田 鵬 付 鑫 孫曉雷 鄧樹才 馬信龍,2△
神經(jīng)根沉降征在腰椎滑脫癥和腰椎間盤突出癥中的差異
田 鵬1付 鑫1孫曉雷1鄧樹才1馬信龍1,2△
目的 評(píng)價(jià)神經(jīng)根沉降征在腰椎滑脫癥(LS)和腰椎間盤突出癥(LDH)患者中的表現(xiàn),并比較其在二者中的差異。方法收集天津市天津醫(yī)院脊柱外科2012年7月—2014年3月行手術(shù)治療的腰椎退行脊柱病患者資料151例,分為L(zhǎng)S組48例和LDH組103例。采用JOA評(píng)分評(píng)估2組患者術(shù)前臨床表現(xiàn),比較2組患者神經(jīng)根沉降征陽性率,分析JOA評(píng)分與神經(jīng)根沉降征的關(guān)系。結(jié)果LS組和LDH患者在JOA評(píng)分差異無統(tǒng)計(jì)學(xué)意義(15.83±3.57 vs 16.76±3.10,t=1.624,P=0.107)。LS組神經(jīng)根沉降征陽性39例(81.25%),而LDH組65例(63.11%),差異有統(tǒng)計(jì)學(xué)意義(χ2=5.028,P=0.031)。LS組中,神經(jīng)根沉降征陽性者JOA評(píng)分低于陰性者(15.33±3.50 vs 18.00± 3.20,t=2.092,P=0.042);而LDH組中,神經(jīng)根沉降征陽性和陰性者JOA評(píng)分差異無統(tǒng)計(jì)學(xué)意義(16.40±3.13 vs 17.37±2.99,t=1.539,P=0.127)。結(jié)論神經(jīng)根沉降征陽性也見于腰椎間盤突出癥中,但在臨床表現(xiàn)更嚴(yán)重的腰椎滑脫癥患者中更易出現(xiàn)。
椎間盤移位;腰椎滑脫;腰椎間盤突出;神經(jīng)根沉降征;JOA評(píng)分
腰椎管狹窄癥是腰椎管容量減少,壓迫椎管及神經(jīng)根管神經(jīng)而出現(xiàn)功能障礙的總稱,是臨床常見脊柱手術(shù)原因之一[1]。腰椎滑脫和椎間盤突出是造成腰椎管狹窄的常見原因。腰椎管狹窄癥的診斷困難在于休息時(shí)疼痛消失,只有體力活動(dòng)時(shí)才出現(xiàn)疼痛及功能受限。評(píng)估腰椎管狹窄癥的常見MRI評(píng)價(jià)方法有硬膜囊橫截面積(cross-sectional area,CSA)、形態(tài)學(xué)等級(jí)A~D和神經(jīng)根沉降征。Barz等[2]早在2010年就提出神經(jīng)根沉降征的概念,指仰臥位MRI中,腰神經(jīng)根不隨重力沉降到硬膜囊背側(cè),依然停留在硬膜囊腹側(cè)和中央,并指出神經(jīng)根沉降征陽性率與腰椎管狹窄癥有關(guān)。最新研究指出神經(jīng)根沉降征陽性最易出現(xiàn)在臨床顯著腰椎管狹窄、且需要手術(shù)干預(yù)的患者中[3]。既往研究大多是比較腰椎管狹窄癥和非特異性腰痛患者,而神經(jīng)根沉降征在腰椎滑脫中的研究相對(duì)較少。本研究觀察單節(jié)段L4~5和L5~S1手術(shù)治療的腰椎間盤突出癥(lumbar disc herniation,LDH)患者中神經(jīng)根沉降征陽性率,同時(shí)分析同期手術(shù)治療的腰椎滑脫癥(lumbar spondylolisthesis,LS)中神經(jīng)根沉降征的表現(xiàn)情況,并比較二者差異。
1.1 一般資料 收集2012年7月—2014年3月天津市天津醫(yī)院手術(shù)治療且影像資料完整的腰椎退行脊柱病患者151例,包括LS 48例和LDH 103例。所有患者均通過病史、體檢及影像學(xué)(X線片、MRI、CT)獲得證實(shí)。排除標(biāo)準(zhǔn)如下:(1)周圍血管性疾病,下肢靜脈曲張或動(dòng)脈閉塞性疾病。(2)下肢關(guān)節(jié)疾病,如髖關(guān)節(jié)和膝關(guān)節(jié)骨性關(guān)節(jié)炎或類風(fēng)濕性關(guān)節(jié)炎等。(3)腰椎既往手術(shù)病史。(4)脊柱蛛網(wǎng)膜炎癥疾病。LS組中L4前滑脫41例,L5前滑脫7例,根據(jù)Meyerding法該組患者均為Ⅰ度滑脫。LDH組中L4~5節(jié)段55例,L5~S1節(jié)段48例。
1.2 方法
1.2.1 神經(jīng)根沉降征在MRI橫斷面上判斷標(biāo)準(zhǔn) 參考Barz 等[2]方法,于MRI T2加權(quán)圖像橫斷面上,在腰椎雙側(cè)小關(guān)節(jié)頂點(diǎn)間作一水平直線,除本節(jié)段離開硬膜囊的神經(jīng)根外,還有其他神經(jīng)根位于連線的腹側(cè),此即為神經(jīng)根沉降征陽性,見圖1A。在連線的腹側(cè)除離開硬膜囊的神經(jīng)根之外若無其他神經(jīng)根,此現(xiàn)象定義為神經(jīng)根沉降征陰性,見圖1B。
1.2.2 神經(jīng)根沉降征評(píng)估 觀察每例患者腰椎MRI橫斷面掃描(包括L1~L5節(jié)段)硬膜囊上神經(jīng)根的分布情況,只要有1個(gè)節(jié)段有神經(jīng)根沉降征陽性,即定義為神經(jīng)根沉降征陽性。由2名脊柱外科醫(yī)師獨(dú)立在MRI掃描上評(píng)估神經(jīng)根沉降征,再進(jìn)一步分析之前,針對(duì)兩名研究者的最初評(píng)級(jí)不一致的神經(jīng)根沉降征,經(jīng)二者協(xié)商后達(dá)成一致。
1.2.3 JOA腰背痛評(píng)分 根據(jù)JOA腰痛評(píng)分系統(tǒng)對(duì)每例患者進(jìn)行術(shù)前評(píng)價(jià)。JOA評(píng)分包括主觀癥狀(9分)、臨床體征(6分)、日常生活受限情況(14分),總計(jì)29分,根據(jù)膀胱功能情況相應(yīng)減分(-6分)[4]。比較LS組和LDH組患者JOA評(píng)分的差異,并比較各組內(nèi)神經(jīng)根沉降征陽性和陰性患者JOA評(píng)分的差異。
1.3 統(tǒng)計(jì)學(xué)方法 應(yīng)用SPSS 19.0軟件進(jìn)行數(shù)據(jù)分析。計(jì)量資料以均數(shù)±標(biāo)準(zhǔn)差(±s)表示,2組間比較采用t檢驗(yàn),計(jì)數(shù)資料采用例表示,組間比較采用χ2檢驗(yàn)。P<0.05表示差異有統(tǒng)計(jì)學(xué)意義。
Fig.1 The performance of nerve root in transverse MRI scan圖1 MRI橫斷面掃描神經(jīng)根表現(xiàn)
2.1 2組臨床一般資料比較 LS組患者年齡大于LDH組,且女性患者比例較高。2組患者JOA腰痛評(píng)分差異無統(tǒng)計(jì)學(xué)意義,見表1。
Tab.1 Comparison of JOA score,gender and age of patients between LS group and LDH group表1 LS組和LDH組患者的年齡、性別、JOA評(píng)分比較
2.2 2組患者神經(jīng)根沉降征陽性率比較 在LS組中,39例神經(jīng)根沉降征陽性,陽性率81.25%;LDH組中65例神經(jīng)根沉降征陽性,陽性率63.11%,低于LS組(χ2=5.028,P<0.05)。神經(jīng)根沉降征陽性節(jié)段位于病變節(jié)段水平以上,見圖2。
2.3 2組患者中神經(jīng)根沉降征陽性和陰性患者JOA評(píng)分比較 LS組中,神經(jīng)根沉降征陽性患者JOA評(píng)分為15.33±3.50,陰性為18.00±3.20,差異有統(tǒng)計(jì)學(xué)意義(t=2.092,P=0.042)。LDH組中,神經(jīng)根沉降征陽性患者JOA評(píng)分為16.40±3.13,陰性為17.37± 2.99,差異無統(tǒng)計(jì)學(xué)意義(t=1.539,P=0.127)。
3.1 腰椎管狹窄癥與神經(jīng)根沉降征的診斷 脊柱MRI被認(rèn)為是腰椎管狹窄癥診斷、描繪病變程度及位置的重要的術(shù)前評(píng)估工具。既往有研究證實(shí)無癥狀群體中椎管狹窄比例較高,然而尋找更有價(jià)值的臨床相關(guān)影像學(xué)指標(biāo)具有一定難度[5]。有研究證實(shí)患者Oswestry功能障礙指數(shù)(Oswestry disability index,ODI)與腰椎管狹窄程度和CSA間無相關(guān)性[6],以致MRI在腰椎管狹窄中診斷作用受到質(zhì)疑[7]。然而,也有研究顯示CSA和形態(tài)學(xué)等級(jí)A~D能夠后較好地評(píng)價(jià)腰椎管狹窄癥[8]。因此神經(jīng)根沉降征在腰椎管狹窄癥中的應(yīng)用越來越多地受到關(guān)注。
3.2 神經(jīng)根沉降征在腰椎管狹窄癥中的應(yīng)用 Barz 等[2]首次報(bào)道了癥狀性腰椎管狹窄癥患者中神經(jīng)根沉降征陽性率為94%,提出該征在診斷腰椎管狹窄癥時(shí)具有較高的靈敏度。本研究中LS組神經(jīng)根沉降征陽性率為81.25%,與既往研究基本一致,本研究納入腰椎滑脫癥,而Barz等[2]研究對(duì)象為中央型腰椎管狹窄患者。也有研究比較腰椎管狹窄癥、腰痛、血管性跛行及無癥狀對(duì)照組患者中神經(jīng)根沉降征陽性情況,證實(shí)其靈敏度為42%~66%,特異度為49%~78%,特別是最小CSA小于80 mm2患者靈敏度從60%提高到96%,神經(jīng)根沉降征能夠區(qū)分腰椎管狹窄癥患者與對(duì)照組,但是該征不能區(qū)分腰椎管狹窄癥和腰痛及血管性跛行[9]。本研究中,LS患者神經(jīng)根沉降征陽性率高于LDH患者,造成此征陽性率差異的原因在于二者造成椎管狹窄的發(fā)病機(jī)制不同。
國(guó)外有學(xué)者發(fā)現(xiàn)腰椎狹窄癥患者伴有神經(jīng)根沉降征陽性時(shí),其狹窄節(jié)段硬膜外壓力平均值達(dá)22 mmHg(1 mmHg=0.133 kPa),其結(jié)果不受狹窄節(jié)段CSA影響,證實(shí)腰椎管狹窄癥患者在狹窄節(jié)段硬膜外壓力升高,從而提出腰神經(jīng)根未沉到硬膜囊背側(cè)是由于狹窄節(jié)段束縛了腰神經(jīng)根[10]。本研究納入的腰椎滑脫癥為退變性,椎管狹窄緩慢進(jìn)展過程中,神經(jīng)根受壓缺血導(dǎo)致?lián)p傷,神經(jīng)損傷修復(fù)過程中逐漸出現(xiàn)炎性反應(yīng),從而引起神經(jīng)根粘連。但是具體的機(jī)制需要后續(xù)繼續(xù)研究。
有研究提出在MRI中硬膜囊最小CSA是定量評(píng)價(jià)椎管狹窄的一種客觀指標(biāo),特別是針對(duì)<100 mm2時(shí)更有臨床意義[11]。但也有研究指出ODI評(píng)分和硬膜囊最小CSA之間不存在相關(guān)性,ODI可能不是評(píng)估腰椎狹窄癥患者最理想的方法[6,12]。因此本研究未進(jìn)行CSA與神經(jīng)根沉降征相關(guān)比較研究。本研究顯示LS組中神經(jīng)根沉降征陽性患者具有較低的JOA評(píng)分,說明其有較嚴(yán)重的臨床表現(xiàn)。國(guó)外有研究證實(shí)在退變腰椎管狹窄癥患者中女性相比于男性有更重的腰腿痛癥狀[13]。本研究中LS組年齡較大且女性比例高,與國(guó)外報(bào)道一致,原因可能是女性患者癥狀重且就醫(yī)接受手術(shù)的比例高,這也需要大宗病例的臨床研究來進(jìn)一步驗(yàn)證。
本研究難免存在一定的局限性。本研究?jī)H是觀察我院手術(shù)治療LS及LDH群體,且是回顧分析術(shù)前MRI上神經(jīng)根沉降征的差異,在隨訪時(shí)大多患者無法再行MRI檢查,不能比較術(shù)前與術(shù)后沉降征的表現(xiàn)差異。今后可在研究前周密設(shè)計(jì)研究計(jì)劃,定期隨訪,力爭(zhēng)獲得完整詳細(xì)的隨訪資料,從而獲得嚴(yán)謹(jǐn)?shù)难芯拷Y(jié)果。
Fig.2 T2-weighted MRI scans of a LDH patient with a positive nerve root sedimentation sign圖2 T2加權(quán)MRI顯示腰椎間盤突出癥患者神經(jīng)根沉降征陽性表現(xiàn)
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(2014-08-08收稿 2014-09-02修回)
(本文編輯 李鵬)
The Different Sign of Nerve Root Sedimentation on MRI in Patients between Lumbar Spondylolisthesis and Lumbar Disc Herniation
TIAN Peng1,F(xiàn)U Xin1,SUN Xiaolei1,DENG Shucai1,MA Xinlong1,2△
1 Tianjin Hospital,Tianjin 300211,China;2 Tianjin Medical University General Hospital
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E-mail:maxinlong8686@sina.com
ObjectiveTo evaluate and compare the presence of the nerve root sedimentation sign in patients with lumbar spondylolisthesis(LS)and lumbar disc herniation(LDH).MethodsOne hundred and fifty-one patients with degenerative lumbar spinal disease treated by surgery from July 2012 to March 2014 were reviewed retrospectively in Tianjin Hospital.All the patients were divided into two groups:LS group(48 cases)and LDH group(103 cases).The clinical outcomes were evaluated by Japanese Orthopedic Association(JOA).The probability of positive sedimentation sign was compared between LS group and LDH group.Correlation between the JOA score and nerve root sedimentation sign were analysed in two groups.ResultsThere was no statistical difference in JOA score between LS group and LDH group(15.83±3.57 vs 16.76± 3.10,t=1.624,P=0.107).A positive sedimentation sign was identified in 39 patients in the LS group(81.25%)but in 65 patients in the LDH group(63.11%).The difference between LS group and LDH group was statistically significant(χ2=5.028, P=0.031).In LS group,JOA scores of patients with positive nerve root sedimentation sign were lower than those of patients with negative nerve root sedimentation sign(15.33±3.50 vs 18.00±3.20,t=2.092,P=0.042);but in LDH group,there was no statistical difference in JOA scores of patients between positive nerve root sedimentation sign and negative nerve root sedimentation sign(16.40±3.13 vs 17.37±2.99,t=1.539,P=0.127).ConclusionA positive sedimentation sign also occurs in patients with LDH,but positive nerve root sedimentation sign are more likely to appear in patients with lumbar spondylolisthesis who have worse clinical symptoms.
intervertebral disk displacement;lumbar spondylolisthesis;lumbar disc herniation;nerve root sedimentation sign;JOA score
R681.5
A
10.3969/j.issn.0253-9896.2014.12.018
國(guó)家自然科學(xué)基金資助項(xiàng)目(81401792);天津市中醫(yī)藥管理局中醫(yī)、中西醫(yī)結(jié)合科研課題(13123);天津市衛(wèi)生局攻關(guān)項(xiàng)目(10KG111)
1天津市天津醫(yī)院(郵編300211);2天津醫(yī)科大學(xué)總醫(yī)院
△通訊作者 E-mail:maxinlong8686@sina.com