腰椎间盘突出症的病理学分型及其对手术方案选择的意义

Pathological classification of lumbar disc protrusion and its guidance for surgical treatment

目的 探讨腰椎间盘突出症的病理学分型及其临床意义.方法 2001年2月至2010年10月手术治疗腰椎间盘突出症812例,根据术中所见分为三型：损伤疝出型,表层纤维环较薄、质软,髓核疝出或游离,容易摘除成块破碎的椎间盘组织;退变突出型,突出部质硬韧,纤维环致密增厚,无破碎组织;椎体后缘骨软骨病伴椎间盘突出型,质硬,范围大,切除困难,合并疝出者为椎体后缘骨软骨病伴椎间盘损伤疝出型.对手术切除的124例前两型椎间盘突出组织行组织学观察.结果 损伤疝出型495例,患者平均年龄38.6岁,80.4％有轻微外伤史,76.8％直腿抬高试验阳性;病理示组织破坏,新生血管化,T淋巴细胞和巨噬细胞浸润,IgG、IgM沉积和IL-7表达,炎症和自身免疫反应明显,超微结构以破坏征象为主.退变突出型215例,平均年龄55.7岁,85.1％间歇性跛行明显,14.9％直腿抬高试验阳性;病理示软骨基质和胶原纤维增生致密、排列紊乱,无炎症和免疫反应或很轻微,超微结构以增生征象为主,细胞合成活跃.椎体后缘骨软骨病伴椎间盘突出型102例,椎体后缘向后突出,椎体相应部位缺损,其中38例伴椎间盘损伤疝出型症状类似损伤疝出型.结论 腰椎间盘突出症有不同的病理学类型、发病机制和临床特点,损伤疝出型炎症和损伤反应明显,需彻底摘除疝出和破碎髓核;退变突出型退变和狭窄明显,以神经微侵袭减压为主,通常无须切除椎间盘.

Objective To introduce a pathological classification of lumbar disc protrusion for guidance of surgical treatment.Methods From February 2001 to October 2010,812 patients of lumbar disc protrusion underwent surgical treatment,and three types of protrusions were defined according to intraoperative findings,namely damage-herniation type,degeneration-protrusion type,and posterior vertebral osteochondrosis with disc protrusion type.All of 124 specimens of the first two types were observed by microscopic pathology,immunohistochemistry and electron microscopy.Results Damage-herniation type was observed in 495 patients,with an average age of 38.6 years old,the history of slight trauma and positive straight leg raising test （SLRT） existed in 80.4％ and 76.8％ of them,respectively.Pathological examinations showed inflammation and revascularization,T-lymphocytes and macrophage infiltration,IgG and IgM deposition,and IL-7 expression,while ultrastructive examination showed mainly destructive signs,which suggested the presence of injury mechanism.Degeneration-protrusion type was observed in 215 patients with an average of 55.7 years old,the intermittent claudicating and positive SLRT existed in 85.1％ and 14.9％ of them,respectively.Pathological examinations showed dense proliferation and disarrangement of the collagenous fibers and cartilage matrix,none or minimal inflammation or immune response,while ultrastructive examination showed mainly hyperplasia signs including active cell synthesis,which suggested the degenerative and proliferative mechanism.The third type protrusion was observed in 102 patients.Osseous protrusion and defect in the vertebral body were showed by X-ray and CT.Conclusion Lumbar disc protrusion has different pathological types,pathogenesis and clinical characteristics.Damage-herniation type had obvious inflammations and damage responses,so the herniated and broken nucleus pulpous should be removed adequately during surgical treatment.Degeneration-protrusion type protrusion had obvious degeneration and stenosis,so the surgery was based on minimally invasive nerve decompression,and discectomy was usually not needed.