胶原酶溶盘术后早期神经根病损临床与实验研究

1、胶原酶溶盘术后早期神经根病损临床与实验研究         08-07-02 10:04:00     作者：张斌，戴闽    编辑：studa20【关键词】  胶原酶；化学溶盘术；神经根；损伤摘  要：目的探讨胶原酶溶盘术后早期出现神经根病损原因，寻找胶原酶溶盘术后出现早期神经根病损预防与处理方法。方法临床回顾分析本院2000年1月2004年12月开展的腰椎间盘突出症胶原酶溶盘术1 280例，其中早期出现神经根病损

2、病例12例（发生率094）。实验将18只日本大耳兔随机分为A、B、C组，A组为后纵韧带完整+盘内注射组，B组为后纵韧带破损+盘内注射组，C组为盘外（硬膜外腔）注射组，大体及光镜下观察不同时间椎间盘及神经根改变。结果临床资料表明腰椎间盘突出症胶原酶盘内+盘外溶盘组胶原酶使用剂量大，出现早期神经根损伤病例明显多于其他组（P005）；12例早期出现神经根病损病例中，10例约在溶盘术后7 d内出现；8例术中均未见明显神经根压迫；随访430个月，症状有不同程度好转，但无1例痊愈，且3 d内手术治疗病例优良率明显高于8 d后手术治疗病例。动物实验显示胶原酶对髓核有明显溶解作用，B组（后纵韧带破损组）神经根

3、出现明显损害，C组（盘外注射组）椎间盘内未见明显溶解，亦未见神经根损害。结论（1）胶原酶溶盘中间产物和残余髓核溢入椎管可导致神经根损害症状，大剂量的盘内外联合溶盘可加剧神经根损害的发生率，对后纵韧带、纤维环破裂、髓核突入椎管的腰椎间盘突出症行胶原酶溶盘术应慎用；（2）胶原酶溶盘术后神经根损害预后差，预后与手术早晚明显有关；（3）胶原酶溶盘术后严格卧床，正确翻身，有助于降低神经根损害的发生率。    关键词：胶原酶；  化学溶盘术；  神经根；  损伤    Clinical and laboratory

4、study of early nerve foot lesion after collagenase chemonacleolysisZHANG Bin,DAI MinDepartment of Orthopaedics Surgery,the First Affiliated Hospital of Nanchang University,Nanchang 330006    Abstract：ObjectiveTo investigate the etioloty of the early nerve root lesion(RNRL) after colla

5、genase chemonucleolyoio(CC) and its prevention and treatmentMethodTwelvehundred and eighty case of lumbar disc herniation undergoint cc were reviewed and analyzedFrom January,2000 to December,2004 with followup time of 430 months,in which 12 cases(094%)had obvious ENRL after CCEighteen rabbits were

6、randomly divided into three groups of six each:Group A,posterior longitudinal ligament intepated+intradisca injection;group B,parterior longitudinal ligamen+booteen+intradiscal injection,and group C,extradiscae injectionThe disc and the nerve roots at the inject side were removed,fixed and examined

7、by microscope,and the changes of the discs end nerve roots were analyzed in different inject side and different time after CCResultAs the collagenase dose was large in groups of intradiscal+intradiscal injections case of ENRL in this group were more than that in other groupsIn the 12 ENRL cases,ten

8、cases of ENRL appeared in about 7 days after CC,8 cases without nerve root compression and all cases were improved in different degree,but no one reeovered completely at follow-up with excellent and good rate of efficiency in the cases operated in 3 days than that in cases operated after 8 daysIn th

9、e experiment rabbits,there lowed obvious lyeis of nucleusPulpus in group A and group B,with severe damage of nerve roots in group B,while in group C,there was no obvious lipis of nucleuss pulpus and damage of nerve rootsConclusion(1)As the larger collagenas dose in the cases with intradiscal and ext

10、radiscal injections can raiseThe incidence of ENRL,it is suggested that CC used in cases with broken posterior longitudenal ligament of and brous anmulus and ,with nucleus pulpuses herniated into spinal canal,CC should be prudent to apply(2)The prognoseo of the ENRL after CC is poor and is related t

11、o operation time(3)The incidence of ENRL after CC can be lowered with absolute bed rest and changing body position after CC    Key words：Collagenase;  Chemonucleolysis;  Early nerve root lesion    1981年胶原酶（Collagenase）溶盘术治疗腰椎间盘突出症在临床上获得成功并报道后，胶原酶逐渐替代木瓜酶成为化学溶盘术

12、的主要药物，并取得满意的疗效，但腰椎间盘突出症胶原酶溶盘术后早期出现神经根病损病例报道逐渐增多，预后差，产生原因争议较大。为探讨胶原酶溶盘术后早期出现神经根病损原因，寻找胶原酶溶盘术后出现早期神经根病损预防与处理方法，作者回顾分析了本院2000年1月2004年12月开展的腰椎间盘突出症胶原酶溶盘术1 280例，重点分析了其中术后早期出现神经根病损症状的12例病例并进行了随访，同时进行了相关动物实验研究，现报告如下。    1  材料、方法及结果    11  临床部分    111&#

13、160; 胶原酶溶盘术病例资料及分析    2000年1月2004年12月本院共开展腰椎间盘突出症胶原酶溶盘术1 280例，早期以盘外溶盘为主，后期以盘内+盘外溶盘及盘内溶盘为主，各组病例数、胶原酶剂量及早期出现神经根病损病例数见下表1，患者年龄2162岁，平均382岁，男女比例151。    表1  溶盘部位、胶原酶剂量与出现神经根病损病例数比较    分  组     病例数     胶原酶剂量（u）&

14、#160;    早期神经根病损病例数盘外溶盘组     411     1 2001 800     1盘内+盘外溶盘组     334     1 8002 400     9盘内溶盘组     526     6001 200 

15、60;   2    盘内+盘外溶盘组使用的胶原酶剂量明显高于盘外溶盘组、盘内溶盘组，盘内+盘外溶盘组出现早期神经根病损病例数亦明显高于盘外溶盘组、盘内溶盘组，行x2检验有显著性差异（P005）。    112  早期出现神经根病损病例资料及分析    1121  病例资料    在1 280例腰椎间盘突出症胶原酶溶盘术病例中，有12例术后早期在轻微外力下突然出现原神经根损伤症状明显加重或合并出现其它神经根损伤症状，作者认为这12例病例出现神经根病损，其中男6例，女6例；年龄3860岁，平均392岁。胶原酶溶盘治疗方案、突然出现症状时间、起因、损伤神经根、与手术间隔时间、随访时间及疗效评定详见表23、图1。    1122  手术前影像学资料    胶原酶溶盘术后早期出现神经根损伤症状的12例病例均常规