ﺑﺮرﺳﯽ ﻣﻘﺎﯾﺴﻪاي ارزش ﺗﺸﺨﯿﺼﯽ دو روش ام آر آي و ﻣﯿﻠﻮﮔﺮاﻓﯽ ﺳﯽ ﺗﯽ ﻣﯿﻠﻮﮔﺮاﻓﯽ در ﺗﻌﯿﯿﻦ ﺳﻄﻮح ﻧﯿﺎزﻣﻨﺪ ﻻﻣﯿﻨﮑﺘﻮﻣﯽ و ﻓﻮراﻣﯿﻨﻮﺗﻮﻣﯽ در ﺑﯿﻤﺎران ﻣﺒﺘﻼ ﺑﻪ ﺗﻨﮕﯽ دژﻧﺮاﺗﯿﻮ ﮐﺎﻧﺎل ﻧﺨﺎع ﮐﻤﺮي ﮐﺎﻧﺪﯾﺪ ﺟﺮاﺣﯽ

Comparison of MRI and Myelography / CT Myelography to Determine the Exact Level of Decompression in Patients Suffering from Degenerative Lumbar Canal Stenosis

زﻣﯿﻨﻪ و ﻫﺪف: ﺗﻨﮕﯽ دژﻧﺮاﺗﯿﻮ ﮐﺎﻧﺎل ﻧﺨﺎع ﮐﻤﺮي ﯾﮑﯽ از ﺑﯿﻤﺎريﻫﺎي ﺷﺎﯾﻊ در ﺣﻮزه ﺟﺮاﺣﯽ اﻋﺼﺎب ﻣﯽﺑﺎﺷﺪ ﮐﻪ در ﺧﺼﻮص روشﻫﺎي ﺗﺸﺨﯿﺼﯽ و ﻣﻌﯿﺎرﻫﺎي ﺗﺸﺨﯿﺺ اﯾﻦ ﺑﯿﻤﺎري اﺗﻔﺎق ﻧﻈﺮ وﺟﻮد ﻧﺪارد. ﻣﯿﻠﻮﮔﺮاﻓﯽ و ﺳﯽ ﺗﯽ ﻣﯿﻠﻮﮔﺮاﻓﯽ ﺑﻪ ﻋﻨﻮان ﯾﮑﯽ از اوﻟﯿﻦ روشﻫﺎي ﺗﺸﺨﯿﺼﯽ ﻫﻨﻮز ﺟﺎﯾﮕﺎه ﺧﻮد را در ﺑﺮﺧﯽ ﻣﻮارد ﺣﻔﻆ ﮐﺮدهاﻧﺪ. از ﻃﺮﻓﯽ ﻧﻘﺺﻫﺎي ام آر آي در ﺷﻨﺎﺧﺖ ﺑﺮﺧﯽ ﭘﺎﺗﻮﻟﻮژيﻫﺎ و ﺟﻨﺒﻪﻫﺎي دﯾﻨﺎﻣﯿﮏ ﺳﺘﻮن ﻓﻘﺮات آﺷﮑﺎر ﺷﺪه اﺳﺖ. ﺑﻪ ﻣﻨﻈﻮر ﻣﻘﺎﯾﺴﻪ ارزش ﺗﺸﺨﯿﺼﯽ اﯾﻦ دو روش، ﻣﻄﺎﻟﻌﺎت اﻧﺪﮐﯽ ﺑﺮ روي ﺗﻨﮕﯽ ﮐﺎﻧﺎل ﻧﺨﺎع ﮐﻤﺮي ﻣﺘﻤﺮﮐﺰ ﺑﻮده ﮐﻪ ﺗﻘﺮﯾﺒﺎً ﻫﻤﻪ آﻧﻬﺎ ﮔﺬﺷﺘﻪﻧﮕﺮ ﺑﻮدهاﻧﺪ. ﻟﺬا اﯾﻦ ﻣﻄﺎﻟﻌﻪ ﺑﻪ ﺻﻮرت آﯾﻨﺪهﻧﮕﺮ و ﺑﺎ ﻫﺪف ﻣﻘﺎﯾﺴﻪ ارزش ﺗﺸﺨﯿﺼﯽ اﯾﻦ دو روش و ﺗﻌﯿﯿﻦ ﻋﻮاﻣﻞ ﻣﺆﺛﺮ ﺑﺮ ﺑﺮﺗﺮي ﻫﺮ روش، ﻃﺮاﺣﯽ ﺷﺪه اﺳﺖ. ﻣﻮاد و روش ﻫﺎ: ﺗﻌﺪاد 83 ﺑﯿﻤﺎر ﻗﺒﻞ از ﻋﻤﻞ ﺟﺮاﺣﯽ ﺗﺤﺖ ام آر آي و ﻣﯿﻠﻮﮔﺮاﻓﯽ - ﺳﯽ ﺗﯽ ﻣﯿﻠﻮﮔﺮاﻓﯽ ﻗﺮار ﮔﺮﻓﺘﻨﺪ. ﺗﺼﺎوﯾﺮ ﺑﻪ ﺻﻮرت ﺑﯽﻧﺎم ﺗﻮﺳﻂ دو ﺟﺮاح اﻋﺼﺎب ارزﯾﺎﺑﯽ ﺷﺪه و ﺗﻌﺪاد ﺳﻄﻮح ﻧﯿﺎزﻣﻨﺪ ﻻﻣﯿﻨﮑﺘﻮﻣﯽ ﺑﺮ ﺣﺴﺐ ﻫﺮ روش ﺛﺒﺖ ﺷﺪ. ارزﯾﺎب دﯾﮕﺮي ﺗﻌﺪاد ﺳﻄﻮح ﺗﻨﮕﯽ را در ﺣﯿﻦ ﻋﻤﻞ ﺟﺮاﺣﯽ ﺛﺒﺖ ﮐﺮد. Inter-Observer Reliability ﺑﺮاي ﻫﺮ روش و ﻫﻤﺎﻫﻨﮕﯽ ﯾﺎﻓﺘﻪﻫﺎي ﻗﺒﻞ از ﻋﻤﻞ ﺑﺎ ﯾﺎﻓﺘﻪﻫﺎي ﺣﯿﻦ ﻋﻤﻞ ﺑﺎ ﻣﺤﺎﺳﺒﻪ ﺿﺮﯾﺐ ﺗﻮاﻓﻖ ﮐﺎﭘﺎ ﻣﺤﺎﺳﺒﻪ ﺷﺪ. ﺗﺄﺛﯿﺮ ﻫﺮ ﯾﮏ از ﯾﺎﻓﺘﻪﻫﺎي دﻣﻮﮔﺮاﻓﯿﮏ، ﺷﺮح ﺣﺎل، ﻣﻌﺎﯾﻨﻪ ﺑﺎﻟﯿﻨﯽ و ﯾﺎﻓﺘﻪﻫﺎي رادﯾﻮﻟﻮژﯾﮏ ﺑﺮ ﺑﺮﺗﺮي ﻫﺮ ﯾﮏ از دو روش ﺑﺎ اﺳﺘﻔﺎده از آزﻣﻮن ﺗﯽ، ﮐﺎي اﺳﮑﻮار و ﺿﺮﯾﺐ ﻫﻤﺒﺴﺘﮕﯽ اﺳﭙﯿﺮﻣﻦ ﻣﻮرد ارزﯾﺎﺑﯽ ﻗﺮار ﮔﺮﻓﺖ. آﻧﺎﻟﯿﺰ دادهﻫﺎ ﺑﺎ اﺳﺘﻔﺎده از ﻧﺮم اﻓﺰار SPSS ﺻﻮرت ﮔﺮﻓﺖ و ﺣﺪ ﻣﻌﻨﯽداري )0/01 < P ( در ﻧﻈﺮ ﮔﺮﻓﺘﻪ ﺷﺪ. ﯾﺎﻓﺘﻪ ﻫﺎ: ﺿﺮﯾﺐ ﺗﻮاﻓﻖ ﮐﺎﭘﺎ ﺑﯿﻦ دو ارزﯾﺎب ﺑﺮاي ام آر آي 0/61 و ﺑﺮاي ﻣﯿﻠﻮﮔﺮاﻓﯽ - ﺳﯽ ﺗﯽ ﻣﯿﻠﻮ ﮔﺮاﻓﯽ 0/56 ﺑﻮد. اﯾﻦ ﺿﺮﯾﺐ ﺑﺮاي ﻫﻤﺎﻫﻨﮕﯽ دو ارزﯾﺎﺑﯽ ام آر آي ﺑﺎ ﯾﺎﻓﺘﻪﻫﺎي ﺣﯿﻦ ﻋﻤﻞ 0/52 و 0/5 و ﺑﺮاي ﻣﯿﻠﻮﮔﺮاﻓﯽ - ﺳﯽ ﺗﯽ ﻣﯿﻠﻮﮔﺮاﻓﯽ 0/43 و 0/45 ﻣﺤﺎﺳﺒﻪ ﺷﺪ. ﭘﺲ از ﺟﺪا ﮐﺮدن ﺑﯿﻤﺎران داراي ﻫﺮﻧﯽ دﯾﺴﮏ از ﺑﯿﻤﺎران ﻓﺎﻗﺪ ﻫﺮﻧﯽ دﯾﺴﮏ، ﮐﺎﭘﺎ در ﻣﯿﻠﻮﮔﺮاﻓﯽ - ﺳﯽ ﺗﯽ ﻣﯿﻠﻮﮔﺮاﻓﯽ ﺑﯿﻤﺎران ﻓﺎﻗﺪ ﻫﺮﻧﯽ دﯾﺴﮏ ﺗﺎ ﺣﺪ 0/36 و 0/39 ﺑﺮاي دو ارزﯾﺎب اﻓﺖ ﮐﺮد. در ﺑﺮرﺳﯽ ﺗﺄﺛﯿﺮ ﻋﻮاﻣﻞ ﻣﺨﺘﻠﻒ ﺑﺮ ارزش ﺗﺸﺨﯿﺼﯽ ﻫﺮ ﯾﮏ از اﯾﻦ دو روش، ﺗﻨﻬﺎ ﻋﺎﻣﻞ ﻣﺆﺛﺮ، ﺗﻨﮕﯽ ﻟﺘﺮال رﺳﺲ ﺑﻮد ﮐﻪ ﻣﯿﻠﻮﮔﺮاﻓﯽ - ﺳﯽ ﺗﯽ ﻣﯿﻠﻮﮔﺮاﻓﯽ در آن ﺗﺎ ﺣﺪ ﻧﺰدﯾﮏ ﺑﻪ ﻣﻌﻨﺎداري دﻗﺖ ﺗﺸﺨﯿﺼﯽ ﺑﺎﻻﺗﺮي داﺷﺖ )0/056 = P(. ﻧﺘﯿﺠﻪ ﮔﯿـﺮي: ام آر آي ﺑﺎ ﺗﻮﺟﻪ ﺑﻪ ﻫﻤﺎﻫﻨﮕﯽ ﺑﯿﺸﺘﺮ ﺑﺎ ﯾﺎﻓﺘﻪﻫﺎي ﺣﯿﻦ ﻋﻤﻞ و Inter-Observer Reliability ﺗﺴﺖ ﺗﺸﺨﯿﺼﯽ اﻧﺘﺨﺎﺑﯽ ﺑﺮاي ﺗﺼﻤﯿﻢﮔﯿﺮي در ﻣﻮرد وﺳﻌﺖ ﻋﻤﻞ ﺟﺮاﺣﯽ ﻣﯽﺑﺎﺷﺪ و ﻣﯿﻠﻮﮔﺮاﻓﯽ - ﺳﯽ ﺗﯽ ﻣﯿﻠﻮﮔﺮاﻓﯽ را ﻣﯽﺗﻮان ﺑﺮاي ﺑﺮرﺳﯽ ﺑﯿﻤﺎران ﻣﺒﺘﻼ ﺑﻪ ﺗﻨﮕﯽ ﻟﺘﺮال رﺳﺲ، ﺑﯿﻤﺎران راﺟﻌﻪ و ﺑﯿﻤﺎران ﺑﺎ ﺳﺎﺑﻘﻪ وﺳﯿﻠﻪﮔﺬاري ﯾﺎ ﺑﻪ ﻋﻨﻮان روش ﺟﺎﯾﮕﺰﯾﻦ ام آر آي و ﺑﺎ ﻫمان دﻗﺖ ﺗﺸﺨﯿﺼﯽ در ﺑﯿﻤﺎران داراي ﻫﺮﻧﯿﺎﺳﯿﻮن دﯾﺴﮏ ﻣﻮرد اﺳﺘﻔﺎده ﻗﺮار داد.

Introduction & Objective: Degenerative lumbar spinal canal stenosis is one of the common entities in neurosurgery. Myelography and CT myelography as one of the first diagnostic procedures still retains its place in some cases. MRI defects in understanding some dynamic aspects of this pathology have been exposed. In order to compare the diagnostic value of these two methods, few studies have focused on lumbar spinal canal stenosis, almost all of them were retrospective. This prospective study designed to compare the diagnostic value of these two methods and to determine the factors affecting reliability of each method. Materials & Methods: 83 patients underwent preoperative MRI and myelography-CT myelography. Pictures were anonymously assessed by two neurosurgeons and the number of levels required laminectomy was recorded according to each modality. Another neurosurgeon intraoperatively assessed the number of levels in need of laminectomy. Inter-observer reliability for each modality and coordination of preoperative findings with intraoperative findings were calculated using kappa coefficient. The impact of demographic, medical history, physical examination and radiologic findings on the superiority of either of the two modalities were analyzed using T test, Chi square and Spearman correlation coefficient. Analysis was performed with SPSS software and (P < 0.01) was considered as significant. Results: Kappa coefficient between two evaluators was 0.61 for MRI and 0.56 for Myelography-CT myelography. This coefficient for agreement of MRI findings with intraoperative findings in 2 evaluations was 0.52 and 0.5 whereas Myelography-CT myelography revealed 0.43 and 0.45 agreement in two evaluations. After excluding the patients with disc herniation, Kappa for myelography/CT myelography has declined considerably to 0.36 and 0.39 in two evaluations. In evaluating the impact of various factors on the diagnostic value of each of these modalities, only lateral recess stenosis was almost related to higher diagnostic value of myelography/CT myelography (P = 0.056). Conclusions: MRI with regard to higher agreement with intraoperative findings and higher Inter-observer reliability should be the diagnostic test of choice to decide on the extent of laminectomy. Myelography/CT myelography can be used for patients with lateral recess stenosis, patients with a history of previous lumbar spine surgery and Instrumentation or as an alternative to MRI with almost the same diagnostic accuracy in patients with disc herniation.