纤维环破裂所致腰腿痛的临床特点及其治疗

目的 探讨单纯纤维环破裂是否为导致腰腿痛的原因及其临床特点和治疗.方法 2001年5月至2008年10月,对34例经保守治疗无效、MRI和CT显示无腰椎间盘突出的腰腿痛患者行电生理和腰椎间盘造影检查,诱发一致性疼痛反应并证实为纤维环破裂者,选择局限性开窗减压、髓核清理术.男15例,女19例,年龄32～72岁,平均45.6岁.病程6～120个月,平均25.8个月.采用日本骨科学会(JOA)下腰痛评分系统(15分)评价手术前、后临床症状、体征及括约肌功能;手术前、后腰腿痛情况行视觉疼痛自我评定尺(VAS)评估.结果 临床主要表现为腰腿痛、跛行和根性损害.X线和CT扫描缺乏特征性.MRI T2WI相显示相应节段椎间盘呈低信号、"黑间盘"或纤维环后方高信号区.EMG提示神经根性损害27例,阳性率79.4%,腓总神经传导速度异常7例,胫神经传导速度异常3例.椎间盘造影34例,38个椎间盘诱发并产生准确的疼痛复制,造影术后CT扫描示造影剂弥散于椎间盘内并通过纤维环裂隙进入椎管.术后随访6～37个月,平均17.4个月.本组术前JOA评分为8.7分,术后为13.5分,恢复率为76.2%;其中优18例,良12例,中3例,差1例,优良率为88.2%.术前腰腿痛VAS评分8.6分,术后2.8分,改善率82.5%.结论 单纯纤维环破裂所致神经根炎性损害是引起腰腿痛的重要原因.MRI和EMG对其诊断具有提示作用,腰椎间盘造影术是目前诊断和选择外科手术治疗的主要依据.局限性开窗减压,髓核清理术是治疗纤维环破裂所致神经根炎性损害简单而有效的方法.

Clinical characteristics and treatment for patients with low back and leg pain caused by lumbar annular tears

Objective To investigate whether annular tears is a cause of low back and radiating leg pain and explore the clinical characteristics and treatment for patients with this condition.Methods A total of 34 patients with low back and radiating leg pain,but without lumbar disc herniation on CT (computed tomography) or MRI (magnetic resonance imaging),were examined by electrophysiological studies and discography to identify whether there were or not annular tears and nerve root injury and decipher the relations between them.The series included 15 males and 19 females with an average age of 45.6 years old and the average duration of symptoms was 25.8 months.All patients with annular tears and positive pain provocation test were treated by local windowing decompression and debridement of nucleus pulposus after failed conservative treatment.The pre- and post-operative functions and pain were evaluated by JOA (Japanese Orthopedic Association) and VAS (visual analog scale) scores respectively.The average followup was 17.4 months.Results The clinical manifestations included low back and radiating leg pain,intermittent claudication and nerve root injury.No significant abnormalities were discovered on X-ray and CT scan.T2W images of magnetic resonance demonstrated a low intensity or black disc in all patients and highintensity zone (HIZ) (n = 21).Electromyography showed nerve root injury (n = 27).Abnormality of conduction velocities of common peroneal nerve (n = 7) and tibial nerve (n = 3) were found.Thirty-four patients with 38 discs displayed pain reproduction on contrast injection during discography and the sites of annular tears were confirmed on CT scan after discography.Pre- and post-operative average JOA scale score was 8.7 points and 13.5 points,the recovery ratio 76.2% and the excellent and good outcomes 88.2%.Pre-and post-operative average VAS score was 8.6 points and 2.8 points.And the recovery rate was 80.5%.Conclusion The annular tears result in low back and radiating leg pain.And the typical characteristics are low back and radiating leg pain,intermittent claudication and nerve root injury.MRI and electrophysiological studies play an important role in diagnosing this condition.Lumbar discography is the decisive method and prerequisite of selecting surgery.Local windowing decompression and debridement of nucleus pulposus is a simple and effective method.