教案：颈腰椎

1、山东大学授课教案（6年制）课程名称：外科学本次授课内容：颈肩痛、腰腿痛教学日期：2007,4,3授课教师姓名：宫明智职称：副主任医师授课对象：临床医学专业6年制授课学时2教材名称外科学6年制授课方式讲课本章节的教学目的与要求：1、了解腰腿痛的病因分类，了解腰椎间盘突出症的病因，熟悉分型及病理，掌握临床表现，熟悉诊断依据，了解治疗方法。2、了解颈椎解剖概要，了解颈肩痛的病因及分类，掌握颈椎病的分型、临床表现，熟悉诊断依据，了解鉴别诊断、治疗方法。授课内容及学时分配第一节腰椎退行性疾病概述：腰腿痛是指下腰、腰舐、舐骼、臀部等处的疼痛，可伴有一侧或两侧下肢痛、马尾神经症状。颈肩痛是指颈、肩、肩胛等处

2、疼痛，有时伴有一侧或两侧上肢痛、颈脊髓损害症状。临床表现多样化，病因复杂化，故诊断、鉴别诊断困难，“病人腰痛，大夫头痛”。第一节腰腿痛1、疼痛容易发生在活动与不活动的交界处，如腰椎与舐椎结合部一下腰痛。腰椎骨折、脊柱结核易发生在胸腰椎结合部一T12,L1处。2、腰椎依靠椎间盘、关节突关节、前后纵韧带、黄韧带、棘上韧带、棘间韧带、横突间韧带等连接，舐棘肌、腰背肌、腹肌等协助增加稳定性。骨骼、肌肉、筋膜、韧带、神经、血管任何组织的病变（外伤、炎症、退行性变、肿瘤、结核、发育不良等）的排列组合能产生许多疾病。另外内脏的疾病向腰部传到、放射、牵涉痛。3、看书873页表腰腿痛病因分类。4、注意疼痛性质：

3、局部疼痛，牵涉痛，放射痛5、压痛点：表浅组织压痛点特定，深部结构（如小关节、椎间盘、椎体）深处压痛，病人往往指不明确。（15分钟）最多见的原因一一腰椎间盘突出症（30分钟）Lumbardiskherniation一、是椎间盘变性，纤维环破裂，髓核突出刺激或压迫神经根、马尾神经所表现的综合征，是腰腿痛的最常见原因之一。2050岁多见，男多于女。长期坐位工作（办公室、汽车司机等），近年年轻化，增多化。二、病因（简略讲）3、 分型1、膨隆型（膨出）2、突出型3、脱垂游离型（脱出）4、休莫结节及经骨突出型4、 临床表现（重要，掌握）（一）症状1、 腰痛2、 坐骨神经痛（Sciatica）坐骨神经（sc

4、iaticnerve）的组成（1,2,3,4,5,的含义），为什么坐骨神经痛？（L4,5L5S1）占90%放射痛（radicularpain）3、 马尾神经症状大小便障碍，鞍区感觉异常。（二）体征1、腰椎侧突代偿性，为缓解疼痛。2、腰部活动受限3、压痛及舐棘肌痉挛4、直腿抬高试验及加强试验(LaseguesignThestraightleg-raisingtest)positiveabove90%)5.健腿抬高试验(Fajersztajnsign)Thecrossstraightleg-raisingtestpositive5、神经系统检查感觉肌力反射(踝反射(theanklejerkrefl

5、exisdecreasedorabsent)肛门反射，肛门括约肌张力低(三)特殊检查1、X-RAYplainfilm2、CTcomputedtomography4、 MRI5、 其他肌电图五、诊断(熟悉)六、鉴别诊断对口腔专业只作了解提醒：注意与腰椎肿瘤、结核鉴别，不要误诊。七、治疗(一)非手术治疗1、 卧床休息2、 牵弓3、4、 理疗、推拿、按摩5、 椎管注药6、 化学溶核（二）手术仅作了解本次课主要外语词汇见打印的短文教具：1、腰椎骨骼标本，2、腰椎解剖挂图，3、多媒体幻灯片思考题：（5分钟）1、什么腰椎间盘突出压迫坐骨神经？2、不作CTMRI如何从查体进行定位诊断？参考教材出症胡有谷主编

6、腰椎间盘突第二节颈椎退行性疾病（50分钟）一、颈椎病概念因颈椎间盘退行性变及其继发性改变，刺激脊髓、神经、血管和食管等组织，并引起症状或体征者称为颈椎病。（Cervicaldegenerativediseaseoccursaspartofthenomalagingprogressandisoftenasymptomatic.Commonlyoccurringsymptomsincludeneckpain,radiculopahy,andmyelopathy）5分（一）复习颈部解剖边讲边提问15分钟1、7个颈椎第一颈椎叫第二颈椎叫横突孔（17有）内走的什么（第16）什么是钩椎关节（下一椎体的钩突

7、与上一椎体的斜坡）2、颈椎之间的连接五个关节后纵韧带的特点（中部厚，故两侧突出）项韧带钙化3、颈丛：颈14神经的前支组成，支配颈部肌肉、膈肌、颈、枕、面部感觉后支组成颈后丛颈2发出的枕大神经（枕下痛，同侧头皮感觉异常）4、臂丛的组成5,6,7,8,1的含义（二）病因与分类除与腰腿痛相似外，椎动脉、交感神经受到刺激引起的头、胸、心、肺、眼、耳等全身症状，因此难以区分。1、病因（Pathogensis）了解退行性变（degenerativechanges）损伤先天性椎管狭窄（12毫米相对，10毫米绝对）2.分型及各自的临床表现掌握15分神经根型颈椎病脊髓型颈椎病（重点讲授）颈脊髓病功能评估JOA1

8、7分法交感神经型颈椎病椎动脉型颈椎病症状多，体征少，症状不特异，常与其它病的症状相似混合型或复合型颈椎病三.诊断熟悉以下10分四.鉴别诊断了解五治疗(Neckpainandradiculopathyusuallyresolvewithnonoperativemodalities.)(一)非手术治疗1 .牵弓2 .颈托、颈围3 .按摩强调强行推拿的危害4 .理疗5 .自我保健特殊职业会计、伏案、电脑6 .药物(二)手术(aims:decompressionandstability)了解1、前路(anteriordiskectomy)2、后路(posteriorsurgicalprocedures

9、)重点颈椎病的分型，各型的临床表现。了解治疗原则主要外语词汇见复印短文教具：颈椎骨骼标本多媒体幻灯片二、颈椎管狭窄症(thecervicalcanalstenosis)矢状径临界值13mm,小于13为椎管狭窄三、颈椎间盘突出症(cervicaldischerniation)四、后纵韧带骨化(ossificationoftheposteriorlongitudinalligament)思考题：1、脊髓型颈椎病为什么发生在下颈椎？参考教材如有精力，可阅读7年制外科学教材。第三学时前20分钟讨论，结合X线片，CT,MRI片回答同学提出的问题20分钟时间集体阅读讲解英文短文，材料每人1份最后5分钟，本

10、次课总结LumbarDiskHerniationSymptomaticdiskherniationsareseeninallagegroupsbuthavetheirpeakinpatientsagedbetween35and45years.Riskfactorsincludesedentaryworkandmotorvehicledriving.Sciatica,characterizedbypainradiatingdowntheleginadermatomaldistribution,isthemostcommonsymptomandisfoundin40%ofpatientswithd

11、iskherniation.PathophysiologyAdiskherniationisusuallyprecededbydegenerativechangesinsidethedisk.Circumferentialtearsintheannulusprogresstoradialtears,andtheseinturnfrequentlycauseinternaldisruptionorfrankherniation.ClinicalfindingsA. SymptomsandSigns:Thetypicalsciaticaiscommonlyprecededbybackpainfor

12、aperiodofdaysorweeks.Themobilityofthelumbarspineisdiminishedmoreinflexionthaninextension.Coughing,sneezing,oravoluntaryValsalvamaneuvercommonlyaggravatestheradiatingpain.Prolongedsittingalsoaccentuatesthepain.Inthemorethan90%ofcases,lumbardiskherniationsarelocalizedatL4-L5andL5-S1.WhentheL4nerveroot

13、isaffected,theremaybeweaknessofthequadricepsmuscle,andthepatellatendonreflexmaybedepressedorabsent.CentralorparacentraldiskherniationsatL4-L5usuallycompromisetheL5nerveroot,wheretheymaycausenumbnessintheL5dermatomeandweaknessofthefootandtoedorsiflexions.AdiskherniationatL5-S1usuallycompromisestheS1n

14、erveroot,causingnumbnessorpainintheS1dermatone,weakplantarflexionofthefoot,lossoftheAchillestendonreflex,ortinglinginthenervedistrbution.Thestraightleg-raisingtestshouldbeperformed.TheLaseguesign（painwhentheaffectedlegiselevated）ispositivein98%ofpatientswithlumbardiskherniation.B. ImagingStudies:MRI

15、isthestandardfordiagnosisofaherniationdisk.28%ofasymptomaticpatientsshowadiskherniationonMRI.CTscanningandmyelographyarefrequentlyusedtoconfirmthediagnosis.TreatmentThegoaloftreatmentistoreturnthepatienttonormalactivitiesasquicklyaspossible.Unnecessarysurgeryshouldbeavoided.A.ConservativeTreatment:T

16、wodaysofbedrestfollowedbyagoodphysicaltherapyprogramwilloftenAnalgesics（止痛剂）epidural（硬膜外）B.SurgeryTreatmentleadtosignificantalleviationofsymptomswithin2or3weeks.nonsteroidalmedicine;corticosteroid（皮质醇）chiropractic（按摩疗法）adjustment;About10%ofpatientswithlumbardiskherniationwillultimatelyrequiresurgery

17、。Surgeryisrecommendedifthesciaticissevereanddisablingandtentionsignsarepositive,ifsymptomspersistwithoutimprovementforlongerthan1month,oriffindingsonclinicalexaminationandindiagnosictestsareconsistentwithnerverootcompromise。Standarddiskectomy;Microdiskectomy。Chemonucleolysisofherniateddisk（化学溶核法）Chy

18、mopapain（木瓜凝乳蛋白酶）Risk:duraltear,wronglevelexploration,hemorrhage,infection,nervedeficitGongmingzhiMay5,2006CervicalspondylosisCervicalspondylosisisdefinedasageneralizeddiseaseprocessaffectingtheentirecervicalspineandrelatedtochronicdiskdegeneration.Inabout90%ofmenolderthan50yearsand90%ofwomenolderth

19、an60years,degenerationofthecervicalspinecanbedemonstratedbyradiographys.Initialdiskchangesarefollowedbyfacetarthropathy,osteophyteformation,andligamentousinstability.Myelopathy,radiculopathy(神经根病),orbothmaybeseensecondary.Pathophysiologygavethefirstaccountofa“spondyloticbarSubsequentworkrevealedthat

20、diskdegenerationandosteoarthritiscouldleadtocordandrootimpingement.ThemostfrequentlyinvolvedlevelsarethemoremobilesegmentsC5-C6,C6-C7,andC4-C5.Thesagittalcervicalcanaldiameterwasappreciablysmaller(3mmonaverage)inthemyelopathicspodyloticspinethanthenormalspine.ClinicalfindingA. SymptomsandSigns:Heada

21、cheiscommonlylocatedintheoccipitalregionandradiatestowardthefrontalarea.Apainful,stiffneck.1. CervicalspondyloticradiculopathyThechiefcomplaintisradiationofpainintotheinterscapularareaandintothearm.Typically,patientshaveproximalarmpainanddistalparesthesias.2. Cervicalspondyloticmyelopathy-Patientsof

22、tenpresentwithparesthesias,dykinesiasprweaknessofthehand,theentireupperextremity,orthelowerextremity.Deepachingpainoftheextremity,broad-basedgait（步态）,lossofbalance,lossofhangdexterity（技巧）,andgeneralmusclewastingarefoundinpatientswithadvancedmyelopathy.Impotence（性无能）isnotuncommoninthesepatients.Deept

23、endonreflexescanbeeitherhyporeflexicorhyperreflexicoThepresenceofHoffmannreflexorBabinskireflexindicateanuppermotorneuronlesionHighcervicalspondylosis（C3-C5）leadstocomplaintsofnumbandclumsy（JfB）hands,whilemyelopathyofthelowercervicalspine（C5-C8）presentwithspasticity（痉挛）andlossofproprioception本体感觉inlegs。B. Imagingstudies：X-rayfilmsmayshowsingleormulti