椎间盘源性腰痛的分型

A new classification of discogenic low back pain

目的介绍一种新的椎间盘源性腰痛的分型方法，以更好地指导临床诊断和治疗。方法通过回顾性分析386例慢性腰痛患者的椎间盘造影术中X线荧光影像和术后CT扫描片，结合术中患者有无一致性疼痛复制反应，将椎间盘源性腰痛进行分型。结果386例腰痛患者共行1056个椎间盘的腰椎间盘造影术，共有192例患者（49．7％）的226个椎间盘（21．4％）出现疼痛复制反应。192例出现疼痛复制反应的患者中，由于纤维环破裂（internal disc disruption，IDD）160例，由于终板破裂（internal endplate disruption，IED）32例，分别占83.3％和16．7％。应用修正的Dallas CT椎间盘造影分级方法评估IDD患者纤维环放射状撕裂程度，应用术中荧光X线影像结合术后CT扫描评估IED患者终板放射状破裂程度。IDD患者纤维环破裂分级越高，椎间盘造影时一致性疼痛比例越大（r=0．604，P=0．000）。IED患者终板破裂程度越大，椎间盘造影时一致性疼痛比例越大（r=0．683，P=0．000）。结论根据临床研究结果，我们将椎间盘源性腰痛分为两种类型，由IDD引起的腰痛和由IED引起的腰痛。临床上这两种类型的椎间盘源性腰痛都要通过腰椎间盘造影术确诊，诊断过程、放射状撕裂方式和疼痛反应方式完全一致，表明其为一种科学、合理的分型方法。

Objective To introduce a new classification of discogenic low back pain so as to better guide clinical diagnosis and treatment. Methods A total of 386 patients with chronic low back pain who underwent lumbar discography were analyzed retrospectively. Discogenic low back pain was classified according to discogram and CT scan after discography combined with pain reproduction response. Results Of the 386 patients with chronic low back pain, 1056 discs underwent discography, and 192 patients （49.7%） with 226 discs （21.4%） showed pain reproduction response. In all 192 cases with pain reproduction response, 160 showed the internal annular disruption （IDD）, and 32 showed the internal endplate disruption （IED）, which accounted for 83.3% and 16.7% respectively. Annular disruption in IDD was graded in 5 levels according to the modified Dallas classification, and endplate disruption in IED was graded in 4 levels according to discogram and CT discography. The higher grade of annular disruption was, the bigger proportion of patients with pain reproduction response in discography occurred. There was a positive correlation between concordant pain reproduction response and the degree of annular disruption （r=0.604 ,P=0.000）. The results were uniform in IED （r=0.683 ,P=0.000）. Conclusion Based on our clinical results, discogenic low back pain can be divided into two types, i.e., discogenic low back pain causing by IDD and IED respectively. The two types of discogenic low back pain are diagnosed by lumbar discography in which operation procedure, radiating tear modality, and assessment of pain response are at equal pace completely, which indicate that the new classification method is scientifically reasonable.