segments had no change compared with that before surgery. The pain visual analogue scale score of the donor site was 0.20 ± 0.41 at the last follow-up. According to the Modified Macnab score, the excellent and good rate was 100%.CONCLUSIONThe application of this new anatomical hook-rod-pedicle screw system to treat young patients with lumbar spondylolysis has the advantages of less trauma, a simple operation and satisfactory clinical effects.     

Familial development of lumbar spondylolysis: a familial case report of 7- and 4-year-old brothers and their father

The incidence of lumbar spondylolysis is affected by sex, race, and congenital abnormalities. These differences suggest a genetic component to the etiology of spondylolysis. However, no definitive evidence has been presented regarding the inheritance of lumbar spondylolysis. We report familial cases of lumbar spondylolysis in 7- and 4-year-old brothers and their father, each of whom visited our clinic complaining of low back pain. Spondylolysis in the fifth lumbar vertebra (L5) was identified in both boys and their father from clinical, radiographic, computed tomographic, and magnetic resonance imaging examinations. Conservative treatment was provided for both boys. No bony union of any spondylolytic lesions was obtained, but they returned to sports activity without low back pain. Frequent development of spondylolysis, even at younger ages, in all male family members might indicate an underlying genetic etiology in lumbar spondylolysis, primarily in the form of autosomal dominant inheritance. However, information on patients and their parents should be considered carefully, as bony union with conservative therapy is not expected in such patients.     

CT在腰椎椎弓峡部不连中的临床应用

目的探讨CT在腰椎椎弓峡部不连诊断中的临床价值及提高检出率。方法用PICKER-1200CT机检查，总结56例不伴有明显椎体移位的腰椎椎弓峡部不连患者凹征象，并结合定位像进行分析。结果腰椎椎弓峡部不连的特征性表现是椎弓骨性环连续性中断。在CT诊断明确的腰椎椎弓峡部不连的病例中，37例在侧位定位像上，同一腰椎上、下小关节突问出现骨质不连续，19例局部骨质结构紊乱、增粗。结论常规CT检查腰椎间盘病变时，在不伴有明显椎体移位的情况下，如果定位像上腰椎椎弓部上、下小关节突间出现骨质不连续，类似椎体“断尾征”，以及局部骨质结构紊乱、增粗时增加扫描范围，对腰椎弓峡部不连的早期诊断有一定意义。     

经Wiltse入路峡部植骨跨运动节段内固定治疗腰椎峡部裂的临床效果

目的观察经Wiltse入路峡部植骨跨运动节段内固定治疗腰椎峡部裂的临床效果。方法以我院2017年3月至2019年11月收治的82例腰椎峡部裂患者为研究对象,以随机数字法将其分成对照组和试验组,各41例。两组患者均拟行峡部植骨跨运动节段内固定治疗,其中对照组患者实施常规入路,而试验组患者实施经Wiltse入路。比较两组患者的围手术期相关指标(切口长度、术中出血量、手术时间、术后引流量、住院时间)及术前、术后7 d的视觉模拟评分(VAS)及Oswestry功能障碍指数(ODI)评分。结果试验组的切口长度、手术时间、住院时间均短于对照组,术中出血量与术后引流量均少于对照组(P<0.05)。术后7 d,两组患者的VAS、ODI评分较术前明显下降,且试验组低于对照组(P<0.05)。结论采取经Wiltse入路峡部植骨跨运动节段内固定治疗腰椎峡部裂患者,可明显缩短患者的切口长度、手术时间、住院时间,减少术中出血量和术后引流量,减轻术后7 d的疼痛与功能障碍,效果理想。     

63例青少年腰椎间盘突出症康复治疗疗效分析及临床病因初探

目的探讨青少年腰椎间盘突出症的病因以及康复治疗的疗效。方法分析自贡市第一人民医院自2007年11月至2011年11月收治的63例青少年腰椎间盘突出症患者的资料,并采用Bridwell评分方法对康复治疗的疗效进行评定,初步分析导致青少年椎间盘突出症的病因。结果对63例患者按照Bridwell评分系统进行评分,其中治疗前平均为(42±12)分,治疗后平均为(80±16)分,治疗前后评分比较差异有统计学意义(P<0.01)。结论青少年腰椎间盘突出症的发病原因比较复杂,外伤及椎间盘早期退行性变可能是其发病的主要原因。康复治疗对青少年腰椎间盘突出症有一定疗效。     

20岁以下青少年腰椎间盘突出症影像学分析

目的探讨青少年腰椎间盘突出症的病因、临床及影像学表现特点。方法回顾性分析16例青少年腰椎间盘突出症的临床和影像学表现。结果L4-5，L5-S1是椎间盘突出的好发部位。16例青少年腰椎间盘突出症的主要CT、MR表现为：①中央型腰椎间盘突出2例，占12．50％；②周围型腰椎间盘突出14例，占87．50％。结论本病的发生与外伤和腰骶部发育异常有关。X线平片对青少年椎间盘突出诊断价值不如CT和MR，CT和MR检查准确性高，且为无创性检查，是诊断青少年腰椎椎间盘突出较为理想的检查方法。     

Expert opinion and controversies in sports and musculoskeletal medicine: the diagnosis and treatment of spondylolysis in adolescent athletes

Standaert CJ, Herring SA. Expert opinion and controversies in sports and musculoskeletal medicine: the diagnosis and treatment of spondylolysis in adolescent athletes.Although spondylolysis is relatively common in adolescent athletes, there are substantial disagreements in the literature concerning the best methods for diagnosing and treating the condition. Controversy particularly arises regarding the optimal use of available imaging modalities in the diagnosis of athletes with suspected pars defects and the extent of activity restriction or brace use required for appropriate treatment. Because there have been no controlled trials on the treatment of spondylolysis and only a very limited number of studies addressing potential imaging strategies, it is difficult to develop true evidence-based guidelines for this condition. Given the current state of the literature, it is our impression that nuclear imaging with single photon emission computed tomography followed by computed tomography, with a limited role for plain radiography, remains the standard for appropriately diagnosing a symptomatic pars lesion. Treatment hinges on activity restriction for an amount of time adequate to allow for symptom resolution and, when possible, potential bony healing followed by a progressive sport-specific rehabilitation program. The biomechanic effects of brace use in this population are not well understood, but there may be some detrimental effects to the use of a brace and there currently is no evidence that the routine use of a rigid brace results in any significant improvement in radiographic or functional outcome.