硬膜内腰椎间盘突出症

Intradural lumbar disc herniation

目的探讨硬膜内腰椎间盘突出症的诊断与手术治疗方式,并对其发病机制进行讨论。方法对5例硬膜内腰椎间盘突出症患者进行了手术治疗,男3例,女2例,年龄28～52岁,平均42岁,并经CT、MRI和手术证实,手术中采用半椎板切除或全椎板切除术,切开硬脊膜和蛛网膜,显露突出的椎间盘髓核组织,并仔细予以摘除,缝合硬脊膜切口,用脂肪、肌肉、或纤维蛋白凝胶覆盖。结果尽管患者术前都有明显的神经症状,术后患者都取得了良好的效果,对病人进行了1～5年的随访,术前腰痛、下肢痛均缓解,明显改善了工作和生活质量。3例患者效果良好,恢复了原工作,其他2例患者术前出现了马尾综合征,仍残留一些神经症状,尿频尿急,会阴部感觉丧失,肌肉萎缩。结论硬脊膜腹侧与后纵韧带粘连是造成硬膜内腰椎间盘突出的主要因素,硬膜内腰椎间盘突出术前很难诊断,通常诊断是在术中确定的,术前诊断应强调MRI的重要性,患者多需要紧急手术,因为神经预后与神经症状出现的时间有关,早期诊断和适当的手术治疗对于取得良好的效果是非常重要的。

Objectlve To investigate the diagnosis and surgical procedure of the intradural lumbar disc herniation （ILDH）,and the possible pathogenic factors are discussed. Methods Five cases of intradural lumbar disc herniation were operated,There were 3 males and 2 females with the age ranged between 28 and 52 and an average of 42 years. And all the five patients were confirmed by CT,MRI and operation. During the operation,the hemilaminotomy or laminectomy of the lumbar were undertaken. An incision were made in the dura and arachnoid,revealing an extruded discal mass. It was carefully removed. The dural gap was closed by suture and by adding fat,muscle,and human fibrin glue. Results Despite preoperatively significant neurological deficits,the prognosis following surgery was good. The followed up period was from 1 to 5 years after operation. The symptoms of lumbar pain ,lower limb pain of 5 cases were relieved. Their quality of life and work were improved remarkably,Three cases satisfactory results were reported,with patients able to go back to work normally,while in the other two cases which preoperation presence of cauda equina syndrome, residual neurologic deficit,mieturition urgency,perineum sensory loss,and muscular hypotrophy were reported. Conclusions Adhesions between the ventral wall of the dura and the posterior longitudinal ligament （PLL） could act as a preconditioning factor in ILDH. Diagnosis of ILDH is difficult and seldom being suspected preoperatively. It is usually diagnosed by during surgery, emphasis on the role of MRI in preoperative diagnosis. Prompt surgery is necessary in most cases because the neurologic prognosis appears to be closely linked to preoperative duration of neurologic symptoms. Early diagnosis and appropriate treatment are important to achieve a better surgical outcome.