微创腰椎间盘分流术治疗椎间盘源性腰痛

Treatment of discogenic low back pain by minimally invasive lumbar disc shunt

目的探讨微创腰椎间盘分流术治疗椎间盘源性腰痛的作用机制并分析其近期临床疗效。方法通过体外实验测定尼龙线分流虹吸管作用的距离；动物椎问盘内置入尼龙线，其尾端埋于肌肉中，组织学检查尼龙线的生物相容性。15例经椎间盘造影诊断为椎间盘源性腰痛，局麻下行腰椎间盘分流术（应用特别设计的工具将尼龙线置人腰椎间盘内），L3-4例、L4-5，6例、L5s17例、L3-4合并L4-5，1例。术后1周、3、12和24个月采用疼痛视觉模拟评分（visualanalogueseale，VAS）、Oswestry功能障碍指数（Oswestrydisabilityindex，ODI）和影像学检查综合评估临床疗效。结果体外实验显示通过尼龙线可将乳酸溶液的pH值从低于4．0调高至7．14；体内实验表明绵羊椎问盘置人尼龙线后，椎问盘内蛋白多糖的含量随着时间推移逐渐增加，且尼龙线周围无炎症反应。所有患者均成功施行腰椎间盘分流术，无手术并发症。术后2年随访，患者VAS评分与ODI评分均有明显下降，VAS改善率达79．16％±12．33％，ODI改善率为77．42％±12．20％；X线片示术后2年椎间盘高度指数与术前相比，差异无统计学意义；MRI示根据改良Thompson分级，分流椎间盘的退变程度无加重，10例患者髓核信号有一定程度的增强。结论经皮腰椎问盘分流术能够明显缓解腰痛，改善腰背部功能，具有创伤小，风险低的优点，有望成为临床治疗椎问盘源性腰痛一种新的微创手术方式。

Objective To study the mechanism of minimaliy invasive lumbar disc shunt on treating discogenic low back pain, and analyze its short-term clinical outcome. Methods First, use nylon suture to perform a shunt study about its ability to change acid fluid＇ s PH. Second, evaluate the influence of proteoglycan＇ s content pre-and post-nylon suture implanting into lumber disc of sheep, meanwhile, observe nylon suture＇ s biocompatibility inside of lumbar disc. Third, a clinical trial is per-formed , which is named ＂disc shunt＂. Fifteen patients were diagnosed as discogenic low back pain by discography. All of them accepted ＂disc shunt＂ through pathway of discography at once, local anesthesia was used in all cases. Patients had shunts （using nylon suture） implanted into the following level of discs： one at L3-4, six at L4-5, seven at L5S1, and one at both L3-4 and L4-5. Clinical outcome evaluation is based on VAS score, ODI score and radiology at one week, three months, one year and two year after implantation. Results In virto study showed pH of lactic acid solution was gradually raised from 4.0 to 7.14 after shunt by nylon suture. Shunted discs of sheep were harvested at one, three, twelve and twenty-four months. Safranine 0 staining showed gradually increasing of proteoglycans in disc. No obvious inflammatory reaction surround nylon suture after 24 months observation. Nylon suture＇ s bioeompatibility was satisfactory inside lumbar disc. For clinical trial study, the low back pain and disability was significantly improved after operation. At the final twenty-four months follow up, evaluations showed all of the patients＇ VAS and ODI scores were reduced significantly, average rate of VAS scores improvement was 79.16%± 12.33%, and average rate of ODI was 77.42%±12.20%. Radiological examinations after implant showed no reduction of disc height index, and no aggressive disc degeneration according to Thompson scale. In addition, shunted discs were whitened under MRI, probably from disc hydration through the disc shunts. Conclusion Percutaneous disc shunt is an efficacious therapy for discogenic low back pain with multi- ple advantages such as being minimally invasive, having few risks, reducing pain and disability, and having treatment concurrent with diagnostic discography.