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脊椎分離症、脊椎分離すべり症

著者: 酒井紀典 徳島大学整形外科

著者: 西良浩一 徳島大学整形外科

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:2016/11/30
患者向け説明資料

概要・推奨   

疾患のポイント:
  1. 脊椎分離症・脊椎分離すべり症とは、腰椎分離症は椎弓の関節突起間部の骨性の非連続性を指す。スポーツ愛好者に多くみられることなどから、疲労骨折の1つと考えられている。
  1. 一般的には小学生~高校生で発生し、スポーツを愛好する青少年が腰椎伸展時痛を訴える場合に最も疑われる疾患である。
 
診断:
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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:
酒井紀典 : 企業などが提供する寄付講座(徳島県厚生連農業協同組合連合会吉野川医療センター・阿南医療センター)[2021年]
西良浩一 : 講演料(エリクエンスインターナショナル,ファイザー(株),久光製薬(株)),研究費・助成金など(ジンマーバイオメット合同会社),奨学(奨励)寄付など(ニューベイシブジャパン(株),日本ストライカー(株),京セラメディカル(株),スミス・アンド・ネフュー(株),旭化成ファーマ(株),メドトロニックソファモアダネック(株),(株)日本エム・ディ・エム),企業などが提供する寄付講座(地域運動器・スポーツ医学(併))[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]

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 腰椎分離症は椎弓の関節突起間部の骨性の非連続性を指す。<図表>
  1. スポーツ愛好者に多くみられることなどから、疲労骨折の1つと考えられている。
  1. 一般的には小学生~高校生で発生する。
  1. 約6%の頻度で認められる。人種差・性差などもあるが一般日本人成人においては5.9%(男性7.9%、女性3.9%)の頻度で認められる。
  1. ひとたび分離が完成すれば、その後椎体すべりや楔状椎など、生涯にわたる変形を残す症例もある。
  1. 分離部周囲に生じるfibrocartilage massやbony ragged edgeは、青壮年期以降に神経根性疼痛の原因になる。
問診・診察のポイント  
問診:
  1. 発症時期を確認する。

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文献 

著者: Koichi Sairyo, Toshinori Sakai, Natsuo Yasui
雑誌名: J Neurosurg Spine. 2009 May;10(5):492-5. doi: 10.3171/2009.2.SPINE08594.
Abstract/Text In this report, the authors described a new minimally invasive technique to repair pars interarticularis defects in adults. The well-established technique using the pedicle screw (PS) and hook-rod system was modified. First, bilateral PSs were inserted percutaneuosly using the Sextant system. Then, through a small skin incision (3-4 cm), an illuminated tubular retractor (Quadrant system; Medtronic Sofamore Danek) was inserted into the pars defect. When this system is used, it is not necessary to detach all the back muscles to access the lytic part. The bursa and fibrocartilaginous mass near the defects were removed. After decortication of the pseudarthrosis at the spondylolytic level, bone grafts were implanted. Finally, the hook part of a hook-rod system was attached to the lamina and the rod was secured at the tulip head of the PSs. The authors performed this procedure in 2 adult patients, 32 and 24 years of age. Immediately after surgery both patients' low-back pain disappeared, and by 3 months postoperatively both had returned to their original work or sports activities.

PMID 19442013  J Neurosurg Spine. 2009 May;10(5):492-5. doi: 10.3171/2・・・
著者: K Higashino, K Sairyo, S Katoh, T Sakai, H Kosaka, N Yasui
雑誌名: Minim Invasive Neurosurg. 2007 Jun;50(3):182-6. doi: 10.1055/s-2007-982511.
Abstract/Text Pars defect (spondylolysis) of the lumbar spine can cause chronic low back pain, and it sometimes requires surgical intervention. Direct repair is selected for the surgery if young adult patients do not present significant disc degeneration and lumbar instability. In order to lessen damages of back muscles during surgery, we added the use of a spinal endoscope to the "Buck's screwing procedure" the direct repair. There are four steps in this procedure: 1) identification of the defect, 2) curettage (refresh) of the defect, 3) percutaneous insertion of the annulated screws and 4) cancellous bone grafting. All these steps can be done endoscopically. We treated 3 young adults--a baseball player, a professional cycle-racer and a sculptor--using this endoscopic procedure. There were no complications during or after the operation. Union was obtained in all defects within 3 months, and they returned to their previous activities within 6 months after the surgery.

PMID 17882757  Minim Invasive Neurosurg. 2007 Jun;50(3):182-6. doi: 10・・・
著者: Koichi Sairyo, Shinsuke Katoh, Tadanori Sakamaki, Shinji Komatsubara, Natsuo Yasui
雑誌名: J Neurosurg. 2003 Apr;98(3 Suppl):290-3.
Abstract/Text The authors describe a new endoscopic technique to decompress lumbar nerve roots affected by spondylolysis. Short-term clinical outcome was evaluated. Surgery-related indications were: 1) radiculopathy without low-back pain; 2) no spinal instability demonstrated on dynamic radiographs; and 3) age older than 40 years. Seven patients, four men and three women, fulfilled these criteria and underwent endoscopic decompressive surgery. Their mean age was 60.9 years (range 42-70 years). No subluxation was present in four patients, whereas Meyerding Grade I slippage was demonstrated in three. For endoscopic decompression, a skin incision of 16 to 18 mm in length was made, and fenestration was performed to identify the affected nerve root. The proximal stump of the ragged edge of the spondylotic lesion, and the fibrocartilaginous mass compressing the nerve root were removed. The follow-up period ranged from 6 to 22 months (mean 11.7 months). Clinical outcome was evaluated using Gill criteria; in three patients the outcome was excellent, and in four it was good. This new endoscopic technique was useful in the decompression of nerve roots affected by spondylolysis, the technique was minimally invasive, and the clinical results were acceptable.

PMID 12691388  J Neurosurg. 2003 Apr;98(3 Suppl):290-3.
著者: K Sairyo, S Katoh, T Ikata, K Fujii, K Kajiura, V K Goel
雑誌名: Spine J. 2001 May-Jun;1(3):171-5.
Abstract/Text BACKGROUND CONTEXT: Although it has been well documented that slippage in patients with spondylolysis is most prevalent during the growth period, the exact time when slippage initiates and halts during the growth period is still unknown. Moreover, the contribution of spinal deformities, such as wedging of the vertebral body to the slippage, remains controversial.
PURPOSE: To clarify when slippage in pediatric spondylolysis initiates and halts.
STUDY DESIGN: Retrospective study.
PATIENT SAMPLE: We radiographically examined 46 athletes under 18 years of age with spondylolysis at the fifth lumbar vertebra (L5). The mean age at the first consultation was 13.3 years. The average follow-up period was 6.0 years.
OUTCOME MEASURES: Longitudinal observation of slippage at L5 on radiogram in correlation with the maturity of the lumbar spine.
METHODS: From a lateral radiogram of each patient, percent slippage, lumbar index (LI), and skeletal age of the affected vertebra were measured. Changes in the percent slippage over time were investigated, and the correlation between the percent slippage and LI was analyzed.
RESULTS: From the cartilaginous stage to the apophyseal stage, the slippage increased in 80.0% of the patients (16 of 20). From the cartilaginous stage to the epiphyseal stage, slippage increased in 11.1% of the patients (3 of 27). None of the patients (0 of 22) showed an increase after the epiphyseal stage. In 20 patients in whom slippage increased during the follow-up period, the percent slippage at the final consultation and the LI at the first consultation showed no significant correlation; however, the percent slippage and the LI at the final consultation were significantly (p<.01) correlated.
CONCLUSION: In conclusion, slippage was more prevalent in individuals of a younger skeletal age whose lumbar spine was immature, and it halted during the epiphyseal stage when the growth period was over and the vertebra matured. Furthermore, the results suggest that wedge deformity of an affected vertebra might be the result rather than the cause of slippage.

PMID 14588344  Spine J. 2001 May-Jun;1(3):171-5.
著者: Shoichiro Takao, Toshinori Sakai, Koichi Sairyo, Tadashi Kondo, Junji Ueno, Natsuo Yasui, Hiromu Nishitani
雑誌名: J Med Invest. 2010 Feb;57(1-2):133-7.
Abstract/Text We studied the lumbar spines of 117 adults (39 women and 78 men) with spondylolysis unrelated to low back pain using multidetector computed tomography (CT). Of the 117 subjects with spondylolysis, including five with multiple-level spondylolysis, there were 124 vertebrae with spondylolysis. In adult lumbar spines with unilateral spondylolysis, there was no significant difference between the incidence of spondylolisthesis in female and male subjects. However, in those with bilateral spondylolysis, there was a significantly higher incidence of spondylolisthesis in female subjects (90.9%) than in males (66.2%). Furthermore, females with bilateral spondylolysis had significant more slippage than males. Lumbar index and lumbar lordosis were not significantly different between male and female subjects, and did not significantly correlate with slippage. In conclusion, to treat acute spondylolysis in adolescents, it is important to obtain bony union at least unilaterally, especially in female subjects, to prevent further slippage.

PMID 20299752  J Med Invest. 2010 Feb;57(1-2):133-7.
著者: Koichi Sairyo, Toshinori Sakai, Natsuo Yasui, Ali Kiapour, Ashok Biyani, Nabil Ebraheim, Vijay K Goel
雑誌名: Arch Orthop Trauma Surg. 2009 Oct;129(10):1433-9. doi: 10.1007/s00402-008-0795-3. Epub 2008 Dec 16.
Abstract/Text STUDY DESIGN: Case series and a biomechanical study using a finite element (FE) analysis.
OBJECTIVES: To report three cases with multi-level spondylolysis and to understand the mechanism biomechanically.
BACKGROUND: Multi-level spondylolysis is a very rare condition. There have been few reports in the literature on multi-level spondylolysis among sports players.
METHODS: We reviewed three cases of the condition, clinically. These patients were very active young sports players and had newly developed fresh L4 spondylolysis and pre-existing L5 terminal stage spondylolysis. Thus, we assumed that L5 spondylolysis may have increased the pars stress at the cranial adjacent levels, leading to newly developed spondylolysis at these levels. Biomechanically, we investigated pars stress at L4 with or without spondylolysis at L5 using the finite element technique.
RESULTS: L4 pars stress decreased in the presence of L5 spondylolysis, which does not support our first hypothesis.
CONCLUSIONS: It seems that multi-level spondylolysis may occur due to genetic and not biomechanical reasons.

PMID 19084979  Arch Orthop Trauma Surg. 2009 Oct;129(10):1433-9. doi: ・・・
著者: Koichi Sairyo, Toshinori Sakai, Natsuo Yasui, Akira Dezawa
雑誌名: J Neurosurg Spine. 2012 Jun;16(6):610-4. doi: 10.3171/2012.2.SPINE10914. Epub 2012 Apr 20.
Abstract/Text OBJECT: Various kinds of trunk braces have been used to achieve bone healing in cases of pediatric lumbar spondylolysis. However, the optimal brace for achieving bone healing is unclear. The purpose of the present study was to determine in what types of spondylolysis bone healing can be achieved and how long it takes.
METHODS: In this prospective study, 63 pars interarticularis defects (spondylolysis) among 37 patients who were younger than 18 years (mean 13.5 ± 2.7 years) were treated using a hard brace. The youngest patient was 8 years old. Based on the results of CT scanning, the lyses were classified into 3 categories: early, progressive, and terminal defects. Progressive defects were further divided into 2 types according to STIR MRI findings: those with high signal intensity at the adjacent pedicle and those with low signal intensity (that is, a normal appearance). A hard brace, such as a molded plastic thoracolumbosacral orthosis, was used to immobilize the trunk. Approximately every 3 months, CT scanning was performed to evaluate bone healing until approximately 6 months.
RESULTS: The union rates were 94%, 64%, 27%, and 0% for the early, progressive with high signal intensity, progressive with low signal intensity, and terminal defects, respectively. It was noted that no terminal defect was healed using conservative treatment. The mean time to healing among the defects that showed bone healing was 3.2, 5.4, and 5.7 months for the early, progressive with high signal intensity, and progressive with low signal intensity groups, respectively.
CONCLUSIONS: Patients with early-stage defects are the best candidates for conservative treatment with a hard brace because more than 90% of such cases can be healed in 3 months.

PMID 22519929  J Neurosurg Spine. 2012 Jun;16(6):610-4. doi: 10.3171/2・・・

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