Study on the Relationship between Lumbar Spinous Proceses Impingement and Intervertebral Disc Degeneration
|School||Taishan Medical College|
|Course||Human Anatomy and Embryology|
|Keywords||Kissing spine low back pain Ligamentum interspinalia Intervertebral discs Distance between the two adjacent spinous processes|
BACKGROUNDLow back pain is a common orthopedic disease and often affects people’s workingcapacity and quality of life. Common causes are chronic strain, degeneration, trauma,inflammation, In clinical practice，it was found that some patients with chronic low back painshowed lumbar spinous process impingement phenomenon on radiographs, mutual collisionbetween the spinous process interaction induced low back pain. Back in1933, Baastrupreported this phenomenon, namely Baastrup,s disease, or“Kissing spine”. In the past80years, Baastrup，s disease has not caused extensive attention and thorough research, by theradiologist and clinician and was neglected. Under this background, the pathophysiologicalmechanisms and the role played by interspinous process in lumbar spine degeneration wasanalysised, for the clinical diagnosis and treatment provide important theoretical basis.Objective(1) Proposed“lumbar spinous impingement syndrome”concept and diagnostic criteria.(2)Analysis“the spinous process of impingement syndrome”of the pathological process.(3) Thisstudy is to explore and evaluate the clinical significance effect of the lower lumbar vertebralspinous process impact phenomena in degenerative lumbar spinal diseases.MethodsIn the treatment of low back pain, a retrospective study was performed and analysis ofQianfo Hill hospital, Ji’nan Police General Hospital from January2010to December2011period spinal surgery on1500cases of lumbar X-ray data, there are856males and644females cases; the age of patients varies from30to73years old,the mean age is53.4years.Found to have" kissing spine" in116patients, there are54males and62females cases, themorbidity of low back pain patients with especially clinical situation was7.7%; the age ofpatients varies from36to70years old,the mean age is46.9years. In116patients" kissing spine" had Chinese staff in23cases, had ponderosus physical strength work history in56cases,37cases had farmers; time of them suffering from illness is3d to20years,on average is2.8years; X-ray films shows" kissing spine": a segment, double segments or three segmentsmay appear,39cases were the L3/4segments;43cases were the L4/5segments;15caseswere the L5/S1segments;19cases were the double segments for more than. MRI showedthat116cases were" kissing spine": simple herniation in59cases; spondylolysis andspondylolisthesis in9cases; at the same time have prominent associated with lumbar canalstenosis in18cases; at the same time have prominent with spondylolisthesis in27cases; atthe same time have prominent with spondylolysis in3cases. All patients according to thesymptoms, signs and lumbar X-ray films and MRI examinations, have been more than3months of regular non operation therapy in asymptomatic patients with remission orexacerbation, affects the quality of work and life, and the choice of open operation treatment.All patients were divided into four groups by different therapy method: conservativetreatment group, total discectomy group (DE), posterior lumbar interbody fusion screw-rodfixation group (PLIF) and interspinous process group (ISP),on the X-ray filmsmeasurement of disease through vertebral segment of preoperative, the range ofmotion(ROM) of the adjacent level were also recorded to assess the biomechanical changebefore and after operation, by using the Japanese Orthopaedic Association (JOA) score forlow back pain and the Visual analogue scale (VAS) and Oswestry disability index (ODI) ofthe preoperative and postoperative to evaluate the surgical results, statistical analysis used theSPSS13.0statistics software, with a mean standard deviation of measurement data, said,paired t test was used to study group, the patients in the lumbar spine degeneration incidence.The posterior approach operation for ligamentum interspinalia specimen for histologicexamination: using hematoxylin and eosin staining observation of ligamentum interspinaliawithout pathological changes. On the future“kissing spine” and to provide the importanttheoretical basis.Results1、“kissing spines” With age, gender, occupation: about related respectively to below40years old,41to55years old,56years old three age stages are divided into3groups, each groupincidence rates were0.20%,1.93%and1.20%, at the age of40patients with minimal morbidity,than the other two age had a significant difference (P <0.01),41~55years old group ofmiddle-aged patients with at most, patients aged56years and older visible second, twogroups of contrast, there were no significant difference (P>0.05).Different occupation andits incidence is not the same, with patients in the nature of work and the labor intensity of distinguish the incidence rates were19.8%,48.2%,31.9%, visible long-term heavy manualworkers its highest incidence rate.2、According to the site of disease onset,“Kissing spine” visible: a segment, doublesegments or three segments may appear,39cases were the L3/4segments (33.6%);43caseswere the L4/5segments (37.1%);15cases were the L5/S1segments (12.9%);19caseswere the double segments for more than(17.1%). Visible" Kissing spine " in the L4/5segments, followed by L3/4segments.3、In116patients“kissing spine” lumbar vertebra MRI display:59cases of the simpleherniation；9cases of the spondylolysis and spondylolisthesis at the same time; have18cases of the prominent associated with lumbar canal stenosis at the same time; have27casesof the prominent with spondylolisthesis at the same time; have3cases of the prominent withspondylolysis in at the same time. Visible" kissing spines" disease and degeneration of thelumbar intervertebral disc herniation and lumbar spondylolisthesis and instability of closelyrelated, lumbar intervertebral disc herniation in the corresponding segment“anastomosisspines”.4、pathological visible interspinous ligament fiber glass like change of chronic injury,degeneration, for the majority of fibrocartilage tissue and a little bone tissue, some densefibrous connective tissue, undamaged portion visible interspinous ligament thickening orskeletal muscle tissue, cartilage degeneration. Spinous process and the spinous process ofrepeated impact, fibrosis, calcification can occur, even ossification. Mainly in the L4/5segment, followed by L3/4and L5/S1segment.5、According to the spinous process impact the site and nature of different divided intothree types:1Duchenne: spinous process end edge of thickening, mast, spinous process withno direct contact between the spinous processes. The false joint type: direct contact withspinous process ends, marginal sclerosis become false joint. The continuous type: two or threeanastomosis of spinous process.6、3months post-operation of follow-up the JOA score, in Group DE, Group PLIF,Group ISP were significantly higher than that in conservative treatment group, there wasstatistically significant difference (P <0.01), Group PLIF, Group ISP JOA score was higherthan that of Group DE, there was statistically significant difference (P <0.05), the significantdifference still existed till6months post-operation and12months post-operation(P <0.01),but no significant difference between group PLIF and group ISP (P>0.05), In treatment，contrast group PLIF，group ISP were significantly higher than that in conservative treatment group and group DE significantly improve the patients JOA score.7、PLIF group: VAS score decreased from7.4±1.5pre-operatively to2.7±0.8at12monthpost-operation; JOA score improved from12.34±0.23to23.60±0.38; ODI score from41.2±5.9to20.1±4.0. In group ISP: VAS score decreased from7.8±1.2pre-operatively to2.8±0.5at12month post-operation; JOA score improved from12.80±0.38to26.83±0.58;ODI score from43.9±9.1to20.7±5.1. No significant difference of clinical effect was foundbetween group PLIF and group ISP (P>0.05).8、preoperation,3months post-operation,6months post-operation, group PLIF, groupISP of operated lumbar segments and adjacent segment range of motion (ROM) respectivelyin group PLIF: operated lumbar segments range of motion (ROM) for"0", the adjacentsegmental range of motion (ROM) after3months post-operation,12months post-operationwere no significant difference between preoperation, there was statistically significantdifference (P <0.05). in group ISP: the operated lumbar segments range of motion (ROM)after3months post-operation,12months post-operation were significantly lower than that inpreoperation, there was statistically significant difference (P <0.01), and no significantdifference between the adjacent upper and lower segmental range of motion (ROM)(P>0.05).Conclusion1、When the lumbar physiological curve. Through large or intervertebral disc height wasreduced, will lead to the adjacent segment of spinous process ends in contact with each other,collision, can become a pseudarthrosis, leading to interspinous rear impact. That is known as"Kissing spine ", also known as the interspinous bone joint disease, or Baastrup`s disease.More common in middle-aged and older female patients, clinical manifestations of longerduration of lumbar pain after median sternotomy, and seat when standing exacerbation of painor fatigue after the increase, rotary motor difficulties, neutral, rest after the symptoms relievedor disappeared, with or without lower extremity numbness, pain. Check the body visiblelumbar lordosis significantly, lower lumbar spinous process gap is small, standing passivehyperextension test positive, typical cases after extended interspinous having clamp meanssense.2、“Kissing spine” with age, occupation and sex related; and stooping, closely related tolong-term load.:onset segments were mainly found in the L4/5segment, followed by L3/4segment; lumbar MRI visible" Kissing spine " disease and lumbar intervertebral discherniation and lumbar spondylolisthesis and instability of closely related, and“Kissingspine” corresponding segment can appear in intervertebral disc degeneration, a prominent symptom.3、with the posterior column biomechanics research, in the same lumbar intervertebraldisc and the rear sides of the plane, small joint may interact with each other. Small jointdamage can contribute to the degeneration of intervertebral disc, intervertebral discdegeneration will involve small joint, cause lumbar instability, and lumbar instability andexacerbation of intervertebral disc degeneration.4、interspinous ligament is an important structure of lumbar posterior column, tomaintaining spinal stability plays an important role, it makes the rear facet joint degenerationof abnormal activity, intervertebral joints and joint capsular laxity occurs secondary to chronicdegenerative changes. They in turn increase the degeneration of intervertebral disc in thebearing load, intervertebral disc height reduction will affect the facet joint degeneration,changed the integral mechanical structure leads to the lumbar spine, lumbar instability. Thus,intervertebral discs, facet joints, interspinous ligament three aspects together to maintain thestability of lumbar spine, lumbar degeneration on, instability and“Kissing spine” relationshipbetween inseparable.5、In the treatment, imaging has the positive performance and no obvious symptoms,requiring no treatment. Pure lumbago patients can choose physiotherapy, local closed. Invalidconservative treatment may be considered for surgical operation treatment, and conservativetreatment and total laminectomy with resection of nucleus pulposus of contrast, discectomycan improve nerve root compression symptoms, but after destruction of the intervertebral discand vertebral inherent bony structure. Intervertebral fusion and fixation, interspinous fusionfixation can significantly improve the clinical symptoms of patients with. Lumbar interbodyfusion fixation can be reconstructed vertebral clearance and foraminal height, increasesegmental stability, but at the expense of the operation section of the function, appearance ofadjacent segment degeneration. Interspinous fusion fixation can properly preserved lumbarsegmental range of motion, to other segments without increasing exercise load on the"anastomosis spines" maintain a certain level of distraction, improved in patients with lowback pain symptoms, prevent lumbar secondary instability and degeneration, and theoperation is simple, the risk of the basic for" zero", no doubt spinal surgical operationtreatment is a new milepost, has good development long view.