手术治疗痛风石性腰椎管狭窄1例

2019-04-19 陈鉴权 中国骨伤

患者男性,20岁,学生,因“腰痛活动受限伴双侧臀部痹痛1月余”于2017年12月来我院就诊。患者1个月前无明显外伤下,开始出现腰背疼痛,伴双侧臀部痹痛,无明显双下肢放射痛,间断门诊行保守治疗,症状反复发作。既往痛风性关节炎病史,但未系统治疗。查体:体型肥胖,BMI指数31。腰椎活动明显受限,以前屈、后伸为主,下蹲受限,L3,4、L4,5椎间隙压痛及叩击痛阳性,双侧髋“4”字试验阴性,双侧直腿抬高试

临床资料

患者男性,20岁,学生,因“腰痛活动受限伴双侧臀部痹痛1月余”于2017年12月来我院就诊。患者1个月前无明显外伤下,开始出现腰背疼痛,伴双侧臀部痹痛,无明显双下肢放射痛,间断门诊行保守治疗,症状反复发作。既往痛风性关节炎病史,但未系统治疗。查体:体型肥胖,BMI指数31。腰椎活动明显受限,以前屈、后伸为主,下蹲受限,L3,4、L4,5椎间隙压痛及叩击痛阳性,双侧髋“4”字试验阴性,双侧直腿抬高试验70°,加强试验阴性,双下肢肌力正常,双下肢肌张力及感觉未见明显异常,双侧膝腱反射减弱,双侧跟腱反射减弱,巴宾斯基征阴性。VAS评分:6分,JOA评分:16分。

实验室检查:血尿酸729μmol/L,血沉30mm/h,C-反应蛋白6.2mg/L,其他检验结果正常。影像学检查(图1):腰椎MRI检查提示腰椎附件骨质破坏,多发小脓肿形成,累及椎管,脊膜增厚并脓肿形成,考虑感染性病变可能(布鲁氏菌感染?结核?),痛风性椎小关节炎亦不能除外,需结合临床和实验室检查。腰椎CT检查提示L3,4水平椎管内稍高密度结节影伴钙化,怀疑脊膜瘤;进一步MRI增强扫描提示L3-L5椎小关节改变,怀疑椎小关节炎,肿瘤侵犯。建议进一步检查。排除手术禁忌证后,全麻下行后路病灶清除、椎管减压、椎弓根钉内固定术,术中见L3、L4椎板、黄韧带及关节突不同程度白色颗粒样结晶沉着,骨质侵蚀,L4椎体后缘对应椎管内见一大小约1.5CM×2.0CM大小的类圆形占位压迫硬膜囊,脊髓神经根受压严重,扩大L3,4、L4,5双侧侧隐窝及根管,探查神经根并松解,清除所有珍珠粉末样组织,探查见神经根松解良好;安装内固定系统,在相应节段行横突间植骨。术后复查X线片内固定位置良好,术后CT见病灶完全清除。病理结果显示大量痛风结晶、周围见多核巨噬细胞。随访3个月,腰痛伴双臀部痹痛基本缓解,VAS评分:2分,JOA评分:19分。术后系统降尿酸药物治疗,定期监测血尿酸指标。



讨论

痛风是单钠尿酸盐(MSU)沉积导致的晶体相关性关节病,嘌呤代谢异常导致血液中尿酸升高。当尿酸结晶破坏关节时表现为剧烈的疼痛,称为痛风。体表痛风石好发于耳廓、膝关节囊、尺骨鹰嘴、指间和掌指关节,以跖趾关节多见。发生在脊柱部位的痛风石比较少,但近年来,国内外对痛风石出现在颈、胸、腰椎部位均有报道。然而,痛风石出现在椎管内,导致神经受压、出现神经损害需要手术治疗的患者比较罕见。Kersley等于1950年首次报道了痛风石侵犯脊柱的病例。1953年Koskoff等报道了第1例由痛风引起的脊髓病。Kao等在2000年首次报道了椎管内痛风石并侵犯胸脊髓的病例。有学者研究,痛风石侵犯脊柱于腰椎多见,可能与腰椎负重大、活动度大有关,颈椎次之,胸椎少见。痛风石首先侵犯脊柱的关节突关节,随着病情的发展,继续侵犯上关节突、椎板、椎弓根,痛风石继续生长,向内压迫硬膜囊后方,继而产生一系列临床症状。本次报道的痛风石性腰椎管狭窄患者,从影像学上上分析,也符合文献报道的侵犯顺序。造成脊柱痛风石病因尚不完全明确,但有学者研究发现高嘌呤饮食、酗酒、使用利尿剂、肾功能不全、尿酸过高、不规律服用降尿酸药物是发生痛风石的危险因素。

本例患者血尿酸长期居高不下,指标控制不良,主要表现为出现腰背痛,加之,过度肥胖,BMI指数31,增加了腰椎负荷。痛风性脊柱病临床症状不典型,不能单凭临床症状诊断,影像学特征性表现显得尤为重要,X线检查无特异性。MRI表现为T1WI低信号、T2WI高信号的占位性病变,但部分患者T1WI可见与软组织相等或稍低信号,T2WI低或高信号。虽然脊柱痛风的MRI异常表现阳性率高,但仍缺乏特异性。CT被认为是对脊柱痛风更敏感、更有特异性的检查,腰椎CT平扫可见关节突关节、椎弓根穿凿样改变及斑片状破坏等影像学特征。因尿酸盐对骨质的破坏以及慢性反复的无菌性炎症,可造成长期慢性腰部不适,加上早期影像特征不明显,需要与腰肌劳损和腰椎器质性病变相鉴别。

Yamamoto等认为虽然脊柱痛风有自己的影像学特征,但应注意与感染及肿瘤如脊柱结核核、中枢神经系统淋巴瘤、转移瘤、脂肪瘤和血管瘤等相鉴别。双源CT(DualenergyCT,DECT)是目前对痛风早期检出率较高的一种检查手段,可明确显示尿酸盐结晶沉积,对疾病的早期诊断具有重大意义。Hu等认为DECT可使痛风诊断的敏感度及特异性分别达到91.9%和85.4%。然后,双源CT检查主要针对于四肢关节痛风的诊断,针对痛风性脊柱病的诊断较少,对脊柱痛风病的诊断需要进一步研究。

对于治疗方式的选择上,针对无脊髓神经受压的患者可先考虑药物治疗,Draganescu等认为药物治疗是基础,督导患者合理、规范用药是关键,因为体内的高尿酸状态会加速尿酸盐的沉积,所以药物治疗必不可少。Dhote等认为药物治疗可以使脊柱痛风石逐渐消失。King等认为脊柱痛风急性发作时,由于尿酸盐的机械性与化学性刺激,造成其周围组织坏死及炎性反应,导致痛风石肿胀,周围组织水肿、充血等。在椎管有限的空间里,压迫及炎症物质的刺激,均可使脊髓的受压及损伤,导致截瘫可导致腰椎痛风患者截瘫,使治疗效果不理想,故应该早期治疗。Hou等认为,脊柱痛风如有神经压迫症状者,即使在急性期也可行病灶清除减压加内固定术,可以获得满意效果。但是痛风急性期行手术治疗,感染的风险较大,需要谨慎。针对椎管明显狭窄、神经受压的患者,建议早期手术治疗,解除神经受压。本例患者L3,4水平硬膜囊后方痛风石形成,导致神经受压,手术方案选择L3-L5后路切开、L4椎板切除、痛风石病灶清除、椎弓根钉内固定、横突间植骨术。术中见关节突关节、黄韧带、椎管内不同程度白色颗粒样结晶沉着,CT影像学表现团块状痛风石与硬脊膜紧密粘连,术中仔细分离后,完整剥离,术中未发现脑脊液漏,术后病理结果也佐证了痛风石性继发腰椎管狭窄的诊断。

笔者团队诊疗体会:(1)诊断明确的痛风性腰椎管狭窄症的患者,建议完善全脊柱MRI或CT检查,明确有无跳跃性痛风石压迫椎管的情况。文献已经有报道跳跃性颈、胸椎痛风石压迫脊髓导致不全瘫的病例。(2)因痛风结晶的严重侵蚀,导致致压物与硬膜囊严重粘连,剥离时很容易出现硬膜囊撕裂、脑脊液漏等并发症,故术中必须仔细分离。完整剥离难度极大,允许少许痛风结晶组织附着于硬膜囊,以免强行分离组织增加手术并发症。(3)督导患者健康低嘌呤饮食、配合降尿酸药物是治疗痛风性腰椎管狭窄症的基础,需要重视并且坚持执行。(4)从长远角度考虑,年轻患者尽量避免腰椎融合。本次报道患者未行椎间融合,减少了手术创伤,只是在关节突关节和横突间有植同种异体骨,后期根据随访的情况而定是否取出内固定。

回顾以往的文献报道,加强宣教,适当功能锻炼,提供个体化的脊柱痛风的预防及治疗策略,督导脊柱痛风患者饮食调节、药物控制等手段,综合抗痛风治疗。存在节段不稳、脊髓神经受压,把握适当的手术时机,及时行手术治疗,预后良好。

原始出处:

陈鉴权. 手术治疗痛风石性腰椎管狭窄1例报告[J]. 中国骨伤, 2019, 32(3):265-268.

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    2019-04-21 saikp
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    2019-04-21 cnxcy