外科脊柱退行性疾病

臨床醫(yī)學(xué)專業(yè)理DegenerativeSpine脊柱退行性疾 MD,SpineLab,DepartmentofOrthopedicSurgery HospitalofZhejiangUniversity→教 歡迎對骨科、脊柱外科 的同學(xué)加盟我們的團(tuán)隊椎間盤由上下軟骨板，中心的髓核及四周的纖軟骨板是透明軟骨，連接于椎體和椎之間維環(huán)表層有細(xì)小血管供應(yīng)及配，而髓核無神盤損傷后難以自行修復(fù)。TheThe脊柱椎間盤的退行性病理學(xué)水分和蛋白黏糖減纖維環(huán)膠原纖纖維環(huán)的纖維小板出 或裂導(dǎo)致椎間盤高度和耐受應(yīng)力的能力退變Twinstudiesrevealingsimilarincidencedespitedifferentoccupations,socioeconomicstatus 軸向疼痛(axialpain)：指軀干的疼痛，如腰，有時有局部壓痛放射痛(radiculouspain)：是神經(jīng)根損害的經(jīng)向末梢放射，感覺運(yùn)動、反射損害體ClinicalAxialpain–neckorDuetoinflammationsurroundingdiseasedstructuresortoinstabilityofthespine神外側(cè)，神腰痛的一些基本80%成人一生中曾經(jīng)有過下腰痛；在是第二大就診原因，僅次于上呼吸道；NIDS應(yīng)用當(dāng)前技術(shù)，僅約15%的腰痛患者可以找出相應(yīng)的病(Idiopathicback下腰絕大多數(shù)腰痛并不需要影像學(xué)檢Redflags發(fā)熱，夜間盜汗，神經(jīng)受壓癥狀，體重下降，病史，嚴(yán)重疼痛治療后無好轉(zhuǎn)等）需要神經(jīng) 上肢放射痛；下肢放射痛（坐骨神經(jīng)痛由于神經(jīng)根受到機(jī) 所引起頸椎多見為C5/6節(jié)段，其次為C6/7節(jié)段腰椎多為L5/S1，其次為胸段脊柱的神經(jīng) 變少見：肋間神經(jīng)痛Radiculopathy–Painisthemostprominent,alongdermatomeofaffectedroot;Lumbardisc定義腰椎間盤突出癥是因腰椎間盤變性，纖維環(huán)破裂，髓核突出激或神經(jīng)根、馬尾神經(jīng)所表現(xiàn)的一種綜合征，是腰腿痛最常見的原因之一。其中以腰3?4、腰4?5、腰5?骶1間隙最高，占90％以上。20-50歲中青年人群多見。病因：腰椎間盤退行性變是基本損傷,特別是積累性勞損是腰椎間退變的主要原因，也是突出的誘因遺傳因素上腰段椎間盤突出少見 L3/4DH:affectsL4root;L4/5DH:affectsL5L5/S1DH:affectsS1臨床表現(xiàn)(一 疼痛加劇；反復(fù)發(fā)作馬尾神經(jīng)受壓：大小便，鞍區(qū)感覺腰椎間盤突出癥和不足，都是坐骨神經(jīng)痛(Sciatica)MechanicalNeurochemicalfactors:immuneClassificationof突脫突脫長時間的輕中度腰痛有時有一個特定事件誘發(fā)腰痛腿痛通常，或者多數(shù)時候，有軸性腰痛臀部疼痛:可能是牽涉痛或放射 PatternsofS1radicularpainmayradiatetothebackofthecalforthelateralaspectorsoleofthefoot;L5radicularpaincanleadtosymptomsonthedorsumoftheL4radiculopathy:aboveortheL2andL3radiculopathycanproduceanteriorormedialthighandgroinpain體格檢視診 , ;觸診神經(jīng)學(xué)檢查感覺:(正常，減退或過敏，缺失L4：內(nèi)踝區(qū)域L5：足背內(nèi)側(cè)，尤其是1、2趾之間S1：足背外側(cè)，足底外側(cè)神經(jīng)學(xué)檢查運(yùn)動L4：股四頭肌力量減退L5Manualmuscletest神經(jīng)學(xué)檢查深部肌腱反SpecificStraightlegraisingtest(SLT):reproducesciaticaat35-70degrees;(forL4,L5&S1radiculopathy);LasègueThefemoralstretchtest:reproduceanteriorthighpain(forupperrootSpecific跟臀試驗（）：L、L間盤突出者;屈頸試驗（Lindner1mLasegue征，即直神經(jīng)系統(tǒng)表現(xiàn)：感覺異常；肌力下降；反射異腰椎間盤突出癥的定 突出間受壓神經(jīng)感覺減減退反跟臀試L3?L小腿膝反_+L4?L小腿足背踇背伸+_L5?足背和外跖反+_X-ray可間接反應(yīng)腰椎退變情況，如椎間隙狹CT:相對少用MRI:最佳檢查方法，無創(chuàng) AxialAxial CT、MRI能確診 脊柱的影像鑒別 （一）與腰痛為主要表現(xiàn)的疾病鑒腰肌勞損第三腰椎弓根腰椎結(jié)(二)與腰痛伴坐骨神經(jīng)痛的疾病神經(jīng)根及馬尾椎管狹窄(三)與坐骨神經(jīng)痛為主的疾梨狀肌綜盆腔疾NonoperativePhysiotherapy:Bedrestshouldbelimitedtonomorethan2to3days;restorestrength,flexibility,andfunction;PharmacologicTreatment:Nonsteroidalanti-inflammatorydrugs(NSAIDs)are agents;musclerelaxants;SelectivetransforaminalsteroidNaturalAbenigndisease:SaalandSaala90%goodorexcellenteinpatientstreatednonoperatively;Anotherstudy:at1year,33%hadgoodresults,49%hadafairresult,and18%hadapoorresult.At4years,goodresultswerereportedin51%,fairresultswerereportedin39%,andpoororbadresultswerereportedin10%.10-yearfollow-upresults:61%improvementinthepredominantsymptom,40%resolutionoflowbacksymptoms,and56%satisfactionrate.Operativeprogressiveneurologiccaudaequinafailureofappropriatenonoperative

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CervicalCervicaldiscssimilartolumbardiscs,NucleuspulpousDiscsbettersupportedonlateralMostcervicaldischerniationsoccurinpostero-lateralmarginsCervicaldiscPatientsusuallypresentwithoneormoreAxialneckRadiculararmNeurapraxiaofupperNon-specificsymptoms:dizzying,nausea,headache,upperbackpain;TreatmentofCervicalradiculopathyoftenresolveswithoutConservativemethodsincludePTandinflammatoryIndicationsforContinuedpainorprogressiveneurologicaldeficitindicateneedforsurgeryAnteriorandposteriorapproachesmaybeFusionwithorwithoutinstrumentationmaybeTypicalsurgery:Anteriorcervical andfusion(ACDF);AnteriorBonegraftorMyelopathyAAgroupofsymptomsresultingfromspinalcordcompression,including:HandDistaloftenmoreDifficultywithbuttons,Otherwise,extensorpattern‘pyramidalTriceps,wristLegBalanceStaggeringTandemgaitdifficultyveryearlyMyelopathySensoryOftenbilateralhanddifficulty,sensorylevelasdiseaseismoresevereaitUppermotorneuronBabinskiresponse,hyperreflexia,Hoffman’ssign,increasedtone,stiffgaitDegenerativemyelopathy–naturalhistoryTypicallythatofStepwisein50%,progressiveinTherefore,patientswithmyelopathyareusuallytreatedsurgically;SurgerytypicallyperformedinexpeditedRelativetorateofLostneurologicalfunctionisoftennotregained–thereasontoperformearlysurgery Cervical腰椎管狹Lumbar 個或多個平面椎管管腔狹窄，馬尾椎管狹窄癥。腰椎管狹窄癥椎管或神經(jīng)通道狹窄所致中老 多見 超過65歲的腰椎手術(shù) 中，LSS是排Threesh