Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_6040_Библиотеки_им_академика_М_И_Перельмана.pdf
Contributors xxiii
Roberto Izzo Department of Neuroradiology, ‘‘Cardarelli’’ Hospital,
Naples, Italy
Mariangela Lombardi Department of Radiology, ‘‘Maggiore della
Carita`’’ University Hospital, Novara, Italy
Angela Lorusso Department of Radiology—Neuroradiology,
‘‘L. Bonomo’’ Hospital, Andria, BT, Italy
Saverio Lorusso Department of Radiology—Neuroradiology,
‘‘L. Bonomo’’ Hospital, Andria, BT, Italy
Pietro Maggi Department of Radiology—Neuroradiology,
‘‘L. Bonomo’’ Hospital, Andria, BT, Italy
Michele Maiorano Department of Radiology—Neuroradiology,
‘‘L. Bonomo’’ Hospital, Andria, BT, Italy
Emanuele Malatesta Department of Radiology, ‘‘Maggiore della
Carita`’’ University Hospital, Novara, Italy
Luigi Manfrè Department of Neuroradiology, ‘‘Cannizzaro’’ Hospital,
Catania, Italy
Achille Marotta Unit of Diagnostic Imaging, Villa Fiorita Clinic,
Capua, CE, Italy
Letizia Mazzini Department of Neurology, ‘‘Maggiore della Carita`’’
University Hospital, Novara, Italy
Rita Merla Department of Radiology, ‘‘Maggiore della Carita`’’ Uni-
versity Hospital, Novara, Italy
Raniero Mignini Department of Neurosurgery, ‘‘L. Bonomo’’ Hospital,
Andria, BT, Italy
Giovanni Miscio Department of Radiology, Scientific Institute Hospital
‘‘Casa Sollievo della Sofferenza’’, San Giovanni Rotondo, FG, Italy
Mario Muto Department of Neuroradiology, ‘‘Cardarelli’’ Hospital,
Naples, Italy
Raffaele Nappi Unit of Diagnostic Imaging, Villa Fiorita Clinic, Capua,
CE, Italy
Michelangelo Nasuto Department of Radiology, University of Foggia,
Foggia, Italy
Francesco Nemore Department of Radiology, ‘‘San Nicola Pellegrino’’
Hospital, Trani, BT, Italy
Valentina Panara Department of Neurosciences and Imaging, Institute
of Advanced Biomedical Technologies, ‘‘G. D’Annunzio’’ University,
Chieti-Pescara, Italy
Gabriele Panzarasa Department of Neurosurgery, ‘‘Maggiore della
Carita`’’ University Hospital, Novara, Italy
xxiv Contributors
Francesco Paradiso Department of Neurosurgery, ‘‘L. Bonomo’’
Hospital, Andria, BT, Italy
Marco Pelle Department of Radiology, ‘‘Maggiore della Carita`’’
University Hospital, Novara, Italy
Gabriele Polonara Department of Neuroradiology, University Hospi tal,
Ancona, Italy
Teresa Popolizio Department of Neuroradiology, Scientific Institute
Hospital ‘‘Casa Sollievo della Sofferenza’’, San Giovanni Rotondo, FG,
Italy
Chiara Potente Department of Neuroradiology, University Hospital,
Ancona, Italy
Martina Quagliozzi Department of Radiology, ‘‘Maggiore della Carita`’’
University Hospital, Novara, Italy
Fabio Quinto Department of Radiology—Neuroradiology,
‘‘L. Bonomo’’ Hospital, Andria, BT, Italy
Francesco Ricciardi Radiology Center, Andria, Italy
Michele Ricciardi Radiology Center, Andria, Italy
Simone Salice Department of Neurosciences and Imaging, Institute of
Advanced Biomedical Technologies, ‘‘G. D’Annunzio’’ University,
Chieti-Pescara, Italy
Michele Santoro Department of Neurosurgery, ‘‘L. Bonomo’’ Hospital,
Andria, BT, Italy
Marianna Schiavariello Department of Radiology—Neuroradiology,
‘‘L. Bonomo’’ Hospital, Andria, BT, Italy
Rosy Setiawati Department of Radiology, Rumah Satik Surabaya Internetional Hospital, Surabaya, Indonesia
Roberto Stanzione Department of Radiology—Neuroradiology,
‘‘L. Bonomo’’ Hospital, Andria, BT, Italy
Alessandro Stecco Department of Radiology, ‘‘Maggiore della Carita`’’
University Hospital, Novara, Italy
Alfredo Tarantino Department of Neuroradiology, ‘‘San Paolo’’ Hospital, BA, Italy
Armando Tartaro Department of Neurosciences and Imaging, Institute
of Advanced Biomedical Technologies, ‘‘G. D’Annunzio’’ University,
Chieti-Pescara, Italy
Domenico Tortora Department of Neurosciences and Imaging, Institute
of Advanced Biomedical Technologies, ‘‘G. D’Annunzio’’ University,
Chieti-Pescara, Italy
Contributors xxv
Anna Totagiancaspro Department of Neurosurgery, ‘‘L. Bonomo’’
Hospital, Andria, BT, Italy
Roberto Trignani Department of Neurosurgery, University Hospital,
Ancona, Italy
Alessio Usurini Department of Radiology, ‘‘Maggiore della Carita`’’
University Hospital, Novara, Italy
Anna Viola Department of Radiology, ‘‘Maggiore della Carita`’’ Uni-
versity Hospital, Novara, Italy
Antonio Volpe Unit of Neuroradiology, Advanced Biomedical Sciences
Department, ‘‘Federico II’’ University, Naples, Italy
Alberto Zuccalà Department of Radiology, ‘‘Maggiore della Carita`’’
University Hospital, Novara, Italy
Part I
Pathology
Saverio Pollice, Pietro Maggi, Tullia Garribba, Saverio Lorusso
and Tommaso Scarabino
1
Causes of surgery and interventional radiology
on spine are represented largely by disk herniation (most commonly lumbar), which we will
discuss further in this treatment. Stenosis of the
vertebral canal, vertebral instability, and vertebral fractures will also be analyzed [1, 2]. The
therapeutic treatment of spinal pathology initially includes conservative therapy and in case
of failure a number of surgical procedures and/or
interventional radiology approaches, with varying degrees of invasiveness, such as discectomy,
vertebroplasty, and surgical stabilization. With
recent advances of intervention techniques and
devices used, minimally invasive approaches are
becoming increasingly popular for the treatment
of spine disorders. In particular, minimally
invasive spine surgery attempts to: decrease
iatrogenic muscle injury, decrease pain and
speed postoperative course by the use of smaller
incisions and specialized instruments.
1.1 Disk Herniation
for permanent disability. 55 % of the population
in European countries reports at least once in life
a variable episode of low back pain and 80 % a
simple low back pain [3]. Who is affected many
times, unfortunately, begin a diagnostic and
therapeutic route involving orthopedic, neurosurgeon, physiatrist, and neurologist. Its natural
history provides for a first time period (of variable length between 3 and 6 weeks) characterized by pain (more or less intense) which is
followed by a second phase in which the painful
symptomatology is attenuated and then disappears leaving the place to symptoms of neurological deficit (decrease in strength of muscle
innervated by the compressed root) [4–7].
Herniated disk, commonly lumbar, is the main
cause for surgery on the spine, not always resolutive. In postoperative course may arise in
fact a recurrence or a fibrous scar that if
hypertrophic can compress and irritate the
affected nerve and require a second operation
(the rate of re-operation is around 3–15 %).
Herniated disk is one of the most common diseases with very high social costs; it is the first
cause for absenteeism from work and the second
S. Pollice (&) P. Maggi T. Garribba S. Lorusso
T. Scarabino
Department of Radiology—Neuroradiology,
‘‘Lorenzo Bonomo’’ Hospital, Andria, Bari, Italy
e-mail: saveriopollice@hotmail.it
T. Scarabino and S. Pollice (eds.), Imaging Spine After Treatment,
DOI: 10.1007/978-88-470-5391-5_1, Springer-Verlag Italia 2014
1.1.1 Lumbar Disk Hernia
Lumbar disk herniation is a degenerative disease
of the intervertebral disk that arises from the
rupture of the annulus fibrosus and subsequent
leakage of nucleus pulposus in spinal canal with
compression on dural sack and nerve root.
Especially in people of 30–50 years with low
back pain, symptoms originate from radiculopathy due to compression of lumbosacral nerve
3
4 S. Pollice et al.
roots (pain radiating along the course of the
sciatic nerve, from gluteal region to the back of
the thigh and posterolateral leg up the ankle) or
crural suffering (pain along the anterior or
anterior-medial thigh, along the course of the
crural nerve), causing functional impairment.
Radicular pain is caused by mechanical compression, inflammatory effects, vascular and
biochemical modifications caused by the contact
between the disk and nerve roots.
Diagnosis involves the collection of anamnestic data; physical examination and clinical
trials to assess root involvement(irritative, deficit,
paretic), diagnostic imaging (X-ray, computed
tomography CT, magnetic resonance MRI), and
instrumental examination (electromyography).
Treatment may be conservative or can contemplate surgical procedures and/or interventional radiology approach. The choice of
treatment depends in general on two elements:
the entity or the persistence of acute symptoms
and the presence of a functional damage. This
latter aspect is sometimes highlighted (in case of
serious damage root) by the decreased (or absent)
functionality of the muscles innervated by that
root. In this case a great help is the electromyographic examination that tells us precisely the
functional status of the root compressed by herniated disk. This test, performed by implanting
small needles along the lower limb, records the
electrical potentials sent along nerve roots to the
muscles for their contraction. Compression (and
inflammatory state that follows) alters the ability
of conducting electrical stimulation along the
nerve fibers and thus alters the electrical characteristics of these pulses. Recording these
changes allows to obtain a quantitative assessment of root damage and also to determine
whether the damage is recent or old.
Conservative therapy for atleast 7–10 days, or
until the disappearanceof intense pain, consists of
absolute abstention from even moderate physical
actions, from assumption of incorrect positions,
or from trunk flexion. Pharmacotherapy, recommended for a short time, involves administration
of corticosteroids (betamethasone or methylprednisolone), nonsteroidal anti-inflammatory
(NSAIDs), painrelievers (tramadol, paracetamol,
paracetamol ? codeine, morphine), muscle
relaxants, and periradicular infiltration therapy.
After the hyperacute phase, physiatric evaluation
may be required to start postural exercises and
neuromuscular electrical stimulation. In addition
to standard medical treatments, several alternative treatments have also been shown to provide
effective pain relief for many patients. Most
common alternative care actually are chiropractic
manipulation, acupuncture, and massage therapy.
Surgical options are: open surgery, microsurgery, and minimally invasive percutaneous
surgery. These are used for different types of
herniated disks: contained or extruded, with and
without dislocated fragment, and with or without
narrow canal. Criteria for elective surgical
indication is the failure of conservative therapy;
the presence of symptoms and signs of sensory
or motor involvement in the corresponding
dermatomer; electromyography positive for
severe root damage and recent documentation of
disk herniation on MRI or CT. The cauda equina
syndrome from herniated disk is an absolute
indication for surgery to be performed urgently.
1.1.2 Cervical Disk Hernia
Cervical hernia is less common than lumbar. It
can show nonspecific symptoms such as neck
pain and shoulder pain. Specific symptoms are
radiculopathy with arms pain or myelopathy with
spasticity, abnormal reflexes, abnormal walking,
and bladder dysfunction. Radiological diagnosis
requires as a first step X-ray of the cervical spine
in double projection (lateral and anteroposterior),
followed by MRI, which still represents the gold
standard. The treatment initially may be pharmacological (analgesics, muscle relaxants,
NSAIDs). Even physiokinesitherapy and the use
of cervical collar may be useful. In absence of
any clinical improvement surgical treatment is
recommended which may include anterior
arthrodesis; anterior microdiskectomy with
interbody fusion anterior cervical discectomy
and fusion (ACDF) or arthroplasty, evolution of
classic ACDF, with implantation of a prosthetic
disk that replaces the degenerated [8].
1 Pathology 5
1.2 Canal Stenosis
Canal stenosis consists in a narrowing of the
central spinal canal, of the root canal, and of the
intervertebral foramina, congenital or acquired,
which causes the compression of one or more
nerve roots. Acquired causes are usually multiple: disk herniation, spondylolisthesis, disk
arthrosis, marginal osteophytes, facet joint
arthrosis with a consequent reduction of canal
amplitude, calcification of the joint capsule,
hypertrophy, and calcification of the posterior
longitudinal ligament and yellow ligaments,
hyperostosis of the plates [9, 10]. Stenosis is also
documented after surgical procedures as a result
of exuberant degeneration.
Symptoms of lumbar stenosis, more frequent
than the remaining districts, are neurogenic
claudication, represented by inability of the
patient to walk long distances for the onset of
pain in the upright position. This pain is
emphasized in walking, with sensation of heavy
legs and progressive lack of strength. CT and
MRI with axial acquisitions allow to accurately
measure the amplitude of the canal, both central
and lateral [11].
Treatment may be conservative: epidural
steroid injections, NSAIDs, calcitonin, prolonged bed rest, magnetotherapy, ionophoresis,
neuro-electrical stimulation, physical therapy
(postural exercises, swimming), corsets, and
external orthoses. Traditional surgery consists of
enlargement of the neural canal through posterior laminectomy without or with foraminotomy,
partial or total arthrodesis with interbody screws
and bars. Minimally invasive surgery instead
uses interspinous devices.
1.3 Vertebral Instability
Vertebral instabilitycan be frommuscle–tendon–
ligament–disk insufficiency secondary to degenerative spinal disease, which can be traumatic or
rarely congenital and can lead to a progressive
failure with consequent alteration of joint
mobility and pain. Instability of degenerative
origin is most common, affecting usually the last
lumbar vertebrae[12–14]. This condition, despite
enormous variability, from simple postural
imbalance can evolve gradually in protrusion,
disk hernia, muscle failure, arthritic degeneration, amplitude reduction of the central, and lateral spinal canal.
With age, joints (intervertebral disk, interapophyseal joints) that allow movements of the
spine (flexion, extension, and rotation) undergo
degenerative changes that alter structure and
functioning. In particular, intervertebral disk
goes through dehydration with reduction of its
thickness and hence distance between the two
bodies which is interposed. The annulus, which
adheres firmly to the edges of the vertebral
bodies, protrudes beyond the limiting bodies,
profiles. The reduction in height of the disk,
placed in the anterior part of the vertebra,
involves on the interapophyseal joints a greater
burden to which they are not predisposed with
wear of the cartilage and increase of ligamentous
laxity (microinstability) that thus determines
inflammatory processes responsible for low back
pain.
Over time, even ligaments that keep vertebrae, together with the joints, stretch out causing
abnormal increase in amplitude of movement
allowed. Moreover, the progressive failure of the
ligaments leads to slipping of vertebra over the
lower (degenerative spondylolisthesis). The
body responds trying to block the abnormal
movements by affixing new bone to strengthen
the joints. Joints hypertrophy and distortion
cause progressive narrowing of canal and related
neurological syndrome (root canal stenosis, sciatic nerve suffering). Osteophytes that are
formed along the edges can form bone bridges
which block the articulation. Osteoporosis may
worsen this context by associating possibly a
‘‘crushing’’ spine.
Symptoms are postural pain (conditioned by
the position of the body), more pronounced at
certain times of the day (getting out of bed) and
accentuated by fatigue, sometimes (especially
when stenosis of the spinal canal coexists)
associated with numbness and weakness in the
lower limbs. In the forms secondary to traumatic
accidents, local acute pain prevails, usually at
6 S. Pollice et al.
the fractured vertebrae, with associated neural
damage (paresis or paralysis). Clinical history of
these individuals allows a diagnosis of instability. The objective evaluation is then indispensable; radiological examinations help to
determine the stage of instability, although
sometimes there is not always a correlation
between clinical and imaging.
X-rays are performed in anteroposterior,
lateral and oblique with associated dynamic
study in the upright (in maximum flexion and
extension) in order to verify the presence of a
slide of a vertebra to the other (in the absence of
congenital anomaly such as spondylolysis with
spondylolisthesis). With X-ray it is also possible
to document the presence of discopathy, osteophytes, spinal deviations, and areas of greatest
sclerosis (index of functional overload). CT scan
evaluates the root canal diameters (central and
lateral), shows the interapophyseal joints, the
epidural fat and muscle atrophy. MRI analyzes
the disk degeneration, the discopathies, the
stages of disk-somatic degeneration (Modic),
and the fatty atrophy of the deep spinal
musculature.
Treatment is multimodal and can include
medical conservative therapy associated with
spinal manipulation, neuro-reflex, and physiokinesitherapy. The neurosurgeon and orthopedic have two options: the traditional stabilization
(‘‘fusion surgery’’) in the macro-instability and
the dynamic stabilization (‘‘non-fusion surgery’’) used instead in the presence of microinstability and in cases where it is necessary to
preserve the movement [15, 16].
1.4 Vertebral Fractures
Vertebral fractures can be the result of trauma,
structural failure for osteoporosis, or primary or
secondary cancer. Posttraumatic fractures are
divided into myelopathic with dislocation of
bone fragments in the canal and spinal cord or
root damage, and non-myelopathic in which
there is a reduction in volume of the vertebral
body with preservation of canal size and neural
structures integrity. Osteoporotic fractures are
rather secondary to a skeletal disease that thins
and weakens bones predisposing them to fracture commonly affecting female subjects after
menopause. Thoracic compression fractures lead
to kyphosis with a disastrous impact on quality
of life. Verebral body has reduction in height
and preservation of the posterior wall thus the
absence of spinal cord damage. Symptoms usually include back pain with breathing difficulty
due to decreased lung capacity. X-ray detects the
distortion of somatic profiles. CT has a better
spatial resolution. In the early phase MRI identifies the intracancellous edema, signal of bone
bruise, and possible fracture, even in absence of
deformation of somatic profiles. In case of nonmyelophatic traumatic fractures treatment may
be conservative with positioning of bust for
3 months associated with MR follow-up. Surgery is quickly necessary in case of unstable
myelopathic fractures. The aim of surgery is to
perform a spinal stabilization with minimally
invasive technique using pedicle screws and
rods percutaneously inserted. The purpose is to
determine bony fusion to prevent segmental
movements. Another therapeutic option is the
percutaneous vertebroplasty [17–19]. Sometimes single or multiple corpectomy may be
necessary to replace the vertebral body, especially in the case of cancer or infection.
References
1. Gallucci M, Caulo M, Masciocchi C (2001) il
Rachide operato. In: Compendio di Risonanza
magnetica a cura di Dal Pozzo G, Utet Ed,
pp 1047–1071
2. Kaech DL (1998) Failed back surgery syndrome:
surgeon’s perspective. Riv Neurorad 11:385–395
3. Jensen MC, Brant-Zawadzki MN, Obuchowski N
et al (1994) MRI of the lumbar spine in people with
outback pain. N Engl J Med 331
4. Davis AR (1994) A long-term outcome analysis of
984 surgically treated herniated lumbar discs.
J Neurosurg 80:415–421
5. Gallucci M, Bozzao A, Orlandi B et al (1995)
Follow-up of surgical treated and untreated disk
pathology. Riv Neurorad 8:86–96
6. Lee JK, Amorosa L, Cho SK et al (2019) Recurrent
lumbar disk herniation. J Am Acad Orthop Surg
18:327–337
1 Pathology 7
7. Splendiani A, Puglielli E, De Amicis R et al (2004)
Spontaneous resolution of lumbar disk herniation:
predictive signs for prognostic evaluation.
Neuroradiology 46:916–922
8. Celestre PC, Pazmiño PR, Mikhael MM et al (2012)
Minimally invasive approaches to the cervical spine.
Orthop Clin North Am 43:137–147
9. Nowicki BH, Haughton VM, Schmidt TA et al
(1996) Occult lumbar lateral spinal stenosis in neural
foramina subjected to physiologic loading. AJNR
17:1605–1614
10. Schönström N, Lindahl S, Willen J et al (1989)
Dynamic changes in the dimensions of the lumbar
spinal canal: an experimental study in vitro. J Orthop
Res 7:115–121
11. Kent DL, Haynor DR, Larson EB et al (1992)
Diagnosis of lumbar spinal stenosis in adults:
metaanalysis of the accuracy of CT, MR and
myelography. AJR 158:1135–1144
12. Gallucci M, Puglielli E, Splendiani A et al (2005)
Degenerative disorders of the spine. Eur Radiol
15:591–598
13. Modic MT, Steimberg PM, Ross JS et al (1988)
Degenerative disk disease: assessment of changes in
vertebral body marrow with MR imaging. Radiology
166:193
14. Rabischong P (1997) Comprehensive approach to the
disco-radicular conflict iv. Neuroradiology 10:5–7
15. Hauger O, Obeid I, Pelé E (2010) Imaging of the
fused spine. J Radiol 91:1035–1048
16. Eif M, Schenke H (2005) The Interspinous-U:
indications, experience, and results. Spinal
Arthroplasty Society, New York
17. Alvarez L, Perez-Higueras A, Granizo JJ et al (2003)
Vertebroplasty in the treatment of vertebral tumors:
post procedural outcome and quality of life. Eur
Spine 12:356–360
18. Anselmetti GC, Bonaldi G, Baruzzi F, et al (2004)
Percutaneous vertebroplasty: results in a large series
of patients. Eur Radiol 14:B-354
19. Dublin AB, Hartman R, Latchaw P et al (2005) The
vertebral body fracture in osteoporosis: restoration of
height using percutaneous vertebroplasty. AJNR
26:489–492
Interventional Radiology
Tommaso Scarabino, Fabio Quinto, Carmine Iaffaldano,
Michele Santoro and Raniero Mignini
2
Interventional radiology of the spine includes a
set of minimally invasive surgical procedures
with percutaneous approach, used primarily for
the treatment of diskal hernia (especially lumbar)
and vertebral collapse of different nature [1].
These techniques involve short time hospitalization, are usually practicable in day surgery,
and do not require general anesthesia.
2.1 Percutaneous Techniques
for Diskal Hernia
Interventional techniques with percutaneous
approach for diskal hernia are based on the
principle of ‘‘empty of nucleus pulposus’’ (both
by physical and chemical ways) in order to
reduce its volume and thus indirectly the compression of nerve root. Compared to surgery,
they are less invasive, with similar efficacy and
lower risk of recurrences, thanks to an external
approach. They also have the advantage of being
repeatable without precluding, in case of failure,
the use of traditional surgery [2].
T. Scarabino F. Quinto
Department of Radiology—Neuroradiology,
‘‘Lorenzo Bonomo’’ Hospital, Andria, Italy
C. Iaffaldano M. Santoro (&) R. Mignini
Department of Neurosurgery,
‘‘Lorenzo Bonomo’’ Hospital, Andria, Italy
e-mail: mike.santoro@tiscali.it
They find indication especially in young
patients with disk protrusion, where disk
degeneration is the only source of pain, and
therefore, all the degenerative phenomena typical of the advanced age are absent. Positive
result is generally quite limited in time and
influenced by the progression of disk degeneration. These procedures include intradiskal electrothermal therapy (IDET), chemonucleolysis,
coblation, laser discectomy, and oxygen ozone
therapy.
2.1.1 Intradiskal Electrothermal
Therapy
IDET or intradiskal electrothermal annuloplasty
(IDEA) is a new and minimally invasive technique for the treatment of diskogenic low back
pain. It involves percutaneous threading of a
flexible catheter into the disk under fluoroscopic
guidance. The catheter, composed of thermal
resistive coil, heats the posterior annulus of the
disk, causing contraction of collagen fibers and
destruction of afferent disk nociceptors. Breakage of heat sensitive hydrogen bonds of the
collagen fibers causes collagen contraction. With
disk temperatures reaching 650 C collagen may
contract as much as 35 % from its original size.
The tightening of annular tissue may enhance
the structural integrity of degenerated disk and
repair the annular fissures. The process of disk
restructuring (as shown by time courses of
patients pain relief) may take several months to
T. Scarabino and S. Pollice (eds.), Imaging Spine After Treatment,
DOI: 10.1007/978-88-470-5391-5_2, Springer-Verlag Italia 2014
9