臨床神經(jīng)病學(xué)課件：12 頸肩痛與頸椎病CBL

頸肩痛與頸椎病CBLCervical&shoulderpainandcervicalspondylosis-CBL頸肩痛18PRECISIONDIAGNOSISANDTREATMENTOFBACKANDNECKPAIN.Bogduk,etal.CONTINUUM:LifelongLearninginNeurology.PainandPalliativeCare.11(6):94-136,December2005.FIGURE4-10Segmentalpatternsofreferredpainfromthecervicalzygapophysialjointsorintervertebraldiscs.NeckPainDistributionAreaCase1男，56歲，因“頸肩痛伴右上肢疼痛麻木2月余”就診Case1低頭時(shí)左頸后部伴右上肢針刺樣疼痛2月余，陣發(fā)性發(fā)作，牽引頸部后可緩解典型頸肩痛癥狀部位：頸后或枕骨區(qū)，肩胛骨內(nèi)側(cè)，向上肢放射性質(zhì)：銳痛或鈍痛誘因：低頭/或頭部轉(zhuǎn)動(dòng)時(shí)持續(xù)時(shí)間：持續(xù)或陣發(fā)性緩解方式：上肢上舉放于頭部或牽引頸部時(shí)伴隨癥狀：上肢麻木無(wú)力等危險(xiǎn)因素：長(zhǎng)期伏案工作Case1既往發(fā)現(xiàn)心臟病3年余。會(huì)計(jì)工作10余年，無(wú)外傷史頸部肌肉緊張，C56棘突壓痛，右肩胛骨內(nèi)側(cè)壓痛，右側(cè)椎間孔擠壓試驗(yàn)陽(yáng)性891011121314

頸肩痛的常見臨床體征椎間孔擠壓試驗(yàn)（Spurling’stest）臂叢牽拉試驗(yàn)（Eton’stest）Hoffmann’ssignRossolimo’ssign頸肩痛常見疾患

頸部筋膜炎肩周炎肩袖損傷頸部炎癥結(jié)核等帶狀皰疹頸部腫瘤肩部腫瘤心臟疾患肺Pancoast腫瘤18頸椎病由頸椎間盤退行性變，繼發(fā)椎間關(guān)節(jié)退行性變，壓迫神經(jīng)根、脊髓或椎動(dòng)脈產(chǎn)生的臨床綜合征。Cervicalspondylosisshouldberegardedasaclinicalsyndromeresultingfromdegenerationoftheintervertebraldiscandintervertebraljoints,consequentpressureonthecervicalnerveroots,cervicalspinalcordorvertebralartery.頸椎病的分型

脊髓型（CervicalSpondylosisMyelopathy)神經(jīng)根型(CervicalSpondylosisRadiculopathy)椎動(dòng)脈型？交感神經(jīng)型？(SympatheticCervicalSpondylosis)

20

Cross-sectionalviewofcervicalspineatlevelofdisc(D).Uncinateprocess(U)formsventralwallofforamen.Root(N)exitsdorsaltovertebralartery(A).21臨床表現(xiàn)clinicalfeatures神經(jīng)根型頸椎病

servicalspinalnerverootpressureorradiculopathy1)頸肩疼痛，上肢放射疼，手指麻木或過敏，肌力減低，腱反射低。

2）頸僵硬，活動(dòng)受限。臂叢神經(jīng)牽拉試驗(yàn)（Eaton）、壓頭試驗(yàn)（Spurling）陽(yáng)性.22X線片roentgenograms神經(jīng)根型頸椎病

1）生理前凸消失；lossofthenormalcervicallordosis.2）椎間隙變窄；Discspacenarrowing.3）骨增生。Hypertrophicchanges,lippingofthevertelralbodiesandostrophytesfromtheposteriorspinaljoints.CT,MRI和Cervicaldiscography23

C5nerverootcompression(IndicativeofC4-5discruptureorotherpathologicalconditionatthatlevel)

SensorydeficitUpperlateralarmandelbow

MotorweaknessDeltoidBiceps(variable)

ReflexchangeBiceps(variable)24C6nerverootcompression(IndicativeofC5-6discherniationorotherlocalpathologicalcondition)

SensorydeficitLateralforearm,thumb,andindexfinger

MotorweaknessBicepsExtensorcarpiradialislongusandbrevis

ReflexchangeBicepsBrachioradialis25

C7nerverootcompression(IndicativeofC6-7discruptureorotherpathologicalconditionatthatlevel)

SensorydeficitMiddlefinger(variablebecauseofoverlap)

MotorweaknessTricepsWristflexors(flexorcarpiradialis)Fingerflexors(variable)

ReflexchangeTriceps26C8nerverootcompression(IndicativeofC7-T1discruptureorotherpathologicalconditionatthatlevel)

SensorydeficitRingfinger,littlefinger,andulnarborderofpalm

MotorweaknessInterosseiFingerflexors(variable)Flexorcarpiulnaris(variable)

ReflexchangeNone27臨床表現(xiàn)Clinicalfeatures2.脊髓型頸椎病

servicalspinalcordpressureormyelopathy1）頸痛不明顯；

2）四肢乏力，胸、腹束帶感，行走困難，大小便功能障礙visceraldisturbancesofbladderandbowel,incontinence；

3）感覺異常，肌張力增高spasticity，腱反射亢進(jìn)hyperactivereflexes,踝陣攣ankleclonus,病理反射陽(yáng)性Babinskisign。28X線片roentgenograms所見與神經(jīng)根型頸椎病相同。頸脊髓造影（Cervicalmyelography）、CT、CTM和MRI檢查可確定病變部位和程度。29臨床表現(xiàn)Clinicalfeatures交感神經(jīng)型頸椎病頭疼、偏頭疼、頭暈、視物不清、耳鳴、聽力下降、心動(dòng)過速或過緩、心率不齊等等。

椎動(dòng)脈型頸椎病

旋轉(zhuǎn)性眩暈為主要癥狀，頭疼（枕部、顳部），視物障礙，等等。交感型頸椎病的診斷CSSS的定義：頸椎間盤退行性變刺激或壓迫交感神經(jīng)纖維，引起的一系列反射性癥狀。

CSSS的診斷標(biāo)準(zhǔn)：1交感神經(jīng)癥狀

2神經(jīng)受壓-影像學(xué)

3排除其他疾患Case2患者，男，69歲，雙上肢麻木，行走不穩(wěn)2年余，加重3個(gè)月

Case2雙上肢感覺減退，雙下肢肌張力增高，雙側(cè)Hoffmann’ssign(+),雙側(cè)踝陣攣（+），雙側(cè)膝腱反射活躍Case2頸椎X線：C45C56C67節(jié)段椎間隙狹窄，鉤椎關(guān)節(jié)增生頸椎MRI：C3-C7多節(jié)段椎間盤突出，椎管狹窄，脊髓明顯受壓35診斷diagnosis中老年；病史和癥狀；體征和神經(jīng)系統(tǒng)檢查；影象學(xué)表現(xiàn)。36鑒別診斷differentialdiagnosis神經(jīng)根型頸椎病

1）肩周炎和腕管綜合征；

2）胸出口綜合征；

3）肌萎縮型側(cè)索硬化癥脊髓型頸椎病

1）骨折、脫位、結(jié)核、腫瘤——脊髓壓迫

2）后縱韌帶骨化OPLL

OssificationofthePosteriorLongitudinalLigament37治療treatment非手術(shù)治療conservativetreatment1）頜枕帶牽引；

2）頸托和圍領(lǐng)；

3）推拿和按摩；

4）理療；

5）自我保健療法；

6）藥物治療。38治療treatment2.手術(shù)治療surgicaltreatment1）前路及前外側(cè)手術(shù)-骨贅和間盤切除

+植骨融合

Anteriorapproach2）后路手術(shù)-椎板切除或椎板成形

Posteriorapproach

頸椎病的手術(shù)適應(yīng)證脊髓型頸椎病，一旦確診，積極手術(shù)；神經(jīng)根型頸椎病，癥狀嚴(yán)重影響生活工作，保守治療無(wú)效；反復(fù)發(fā)作的其他各型前路：方式及適應(yīng)證：1-3個(gè)節(jié)段椎間盤突出或骨贅致脊髓神經(jīng)根腹側(cè)受壓者；孤立型OPLL；局限型椎管狹窄后路:方式及適應(yīng)證：脊髓型頸椎病多節(jié)段椎管狹窄或OPLL；頸椎黃韌帶骨化致脊髓背側(cè)受壓者

頸椎病的預(yù)防避免長(zhǎng)期低頭伏案工作睡眠時(shí)枕頭應(yīng)墊在頸部頸部功能鍛煉避免頸部外傷41Types(configurations)ofgraftsusedinanteriorarthrodesisofcervicalspine.TypeI,RobinsonandSmith;TypeII,Cloward;TypeIII,BaileyandBadgley.Numbersaremeansforload-bearingcapacityforeach.42Placementofkeystonegraftshowninlinedarea.43

Anteriorfusionofcervicalspine.Troughhasbeencutinanterioraspectofvertebralbodies,intervertebraldiscspaceshavebeenclearedandfilledwithiliacbonechips,andiliacgrafthasbeenmortisedintotrough.44v4546474849

ORIONanteriorcervicalplatesystem.A,Bonegraftandplateposition.B,Cephalad/caudadscrewangulation.C,Standardcranialandcaudalangulationofscrews.D,Plateholderlockedintoplate.505152Case7-唐**,63C34間盤突出頭暈（5分）（4分）Case1相紅F/44前路C4腫瘤切除，人工椎體植入，鋼板內(nèi)固定AwlPusherPerforatorBoneblocks