间盘源性腰痛.ppt

间盘源性腰痛-复制疼痛好还是抑制疼痛好？,刘宪义北京大学第一医院,DEFINITION：,DBP（discogenicbackpain）：伴或不伴下肢放射痛的慢性腰痛，起自椎间盘本身，由椎间盘内部正常结构破坏和生化改变引起的腰痛或放射痛,椎间盘内破裂（IDDInternalDiscDisrupation/Derangement）纤维环放射状撕裂RadialTearofannulus痛性纤维环撕裂PainfulAnnulusTear痛性椎间盘病PainDarkDiscDisease退变性椎间盘疾病（DDDDegenerativeDiscDisease)腰椎僵硬LumbarSpondylosis孤立性椎间盘吸收IsolatedDiscResorption节段不稳（SegmentalInstability),Zdeblickclassification:,IDDaccountfor39%ofDBP,ThomasA.Zdeblick,MDTheSpine4thedition750,Theconceptof“internaldisruptions”wasproposedbyCrock,in1970and1986.Lowbackpainmayoccurredwithoutnerverootcompression.,IDD(InternalDiscDisrupation/Derangement),0Normal1Contrastagentinfiltratetoinner1/3ofAnnulus2Contrastagentinfiltratetoouter1/3ofAnnulus3ContrastagentinfiltrateacrosstheouterannulusCTDshowsgrade2mayinducingpain!,DallasclassificationofAnnulusrupturebyCTD,ModifiedDallasDiscogram,Pathogenesis：,椎间盘造影术后的CT轴向扫描,Pathogenesis：,Pathogenesis：,Granulationtissue,SP-,Pathogenesis：,SP-,NF-,VIP-,Pathogenesis：,Exclude：Backpainbutnot“back”disease（2%）Seldomseveredisease（infection,AS）MuscularfasicalradicularpainAcuteinjury,Diagnosis：,ChouR,etal.AnnIntMed2019DiagnosisandTreatmentofLowBackPain:AJointClinicalPracticeGuidelinefromtheAmericanCollegeofPhysiciansandtheAmericanPainSociety.,EuropeanGuidelinesForTheManagementOfAcuteandChronicNonspecificLowBackPainInPrimaryCare2019,GuidelineofLBP:,Diagnosis：,Clinicalcharacters,Cannotsitorwalkforalongtime.,2.Withorwithoutradiatingpain.,Clinicalcharacters,Xray:negativeCT:degenerativechanges.,MRI:T2-weighted:“blackdisc”,Theconceptof“HIZ(HighIndensityZone)”wasfirstproposedbyAprill,in1992.,MRIhighindensityarea,Saifuddin.Etc:Specificity:96;Sensitivity27.Lam.Etc:Specificity:82,Sensitivity:89.AprillandBogduk：Specificity:89%，Sensitivity:71%,provocativepain;Morphologicalchangesofthecontrastagent,5.Discography:“goldstandard”?,5.Discography:“goldstandard”?,SPNFVIP,Lindblom1940propose1950widespreadBlocket&Ohnmeiss：psychologicalproblems-FalsePositiveCarragee：FalsePositive：50Domestic：FalsePositive：47%,5.Discography:“goldstandard”?,Doctor-patientSubjective-objective,5.Discography:,CASEREVIEW:,Female,44y.History：lowbackpainfor2years.aggravatedfor3months.Cannotsit,stand,walkforalongtimeduetotheseverepain.Physicalexamination：notendernessonlumbarvertebra.Noneuro-signs.,X-RAY&MRI:,MRI:blackdiscsandHIZ,Howtoselecttheresponsibledisc?,Multi-discSeverepain:pain,pain,pain!PhysicalpainorPsychologicalpain?,ProvokeInhibit,BAZINGA!,lidocaineisadministeredintradiscallytoinhibitpain.Isitright?,CASEREVIEW:,CASEREVIEW:,AfteradministeredintradiscallyatL4/5-painrelievedobviously.ResidualpainAfteradministeredintradiscallyatL5/S1-paindisappeared.,Research-Method:,2009-8-2019-512patientsDiagnosedasDBPbysymptoms,physicalsignandimagingAverageagewas37.3,Research-Method:,AllpatientswasadministereddiscpunctureunderC-armguiding.Method:,Provoking:contrastagent(Omnipaque)-administeredintradiscallyatresponsiblediscoradjacentdisc-observethepatientsreactions.,Research-Criterion:,Inhibting:lidocaine(Concentrationof1%)-administeredintradiscallyatresponsiblelevel-observethepatientsreactions.,Research-Criterion:,Results:,Provokingpaingroup(6patients):4patientswerepositive.Averageoperationtime:45minutes.Theremainingwereadministratedby“inhibitingpain”-painreleased,Inhibitingpaingroup(6patients):Allpositive-paindisappear,Averageoperationtime:25minutes.,Results:,DISSCUSSION:,腰痛6个月以上；系统保守治疗无效；神经系统检查正常；直腿抬高试验阴性；椎间盘造影有1-2个椎间盘异常，并有6/10原疼痛强度的诱发疼痛（DerbyR，etal：Neuromodulation，2000，3（2）：82）,间盘源性痛诊断标准,Inducethepain-Difficult!,SeverepainPain:beforeduringafterradiographyFalse-positiveMulti-discpathologicalchanges（atleasttwodiscs）NotypicalHIZ,Inhibitthepain-?,Moreeffective&efficientHighreliabilityAcceptedbypatients,YinXXM/31DBP,CASEREVIEW:,Allimagesareauthorizedbythepatient!,FalsePositive？,Inhibitthepain-?,DBP-painreleased!LDH,DLSS,VCF-painreleased?,Casereview:,Sciatica-inefficac