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病例漫谈105:椎管积气引起腰椎间盘源性疾病:一则病例报告 [复制链接]

1#

Vacuum disc phenomenon is a condition seen frequently with degenerative disc disease and is characterized by the collection of gas in the disc space. It is also known as 'phantom nucleus'. Accumulation of gas may be either intradiscal or spread into the intraspinal canal. Although the accumulation of gas within the disc space does not have clinical significance, clinical symptoms maybe be observed when it occurs within the spinal canal. Gas accumulation in the spinal canal may be trapped in a simple cystic structure or associated with a disc herniation. Ball-valve type connection may cause an increase in the pressure of gas inside the gas containing disc or cyst in the epidural space. Typical symptoms include increased pain when standing and walking.

椎间盘真空现象是常见的退行性椎间盘疾病,其特征是气体在盘空间的积聚。他也被称为“幻核”。积气可能发生在椎间盘内,也可能分散在椎管内。虽然椎间盘内气体的积累不具有临床意义,但当该现象发生在椎管内时,可能观察到临床症状。积气的产生可能是因为气体被困在一简单囊状结构中,也有可能与椎间盘突出症有关联。球阀型连接可能会导致硬膜外腔内囊肿或椎间盘内的气体压力增加。典型的症状包括站立和行走时的疼痛增加。


We present an unusual case of symptomatic intraspinal gas accumulation associated with vacuum disc phenomenon treated with L5-S1 hemilaminectomy and foraminotomy.

文中讲述一例椎管内积气导致临床病症出现的特别案例,该案例采用L5-S1半椎板和椎间孔切除手术来治疗椎间盘真空现象。


Case report

A 60-year-old female with back and left leg pain for 5 months was admitted to our clinic. The patient had not responded to conservative management with a non-steroidal anti-inflammatory drug and muscle relaxant for 3 weeks. The patient had neurogenic claudication in the left leg. Back and leg pain increased when standing and decreased when lying down and leaning forward. The straight leg raise test was 50 degrees on the left leg. Routine laboratory investigations were normal. Direct radiographies showed narrowing of the L5-S1 disc space. In magnetic resonance imaging (MRI), there was a narrowing of the L5-S1 disc space with vacuum disc phenomenon and a hypointense cystic mass on T1 (Figs. 1a and b) and T2-weighted images (Figs. 1c and d). A left L5-S1 laminotomy was performed. The nerve root was pushed posteriorly by the cystic mass. The cyst wall was adherent to the root and dura mater and was released after removal of the gas using a syringe inside the cyst wall. The cyst wall was excised partially from the root and dura mater. The degenerated disc was evacuated and foraminotomy was performed. Pathology of the cyst wall was reported as a simple cyst. The patient was pain-free on the first postoperative day and follow-up MRI revealed the absence of the gas containing cystic mass.

病例报告

一名60岁的女性患者,背部和左腿疼痛了5个月,被送往我们的诊所接受治疗。对其采取了为期3周的保守治疗,使用了非甾体类抗炎药和肌松药,患者症状并没有好转。左腿发生神经性跛行症状。站立时背部和腿部疼痛增加,躺下和前倾时疼痛感相对降低。左腿直腿抬高测试结果为50度。实验室常规检查项均在正常值范围内。X光检查结果显示L5-S1椎间隙变窄。磁共振成像MRI显示,有一个狭窄的L5-S1椎间隙出现真空盘现象,在T1图像(图1a和b)和T2加权影像(图1c和d)出现一低信号囊性肿块。对患者进行了左L5-S1椎板切开术。神经根受到囊性肿块的压迫。使用注射器去除囊肿壁内的积气后释放出附着于神经根和硬脑膜的囊肿壁,并进行部分切除。退变性椎间盘被取出,并进行了椎间孔切开术。囊肿壁的病理报告为一个简单的囊肿。术后第一天,病人无疼痛症状发生,随访MRI显示不存在包含积气的囊性肿块。


Fig. 1. (a) Sagittal and (b) axial T1-weighted images showing the vacuum disc phenomenon and hypointense cystic mass in the spinal canal.

(c) Sagittal and (d) axial T2-weighted images showing the hypointense cystic mass compressing the left L5 root.

图1 (a)矢状面和(b)轴向T1加权像显示椎管内真空现象和低信号囊性肿块。

(c)矢状面和(d)轴向T2加权像显示低信号囊性肿块压迫左L5神经根。


Discussion

Biomechanical insufficiency of the disc tissue leads to a cleft in the disc annulus and the gas around the surrounding tissue accumulates in this cleft due to its negative pressure. Gas in the disc space may spread into the vertebrae by way of the subchondral bone or into the spinal canal. While the incidence of the vacuum disc phenomenon is around 1 to 20% as detected on direct radiography, this rate increases to 25 to 46% with computed tomography (CT). Although CT is the most reliable diagnostic tool for displaying the gas accumulation in the lumbar spine, Berns et al. claimed that a gradient echo sequence MRI is as sensitive as CT. The MRI of our patient revealed vacuum disc phenomenon at the L5-S1 disc level and a gas-filled cystic mass which was hypointense on T1 and T2-weighted images related to the L5-S1 disc space. While a vacuum disc phenomenon in a herniated disc is surrounded by a soft tissue mass with an irregular outline, a gas-filled cyst in the epidural space is distinguished by its regular outline. The cystic mass in our patient was regular in appearance, and the pathology report did not reveal any disc tissue.

讨论

椎间盘组织的生物力学功能不全导致裂瓣环,产生负压,气体在裂缝中围绕周围组织积聚。积气在椎间盘内可能经由软骨下骨扩散到椎骨或椎管内。X射线直接检测结果表明椎间盘真空现象发生率大约是1%-20%,而进行计算机断层扫描(CT)检查则此概率增加到25%-46%。尽管CT在显示腰椎间盘积气方面被认为是最可靠的诊断工具,但是伯恩斯等人声称梯度回波序列的磁共振成像(MRI)和CT一样灵敏。本例患者的MRI表明在L5-S1椎间盘水平出现真空盘现象,T1和T2加权图像显示L5-S1椎间隙出现低信号的含气囊性肿块。椎间盘突出症中,椎盘真空现象是由一个不规则轮廓的软组织肿块包围,而在硬膜外腔内含气囊肿具有规则的轮廓特征。本例患者的囊性肿块在外观轮廓上是规则的,同时病理学报告没有显示任何椎间盘组织。


Gas-containing disc herniation occurs by two mechanisms; herniation of a gas-containing disc or the spreading of gas into the disc tissue by the ball-valve mechanism. Intraspinal gas accumulation reported cases has been associated with the intradiscal vacuum phenomenon, indicating the relationship between the disc space and intraspinal canal gas accumulation. If the fibrous ring of the disc tears, the gas inside the disc moves towards the epidural space. The motion of the vertebrae may cause pressure between the disc and epidural space, provoking the movement of the gas inside the disc toward the epidural space. The symptoms in our case increased during walking and in extension but decreased in flexion and when leaning forward. This points out to the effect of the ball-valve mechanism in the occurrence of symptoms. Trauma, infection, neoplasm, osteonecrosis, spinal injection procedures and spinal surgery are reported as other causes of gas accumulation in the spinal canal.

含气腰椎间盘突出症的发生通过两种机制:椎间盘突出导致积气或者气体经由球瓣机制扩散到椎间盘组织内。椎管内积气报告病例已经与椎间盘真空现象关联,表明椎间盘和椎管内积气之间存在关系。如果椎间盘纤维环撕裂,椎间盘内气体会向硬膜外间隙移动。脊椎骨的运动可能导致椎间盘和硬膜外间隙之间产生压力,引起椎间盘内气体向硬膜外间隙运动。本例患者在行走和伸展时症状加重,而在前倾和屈曲时病症缓和。这指出了球瓣机制在发病机制中的作用。创伤、感染、肿瘤、股骨头坏死、椎管内注射过程和脊柱外科手术被报道为导致椎管内积气的其他因素。


The treatment of intraspinal gas accumulation varies from conservative to surgical exploration. Although spontaneous regression of intraspinal gas accumulation has been reported, Mortensen et al. claimed that gas accumulation in the disc space and intraspinal canal cannot be absorbed due to the absence of a vascular network in the surrounding tissue. Therefore, examinations must be repeated before any invasive procedure. While Bosser et al. proposed needle aspiration under CT guidance, recurrence rates are high.

椎管内积气的治疗不同于保守的手术探查。虽然椎管内积气的自然消退已有报道,Mortensen等人声称在椎间盘和椎管内积气不能被吸收是由于周围组织内血管网的缺失。因此,在行任何侵入性手术之前,必须进行检查。同时Bosser等人提出了在CT引导下进行针穿刺,但此方法复发率很高。


In conclusion, when the underlying pathophysiologic mechanism is considered, surgery is the best treatment when adequate conservative treatment fails for vacuum disc phenomenon and accumulation of gas within the spinal canal.

总之,基础的病理生理机制认为,对真空盘现象和椎管内积气采用适当保守治疗失败时,手术是最好的治疗方法。


由MediCool医库软件 朱勇 王露黔 编译

原文来自Acta Orthop Traumatol Turc

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