Change of paravertebral muscle in patients with lumbar degenerative disease

doi:10.3969/j.issn.2095-4344.2014.44.028

Abstract

Abstract:

BACKGROUND: Lumbar paravertebral muscles play an important role for lumbar spinal stability. Increasing studies emphasize on the change of paravertebral muscles in patients with lumbar degenerative disease and therefore have important clinical significance for the rehabilitation training of paravertebral muscle in patients with lumbar degenerative disease.
OBJECTIVE: To review the research progress of the change of paravertebral muscle in patients with lumbar degenerative disease and to look into the future development prospects.
METHODS: A computer-based online search of PubMed and WANFANG DATA between 1986 and 2014 was performed with the key words “lumbar vertebra, paravertebral muscle, psoas major, multifidus muscle, cross sectional area, muscle atrophy, fatty infiltration, muscle biopsy, MRI, electromyography” in English and Chinese, respectively. The clinical and experimental studies addressing the changes of paravertebral muscle in patients with lumbar degenerative disease were included. According to the inclusion and exclusion criteria, 48 literatures were included into the final analysis, 8 Chinese and 40 English.
RESULTS AND CONCLUSION: The change of paravertebral muscle in patients with lumbar degenerative disease includes muscle atrophy and fatty infiltration. The changes of paravertebral muscles are often detected with B-ultrasound, CT, MRI, EMG and muscle biopsy. Due to the differences of sample size, age and study method, there are different results, even conflicting. So some limitations of sample size, age and study method are needed to obtain accurate results. In addition, further studies will focus on the verification of which nerve specifically dominants lumbar paravertebral muscles.

中国组织工程研究杂志出版内容重点：人工关节；骨植入物；脊柱；骨折；内固定；数字化骨科；组织工程

全文链接：

Key words: lumbar vertebra, spinal stenosis, radiculopathy, reviews

CLC Number:

R318

Qiao Pei-liu, Tayier•Abuduhadeer . Change of paravertebral muscle in patients with lumbar degenerative disease[J]. Chinese Journal of Tissue Engineering Research, 2014, 18(44): 7205-7210.

Figures/Tables 1

2.1 腰部椎旁肌的解剖腰椎周围的主要肌肉分为前后两群，前群主要包括腰大肌、腰小肌和腰方肌，后群主要为多裂肌、竖脊肌、半棘肌、回旋肌和横突间肌，竖脊肌，又称为骶脊肌，包括髂肋肌、最长肌、棘肌。脊神经根由椎管内发出，向远端延续成脊神经，每个腰椎都有与之对应的腰神经，每根腰神经分为前支与后支，后支发出3条神经干，分别是外侧神经干、中内神经干和内侧神经干。多裂肌是腰椎肌群中最近中线的肌肉，由起于椎板及棘突的多束肌纤维组成，其主要特征是肌纤维从头端向尾端连续及跨多节段放射状分布与下位腰椎的棘突，并受其附着椎体的下位腰椎脊神经后支的中内神经干支配，棘间肌、横突间肌中间内侧部也同样受此神经的支配。竖脊肌起于单个腰椎骨上，止于髂嵴。外侧神经干分布与髂肋肌，中内神经干分布于最长肌。腰大肌起于T12椎体下缘到L5上缘的相邻椎体及椎间盘纤维环，止于股骨小转子及其下方2 cm的股骨干[1]。前支分布于腰椎前部结构，包括腰大肌大部及横突间肌外侧部、横突间韧带和椎间盘外侧部[2]。 2.2 腰椎椎旁肌对于腰椎的稳定作用脊柱的稳定性，指在承受内在或外在负荷的情况下，组成脊柱的各个部分之间保持在相对正常的生理范围内，就是脊柱结构维持本身生理平衡位置的能力。Panjabi[3]提出脊柱稳定性的三亚系模型，即主动亚系、被动亚系、神经控制亚系。主动亚系，是由肌肉和肌腱构成，与神经控制亚系协同活动，共同维持脊柱在中位区域的稳定。被动亚系，即由椎体、韧带、关节突和关节囊等成分组成，在脊柱活动中起着应力感应和支撑作用，同时将应力的变化及时地反馈给神经控制亚系。神经控制亚系，即神经肌肉运动控制系统，对外来信号作出反应，通过主动亚系来达到稳定脊柱的目的。3个亚系是独立因素，某一个因素损害，可以通过其它要素加以代偿。当各个亚系之间的功能无法代偿的时候，脊柱的稳定性就会逐渐丧失，出现各种临床症状，故脊柱的主动亚系即椎旁肌在脊柱的稳定中起着重要作用。Borgbuis等[4]将核心稳定看成是腰-骨盆-髋复合体的肌肉功能状态和运动控制的产物。腰椎的稳定分为内源性稳定和外源性稳定，腰椎的关节和韧带为腰椎提供了内源性稳定，腰部椎旁肌的调节和控制起外源性稳定作用。如果将椎旁肌去除，只剩下韧带、椎间盘和椎体等结构的腰椎，将压力增加到88 N，腰椎就会出现不稳定，而正常机体的腰椎在承受2 600 N的压力时也不会出现腰椎不稳定[5]，另外有学者观察到，将椎旁肌去除，只剩下韧带、椎间盘和椎体等结构的脊柱，将无法承受机体的垂直压缩载荷[6]，充分说明了椎旁肌对脊柱的稳定具有重要的作用。腰大肌具有稳定腰椎的作用主要承担着维持腰段脊柱前倾的姿势稳定[7]。另外，腰大肌还能有效调节腰椎曲[8-9]。根据最新提出的核心稳定概念，脊柱稳定更多的是一种动态稳定，竖脊肌具有发挥运动和力量的作用，具有稳定脊柱的作用[10]，多裂肌在脊柱的稳定和运动控制方面发挥着重要的作用[1、11]，多裂肌能使腰椎发生一定的旋转活动[12]。多裂肌与竖脊肌作为协同肌，二者在维持脊柱正常运动与稳定方面是相辅相成、密切相关的。故将竖脊肌和多裂肌作为腰背伸肌群一起研究。 2.3 腰椎退行性病变中腰椎椎旁肌的组织学变化腰部椎旁肌中包含Ⅰ型纤维(慢颤搐纤维)和Ⅱ型纤维(快慢颤搐纤维)，Ⅱ型纤维分为ⅡB型纤维和ⅡC型纤维。在正常人中，椎旁肌中慢肌纤维Ⅰ占有很高的比例，它对于维持姿势具有重要作用，与男性相比，Ⅰ型纤维在女性中比例更高，进而更好的适应有氧运动。慢性腰痛患者椎旁肌异常包括Ⅱ纤维萎缩，Ⅰ型纤维转换为Ⅱ型萎缩，以及非特异性异常数量的增加[13]。Ⅰ型纤维随着年龄的增加而增加[14]。但是，Crossman等[15]发现正常人和下腰痛患者纤维大小没有差异。Mannion等[16]报道耐受性较差的下腰痛患者的Ⅰ型纤维比例相对于ⅡB型纤维和ⅡC型纤维减少。Ⅰ型纤维转化为Ⅱ型纤维与身体失调和废用性有关[17]。纤维类型改变与症状持续时间有关系，这进一步证明了身体失调的对于纤维类型转化的作用[16]。纤维类型分布在下腰痛患者3个月的康复训练后没有改变，尽管肌肉性能得以提高，腰部经过8周的家庭训练过程之后的5周密集训练与男性多裂肌Ⅱ型纤维的明显增加有关，这一发现反映了训练的特异性，此项训练在女性患者中于多裂肌Ⅱ型纤维没有关系[18]。 2.4 影响腰部椎旁肌横截面积及病理改变的各种因素腰部椎旁肌的变化与很多因素有关，Fortin等[19]发现随着年龄的增加多裂肌和竖脊肌的横截面积逐渐减小，脂肪浸润增加，肌肉组成发生变化，年龄和体质量指数与椎旁肌改变程度有明显的相关性。Paalanne等[20]发现女性的多裂肌脂肪含量明显高于男性，男性多裂肌的横截面积明显大于女性，多裂肌横截面积的改变与疼痛程度没有关系。Kalichman等[21]发现男性椎旁肌肉密度高于女性，年轻人椎旁肌肉密度高于年长者，体质量偏轻者椎旁肌密度高于超重者。多裂肌和竖脊肌密度与腰椎小关节骨性关节炎有明显的相关性，多裂肌密度和椎体滑脱有明显相关性，竖脊肌密度与椎间盘突出有明显的相关性。Ploumis等[22]发现腰痛持续时间、疼痛程度与肌肉萎缩没有相关性。Akgul等[23]发现强直性脊柱炎与放射学阴性脊柱关节炎患者比较，前者多裂肌、竖脊肌、腰大肌横截面积明显减小。但是，强直性脊柱炎患者脂肪浸润评分高于放射学阴性脊柱关节炎患者，椎旁肌脂肪浸润与强直性脊柱炎和放射学阴性脊柱关节炎患者的脊柱功能有关系。综上所述，腰椎椎旁肌的改变与年龄、性别、体质量指数有关，而与腰痛持续时间和疼痛程度没有相关性。 2.5 腰背伸肌群横截面积的研究多裂肌横截面积减小和脂肪浸润被认为是腰痛的危险因素和原因[24]。多裂肌改变已经被报道存在于有慢性腰痛和腰椎退行性疾病的成年患者中[25-26]。关于正常人多裂肌是否存在不对称的讨论已经很多相关报道，Hyun等[27]发现正常人双侧多裂肌截面积对比无差异，但是，有学者应用B超发现正常人同一层面双侧多裂肌横截面积对比存在不同程度的不对称，而且认为多裂肌不对称超过10%被认为是腰部异常的潜在因素[28-29]。Niemeläinen等[30]利用MRI研究600个正常男性多裂肌横截面积在各个层面和左右两侧的差异，发现多裂肌横截面积左侧大于右侧，两侧不对称程度从0.1%到44.3%，至少40%的正常人双侧不对称程度超过10%，竖脊肌右侧横截面积比左侧更大，竖脊肌两侧不对称程度从L3到L5层面逐渐增加，脂肪浸润程度亦增加。Battié等[31]发现多裂肌脂肪浸润可以对腰椎间盘疾病的诊断有指导意义，但是在单个样本的基础上可靠性较差。但是，Msrras等[32]发现在正常人双侧竖脊肌横截面积对比无明显差异。多裂肌萎缩主要以肌肉萎缩和脂肪浸润的形式表现出来，神经根病变一直被认为是导致肌肉萎缩的原因之一，有报道发现多裂肌横截面积在椎间盘和神经受损后减小[33-34]。为了证实这一点，Shafaq等[35]发现有单侧神经根病变的腰椎椎管狭窄患者有症状侧多裂肌横截面积明显减小，脂肪浸润增加，退行性腰椎侧凸患者凹侧多裂肌MRI高信号强度改变，凹侧多裂肌横截面积明显小于凸侧，脂肪浸润百分比明显高于凸侧，认为退行性腰椎侧凸患者凹侧更容易出现肌肉萎缩，神经根病变和脊柱畸形可能促使椎旁肌退变的发生。同样，谢冬晓等[36]发现有单侧神经根症状的腰椎椎管狭窄患者在 L4和L5水平两侧多裂肌横截面积和脂肪浸润对比有差异。但是，Yarjanian等[37]发现腰背伸肌群横截面积从正常人到腰痛患者再到腰椎椎管狭窄患者逐渐减小，椎管狭窄患者比腰痛者更易出现腰背伸肌群萎缩，但是腰背伸肌群萎缩的程度并不能用腰背伸肌群去神经性的程度所解释，认为腰背伸肌群的萎缩可能是可逆的。Lee等[38]利用MRI发现在有慢性腰痛中年男性患者中，腰背伸肌群横截面积的大小、性别和体质量指数是影响腰背部力量的因素。 2.6 腰大肌横截面积的研究一些学者认为腰大肌萎缩性改变与单侧椎间盘突出和单侧腰痛有关[39]，单侧椎间盘突出者发生突出侧腰大肌横截面积减小，单侧腰痛患者肌肉萎缩发生于疼痛侧。但是，Danneels等[40]发现慢性腰痛患者和正常人对比腰大肌横截面积没有明显差异。针对两种相互对立的结果，Arbanas等[41]发现在所有层面腰痛患者腰大肌横截面积较正常人增大，腰痛患者左侧和右侧腰大肌横截面积对比无差异。超过80%的检查者，不管是正常人还是患者，没有表现出任何腰大肌脂肪浸润的征象，腰大肌横截面积与腰部伸肌群脂肪浸润成负相关。此项结果与Ropponen等[42]的结果相似，发现在腰痛患者腰大肌没有或者有极少脂肪浸润的同时腰部伸肌群脂肪浸润达到较高的程度。另外，Kim等[43]发现绝经后腰椎骨折及骨质疏松与腰大肌改变有关系，绝经后腰椎骨折及骨质疏松患者腰大肌横截面积减小。朱康等[44]认为椎旁肌横截面积的形态学变化可能是退行性腰椎滑脱重要因素，其中腰大肌的萎缩是主要影响因素。 2.7 康复训练对腰椎退行性疾病患者的腰椎椎旁肌横截面积变化的研究腰部椎旁肌康复训练对于腰椎退行性疾病的治疗具有重要作用，静态稳定训练、动态训练和动静态结合的训练已经成功的在治疗腰痛中应用，Danneels等[45]报道慢性腰痛患者经过10周，每周3次的平衡训练和之后的动静态力量训练后，肌肉横截面积在L3和L4层面明显增加3%-4%。Lescher等[46]发现慢性腰痛患者在进行了为期3个月，1周2次的现代积极的物理治疗和低强度有氧舞蹈治疗之后，腰部椎旁肌横截面积增加8%。Storheim等[47]发现亚急性腰痛患者经过综合训练后椎旁肌的横截面积和密度有增加的趋势，而没有训练的患者在L4-L5层面椎旁肌横截面积明显减小，两组患者对比在L4-L5层面有明显的差异。经过训练的患者的背部扩展强度增加。但是，Kaser等[18]慢性腰痛患者通过3个月的物理治疗、肌肉训练和有氧运动后发现3个月的运动治疗对于逆转慢性腰痛患者肌肉的糖酵解没有效果，对于改变肌肉的大小没有作用。另外，Enomoto等[48]利用肌电图发现在站立位，腰椎后凸患者比腰椎椎管狭窄患者的腰背伸肌群活力更强，更容易产生肌肉疲劳。"

References

[1]赵东风,范顺武,杨迪生,等译. The Biomechanics of Back Pain.腰痛的生物力学[M].北京:北京大学出版社,2005:28.
[2]海涌,郑召民,陈仲强,等译. The lumbar spine.腰椎外科学[M].济南;山东科学技术出版社,2006:56-57.
[3]Panjabi MM. The stabilizing system of the spine. Part I. Function, dysfunction, adaption, and enhancement. J Spinal Disord. 1992;5:383-389.
[4]Borghuis J, Hof AL, Lemmink KA.The importance of sensory-motor control improviding core stability: implications for measurement and training. Sports Med. 2008;38(11): 893-961.
[5]刘邦忠,李泽兵.躯干肌在腰椎稳定性中的作用[J].中华物理医学与康复杂志,2003,25(1):47-48.
[6]韦峰,兰杰,杨欢,等译. Orthopaedic Knowledge Update:Spine 3.美国骨科医师协会.脊柱外科学[M]. 3版.北京:北京大学医学出版社, 2013: 20-22.
[7]Regev GJ, Kim CW, Lee YP, et al. Psoas Muscle Architectural Design, In Vivo Sarcomere Length Range,and Passive Tensile Properties Support Its Role as a Lumbar Spine Stabilizer. Spine. 2011;36(26):E1666-1674.
[8]韦以宗,桂清民,孙永章,等. 腰大肌作用与腰曲关系的动态下 X 线片研究[J]. 中国临床解剖学杂志, 2005,23(16):579-582.
[9]韦以宗,田新宇,王慧敏,等.腰大肌与腰椎运动力学关系动物实验研究[J]. 中国临床解剖学杂志,2011,29(1):97-99.
[10]Ng J, Richardson CA, Ga J, et al. Electromyographic amplitude a5nd frequency changes in the iliocostalis lumborum and multefidus muscles during a trunk holding test. Phys Ther. 1997;77(9):954-961.
[11]Moseley GL,Hodges PW,Gandevia SC.Deep and superficial fibers of the lumbar multifidus muscle are differentially active during voluntary arm movements. Spine. 2003;27(2):29-36.
[12]Andersson EA,Grundstrom H,Thorstensson A. Diverging intramuscular activity patterns in back and abdominal muscles during trunk rotation. Spine. 2002;27(6):152-160.
[13]Demoulin C, Crielaard JM, Vanderthommen M. Spinal muscle evaluation in healthy individuals and low-back-pain patients: a literature review. Joint Bone Spine. 2007;74:9-13.
[14]Mannion AF, Kaser L, Weber E, et al. Influence of age and duration of symptoms on fibre type distribution and size of the back muscles in chronic low back pain patients. Eur Spine J. 2000;9:273-281.
[15]Crossman K, Mahon M, Watson PJ, et al. Chronic low back pain-associated paraspinal muscle dysfunction is not the result of a constitutionally determined ‘‘adverse’’ fiber-type composition. Spine. 2004;29:628-634.
[16]Mannion AF, Connolly B, Wood K, et al. The use of surface EMG power spectral analysis in the evaluation of back muscle function. J Rehabil Res Dev. 1997;34:427-439.
[17]Haggmark T, Eriksson E, Jansson E. Muscle fiber type changes in human skeletal muscle after injuries and immobilization. Orthopedics. 1986;9:181-185.
[18]Kaser L, Mannion AF, Rhyner A, et al. Active therapy for chronic low back pain: part 2. Effects on paraspinal muscle cross-sectional area, fiber type size, and distribution. Spine. 2001;26:909-919.
[19]Fortin M, Videman T, Gibbons LE, et al. Paraspinal Muscle Morphology and Composition: A 15-yr Longitudinal Magnetic Resonance Imaging Study. Med Sci Sports Exerc. 2014;46(5): 893-901.
[20]Paalanne N, Niinimäki J, Karppinen J,et al. Assessment of Association Between Low Back Pain and Paraspinal Muscle Atrophy Using Opposed-Phase Magnetic Resonance Imaging. Spine. 2011;36: 1961-1968.
[21]Kalichman L, Hodges P, Li L, et al. Changes in paraspinal muscles and their association with low back pain and spinal degeneration: CT study. Eur Spine J. 2010;19:1136-1144.
[22]Ploumis A, Michailidis N, Christodoulou P, et al. Ipsilateral atrophy of paraspinal and psoas muscle in unilateral back pain patients with monosegmental degenerative disc disease. Br J Radiol. 2011; 84:709-713.
[23]Akgul O, Gulkesen A, Akgol G, et al. MR-defined fat infiltration of the lumbar paravertebral muscles differs between non-radiographic axial spondyloarthritis and established ankylosing spondylitis. Mod Rheumatol.2013;23:811-816.
[24]Kjaer P, Bendix T, Sorensen JS,et al. Are MRI-defined fat infiltrations in the multifidus muscles associated with low back pain? BMC Med. 2007;5:1-10.
[25]Lee JC, Cha JG, Kim Y, et al. Quantitative analysis of back muscle degeneration in the patients with the degenerative lumbar flat back using a digital image analysis: comparison with the normal controls. Spine (Phila Pa 1976). 2008;33 : 318-325 .
[26]Hodges P, Holm AK, Hansson T, et al. Rapid atrophy of the lumbar multifidus follows experimental disc or nerve root injury.Spine (Phila Pa 1976). 2006;31: 2926-2933 .
[27]Hyun JK, Lee JY, Lee SJ, et al. Asymmetric atrophy of multifidus muscle in patients with unilateral lumbosacral radiculopathy. Spine (Phila Pa1976). 2007;32:E598-602.
[28]Yanik B, Keyik B, Conkbayir I. Fatty degeneration of multifidus muscle in patients with chronic low back pain and in asymptomatic volunteers: quantification with chemical shift magnetic resonance imaging. Skeletal Radiol.2013;42: 771-778.
[29]Hides J, Gilmore C, Stanton W, et al. Multifidus size and symmetry among chronic LBP and healthy asymptomatic subjects. Man Ther. 2008;13:43-49.
[30]Niemeläinen R, Briand MM, Battié MC. Substantial asymmetry in paraspinal muscle cross-sectional area in healthy adults questions its value as a marker of low back pain and pathology. Spine. 2011;25: 2152-2157.
[31]Battié MC, Niemelainen R, Gibbons LE, et al. Is level- and side-specific multifidus asymmetry a marker for lumbar disc pathology? Spine J. 2012;12: 932-939.
[32]Marras WS, Jorgensen MJ, Granata KP, et al. Female and male trunk geometry: size and prediction of the spine loading trunk muscles derived from MRI. Clin Biomech (Bristol, Avon). 2001;16:38-46.
[33]Hodges P, Holm AK, Hansson T, et al. Rapid atrophy of the lumbar multifidus follows experimental disc or nerve root injury.Spine (Phila Pa 1976). 2006;31: 2926-2933.
[34]Hyun JK,Lee JY,Lee SJ, et al. Asymmetric atrophy of multifidus muscle in patients with unilateral lumbosacral radiculopathy. Spine. 2007;32: E598-602.
[35]Shafaq N, Suzuki A, Matsumura A, et al. Asymmetric Degeneration of Paravertebral Muscles in Patients With Degenerative Lumbar Scoliosis. Spine (Phila Pa 1976). 2012;37(16):1398-1406.
[36]谢冬晓,丁文元,申勇,等. 退变性腰椎侧凸两侧椎旁肌的影像学差异及其临床意义[J].中华外科杂志,2012,50(11):975-980.
[37]Yarjanian JA, Fetzer A, Yamakawa KS, et al. Correlation of paraspinal atrophy and denervation in back pain and spinal stenosis relative to asymptomatic controls. Spine J. 2013;5(1): 39-44.
[38]Lee HJ, Lim WH, Park JW, et al. The Relationship between Cross Sectional Area and Strength of Back Muscles in Patients with Chronic Low Back Pain. Ann Rehabil Med. 2012; 36: 173-181.
[39]Ploumis A, Michailidis N, Christodoulou P, et al. Ipsilateral atrophy of paraspinal and psoas muscle in unilateral back pain patients with monosegmental degenerative disc disease. Br J Radiol. 2011;84: 709-713.
[40]Danneels LA, Vanderstraeten GG, Cambier DC, et al. CT imaging of trunk muscles in chronic low back pain patients and healthy control subjects. Eur Spine J. 2000;9:266-272.
[41]Arbanas J, Pavlovic I, Marijancic V, et al. MRI features of the psoas major muscle in patients with low back pain. Eur Spine J. 2013;22:1965-1971.
[42]Ropponen A, Videman T, Battie MC. The reliability of paraspinal muscles composition measurements using routine spine MRI and their association with back function. Man Ther. 2008;13:349-356.
[43]Kim JY, Chae SU, Kim GD, et al. Changes of Paraspinal Muscles in Postmenopausal Osteoporotic Spinal Compression Fractures: Magnetic Resonance Imaging Study. J Bone Metab. 2013;20:75-81.
[44]朱康,孙根文,乔培柳,等.椎旁肌横截面积变化可导致退行性腰椎滑脱[J].中国组织工程研究,2014,18(9):1392-1397.
[45]Danneels LA, Vanderstraeten GG, Cambier DC, et al. The effects of three different training modalities on the cross sectional area of the lumbar multifidus muscle in patients with chronic low back pain. Br J Sports Med. 2001;35:186-191.
[46]Lescher S, Bender B, Eifler R, et al. Isometric Non-Machine-Based Prevention Training Program.Effects on the Cross-Sectional Area of the Paravertebral Muscles on Magnetic Resonance Imaging. Clin Neuroradiol. 2011;21: 217-222.
[47]Storheim K, Holm I, Gunderson R, et al. The Effect of Comprehensive Group Training on Cross-sectional Area, Density, and Strength of Paraspinal Muscles in Patients Sick-Listed for Subacute Low Back Pain. J Spinal Disord Tech. 2003;16(3):271-279.
[48]Enomoto M, Ukegawa D, Sakaki K, et al. Increase in Paravertebral Muscle Activity in Lumbar Kyphosis Patients by Surface Electromyography Compared With Lumbar Spinal Canal Stenosis Patients and Healthy Volunteers. J Spinal Disord Tech. 2012;25(6):E167-173.