Transizyonel vertebra tipleri ile disk - ftr.med.ege.edu.tr
Transizyonel vertebra tipleri ile disk - ftr.med.ege.edu.tr
Transizyonel vertebra tipleri ile disk - ftr.med.ege.edu.tr
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ARAfiTIRMA Ege Fiz T›p Reh Der 2001; 7 (1-2): 45-49TRANS‹ZYONEL VERTEBRA T‹PLER‹ ‹LE D‹SK DEJENERASYONUNUN‹L‹fiK‹S‹THE RELATIONSHIP BETWEEN TYPES OF TRANSITIONAL VERTEBRAEAND DISC DEGENERATIONÖzlem BAYSAL 1 Tamer BAYSAL 2 Zuhal ALTAY 1 Fatma F‹DAN 1‹nönü Üniversitesi T›p Fakültesi, Turgut Özal T›p Merkezi, Malatya1 Fiziksel T›p ve Rehabilitasyon Anabilim Dal›2 Radyodiagnostik Anabilim Dal›Anahtar Sözcükler: <s<strong>tr</strong>ong>Transizyonel</s<strong>tr</strong>ong> <s<strong>tr</strong>ong>vertebra</s<strong>tr</strong>ong>, Disk dejenerasyonu, Bilgisayarl› tomografiKey Words: Transitional <s<strong>tr</strong>ong>vertebra</s<strong>tr</strong>ong>e, Disc d<s<strong>tr</strong>ong>ege</s<strong>tr</strong>ong>neration, Computed tomographyBu yaz› Van Yüzüncü Y›l Üniversitesi taraf›ndan 20-22 Nisan 2000 tarihinde düzenlenenBel A¤r›lar› 2000 Sempozyumu’nda poster olarak sunulmufltur.ÖZETMekanik bel a¤r›s› nedenlerinden biri olarak kabul ed<s<strong>tr</strong>ong>ile</s<strong>tr</strong>ong>n lumbosakral <strong>tr</strong>ansizyonel <s<strong>tr</strong>ong>vertebra</s<strong>tr</strong>ong> <s<strong>tr</strong>ong>ile</s<strong>tr</strong>ong> lumbosakral<s<strong>tr</strong>ong>disk</s<strong>tr</strong>ong> dejenerasyonu aras›ndaki iliflki tart›flmal›d›r. Bu çal›flmada <strong>tr</strong>ansizyonel <s<strong>tr</strong>ong>vertebra</s<strong>tr</strong>ong>l› 38 hastada direkgrafide <s<strong>tr</strong>ong>disk</s<strong>tr</strong>ong> yükseklikleri ölçümü yap›lm›fl ve bilgisayarl› tomografide lumbosakral <s<strong>tr</strong>ong>disk</s<strong>tr</strong>ong> dejenerasyonuvarl›¤› araflt›r›ld›. Disk yükseklikleri ölçümlerinde; 5 L-S 1 <s<strong>tr</strong>ong>disk</s<strong>tr</strong>ong> yüksekli¤inin di¤erlerine göre belirgin olarakazald›¤› saptand›. <s<strong>tr</strong>ong>Transizyonel</s<strong>tr</strong>ong> <s<strong>tr</strong>ong>vertebra</s<strong>tr</strong>ong> <s<strong>tr</strong>ong>tipleri</s<strong>tr</strong>ong> <s<strong>tr</strong>ong>ile</s<strong>tr</strong>ong> <s<strong>tr</strong>ong>disk</s<strong>tr</strong>ong> yüksekliklerinin de¤erlendirmesinde, tip 2 <strong>tr</strong>ansizyone l<s<strong>tr</strong>ong>vertebra</s<strong>tr</strong>ong>ya sahip hastalarda L 4-5 <s<strong>tr</strong>ong>disk</s<strong>tr</strong>ong> yüksekli¤inin di¤er tip <strong>tr</strong>ansizyonel <s<strong>tr</strong>ong>vertebra</s<strong>tr</strong>ong>l› hastalara göre dahadar oldu¤u bulundu (p
<strong>tr</strong>ansitional <s<strong>tr</strong>ong>vertebra</s<strong>tr</strong>ong>e in Type 2 might occur more than other types due to abnormal torque moments leadingto instability and s<strong>tr</strong>ess on this level. It is concluded that patients with lumbosacral <strong>tr</strong>ansitional <s<strong>tr</strong>ong>vertebra</s<strong>tr</strong>ong>eshould be evaluated more carefully for L 4-5 disc herniation.G‹R‹fiMekanik bel a¤r›s› nedenlerinden biri olarakkabul ed<s<strong>tr</strong>ong>ile</s<strong>tr</strong>ong>n lumbosakral <strong>tr</strong>ansizyonel <s<strong>tr</strong>ong>vertebra</s<strong>tr</strong>ong>n›n(TV) genel populasyonda görülme oran›%4-15 olarak bildirilmektedir (1-3). LumbosakralTV konjenital olarak 5. lumbar <s<strong>tr</strong>ong>vertebra</s<strong>tr</strong>ong>n›n<strong>tr</strong>ansvers proçesinde uzama ve birincisakral segmentin b<s<strong>tr</strong>ong>ile</s<strong>tr</strong>ong>flenleri <s<strong>tr</strong>ong>ile</s<strong>tr</strong>ong> de¤iflik derecelerdefüzyonu (sakralizasyon) <s<strong>tr</strong>ong>ile</s<strong>tr</strong>ong> karakterizedir.Komflu iliak kemi¤e füzyon da bu bulguyaefllik edebilir. Birinci sakral segmentinlumbar <s<strong>tr</strong>ong>vertebra</s<strong>tr</strong>ong>lara benzeyecek flekilde anormal<strong>tr</strong>ansvers proçeslere sahip olmas› (lumbarizasyon)ise daha az s›kl›kla görülür (4).TV’de lumbosakral <s<strong>tr</strong>ong>disk</s<strong>tr</strong>ong>in geliflimsel olarakdar oldu¤u bilinmekle beraber, bunun <s<strong>tr</strong>ong>disk</s<strong>tr</strong>ong>dejenerasyonunu göster<s<strong>tr</strong>ong>med</s<strong>tr</strong>ong>i¤i iddia edilmifltir(4,5).Bu çal›flmada, lumbosakral TV saptanan 38hastada TV <s<strong>tr</strong>ong>tipleri</s<strong>tr</strong>ong> <s<strong>tr</strong>ong>ile</s<strong>tr</strong>ong> lumbar <s<strong>tr</strong>ong>disk</s<strong>tr</strong>ong> dejenerasyonuaras›ndaki iliflki direk grafide <s<strong>tr</strong>ong>disk</s<strong>tr</strong>ong>yükseklikleri ölçümü ve bilgisayarl› tomografide(BT) <s<strong>tr</strong>ong>disk</s<strong>tr</strong>ong> dejenerasyonu tesbitine dayanarakaraflt›r›lm›flt›r.GEREÇ VE YÖNTEMBu çal›flmaya ‹nönü Üniversitesi T›p FakültesiFiziksel T›p ve Rehabilitasyon Klini¤i’ne bela¤r›s› nedeniyle baflvuran ve direk lumbosakralradyograf<s<strong>tr</strong>ong>ile</s<strong>tr</strong>ong>rinde TV saptanan 38 hasta(24 kad›n, 14 erkek) al›nd›. Disk dejenerasyonuriskinin 40 yafl üzerinde artmas› nedeniyle,40 yafl›n alt›ndaki hastalar çal›flmayadahil edildi. Siyataljisi olan hastalar veya baflkapatoloj<s<strong>tr</strong>ong>ile</s<strong>tr</strong>ong>re ait radyolojik bulgular› olan hastalarçal›flma d›fl› tutuldu. TV tesbitinde, sabitanatomik referans noktas› olarak üçüncülumbar <s<strong>tr</strong>ong>vertebra</s<strong>tr</strong>ong> al›nd›. L 3 <s<strong>tr</strong>ong>vertebra</s<strong>tr</strong>ong>n›n seçilmenedeni <strong>tr</strong>ansvers proçesi en uzun ve yatayuzanan en kaudal yerleflimli lumbar <s<strong>tr</strong>ong>vertebra</s<strong>tr</strong>ong>olmas› idi. Hastalar›n TV <s<strong>tr</strong>ong>tipleri</s<strong>tr</strong>ong> ön-arka direklumbosakral graf<s<strong>tr</strong>ong>ile</s<strong>tr</strong>ong>rinde belirlendi. TV’lerin s›n›fland›r›lmas›radyomorfolojik olarak Castellvi’nintan›mlad›¤› flekilde yap›ld› (6). Bu s›n›flamayagöre:Tip 1 (Displastik <strong>tr</strong>ansvers proçes) de üçgenfleklinde, geniflli¤i en az 19 mm olan bir <strong>tr</strong>ansversproçes bulunur.Tip 2 (‹nkomplet lumbarizasyon/sakralizasyon)de genifl bir <strong>tr</strong>ansvers proçes bulunur ve<strong>tr</strong>ansvers proçeslerle sakrum aras›nda psödoartikülasyonoluflur.Tip 3 (Komplet lumbarizasyon/sakralizasyon)de <strong>tr</strong>ansvers proçes <s<strong>tr</strong>ong>ile</s<strong>tr</strong>ong> sakrum aras›nda gerçekbir kemik füzyonu vard›r.Tip 4 (Mikst) de bir tarafta tip 2 (psödoartikülasyon),di¤er tarafta tip 3 (kemik füzyonu)<strong>tr</strong>ansizyonel <s<strong>tr</strong>ong>vertebra</s<strong>tr</strong>ong> vard›r.Tip 1, 2 ve 3’de patoloji unilateral veya bilateralolabilir.L 1-2 , L 2-3 , L 3-4 , L 4-5 ve L 5 –S 1 <s<strong>tr</strong>ong>disk</s<strong>tr</strong>ong> yüksekliklerilateral lumbosakral grafide iki komflu<s<strong>tr</strong>ong>vertebra</s<strong>tr</strong>ong> end platelerinin orta noktalar› aras›ndakimesafenin (mm) ölçülmesi <s<strong>tr</strong>ong>ile</s<strong>tr</strong>ong> saptand›.BT <s<strong>tr</strong>ong>ile</s<strong>tr</strong>ong> yap›lan incele<s<strong>tr</strong>ong>med</s<strong>tr</strong>ong>e lateral lumbosakralbölge skenogram› al›nd›. Bu skenogram üzerindeL 1-2 , L 2-3 , L 3-4 , L 4-5 ve L 5 –S 1 <s<strong>tr</strong>ong>disk</s<strong>tr</strong>ong> yükseklikleri3 mm kal›nl›k 2 mm interval de¤erlerikullan›larak tarand›. Bu <s<strong>tr</strong>ong>disk</s<strong>tr</strong>ong> aral›klar›<s<strong>tr</strong>ong>disk</s<strong>tr</strong>ong> dejenerasyonu (bulging ve herni) aç›s›ndande¤erlendirildi.‹statistiksel de¤erlendir<s<strong>tr</strong>ong>med</s<strong>tr</strong>ong>e ki-kare testi kullan›ld›.BULGULARÇal›flmaya al›nan 38 hastan›n 24'ü kad›n 14'üerkekti. Hastalar›n yafl ortalamas› 32.47±7.47(18-40) idi. Hastalar›m›zda TV <s<strong>tr</strong>ong>tipleri</s<strong>tr</strong>ong>nden ens›k Tip 1 (14) ve Tip 4’e (11) rastland› (fiekil1,2).Disk yükseklikleri ölçümlerinde; L 5 –S 1 <s<strong>tr</strong>ong>disk</s<strong>tr</strong>ong>yüksekli¤inin, di¤erlerine göre belirgin olarakazald›¤› saptand› (Tablo 1). TV <s<strong>tr</strong>ong>tipleri</s<strong>tr</strong>ong> <s<strong>tr</strong>ong>ile</s<strong>tr</strong>ong> <s<strong>tr</strong>ong>disk</s<strong>tr</strong>ong>46 Ege Fiz T›p Reh Der
yüksekliklerinin de¤erlendirmesinde, Tip 2 TV’yesahip hastalarda L 4-5 <s<strong>tr</strong>ong>disk</s<strong>tr</strong>ong> yüksekli¤inin di¤ertip TV’li hastalara göre daha dar oldu¤ubulundu (p
neden oldu¤u iddia edilmifltir. Bu durum blok<s<strong>tr</strong>ong>vertebra</s<strong>tr</strong>ong> veya füzyona komflu spinal segmentlerdegörülen hipermobiliteye benzetilmifltir.TV üst seviyesindeki hipermobilitenin <s<strong>tr</strong>ong>disk</s<strong>tr</strong>ong>dejenerasyonu ve faset eklem de¤ifliklikleriniart›rarak, spinal kanal veya nöral foramenlerdedarl›k görülmesine sebep oldu¤u bildirilmifltir(12). TV ve sakrum aras›nda çok k›s›tl›olan hareket bu <s<strong>tr</strong>ong>vertebra</s<strong>tr</strong>ong>n›n <strong>tr</strong>ansvers proçesarac›l›¤› <s<strong>tr</strong>ong>ile</s<strong>tr</strong>ong> sakrum veya iliak kemi¤e eklemyapmas› <s<strong>tr</strong>ong>ile</s<strong>tr</strong>ong> aç›klanabilir. TV <s<strong>tr</strong>ong>ile</s<strong>tr</strong>ong> sakrumaras›ndaki <s<strong>tr</strong>ong>disk</s<strong>tr</strong>ong> s›kl›kla kal›nt› fleklindedir.Patolojik olarak bu <s<strong>tr</strong>ong>disk</s<strong>tr</strong>ong>ler s›kl›kla fibrözyap›da olup, nükleer materyali ya yoktur yada azd›r. Bu sebeple, TV ve sakrum aras›nda<s<strong>tr</strong>ong>disk</s<strong>tr</strong>ong> hernisine nadiren rastland›¤›, <strong>tr</strong>ansizyonellumbosakral <s<strong>tr</strong>ong>vertebra</s<strong>tr</strong>ong>ya daima lumbosakral<s<strong>tr</strong>ong>disk</s<strong>tr</strong>ong>teki konjenital incelmenin efllik etti¤ibildirilmifltir (1,5,9). L 5 ’in sakruma bilateralkemik füzyonu <s<strong>tr</strong>ong>ile</s<strong>tr</strong>ong> birleflti¤i durumlarda <s<strong>tr</strong>ong>disk</s<strong>tr</strong>ong>yüksekli¤inde azalma çok belirgin olarak bildirilmifltir.Bu durumun inter<s<strong>tr</strong>ong>vertebra</s<strong>tr</strong>ong>l <s<strong>tr</strong>ong>disk</s<strong>tr</strong>ong>indejenerasyonu veya deplasman› olarak de¤erlendirilmemesigerekti¤i ve lumbosakral TVtipinin lumbosakral <s<strong>tr</strong>ong>disk</s<strong>tr</strong>ong> yüksekli¤ini belirle<s<strong>tr</strong>ong>med</s<strong>tr</strong>ong>eönemli bir etkisinin oldu¤u belirtilmifltir(11).Castellvi ve ark. TV ve <s<strong>tr</strong>ong>disk</s<strong>tr</strong>ong> patolojisi aras›ndakiiliflkiyi radyolojik perspektiften tan›mlamakiçin ilk modern giriflimde bulunmufl olanaraflt›rmac›lard›r. Miyelografide <s<strong>tr</strong>ong>disk</s<strong>tr</strong>ong> hernisiyleuyumlu eks<strong>tr</strong>adural defektlerin, TV seviyesiüzerindeki <s<strong>tr</strong>ong>disk</s<strong>tr</strong>ong>te görülme s›kl›¤›n›n artm›floldu¤unu saptam›fllard›r. Bu defektler <s<strong>tr</strong>ong>ile</s<strong>tr</strong>ong> özelTV <s<strong>tr</strong>ong>tipleri</s<strong>tr</strong>ong> aras›ndaki iliflkiyi araflt›rm›fllar;sakrum ve <strong>tr</strong>ansvers proçesler aras›nda tekveya çift tarafl› psödoartikülasyonun görüldü¤ütip 2’de, TV üst seviyesinde <s<strong>tr</strong>ong>disk</s<strong>tr</strong>ong> hernisigörülme s›kl›¤›n›n daha fazla oldu¤unu bildirmifllerdir(6). Dai, kronik bel a¤r›l› ve sa¤l›kl›iki grubun direk radyograf<s<strong>tr</strong>ong>ile</s<strong>tr</strong>ong>rini karfl›laflt›rm›fl,sa¤l›kl› 184 kiflinin sadece 29’unda (%15.8),bel a¤r›l› 276 kiflinin 97’sinde (%35.1) TVoldu¤unu saptam›flt›r. Yine hasta grubunda,Castellvi tip 2 TV’nin insidans›n› kon<strong>tr</strong>ol grubunagöre oldukça anlaml› düzeyde yüksek(p
Bu bulgular, tip 2 TV’ li hastalarda <s<strong>tr</strong>ong>vertebra</s<strong>tr</strong>ong>lar›nyük da¤›l›m dengesinin ve spinal mekani¤indaha fazla bozuldu¤unu sonuçta oluflaninstabilite ve s<strong>tr</strong>esin di¤er tiplere göre dahafazla olmas› nedeniyle, TV seviyesi üzerindeki(L 4-5 ) <s<strong>tr</strong>ong>disk</s<strong>tr</strong>ong> hernisinin daha fazla görüleb<s<strong>tr</strong>ong>ile</s<strong>tr</strong>ong>ce¤inigöstermektedir. Lumbosakral TV tesbited<s<strong>tr</strong>ong>ile</s<strong>tr</strong>ong>n hastalar›n L 4-5 <s<strong>tr</strong>ong>disk</s<strong>tr</strong>ong> hernisi yönündendaha dikkatli de¤erlendirilmesi gerekti¤ikanaatine var›lm›flt›r.KAYNAKLAR1. Elster AD. Bertolotti’s syndrome revisited. Spine 1989; 14: 1373-1377.2. Hahn PY, S<strong>tr</strong>obel JJ, Hahn FJ. Verification of lumbosacral segments on MR images: identification of <strong>tr</strong>ansitional <s<strong>tr</strong>ong>vertebra</s<strong>tr</strong>ong>e.Radiology 1992; 182: 580-1.3. Vergauwen S, Parizel PM, Von Breus<s<strong>tr</strong>ong>ege</s<strong>tr</strong>ong>m L. Dis<strong>tr</strong>ibution and incidence of d<s<strong>tr</strong>ong>ege</s<strong>tr</strong>ong>nerative spine changes in patients with alumbosacral <strong>tr</strong>ansitional <s<strong>tr</strong>ong>vertebra</s<strong>tr</strong>ong>e. Eur Spine J 1997; 6: 168-172.4. Nicholson A.A, Roberts G.M, Williams L.A. The measured height of the lumbosakral disc in patients with and without <strong>tr</strong>ansitional<s<strong>tr</strong>ong>vertebra</s<strong>tr</strong>ong>e. Br J Radiol 1988; 61: 454-455.5. De Palma AF, Rothman R.H. Congenital and acquired abnormalities of the lumbar spine. Philadelphia: WB Saunders Company,1970: 260-265.6. Castellvi AE, Goldstein LA, Donald PK. Lumbosacral <strong>tr</strong>ansitional vertabrae and their relationship with lumbar ex<strong>tr</strong>adural defects.Spine 1984; 9: 493-495.7. Cox JM. Transitional segment. Low Back Pain. Mechanism, Diagnosis and Treatment. Baltimore: Williams & Wilkins 1991:243-256.8. Mc Culloch JA, Waddel G. Variation of lumbosacral myotomes with bony segmental abnormalities. J Bone Joint Surg 1980; 62B:475-480.9. Murray RO, Jacobson HG. Radiology of skeletal disorders. Edinburgh: Churchill Livingstone, 1985: 16.10. Paajanen H, Erkintalo M, Kuusela T, et al. Magnetic resonance study of disc d<s<strong>tr</strong>ong>ege</s<strong>tr</strong>ong>neration in young low-back pain patients. Spine1989; 14: 982-98511. Hsieh CY, Vanderford JD, Moreau SR, et al. Lumbosacral <strong>tr</strong>ansitional segments: classification, prevalence, and effect on <s<strong>tr</strong>ong>disk</s<strong>tr</strong>ong>height. J Manipulative Physiol Ther 2000; 23: 483-489.12. Cailliet R. Low back pain syndrome. Philadelphia, FA Davis. 1966.13. Dai L. Lumbosacral <strong>tr</strong>ansitional <s<strong>tr</strong>ong>vertebra</s<strong>tr</strong>ong>e and low back pain. Bull Hosp Jt Dis 1999; 58: 191-193.14. Keim HA, Kirkaldy-Willis WH. Low back pain. Clin Symp 1980; 32: 1-35.15. Stinchfield FE, Sinton WA. Clinical significance of the <strong>tr</strong>ansitional lumbosakral <s<strong>tr</strong>ong>vertebra</s<strong>tr</strong>ong>e: Relationship to back pain, disc diseaseand sciatica. J Amer Med Assoc. 1955; 157: 1107-1109.16. Wigh R, Anthony HF. Transitional lumbosacral discs. Spine 1980; 6: 168-171.Cilt 7, Say› 1-2, Ocak-Nisan 200149