破裂型腰椎间盘突出症非手术治疗后的转归

Clinical prognosis of posterior longitudinal ligament ruptured lumbar disc herniation after conservative treatment

中文关键词:  腰椎间盘突出症  后纵韧带破裂  非手术治疗  吸收

英文关键词:Lumbar disc herniation  Posterior longitudinal ligament ruptured  Conservative treatment  Resorption

中文摘要:

  【摘要】 目的：探讨破裂型腰椎间盘突出症非手术治疗后的转归。方法：对我院2008年6月~2011年6月期间治疗的107例破裂型腰椎间盘突出症患者进行前瞻性研究，男60例，女47例；年龄39.9±14.3岁（16~60岁）；病程16.94±21.01个月（3d~10年），其中＜1年52例，＞1年55例；突出节段：L3/4 6例，L4/5 46例，L5/S1 55例。突出物Iwabuchi分型1型51例，2型12例，3型10例，4型8例，5型26例。31例伴有突出椎间盘相邻终板Modic改变。治疗前JOA评分11.87±5.62分（5~21分）。均采用非手术治疗，治疗3~6个无效或治疗过程出现症状进行性加重、伴马尾神经症状者采用手术治疗。统计患者手术率，对非手术治疗者在治疗后1个、3个月、6个月、1年和3年时进行JOA评分，计算JOA评分改善率，采用改善优良率评估疗效，并根据术前和末次随访时的MRI图像计算突出物体积及吸收率。结果：86例患者完成非手术治疗，治疗后1个月、3个月、6个月、1年、3年的JOA评分分别为19.65±2.77、21.77±2.81、23.55±2.78、24.02±3.01、23.99±3.15分，与治疗前比较，差异均有显著统计学意义（P＜0.01），JOA评分改善优良率分别为40.69%、80.23%、82.56%、83.72%、82.56%。其中20例患者突出椎间盘出现了明显重吸收（RR＞50%），占18.7%，3年随访其疗效优良率为100%；其余66例无明显重吸收，疗效优良率为81.82%。经Spearman等级相关分析，吸收率与治疗后3年时JOA评分改善率呈中等正相关（r=0.488，P＜0.001）。21例患者在非手术治疗过程出现症状进行性加重或伴马尾神经症状，改行手术治疗，手术率为19.6%；其中病程＞1年12例，Iwabuchi分型为2、3、4型14例，伴有相邻终板Modic改变14例。结论：病程＜1年、Iwabuchi分型为1或5型、不伴有相邻终板Modic改变的破裂型腰椎间盘突出症采用非手术治疗可取得较好疗效，并且部分患者发生突出物重吸收现象。

英文摘要:

  【Abstract】 Objectives: To explore the clinical prognosis of posterior longitudinal ligament(PLL) ruptured lumbar disc herniation(LDH) via conservative treatment. Methods: From June 2008 to June 2011, 107 cases with PLL-ruptured LDH were studied prospectively. Among them, 60 were male and 47 were female, aged 16~60 years old, with an average age of 39.9±14.3. The disease course was 3 days to 10 years, averaging 16.9±21.0 months, 52 cases were shorter than 1 year and the other 55 cases were longer than 1 year. And the diseased level located at: L3/4 in 6 cases, L4/5 in 46 cases, L5/S1 in 55 cases. JOA score was 5-21 with an average of 11.87±5.62. The Iwabuchi type of the protrusion: 51 cases in type 1, 12 cases in type 2, 10 cases in type 3, 8 cases in type 4, and 26 cases in type 5. 31 cases accompanied with Modic changes in adjacent endplate. All patients accepted conservative treatment. Surgery was considered only if no responsible to conservative treatment after 3~6 months, or suffering from exacerbated and progressive radicular symptom or cauda equina signs during treatment period. The JOA score and improvement rate at the 1st, 3rd, 6th month and the 1st, 3rd year after first visit were recorded respectively, and the resorption rate of the protrusion was calculated on MR image. Results: 86 cases underwent conservative treatment. The JOA score at the 1st, 3rd, 6th months and the 1st, 3rd years after conservative treatment was 19.65±2.77, 21.77±2.81, 23.55±2.78, 24.02±3.01, 23.99±3.15 respectively, significantly statistical differences were found at every time point copared with the time point before treatment(P＜0.01). The excellent and good rate at each time point was 40.69%, 80.23%, 82.56%, 83.72% and 82.56% respectively. In the patients who accepted non-operative therapy: 20 cases(18.7%) presented with obvious resorption of herniated nuclea pulpsus, the excellent and good rate was 100% at the 3-year follow-up. The other 66 cases showed no obvious resorption, the excellent and good rate was 81.82%. The resorption rate and the improvement rate of JOA scores at 3 years after treatment showed a significant linear positive correlation(r=0.488, P＜0.001). 21 cases finally suffered from exacerbated progressive radicular symptom or cauda equina neurological signs during any term in the treatment period and had operation, the operation rate was 19.63%. Among them, 12 cases′s disease course were longer than 1 year, 14 cases′s Iwabuchi type were type 2, 3, 4, 14 cases accompanied with Modic change in adjacent endplate. Conclusions: After conserva-tive treatment, symptoms of PLL-ruptured LDH can be alleviated and herniation resorption can be found in some cases with the following characteristics: the disease course shorter than 1 year, Iwabuchi type 1 or type 5, no Modic change in adjacent endplate.