L4～5后路内固定术后早期X片相关指数变化及其分析
|
摘要
目的：通过对后路腰椎融合内固定手术前后X线片选定指标的测量,客观评价手术特点及早期对腰椎大体结构和生理功能的影响。并结合手术疗效,分析腰椎大体结构的变化与疗效是否具有相关性,以对手术方法做出客观的评价,完善手术方式及术后处理事项。
方法：搜集经后路行L4/5椎间盘摘除、椎间植骨融合、椎弓根钉内固定手术(以下简称PLIF术)的病人40例,男19例,女21例,年龄范围42-72岁。单纯L4/5椎间盘突出并椎管狭窄症28例,L4滑脱12例。随访时间6-24个月,分别测量各患者术前及术后1-2年的腰椎相关指数,包括腰椎前凸角度、腰骶角、骶骨倾斜角、L3/4椎间隙高度。随访其手术疗效,统计术前及术后随访时的指标变化,分析与疗效的关系,并用SPSSI3.0统计软件作相关性统计分析。
结果：L4/5腰椎间盘突出并椎管狭窄症或者腰椎滑脱行后路减压植骨融合内固定手术,两年内优良率为95%,对腰椎侧位片测量数据进行统计学分析,其结果如下：
(1)术后腰椎前凸角度、骶骨倾斜角较术前增大(P<0.05),L3/4椎间隙高度减小(P<0.05),腰骶角改变无统计学意义(P>0.05)。
(2)腰椎间盘突出症组与腰椎滑脱组,腰骶角手术间后的改变有差别(P<0.05),腰椎间盘突出症组腰骶角术后增大,腰椎滑脱组术后腰骶角减小。腰椎前凸角度、骶骨倾斜角、L3/4椎间隙高度手术前后的改变均无统计学意义(P>0.05)。
(3)术后一年内与术后两年内腰椎前凸角度、骶骨倾斜角、腰骶角、L3/4椎间隙高度改变均无统计学意义(P>0.05)。
(4)患者术后两年内的自觉腰腿痛症状与手术前后腰椎前凸角度、骶骨倾斜角、腰骶角、L3/4椎间隙高度的改变无直接关系(P>0.05)
(5)腰椎间盘突出症组与腰椎滑脱组病人术前的腰椎前凸角度、骶骨倾斜角、腰骶角、L3/4椎间隙高度的差别均无统计学意义(P>0.05)。
(6)腰椎间盘突出症组与腰椎滑脱组病人术后的腰椎前凸角度、骶骨倾斜角差别无统计学意义(P>0.05)；腰骶角、椎间隙高度差别有统计学意义(P<0.05),腰椎间盘突出症组病人术后腰骶角和椎间隙高度值均大于腰椎滑脱组。
结论：PLIF手术是治疗腰椎间盘突出并椎管狭窄症及腰椎滑脱症的有效手术治疗方法之一。
(1)手术使病人的腰椎前凸角度、骶骨倾斜角均得以改善,恢复腰椎的功能活动。
(2)L4-5PLIF手术后可导致其邻近上一节段椎间隙降低,说明导致邻近节段的退变。
(3)L4-5PLIF手术后两年内其邻近下一阶段退变不明显。
(4)患者术后两年内残余的腰腿痛症状与分析的腰椎前凸角度、骶骨倾斜角、腰骶角及椎间隙高度均无直接相关性。
Objective:The thesis aims to give an objective evaluation of the characteristic of posterior lumbar interbody fusion internal fixation and the influence of operation to the construction and function of lumbar through measuring the selected indexes of Pro and Post operation X-ray. Furthermore, the relation between general lumbar structure variation and curative effect will be analyzed based on the actual curative effect. The purpose of the research is to evaluate objectively the curative effect of lumbar operations and to improve the surgical procedure and postoperative management issues.
Methods:Cases of 40 patients who had experienced L4/5 disc removal, intervertebral bone graft fusion and posterior lumbar interbody fusion internal fixation were collected for study. There are 19 male and 21 female patients aged from 42 to 72, of which 28 cases of L4/5lumbar intervertebral disc herniation and spinal stenosis,12 cases of lumbar spondylolisthesis. The following-up period is 12 to 24 months after operation, during which the lumbar correlation indexes was recorded, including the ante-protruding index, sacrum slant angle, lumbosacral angle and L3/4 intervertebral space altitude etc. The relation between the curative effect and the correlation indexes is studied according to the follow-up investigation. Statistics are collected and analyzed by image processing system and SPSS 13.0 statistical software.
Results:Posterior lumbar interbody fusion in treatment of L4/5 lumbar disc herniation and spinal stenosis or lumbar spondylolisthesis, the excellent rate was 95% in two years. Analyses statistically the measuring data of lumbar side position piece, As a result:
1. After operation, lumbar lordotic angle,sacral slope angles were improved(P< 0.05), L3/4 intervertebral space altitude decreased(P<0.05), lumbosacral angle showed no significant differences (P>0.05) resulted from the operation.
2. By testing, the lumbosacral angle of the group of lumbar disc herniation and spinal stenosis and the group of lumbar spondylolisthesis was found different after the surgery (P<0.05).In group of lumbar disc herniation and spinal stenosis, lumbosacral angle increased; in group of lumbar spondylolisthesis, lumbosacral angle decreased. Lumbar lordotic angle, sacral slope angles, L3/4 intervertebral space altitude showed no nificant differences before and after the operation (P>0.05)
3.1 or 2 years after the operation, lumbar lordotic angle, sacral slope angles, lumbosacral angle, L3/4 intervertebral space altitude showed no significant difference (P>0.05)
4. In the two years of postoperation,the painful symptom of the patient is not directly connected to the change of the space altitude of lumbar lordotic angle, sacral slope angles, lumbosacral angle, L3/4 intervertebral after the operation (P >0.05)
5. The space altitude of lumbar lordotic angle, sacral slope angles, lumbosacral angle and L3/4 intervertebral showed no significant differences before the operation in the group of lumbar disc herniation and spinal stenosis and the group of lumbar spondylolisthesis (P>0.05)
6. After the surgery, lumbar lordotic angle, sacral slope angles showed no significant differences in the group of lumbar disc herniation and spinal stenosis. In the group of lumbar spondylolisthesis (P>0.05), the space altitude of lumbosacral angle, L3/4 intervertebral have changed (P<0.05).In the group of lumbar disc herniation and spinal stenosis, the space altitude of lumbosacral angle and L3/4 intervertebral is greater than the group of lumbar spondylolisthesis after the operation.
Conclusion:PLIF operation is one of the efficient methods to treat the L4/5 lumbar disc herniation and spinal stenosis or lumbar spondylolisthesis.
1. The operation can improve the lumbar lordotic angle and sacral slope angles, and the function of lumbar spine can recover.
2. The L4-5 PILF operation can narrow the space with the upper adjacent segment, from which the conclusion can be drawn that PILF operation leads to ASD of the upper adjacent segment.
3. The ASD of the lower adjacent segment is not obvious within the two years after the L4-5 PLIF operation.
4. In the two years of postopration,the follow-up result showed that remnant symptom has no direct correlation with the intervertebral space altitude of lumbar lordotic angle, sacral slope angles, lumbosacral angle and L3/4.
方法：搜集经后路行L4/5椎间盘摘除、椎间植骨融合、椎弓根钉内固定手术(以下简称PLIF术)的病人40例,男19例,女21例,年龄范围42-72岁。单纯L4/5椎间盘突出并椎管狭窄症28例,L4滑脱12例。随访时间6-24个月,分别测量各患者术前及术后1-2年的腰椎相关指数,包括腰椎前凸角度、腰骶角、骶骨倾斜角、L3/4椎间隙高度。随访其手术疗效,统计术前及术后随访时的指标变化,分析与疗效的关系,并用SPSSI3.0统计软件作相关性统计分析。
结果：L4/5腰椎间盘突出并椎管狭窄症或者腰椎滑脱行后路减压植骨融合内固定手术,两年内优良率为95%,对腰椎侧位片测量数据进行统计学分析,其结果如下：
(1)术后腰椎前凸角度、骶骨倾斜角较术前增大(P<0.05),L3/4椎间隙高度减小(P<0.05),腰骶角改变无统计学意义(P>0.05)。
(2)腰椎间盘突出症组与腰椎滑脱组,腰骶角手术间后的改变有差别(P<0.05),腰椎间盘突出症组腰骶角术后增大,腰椎滑脱组术后腰骶角减小。腰椎前凸角度、骶骨倾斜角、L3/4椎间隙高度手术前后的改变均无统计学意义(P>0.05)。
(3)术后一年内与术后两年内腰椎前凸角度、骶骨倾斜角、腰骶角、L3/4椎间隙高度改变均无统计学意义(P>0.05)。
(4)患者术后两年内的自觉腰腿痛症状与手术前后腰椎前凸角度、骶骨倾斜角、腰骶角、L3/4椎间隙高度的改变无直接关系(P>0.05)
(5)腰椎间盘突出症组与腰椎滑脱组病人术前的腰椎前凸角度、骶骨倾斜角、腰骶角、L3/4椎间隙高度的差别均无统计学意义(P>0.05)。
(6)腰椎间盘突出症组与腰椎滑脱组病人术后的腰椎前凸角度、骶骨倾斜角差别无统计学意义(P>0.05)；腰骶角、椎间隙高度差别有统计学意义(P<0.05),腰椎间盘突出症组病人术后腰骶角和椎间隙高度值均大于腰椎滑脱组。
结论：PLIF手术是治疗腰椎间盘突出并椎管狭窄症及腰椎滑脱症的有效手术治疗方法之一。
(1)手术使病人的腰椎前凸角度、骶骨倾斜角均得以改善,恢复腰椎的功能活动。
(2)L4-5PLIF手术后可导致其邻近上一节段椎间隙降低,说明导致邻近节段的退变。
(3)L4-5PLIF手术后两年内其邻近下一阶段退变不明显。
(4)患者术后两年内残余的腰腿痛症状与分析的腰椎前凸角度、骶骨倾斜角、腰骶角及椎间隙高度均无直接相关性。
Objective:The thesis aims to give an objective evaluation of the characteristic of posterior lumbar interbody fusion internal fixation and the influence of operation to the construction and function of lumbar through measuring the selected indexes of Pro and Post operation X-ray. Furthermore, the relation between general lumbar structure variation and curative effect will be analyzed based on the actual curative effect. The purpose of the research is to evaluate objectively the curative effect of lumbar operations and to improve the surgical procedure and postoperative management issues.
Methods:Cases of 40 patients who had experienced L4/5 disc removal, intervertebral bone graft fusion and posterior lumbar interbody fusion internal fixation were collected for study. There are 19 male and 21 female patients aged from 42 to 72, of which 28 cases of L4/5lumbar intervertebral disc herniation and spinal stenosis,12 cases of lumbar spondylolisthesis. The following-up period is 12 to 24 months after operation, during which the lumbar correlation indexes was recorded, including the ante-protruding index, sacrum slant angle, lumbosacral angle and L3/4 intervertebral space altitude etc. The relation between the curative effect and the correlation indexes is studied according to the follow-up investigation. Statistics are collected and analyzed by image processing system and SPSS 13.0 statistical software.
Results:Posterior lumbar interbody fusion in treatment of L4/5 lumbar disc herniation and spinal stenosis or lumbar spondylolisthesis, the excellent rate was 95% in two years. Analyses statistically the measuring data of lumbar side position piece, As a result:
1. After operation, lumbar lordotic angle,sacral slope angles were improved(P< 0.05), L3/4 intervertebral space altitude decreased(P<0.05), lumbosacral angle showed no significant differences (P>0.05) resulted from the operation.
2. By testing, the lumbosacral angle of the group of lumbar disc herniation and spinal stenosis and the group of lumbar spondylolisthesis was found different after the surgery (P<0.05).In group of lumbar disc herniation and spinal stenosis, lumbosacral angle increased; in group of lumbar spondylolisthesis, lumbosacral angle decreased. Lumbar lordotic angle, sacral slope angles, L3/4 intervertebral space altitude showed no nificant differences before and after the operation (P>0.05)
3.1 or 2 years after the operation, lumbar lordotic angle, sacral slope angles, lumbosacral angle, L3/4 intervertebral space altitude showed no significant difference (P>0.05)
4. In the two years of postoperation,the painful symptom of the patient is not directly connected to the change of the space altitude of lumbar lordotic angle, sacral slope angles, lumbosacral angle, L3/4 intervertebral after the operation (P >0.05)
5. The space altitude of lumbar lordotic angle, sacral slope angles, lumbosacral angle and L3/4 intervertebral showed no significant differences before the operation in the group of lumbar disc herniation and spinal stenosis and the group of lumbar spondylolisthesis (P>0.05)
6. After the surgery, lumbar lordotic angle, sacral slope angles showed no significant differences in the group of lumbar disc herniation and spinal stenosis. In the group of lumbar spondylolisthesis (P>0.05), the space altitude of lumbosacral angle, L3/4 intervertebral have changed (P<0.05).In the group of lumbar disc herniation and spinal stenosis, the space altitude of lumbosacral angle and L3/4 intervertebral is greater than the group of lumbar spondylolisthesis after the operation.
Conclusion:PLIF operation is one of the efficient methods to treat the L4/5 lumbar disc herniation and spinal stenosis or lumbar spondylolisthesis.
1. The operation can improve the lumbar lordotic angle and sacral slope angles, and the function of lumbar spine can recover.
2. The L4-5 PILF operation can narrow the space with the upper adjacent segment, from which the conclusion can be drawn that PILF operation leads to ASD of the upper adjacent segment.
3. The ASD of the lower adjacent segment is not obvious within the two years after the L4-5 PLIF operation.
4. In the two years of postopration,the follow-up result showed that remnant symptom has no direct correlation with the intervertebral space altitude of lumbar lordotic angle, sacral slope angles, lumbosacral angle and L3/4.
引文
[1]戴力扬,侯铁胜.腰椎间盘突出症的生物力学研究.中国矫形外科杂志.1994.(02)：89-92+128.
[2]胡有谷.腰椎间盘突出症的影像学诊断(二).中国脊柱脊髓杂志.1995.(06)：271-273.
[3]傅建峰,倪家骧.腰椎间盘突出症的发病机理及治疗现状.中国疼痛医学杂志.2000.(01)：47-52.
[4]马远征,范玉山,孔祥星,曲之春,白一冰,张波,张红旭.牵引提拉式脊柱滑脱复位方法.中华骨科杂志.1994.(01)：28-31.
[5]Aihara T, Takahashi K, Yamagata M, Moriya H, Tamaki T. Biomechanical functions of the iliolumbar ligament in L5 spondylolysis. J Orthop Sci.2000. 5(3):238-42.
[6]徐又佳,董启榕,沈忆新.胸腰段椎体内压力分布与骨折的相关性研究.中华创伤杂志.2000.(08)：12-14.
[7]Shenkin HA, Hash CJ. Spondylolisthesis after multiple bilateral laminectomies and facetectomies for lumbar spondylosis. Follow-up review. J Neurosurg.1979.50(1):45-7.
[8]Iida Y, Kataoka O, Sho T, et al. Postoperative lumbar spinal instability occurring or progressing secondary to laminectomy. Spine (Phila Pa 1976). 1990.15(11):1186-9.
[9]Shenkin HA, Hash CJ. Spondylolisthesis after multiple bilateral laminectomies and facetectomies for lumbar spondylosis. Follow-up review. J Neurosurg.1979.50(1):45-7.
[10]Abumi K, Panjabi MM, Kramer KM, Duranceau J, Oxland T, Crisco JJ. Biomechanical evaluation of lumbar spinal stability after graded facetectomies. Spine (Phila Pa 1976).1990.15(11):1142-7.
[11]Chen CS, Cheng CK, Liu CL. A biomechanical comparison of posterolateral fusion and posterior fusion in the lumbar spine. J Spinal Disord Tech.2002. 15(1):53-63.
[12]Gillet P. The fate of the adjacent motion segments after lumbar fusion. J Spinal Disord Tech.2003.16(4):338-45.
[13]Chou WY, Hsu CJ, Chang WN, Wong CY. Adjacent segment degeneration after lumbar spinal posterolateral fusion with instrumentation in elderly patients. Arch Orthop Trauma Surg.2002.122(1):39-43.
[14]Levin DA, Hale JJ, Bendo JA. Adjacent segment degeneration following spinal fusion for degenerative disc disease. Bull NYU Hosp Jt Dis.2007. 65(1):29-36.
[15]McNally DS, Shackleford IM, Goodship AE, Mulholland RC. In vivo stress measurement can predict pain on discography. Spine (Phila Pa 1976).1996. 21(22):2580-7.
[16]Penta M, Sandhu A, Fraser RD. Magnetic resonance imaging assessment of disc degeneration 10 years after anterior lumbar interbody fusion. Spine (Phila Pa 1976).1995.20(6):743-7.
[17]Dekutoski MB, Schendel MJ, Ogilvie JW, Olsewski JM, Wallace LJ, Lewis JL. Comparison of in vivo and in vitro adjacent segment motion after lumbar fusion. Spine (Phila Pa 1976).1994.19(15):1745-51.
[18]Kahanovitz N, Arnoczky SP, Levine DB, Otis JP. The effects of internal fixation on the articular cartilage of unfused canine facet joint cartilage. Spine (Phila Pa 1976).1984.9(3):268-72.
[19]Untch C, Liu Q, Hart R. Segmental motion adjacent to an instrumented lumbar fusion:the effect of extension of fusion to the sacrum. Spine (Phila Pa 1976). 2004.29(21):2376-81.
[20]Lee CK, Langrana NA. Lumbosacral spinal fusion. A biomechanical study. Spine (Phila Pa 1976).1984.9(6):574-81.
[21]Saal JA, Saal JS. Intradiscal electrothermal treatment for chronic discogenic low back pain:a prospective outcome study with minimum 1-year follow-up. Spine (Phila Pa 1976).2000.25(20):2622-7.
[22]Wiltse LL, Winter RB. Terminology and measurement of spondylolisthesis. J Bone Joint Surg Am.1983.65(6):768-72.
[23]Imada K, Matsui H, Tsuji H. Oophorectomy predisposes to degenerative spondylolisthesis. J Bone Joint Surg Br.1995.77(1):126-30.
[24]Adams MA, Hutton WC. The effect of posture on the role of the apophysial joints in resisting intervertebral compressive forces. J Bone Joint Surg Br. 1980.62(3):358-62.
[25]Whyne CM, Hu SS, Klisch S, Lotz JC. Effect of the pedicle and posterior arch on vertebral body strength predictions in finite element modeling. Spine (Phila Pa 1976).1998.23(8):899-907.
[26]王守丰,邱勇.生物力学因素对椎体生长板的影响和临床意义.中国脊柱脊髓杂志.2006.(04)：301-303.
[27]Leferink VJ, Keizer HJ, Oosterhuis JK, der Sluis CK v, ten DHJ. Functional outcome in patients with thoraco lumbar burst fractures treated with dorsal instrumentation and transpedicular cancellous bone grafting. Eur Spine J.2003. 12(3):261-7.
[28]Broberg KB. On the mechanical behaviour of intervertebral discs. Spine (Phila Pa 1976).1983.8(2):151-65.
[29]Thompson RE, Pearcy MJ, Downing KJ, Manthey BA, Parkinson IH, Fazzalari NL. Disc lesions and the mechanics of the intervertebral joint complex. Spine (Phila Pa 1976).2000.25(23):3026-35.
[30]Meakin JR, Hukins DW Effect of removing the nucleus pulposus on the deformation of the annulus fibrosus during compression of the intervertebral disc. J Biomech.2000.33(5):575-80.
[31]Niosi CA, Oxland TR. Degenerative mechanics of the lumbar spine. Spine J. 2004.4(6 Suppl):202S-208S.
[32]Abumi K, Panjabi MM, Kramer KM, Duranceau J, Oxland T, Crisco JJ. Biomechanical evaluation of lumbar spinal stability after graded facetectomies. Spine (Phila Pa 1976).1990.15(11):1142-7.
[33]田慧中,王以进,李永年.后部结构切除对腰椎稳定性影响的实验研究.中华骨科杂志.1994.(09):557-560.
[34]Asano S, Kaneda K, Umehara S, Tadano S. The mechanical properties of the human L4-5 functional spinal unit during cyclic loading. The structural effects of the posterior elements. Spine (Phila Pa 1976).1992.17(11):1343-52.
[35]Johnsson KE, Willner S, Johnsson K. Postoperative instability after decompression for lumbar spinal stenosis. Spine (Phila Pa 1976).1986.11(2): 107-10.
[36]Barber JW, Boden SD, Ganey T, Hutton WC. Biomechanical study of lumbar pedicle screws:does convergence affect axial pullout strength. J Spinal Disord. 1998.11(3):215-20.
[37]Ruland CM, McAfee PC, Warden KE, Cunningham BW. Triangulation of pedicular instrumentation. A biomechanical analysis. Spine (Phila Pa 1976). 1991.16(6 Suppl):S270-6.
[38]Boos N, Webb JK. Pedicle screw fixation in spinal disorders:a European view. Eur Spine J. 1997.6(1):2-18.
[39]贾连顺.腰椎滑脱和腰椎滑脱症(一).中国矫形外科杂志.2001.(08):87-89+108.
[40]Park P, Garton HJ, Gala VC, Hoff JT, McGillicuddy JE. Adjacent segment disease after lumbar or lumbosacral fusion: review of the literature. Spine (Phila Pa 1976).2004.29(17):1938-44.
[41]Etebar S, Cahill DW. Risk factors for adjacent-segment failure following lumbar fixation with rigid instrumentation for degenerative instability. J Neurosurg.1999.90(2 Suppl):163-9.
[42]Cheh G, Bridwell KH, Lenke LG, et al. Adjacent segment disease followinglumbar/thoracolumbar fusion with pedicle screw instrumentation: a minimum 5-year follow-up. Spine (Phila Pa 1976).2007.32(20):2253-7.
[43]赵平,冯天有.腰椎力学结构失衡与椎间盘突出的发病.中医正骨.1993.(03)：37-39.
[44]郭世绂,临床骨科解剖学,天津,天津科学技术出版社,1998,245·
[45]章瑛,周江南.腰三横突综合征的同根神经反射现象.颈腰痛杂志.2002.(01)：6-8.
[46]韦坚.脊柱生理曲线变化的生物力学基础及临床意义.广西中医药.1999.(01)：50-52.
[47]Butler D, Trafimow JH, Andersson GB, McNeill TW, Huckman MS. Discs degenerate before facets. Spine (Phila Pa 1976).1990.15(2):111-3.
[48]Pope MH, Frymoyer JW, Krag MH. Diagnosing instability. Clin Orthop Relat Res.1992. (279):60-7.
[49]李勇,刘家勇.腰椎间盘突出症手法治疗机理研究进展.中医正骨.2001.(06)：55-56.
[50]岑炳奎.腰椎间盘突出症的X线平片诊断(附200例报告).右江医学.2000.(02)：110-111.
[51]Dunlop RB, Adams MA, Hutton WC. Disc space narrowing and the lumbar facet joints. J Bone Joint Surg Br.1984.66(5):706-10.
[52]熊敏,徐吉,吴荣博,王坤.腰椎间盘突出病程中腰椎生理弧度僵直的生物力学改变.中国临床康复.2003.(06):933.
[53]戴力杨.腰椎屈伸活动对椎管容量的影响.第二军医大学学报.1989.(05)：503.
[54]Winterstein JF. Measuring the sacral inclination angle in clinical practice:is there an alternative to radiographs. J Manipulative Physiol Ther.2002.25(2): 139-40; author reply 140.
[55]Jager M, Luttmann A. Biomechanical analysis and assessment of lumbar stress during load lifting using a dynamic 19-segment human model. Ergonomics. 1989.32(1):93-112.
[56]Evcik D, Yucel A. Lumbar lordosis in acute and chronic low back pain patients. Rheumatol Int.2003.23(4):163-5.
[57]Shao X, Xu KB.The Practical Cervicodynia and Lum bodynia[M].The first edition, Beijing Peoples'M ilitary M edical Press,1992:199-202.Chines
[58]Mitnitski A, Yahia L, Newman N, Gracovetsky S, Feldman A. Coordination between the lumbar spine lordosis and trunk angle during weight lifting. Clin Biomech (Bristol, Avon).1998.13(2):121-127.
[59]刘植珊,高建章,程庭英.棘间韧带损伤性腰痛的诊断和治疗.中华骨科杂志,1984,4(1)10
[60]丁宇,赵卫东,张勇.脊柱融合内固定致邻近节段退变的生物力学机制.中国临床解剖学杂志.2003.(04):371-374.
[61]戴力扬.椎间盘切除对腰椎应力分布影响的研究.第二军医大学学报.1992.(01)：25.
[62]Cunningham BW, Kotani Y, McNulty PS, Cappuccino A, McAfee PC. The effect of spinal destabilization and instrumentation on lumbar intradiscal pressure:an in vitro biomechanical analysis. Spine (Phila Pa 1976).1997. 22(22):2655-63.
[63]瞿东滨,钟世镇.脊柱融合术后邻近节段退变及其机制.中国脊柱脊髓杂志.1998.(06)：47-49.
[64]Aota Y, Kumano K, Hirabayashi S. Postfusion instability at the adjacent segments after rigid pedicle screw fixation for degenerative lumbar spinal disorders. J Spinal Disord.1995.8(6):464-73.
[65]Goto K, Tajima N, Chosa E, et al. Effects of lumbar spinal fusion on the other lumbar intervertebral levels (three-dimensional finite element analysis). J Orthop Sci.2003.8(4):577-84.
[66]Lee CK, Langrana NA. Lumbosacral spinal fusion. A biomechanical study. Spine (Phila Pa 1976).1984.9(6):574-81.
[67]Dekutoski MB, Schendel MJ, Ogilvie JW, Olsewski JM, Wallace LJ, Lewis JL.Comparison of in vivo and in vitro adjacent segment motion after lumbar fusion. Spine (Phila Pa 1976).1994.19(15):1745-51
[68]Cunningham BW, Kotani Y, McNulty PS, Cappuccino A, McAfee PC. The effect of spinal destabilization and instrumentation on lumbar intradiscal pressure:an in vitro biomechanical analysis. Spine (Phila Pa 1976).1997. 22(22):2655-63.
[69]Aota Y, Kumano K, Hirabayashi S. Postfusion instability at the adjacent segments after rigid pedicle screw fixation for degenerative lumbar spinal disorders. J Spinal Disord.1995.8(6):464-73.
[70]Etebar S,'Cahill DW. Risk factors for adjacent-segment failure following lumbar fixation with rigid instrumentation for degenerative instability. J Neurosurg.1999.90(2 Suppl):163-9.
[2]胡有谷.腰椎间盘突出症的影像学诊断(二).中国脊柱脊髓杂志.1995.(06)：271-273.
[3]傅建峰,倪家骧.腰椎间盘突出症的发病机理及治疗现状.中国疼痛医学杂志.2000.(01)：47-52.
[4]马远征,范玉山,孔祥星,曲之春,白一冰,张波,张红旭.牵引提拉式脊柱滑脱复位方法.中华骨科杂志.1994.(01)：28-31.
[5]Aihara T, Takahashi K, Yamagata M, Moriya H, Tamaki T. Biomechanical functions of the iliolumbar ligament in L5 spondylolysis. J Orthop Sci.2000. 5(3):238-42.
[6]徐又佳,董启榕,沈忆新.胸腰段椎体内压力分布与骨折的相关性研究.中华创伤杂志.2000.(08)：12-14.
[7]Shenkin HA, Hash CJ. Spondylolisthesis after multiple bilateral laminectomies and facetectomies for lumbar spondylosis. Follow-up review. J Neurosurg.1979.50(1):45-7.
[8]Iida Y, Kataoka O, Sho T, et al. Postoperative lumbar spinal instability occurring or progressing secondary to laminectomy. Spine (Phila Pa 1976). 1990.15(11):1186-9.
[9]Shenkin HA, Hash CJ. Spondylolisthesis after multiple bilateral laminectomies and facetectomies for lumbar spondylosis. Follow-up review. J Neurosurg.1979.50(1):45-7.
[10]Abumi K, Panjabi MM, Kramer KM, Duranceau J, Oxland T, Crisco JJ. Biomechanical evaluation of lumbar spinal stability after graded facetectomies. Spine (Phila Pa 1976).1990.15(11):1142-7.
[11]Chen CS, Cheng CK, Liu CL. A biomechanical comparison of posterolateral fusion and posterior fusion in the lumbar spine. J Spinal Disord Tech.2002. 15(1):53-63.
[12]Gillet P. The fate of the adjacent motion segments after lumbar fusion. J Spinal Disord Tech.2003.16(4):338-45.
[13]Chou WY, Hsu CJ, Chang WN, Wong CY. Adjacent segment degeneration after lumbar spinal posterolateral fusion with instrumentation in elderly patients. Arch Orthop Trauma Surg.2002.122(1):39-43.
[14]Levin DA, Hale JJ, Bendo JA. Adjacent segment degeneration following spinal fusion for degenerative disc disease. Bull NYU Hosp Jt Dis.2007. 65(1):29-36.
[15]McNally DS, Shackleford IM, Goodship AE, Mulholland RC. In vivo stress measurement can predict pain on discography. Spine (Phila Pa 1976).1996. 21(22):2580-7.
[16]Penta M, Sandhu A, Fraser RD. Magnetic resonance imaging assessment of disc degeneration 10 years after anterior lumbar interbody fusion. Spine (Phila Pa 1976).1995.20(6):743-7.
[17]Dekutoski MB, Schendel MJ, Ogilvie JW, Olsewski JM, Wallace LJ, Lewis JL. Comparison of in vivo and in vitro adjacent segment motion after lumbar fusion. Spine (Phila Pa 1976).1994.19(15):1745-51.
[18]Kahanovitz N, Arnoczky SP, Levine DB, Otis JP. The effects of internal fixation on the articular cartilage of unfused canine facet joint cartilage. Spine (Phila Pa 1976).1984.9(3):268-72.
[19]Untch C, Liu Q, Hart R. Segmental motion adjacent to an instrumented lumbar fusion:the effect of extension of fusion to the sacrum. Spine (Phila Pa 1976). 2004.29(21):2376-81.
[20]Lee CK, Langrana NA. Lumbosacral spinal fusion. A biomechanical study. Spine (Phila Pa 1976).1984.9(6):574-81.
[21]Saal JA, Saal JS. Intradiscal electrothermal treatment for chronic discogenic low back pain:a prospective outcome study with minimum 1-year follow-up. Spine (Phila Pa 1976).2000.25(20):2622-7.
[22]Wiltse LL, Winter RB. Terminology and measurement of spondylolisthesis. J Bone Joint Surg Am.1983.65(6):768-72.
[23]Imada K, Matsui H, Tsuji H. Oophorectomy predisposes to degenerative spondylolisthesis. J Bone Joint Surg Br.1995.77(1):126-30.
[24]Adams MA, Hutton WC. The effect of posture on the role of the apophysial joints in resisting intervertebral compressive forces. J Bone Joint Surg Br. 1980.62(3):358-62.
[25]Whyne CM, Hu SS, Klisch S, Lotz JC. Effect of the pedicle and posterior arch on vertebral body strength predictions in finite element modeling. Spine (Phila Pa 1976).1998.23(8):899-907.
[26]王守丰,邱勇.生物力学因素对椎体生长板的影响和临床意义.中国脊柱脊髓杂志.2006.(04)：301-303.
[27]Leferink VJ, Keizer HJ, Oosterhuis JK, der Sluis CK v, ten DHJ. Functional outcome in patients with thoraco lumbar burst fractures treated with dorsal instrumentation and transpedicular cancellous bone grafting. Eur Spine J.2003. 12(3):261-7.
[28]Broberg KB. On the mechanical behaviour of intervertebral discs. Spine (Phila Pa 1976).1983.8(2):151-65.
[29]Thompson RE, Pearcy MJ, Downing KJ, Manthey BA, Parkinson IH, Fazzalari NL. Disc lesions and the mechanics of the intervertebral joint complex. Spine (Phila Pa 1976).2000.25(23):3026-35.
[30]Meakin JR, Hukins DW Effect of removing the nucleus pulposus on the deformation of the annulus fibrosus during compression of the intervertebral disc. J Biomech.2000.33(5):575-80.
[31]Niosi CA, Oxland TR. Degenerative mechanics of the lumbar spine. Spine J. 2004.4(6 Suppl):202S-208S.
[32]Abumi K, Panjabi MM, Kramer KM, Duranceau J, Oxland T, Crisco JJ. Biomechanical evaluation of lumbar spinal stability after graded facetectomies. Spine (Phila Pa 1976).1990.15(11):1142-7.
[33]田慧中,王以进,李永年.后部结构切除对腰椎稳定性影响的实验研究.中华骨科杂志.1994.(09):557-560.
[34]Asano S, Kaneda K, Umehara S, Tadano S. The mechanical properties of the human L4-5 functional spinal unit during cyclic loading. The structural effects of the posterior elements. Spine (Phila Pa 1976).1992.17(11):1343-52.
[35]Johnsson KE, Willner S, Johnsson K. Postoperative instability after decompression for lumbar spinal stenosis. Spine (Phila Pa 1976).1986.11(2): 107-10.
[36]Barber JW, Boden SD, Ganey T, Hutton WC. Biomechanical study of lumbar pedicle screws:does convergence affect axial pullout strength. J Spinal Disord. 1998.11(3):215-20.
[37]Ruland CM, McAfee PC, Warden KE, Cunningham BW. Triangulation of pedicular instrumentation. A biomechanical analysis. Spine (Phila Pa 1976). 1991.16(6 Suppl):S270-6.
[38]Boos N, Webb JK. Pedicle screw fixation in spinal disorders:a European view. Eur Spine J. 1997.6(1):2-18.
[39]贾连顺.腰椎滑脱和腰椎滑脱症(一).中国矫形外科杂志.2001.(08):87-89+108.
[40]Park P, Garton HJ, Gala VC, Hoff JT, McGillicuddy JE. Adjacent segment disease after lumbar or lumbosacral fusion: review of the literature. Spine (Phila Pa 1976).2004.29(17):1938-44.
[41]Etebar S, Cahill DW. Risk factors for adjacent-segment failure following lumbar fixation with rigid instrumentation for degenerative instability. J Neurosurg.1999.90(2 Suppl):163-9.
[42]Cheh G, Bridwell KH, Lenke LG, et al. Adjacent segment disease followinglumbar/thoracolumbar fusion with pedicle screw instrumentation: a minimum 5-year follow-up. Spine (Phila Pa 1976).2007.32(20):2253-7.
[43]赵平,冯天有.腰椎力学结构失衡与椎间盘突出的发病.中医正骨.1993.(03)：37-39.
[44]郭世绂,临床骨科解剖学,天津,天津科学技术出版社,1998,245·
[45]章瑛,周江南.腰三横突综合征的同根神经反射现象.颈腰痛杂志.2002.(01)：6-8.
[46]韦坚.脊柱生理曲线变化的生物力学基础及临床意义.广西中医药.1999.(01)：50-52.
[47]Butler D, Trafimow JH, Andersson GB, McNeill TW, Huckman MS. Discs degenerate before facets. Spine (Phila Pa 1976).1990.15(2):111-3.
[48]Pope MH, Frymoyer JW, Krag MH. Diagnosing instability. Clin Orthop Relat Res.1992. (279):60-7.
[49]李勇,刘家勇.腰椎间盘突出症手法治疗机理研究进展.中医正骨.2001.(06)：55-56.
[50]岑炳奎.腰椎间盘突出症的X线平片诊断(附200例报告).右江医学.2000.(02)：110-111.
[51]Dunlop RB, Adams MA, Hutton WC. Disc space narrowing and the lumbar facet joints. J Bone Joint Surg Br.1984.66(5):706-10.
[52]熊敏,徐吉,吴荣博,王坤.腰椎间盘突出病程中腰椎生理弧度僵直的生物力学改变.中国临床康复.2003.(06):933.
[53]戴力杨.腰椎屈伸活动对椎管容量的影响.第二军医大学学报.1989.(05)：503.
[54]Winterstein JF. Measuring the sacral inclination angle in clinical practice:is there an alternative to radiographs. J Manipulative Physiol Ther.2002.25(2): 139-40; author reply 140.
[55]Jager M, Luttmann A. Biomechanical analysis and assessment of lumbar stress during load lifting using a dynamic 19-segment human model. Ergonomics. 1989.32(1):93-112.
[56]Evcik D, Yucel A. Lumbar lordosis in acute and chronic low back pain patients. Rheumatol Int.2003.23(4):163-5.
[57]Shao X, Xu KB.The Practical Cervicodynia and Lum bodynia[M].The first edition, Beijing Peoples'M ilitary M edical Press,1992:199-202.Chines
[58]Mitnitski A, Yahia L, Newman N, Gracovetsky S, Feldman A. Coordination between the lumbar spine lordosis and trunk angle during weight lifting. Clin Biomech (Bristol, Avon).1998.13(2):121-127.
[59]刘植珊,高建章,程庭英.棘间韧带损伤性腰痛的诊断和治疗.中华骨科杂志,1984,4(1)10
[60]丁宇,赵卫东,张勇.脊柱融合内固定致邻近节段退变的生物力学机制.中国临床解剖学杂志.2003.(04):371-374.
[61]戴力扬.椎间盘切除对腰椎应力分布影响的研究.第二军医大学学报.1992.(01)：25.
[62]Cunningham BW, Kotani Y, McNulty PS, Cappuccino A, McAfee PC. The effect of spinal destabilization and instrumentation on lumbar intradiscal pressure:an in vitro biomechanical analysis. Spine (Phila Pa 1976).1997. 22(22):2655-63.
[63]瞿东滨,钟世镇.脊柱融合术后邻近节段退变及其机制.中国脊柱脊髓杂志.1998.(06)：47-49.
[64]Aota Y, Kumano K, Hirabayashi S. Postfusion instability at the adjacent segments after rigid pedicle screw fixation for degenerative lumbar spinal disorders. J Spinal Disord.1995.8(6):464-73.
[65]Goto K, Tajima N, Chosa E, et al. Effects of lumbar spinal fusion on the other lumbar intervertebral levels (three-dimensional finite element analysis). J Orthop Sci.2003.8(4):577-84.
[66]Lee CK, Langrana NA. Lumbosacral spinal fusion. A biomechanical study. Spine (Phila Pa 1976).1984.9(6):574-81.
[67]Dekutoski MB, Schendel MJ, Ogilvie JW, Olsewski JM, Wallace LJ, Lewis JL.Comparison of in vivo and in vitro adjacent segment motion after lumbar fusion. Spine (Phila Pa 1976).1994.19(15):1745-51
[68]Cunningham BW, Kotani Y, McNulty PS, Cappuccino A, McAfee PC. The effect of spinal destabilization and instrumentation on lumbar intradiscal pressure:an in vitro biomechanical analysis. Spine (Phila Pa 1976).1997. 22(22):2655-63.
[69]Aota Y, Kumano K, Hirabayashi S. Postfusion instability at the adjacent segments after rigid pedicle screw fixation for degenerative lumbar spinal disorders. J Spinal Disord.1995.8(6):464-73.
[70]Etebar S,'Cahill DW. Risk factors for adjacent-segment failure following lumbar fixation with rigid instrumentation for degenerative instability. J Neurosurg.1999.90(2 Suppl):163-9.