Chataigner H, Onimus M, Polette A
Service de Chirurgie des Scolioses et Orthopédie Infantile, CHU Saint-Jacques, Besançon.
Rev Chir Orthop Reparatrice Appar Mot. 1998 Nov;84(7):583-9.
To determine predictive factors allowing to improve the results of fusion in low back pain treatment.
Fifty six patients were retrospectively reviewed. Average age at surgery was 42. In 29 cases, discectomy or nucleolysis had been previously performed. All patients were treated by anterior lumbar interbody fusion. Functional results were assessed by the Beaujon index, with determination of a relative improvement rate. Results were analyzed according to clinical symptoms, fused level, previous surgery, association to posterior osteosynthesis and MRI changes. MRI changes were classified according to Modic types.
The average relative improvement rate was 66 per cent. Pain topography, previous surgery, fused level, association with posterior osteosynthesis had not statistical effect on the functional result. Inversely, a close relation was observed between pre-operative MRI changes and the result of surgery: best results were observed in Modic I changes on adjacent vertebral end plates, with decreased signal of T1 and increased signal on T2 weighted images, suggesting inflammatory changes; poor results were observed in isolated disc degeneration without vertebral end-plates changes; poor results were observed in Modic II changes with increased signal on both T1 and T2 weighted images, suggesting degenerative changes; but among 5 non unions, 3 were observed in Modic II changes.
The authors identify a lumbar disc dysfunction syndrome characterized by mechanical pain, with disc narrowing and anterior condensation of the vertebral plates on MRI (Modic I changes). This syndrome should be differentiated from common degenerative disc disease, without vertebral plates abnormalities (the "black disc" on MRI).
Anterior fusion is effective for the treatment of low-back pain due to degenerative disc disease, when associated to vertebral plate changes; as the pathology is mainly anterior. We prefer an anterior mini-invasive approach; furthermore, posterior elements are intact and canal exploration is unnecessary. However, an additional posterior osteosynthesis is preferable in Modic type II, as non union rate is increased by fatty degenerative involution.
确定能够改善腰痛治疗中融合效果的预测因素。
对56例患者进行回顾性研究。手术时的平均年龄为42岁。其中29例患者此前曾接受过椎间盘切除术或髓核溶解术。所有患者均接受了前路腰椎椎间融合术。通过博让指数评估功能结果，并确定相对改善率。根据临床症状、融合节段、既往手术情况、是否联合后路接骨术以及MRI变化对结果进行分析。MRI变化根据莫迪克类型进行分类。
平均相对改善率为66%。疼痛部位、既往手术、融合节段、是否联合后路接骨术对功能结果无统计学影响。相反，术前MRI变化与手术结果之间存在密切关系：在相邻椎体终板出现莫迪克I型变化（T1加权像信号降低，T2加权像信号增加，提示炎症改变）时，手术效果最佳；在单纯椎间盘退变而椎体终板无变化时，手术效果较差；在T1和T2加权像信号均增加的莫迪克II型变化（提示退变改变）时，手术效果较差；但在5例未融合病例中，有3例为莫迪克II型变化。
作者识别出一种以机械性疼痛为特征的腰椎间盘功能障碍综合征，MRI表现为椎间盘狭窄和椎体终板前缘骨质增生（莫迪克I型变化）。该综合征应与常见的无椎体终板异常的退行性椎间盘疾病（MRI上的“黑椎间盘”）相鉴别。
前路融合术对于因退行性椎间盘疾病导致的腰痛且伴有椎体终板改变时有效，因为病变主要位于前方。我们更倾向于前路微创入路；此外，后方结构完整，无需进行椎管探查。然而，在莫迪克II型变化时，额外的后路接骨术更为可取，因为脂肪性退变会增加不融合率。
Zotero 插件