非特異性腰痛の可視化治療• 出沢明PEDセンター• 出沢明

Recommendations in the European clinical guidelines fordiagnosis and treatment of chronic low back pain
• Diagnosis• Diagnostic triage to exclude specific pathology and nerve root pain
• Assessment of prognostic factors (yellow flags) such as work related factors,
psychosocial distress, depressive mood, severity of pain and functional
impact, prior episodes of low back pain, extreme symptom reporting, andpatient's expectations• Imaging is not recommended unless a specific cause is strongly suspected• Magnetic resonance imaging is best option for radicular symptoms, discitis, orneoplasm• Plain radiography is best option for structural deformities

可視化治療• 後枝内側枝• 上殿皮神経• Far out
• 梨状筋と坐骨神経の異常• HIZ• Furcal nerve• 多裂筋の変性• Adamkiewicz動脈長期外来待患者の下肢痛の変化

椎間板ヘルニア

ｓｃｓ

原因不明

JOA（23,000）

JSRS（3,300）
JOSKAS(3,600)

JESMISS(335)

JSES(１4，０(response rate 56.4%) Mean 1148facility

70

asked to fill in the survey form with ％the details of
the operations and relevant incidents as well as the incident levels.

1300601150

50

1000

40

850

30

2005

2006

2007

2008

2009

2010

2011

％
facility

2012

2013

2014

700

undertook spinal endoscopic surgery
28300

21.6% of the responding facilities
24.8

263

21.5

225

18.3

188

15

150
2006

2007

2008

2009

2010％

2011

2012
facility

2013

2014

Number of endoscopy (Japan)
13731

14000

13004
11154 10962
10099

10500

• total
7543
6239 6459

7000
4611

3500

0
2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

MED
PED
MEL
cervicaltotal

Each MIS procedure
グラフタイトル
140

134

133

115
105

105
100
94
89

109
102

91

82
74
70

78

71

61
55
48
44

43
36

35035
31

270000411281200620072008

2009201020112012

2013

MED
cervicalPED

141192014

1220152016

MEL

Number of incident
In a multicenter study of over 100.000 MISS cases for decade
400361335287284

300

267

186200
161
124

133

1006602005 2006 2007 2008 2009 2010 2011 2012 2013 2014

Incident ratio
32.81
2.69

2.62
2.49

2.25

2.47

2.39

2.58
2.4

2.13

1.57

1.5

Mean 2.415%

0.7502005 2006 2007 2008 2009 2010 2011 2012 2013 2014

4complications• Dural tear

MEL>MED>cervical>PELD• 2.92

• SEH

0.24

0.32

0.130.13

cervical > MEL> MED>PELD0.23• Nerve injury

0.47

MEL ＞cervical ＞ MED ＞PELD
0.48• Infections

1.37

0.05

0.04

0.03

PELD >cervical > MEL> MED
0.47
0.23
0.14

0.13

Treatment• Recommended—Cognitive behaviour therapy, supervised exercise
therapy, brief educational interventions, and multidisciplinary(biopsychosocial) treatment, short term use of non-steroidal antiinflammatory drugs and weak opioids.
• To be considered—Back schools and short courses of manipulationand mobilisation, noradrenergic or noradrenergic-serotoninergic
antidepressants, muscle relaxants, and capsicum plasters.
• Not recommended—Passive treatments (for example, ultrasoundand short wave) and gabapentin. Invasive treatments are in general
not recommended in chronic non-specific low back pain.

Structuralsourcesoflowbackpain• 1. Zygapophyseal joint• Mooney V Clin Orthop RR1976.149-56• McCall IWSpine1979:4.441-6• Fukui S Clin J Pain 1997,303-7

• 2．

ＳＣＮ

• Bogduk N Med J Aust.1980.537-41• ３．

Transverse run of nerve root

• KellgrenJH Clin Sci.1939.35-46• Feinstein B JBJSAm1954.981-7• 4．

Piriformis synd

• 5.
• 6.
• 7.
• 8.

Sinuvertbral nerve
segmental vessel
anomally of nerve
muscle of back

• KellgrenJH Clin Sci.1938.３．１７５−１９０• Bogduk N Med J Aust.1980.537-41

MRミエログラフィー撮影法 (BASG：Balanced Steady State
Acquisition with Rewound Gradient Echo)• BASGあるいは3D-COSMICシーケンスは、全ての方向の傾斜磁場加量のバランスをとる方法である。撮像条件として短TR・短TEを用いることで、定常状態(縦磁化が一定の状態)で信号を取得する。
• Sliding MIPは、3次元的に収集したボリュームデータに対し、ある程度の薄いスラブ厚（5~10mm程度）のMIP像を平行移動させながら表示する。Sliding MIPでは薄いスラブ厚を複数表示させることができるため、詳細な情報を評価できるようになり有用性が高い。

Sliding MIP処理MIP処理

ボリュームデータ

MIP像
Sliding MIPは、3次元的に収集したボリュームデータに対し、ある程度の薄いスラブ厚（5~10mm程度）のMIP像を平行移動させながら表示する手法です。
従来のMIPでは厚いスラブ厚（全体を1枚の画像で表示するため）であるため、前後関係を評価し難い点がありましたが、Sliding MIPでは薄いスラブ厚を複数表示させることができるため、詳細な情報を評価できるよBASG 画像

聴神経3D

脊椎神経根

門脈MRA

心臓CINE

全下肢MRA

日立

Philips

SIEMENSGE

BASG

Balanced FFE

True FISP

FIESTAOblique pediculectomy
to caudal migration

07:14:13!20

Beaton;JBJS,1938(Pecina;acta anat1979)
Tibial N.

Common Pero. N.

2.1(0.8)%

0.8(0)%

7.1（20.8)%90(78.5)％

右臀部痛

ZiostationStructural sources of low back pain
• 1. Zygapophyseal joint• 2． ＳＣＮ• ３．

Transverse run of nerve root

• 4．

Piriformis synd

• 5.
• 6.
• 7.
• 8.

Sinuvertbral nerve
segmental vessel
anomaly of nerve
muscle of back（M. Multifidus)

椎間関節症

椎間関節症• Stage1 98/196

264/196333/196Rhizotomy

RHizolysis

47歳女性両臀部痛
下肢に関連痛Kempサイン陽性
MRI正常The Medial Branch• The medial branch originates from the stem of the PRSN on the superiorside of the transverse process of the lower vertebra as the other twobranches do. After the origin, the medial branch takes a posteromedialdirection. After passing through the area posterior to the origin of thetransverse process, the branch always passes on the bony floor underthe mammilloaccessory ligament. Then, it delivers branches to the upperand lower facet joints before providing branches to the multifidus muscle.
The mammilloaccessory ligament is a collagen-rich part of the origin of
the longissimus and iliocostalis muscles. The ligament covers, fixes, andprotects the medial branch as a strong bundle, which contains the medial
branch in a fat tissue cover. The medial branch supplies motor fibers tothe multifidus muscle while it runs along the spinous process andinterspinous ligament in the multifidus muscle. The extension of the mainstem of the medial branch produces fine branches in the subcutaneous
region to supply the cutaneous region near the midline. The close regionof the skin to the midline is bilateral supply.

Rhizotomy

Rhizotomy
Rhizolysis

Outcome between Rhizolysis &RhizotomyStructural sources of low back pain
• 1. Zygapophyseal joint• 2． ＳＣＮ(superior cluneal nerve)上殿皮神経• ３．

Transverse run of nerve root

• 4．

Piriformis synd

• 5.
• 6.
• 7.
• 8.

Sinuvertbral nerve
segmental vessel
anomally of nerve
muscle of back（M. Multifidus)

pathoanatomy• Tholacolumbar fascia• Artery• Osteofibrous tunnel

pathoanatomy• Tholacolumbar fascia• Artery• Osteofibrous tunnelpathoanatomy• Tholacolumbar fascia• Artery• Osteofibrous tunnel