腰椎间盘突出症疗效不佳的临床观察

目的 分析腰椎间盘突出症手术疗效不佳的原因，探讨提高疗效的方法。方法 随访本院1993-2003年腰椎间盘突出症行后路髓核摘除术病例236例，对术后腰腿痛症状未缓解或症状消失后再复发者复查X片、CT或MRI了解病因。结果手术疗效不佳者25例。疗效不佳的主要原因为残留髓核再突出、术后脊柱不稳倾向增加、对侧隐窝狭窄认识不足、神经根损伤、极外侧型椎问盘突出漏切、感染、术后椎管内瘢痕黏连等。全椎板切除术较椎板问开窗术更易发生椎管内瘢痕黏连（P＜0．01）。结论首次手术时应尽可能取净髓核组织，对动力位摄片发现有椎问不稳倾向者行后外侧植骨或椎体问植骨融合，常规探查并妥善处理侧隐窝，牵拉神经根时间不应过长且用力轻柔。行腰椎间盘CT和MRI扫描时，应注意包括椎间盘相邻上下椎体的1／3部，以防止遗漏极外侧型椎问盘突出，尽量采用椎板间开窗术式以减少脊柱创伤，术中间断冲洗，术毕持续负压引流，以减少术后黏连，术中应严格无菌操作。     

CT引导下胶原酶注射颈椎间盘溶解术的临床研究

目的:研究CT引导下胶原酶注射颈椎间盘溶解术治疗颈椎间盘突出症的价值。方法:对15例颈椎间盘突出症患者在CT引导下行胶原酶注射颈椎间盘溶解术。结果:15例均成功,随访1~16个月,优良率93.3%,未见并发症发生。结论:CT引导下行胶原酶注射颈椎间盘溶解术治疗颈椎间盘突出症安全有效,值得进一步研究。     

椎管扩大成形术治疗腰椎管狭窄

目的：探讨椎管扩大成形术治疗腰椎管狭窄的效果。方法：椎板减压后复位，用棘突或髂骨植于一侧开槽处扩大椎管，并进行椎板及关节突关节植骨，对54例随访病人的手术前后临床表现及X线和CT进行比较。结果：随访6—39个月，临床优良率为81．1％。随访X线片显示椎板明显后移，CT测量与术前对比显示椎管内径扩大明显。结论：椎管扩大成形术操作简单，效果满意，术后并发症少，是治疗腰椎管狭窄的又一选择。     

Detailed pathological changes of human lumbar facet joints L1–L5 in elderly individuals

Facet joints play an important role in intervertebral load transmission and are crucial for rotational kinematics. Clinically, the role of facet joints as a possible source of low back pain is seen as controversial and at present is not sufficiently investigated. In this study, human lumbar facet (zygapopyhysial) joints from donors with advanced age were analyzed macroscopically, for degenerative changes. The aim was to determine the extent and morphology of degenerative changes in these joints. Lumbar facet joints (L1–L5) of 32 donors were studied (mean age 80.1±11.2 years). Joint capsules were carefully removed and joint surfaces (5 zones) examined using magnifying glasses and probes. In the result, the majority of facet joints showed cartilage defects of varying extent. Defects were located mostly at the margins of the articular surface, the central zone being relatively well preserved. Defect localization was different between superior (most cartilage defects in superior zone) and inferior (most defects inferiorly) facets. Further, defects were more severe caudal (level of L5) and in older persons. Osteophytes were present in up to 30%, located mostly at the latero-dorsal enthesis of the joint capsule on the superior facet. In conclusion, most margins of the articular facets are subject to degenerative changes in the lumbar spine of elderly persons, the topographical pattern being different in superior and inferior facets. This observation can be explained by the segmental motion patterns during extension/flexion movements of the facets. Sometimes, due to the marginal extension, it is obvious that not all changes can be assessed by CT or MRI.     

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.     

The value of a pantaloon cast test in surgical decision making for chronic low back pain patients: a systematic review of the literature supplemented with a prospective cohort study

The results of lumbar fusion in chronic low back pain (LBP) patients vary considerably, and there is a need for proper patient selection. Lumbosacral orthoses have been widely used to predict outcome, however, with little scientific support. The aim of the present study was to determine the value of a pantaloon cast test in selecting chronic LBP patients for lumbar fusion or conservative management. First, a systematic review of the literature was carried out in which two independent reviewers identified studies in Medline, Cochrane and Current Contents databases. Three papers met the selection criteria. In the only study with a control group, a significantly better outcome after fusion compared to conservative treatment was found in patients who reported significant pain relief while in a cast (i.e. a positive cast test). The results of lumbar fusion, however, were not significantly different for patients with a positive and those with a negative cast test. In addition to the review, a clinical cohort study of 257 LBP patients, who had been allocated to either lumbar fusion or conservative management by a temporary external transpedicular fixation trial, was performed. Prior to allocation, all had undergone a pantaloon cast test. Patients with no history of prior spine surgery and with a positive pantaloon cast test had a better outcome after lumbar fusion than those treated conservatively (P = 0.002, χ ² test). In patients with previous spine operations the outcomes were poor and the test was of no value. From the literature and the present patient cohort, it was concluded that only in chronic LBP patients without prior spine surgery, a pantaloon cast test with substantial pain relief suggests a favorable outcome of lumbar fusion compared to conservative management. The test has no value in patients who have had previous spine surgery.     

Is herniography useful?

Herniography has been used for 25 years in the diagnosis of occult herniation but has not gained widespread acceptance in the UK, despite studies confirming its high sensitivity and specificity for occult hernias and an excellent record of safety and patient acceptability. The traditional approach in the UK to suspected occult groin herniation has been surgical exploration. This study examined the use of herniography in a single district general hospital to assess its impact in limiting unnecessary groin explorations and allowing discharge of patients without hernias. The case notes of 90 successive patients referred for herniography by the department of general surgery in a single UK district general hospital over an 18-month period were reviewed. Eighty-seven completed examinations were analysed in which 23 hernias were diagnosed in 20 patients. Thirteen patients have undergone hernia repair with resolution of symptoms. There were no false positive examinations, although two inguinal hernias were incorrectly diagnosed radiologically as femoral hernias; there were two false negative examinations where additional hernias were found at laparoscopic repair. There were no reported complications. Twenty-four patients were discharged directly from the surgical clinic after a negative herniogram. Thirty patients were referred to other specialities. No patient had undergone groin exploration after a negative herniogram. Herniography is a useful tool in assessing obscure groin pain and potential occult herniation. It can reliably rule out the presence of a hernia and avoid the need for surgical exploration. Many patients with a negative herniogram can be reassured and discharged, whilst others may be referred on to other specialities safe in the knowledge that an occult hernia has been excluded.     

Sciatic Neuropathy: Case Report and Discussion of the Literature on Postoperative Sciatic Neuropathy and Sciatic Nerve Tumors

Sciatic nerve injury and dysfunction is not an uncommon cause of lower extremity symptoms in a musculoskeletal practice. We present the case of a man who presented with lower extremity weakness, pain, and cramps, and was initially diagnosed at an outside institution with bilateral S1 radiculopathies and recommended for spine surgery. He came to us for a second opinion. Electrodiagnostic testing revealed an isolated sciatic neuropathy and the patient was referred for imaging, which showed a sciatic nerve sheath tumor. Review of the literature on sciatic neuropathies shows that there can be many possible etiologies of sciatic nerve dysfunction, but that hip arthroplasty continues to be the leading risk factor. Sciatic nerve tumors are not commonly described in the literature and their definitive management remains unclear.     

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。     

腹腔镜下切口疝补片修补术的临床应用

目的 探讨腹腔镜下腹壁切口疝修补术的手术方法、安全性等问题。方法对2004年3月至2006年5月79例行腹腔镜下补片修补术治疗腹壁切口疝病人的临床资料进行分析。结果 78例（98．7％）手术成功，1例因腹腔内广泛粘连而中转开放修补。平均手术时间为88min，平均术后住院4．6d，18例（22．8％）病人术中发现有1个以上的隐匿性缺损。术后并发症：术后短期内修补区腹壁明显疼痛58例（73．4％）。腹壁缝合点较长时间疼痛6例（7．6％），浆液肿14例（17．7％），无手术死亡，1例术后出现肠瘘，经保守治疗好转，1例腰部切口疝的病人术后复发。结论 多数病人腹壁切口疝可以经腹腔镜行粘连松解及补片修补术，并可在术中发现其他隐性缺损，手术安全性较高。对腹腔内广泛粘连而影响操作器械进入及粘连分离者，应及时中转开腹手术。