мрт-диагностика состояния позвоночника после дискэктомии

ÄËß ÏÐÀÊÒÈ×ÅÑÊÈÕ ÂÐÀ×ÅÉ
ÌÐÒ-ÄÈÀÃÍÎÑÒÈÊÀ ÑÎÑÒÎßÍÈß ÏÎÇÂÎÍÎ×ÍÈÊÀ
ÏÎÑËÅ ÄÈÑÊÝÊÒÎÌÈÈ
ÓÄÊ 616.721.1-089-073.756.8
À.Â. Õîëèí, Ê.È. Ñåáåëåâ
ÃÎÓ ÄÏÎ «Ñàíêò-Ïåòåðáóðãñêàÿ ìåäèöèíñêàÿ àêàäåìèÿ
ïîñëåäèïëîìíîãî îáðàçîâàíèÿ Ðîñçäðàâà»,
ðåêòîð – ä.ì.í. Î.Ã. Õóðöèëàâà
Ñàíêò-Ïåòåðáóðã
Ïåðå÷èñëåíû âîçìîæíûå áëèæàéøèå è îòäàëåííûå îñëîæíåíèÿ ïîñëå îïåðàöèè äèñêýêòîìèè, îïèñàíû èõ êëèíè÷åñêèå ïðîÿâëåíèÿ è ìåòîäû äèàãíîñòèêè. Äàíà ïîäðîáíàÿ ÌÐÒ-êàðòèíà ïîçâîíî÷íèêà â áëèæàéøèå 6 ìåñÿöåâ ïîñëå îïåðàòèâíîãî âìåøàòåëüñòâà.
Êëþ÷åâûå ñëîâà: äèñêýêòîìèÿ, îñëîæíåíèÿ, ìàãíèòíî-ðåçîíàíñíàÿ òîìîãðàôèÿ.
MAGNETIC RESONANCE TOMOGRAPHY OF SPINE AFTER DISKECTOMY
A.V. Kholin, K.I. Sebelev
The author lists then possible immediate and remote complications after diskectomy and describes clinical presentations and
methods of diagnostics at this pathology. Detailed MR-imaging of spine in 6 months after operation is presented.
Key words: diskectomy, complications, ìagnetic resonance tomography.
Îöåíêà ñîñòîÿíèÿ ïîÿñíè÷íîãî îòäåëà ïîçâîíî÷íèêà ïîñëå îïåðàöèè ÿâëÿåòñÿ âàæíîé è
ñëîæíîé çàäà÷åé. Îò ïðàâèëüíîé òðàêòîâêè âûÿâëåííûõ èçìåíåíèé çàâèñèò âûáîð äàëüíåéøåé
òàêòèêè ëå÷åíèÿ ïàöèåíòà.
 ïåðâûå äíè ïîñëå îïåðàöèè íàáëþäàåòñÿ
îò¸ê ìÿãêèõ òêàíåé è èõ ïðîïèòûâàíèå êðîâüþ.
Ìàññ-ýôôåêò â ýòîò ïåðèîä ìîæåò ñèìóëèðîâàòü
íåóäàë¸ííóþ ãðûæó. ×àñòî òàêèå íàõîäêè ïðè
ÌÐÒ íàçûâàþò «ïñåâäîãðûæåé». Èçâåñòíî, ÷òî
å¸ íàëè÷èå è ðàçìåðû íå êîððåëèðóþò ñ îòäàë¸ííûìè ïîñëåîïåðàöèîííûìè èçìåíåíèÿìè. Îò¸ê
èñ÷åçàåò ïðèìåðíî ÷åðåç 3 íåäåëè ïîñëå îïåðàöèè, õîòÿ ïñåâäîãðûæè ñîõðàíÿþòñÿ â òå÷åíèå
2 ìåñ. è äàæå äîëüøå.
 ïåðâûå ìåñÿöû ïîñëå îïåðàöèè îòìå÷àåòñÿ
ïîâûøåííûé ñèãíàë íà Ò2-çàâèñèìûõ ÌÐÒ îò
êîñòíîãî ìîçãà, çàìûêàòåëüíûõ ïëàñòèíîê è ïóëüïîçíîãî ÿäðà. Ýòî îòðàæàåò îòåê è àñåïòè÷åñêîå
âîñïàëåíèå. Äî 6 ìåñÿöåâ ïîñëå îïåðàöèè ñîõðàíÿþòñÿ ðåàêòèâíûé ýïèäóðèò, àðàõíîèäèò è äèñöèò. Îíè âèäíû êàê êîíòðàñòíîå óñèëåíèå îáîëî÷åê, ýïèäóðàëüíîãî ïðîñòðàíñòâà è çàìûêàòåëüíûõ
ïëàñòèí. Íàðóøåíèå ãåìàòîýíöåôàëè÷åñêîãî áàðüåðà ïðèâîäèò òàêæå è ê êîíòðàñòèðîâàíèþ êîðåøêà. Ó áîëüøåé ÷àñòè ïàöèåíòîâ â îòâåò íà îïåðàöèþ íàáëþäàåòñÿ êîíòðàñòèðîâàíèå äóãîîòðîñò÷àòîãî ñóñòàâà, ñîõðàíÿþùååñÿ áîëüøå 6 ìåñ. [4, 6].
ÒÐÀÂÌÀÒÎËÎÃÈß
È
ÎÐÒÎÏÅÄÈß
Ïîñëå 6 ìåñ. ðåàêòèâíûé îò¸ê è âîñïàëåíèå ñòèõàþò, äèñê ïîñòåïåííî ïðèîáðåòàåò òèïè÷íî íèçêóþ èíòåíñèâíîñòü ñèãíàëà, è â í¸ì ïîÿâëÿåòñÿ
ëèíèÿ ôèáðîçà. Ê 6 ìåñ. îò¸ê â ïåðåäíåì ýïèäóðàëüíîì ïðîñòðàíñòâå ñìåíÿåòñÿ ôèáðîçîì, êîòîðûé ó áîëüøèíñòâà ïàöèåíòîâ óæå íå óìåíüøàåòñÿ â îáú¸ìå, ëèáî óìåíüøàåòñÿ î÷åíü íåçíà÷èòåëüíî â òå÷åíèå ïåðâîãî ãîäà ïîñëå îïåðàöèè [24].
Ó ÷àñòè ïàöèåíòîâ ïîñëå îïåðàöèè äèñêýêòîìèè â ðàçíûå ñðîêè âîçíèêàþò ðåöèäèâíûå áîëè.
 çàðóáåæíîé ëèòåðàòóðå òàêîå ñîñòîÿíèå îáîçíà÷àåòñÿ òåðìèíîì “failed back surgery syndrome
(FBSS)”, ò. å. ñèíäðîì íåóäà÷íûõ îïåðàöèé.
×àñòîòà ýòîãî ñèíäðîìà ñîñòàâëÿåò 10–40%
[1, 8, 11, 14, 22]. Ñóùåñòâåííûé ðàçáðîñ â
ñòàòèñòèêå ñâÿçàí ñ ðàçíûìè ïðè÷èíàìè: ïîäáîðîì áîëüíûõ äëÿ îïåðàöèîííîãî ëå÷åíèÿ,
òèïîì îïåðàöèè, ðåàáèëèòàöèîííûìè ìåðîïðèÿòèÿìè è îöåíêîé ñîñòîÿíèÿ ïîñëå îïåðàöèè. Êëèíè÷åñêîå óõóäøåíèå ïî ñðàâíåíèþ ñ
äîîïåðàöèîííûì ñîñòîÿíèåì íàõîäèòñÿ â ïðåäåëàõ 1–10%. Îñíîâíûå ïðè÷èíû ðåöèäèâíîãî
áîëåâîãî ñèíäðîìà:
1) íåïîñðåäñòâåííî ñâÿçàííûå ñ îïåðàöèåé,
âñòðå÷àþòñÿ îòíîñèòåëüíî ÷àñòî:
– àäãåçèâíûé àðàõíîèäèò;
– èíôåêöèè;
– ÿòðîãåííûå (ïîâðåæäåíèå êîðåøêà);
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ÄËß ÏÐÀÊÒÈ×ÅÑÊÈÕ ÂÐÀ×ÅÉ
– ïîñëåîïåðàöèîííîå ñîñòîÿíèå – ýïèäóðàëüíûé ôèáðîç, ñòåíîç ïîçâîíî÷íîãî êàíàëà (îòâåðñòèÿ) ñ êîìïðåññèåé êîðåøêà;
2) íå ñâÿçàííûå ñ ãðûæåé äèñêà è îïåðàöèåé,
âñòðå÷àþòñÿ ðåäêî:
– ïåðâè÷íûå îïóõîëè è ìåòàñòàçû â ïîçâîíêè;
– çàáîëåâàíèÿ ïîçâîíî÷íèêà – îñòåîïîðîç è
êîìïðåññèîííûå ïåðåëîìû, âîñïàëèòåëüíûå çàáîëåâàíèÿ ñóñòàâîâ (ðåâìàòîèäíûé àðòðèò,
ñèíäðîì Ðåéòåðà è ò. ä.);
– èððàäèàöèÿ áîëåé ïðè ïàíêðåàòèòå, ðàññëàèâàþùåé àíåâðèçìå áðþøíîé àîðòû, ðàêå ïðåäñòàòåëüíîé æåëåçû.
Áëèæàéøåå îñëîæíåíèå îïåðàöèè – áàêòåðèàëüíûé ñïîíäèëîäèñöèò. Åãî ÷àñòîòà, ïî äàííûì
ëèòåðàòóðû, ñîñòàâëÿåò 0–12% (â ñðåäíåì 1–3%).
Íàñòîðàæèâàòü äîëæíî óñèëåíèå áîëåâîãî ñèíäðîìà è âîñïàëèòåëüíàÿ ðåàêöèÿ êðîâè. Ïðè
ÌÐÒ âèäíà ðàçìûòîñòü çàìûêàòåëüíûõ ïëàñòèíîê è îò¸ê êîñòíîãî ìîçãà. Ýòè ñèìïòîìû íåñïåöèôè÷íû, òàê êàê ðåàêòèâíûé àñåïòè÷åñêèé äèñöèò âûãëÿäèò òàê æå. Ôîðìèðîâàíèå ýïèäóðàëüíîãî àáñöåññà ïðîèñõîäèò ïîçæå, êîãäà
êëèíè÷åñêèå ïðîÿâëåíèÿ óæå î÷åâèäíû.
Îòäàë¸ííûìè ïîñëåäñòâèÿìè äèñêýêòîìèè
ÿâëÿþòñÿ ñóæåíèå îòâåðñòèÿ çà ñ÷¸ò íèçêîãî
äèñêà (åãî îñòàòêà) è ãèïåðòðîôèè äóãîîòðîñò÷àòîãî ñóñòàâà; ýïèäóðàëüíûé ôèáðîç ñ íàðóøåíèåì ïèòàíèÿ äèñêà.
Èñòìè÷åñêèé ñïîíäèëîëèñòåç è áîêîâîé ñòåíîç ïîçâîíî÷íîãî êàíàëà ñîñòàâëÿþò ñâûøå 50%
ïðè÷èí ðåöèäèâíûõ áîëåé [8, 29]. Ïðè óìåíüøåíèè âûñîòû äèñêà â ïåðâóþ î÷åðåäü ñòðàäàåò
áîêîâîé (ñóáàðòèêóëÿðíûé) êàðìàí – ìåñòî âõîäà êîðåøêà â ìåæïîçâîíî÷íûé êàíàë. Ïðè÷èíîé
áîëåé ñëóæèò îò¸ê êîðåøêà. Îí âîçíèêàåò ïðè
íàðóøåíèè âåíîçíîãî îòòîêà èç-çà êîìïðåññèè
çàäíåãî êîðåøêà, îáû÷íî îñòåîôèòîì.
Àäãåçèâíûé àðàõíîèäèò – íàèìåíåå èçó÷åííàÿ
ïðè÷èíà ðåöèäèâíîãî áîëåâîãî ñèíäðîìà. ×àñòî
òåðìèíû «àðàõíîèäèò» è «ìåíèíãèò» èñïîëüçóþò
êàê ðàâíîçíà÷íûå, ÷òî ïî ñóòè ñâîåé íåâåðíî. Ìåíèíãèò – ýòî äèôôóçíîå âîñïàëåíèå îáîëî÷åê ìîçãà, êàê ïðàâèëî, áàêòåðèàëüíîé ýòèîëîãèè. Àðàõíîèäèò îãðàíè÷èâàåòñÿ òîëüêî ïàóòèííîé îáîëî÷êîé è ñâÿçàí ñ íåñïåöèôè÷åñêîé âîñïàëèòåëüíîé
ðåàêöèåé. Ñâåäåíèÿ î í¸ì â ëèòåðàòóðå î÷åíü ïðîòèâîðå÷èâûå, îò ïîëíîãî îòðèöàíèÿ åãî ñóùåñòâîâàíèÿ äî àáñîëþòèçàöèè åãî çíà÷åíèÿ. Êëèíè÷åñêèå ïðîÿâëåíèÿ ëþìáî-ñàêðàëüíîãî àðàõíîèäèòà
â çàðóáåæíîé ëèòåðàòóðå ÷àñòî îáîçíà÷àþò êàê
“regional complex pain disorder” (RCPD), à ó íàñ
÷àùå êàê «êàóçàëãèÿ». Ïîñëåîïåðàöèîííûé àðàõíîèäèò ïðèâîäèò ê ñëèïàíèþ êîðåøêîâ è ôîðìèðîâàíèþ «ïóñòîãî» äóðàëüíîãî ìåøêà. Ýòî ñîñòîÿíèå îòðàæàåò íå òîëüêî ðàñïîëîæåíèå êîðåøêîâ,
íî è èõ àòðîôèþ âñëåäñòâèå íàðóøåíèÿ ïèòàíèÿ.
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Ïîñëå ñòèõàíèÿ ðåàêòèâíîãî ýïèäóðèòà îñòà¸òñÿ ãðàíóëÿöèîííàÿ òêàíü, èç êîòîðîé ïîñòåïåííî ôîðìèðóåòñÿ ýïèäóðàëüíûé ôèáðîç è ìÿãêîòêàííûé ðóáåö. Âûðàæåííîñòü ýïèäóðàëüíîãî
ôèáðîçà çàâèñèò îò ñâîéñòâ òêàíåé, òèïà è îáú¸ìà
îïåðàöèè (ãåìèëàìèíýêòîìèÿ, ìàëîèíâàçèâíàÿ è
ò. ï.). Ñàìî ïî ñåáå ðàçâèòèå ýïèäóðàëüíîãî ôèáðîçà íå ÿâëÿåòñÿ ïàòîëîãè÷åñêèì ñîñòîÿíèåì. Îäíàêî, åñëè ôèáðîç ìóôòîîáðàçíî îõâàòûâàåò êîðåøîê, îí íàðóøàåò åãî ïèòàíèå [19]. Ïðåäïîëîæèòåëüíî, ñ ôèáðîçîì ñâÿçàíî îêîëî 8%
ðåöèäèâíûõ áîëåé. Ñêîðåå âñåãî, ìåæäó âûðàæåííîñòüþ ôèáðîçà è âåðîÿòíîñòüþ ðåöèäèâíîãî áîëåâîãî ñèíäðîìà èìååòñÿ êîððåëÿöèÿ [20, 25], ÷òî
çàìå÷åíî íå âñåìè èññëåäîâàòåëÿìè [10].
Ðåöèäèâíûå ãðûæè äèñêîâ ïîñëå ëàìèíýêòîìèè ñîñòàâëÿþò 15–20% [3] è íåñêîëüêî íèæå –
ïîñëå ìèêðîõèðóðãè÷åñêèõ îïåðàöèé [2], ÷òî
ïðèìåðíî â 2 ðàçà ÷àùå ýïèäóðàëüíîãî ôèáðîçà. Ðåöèäèâíîé ñ÷èòàåòñÿ âûÿâëåííàÿ ãðûæà íà
óðîâíå îïåðàöèè, íà òîé æå èëè ïðîòèâîïîëîæíîé ñòîðîíå, ïîñëå áåçáîëåâîãî èíòåðâàëà íå
ìåíüøå 6 ìåñ.  ëèòåðàòóðå èìåþòñÿ âåñüìà ïðîòèâîðå÷èâûå ñâåäåíèÿ î ôàêòîðàõ ðèñêà ðåöèäèâà ãðûæè. Åñòü äàííûå, ÷òî ïðè äèàáåòå ðåöèäèâû ãðûæè âñòðå÷àþòñÿ ÷àùå [26], íî ýòî
ïîäòâåðæäàåòñÿ íå âñåìè èññëåäîâàíèÿìè [21].
Îòñóòñòâèå ôðàãìåíòà äèñêà â ãðûæå (äèôôóçíûé ïðîëàïñ ôèáðîçíîãî êîëüöà), ïî äàííûì
E.J. Carragee ñ ñîàâòîðàìè, ñâÿçàíî ñ áîëåå âûñîêîé ÷àñòîòîé å¸ ðåöèäèâîâ ïîñëå îïåðàöèè
[9]. Äðóãèå èññëåäîâàòåëè íå âèäåëè ñâÿçè ðåöèäèâîâ ñ ôîðìîé è òèïîì ãðûæè [17, 27].
Äèôôåðåíöèàëüíàÿ äèàãíîñòèêà ìåæäó ôèáðîçîì è ðåöèäèâíîé ãðûæåé ÿâëÿåòñÿ êëþ÷åâûì
ìîìåíòîì â âûáîðå òàêòèêè ëå÷åíèÿ. Èíòåíñèâíîñòü ñèãíàëà íà íåêîíòðàñòèðîâàííûõ ÌÐÒ ïðè
ýòèõ çàáîëåâàíèÿõ îäèíàêîâàÿ. Ãðûæà ÿâëÿåòñÿ
ïðîäîëæåíèåì äèñêà, è îíà îáû÷íî îòãðàíè÷èâàåòñÿ ãèïîèíòåíñèâíîé çàäíåé ïðîäîëüíîé ñâÿçêîé. Îäíàêî ïðè ñåêâåñòðàöèè ýòà ñâÿçü òåðÿåòñÿ
è ïîäîáíî ôèáðîçó ñåêâåñòð ìîæåò ðàñïîëàãàòüñÿ â ñòîðîíå îò äèñêà. Ðåòðàêöèÿ äóðàëüíîãî ìåøêà â ñòîðîíó îáðàçîâàíèÿ êîñâåííî óêàçûâàåò íà
ôèáðîç [25], êîìïðåññèÿ äóðàëüíîãî ìåøêà õàðàêòåðíåå äëÿ ãðûæè. Ýòè ïðèçíàêè èìåþò î÷åíü
íåâûñîêóþ ñòåïåíü ñïåöèôè÷íîñòè. Äèñê è ãðûæà – îáðàçîâàíèÿ áåññîñóäèñòûå, à ãðàíóëÿöèîííàÿ òêàíü è ôèáðîç, íàïðîòèâ, ñîäåðæàò ñîñóäû.
Ïîýòîìó îíè êîíòðàñòèðóþòñÿ, ÷òî ïîçâîëÿåò
îòëè÷àòü ðóáåö îò ðåöèäèâíîé ãðûæè (ðèñ.). Êîíòðàñòèðîâàíèå ñâÿçàíî ñ íàëè÷èåì âàñêóëÿðèçàöèè, òî÷íîñòü ìåòîäà ïðåâûøàåò 90% [13]. Ïðîáëåìà ñîñòîèò â òîì, ÷òî ðåöèäèâíàÿ ãðûæà è ýïèäóðàëüíûé ôèáðîç íå èñêëþ÷àþò äðóã äðóãà, à
÷àñòî ñîñóùåñòâóþò. Ýòî ñóùåñòâåííî çàòðóäíÿåò ïîñòàíîâêó ïðàâèëüíîãî äèàãíîçà.
ÒÐÀÂÌÀÒÎËÎÃÈß
È
ÎÐÒÎÏÅÄÈß
ÐÎÑÑÈÈ
ÄËß ÏÐÀÊÒÈ×ÅÑÊÈÕ ÂÐÀ×ÅÉ
à
á
Ðèñ.
Ñîñòîÿíèå ïîñëå ãåìèëàìèíýêòîìèè è äèñêýêòîìèè íà óðîâíå L5/S1:
à – Ò2-çàâèñèìàÿ ñàãèòòàëüíàÿ òîìîãðàììà, ýïèäóðàëüíûé ôèáðîç; á – àêñèàëüíàÿ Ò1-çàâèñèìàÿ òîìîãðàììà
Ëèòåðàòóðà
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ÑÂÅÄÅÍÈß ÎÁ ÀÂÒÎÐÀÕ:
Õîëèí Àëåêñàíäð Âàñèëüåâè÷ – ä.ì.í. ïðîôåññîð, çàâåäóþùèé êàôåäðîé ëó÷åâîé äèàãíîñòèêè Ñàíêò-Ïåòåðáóðãñêîé
ìåäèöèíñêîé àêàäåìèè ïîñëåäèïëîìíîãî îáðàçîâàíèÿ
e-mail: holin1959@list.ru;
Ñåáåëåâ Êîíñòàíòèí Èâàíîâè÷ – ê.ì.í. äîöåíò êàôåäðû ëó÷åâîé äèàãíîñòèêè Ñàíêò-Ïåòåðáóðãñêîé ìåäèöèíñêîé àêàäåìèè
ïîñëåäèïëîìíîãî îáðàçîâàíèÿ.
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