CT椎间盘造影结合关节突关节封闭在退变性脊柱源性疼痛诊治中作用
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摘要
背景和目的:腰痛是临床中最常见的引起失能的原因之一,是脊柱疾患最常见而且极其复杂的综合症,是多种疾病的共同表现。尽管CT、MRI等无创检查技术已经普及,但是仍然有许多腰腿痛患者的诊断不能明确,更无法进行有效地治疗。由于椎间盘、关节突关节、或特定运动节段其他结构的劳损导致的退变性脊柱疼痛,因其复杂多变的临床表现而成为诊治的难点。这一类疾病中尤以椎间盘源性腰痛和关节突源性腰痛为代表。椎间盘源性腰痛和关节突源性腰痛二者临床表现类似,甚至重叠,X线等影像学检查无明显阳性改变,CT、MRI等检查尽管可以提供一定帮助,但是大多数病人仍然需要进行CT椎间盘造影和关节突关节封闭等有创性检查来明确诊断和治疗方案。而多节段椎间盘突出的病人也需要通过CT椎间盘造影和关节突关节封闭等有创性检查来明确责任间盘,以确定手术治疗方案。本研究将CT椎间盘造影和关节突关节封闭结合,用于退变性脊柱疼痛的诊治,以期为此类疾患的诊治提供新的思路。
方法:临床症状、体征与CT、MRI检查结果不符的退变性脊柱疼痛病人及CT、MRI检查显示多节段椎间盘病变,需要明确责任间盘以决定治疗方案的病人在除外结核、恶性肿瘤等其它原因造成腰痛后,进行CT椎间盘造影和关节突关节封闭检查。明确诊断后,根据检查结果给予适当的外科手术治疗。采用自身对照形式、配对设计的方法,比较术前与术后近期(1月)的JOA和VAS评分,研究CT椎间盘造影结合关节突关节封闭在退变性脊柱疼痛诊断治疗中的作用。
结果:
1. CT造影椎间盘结果
共造影检查93个间盘,其中造影阳性间盘39个(2例术前MRI显示2节段异常,造影显示1节段异常;1例术前MRI显示1节段异常,造影显示2节段异常)。
2.关节突关节封闭结果
共进行关节突关节封闭54个。阳性结果4例,1例为术前MRI信号无改变节段,3例为术前MRI信号改变节段,但造影结果阴性。
3.手术治疗节段结果
对造影检查阳性和关节突关节封闭试验阳性节段行后路椎间盘切除椎板间融合椎弓根钉棒系统内固定手术,共手术治疗31例患者共51个间盘。单节段融合18例,多节段融合12例。
4.临床综合评价结果
所有病人均完成术后近期随访(1个月),自觉临床生活质量明显提高。统计学显示手术前后有显著性差异。
5.并发症
CT椎间盘造影病例中有4例出现术后当日腰腿痛症状加重。手术治疗病例有11例出现术后短时间腰腿痛症状加重,均于术后一周内改善。全部病人无明显近期并发症。
结论:CT椎间盘造影结合关节突关节封闭可以较好的应用于退变性脊柱疼痛诊治。对于椎间盘源性、关节突源性的疼痛诊断的可以起到明确诊断和鉴别诊断作用。对于多节段脊柱退变,可以明确病变节段,指导手术治疗。
Background and Objection: Low back pain is one of the most common reasons of disability and extremely complex syndrome in spinal disorders and a common performance of various diseases. Although the CT,MRI and other non-invasive technique has been popular, there are still many patients with low back pain can not have definite diagnosis, not to mention dffective treatment.Due to the degenerative segment of intervertebral disc, zygapophysial joint pain. The discogenic low back pain and zygapophysial joint pain have similar clinical manifestations,even overlaps. X-ray and other imaging examination have provide some helps,most of patients still meed to carry out some invasive checks to identify diagnosis and treatment’s program such as CT discography and zygapophysial joint block. While the patients with multiple-segments disc lesions need to be identified the“responsible disc”by some invasive checks such as CT discography and zygapophysial joint block. In this study,we can provide a new way for this disease, combining CT discograpy and zygapophysial joint block for diagnosing and treating degenerative low back pain.
Methods: These patients of the degenerative low back pain whose clinical symptoms, signs and CT, MRI examination do not match and the patients whose CT, MRI examination revealed multiple-segment lesions need to be identified the“responsible disc”to determine the treatment, eliminating tuberculosis,cancer and other diseases,have to do CT discography and zygapophysial joint block examination. According to the results, the appropriate surgical treatment is given to the patient after the definite diagnosis. By a form of self-control, matching design method, compared the preoperative of the JOA and VAS criterion with the post-operative of the JOA and VAS criterion recently(1 month), we studied the effect of CT discography and zygapophysial joint block in diagnosing and treating degenerative low back pain.
Results:
1. CT discography results
CT discography results were performed 93 discs,the positive 39 discs ( Two cases of preoperative MRI signal change in two segments but CT discography in one segment. One cases of preoperative MRI signal changes in one segments but CT discography in two segments.).
2. Zygapophysial joint block results
Zygapophysial joint block resultsed in the closure of a facet joint closed 54. The positive results of four cases, one case of the preoperative MRI signal no change in segments, three cases of the preoperative MRI signal change in segment, but the discography negative results.
3. Surgical treatment of segment results
we performed on the positive discography and the positive zygapophysial joint block with posterior disc kectomy integrate the intervertebral plate fusion and the pedicle screw fixation rod system,a total of 31 cases of surgical treatment in patients with a total of 51 intervertebral discs. Signal fusion in 18 cases, multi-segment fusion in 12 cases.
4. Clinical Evaluation Results
Clinical results of comprehensive evaluation of all patients are conscious of improvement of their life’s quality dramatically after surgical treatment(1 month).Statistics shows that patients of the pre-operative and post-operative are different significantly.
5. Complications
The pain of four patients in leg and lumbar aggravate in CT discography after operation. The symptoms of 11 cases in low back pain aggravate immediately,but release in one week. All the patients had no complications in the near future.
Conclusions: CT discography and zygapophysial joint block can be better used in diagnosis and treatment of degenerative low back pain. For discogenic low back pain and zygapophysial joint pain can play a definite role in the diagnosis and differential diagnosis. For multi-segments of spinal degeneration, the segments of disease can be clearly determined , guiding surgical treatment.
方法:临床症状、体征与CT、MRI检查结果不符的退变性脊柱疼痛病人及CT、MRI检查显示多节段椎间盘病变,需要明确责任间盘以决定治疗方案的病人在除外结核、恶性肿瘤等其它原因造成腰痛后,进行CT椎间盘造影和关节突关节封闭检查。明确诊断后,根据检查结果给予适当的外科手术治疗。采用自身对照形式、配对设计的方法,比较术前与术后近期(1月)的JOA和VAS评分,研究CT椎间盘造影结合关节突关节封闭在退变性脊柱疼痛诊断治疗中的作用。
结果:
1. CT造影椎间盘结果
共造影检查93个间盘,其中造影阳性间盘39个(2例术前MRI显示2节段异常,造影显示1节段异常;1例术前MRI显示1节段异常,造影显示2节段异常)。
2.关节突关节封闭结果
共进行关节突关节封闭54个。阳性结果4例,1例为术前MRI信号无改变节段,3例为术前MRI信号改变节段,但造影结果阴性。
3.手术治疗节段结果
对造影检查阳性和关节突关节封闭试验阳性节段行后路椎间盘切除椎板间融合椎弓根钉棒系统内固定手术,共手术治疗31例患者共51个间盘。单节段融合18例,多节段融合12例。
4.临床综合评价结果
所有病人均完成术后近期随访(1个月),自觉临床生活质量明显提高。统计学显示手术前后有显著性差异。
5.并发症
CT椎间盘造影病例中有4例出现术后当日腰腿痛症状加重。手术治疗病例有11例出现术后短时间腰腿痛症状加重,均于术后一周内改善。全部病人无明显近期并发症。
结论:CT椎间盘造影结合关节突关节封闭可以较好的应用于退变性脊柱疼痛诊治。对于椎间盘源性、关节突源性的疼痛诊断的可以起到明确诊断和鉴别诊断作用。对于多节段脊柱退变,可以明确病变节段,指导手术治疗。
Background and Objection: Low back pain is one of the most common reasons of disability and extremely complex syndrome in spinal disorders and a common performance of various diseases. Although the CT,MRI and other non-invasive technique has been popular, there are still many patients with low back pain can not have definite diagnosis, not to mention dffective treatment.Due to the degenerative segment of intervertebral disc, zygapophysial joint pain. The discogenic low back pain and zygapophysial joint pain have similar clinical manifestations,even overlaps. X-ray and other imaging examination have provide some helps,most of patients still meed to carry out some invasive checks to identify diagnosis and treatment’s program such as CT discography and zygapophysial joint block. While the patients with multiple-segments disc lesions need to be identified the“responsible disc”by some invasive checks such as CT discography and zygapophysial joint block. In this study,we can provide a new way for this disease, combining CT discograpy and zygapophysial joint block for diagnosing and treating degenerative low back pain.
Methods: These patients of the degenerative low back pain whose clinical symptoms, signs and CT, MRI examination do not match and the patients whose CT, MRI examination revealed multiple-segment lesions need to be identified the“responsible disc”to determine the treatment, eliminating tuberculosis,cancer and other diseases,have to do CT discography and zygapophysial joint block examination. According to the results, the appropriate surgical treatment is given to the patient after the definite diagnosis. By a form of self-control, matching design method, compared the preoperative of the JOA and VAS criterion with the post-operative of the JOA and VAS criterion recently(1 month), we studied the effect of CT discography and zygapophysial joint block in diagnosing and treating degenerative low back pain.
Results:
1. CT discography results
CT discography results were performed 93 discs,the positive 39 discs ( Two cases of preoperative MRI signal change in two segments but CT discography in one segment. One cases of preoperative MRI signal changes in one segments but CT discography in two segments.).
2. Zygapophysial joint block results
Zygapophysial joint block resultsed in the closure of a facet joint closed 54. The positive results of four cases, one case of the preoperative MRI signal no change in segments, three cases of the preoperative MRI signal change in segment, but the discography negative results.
3. Surgical treatment of segment results
we performed on the positive discography and the positive zygapophysial joint block with posterior disc kectomy integrate the intervertebral plate fusion and the pedicle screw fixation rod system,a total of 31 cases of surgical treatment in patients with a total of 51 intervertebral discs. Signal fusion in 18 cases, multi-segment fusion in 12 cases.
4. Clinical Evaluation Results
Clinical results of comprehensive evaluation of all patients are conscious of improvement of their life’s quality dramatically after surgical treatment(1 month).Statistics shows that patients of the pre-operative and post-operative are different significantly.
5. Complications
The pain of four patients in leg and lumbar aggravate in CT discography after operation. The symptoms of 11 cases in low back pain aggravate immediately,but release in one week. All the patients had no complications in the near future.
Conclusions: CT discography and zygapophysial joint block can be better used in diagnosis and treatment of degenerative low back pain. For discogenic low back pain and zygapophysial joint pain can play a definite role in the diagnosis and differential diagnosis. For multi-segments of spinal degeneration, the segments of disease can be clearly determined , guiding surgical treatment.
引文
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10. Milette P,Fontaine S,Lepanto L.Differentiating lumbar disc protrusions,disc bulges,and discs wirh nomal contour but abnormal signal intenisty: magnetic resonance imaging with discographic correlations. Spine,1999,24:44-53.
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22. Song KJ, Lee KB: Bilateral facet dislocation on L4-5 without neurologic deficit. J Spinal Disord 2005; 18:462–464
23. Little JS, Khalsa PS: Material properties of the human lumbar facet joint capsule. J Biomech Eng 2005; 127:15–24
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2. North American Spine Society. Position statement on discography [J]. Spine, 1988, 13 (12):1343.
3. Carrage EJ, Tanner CM, Yang B, et al. False-positive findings on lumbar discography: reliability of subjective concordance assessment during provocative disc injection[J]. Spine,1999,24(23):2542-2547.
4. Adams MA The stages of degeneration as revaled by discograms.J Bone Joint Surg(Br), 1986, 68:36-41.
5. Sachs BL,Vanharanta H,Spivey MA,et al. Dallas discogram description: a new classification of CT/discography in low-back disorders. Spine,1987,12:287-294.
6. Keith HB,Ronald LD.脊柱外科学.第2版.胡有谷主译.北京:人民卫生出版社.2000.1419-1429.
7. Crock HV.Reappraisal of intervertebral disc lesions [J].Med J Aust, 1970, 1(20):983-989.
8.彭宝淦,侯树勋,吴闻文,等.化学性神经根炎[J].中华骨科杂志, 2006, 26(4):223-227.
9. Horton WC,Daftari TK. Which disc as visualized by magnetic resonance imaging is actually a source of para?a correlation between magnetic resonance imaging and discography[J].
10. Milette P,Fontaine S,Lepanto L.Differentiating lumbar disc protrusions,disc bulges,and discs wirh nomal contour but abnormal signal intenisty: magnetic resonance imaging with discographic correlations. Spine,1999,24:44-53.
11. Carragee EJ,Paragioudakis SJ,Khurana S.2000 Volvo Award winner in clinical studies:lumbar high-intensity zone and discography in subjects without low back probiems.Spine,2000,25:2987-2992.
12. Ghormley RK: Low back pain with special reference to the articular facets, with presentation of an operative procedure. JAMA 1933; 101:1773–7.
13. Cohen SP, Hurley RW, Christo PJ, Winkley J, Mohiuddin MM, Stojanovic MP: Clinical predictors of success and failure for lumbar facet radiofrequency denervation. Clin J Pain 2007; 23:45–52
14. St?nder M, M?rz U, Steude U et al. The facet syndrome:frequent cause of chronicbackaches.MMW Fortschr Med.2006 26,148(43):33-34.
15. Dreyfuss PH,Dreeyer SI Lumbar zygapophysea (facet) joint injections Contemporary concepts in spine care [R].RosemonⅡ:North American Spine Society 1994.
16. Dellmich D, Kob A, Deubler R,et al. Aute Trearment of Facet Syndrome by CT-Guide Injection of Dexamethaxone-21-Palmitate Alone and in Combination with Mepivacaine. Clin Drug Investig.2004,24(10):559-567.
17. Deyo RA,Nachemson A,Mirza SK: Spinal-fusion surgery: The case for restraint. N Engl J Med 2004,350:722-726.
18. Poynton AR,Hinman A, Lutz G,et al. Discography-induced acute lumbar disc hemination: a report of five cases. J Spinal Disord Tech 2005,18(2):188-192.
19. Zheng Y,Liew SM,Simmons ED. Spine,2004,29(19):2140-2145.
20. Simmons EH,Segil CM.An evaluation of discography in the localization of symptomatic levels in discogenic disease of the spine [J].Clinorthop,1975,108:57-69.
21.胡有谷,李放,张永刚,等.椎间盘源性腰痛[J].中华脊柱脊髓杂志,2004,14(6): 327-330.
22. Song KJ, Lee KB: Bilateral facet dislocation on L4-5 without neurologic deficit. J Spinal Disord 2005; 18:462–464
23. Little JS, Khalsa PS: Material properties of the human lumbar facet joint capsule. J Biomech Eng 2005; 127:15–24
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