Dynesys动态固定与经椎间孔椎间融合术治疗退变性L5/S1椎间盘突出症的疗效比较

目的 对比分析后路经椎弓根动态固定与经椎间孔椎间融合术（transforminal lumbar interbody fusion, TLIF）治疗退变性L₅/S₁椎间盘突出症的临床疗效。方法 回顾性分析2011年1月至2015年1月我科收治的82例退变性L₅/S₁椎间盘突出症病人,所有病例均符合纳入标准。其中38例采用Dynesys动态内固定术（Dynesys组）,44例采用经椎间孔椎间融合术（TLIF组）。比较两组术后1、3、6、12、24个月评估临床和影像学结果。结果 末次随访时,两组Oswestry功能障碍指数（the Oswestry disability index, ODI）评分和疼痛视觉模拟评分（visual analogue score, VAS）均较术前显著改善,差异均有统计学意义（P均＜0.05）。Dynesys组和TLIF组L₅/S₁的活动度（range of motion, ROM）分别从7.5°±2.6°降至5.2°±2.4°和7.2°±2.3°降至0°（P＜0.05）。L_4/5的ROM分别从8.6°±2.8°增至10.1°±2.6°和8.4°±2.5°增至12.5°±2.9°（P＜0.05）。Dynesys组和TLIF组发生L_4/5邻近节段退变（adjacent segment degenelation, ASD）的例数分别为2例（5.25%）和11例（25.00%）。末次随访时,两组ROM和ASD比较,差异均有统计学意义（P均＜0.05）。结论 Dynesys与TLIF治疗退变性L₅/S₁椎间盘突出症均能获得满意的临床疗效。与TLIF比较,Dynesys有利于保持ROM和减少ASD的发生,可作为退变性L5/S1椎间盘突出症的优选术式。     

L4退行性滑脱的骨性参数特征

目的 比较L₄退行性滑脱和L₄/L₅椎间盘突出症患者骨性参数的差异,分析L₄退行性滑脱发生的危险因素。方法 回顾性分析21例L₄退行性滑脱（A组）及18例L₄/L₅椎间盘突出症患者（B组）的病例资料。通过测量腰椎矢状位X线片、45°双斜位X线片及CT获得骨性参数,矢状位X线片参数包括Taillard指数、腰椎指数（LI）、矢状面旋转度（SR）、骶骨水平角（SS）、腰椎前凸角（LL）、腰椎双凹指数（DCI）、L₄/L₅椎间盘角（IDA）、L₄/L₅椎间盘指数（DI）、腰椎重力线指数（LGLI）;45°双斜位X线片参数包括L₄椎体高度（h）、L₄小关节倾斜角（α）、L₃下关节突至L₄峡部距离（d）、L₅上关节突至L₄峡部距离（e）、L₄峡部宽度（k）;CT参数为L₄小关节角（θ）;比较2组各参数的差异,并分析各参数间的相关性。基于MRI图像,应用Pfirrmann椎间盘退行性变分级系统对2组患者L₄/L₅椎间盘进行分级,比较2组椎间盘退行性变分级的差异。结果 A组患者LI、IDA、DI、d、e、θ均明显小于B组,而LGLI、α以及L₄/L₅椎间盘退行性变程度均明显大于B组,差异均有统计学意义（P<0.05）。相关性分析显示Taillard指数与LI、θ呈负相关,与LGLI呈正相关。结论 椎间盘退行性变、α增大、LGLI增大、θ减小、LI减小、IDA减小、DI减小、关节突至峡部距离减小可能是L₄退行性滑脱发生的危险因素。     

经皮后外侧腰椎间孔入路椎间盘工作区域的解剖学研究

 目的 通过对健康成人尸体标本的解剖和测量, 对经皮后外侧腰椎间孔入路的椎间盘工作区域进行应用解剖学研究。方法 对 25具尸体标本(年龄 45~65岁, 身高 150~176 cm)进行腰椎椎间孔解剖学研究, 首先在矢状面上测量椎间隙后缘高度(h), 神经根与椎间盘平面的倾斜角(茁), 神经根后缘与椎间盘最后缘水平距离(d), 椎间孔在上、下终板平面上的神经根后缘与下位椎体上关节突外缘的距离(a1, a2);去除关节突后显露神经根与硬膜, 冠状面上在上、下终板平面上测量神经根内缘与硬膜外缘的距离(b1, b2)。结果 在椎间孔矢状面和冠状面上椎间盘区域分别为两个”梯形冶。矢状面上测量参数: h为(7.0±1.1) mm, 茁为 77.6°±8.4°, d为(3.4±2.3) mm, a1为(9.4±2.2) mm, a2为(10.8±4.6) mm。冠状面上 b1为(9.9±2.7) mm, b2为(17.7±2.1) mm。除神经根倾斜角度(β)逐渐缩小外, 其余参数均随腰椎节段而逐渐增大。结论 后外侧腰椎间孔入路的椎间盘工作区域可模拟为由矢状面和冠状面”梯形冶所合成的立体结构。通过对立体结构解剖的研究比较可以指导临床操作, 如椎间孔镜工作通道的大小及椎间孔穿刺针角度等。     

腰椎椎间隙高度与上位椎体高度的比值与椎间盘退行性变Pfirrmann分级的相关性

目的 探讨腰椎椎间隙高度与上位椎体高度的比值与椎间盘退行性变程度之间的关系,为腰椎椎间盘退行性疾病的诊断和治疗提供客观准确的依据。方法 回顾性分析2019年1月—2019年6月来本院就诊的61例腰椎椎间盘退行性变患者临床资料。在腰椎侧位X线片上测量腰椎椎间隙及相应上位椎体的高度,并计算椎间隙高度与上位椎体高度的比值;在腰椎矢状位MRI上评估腰椎椎间盘退行性变Pfirrmann分级;比较不同Pfirrmann分级椎间盘的椎间隙高度与上位椎体高度比值的差异,并采用Spearman相关分析研究椎间隙高度与上位椎体高度比值与相应节段椎间盘Pfirrmann分级之间的相关性。结果 除L₁/L₂节段,其余各节段椎间隙高度与上位椎体高度比值均随着Pfirrmann分级增加而逐渐减小,差异均有统计学意义（P < 0.05）。相同Pfirrmann分级的不同节段椎间盘之间椎间隙高度与上位椎体高度比值差异无统计学意义（P > 0.05）。Spearman相关分析结果显示,L₂/L₃、L₃/L₄、L₄/L₅、L₅/S₁节段Pfirrmann分级与椎间隙高度与上位椎体高度比值呈负相关（r =-0.568,P < 0.05）。结论 临床上测量L₂/L₃、L₃/L₄、L₄/L₅、L₅/S₁节段椎间隙高度与上位椎体高度比值对腰椎椎间盘退行性疾病的诊断可能具有重要意义。     

经改良的Jaslow技术治疗复发性腰椎间盘突出症

目的：采用经改良的Jaslow技术治疗复发性腰椎间盘突出症,评价其临床疗效。方法：自2002年1月至2008年12月,采用改良Jaslow技术进行手术治疗62例复发性腰椎间盘突出症患者,男42例,女20例;年龄36～70岁,平均53.6岁。首次术式：扩大开窗20例,单侧半椎板切除20例,双侧半椎板切除8例,全椎板切除14例。手术节段：L_3,4 2例,L_4,5 32例,L₅S₁ 15例,L_3,4、L_4,5 3例,L_4,5、L₅S₁ 10例。临床症状主要为下腰痛和放射痛。通过手术前后的JOA评分变化(包括主观症状、自理能力、疼痛等方面)、以及手术节段的椎间隙高度比、植骨融合情况评价临床疗效。结果：62例均获随访,时间1～5年,平均3年。末次随访影像学检查椎间隙高度比由术前(62.5±10.4)%恢复至术后(90.5±10.3)%,融合率96.8%(60/62).JOA评分由(10.42±2.50)提高至末次随访时(24.26±2.35)(P<0.001).疗效结果：优39例,良14例,中9例。结论：改良的Jaslow技术治疗复发性腰椎间盘突出症减压充分、椎间融合可靠,手术安全性高,临床疗效满意,是一种比较理想的手术方法。     

Bryan颈椎人工椎间盘置换术的长期疗效观察

目的 评估Bryan颈椎人工椎间盘置换术的长期疗效。方法 对2004年12月至2008年8月于我院行Bryan颈椎人工椎间盘置换术的20例病人进行回顾性分析,男15例,女5例,平均年龄为（43.85±3.70）岁,其中单节段9例,双节段11例,C_3/4 2例、C_4/5 9例、C_5/6 15例、C_6/7 5例。①收集并比较其术前、术后1周、术后2年及末次随访的改良日本骨科协会（modified Japanese Orthopaedic Association, mJOA）评估治疗分数、疼痛视觉模拟量表（visual analogue scale, VAS）评分、颈椎功能障碍指数（neck disability index, NDI）以及Odom''s分级。②通过其术前、术后早期及末次随访时的X线侧位片及颈椎过屈过伸位片,评估其颈椎曲度、颈椎活动度（ROM）。③MRI T2加权像上根据Miyazaki分级标准评估Bryan人工椎间盘置换术后邻近节段的退变情况。④通过X线片及CT片根据McAfee标准评价异位骨化的发生情况。结果 ①术前及末次随访时的mJOA评分分别为（13.30±2.83）分、（15.25±2.07）分,VAS评分分别为（4.10±3.81）分、（1.55±1.53）分,NDI分别为（11.45±9.52）分、（6.00±4.78）分,所有评价指标末次随访时较术前均有显著改善,差异均有统计学意义（P均＜0.05）。末次随访时Odom''s分级为优8例,良8例,可2例,差2例。②脊柱功能单位（FSU）曲度及C₂~C₇曲度：术前分别为2.33°±4.08°、18.78°±6.68°,术后早期为4.12°±6.43°、20.00°±9.98°,末次随访时分别为3.21°±6.56°、15.61°±6.73°。FSU ROM及C₂~C₇ ROM：术前分别为9.15°±2.80°、47.28°±9.75°,术后早期为9.27°±3.83°、40.81°±14.66°,末次随访分别为9.37°±3.97°、42.03°±10.97°。3个时间点的FSU曲度及FSU ROM比较,差异均无统计学意义（P均＞0.05）,但C₂~C_{7 ROM术后较术前明显减少,与邻近节段ROM变化趋势一致。末次随访时,43个邻近节段中46.5%发生邻近节段退变（adjacent segment degeneration, ASD）,以C5/6最为常见,但均无临床表现;末次随访时31个手术节段中有23例（74.2%）发生异位骨化,其中严重异位骨化（Ⅲ、Ⅳ级）发生率为22.6%,C5/6最为常见。结论 Bryan颈椎人工椎间盘置换术治疗颈椎退变性疾病可以取得持久稳定的临床效果,尽管异位骨化发生率较高,但大部分保留手术节段活动,同时邻近节段仍可见退变,但均无临床症状。}     

高低位腰椎椎间盘突出症患者脊柱-骨盆矢状面形态变化

目的 比较高位与低位腰椎椎间盘突出症（LDH）患者脊柱-骨盆矢状面形态学差异，探讨脊柱-骨盆矢状面形态学参数异常与高位LDH发生的关系。方法 纳入2006年1月—2022年1月收治的高位LDH患者53例（高位组），同时期性别、年龄和体质量指数（MBI）匹配的低位LDH患者53例（低位组）及单纯下腰部疼痛的非LDH患者53例（对照组）。在站立位全脊柱侧位X线片上测量3组矢状面平衡（SVA）、胸椎后凸角（TK）、腰椎前凸角（LL）、腰骶前凸角（LSL）、骶骨倾斜角（ST）、骨盆入射角（PI）、骨盆倾斜角（PT）、骶骨倾斜角（SS）等脊柱-骨盆矢状面参数。结果 高位组SVA、TK明显高于对照组，LL、ST、PI、PT及SS明显低于对照组；高位组TK明显高于低位组，LL、ST及PI明显低于低位组；差异均有统计学意义（P<0.05）。高位组L₁/L₂节段患者的LL、ST较L₂/L₃节段患者有下降趋势，但差异无统计学意义（P>0.05）。结论 骨盆水平化导致的胸腰段过度代偿可能是高位LDH发生、发展的机制之一。     

L4～S1椎弓根形态与椎板间及椎间孔大小的相关性

目的 研究腰椎椎弓根形态（长度及角度）与L₄/L₅和L₅/S₁节段椎板间及椎间孔大小的相关性。方法 回顾性分析海军军医大学长征医院2020年1月—2022年6月收治的50例L₄/L₅或L₅/S₁单节段腰椎椎间盘突出症（LDH）患者作为研究组，并选取同时期50名健康志愿者作为对照组。测量2组腰椎正侧位X线片上L₄/L₅和L₅/S₁节段椎板间的最大高度和宽度，在CT上测量椎弓根长度和角度、椎间孔最小高度和宽度，采用逐步多元线性回归的多元相关性来确定相关变量对椎间孔及椎板间大小的独立影响。结果 2组L₄~S₁椎弓根长度、L₄/L₅及L₅/S₁节段椎间孔和椎板间高度差异无统计学意义（P>0.05）。研究组S₁椎弓根外展角小于对照组；研究组L₄椎弓根头倾角低于对照组，S₁椎弓根头倾角高于对照组；研究组L₄与L₅、L₅与S₁椎弓根头倾角差值低于对照组；研究组L₄/L₅和L₅/S₁节段椎间孔宽度、椎板间宽度小于对照组；以上指标差异均有统计学意义（P<0.05）。Pearson相关分析显示，年龄与椎板间高度和宽度及椎间孔高度呈负相关，椎弓根外展角与椎板间宽度呈正相关，椎弓根长度与椎间孔宽度呈正相关，相邻腰椎椎弓根头倾角差值与椎间孔宽度呈正相关，椎板间宽度与椎间孔宽度呈正相关。多重线性回归分析显示，患者的年龄、椎弓根长度及角度与椎板间及椎间孔大小独立相关，L₅、S₁椎弓根外展角与椎板间宽度显著正相关，L₅椎弓根头倾角与L₄/L₅及L₅/S₁椎间孔高度显著负相关；相邻腰椎椎弓根头倾角差值与椎间孔宽度显著正相关。结论 椎板间及椎间孔高度和宽度会随着患者年龄增长而变小，椎板间宽度随着L₅、S₁椎弓根外展角度增大而变大，L₅椎弓根头倾角越大，相邻椎间孔高度越小；相邻椎体椎弓根头倾角差值增加，椎间孔宽度增大。椎弓根角度和长度影响椎板间及椎间孔的大小，这些变化可能会影响手术难度和手术方式选择。     

腰椎弓根延长术对关节突关节力学影响的有限元分析

目的 探讨腰椎椎弓根延长术对关节突关节生物力学的影响,分析关节突关节发生异常应力变化前椎弓根的最大延长长度。方法 取1名腰椎健康志愿者的CT图像,建立L₃~L₅正常腰椎的有限元模型,在其基础上构建L₄椎弓根延长术后模型,L₃椎体上表面均施加垂直于水平面400 N的压力,模拟正常人腰椎所承载重力,固定支撑L₅椎体下表面。通过建立不同椎弓根延长长度的术后模型,分析在力矩为5 Nm时L_3/4的应力分布云图及相应的应力-应变曲线,得出相同力矩下L_3/4关节突关节应力极值随椎弓根延长长度变化的曲线图。结果 施加5 Nm力矩下,L_3/4小关节左旋工况下应力先随延长长度的增加而增加,在椎弓根延长3.8 mm时达到最大,为9.133 MPa;随后,L_3/4小关节的应力骤然减小,曲线发生不可逆变化。结论 力矩加载为5 Nm时腰椎弓根延长术的最大延长距离为3.8 mm,临床应结合腰椎管狭窄的严重程度,选择减压所需的延长长度,取得更好的手术疗效。     

髂腰韧带的横断位CT表现及其在腰骶部椎体节段定位中的价值

目的：初步研究髂腰韧带的横断位CT表现,重点探讨髂腰韧带在腰骶段移行椎中的定位作用。方法：选2008年5月至2010年3月因腰背部症状拟诊椎间盘病变来院行CT扫描的706例患者,其中男436例,女270例;年龄25～82岁,平均44岁。所有患者均进行单层螺旋CT横断位扫描,其中移行椎患者78例,均经X线摄片或透视证实。在横断面CT图像上观察髂腰韧带的形态、位置及走行,了解其位置是否相对恒定;研究髂腰韧带与腰椎节段的关系,并与另外4种常用的腰骶椎节段CT定位方法作对照。结果：628例具有正常腰骶节段的患者其髂腰韧带的主要部分均起自L₅横突,止于髂嵴,3例可见髂腰韧带细小分支从L_4,5椎间盘后外缘同时发出,其形态可分双束型占71.8%(451/628)及单束型占28.2%(177/628);78例移行椎患者的髂腰韧带亦起源于L₅横突;以髂腰韧带作为L₅椎体水平的定位标记,均得到准确定位,其准确率明显高于其他定位方法,与髂嵴定位法比较差异具有统计学意义(P<0.05).结论：髂腰韧带主体起源于L₅横突,其解剖位置相对恒定,可将其作为L₅的解剖定位标志,以判断腰骶部移行椎类型和进行椎间盘定位。     

内窥镜下保留大部分黄韧带治疗腰椎间盘突出症

目的：探讨内窥镜下保留大部分黄韧带治疗腰椎间盘突出症的手术技巧和近期临床效果。方法：52例腰椎间盘突出症患者,男31例,女21例;年龄28～45岁,平均36岁;其中L4,524例,L5S128例。在内窥镜操作下,咬除上位椎板下缘1/4～1/3骨组织,纵向扩大骨窗,角度小刮匙在下位椎板上缘外侧分离出浅层黄韧带,用咬骨钳沿椎板上缘横行咬除浅层黄韧带成一小凹槽,用髓核钳在凹槽处钳夹黄韧带浅层向近端牵拉剥离并切除,保留深层黄韧带,然后用椎板咬骨钳在黄韧带外侧咬除小关节内侧1/4～1/3,扩大侧隐窝,游离黄韧带外缘,椎板咬骨钳咬除黄韧带外侧1/3入椎管,保留内侧2/3,神经根钩仔细分离突出椎间盘周围的组织,尽可能保留神经根周围及硬膜外脂肪,将硬脊膜及神经根牵向内侧,摘除突出的髓核。结果：52例中46例获得随访,随访时间5～51个月,平均34.5个月。疗效评定按Nakai标准,优34例,良9例,可3例。手术时间45～75min,出血40～80ml,均无神经根损伤和硬脊膜撕裂等并发症。结论：内窥镜下保留大部分黄韧带,技术上操作可行且尽可能的保留了人体的自然解剖结构,最大限度地维持了脊柱的稳定性,临床效果好。     

节段定位斜扳法治疗腰椎间盘突出症

目的：通过改变脊柱弯曲，旋转角度进行节段定位，研究节段定位斜扳法治疗腰椎间盘突出症的效果，提高对本手法治疗腰椎间肋突出症的认识，。方法：采用节段定位斜扳法治疗腰椎间盘突出症911例，用手法把脊柱控制到一定的屈曲及旋转角度，施以斜扳法，让屈曲，旋转应力集中于病变节段的椎间盘，以治疗腰椎间盘突出症，结果：911例患者中，临床治愈208例，显效330例，好转361例，无效12例，显效率59％。结论：采用相对准确的节段定位，施以斜扳手法，可较好地缓解神经根受压和调整后关节紊乱，改善或解除临床症状。     

临床症状体征与影像学检查分离的腰椎间盘突出症的发生机制研究进展

临床会出现少数症状体征与影像学检查结果不相符的腰椎间盘突出症患者,而单纯用传统的突出髓核直接机械压迫刺激神经根的理论不能解释这种反常的腰椎间盘突出症。腰椎间盘髓核的突出与患者临床症状体征的出现受多因素、多环节的影响,脊神经根的间接性机械压迫与神经根牵张效应为主要因素,而反常症状体征的产生往往与突出的髓核自身位置的迁移、神经系统对信息的传递以及髓核与硬膜囊或神经根的相互作用密切相关。此外,突出的髓核组织所继发的局部微循环、炎症改变,相应节段的骨质增生退变和腰椎应力姿势改变诱发此类反常腰椎间盘突出症患者出现多样性的症状体征。同时,一些患者还存在神经或椎体的先天性发育异常,并可能出现影像学检查上的误诊或漏诊。突出髓核对硬膜囊以及周围神经根之间的确切相互作用机制及其继发的局部病理生理、生物力学改变,病变责任节段的确定以及如何克服影像学检查的局限性需进一步研究。     

借助3D-MRI扫描探讨脊柱(定点)旋转复位法治疗腰椎间盘突出症的临床研究

目的:观察脊柱(定点)旋转复位法治疗腰椎间盘突出症前后突出髓核与神经根的三维空间位置变化,探索该手法治疗腰椎间盘突出症的机制。方法:2009年4月至2011年6月采用脊柱(定点)旋转复位法治疗L5S1腰椎间盘突出症52例,男33例,女19例;年龄19～55岁,平均34.6岁。治疗前后均进行3D-MRI扫描,观察突出髓核与受累神经根解剖关系及核磁冠状位脊柱-骨盆构形变化。结果:MRI显示患者突出髓核与受累神经根解剖关系分为腋侧、肩侧、前方、包围4种类型。手法治疗后触诊患椎椎体位移消失,腰腿痛锐减。所有患者获随访,时间2～28个月,平均12个月,疾病未复发,所有患者恢复原工作或学习。3D-MRI轴位与入院时对照所有病例突出髓核大小形态无显著变化,患者腰椎-骨盆的曲线均有改变。结论:腰椎间盘突出症存在单(多)个椎体位移。椎体位移致腰椎-骨盆构形改变造成髓核及受累神经根生物力学特性的改变,脊柱(定点)旋转复位法纠正患椎椎体位移,恢复了脊柱内外因素平衡,从而达到治疗目的。     

IL-1β promotes disc degeneration and inflammation through direct injection of intervertebral disc in a rat lumbar disc herniation model

BACKGROUND CONTEXTLumbar intervertebral disc herniation (LDH) is a common disease that causes low back pain, radiating leg pain, and sensory impairment. Preclinical studies rely heavily upon standardized animal models of human diseases to predict clinical treatment efficacy and to identify and investigate potential adverse events in human subjects. The current method for making the LDH model involves harvesting the nucleus pulposus (NP) from autologous coccygeal discs and applying to the lumbar nerve roots just proximal to the corresponding dorsal root ganglion. However, this surgical method generates a model that exhibits very different characteristics of disc herniation than that observed in human.PURPOSETo produce a rat LDH model that better resembles disc herniation in humans and a standardized and uniform LDH model using Interleukin-1 beta (IL-1β).STUDY DESIGNExperimental rat LDH model.METHODSWe exposed the L5–6 disc dorsolaterally on the right side through hemi-laminectomy without nerve compression. Herniation was initiated by puncturing the exposed disc with a 30-gauge needle at a depth of 4 mm. Interleukin-1 beta (IL-1β) was injected simultaneously to heighten the pathological processes of disc degeneration, including inflammatory responses, matrix destruction, and herniation of the NP. We performed histological staining to assess morphological changes, immunohistochemistry to analyze inflammation- and pain-related expression within and around the puncture site of the L5–6 disc, and real-time polymerase chain reaction to examine expression of markers for degenerative processes. In addition, we performed locomotor tests on the rats.RESULTSWe found that the IL-1β groups showed that the border between the annulus fibrosis and nucleus pulposus was severely interrupted compared to that of the control (puncture only) group. And, the injection of IL-1β leads to accelerated disc degeneration and inflammation in a more consistent manner in LDH model. Functional deficit was consistently induced by puncturing and injection of IL-1β in the exposed disc.CONCLUSIONSThe method proposed here can be used as an index to control the severity of disc degeneration and inflammation through the injected IL-1β concentration concurrent with surgically induced herniation.CLINICAL SIGNIFICANCEOur proposed model may facilitate research in drug development to evaluate the efficacy of potential therapeutic agents for disc herniation and neuropathic pain and may also be used for nonclinical studies to more accurately assess the effectiveness of various treatment strategies according to the severity of disc degeneration.     

腰椎间盘突出症非对称性下肢放射痛的原因及治疗

目的：探讨腰椎间盘突出症导致非对称性下肢放射痛的原因及治疗。方法：回顾性分析了手术治疗的53例病人。其中全椎板切除39例，扩大半椎板切除14例。结果：对侧侧隐窝狭窄23例，游离髓核组织压迫对侧神经根24例，脊髓丘脑侧束内存在不交叉纤维6例。结论：对侧侧隐窝狭窄和游离髓核组织压迫对侧神经根是导致非对称性下肢放射痛的主要原因，手术日寸要注意对对侧侧隐窝减压，除游离的髓核组织。只有确定无导致对侧下肢放射痛的原因后。才能确定为脊髓丘脑侧束内存在不交叉纤维。     

Dorsal compression of the epidural cord due to free sequestral lumbar prolapse

Due to the anatomical situation, intervertebral disc herniation usually results in compression of the anterior epidural space, with lateral or medial irritation of nerve root or cauda equina. Rare locations are an intra- or extraforaminal position or dislocation dorsally. Three patients with dorsal cauda equina compression caused by a sequestered herniated nucleus pulposus (HNP) are reported. The patients complained mainly of severe back pain. In two patients nondermatome-related leg pain was observed; one patient suffered additionally from incomplete cauda equina syndrome. In all cases magnetic resonance imaging and computed tomography diagnosed neoplastic tissue.     

The effectiveness of chemonucleolysis with condoliase for treatment of painful lumbar disc herniation

BackgroundChemonucleolysis with condoliase, which degrades chondroitin sulfate, could be a new, minimally invasive therapeutic option for patients with lumbar disc herniation (LDH). The purpose of this study was to analyze prognostic factors for clinical outcomes in LDH patients subjected to chemonucleolysis with condoliase.MethodsInclusion criteria for this procedure were 1) 18–70 years of age; 2) unilateral leg pain and positive straight leg raise (SLR) (<70°) or femoral nerve stretching test; 3) subligamentous extrusion verified on magnetic resonance imaging; 4) neurological symptoms consistent with a compressed nerve root on magnetic resonance imaging (MRI) images; and 5) minimum six months of follow-up. In total, 82 patients (55 men, 27 women; mean age, 47.2 ± 15.5 years; mean follow-up, 9.1 ± 3.0 months) who underwent chemonucleolysis with condoliase for painful LDH were included. An improvement of 50% or more in the Visual analogue scale (VAS) of leg pain was classified as effective.ResultsSeventy patients (85.4%) were classified into the effective (E) group and 12 patients (14.6%) into the less-effective (L) group. Surgical treatment was required in four patients. No severe adverse complications were reported; 41.3% of the patients developed disc degeneration of Pfirrmann grade 1 or more at the injected disc level. Univariate analysis revealed that young age (p = 0.036), without history of epidural or nerve root block (p = 0.024), and injection into the central portion of the intervertebral disc (p = 0.014) were significantly associated with clinical effectiveness. A logistic regression analysis revealed that injection into the central portion of the intervertebral disc (p = 0.049; odds ratio, 4.913; 95% confidence interval, 1.006–26.204) was significantly associated with clinical effectiveness.ConclusionsChemonucleolysis with condoliase is a safe and effective treatment for painful LDH; 85.4% of the patients showed improvement after the treatment without severe adverse events. To obtain the best outcome, condoliase should be injected into the center of the intervertebral disc.     

The effect of age on inflammatory responses and nerve root injuries after lumbar disc herniation: an experimental study in a canine model

STUDY DESIGN: An experimental investigation on the effect of age on pathologic events surrounding the herniated disc and at the adjacent nerve root. OBJECTIVES: To investigate the role of age on the inflammatory responses and nerve root damage surrounding a sequestered lumbar disc fragment using a dog model. SUMMARY OF BACKGROUND DATA: Lumbar disc herniation is manifested in patients by variable clinical findings, natural history, and resorption phenomena in which the variability is particularly noted among patients with different ages. There are no previous reports on the effect of age on pathologic events induced by the herniated disc. METHODS: Six beagle dogs, including two animals of each age group of 6, 12, and 24 months (human equivalent ages of 10, 15, and 24 years), were used in this study. The dogs underwent L4-L5, L5-L6, and L6-L7 laminotomy and discectomy under general anesthesia. An autologous intervertebral disc from the tail was divided into anulus fibrosus and nucleus pulposus fragments. The anulus fibrosus and nucleus pulposus fragments were placed in the anterolateral epidural space of L5-L6 and L6-L7, respectively. The L4-L5 discectomy site served as a control. Dogs were killed at 12 weeks after surgery. The lumbar spine was removed en bloc, and histologic sections were prepared consecutively and examined. RESULTS: In the nucleus pulposus group at L6-L7, neovascularity, and intensive infiltration of lymphocytes, macrophages, and fibroblasts were observed surrounding the nucleus pulposus fragment in the 24-month-old group only. Degenerative changes of the nerve root fibers were observed in the 24-month-old group only. In the control and anulus fibrosus groups at L4-L5 and L5-L6, there were no marked inflammatory reactions in all age groups. The nerve root fibers around the anulus fibrosus were normal in all age groups. CONCLUSIONS: There is an effect of age on the inflammatory response and nerve root injury caused by the herniated disc. The apparent neuroprotective mechanism in the young animal, and the apparent inflammatory and resorption changes of the nucleus pulposus fragment in the older animal are quite intriguing.     

Comparison of neuropathic pain induced by the application of normal and mechanically compressed nucleus pulposus to lumbar nerve roots in the rat.

We studied whether applying nucleus pulposus tissue, obtained from tail intervertebral discs that had been subjected to chronic mechanical compression, to the lumbar nerve roots produces hyperalgesia, which is thought to be a pain-related behavior in the rat. An Ilizarov-type apparatus was used for immobilization and chronically applied compression of the rat tail for eight weeks. Three weeks after application of extracted nucleus pulposus tissue on the lumbar nerve roots, motor function, sensitivity to noxious mechanical stimuli was measured. Eight weeks after application of the apparatus, the instrumented vertebrae were resected and sections were stained with hematoxylin and eosin to evaluate degeneration of the intervertebral disc. Mechanical hyperalgesia observed in rats treated with the compressed nucleus pulposus tissue was greater and of longer duration than in the rats treated with normal and non-compressed discs. The nucleus pulposus in the instrumented vertebrae showed some histological degeneration. In conclusion, chronic mechanical compression of nucleus pulposus, which resulted in degeneration to some extent, enhanced mechanical hyperalgesia, which was induced by application of nucleus pulposus on the nerve root in the rat. Degenerative intervertebral discs might induce more significant pain than normal intervertebral discs.