Fundamentals of intervertebral disc degeneration and related discogenic pain

Lumbar intervertebral disc degeneration is thought to be the main cause of low back pain,although the mechanisms by which it occurs and leads to pain remain unclear.In healthy adult discs,vessels and nerves are present only in the outer layer of the annulus fibrosus and in the bony endplate.Animal models,and histological and biomechanical studies have shown that annulus tear or endplate injury is the initiating factor for painful disc degeneration.Injury to the disc triggers a local inflammatory repair response that activates nociceptors and promotes the synthesis of neuropeptides such as substance P and calcitonin generelated peptide,by dorsal root ganglion neurons.These neuropeptides are transported to injured discs and act as pro-inflammatory molecules,promoting the production of an“inflammatory soup”by inducing vasodilatation and plasma extravasation as well as by promoting the release of chemical mediators from disc cells and infiltrating immune cells,causing neurogenic inflammation that leads to progressive disc degeneration and discogenic pain.

Pathophysiology, diagnosis, and treatment of discogenic low back pain

Discogenic low back pain is a serious medical and social problem, and accounts for 26%-42% of the patients with chronic low back pain. Recent studies found that the pathologic features of discs obtained from the patients with discogenic low back pain were the formation of the zones of vascularized granulation tissue, with extensive innervation in fissures extending from the outer part of the annulus into the nucleus pulposus. Studies suggested that the degeneration of the painful disc might originate from the injury and subsequent repair of annulus fibrosus. Growth factors such as basic fibroblast growth factor, transforming growth factor β1, and connective tissue growth factor, macrophages and mast cells might play a key role in the repair of the injured annulus fibrosus and subsequent disc degeneration. Although there exist controversies about the role of discography as a diagnostic test, provocation discography still is the only available means by which to identify a painful disc. A recent study has classified discogenic low back pain into two types that were annular disruption-induced low back pain and internal endplate disruption-induced low back pain, which have been fully supported by clinical and theoretical bases. Current treatment options for discogenic back pain range from medicinal anti-inflammation strategy to invasive procedures including spine fusion and recently spinal arthroplasty. However, these treatments are limited to relieving symptoms, with no attempt to restore the disc's structure. Recently, there has been a growing interest in developing strategies that aim to repair or regenerate the degenerated disc biologically.

Systematic Review and Meta-analysis of Efficacy and Safety of Tenghuang Jiangu Tablet(藤黄健骨片)in the Treatment of Discogenic Low Back Pain

Objective:To systematically evaluate the efficacy and safety of Tenghuang Jiangu Tablet(藤黄健骨片)in the treatment of discogenic low back pain.Methods:CNKI,WanFang,CBM,VIP,PubMed,EMbase,Cochrane Library and Web of Science were systematically searched to collect the randomized controlled trials(RCTs)of Tenghuang Jiangu Tablet in the treatment of discogenic low back pain.Literature screening and data extraction according to the set criteria were conducted.Cochrane Risk Bias assessment tool was used to evaluate the quality of included RCTs,and Meta-analysis was performed using RevMan 5.4.1 software.Results:A total of 4 studies were included,with a total sample size of 404 cases.The results of Meta-analysis suggested that Tenghuang Jiangu Tablet combined with conventional treatment in the treatment of discogenic low back pain was superior to conventional treatment alone in terms of total clinical response rate(RR=1.21,95%CI[1.09,1.35],P=0.0004),excellent rate of curative effect(RR=1.24,95%CI[1.10,1.41],P=0.0007),lower VAS score(MD=-0.62,95%CI[-0.79,-0.44],P<0.00001)and JOA score(MD=1.84,95%CI[1.35,2.33],P<0.00001).There was no statistical significance in the incidence of adverse reactions between Tenghuang Jiangu Tablet combined with conventional treatment and conventional treatment alone(RR=0.76,95%CI[0.04,15.42],P=0.86).Conclusion:Based on existing research and methods,Tenghuang Jiangu Tablet combined with conventional therapy is effective on discogenic low back pain.Conventional therapy combined with Tenghuang Jiangu Tablet for the treatment of discogenic low back pain may be better than conventional therapy alone.All the adverse reactions occurred during the treatment were mild.There is no evidence that Tenghuang Jiangu Tablet can cause serious adverse reactions.However,the number of existing clinical studies is small and the quality is generally not high.It is suggested to carry out more large-sample and high-quality RCTs,and pay more attention to the long-term efficacy of drugs and the occurrence of adverse reactions,so as to further verify the above conclusions.

Discogenic pain: Who cares?

Chronic low back pain has a huge impact on daily living and a negative economic and professional effect. It is a matter of debate and concern for all health professionals involved, particularly spine surgeons. Recent discoveries on the innervation and biochemical properties of the intervertebral disc clarify the role of this structure as a possible cause of chronic low back pain. However, multiple causes may be present in the same patient making the diagnosis a challenging process. Discogenic pain is defined as a chronic low back pain induced by a degenerative disc disease. There are no specific characteristics of discogenic pain, although it has a higher incidence in younger age, it is usually localized medially in the back, worsens with axial loading and improves with recumbence. In the last decades we have assisted the emergence of multiple treatment techniques. However, neither the conservative treatment nor the interventional management has strong evidence in treating discogenic pain. Randomized control clinical trials are sought to improve patient outcome. Meanwhile, we believe each patient should be approached on an individual base. Discogenic pain: we care.

Role of neurogenic inflammation in intervertebral disc degeneration

In healthy intervertebral discs(IVDs),nerves and blood vessels are present only in the outer annulus fibrosus,while in degenerative IVDs,a large amount of nerve and blood vessel tissue grows inward.Evidence supports that neurogenic inflammation produced by neuropeptides such as substance P and calcitonin gene related peptide released by the nociceptive nerve fibers innervating the IVDs plays a crucial role in the process of IVD degeneration.Recently,non-neuronal cells,including IVD cells and infiltrating immune cells,have emerged as important players in neurogenic inflammation.IVD cells and infiltrating immune cells express functional receptors for neuropeptides through which they receive signals from the nervous system.In return,IVD cells and immune cells produce neuropeptides and nerve growth factor,which stimulate nerve fibers.This communication generates a positive bidirectional feedback loop that can enhance the inflammatory response of the IVD.Recently emerging transient receptor potential channels have been recognized as contributors to neurogenic inflammation in the degenerative IVDs.These findings suggest that neurogenic inflammation involves complex pathophysiological interactions between sensory nerves and multiple cell types in the degenerative IVDs.Clarifying the mechanism of neurogenic inflammation in IVD degeneration may provide in-depth understanding of the pathology of discogenic low back pain.

Therapeutic observation on heat-sensitive acupoint for treatment of Irishmen with discogenic low back pain

Objective To observe the therapeutic difference in treatment of Irishmen with discogenic low back pain （arthritis of cold-damp syndrome type） between heat-sensitive acupoint and acupuncture. Methods Eighty-two patients were randomly assigned to the heat-sensitive group （43 cases） and the acupuncture group （39 cases）. Corresponding heat-sensitive points in the lumbosacral area were selected in the heat-sensitive group. Then moxibustion was performed at the heat-sensitive acupoint, thus conducting the moxibustion sensation. The treatment was ended when the sensation conduction was finished. If there appeared no moxibustion sensation, moxibustion at the corresponding painful point was lasted for 30 min. Needling was performed in the acupuncture group at corresponding Jiájǐ（夹 脊 EX-B 2）, Back-shu point, Wěizhōng （委中 BL 40）; matching points included Huántiào （环跳 GB 30）, Fēngshì（风市 GB 31）, Yánglíngquán （阳陵泉 GB 34）, Zhìbiān （秩边 BL 54）, etc. The waste was irradiated with TDP after needling, with the maintaining time of 30 min. The treatment was carried out twice weekly, four weeks as one therapeutic course. The therapeutic effect was statistically calculated after 8-week treatment. Results Nineteen cases were clinically cured, 20 improved, 4 failed, and the effective rate 90.7%（39/43） in the heat-sensitive group, while 9 clinically cured, 25 improved, 5 failed, and the effective rate 87.2%（34/39） in the acupuncture group. Signif icant difference was shown in the clinically cured case by 2 test （P0.05）. Conclusion Heat-sensitive acupoint was superior to traditional acupuncture in treatment Irishmen with discogenic low back pain.

Management of lumbar zygapophysial (facet) joint pain

AIM: To investigate the diagnostic validity and therapeutic value of lumbar facet joint interventions in managing chronic low back pain.METHODS: The review process applied systematic evidence-based assessment methodology of controlled trials of diagnostic validity and randomized controlled trials of therapeutic efficacy. Inclusion criteria encompassed all facet joint interventions performed in a controlled fashion. The pain relief of greater than 50% was the outcome measure for diagnostic accuracy assessment of the controlled studies with ability to perform previously painful movements, whereas, for randomized controlled therapeutic efficacy studies, the primary outcome was significant pain relief and the secondary outcome was a positive change in functional status. For the inclusion of the diagnostic controlled studies, all studies must have utilized either placebo controlled facet joint blocks or comparative local anesthetic blocks. In assessing therapeutic interventions, short-term and long-term reliefs were defined as either up to 6 mo or greater than 6 mo of relief. The literature search was extensive utilizing various types of electronic search media including Pub Med from 1966 onwards, Cochrane library, National Guideline Clearinghouse, clinicaltrials.gov, along with other sources includingprevious systematic reviews, non-indexed journals, and abstracts until March 2015. Each manuscript included in the assessment was assessed for methodologic quality or risk of bias assessment utilizing the Quality Appraisal of Reliability Studies checklist for diagnostic interventions, and Cochrane review criteria and the Interventional Pain Management Techniques- Quality Appraisal of Reliability and Risk of Bias Assessment tool for therapeutic interventions. Evidence based on the review of the systematic assessment of controlled studies was graded utilizing a modified schema of qualitative evidence with best evidence synthesis, variable from level Ⅰ to level Ⅴ.RESULTS: Across all databases, 16 high quality diagnostic accuracy studies were identified. In addition, multiple studies assessed the influence of multiple factors on diagnostic validity. In contrast to diagnostic validity studies, therapeutic efficacy trials were limited to a total of 14 randomized controlled trials, assessing the efficacy of intraarticular injections, facet or zygapophysial joint nerve blocks, and radiofrequency neurotomy of the innervation of the facet joints. The evidence for the diagnostic validity of lumbar facet joint nerve blocks with at least 75% pain relief with ability to perform previously painful movements was level Ⅰ, based on a range of level Ⅰ to Ⅴ derived from a best evidence synthesis. For therapeutic interventions, the evidence was variable from level Ⅱ to Ⅲ, with level Ⅱ evidence for lumbar facet joint nerve blocks and radiofrequency neurotomy for long-term improvement(greater than 6 mo), and level Ⅲ evidence for lumbosacral zygapophysial joint injections for short-term improvement only.CONCLUSION: This review provides significant evidence for the diagnostic validity of facet joint nerve blocks, and moderate evidence for therapeutic radiofrequency neurotomy and therapeutic facet joint nerve blocks in managing chronic low back pain.

Imaging of low back pain： comparative role of high intensity zone in diagnosing the discogenic low back pain with evidence-based radiology

Background Discography is a gold standard for the diagnosis of the low back pain （LBP）, but it has potential dangers for the development of discitis, cerebral spinal fluid leakage, retroperitoneal bleeding, acute new back pain and the tremendous radiation exposure to the patient. Using ＂evidence-based radiology＂ methods, the comparative roles of high intensity zone （HIZ） in diagnosing discogenic LBP were evaluated. Methods A focused clinical question was designed and a Pubmed and manual search were performed to identify the role of HIZ on MRI T2WI compared with discography. The studies retrieved were assessed for validity and strength. Sensitivity, specificity, likelihood ratios （LRs） and graphs of conditional probability were evaluated from the best current study by evidence-based radiology. Results Best evidence was retrieved in ten articles from 1992 to 2007. The best evidence level was lb and the strength of the evidence included： sensitivity 0.63 （0.51,0.76）, specificity 0.97 （0.92, 1.00）, positive predictive value 0.95, negative predictive value 0.72, positive LRs 18.37 and negative LRs 0.38. The gold standard of discogenic LBP is the provocative discography. Conclusions For suspected discogenic LBP, HIZ is limited for the diagnosis if HIZ is positive, which suggests further discography. In contrast HIZ is a good test for diagnosis if HIZ is negative, which indicates the disease can be excluded.

Fluoroscopy-guided Bipolar Radiofrequency Thermocoagulation Treatment for Discogenic Low Back Pain

Background：The efficacy of percutaneous intradiscal radiofrequency thermocoagulation （PIRFT） for the treatment of discogenic low back pain （LBP） remains controversial.However,all the PIRFT studies utilized monopolar radiofrequency thermocoagulation （RFTC）.The aim of this study was to investigate the safety and efficacy of bipolar RFTC for the treatment of discogenic LBP.Methods：A total of 23 patients with discogenic LBP were treated with single-level bipolar RFTC.The patients were assessed before the procedure and at 1 week,1 month,3 months,6 months,and 1 year after the procedure.The primary outcome included the visual analog scale （VAS） score and the Oswestry Disability Index （ODI） score.The secondary outcome included pain relief,reduction of analgesic dose,and patient satisfaction.Results：The VAS and ODI scores were significantly decreased after bipolar RFTC treatment at all time points of follow-up （P 〈 0.05）.Bipolar RFTC treatment also resulted in a significant change in all secondary measures,such as pain relief,reduction of analgesic dose,and patient satisfaction.No serious complications or neurological sequelae were observed in any of the patients.Conclusions：Bipolar RFTC treatment can significantly attenuate pain and improve the function of patients with discogenic LBP.

PELAN治疗DLBP的疗效评价及影响预后的可变因素研究

目的评价经皮内镜下腰椎纤维环髓核成形术治疗间盘源性腰痛的效果并探讨影响其预后的可变因素。方法选择89例手术患者为研究对象。术后行短期(3~4周)及长期(至少12个月)随访。临床疗效采用数字疼痛评分法(NRS)、Oswestry功能障碍指数%(ODI%)和改良的Macnab标准进行评价。将NRS评分减少≥50%、ODI%下降≥40%和Macnab标准评定为良或优的患者视为治疗成功组,其余患者视为治疗失败组。比较探讨2组间影响预后的临床表现及影像学可变因素。结果术后短期和长期随访疗效结果比较,NRS评分明显减少的患者数分别为62例(69.7%)和68例(76.4%),ODI%明显降低的患者数分别为59例(66.3%)和68例(76.4%),Macnab评定为良或优的患者比例分别为61%和65.2%。弯腰疼痛与预后结果良好明显相关,Modic分型改变与预后结果较差明显相关。结论经皮内镜下腰椎纤维环髓核成形术治疗间盘源性腰痛的疗效满意,弯腰疼痛是预后疗效良好的可变因素,Modic分型改变预后疗效较差的可变因素。

注射针刀对椎间盘源性下腰痛患者疼痛程度及炎症反应的影响

目的:观察注射针刀治疗对椎间盘源性下腰痛患者的治疗效果。方法:将90例确诊为椎间盘源性下腰痛的病例随机分为注射针刀组、注射组与针刀组各30例,注射针刀组运用注射针刀治疗,注射组给予痛点局部注射治疗,针刀组给予常规小针刀治疗。于3组治疗1个月后评价患者临床疗效,通过观察疼痛直观模拟评分(VAS)、日本骨科学会腰椎疗效评分(JOA)与功能障碍指数(ODI)的变化对3组治疗后局部疼痛和整体症状的改善状况进行评价,抑郁自评量表(SDS)观察3组抑郁状态,并检测3组治疗前后血清中六酮前列腺素F1α(PGF1α)、肿瘤坏死因子α(TNF-α)、白细胞介素-1β(IL-1β)与白细胞介素-6(IL-6)水平的变化。结果:3组患者治疗前各指标比较差异无统计学意义(P>0.05);治疗结束后,注射针刀组临床疗效优于注射组和针刀组(P<0.05);与注射组、针刀组比较,注射针刀组VAS、ODI与SDS评分明显下降,JOA评分明显提升,差异有统计学意义(P<0.05),血清中PGF1α、TNF-α、IL-1β及IL-6炎症因子水平较注射组和针刀组均有明显下调,差异有统计学意义(P<0.05);注射组VAS、ODI和SDS评分及血清PGF1α、TNF-α、IL-1β及IL-6水平显著低于针刀组,JOA评分较针刀组明显提升,差异有统计学意义(P<0.05)。结论:注射针刀对椎间盘源性下腰痛具有良好的治疗效果,疗效优于局部注射和单纯小针刀治疗,其作用机制可能与降低炎性细胞因子水平、抑制炎症反应相关。

中医特色康复联合核心肌群训练在椎间盘源性腰痛中的应用

目的探讨中医特色康复联合核心肌群训练治疗椎间盘源性腰痛(DLBP)的效果及对患者腰椎功能、多裂肌横截面积、腰大肌横截面积的影响。方法选取2018年5月至2020年6月收治的180例DLBP患者作为研究对象,采用随机数字表法分为3组,每组60例。中医组用中医特色康复治疗,训练组用核心肌群训练,联合组加用中医特色康复联合核心肌群训练,均于治疗8周后进行疗效观察。统计对比3组疗效、视觉模拟评分法(VAS)、功能障碍指数问卷表(ODI)评分、Rdand Morris问卷(RMQ)、多裂肌横截面积、腰大肌横截面积。结果联合组治疗8周后总有效率(100.00%)高于中医组(81.67%)、训练组(85.00%),差异有统计学意义(P<0.05);联合组治疗4、8周后VAS评分、ODI评分低于中医组、训练组,差异有统计学意义(P<0.05);联合组治疗4、8周后多裂肌横截面积、腰大肌横截面积及RMQ评分高于中医组、训练组,差异有统计学意义(P<0.05);中医组、训练组各指标比较,差异无统计学意义(P>0.05)。结论中医特色康复联合核心肌群训练应用于DLBP患者中效果显著,能减轻疼痛,改善患者病情。

白细胞介素1β调控信号素3A表达诱发椎间盘退变的机制

背景:信号素3A是重要的神经血管生长抑制因子,目前尚不清楚信号素3A是如何参与盘源性腰痛发病的,研究信号素3A在椎间盘退变中的潜在机制可为防治盘源性腰痛提供新的靶点和理论依据。目的:通过激活核因子κB信号通路影响信号素3A的表达,探讨白细胞介素1β诱导大鼠椎间盘退变的机制。方法:采用RT-qPCR检测人未退变与退变髓核组织内的信号素3A mRNA表达。分离培养SD大鼠髓核细胞,传代至第3代时分3组培养:空白对照组常规培养48 h,退变组加入10 ng/mL白细胞介素1β干预48 h,退变+抑制剂组加入5μmol/L核因子κB信号通路特异性抑制剂BAY11-7082干预1 h后加入白细胞介素1β干预48 h。干预结束后,采用CCK-8法检测细胞活力,Annexin V/FITC染色法检测细胞凋亡,RT-qPCR检测细胞基质、血管、神经标志物及信号素3A的mRNA表达,Western blot检测标志蛋白、核因子κB信号通路蛋白p65及p-p65的蛋白表达。结果与结论:①RT-qPCR检测显示,人退变髓核组织内的信号素3A mRNA表达低于未退变髓核组织(P<0.05);②CCK-8检测与Annexin V/FITC染色显示,与空白对照组比较,退变组髓核细胞活力降低、凋亡率增加(P<0.05);与退变组比较,退变+抑制剂组髓核细胞活力升高、凋亡率降低(P<0.05);③RT-qPCR检测显示,与空白对照组比较,退变组Ⅱ型胶原蛋白、聚蛋白多糖、信号素3A的mRNA表达降低(P<0.05),CD31、神经丝蛋白200的mRNA表达升高(P<0.05);与退变组比较,退变+抑制剂组Ⅱ型胶原蛋白、聚蛋白多糖、信号素3A的mRNA表达升高(P<0.05),CD31、神经丝蛋白200的mRNA表达降低(P<0.05);④Western blot检测显示,与空白对照组比较,退变组Ⅱ型胶原蛋白、聚蛋白多糖、信号素3A的蛋白表达降低(P<0.05),CD31、神经丝蛋白200、p65及p-p65的蛋白表达升高(P<0.05);与退变组比较,退变+抑制剂组Ⅱ型胶原蛋白、聚蛋白多糖、信号素3A的蛋白表达升高(P<0.05),CD31、神经丝蛋白200、p65及p-p65的蛋白表达降低(P<0.05);⑤结果表明,白细胞介素1β通过激活核因子κB信号通路抑制信号素3A的表达,同时促进细胞外基质的降解和椎间盘内血管神经的长入,可能为椎间盘退变及相关盘源性腰痛的诱发因素之一。

自体富血小板血浆治疗椎间盘源性腰痛的研究进展

椎间盘源性腰痛(discogenic low back pain,DLBP)是临床上最常见的腰痛类型,约39%的慢性腰痛是由于椎间盘病变引起的。DLBP有着长期、持续、反复的特点,影响病人生活质量和工作效率,对社会也造成了巨大的负担。既往临床上DLBP的治疗方法只能简单缓解疼痛症状并不能治疗椎间盘破裂。近年来富血小板血浆(platelet-rich plasma,PRP)在再生医学领域的应用越来越广泛,体外细胞及动物研究表明其有显著的促椎间盘再生作用。本文以自体PRP在DLBP治疗中的应用进展进行综述,以进一步增强对于DLBP致病机制的认识,并结合自体PRP在临床中的广泛应用,以此为临床DLBP的治疗提供参考。

经椎间孔硬膜外联合双侧L_(2)神经根阻滞治疗盘源性腰痛的临床研究

目的:评价经椎间孔硬膜外联合双侧L_(2)神经根阻滞治疗盘源性腰痛(discogenic low back pain,DLBP)的临床疗效。方法:采用前瞻性随机对照研究方法,选取2022年6月至2023年6月中日友好医院疼痛科符合纳入标准的慢性盘源性腰痛病人,计算机产生随机数字表法分为研究组和对照组,研究组采用病变间盘节段硬膜外阻滞联合L2神经根阻滞,对照组采用病变间盘节段硬膜外阻滞。评价两组治疗后第1、3、6个月疼痛数字分级评分法(numerical rating scale,NRS)评分、Oswestry功能障碍指数(Oswestry disability index,ODI)评分。结果:符合纳入标准的DLBP病人共92例,研究组(n=46)和对照组(n=46)。治疗后第1、3个月研究组和对照组NRS评分分别为1.7±0.6 vs.2.7±0.4和2.2±0.4 vs.3.2±0.5,两组比较差异有统计学意义(P<0.05)。治疗后第1、3个月研究组和对照组ODI评分分别为12.2±1.7 vs.17.4±2.1和16.1±2.1 vs.20.4±2.9,两组比较差异有统计学意义(P<0.05)。治疗后第6个月研究组和对照组NRS评分分别为3.0±0.5 vs.3.2±0.6,ODI评分分别为21.4±2.0 vs.23.1±1.7,两组NRS、ODI评分差异均无统计学意义。与基础值相比,两组在治疗后第1、3、6个月NRS、ODI评分均显著降低(P<0.001)。结论:经椎间孔硬膜外阻滞能够有效减轻DLBP,改善运动障碍。联合L2神经根通路治疗较单纯硬膜外阻滞更有效。

MRI在椎间盘退变导致的椎间盘源性下腰痛诊断与评估中的应用进展

下腰痛是常见的健康问题,对个人和社会造成了沉重的负担,椎间盘退变引起的椎间盘源性下腰痛是最常见的病因之一。MR技术常用于椎间盘退变及其并发症的常规诊断。近年来,随着人工智能和定量技术的发展,基于T2WI的纹理分析以及各种MR定量技术逐渐成为椎间盘源性下腰痛早期诊断、致痛性椎间盘识别以及治疗方案决策、椎间盘再生医学疗效评估的重要工具。多模态影像融合、人工智能辅助诊断等有望在椎间盘源性下腰痛的诊断和治疗、椎间盘新兴治疗的发展中发挥不可替代的作用,致痛性椎间盘的高特异性识别序列如CEST、MRS等的应用以及椎间盘源性下腰痛与脑功能结合研究也将带来临床治疗方案的优化。本文重点对T2WI、定量MRI等MRI技术在腰椎退行性改变引起的椎间盘源性下腰痛中的应用现状和发展趋势予以综述,旨在为其早期诊断和椎间盘再生医学疗效评估提供更具潜力的MRI技术支持。

椎间盘造影在诊断椎间盘源性腰痛中的应用

目的探讨椎间盘造影在诊断椎间盘源性腰痛中的应用价值。方法对19例椎间盘源性腰痛患者行椎间盘造影检查。根据注入造影剂时阻力的大小、注射过程中询问患者是否有与平时相同或者类似的疼痛以及通过造影剂聚集情况对椎间盘纤维环破裂程度进行分级。结果19例患者均穿刺成功。12例术中造影时疼痛与造影前相似,2例疼痛重于造影前,5例诱发疼痛不明显。患者均获得随访,时间3~12个月。14例(27个)纤维环2、3级破裂,注射造影剂时阻力较小,患者均有与平时相同或者类似的疼痛,其中23个纤维环3级破裂者行椎间盘切除+椎弓根螺钉固定+椎间植骨融合术,术后腰痛均基本消失。其余5例诱发疼痛不明显者行非手术治疗,疼痛有所缓解,但停止非甾体类止痛药后疼痛复发甚至加重。结论椎间盘造影在确定椎间盘源性腰痛的病变部位具有临床指导作用。

胸腰筋膜平面阻滞对椎间盘源性腰痛患者围术期镇痛的效果

目的探讨超声引导下双侧胸腰筋膜平面阻滞(TLIPB)对行经皮椎间孔镜腰椎间盘切除术(PTED)的椎间盘源性腰痛(DLBP)患者的围术期镇痛效果。方法选取57例椎间盘源性腰痛患者,使用计算机生成的随机编号将患者分为A组(对照组)28例患者,B组(超声引导下双侧胸腰筋膜平面阻滞组)29例患者。比较两组患者术前(t_(0))、术后2 h(t_(1))、术后6 h(t_(2))、术后12 h(t_(3))及术后24 h(t_(4))静息和翻身时视觉模拟疼痛评分(VAS)的差异。比较两组患者术前及术后24 h 15项恢复质量评分(QoR-15)的差异。比较两组患者入室后(T_(0))、切皮时(T_(1))、椎间孔成形时(T_(2))、外科医生认定疼痛最剧烈时(T_(3))、手术结束时(T_(4))的平均动脉压(MAP)和心率(HR)变化的差异。记录术中及术后24 h内不良事件。结果所有患者均顺利完成手术和超声引导下双侧TLIPB,无椎间隙感染,无脊髓、神经根和血管损伤,无恶心呕吐等严重并发症。两组患者组内术后各时间点静息及翻身时VAS评分及术后24 h QoR-15评分均较术前显著降低,差异有统计学意义(P<0.05)。两组患者术前及术后各时间点静息时VAS评分差异无统计学意义(P>0.05)。两组患者术后2 h、术后6 h及术后12 h翻身时VAS评分差异有统计学意义(P<0.05),其余时间点差异无统计学意义(P>0.05)。两组患者术前及术后24 h QoR-15评分相比差异有统计学意义(P<0.05),且两组患者术后24 h QoR-15评分相比差异有统计学意义(P<0.05)。两组患者椎间孔成形时(T_(2))和外科医生认定疼痛最剧烈时(T3)时MAP及HR差异有统计学意义(P<0.05)。结论超声引导下双侧胸腰筋膜平面阻滞可以有效缓解PTED术后疼痛,减少围术期应激反应及不良事件的发生,加速患者术后康复。

Percutaneous Nucleoplasty Using Coblation Technique for the Treatment of Chronic Nonspecific Low Back Pain： 5-year Follow-up Results

Background： This study evaluated the efficacy of percutaneous nucleoplasty using coblation technique for the treatment of chronic nonspecific low back pain （LBP）, after 5 years of follow-up. Methods： From September 2004 to November 2006, 172 patients underwent percutaneous nucleoplasty for chronic LBP in our department. Forty-one of these patients were followed up for a mean period of 67 months. Nucleoplasty was performed at L3/4 in 1 patient; L4/5 in 25 patients; L5/$1 in 2 patients; L3/4 and L4/5 in 2 patients; L4/5 and L5/$1 in 7 patients; and L3/4, L4/5, and L5/$1 in 4 patients. Patients were assessed preoperatively and at 1 week, 1 year, 3 years, and 5 years postoperatively. Pain was graded using a 10-cm Visual Analogue Scale （VAS） and the percentage reduction in pain score was calculated at each postoperative time point. The Oswestry Disability Index （ODI） was used to assess disability-related to lumbar spine degeneration, and patient satisfaction was assessed using the modified MacNab criteria. Results： There were significant differences among the preoperative, 1-week postoperative, and 3-year postoperative VAS and ODI scores, but not between the 3- and 5-year postoperative scores. There were no significant differences in age, sex, or preoperative symptoms between patients with effective and ineffective treatment, but there were significant differences in the number of levels treated, Pfirrmann grade of intervertebral disc degeneration, and provocative discography findings between these two groups. Excellent or good patient satisfaction was achieved in 87.9% of patients after 1 week, 72.4% after 1 year, 67.7% after 3 years, and 63.4% at the last follow-up. Conclusions： Although previously published short- and medium-term outcomes after percutaneous nucleoplasty appeared to be satisfactory, our long-term follow-up results show a significant decline in patient satisfaction over time. Percutaneous nucleoplasty is a safe and simple technique, with therapeutic effectiveness for the treatment of chronic LBP in selected patients. The technique is minimally invasive and can be used as part of a stepwise treatment plan for chronic LBP.

自体富血小板血浆治疗椎间盘源性腰痛的研究进展

椎间盘源性腰痛(discogenic low back pain,DLBP)为临床最常见的腰痛类型,是导致残疾和生产力丧失的主要原因之一,对患者的日常工作和生活产生严重影响。自体富血小板血浆(platelet-rich plasma,PRP)中,各种生物活性成分比例最接近自身,不会产生免疫反应,取材方便,费用低廉,近年有研究表明其含有丰富的生长因子可以促进椎间盘内细胞和组织的增殖,有显著的促椎间盘再生作用。本文通过DLBP发病机制、PRP治疗DLBP的原理和PRP在临床中的应用加以分析,为临床治疗DLBP提供新的思路。