腰椎间盘突出症及其突出时间的法医学研究
摘要
目的
腰椎间盘突出是一种常见病，也常见于外伤后。在法医实践中，由于被鉴定人的特殊心理作用，常常隐瞒曾经患过腰椎间盘突出的事实，给法医学鉴定工作带来困难。准确认定腰椎间盘突出时间尤为重要。本研究拟对已知不同突出时间的腰椎间盘突出患者进行询问病史、体格检查和磁共振扫描，记录临床表现、突出时间、突出髓核及同层间盘的信号强度、突出髓核大小、突出间盘厚度、有无神经根受压、有无黄韧带肥厚、突出间盘变性程度、突出类型等指标，观察突出时间不同的腰椎间盘的临床表现及磁共振表现特点，寻找与腰椎间盘突出时间相关的指标，并根据临床表现及磁共振所见初步判断腰椎间盘突出的时间。
方法
对已知不同突出时间的腰椎间盘突出患者进行询问病史、体格检查和磁共振扫描，记录患者临床表现、突出时间、突出髓核及同层间盘的信号强度、突出髓核大小、突出间盘厚度、有无神经根受压、有无黄韧带肥厚、突出间盘变性程度、突出类型等指标。将病例分组，突出时间小于2个月的病例为一组，突出时间大于4个月的病例为一组。用SPSS11.0对下列项目进行统计分析：
1．比较两组病例临床表现的差异。
2．比较两组病例MRI表现的差异。
(1)作突出时间与突出髓核信号强度百分改变、突出髓核的大小、突出间盘厚度的相关分析。
(2)两组间突出髓核信号强度百分改变、突出髓核大小、突出
间盘厚度均值的比较。
(3)两组间神经根受压、黄韧带肥厚、突出间盘变性程度、突
出间盘类型之间的比较。
结果
1.两组病例临床表现的统计分析结果:
(l)两组间的下列指标差别有统计学意义:腰椎活动受限、直
腿抬高试验阳性、跟健反射减弱、肌力下降。在突出时间小于2个
月组腰椎活动受限阳性率及直腿抬高试验阳性率均高。在突出时
间大于4个月组跟胜反射减弱阳性率及肌力下降阳性率均高。
(2)两组间的下列指标差别无统计学意义:坐骨神经痛、脊柱
侧弯、腰椎压痛、感觉异常。
(3)突出时间小于2个月组所有病例均有腰疼，均无排尿功
能障碍。突出时间大于4个月组35例有腰疼，占87.5%，3例有
排尿功能障碍，占7.5%。
2.两组病例MRI表现的统计分析结果:
(1)突出时间与突出髓核信号强度百分改变(r二0.912，P<
0.01)相关，与突出髓核大小(r二0.243，P>0.05)、突出间盘厚度
(r二0.130，P>0.05)均不相关。
(2)两组间突出髓核信号强度百分改变有显著性差异(p<0.
01)，突出时间小于2个月组突出髓核信号强度百分改变小于突出
时间大于6个月组。
(3)两组间在有无神经根受压上有差别(p<0.01)，突出时间
小于2个月组神经根受压阳性率高。在突出时间小于2个月组没
有见到黄韧带肥厚病例。在突出时间大于4个月组6例有黄韧带
肥厚，占15%。在突出间盘变性程度、突出间盘类型上两组之间
差别均无显著性意义。
结论
1.腰椎间盘突出的时间与临床表现有关。
2.腰椎间盘突出的时间与突出位核信号强度百分改变、有无
神经根受压、有无黄韧带肥厚有关。
3.腰椎间盘突出的时间与突出髓核大小、突出间盘厚度、突出
间盘变性程度、突出类型无关。
_4.磁共振表现可以初步判定腰椎间盘突出的时间，可以应用
于法医鉴定的实际工作中。
Objectives
Lumber intervertebral discs protrusion has a high incidence rate. It can be caused by injury. The person concerned often hide the truth of the history of lumber intervertebral discs protrusion and become a handicap of forensic medicine evaluation. To identification when lumber intervertebral discs protrusion happen and how it happen is more and more important and urgentent. we will study clinical situation and MRI of lumber intervertebral discs protrusion , recording percentage changes of MRI signal intensity and other image characteristic. We will study MRI signal intensity of protruded nucleus pulposus , the size of protruded nucleus pulposus , discs hight, neural root compression degree ,thicken ligamenta flava ,discs degeneration degree, protrusion type and their relation with incident time.
Methods
Divide the 70 pations into two groups: less than 2 monthes is one group, exceed 4 monthes is other group, record the evalue of MRI signal intensity the size of protruded nucleus pulposus , protrusion type, discs hight,dies degeneration degree, neural root compression degree thicken fligamenta flava. Do statistic analysis with SPSS11.0.
1. Contrast the clinical situation between the two groups.
2. Contrast the MRI between the two groups.
(1) Do the correction analy between incident time and below entry: MRI signal intensity of protruded nucleus pulposus , the size of protroed nucleus pulposus ,the discs hight.
(2)Do t - test between the two groups in the below entry: MRI signal intensity of protruded nucleus pulposus , the size of protruded nucleus pulposus ,the discs hight.
(3)Do x2 - test between the two groups about the below entry: degeneration degree,neural root compression degree ,thicken ligamen-ta flava ,the type of the protrusion.
Result
1. The clinical situation difference between the two groups:
(1) Between the two groups has a sharp difference in the positive of straight raise leg test, tendon reflect weaken and muscle strength weaken, the group of less than 2 monthes has a high positive rate in straight raise leg test. The group of exceed 4 monthes has a high positive rate in tendon reflect weaken and muscle strength weaken.
(2) there is no difference between the two groups in the positive of sciatica, spine curvature, lumber spine tenderness, sensation abnormality.
(3) All cases of less than 2 monthes has lumbag and hasnt mic-tion abnormality.
2. The MRI difference between the two groups;
(1) there is correlation between incident time and MRI signal intensity of protruded nucleus pulposus . There is no correlation between incident time and the size of protruded nucleus pulposus , protrusion
discs hight, totle sum of degenerate discs.
(2) Between the two groups has a sharp difference in the MRI signal intensity of protruded nucleus pulposus . the group of less than 2 monthes has a lower evalue than the group of exceed 4 monthes . There is less significant between the two groups in the totle sum of degenerate discs.
(3)Between the two groups has a sharp difference in the neural root compression degree , thicken ligamenta flava . The group of less than 2 monthes has a high positive rate in neural root compression , thicken ligamenta flava . There is no correlation between the two groups in degeneration degree.
Conclusion
1. there is correlation between incident time and clinical situation.
2. there is correlation between incident time and MRI signal intensity of protruded nucleus pulposus .
3. There is no correlation between incident time and the size of protruded nucleus pulposus , protruded discs hight.
4. MRI will mae a role in identifying the range of incident time of lumber intervertebral discs protrusion in clinical forensic.
腰椎间盘突出是一种常见病，也常见于外伤后。在法医实践中，由于被鉴定人的特殊心理作用，常常隐瞒曾经患过腰椎间盘突出的事实，给法医学鉴定工作带来困难。准确认定腰椎间盘突出时间尤为重要。本研究拟对已知不同突出时间的腰椎间盘突出患者进行询问病史、体格检查和磁共振扫描，记录临床表现、突出时间、突出髓核及同层间盘的信号强度、突出髓核大小、突出间盘厚度、有无神经根受压、有无黄韧带肥厚、突出间盘变性程度、突出类型等指标，观察突出时间不同的腰椎间盘的临床表现及磁共振表现特点，寻找与腰椎间盘突出时间相关的指标，并根据临床表现及磁共振所见初步判断腰椎间盘突出的时间。
方法
对已知不同突出时间的腰椎间盘突出患者进行询问病史、体格检查和磁共振扫描，记录患者临床表现、突出时间、突出髓核及同层间盘的信号强度、突出髓核大小、突出间盘厚度、有无神经根受压、有无黄韧带肥厚、突出间盘变性程度、突出类型等指标。将病例分组，突出时间小于2个月的病例为一组，突出时间大于4个月的病例为一组。用SPSS11.0对下列项目进行统计分析：
1．比较两组病例临床表现的差异。
2．比较两组病例MRI表现的差异。
(1)作突出时间与突出髓核信号强度百分改变、突出髓核的大小、突出间盘厚度的相关分析。
(2)两组间突出髓核信号强度百分改变、突出髓核大小、突出
间盘厚度均值的比较。
(3)两组间神经根受压、黄韧带肥厚、突出间盘变性程度、突
出间盘类型之间的比较。
结果
1.两组病例临床表现的统计分析结果:
(l)两组间的下列指标差别有统计学意义:腰椎活动受限、直
腿抬高试验阳性、跟健反射减弱、肌力下降。在突出时间小于2个
月组腰椎活动受限阳性率及直腿抬高试验阳性率均高。在突出时
间大于4个月组跟胜反射减弱阳性率及肌力下降阳性率均高。
(2)两组间的下列指标差别无统计学意义:坐骨神经痛、脊柱
侧弯、腰椎压痛、感觉异常。
(3)突出时间小于2个月组所有病例均有腰疼，均无排尿功
能障碍。突出时间大于4个月组35例有腰疼，占87.5%，3例有
排尿功能障碍，占7.5%。
2.两组病例MRI表现的统计分析结果:
(1)突出时间与突出髓核信号强度百分改变(r二0.912，P<
0.01)相关，与突出髓核大小(r二0.243，P>0.05)、突出间盘厚度
(r二0.130，P>0.05)均不相关。
(2)两组间突出髓核信号强度百分改变有显著性差异(p<0.
01)，突出时间小于2个月组突出髓核信号强度百分改变小于突出
时间大于6个月组。
(3)两组间在有无神经根受压上有差别(p<0.01)，突出时间
小于2个月组神经根受压阳性率高。在突出时间小于2个月组没
有见到黄韧带肥厚病例。在突出时间大于4个月组6例有黄韧带
肥厚，占15%。在突出间盘变性程度、突出间盘类型上两组之间
差别均无显著性意义。
结论
1.腰椎间盘突出的时间与临床表现有关。
2.腰椎间盘突出的时间与突出位核信号强度百分改变、有无
神经根受压、有无黄韧带肥厚有关。
3.腰椎间盘突出的时间与突出髓核大小、突出间盘厚度、突出
间盘变性程度、突出类型无关。
_4.磁共振表现可以初步判定腰椎间盘突出的时间，可以应用
于法医鉴定的实际工作中。
Objectives
Lumber intervertebral discs protrusion has a high incidence rate. It can be caused by injury. The person concerned often hide the truth of the history of lumber intervertebral discs protrusion and become a handicap of forensic medicine evaluation. To identification when lumber intervertebral discs protrusion happen and how it happen is more and more important and urgentent. we will study clinical situation and MRI of lumber intervertebral discs protrusion , recording percentage changes of MRI signal intensity and other image characteristic. We will study MRI signal intensity of protruded nucleus pulposus , the size of protruded nucleus pulposus , discs hight, neural root compression degree ,thicken ligamenta flava ,discs degeneration degree, protrusion type and their relation with incident time.
Methods
Divide the 70 pations into two groups: less than 2 monthes is one group, exceed 4 monthes is other group, record the evalue of MRI signal intensity the size of protruded nucleus pulposus , protrusion type, discs hight,dies degeneration degree, neural root compression degree thicken fligamenta flava. Do statistic analysis with SPSS11.0.
1. Contrast the clinical situation between the two groups.
2. Contrast the MRI between the two groups.
(1) Do the correction analy between incident time and below entry: MRI signal intensity of protruded nucleus pulposus , the size of protroed nucleus pulposus ,the discs hight.
(2)Do t - test between the two groups in the below entry: MRI signal intensity of protruded nucleus pulposus , the size of protruded nucleus pulposus ,the discs hight.
(3)Do x2 - test between the two groups about the below entry: degeneration degree,neural root compression degree ,thicken ligamen-ta flava ,the type of the protrusion.
Result
1. The clinical situation difference between the two groups:
(1) Between the two groups has a sharp difference in the positive of straight raise leg test, tendon reflect weaken and muscle strength weaken, the group of less than 2 monthes has a high positive rate in straight raise leg test. The group of exceed 4 monthes has a high positive rate in tendon reflect weaken and muscle strength weaken.
(2) there is no difference between the two groups in the positive of sciatica, spine curvature, lumber spine tenderness, sensation abnormality.
(3) All cases of less than 2 monthes has lumbag and hasnt mic-tion abnormality.
2. The MRI difference between the two groups;
(1) there is correlation between incident time and MRI signal intensity of protruded nucleus pulposus . There is no correlation between incident time and the size of protruded nucleus pulposus , protrusion
discs hight, totle sum of degenerate discs.
(2) Between the two groups has a sharp difference in the MRI signal intensity of protruded nucleus pulposus . the group of less than 2 monthes has a lower evalue than the group of exceed 4 monthes . There is less significant between the two groups in the totle sum of degenerate discs.
(3)Between the two groups has a sharp difference in the neural root compression degree , thicken ligamenta flava . The group of less than 2 monthes has a high positive rate in neural root compression , thicken ligamenta flava . There is no correlation between the two groups in degeneration degree.
Conclusion
1. there is correlation between incident time and clinical situation.
2. there is correlation between incident time and MRI signal intensity of protruded nucleus pulposus .
3. There is no correlation between incident time and the size of protruded nucleus pulposus , protruded discs hight.
4. MRI will mae a role in identifying the range of incident time of lumber intervertebral discs protrusion in clinical forensic.
引文
1. Lipson SJ, Muir H. Proteoglycans in esperimental intervertebral disc degeneration. Spine, 1981,6:194-210
2. Melose J, Ghosh P,Taylor TK,et al. A longitudinal study of the intervertebral disc by surgical damage to the annulus fibrosus. J Orthop Res, 1992,10:665-676
3. Kaapa E, Holm S, Inkinen R, et al. Proteoglycan chemistry in experimentaUy injured porcine intervertebral disc. J Spinal Discord, 1994,7:296 - 306
4．朱庆三，许测民．腰间盘髓核中胶原及蛋白多糖含量测定．中华外科杂志，1994，32(8)，463-465
5．赵宗文，张小明．腰间盘突出症突出物的CT分析．川北医学院学报 2000，15(1)：56-57
6. McCulloch J, Imoue S, Moriya H, et al. Clinlcal entities: surgical indicationd and techniques In: Weinstein JN, wiesel SW, eds. The lumbar spine: the international society for the study of the lumbar spine. Philadelphia: WB Saunders, 1990:393 - 421
7. Hisao Masui, MS, Masahiko Kanamori, MD. Familial predisposition for lumber degenerative disc disease A case-control study. Spine, 1998,23(9): 1029-1034
8．侯树勋，彭宝淦．椎间盘退变性疾病研究现状与展望．中国临床康复，2002，6(14)：2096-2097
9. Haro H, Shinomiya K, Komori H, et al. Upregulated expression of chemokines in herniated muclers pulposus resorption [J]. Spine, 1996,21:1647-1652
10．徐亮，代成甫．髓核组织TNFα、IL-6与腰椎间盘突出症的相
关性检测及其意义．河南医药信息，2001，9(11)：1-4
11. Hoch RC, Rodriguez R, Manning T, et al. Effects of accidental trauma oncytokine and endotoxin production. Crit Care Med,1993, 197:155 - 156
12．王传疆，原泉．实验性持续神经根受压减压后早期神经变化的研究．中国医科大学学报,2001，30(4)：261-263
13．方国华，欧阳甲．腰椎间盘突出物大小与临床关系分析．颈腰痛杂志．1994，15(3)，141-143
14．姜宏，施杞．腰椎间盘突出后的自然吸收及其临床意义．中华骨科杂志，1998，18(12)：755-756
15．安达公，老原有男，渡边尚，他．腰椎间板保存疗法MR所见经时变化临床症状检讨．整形外科，1996，47：1424-1428
16．中村孝文，池田天使，千田治道，他．脱出椎间板自然经过．骨关节韧带，1996，9：1413-1422
17. Ellieser Avrahami, MD, Irena Wigler, MD. Computed tomegraphic (CT) demonstration of calcification of the ligamenta flava of the lumbosacral spine associated with protrusion of the intervertebral disc. Spine, 1990,15(1):21-23
18．裴仁全．椎间盘退变的MRI与病理学研究．中华放射学杂志，1995，(29)3：175
19. Yu SW,Haughton VM,SetherLA et al. Criteria for classifying normal and degenerative lumber intervertertebral disk. Radiology, 1989,170:523
20．谢其扬，叶君健．突出的腰椎间盘退变程度病理学初步研究．福建医科大学学报，2002，36(1)：20-2221．尚铁松，王云钊．腰椎间盘退变的X线、MRI表现与病理对照．中华放射学杂志，2002，36(9)：828-832
2. Melose J, Ghosh P,Taylor TK,et al. A longitudinal study of the intervertebral disc by surgical damage to the annulus fibrosus. J Orthop Res, 1992,10:665-676
3. Kaapa E, Holm S, Inkinen R, et al. Proteoglycan chemistry in experimentaUy injured porcine intervertebral disc. J Spinal Discord, 1994,7:296 - 306
4．朱庆三，许测民．腰间盘髓核中胶原及蛋白多糖含量测定．中华外科杂志，1994，32(8)，463-465
5．赵宗文，张小明．腰间盘突出症突出物的CT分析．川北医学院学报 2000，15(1)：56-57
6. McCulloch J, Imoue S, Moriya H, et al. Clinlcal entities: surgical indicationd and techniques In: Weinstein JN, wiesel SW, eds. The lumbar spine: the international society for the study of the lumbar spine. Philadelphia: WB Saunders, 1990:393 - 421
7. Hisao Masui, MS, Masahiko Kanamori, MD. Familial predisposition for lumber degenerative disc disease A case-control study. Spine, 1998,23(9): 1029-1034
8．侯树勋，彭宝淦．椎间盘退变性疾病研究现状与展望．中国临床康复，2002，6(14)：2096-2097
9. Haro H, Shinomiya K, Komori H, et al. Upregulated expression of chemokines in herniated muclers pulposus resorption [J]. Spine, 1996,21:1647-1652
10．徐亮，代成甫．髓核组织TNFα、IL-6与腰椎间盘突出症的相
关性检测及其意义．河南医药信息，2001，9(11)：1-4
11. Hoch RC, Rodriguez R, Manning T, et al. Effects of accidental trauma oncytokine and endotoxin production. Crit Care Med,1993, 197:155 - 156
12．王传疆，原泉．实验性持续神经根受压减压后早期神经变化的研究．中国医科大学学报,2001，30(4)：261-263
13．方国华，欧阳甲．腰椎间盘突出物大小与临床关系分析．颈腰痛杂志．1994，15(3)，141-143
14．姜宏，施杞．腰椎间盘突出后的自然吸收及其临床意义．中华骨科杂志，1998，18(12)：755-756
15．安达公，老原有男，渡边尚，他．腰椎间板保存疗法MR所见经时变化临床症状检讨．整形外科，1996，47：1424-1428
16．中村孝文，池田天使，千田治道，他．脱出椎间板自然经过．骨关节韧带，1996，9：1413-1422
17. Ellieser Avrahami, MD, Irena Wigler, MD. Computed tomegraphic (CT) demonstration of calcification of the ligamenta flava of the lumbosacral spine associated with protrusion of the intervertebral disc. Spine, 1990,15(1):21-23
18．裴仁全．椎间盘退变的MRI与病理学研究．中华放射学杂志，1995，(29)3：175
19. Yu SW,Haughton VM,SetherLA et al. Criteria for classifying normal and degenerative lumber intervertertebral disk. Radiology, 1989,170:523
20．谢其扬，叶君健．突出的腰椎间盘退变程度病理学初步研究．福建医科大学学报，2002，36(1)：20-2221．尚铁松，王云钊．腰椎间盘退变的X线、MRI表现与病理对照．中华放射学杂志，2002，36(9)：828-832