脊柱椎间盘退变和骨化性疾病的临床影像学和流行病学研究

脊柱椎间盘退变和骨化性疾病的临床影像学和流行病学研究 苏州大学博士学位论文脊柱椎间盘退变和骨化性疾病的临床影像学和流行病学研究姓名郭炯炯申请学位级别博士专业骨外科学指导教师唐天驷20100301脊柱椎间盘退变和骨化性疾病的临床影像学和流行病学研究 中文摘要 I脊柱椎间盘退变和骨化性疾病的临床影像学 和流行病学研究 中文摘要 第一部分 中国南方人群中腰椎间盘退变的影像学和流行病学研究 —— 1736例脊柱磁共振图像的研究 【目的】 评估中国南方都市人群中腰椎间盘退行性变化的程度发生率和在不同椎间节段的分布状况。研究椎间盘退变在不同年龄和性别组中的变化。为将来椎间盘退变病因学研究和预防提供依据。 【方法】 通过公开邀请总共有1736例志愿者参加了该研究其中1068例为女性668例为男性年龄范围在8岁至88岁之间平均年龄为38.04岁。对所有参加者进行了影像学检查临床体格检查和症状学评分。用0.2 T和1.5 T的磁共振系统进行脊柱扫描。腰椎T2的矢状位序列成像 TR3000 毫秒 TE 92毫秒 层间距slice thickness5 mm。在所得MRI图像的基础上我们依据新设计的评分系统对腰椎间盘退变和椎间盘凸出进行评分。评估每个腰椎节段的许莫氏结节Schmorl nodes高信号区HIZ和骨髓信号的改变。两位医师共同进行影像学诊断评估。 【结果】 许莫氏结节的发生与性别相关许莫氏结节在男性中发生率更高。卡方检验发现许莫氏结节OR : 227.9骨髓信号改变OR : 20.2和高信号区OR : 20.4三种影像学表现与腰椎间盘退变的相关性依次增强均具有高度统计学意义 P0.0005。高信号区和骨髓信号改变与年龄呈显著相关性有高度统计学意义 P0.0005。许莫氏结节和高信号区在腰椎中的分布规律为许莫氏结节从上头端至下尾端呈降序分布椎间盘高信号区从上至下呈升序分布。腰椎间盘退变评分DDD分数和腰椎间盘凸出评分凸出分数与身体质量指数呈正相关有高度统计学意义 P0.0005。我们发现两种腰椎间盘退变评分结果在男女性别间无明显差异。从上头端至下尾端腰椎间盘节段的退变发生呈持续升高趋势。腰椎间盘退变在男女性别之间有一定程度的差异 P0.05。腰椎间盘退变在年轻人群中中文摘要 脊柱椎间盘退变和骨化性疾病的临床影像学和流行病学研究 II总体发生率高男性中为35.3女性中为33.9。 【结论】 许莫氏结节的发生与年龄因素无关其分布在男女性别之间有明显差异。研究发现腰椎间盘退变在中国南方都市人群中呈高发状态特别是年轻成人中常见。身体质量指数与腰椎间盘退变显著相关。25-35岁年龄段的男性比女性更易患腰椎间盘退变。我们考虑是外界环境因素所致。 【关键词】 腰椎椎间盘退变流行病发生率磁共振 第二部分 腰背痛临床症状与磁共振MRI影像学的相关性研究 【目的】 在中国南方普通都市人群中进行大规模的前瞻性MRI 影像学和临床相关性研究以评估腰背痛腰椎间盘退变影像学表现和其他结果测量指标之间的相关性。 【方法】 椎间盘退变是一生理性变化。在无症状人群中核磁共振影像MRI上也可发现脊柱结构异常。迄今尚无大样本椎间盘退变影像学表现与腰背痛症状的相关性研究。通过公开邀请的方式共有854例志愿者参加了本项临床流行病和影像学研究其中男性294例女性560例年龄在16岁至63岁之间平均36.83岁。所有参加者都进行了腰椎MRI检查并调查了腰背痛和坐骨神经痛的症状特点和严重程度。两位有经验的医师共同评估MRI图像上椎间盘退变和椎间盘凸出的严重程度并进行腰椎间盘退变评分。当腰背痛或坐骨神经痛存在时记录疼痛的持续时间频率和严重度。对样本人群进行疼痛视觉模拟评分VAS伤残功能指数ODIRoland Morris腰背痛功能障碍调查表RMQ和SF-36评分以评估临床疼痛及综合健康情况。 【结果】 腰背痛的临床症状与腰椎MRI上的椎间盘退变和椎间盘突出 表现之间有明显的相关性。SF-36评分中的生理功能PF分数疼痛视觉模拟评分VAS 腰背痛功能障碍调查表RMQ评估腰背痛效果更灵敏。PF、VAS和ODI与MRI上的腰 椎间盘退变表现相关。通过ROC曲线发现PFVASODI的ROC曲线下面积分别为 0.6070.5960.583。三者可以在一定程度上诊断是否存在椎间盘脊柱椎间盘退变和骨 化性疾病的临床影像学和流行病学研究 中文摘要 III退变但诊断性较弱。单纯坐骨 神经痛的志愿者SF-36评分中心理部分分数高于有腰背痛的志愿者。 【结论】 脊柱 椎间盘退变在南方都市人群中较为常见。椎间盘影像学退变程度和腰背痛严重性之 间有明显的相关性。相比其他评分系统SF-36的生理功能PF评分能更好地评估是否 存在腰椎间盘退变和腰背痛的严重程度。单纯坐骨神经痛患者的心理健康状况优于 腰背痛患者。虽然环境和身体因素对椎间盘退变有影响但它们的作用程度不同。腰 椎间盘退变自然进程可以被行为和环境因素所改变。 【关键词】腰椎腰背痛椎间盘 退变临床评分磁共振影像 第三部分 脊柱黄韧带骨化及其合并后纵韧带骨化的流行 病学、临床影像学研究和Meta分析 【目的】评估脊柱黄韧带骨化OLF在普通人群中 的发生率、形态和分布等流行病学特征并探讨脊柱后纵韧带OPLL合并黄韧带骨化的 诊断及治疗。 【方法】 2001年2月至2006年9月间对1736例中国南方人群进行磁共 振扫描所有可能的OLF均再行CT检查以证实。根据OLF累及的节段分为单一型连续 型非连续型根据矢状位T2像上OLF的形态学特征分为三角形圆形和鸟喙形三种。检 索Ovid MedlinePubMedEmbase和中国生物文献数据库1980至2008年搜集全部有关 OLF前后联合压迫TOO的病例报道。 【结果】66OLF的流行病学研究和OPLL合并 例3.8发现有脊柱OLF。45例68.2的OLF为单一节段21例31.8累及多节段。单一型OLF 为45例68.2连续型11例16.7不连续型10例15.2形态学上92个OLF中17个18.5为三角形 75个81.5为圆形。OLF最常见于下胸椎其次是上胸椎。纳入研究的OLF流行病学研 究共有4篇TOO的报道13篇。所有研究认为TOO首选手术治疗JOA评分适应评估TOO 患者的术后疗效。统计学分析显示女性TOO患者的预后劣于男性。在所有检出的 TOO病例基础上用二种新的分类法对TOO进行分类。 中文摘要 脊柱椎间盘退变和 骨化性疾病的临床影像学和流行病学研究 IV【结论】 OLF在中国南方人群中的发 病率约为3.8发生率与年龄和性别相关32的多节段OLF和15的非连续性OLF以及合 并TOO发生的可能均提示了全脊柱MRI检查的必要性对于TOO除了治疗责任骨化物 外非责任骨化物也要充分考虑减压的可能性新设计的二种OLF和二种TOO分型方法 帮助更好地定义和分类OLF、TOO但分型方法能否进一步指导治疗还有待进一步研 究。 【关键词】骨化黄韧带后纵韧带前后联合 作 者郭炯炯 指导老师唐天驷 教授 Clinical imaging and prevalence study of degenerative spinal diseases in southern Chinese Abstract VClinical imaging and prevalence study of degenerative spinal diseases in southern Chinese Abstract Part : ?Prevalence and types of abnormalities of the spine in urban southern Chinese: A study of 1736 population MRI scans of the whole spine 【Objective】To estimate the extent prevalence and distribution of degenerative changes of lumbar disc and some spinal structural abnormalities in an urban population of southern China. This study also determined the variation of these abnormalities in different age and gender groups. 【Methods】A total of 1736 urban southern Chinese volunteers 1068 women 668 men between 8 and 88 years of age mean 38.04 years were recruited by open invitation. Radiologic examinations clinical interviews and physical examinations were administered to all the participants. T2-weighted 5-mm spin-echo MRI sequences of the whole spine were obtained. On MRIs disc degeneration and disc bulging were scored using our new methods. Schmorl nodes high intensity zones and marrow changes were assessed for each lumbar segment. The 2 observers reviewed together and settled by consensus differences. 【Results】There was also a significant trend P0.0005 for an overall association between Schmorl nodes and gender higher in men. In chi-square test increasing in the strengths Schmorl nodes marrow changes and HIZ were showed a significant positive association with LDD OR:227.9 20.2 2.4 respectively P0.0005. There was also a statistically significant association between Schmorl nodes and marrow changes OR 1.7 P0.05. HIZ and marrow changes showed significant association with ageP0.0005. The distributive sequence of the Schmorl nodes in lumbar in decreasing order is from upper to lower but HIZ is in a reverse order in disc levels. Both DDD and bulge scores showed a significant positive association with BMIP0.0005.We found no significant Abstract Clinical imaging and prevalence study of degenerative spinal diseases in southern Chinese VIdifference in both scores between genders. Among the different areas of degeneration there was a consistent increase in prevalence of LDD from the upper to lower disc levels. There was some variation in LDD across sex groupsP0.05. The prevalence of LDD in younger were also high 35.3 in men and 33.9 in women. 【Conclusions】Schmorl nodes differ greatly between genders and are not age-related changes. A high prevalence of LDD existed in this urban southern Chinese sample. BMI was found to be correlated with LDD. In young adults degenerative disc findings are relatively common. Men aged 25 to 35 years are more likely to have LDD than women. We presumed that is attributed to environmental factors. 【Keywords】 degenerative disc disease intervertebral disc degeneration lumbar prevalence magnetic resonance imaging Part ?: Correlation of MRI abnormalities and low back pain in a population study of 854 subjects 【Objective】 The authors perform a prospective large scale study of quality of life and MRI findings in subjects from a general urban population of southern China with or without LBP in order to estimate the associations among LBP DDD and some outcome measurements. 【Methods】Intervertebral disc degeneration is part of ageing and abnormalities on MRI scans can be found in asymptomatic individuals. To date there is no large scale population study examining the relationship between MRI findings and symptoms of low back pain LBP. A total of 854 volunteers 560 women 294 men between 16 and 63 years of age were recruited. All underwent a MRI examination of the lumbar spine and answered questions in relation to the presence and severity of LBP and sciatica. On MRIs the severity of disc degeneration and herniation were scored by 2 experienced clinicians and differences were settled by consensus. Duration frequency and severity of LBP were recorded if present. These subjects were also objectively assessed by the visual analogue scale VAS Oswestry Disability Index ODI Roland Morris Questionnaire RMQ and SF-36. Clinical imaging and prevalence study of degenerative spinal diseases in southern Chinese Abstract VII【Results】There was significant association between MRI findings of degeneration herniation and LBP. RMQ VAS and physical function PF of the SF-36 were better than others as rating scales of LBP. Statistically significant correlations were found between three measurements ODI VAS PF and disc degenerative changes on MRI. ROC curve was used as a quantitative method for assessing a scale’s ability to distinguish subjects who have DDD from those who have not. PF VAS and ODI showed significant but weak correlations with DDD. Their areas under ROC curve were 0.607 0.596 and 0.583 respectively. The mental component summary of SF-36 in the subjects who only had sciatica was higher than those who had LBP. 【Conclusions】Although conceding that certain structural degenerative abnormalities of the spine are common in general population the present study has been able to show a significant association between DDD and the presence or severity of LBP. PF was relatively a better way to predict the presence of DDD and rate LBP. 【Keywords】low back pain degenerative disc disease MRI Part ?: Clinical imaging study and meta-analysis of ossification of the ligamentum flavum and posterior longitudinal ligament 【Objective】 To evaluate the prevalence morphology and distribution of ossification of the ligamentum flavum OLF in a population and provide appropriate guidelines for treatment of tandem ossification of the posterior longitudinal ligament OPLL and ligamentum flavum OLF using the method of systematic review. 【Methods】 A total of 1736 southern Chinese volunteers were recruited between February 2001 and September 2006. Sagittal MRI was administered to all the participants. Presence of OLF was identified and subsequently confirmed by CT scans. The distribution of OLF was classified into three types. While the morphology of the lesion was classified into triangular round and beak shapes. An English and Chinese literature search from January 1980 to December 2006 was conducted. The key words for search were OLF or OLF and OPLL. 【Results】 OLF was identified in a total of 66 subjects or 3.8 of the population. Abstract Clinical imaging and prevalence study of degenerative spinal diseases in southern Chinese VIIIThe isolated type was found in 4568.2 cases continuous type in 1116.7 and non-continuous type in 1015.2. The majority of the segments had a round morphology 81.5 while 1718.5 segments were triangular in shape. 4 articles that reported on the prevalence of OLF and 13 reports of tandem OPLL and OLF TOO were identified by the detailed review. All studies advocated that the primary therapy for TOO should be operative. The clinical outcomes of surgery were evaluated in most reports predominantly using the JOA scores. A higher rate of women was found in the failure group of TOO. A new two-stage classification to aid selection of surgical technique in individual patients is presented. 【Conclusion】This study demonstrated that OLF is not uncommon and that some 15 of the lesions are non-continuous and therefore could be missed. The authors recommend that for patients with suspected ossification of the spine should undergo routine MRI screening of the whole spine. The correlation of the classifications of TOO with surgical treatments is likely but needs to be examined in further studies. 【Keywords】ossification ligamentum flavum posterior longitudinal ligament tandem Written by: Dr. Jiong Jiong Guo Supervised by: Prof. Tiansi Tang 脊柱椎间盘退变和骨化性疾病的临床影像学和流行 病学研究 英文缩略词表 121英文缩略词表 英文缩写 英文全称 中文全称 LBP low back pain 腰背痛 DDD degenerative disc disease 椎间盘退变性疾病 LDD lumbar disc degeneration 腰椎间盘退变 OYL ossification of yellow ligament 黄韧带 骨化 OLF ossification of ligamentum flavum 黄韧带骨化 OFL ossification of flaval ligament 黄韧带骨化 OPLL ossification of the posterior longitudinal ligament 后纵韧 带骨化 MRI magnetic resonance imaging 磁共振 CT computerized tomography 计算 机断层扫描术 HIZ high intensity zone 高信号区 TOO tandem OPLL and OLF 后纵 韧带合并黄韧带骨化 SN schmorl nodes 许莫氏结节 BMI body mass index 身体质 量指数 VAS visual analogue scale 疼痛视觉模拟评分 ODI Oswestry disability index 伤残功能指数 RMQ Roland Morris Questionnaire 腰背痛调查表 LDH lumbar disc herniation 腰椎间盘突出 DHN disc height narrowing 椎间隙狭窄 HNP herniated nucleus pulposus 髓核突出 英文缩略词表 脊柱椎间盘退变和骨化性疾病的临床影像学和流行病学研究 122英文缩写 英文全称 中文全称 LCS lumbar canal stenosis 腰椎管狭窄 MID minimally invasive discectomy 微创椎间盘切除术 JOA Japanese Orthopaedic Association Score 日本骨科学会评分 SF-36 short form-36 SF-36评分 PCS physical component score 生理部分评分 MCS mental component score 心理部分评分 PF physical function 生理功能 RP role physical 体格 BP bodily pain 身体疼痛 GH general health 综合健康 MH mental health 心理健康 RE role emotional 情感 SF social function 社会功能 VT vitality 活力 脊柱椎间盘退变和骨化性疾病的临床影像学和流行病学研究 引 言 1引 言 腰背痛疾病是目前常见病、多发病。据有关统计数据表明美国每年因腰背痛疾病就诊者仅次于上呼吸道感染而居第二位其中女性多于男性比例大致为5:3。1989年美国用于腰背痛的医疗费及赔偿费为114亿美元 万个工作日以上在英国每年2的人口和25左右的就仅华盛顿特区每年腰背痛损失100 业人员患有腰背痛疾病。瑞典Nachemson经30年悉心研究发现80的人曾经有过腰背痛病史其中4持续3个月以上成为慢性腰背痛患者女性发病率明显高于男性。香港卫生事物署统计数字表明超过80的香港人在一生中出现腰背痛在2000年因腰背痛损失323485个工作日涉及2亿港币的赔偿1-5。虽然我国没有正式公布的统计数字但从一些医疗机构的局部范围调查来看我国腰背痛的发病率不低于国外统计水平因此可以说腰背痛的防治是目前疼痛学科迫切需要重视、解决的问。2002-2012年是联合国发起的“骨与关节十年”中国又是这一的主要参与国。让亿万患腰背痛疾病的患者尽快摆脱疼痛的折磨是每一个脊柱外科医师刻不容缓、责无旁贷的责任也是当前我国构建和谐社会的要求。 腰椎间盘退变是腰背痛的最常见病因。与癌症和传染病发病比例相对下降相反慢性非传染病的发病率正逐年上升。作为常见的慢性病之一腰椎间盘退变性疾病正对患者生活质量有严重的不利影响和对家庭、社区和整个社会产生巨大负面的、并且被低估的经济影响。常见、可变更的危险因素是导致脊柱椎间盘退变的主要原因。目前引起椎间盘退变的有力学、生物化学、基因学、自身免疫等理论学说但尚无定论。中国目前腰椎间盘退变的情况令人担忧。随着经济和社会的发展、全球化和都市化进程的加速、计划经济到市场经济的转变这些都导致人们生活习惯的变化。随着越来越多的人涌向城市他们的生活方式趋向于久坐。据世界卫生组织中国代表处的报告623.