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頚椎椎間板ヘルニア

著者: 佐藤哲朗 仙台整形外科病院

監修: 酒井昭典 産業医科大学 整形外科学教室

著者校正/監修レビュー済:2021/03/31
参考ガイドライン:
  1. 日本整形外科学会/日本脊椎脊髄病学会:頸椎症性脊髄症診療ガイドライン 第3版
患者向け説明資料
薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
佐藤哲朗 : 特に申告事項無し[2021年]
監修:酒井昭典 : 講演料(旭化成ファーマ(株),第一三共(株),中外製薬(株)),奨学(奨励)寄付など(旭化成ファーマ(株),第一三共(株),中外製薬(株))[2021年]

改訂のポイント:
  1. 定期レビューを行い、表現に手を加えた。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 頚部椎間板ヘルニアとは、頚椎椎間板組織が後方線維輪を破って後方あるいは後側方に脱出する病態である。
  1. 男性に多く、40~60歳代に多い。
  1. 椎間板の変性過程で髄核、線維輪が軟骨板を含んで断片化し、この断片が脆弱となった後縦靱帯を穿破して脱出する。脱出の形態は、Ⅰ型:靱帯内脱出(脱出腫瘤が後縦靱帯の深層を穿破し、浅・深層間にとどまるもの)、II型:後縦靱帯浅層穿破(靱帯を破り、一部が硬膜外腔に脱出したもの)、Ⅲ型:硬膜外腔遊離片に分けられる[1]
 
頚椎椎間板ヘルニアの脱出形態

脱出の形態は、
Ⅰ型:靱帯内脱出(脱出腫瘤が後縦靱帯の深層を穿破し、浅・深層間にとどまるもの)、
II型:後縦靱帯浅層穿破(靱帯を破り、一部が硬膜外腔に脱出したもの)、
Ⅲ型:硬膜外腔遊離片、
に分けられる。

 
  1. 脊柱管内への脱出方向から、正中ヘルニア、傍正中ヘルニア、外側ヘルニアに分けられる。正中、傍正中のものは脊髄症を起こしやすく、外側型は神経根症を起こしやすい[1][2]
  1. 正中ヘルニア:術前MRIa:矢状断像b:横断断像(C5/6):<図表>
  1. 傍正中ヘルニア:術前MRIa:矢状断像b:横断断像(C3/4):<図表>
  1. 外側ヘルニア:術前MRI(横断像):<図表>
  1. 神経根症を引き起こすヘルニアはC6/7椎間に最も多く、次いでC5/6、C7/T1、C4/5の順である[3]。脊髄症を引き起こすものはC5/6椎間に最も多く、次いでC4/5、C3/4の順である[1]
  1. 頚椎椎間板ヘルニアの自然縮小とそれに伴う症状の改善が報告されている[4][5]
問診・診察のポイント  
問診:
  1. 事故などを契機に発症か

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文献 

著者: F Murphey, J C Simmons, B Brunson
雑誌名: Clin Neurosurg. 1973;20:9-17.
Abstract/Text
PMID 4762825  Clin Neurosurg. 1973;20:9-17.
著者: K Mochida, H Komori, A Okawa, T Muneta, H Haro, K Shinomiya
雑誌名: Spine (Phila Pa 1976). 1998 May 1;23(9):990-5; discussion 996-7.
Abstract/Text STUDY DESIGN: A retrospective study of cervical disc herniation using results of repeated magnetic resonance imaging examinations.
OBJECTIVES: To clarify the cervical disc herniation morphological changes over time in order to establish a strategy for treatment.
SUMMARY OF BACKGROUND DATA: In the authors' previous magnetic resonance imaging follow-up study of patients with lumbar disc herniation, spontaneous regression was observed in the sequestration-type lesions, and it was found that the tendency toward regression differed based on the anatomic position of extruded disc material.
METHODS: Thirty-eight patients with cervical disc herniation who underwent repeated magnetic resonance imaging examinations were studied. The changes over time in herniated disc size were evaluated using this imaging technique. Evaluation showed the characteristics of those in whom spontaneous regression was found, such as extrusion pattern, and the clinical outcome was evaluated by symptoms.
RESULTS: In 15 patients (40%), the volume of herniated material was decreased. The interval from onset of symptoms to the initial examination was significantly shorter in the regression group than in the group that showed no change in disc herniation. By extrusion pattern, cervical disc herniation, which was divided into migration type on sagittal view and lateral type on axial view, most frequently exhibited spontaneous regression. All of the patients with radicular pain and upper limb amyotrophy were treated successfully with conservative therapy.
CONCLUSION: Although the possibility of the combination of hemorrhage and disc material could not be denied, active resorption of herniated material probably occurred during the acute phase. Extruded material exposed to the epidural space may be resorbed more quickly than that beneath the ligament. Vascular supply probably plays a role in the mechanism of resorption. The phase and position of extrusion were the significant factors affecting cervical disc herniation resorption. It was demonstrated that examination performed during the acute phase using magnetic resonance imaging is necessary for elucidation of the pathogenesis of cervical disc herniation, and that migrating, lateral-type herniations regress so frequently that conservative treatment should be chosen not only for patients with radicular pain, but also for those with upper limb amyotrophy.

PMID 9589536  Spine (Phila Pa 1976). 1998 May 1;23(9):990-5; discussi・・・
著者: M Yoshida, T Tamaki, M Kawakami, N Hayashi, M Ando
雑誌名: Spine (Phila Pa 1976). 1998 Nov 15;23(22):2391-7.
Abstract/Text STUDY DESIGN: The outcome of a herniated disc in patients with cervical myelopathy treated by laminoplasty without discectomy and in those treated conservatively was studied by magnetic resonance imaging.
OBJECTIVES: To compare the surgical results of laminoplasty with those of anterior spinal fusion in patients with myelopathy caused by to cervical disc herniation and to make a treatment strategy for cervical disc herniation depending on these results.
SUMMARY OF BACKGROUND DATA: Anterior discectomy and spinal fusion have had acceptable surgical results, but many complications have been reported, especially adjacent segment degeneration and bone graft complications.
METHODS: Forty-seven patients with cervical disc herniation were examined in this study. Of them, 32 patients (mean age, 56 years) underwent laminoplasty without resection of the herniated disc. Seven patients with mild cervical myelopathy and 8 patients with radiculopathy (mean age, 53 years) were treated conservatively. As a control group, 44 patients (mean age, 50.3 years) who underwent anterior spinal fusion were examined. All patients in the laminoplasty group also had congenital spinal canal stenosis in which the ventrodorsal canal diameter was less than 13 mm. The association between the outcome of a herniated disc and clinical features was investigated. The severity of myelopathy was evaluated according to the Japanese Orthopaedic Association's scoring system. Surgical outcomes were evaluated by the system of Hirabayashi for determining recovery rate.
RESULTS: The recovery rate averaged 67.9% in laminoplasty and 68.8% in anterior spinal fusion. There were no significant differences between the groups. No patients underwent anterior spinal fusion after laminoplasty. Follow-up magnetic resonance imaging showed regression of the size of the herniated disc in 15 of the 20 patients in the laminoplasty group and in 12 of 15 patients treated conservatively. In the MRI studies of the natural course of disc herniation, the size of the herniated disc decreased to almost half in 1 to 2 months and almost disappeared within 3 months after surgery.
CONCLUSIONS: The size of the herniated disc in cervical lesions regressed as it does in the lumbar lesions. Laminoplasty for patients with narrowed spinal canals showed favorable surgical results. Therefore, the therapeutic method for cervical disc herniation should be chosen after taking the natural history of the disc herniation into consideration.

PMID 9836352  Spine (Phila Pa 1976). 1998 Nov 15;23(22):2391-7.
著者: M Matsumoto, K Chiba, M Ishikawa, H Maruiwa, Y Fujimura, Y Toyama
雑誌名: Spine (Phila Pa 1976). 2001 Jul 15;26(14):1592-8.
Abstract/Text STUDY DESIGN: A retrospective follow-up study of conservatively treated patients with mild cervical myelopathy caused by cervical soft disc herniation.
OBJECTIVE: To investigate the outcome of conservative treatment for patients with mild myelopathy caused by cervical soft disc herniation and to evaluate usefulness of magnetic resonance findings in the prediction of the outcomes.
SUMMARY OF BACKGROUND DATA: Recent studies on conservative treatment for cervical soft disc herniation have focused mainly on radiculopathy, and not on myelopathy.
METHODS: Twenty-seven patients with mild cervical myelopathy secondary to cervical soft disc herniation were treated conservatively for more than 6 months by cervical bracing and restriction of daily activities. Of the 27 patients, 17 patients (Group A) underwent conservative treatment only and it was associated with improvement in their neurologic deficits, while the other 10 patients (Group B) ultimately underwent decompression surgery because of neurologic deterioration. Comparisons between the two groups were made in regard to JOA scores, patient satisfaction, and magnetic resonance findings, including location of the disc herniation (focal or diffuse in the sagittal plane, median or paramedian in the axial plane).
RESULTS: The JOA scores were 13.6 +/- 1.6 in Group A and 14.1 +/- 1.6 in Group B before treatment, 14.9 +/- 1.0 and 12.9 +/- 2.1, respectively, at 3 months, and 16.2 +/- 0.8 and 16.0 +/- 1.2, respectively, at the final follow-up. The JOA scores at 3 months were significantly lower in Group B than in Group A. Satisfaction with the results of treatment at the final follow-up was reported by 77% of the patients in Group A and 90% in Group B. Focal-type herniation was present in 47% of the patients in Group A and 70% in Group B, while median-type herniation was diagnosed in 77% in Group A and 30% in Group B. Follow-up magnetic resonance imaging of the patients in Group A showed spontaneous regression of a herniated mass in 10 patients (59%). Diffuse-type herniations were more likely to regress spontaneously than focal-type herniations (78% vs. 37%).
CONCLUSIONS: Conservative treatment is an effective treatment option for mild cervical myelopathy caused by cervical soft disc herniation. A good outcome can be expected in patients with a median-type and/or diffuse-type herniation on magnetic resonance imaging.

PMID 11462093  Spine (Phila Pa 1976). 2001 Jul 15;26(14):1592-8.
著者: W B Scoville, G J Dohrmann, G Corkill
雑誌名: J Neurosurg. 1976 Aug;45(2):203-10. doi: 10.3171/jns.1976.45.2.0203.
Abstract/Text Late results of cervical disc surgery have been reported and statistically studied in 383 cases: 83% were lateral discs, 13% were central spondylosis discs, and 4% central soft discs. Central spondylosis occured at a higher spinal level, and caused cord compression with or without weakness of the hands, but no pain. A posterior approach was used in all lateral discs, and either an anterior or a posterior approach, with or without fusion, for central discs. Preoperative myelography was always done and is recommended postoperatively in central disc surgery to evaluate the results. Our results were good to excellent in 95% of lateral discs, in 64% of central spondylosis discs, and in an unexpected 91% of 11 cases of central soft discs. There were no recurrences and no serious complications, although 20% developed other cervical or lumbar disc herniations.

PMID 939979  J Neurosurg. 1976 Aug;45(2):203-10. doi: 10.3171/jns.19・・・

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