傷筋腰椎間盤突出癥

1、腰椎間盤突出癥the syndromes of lumbar intervertebral disc protrusion定義腰部遭受較重的外力，腰部椎間盤纖維環(huán)部分或全部破裂，髓核向外突出，壓迫神經(jīng)根或脊髓，引起腰痛和一系列神經(jīng)癥狀。腰突癥區(qū)別：腰椎間盤突出癥與腰椎間盤突出Lumbar pain syndrome caused by degeneration of lumbar intervertebral disc, partially or completely ruptured annular fibrosus, bulged or herniated nucleus due to e

2、xternal force that may irritate the spinal cord and press nerve root.病因病理etiology內(nèi)因：椎間盤退行性改變，椎間盤發(fā)育上的缺陷。外因：外傷（扭、閃、挫），勞損，風(fēng)寒濕邪氣侵襲。The internal cause of the disease is the degeneration of lumbar intervertebral , or development defect of intervertebral discs. The external causes are injury, strain and in

3、vasion of pathogenic wind and cold.椎間盤intervertebral disc椎間盤是連接相鄰椎體的屈戌關(guān)節(jié)，對(duì)脊椎起緩沖和吸收振蕩的作用。屈戌關(guān)節(jié)：又名滑車關(guān)節(jié)，關(guān)節(jié)頭呈滑車狀，另一骨有與其相適應(yīng)的關(guān)節(jié)窩。通常是只能在冠狀軸作屈伸運(yùn)動(dòng)，如手指關(guān)節(jié)。Lumbar intervertebral disc is located between two connective vertebras, forming the weight-bearing joints of the vertebra and serving as the ginglymus of the

4、 spinal column.disc椎間盤的組成：上下是軟骨板，周圍是纖維環(huán)，中央是髓核。纖維環(huán)是由堅(jiān)韌致密的彈性纖維在軟骨基質(zhì)中交織而成，與上下椎體緊密相連。Intervertebral disc consists of annular fibrosus, nucleus pulposus and cartilages.Annular fibrosus is composed of tenacious interlaced elastic fibers in cartilage matrix and are connected tightly with the adjacent verte

5、bras.disc髓核是一種含水分較多的膠狀物，纖維環(huán)與上下椎體面上的軟骨扳，把髓核限制在一個(gè)球形腔內(nèi)。Nucleus pulposus contains hydrous jell.The annular fibrosus and the soft board on the surface of the adjacent vertebras confine the nucleus pulposus in the global cavity.degeneration退變：髓核脫水，椎間盤失去彈性。突出：過度負(fù)重，扭、挫、閃使椎間盤受力不均勻，盤內(nèi)壓力過大而發(fā)生纖維環(huán)破裂，髓核突出。With th

6、e increase of age as well as the influence of pressing, pulling and twisting by external force, the intervertebral discs eventually degenerate, dehydrate, and lose their flexibility, making the intervertebral spaces narrow and the ligaments loose or causing fissures.特點(diǎn)character好發(fā)年齡：2040歲?！拔迨?、四十腰”好發(fā)

7、部位：L4、5 和 L5、S1。因?yàn)長(zhǎng)4、5是上半身力的支點(diǎn)，而L5、S1的活動(dòng)度最大，容易引起退變和損傷；后縱韌帶從L1開始逐漸變窄，至L5、S1處只有原來的一半。The incidence is high among workers aging from 20 to 40.The most commonly encountered lumbar disc protrusion often happens in the disc L4/L5, and L5/S1.病理分型1根據(jù)髓核突出的方向，分為三型：1.向后突出2.向前突出3.向椎體內(nèi)突出Directions of protrusion

8、of disc:1.Forward protrusion2.backward protrusion3.inward protrusion to vertebral body.病理分型2根據(jù)髓核突出的程度，分為三型：1.隱藏型（幼弱型）：纖維環(huán)不全破裂，外層保持完整，髓核輕度突出，適當(dāng)休息可以回納。2.突出型：纖維環(huán)裂隙較大，外層保持完整，髓核突出較大，經(jīng)手法復(fù)位可治愈。3.破裂型：纖維環(huán)完全破裂， 髓核向外突出，有的與神經(jīng)根粘連，有的沒有。Degree of nucleus pulposus protrusion1. hidden truded type3.ruptured

9、type病理分型3根據(jù)向后突出的部位不同，分三型：1.單側(cè)：髓核從一側(cè)的側(cè)后方突入椎管，壓迫神經(jīng)根。2.雙側(cè)：1.少見。2.雙下肢癥狀交替加重3.中央型：髓核由中央向后突出，壓迫馬尾神經(jīng)，造成大小便障礙。區(qū)別：CT報(bào)告的中央型突出與教材的中央型突出的區(qū)別。The place of protrusion:1.single side2.double sides3.center診斷（臨床表現(xiàn)）腰部有外傷史和積累勞損史。復(fù)發(fā)則有受寒史。腰痛及下肢放射痛（過膝），不能久坐久站，“坐得太久得坐骨神經(jīng)”腹壓增加，疼痛加重：咳嗽、噴嚏、大便等。Has a history of injury and chron

10、ic strain ,or being attacked by cold evil.Low back pain and the radioactive pain in the lower limb.Coughing , sneezing and pushing hard while defecating may add pressure of abdomen and worse the pain.Clinical manifestations腰背部板滯，活動(dòng)障礙，腰椎畸形：側(cè)彎，生理曲度消失主觀麻木感：小腿后外側(cè)、足跟、或足背麻木?；贾珳囟认陆导∪馕sStiff waist , difficu

11、lty to bend in mild cases , inability to turn the waist in severe cases.Deformity of lumbar vertebra, scoliosis, lordosis, physiology curvature disappear.Numbness in the lower limb,such as crural region, calcar pedis and lateral side of dorsum.Lower temperature of affected low limb.Muscle is atrophy

12、.檢查1、直腿抬高試驗(yàn)及直腿抬高加強(qiáng)試驗(yàn)陽(yáng)性2、屈頸試驗(yàn)陽(yáng)性3、下肢后伸試驗(yàn)陽(yáng)性1.leg raising test and foot dorsum flexing test.2.neck bending test3. leg backward extending test4、挺腹試驗(yàn)陽(yáng)性（腹壓增高）5、壓痛、放射痛（L4、L5）：坐骨神經(jīng)通路6、小腿前、后外側(cè)感覺減退4.abdomen straightened test5.Evident tenderness, radioactive pain.6.numbness of crural and calf region.7、趾肌力減退（伸足大

13、趾試驗(yàn)，屈足大趾試驗(yàn)），8.膝、跟腱反射減弱或消失。7.the force is weak of leg , especially big toe flexing upward or downward, 8.knee tendon and ankle tendon reflex are reduced or disappear.X片檢查X filmX片：脊柱側(cè)彎，椎間隙變窄，椎體邊緣唇樣增生。（不能確診）排除：腰椎結(jié)核，骨關(guān)節(jié)炎，骨折，腫瘤，脊椎滑脫。確診：CT、MRI、脊髓碘油或碘水造影碘過敏試驗(yàn)The orthograph film sometimes shows lumbar scoli

14、osis, the lateral film shows disappearance of the lumbar anterior protrusion.Narrowed vertebral spaces and hyperosteogeny of the adjacent vertebrao on the margin.Rule out pulmonary tuberculosis , tumor, bone fracture, or congenital deformity of lumbosacral vertebrae.CTUsing CT to test the shape and

15、caliber of lumbar spinal canal is a very significant way to help diagnose lumbar intervertebral disc hernia. It can clearly show the factors responsible for pressure on the lumbar and sacral nerve roots. The stereoscopic display can demonstrate the degree and area of the protrusion of intervertebral

16、 discs.突出程度與癥狀的關(guān)系輕度突出：4MM以下，中度突出：48MM之間，重度突出：8以上在臨床工作中，少數(shù)患者的臨床癥狀不一定與突出程度成正相關(guān)。癥狀與突出程度、突出物的位置、椎管的大小都有一定的關(guān)聯(lián)。Mild protrusion: below 4mm.Middle protrusion : between 48mm.Serious protrusion: over 8mm.鑒別診斷differentiate diagnosis1.急性腰扭傷：外傷史，劇烈腰痛，脊柱側(cè)彎。CT、MRI 確診。2.慢性腰肌勞損：病程長(zhǎng)、癥狀輕、痛點(diǎn)廣泛。 CT、MRI 確診。1.acute waist

17、sprain2. chronic strain of low back muscle3.梨狀肌綜合征：外傷史，臀部疼痛，梨狀肌壓痛，梨狀肌緊張?jiān)囼?yàn)陽(yáng)性。4.增生性脊柱炎：老年人腰痛，晨僵，晨起疼痛加重。X片：脊椎骨質(zhì)增生。治療目的：1、增加局部痛域，放松腰肌2、降低盤內(nèi)壓力，增加盤外壓力，促使突出物回納3、改變突出物與神經(jīng)根位置關(guān)系4、加強(qiáng)氣血循行，促使神經(jīng)根炎性水腫的吸收。治療治則：舒筋通絡(luò)、松解粘連、解痙止痛、整復(fù)減壓取穴：阿是穴、腰背部及下肢，腎俞、大腸俞、承扶、殷門、委中、承山、昆侖；居髎、環(huán)跳、風(fēng)市、陽(yáng)陵泉、絕骨、丘墟。手法：揉、按壓、滾、彈撥、運(yùn)動(dòng)關(guān)節(jié)類手法。操作1.循經(jīng)按揉法：解

18、除背腰臀部肌肉痙攣（滾、按、揉）2.拔伸推壓法：拉寬椎間隙，降低盤內(nèi)壓力，擴(kuò)大椎間孔（手法或機(jī)械牽引），拇指或肘尖按壓患處。3.理筋整復(fù)法：調(diào)整后關(guān)節(jié)，松解粘連（腰椎斜扳或旋轉(zhuǎn)扳法，強(qiáng)制直腿抬高）4.踩蹺、背晃法：增加盤外壓力（按壓、震動(dòng)腰部，后伸扳法）5.整理手法：使損傷的神經(jīng)根恢復(fù)功能（沿神經(jīng)根滾、按、揉、點(diǎn)、拿）預(yù)后推拿配合功能鍛煉效果較好針灸、拔火罐、中藥、西藥理療：超短波、磁療、超激光、電腦中頻、紅外線、周林頻譜、寬頻、低周波劇烈疼痛、保守治療半年效果不明顯的建議手術(shù)治療。注意事項(xiàng)1.臥硬板床、帶腰圍，減少椎間盤承受的壓力。2.注意保暖。3.功能鍛煉：拱橋勢(shì)、飛燕勢(shì)，倒走。4.中央型腰椎間盤突出癥不宜推拿治療坐骨神經(jīng)痛根性椎間盤突出癥、椎管內(nèi)腫瘤、增生性腰椎炎、腰骶神經(jīng)根炎腹壓增加時(shí)疼痛明顯加重