腰腿痛和颈肩痛.ppt

腰腿痛及颈肩痛,四川大学华西医院骨科刘浩教授博导,本次课教学目的,1.了解颈肩痛、腰腿痛的病因及病理生理。2.掌握颈椎病、腰椎间盘突出症的治疗原则。3.熟悉颈椎病、腰椎间盘突出症的分类、诊断和鉴别诊断。,本次课内容,腰腿痛一、腰腿痛的病因、检查、处理原则二、腰椎间盘的解剖，椎间盘变性进程与椎间盘脱出症的病因、病理特点，诊断、治疗、手术适应证三、腰椎管狭窄症的病因、临床表现及诊断、治疗四、腰椎滑脱的特点、治疗与防治,本次课内容,颈肩痛一、解剖生理概要二、颈椎病病因、分类、临床表现及诊断、治疗，防治,Thecauseoflowbackpaininclude:-postureinwrongpositionputthebackatriskdoingsomethingwhichcoulddamageyourback-liftwrongly,weightbeyondyoubodylimitmedicalproblemwhichaffectback,腰腿痛,Thelumbarvertebralcanalisroughlytriangularinshapeandisnarrowestinitsanteroposteriordiameterintheaxialplane.Theaverageanteroposteriordiameterofthelumbarcanalinadults,asdeterminedbyanatomicandradiographicstudies,rangesfrom15to23mm.,Thecanalisboundedanteriorlybytheposterioredgeofthevertebralbodyincludingtheposteriorlongitudinalligament,whichiscloselyapposedtotheposteriorvertebralbodysurface,laterallybythepedicles,posterolaterallybythefacetjointsandarticularcapsules,andposteriorlybythelaminaandligamentaflava(yellowligaments),Normalanatomicstructuresofthelumbarspineatthethirdthroughthefifthlumbarlevels.Notethecloseassociationbetweenthenerverootsandtheduraltube,andtheligamentumflavum,thefacetjoints,thepediclesandthelamina.Theligamentumflavum(interlaminarligament)attacheslaterallytothefacetcapsules.,Posteriorviewofthelumbarregionofthespinalcanal,demonstratingtheconusmedullarisattheL1toL2levelandthecaudaequinanerverootsinferiorly.,腰腿痛常见原因,软组织原因（已讲）腰椎间盘突出症腰椎管狭窄症腰椎滑脱其他,腰椎间盘突出症,Thespineismadeupofbones(vertebrae)thatareseparatedbysoftcushions(intervertebraldiscs).Thesediscsactascushionsbetweenthevertebrae.Theyabsorbenergywhilethespinalcolumnflexes,extends,andtwists.Nervesfromthespinalcordexitthespinalcolumnbetweeneachvertebra.,病因,退变，从18岁开始，不可逆转加重因素外伤职业因素妊娠遗传易感因素腰骶先天异常,病理生理,退变纤维环胶原成分改变软骨终板龟裂髓核弹性蛋白减少，含水量下降,临床表现,症状腰痛和坐骨神经痛下腹部或大腿前侧痛麻木间歇性行走痛马尾综合征肌肉瘫痪,临床表现,体征脊柱外形改变压痛腰椎活动度减低肌肉萎缩，肌力下降感觉减退腱反射改变,临床表现,特殊体征直腿抬高试验直腿抬高加强试验健肢抬高试验仰卧挺腹试验股神经牵拉试验屈颈试验,不同部位椎间盘突出所影响的神经根,注：所产生的症状体征可由所影响神经根推出，或见1052页表,临床表现,影响学检查腰椎X片CTMRI仅有影响学改变而没有症状体征，不能诊断为椎间盘突出症,治疗,非手术治疗牵引，理疗，局部用药手术治疗椎间盘摘除术，非常成熟其他，有待验证,Incisionismadeoverthelowerback,inthemidlinearea.,Thebonethatcurvesaroundandcoversthespinalcord(lamina)isremoved(laminectomy)thetissuethatiscausingpressureonthenerveorspinalcordisremovedTheholethroughwhichthenervepassesisenlargedtopreventfurtherpressureonthenerveSometimes,apieceofbone(bonegraft)ormetalrods(suchasHarringtonrods)areusedtostrengthentheareaofsurgery.,Physicaltherapyissometimesnecessarytooptimizespinalmobility.,腰椎管狭窄症,LumbarSpineStenosisisaCommonCauseofBackandLegPainLumbarspinestenosismostcommonlyaffectsthemiddle-agedandelderlypopulation.Entrapmentofthecaudaequinarootsbyhypertrophyoftheosseousandsofttissuestructuressurroundingthelumbarspinalcanalisoftenassociatedwithincapacitatingpaininthebackandlowerextremities,difficultyambulating,legparesthesiasandweaknessand,inseverecases,bowelorbladderdisturbances.,概述,病因与病理,任何原因所致椎管容积变小,Posteriorviewofthelumbarregionofthespinalcanal,demonstratingtheconusmedullarisattheL1toL2levelandthecaudaequinanerverootsinferiorly.,分型,中央型椎管狭窄失状径小于10mm神经根管狭窄侧隐窝狭窄,临床表现,特点：中老年，重体力劳动者。长期下腰痛。症状重，体征轻症状间歇性跛行体位性跛行缺血性跛行体征腰5、骶1神经分布区混合症状,影像学检查,X线片CTMRI,Axialcomputedtomographic(CT)scanatasinglelumbarvertebrallevelfollowinginjectionofintrathecalcontrastmedium.Notethelumbarcanalnarrowingproducedbyhypertrophiclaminaandpedicles.Posterolateralimpingementonthethecalsacgivestheclassiccloverleafortrefoilshapetothecanal.,UnenhancedT1-weightedaxialmagneticresonancescanatalumbarlevelshowingseverestenosis.Thecombinationofligamentandfacetjointhypertrophyconcentricallyreducesthediameterofthelumbarcanal.Thesignificantreductionintherelativeamountofepiduralfatandsubarachnoidcerebralspinalfluidsignalisfurtherevidenceofthedegreeofcanalstenosis.UnenhancedT1-weightedsagittalmagneticresonancescanofthelumbosacralspineshowingseverecanalstenosisattheL4-5level,producedbyacombinationofdischerniation,spondyloarthritisandposteriorelementhypertrophy.Comparethisstenosiswiththemoderatedegreeofstenosisobservedatlevelsabove.MildspondylolisthesisisalsoevidentatL5-S1.,鉴别诊断,腰椎间盘突出症腰椎关节突关节综合征纤维组织炎,治疗,非手术治疗理疗封闭药物对症治疗手术治疗,手术方法,腰椎滑脱lumbarspondylolisthesis,临床表现,腰痛合并或不合并相应神经根症状影像学改变,治疗,非手术治疗休息、理疗药物对症治疗支俱：腰围等手术治疗二度以上滑脱,手术治疗,滑脱复位神经减压腰椎融合,临床资料,2003年3月至2004年4月6例2063岁腰椎间盘突出症腰椎退变性不稳，峡部裂脊柱滑脱的患者融合节段,Case1,Case1,Case1,Case1,Case2,Case2,Case2,Case3,颈椎退行性疾病,概述,Painlocatedintheneckisacommonmedicalcondition.Neckpaincancomefromanumberofdisordersanddiseasesofanystructureintheneck.Neckpainisalsoreferredtoascervicalpain.,Therearesevenvetebraethatarethebonybuildingblocksofthespineintheneckthatsurroundthespinalcordandcanal.Betweenthesevertebraearediscs,andnearbypassthenervesoftheneck.Withintheneck,structuresincludetheneckmuscles,arteries,veins,lymphglands,thyroidgland,parathyroidglands,esophagus,larynx,andtrachea.,颈椎的结构,Thecervicalspinalcolumnismadeupofvertebralbodieswhichprotectthespinalcord.,Cervicalspinediseaseisusuallycausedbyherniatedintervertebraldiscsabnormalgrowthofbonyprocessesonthevertebralbodies(osteophytes),whichcompressspinalnervesTraumaandnarrowing(stenosis)ofthespinalcolumnaroundthespinalcord.,Symptomsofcervicalspineproblemsincludepainthatinterfereswithdailyactivitiesneckpainthatextends(radiates)totheshoulderorarmweaknessofarmsorlegsnumbnessofarms,hands,orfingers,颈椎退行性疾病的症状,Indiagnosingthecauseofneckpain,itisimportanttoreviewthehistoryofthesymptoms.Inreviewingthehistory,thedoctorwillnotethelocation,intensity,duration,andradiationofthepain.Anypastinjurytotheneckisnoted.Theneckisexaminedatrestandinmotion.Tendernessisdetected.Anexaminationofthenervoussystemisperformed.,颈椎退行性疾病的诊断,FurthertestingofundiagnosedneckpaincanincludeX-rayevaluationCTscanbonescanMyelogramelectricaltestssuchaselectromyography(EMG)andnerveconductionvelocitytest(NCV).,颈椎退行性疾病的诊断,颈椎退行性疾病的治疗,Thetreatmentofneckpaindependsonitsprecisecause.Treatmentoptionsincluderest,heat/iceapplications,traction,softcollar,physicaltherapy(ultrasoun,massage,manipulation),localinjectionsofcortisoneoranesthetics,topicalanestheticcreams,topicalpainpatches,musclerelaxants,analgesics,andsurgicalprocedures.,颈椎退行性疾病的分类,颈椎病颈椎管狭窄症颈椎间盘突出症其他,颈椎病,病因：退变分类神经根型颈椎病脊髓型颈椎病椎动脉型颈椎病交感型颈椎病,影像学检查,X片检查正侧位，左右斜位CTMRI,治疗,非手术治疗理疗封闭药物对症治疗手术治疗脊髓型颈椎病,颈椎管狭窄症,病因与病理,原发性继发性,临床表现,脊髓症状椎管失状径减小Pavlov比值小于0.75,治疗,手术治疗脊髓减压椎管扩大成形,椎管减压技术,椎管减压技术,椎管减压技术,椎管减压技术,颈椎间盘突出症,临床表现,颈痛神经根症状体征脊髓症状体征影像学改变,治疗,非手术治疗牵引，理疗，局部用药手术治疗椎间盘摘除术，非常成熟其他，有待验证,Thesurgeryisdonewhilethepatientisdeepasleepandpain-free(generalanesthesia).Fortheneck(cervicalspine),anincisionmaybemadeeitherinthebackoftheneck(posteriorcervical)orinthefrontsideoftheneck(anteriorcervical),dependingonthelocationoftheproblem.,Thebonethatcurvesaroundandcoversthespinalcord(lamina)isremoved(laminectomy)andthetissuethatiscausingpressureonthenerveorspinalcordisremoved.Thehol