胸腰段楔变椎体与邻近腰椎间盘突出的关系及手术治疗策略
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摘要
腰椎间盘突出是非常常见的脊柱疾病。然而绝大多数的腰椎间盘突出集中于L4/5、L5/S1椎间盘。被称为高位腰椎间盘突出的T12/L1、L1/2、L2/3、L3/4突出相对较为少见。仅占腰椎间盘突出症的约1%~5%。
不同于常见的下腰椎椎间盘突出症的常见症状是由于L4~S1神经根受压引起的坐骨神经痛，高位腰椎间盘突出的受压神经根可以是马尾神经的任何神经根，因此也就没有典型症状，其症状可以是股神经症状、坐骨神经症状、马尾综合征。其症状的多样性导致高位腰椎间盘突出易被漏诊。
临床上对于高位腰椎间盘突出较少有描述。在MRI出现以前，高位腰椎间盘突出的诊断较为困难。MRI问世后，其广泛应用使高位腰椎间盘突出的诊断变的容易。据报道在高位腰椎间盘突出较易发生于重体力劳动者。仅有不到5%的腰椎间盘突出发生于高位腰椎间盘。MRI可以显示早期的椎间盘病变，因此高位腰椎间盘突出的发生率在影像技术的提高后，也显著的高于以前。
胸腰段的椎体改变被认为是高位腰椎间盘突出的原因之一。其改变包括休门氏病导致的椎体前缘变窄，压缩骨折后出现的椎体楔形变，椎体的终板损伤，脊柱的后滑脱。椎间盘的退变常见于骨折的椎体的邻近椎间盘。不同于低位腰椎间盘突出多见于老年患者，孤立的高位腰椎间盘突出常见于相对较为年轻的中年人。有些高位腰椎间盘突出也见于脊柱滑脱的上一节段。
胸腰段是常见的脊柱骨折最常见的好发部位。其中压缩骨折是最常见发生的类型。压缩骨折后椎体周围的受力与正常椎体相比，其横向剪切力更大。可能这是造成高位腰椎间盘突出的一个主要原因。
针对高位腰椎间盘突出症好发于胸腰段楔形变椎体的临近节段这一现象，我们拟对胸腰段楔形变椎体的周围受力进行测量，观察椎体周围椎体的生物力学改变，特别是将高位腰椎间盘突出症患者临近椎体的楔形压缩率与正常人进行比较，以探讨高位腰椎间盘突出与楔形椎体的关系，同时回顾性分析对楔形压缩骨折对邻近椎间盘退变的远期影响，观察不同手术方式对治疗高位腰椎间盘突出的效果。
第一部分羊的胸12至腰2节段楔形椎体对邻近椎间盘的生物力学影响
目的：在羊的尸体标本上制作楔形椎体模型，分别比较正常椎体和楔形椎体对邻近椎间盘的生物力学影响。
方法：选取20具成年羊的胸12至腰2节段椎体及椎间盘作为标本。随机分为实验组和对照组，各10例。将实验组的腰1椎体中部使用摆锯进行横向截骨并固定，制作楔形椎体模型。分别将实验组和对照组标本模型加载固定于生物力学机，在设定载荷下进行轴向压缩运动，观察上位和下位椎间隙内压力的变化，然后更改载荷，测试不同载荷椎间隙内压力的变化并进行对比。
结果：在相同的载荷下，楔形椎体组与对照组比较，相邻上位和下位椎间隙内的压力降低，且随着载荷加大差异有增强趋势，200N时无显著性差异（P>0.05），400N、800N时两组比较，开始出现显著性差异（P<0.05）具有统计学意义（P<0.05）。楔形椎体组的上位和下位椎间隙内压力明显高于对照组。
结论：在轴向循环载荷下，未经楔形截骨组比楔形截骨组的具有较小的椎间隙内压力。本研究从生物力学角度证实了楔形椎体组的邻近椎间盘内压力改变。
第二部分高位腰椎间盘突出与邻近楔形椎体之间的相关性研究
目的：回顾性分析楔形椎体周围椎间盘的变化。
方法：对我院自2003年1月至2012年9月收治的高位腰椎间盘突出病人的影像资料进行回顾性分析。其中男性28例，女性19例，平均年龄41.2±5.6岁。征集同龄健康志愿者进行对比。收集并分析两组患者的年龄、性别、体重指数、外伤史、基础疾病情况等。比较两组的高位腰椎间盘突出周围邻近椎体的楔形率。
结果：研究组与对照组在年龄、性别、体重指数、基础疾病情况等方面均没有统计学差异。实验组和对照组年龄分别为41.2±5.6岁和42.1±0.6岁，差别无统计学差异。实验组在邻近椎体压缩率上均值为5.20±1.11°，显著大于对照组，具有统计学差异。实验组中有40例存在有较早时间的外伤史。
结论：高位腰椎间盘突出的病人其邻近椎体的楔形压缩率显著高于正常人。不能排除外伤因素是造成椎间盘损害的原因，但也不能排除楔形椎造成的生物力学改变是造成椎间盘损伤的原因之一。
第三部分治疗高位腰椎间盘突出手术方式的选择与效果评价
目的：探讨不同手术方式对高位腰椎间盘突出的治疗效果的评价
方法：对我院自2003年1月至2012年9月就诊的高位腰椎间盘突出病人的影像资料及临床效果进行回顾性分析。其中男28例，女19例，平均年龄41.2±5.6岁。其中13例采用侧前路手术治疗，20例采用经椎间孔减压椎间融合术治疗，14例采用单纯椎间孔减压髓核摘除术治疗。收集并分析三组患者的年龄、性别、体重指数、外伤史、基础疾病情况、腰椎不稳评价、远期融合率等。比较两组患者的术前和术后VAS评分。所有患者均未进行内固定物移除。
结果：47例患者术后获12-50个月（平均25.6±5.4个月）随访。三组患者的年龄、性别、体重指数、住院时间等临床基本特征比较，均无统计学差异。侧前路手术组与后路手术组围手术期时间无统计学意义。但后路手术组的手术时间明显低于侧前路手术组，其中侧前路手术组为175±22min分钟，后路经椎间孔减压椎间融合术为133±18分钟，后路单纯椎间盘摘除术组为84±31min，差异具有统计学意义(P<0.05)。出血量亦有差异(P<0.05)，侧前路手术组为853±209ml，后路经椎间孔减压椎间融合术为334±127ml，后路单纯椎间盘摘除术组为121±24ml。术后随访，所有植骨均融合。手术并发症上，侧前路手术组术后伤口愈合不良一例，术后5天伤口见红肿，给予抗生素治疗后好转。一例因术中牵拉L3神经根，出现术后相应皮肤感觉区域麻木，随访至术后3个月时消失。后路单纯椎间盘摘除术组术中下关节突骨折一例，将其取出后未采用内固定治疗，术后随访患者诉腰痛不缓解，至术后14个月腰痛仍然存在，最终采用内固定融合术。后路经椎间孔入路减压内固定术组有一例患者术后出现L3神经感觉区域疼痛，皮肤感觉减退，股四头肌肌力下降，行翻修手术后疼痛症状缓解，至术后6个月随访时已恢复正常。经VAS评分，侧前路手术组，后路经椎间孔入路减压内固定术组和后路单纯椎间盘摘除术组VAS改善率分别为85.0±9.5分，81.4±8.5分和71.3±8.4，差异存在统计学意义，后路单纯椎间盘摘除术组的改善率较低。
结论：三种手术方式均能达到的对高位腰椎间盘突出进行减压的目的，但侧前路手术组的手术时间较长，出血量较多。坚强的内固定有助于患者早期负重活动，能够获得良好的治疗效果。侧前路和后路手术均是治疗高位腰椎间盘突出的不错选择。
Lumbar disc herniation is very common in spine diseases. Review ofliterature showed that most lumbar disc herniations are found in the lowerlevels. Disc herniations at the T12/L1、L1/2、L2/3、L3/4levels were reportedin less than1%～5%of the cases.
Unlike lower lumbar disc herniation’s typical symptom is ‘sciatica’, thesymptoms of upper lumbar disc herniation are various because it usuallyconsists of a compact neural component and conus medullaris in the dural sac.There is no so-called classic symptom for upper lumbar disc herniation, thesymptoms can be varies, such as femoral nerve involvement, sciatica andcauda equine syndrome. So it is easy to be misdiagnosed.
Few articles focus on upper lumbar disc herniation. The MRI scan hasallowed visualization of early degenerative changes within the discs as well asadvanced structural changes. By reviewing consecutive MRI scans of patientswith back and/or leg pain, the authors showed that the incidence of upperlumbar disc herniation and degeneration is more common than previouslybelieved and extrapolated that altered mechanics may be associated with theseupper lumbar disc lesions.
Upper lumbar disc degeneration or herniation are often associated withpre-existing or coexisting abnormalities which include Scheuermann’s diseaseand end-plate defects, compression deformity of the vertebral body,retrolisthesis and a limbus vertebra, previous fractures. Unlike the patientswith lower lumbar disc herniations are mostly senior people, the patients withhigh lumbar disc herniations are relatively young.
Thoracolumar spine is the most popular lesion of spinal fracture.Compression fracture is the most popular type of fracture. Wedge-shaped vertebra can change the mechanics of adjacent levels by increasing the angleof superior endplate tilt. the composite mass of the superior vertebral levels,head and arms may translate slightly anteriorly. The moment arm distancebetween the vertebral centroid and composite centre of mass of the trunk willincrease, thereby increasing the flexion moment at that level, and contiguouslevels. As a result shear forces were greater at the level of WSV and one levelabove, while compression forces were greater at one level below WSVcompared to equivalent level mean forces of the non-fracture group.
Based on the above theory we suggested to evaluate the force ofwedge-shaped vertebra, to compare the Cobb angles of high lumbar discherniation’s adjacent vertebra, in order to prove the relationship between highlumbar disc herniation and adjacent wedge-shaped vertebra, and to evaluatethe outcome of different surgery and treatment.Part1The biomechanical influence of wedge-shaped vertebra to adjacent
disc in goats
Objective: The purpose of this study was to compare the biomechanicalinfluence around normal vertebra and wedge-shaped vertebra of goats
Methods: Twenty fresh frozen thoracolumbar goat spine samples(T12-L2)were used for the test. The samples were randomly distributed into studygroup and control group. The L1vertebra bodies’ of the study group wereundergone osteotomy and fixation in order to make the wedge-shaped vertebramodel. Each model was successively loaded using an increasing axial force(200N,400N，800N), analyze the difference of the inner pressure of discs.
Results: No significantly change was detected in our study group andcontrol group during200N loading, while after using the400N load,significantly difference was found between the two groups, the wedge-shapedgroup has higher inner pressure than control group,.
Conclusion: our study showed the discs adjacent to the wedge-shapedvertebra have the tend to degenerate faster than the discs adjacent to thenormal vertebra.
Part2Correlative Analysis of Isolated Upper Lumbar Disc Herniationand Adjacent Wedge-shaped Vertebrae
Objective: To study the relationship between isolated upper lumbar discherniation and adjacent wedge-shaped vertebrae.
Methods: From January2003to0ctobor2012,47patients (27males and20females; mean age,41.2±5.6years) with single-level upper lumbar discherniation and47sex and age-matched asymptomatic healthy control subjectswere studied by radiograph. Age, body mess index and kyphotic angle of theobjective vertebrae were compared.
Results: Average kyphotic angle in the study group was found to be11o(4-22o), meanwhile average kyphotic angle in the control group was2o (0-7o).The kyphotic angles of the study group were statistically significantly largerthan those of the control group (P<0.05). The correlations between the age andkyphotic angles, body mess index and the kyphotic angles in the study groupand the control group were uncorrelated or low correlated (Pearson’scorrelation coefficient:-0.146,-0.004,0.049,0.185)
Conclusions: Wedge-shaped vertebrae are closely associated withadjacent upper lumbar disc herniation. When wedge-shaped vertebrae werelocated and accompanied with symptoms, upper lumbar disc herniation shouldbe alerted.
Part3The comparison for different treatment for upper lumbar discherniation
Objective: to evaluate the outcomes of different treatment for upperlumbar disc herniation
Methods: From January2003to0ctobor2012,47patients (27males and20females; mean age,41.2±5.6years) with single-level upper lumbar discherniation were undergone the operation treatment, the patients were randomlydistributed into anterior operation group (13case), transforaminal lumbarinterbody fusion (TLIF) group (20cases) and discectomy group (14cases).The age, sex, body mess index, instability of lumbar and rate of fusion werecompared in all3groups. The VAS score were compared before and after operation. There was no removement of hardware.
Results: All of the cases were followed12-50months (mean25.6±5.4months) after operation. There was no significant difference between thegeneral parameters of cases’ age, sex, body mess index. The operation timeand blood loss of the posterior operation group were significantly lower thananterior group. All of the cases for fusion operation were fused. The anteriorgroup has more complications than other groups. There was significantdifference between the VAS improvement rate, the discectomy group was thelowest.
Conclusion: all of the three operation methods can achieve thedecompression aim for upper lumbar disc herniation. But the anterior group’sshortcoming is longer operation time and more blood loss. The stronghardware fixation can help patients get up early and get better treatmentoutcome.
不同于常见的下腰椎椎间盘突出症的常见症状是由于L4~S1神经根受压引起的坐骨神经痛，高位腰椎间盘突出的受压神经根可以是马尾神经的任何神经根，因此也就没有典型症状，其症状可以是股神经症状、坐骨神经症状、马尾综合征。其症状的多样性导致高位腰椎间盘突出易被漏诊。
临床上对于高位腰椎间盘突出较少有描述。在MRI出现以前，高位腰椎间盘突出的诊断较为困难。MRI问世后，其广泛应用使高位腰椎间盘突出的诊断变的容易。据报道在高位腰椎间盘突出较易发生于重体力劳动者。仅有不到5%的腰椎间盘突出发生于高位腰椎间盘。MRI可以显示早期的椎间盘病变，因此高位腰椎间盘突出的发生率在影像技术的提高后，也显著的高于以前。
胸腰段的椎体改变被认为是高位腰椎间盘突出的原因之一。其改变包括休门氏病导致的椎体前缘变窄，压缩骨折后出现的椎体楔形变，椎体的终板损伤，脊柱的后滑脱。椎间盘的退变常见于骨折的椎体的邻近椎间盘。不同于低位腰椎间盘突出多见于老年患者，孤立的高位腰椎间盘突出常见于相对较为年轻的中年人。有些高位腰椎间盘突出也见于脊柱滑脱的上一节段。
胸腰段是常见的脊柱骨折最常见的好发部位。其中压缩骨折是最常见发生的类型。压缩骨折后椎体周围的受力与正常椎体相比，其横向剪切力更大。可能这是造成高位腰椎间盘突出的一个主要原因。
针对高位腰椎间盘突出症好发于胸腰段楔形变椎体的临近节段这一现象，我们拟对胸腰段楔形变椎体的周围受力进行测量，观察椎体周围椎体的生物力学改变，特别是将高位腰椎间盘突出症患者临近椎体的楔形压缩率与正常人进行比较，以探讨高位腰椎间盘突出与楔形椎体的关系，同时回顾性分析对楔形压缩骨折对邻近椎间盘退变的远期影响，观察不同手术方式对治疗高位腰椎间盘突出的效果。
第一部分羊的胸12至腰2节段楔形椎体对邻近椎间盘的生物力学影响
目的：在羊的尸体标本上制作楔形椎体模型，分别比较正常椎体和楔形椎体对邻近椎间盘的生物力学影响。
方法：选取20具成年羊的胸12至腰2节段椎体及椎间盘作为标本。随机分为实验组和对照组，各10例。将实验组的腰1椎体中部使用摆锯进行横向截骨并固定，制作楔形椎体模型。分别将实验组和对照组标本模型加载固定于生物力学机，在设定载荷下进行轴向压缩运动，观察上位和下位椎间隙内压力的变化，然后更改载荷，测试不同载荷椎间隙内压力的变化并进行对比。
结果：在相同的载荷下，楔形椎体组与对照组比较，相邻上位和下位椎间隙内的压力降低，且随着载荷加大差异有增强趋势，200N时无显著性差异（P>0.05），400N、800N时两组比较，开始出现显著性差异（P<0.05）具有统计学意义（P<0.05）。楔形椎体组的上位和下位椎间隙内压力明显高于对照组。
结论：在轴向循环载荷下，未经楔形截骨组比楔形截骨组的具有较小的椎间隙内压力。本研究从生物力学角度证实了楔形椎体组的邻近椎间盘内压力改变。
第二部分高位腰椎间盘突出与邻近楔形椎体之间的相关性研究
目的：回顾性分析楔形椎体周围椎间盘的变化。
方法：对我院自2003年1月至2012年9月收治的高位腰椎间盘突出病人的影像资料进行回顾性分析。其中男性28例，女性19例，平均年龄41.2±5.6岁。征集同龄健康志愿者进行对比。收集并分析两组患者的年龄、性别、体重指数、外伤史、基础疾病情况等。比较两组的高位腰椎间盘突出周围邻近椎体的楔形率。
结果：研究组与对照组在年龄、性别、体重指数、基础疾病情况等方面均没有统计学差异。实验组和对照组年龄分别为41.2±5.6岁和42.1±0.6岁，差别无统计学差异。实验组在邻近椎体压缩率上均值为5.20±1.11°，显著大于对照组，具有统计学差异。实验组中有40例存在有较早时间的外伤史。
结论：高位腰椎间盘突出的病人其邻近椎体的楔形压缩率显著高于正常人。不能排除外伤因素是造成椎间盘损害的原因，但也不能排除楔形椎造成的生物力学改变是造成椎间盘损伤的原因之一。
第三部分治疗高位腰椎间盘突出手术方式的选择与效果评价
目的：探讨不同手术方式对高位腰椎间盘突出的治疗效果的评价
方法：对我院自2003年1月至2012年9月就诊的高位腰椎间盘突出病人的影像资料及临床效果进行回顾性分析。其中男28例，女19例，平均年龄41.2±5.6岁。其中13例采用侧前路手术治疗，20例采用经椎间孔减压椎间融合术治疗，14例采用单纯椎间孔减压髓核摘除术治疗。收集并分析三组患者的年龄、性别、体重指数、外伤史、基础疾病情况、腰椎不稳评价、远期融合率等。比较两组患者的术前和术后VAS评分。所有患者均未进行内固定物移除。
结果：47例患者术后获12-50个月（平均25.6±5.4个月）随访。三组患者的年龄、性别、体重指数、住院时间等临床基本特征比较，均无统计学差异。侧前路手术组与后路手术组围手术期时间无统计学意义。但后路手术组的手术时间明显低于侧前路手术组，其中侧前路手术组为175±22min分钟，后路经椎间孔减压椎间融合术为133±18分钟，后路单纯椎间盘摘除术组为84±31min，差异具有统计学意义(P<0.05)。出血量亦有差异(P<0.05)，侧前路手术组为853±209ml，后路经椎间孔减压椎间融合术为334±127ml，后路单纯椎间盘摘除术组为121±24ml。术后随访，所有植骨均融合。手术并发症上，侧前路手术组术后伤口愈合不良一例，术后5天伤口见红肿，给予抗生素治疗后好转。一例因术中牵拉L3神经根，出现术后相应皮肤感觉区域麻木，随访至术后3个月时消失。后路单纯椎间盘摘除术组术中下关节突骨折一例，将其取出后未采用内固定治疗，术后随访患者诉腰痛不缓解，至术后14个月腰痛仍然存在，最终采用内固定融合术。后路经椎间孔入路减压内固定术组有一例患者术后出现L3神经感觉区域疼痛，皮肤感觉减退，股四头肌肌力下降，行翻修手术后疼痛症状缓解，至术后6个月随访时已恢复正常。经VAS评分，侧前路手术组，后路经椎间孔入路减压内固定术组和后路单纯椎间盘摘除术组VAS改善率分别为85.0±9.5分，81.4±8.5分和71.3±8.4，差异存在统计学意义，后路单纯椎间盘摘除术组的改善率较低。
结论：三种手术方式均能达到的对高位腰椎间盘突出进行减压的目的，但侧前路手术组的手术时间较长，出血量较多。坚强的内固定有助于患者早期负重活动，能够获得良好的治疗效果。侧前路和后路手术均是治疗高位腰椎间盘突出的不错选择。
Lumbar disc herniation is very common in spine diseases. Review ofliterature showed that most lumbar disc herniations are found in the lowerlevels. Disc herniations at the T12/L1、L1/2、L2/3、L3/4levels were reportedin less than1%～5%of the cases.
Unlike lower lumbar disc herniation’s typical symptom is ‘sciatica’, thesymptoms of upper lumbar disc herniation are various because it usuallyconsists of a compact neural component and conus medullaris in the dural sac.There is no so-called classic symptom for upper lumbar disc herniation, thesymptoms can be varies, such as femoral nerve involvement, sciatica andcauda equine syndrome. So it is easy to be misdiagnosed.
Few articles focus on upper lumbar disc herniation. The MRI scan hasallowed visualization of early degenerative changes within the discs as well asadvanced structural changes. By reviewing consecutive MRI scans of patientswith back and/or leg pain, the authors showed that the incidence of upperlumbar disc herniation and degeneration is more common than previouslybelieved and extrapolated that altered mechanics may be associated with theseupper lumbar disc lesions.
Upper lumbar disc degeneration or herniation are often associated withpre-existing or coexisting abnormalities which include Scheuermann’s diseaseand end-plate defects, compression deformity of the vertebral body,retrolisthesis and a limbus vertebra, previous fractures. Unlike the patientswith lower lumbar disc herniations are mostly senior people, the patients withhigh lumbar disc herniations are relatively young.
Thoracolumar spine is the most popular lesion of spinal fracture.Compression fracture is the most popular type of fracture. Wedge-shaped vertebra can change the mechanics of adjacent levels by increasing the angleof superior endplate tilt. the composite mass of the superior vertebral levels,head and arms may translate slightly anteriorly. The moment arm distancebetween the vertebral centroid and composite centre of mass of the trunk willincrease, thereby increasing the flexion moment at that level, and contiguouslevels. As a result shear forces were greater at the level of WSV and one levelabove, while compression forces were greater at one level below WSVcompared to equivalent level mean forces of the non-fracture group.
Based on the above theory we suggested to evaluate the force ofwedge-shaped vertebra, to compare the Cobb angles of high lumbar discherniation’s adjacent vertebra, in order to prove the relationship between highlumbar disc herniation and adjacent wedge-shaped vertebra, and to evaluatethe outcome of different surgery and treatment.Part1The biomechanical influence of wedge-shaped vertebra to adjacent
disc in goats
Objective: The purpose of this study was to compare the biomechanicalinfluence around normal vertebra and wedge-shaped vertebra of goats
Methods: Twenty fresh frozen thoracolumbar goat spine samples(T12-L2)were used for the test. The samples were randomly distributed into studygroup and control group. The L1vertebra bodies’ of the study group wereundergone osteotomy and fixation in order to make the wedge-shaped vertebramodel. Each model was successively loaded using an increasing axial force(200N,400N，800N), analyze the difference of the inner pressure of discs.
Results: No significantly change was detected in our study group andcontrol group during200N loading, while after using the400N load,significantly difference was found between the two groups, the wedge-shapedgroup has higher inner pressure than control group,.
Conclusion: our study showed the discs adjacent to the wedge-shapedvertebra have the tend to degenerate faster than the discs adjacent to thenormal vertebra.
Part2Correlative Analysis of Isolated Upper Lumbar Disc Herniationand Adjacent Wedge-shaped Vertebrae
Objective: To study the relationship between isolated upper lumbar discherniation and adjacent wedge-shaped vertebrae.
Methods: From January2003to0ctobor2012,47patients (27males and20females; mean age,41.2±5.6years) with single-level upper lumbar discherniation and47sex and age-matched asymptomatic healthy control subjectswere studied by radiograph. Age, body mess index and kyphotic angle of theobjective vertebrae were compared.
Results: Average kyphotic angle in the study group was found to be11o(4-22o), meanwhile average kyphotic angle in the control group was2o (0-7o).The kyphotic angles of the study group were statistically significantly largerthan those of the control group (P<0.05). The correlations between the age andkyphotic angles, body mess index and the kyphotic angles in the study groupand the control group were uncorrelated or low correlated (Pearson’scorrelation coefficient:-0.146,-0.004,0.049,0.185)
Conclusions: Wedge-shaped vertebrae are closely associated withadjacent upper lumbar disc herniation. When wedge-shaped vertebrae werelocated and accompanied with symptoms, upper lumbar disc herniation shouldbe alerted.
Part3The comparison for different treatment for upper lumbar discherniation
Objective: to evaluate the outcomes of different treatment for upperlumbar disc herniation
Methods: From January2003to0ctobor2012,47patients (27males and20females; mean age,41.2±5.6years) with single-level upper lumbar discherniation were undergone the operation treatment, the patients were randomlydistributed into anterior operation group (13case), transforaminal lumbarinterbody fusion (TLIF) group (20cases) and discectomy group (14cases).The age, sex, body mess index, instability of lumbar and rate of fusion werecompared in all3groups. The VAS score were compared before and after operation. There was no removement of hardware.
Results: All of the cases were followed12-50months (mean25.6±5.4months) after operation. There was no significant difference between thegeneral parameters of cases’ age, sex, body mess index. The operation timeand blood loss of the posterior operation group were significantly lower thananterior group. All of the cases for fusion operation were fused. The anteriorgroup has more complications than other groups. There was significantdifference between the VAS improvement rate, the discectomy group was thelowest.
Conclusion: all of the three operation methods can achieve thedecompression aim for upper lumbar disc herniation. But the anterior group’sshortcoming is longer operation time and more blood loss. The stronghardware fixation can help patients get up early and get better treatmentoutcome.
引文
1Briggs AM, Wrigley TV, van Dieen JH, et al. The effect of osteoporoticvertebral fracture on predicted spinal loads in vivo. Eur Spine J2006;15:1785-95
2De Schepper EI, Damen J, Bos PK, et al. Disk degeneration of the upperlumbar disks is associated with hip pain. Eur Spine J2013;22:721-6
3Hsu K, Zucherman J, Shea W, et al. High lumbar disc degeneration.Incidence and etiology. Spine (Phila Pa1976)1990;15:679-82
4Huang MH, Barrett-Connor E, Greendale GA, et al. Hyperkyphoticposture and risk of future osteoporotic fractures: the Rancho Bernardostudy. J Bone Miner Res2006;21:419-23
5Kerttula LI, Serlo WS, Tervonen OA, et al. Post-traumatic findings of thespine after earlier vertebral fracture in young patients: clinical and MRIstudy. Spine (Phila Pa1976)2000;25:1104-8
6Modic MT, Pavlicek W, Weinstein MA, et al. Magnetic resonanceimaging of intervertebral disk disease. Clinical and pulse sequenceconsiderations. Radiology1984;152:103-11
7Paajanen H, Alanen A, Erkintalo M, et al. Disc degeneration inScheuermann disease. Skeletal Radiol1989;18:523-66
1Briggs AM, Wrigley TV, van Dieen JH, et al. The effect of osteoporoticvertebral fracture on predicted spinal loads in vivo. Eur Spine J2006;15:1785-95
2Brown MD, Gomez-Marin O, Brookfield KF, et al. Differential diagnosisof hip disease versus spine disease. Clin Orthop Relat Res2004:280-4
3de Schepper EI, Damen J, Bos PK, et al. Disk degeneration of the upperlumbar disks is associated with hip pain. Eur Spine J2013;22:721-6
4Elias WJ, Simmons NE, Kaptain GJ, et al. Complications of posteriorlumbar interbody fusion when using a titanium threaded cage device. JNeurosurg2000;93:45-52
5Hsu K, Zucherman J, Shea W, et al. High lumbar disc degeneration.Incidence and etiology. Spine (Phila Pa1976)1990;15:679-82
6Iwasaki M, Akino M, Hida K, et al. Clinical and radiographiccharacteristics of upper lumbar disc herniation: ten-year microsurgicalexperience. Neurol Med Chir (Tokyo)2011;51:423-6
7Kerttula LI, Serlo WS, Tervonen OA, et al. Post-traumatic findings of thespine after earlier vertebral fracture in young patients: clinical and MRIstudy. Spine (Phila Pa1976)2000;25:1104-8
8Kerttula LI, Serlo WS, Tervonen OA, et al. Post-traumatic findings of thespine after earlier vertebral fracture in young patients: clinical and MRIstudy. Spine (Phila Pa1976)2000;25:1104-8
9Osti OL, Vernon-Roberts B, Fraser RD.1990Volvo Award inexperimental studies. Anulus tears and intervertebral disc degeneration.An experimental study using an animal model. Spine (Phila Pa1976)1990;15:762-7
10Paajanen H, Alanen A, Erkintalo M, et al. Disc degeneration inScheuermann disease. Skeletal Radiol1989;18:523-6
1Albeck MJ, Hilden J, Kjaer L, et al. A controlled comparison ofmyelography, computed tomography, and magnetic resonance imaging inclinically suspected lumbar disc herniation. Spine (Phila Pa1976)1995;20:443-8
2Estridge MN, Rouhe SA, Johnson NG. The femoral stretching test. Avaluable sign in diagnosing upper lumbar disc herniations. J Neurosurg1982;57:813-7
3Harms J, Rolinger H.[A one-stager procedure in operative treatment ofspondylolistheses: dorsal traction-reposition and anterior fusion (author'stransl)]. Z Orthop Ihre Grenzgeb1982;120:343-7
4Hsu K, Zucherman J, Shea W, et al. High lumbar disc degeneration.Incidence and etiology. Spine (Phila Pa1976)1990;15:679-82
5Iwasaki M, Akino M, Hida K, et al. Clinical and radiographiccharacteristics of upper lumbar disc herniation: ten-year microsurgicalexperience. Neurol Med Chir (Tokyo)2011;51:423-6
6Moore KR, Pinto MR, Butler LM. Degenerative disc disease treated withcombined anterior and posterior arthrodesis and posterior instrumentation.Spine (Phila Pa1976)2002;27:1680-6
7Tamir E, Anekshtein Y, Melamed E, et al. Clinical presentation andanatomic position of L3-L4disc herniation: a prospective and comparativestudy. J Spinal Disord Tech2004;17:467-9
8Yan DL, Pei FX, Li J, et al. Comparative study of PILF and TLIFtreatment in adult degenerative spondylolisthesis. Eur Spine J2008;17:1311-6
9齐强,陈仲强,刘忠军, et al.胸腰段椎间盘突出症的手术治疗及入路选择.中国脊柱脊髓杂志2006:133-7
10杨海涛,王林.两种不同手术方式治疗高位腰椎间盘突出症的临床疗效比较.中华临床医师杂志(电子版)2012:1000-2
1Albeck MJ, Hilden J, Kjaer L, et al. A controlled comparison ofmyelography, computed tomography, and magnetic resonance imaging inclinically suspected lumbar disc herniation. Spine (Phila Pa1976)1995;20:443-8
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3Aquarius R, Homminga J, Verdonschot N, et al. The fracture risk ofadjacent vertebrae is increased by the changed loading direction after awedge fracture. Spine (Phila Pa1976)2011;36:E408-12
4Bosacco SJ, Berman AT. Surgical management of lumbar disc disease.Radiol Clin North Am1983;21:377-93
5Briggs AM, Wrigley TV, van Dieen JH, et al. The effect of osteoporoticvertebral fracture on predicted spinal loads in vivo. Eur Spine J2006;15:1785-95
6Brown MD, Gomez-Marin O, Brookfield KF, et al. Differential diagnosisof hip disease versus spine disease. Clin Orthop Relat Res2004:280-4
7Choi JW, Lee JK, Moon KS, et al. Transdural approach for calcifiedcentral disc herniations of the upper lumbar spine. Technical note. JNeurosurg Spine2007;7:370-4
8Cianci PE, Piscatelli RL. Femoral neuropathy secondary to retroperitonealhemorrhage. JAMA1969;210:1100-1
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2De Schepper EI, Damen J, Bos PK, et al. Disk degeneration of the upperlumbar disks is associated with hip pain. Eur Spine J2013;22:721-6
3Hsu K, Zucherman J, Shea W, et al. High lumbar disc degeneration.Incidence and etiology. Spine (Phila Pa1976)1990;15:679-82
4Huang MH, Barrett-Connor E, Greendale GA, et al. Hyperkyphoticposture and risk of future osteoporotic fractures: the Rancho Bernardostudy. J Bone Miner Res2006;21:419-23
5Kerttula LI, Serlo WS, Tervonen OA, et al. Post-traumatic findings of thespine after earlier vertebral fracture in young patients: clinical and MRIstudy. Spine (Phila Pa1976)2000;25:1104-8
6Modic MT, Pavlicek W, Weinstein MA, et al. Magnetic resonanceimaging of intervertebral disk disease. Clinical and pulse sequenceconsiderations. Radiology1984;152:103-11
7Paajanen H, Alanen A, Erkintalo M, et al. Disc degeneration inScheuermann disease. Skeletal Radiol1989;18:523-66
1Briggs AM, Wrigley TV, van Dieen JH, et al. The effect of osteoporoticvertebral fracture on predicted spinal loads in vivo. Eur Spine J2006;15:1785-95
2Brown MD, Gomez-Marin O, Brookfield KF, et al. Differential diagnosisof hip disease versus spine disease. Clin Orthop Relat Res2004:280-4
3de Schepper EI, Damen J, Bos PK, et al. Disk degeneration of the upperlumbar disks is associated with hip pain. Eur Spine J2013;22:721-6
4Elias WJ, Simmons NE, Kaptain GJ, et al. Complications of posteriorlumbar interbody fusion when using a titanium threaded cage device. JNeurosurg2000;93:45-52
5Hsu K, Zucherman J, Shea W, et al. High lumbar disc degeneration.Incidence and etiology. Spine (Phila Pa1976)1990;15:679-82
6Iwasaki M, Akino M, Hida K, et al. Clinical and radiographiccharacteristics of upper lumbar disc herniation: ten-year microsurgicalexperience. Neurol Med Chir (Tokyo)2011;51:423-6
7Kerttula LI, Serlo WS, Tervonen OA, et al. Post-traumatic findings of thespine after earlier vertebral fracture in young patients: clinical and MRIstudy. Spine (Phila Pa1976)2000;25:1104-8
8Kerttula LI, Serlo WS, Tervonen OA, et al. Post-traumatic findings of thespine after earlier vertebral fracture in young patients: clinical and MRIstudy. Spine (Phila Pa1976)2000;25:1104-8
9Osti OL, Vernon-Roberts B, Fraser RD.1990Volvo Award inexperimental studies. Anulus tears and intervertebral disc degeneration.An experimental study using an animal model. Spine (Phila Pa1976)1990;15:762-7
10Paajanen H, Alanen A, Erkintalo M, et al. Disc degeneration inScheuermann disease. Skeletal Radiol1989;18:523-6
1Albeck MJ, Hilden J, Kjaer L, et al. A controlled comparison ofmyelography, computed tomography, and magnetic resonance imaging inclinically suspected lumbar disc herniation. Spine (Phila Pa1976)1995;20:443-8
2Estridge MN, Rouhe SA, Johnson NG. The femoral stretching test. Avaluable sign in diagnosing upper lumbar disc herniations. J Neurosurg1982;57:813-7
3Harms J, Rolinger H.[A one-stager procedure in operative treatment ofspondylolistheses: dorsal traction-reposition and anterior fusion (author'stransl)]. Z Orthop Ihre Grenzgeb1982;120:343-7
4Hsu K, Zucherman J, Shea W, et al. High lumbar disc degeneration.Incidence and etiology. Spine (Phila Pa1976)1990;15:679-82
5Iwasaki M, Akino M, Hida K, et al. Clinical and radiographiccharacteristics of upper lumbar disc herniation: ten-year microsurgicalexperience. Neurol Med Chir (Tokyo)2011;51:423-6
6Moore KR, Pinto MR, Butler LM. Degenerative disc disease treated withcombined anterior and posterior arthrodesis and posterior instrumentation.Spine (Phila Pa1976)2002;27:1680-6
7Tamir E, Anekshtein Y, Melamed E, et al. Clinical presentation andanatomic position of L3-L4disc herniation: a prospective and comparativestudy. J Spinal Disord Tech2004;17:467-9
8Yan DL, Pei FX, Li J, et al. Comparative study of PILF and TLIFtreatment in adult degenerative spondylolisthesis. Eur Spine J2008;17:1311-6
9齐强,陈仲强,刘忠军, et al.胸腰段椎间盘突出症的手术治疗及入路选择.中国脊柱脊髓杂志2006:133-7
10杨海涛,王林.两种不同手术方式治疗高位腰椎间盘突出症的临床疗效比较.中华临床医师杂志(电子版)2012:1000-2
1Albeck MJ, Hilden J, Kjaer L, et al. A controlled comparison ofmyelography, computed tomography, and magnetic resonance imaging inclinically suspected lumbar disc herniation. Spine (Phila Pa1976)1995;20:443-8
2Albert TJ, Balderston RA, Heller JG, et al. Upper lumbar disc herniations.J Spinal Disord1993;6:351-9
3Aquarius R, Homminga J, Verdonschot N, et al. The fracture risk ofadjacent vertebrae is increased by the changed loading direction after awedge fracture. Spine (Phila Pa1976)2011;36:E408-12
4Bosacco SJ, Berman AT. Surgical management of lumbar disc disease.Radiol Clin North Am1983;21:377-93
5Briggs AM, Wrigley TV, van Dieen JH, et al. The effect of osteoporoticvertebral fracture on predicted spinal loads in vivo. Eur Spine J2006;15:1785-95
6Brown MD, Gomez-Marin O, Brookfield KF, et al. Differential diagnosisof hip disease versus spine disease. Clin Orthop Relat Res2004:280-4
7Choi JW, Lee JK, Moon KS, et al. Transdural approach for calcifiedcentral disc herniations of the upper lumbar spine. Technical note. JNeurosurg Spine2007;7:370-4
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9de Schepper EI, Damen J, Bos PK, et al. Disk degeneration of the upperlumbar disks is associated with hip pain. Eur Spine J2013;22:721-6
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