目前商品化的产品有三种:一是美国礼来公司产品,复泰奧,5210元/支,可用28天,一年13支;二是珍固(国产),103元/支,一天一支,粉针剂,需现用现配,x365天/年;三是欣复泰针(国产),960元/支,可用30天,12支/年。第一,三种使用方便,老人可以自己操作,第二种需要专业人员帮忙,比较麻烦。都是需要每天皮下注射使用。
治疗前 患者14年前在国外做个腰椎手术。此次左下肢下地就放电样剧痛。CT显示腰4/5椎间盘突出,腰4/5左侧腰5上关节突增生顶着神经根。从外地赶到我门诊。背部已经被某中医院艾灸溃烂成这样了。 治疗中 予以侧入路孔镜微创1厘米切口下摘除椎间盘,磨除腰5向上增生关节突骨赘。术中确认骨赘已完全磨除,神经根充分松解。 治疗后 治疗后0天 术后两小时,患者可自由下地行走,无任何疼痛。予以复查CT显示增生的骨赘被完全磨除。
治疗前 患者因为疫情,迟迟就医,就医时已经四肢无力麻木,行走不稳。病情严重。诊断:脊髓型颈椎病,后纵韧带骨化,颈椎管狭窄症,脊髓变性。 治疗中 予以行颈椎后路单开门椎管扩大成型术。如果症状无缓解准备前路二期手术 治疗后 治疗后730天 患者门诊复查。肌力已经恢复正常,无需二期前路手术。
治疗前 这是一个高龄患者搬东西导致胸椎骨折,胸背部疼痛,因为骨质疏松症这种轻微的外伤就导致了胸椎骨折,住院后予以查胸椎磁共振,显示胸12椎体骨质疏松性压缩性骨折。 治疗中 予以行微创骨水泥椎体强化,就是PKP手术。术后两小时即可下地行走 治疗后 治疗后0天 戴腰围下地行走。仅胸背部肌肉酸痛,行走方便,复查X片骨水泥分布良好
椎间孔鏡治疗腰椎间盘突出症椎间孔镜于1999年由美国Anthony Yeung教授首创(杨氏技术),并在2002年德国脊柱外科学会Thomas Hoog Land 教授在杨氏技术基础上予以发展,目前创新的Thessys技术得到脊柱领域学者的广泛认同。该技术目前不仅治疗椎间盘突出,还大量用于各类骨性狭窄、老年性退变的治疗,由于Thessys椎间孔镜脊柱微创技术作用于纤维环之外,因而可以最大程度地保持纤维环的完整性和保持脊柱的稳定性,在同类手术中对病人创伤最小、效为确切。椎间孔镜脊柱微创技术代表一种全新的脊柱微创手术概念。可以开展从颈椎到腰5骶1所有节段的椎间盘突出、椎间孔成型和纤维环修复。手术的满意疗效可以达到75%--90%[[。由于它的诸多优越性,目前国际脊柱微创外科领域已经公认椎间孔镜在不领域的主导。1、基本原理随着脊柱内窥镜下经椎间孔入路的发展成熟及应用,大家逐渐接受Thessys技术的应用,也成为目前椎间孔镜技术的主流方法。其操作的基本原理:其目的是通过在椎间孔的安全三角区、在椎间盘纤维环之外,彻底清除突出或脱垂的髓核和增生的骨质来解除对神经根的压力,消除对神经压迫造成的疼痛。其手术方法是通过椎间孔镜和相应的配套手术器械、成像处理系统、以及Ellman双频射频机,共同组成的一个脊柱微创手术系统。在彻底切除突出或脱垂髓核的同时,清除骨质增生、治疗椎管狭窄、可以使用射频技术修补破损的环等。在这里需要说明的是关于Yeung技术与Thessys技术的关键区别在于是否进入椎间盘内。Yeung技术也容易让医生产生混淆,经常理解为椎间盘切吸术的翻版[1][2]。早期开展此技术的医院就是因为做过手术的病人复发率高,使得医生没有信心继续这样的实例存在。在这一技术的操作过程,医生必须依据高品质的C臂成像及摄像和术得以顺利的完成。2、手术方法为了精确确定突出髓核的位置和性质,以及椎间孔骨质增生的情况,手术前要进行彻底的临床和神经---骨科检查。影像学检查,特别是MRI是精确确定髓核大小、位置和性质的重要手段。最后通过椎间盘造影来确诊。合适的病人体位和入路的精确设计是术结果的关键。椎间孔镜将方法和技术结合在一起,可以做从颈椎到腰5骶1所有的椎间盘髓核摘除,纤维环成型,切除骨质增生等手术。任何突出甚至游离的髓核组织都可以通过这个系统摘除。使用这个方法到达突出椎间盘的特殊途径是通过椎间孔安全三角区,在椎间盘脱出时,椎间孔通常狭窄明显,需要通过磨钻孔镜,使用特殊研制的咬钳,抓紧器等摘除脱落的髓核组织。关于脊柱内窥镜下经椎工作通道得以顺利进入,这才是关于椎间孔镜的核心技术之一。具体的手术步骤可具体分为九个部分。第一步:术前准备需要腰椎的磁共振了解突出物的形态,腰椎的DR了解椎间孔及髂棘的高度;第二步:标记进针的部位一般旁开距为11-14厘米之间,并标记;第三步:局部麻醉;第四步:穿刺并放置导丝直到椎间盘内;第五步:椎间盘造影使用亚甲蓝和碘海醇混合比例1:4注入1-2毫升将髓核染为蓝色,便于观察椎间盘突出物的形态及摘除;第六步:用磨钻逐级扩大椎间孔。第七步:放置工作套管及椎间孔镜;第八步:摘除染色突出的髓核组织并探查;第九步:应用双极射频消纤维环。3、技术优势很长一段时间内,椎板切除术和腰椎间盘摘除术是治疗严重椎间盘突出症患者的唯一手术治疗方法。由于缺少良好的特异性诊断方法和治疗方法,医生根据患者的情况继续向患者提供各种各样的物理疗法。面对新的手术治疗,一些保守的医生在他们等待新疗法的科学证明时仍然顽固坚持原有的观点[4]。到目前为止,保守疗法是唯一没有收到挑战的治疗方法。然而,做为一种可行的新技术和新方法,可以减轻疼痛、提供更好的特异性诊断的“灰色区域”治疗方法是架在保守疗法和手术治疗之间的一座桥梁。椎间孔镜脊柱微创技术是一套完善和成熟的技术,由著名的德手术后才开始向全世界推广。它主要具有以下一些主要优越性:(1)适应症广泛:能处理几乎所有类型椎间盘突出,部分椎管狭窄椎间孔狭窄、钙化等骨性病变。窥镜下使用特殊的射频电极,可行纤维环成型术和窦椎神经分支间盘源性疼痛。(2)通过侧方入路直接达到病变位置,避免后路手术对椎管的干扰,不咬除椎板,不破坏椎旁肌肉和韧带,对脊柱稳定性无的粘连。还可以防止术后节段性不稳定和滑脱的(3)安全性高,病人仅需局部麻醉,手术中可以随时观察病人的反应。(4)并发症创伤小,神经损伤和血栓形成的风险极低。(5)皮肤切口仅7mm。康复快,术后次日可下地活动,平均3—6周恢复正常工作和体育锻炼。(6)病人满意度高,舒适度极高,立即缓解疼痛,术后疼痛轻微,大小便自理,护理简单。(7)同时使用的Ellman射频电极对可以保护纤维环及后纵韧带的完整性,从而减少术后椎间盘突出复发率。同时可以切除钙化的椎间盘;特制的双极射频电极在椎间盘手术中可进行良好的止血及纤维环修补成型术。(8)已经发表的国际文献报告了在术后1年和2年的随访中,获得的成功率超过90%,早期复发率低于5%。在开放手术复发的病人当中,成功率超过84%。4、技术比较现在多数学者认为:后路椎间盘镜和常规小切口开放手术相比没有优势,对脊柱的影响程度基本一样,同时视野有限,并不利于在临床操作,从国际上看后路椎间盘镜的使用,欧美国家医院开展这项技术的并不多见,。而中国有超过500家医院购买后路椎间盘镜,但2/3以上的医院在购买初期做过一些手术后,基本不再使用,另有少部分医院偶尔开展,这一点笔者医院的发展路程是非常符合这种认识的,我们在开展了近200例后,也基本停用后路椎间盘镜的手术。微创技术必然是外科的发展方向。然而后路椎间盘镜的手术入路和治疗过程,与小切口开放手术相一致都要实施硬膜外麻醉、椎板开窗、剥离肌肉和韧带、干扰椎管、牵拉神经、易造成术中出血干扰视野并增大风险;不能适用于极外侧型突出和椎间盘源性疼痛的治疗;术后瘢痕组织容易造成椎管及神经的粘连,手术的再次补救也是非常困难的[4]。椎间孔镜技术可以处理胸腰椎节段所有类型的椎间盘突出,不仅可以直接摘除突出的组织,如果有必要,也可以将整个椎间盘摘除干净,以便进行融合与固定。该技术微创的核心是不通过后路,手术后不会在后方留下瘢痕,不会造成椎管和神经的粘连,即使手术失败,再进行后路手术从后方看起来就跟没有进行过手术一样。所用设备不仅完成微创手术,也兼顾部分疼痛治疗领域的需要。比如该套系统所用的射频机可做“射频消融”即IDET,主要用于椎间盘源性疼痛的神经毁损,并行纤维环成形术,如有必要,也可做椎间盘内髓核消融和部份靶点消融治疗。椎间孔镜技术在脊柱微创手术中优势骨科专家导读:(1)椎间孔镜技术与脊柱内窥镜类似,是一个配备有灯光的管子,它从患者身体侧方或者侧后方进入椎间孔,在安全三角区做手术。(2)椎间孔镜通过在椎间孔安全三角区、椎间盘纤维环之外,彻底清除突出或脱垂的髓核和增生的骨质来解除对神经根的压力消除疼痛。(3)椎间孔镜下椎间盘摘除术的选择标准与椎板切开、椎间盘摘除术的选择标准并没有本质的差别。(4)椎间孔镜骨科临床优势:国内2008年已经成功为许多腰椎间盘突出的患者实施了椎间盘髓核摘除手术,取得效果可靠,即刻解除患者的痛苦,手术后短期恢复正常工作。(5)椎间孔镜技术:在内窥镜监视下摘除椎间盘突出组织,比通常的后路手术创伤小,可以同时进行射频纤维环修补。(6)椎间孔镜技术与后路椎间盘镜技术(MED)其相比具备创伤更小,出血更少,麻醉更简便,术后恢复更快及经济负担更轻等明显的优势椎间孔镜技术简介:椎间孔镜与脊柱内窥镜类似,是一个配备有灯光的管子,它从病人身体侧方或者侧后方(可以平可以斜的方式)进入椎间孔,在安全工作三角区实施手术。在椎间盘纤维环之外做手术,在内窥镜直视下可以清楚的看到突出的髓核、神经根、硬膜囊和增生的骨组织。然后使用各类抓钳摘除突出组织、镜下去除骨质、射频电极修复破损纤维环。手术创伤小:皮肤切口仅7mm,如同一个黄豆粒大小,出血不到20ml,术后仅缝1针。 是同类手术中对病人创伤最小、效果最好的椎间盘突出微创疗法。椎间孔镜技术治疗原理:椎间孔镜通过在椎间孔安全三角区、椎间盘纤维环之外,彻底清除突出或脱垂的髓核和增生的骨质来解除对神经根的压力,消除由于对神经压迫造成的疼痛,其手术方法是通过特殊设计的椎间孔镜和相应的配套脊柱微创手术器械、成像和图像处理系统等共同组成的一个脊柱微创手术系统。在彻底切除突出或脱垂髓核的同时,清除骨质增生、治疗椎管狭窄、可以使用射频技术修补破损的纤维环等。椎间孔镜路入的椎间盘突出横切面图解:A:单纯椎间盘突出和部分脱垂型病例,首选后外侧安全三角区入路。B:远外侧水平入路适用于中央巨大型突出。C:后路或椎板间入路适用游离或钙化型患者 。D:适用于几乎所有类型椎间盘突出及部分骨性狭窄病例。椎间孔镜技术在脊柱微创手术的适应人群:椎间孔镜下或内镜下显微椎间盘摘除术的选择标准与椎板切开、椎间盘摘除术的选择标准并没有本质的差别。选择行微创手术的椎间盘突出症患者必须表现出神经根受压的症状和体征,并须满足以下条件: 1.持续或反复发作根性疼痛; 2.根性疼痛重于腰痛。如腰痛症状大于腿痛的中度以下膨出的患者可先做低温等离子髓核成形术; 3.经严格保守治疗无效。包括运用甾体或非甾体消炎止痛药、理疗、作业或条件训练程序,建议至少保守治疗4-6周,但如果出现神经症状进行性加重,则需要立即手术; 4.没有药物滥用及心理疾病史; 5.直腿抬高试验阳性,弯腰困难; 6.为了精确确定突出或脱垂的髓核的位置和性质,以及椎间孔骨质增生的情况,手术前要进行彻底的影像学检查,特别是CT和MRI是精确确定髓核大小、位置和性质的重要手段。椎间孔镜技术与骨科其他治疗方法比较:据了解,该技术通过特殊的外侧椎间孔入路途径,在内窥镜监视下摘除椎间盘突出组织,比通常的后路手术创伤小。典型的椎板切除术为了接近目标点,必然对脊柱稳定重要作用的结构造成广泛破坏,这通常要求立即进行脊柱融合。相反地,椎间孔镜技术通过专利的扩孔器和相应的医疗仪器,逐渐扩大椎间孔,完全摘除任何突出或脱出的碎片以及变性的炎性髓核。并可对病变部位进行持续灌洗消炎,运用射频电极修补纤维环,消融神经致敏组织,阻断环状神经分支,解除患者软组织的疼痛。椎间孔镜与其他治疗比较: 髓核机械切除减压、化学髓核溶解或激光气化等间接减压技术相比,椎间孔镜下椎间盘摘除术是针对性切除突出椎间盘碎片、减压神经根的直接技术。而近年被广大认可的后路椎间盘镜技术(MED),虽然可应用于各类腰椎间盘突出症,但是因其手术入路及手术过程与小切口开放手术方法相同,都需经椎旁肌入路和实施椎板开窗,肌肉韧带和骨质结构切除,因此其微创性有限。椎间孔镜技术与其相比具备创伤更小,出血更少,麻醉更简便,术后恢复更快及经济负担更轻等明显的优势。我院椎间孔镜脊柱微创治疗技术已顺利开展2011年9月起我院先后引进德国Joimax,Max-more,Think,Spindos,国内天松,冠龙等椎间孔镜系统,利用现有的介入室大型DSA,胃肠透视机,及飞利浦术中CT,西门子C-臂机等,成功开展了颈胸腰椎间盘突出症和腰椎椎管狭窄症的微创治疗。并进而扩大到化脓性脊柱炎,黄韧带骨化,关节突囊肿,硬膜外脂肪过多症等等领域。椎间孔镜脊柱微创技术的目的是通过在椎间孔安全三角区、椎间盘纤维环之外,彻底清除突出或脱垂的髓核和增生的骨质来解除对神经根的压力,消除对神经压迫造成的疼痛。其手术方法是通过特殊设计的椎间孔镜和相应的配套脊柱微创手术器械、成像和图像处理系统、以及Ellman双频射频机,共同组成的一个脊柱微创手术系统。手术在病人清醒状态下行局麻穿刺,微小皮肤切口完成,对椎管内无干扰,于椎间孔镜下取出突出变性髓核组织,创伤小,不破坏椎旁肌、韧带、不影响脊柱稳定性,通过椎间孔内镜能清晰观察到椎管和神经根,内镜直视下取出突出变性髓核组织。在彻底切除突出或脱垂髓核的同时,清除骨质增生、治疗椎管狭窄、可以使用射频技术修补破损的纤维环等。椎间孔镜技术优势:1微创 通过侧方入路到达目标区域,避免传统后路手术对椎管和神经的干扰,不咬除椎板,不破坏椎旁肌肉和韧带,对脊柱稳定性无影响。2直接 直接切除突出间盘,手术减压明确。3适应症广 能处理大部分椎间盘突出,部分椎管狭窄、椎间孔狭窄等病变。窥镜下使用特殊的射频电极,可行纤维环成型和环状神经分支阻断,治疗椎间盘源性疼痛。4并发症低 创伤小,形成血栓和感染的几率低;术后不会在后方重要结构处留下瘢痕,造成椎管和神经的粘连。5安全性高 局部麻醉,术中能与病人互动,不伤及神经和血管;基本不出血,手术视野清晰,大大降低误操作的风险;6 康复快 术后次日可下地活动,平均3—6周恢复正常工作和体育锻炼。7 病人满意度高 立即缓解疼痛,大小便自理,护理简单,无需使用抗生素,皮肤切口仅7mm,符合美学观点。
慢性腰腿痛是现代社会人们所关注的一个重要问题,临床实践已经证实许多慢性腰腿痛是由椎间盘退变所引起。据报道,28-43%的慢性腰腿痛来源于椎间盘的病变。然而,椎间盘源性疼痛的诊断却相当棘手,目前公认椎间盘内造影术是诊断椎间盘源性疼痛的较为准确的方法之一。本文综述了国内外近十年椎间盘内造影术在疼痛领域应用情况的相关报道,分析其临床应用的优越性与局限性,并展望其未来发展前景。 1 发展历史 1.1 定义 椎间盘造影术( discography) 又称髓核造影术,是在X线透视或CT扫描引导下,将一定剂量的造影剂注入椎间盘髓核腔内,通过观察髓核和纤维环的形态大小,判断椎间盘的病理特点。早在20 世纪初,Schmorl即开始将铅丹溶成液体作为造影剂注入尸体的椎间盘进行研究,随后瑞典的Lindblom 用碘司特作为造影剂注入活体椎间盘, 1948年该技术开始用于临床诊断腰椎间盘突出症。随着CT、MRI等影像技术的逐渐推广,又开始对椎间盘造影技术的进一步研究。 1.2 椎间盘内造影的目的及意义 椎间盘造影术作为一项诊断技术, 其目的主要有:判断患者的下腰痛是否为椎间盘源性;明确引起疼痛的椎间盘节段;评估椎间盘的形态;寻找责任间盘。国内彭宝淦等报道行椎间盘造影,共计100余例,表明其不仅能够直接显示髓核大小、形态及纤维环是否完整, 并且能够复制出患者的疼痛症状, 帮助医生判断致痛性椎间盘(责任椎间盘) 的存在, 从而指导手术。椎间盘造影术在诊断椎间盘源性下腰痛和颈痛的病因方面, 是目前惟一有效的手段,尤其对盘源性下腰痛的诊断具有一定的敏感性,对判断引起疼痛的椎间盘的定位诊断具有较高的价值。美脊柱协会执行委员会认为椎间盘造影适用于椎间盘性下腰痛的诊断试验。北美脊柱外科协会执行委员会认为,诱发性椎间盘造影检查适用于椎间盘源性下腰痛, 是确诊椎间盘源性下腰痛的唯一方法,造影出现的典型阳性征象是患者在造影过程中出现与平时完全一致的疼痛。椎间盘造影有三大优点:(1)当注射造影剂后,可以通过X 线透视、X 线摄片,CT扫描以观察椎间盘内解剖结构以及造影剂在盘内的分布情况,采用MRI实施椎间盘造影时,可以注射含钆的造影剂。(2)当注射造影剂后,复制出原有疼痛,即可准确的找到责任间盘。(3)有学者认为,在造影过程中监测间盘内压力,可以为治疗提供帮助。因此,椎间盘造影术在临床中广为应用。 2 椎间盘的解剖及病理基础 2.1 椎间盘的生理结构 成人椎间盘由纤维环、髓核和软骨板组成。由于纤维环结构不平衡,髓核在椎间盘中的位置略偏后,在脊柱的不同部位,椎间盘的大小和形状也不同。在站立位或静坐6 h后,椎间盘的容积减少,使椎间盘的高度减少16%-21%。而卧床休息一夜后,MRI检查发现椎间盘的T2 加权像信号增强25%。 2.2 椎间盘的病理生理 椎间盘是由蛋白多糖和胶原组成,其内部为相对呈液态的髓核,外面有坚硬、薄片状纤维环所包绕。椎间盘的正常退行性变是一种生理趋势,在创伤、异常退行性变过程中会发生多种生物化学和结构的变化,如软骨终板变薄透明化,纤维环发生放射状撕裂,间盘周围及裂隙间富含血管的肉芽组织形成,这些肉芽组织中含有大量疼痛感受器,机械性或化学性刺激侵犯到椎间盘的神经末梢疼痛感受器,则会引起疼痛。腰椎间盘髓核变性导致纤维环应力分布失去平衡和内层纤维环撕裂是腰椎间盘内紊乱的病理学基础。当内层纤维环破裂后, 纤维环内层的窦椎神经分支易受到来自于髓核的机械因素和化学因素的刺激, 出现椎间盘源性腰痛。对于多数患者,椎间盘源性的疼痛,是由机械刺激、化学因子刺激或炎症反应等综合因素所产生。这也为我们的治疗提供了针对性治疗的依据。随着退行性变进一步发展,纤维环中Ⅱ型胶原增加,伴随着髓核水分的丢失, 椎间盘正常流体力学特性逐渐消失。蛋白多糖和胶原的含量随着退行性变而下降,直接导致了椎间盘张力的下降和水分结合力的下降,同时,随着营养神经及血管的退行性改变,会出现间盘内细胞的死亡或凋亡,造成间盘结构发生明显改变,使椎间盘的高度下降,传递至小关节的负荷增加,加快了小关节囊的退行性变,从而产生了各种各样的临床症状。 3 椎间盘造影方法 3.1 椎间盘造影的穿刺 椎间盘造影通常采用神经刺激针(100 mm或150 mm) 作为穿刺针, 这种针比较细, 操作时对于神经、血管、椎间盘的损伤比较小。针刺的途径根据体位通常分3种, 分别为俯卧位的硬脊膜旁途径、经硬膜途径和侧卧位的椎旁途径。椎间盘造影可以在X线透视、X 线摄片及CT扫描下进行。 3.2 椎间盘内注射造影剂后的情况 正常的椎间盘纤维环完整、弹性好,并能维持一定的容量和内压。有报道, 正常腰椎间盘内能接受液体的容纳量大约为0.5-1.0 mL,最多容纳液体4mL。但另一些学者认为, 正常腰椎间盘容纳量仅为1.5-2.5 mL, 一旦超过3mL即可考虑椎间盘病变。正常的椎间盘内注入造影剂时会在椎间盘内产生较大压力, 造影剂注入量一般为1.0~1.5 ml。发生退变的椎间盘纤维环膨出、破裂或放射状撕裂时,造影剂向纤维环浸润并经破裂处溢出, 则理论上造影剂注入量会大于正常椎间盘容量。注入造影剂时应根据注射时遇到的阻力、剂量及影像学显示结果等综合判断间盘的病变情况,但要注意一点,在影像学定位扫描下,针尖位置较好时,注射造影剂阻力很大时,切忌不要暴力注射,以免造成医源性间盘破裂。注射造影剂后,根据是否诱发出与平时性质、程度相同的疼痛表现,可鉴别是否有椎间盘源性腰痛。同时,可根据注入造影剂的剂量和分布来判断纤维环撕裂程度,为进一步治疗提供依据。 3.3 椎间盘造影阳性标准 3.3.1 根据国际疼痛学会椎间盘源性疼痛及Walsh制定的椎间盘造影阳性标准: (1) 造影显示间盘结构上有退变;(2) 诱发痛与平时的疼痛类似或一致;(3) 至少有一阴性对照间盘。 3.3.2 根据向椎间盘内注入造影剂时患者的反应,分为三类:(1)一致性疼痛, 即与平时性质、程度、部位完全一致的腰痛; (2)非一致性疼痛, 即诱发的腰痛与患者平时腰痛在性质、程度、部位上有一定差异; (3)无痛,即注入造影剂未诱发任何腰痛。其中(1)判定为阳性, (2)、(3)为阴性。 3.4 椎间盘造影形态学分型 3.4.1 Sachs 等通过椎间盘造影来评估椎间盘损伤纤维环撕裂程度和椎间盘退行性变程度, 纤维环破裂程度共分4 级:0 级为造影剂完全在正常髓核内; 1 级为造影剂沿着裂隙流入内层纤维环;2 级为造影剂流入外层纤维环, 3 级为造影剂流出纤维环外层或流入硬膜外腔。0 级和1级为正常, 2 级和3级表示纤维环撕裂。 3.4.2 根据DallasCT椎间盘造影评价系统(Dallas discogram description, DDD)对造影阳性椎间盘的形态进行分型。对纤维环退变与纤维环破裂这两种现象按严重程度进行分级。(1)按纤维环退变程度分为4级:造影剂充填正常髓核空间为正常,退变级别为0级;纤维环退变后造影剂充填纤维环面积占正常纤维环面积10%以下时退变级别为1级;造影剂充填纤维环面积10%~50%为2级;造影剂充填纤维环面积大于50%为3级。(2) 按纤维环破裂程度分为4级:造影剂无外渗,完全局限于髓核内为0级;纤维环破裂后造影剂延伸达纤维环1/3未超过2/3时为1级;达2/3未超外缘为2 级;超过外缘为3级。 4 正确处理椎间盘造影结果与临床表现及影像学资料的关系。 4.1 椎间盘造影形态学变化与造影阳性诱发痛之间的关系 DallasCT椎间盘造影分级方法对纤维环的评估包括两个方面,纤维环退变和纤维环撕裂。对纤维环退变的评估以造影剂充填纤维环的面积为衡量指标,对纤维环撕裂的评估以造影剂自髓核溢出到纤维环的径线距离为衡量指标。国内有学者报道30例经椎间盘造影确诊为椎间盘源性腰痛患者中,纤维环退变为2级、3级的椎间盘在椎间盘造影阳性的椎间盘中占63.2%,而纤维环撕裂为2级、3级的椎间盘在椎间盘造影阳性的椎间盘中占94.7%,说明Dallas纤维环撕裂分级较纤维环退变分级更能提示椎间盘源性腰痛的诊断。早期的研究发现,椎间盘外层纤维环破坏与椎间盘造影的阳性诱发痛有强烈的相关性。一些研究发现在椎间盘内造影时,撕裂或破裂型椎间盘中,88%出现一致性疼痛, 而非撕裂或破裂型中仅48%出现一致性疼痛;出现一致性疼痛的椎间盘中97%有造影剂突破纤维环内层, 而无一致性疼痛的椎间盘仅为57%。有学者应用Dallas 椎间盘造影分级方法评估纤维环撕裂、退变程度和疼痛复制反应之间的关系,发现纤维环破裂未延伸至外层者无一例出现疼痛复制反应。以上结果表明椎间盘退变程度越重, 越容易出现纤维环撕裂和一致性疼痛反应。Colhoun 等将162例椎间盘造影后接受椎间融合术的患者分为两组, 结果椎间盘造影形态学和诱发痛均为阳性组患者手术成功率为88%, 而椎间盘造影形态学阳性而诱发痛阴性组仅为52%,说明椎间盘造影诱发痛在诊断椎间盘源性下腰痛中具有更重要的价值。 4.2 椎间盘造影结果和MRI影像之间的关系 MRI是诊断椎间盘退变最敏感的方法,临床中同一病例中多节段椎间盘信号发生改变的情况非常多见。传统腰椎CT及MRI等影像学检查对于单节段腰椎间盘病变, 结合临床表现及体格检查, 多可以明确诊断。但对于两个或两个以上椎间盘均有退变而责任节段不明确者, 单纯MRI信号改变无法区分产生症状的椎间盘来源,其诊断特异性较差。Aprill等首次提出HIZ的概念,即出现于纤维环后外侧的高信号变化,认为MRI影像上纤维环后方的高信号区与椎间盘造影诱发痛有密切关系,诊断疼痛的敏感度为82%, 特异度为89%, 阳性预测值为90%。但由于MRI分辨率及主观因素的影响,对高信号区的判断存在差异,得出的结论很难统一。 关于HIZ的解剖学及病理学基础,目前尚存在争议。 Aprill等认为其代表纤维环撕裂后的炎性反应。Schellhas等认为HIZ代表纤维环3~5级的撕裂,其高信号为髓核液填充所致。Rickeson等认为其代表椎间盘边缘由炎性诱导形成的新生血管或肉芽组织。彭宝淦等研究发现,对应高信号区的椎间盘组织表现为沿纤维环裂隙形成的不同程度的血管化肉芽组织。另一些学者研究发现在椎间盘造影过程中,MRI显示后缘出现T2加权象高信号、高亮点的椎间盘,在造影过程中全部诱发出疼痛,说明MRI-T2加权象纤维环后方的高信号与诊断椎间盘源性疼痛有密切的相关性,但仍缺乏大样本数据支持。对于MRI显示多节段间盘病变的患者,行椎间盘造影并且能够复制出原有疼痛者,则可以直接针对相应节段的间盘进行治疗,而其他节段MRI异常的间盘则不予考虑。目前临床常通过症状及MRI 的“黑椎间盘”表现排除腰椎间盘突出而怀疑椎间盘源性腰痛,而造影阳性的椎间盘数量要远低于MRI 所显示的“黑椎间盘”数量,说明MRI所显示的“黑椎间盘”并不全是引起腰痛的“责任”椎间盘。虽然慢性腰腿痛患者中MRI-T2加权象上纤维环后方存在的HIZ以及“黑椎间盘”对椎间盘源性腰痛有较高的提示作用,但尚不能取代椎间盘造影术在椎间盘源性腰痛诊断中的地位。 5 椎间盘造影的应用 5.1 椎间盘造影的适应症 (1)盘源性腰痛:腰背部疼痛、不能耐受长时间坐位、无放射性的四肢或腹部疼痛、无神经根支配的功能障碍区、可疑直腿抬高试验、无反射异常; (2)除外小关节源性、肿瘤性、感染性以及外伤性等; (3)无神经根受压导致的疼痛征象; (4)作为臭氧、胶原酶、射频等等微侵袭治疗方法的术前检查; (5)评估在CT或MRI检查无异常却有临床症状的患者的病变节段,及影像学表现与临床症状不相符合者; (6)确诊在CT或MRI检查中多节段病变的责任间盘; (7)对于一些腰椎术后疼痛综合症的患者,由于含有内固定物,行CT或MRI 检查会受影响,间盘造影可以显示间盘结构以及病变。 5.2 椎间盘造影的禁忌症 凝血障碍:血小板〈50000/mm3;全身感染或穿刺点皮肤感染;孕妇;椎间盘手术后;椎间盘平面脊髓显著受压;造影剂过敏。 5.3 椎间盘造影的并发症 出血;感染;药物过敏;头痛;硬膜外血肿、脓肿等,其中最常见的是椎间盘造影所造成的一过性疼痛加重,较少见但严重的并发症有椎间盘炎、脓肿形成、急性椎间盘突出。椎间盘造影开始应用以来,感染、神经损伤、出血等并发症的发生率很低,尤其是感染率极少,这与临床中预防性应用抗生素,严格的无菌操作密切相关。 5.4 椎间盘造影并发症的预防 为了预防以上并反症的发生,尤其是感染的发生,预防性应用抗生素是非常有必要的。由于椎间盘炎一旦发生结果十分可怕,因此1999年美国疾病控制中心(CDC)以及预防外科部位感染的指南均提出,在行椎间盘造影及其他椎间盘内操作时,均应常规预防性使用抗生素。体外实验证实,头孢唑啉及克林霉素与造影剂混合后,仍可发挥其抗菌作用。 6 展望 椎间盘造影目前被越来越多的临床医生应用,其主要是用于判断病变间盘节段,以及是否需要进一步治疗。椎间盘造影技术并非很复杂,随着影像学的发展,将使所得图片更加清晰,从而使造影时穿刺更容易与安全,同时减少并发症和缩短操作时间,以及减少患者及操作者的放射线曝光剂量。钆剂造影剂的应用,使碘造影剂过敏的患者有了更多的选择,并在 MRI引导下实施椎间盘造影, Slipman等应用MRI引导对14例碘造影剂过敏的患者的58个腰椎间盘实施了椎间盘造影,选择含钆的造影剂Gd-DTPA,显示7个椎间盘撕裂、7个椎间盘有裂隙,14例患者均未发生严重的过敏反应。MRI较CT提供了更多神经相关的信息,图像更清晰,定位更准确。然而,椎间盘造影作为诊断椎间盘源性疼痛的准确性及其对临床的指导意义方面仍存在争论,因此今后的研究应采用大样本、多中心的临床试验,进一步证实其有效性。虽然预防性应用抗生素对预防椎间盘感染起到很大的作用,但这些结论都源自动物实验,并无临床研究证实,并且抗生素的选择、剂量及用药时间等,仍无定论,因此关于椎间盘造影时应用抗生素的问题仍需进一步探讨。有关椎间盘造影诱发痛阳性与纤维环外层撕裂程度的关系,及其与临床症状的相关性及相关性程度,亦需进一步研究证实。由上可见,椎间盘内造影术虽然有其独特的优越性,但能否真正将其作为一种诊断性的工具,还需要大量的临床研究证实。
由于抗结核的药物使用,现代的诊断手段的提高,及外科治疗技术的进步,在有抗生素预防的时代,脊柱结核的临床疗效已明显提高。MRI在畸形形成前对结核引起的病变的诊断的敏感性达100%,特异性达88%。神经功能障碍与畸形是脊柱结核最严重的并发症。保守治疗的病人显示会增加15度的畸形,在儿童,即使结核病灶已经治愈,后凸畸形仍会继续增加。脊柱结核的首选治疗不是手术治疗,但手术治疗可以防止及治疗并发症。手术治疗的手术指征包括椎体病变、治疗耐受、严重后凸畸形、进展性神经功能受损、保守治疗无效或恶化。后凸角为60度或大于60度或后凸角可能进展的活动期的病人需要行前路减压、后路截骨矫形固定及前后路植骨术.迟发性截瘫重在预防而不是治疗。为获得好的临床疗效应对于无症状型的脊柱结核应保持高度警惕。由于HIV的出现及多重耐药,治疗耐受型脊柱结核正在增加。Tuberculosis of the spine, if not treated adequately,may cause serious sequelae. Potent antitubercular drugs, modern diagnostic aids and advances in the surgical management have improved the outcome, but certain issues remain. These include the importance of early diagnosis in order to prevent and, if necessary,to treat kyphotic deformity, the principles of treating uncomplicated and complicated cases, the diagnosis and management of atypical presentations, the management of the sequelae of severe kyphotic deformity and the emergence of multidrug resistance.如果不及时救治,脊柱结核可能引起严重后果,强力抗结核药的出现、现代诊断技术的提高及外科治疗技术的进步明显提高了治疗疗效,但还存在一些问题尚待解决。这些问题包括脊柱结核的早期诊断以防止后凸畸形、如果出现后凸畸形治疗的必要性,有并发症及无并发症的治疗原则,无症状结核的诊断及治疗,严重后凸畸形导致的严重后果的治疗及多重耐药出现后的治疗。Spinal tuberculosis is indolent and slowgrowing and can be diagnosed both clinically and radiologically in endemic regions.1,2 However,the lesions are best seen by MRI rather than by radiography.3 The low signal on T1-weighted images and the bright signal on T2-weighted images in affected vertebral bodies, the relative preservation of the disc, the presence of a septate pre- and paravertebral or intra-osseous abscess with a subligamentous extension and breaching of the epidural space, (Fig. 1) are all characteristically seen on MRI.4-6 The imaging features, with high sensitivity and specificity are disruption of the end-plate, 100% and 81.4% respectively, paravertebral soft-tissue shadow (96.8%, 85.3%) and a high signal intensity of the intervertebral disc on the T2-weighted image (80.6%, 82.4%). The overall sensitivity and specificity for diagnosis are 100% and 88.2%, respectively.6 A well-defined abnormal paravertebral signal and a smooth-walled abscess are seen in 90% of tuberculous lesions, but not in a pyogenic vertebral abscess.7,8 A pattern of bone destruction with relative preservation of the disc and heterogenous enhancement may differentiate spondylitic tuberculosis from pyogenic discitis, which may show peridiscal bone destruction and homogenous enhancement.7 The presence of an abscess and bone fragments differentiate spinal tuberculosis from neoplasia and if there is doubt an image-guided biopsy is indicated.9脊柱结核是无痛的进展缓慢的疾病,在地方流行区域可通过临床及放射学诊断,但是MRI检查比放射学更易发现结核病变。受累椎体通常在MR表现上是T1加权像是低信号,在T2加权像上是高信号。椎间盘相对完整。有分隔的椎前和椎旁脓肿、或骨内脓肿在韧带下延伸并突破到硬膜外腔(图1)MRI上典型特征。终板在影像学特征的高度敏感及高度特异,分别是100%及81.4%,椎旁软组织影(96.8%,85.3%),椎间盘在T2加权像高信号(80.6%,82.4%),诊断总的敏感率及特异度分别是100%与88.2%。异常椎旁信号及边缘光滑脓肿可见于90%结核病变,但不见于化脓性椎体脓肿7-8。骨质破坏、椎间盘相对完整及异形性增强可能区别结核性脊柱炎与化脓性椎间盘炎。化脓性椎间盘炎可出现皮质骨破坏与同质增强。脓肿与骨小块出现可区别脊柱结核与肿瘤,如果存在鉴别困难可行影像学引导下骨活检9。An MR scan will detect a tubercular lesionbefore it can be seen on a plain radiograph.10-12Multiple level tubercular lesions in the spine are observed in 16.3% to 71.4% of cases when an MRI study of the whole spine is performed.13-15 The diffuse hyperintense signal on the T2-weighted and the hypointense appearance on the T1-weighted images are suggestive of liquid extradural compression. Caseoustissue shows hyperintensity and granulation tissue heterogenous hyperintensity on T1- and T2-weighted images. The changes in the spinal cord may be interpreted as oedema of the cord, myelomalacia, atrophy of the cord and syringomyelia.16 Oedema of the cord is compatible with good neurological recovery following treatment, while myelomalacia, accompanied by a severe neurological deficit may show incomplete recovery.16 Mild atrophy of the cord is observed even when there is a successful neurological outcome. Moderate to severe atrophy, with or without syringohydromyelia, is seen in late-onset paraplegia.16MRI扫描可在X平片检查之前发现结核病变10-12,一项对整个脊柱MRI扫描研究发现多节段脊柱病变发生率在16.3%-71.4%。13-15.硬膜外出现T2加权像高信号弥散,T1加权像低信号提示硬膜外液体压缩。干酪样组织及肉芽组织异质化在T1,T2像上均为高信号。脊髓的改变有脊髓水肿、脊髓软化、脊髓萎缩、及脊髓空洞形成。脊髓水肿治疗后与神经功能恢复相一致。脊髓软化伴严重神经功能缺陷者可能不能完全恢复。16 即使神经功能恢复很成功在MRI上仍可发现脊髓有轻度的萎缩。中到重度萎缩伴或不伴脊髓空洞见于迟发性截瘫病人。16CT will delineate bone destruction earlier. Lesions of less than 1.5 cm are better appreciated than on plain radiography, but it is less accurate in defining the epidural extension of the disease. The bone destruction observed is either fragmentary (47%), osteolytic (33%) subperiosteal (10%) or localised and sclerotic (10%). Granulation tissue is seen as a high attenuation lesion and an abscess or caseous tissue as of low attenuation. Bone destruction with the shadow of a paravertebral abscess showing bone expansion with heterotopic bone or calcification is considered to be a sign of a tuberculous lesion.17,18CT可发现早期骨破坏,当病变小于1.5CM时,CT检查明显优于X线平片。但对于硬膜个疾病其精确度欠佳 。骨质破坏表现为小碎骨块(47%)、溶骨性破坏(33%)、骨膜下(10%)或局限性骨质硬化(10%),肉芽组织被认为是高度衰减病变,脓肿或干酪样组织被认为是低度衰减病变。表现为骨膨胀伴异位骨或钙化的骨质破坏伴椎旁脓肿被认为是结核病变的典型表现。17,18Relative lymphocytosis, a low level of haemoglobin and a raised ESR are found in active tubercular disease. The mantoux test is non-diagnostic in an endemic region and may be negative in an immunodeficient state. The sensitivity of staining for acid-fast bacilli may vary from 25% to 75%. Culture of acid-fast bacilli requires a long incubation period of four to six weeks, although Bactec radiometric culture takes less than two weeks.19 The serological tests are non-diagnostic in lesions with a low level of bacilli. The immunoglobulin (Ig) G and IgM titres show significant differences between the initiation of treatment and at three months later, but do not correlate with the stage, the recovery of the disease or the duration of antituberculous treatment.20,21 The polymerase chain reaction is an efficient and rapid method of diagnosis and can differentiate between typical and atypical mycobacteria. It analyses the expression of genes, even from the single cell. A positive result from a polymerase chain reaction is not a substitute for culture and is not indicative of the activity of the disease, since it does not differentiate live from dead micro-organisms and has been obtained from an ‘ancient’ sample of bone tissue.20,2活动性结核病常见淋巴细胞计数相对升高、血红蛋白降低及血沉升高。孟德尔试验在地方流行区域没有诊断意义,对于免疫缺陷者有可能结果为阴性。快速抗酸杆菌染色检查敏感性不同,波动范围在25%-75%。快速抗酸杆菌需要4-6周长的潜伏期,但Bactec检验需要不到2周的时间。当结核杆菌水平低时血清检测在结核病变没有诊断意义。免疫球蛋白IgG与IgM在治疗前与治疗后3个月相比有明显差异。但与结核所处时期、恢复及抗结核药物持续时间没有关系。20-21.PCR(聚合酶联反应)是快速有效诊断结核的一个方法,而且能区分典型与非典型结核分支杆菌。它可以分析基因表达甚至是单细胞的也可进行分析。PCR的阳性结果不能替代常检查,而且因为它不能从来源于死的微小机体分化活的杆菌,因此对于活动性疾病没有意义。它仅可从“古老的”骨组织样本获得杆菌。20-22A CT/fluoroscopic-guided fine-needle aspiration cytology biopsy is diagnostic for spinal lesions in between 88.5% and 96.4% of cases.23,24 In a series of 29 cases in which adequate tissue could be procured, cytological findings of epitheloid granulomas (89.7%), a granular necrotic background (82.8%) and lymphocytic infiltration (75.9%) were observed. The smear for acid-fast bacilli was positive in 51.7% and culture could be obtained in 82.8% of untreated cases.23-25 Culture, staining for acid-fast bacilli and histopathology are not capable of ascertaining the diagnosis in all cases, hence tissue from a biopsy should always be subjected to staining, culture and sensitivity, a polymerase chain reaction and histopathological examination.CT及X线透视下细针穿刺细胞学活检在诊断脊柱病变中占88.5%与96.4%,23,24.在29例病例中,获取足够组织细胞学发现为内上皮肉芽肿(89.7%)。有颗粒坏死背景(82.8%)淋巴细胞炎性反应(75.9%)。快速抗酸染色涂片51.7%为阳性,在未治疗的病例,微生物培养阳性率可达82.8%。23-25微生物培养、抗酸染色、组织病理学并不能确诊所有病例,因此,来源于活检的组织总是从属于染色,细菌培养与敏感性测定、PCR及组织病理学检查。The neurological deficit in tuberculosis of the spineThe worst complications of tuberculosis of the spine are para- or tetraplegia, hemiplegia or monoplegia.26,27 Paraplegia with active disease may be caused by mechanical pressure on the spinal cord by an abscess, granulation tissue, tubercular debris and caseous tissue, or by mechanical instability produced by pathological subluxation or dislocation. Oedema of the spinal cord, myelomalacia or direct involvement of the meninges and cord by tubercular infection and inflammation, infective thrombosis or endartertitis of spinal vessels may also lead to neural loss. Epidural involvement is observed in over 80% of cases without clinical evidence of a neurological deficit.6 Encroachment of the canal of up to 76% is compatible with an intact neural state. In the presence of mechanical instability the patient may develop neurological deficit at a lesser canal encroachment.28Paraplegia with healed disease (Fig. 2) may occur when the initial lesion has healed with a residual severe deformity ten to 20 years before. It is produced by stretching the spinal cord over an internal anterior bony projection, producing gliosis. MRI shows severe atrophy of the cord and/or syringohydromyelia, or constricting scarring of and around the dura.16,27 Reactivation of the disease is found in 30% to 40% of cases on exploration.29 Symptomatic severe stenosis of the lumbar canal and ossification of the ligamentum flavum adjacent to severe kyphosis may produce an incomplete neurological deficit.30,31如果原病变已经治愈但残留有严重畸形10年到20年截瘫仍可能发生。(图2)原因是因为内前方骨性突出物上的脊髓延伸,产生神经胶质增生而致。MRI示脊髓萎缩或脊髓空洞或硬膜周围压缩性瘢痕形成。16,27.经过研究发现结核复发率为30%到40%。29.严重后凸畸形相邻节段的有症状严重腰椎管狭窄与黄韧带骨化可能导致不完全性神经功能缺陷。Spinal deformityThe development of kyphosis is the rule rather than the exception. Patients treated conservatively have a mean increase in deformity of 15° and in between 3% and 5% the final deformity is > 60°.32,33 After anterior decompression and bone grafting kyphosis continues to increase for six months.34 Slippage and breakage of the graft, with consequent progression of the kyphosis and neurological deficit, are more frequent when the graft spans two disc levels.35,36In children the kyphosis continues to increase even after healing of the lesion. The growth potential of vertebral bodies may be destroyed by the disease, surgical resection and debridement or by the effect of biomechanical forces on the growth plate of both the fusion mass and the vertebral segment within the kyphotic region.37 Progression of the kyphosis is found to be worst when anterior resection and fusion alone are performed. It is least when both anterior and posterior fusion is undertaken or with anterior debridement alone, when some growth potential is preserved. 38 The unabated growth of the posterior column may also add to the progression, but in their study Upadhyay et al39 did not notice any evidence of disproportionate growth of the posterior spine脊柱畸形后凸畸形的发展是有规律而不是所谓的例外,保守治疗的病人平均畸形增加的角度为15度,并且以3%-5%一速率增长,最后畸形的角度可大于60度32-33。前路减压与植骨术后6月后凸畸形继续增加34.当植骨跨越两个节段时常见植骨滑移,断裂、后凸畸形进展及神经功能缺陷。35,36.儿童患者,即使结核已治愈,后凸畸形仍可继续增加。椎体的生长势能可能会被病变、外科切除与清创或在融合节段上的生长面与后凸椎体节段生物机械力破坏。37.当仅行前路减压与融合术时后凸畸形进展最严重。因此手术时应行前后路联合融合术,当椎体生长势能保留时可仅行前路病灶清除。38后路不衰减的生长也可能导致后凸畸形进展,但在Upadhyay等的研究中没有发现脊柱后路不成比例生长的证据。Rajasekaran40,41 observed continued progression of the deformity during the quiescent phase until the growth was complete in 40% of his patients, while 43% had spontaneous improvement and 17% showed no change. The progression of deformity was either of an angular kyphosis or by a buckling collapse.41 The status of the posterior column and the type of stabilisation undertaken were the main factors determining deformity.The vertebrae can restabilise when there is a large contact area on the distal vertebrae (type-A restabilisation), usually seen when the vertebral body is partially destroyed or in the lumbar region. When vertebral destruction is severe, with marked loss of vertebral height, and the patient already has a moderate kyphosis, one or both facets may sublux or dislocate, with the proximal vertebra stabilizing with point contact on the distal (type-B restabilisation). The compressive force produces suppression of growthresulting in a deformity of between 40° and 60°. The remaining part of the vertebral body may grow as a wedge. Type-C restabilisation occurs when there is severe destruction of the anterior column. The dislocation of both facets leads to a buckling collapse. The proximal vertebral body may rotate through 90° with its anterior border resting on the distal vertebra. The horizontal vertebrae are spared gravitational forces and hence grow longer, adding to the kyphosis. Buckling collapse is likely to occur in children younger than seven years of age with three or more vertebral bodies affected in the dorsal or dorsolumbar spine. Signs of a ‘spine at risk’ include retropulsion, subluxation, lateral translation or toppling.40-42Rajasekaran40,41观察到他的40%的病人在静止相到生长结束时脊柱畸形持续进展,43%自行矫正17%的病人没有改变。脊柱畸形的改变表现为后凸角度或椎体塌陷的改变。41.后柱状态及稳定类型是决定脊柱畸形的主要因素。当椎体间有大的接触面积时椎骨可------(A型----)通常当椎体部分破坏或在腰椎部位。当椎体破坏严重,随着椎间高度的丢失,病人已经有中度的后凸畸形,一侧或双侧椎间关节半脱位或脱位。近端椎体与远端椎椎体通过点接触而稳定。(B型----)压缩的力量压抑了生长进而导致了40度到60度的畸形。椎体其余部位仍可像楔子样生长。当前柱严重破坏时可发生C型 ---。双侧关节脱位将导致椎体塌陷。近端椎体可通过旋转90度与静止在远端椎体。水平的椎体省重力因此长得更长,增加了后凸畸形。椎体塌陷常发生于小于7岁的小孩,常累及3个或更多的背侧或腰背侧椎体。脊柱危险的体征包括后移、半脱位、横向平移或倾倒。40-42Other complications include a large retropharyngeal abscess producing problems with swallowing and hoarseness. Tubercular arteritis and a pseudo-aneurysm in association with an adjacent lesion has also been described.43 The local instability and angular kyphotic deformity accelerate the degeneration of involved segments and ossification of the ligamentum flavum is likely to develop in response to the repetitive stimulus of excessive wear.30,31 The spinal cord may undergo intrinsic changes to produce late-onset paraplegia. Patients develop painful costopelvic impingement and a reduced vital capacity, resulting in respiratory compromise.2,21其它并发症包括咽后壁大脓肿导致吞咽困难、声嘶。还有邻近结核病变部位发生的结核性动脉炎及假性动脉瘤的报道。43.局部不稳及后凸畸形加速了相邻节段的退变与黄韧带骨化其形成可能与过度摩擦反复刺激有关。30,31、脊髓可能会发生本质上的改变进而产生迟发性截瘫。病人发展成为疼痛性的局部骨盆撞击征和减少肺活量导致呼吸器官损害。Principles of treatmentBefore the advent of antibiotics only 25% of patients achieved healing when treated in a sanatorium. The remainder died from military disease.21 Later treatment, such as posterior spinal fusion without curettage of the diseased bone, gave disappointing results.21 The introduction of antibiotics allowed bacterial control of the disease and healing, but with a residual kyphosis. With improvements in imaging and diagnostics, better operating-theatre facilities, the introduction of intensive-care units and the use of modern spinal instrumentation, healing may be achieved with minimal or no spinal deformity.44,45治疗原则在抗生素出现之前,通过疗养治疗的结核治愈率仅为25%。其余的均死于陆军病21,后来的治疗如不行骨切除的脊柱后中融合术疗效也不满意。21.抗生素的引入可以控制及治愈结核,但残留有后凸畸形。随着影像学技术与诊断水平的提高,以及更好的手术室设备的出现,ICU的引入以及现代脊柱器械的使用,结核可以治愈并且仅残留很少或没有畸形。Tuberculosis of the spine without a deficit. The choice of treatment of uncomplicated tuberculosis of the spine was at one time controversial. The divergent philosophies of management by radical surgery or by ambulant chemotherapy were resolved by the multicentre trial organised by the Medical Research Council (MRC) of the United Kingdom. Conservative treatment involving the use of two or three antituberculous drugs with bedrest or ambulant chemotherapy, the radical clearance of a lesion and the Hong Kong method of anterior debridement and fusion or anterior debridement alone, gave similar long-term results with no late relapse or late-onset paraplegia.46 The only advantage of the radical operation was less late deformity compared with debridement.46 The cure rate for conservative treatment and for the Hong Kong method was 85% and 89.9%, respectively. Tuberculosis of the spine is a medical disease and should be treated with antituberculous drugs, rest and mobilisation with a suitable orthosis.47-50 Surgeryis indicated if the diagnosis is uncertain, for a panvertebral lesion, a potentially unstable spine which should be stabilised, for refractory disease, in an adult with kyphosis of 60° or more and in children when the kyphosis is likely to progress with growth.27没有神经功能缺陷的脊柱结核的治疗原则 无并发症的脊柱结核的治疗方式的选择曾经存在争议。MRC(医学研究委员会 英国)通过一项多中心实验解决了是激进的手术治疗还是非卧床的药物来治疗脊柱结核的争议。保守治疗包括口服2到3种抗结核药物伴卧床休息或非卧床休息。激进的病灶清除与香港的前路病灶清除与融合或仅行病灶清除在长期的随访结果类似,没有晚期复发或迟发性截瘫。46.激进的手术治疗与单纯病灶清除的唯一优点是晚期畸形少一些。保守治疗与香港手术方法的治愈率分别是85%与89.9%。脊柱结核可以通过抗结核药物、休息及矫形器制动来治疗。47-50手术的指征是诊断不确定、伴有椎体病变,应该稳定而实际可能不稳定的脊柱病变,及治疗耐受性结核,成人后凸畸形大于60度或更大,小孩后凸可能随着生长进展的脊柱结核。27Antitubercular drugs are found in pus and granulation tissues at well above the minimum inhibitory concentration. 51-53 Isoniazid, rifampicin and pyrazinamide have been found above minimum inhibitory concentration in foci outside the sclerotic wall, and at undetected levels in foci inside the sclerotic wall.54 Sclerotic bone seems to play an important role in blocking the penetration of antituberculous drugs into the disease focus.54在脓液及肉芽组织中的抗结核药均发现其浓度高于最小抑菌浓度51-53,在硬化带外侧异烟肼、利复平,吡嗪酰胺的药物浓度均高于最小抑菌浓度,而在硬化带内侧没有检测到药物含量。硬化骨似乎在阻止结核药物进入病灶组织中起了很重要的作用。54A daily dosage regime and an intermittent short course as described below, are currently the treatment of choice. In vitro exposure of tubercle bacilli to antituberculous drugs is followed by a lag period of several days before growth begins again. Hence maintenance of a continuous inhibitory concentration of the drug is not necessary to kill or to inhibit growth of Mycobacterium tuberculosis.55-57 The most popular protocol is to use rifampicin, isoniazid, ethambutol and pyrazinamide for an initial two months followed by a maintenance phase of rifampicin and isoniazid for six, nine, 12 or 18 months. It was found that antituberculous therapy for six or nine months, with surgical excision of the lesion and bone grafting, produced clinical and radiological results comparable to those at 18 months.58,59 Even in the presence of paraplegia, a combination of surgery when indicated and a short course of drug treatment for nine months was effective60 if given under supervision. Recurrence after a short-course regime has also been described. Five of eight patients who had a six-month regime relapsed, while none of 30 patients, who had treatment for nine months or longer, did.61以下所述的常规剂量、间隙短程治疗是目前治疗方式的一个选择。体外暴露结核杆菌对使用抗结核药物时在再次生长前有几天的迟滞期。因此持续的药物抑菌浓度的维持对于杀灭或抑制结核杆菌的生长是没有必要的。55-57.目前最流行的药物治疗方案是异烟肼、利复平、吡嗪酰胺、乙胺丁醇口服两个月,然后用利复平、异烟肼维持6、9、12或18个月。文献有报道结核药物使用6个月或9个月并行病灶清除植骨术的病人的临床与放射学结果与使用18个月结核药物的病人疗效是类似的。59,59.。即使存在截瘫、如果进行监督、外科手术与9鼐月的短期药物治疗也是有效的。60 .短程治疗的复发率也有报道,其中有8例中的5例行6个月的短程治疗后出现复发,但在9个月或更长时的短程治疗的30例病人没有一例复发。The radiological evidence of healing lags behind by three months. In the absence of reliable serological and immunological markers of healing, the ‘healed status’ is achieved if there is clinical and radiological evidence of healing with no recurrence after two years. Short-course regimes after surgery and ambulant chemotherapy have both given encouraging results. Since the MRC trial failed to resolve the issue of the duration of drug treatment for spinal disease, a well planned and executed randomised, control trial is needed to establish this.治愈的放射学证据要滞后3个月。在缺乏可靠的血清学与治愈的免疫的标志物下,治愈即是指有临床与放射学治愈证据术两年后不复发即为治愈。手术后短程治疗与非卧床的药物治疗均取得了满意的疗效。由于MRC试验没有解决结核药物治疗脊柱结核的持续时间问题,需要一个计划好的可执行的随机对照试验来证实。Tuberculosis of the spine with a neurological deficit. The best treatment of spinal tuberculosis with paraplegia is to prevent the development of the paraplegia.27,62 The objective is to decompress the spinal cord by conservative treatment and/or surgery, to stabilise the spine if needed and to respond appropriately to direct involvement of the spinal cord and meninges. Surgical treatment is practised worldwide even for a minimal grade of neurological deficit. Tuli62 observed neurological recovery in 30% to 40% of patients having drug treatment and rest for four to six weeks while waiting for surgery or being made fit for it. However, waiting for a few weeks under these circumstances is clearly not justified.62 The patients in whom MRI shows a relatively preserved cord with evidence of myelitis or oedema and a predominantly fluid collection in the extradural space, respond well to conservative treatment if mechanical compression is the only cause of the neurological deficit.16,27,63 Early surgical decompression is indicated when MRI shows that the extradural compression is due to granulation tissue or caseous tissue, with little fluid component compressing the spinal cord, and with features of oedema of the cord, myelitis or myelomalacia. The indications for surgical decompression with or without stabilisation are development, no improvement or worsening of neural deficit after conservative treatment,16,27 the acute onset of a severe grade of paraplegia and paraplegia with involvement of the neural arch, or panvertebral involvement with or without pathological subluxation or dislocation.27,63有神经功能缺陷的脊柱结核 伴有截瘫的脊柱结核的最好治疗是防止截瘫症状发展27,62.脊髓减压的目的是通过保守和或手术稳定脊柱、如果需要对涉及的脊髓与硬脑膜进行合适的减压。即使有轻微级别的神经功能缺陷在世界范围内均使用手术治疗。Tuli等观察到在等待手术治疗的病人中经过药物治疗与休息4-6周后约30-40%的病人神经功能得到恢复。然而,在这些条件下等上几周的方式还未明确证实其合理性62.MRI示有脊髓炎、水肿、及液体主要积聚于硬膜外的这类病人,如果神经功能缺陷的原因仅为机械性压迫可以行保守治疗。16,27,63 当MRI示硬膜外压迫是因为肉芽组织、或干酪样组织仅有少量液体构成的组织压迫到脊髓并有脊髓水肿、脊髓炎、或脊髓软化等原因造成需要行早期手术治疗。伴或不伴稳定术的手术减压的指征是发展的,保守治疗后症状无改善或加剧16.27.急性严重截瘫或累及椎弓的截瘫或椎体病变伴或不伴病理性脱位或半脱位,27,63.Instrumented stabilisation. Instrumented stabilisation can safely be performed in a tubercular infected bed.64 In most reported series this was done in patients with a mild initial kyphosis of 30° to 35° in order to prevent further deterioration. 63 The indications for instrumented stabilisation are panvertebral disease, long segment disease in which the bone graft after anterior decompression is more than the length of two vertebral bodies65 or when correction of a kyphosis is contemplated.35,66 The span of anterior instrumentation in long segment disease requires a wider exposure. Posterior instrumentation, such as the use of a Hartshill implant, can take purchase in healthy vertebrae one segment above and below.35 Pedicle screw fixation can also be used.固定器械 结核病灶床放置固定器械是安全的64,在多数病例报道中对30到35度的轻度后凸畸形行内固定的目的是防止恶化63.内固定使用的指征是椎体病变、前路减压后长节段病变超过两个椎体或预计行后凸畸形有矫正时,35,36.前路长节段固定需要广泛的显露。后路固定如Hartshill固定物的使用,可在健康椎体的上或下缘取得.35.也可使用椎弓根螺钉固定。Correction of kyphosis in active disease. This is indicated when the patient presents with a severe kyphosis of ≥ 60°, or if the kyphosis is likely to heal with this amount of deformity. This will occur if three or more vertebrae are involved with a loss of 1.5 or more vertebral bodies in the dorsal or dorsolumbar spine.6,44,66,67 Children younger than seven years of age, with three or more affected vertebral bodies in the dorsal or dorsolumbar spine and two or more ‘at-risk signs’, are likely to have progression of the kyphosis with growth and should undergo correction.40-42活动性病变的后凸畸形矫正 当患者后凸畸形≥60度时或者如果后凸畸形的角度可能得以治愈时是矫正的指征。如果累及3个或更多椎骨伴有腰背部1.5个或更多椎体丢失6,44,66,67或行手术治疗,小于7岁的小孩的腰背部3个或更多椎体受累或2个或更多椎体处于危险状态预示着后凸畸形将随着生长而进展加重,因此也应该行矫形手术。At operation, anterior decompression or corpectomy, shortening of the posterior column, posterior instrumented stabilisation, grafting of the anterior gap and posterior fusion are performed in a sequential manner in a single stage.66 During the procedure the spinal cord should be kept under vision in case it should become elongated. Correction of the kyphosis can be done by:a) a single-stage transpedicular approach;68-71b) two-stage anterior decompression and bone graftingfollowed by correction of the kyphosis and posteriorinstrumentation72,73 orc) a single-stage correction by an extrapleural anterolateralapproach.35,44,66手术时,一期行前路减压、椎体切除、后柱缩短、后路固定、前路植骨后路融合按顺序进行66。在手术操作中,脊髓应在直视下进行以防其变长。后凸矫形可按以下方案执行:a)一期行椎弓根入路68-71b)2期行前路减压与植骨然后行后凸矫形与后路固定72,73c)通过胸膜外前路一期矫形35,44,66The soft tissue on the lateral wall of the pedicle and vertebral body should be removed by blunt dissection and elevated on both sides by a single-stage transpedicularapproach. The cancellous bone and granulation tissue should be curetted until the residual bony cortex remains. A dorsal closing-wedge osteotomy is undertaken. Before performing decompression and closing the wedge osteotomy the pedicle screws should be placed in the proximal and distal vertebral bodies, or Hartshill segmented spinal instrumentation undertaken later. During closure the thecal sac should be constantly kept under vision to avoid compromise of the cord.68-71椎体与椎弓根外侧的软组织应通过钝的剥离子移开,两侧的软组织通过一期椎弓根入路剥离。去除松质骨与肉芽组织保留皮质骨,背侧楔形截骨。在减压前关闭楔形切骨面,在椎体远端与近端置入椎弓根螺钉或行Hartshill节段脊柱内固定系统。在关闭壳膜囊时,应该经常保持直视下操作以防损伤脊髓。Correction of the kyphosis can be achieved by anterior decompression through a transthoracic transpleural or retroperitoneal approach with grafting of the gap, followed by posterior instrumentation through a midline posterior approach at the same time or two to three weeks later. Moon et al72 initially performed posterior instrumentation followed by an anterior procedure in two stages in their early cases, but later did both in the same operation. The correction achieved was from 37° to 15°, finally healing at 18°.72 Louw73 performed transthoracic anterior decompression and vascularised rib grafting during the same procedure, or two weeks later, by shortening of the posterior column with a multilevel posterior osteotomy, instrumentation and fusion. The overall length of the anterior column was not altered and the kyphosis was corrected by an anterior graft acting as a pivot. The mean pre-operative kyphosis of 56° was corrected to 27°, which healed at 30°。后凸畸形矫形可通过经胸腔入路或腹膜入路前路减压与间隙植骨来完成,然后可同时或术后2-3周通过后正中入路行后路内固定术。72Moon等在他的病例中首先报道了分二期行前路手术后再行后路内固定术,但后来在一次手术完成。其矫正度从37矫正到15度最后为18度。Louw等报道了经胸腔入路前路减压然后同期或2周后行带血管的肋骨骨移植,通过后路多节段截骨缩短后柱、内固定融合术。前柱有总长度没有改变,通过前路支撑植骨来矫正后凸畸形。其平均术前后凸角为56度,术后长形到27度,治愈时为30度。The anterior and posterior columns of the vertebral body can be exposed by an extrapleural anterolateral approach in the lateral position to correct a kyphosis (Fig. 3).35,44,66 The thoracic cavity and diaphragm are not violated, thus pulmonary morbidity is avoided. The lateral position reduces the risk of a neural deficit and obviates the need for temporary stabilisation.The cervical and lumbar kyphosis should be corrected at a lesser degree. Lumbar kyphosis is best corrected by a pedicle subtraction osteotomy. However, for cervical kyphosis (Fig. 4) it may be necessary to resort to cervical traction followed by anterior decompression, bridging the gap by a bone graft and anteriorinstrumented stabilization using a plate.前柱与后柱的椎体可以通过侧卧位的胸膜外前外侧入路来矫正后凸畸形(图3)35.44.66胸腔与膈不会受到侵犯。因此肺的并发症可以避免。侧卧位降低了神经损伤的危险、排除了临时固定的需要。颈椎与腰椎的后凸矫正不要过大,腰椎后凸畸形矫正应在牵引下截骨。然而,颈椎后凸(图4)行前路减压、植骨及前路钢板内固定时颈椎牵引是有必要的。Healed kyphosis and late onset paraplegia. Correction of a kyphosis in a patient with poor pulmonary function is a difficult procedure with a high risk of neurological injury.Yau et al74 described a multistage procedure with spinal osteotomy and halopelvic distraction with an anterior and posterior fusion. The mean pre-operative kyphosis of 115.5° was corrected to 87.2° with three deaths in 29 patients. The authors concluded that this was a relatively small reward for such a major undertaking. Moon75 believed that cosmetic correction of a long-standing severe healed kyphosis should not be performed. Such corrective surgery may be undertaken in severe deformity with recurrent disease and when paraplegia or death from chest complications is imminent. Recently, correction of a healed kyphosis of the lower dorsal and dorsolumbar spine by transpedicular subtraction osteotomy has been described.76 A mean pre-operative kyphosis of 58.8° was corrected to 17.9° with no major intra-operative complications. Anterior decompression and fusion are advocated in all such cases.77,78 The internal bony prominence may be removed by a transthoracic transpleural approach. The extrapleural anterolateral approach allows direct exposure of this without jeopardising the already compromised pulmonary function. 78 The spinal cord has very little physiological, neural and vascular reserve, hence the high risk of neurological deterioration. The internal kyphectomy allows the spinal cord to transpose anteriorly. The response to anterior decompression is faster, better and safer in patients with a reactivation of tubercular disease,78 while with healed disease decompression is technically more difficult and recovery less satisfactory.79 Neurological deterioration, transient or permanent, and cerebrospinal fluid fistulae have been described and the patient should be warned before the surgery about the possibility of complications.79 Internal kyphectomy is still worth performing in moderate and severe paraplegia since even mild sensory recovery may improve the quality of life.后凸畸形伴迟发性截瘫的治疗 肺功能差的患者行矫形术时操作困难、神经损伤的风险大。Yau等报道了多期手术脊柱截骨骨盆牵引下前后路融合术。术前平均后凸角度为115.5度,术后矫形到87.2度,29例病例,3例死亡。作者结论认为这么大的手术相对来讲获益较少。Moon等认为长期站立的严重后凸畸形的美容矫形术不应执行。严重后凸畸形伴复发病变应行矫形术,当胸部并发症导致死亡或截瘫时才是紧急矫形术。近来,有文献报道了经椎弓根牵引下截骨治疗下腰及腰背侧后凸畸形的矫形术。76.术前平均角度为58.8度术后矫正到17.9度。术中无主要并发症。前路减压与融合得到了广泛支持。77.78.经胸腔入路时内部骨突去除。胸膜外前外侧入路要求直接暴露不损伤已经受损的肺功能78.脊髓有小的生理的神经与血管保留,因此有神经功能恶化的风险。内部后凸骨切除要求脊髓转位至前方。相对来讲对于再发结核疾病的病人前路减压更快、更好更安全,78.然而,治疗的疾病减压在技术上来讲更难恢复的满意度较低。79. 暂时或永久的神经功能恶化、脑脊液瘘等可能发生并发症术前应该向病人讲明79.即使轻度神经功能恢复可以提高病人生活质量因此对于中重度截瘫行后凸截骨术仍是有价值的。Atypical spinal tuberculosisThe typical paradiscal tubercular lesion is well-described, easily recognised and treated80,81 Atypical spinal tuberculosis is defined as compressive myelopathy with no visible or palpable spinal deformity and without the radiological appearance of a typical vertebral lesion.80-83 Such lesions are relatively uncommon, mimic low-grade pyogenic infection, brucella and sickle-cell spondylitis, hydatid disease, lymphoma and malignant deposits and are difficult to diagnose diagnose and treat in the early stages with more chance of neurological complications.80,81 Atypical lesions may present as an intraspinal tubercular granuloma, involvement of the neural arch, compressive myelopathy in single vertebral disease, a concertina collapse of a vertebra or a sclerotic vertebra with bridging of the intervertebral body.非典型的脊柱结核典型的椎间盘旁的结核很容易描述并且容易识别与治疗80,81.非典型脊柱结核定义为有脊髓压迫没有明显或触及不到脊柱畸形,没有的椎体病变的X线表现。80-83.此种病变相对少见,有些像低度的化脓性感染,布氏菌与鎌状细胞脊柱炎,棘球蚴病,淋巴瘤和恶性沉着并且在早期有更多的神经并发症故诊断治疗困难80,81。非典型病变可能表现为椎管内结核样肉芽肿,波及神经弓,压迫单椎体病变的脊髓,手风琴样椎体塌陷或椎体间桥接样硬化。Granulomatous lesions of the epidural, intradural, or intramedullary spaces present as a compressive myelopathy, the spinal tumour syndrome, without obvious radiological signs.84,85 An extradural lesion may not have bony destruction or there may be a small lesion of a vertebral body not discernible on radiographs. MRI will demonstrate the lesion. Operation is the treatment of choice in order to procure tissue for histological diagnosis and to decompress the spinal cord. A laminectomy is required for an extradural extraosseous granuloma, but if the vertebral body is diseased, anterior or anterolateral decompression is indicated. Usually an extradural granuloma shows good neurological recovery after surgery.84,85 Laminectomy is the operation of choice for a subdural granuloma. The dura is opened where it is tense. These patients also show good recovery. An intramedullary granuloma presents with a painless, compressive myelopathy with a past history of tuberculosis. The differential diagnosis includes solid tumours of the spinal cord and cysticercosis. Gadoliniumenhanced MRI is the investigation of choice. An intramedullary tuberculoma, if suspected on MRI, may resolve with antituberculous therapy and close observation of the neurological status.86,87 Surgical decompression and myelotomy are indicated in order to decompress the spinal cord and to ascertain the diagnosis if the neurological status deteriorates. Tubercular granuloma should be considered in the differential diagnosis of spinal tumour syndrome in zones endemic for tuberculosis.86,87 Between 2% and 10% of all tubercular spines have a sole lesion in the posteriorelements,2,83 with a higher incidence of paraplegia.82,83 It may affect the spinous process, the laminae,pedicles, apophyseal joints and transverse processes, with involvement of the pedicle being the most common. Plain radiography does not demonstrate these lesions, but the absence of a pedicular shadow in the anteroposterior view is suggestive of a pedicular lesion.80 CT and MRI can clearly delineate such lesions. Fine-needle aspiration cytology is a useful diagnostic investigation. Chemotherapy is indicated in cases with no neurological deficit and a laminectomy in those with signs of neurological involvement.81硬膜外、硬膜内或髓内间隙的肉芽样病变压迫脊髓出现肿瘤样病变,而无明显的放射学表现84,85.硬膜外病变或能没有骨质破坏或仅有微小的椎体病变但放射学检查查出,MRI可以明确病变。为了获得组织病理学诊断及脊髓减压可以进行手术治疗。对于硬膜外骨外肉芽肿可以行椎板切除术,但是如果椎体有病变,需行前路或前外侧减压。通常硬膜外肉芽肿术后神经功能恢复好。在硬膜紧张处打开硬膜。此类病人恢复也好。髓内肉芽肿表现为无痛,有结核病史、压迫脊髓。不同的诊断包括脊髓硬肿瘤,囊虫病。MRI增强鉴别诊断一种选择。如果MRI怀疑髓内结核瘤可以行抗结核药物治疗并观察近期的神经功能状态。86,87.如果神经症状恶化可行髓内减压及脊髓切开以减压脊髓并明确诊断。结核性肉芽肿 与脊柱肿瘤症状的鉴别诊断是脊柱结核好发于结核高发病区。86,87.脊柱结核中约2%-10%的病例仅表现为单纯的后部结构病变伴较高的截瘫发病率。2,82,83.并可能影响到棘突、椎板、椎弓根,骨性关节及横突,以波及椎弓根最为常见。X平片不能发现此类病变,但在椎弓根阴影缺失的情况下前后位X片可以发现椎弓根病变。80.CT与MRI可以清楚的发现此类病变。细针穿刺抽吸细胞学检查对于诊断是有帮助的。只要诊断明确即使没有神经缺陷症状也需用化疗,椎板切除术的适应征是有神经功能病变的体征时行椎板切除。Tuberculous infection can start in the centre of the vertebral body which will be weakened by permeation with granulation tissue and may show concentric collapse.81 Plain radiography may show collapse of the body with preservation of the adjacent disc space. MRI usually differentiates tuberculous disease from other pathologies and will show inflammatory changes in adjacent vertebrae. CTguided biopsy is indicated for tissue diagnosis.82,88结核感染始于椎体中央,是因为椎体中央有肉芽组织长入并且椎体成向心性塌陷81.X平片可以显示出椎体塌陷而相邻椎间盘间隙保留。MRI常用来鉴别结核与其它病变并且可以显示出相邻椎体的炎性改变。CT引导下穿刺活检是组织学诊断的指征。82,88Multidrug-resistant tuberculosisThis occurs when the organism develops resistance to rifampicin and isoniazid while resistance to any other drug is described as ‘other drug resistance’.89 The survival rate at five years for a patient with multidrug-resistant tuberculosis is 50%, similar to that of a patient with spinal tuberculosis in the pre-antibiotic era. Between 60% and 90% of HIV-positive cases have extrapulmonary tuberculosis. 90 Multidrug-resistant tuberculosis has developed because of erratic drug ingestion, monotherapy, suboptimal drug dosages, and inadequate duration of non-adherence to the drug treatment.89If there has been no clinical improvement after adequate chemotherapy for three months and there is persistent growth of Mycobacterium from the sputum, development of multidrug-resistant pulmonary tuberculosis must be suspected. Since spinal tuberculosis is a paucibacillary disease and there is difficulty in procuring repeated samples of tissue from which to isolate the organism, the clinical criteria for suspicion of multidrug-resistant tuberculosis must be defined. Before resistance is demonstrated on culture and sensitivity, it is prudent to label suspected patients as ‘therapeutically refractory cases’. Suspicion may be raised by a lack of clinical or radiological improvement, by the appearance of a new lesion or a cold abscess or by an increase in bone destruction after chemotherapy for three to five months.多重耐药结核当器官对异烟肼、利复平形抵抗或对其它任何药物形成抵抗时称为抗药性89.结核抗药性的病人5年生存率为50%,与抗生素前时期脊柱结核的生存率类似。60-90的HIV阳性患者都有肺外结核90.多重耐药的形成是是为服药不规律,单一治疗,低剂量药物及服药待续时间不足非持续性的药物治疗89.如果足量化疗3个月后临床症状无改善痰液中结核杆菌持续生长改变必须怀疑多重耐药肺结核。由于脊柱结核是一个含菌量少的疾病因此获得反复抽取的组织样本存在困难,如果从样本里分离出怀疑多重耐药结核的临床标准时必须予以确定。在耐药性被微生物测定及敏感性测定前,诊断疑似病例为治疗耐受型病例时需谨慎。在临床或放射学检查无改善,又出现新的变或冷脓肿或在化疗后3-5个月骨质破坏增加应该高度怀疑为治疗耐受病例。The dose and duration of antituberculous drugs taken in the past should be listed. Early surgery is indicated to ascertain the diagnosis, identify the organism, perform culture and sensitivity tests and to reduce the bacterial load. Conventional bacteriological microscopy and cultures have limited sensitivity, specificity and a delayed diagnosis. Culture in Bactec radioactive liquid medium and genotypic analysis involving amplification by polymerase chain reaction followed by post-amplification analysis of mutation, have reduced the turnaround time to days rather than weeks or months.91-93 The conventional assay must still be performed. Drugs for multidrug-resistant tuberculosis are toxic, expensive, and are taken for a longer period of time. Therefore this condition is better prevented than treated. A minimum of four and preferably six bacteriocidal drugs should be used. A single drug should never be added to a failing regime and all drugs should be used for 24 months or longer. The adverse drug reactions and hepatic sideeffects should be monitored diligently.应详细记录结核药物的亣量及持续时间。早期手术的指征是需明确诊断、鉴别生物体、行微生物培养及敏感性检查、减少细菌接种量。目前常规的细菌学显微镜检及微生物培养已经限制了敏感性、特异性及延迟了诊断。巴氏放射性液体培养基微生物培养及通过PCR扩增的基因分析及PCR扩增后变异分析把出报告时间减少到了天而不是周或月91-93.常规化验仍必须检查中。治疗多重耐药结核瓣药物是有毒的、价格贵并且须服用更长时间。因此,对多重耐药的预防为主。最少服用4种药物推荐6种杀菌药物。单一的药物不要使用于失败病例,并且所有药物均使用24个月或更久。应该经常观察药物的不良反应与肝毒性副作用。No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.本研究没有收到任何形式、任何商业集团直接或间接对的资助
选择性神经根阻滞(selective nerve root block,SNRB)是在影像设备引导下,对可能引起神经根痛的病变神经根进行穿刺阻滞的微创技术,同时具有诊断和治疗的双重作用。早期认为SNRB就是椎旁阻滞(Paravertebral Block, PVB),因进针点位于椎旁脊神经的椎间孔附近。1971年,Macnab[1]首先报道在X线透视引导下使用造影剂显示神经根走行并注射利多卡因进行麻醉,使之与椎旁阻滞区别开来,真正确立了当代选择性神经根阻滞的方法。近年来,随着影像引导设备的快速发展,SNRB逐渐在临床得以广泛开展,国内外文献报道不甚枚举,但很多文献将TFESI混淆为SNRB,而且很多学者过多地强调了SNRB的治疗价值,而忽视了其诊断价值,因而有必要对SNRB的操作技术及临床应用价值的研究现状和进展做一综述。解剖及病理生理学基础对于腰腿痛的病因, 除椎间盘突出和椎管狭窄外, 近年来腰椎管外的解剖结构对腰神经根和腰神经后支的卡压越来越受到学者们的重视[2,3]。腰神经根自脊髓发出, 穿出硬脊膜囊后, 前、后根居于固有的根鞘内, 至椎间管外口远侧根鞘续为神经外膜, 神经根向前下外斜行。腰神经根离开硬膜囊后, 斜形向下至椎间孔外口穿出, 要经过一条较为狭窄的骨-纤维性通道, 称之为腰神经根管, 它包括侧隐窝和其向前外方延伸的椎间孔两部分。神经根管内宽外窄, 前后略扁, 如同小口朝外的漏斗。侧隐窝的外界是椎弓根,后壁是上关节突、椎板、黄韧带共同构成的顶部, 前面是由上下椎体的后外侧部及相邻椎间盘共同构成的底部。椎间孔上下界为椎弓根, 底部自上而下分别为上位椎体的后下缘、椎间盘和下位椎体的后上缘, 顶部由黄韧带构成, 黄韧带后面是关节突关节。腰神经通道腔与腰神经根之间保持一定的空间比例关系。当正常的空间比例关系发生改变, 就会使腰神经根在通道的某一部位受到卡压, 出现症状。神经根痛的病理生理学基础尚不完全清楚。神经通道腔壁在长期炎性刺激, 慢性劳损, 或椎间盘突出, 黄韧带肥厚, 小关节突增生等因素作用下, 出现某一部位的骨性或非骨性狭窄, 造成腔隙与神经根空间比例缩小, 神经根受压。神经根受机械压迫损伤后, 可以造成神经内毛细血管通透性增高, 导致水肿形成,造成神经传导的变化并降低对脊神经根的营养支持,导致神经损伤和功能改变。除了由机械压迫引起疼痛外, 神经根化学性炎症也起重要的作用。研究发现在疼痛的神经根周围组织中磷脂酶A2、P物质、降钙素相关生成因子等化学致痛物质明显增多是其主要的佐证。SNRB直接将局麻药和类固醇药物注射到神经根周围,一般认为局麻药可通过减少炎症组织的痛觉传入而暂时缓解疼痛,或可通过阻断产生疼痛的持续性神经活动而达到长期镇痛效果。进一步研究发现在局麻药中加入类固醇药物镇痛效果更好,可能是由于糖皮质激素通过抑制前列腺素合成而具有抗炎和免疫抑制作用[4], 一方面减少炎性介质和免疫物质的释放, 从而减少对伤害感受器的刺激和致敏, 另一方面减轻神经根的充血、水肿, 间接地起到机械减压的作用, 增加神经根的血供, 从而达到治疗根性神经痛的目的。适应症和禁忌症适应 引起脊柱相关性疼痛的原因很多,常见的有椎间盘膨突以及脊柱退行性变引起的机械性压迫,此外还有骨折、感染、肿瘤、脊柱术后或多种因素共同作用的结果。部分患者影像学检查结果与临床症状、体征不相吻合,在这种情况下,诊断性选择性神经根阻滞是寻找病变神经根的可靠手段。诊断性选择性神经根阻滞的适应症包括:①不典型腰腿痛;②影像学表现和临床表现不符;③肌电图和MRI检查结果不确定或模棱两可;④神经分布异常,如神经根联合或分叉变异;⑤腰椎术后不典型腰腿痛;⑥移行椎患者。当上述临床或影像学检查不能明确腰腿痛的确切来源以及需要进行外科术前效果评估时,选择性神经根阻滞可用来明确疼痛是否来自该神经根并预测手术治疗的效果[5]。以治疗为目的腰神经根阻滞的适应症很多,神经根痛患者是其主要适应证, 并且近期MRI或CT检查结果排除椎间盘脱出或肿瘤所致的根性疼痛。考虑行SNRB的根性疼痛患者包括:①影像学检查不明确或仅有轻微异常者;②影像学检查有多节段椎间盘病变,但还不需要手术治疗者;③手术后患者重新出现难以解释的复杂疼痛;④神经系统体检不确定者;⑤以及要求短时间缓解疼痛的根性疼痛患者,如椎间盘脱出患者术前镇痛。SNRB禁忌症同其他经皮穿刺手术操作,包括:①凝血功能异常;②对注射液任何一种成分有严重过敏反应者;③全身性感染或穿刺点皮肤感染。操作技术传统腰椎神经根阻滞在透视引导下进行。患者俯卧于带C臂X线机的检查床上,X线球管与检查床垂直,透视确定疼痛侧横突尖端在体表的投影并作标记。旋转C形臂的球管至患侧,以显示“苏格兰狗”的影像,直到所需注射的神经根对应椎体的上关节突恰好投影在椎体前后缘中点,同时应使椎体的上终板重叠呈线状。透视下前后位的椎弓根影像圆形的钟表,针尖应位于“6点钟”的下方,恰好位于神经根和背根的连接部。该处由神经根孔外缘、椎弓根下缘的切线和神经根的上缘构成一个三角形,称“安全三角(safe triangle)”[6]。 神经根走行于椎弓根(“苏格兰狗”眼)下方数毫米和椎体上方1-2mm处,此处即为穿刺点。定位后即可用1%利多卡因进行表皮及深层组织局部浸润麻醉,使用22#或25#穿刺针对准上关节突尖端进针,间断透视下向椎弓根推进,碰到椎弓根骨质后调整球管到正位。透视下使针尖位于椎弓根下“6点钟”,穿刺针深度已达椎体后缘或出现根性疼痛则停止。S1神经根阻滞通过骶后孔达到S1神经根。先轻刺后孔上缘的骨质以决定深度,然后向下刺入骶孔。由于骶前孔与后孔相通,刺入过深有可能进入盆腔,针的刺入方向稍向内倾斜即可避免。缓慢进针碰到骨质或诱发根性疼痛时停止进针。近来,许多文献报道并倡导在CT引导下进行SNRB。CT扫描软组织分辨率高,可清晰显示神经根、背根神经节和周围组织结构,在CT引导下能准确选择最佳穿刺点、角度及深度, 使针尖准确到达神经根周围位置, 并能避开血管等重要结构, 使手术安全、准确, 用药量少,并大大降低了并发症的发生率。但手术时间长是CT引导的最大弊端,低剂量CT透视这一新技术的出现很好地解决了这一问题。低剂量CT透视引导下SNRB与传统X线透视引导一样,操作者可在床旁实时快速成像引导下进行穿刺,在明显缩短手术时间的同时保留了CT引导的优势。另外, 采用间断低剂量CT透视引导技术,可大大降低患者和操作者所接受的射线剂量[7]。也有学者选择在超声引导下穿刺,穿刺成功后在透视引导下注射,以防止血管内注射的发生[8]。如穿刺成功或患者出现神经根性疼痛时,在注射治疗药物之前先注射0.5-1ml非离子对比剂,确定是神经根周围注射而不是神经根内注射。一旦神经根外膜下的扩散被神经造影证实,可以将诊断性或治疗性药液缓慢注射至神经根鞘中。神经根阻滞用于诊断时尽可能用少量药物, 使之作用于单独的神经根, 注入的药物量多时, 药物扩散到硬膜外间隙, 不仅神经根被阻滞而且也出现硬膜外阻滞状态。每根神经注射剂量不宜超过2ml(复方倍他米松1-2mg和局部麻醉药的混合液1-2ml),慢速注射并控制注射剂量可减少药物沿神经根袖至硬膜外腔,因为这种分流可使选择性神经根阻滞丧失特异性。若在神经根阻滞后出现镇痛, 则可以肯定该神经根就是患病部位,如仍有残留疼痛时, 说明除该神经根之外还有与疼痛有关的其他神经, 此时应把与疼痛有关的神经再作阻滞,来确定患病部位。上述选择性神经根阻滞是通过针尖机械性刺激神经根复制根性疼痛,通过神经根周围注射局麻药物来预测治疗效果。但由于针尖刺戳神经根的时间非常短暂,患者在如此短暂的时间内很难做出正确的判断,而如果反复刺戳又容易造成神经根的损伤。文献报道针尖刺到周围的韧带或椎间盘也会出现根性疼痛,从而造成假阳性。另外,神经根周围注射局麻药是否能预测治疗效果也受到了很多学者的质疑。最近,有学者报道在影像引导下以射频电刺激神经生理定位预测病变神经根节段,较传统针尖机械刺激更能准确复制患者疼痛的部位,大大降低了假阳性和假阴性的发生率[9]。并发症影像引导下SNRB并发症少见,文献中仅有个案报道,包括感染、硬膜外血肿、神经根损伤以及血管内注射引起暂时性下肢瘫痪、脊髓梗死甚至死亡[10,11]。为了避免并发症,需要很好的掌握邻近血管和神经结构的解剖。Adamkiewicz动脉是脊髓前动脉最大的分支,可以由T7-L4的任何节段椎间孔的上部沿着椎间孔的腹侧面进入脊髓腔,80%的个体从T9和L1水平的左侧进入椎管[12]。无论是由于穿刺针直接刺伤或局麻药/类固醇药物间接损伤该动脉,均可引起脊髓前动脉缺血和永久性下肢运动障碍[10]。针尖置于椎间孔的后部安全区域可以减少药物进入脊髓供应血管的危险。在透视实时动态监视下注射造影剂可以显示最终的针尖位置,并能检测出进入血管的注射[13]。在CT非实时动态监视下注射造影剂时,应间断轻柔回抽注射器,以确认针尖未进入血管内。同时也应尽量避免对神经根的直接注射,后者会引起患者严重的、持续的根性疼痛。当针尖进针过于靠近中线以及当针尖向神经根位置过于偏外侧刺中神经根袖时,可能有注射进入蛛网膜下腔的危险。对神经根或脊髓造成的直接损伤也可能发生。注射用皮质激素有颗粒型(Depo-Medrol)和非颗粒型(Decadron)两种。直接将颗粒型激素药注入供应脊髓的动脉中会导致严重的脊髓梗死,所以应选用非颗粒型药物。效果评价国内外关于选择性神经根阻滞治疗效果的文献报道不甚枚举,但很多文献将经椎间孔硬膜外类固醇注射术(transforaminal epidural steroid injection,TFESI)混淆为SNRB[14,15]。TFESI是治疗神经根性疼痛的一种经典的保守治疗方法,但其疗效存在争议,一般认为能获得短期疗效,但不能避免手术,这与治疗时甾体类药物未能选择性作用于病变神经根有关。硬膜外腔注射时,为了使药物进入较大的硬膜外间隙,常需要注射相对较大的药物剂量,但到达病变神经根的药量少,所以经常没有疗效或疗效很差,且不能准确判断疼痛来源的病变神经根。而SNRB在影像引导下,先经造影证实靶神经根,然后将少量的高浓度药物直接注射到病变神经根周围,目标性强,准确性大,安全性高,同时可减少注射容量和药物剂量,减少了药物不良反应和相关并发症的发生[16]。SNRB与TFESI相比较,可降低高皮质醇血症、高血糖及水潴留的发生率,减少误入硬膜外腔、血管的危险性,从而避免硬膜外感染和粘连[17]。SNRB治疗效果受多种因素影响,包括患者的选择、针尖位置是否准确以及阻滞剂的弥散范围等。吴春根[18]等在CT引导下背根神经节周围注射复方倍他米松治疗76例腰根性神经痛患者,发现对比剂有三种分布类型,分别为椎间孔神经根外侧分布型(12例,16%)、神经根周围分布型(11例,14%)和神经根周围分布并进入椎管硬膜外腔型(53例,70%),结果显示对比剂在椎间孔神经根周围分布并进入椎管硬膜外腔组疼痛缓解率较其他两组高,推测原因可能为倍他米松不仅阻滞了脊神经主干,同时阻滞了窦椎神经及疼痛感受器。对比剂的分布类型除主要与针尖位置有关外,还可能与局部硬膜外腔内的压力有关,对于腰椎间盘突出症和椎管狭窄病例,对比剂很难弥散到炎性病变的部位,一定程度影响了疗效[19]。国内关于SNRB的文献报道过多地强调了它的治疗价值,需要明确的是,除了对于由可逆性炎症引起的根性疼痛患者,SNRB术中注射类固醇和局部麻醉剂的混合液有较长期的治疗效果,部分患者可免于手术治疗。对于大多数临床或影像学诊断不明确的根性疼痛患者,SNRB的主要价值在于寻找正确的致痛节段,从而减少手术范围,并预测手术治疗的效果。SNRB预测病变神经根的准确性受很多因素影响,包括穿刺部位是否准确、是否充分阻滞或过度注射等。国内外文献报道SNRB确定正确致痛节段的准确率在31%-100%之间不等,究其原因,大多数属于回顾性研究且样本量较小,操作方法描述不详,疼痛缓解标准设定不一,仅对推测的致痛节段进行选择性神经根阻滞而未对其他节段进行试验性阻滞对照研究,因而无法准确判断SNRB对神经根痛患者正确致痛节段预测的敏感度、特异度、准确度及阳性和阴性预测值。Yeom JS[20]等进行的前瞻性、对照、单盲研究显示诊断性选择性神经根阻滞的敏感度为57%,特异度为86%,准确度为73%,阳性预测值为77%,阴性预测值为71%。大量文献证实,在SNRB术中注射类固醇有很好的阴性预测价值,对有根性疼痛病史超过1年的患者,若对SNRB长期效果不好,则他们进行手术治疗的效果也较差;相反,若SNRB长期效果较好,则他们手术治疗效果也佳。综上所述,影像引导下SNRB阻滞的目标性强,准确性大,安全性高,有助于确诊病变的脊神经根。同时可减少注射容量和药物剂量,减少了药物不良反应和相关并发症的发生,是一种微创、有效的治疗方法,可作为手术前最后的保守治疗手段。参考文献1. 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Selective Lumbar Nerve Root Blocks with CT Fluoroscopic Guidance: Technique, Results,Procedure Time, and Radiation Dose. AJNR Am J Neuroradiol,2004,25:1592~1594.8. Nakagawa M, Shinbori H, Ohseto K. Ultrasound-guided and fluoroscopy-assisted selective cervical nerve root blocks. Masui,2009,58:1506~1511.9. Haynsworth RF Jr.Selective Nerve Root Blocks: A New Technique Using Electrical Stimulation. Pain Physician,2003,6:517~520.10. Houten JK, Errico TJ. Paraplegia after lumbosacral nerve root block: report of three cases. Spine J, 2002,2:70~75.11. McMillan MR, Crumpton C. Cortical blindness and neurologic injury complicating cervical transforaminal injection for cervical radiculopathy. Anesthesiology, 2003, 99:509~511.12. Takase K, et al. Demonstration of the artery of Adamkiewicz at multi-detector row helical CT. Radiology,2002,223:39~45.13. Stojanovic M, Vu T, Caneris O, et al. The role of fluoroscopy in cervical epidural steroid injections: an analysis of contrast dispersal patterns. Spine, 2002,27:509~514.14. Narozny M, Zanetti M, Boos N. Therapeutic efficacy of selective nerve root blocks in the treatment of lumbar radicular leg pain. Swiss Med Wkly, 2001, 131:75~80.15. Vad VB, Bhat AL, Lutz GE, et al. Transforaminal epidural steroid injection in lumbosacral radiculopathy: a prospective randomized study. Spine , 2002,27:11~16.16. Eckel TS, Bartynski WS. Epidural steroid injections and selective nerve root blocks. Tech Vasc Interv Radiol,2009,12:11-21.17. 洪盾,方向前,范顺武,等.选择性神经根阻滞治疗腰神经根性下肢痛疗效观察.浙江医学,2004,26:673~674.18. 吴春根,李明华,程永德,等.CT引导下脊神经周围注射复方倍他米松治疗腰根性神经痛.介入放射学杂志,2006,15:735~737.19. 童国海,黄蔚,陈玮,等.CT引导硬膜外皮质类固醇注射治疗坐骨神经痛的远期疗效评价.介入放射学杂志,2005,14:287~289.20. Yeom JS, Lee JW, Park KW,et al. Value of diagnostic lumbar selective nerve root block: a prospective controlled study. AJNR Am J Neuroradiol,2008,29:1017~1023.
这是在椎间盘突出症患者中系常见的问题。手术只能解决神经根硬膜囊的压迫导致的腿痛麻木乏力症状,对于腰椎间盘退变本身无法改变,所以手术效果而言,腿痛麻木效果良好,短期内迅速缓解,麻木乏力需要时间稍长。但是对于腰骶部酸痛隐痛不适,大多数短期内轻微缓解,长期观察效果较差。这些症状只能靠长期的保健锻炼,延缓退变,增强脊柱稳定来解决。所以术后脊柱侧弯,行走跛行可能需要一段时间,具体多长时间大家没有定论,我们认为3周左右可能需要。
温州医科大学附属第二医院脊柱外科王胜回复:一般建议:刚刚术后需要腰围保护1月,仅仅是大小便或者饮食时可以起床活动10分钟,其他时间卧床为主;5天后可以单独完成洗澡活动,避免半卧位看书看电视及手机;腰围保护下坐如钟,站如松,走如风;10到12周后,腰腿痛基本缓解最大化,此时可以循序渐进进行腰背肌功能锻炼;最佳锻炼推荐游泳,实在不能或不愿意,可以进行飞燕式,五点式腰背肌功能锻炼,每个动作5-8秒/个,20个为一组,自觉累了就休息,逐步增加数量及频率等;1月后复查后,可以去除腰围,逐步恢复正常生活工作。不过,始终建议坚持锻炼,避免弯腰负重等。