Clinical typing and treatment strategies of lumbar degenerative diseases
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摘要:
目的 提出一种腰椎退变性疾病（LDD）的临床分型及各分型的诊断标准和相应的外科治疗策略。 方法 选择2017年6月至2022年5月海军军医大学第二附属医院骨科收治的LDD患者共245例，按照提出的临床分型诊断标准将患者分为神经根型（42例）、椎间盘突出型（73例）、椎管狭窄型（61例）、滑脱型（29例）和局部型（40例）。比较各分型LDD的治疗效果，应用一致性检验评估分型方法的可靠性。 结果 手术治疗205例，非手术治疗40例。手术方法主要为改良经椎间孔入路腰椎椎体间融合术。患者随访时间为（20.37±6.13）个月。按照Nakai标淮，临床疗效为优146例（59.59%）、良89例（36.33%）、可8例（3.27%）、差2例（0.82%），优良率为95.92%。各分型LDD的疗效比较差异无统计学意义（P＞0.05）。临床一致性评价结果证实该分型方法在观察者内、观察者间均具有良好的一致性。 结论 该临床分型有助于深化对LDD发病机制的认识，提高诊断的准确率，优化治疗方案。 Abstract:Objective To propose a clinical typing method for lumbar degenerative disease (LDD), including the diagnostic criteria for each type and the corresponding surgical treatment strategies. Methods A total of 245 LDD patients who were admitted to Department of Orthopaedics, The Second Affiliated Hospital of Naval Medical University from Jun. 2017 to May 2022 were enrolled and assigned to nerve root type (42 cases), disc herniation type (73 cases), spinal stenosis type (61 cases), spondylolisthesis type (29 cases), and local type (40 cases) according to our diagnostic criteria of clinical typing. Treatment outcomes of various groups were compared and the reliability of the typing method was assessed using consistency test. Results A total of 205 cases received surgical treatment and 40 cases received non-surgical treatment. The surgical approach was modified transforaminal lumbar interbody fusion. The patients were followed up for (20.37±6.13) months. According to Nakai's evaluation criteria, the clinical effect was excellent in 146 (59.59%) cases, good in 89 (36.33%) cases, fair in 8 (3.27%) cases, and poor in 2 (0.82%) cases, with an excellent and good rate of 95.92%. There were no significant differences in the treatment effects among different types of LDD (P > 0.05). The results of clinical consistency evaluation confirmed that the typing method had good consistency both within observers and between observers. Conclusion This clinical typing method can help to further understand the pathogenesis of LDD, improve the accuracy of diagnosis and optimize the treatment plan. -
腰椎作为人体脊柱的重要组成部分，承载着支撑身体重量和维持身体姿态的双重任务[1-2]。然而，随着个体年龄的增长，腰椎不可避免地会出现退行性改变，加之长期劳损、姿势不良、外力损伤等因素的叠加影响，腰椎退变性疾病（lumbar degenerative disease，LDD）的发病率逐年上升[3-6]。这类疾病不仅影响患者日常生活质量，严重时甚至导致劳动能力丧失，给患者和社会带来沉重的负担。
LDD的临床表现复杂多样，从轻微的腰痛、活动受限到严重的下肢放射痛、间歇性跛行，甚至大小便功能障碍等，不一而足[7-8]。因此，其治疗方法也多种多样，包括但不限于保守治疗、药物治疗、微创手术治疗及传统的开放手术治疗等[3, 9]。然而，由于LDD的复杂性和个体差异，如何选择合适的治疗方法一直是临床面临的挑战[10]。
为了更好地指导临床治疗，提高LDD的治疗效果，本研究对LDD进行新的临床分型，并深入探讨各分型的特点及其相应的治疗策略。通过回顾分析应用该临床分型LDD患者的临床数据，验证该分型方法在临床实践中的有效性，为LDD的诊治提供参考。
1 资料和方法
1.1 临床资料
对2017年6月至2022年5月海军军医大学第二附属医院骨科收治的LDD患者的临床资料进行回顾性分析。纳入标准：（1）有不同程度的下腰痛或下肢神经症状，术前MRI检查提示存在多节段的腰椎退变性改变；（2）经6个月保守治疗后症状无明显改善；（3）采用同一术式，且根据LDD的临床分型采取相应的手术应对策略。排除标准：（1）有腰椎手术史或退行性腰椎侧弯、其他脊柱疾病（如感染性疾病、强直性脊柱炎、脊柱肿瘤、骨折或神经系统疾病）；（2）有心理障碍者；（3）有外科医师认为不适合参与当前研究的其他疾病。本研究获得海军军医大学第二附属医院伦理委员会审批。
1.2 LDD的临床分型及其诊断标准
根据LDD患者临床表现的具体特征，将LDD分为神经根型、椎间盘突出型、椎管狭窄型、滑脱型和局部型5个分型。LDD各型的诊断标准见表 1。
表 1 LDD临床分型的诊断标准Table 1 Diagnostic criteria for clinical typing of LDDType Diagnostic criteria Nerve root type 1. Clinical manifestations: the patient shows symptoms of pain or numbness in one or both lower limbs.
2. Physical examination: abnormal sensations in the lower limbs can be found, which can be seen in either one or both sides. The tendon reflexes of the lower limbs are active or hyperactive.
3. Imaging examination: MRI examination of the corresponding segment shows compression of the dura mater, positive caudal nerve sedimentation sign, and sometimes the spinal cord morphology appears round instead of the normal clover-leaf structure.
4. Neuromuscular electrophysiological examination can detect nerve damage in the corresponding segment.Disc herniation type 1. Clinical manifestations: patients usually experience symptoms of low back pain and leg pain, with the leg pain often more severe than the back pain, and may be accompanied by typical radicular sciatica.
2. Physical examination: the most common manifestations are sensory abnormalities in the unilateral lower limbs, such as abnormal pain perception in the leg or foot due to a single nerve root, and the area of sensory abnormality is consistent with the innervated area of the dermatome of the corresponding segmental spinal nerve. The tendon reflexes of the lower limbs may be reduced or absent.
3. Imaging examination: CT or MRI examination of the lumbar intervertebral discs reveals signs of disc herniation.
4. Neuromuscular electrophysiological examination can detect nerve damage in the corresponding segment.Spinal stenosis type 1. Clinical manifestations: patients usually experience soreness and distending pain in the lumbar and sacral regions, accompanied by numbness, distention, and pain in both lower limbs, especially intermittent claudication when walking.
2. Physical examination: sensory dysfunction usually affects both lower limbs, with weakened or absent tendon reflexes in the lower limbs.
3. Imaging examination: CT or MRI examination of the lumbar spine will show that the transverse diameter of the lumbar spinal canal is less than 13 mm, which is a key indicator for the diagnosis of spinal stenosis.
4. Neuromuscular electrophysiological examination can detect nerve damage in the corresponding segment.Spondylolisthesis type 1. Clinical manifestations: at the early stages, patients may experience soreness in the lower lumbar region, which may worsen after exertion and may radiate to the sacrococcygeal region, buttocks, and posterior aspect of the thighs. In patients with severe spondylolisthesis, there may be indentation in the lumbar region, protrusion of the abdomen, and even shortening of the trunk, resulting in a waddling gait.
2. Physical examination: sensory dysfunction often involves both lower limbs, with weakened or absent tendon reflexes in the lower limbs.
3. Imaging examination: X-ray imaging is the primary diagnostic tool for lumbar spondylolisthesis, allowing observation of the stability of the lumbar series, the degree of slippage, and the presence of congenital isthmic spondylolisthesis. CT and MRI scans can further clarify the compression of the spinal cord or nerves.
4. Neuromuscular electrophysiological examination can detect nerve damage in the corresponding segment.Local type 1. Clinical manifestations: patients usually experience local low back pain or discomfort, which may be accompanied by limited range of motion.
2. Physical examination: the doctor may find tenderness, percussion pain, or abnormal range of motion in the local lumbar vertebrae. The tendon reflexes of the lower limbs are normal.
3. Imaging examination: imaging studies such as X-ray, CT, or MRI may reveal local lumbar lesions, such as bone hyperplasia, small joint disorders, and edema signs in the muscle and ligament tissues of the painful area.
4. Neuromuscular electrophysiological examination is normal.
5. Note that patients with lumbar disc herniation who do not have lower limb neurologic symptoms may also be included in this category if they meet the first 3 criteria.LDD: Lumbar degenerative disease; MRI: Magnetic resonance imaging; CT: Computed tomography. 1.3 手术方法
本研究入组患者的手术方法为改良经椎间孔入路腰椎椎体间融合术（transforaminal lumbar interbody fusion，TLIF）[10-11]，所有手术均由同一位医师完成。步骤如下：（1）患者麻醉成功后取俯卧位。（2）显露手术节段双侧关节突关节和椎板，完成双侧椎弓根螺钉（山东康盛医疗器械有限公司或大博医疗科技股份有限公司生产）植入。（3）将融合侧关节突关节切除后植入合适大小的融合器。如该节段不存在椎间盘退变或不稳则不进行融合处理，如对侧无症状则不处理，如存在神经压迫症状则进行开窗减压。（4）术中X线透视确认螺钉和融合器位置无误后放置引流管，冲洗后关闭切口。所有患者均于术后5~7 d下地活动，佩戴腰围8~12周。
1.4 不同临床分型LDD的手术治疗方案
对于神经根型LDD，由于其存在神经根高张力表现，且术中通过神经根张力测定仪检测（图 1）发现其张力显著高于正常值，因此手术时对相应节段进行短缩，以降低神经根高张力[12]。具体操作方法是在进行椎间融合时，融合器的位置应置于椎间隙的前三分之一，且融合器大小的选择应符合椎间相对性张力原则[13]，即确保融合器的大小能够适应患者正常生理情况下的椎间高度，避免过度撑开。在安装好连接棒后，融合节段双侧都进行加压操作，以达到对手术节段进行短缩的目的，手术完毕后，采用神经根张力测定仪进行检测，所有病例相应节段的神经根张力均明显下降。
图 1 神经根张力测定仪Fig. 1 Neuroroot tension measuring instrumentPatent number: CN202210229485.6. The numerical value represents the measured tension of the nerve root during the surgery.
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对于椎间盘突出型LDD，当突出位于一侧时，仅进行症状侧减压，对侧若无症状则不予处理。对于椎管狭窄型和滑脱型LDD，当双侧都出现神经压迫症状时，为了确保手术疗效，需要进行双侧减压处理。本研究中采取的策略是：针对症状较为严重的一侧进行扩大减压的同时进行椎间融合，而对于症状相对较轻的一侧则仅进行开窗减压。对于局部型LDD，则采用药物、理疗、针炙等方法保守治疗。
采用视觉模拟量表（visual analogue scale，VAS）和Oswestry功能障碍指数（Oswestry disability index，ODI）评分评价患者治疗前和最后随访时的症状。采用Nakai标准评价患者的手术效果，治疗效果分为优、良、可、差4个等级。
1.5 LDD临床分型的一致性评价
对3名住院医师进行LDD临床分型培训。在培训过程中，对每位医师详细阐述各类LDD的特定诊断标准（表 1），确保他们能够准确理解和应用。完成培训后，对每位医师的临床分型掌握情况进行测试，医师通过测试后开始独立对入选病例进行分型评价。3个月后，将所有入组患者进行重新排列，然后再次进行临床分型评价。为确保结果客观和准确，另选择1名医师独立负责记录所有分型结果，以便后续进行一致性分析。
1.6 统计学处理
应用SPSS 26.0软件进行统计学分析。计量资料以x±s表示，多组间比较采用方差分析；计数资料以例数和百分数表示，组间比较采用Fisher确切概率法。一致性分析采用Kappa检验，Kappa值≤0.20为一致性较差，0.21~0.40为一致性一般，0.41~0.60为一致性中等，0.61~0.80为高度一致，0.81~1.00为几乎完全一致。通常认为Kappa值＞0.60表示一致性良好，而Kappa值≤0.40则意味着一致性很差。检验水准（α）为0.05。
2 结果
2.1 患者的临床资料
神经根型患者42例（男25例、女17例），平均年龄为（62.0±13.1）岁；椎间盘突出型73例（男42例、女31例），平均年龄为（63.5±14.5）岁；椎管狭窄型61例（男35例、女26例），平均年龄为（64.1±13.5）岁；滑脱型29例（男18例、女11例），平均年龄为（65.5±12.0）岁；局部型40例（男26例、女14例），平均年龄为（61.5±14.1）岁；合计男性LDD患者146例，女性患者99例，共245例，平均年龄为（62.9±13.8）岁。神经根型、椎间盘突出型、椎管狭窄型、滑脱型和局部型占比分别为17.14%、29.80%、24.90%、11.84%、16.33%。手术患者中单节段113例，双节段75例，3个及以上节段17例，非手术治疗40例。所有患者均获得随访，随访时间为（20.37±6.13）个月。典型神经根型LDD患者影像资料见图 2。
图 2 神经根型LDD影像学表现Fig. 2 Imaging of nerve root type of LDDA 65-year-old female patient was admitted with a 2-year history of bilateral lower limb pain and numbness. The pain radiated from both buttocks to the posterior thighs and the posterolateral calves. Physical examination revealed bilateral lower limb muscle strength of grade Ⅳ and hyperactive tendon reflexes. Preoperative anteroposterior (A) and lateral (B) X-ray images indicated degenerative changes in the lumbar spine. MRI scans at L3/4 (C, D), L4/5 (E, F), and L5/S1 (G, H) in anteroposterior and lateral views showed no significant signs of nerve compression, but a positive cauda equina sedimentation sign was noted. The patient was diagnosed with nerve root type of LDD and underwent modified transforaminal lumbar interbody fusion surgery. Postoperative anteroposterior (I) and lateral (J) X-rays showed good implant positioning. Postoperatively, the lower limb symptoms were significantly relieved, and the muscle strength improved. LDD: Lumbar degenerative disease; MRI: Magnetic resonance imaging.下载:
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2.2 手术情况
所有手术病例均成功完成。神经根型LDD患者的平均手术时间为（121.32±19.91）min，平均出血量为（173.14±48.24）mL，平均住院时间为（9.50±3.54）d。椎间盘突出型患者的平均手术时间为（147.25±31.30）min，平均出血量为（200.13±32.54）mL，平均住院时间为（12.05±2.71）d。椎管狭窄型LDD患者的平均手术时间为（130.05±21.87）min，平均出血量为（189.43±40.14）mL，平均住院时间为（11.62±2.68）d。滑脱型LDD患者平均手术时间为（139.74±12.41）min，平均出血量为（208.34±53.74）mL，平均住院时间为（12.86±2.40）d。上述4个分型LDD患者的手术时间、出血量及住院时间差异均无统计学意义（均P＞0.05）。
各分型LDD患者治疗前后VAS和ODI评分见表 2，治疗后各分型患者末次随访时的VAS和ODI评分均较治疗前改善（均P＜0.05），治疗前后组间比较VAS和ODI评分差异均无统计学意义（均P＞0.05）。采用Nakai标准对所有患者的最终治疗效果进行评价，结果显示优146例（59.59%）、良89例（36.33%）、可8例（3.27%）、差2例（0.82%），优良率为95.92%。见表 3。Fisher确切概率法分析结果表明各分型LDD患者疗效比较差异无统计学意义（P＞0.05）。
表 2 不同临床分型LDD患者治疗前后的VAS和ODI评分Table 2 VAS and ODI scores of LDD patients with different clinical types before and after treatmentx±s Type n VAS score ODI score At admission At final follow-up At admission At final follow-up Nerve root type 42 6.83±1.21 2.41±0.92* 58.13±10.04 18.05±7.11* Disc herniation type 73 7.22±1.13 2.87±1.14* 60.23±9.41 20.16±8.20* Spinal stenosis type 61 7.09±1.34 2.61±0.87* 59.12±11.53 19.21±6.13* Spondylolisthesis type 29 7.41±1.17 2.73±0.91* 61.04±8.12 21.22±7.09* Local type 40 6.52±1.43 2.33±1.14* 56.12±12.09 17.25±8.13* *P＜0.05 vs the same indicator preoperatively. LDD: Lumbar degenerative disease; VAS: Visual analogue scale; ODI: Oswestry disability index. 表 3 根据Nakai标准评价不同临床分型LDD患者的治疗效果Table 3 Surgical outcomes in patients with different clinical types of LDD based on Nakai criterian (%) Type N Excellent Good Fair Poor Nerve root type 42 28 (66.67) 14 (33.33) 0 0 Disc herniation type 73 43 (58.90) 26 (35.62) 3 (4.11) 1 (1.37) Spinal stenosis type 61 35 (57.38) 23 (37.70) 2 (3.28) 1 (1.64) Spondylolisthesis type 29 16 (55.17) 12 (41.38) 1 (3.45) 0 Local type 40 24 (60.00) 14 (35.00) 2 (5.00) 0 Total 245 146 (59.59) 89 (36.33) 8 (3.27) 2 (0.82) LDD: Lumbar degenerative disease. 2.3 术后并发症
术后并发脑脊液漏6例、深部组织感染1例、融合器移位5例、尿路感染或尿潴留2例、术后谵妄2例、肺部感染1例、下肢血栓形成2例（表 4）。其中1例深部组织感染患者予二次手术清创，5例融合器移位患者予二次手术重新进行调整后均获得痊愈，其余患者均经对症治疗后好转，患者均顺利出院，随访期间未再复发。Fisher确切概率法分析结果显示各分型间术后并发症的发生率差异无统计学意义（P＞0.05）。
表 4 各分型LDD患者的术后并发症Table 4 Postoperative complications in patients with different types of LDDn Complication Nerve root
type N＝42Disc herniation
type N＝73Spinal stenosis
type N＝61Spondylolisthesis
type N＝29Local type
N＝40Cerebrospinal fluid leakage 0 2 3 1 0 Deep tissue infection 0 0 1 0 0 Cage displacement 0 3 2 0 0 Urinary tract infection or retention 0 1 0 1 0 Delirium 0 2 0 0 0 Pneumonia 0 0 0 1 0 Lower limb thrombosis 0 0 2 0 0 Total 0 8 8 3 0 LDD: Lumbar degenerative disease. 2.4 临床分型一致性评价
住院医师A、B和C在进行临床分型测试时，均表现出高度的观察者内一致性，Kappa值分别为0.990、0.984和0.990。在观察者间的Kappa值也维持在较高水平。在第1次测试中，住院医师A与B、A与C及B与C之间的Kappa值分别为0.953、0.948和0.995；在第2次测试中，Kappa值分别为0.990、0.984和0.984。
3 讨论
研究表明当静态或动态牵拉神经根时，神经根可以伸长并出现横截面积减小[14]；电生理监测结果显示，随着神经根牵拉力的增加，神经传导速度和电位幅度逐渐下降，整合的动作电位面积变小甚至消失，最终神经根传导被完全阻断[15]。牵拉张力不仅可以直接导致神经传导异常，还能减少神经根的血流量并导致神经缺血损伤[16-17]。本团队前期研究证实LDD中存在神经根的轴向牵拉损伤，且与疾病的进展和预后密切相关[18-19]；并在此基础上提出了神经根牵拉损伤的致病机制，即在LDD的进展过程中，神经根和脊柱退变的速度不匹配，神经根的退变速度快于脊柱，因此造成神经根的被动牵拉张力逐渐增加[20]。尤其在老年患者中，神经根和血管弹性下降，脆性增加，血流量减少，使得神经根更容易受到牵拉张力的损伤，进而出现下肢神经症状[19-20]。综上所述，在本研究中，将由神经根牵拉损伤引起的这类LDD命名为神经根型腰椎病。
本研究在既往研究基础上首次提出了一种新的LDD临床分型，这对于提高LDD的诊断准确性、优化治疗方案及改善患者预后具有重要意义。临床分型一致性评价结果表明无论是单次测试还是多次测试之间，各位医师在分型判断上都展现出良好的一致性，这充分证明了该分型方法不仅判断准确，而且易于学习和掌握。在该分型中，本团队首次提出了神经根型LDD的概念及其诊断标准，此类疾病既往容易被漏诊或误诊，呈隐匿性进展。该病具有以下特点：在传统的腰椎MRI检查中并未发现明显的神经压迫征象，但患者具备典型的神经源性疼痛或感觉障碍，且范围与神经皮节支配区一致，神经肌电图检查可发现神经源性损害。此类患者保守治疗效果差，往往辗转多家医院而得不到有效的治疗。本团队对此类患者进行严格评估后采取了手术治疗，术中通过自主研发的神经根张力测定仪检测观察到患者普遍存在神经根高张力表现，且术前患者腰椎MRI横断面图像通常可见马尾神经沉降征阳性，有时还可观察到相应节段脊髓呈现圆形饱满状态，而并非正常人群中的三叶草样结构，因此推测此种现象与脊髓神经处于高张力状态有关。
对于神经根型LDD的外科手术治疗，本团队通常选择改良TLIF，目的在于改善神经高张力状态，而并非传统意义上的解除机械性压迫。为了实现这一目标，需要对手术节段进行适当的短缩以降低脊髓神经的张力。因此，实现有效的短缩是确保手术成功的关键[12]。首先，椎间融合操作时融合器植入的位置应尽可能靠近椎间隙的前方，理想的位置应位于椎间隙前三分之一，同时融合器大小的选择应当符合本团队提出的椎间隙相对张力原则，以避免采用较大的融合器造成对椎间隙的过度撑开，同时亦可保证维持椎间隙的生理高度[13]。其次，安装好连接棒后，应对融合节段进行双侧加压处理，以实现手术节段的短缩，此时即可通过神经张力测定仪检测神经根张力以判断短缩的效果，从而确保理想的疗效。
需要特别指出的是，神经根型LDD属于LDD的一种特殊类型，神经肌电图检测是发现此类疾病的重要手段，常可发现下肢神经源性损害，同时神经根型LDD与腰椎间盘突出和腰椎管狭窄疾病的发病机制不同，后两者影像学检查可发现明确的神经压迫表现，体格检查通常可见下肢腱反射减弱或消失。而神经根型LDD的发病机制主要是轴向牵张力增加，而非横断面上的机械性神经压迫，因此，其影像学检查通常不存在神经压迫征象，体格检查可发现患者下肢腱反射活跃或亢进，这是该病与腰椎间盘突出症和腰椎管狭窄症鉴别的关键点。临床上对于影像学检查能够发现明确神经压迫症状的情况，例如腰椎间盘突出症和椎管狭窄症患者，我们通常将其归于这2种疾病诊断，而神经根型LDD的诊断必须满足影像学检查未发现明确的神经压迫表现这个先决条件。
对于椎间盘突出型LDD，由于突出的椎间盘压迫脊髓或神经根，导致腰痛、下肢放射痛等症状，因此，轻度患者可通过物理治疗、药物治疗等方法缓解症状。对于突出严重、症状明显的患者，应及时采取手术治疗，如后路椎板开窗髓核摘除术、微创孔镜手术和椎间融合术等[21-24]。椎管狭窄型LDD是由于腰椎管容积减小，压迫脊髓或神经根，导致腰痛、间歇性跛行等症状。对于轻度患者，可通过物理疗法、药物治疗等缓解症状。对于严重狭窄的患者，应考虑手术治疗，如TLIF、后路腰椎椎体间融合术和微创手术等[25-28]。滑脱型LDD是指腰椎椎体间连接异常，导致上位椎体相对于下位椎体部分或全部滑移。轻度滑脱可通过康复训练、药物治疗等方法缓解症状，如腰背肌锻炼、直腿抬高训练等。对于严重滑脱或症状持续加重的患者，应考虑手术治疗，如微创腰椎融合术、脊柱融合术等[29-32]。局部型LDD主要表现为腰椎局部疼痛、活动受限，可能与腰椎区域肌肉劳损、韧带钙化、筋膜炎等因素有关[33-34]。治疗策略通常选择保守治疗，包括休息、物理治疗、按摩等，以缓解疼痛和改善活动功能。对于疼痛严重的患者，可考虑药物治疗，如选择非甾体抗炎药、肌肉松弛剂等，必要时采取局部封闭治疗[35-38]。
本研究所提出的LDD临床分型是基于疾病的临床表现、影像学特征、病理学改变等多方面因素进行分类。这种分型方法旨在更全面地描述LDD疾病的特征，从而指导治疗决策和预后评估。与之前提出的LDD神经功能分型[39]相比，该临床分型具有更广泛的考虑因素，两者之间是相辅相成的。神经功能分型主要关注神经本身所处的功能状态，为手术的减压范围和方式选择提供参考，但它并不深入探讨导致这些病理状态的具体机制[39]。相对而言，临床分型不仅考虑神经的病理状态，还关注了疾病的整体表现，包括症状、体征、影像学改变等，从而更全面地反映疾病的本质，更好地贴近临床实际需求，由于大部分类型与传统的LDD疾病名称一致，更易于临床医师接受和灵活运用。最为关键的是，该临床分型首次将具有神经高张力表现的一类隐匿性LDD命名为神经根型LDD，这有助于外科医师更好地认识此类疾病的临床特点和及时进行外科干预，有助于最大限度减轻此类患者的痛苦，提高手术疗效。
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图 1 神经根张力测定仪
Fig. 1 Neuroroot tension measuring instrument
Patent number: CN202210229485.6. The numerical value represents the measured tension of the nerve root during the surgery.
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图 2 神经根型LDD影像学表现
Fig. 2 Imaging of nerve root type of LDD
A 65-year-old female patient was admitted with a 2-year history of bilateral lower limb pain and numbness. The pain radiated from both buttocks to the posterior thighs and the posterolateral calves. Physical examination revealed bilateral lower limb muscle strength of grade Ⅳ and hyperactive tendon reflexes. Preoperative anteroposterior (A) and lateral (B) X-ray images indicated degenerative changes in the lumbar spine. MRI scans at L3/4 (C, D), L4/5 (E, F), and L5/S1 (G, H) in anteroposterior and lateral views showed no significant signs of nerve compression, but a positive cauda equina sedimentation sign was noted. The patient was diagnosed with nerve root type of LDD and underwent modified transforaminal lumbar interbody fusion surgery. Postoperative anteroposterior (I) and lateral (J) X-rays showed good implant positioning. Postoperatively, the lower limb symptoms were significantly relieved, and the muscle strength improved. LDD: Lumbar degenerative disease; MRI: Magnetic resonance imaging.
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表 1 LDD临床分型的诊断标准
Table 1 Diagnostic criteria for clinical typing of LDD
Type Diagnostic criteria Nerve root type 1. Clinical manifestations: the patient shows symptoms of pain or numbness in one or both lower limbs.
2. Physical examination: abnormal sensations in the lower limbs can be found, which can be seen in either one or both sides. The tendon reflexes of the lower limbs are active or hyperactive.
3. Imaging examination: MRI examination of the corresponding segment shows compression of the dura mater, positive caudal nerve sedimentation sign, and sometimes the spinal cord morphology appears round instead of the normal clover-leaf structure.
4. Neuromuscular electrophysiological examination can detect nerve damage in the corresponding segment.Disc herniation type 1. Clinical manifestations: patients usually experience symptoms of low back pain and leg pain, with the leg pain often more severe than the back pain, and may be accompanied by typical radicular sciatica.
2. Physical examination: the most common manifestations are sensory abnormalities in the unilateral lower limbs, such as abnormal pain perception in the leg or foot due to a single nerve root, and the area of sensory abnormality is consistent with the innervated area of the dermatome of the corresponding segmental spinal nerve. The tendon reflexes of the lower limbs may be reduced or absent.
3. Imaging examination: CT or MRI examination of the lumbar intervertebral discs reveals signs of disc herniation.
4. Neuromuscular electrophysiological examination can detect nerve damage in the corresponding segment.Spinal stenosis type 1. Clinical manifestations: patients usually experience soreness and distending pain in the lumbar and sacral regions, accompanied by numbness, distention, and pain in both lower limbs, especially intermittent claudication when walking.
2. Physical examination: sensory dysfunction usually affects both lower limbs, with weakened or absent tendon reflexes in the lower limbs.
3. Imaging examination: CT or MRI examination of the lumbar spine will show that the transverse diameter of the lumbar spinal canal is less than 13 mm, which is a key indicator for the diagnosis of spinal stenosis.
4. Neuromuscular electrophysiological examination can detect nerve damage in the corresponding segment.Spondylolisthesis type 1. Clinical manifestations: at the early stages, patients may experience soreness in the lower lumbar region, which may worsen after exertion and may radiate to the sacrococcygeal region, buttocks, and posterior aspect of the thighs. In patients with severe spondylolisthesis, there may be indentation in the lumbar region, protrusion of the abdomen, and even shortening of the trunk, resulting in a waddling gait.
2. Physical examination: sensory dysfunction often involves both lower limbs, with weakened or absent tendon reflexes in the lower limbs.
3. Imaging examination: X-ray imaging is the primary diagnostic tool for lumbar spondylolisthesis, allowing observation of the stability of the lumbar series, the degree of slippage, and the presence of congenital isthmic spondylolisthesis. CT and MRI scans can further clarify the compression of the spinal cord or nerves.
4. Neuromuscular electrophysiological examination can detect nerve damage in the corresponding segment.Local type 1. Clinical manifestations: patients usually experience local low back pain or discomfort, which may be accompanied by limited range of motion.
2. Physical examination: the doctor may find tenderness, percussion pain, or abnormal range of motion in the local lumbar vertebrae. The tendon reflexes of the lower limbs are normal.
3. Imaging examination: imaging studies such as X-ray, CT, or MRI may reveal local lumbar lesions, such as bone hyperplasia, small joint disorders, and edema signs in the muscle and ligament tissues of the painful area.
4. Neuromuscular electrophysiological examination is normal.
5. Note that patients with lumbar disc herniation who do not have lower limb neurologic symptoms may also be included in this category if they meet the first 3 criteria.LDD: Lumbar degenerative disease; MRI: Magnetic resonance imaging; CT: Computed tomography. 表 2 不同临床分型LDD患者治疗前后的VAS和ODI评分
Table 2 VAS and ODI scores of LDD patients with different clinical types before and after treatment
x±s Type n VAS score ODI score At admission At final follow-up At admission At final follow-up Nerve root type 42 6.83±1.21 2.41±0.92* 58.13±10.04 18.05±7.11* Disc herniation type 73 7.22±1.13 2.87±1.14* 60.23±9.41 20.16±8.20* Spinal stenosis type 61 7.09±1.34 2.61±0.87* 59.12±11.53 19.21±6.13* Spondylolisthesis type 29 7.41±1.17 2.73±0.91* 61.04±8.12 21.22±7.09* Local type 40 6.52±1.43 2.33±1.14* 56.12±12.09 17.25±8.13* *P＜0.05 vs the same indicator preoperatively. LDD: Lumbar degenerative disease; VAS: Visual analogue scale; ODI: Oswestry disability index. 表 3 根据Nakai标准评价不同临床分型LDD患者的治疗效果
Table 3 Surgical outcomes in patients with different clinical types of LDD based on Nakai criteria
n (%) Type N Excellent Good Fair Poor Nerve root type 42 28 (66.67) 14 (33.33) 0 0 Disc herniation type 73 43 (58.90) 26 (35.62) 3 (4.11) 1 (1.37) Spinal stenosis type 61 35 (57.38) 23 (37.70) 2 (3.28) 1 (1.64) Spondylolisthesis type 29 16 (55.17) 12 (41.38) 1 (3.45) 0 Local type 40 24 (60.00) 14 (35.00) 2 (5.00) 0 Total 245 146 (59.59) 89 (36.33) 8 (3.27) 2 (0.82) LDD: Lumbar degenerative disease. 表 4 各分型LDD患者的术后并发症
Table 4 Postoperative complications in patients with different types of LDD
n Complication Nerve root
type N＝42Disc herniation
type N＝73Spinal stenosis
type N＝61Spondylolisthesis
type N＝29Local type
N＝40Cerebrospinal fluid leakage 0 2 3 1 0 Deep tissue infection 0 0 1 0 0 Cage displacement 0 3 2 0 0 Urinary tract infection or retention 0 1 0 1 0 Delirium 0 2 0 0 0 Pneumonia 0 0 0 1 0 Lower limb thrombosis 0 0 2 0 0 Total 0 8 8 3 0 LDD: Lumbar degenerative disease. -
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