1、Spinal Disorders Fundamentals of Diagnosis and TreatmentSpinal Disorders Fundamentals of Diagnosis and TreatmentSpinal Disorders Fundamentals of Diagnosis and TreatmentSpinal Disorders Fundamentals of Diagnosis and Treatment 腰腿痛：腰腿痛：下腰部、腰骶部、骶髂部、臀部下腰部、腰骶部、骶髂部、臀部的疼痛，可伴有一侧或两侧下肢痛或马尾的疼痛，可伴有一侧或两侧下肢痛或马尾神经症
2、状。神经症状。颈肩痛：颈肩痛：颈、肩、肩胛等处疼痛，伴或者颈、肩、肩胛等处疼痛，伴或者不伴一侧或者双侧上肢痛、颈脊髓损害症不伴一侧或者双侧上肢痛、颈脊髓损害症状。状。Spinal Disorders Fundamentals of Diagnosis and Treatment Back pain more than 80%据瑞典统计资料，53%从事轻体力劳动者和64%从事重体力劳动者发生过明显的腰痛。Neck pain more than 60%.最常见于40岁以下女性，从事坐位工作，颈椎处于前伸位，颈椎生理曲度丧失。青年急性颈部疼痛-突然的颈部活动导致严重的颈和肩部疼痛，保护性肌肉筋挛和活
3、动受限Spinal Disorders Fundamentals of Diagnosis and Treatment Unwholesome posture Degeneration of intervertebral disc and zygapophyseal joints Deformity Trauma Cancer Metastatic tumor Lung,Kidney,Prostate or Mammary Gland OtherSpinal Disorders Fundamentals of Diagnosis and Treatmentno morphological co
4、rrelate can be detected which would satisfactorily explain the pain.About 85%Can be managed non-operatively with physical therapy and analgetic medication Will return to an acceptable pain level within 3 weeks To normal within 3 monthsGenerally,spinal pain is common,benign,and self-limitingSpinal Di
5、sorders Fundamentals of Diagnosis and Treatment LDH LDH是腰腿痛的最常见原因，好发年龄在20-5020-50岁岁之间，儿童和青少年（10-18岁）及老年人（60岁以上）少见。好发的椎间隙在L4-5L4-5和和L5-S1L5-S1（90-96%），L3-4和L2-3间隙突出少见（少于5%）。椎间盘是位于两个相邻椎体之间的具有弹性的盘状结构，它由3部分：a.纤维环（位于外周）b.髓核（位于中央）c.软骨终板（位于上方和下方）椎间盘的主要生理功能有：椎间盘的主要生理功能有：a.a.连接各脊椎成为一个整体连接各脊椎成为一个整体脊柱；脊柱；b.b.吸
6、吸收震荡；收震荡；c.c.允许脊柱作有限范围的活动；允许脊柱作有限范围的活动；d.d.维持脊柱的生理曲度。维持脊柱的生理曲度。成人的椎间盘无血液供应。Spinal Disorders Fundamentals of Diagnosis and Treatment 腰椎间盘和邻近结构的关系 -椎管前壁的一部分，神经根和马尾神经紧贴椎间盘的后方下行。如果椎间盘发生破裂，其组成成分进入椎管，神经根或马尾可能受累 -椎间盘突出引起腰腿痛的直接病理基础。Spinal Disorders Fundamentals of Diagnosis and Treatment 1.基本发病机制-椎间盘退变 随着年龄
7、增加和反复慢性损伤，纤维环的强度变弱，在纤维环之间出现裂隙，髓核在负荷的作用下经纤维环裂隙突出这就是形成影像学上的椎间盘突出或临床上所说的腰椎间盘突出症的实质过程。2.诱发因素 外伤，职业，妊娠，遗传，先天异常等Spinal Disorders Fundamentals of Diagnosis and Treatment1.膨隆型(Prolapsed type):仅内层纤维环破裂而外层纤维环完整，髓核突出形成局限性隆起。2.突出型(Extruded type):即纤维环完全破裂，髓核进入椎管，后纵韧带完整，突出部分仍有蒂与原椎间盘相连。3.脱垂游离型(Sequestered type):即突
8、出的椎间盘碎片完全脱离原椎间盘成为游离体。4.许莫氏结节及经骨突出型 -根据纤维环破裂的程度分型Spinal Disorders Fundamentals of Diagnosis and Treatment 1.腰痛腰痛(Lumbago or back pain):it is the initial symptoms for most patients,about 91 per cent patients have this experience.The pain originates from outer annulus fibrosus and posterior longitudial
9、 ligament which are stimulated by herniated disc tissue,and the property of the pain is referred pain.The back pain is usually chronic and recurrent.-是大是大多数患者最先出现的症状，发生率约多数患者最先出现的症状，发生率约91%。这是由于突出。这是由于突出物刺激外层纤维环和后纵韧带上的窦椎神经而产生的下物刺激外层纤维环和后纵韧带上的窦椎神经而产生的下腰部感应痛，也可引起臀部痛。腰部感应痛，也可引起臀部痛。Spinal Disorders Fund
10、amentals of Diagnosis and Treatment 2.坐骨神经痛和麻木坐骨神经痛和麻木(Sciatica and anaesthesia)L4-L5和 L5-S1椎间盘突出最常见，占90-96%。这两个间隙的突出分别影响L5和S1神经根，而L5神经根和S1神经根是组成坐骨神经的主要部分，所以当L5或S1神经根受累时可产生沿坐骨神经行程的放射性疼痛。疼痛产生的可能机制为：a.破裂椎间盘组织产生的化学性物质或自身免疫反应导致神经根炎症性变化；b.突出物对已有炎性变的神经根的机械性压迫或牵张；c.受压的神经根血液循环障碍导致缺血缺氧。同时可出现L5或S1神经根支配的皮肤区域感觉
11、麻木。Spinal Disorders Fundamentals of Diagnosis and Treatment 3.Cauda equina syndrome:if a large mass of disc tissue protrudes to midline,the cauda equina can be compressed to cause urinary and bowel disturbance and paresthesia in perineum.有少数患者，突出的椎间盘组织较大同时压迫神经根和马尾神经，引起坐骨神经痛和大、小便功能障碍，马鞍区感觉障碍。发生率约0.82
12、4.4%Spinal Disorders Fundamentals of Diagnosis and Treatment 1、姿势异常、姿势异常(Abnormal posture)：为减轻疼痛：为减轻疼痛而不由自主地出现的代而不由自主地出现的代偿性腰椎侧弯。与椎间偿性腰椎侧弯。与椎间盘突出的部位有关盘突出的部位有关 Spinal Disorders Fundamentals of Diagnosis and Treatment 2.腰部活动受限(The movement range of lumbar spine is limited):almost all patients exhibit
13、decreased lumbar movement range,especially obvious in lumbar flexion-owing to the nerve root tension increasing in flexion position.几乎全部患者都有不同程度的腰部活动受限，严重者连翻身都困难，以腰前屈腰前屈受限受限最明显。3.Tenderness and spasm of muscle erector spinae（竖柱肌）.在突出间隙疼痛侧棘突间旁一横指处按压可有明显压痛和沿坐骨神经传导的放射痛，部分患者的竖柱肌出现痉挛。Spinal Disorders Fun
14、damentals of Diagnosis and Treatment4.Straight leg raising testand Bragard sign:The patient lies supine with the head flat,one of the examiner,s hands is placed on the ilium to stabilize the pelvis,and the other hand slowly elevates the leg by the heel with the knee straight.When leg pain or radicul
15、ar symptoms are produced within 60-70,this test is considered positive.Spinal Disorders Fundamentals of Diagnosis and Treatment 5、神经系统表现、神经系统表现(Neurologic Examination)：。L5神经根受累时在小腿前外侧和足的内侧、大足趾出现感觉减退；踝及趾被伸肌力下降；S1神经根受累在小腿后外侧、外踝、足外侧、小足趾出现感觉减退。趾和足跖屈肌力减弱，踝反射减弱或者消失。-当突出的椎间盘较大时可同时压迫两个节段的神经根，出现相应的两个神经根受损的征象
16、。膝反射减弱提示膝反射减弱提示L2-L4神经根受累；神经根受累；L5神经根神经根受损不引起腱反射改变。马尾神经受损时肛门受损不引起腱反射改变。马尾神经受损时肛门括约肌张力下降，肛门反射减弱或消失括约肌张力下降，肛门反射减弱或消失。Spinal Disorders Fundamentals of Diagnosis and TreatmentSpinal Disorders Fundamentals of Diagnosis and TreatmentSpinal Disorders Fundamentals of Diagnosis and TreatmentSpinal Disorders
17、Fundamentals of Diagnosis and TreatmentSpinal Disorders Fundamentals of Diagnosis and Treatment鉴别诊断 LDH should be differentiated from a lot of diseases which can cause back and/or leg pain,such as lumbar spine tuberculosis and tumor,spondylolisthesis,spinal canal stenosis,nerve root and cauda equia
18、tumor.LDH应当和许多能够引起腰痛或腿痛的疾病相鉴别，如脊柱结核、肿瘤、腰椎滑脱、腰椎管狭窄、神经根或马尾肿瘤。Spinal Disorders Fundamentals of Diagnosis and Treatment鉴别诊断Spinal Disorders Fundamentals of Diagnosis and Treatment 坚决反对以影像学资料为决定坚决反对以影像学资料为决定是否手术的主要依据的错误做是否手术的主要依据的错误做法。法。Spinal Disorders Fundamentals of Diagnosis and Treatment 定义:颈椎间盘退变,及
19、其继发性椎间关节退行性变所致脊髓、神经、血管损害而表现的相应的症状和体征。Spinal Disorders Fundamentals of Diagnosis and TreatmentSpinal Disorders Fundamentals of Diagnosis and Treatment 1.Disc degeneration 2.Trauma and fatigue 3.Developmental spinal canal stenosisDisc degeneration and hernation Spinal Disorders Fundamentals of Diagnos
20、is and TreatmentSpinal Disorders Fundamentals of Diagnosis and Treatment Vertebral artery 根据侵犯的部位不同而分型Spinal Disorders Fundamentals of Diagnosis and Treatment Radiculopathy type is the most common type of all types(50-60%).It is caused owing to one or more nerve roots being compressed by herniated d
21、isc or ostephyte.The most frequently involved nerve roots are C5 C6 C7.The clinical manifestation is radicular pain,numbness,motion difficulty,or muscle atrophy.Brachial plexus traction test signs(Eaton test)may be positive.Spinal Disorders Fundamentals of Diagnosis and Treatment Cervical spondyloti
22、c myelopathy is the most common type of spinal cord dysfunction（功能障碍）功能障碍）,it can causes severe dysfunction of extermities and bladder.Especially,it can cause hand dysfunction resulting in disability（残疾）残疾）due to intrinsic muscle（手内在肌手内在肌）atrophy（萎缩）萎缩）.Spinal Disorders Fundamentals of Diagnosis and
23、 TreatmentThe main clinical signs include abnormal gait（步态异常）步态异常）,lower extremity spasticity（痉痉挛）挛）,hyperreflexia（反射反射亢进）亢进）of Achilles tendon reflex and patella reflex,ankle and patella clonus（阵挛）阵挛）,positive Babinski signs.Spinal Disorders Fundamentals of Diagnosis and Treatment This type can cau
24、se a series of symptoms,including vertigo（眩晕）眩晕）,headache,disturbance of vision,sudden fall to ground（猝猝倒）倒）,etc.Because this type can cause a variety of symptoms,the diagnosis is often uncertain.Spinal Disorders Fundamentals of Diagnosis and TreatmentSpinal Disorders Fundamentals of Diagnosis and T
25、reatmentSpinal Disorders Fundamentals of Diagnosis and TreatmentCervical spondylotic myelopathy Spinal Disorders Fundamentals of Diagnosis and TreatmentSpinal Disorders Fundamentals of Diagnosis and Treatment脊髓型Spinal Disorders Fundamentals of Diagnosis and Treatment右上肢疼痛麻木一月余入院神经根型颈椎病Spinal Disorde
26、rs Fundamentals of Diagnosis and TreatmentSpinal Disorders Fundamentals of Diagnosis and TreatmentSpinal Disorders Fundamentals of Diagnosis and TreatmentSpinal Disorders Fundamentals of Diagnosis and TreatmentSpinal Disorders Fundamentals of Diagnosis and TreatmentSpinal Disorders Fundamentals of D
27、iagnosis and TreatmentSpinal Disorders Fundamentals of Diagnosis and Treatment 62岁男性，四肢麻木乏力5年加重半年 PE：颈部活动受限，双上肢肌力减弱，感觉减退，双下肢感觉减退，肌力正常，双膝反射亢进，余正常。Spinal Disorders Fundamentals of Diagnosis and TreatmentSpinal Disorders Fundamentals of Diagnosis and TreatmentSpinal Disorders Fundamentals of Diagnosis and TreatmentSpinal Disorders Fundamentals of Diagnosis and Treatment后路C2-6全椎板减压+summit 前路C4次全切+钛网Spinal Disorders Fundamentals of Diagnosis and TreatmentThank You!
