椎间盘—终板退变与退变性腰椎侧凸骨性结构参数的相关性研究
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摘要
目的:退变性腰椎侧凸发病原因复杂,病程相对较长,呈渐进性发展,在疾病发展的不同阶段对人体造成不同程度和不同形式的不可逆性损害,可以表现为椎间隙不匀称性变窄,椎体楔形变,关节突关节方向不对称等一系列不对称的骨性结构形态学改变。这种不对称骨性结构改变一方面是腰椎侧凸引起力学负荷的不对称分布所导致的继发性改变,是腰椎侧凸程度的一个指标;另一方面也影响或加重腰椎侧凸的进展。目前对于骨性结构的不对称改变与退变性腰椎侧凸的关系研究较少,而且多数的研究主要集中在椎间盘退变与退变性腰椎侧凸的关系上,认为退变性腰椎侧凸与椎间盘的退变关系密切,但椎间盘退变导致腰椎侧凸的机制和过程至今仍不清楚。并且,以往关于椎间盘退变与退变性腰椎侧凸的研究大多忽略了终板的退变。椎间盘和终板在结构和功能上是密不可分的,椎间盘退变与终板退变互为影响。从结构上讲,椎体终板中的软骨终板部分作为椎间盘组成的一部分在椎间盘的结构和功能上发挥了重要的作用;而椎体终板中的骨性终板部分作为椎体的一部分起着连接相邻椎间盘的作用,而且也是椎间盘营养的通路。可见,终板退变可能更容易造成椎间隙和椎体的骨性结构的形态学改变,本研究将椎间盘和终板视为一个功能整体,探讨其退变程度与退变性腰椎侧凸患者骨性结构参数的相关性,分析不对称骨性结构参数与腰椎侧凸角和腰椎前凸角的关系,旨在揭示椎间盘-终板退变和不对称骨性结构参数在退变性腰椎侧凸的发生、发展中的重要作用,为退变性腰椎侧凸的预防和治疗提供理论依据。
方法:回顾分析2008年12月-2010年12月经我院诊治的原发性退变性腰椎侧凸的120例病例组患者的影像学资料,男47例,女73例;年龄50～77岁,平均61.5岁。选取同时期、同年龄段及同性别比诊断为腰椎退变性疾病并除外腰椎侧凸的89例对照组患者的影像学资料。所有患者均行腰椎X线、CT及MRI检查。病例组资料以主弯曲内椎体、椎间盘及邻近终板为观测对象,对照组以L1～L4椎体、椎间盘及邻近终板为观测对象。X线片分别测量各个椎体及椎间两侧高度,CT片测量各个椎体的两侧关节突关节面矢状角,分别计算椎体和椎间两侧平均高度及关节突平均矢状角作为骨性结构参数,两侧骨性结构参数均进行配对t检验比较,如两侧差异有统计学意义,其差值为不对称度,用不对称度描述骨性结构参数的不对称性。测量病例组患者的腰椎侧凸角及腰椎前凸角。采用评分法对各个椎间盘及邻近终板退变程度进行量化,其评分代表椎间盘-终板退变的程度。比较两组的骨性结构参数,分析骨性结构参数与椎间盘-终板退变、腰椎侧凸角及腰椎前凸角的关系。
结果:经t检验比较,病例组凹侧与凸侧各骨性结构参数有显著性差异(P<0.05),可用不对称度描述其不对称性;对照组两侧各骨性结构参数无显著性差异(P>0.05);对照组一侧与病例组凹侧骨性结构参数有显著性差异(P<0.05),与病例组凸侧无显著性差异(P>0.05);病例组与对照组椎间盘-终板退变评分有显著性差异(P<0.05)。相关性分析显示,椎间盘-终板退变与骨性结构参数不对称度有相关性(P<0.05),腰椎侧凸角与骨性结构参数不对称度呈正相关(0 结论:退变性腰椎侧凸椎间盘-终板退变程度较重,骨性结构参数呈不对称分布,其不对称度与椎间盘-终板的不对称退变相关;腰椎侧凸角随骨性结构参数不对称度的加重而进展,而前凸角度反而呈减小趋势,以椎间不对称度的影响更大;不对称骨性结构在退变性腰椎侧凸的发生、发展中起着重要的作用,可能是侧凸渐近性发展的生物力学因素,椎间盘-终板退变可能有病因学意义。
Objective: Degenerative lumbar scoliosis(DLS) had a complex cause, a relative longer course and resulted in some unsymmetry lesion in grandul advancement, including the inteval unsymmetry marrow, the vertebral wedge-shape and the unsymmetry direction of facet joint. This unsymmetry bony construction changes was not only the result of unsymmetry load resulted as DLS, but also was factor the advancement of DLS. the study of relation between unsymmetry bony change and DLS was less at present. In the study of relation between intervertebral disc degeneration and DLS, its close relation was knowed but its mechanism and process not knowed maybe because of the ignored endplate degeneration. The cartilage endplate of vertebral body was a part of intervertebral disc and played significant roles at construction and function. The bony endplate of vertebral body was a nutrient passage of intervertebral disc by connecting adjacent intevertebral disc. So the endplate degeneration easily resulted in the bony structural change of intervertebral place and vertebral body. In this study, the intervertebral disc and endplate regarded as a function entirety, to analyse the relationship of between unsymmetry bony structural parameter, lumbar scoliosis angle and lumbar lordosis angle. To disclose the role of intervertebral disc-endplate degeration and unsymmetry bony structural parameter in DSL, to provide some theory of prevention and treatment for DLS.
Method: The imaging data of 120 patients who diagnosed primary degenerative lumar scoliosis in our hospital from Dec. 2008 to Dec. 2010 ,including 47 male and 73 female aged 50～77 years old(average 61.5 years old) were retrospectively reviewed as the case group. The imaging data of 89 patients who diagnosed lumbar degenerative disease excluding lumbar scoliosis were selected as the control group . the two group meet same time period, same age period and same sex ratio, and all cases were performed X-ray, CT and MRI. The vertebral body, intervertebral disc and adjacent endplate of main curve in case group but L1～L4 in control group were selected as the observed object. The measurement of vertebral and intervertebral height of both sides on frontal X-ray, the measurement of facet joint sagittal angle of both sides on CT were performed. The vertebral average height, intervertebral average height and facet average sagittal angle of both sides were regarded as bony structural parameter to undertake pairiong t-test, if the difference of both sides had statistical significance, the difference value of both sides was described as the asymmetry degree. The lumbar scoliosis angle and lumbar lordosis angle were measured in case group. The quantitative grading methods were used in the intervertebral disc and endplate degeneration, and the scoring was conincident with its degeneration degree. The correlation between intervetebral disc-endplate degeneration and asymmetric bony structural parameter, the relationship of asymmetric bony structural parameter, lumbar scoliosis angle and lumbar lordosis angle were analyzed through the comparision of bony structural parameter between the case group and the control group.
Result: by t test, the difference of bony sturctural parameter between convex and concave side in case group had statistical significance(P<0.05), but in control group that of both sides had no statistical significance(P>0.05).The difference of body sturctural parameter between one side in control group and convex side in case group had no statistical significance(P>0.05), but the difference between one side in control group and concave side in the case group had statistical significance(P<0.05). By correlative analysis, the scoring of intervertebral disc-endplate degeneration had good correlativity with each of bony sturctural parameter(P<0.05). The asymmetric bony sturctural parameter showed positive correlation with the lumbar scoliosis angle(0 Conclusion: The intensity of intervertebral disc-endplate degeneration was more severe in degenerative lumbar scoliosis and the bony structural parameter showed asymmetric feature which significantly correlated with asymmetric intervertebral disc-endplate degeneration. Lumbar scoliosis angle advanced with aggravation of bony structural asymmetric degree, but lumbar lordosis angle decreased instead. The asymmetric bony construction maybe played a biomechanical force role in the grandul advancement of lumbar scoliosis, so all reasoned probably for asymmetric degeneration of intervertebral disc-endplate.
方法:回顾分析2008年12月-2010年12月经我院诊治的原发性退变性腰椎侧凸的120例病例组患者的影像学资料,男47例,女73例;年龄50～77岁,平均61.5岁。选取同时期、同年龄段及同性别比诊断为腰椎退变性疾病并除外腰椎侧凸的89例对照组患者的影像学资料。所有患者均行腰椎X线、CT及MRI检查。病例组资料以主弯曲内椎体、椎间盘及邻近终板为观测对象,对照组以L1～L4椎体、椎间盘及邻近终板为观测对象。X线片分别测量各个椎体及椎间两侧高度,CT片测量各个椎体的两侧关节突关节面矢状角,分别计算椎体和椎间两侧平均高度及关节突平均矢状角作为骨性结构参数,两侧骨性结构参数均进行配对t检验比较,如两侧差异有统计学意义,其差值为不对称度,用不对称度描述骨性结构参数的不对称性。测量病例组患者的腰椎侧凸角及腰椎前凸角。采用评分法对各个椎间盘及邻近终板退变程度进行量化,其评分代表椎间盘-终板退变的程度。比较两组的骨性结构参数,分析骨性结构参数与椎间盘-终板退变、腰椎侧凸角及腰椎前凸角的关系。
结果:经t检验比较,病例组凹侧与凸侧各骨性结构参数有显著性差异(P<0.05),可用不对称度描述其不对称性;对照组两侧各骨性结构参数无显著性差异(P>0.05);对照组一侧与病例组凹侧骨性结构参数有显著性差异(P<0.05),与病例组凸侧无显著性差异(P>0.05);病例组与对照组椎间盘-终板退变评分有显著性差异(P<0.05)。相关性分析显示,椎间盘-终板退变与骨性结构参数不对称度有相关性(P<0.05),腰椎侧凸角与骨性结构参数不对称度呈正相关(0
Objective: Degenerative lumbar scoliosis(DLS) had a complex cause, a relative longer course and resulted in some unsymmetry lesion in grandul advancement, including the inteval unsymmetry marrow, the vertebral wedge-shape and the unsymmetry direction of facet joint. This unsymmetry bony construction changes was not only the result of unsymmetry load resulted as DLS, but also was factor the advancement of DLS. the study of relation between unsymmetry bony change and DLS was less at present. In the study of relation between intervertebral disc degeneration and DLS, its close relation was knowed but its mechanism and process not knowed maybe because of the ignored endplate degeneration. The cartilage endplate of vertebral body was a part of intervertebral disc and played significant roles at construction and function. The bony endplate of vertebral body was a nutrient passage of intervertebral disc by connecting adjacent intevertebral disc. So the endplate degeneration easily resulted in the bony structural change of intervertebral place and vertebral body. In this study, the intervertebral disc and endplate regarded as a function entirety, to analyse the relationship of between unsymmetry bony structural parameter, lumbar scoliosis angle and lumbar lordosis angle. To disclose the role of intervertebral disc-endplate degeration and unsymmetry bony structural parameter in DSL, to provide some theory of prevention and treatment for DLS.
Method: The imaging data of 120 patients who diagnosed primary degenerative lumar scoliosis in our hospital from Dec. 2008 to Dec. 2010 ,including 47 male and 73 female aged 50～77 years old(average 61.5 years old) were retrospectively reviewed as the case group. The imaging data of 89 patients who diagnosed lumbar degenerative disease excluding lumbar scoliosis were selected as the control group . the two group meet same time period, same age period and same sex ratio, and all cases were performed X-ray, CT and MRI. The vertebral body, intervertebral disc and adjacent endplate of main curve in case group but L1～L4 in control group were selected as the observed object. The measurement of vertebral and intervertebral height of both sides on frontal X-ray, the measurement of facet joint sagittal angle of both sides on CT were performed. The vertebral average height, intervertebral average height and facet average sagittal angle of both sides were regarded as bony structural parameter to undertake pairiong t-test, if the difference of both sides had statistical significance, the difference value of both sides was described as the asymmetry degree. The lumbar scoliosis angle and lumbar lordosis angle were measured in case group. The quantitative grading methods were used in the intervertebral disc and endplate degeneration, and the scoring was conincident with its degeneration degree. The correlation between intervetebral disc-endplate degeneration and asymmetric bony structural parameter, the relationship of asymmetric bony structural parameter, lumbar scoliosis angle and lumbar lordosis angle were analyzed through the comparision of bony structural parameter between the case group and the control group.
Result: by t test, the difference of bony sturctural parameter between convex and concave side in case group had statistical significance(P<0.05), but in control group that of both sides had no statistical significance(P>0.05).The difference of body sturctural parameter between one side in control group and convex side in case group had no statistical significance(P>0.05), but the difference between one side in control group and concave side in the case group had statistical significance(P<0.05). By correlative analysis, the scoring of intervertebral disc-endplate degeneration had good correlativity with each of bony sturctural parameter(P<0.05). The asymmetric bony sturctural parameter showed positive correlation with the lumbar scoliosis angle(0
引文
1 Ploumis A,Transfledt E E, Denis F. Degenerative lumbar scoliosis associated with spinal stenosis. Spine,2007,7:428-436
2 Kobayashi T,Atsuta Y, Takemitsu M, et al.A prospective study of de novo scoliosis in a community based cohort. Spine,2006,31:178-182
3 Faldini C, Pagkrati S, Grandi G. Degenerative lunbar scoliosis: features and surgical treatment. J Orthp Traumatol,2006,7:67-71
4 Modic MT,Steinberg PM,Ross JS,et al.Degenerative disk disease:assessment of changes in vertebral body marrow with MR imaging.Radiology,1988,166:193-199
5 Kokkonen SM, Kurunlahti M, Tervonen O, et al. Endplate degenerationobserved on magnetic resonance imaging of the lumbar spine: correlation with pain provocation and disc changes observed on computed tomography discography. Spine,2002,27:2274-2278
6 Christian WA, Alexander M, Marco Z, et al. Magnetic resonance classification of lumbar intervertebral disc degeneration. Spine, 2001,26:1873-1878
7 Haschtmann D, Stoyanov J, Gedet P, et al, Vertebral endplate trauma induces disc cell apotosis and promotes organ degeneration in vitro. Eur Spine, 2008,17:289-299
8 Ayotte DC, Ito K, Perren SM, et al, Direction-dependent constriction flow in a poroelastic solid: the intervertebral disc valve. Biomech Eng. 2000,122:587-593
9 Brinckmann P, Frobin W, Hierholzer E, et al. Deformation of the vertebral end-plate under axial laoding of the spine. Spine 1983,8:851-856
10 Holmes AD, Hukins DWL, Freemont AJ. End-plate displacement during compression of lumbar vertebra-disc-vertebra segments and the mechanism of failure. Spine, 1993,18:128-135
11 Benner B, Ehni G.. Degenerative lumbar scoliosis. Spine,1979,4:548-552
12 Fujiwara A, Tamai K, An HS, et al. Orientation and osteoarthritis of the lumbar facet joint. Clin Orthop Relat Res, 2001,385:88-94
13 Schwab FJ, Smith VA, Biserni M, et al. Spine, 2002;27:387-392
14 Tribus CB. Degenerative lumbar scoliosis: evaluation and management. J Am Acad Orthop Surg, 2003,11:174-183
15 Daffner SD, Vaccaro AR. Adult degenerative lumbar scoliosis. Am J Orthop, 2003,32:77-82
16 Murata Y, Takahashi K, Hanaoka E, et al. Changes in scoliotic curvature and lordotic angle during the early phase of degenerative lumbar scoliosis. Spine,2002,27:2268-2273
17刘伟,贾连顺,陈雄生等.退变性腰椎侧凸的临床特点及外科治疗[J].中华骨科杂志,2007,27(11):808-813.
1 Sengupta DK,Herkowitz HN. Lumbar spinal stenosis: treatment strategies and indications for surgery .Orthop Clin North AM,2003,34(2):281-295
2 Vanderpool DW, James JI, Wynne- Davies R. Scoliosis in the elderly. Bone Joint Surg Am,1969,51(3):446-455
3 Pritchett JW, Bortel DT. Degenerative symptomatic lumbar scoliosis. Spine,1993, 18(6):700-703
4 Murata Y, Takahashi K, Hanaoka E, et al. Changes in scoliotic curvature and lordotic angle during the early phase of degenerative lumbar scoliosis.Spine, 2002, 27( 20) : 2268-2273
5 Sengupta DK,Herkowitz HN. Lumbar spinal stenosis: treatment strategies and indications for surgery .Orthop Clin North AM,2003,34(2):281-295
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7 Benner B, Ehni G. Degenerative lumbar scoliosis. Spine,1979,4(6):548-552
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10 Brinckmann P, Frobin W, Hierholzer E, et al. Deformation of the vertebral end-plate under axial laoding of the spine. Spine 1983,8:851-856
11 Holmes AD, Hukins DWL, Freemont AJ. End-plate displacement during compression of lumbar vertebra-disc-vertebra segments and the mechanism of failure. Spine, 1993;18:128-135
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14 Fujiwara A, Tamai K, An HS, et al. Orientation and osteoarthritis of the lumbar facet joint. Clin Orthop Relat Res, 2001,385:88-94
15 Faldini C, Pagkrati S, Grandi G, et al.Degenerative lumbar scoliosis:features and surgical treatment .J Orthop Traumatol, 2006, 7( 2) : 67-71
16 Kobayashi T, Atsuta Y, Takemitsu M, et al.A prospective study of de novo scoliosis in a community basedcohort .Spine,2006, 31(2):178- 182
17 Daffner SD, Vaccaro AR. Adult degenerative lumbar scoliosis. Am J Orthop,2003,32(2):77-82
18 Murata Y, Takahashi K, Hanaoka E, et al. Changes in scoliotic curvature and lordotic angle during the early phase of degenerative lumbar scoliosis.Spine, 2002,27(20): 2268-2273
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32 Sears W. Posterior Lumbar interbody fusion for degenerative spondylolisthesis: restoration of sagittal balance using insert-and-rotateinterbody spacers. The Spine Journal,2005,5:170-179
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2 Kobayashi T,Atsuta Y, Takemitsu M, et al.A prospective study of de novo scoliosis in a community based cohort. Spine,2006,31:178-182
3 Faldini C, Pagkrati S, Grandi G. Degenerative lunbar scoliosis: features and surgical treatment. J Orthp Traumatol,2006,7:67-71
4 Modic MT,Steinberg PM,Ross JS,et al.Degenerative disk disease:assessment of changes in vertebral body marrow with MR imaging.Radiology,1988,166:193-199
5 Kokkonen SM, Kurunlahti M, Tervonen O, et al. Endplate degenerationobserved on magnetic resonance imaging of the lumbar spine: correlation with pain provocation and disc changes observed on computed tomography discography. Spine,2002,27:2274-2278
6 Christian WA, Alexander M, Marco Z, et al. Magnetic resonance classification of lumbar intervertebral disc degeneration. Spine, 2001,26:1873-1878
7 Haschtmann D, Stoyanov J, Gedet P, et al, Vertebral endplate trauma induces disc cell apotosis and promotes organ degeneration in vitro. Eur Spine, 2008,17:289-299
8 Ayotte DC, Ito K, Perren SM, et al, Direction-dependent constriction flow in a poroelastic solid: the intervertebral disc valve. Biomech Eng. 2000,122:587-593
9 Brinckmann P, Frobin W, Hierholzer E, et al. Deformation of the vertebral end-plate under axial laoding of the spine. Spine 1983,8:851-856
10 Holmes AD, Hukins DWL, Freemont AJ. End-plate displacement during compression of lumbar vertebra-disc-vertebra segments and the mechanism of failure. Spine, 1993,18:128-135
11 Benner B, Ehni G.. Degenerative lumbar scoliosis. Spine,1979,4:548-552
12 Fujiwara A, Tamai K, An HS, et al. Orientation and osteoarthritis of the lumbar facet joint. Clin Orthop Relat Res, 2001,385:88-94
13 Schwab FJ, Smith VA, Biserni M, et al. Spine, 2002;27:387-392
14 Tribus CB. Degenerative lumbar scoliosis: evaluation and management. J Am Acad Orthop Surg, 2003,11:174-183
15 Daffner SD, Vaccaro AR. Adult degenerative lumbar scoliosis. Am J Orthop, 2003,32:77-82
16 Murata Y, Takahashi K, Hanaoka E, et al. Changes in scoliotic curvature and lordotic angle during the early phase of degenerative lumbar scoliosis. Spine,2002,27:2268-2273
17刘伟,贾连顺,陈雄生等.退变性腰椎侧凸的临床特点及外科治疗[J].中华骨科杂志,2007,27(11):808-813.
1 Sengupta DK,Herkowitz HN. Lumbar spinal stenosis: treatment strategies and indications for surgery .Orthop Clin North AM,2003,34(2):281-295
2 Vanderpool DW, James JI, Wynne- Davies R. Scoliosis in the elderly. Bone Joint Surg Am,1969,51(3):446-455
3 Pritchett JW, Bortel DT. Degenerative symptomatic lumbar scoliosis. Spine,1993, 18(6):700-703
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