腰椎间盘突出症髓核摘除神经根管探查扩大术的探讨和研究
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摘要
目的：(1)总结术前诊断单纯腰椎间盘突出症手术探查发现有神经根管狭窄的发病率。
(2)探讨神经根管探查、扩大术对腰椎间盘突出症手术短期、近期和远期疗效的意义。
(3)探讨是否将神经根管探查术作为腰椎间盘突出症手术中的常规步骤。
方法：将328例术前诊断的单纯腰椎间盘突出症患者随机分成两组：髓核摘除术组(A组)160例和髓核摘除并神经根管探查、扩大术组(B组)168例。对A组病例只行髓核摘除术，而B组病例在行髓核摘除后，常规探查神经根管，若发现有神经根横向移动＜1cm，或神经根管入口及中间狭区骨性或软组织性压迫，则给予切除压迫物，骨性神经根管潜行扩大。通过短期(1月内)、近期(1年内)和远期(1-15年)随访、观察和分析，评价疗效。
结果：A组(髓核摘除术组)随访总有效率分别为：短期90％，近期88％，远期84％；有36例(22.5％)患者在0.5-5年间接受了二次椎间盘手术，其中28例原因为神经根管狭窄。B组(髓核摘除并神经根管探查、扩大术组)168例病例术中发现88例(52.4％)有不同程度神经根管狭窄，且均为年龄40岁以上、平均病程5.8年的患者；随访总有效率分别为：短期98％，近期95％，远期92％。两组间比较有显著差异性(P＜0.05)。
结论：术前诊断的单纯腰椎间盘突出症的患者术中发现合并神经根管狭窄的发病率较高(52.4％)，尤其40岁以上、病程较长的单纯腰椎间盘突出症患者。髓核摘除的同时神经根管常规探查、有效扩大对进一步明确诊断，提高椎间盘手术疗效具有极其重要的的意义。
Objective: Summarize the incidence of lumbar nerve root canal stenosis during diskectomy for lumbar disc herniation. Study the clinical meaning of nerve root canal's check and decompression besides diskectomy for lumbar disc herniation. Research if it is a proper way of that nerve root canal stenosis during diskectomy for lumbar disc herniation.
Method: 328 patients of simple lumbar disc herniation were divided into group A( diskectomy, 160 cases) and group B( nerve root canal's check and decompression besides diskectomy, 168 cases), group A we only gave them diskectomy ,but group B We not only gave them diskectomy ,but also checked all their lumbar nerve root canal ,and examined if they had a few stenosis.One side,to confirm and modify diagnose of before operation, another side, patients who have had a few stenosis were be gone on decompression.After operation,appraise the incidence of lumbar nerve root canal stenosis and curative effect through observation, analysis and follow up.
Results: group A( diskectomy, 160 cases) were followed up and excellent: short-term 90%,in the near future 88%, long-term 84%;36 cases were accepted second operation during 0.5 year to 5 year and 28 cases had nerve root canal stenosis. group B( nerve root canal's check and decompression besides diskectomy, 168 cases):88 cases(52.4 % ) were found having nerve root canal stenosis, their age were over 40y and their disease course were comparative long; group B were followed up and excellent.short-term 98%,in the near future95%, long-term 92%.
Conclusion: There is a high incidence of lumbar nerve root canal stenosis during diskectomy for lumbar disc herniation, especially among these patients of their age were over 40y and their disease course were comparative long. It is correct operation of that nerve root canal check and decompression during diskectomy for lumbar disc herniation.
(2)探讨神经根管探查、扩大术对腰椎间盘突出症手术短期、近期和远期疗效的意义。
(3)探讨是否将神经根管探查术作为腰椎间盘突出症手术中的常规步骤。
方法：将328例术前诊断的单纯腰椎间盘突出症患者随机分成两组：髓核摘除术组(A组)160例和髓核摘除并神经根管探查、扩大术组(B组)168例。对A组病例只行髓核摘除术，而B组病例在行髓核摘除后，常规探查神经根管，若发现有神经根横向移动＜1cm，或神经根管入口及中间狭区骨性或软组织性压迫，则给予切除压迫物，骨性神经根管潜行扩大。通过短期(1月内)、近期(1年内)和远期(1-15年)随访、观察和分析，评价疗效。
结果：A组(髓核摘除术组)随访总有效率分别为：短期90％，近期88％，远期84％；有36例(22.5％)患者在0.5-5年间接受了二次椎间盘手术，其中28例原因为神经根管狭窄。B组(髓核摘除并神经根管探查、扩大术组)168例病例术中发现88例(52.4％)有不同程度神经根管狭窄，且均为年龄40岁以上、平均病程5.8年的患者；随访总有效率分别为：短期98％，近期95％，远期92％。两组间比较有显著差异性(P＜0.05)。
结论：术前诊断的单纯腰椎间盘突出症的患者术中发现合并神经根管狭窄的发病率较高(52.4％)，尤其40岁以上、病程较长的单纯腰椎间盘突出症患者。髓核摘除的同时神经根管常规探查、有效扩大对进一步明确诊断，提高椎间盘手术疗效具有极其重要的的意义。
Objective: Summarize the incidence of lumbar nerve root canal stenosis during diskectomy for lumbar disc herniation. Study the clinical meaning of nerve root canal's check and decompression besides diskectomy for lumbar disc herniation. Research if it is a proper way of that nerve root canal stenosis during diskectomy for lumbar disc herniation.
Method: 328 patients of simple lumbar disc herniation were divided into group A( diskectomy, 160 cases) and group B( nerve root canal's check and decompression besides diskectomy, 168 cases), group A we only gave them diskectomy ,but group B We not only gave them diskectomy ,but also checked all their lumbar nerve root canal ,and examined if they had a few stenosis.One side,to confirm and modify diagnose of before operation, another side, patients who have had a few stenosis were be gone on decompression.After operation,appraise the incidence of lumbar nerve root canal stenosis and curative effect through observation, analysis and follow up.
Results: group A( diskectomy, 160 cases) were followed up and excellent: short-term 90%,in the near future 88%, long-term 84%;36 cases were accepted second operation during 0.5 year to 5 year and 28 cases had nerve root canal stenosis. group B( nerve root canal's check and decompression besides diskectomy, 168 cases):88 cases(52.4 % ) were found having nerve root canal stenosis, their age were over 40y and their disease course were comparative long; group B were followed up and excellent.short-term 98%,in the near future95%, long-term 92%.
Conclusion: There is a high incidence of lumbar nerve root canal stenosis during diskectomy for lumbar disc herniation, especially among these patients of their age were over 40y and their disease course were comparative long. It is correct operation of that nerve root canal check and decompression during diskectomy for lumbar disc herniation.
引文
[1] A.H.克伦肖 主编．过邦辅，蔡体栋，等译．坎贝尔骨科手术大全[M]．上海：上海远东出版社，1991：1701-1702．
[2] 赵定麟．脊柱外科学[M]．上海：上海科学技术文献出版社，1997：503-504．
[3] 陈晓亮，胡有谷．腰椎间盘组织的超微结构观察．青岛医学院学报，1987：23：1．
[4] Maroudas A et al. Factors involved in the nutrition of the adult lumbar intervertebral disc: J Bone Sueg 1973; 55-A: 658.
[5] Nachemson A. Moriis J. Invivo measurements of introadiscal pressure J Bone Joint Surg 1964; 64A: 1077.
[6] Brown T, et al. some mechamical tests on lumbo-sacral spine with particular referena to the intervertebral discs: a preliminary report. J Bone joint surg 1975; 39A: 1135.
[7] Deuber MM. Bulging of lumbar intervertebral disks. J Biomech Eng 1982; 104: 187.
[8] Adams MA et al. Diurnal changes in spinal mechanics and their clinical significance. J Bone Joint Surg 1990; 72B: 266.
[9] Markalf KL. Morris JM. The structural components of the intervertebral disc. J Bone Joint Surg 1976; 56A: 675.
[10] Farfan HF, et al. lumbar intervertebral disc degeration J Bone Joint Surg 1972; 54A: 492.
[11] De. Candido P, et al: Magnetic resonance assessment of the distribution of lumbar spine disc degenerative changes. J Spinal Disord. 1988; 1: 9.
[12] Schmorl G, et al: The Human Spine in Health and Disease, Grune & Stratton, New York, 1955.
[13] 胡有谷主编．腰椎间盘突出症[M]．北京：人民卫生出版社，1996：121-122．
[14] Macnab I: Bachache, Willians, Baltimore, 1977.
[15] 宋献文。中医手法推拿治疗腰椎间盘突出症的疗效分析和治疗机制研究．天津医药杂志骨科附刊，1962：484．
[16] 陶甫．有关腰椎间盘纤维环破裂的一些问题的探讨．中华骨科杂志，1981；1：72．
[17] Spanger, DM. Lumbar disectomy, results with limited disc excision and foraminotomy. Spine 1982; 7: 604.
[18] Marchand F, Ahmed AM. Investigation of the laminate of lumbar disc annulus fibrosus. Spine1990; 15(5): 402-410.
[19] Haughton VM, Lim TH, An H. Intervertebral disk appearance correlated with stiffness of lumbar spinal motion segments. AJNR Am J Ueuroradiol 1999; 20(6): 1161-1165.
[20] Harris RI, Mcnab I. structural changes in the lumbar intervertebral disc. J Bone Joint Surg 1954; 36B: 304-322.
[21] Thompson JP Pearce RH, Schechter MT, et al. Preliminary evaluation of a scheme for grading the gtossmorphology of the human intervertebral disc. Spine 1990; 15: 411-415.
[22] Mcnally DS, Adams MA, Goodship AE. Can intervertebral disc prolapse be predicted. By disc mechanics? Spine 1993;18(11) :1525-1530.
[23] Yasuraa T, Makino E, Saito S, et al. Clinico-pathological study on lumbar intervertebral disc herniation. 1. Changes in the intervertebral disc relation with age including schmorl's node.seikei saigaigeka 1986;29:1565-1578.
[24] Nathan H:0steophytes of the vertebral column: an anatomical study of their development according to age race and sex, with consideration as to their etiology and significance, J Bone Surg. 1962;44A:243.
[25] Hamanishi C, Kawabate T, Yosii T, et al. Schmorl's nodes on magnetic resonance imaging; their incidence and clinical relevance. Spine 1994;4:450-453.
[26]Stabler A, Bellan M, Weiss M, et al.MR imaging of enhancing intraosseous disk herniation (Schmorls node).AJR 1997:168:933-938.
[27]Sorensen KH. Scheuermanns juvenile kyphosis. Copenhagen: Munksgaard 1964.
[28]Paajanen H, Alen A, Erkintalo M, et al.Disc degeneiation in Scheueimann disease. Skeletal Radiol 1989;18:523-526.
[29] Bailey P, Casamajor L. Osteo-arthritis of the spine as a cause of compression of the spinal nervre roots. With report of 5 cases. J Ner Ment Dis 1911:38:588-609.
[30] Goldthwait JE. The lumbo-sacral articulation. An explanation of many casesof "lumbage" , "sciatica" and paraplegia. Boston Med Surg J1911; 164: 365-372.
[31] Olmarker K, Hasue M. Classification and pathophysiology of spinal pain syndromes. In: JN Weinstein, B Rydevik, eds. Essentials of the spine. New York: Raven Press, 1995.
[32] Sachs B, Fraenkel J. Progressive anchylotic rigidity of the spine. J Nerve Ment Dis 1900; 27: 1-15.
[33] Olmarker K, Rydevik B, Nordborg C. Autologous nucleus pulposus induces neurophysiologic and histologic changes in porcine cauda equine nerve roots. Spine 1993; 11: 1425-1432.
[34] 邓相华，吴祖尧．腰椎间盘突出症发病机制和硬膜外激素注射疗法(文献综述)，国外医学参考资料 外科学分册，1979；6：149．
[35] Hakelius A. Prognosis in sciatica: aclinical follow-up of surgical and nonsurgical treatment. Acta Orthop Scand Suppl1970; 129.
[36] Weber H, Lumbar disc herniation. A controlled prospective study with ten years of observation. Spine1983; 8: 131-140.
[37] Weber H, Holme I, Amlie E. The natural course of acute sciatica with nerve root symptoms in a double blind placebo controlled trial evaluating the effect of piroxicam. Spine1993; 18: 1433-1438.
[38] Fraser RD. Chymopapain for the treatment of intervertebral disc herniniation: the final report of a double blind study. Spine1984; 9: 815-818.
[39] 姜宏，等．腰椎间盘突出后的自然吸收及其临床意义．中华骨科杂志， 1998，18：755-757．
[40] 胥少汀，葛宝丰，徐印坎．实用骨科学[M]．北京：人民军医出版社，2002：1507-1528．
[41] 胡有谷主编．腰椎间盘突出症[M]．北京：人民卫生出版社，1996：141-326．
[42] Bonney G: Arterial disease as a cause of pain in the buttock and thing, J Bone Joint Surg. 1956; 38B: 686.
[43] Epstein BS: Low back pain associated with variese of the epidural veins simulating heriation of the nucleus, Am J Roentg. 1947; 57: 736.
[44] 张生志，柳光元，杨建都，等．多功能床牵引配以药物治疗腰椎间盘突出症[J]，颈腰痛杂志，2000，21(1)：63-64．
[45] Jansen EF, Balls AK: Chymopapin: A new crystalline proteinase from papaya lates. J Boil Chem. 1941; 137: 459.
[46] Smith L: Enzyme dissolution of the nucieus pulposes. Nature, 1963; 198: 1311.
[47] McCulloch JA: Chemonucleolysis: Experience with 2000 cases. Clin Orthop, 1977; 122: 367.
[48] Sussman BJ, et al: Experimental intervertebral discolysis Clin Orthop, 1971; 80: 181.
[49] 上海医药工业研究院生物化学研究室：国外胶原蛋白质酶和其他方面的应用．医药工业 1973；(8)4．
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[59] Burton CV. Causes of failure of surgery on the lumbar spine. Clin Orthop, 1981, 157: 191.
[2] 赵定麟．脊柱外科学[M]．上海：上海科学技术文献出版社，1997：503-504．
[3] 陈晓亮，胡有谷．腰椎间盘组织的超微结构观察．青岛医学院学报，1987：23：1．
[4] Maroudas A et al. Factors involved in the nutrition of the adult lumbar intervertebral disc: J Bone Sueg 1973; 55-A: 658.
[5] Nachemson A. Moriis J. Invivo measurements of introadiscal pressure J Bone Joint Surg 1964; 64A: 1077.
[6] Brown T, et al. some mechamical tests on lumbo-sacral spine with particular referena to the intervertebral discs: a preliminary report. J Bone joint surg 1975; 39A: 1135.
[7] Deuber MM. Bulging of lumbar intervertebral disks. J Biomech Eng 1982; 104: 187.
[8] Adams MA et al. Diurnal changes in spinal mechanics and their clinical significance. J Bone Joint Surg 1990; 72B: 266.
[9] Markalf KL. Morris JM. The structural components of the intervertebral disc. J Bone Joint Surg 1976; 56A: 675.
[10] Farfan HF, et al. lumbar intervertebral disc degeration J Bone Joint Surg 1972; 54A: 492.
[11] De. Candido P, et al: Magnetic resonance assessment of the distribution of lumbar spine disc degenerative changes. J Spinal Disord. 1988; 1: 9.
[12] Schmorl G, et al: The Human Spine in Health and Disease, Grune & Stratton, New York, 1955.
[13] 胡有谷主编．腰椎间盘突出症[M]．北京：人民卫生出版社，1996：121-122．
[14] Macnab I: Bachache, Willians, Baltimore, 1977.
[15] 宋献文。中医手法推拿治疗腰椎间盘突出症的疗效分析和治疗机制研究．天津医药杂志骨科附刊，1962：484．
[16] 陶甫．有关腰椎间盘纤维环破裂的一些问题的探讨．中华骨科杂志，1981；1：72．
[17] Spanger, DM. Lumbar disectomy, results with limited disc excision and foraminotomy. Spine 1982; 7: 604.
[18] Marchand F, Ahmed AM. Investigation of the laminate of lumbar disc annulus fibrosus. Spine1990; 15(5): 402-410.
[19] Haughton VM, Lim TH, An H. Intervertebral disk appearance correlated with stiffness of lumbar spinal motion segments. AJNR Am J Ueuroradiol 1999; 20(6): 1161-1165.
[20] Harris RI, Mcnab I. structural changes in the lumbar intervertebral disc. J Bone Joint Surg 1954; 36B: 304-322.
[21] Thompson JP Pearce RH, Schechter MT, et al. Preliminary evaluation of a scheme for grading the gtossmorphology of the human intervertebral disc. Spine 1990; 15: 411-415.
[22] Mcnally DS, Adams MA, Goodship AE. Can intervertebral disc prolapse be predicted. By disc mechanics? Spine 1993;18(11) :1525-1530.
[23] Yasuraa T, Makino E, Saito S, et al. Clinico-pathological study on lumbar intervertebral disc herniation. 1. Changes in the intervertebral disc relation with age including schmorl's node.seikei saigaigeka 1986;29:1565-1578.
[24] Nathan H:0steophytes of the vertebral column: an anatomical study of their development according to age race and sex, with consideration as to their etiology and significance, J Bone Surg. 1962;44A:243.
[25] Hamanishi C, Kawabate T, Yosii T, et al. Schmorl's nodes on magnetic resonance imaging; their incidence and clinical relevance. Spine 1994;4:450-453.
[26]Stabler A, Bellan M, Weiss M, et al.MR imaging of enhancing intraosseous disk herniation (Schmorls node).AJR 1997:168:933-938.
[27]Sorensen KH. Scheuermanns juvenile kyphosis. Copenhagen: Munksgaard 1964.
[28]Paajanen H, Alen A, Erkintalo M, et al.Disc degeneiation in Scheueimann disease. Skeletal Radiol 1989;18:523-526.
[29] Bailey P, Casamajor L. Osteo-arthritis of the spine as a cause of compression of the spinal nervre roots. With report of 5 cases. J Ner Ment Dis 1911:38:588-609.
[30] Goldthwait JE. The lumbo-sacral articulation. An explanation of many casesof "lumbage" , "sciatica" and paraplegia. Boston Med Surg J1911; 164: 365-372.
[31] Olmarker K, Hasue M. Classification and pathophysiology of spinal pain syndromes. In: JN Weinstein, B Rydevik, eds. Essentials of the spine. New York: Raven Press, 1995.
[32] Sachs B, Fraenkel J. Progressive anchylotic rigidity of the spine. J Nerve Ment Dis 1900; 27: 1-15.
[33] Olmarker K, Rydevik B, Nordborg C. Autologous nucleus pulposus induces neurophysiologic and histologic changes in porcine cauda equine nerve roots. Spine 1993; 11: 1425-1432.
[34] 邓相华，吴祖尧．腰椎间盘突出症发病机制和硬膜外激素注射疗法(文献综述)，国外医学参考资料 外科学分册，1979；6：149．
[35] Hakelius A. Prognosis in sciatica: aclinical follow-up of surgical and nonsurgical treatment. Acta Orthop Scand Suppl1970; 129.
[36] Weber H, Lumbar disc herniation. A controlled prospective study with ten years of observation. Spine1983; 8: 131-140.
[37] Weber H, Holme I, Amlie E. The natural course of acute sciatica with nerve root symptoms in a double blind placebo controlled trial evaluating the effect of piroxicam. Spine1993; 18: 1433-1438.
[38] Fraser RD. Chymopapain for the treatment of intervertebral disc herniniation: the final report of a double blind study. Spine1984; 9: 815-818.
[39] 姜宏，等．腰椎间盘突出后的自然吸收及其临床意义．中华骨科杂志， 1998，18：755-757．
[40] 胥少汀，葛宝丰，徐印坎．实用骨科学[M]．北京：人民军医出版社，2002：1507-1528．
[41] 胡有谷主编．腰椎间盘突出症[M]．北京：人民卫生出版社，1996：141-326．
[42] Bonney G: Arterial disease as a cause of pain in the buttock and thing, J Bone Joint Surg. 1956; 38B: 686.
[43] Epstein BS: Low back pain associated with variese of the epidural veins simulating heriation of the nucleus, Am J Roentg. 1947; 57: 736.
[44] 张生志，柳光元，杨建都，等．多功能床牵引配以药物治疗腰椎间盘突出症[J]，颈腰痛杂志，2000，21(1)：63-64．
[45] Jansen EF, Balls AK: Chymopapin: A new crystalline proteinase from papaya lates. J Boil Chem. 1941; 137: 459.
[46] Smith L: Enzyme dissolution of the nucieus pulposes. Nature, 1963; 198: 1311.
[47] McCulloch JA: Chemonucleolysis: Experience with 2000 cases. Clin Orthop, 1977; 122: 367.
[48] Sussman BJ, et al: Experimental intervertebral discolysis Clin Orthop, 1971; 80: 181.
[49] 上海医药工业研究院生物化学研究室：国外胶原蛋白质酶和其他方面的应用．医药工业 1973；(8)4．
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