脊柱退行性疾病-英文

脊柱退行性疾病Spinaldegenerativediseases

長(zhǎng)治醫(yī)學(xué)院附屬和平醫(yī)院骨科裴衛(wèi)衛(wèi)Whatiscalleddegeneration?

Wealsofoundotherphenomenon.SomePeopleareonly40yearsold,butlookslike60yearsofageortheopposite。影響因素influencefactors過度負(fù)荷overload不良體位poorposture慢性勞損chronicstrain外傷injury慢性炎癥chronicinflammation先天因素congenitalfactorsAnatomyoftheSpineSagittalViewAP-viewLordosisKyphosisLordosisDevelopmentofDiscandSpinalCurvature

Newborn25years4years-

nosignificantcurvature-DiscHeight=VertebralBodyHeight-Double-Scurvature-DiscHeight=40%ofVBH-biconcave-biconvexshapeofintervertebralspace-DiscHeight=25%ofVBHIntervertebraldiscAnulusfibrosusNucleusPulposusNewborn65yearsNovascularisationofdisc7years70years30yearsWatercontentinthenucleuspulposusdecreasedwithage

FacetJoints

Cervicalvertebrae——sloping

Thoracicvertebrae——coronal

Lumbarvertebrae——sagittalLigamentsAnteriorlongitudinalligamentPosteriorlongitudinalligament

BloodSupplyLoadTransfer80%20%TheFUNCTIONALUNITofthespineComprisedof:TwoadjacentvertebraeIntervertebraldiscConnectingligamentsTwofacetjointsandcapsulesIntradiscalPressureBiomechanics18,31,24,62,75,011,011,023,017,0頸椎退行性疾病

cervicaldegenerativedisease包括：一、頸椎病二、頸椎管狹窄癥三、頸椎間盤突出癥四、頸椎后縱韌帶骨化

including一、Cervicalspondylosis二、Cervicalcanal

stenosis三、Cervicaldischerniation四、Ossificationofcervicalposteriorlongitudinalligament一、頸椎病Cervicalspondylosis

發(fā)病率隨著年齡的增加而顯著提高

40～50歲的發(fā)病率為20％，60歲以上者達(dá)50％，

70歲以上則更高。目前發(fā)病年齡趨于年輕化

定義Concept頸椎間盤退變及其繼發(fā)性改變，刺激或壓迫相鄰脊髓、神經(jīng)、血管等組織，并引起相應(yīng)的癥狀或體征者，稱為頸椎病。Cervicalspondylosisisadisorderinwhichthereisabnormalwearonthecartilageandbonesoftheneck.分型Classification

脊髓型CervicalSpondylotic

MyelopathyCSM

神經(jīng)根型CervicalSpondylotic

RadiculopathyCSR

交感神經(jīng)型SympatheticCervicalSpondylosisSCS椎動(dòng)脈型CervicalSpondylosisofVertebralarterytype其它（食道壓迫型、頸型、混合型）

CSM以頸脊髓受損為主要臨床表現(xiàn)的頸椎病。主要表現(xiàn)為走路不穩(wěn)、四肢麻木、大小便困難等。Mainclinicalmanifestations:Cervicalspinalcordinjury，suchasunsteadywalk,numbnessoflimbs,micturitionanddefecationdifficultiesCSR

1.多見于30歲以上者M(jìn)orecommoninpeopleover30yearsold2.起病緩慢、病程長(zhǎng)，反復(fù)發(fā)作。Slowonset,longcourseofdisease,recurrentseizures.3.頸肩部疼痛，下頸椎病變可向前臂放射。

Neckandshoulderpain,somecanradiatetothearm

SCS

主要表現(xiàn)為頭暈、眼花、耳鳴、手麻、心動(dòng)過速、心前區(qū)疼痛等一系列癥狀。X線片有失穩(wěn)或退變，椎動(dòng)脈造影陰性。

Mainclinicalmanifestations:dizziness,tinnitus,numbnessofhand,heartbeattachycardia,precordialpain.X-ray:degenerationofcervicalvertebra.Vertebralarteryangiographynegative.CervicalSpondylosisofVertebralarterytype以椎基底動(dòng)脈供血不足為主要臨床表現(xiàn)的頸椎病。主要表現(xiàn)為頭痛，頭暈，黑朦等癥狀，與頸部旋轉(zhuǎn)有關(guān)。

Mainclinicalmanifestations:vertebralbasilararteryinsufficiency，suchasheadache,dizzinessandamaurosis,relatetotheneckrotation.食管型頸椎病

Esophagustypecervicalspondylosis

AspecialtypeofCSThroatdiscomfort,foreignbodysensationisanearlysymptomLatemanifestationsisdysphagia

Oftenaccompaniedbysymptomsofothercervicalspondylosis

頸型

Necktypecervicalspondylosis以頸部酸、痛、麻、僵為主要臨床表現(xiàn)或頸項(xiàng)部壓迫感的頸椎病，癥狀集中在頸部，轉(zhuǎn)動(dòng)不靈活。Mainclinicalmanifestations:aciddistention、pain、numbnessandstiffintheneck.Mixedtypeofcervicalspondylosis

具備以上兩種或兩種以上的表現(xiàn)者，即可確診。

Withtwoormorethantwokindsofperformanceabove.DiagnosisMustbehavethreeconditions:

CervicaldegenerativechangesRelevantclinicalmanifestationsRelevantclinicalmanifestationsareconsistentwithimagingfindingsTreatmentIndicatioMildsymptomsCannottolerateoperationMethodsCorrectbadpostureTractionMassage—cautiouslyusePhysiotherapyMedicationsexpectanttreatmentsurgicaltherapy

IndicatioFormalexpectanttreatmentfor3~6monthsisinvalidSymptomofCSMaggravateprogressivelyorsuddenlyorMRIshowedthatthecervicalspinalcordsignalchangesSymptomofCSRimpactqualityoflife手術(shù)方式手術(shù)目的surgicalpurpose

徹底減壓Completedecompression重建脊柱穩(wěn)定性Reconstructionofspinalstability

開放式：Openoperation

前路—直接減壓Anteriorcervicaloperation—Directdecompression

后路—間接減壓Posteriorcervicaloperation—Indirectdecompression

微創(chuàng)式：MicroinvasiveoperationCase1頸前路椎間盤摘除、取自體髂骨椎間植骨融合、內(nèi)固定術(shù)Case2頸前路椎間盤摘除、椎間融合器植骨融合、內(nèi)固定術(shù)Case3頸前路椎體次全切除、椎間鈦籠植骨融合、內(nèi)固定術(shù)Case4頸后路單開門椎管擴(kuò)大成形術(shù)Case5頸后路單開門椎管擴(kuò)大成形后路支撐鋼板內(nèi)固定術(shù)Case5頸椎人工間盤置換術(shù)頸椎管狹窄癥

CervicalcanalstenosisEtiologyandpathologyCongenitaldevelopmentalCCSDegenerativeoriatrogenicCCSCCScanbesingleormultisegmentalstenosis,commonintheC4,5andC6,7segmentsClinicalmanifestation

SymptomsaresimilartothesymptomsofCSX-rayCTMRIA:椎管失狀徑A≥13mm正常A＜13mm相對(duì)狹窄A＜10MM絕對(duì)狹窄B:椎體中失狀徑A:B＜0.75狹窄

椎管正中失狀徑≥13mm正常＜13mm相對(duì)狹窄＜10mm絕對(duì)狹窄Cervicalintervertebraldiscdegeneration

Externalforce

causeruptureofannulusfibrosus

andlongitudinalligamentNucleuspulposus

protrudeintospinalcanalThepainofnerverootandsignsofspinalcompression.頸椎間盤突出癥

CervicaldischerniationRelationshipbetweenCDHandCS頸椎間盤突出癥是頸椎病發(fā)病過程的病理變化之一

CDHisoneofthepathologicalchangesinthepathogenesisofCS頸椎間盤突出癥的致壓物只能是突出的髓核，而頸椎病可以是髓核以外的其他組織

Inducedpressurecanonlybeprotrudingnucleuspulposus，howeveritcanbe

othertissuesexceptthenucleuspulposus男性，40歲，煤礦工人，既往無四肢麻木、無力病史，摔傷后出現(xiàn)頸部不適伴雙上肢放射性麻木、行走不穩(wěn)1個(gè)月，經(jīng)頸圍制動(dòng)、脫水、激素及神經(jīng)營(yíng)養(yǎng)治療效果不佳。頸椎后縱韌帶骨化癥

Ossificationofcervicalposteriorlongitudinalligament頸椎后縱韌帶異常增殖并骨化，壓迫脊髓和神經(jīng)根，產(chǎn)生感覺、運(yùn)動(dòng)功能障礙。Cervicalposteriorlongitudinalligamentabnormally

proliferateandossify，whichcanconstrictthespinalcordandnerveroot，andthenleadtoparalysisEtiologyTheexactmechanismisnotclear，butthereareseveralhypothesisTheoryofheredityMechanicaldamagetheoryDisturbanceofcarbohydratemetabolismtheoryThewholebodybonehypertrophytheoryEpidemiologyTheincidenceofOPLLinEastAsiaishigherJapan

1.9～4.3%(over30yearsold.）Korea

3.6%Taiwan

2.8%China

1.6~1.8%ClinicalcharacteristicsAchronic,progressive,spinalcordornerverootcompressionsymptomsIt‘ssymptomsareverysimilartoCCSorCSX-ray,CT

andMRIcanimprovethediagnosisClassification-

SagittalSectionTopicaltypeSegmentaltype

SuccessivetppeMixedtypeClassification-Coronalsection圖１點(diǎn)狀骨化圖２蕈傘狀骨化圖３山丘狀骨化圖４偏一側(cè)骨化測(cè)量椎管狹窄率ImagingevaluationofOPLL減壓不徹底神經(jīng)功能障礙無改善或加重ImagingevaluationofOPLLVerydifficultHigh-riskMorecomplicationsPoorprognosisTreatment

Operationistheonlyeffectivemeans

ChallengeHowtoselectthereasonableoperation?successivetypeandMixedtypeossificrange>3vertebralsegmentsCervical

canalstenosis

>50%Posteriorcervicaloperation/IndirectdecompressionLaminectomyLaminoplastyLaminectomy+internalfixationTopicaltypeandSegmentaltypeossificrange＜3vertebralsegmentsCervical

canalstenosis

＜50%Anteriorcervicaloperation/Directdecompression

Discectomy

Corpectomydecompression

腰椎退行性疾病

lumbardegenerativedisease包括：一、腰椎間盤突出癥二、腰椎管狹窄癥三、腰椎滑脫癥

including一、LumbarDiscHerniation二、lumbarspinalstenosis三、lumbarspondylolisthesis腰椎間盤突出癥

LumbarDiscHerniationLDHEpidemiologySymptomaticLDHareseeninallagegroupsbuthavetheirpeakinpatientsagedbetween35and45years.Exceptsmoking,occupationalfactorsincludesedentaryworkanddriverarethemainreasonsforLDHClassification—Degeneration/BulgingMildsevereCentralPosterlateral

LateralClassification—ProtrusionClassification—Extrusion

Classification—Sequestration

Classification—Schmorl's

nods

SymptomsHowcanwerecognizeaherniateddisk?LowerbackpainSciaticaPain,weakness,numbnessortinglingin

thelegs,buttocksandfeetProblemswithbowel,bladderorerectile

function,inseverecasesGeneralSignsChangesoflumbarcurvatureCompensatoryscoliosisStraightleg-raising(SLR)testSLRstrengthentestFemoralnervestretchingtest

NeurologicsignsSensibilityMuscleforceDeeptendonreflexMuscleatrophyWecaninitiallylocatetheintervertebraldiscProtrusionoftheL3/4discProtrusionoftheL4/5discProtrusionoftheL5/S1disc

ImagingexaminationX-rayCTMRILumbarmyelography

TreatmentExpectanttreatmentSurgicaltreatmentExpectanttreatmentYoungFirstattackShortcourseSymptomscanberelievedbyrestNospinalstenosis

Nospondylolisthesis

SurgicaltreatmentThestrictexpectanttreatmentisinvalidCauda

equinasyndromeClassical-discectomyLumbararthroscopicdiscectomyPLDPLDDLumbartunnelMEDdiscectomyMLDAnteriorlumbardiscectomy,

interbodyfusion

Lumberartificialdiscreplacement腰椎管狹窄癥

lumbarspinalstenosisLSS，causedbyvariousreasons

，canconstrictspinalcordandnerverootandleadtocorrespondingnervedysfunction，OneofthecommondiseasesoflowerbackandlegpainEtiologyandpathologyCongenitaldevelopmentalLSSDegenerativeLSSTraumaticoriatrogenic

LSSBesingleormultisegmentalstenosis

CommonintheL4/5EpidemiologyMorecommoninelderlypatients,morethan50yearsoldItiscommoninL4/5，secondaryinL5/S1ClinicalmanifestationChroniclowbackpainMildpainordiscomfortSlowlyaggravationAlleviationaftertheactivityCoughwithoutaggravating

ClinicalmanifestationNeurogenicIntermittentClaudicationNICLCompressionbloodcirculatorydisorderInflammatorystimulusSymptomsarecloselyrelatedwithlumbarpostureAlleviationinflexionAggravationinextensionUphilliseasierthandownhillCanride，hardtowalkClinicalmanifestationLowerlimbneurologicalsymptomsClinicalmanifestationImagingexamination

——X-ray

Transversediameter＜18mmSagittaldiameter＜13mmValuablemethodDisplaythelocationanddegreeofthediseaseImagingexamination

——Lumbarmyelography

CoincidencerateishighTransversediameter＜18mmSagittaldiameter＜13mmNerverootcanal＜3mmImagingexamination

——CT

HighdiagnosticcoincidencerateDifferentialdiagnosissignificanceImagingexamination

——MRI

TreatmentExpectantSurgicalDecompressionFusionX-Stop腰椎滑脫

Thelumbarspondylolithesis

Spondylo——椎體Lithesis——滑移HistoryIn1782,theBelgianHerbinlaux,whoisanfirstdescribedaphenomenonofdystociacausedbyL5spondylolithesisIn1854,theGermandoctorKilianfirstproposedthespondylolisthesisandgivethedescriptionInthe1950s,domesticgraduallybegantoreportspondylolisthesis.EpidemiologyTheincidencerateisabout5%Varingfromtheage,regionandrace,occupation,gender

MorbidityrateincreasewiththegrowthofageMorewomen