骨科學教學課件：neck pain

Anunpleasantsensoryandemotionalexperienceassociatedwithactualorpotentialtissuedamage,ordescribedintermsofsuchdamageThefifthvitalsignPainNeckPainComposeofneckVertebraeMusclesLigamentsNervesDiscsVertebralarteryWhatcausesneckpain?MusclestrainsInjuryInfectiontumorWhatcausesneckpain?DegenerativeconditionsCervicalspondylosisWhatiscervicalspondylosis?

CervicalSpondylosisisprogressivedegeneration(destruction)ofthespine.SPONDYLOisaGreekwordmeaningvertebra.Spondylosisgenerallymeanschangesinthevertebraljointcharacterizedbyincreasingdegenerationoftheinter-vertebraldiscwithsubsequentchangesinthebonesandsofttissue.CervicalSpondylosisCervicalspondylosisisageneraltermencompassinganumberofdegenerativeconditionsDegenerativediscdisease(DDD)SpinalstenosisWithorwithoutdegenerativefacetjointsWithorwithouttheformationofosteophytesWithorwithoutaherniateddiscOnesinglecomponentasadiagnosisisrareAnatomyAnatomyAnatomyAnatomyPathophysiologyDegenerativeoftheSpineDegenerativeprocessesofagingoccuratdifferentrates,locations,andmodalities,basedontheuniqueattributesofindividuals(factorsknowntoinfluencedegenerativediseasesofthespineincludelifestyle,workpatterns,diet,andevengenetics)DegenerativeDiscDiseaseTheprocessisthoughttobeginintheannulusfibrosiswithchangestothestructureandchemistryoftheconcentriclayersOvertime,theselayerssufferalossofwatercontentandproteoglycan,whichchangesthedisc’smechanicalproperties,makingitlessresilient

tostressandstrainDegeneratedPathologyDegenerativeDisease:FacetJointsChangesindiscstructureandfunctioncanleadtochangesinthearticularfacets,especiallyhypertrophy(overgrowth),resultingfromtheredirectionofcompressiveloadsfromtheanteriorandmiddlecolumnstotheposteriorelementsDegenerativeDisease:OsteophytesTherealsomaybehypertrophyofthevertebralbodiesadjacenttothedegeneratingdisc;thesebonyovergrowthsareknownasosteophytes

(orbonespurs)HerniatedNucleusPulposusTheprogressivedegenerationofadisc,ortraumaticevent,canleadtoafailureoftheannulustoadequatelycontainthenucleuspulposusThisisknownasherniatednucleuspulposus(HNP)oraherniateddiscHerniatedNucleusPulposusVaryingdegreesDiscbulgeMildsymptomsUsuallygoawaywith

nonoperativetreatmentRarelyanindication

forsurgeryExtrusion(herniation)Moderate/severesymptomsNonoperativetreatmentPathophysiologySpinalcanalsizeMechanicalfactorsstaticdynamicRoleofischemiaPathophysiologySymptomsHeadachesparticularinthebackoftheheadormigraineChronicneckstiffnessthatprogressivelyworsensChronicneckpainSymptomsofnerverootcompressionCervicalspondyloticradiculopathySymptomsofnerverootcompressionNeckpainradiatingintothearm,shoulderorchestnumbnessinthefingersmotorweaknessofarmsMayresemblecarpeltunnelsyndromerotatorcuffproblemsgoutSymptomsofvertebralarterycompressionSymptomsofvertebralarterycompressionOcularproblemsDoublevisionVertigoDizzinessTinnitusringingintheearsUnsteadinesswhenneckisturnedincertaindirectionsSymptomsofspinalstenosisNeckpainPain,dysthesias,anesthesiasinarmsandhandsBilateralPavlovRatio:canal(a)/body(b)<0.75SpinalStenosiscloverleaf

patternOvalortriangleshapeSpinalStenosisT2-andT1-weightedsagittalsatmidspineshowingspinalcanalstenosisfromC4/C5/C6levelSpinalStenosisStenoticNormalSymptomsofspinalcordcompressionCervicalspondyloticmyelopathyLossofsensationOrAbnormalsensations

oftheshouldersarmsorlegsWeaknessofarmsorlegsLossofcontrolofthebladderorbowelsLossofbalanceunsteadygaitimpairmentofproprioception

DiagnosisHistorySymptomsandsignsPhysicalexaminationRadiologicalexaminationEMGDiagnosis-physicalexaminationPostureROMofcervicalspine

passiveandactiveagainst

resistancePalpationTriggerpointNeurologicalexaminationDiagnosis-physicalexaminationSensationMotorReflexDiagnosis-physicalexaminationDiagnosis-physicalexaminationSpecialtestfornerverootcompressionSpurlingtestPosition:sitwithheadtilttobothsidesandbackward

Maneuver:compresstheheadandforcetransmittospineandnarrowtheintervertebralforamina

Positive:upperextremityradicularpainorparesthesiaproducedorintensifiedDiagnosis-physicalexaminationDistractiontestDiagnosis-physicalexaminationMuscletoneAnkleclonusDeeptendorreflexesbriskPathologicreflexes

Hoffmann’ssignBabinski’ssignDiagnosis–XrayDiagnosis-MRITreatmentconservativetreatmentRestandImmobilizationPhysicaltherapyTreatmentconservativetreatmentPainrelievingdrugs

NSAIDS(non-steroidalanti-inflammatorymedications)musclerelaxantsCervicaltractionOperation-IndicationNorespondtoaconservativetreatmentprotocolorshowsevidenceofdeterioratingmyelopathyorradiculopathyOperation-surgical

procedureACDFanteriorcervicaldisectomyandfusionOperation-surgical

procedureAdjacentSegmentDisease/Degeneration(ASD)HilibrandASD

incidence2.9％／year5yearfollow-upafterACDF，9－17％reoperationbecauseofASDpreoperation3mpostop3yrpostopOperation-surgical

procedureCervicalarthropastyOperation-surgicalprocedureCervicalarthropasty影像資料C4/5C5/6Operation-surgical

procedureLaminoplastyPreventionMaintaingoodpostureTakefrequentstretchbreaksfromdesk/computerworkAvoidactivitiesthatcausethenecktohyperflexorhyperextendLowbackpainLowbackpainLowbackpainLowbackpainIntervertebraldiscsseparatethevertebrae.Adiscismadeoftwoparts.Thecenter,calledthenucleus,isspongy.Itprovidesmostofthedisc'sabilitytoabsorbshock.Thenucleusisheldinplacebythe

annulus,aseriesofstrongligamentringssurroundingit.CausesoflowbackpainMusclestrainLumbardischerniationLumbarstenosisSpondylolisthesisPiriformissyndromeCausesoflowbackpainScoliosisOsteoporosisTraumafracturesSpinalinfectionsSpinaltumorsLumbardischerniationDegenerativechangesDegenerationProlapseExtrusionSqeuestrationLumbarDiscNomenclatureFigure3.Bulgingdisc.A,Normaldisc(forcomparison);nodiscmaterialextendsbeyondtheperipheryofthediscspace,depictedherebythebrokenline.B,Symmetricbulgingdisc;annulartissueextends,usuallybylessthan3mm,beyondtheedgesofthevertebralapophysessymmetricallythroughoutthecircumferenceofthedisc.C,Asymmetricbulgingdisc;annulartissueextendsbeyondtheedgesofthevertebralapophysis,asymmetricallygreaterthan25%ofthecircumferenceofthedisc.LumbarDiscNomenclatureFigure4.Herniateddisc:protrusion.Axial(A)andsagittal(B)images

demonstratedisplaceddiscmaterialextendingbeyondlessthan25%of

thediscspace,withthegreatestmeasure,inanyplane,ofthedisplaced

discmaterialbeinglessthanthemeasureofthebaseofdisplaceddisc

materialatthediscspaceoforigin,measuredinthesameplane.LumbarDiscNomenclatureFigure5.Herniateddisc:extrusion.Axial(A)andsagittal(B)images

demonstratethatthegreatestmeasureofthedisplaceddiscmaterialis

greaterthanthebaseofthedisplaceddiscmaterialatthediscspaceof

origin,whenmeasuredinthesameplane.

LumbarDiscNomenclatureFigure6.Herniateddisc:sequestration.Axial(A)andsagittal(B)imagesshowthatasequestrateddiscisanextrudeddiscinwhichthedisplaceddiscmaterialhaslostallconnectionwiththediscoforigin.LumbardischerniationLumbardischerniationintermittentorcontinuousbackpain

(thismaybemadeworsebymovement,coughing,sneezing,orstandingforlongperiodsoftime)spasmofthebackmusclessciaticapainthatstartsnearthebackorbuttockandtravelsdownthelegtothecalforintothefootmuscleweaknessinthelegsnumbnessinthelegorfootcaudaequinasyndromechangesinbladderorbowelfunctiondecreasedreflexesatthekneeorankleS1nerverootL5nerverootL4nerverootLumbardischerniationstraightlegraising(SLR)testPosition:lieasstraightaspossibleonatableinthesupineposition.Slowlyraiseoneleg-kneeabsolutelystraight-untilpainisexperiencedinthethigh,buttockandcalfLumbardischerniationBragard'stest

recordangle

atwhichpainoccurs-anormalvaluewouldbe80-90degrees-higherinpeoplewithligamentlaxityLumbardischerniationXray&CTThefirstdiagnostictoolMRIconservativetherapybedrestpatienteducationonproperbodymechanics(tohelpdecreasethechanceofworseningpainordamagetothedisc)physicaltherapy,whichmayincludeultrasound,massage,conditioning,andexerciseprogramsweightcontrolmedications(tocontrolpainand/ortorelaxmuscles)Operation-IndicationsfailureofacceptablepaincontrolbynonoperativemeasuresprogressiveneurologicaldeficitcaudaequinasyndromeOperationMicrodiscectomyEndoscopicDiscectomyTransforaminalEndoscopicDiscectomySpondylolisthesisSpodylolisthesisoccurswhenonevertebraslipsforwardinrelationtoanadjacentvertebra,usuallyinthelumbarspine.SpondylolisthesisDysplasticspondylolisthesisIsthmicspondylolisthesisDegenerativespondylolisthesisSpondylolisthesisSpinalstenosisLumbarspinalstenosis

ischaracterizedbynarrowingofthespinalcanaland/ortheintervertebra