今日の臨床サポート

腰椎椎間板ヘルニア

著者: 射場英明 川崎医科大学 脊椎・災害整形外科学教室

著者: 中西一夫 川崎医科大学 脊椎・災害整形外科学教室

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:2021/11/10
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腰椎椎間板ヘルニア診療ガイドライン2021 (改訂第3版)
  1. 脊椎脊髄病学 第2版、金原出版
  1. 標準整形外科 第14版、医学書院
  1. 脊椎脊髄ジャーナル:2019年no.12 腰椎椎間板ヘルニアに対する化学的融解術NOW
  1. 脊椎脊髄ジャーナル:2019年no.9 脊椎内視鏡手術の進歩
  1. 慢性疼痛治療ガイドライン作成ワーキンググループ:慢性疼痛治療ガイドライン
患者向け説明資料

概要・推奨   

  1. 男性に多く(2~3:1)、好発年齢は20~40歳代が中心で、好発レベルとしてはL4/5、L5/S、である(ガイドライン推奨grade C
  1. ヘルニアのサイズが大きいものや、遊離脱出したものや、MRIでリング状に造影されるものは高率に自然退縮する(ガイドライン推奨grade B)
  1. 問診および理学的所見が重要である(ガイドライン推奨grade B)
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が 必要と
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要とな ります
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧に はご契
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となりま す。閲
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:
射場英明 : 未申告[2021年]
中西一夫 : 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. 画像診断をはじめとする診断技術の進歩により病変の早期かつ正確な診断が可能となり、数々の優れた薬剤や高度な手術法の開発により優れた治療成績が得られるようになった。しかし一方で、幾多の診断技術や治療法のオプションの中から、個々の患者のために最も適切な方法を選ぶにあたり、何らかのガイドラインが必要となり、腰椎椎間板ヘルニア診療ガイドライン改訂第3版が作製され、それを参考に改訂した。

病態・疫学・診察

疾患情報(疫学・病態)  
疫学
  1. 腰椎椎間板ヘルニアは腰痛・下肢痛を来す代表的な疾患である。
  1. 腰椎椎間板ヘルニアは一般的な疾患であるが、有病率についての詳細な報告はない。
  1. 椎間板は髄核とその周囲を取り囲んでいる線維輪より構成される。
  1. 髄核は水分を多く含んでいるが、加齢とともに含水量が低下してくる。
  1. 髄核の含水量の低下に、反復する捻転負荷が加わると線維輪に断裂が生じる。
  1. 断裂は腰椎後縦靱帯の最も薄い後外側に多く発生する。
  1. 断裂部より髄核ないしは線維輪の一部が後方に逸脱し、神経を圧迫することで発症する。
  1. 男性に多く(2~3:1)、好発年齢は20~40歳代が中心で、好発レベルとしてはL4/5、L5/S、である。
  1. 年齢の上昇とともに高位腰椎椎間板ヘルニアの発生する確率が高くなるとの報告がある[1]
  1. 発生の要因として、環境因子(スポーツや労働や喫煙など)や遺伝因子などが指摘されているが、詳細は不明である[2][3]
 
病態:
  1. 膨隆(bulging)、突出(protrusion)、脱出(extrusion)、遊離(sequestration)に大きく分類される。
  1. さらに脱出型は、後縦靱帯を穿破していないsubligamentous extrusionと、穿破しているtransligamentous extrusionに分類されている。
  1. ヘルニアにより圧迫を受ける神経根はヘルニア高位より1椎下の椎間孔から出る神経根であるが、突出が外側の場合いは(つまり椎間孔を出た後での圧迫)1レベル高位の神経根が圧迫を受ける[4]
  1. 自然縮小することが明らかになってはいるが、60%以上の例で画像上の退縮が認められる。
  1. 自然縮小する時期を明確にした報告はないが、2~3カ月で著明に退縮するヘルニアも少なくない[6][7]
  1. ヘルニアのサイズが大きいものや、遊離脱出したものや、MRIでリング状に造影されるものは高率に自然退縮する[5][6][8][9] [10]
問診・診察のポイント  
問診:
  1. 問診および理学的所見が重要である。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

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文献 

著者: Ruben Dammers, Peter J Koehler
雑誌名: Surg Neurol. 2002 Sep-Oct;58(3-4):209-12; discussion 212-3. doi: 10.1016/s0090-3019(02)00797-8.
Abstract/Text BACKGROUND: Prompted by the clinical impression that L4 radicular syndrome and disc herniations at L3-4 occurred at older ages we studied the correlation between age and level of herniated discs.
METHODS: We retrospectively correlated mean age and level of disc herniation of patients suffering from lumbar disc herniation. Data from 1431 patients were obtained from the neurologic database of the Atrium Medical Center Heerlen from 1995 through 1998. Nonparametric data were analyzed with the Mann-Whitney U test, and correlation was analyzed using linear regression.
RESULTS: Mean ages of the patients with disc herniation at L5-S1, L4-5, L3-4, and L2-3 were 44.1 +/- 0.5 years, 49.5 +/- 0.6 years, 59.5 +/- 0.9 years, and 59.6 +/- 2.7 years, respectively. Mean ages were significantly higher with herniation levels at L4-5, L3-4, and L2-3 compared to L5-S1 (p < 0.0001). Analogously, the mean age of patients with disc herniation at L3-4 was significantly higher compared to those with herniation at L4-5 (p < 0.0001). No difference in mean age was seen between L3-4 and L2-3 (p = 0.815). A strong correlation was observed between the level of herniation and increasing age (R = 0.371; p < 0.0001).
CONCLUSION: These results indeed prove that with increasing age, lumbar disc herniation is more cranially localized. It may help in understanding the patho-anatomic process of disc herniation, and in recognizing higher level radicular syndromes in advanced age.

PMID 12480218  Surg Neurol. 2002 Sep-Oct;58(3-4):209-12; discussion 21・・・
著者: M Heliövaara
雑誌名: J Chronic Dis. 1987;40(3):259-64.
Abstract/Text Various occupations were studied for the prediction of herniated lumbar intervertebral disc or sciatica in 592 men and women who had been discharged from hospital with these diagnoses during an 11-year follow-up after a health examination. The cases were compared with 2140 controls matched individually for sex, age and place of residence. Subjects who, at the initial examination before the follow-up, had reported a history of back pain or sciatica were excluded. In men, the risk of being hospitalized due to herniated lumbar disc or sciatica was lowest in professional and related occupations, significantly higher in all other groups and highest among blue-collar workers in industry and among motor vehicle drivers. The variation in the risk between occupational groups of women proved less but was nevertheless still apparent. However, in women, but not in men, the risk was significantly associated with self-assessed strenuousness of work.

PMID 3818882  J Chronic Dis. 1987;40(3):259-64.
著者: J L Kelsey, P B Githens, T O'Conner, U Weil, J A Calogero, T R Holford, A A White, S D Walter, A M Ostfeld, W O Southwick
雑誌名: Spine (Phila Pa 1976). 1984 Sep;9(6):608-13.
Abstract/Text An epidemiologic case-control study to identify risk factors for acute prolapsed lumbar intervertebral disc was undertaken in Connecticut during 1979-1981. This paper focuses on nonoccupational factors of possible etiologic significance. Persons in their 30s were affected most frequently. Among surgical cases, the ratio of men to women was 1.5 to 1, while among probable and possible cases not undergoing surgery, the male to female ratio was about 1 to 1. Cigarette smoking in the past year was associated with an increased risk for prolapsed disc. The greater the number of hours spent in a motor vehicle, the higher the risk. Use of Swedish and Japanese cars was associated with a lower-than-average risk, while use of other cars was associated with a higher-than-average risk. For each type of car, older cars were associated with higher risks than newer cars. Variables that did not affect the risk for prolapsed lumbar disc in this study included height, weight, number of pregnancies, number of children, frequency of wearing shoes with high heels, smoking cigars or pipes, and participation in baseball or softball, golf, bowling, swimming, diving from a board, tennis, bicycling or jogging.

PMID 6495031  Spine (Phila Pa 1976). 1984 Sep;9(6):608-13.
著者: K Bush, N Cowan, D E Katz, P Gishen
雑誌名: Spine (Phila Pa 1976). 1992 Oct;17(10):1205-12.
Abstract/Text The purpose of this study was to assess the natural history of sciatica due to lumbosacral nerve root compromise and to evaluate the pathomorphologic changes that accompany the natural resolution of the disease. One hundred sixty-five consecutive patients, 114 males and 51 females, with an average age of 41 years (range, 17-72) and an average duration of symptoms of 4.2 months (range, 1-72) presenting with sciatica thought to be due to lumbosacral nerve root compromise were admitted to the study. The cornerstone of treatment was the serial epidural administration of steroid and local anesthetic by the caudal route on an outpatient basis. Lumbar epidural injection or periradicular infiltration at the appropriate level, confirmed under image intensifier, was the next step before considering surgical decompression. An average of three injections (range, 0-8) was received by each patient. Patients underwent clinical examination and computed tomography. Twenty-three patients (14%) underwent surgical decompression. The remainder were clinically assessed at 1 year after presentation, and 111 were rescanned at the appropriate levels. All conservatively managed patients made a satisfactory clinical recovery: average reduction of pain on the visual analog scale was 94% (range, 45-100), and 64 (76%) of the 84 disc herniations and 7 (26%) of the 27 disc bulges showed partial or complete resolution (chi-square = 20.27, P = 0.0001). Thus a high proportion of patients with discogenic sciatica make a satisfactory recovery with aggressive conservative management, and this recovery is accompanied by resolution of disc herniations in a significant number. Only a small proportion of patients needed surgical decompression.

PMID 1440010  Spine (Phila Pa 1976). 1992 Oct;17(10):1205-12.
著者: H Komori, K Shinomiya, O Nakai, I Yamaura, S Takeda, K Furuya
雑誌名: Spine (Phila Pa 1976). 1996 Jan 15;21(2):225-9.
Abstract/Text STUDY DESIGN: The present study retrospectively investigated the morphologic changes that occurred during conservative treatment of patients with unilateral leg pain resulting from herniated nucleus pulposus without significant lumbar canal stenosis.
OBJECTIVES: The results were correlated with clinical outcomes and extruding forms to determine which type of herniated nucleus pulposus had the greatest capacity for spontaneous regression and how rapidly such regression might occur.
SUMMARY OF BACKGROUND DATA: The study population consisted of 77 patients with radiculopathy.
METHODS: All patients complained primarily of unilateral leg pain, and 94% had positive tension signs. Additionally, 32% exhibited muscle weakness corresponding to the symptomatic nerve root. All patients were studied more than twice using magnetic resonance imaging during conservative therapy at a mean interval of 150 days. Morphologic changes on magnetic resonance imaging fell into four categories, with herniated nucleus pulposus classified into three types using T1-weighted sagittal views. Each patient was reexamined on the same scanner; 53 patients were examined twice, and 24 patients were examined more than three times.
RESULTS: Morphologic changes, with the exception of 13 false-negative cases, basically corresponded to clinical outcome. In half of the cases that showed some improvement at follow-up evaluation, improvement of clinical findings were seen before those observed on magnetic resonance imaging. Migrating herniated nucleus pulposus frequently presented an obvious decrease in size, and even disappearance in seven cases. The further the herniated nucleus pulposus migrated, the more decrease in size could be observed. The cases apparently corresponding to "protrusion" showed little or no change on follow-up magnetic resonance imaging. Regarding the mechanism of herniated nucleus pulposus disappearance, exposure to the vascular supply undoubtedly took a part, although many factors were suspected to have some influence.
CONCLUSION: Morphologic changes on magnetic resonance imaging mainly corresponded to clinical outcomes but tended to lag behind improvement of leg pain. Disappearance of herniate nucleus pulposus was seen frequently in the cases of migrating disc herniation, and it was presumed that exposure to the vascular supply had a lot to do with this phenomenon.

PMID 8720408  Spine (Phila Pa 1976). 1996 Jan 15;21(2):225-9.
著者: Reijo A Autio, Jaro Karppinen, Jaakko Niinimäki, Risto Ojala, Mauno Kurunlahti, Marianne Haapea, Heikki Vanharanta, Osmo Tervonen
雑誌名: Spine (Phila Pa 1976). 2006 May 15;31(11):1247-52. doi: 10.1097/01.brs.0000217681.83524.4a.
Abstract/Text STUDY DESIGN: A follow-up of disc herniation (herniated nucleus pulposus [HNP]) resorption on magnetic resonance imaging (MRI).
OBJECTIVE: To assess the determinants of resorption of HNP.
SUMMARY OF BACKGROUND DATA: Neovascularization in the outermost areas of HNP, presenting as an enhancing rim in gadolinium diethylenetriamine pentaacetic acid MR images, is thought to be a major determinant of spontaneous resorption of HNP.
METHODS: Patients with HNP-induced sciatica at baseline were rescanned at 2 months (N = 74) and after 12 months (N = 53). The volume of HNP (mm), thickness (mm) and extent (%) of enhancement, and the degree of HNP migration (Komori classification) were analyzed. Repeated measures analysis of covariance was used in statistical analysis.
RESULTS: Significant resorption of HNP occurred from baseline to 2 months, although the resorption rate was more pronounced over the whole 1-year follow-up. Higher baseline scores of rim enhancement thickness, higher degree of HNP displacement in the Komori classification, and age category 41-50 years were associated with a higher resorption rate. Thickness of rim enhancement was a stronger determinant of spontaneous resorption than extent of rim enhancement. Clinical symptom alleviation occurs concordantly with a faster resorption rate.
CONCLUSIONS: MRI is a useful prognostic tool for identifying patients with HNP-induced sciatica with a benign natural course.

PMID 16688039  Spine (Phila Pa 1976). 2006 May 15;31(11):1247-52. doi:・・・
著者: M C Jensen, M N Brant-Zawadzki, N Obuchowski, M T Modic, D Malkasian, J S Ross
雑誌名: N Engl J Med. 1994 Jul 14;331(2):69-73. doi: 10.1056/NEJM199407143310201.
Abstract/Text BACKGROUND: The relation between abnormalities in the lumbar spine and low back pain is controversial. We examined the prevalence of abnormal findings on magnetic resonance imaging (MRI) scans of the lumbar spine in people without back pain.
METHODS: We performed MRI examinations on 98 asymptomatic people. The scans were read independently by two neuroradiologists who did not know the clinical status of the subjects. To reduce the possibility of bias in interpreting the studies, abnormal MRI scans from 27 people with back pain were mixed randomly with the scans from the asymptomatic people. We used the following standardized terms to classify the five intervertebral disks in the lumbosacral spine: normal, bulge (circumferential symmetric extension of the disk beyond the interspace), protrusion (focal or asymmetric extension of the disk beyond the interspace), and extrusion (more extreme extension of the disk beyond the interspace). Nonintervertebral disk abnormalities, such as facet arthropathy, were also documented.
RESULTS: Thirty-six percent of the 98 asymptomatic subjects had normal disks at all levels. With the results of the two readings averaged, 52 percent of the subjects had a bulge at at least one level, 27 percent had a protrusion, and 1 percent had an extrusion. Thirty-eight percent had an abnormality of more than one intervertebral disk. The prevalence of bulges, but not of protrusions, increased with age. The most common nonintervertebral disk abnormalities were Schmorl's nodes (herniation of the disk into the vertebral-body end plate), found in 19 percent of the subjects; annular defects (disruption of the outer fibrous ring of the disk), in 14 percent; and facet arthropathy (degenerative disease of the posterior articular processes of the vertebrae), in 8 percent. The findings were similar in men and women.
CONCLUSIONS: On MRI examination of the lumbar spine, many people without back pain have disk bulges or protrusions but not extrusions. Given the high prevalence of these findings and of back pain, the discovery by MRI of bulges or protrusions in people with low back pain may frequently be coincidental.

PMID 8208267  N Engl J Med. 1994 Jul 14;331(2):69-73. doi: 10.1056/NE・・・
著者: J Y Maigne, B Rime, B Deligne
雑誌名: Spine (Phila Pa 1976). 1992 Sep;17(9):1071-4.
Abstract/Text The authors prospectively followed the natural evolution of lumbar disc herniation in 48 patients treated by conservative measures. The initial computed tomographic scan was obtained during the acute phase of the disc herniation and the second was performed 1-48 months after healing. The initial computed tomographic scan allowed classification of the herniations according to size: 13 were considered small, 20 medium and 15 large. Comparison with follow-up computed tomographic scans showed that 9 of the herniations decreased by at least 25%, 8 decreased between 50 and 75% and 31 decreased between 75 and 100%. In the later group, a few had disappeared even though the second computed tomographic scan was performed as early as the month immediately after successful treatment. The largest herniations were those which had the greatest tendency to decrease in size. It is postulated that this could be secondary to the herniation breaking through the outer fibers of the anulus and entering the epidural space.

PMID 1411759  Spine (Phila Pa 1976). 1992 Sep;17(9):1071-4.
著者: H Komori, A Okawa, H Haro, T Muneta, H Yamamoto, K Shinomiya
雑誌名: Spine (Phila Pa 1976). 1998 Jan 1;23(1):67-73.
Abstract/Text STUDY DESIGN: This study was designed to investigate the morphologic changes in contrast-enhanced magnetic resonance imaging that occur during conservative treatment of patients with unilateral leg pain resulting from herniated nucleus pulposus without significant lumbar canal stenosis.
OBJECTIVES: To compare the morphologic results with clinical outcomes to ascertain whether enhanced magnetic resonance imaging contributes to the management of lumbar disc herniation.
SUMMARY OF BACKGROUND DATA: Contrast-enhanced magnetic resonance imaging has already been reported to be useful in the postoperative examination of the lumbar spine and in visualization of symptomatic nerve roots. However, there have been few reports about its usefulness in the conservative management of herniated nucleus pulposus or about the correlation between herniated nucleus pulposus regression and enhanced effect. The study population consisted of 48 patients with radiculopathy. All patients primarily reported unilateral leg pain, and 94% had positive tension signs. Additionally, 38% exhibited muscle weakness corresponding to the symptomatic nerve root.
METHODS: All patients were studied twice or more using gadolinium-magnetic resonance imaging during conservative therapy, at a mean interval of 191 days. Changes in the size of the herniated nucleus pulposus on precontrast images fell into four categories, with changes in enhancement on postcontrast images classified into two categories: "enlargement" and "no change."
RESULTS: In all cases of migrating type herniated nucleus pulposus, circular enhancement was seen on postcontrast images. In 17 of 22 cases, the enhanced area gradually thickened and intruded into the migrated disc materials as the size of the herniated nucleus pulposus decreased; the herniated nucleus pulposus disappeared in nine cases and showed a marked decrease in seven cases. These cases showed good clinical courses of sciatica. In the other five patients, in whom there were no changes in the enhanced area, there was less of a tendency for the herniated nucleus pulposus to decrease in size, and there were poorer clinical results. In six cases of extruding-type herniated nucleus pulposus, no enhanced effects were observed throughout the follow-up period. The other 20 cases showed enhancement that was relatively weaker than that of migrating disc herniation. Extension or expansion of the enhanced area was observed in the follow-up images of 15 cases, though only four showed obvious changes in the size of the herniated nucleus pulposus. These 15 cases had better clinical results than the other cases, in which enhanced effects did not change or were not observed.
CONCLUSION: Contrast-enhanced magnetic resonance imaging is a useful prognostic parameter, and multiple use contributes to the proper management of lumbar disc herniation.

PMID 9460155  Spine (Phila Pa 1976). 1998 Jan 1;23(1):67-73.
著者: E P Szypryt, P Twining, G P Wilde, R C Mulholland, B S Worthington
雑誌名: J Bone Joint Surg Br. 1988 Nov;70(5):717-22. doi: 10.1302/0301-620X.70B5.3192567.
Abstract/Text Forty-two consecutive patients with suspected lumbar disc protrusions were studied prospectively to compare the diagnostic accuracy of low-field strength MRI with that of radiculography. Thirty patients subsequently underwent surgical exploration at 33 levels and the operative findings were compared to both methods of diagnostic imaging. All patients had MRI studies, whilst 29 patients also had radiculography. Both studies were evaluated without prior knowledge of the clinical signs, operative findings or the results of other imaging techniques. MRI predicted the correct diagnosis in 29 of the 33 levels explored, an accuracy of 88%. All discs proven to be abnormal demonstrated a reduced signal from the nucleus pulposus. There were two false positive results and two doubtful cases but no false negatives. Radiculography predicted the correct diagnosis in 24 of 32 levels explored, an accuracy of 75%. There were two false positive results, five doubtfuls and one false negative. The overall accuracy when both tests were considered rose to 94%. Of the remaining 12 patients all except one showed good correlation between the MRI and radiculographic findings. These results indicate that low field strength MRI is slightly better than radiculography in diagnosing lumbar disc protrusions.

PMID 3192567  J Bone Joint Surg Br. 1988 Nov;70(5):717-22. doi: 10.13・・・
著者: S D Boden, D O Davis, T S Dina, N J Patronas, S W Wiesel
雑誌名: J Bone Joint Surg Am. 1990 Mar;72(3):403-8.
Abstract/Text We performed magnetic resonance imaging on sixty-seven individuals who had never had low-back pain, sciatica, or neurogenic claudication. The scans were interpreted independently by three neuro-radiologists who had no knowledge about the presence or absence of clinical symptoms in the subjects. About one-third of the subjects were found to have a substantial abnormality. Of those who were less than sixty years old, 20 per cent had a herniated nucleus pulposus and one had spinal stenosis. In the group that was sixty years old or older, the findings were abnormal on about 57 per cent of the scans: 36 per cent of the subjects had a herniated nucleus pulposus and 21 per cent had spinal stenosis. There was degeneration or bulging of a disc at at least one lumbar level in 35 per cent of the subjects between twenty and thirty-nine years old and in all but one of the sixty to eighty-year-old subjects. In view of these findings in asymptomatic subjects, we concluded that abnormalities on magnetic resonance images must be strictly correlated with age and any clinical signs and symptoms before operative treatment is contemplated.

PMID 2312537  J Bone Joint Surg Am. 1990 Mar;72(3):403-8.
著者: T W Stadnik, R R Lee, H L Coen, E C Neirynck, T S Buisseret, M J Osteaux
雑誌名: Radiology. 1998 Jan;206(1):49-55. doi: 10.1148/radiology.206.1.9423651.
Abstract/Text PURPOSE: To evaluate the prevalence and radiologic findings of annular tear (especially of contrast material enhancement), bulging disk, and disk herniation on T2-weighted and gadolinium-enhanced T1-weighted magnetic resonance (MR) images in people without low back pain (LBP) or sciatica.
MATERIALS AND METHODS: Thirty-six volunteers without LBP and/or sciatica (18 with no symptoms in their lifetime and 18 who were pain free for at least 6 months) were examined with sagittal and axial T2-weighted fast spin-echo (SE) and sagittal gadolinium-enhanced T1-weighted fast SE imaging. The prevalence and MR findings of bulging disk, focal protrusion, extrusion, and nonenhancing or enhancing annular tears were assessed.
RESULTS: The prevalence of bulging disk and focal disk protrusion was 81% (29 volunteers) and 33% (12 volunteers), respectively. There were no extrusions. Twenty-eight annular tears were found in 20 patients (56%); 27 tears (96%) also showed contrast enhancement.
CONCLUSION: Annular tears and focal disk protrusions on MR images, with or without contrast enhancement, are frequently found in an asymptomatic population. Extruded disk herniation, displacement of nerve root, and interruption of annuloligamentous complex are unusual findings in an asymptomatic population and can be more closely related to patients with LBP or sciatica.

PMID 9423651  Radiology. 1998 Jan;206(1):49-55. doi: 10.1148/radiolog・・・
著者: P C Vroomen, M C de Krom, J A Knottnerus
雑誌名: J Neurol. 1999 Oct;246(10):899-906.
Abstract/Text We conducted a systematic review of the literature from 1965-1994 to assess the value of history and physical examination in the diagnosis of sciatica due to disc herniation; we also included population characteristics and features of the study design affecting diagnostic value. Studies on the diagnostic value of history and physical examination in the diagnosis of sciatica due to disc herniation are subject to important biases, and information on numerous signs and symptoms is scarce or absent. Our search revealed 37 studies meeting the selection criteria; these were systematically and independently read by three readers to determine diagnostic test properties using a standard scoring list to determine the methodological quality of the diagnostic information. A meta-analysis was performed when study results allowed statistical pooling. Few studies investigated the value of the history. Pain distribution seemed to be the only useful history item. Of the physical examination signs the straight leg raising test was the only sign consistently reported to be sensitive for sciatica due to disc herniation. However, the sensitivity values varied greatly, the pooled sensitivity and specificity values being 0.85 and 0.52, respectively. The crossed straight leg raising test was the only sign shown to be specific; the pooled sensitivity and specificity values were 0.30 and 0.84, respectively. There was considerable disagreement on the specificity of the other neurological signs (paresis, sensory loss, reflex loss). Several types of bias and other methodological drawbacks were encountered in the studies limiting the validity of the study results. As a result of these drawbacks it is probable that test sensitivity was overestimated and test specificity underestimated.

PMID 10552236  J Neurol. 1999 Oct;246(10):899-906.
著者: S Jaovisidha, S Techatipakorn, P Apiyasawat, W Laohacharoensombat, M Poramathikul, P Siriwongpairat
雑誌名: J Med Assoc Thai. 2000 Aug;83(8):865-71.
Abstract/Text Due to a wide range of normal disk space heights at lumbosacral (LS) junction, we conducted this study to evaluate how to diagnose degenerative disk disease (DDD) of LS junction and how much information we can obtain from plain radiography regarding this condition. We retrospectively reviewed lateral LS spine films and magnetic resonance (MR) imaging in 100 patients presented with low back pain. Anterior disk height (ADH) and posterior disk height (PDH) were directly measured from plain radiographs. Signs of DDD were recorded from both plain radiographs and MR imaging. We found that ADH < 11.3 mm or PDH < 5.5 mm indicate DDD at LS junction with 95 per cent confidence interval. When spondylolisthesis presented, disks were all degenerated. Endplate sclerosis had significant relative risk (p < 0.05) for lateral neural canal stenosis and disk herniation. No radiographic finding showed significant relative risk for nerve root compression.

PMID 10998839  J Med Assoc Thai. 2000 Aug;83(8):865-71.
著者: U M Ahn, N U Ahn, J M Buchowski, E S Garrett, A N Sieber, J P Kostuik
雑誌名: Spine (Phila Pa 1976). 2000 Jun 15;25(12):1515-22.
Abstract/Text STUDY DESIGN: A meta-analysis of surgical outcomes of cauda equina syndrome secondary to lumbar disc herniation.
OBJECTIVES: To determine the relationship between time to decompression after onset of cauda equina syndrome and clinical outcome, and to identify preoperative variables that were associated with outcomes.
SUMMARY OF BACKGROUND DATA: The timing of surgical decompression for cauda equina syndrome is controversial. Although most surgeons recommend emergent decompression, results in certain studies show that delayed surgery may provide a satisfactory outcome.
METHODS: A meta-analysis was performed to determine the correlation between timing of decompression and clinical outcome. One hundred four citations were reviewed, and 42 met the inclusion criteria. Preoperative and postoperative data were recorded. Length of time to surgery was broken down into five groups: less than 24 hours, 24-48 hours, 2-10 days, 11 days to 1 month, and more than 1 month. Logistic regression was used to determine the association between preoperative variables and postoperative outcomes.
RESULTS: Outcomes were analyzed in 322 patients. Preoperative chronic back pain was associated with poorer outcomes in urinary and rectal function, and preoperative rectal dysfunction was associated with worsened outcome in urinary continence. In addition, increasing age was associated with poorer postoperative sexual function. No significant improvement in surgical outcome was identified with intervention less than 24 hours from the onset of cauda equina syndrome compared with patients treated within 24-48 hours. Similarly, no difference in outcome occurred in patients treated more than 48 hours after the onset of symptoms. Significant differences, however, were found in resolution of sensory and motor deficits as well as urinary and rectal function in patients treated within 48 hours compared with those treated more than 48 hours after onset of symptoms.
CONCLUSIONS: There was a significant advantage to treating patients within 48 hours versus more than 48 hours after the onset of cauda equina syndrome. A significant improvement in sensory and motor deficits as well as urinary and rectal function occurred in patients who underwent decompression within 48 hours versus after 48 hours.

PMID 10851100  Spine (Phila Pa 1976). 2000 Jun 15;25(12):1515-22.
著者: Nanna B Finnerup, Nadine Attal, Simon Haroutounian, Ewan McNicol, Ralf Baron, Robert H Dworkin, Ian Gilron, Maija Haanpää, Per Hansson, Troels S Jensen, Peter R Kamerman, Karen Lund, Andrew Moore, Srinivasa N Raja, Andrew S C Rice, Michael Rowbotham, Emily Sena, Philip Siddall, Blair H Smith, Mark Wallace
雑誌名: Lancet Neurol. 2015 Feb;14(2):162-73. doi: 10.1016/S1474-4422(14)70251-0. Epub 2015 Jan 7.
Abstract/Text BACKGROUND: New drug treatments, clinical trials, and standards of quality for assessment of evidence justify an update of evidence-based recommendations for the pharmacological treatment of neuropathic pain. Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE), we revised the Special Interest Group on Neuropathic Pain (NeuPSIG) recommendations for the pharmacotherapy of neuropathic pain based on the results of a systematic review and meta-analysis.
METHODS: Between April, 2013, and January, 2014, NeuPSIG of the International Association for the Study of Pain did a systematic review and meta-analysis of randomised, double-blind studies of oral and topical pharmacotherapy for neuropathic pain, including studies published in peer-reviewed journals since January, 1966, and unpublished trials retrieved from ClinicalTrials.gov and websites of pharmaceutical companies. We used number needed to treat (NNT) for 50% pain relief as a primary measure and assessed publication bias; NNT was calculated with the fixed-effects Mantel-Haenszel method.
FINDINGS: 229 studies were included in the meta-analysis. Analysis of publication bias suggested a 10% overstatement of treatment effects. Studies published in peer-reviewed journals reported greater effects than did unpublished studies (r(2) 9·3%, p=0·009). Trial outcomes were generally modest: in particular, combined NNTs were 6·4 (95% CI 5·2-8·4) for serotonin-noradrenaline reuptake inhibitors, mainly including duloxetine (nine of 14 studies); 7·7 (6·5-9·4) for pregabalin; 7·2 (5·9-9·21) for gabapentin, including gabapentin extended release and enacarbil; and 10·6 (7·4-19·0) for capsaicin high-concentration patches. NNTs were lower for tricyclic antidepressants, strong opioids, tramadol, and botulinum toxin A, and undetermined for lidocaine patches. Based on GRADE, final quality of evidence was moderate or high for all treatments apart from lidocaine patches; tolerability and safety, and values and preferences were higher for topical drugs; and cost was lower for tricyclic antidepressants and tramadol. These findings permitted a strong recommendation for use and proposal as first-line treatment in neuropathic pain for tricyclic antidepressants, serotonin-noradrenaline reuptake inhibitors, pregabalin, and gabapentin; a weak recommendation for use and proposal as second line for lidocaine patches, capsaicin high-concentration patches, and tramadol; and a weak recommendation for use and proposal as third line for strong opioids and botulinum toxin A. Topical agents and botulinum toxin A are recommended for peripheral neuropathic pain only.
INTERPRETATION: Our results support a revision of the NeuPSIG recommendations for the pharmacotherapy of neuropathic pain. Inadequate response to drug treatments constitutes a substantial unmet need in patients with neuropathic pain. Modest efficacy, large placebo responses, heterogeneous diagnostic criteria, and poor phenotypic profiling probably account for moderate trial outcomes and should be taken into account in future studies.
FUNDING: NeuPSIG of the International Association for the Study of Pain.

Copyright © 2015 Elsevier Ltd. All rights reserved.
PMID 25575710  Lancet Neurol. 2015 Feb;14(2):162-73. doi: 10.1016/S147・・・
著者: A Sepehrnia, W J van Ouwerkerk
雑誌名: Neurosurg Rev. 1996;19(4):227-30.
Abstract/Text In patients operated on for herniated lumbar disc, epidural morphine was administered intraoperatively at the end of the procedure. A 10 milligram dose of morphine provided significant pain relief expressed by less requirement for strong analgesics on the day of operation and the day following, as well as for sedatives during the postoperative observation period of four days in comparison to a control group of patients. The only side effect observed was urinary retention.

PMID 9007884  Neurosurg Rev. 1996;19(4):227-30.

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