外科學(xué)教學(xué)腰椎間盤突出癥

1、腰椎間盤突出癥lumbar disc herniation , LDH,廣西醫(yī)科大學(xué)第一臨床醫(yī)學(xué)院外科學(xué)教研室 楊勁松主講,Structural support and balance for upright posture,Functions of the Spine,Protection Spinal cord and nerve roots,Functions of the Spine,Internal organs,Fle

2、xibility of motion in six degrees of freedom,Functions of the Spine,Left and RightSide Bending,Flexion and Extension,Left and Right Rotation,Vertebral Structures,Body,,,Pedicle,,Lamina,,Superior Articular Process,,Spino

3、usProcess,,Transverse Process,,Vertebral Foramen,,Vertebral Structures,Articular processes,Superior Articular Process,,Pars interarticularis,Inferior Articular Process,,,Zygapophyseal Joint(Facet Joint),,Lumbar Vertebr

4、ae,Body - L1 to L5 progressive increase in mass,Pedicles - longer and wider than thoracic; oval shaped,Spinous processes - horizontal, square shaped,Transverse processes - smaller than in thoracic region,Intervertebral f

5、oramen - large, but with increased incidence of nerve root compression,Intervertebral Disc,Vertebral Structures,End Plate,Cartilaginous,Bony,Fibrocartilaginous joint of the motion segmentMakes up ¼ the length of th

6、e spinal columnPresent at levels C2-C3 to L5-S1Allows compressive, tensile, and rotational motion,Intervertebral Disc,Intervertebral Disc,Annulus FibrosusOuter portion of the disc,Lamellae,,,Great tensile strength,Mad

7、e up of lamellae,,Annulus Fibrosus,,Layers of collagen fibersArranged obliquely 30° Reversed contiguous layers,,Intervertebral Disc,Nucleus Pulposus,Nucleus Pulposus,,,Inner structureGelatinousHigh water content

8、Resists axial forces,The Intervertebral Disc,Has two rolesShock absorber of axial forcesPivot point in motion segment,LPNP--病理分型,1 纖維環(huán)膨出2 纖維環(huán)局限性突出3 椎間盤突出4 椎間盤脫出5 游離型椎間盤,Herniated Disc: 4 degrees,Nuclear herniation

9、: nucleus ruptures. No disruption of outer annular fibersDisc protrusion: ruptured nucleus causes outer fibers to bulgeNuclear extrusion: Complete split in annulus. Material leaks but remains attached to nucleusSeq

10、uestered nucleus: Leaked substance no longer attached to nucleus,,INTRODUCTION,The back and leg pain since - Greeks recognized it.In the fifth century AD Aurelianus clearly described the symptoms of sciatica. The sciat

11、ica arose from either hidden causes or observable causes- a fall, a violent blow, pulling, or straining.,INTRODUCTION,Mixter and Barr in their classic paper published in 1934 again attributed sciatica to lumbar disc hern

12、iation.,Definition,Ruptured discs are among the most common and painful of all back ailments. The condition occurs when the outer cover of a disc is torn and the soft inner tissue extrudes. The extrusion often puts pres

13、sure on the spinal nerves, causing back and leg pain which can be severe.腰椎間盤突出癥是因椎間盤變性，纖維環(huán)破裂，髓核突出刺激或壓迫神經(jīng)根、馬尾神經(jīng)所表現(xiàn)的一種綜合征。,CIinicaI Presentation,The following are risk factors for herniated disc disease in the lumbar sp

14、ine:smoking, pro-longed daily driving of motor vehicles, and frequent repetitive lifting of heavy objects and twisting. It is more common in males than females and has a maximal incidence in the third and fourth decade

15、s of life.,CIinicaI Presentation,A symptom- HNP. Sciatica is pain along the course of the sciatic nerve. The classic symptom is low back pain with radiation of severe pain down the back of the leg to the ankle and foot.

16、It may be associated with neurological signs such as motor and sensory loss and occasionally bladder involvement.,神經(jīng)根性痛的原因,壓迫改變神經(jīng)根的傳導(dǎo)、營(yíng)養(yǎng)狀態(tài)，通過影響局部血運(yùn)和腦脊液的營(yíng)養(yǎng)，機(jī)械直接損傷神經(jīng)內(nèi)部，神經(jīng)根受壓變形，有張力，壓迫神經(jīng)根可引傳導(dǎo)性損傷，功能改變。同周圍神經(jīng)一樣，單純壓迫不引起根痛，沒有炎

17、癥和刺激因素壓迫只產(chǎn)生感覺缺失，運(yùn)動(dòng)無力，反射異常，但無痛。如有化學(xué)炎癥和代謝因素產(chǎn)生炎性反應(yīng)存在~~~`,The levels of lumbar HNP,The most common levels - L4--L5 and L5--Sl. For this reason, radicular symptoms almost always refer to symptoms below the level of the knee,

18、 in the L5 or S1 dermatome. Leg symptoms can vary from numbness to dysesthesia to true pain.The herniation of the L4--L5 disc can compress the S5 and The lumbosacral disc causes compression of the S1 nerve root.,臨床表現(xiàn)－

19、癥狀,1 腰痛和坐骨神經(jīng)痛－95％2 下腹痛或大腿前側(cè)痛－L2.3.4N根受累3 麻木－按受累N區(qū)域皮節(jié)分布4 間歇性跛行－行走時(shí)加重對(duì)N根壓迫5 馬尾綜合征－會(huì)陰部麻木 刮約肌功能障礙6 肌癱瘓－L5N根 脛前肌.腓骨長(zhǎng)短肌 拇.趾長(zhǎng)伸肌 S1N根小腿三頭肌 但少見,臨床表現(xiàn)－體征,1.脊柱外形2.壓痛點(diǎn)3.腰椎運(yùn)動(dòng)4.肌肉萎縮與肌力改變

20、5.感覺減退6.腱反射改變7特殊試驗(yàn),1直腿抬高試驗(yàn),2直腿抬高加強(qiáng)試驗(yàn)（Bragard 征）,,The most notable of these is the Lasègue sign, or straight-leg raising test, described by Forst in 1881 but attributed to Lasègue, his teacher.,This test was

21、devised to distinguish hip disease from sciatica.,Protrusion of the L4/5 disc,It may cause L5 root pressure with pain radiating down the leg to the dorsum of the foot. There may be numbness on the outer side of the calf

22、 and medial two-thirds of the dorsum of the foot with weakness of dorsiflexion, particularly of the foot and toes.,Protrusion of the L4/5 disc,,,Protrusions at the L4/5 level will thus compress the L5 root, while protru

23、sions at the L5/S1 level will compress the first sacral root.,Protrusion of the L5/S1 disc,It will press on the S1 nerve root and may lead to pain and numbness on the outer side of the foot and under side of the heel.,Pr

24、otrusion of the L5/S1 disc,There may be weakness of both eversion and plantarflexion of thefoot with a diminished or absent ankle jerk.,影像學(xué)檢查,注意 1.必須與臨床表現(xiàn)相結(jié)合 2.不能僅以影像學(xué)檢查為依據(jù) 3.不能片面強(qiáng)調(diào)影像學(xué)檢查1.腰椎X線平片2.CT CTM3.M

25、RI,Plain X-rays,Plain X-rays are of very limited value in the investigation of a lumbar radiculopathy. Beside Marked focal disc space narrowing, plain X-rays are often normal. But its most important value is rule out t

26、he bony disorders of the lumbar spine, TB, Tumor.,腰椎X線平片,,正位,側(cè)位,Plain CT,CT is recommended as the initial investigation for the evaluation of lumbar disc disease, It can show many disorders of the level:,,,解剖結(jié)構(gòu)變化,,MRI,M

27、RI is now the screening technique of choice for the accurate definition of lumbar disc herniation. Using T2-weighted images, the nucleus pulposus and annulus fibrosus can be distinguished. Sagittal imaging using both T

28、l and T2 sequences defines the degree of disc protrusion and the extent of any spinal stenosis.,,,MRI,Axial views are more valuable in assessing nerve root compression. Even in the absence of disc protrusion, MRI can id

29、entify tears in the annulus fibrosus which sometimes enhance with gadolinium.,,,臨床表現(xiàn),流行病學(xué)常見于20～50歲患者男女比4～6:1多有彎腰勞動(dòng)或長(zhǎng)期坐位工作史,癥狀腰痛坐骨神經(jīng)痛馬尾神經(jīng)受壓體征腰椎側(cè)突腰部活動(dòng)受限壓痛及骶棘肌痙攣直腿抬高試驗(yàn)及加強(qiáng)實(shí)驗(yàn)神經(jīng)系統(tǒng)表現(xiàn),神經(jīng)系統(tǒng)表現(xiàn)感覺異常肌力下降反射異常,診斷,根據(jù)病史、癥狀

30、、體征及X線平片可作出初步診斷結(jié)合CT、MRI，能更準(zhǔn)確作出病變間隙、突出方向、突出物大小、神經(jīng)受壓情況及主要引起癥狀部位的診斷與腰腿痛的其他疾病鑒別,治療,非手術(shù)治療適應(yīng)癥 年輕、初次發(fā)作者 病程短者 休息后癥狀可自行緩解者 X線檢查無椎管狹窄方法 絕對(duì)臥床休息 持續(xù)牽引 理療、推拿、按摩 皮質(zhì)激素硬膜外注射 髓核化學(xué)溶解法手術(shù)治療,Indication

31、s for operation on prolapsed discs,No improvement in the symptoms and signs after 6 weeks rest.An increase in the neurological deficit.Bladder or bowel involvement suggesting a cauda equine syndrome. It is mandatory an

32、d urgent only in cauda equina syndrome with significant neurological deficit, especially bowel or bladder disturbance. Intractable pain. The pain should have been decreased by rest, antiinflammatory medication, recurrin

33、g after the conservative care. The progressive or unresponsive lesions with appreciable neurological signs despite conservative management.,與腰痛為主要表現(xiàn)疾病鑒別 腰肌勞損和棘上棘間韌帶損傷 第三腰椎橫突綜合征 椎弓根峽部不連與脊椎滑脫癥 腰椎腫瘤或結(jié)核與腰痛伴坐