外侧椎间盘突出与内侧椎间盘突出的比较

1、1Medicine (Baltimore). 2016 Feb; 95(7): e2733.Published online 2016 Feb 18. doi:  10.1097/MD.0000000000002733PMCID: PMC4998615Clinical and Radiological Characteristics of Lumbosacral Lateral Disc Herniation in Comparison With Those of Medial Disc HerniationJung Hwan Lee, MD, PhD

2、and Sang-Ho Lee, MD, PhDMonitoring Editor: Kazuo Hanaoka.Author information  Article notes  Copyright and License information Author InformationFrom the Department of Physical Medicine and Rehabilitation (JHL) and Department of Neurosurgery, Wooridul Spine Hospital, Seo

3、ul, Korea (SHL).Correspondence: Jung Hwan Lee, Department of Physical Medicine and Rehabilitation, Wooridul Spine Hospital, 46-17 Chungdam-Dong, Gangnam-Gu, Seoul, Korea (e-mail: j986802).Abbreviations: MRI = magnetic resonance image, NRS = numeric rating scale.数字评定量表The authors have no funding and

4、conflict of interests to disclose.This is an open access article distributed under the Creative Commons Attribution-ShareAlike License 4.0, which allows others to remix, tweak, and build upon the work, even for commercial purposes, as long as the author is credited and the new creations are licensed

5、 under the identical terms. /licenses/by-sa/4.0eceived December 29, 2015Received in revised form January 13, 2016Accepted January 15, 2016Go to:AbstractLateral disc herniation (foraminal and extra foraminal) has clinical characteristics that are different from those of media

6、l disc herniation (central and subarticular), including older age, more frequent radicular pain, and neurologic deficits. This is supposedly because lateral disc herniation mechanically irritates or compresses the exiting nerve root or dorsal root ganglion inside of a narrow canal more directly than

7、 medial disc herniation. The purpose of this study was to investigate clinical and radiological characteristics of lateral disc herniation in comparison with medial disc herniation. The 352 subjects diagnosed with localized lumbosacral disc herniation and followed up for at least 12 months after com

8、pletion of treatment were included and divided into medial and lateral disc herniation groups, according to the anatomical location of the herniated disc in axial plain of magnetic resonance image. Clinical and radiological data were obtained and compared between the two groups. The lateral group in

9、cluded 74 (21%) patients and the medial group included 278 (79%). Mean age of the lateral group was significantly higher than that in the medial group. The lateral group showed a significantly larger proportion of patients with radiating leg pain and multiple levels of disc herniations than the medi

10、al group. No significant differences were found in terms of gender, duration of pain, pretreatment numeric rating scale, severity of disc herniation (protrusion and extrusion), and presence of weakness in leg muscles. The proportion of patients who underwent surgery was not significantly different b

11、etween the 2 groups. However, the proportion of patients who accomplished successful pain reduction after treatment was significantly smaller in the lateral than in the medial group. In conclusion, patients with lateral disc herniation were older and had larger proportion of radiating leg pain than

12、those with medial disc herniation. Lateral disc herniation was more associated with multiple disc herniations and worse clinical outcomes after treatment than medial disc herniation.Lateral disc herniation (foraminal and extra foraminal) has clinical characteristics that are different from those of

13、medial disc herniation (central and subarticular), including older age, more frequent radicular pain, and neurologic deficits. 侧椎间盘突出(孔的和额外的孔的)临床特点,不同于内侧椎间盘突出(中部和subarticular),包括年龄、更频繁的神经根疼痛,和神经损伤。This is supposedly because lateral disc herniation mechanically irritates or compresses the exiting ner

14、ve root or dorsal root ganglion inside of a narrow canal more directly than medial disc herniation. 这可能是因为侧椎间盘突出比内侧椎间盘更直接机械刺激或压缩现有神经根或背根神经节内狭窄的通道。The purpose of this study was to investigate clinical and radiological characteristics of lateral disc herniation in comparison with medial disc herniatio

15、n. 本研究的目的是探讨外侧椎间盘突出与内侧椎间盘突出的临床和放射学特征。The 352 subjects diagnosed with localized lumbosacral disc herniation and followed up for at least 12 months after completion of treatment were included and divided into medial and lateral disc herniation groups, 352例诊断为局部腰骶椎间盘突出和随访治疗至少12个月后完成包括分为内侧和外侧椎间盘突出组, acc

16、ording to the anatomical location of the herniated disc in axial plain of magnetic resonance image. 根据椎间盘突出的解剖位置轴向平原的磁共振图像。Clinical and radiological data were obtained and compared between the two groups. The lateral group included 74 (21%) patients and the medial group included 278 (79%).通过临床和影像学数据

17、得到两组之间的比较。外侧组包括74名(21%)患者和内侧组包括278名(79%)。Mean age of the lateral group was significantly higher than that in the medial group. 侧组的平均年龄明显高于内侧。The lateral group showed a significantly larger proportion of patients with radiating leg pain and multiple levels of disc herniations than the medial group. 外

18、侧组显示的患者腿部放射痛和多级椎间盘突出比内侧疼痛比例明显增大。No significant differences were found in terms of gender, duration of pain, pretreatment numeric rating scale, severity of disc herniation (protrusion and extrusion), and presence of weakness in leg muscles. 在性别方面没有发现显著差异，疼痛持续时间,预处理数字评定量表,严重的椎间盘突出(突出和挤压),并在腿部肌肉存在弱点。Th

19、e proportion of patients who underwent surgery was not significantly different between the 2 groups. 病人接受手术的比例两组之间没有明显不同。However, the proportion of patients who accomplished successful pain reduction after treatment was significantly smaller in the lateral than in the medial group. 然而,患者的比例完成成功的治疗后的

20、外侧比内侧组疼痛减少明显较小。 In conclusion, patients with lateral disc herniation were older and had larger proportion of radiating leg pain than those with medial disc herniation. 总之,侧椎间盘突出患者年龄,有较大比例的辐射比与内侧椎间盘突出腿部疼痛。 Lateral disc herniation was more associated with multiple disc herniations and worse clinical o

21、utcomes after treatment than medial disc herniation. 侧椎间盘更与多个椎间盘突出和治疗后临床结果比内侧椎间盘突出。 INTRODUCTIONIncidence of lateral disc herniation is lower than that of medial disc herniation and has been reported to account for 7% to 12% of all lumbosacral disc herniations.13 侧椎间盘突出发病率低于内侧椎间盘突出有报道占7%到12%的所有

22、腰椎间盘突出症。Lateral disc herniation has different clinical characteristics from medial disc herniation. 侧椎间盘突出从内侧椎间盘突出有不同的临床特点。Patients with lateral disc herniation can manifest with more severe clinical symptoms, including severe radicular pain, or more frequent motor and sensory neurological deficits

23、than those with medial disc herniation,4 because the herniated disc fragment is located in or around a narrow root foramen, through which nerve root passes, resulting in direct compression of dorsal root ganglion which is a pain sensitive structure. 外侧椎间盘突出患者可以与更严重的临床症状,包括严重的神经根疼痛,或更频繁的运动和感觉神经功

24、能缺损比内侧椎间盘突出,4,因为椎间盘突出片段位于左右狭窄根孔,通过该神经根,导致直接压缩的背根神经节疼痛敏感结构。2,5Additionally, clinical outcomes of lateral disc herniation after transforaminal injection or surgery were found to be worse than those of medial disc herniation.5,6 此外，经椎间孔注射或手术后外侧型腰椎间盘突出症的临床结果被发现是比内侧椎间盘突出症的恶化。To our knowledge, no stu

25、dy has identified the clinical and radiological characteristics of patients with lateral disc herniation in comparison with medial disc herniation. 我们的知识 没有已经确定了的研究患者的临床和影像学特征与内侧与外侧椎间盘突出相比。The purpose of this study was to investigate clinical and radiological characteristics of lateral (foraminal an

26、d extraforaminal) disc herniation in comparison with medial (central and subarticular) disc herniation, which might provide useful information about lateral disc herniation, helping in diagnosis and prediction of prognosis after treatment in these patients. 本研究的目的是调查的临床和放射学特征侧(椎间孔內型孔的和椎间孔外型)椎间盘突出与内侧

27、相比(中央型和下关节面型subarticular)椎间盘突出,对侧椎间盘突出这可能提供有用的信息,帮助诊断和预测这些患者的治疗后的预后。Go to:METHODSThis study was approved by Institutional Review Board of our hospital. This was retrospective study so that informed consent was not required. 本研究是我们医院的机构审查委员会批准，这是回顾性研究,知情同意并不是必需的。Patients who visited our hospital with

28、 chief complaint of back and/or radiating leg pain and were diagnosed with lumbosacral disc herniation through clinical and radiological evaluation, including lumbosacral magnetic resonance image (MRI) from January 2014 to June 2014, were chosen. Disc herniation was defined as a localized displaceme

29、nt of disc material beyond the limits of the intervertebral disc space. 就诊于我们医院的病人的主诉和/或辐射腿部疼痛,被诊断为腰骶椎间盘突出通过临床和放射学评估,包括腰骶的磁共振影像(MRI)从2014年1月到2014年6月,被选择。椎间盘突出是定义为一个盘材料的局部位移超越极限的椎间盘空间。 “Localized” was defined as less than 25% of the disc circumference. “局部的”被定义为不到25%的阀瓣周长7 Patients with bulging

30、disc involving greater than 25% of its circumference, spinal stenosis, severe disc degeneration, significant instability, spinal tumor, prominent scoliosis (Cobb angle >15°), and previous lumbar surgery were excluded. 椎间盘膨出患者包括大于25%的周长,脊髓狭窄,严重的椎间盘变性,重大不稳定,脊髓肿瘤,著名脊柱侧凸(Cobb角> 15°),和以前的

31、腰椎手术被排除在外。 Patients diagnosed with vertebral bone fractures and infectious diseases, such as discitis or spondylitis, evidenced by MRI were also excluded. 病人诊断为椎骨折和传染病,如关节盘炎或脊柱炎,通过MRI证明也被排除在外。Among the 635 patients diagnosed with disc herniation, those with sequestered and migrated disc herniations

32、were excluded because anatomical classification of these types in axial plane is difficult to be determined. 在635例诊断为椎间盘突出的患者中,隔离和迁移椎间盘突出被排除在外,因为解剖分类这些类型的轴面是很难确定的。 Disc herniation was divided into central, sub articular, foraminal, and extra foraminal according to anatomical landmarks such as medial

33、 edge of the articular facets and medial or lateral border of pedicles on axial plane. 椎间盘突出症分为中央，关节下，椎间孔和椎间孔外，根据解剖标志，如关节面内侧或外侧缘的轴面椎弓根内侧缘。7 Diagnoses and classifications of disc herniation were performed by radiologists specialized in spine diseases. 椎间盘突出的诊断和分类是由放射科医生专业脊柱疾病执行。To investigate th

34、e clinical characteristics of foraminal and extra foraminal disc herniation compared with central and subarticular disc herniation, we established 2 groups对椎间孔內型的和椎间孔外型的椎间盘突出的临床特点与中央和subarticular下关节椎间盘突出相比,我们建立了2组: a medial group including central and subarticular disc herniation, and a lateral grou

35、p including foraminal and extraforaminal disc herniation. 内侧组包括中央和subarticular椎间盘突出,和横向组织包括椎间孔內型的和椎间孔外型椎间盘突出。Multiple disc herniations with foraminal disc herniation observed in MRI were included in the lateral group. 与孔的多个椎间盘突出椎间盘突出在MRI中包括外侧组。The 352 patients who were followed up for at least 12 mo

36、nths after completion of treatment were included in this study. 352年随访的患者至少12个月完成治疗后被纳入本研究。Clinical characteristics such as age, gender, duration of pain, location of dominant pain (axial or leg pain), numeric rating scale (NRS) at pretreatment, number of disc herniations, severity of disc herniatio

37、n (protrusion or extrusion), presence of leg muscles weakness, treatment method (conservative or surgical), and clinical outcome (successful or unsuccessful) were investigated. 临床特征如年龄、性别、疼痛持续时间,主要的位置疼痛(轴向或腿部疼痛),数字评定量表(NRS)预处理、椎间盘突出、严重的椎间盘突出(突出或挤压),腿部肌肉的存在的弱点,处理方法(保守或手术)和临床结果(成功或失败)。In terms of trea

38、tment method, patients who received only conservative management were regarded as conservative, whereas, those who underwent surgery due to failure of conservative management were defined as surgery. Successful clinical outcome was defined as 50% or more reduction of NRS after at least 12 months of

39、treatment in comparison with pretreatment NRS.These data were compared between the medial and lateral groups. In addition, clinical outcomes were compared in whole subjects as well as in the conservative and surgery subgroups.Statistical AnalysisThe SPSS version 14.0 statistical package (SPSS Inc.,

40、Chicago, IL) was used for statistical analysis. Chi-square test was used to compare gender proportions, location of dominant pain (axial or leg pain), number of disc herniations, severity of disc herniation (protrusion or extrusion), presence of leg muscles weakness, treatment method (conservative o

41、r surgical), and clinical outcome (successful or unsuccessful) between the lateral and the medial groups. Student's t-test was performed to compare differences in age, duration of pain, and pretreatment NRS between the 2 groups. Results were considered statistically significant if the 

42、P value was less than 0.05.RESULTSAmong the 352 patients, the lateral group included 74 (21%) patients and the medial group included 278 (79%) patients. 在352例,外侧组包括74名(21%)患者和内侧集团包括278名(79%)患者。Mean age of the lateral group was significantly higher than the medial group. 侧组的平均年龄明显高于内侧。 The later

43、al group showed significantly larger proportion of patients with radiating leg pain and multiple levels of disc herniations than the medial group. 外侧群显示显著更大比例的患者辐射腿部疼痛和多级比内侧组椎间盘突出。 No significant differences were found in terms of gender proportions, duration of pain, pretreatment NRS, severity of d

44、isc herniation, and presence of leg muscles weakness. 没有发现显著差异在性别比例方面,持续疼痛,预处理NRS,椎间盘突出的程度,腿部肌肉的存在的弱点。The proportion of patients who underwent surgery was not significantly different between both groups. However, the proportion of patients who accomplished successful pain reduction after treatment w

45、as significantly smaller in the lateral than the medial group病人接受手术的比例在两组之间没有明显不同。然而,患者完成成功的治疗后疼痛减少的比例,外侧比内侧组明显较小(Table (Table11).TABLE 1Comparison of Clinical and Radiological Characteristics Between Lateral and Medial Disc Herniation比较的临床和放射学特征之间的外侧和内侧椎间盘突出In terms of conservative and surgery

46、 treatment subgroups, the lateral group showed trends toward poorer outcomes than the medial group, which was statistically insignificant子组的保守和手术治疗,外侧比内侧群显示趋势的不好结果,这在统计学上并不显著(Table (Table22).TABLE 2Comparison of Clinical Outcomes According to Treatment Method (Conservative Managements and Surge

47、ry) Between Lateral and Medial Disc Herniation侧位间盘突出症的治疗方法（保守治疗和手术治疗）的临床疗效比较DISCUSSIONIn this study, the ratio of lateral to medial disc herniation was approximately 1:4. The proportion of lateral disc herniation in our study was relatively higher than in other reports, which mentioned that lateral

48、disc herniation accounted for approximately 7% to 12% of lumbar disc herniations.1,2,8 在这项研究中，外侧向内侧椎间盘突出症的比例约为1:4。我们在研究外侧型腰椎间盘突出症的比例比其他报道相对较高，其中提到，外侧型腰椎间盘突出症约占7%至12%的腰椎间盘突出症。This might be because the criteria of our study were different and stricter than those of other studies. We selected only

49、 the patients with localized disc herniation (less than 25% of circumference) as suggested in recent recommendations这可能是因为我们的研究的标准是不同的，比其他研究更严格。我们只选择了局部椎间盘突出症（小于25%的周长），建议在最近的建议。.9 In addition, we excluded migrated and sequestrated disc herniation, which could have resulted in more decrease in

50、the number of medial disc herniation in comparison with lateral disc herniation. 另外，我们排除了迁移和游离的椎间盘突出症，这可能会导致椎间盘突出的内侧与外侧型腰椎间盘突出症比较数量减少。The way of classification of multiple disc herniations also contributed to larger proportion of lateral disc herniation because if at least 1 of the multiple disc her

51、niations was determined as foraminal or extraforaminal, it was included in the lateral group. 对多个椎间盘突出症的分类方式也有助于外侧型腰椎间盘突出症的比例较大，因为如果至少有1个以上椎间盘突出症被确定为椎间孔內型或椎间孔外型，还包括在椎间孔侧面基。Our study demonstrated that lateral disc herniation was more associated with multiple disc herniations. This result was unique t

52、o our study, as to our knowledge, the relationship between lateral disc herniation and multiple disc lesions has not been presented before in the literature. 我们的研究表明，外侧型腰椎间盘突出症多伴有多个椎间盘突出症。这一结果是独特的，我们的研究中，我们的知识，横向椎间盘突出症和多个椎间盘病变之间的关系还没有被提出之前，在文献中。We postulated that disc degeneration and herniation cou

53、ld increase the instability of the adjacent disc segment, especially in rotational or lateral bending motion, which caused lateral side annular tearing. A biomechanical study identified that 1 level disc herniation increases the range of translational and angular motion at the adjacent level, but no

54、t to the degree of significant instability我们假设，椎间盘退变和突出可能会增加相邻的椎间盘的不稳定，特别是在旋转或横向弯曲运动，这引起横向侧环撕裂。生物力学研究表明，1级椎间盘突出增加的范围内的平移和角运动在相邻的水平，但不显着的不稳定的程度。.10 However, this study included 1 level of disc herniation and observed only angular and translational motion in the sagittal plane, without including

55、rotational or lateral motion. Other studies presented results that could support our assumption. 然而，这项研究包括1个水平的椎间盘突出，观察到的只有在矢状面上的角度和平移运动，不包括旋转或横向运动。其他研究提出的结果，可以支持我们的假设。Two level disc degenerations caused more segmental hypermobility of adjacent disc levels during lateral bending and twisting than du

56、ring flexion-extension. 两级椎间盘退变侧弯和扭转比在屈伸过程中产生过多节段相邻椎间盘水平11 Disc degeneration caused marked segmental instability, which was more prominent in lateral bending than flexion-extension.12 Two studies about spondylolisthesis and its associated disc herniation pattern stated that spondylolisthes

57、is increases susceptibility of lateral disc herniation by increasing lateral instability. 椎间盘退变引起明显的节段性不稳定，在侧弯比屈伸更突出。两项关于腰椎滑脱及其椎间盘突出模式的研究表明，通过增加横向不稳定性，增加了腰椎间盘突出症的易感性。This suggests that segmental instability is more closely related to lateral instability and lateral disc herniation.13,14 One bio

58、mechanical study revealed that combined motions of lateral bending, flexion, and axial rotation caused tear from the nucleus to posterolateral annulus, which suggested that unstable and asymmetrical spinal motions could lead to lateral disc herniation. 这表明，节段性不稳定更密切相关的横向不稳定和横向椎间盘突出。一个生物力学研究表明，侧弯屈的组合

59、运动，和轴向旋转引起的从后外侧环的撕裂，表明不稳定的和非对称的脊柱运动可能导致外侧型腰椎间盘突出症。15 Our results could be explained by the combination of these mechanisms. Multisegmental disc problems produced motional instability of adjacent levels, especially in lateral and rotational motions, which could contribute to lateral annular rupt

60、ure and consequently lateral rather than medial disc herniation. 我们的研究结果可以解释这些机制的结合。多节段椎间盘的问题产生的相邻水平运动的不稳定，尤其是在横向和旋转运动，这将有助于横向环形断裂，因此外侧比内侧椎间盘突出。Our study demonstrated that the mean age of lateral disc herniation was higher than that of medial disc herniation. This was also found elsewhere in the literature, but without an explanation.4,5,16