腰椎間盤綜合征的介紹

　　腰椎間盤位于兩個椎體之間，是一個具有流體力學特性的結構，由髓核、纖維環(huán)和軟骨板三部分構成。接下來小編為大家整理了腰椎間盤綜合征的介紹，希望對你有幫助哦!

　　Essentials of Diagnosis

　　診斷要點

　　Low back pain radiating into the thigh， leg， and foot.

　　下腰背痛放射至大腿、小腿及足部

　　Parestheasia in the affected dermatome.

　　受累區(qū)皮膚感覺異常

　　General Considerations

　　概述

　　Relapse of low back pain may or may not be associated with leg pain. Patients who present with low back and leg pain frequently recall earlier episodes of postexertional pain limited to the low back. Though specific evidence is lacking， the pattern of leg pain developing secondarily has led many clinicians to attribute the initial episode of localized low back pain to early degeneration of the annulus. With annulus degeneration， the nucleus pulposus bulges into the defect， causing further concentration of stress on the damaged fibers. The annulus is richly innervated with painfibers， and further degeneratinon tends to be associated with more frequent and more intense episodes of pain. Locking and stiffness characterize the painfree periods. Degeneration continues with alteration in the collagen stucture of both the annulus and the nucleus， culminating in fibrosis and unclear fragmentation. The shock-absorbing capacity of the nucleus is diminished， and forces are transmitted in a progressively irregular fashion. Fragments of the deteriorating nuclesus are pushed out ward against or through the weakened annulus， which tends to be weakest at the lateral margin of the posterolongitudinal ligament. The protrusion begins as a posterolateral bulge that causes variable compression and irritation of neural structures.

　　下腰背痛復發(fā)不一定伴有小腿疼痛。有下腰背及小腿痛的病人?；貞浺郧霸谟昧筇弁矗洳课幌抻谙卵巢?。雖然缺乏特征的證明，繼發(fā)的腿部疼痛已導致許多臨床醫(yī)生將局限性的下腰背痛的最初發(fā)作歸咎于纖維環(huán)的早期變性，因纖維環(huán)變性，髓核向缺失部突出，使應力進一步集中在受損的纖維上。纖維環(huán)內有豐富的痛覺神經纖維，進一步變性使疼痛發(fā)作更頻繁更強烈。無痛期間的特征是固定和僵凝，變性持續(xù)下去，纖維環(huán)和髓核的膠原結構發(fā)生變化并以纖維化及髓核碎裂告終。髓核吸收震蕩能力下降，作用力逐漸以不規(guī)則的形式傳導，受損髓核的碎片被推向外，碰著或突破微弱的纖維環(huán)，并使后縱韌帶側緣變得最薄弱。髓核開始在后外側突出，引起不同程度的神經結構受壓和刺激。

　　The contents of the neurl tube bbelow the first lumbar segment consist of nerve roots only. Each nerve root emerges below its respective vertebra. The L4-5 and L5-S1 disk levels correspond to the region of maximal mechanical stress in the lumbar spine. Disk protruions at these levels are likely to involve the portion of the root above the exit at the next lower interspace. Lesions affecting the L5 and S1 nerve roots account for over 90% of disk-mediated nerve root lesions.

　　在第一腰椎節(jié)段以下的椎管內只有神經根，每個神經根在各自的椎體下方突出。腰4~5及腰5~骶1椎間盤水平面相當于腰脊柱中最大的機械應力區(qū)域。此平面的椎間盤突出可累及到下一個椎間隙出口以下的神經根，椎間盤突出影響到腰5及骶190%以上的神經根病變是因此而造成的。

　　Clinical Findings

　　臨床表現(xiàn)

　　a. Symptoms and Signs： Sciatica， or pain radiating down the leg， is the most common presentation. Presenting complanints of the patient with established diskogenic back pain are remarkable for radicular symptoms. Prolonged compression results in nerve root inflammation and pain referred in a dermatomal distribution. The onset of leg pain is usually insidious， but pain may begin acutely when sudden disk hernia tion follow injury.

　　a.癥狀及體征：最常出現(xiàn)的是坐骨神經痛，即向下放射至小腿的疼痛。有椎間盤源性的背痛病人，神經根癥狀是明顯的，長期壓迫導致神經根炎癥及疼痛牽涉到皮節(jié)分布區(qū)，小腿疼痛常常不知不覺的發(fā)作。但傷后的突發(fā)椎間盤突出，疼痛也可以急性開始。

　　Pain is piercing and typically radiates from the thigh into the leg and foot. Activities such as coughing， sneezing， or bearing down during bowel movements increase intra-abdominal pressure， which is directly transmitted to intraspinal structures， provoking or exacerbating pain.

　　疼痛為刺痛，并典型的的由大腿移至小腿及足部、咳嗽、打噴嚏或用力排便等活動增加腹內壓時，壓力可直接傳導致脊柱內結構，而可激起或加重疼痛。

　　When nerve root compression results from annular bulging， it is often accentuated by prolonged sitting or standing and relieved at least partially by rest. Apatient usually prefers to sleep on one side in the fetal position and when stiting prefers a straight-back chair. When disk extrusion occurs， pain may be less responsive to rest.

　　由纖維環(huán)突出導致的神經根受壓時，常常在久坐或久遠站后疼痛加重，休息后至少可使疼痛部分緩解，病人更喜歡側臥。坐時寧愿坐一直背椅，當椎間盤突出發(fā)生時，疼痛對休息的反應不顯著。

　　Compression of nerve roots often produces objective sensory changes early， with paresthesia and loss of sensating detectable in the affected dermatome. With continued root compression. Motor weakness may develop. With involvement of the L4 root， the patellar tendon reflex may be diminished and slight quadriceps weakness may be observed. Sensation may be diminished over the medial calf. With involvement of the L5 5 root， weakness is frequently manifested by loos of strength in great toe dorsiflexion. Pain and numbness are present in the anteromedial leg and foot. First sacral root involvement affects the calf musles， and the Achilles reflex may be lost on the involved side. Weakness is best demonstrated by the patient's inability to rise on the toes repeatedly. Sensory findings include pain and numbness in the posterolateral leg and foot. Muscle atrophy may accompany sensory and motor changes.

　　神經根受壓常很早即產生客觀的感覺變化，在受影響的皮節(jié)區(qū)有感覺異常及感覺缺失，神經根持續(xù)受壓，可發(fā)生運動肌無力，若累及腰4神根，可見膝腱反射減弱和輕度股四頭肌無力，小腿肌肉感覺減退。當腰5神經根受累時，常表現(xiàn)為 趾背伸無力，小腿前內側及足出現(xiàn)疼痛和麻木。骶1神經根受累時，影響小腿肌肉。受累側跟腱反射消失，病人不能反復用足尖踮立，感覺癥狀包括小腿后外側和足有疼痛及麻木感。伴隨著感覺和運動肌的變化。可出現(xiàn)肌肉萎縮。

　　Occasionally， acute posterior midline disk prolapse at the L2-3 level may cause compression of many nerve roots in the cauda equina. This is known as acute cauda equina syndrome. This is a surgical emergency! Symptoms include intense leg pain in one or both extremities， with severe muscle weakness or paralysis. Compression of sacral roots results in acute urinary retention. Decompression of the cauda equina is undertaken after mylographic confirmation of the lesion.

　　偶爾在腰2~3水平后正中位的椎間盤急性脫出，可使馬尾部許多神經根受壓。此即解性馬尾神經綜合征。這是一種外科急癥。其癥狀有一側或兩側小腿的劇烈疼痛，并有嚴重的肌肉無力或癱瘓。骶神經根受壓導致急性尿潴留。脊造影證實有病變后，可作馬尾減壓術。

　　b. Diagnostic Test： With less well defined signs of root compression， several tests may help to detect the presence of lumbar disk disease. The straight leg-raising test is performed by lifting the extended leg of the supine patient. The test produces tension in the lumbosacral roots and frequently reproduces sciatica in the presence of inflamed or irritated lumbosacral roots.

　　b.診斷性試驗：沒有明確的神經根受壓體征時節(jié)，幾種試驗有助于檢查腰椎間盤病的存在，直腿拭驗高試驗的操作方法是：病人在仰臥位時使傷肢伸直抬高。此試驗可使腰骶部神經根處產生張力，常使有炎癥的或受激惹的腰骶神經根再產生坐骨神經痛。

　　The straight leg-raising test can also be performed on the leg without symptoms. The test is positive if it produces sciatica in the symoptomatic leg. Many clinicians believe that a positive test is strong evidence of disk herniation.

　　在小腿沒有癥狀時亦可作直腿抬高試驗，如使受累小腿產生坐骨神經痛，則為陽性。多數(shù)臨床醫(yī)生認為，陽性結果果信間盤脫出的有力證據(jù)。

　　Laseque's test is performed with the patient lying supine. The hip and knee are flexed 90 degrees. The knee is then slowly extended， producing sciatic stretch as in the straight leg-raising maneuver.

　　Leaseque試驗是在病人仰臥時操作，髖和膝關節(jié)曲90度，然后逐漸伸直膝關節(jié)，這和直腿抬高方法一樣，可以產生坐骨神經牽拉。

　　c. X-Ray Findings： X-ray examination may reveal degenerative changes， such as disk space narrowing and osteophytosis， or results may be entirely normal.

　　c.X線表現(xiàn)：X線檢查可顯示退行性變化，如椎間隙變狹窄和骨贅病，但結果也可以完全正常。

　　Differential Diagnosis

　　鑒別診斷

　　Whether nerve root signs are present or not， the main differential concern with back pain is spinal tumor. The most common extradural tumors in adults are metastatic， most often from carcinoma of the breast in women and the prostate in men. Lung， thyroid， and uterine tumors are less common sources of metastases. Multiple myeloma also frequently involves the spine and often causes pain by weakening of bony structures， causing pathologic fractures. Intradural spinal tumors are less common than metastases in adults and include neurofibromas， meningiomas， and ependymomas. Diagnosis of these slow-growing tumors is often quite difficult， as symptoms may mimic diskogenic pain and may appear to improve with conservative measures. Metastatic tumors of bone are often detected on routine x-ray studies.

　　不管有無神經根性癥狀，涉及到背痛的主要鑒別診斷是脊椎腫瘤。在成人最常見的硬膜外腫瘤是轉移性的、多來自婦女乳腺癌和男性的前列腺癌，源于肺、甲狀腺及子宮的腫瘤轉移較少。多發(fā)性骨髓瘤也常累及脊柱，并常導致骨質結構脆弱而產生疼痛，也可以引起病理骨折，成人硬脊腫瘤神經纖維瘤，腦膜瘤和室管膜瘤，較轉移腫瘤少見。診斷這些生長緩慢的腫瘤常常是十分困難的，其癥狀很像椎間盤突出的疼痛，而且經保守治療后疼痛也可改善。通過常規(guī)X線檢查可以發(fā)現(xiàn)骨的轉移性腫瘤。

　　The history may suggest the possibility of spinal tumor. A history of primary tumors elsewhere should immediately raise this suspicion. The complaint of pain that is more severe at night than during the day is also strongly suggestive of spinal tumor. The reasons for this phenomenon are unclear but may be related to nocturnal increase in cerebrospinal fluid pressure. Persistent bilateral leg pain with no history of back pain also suggests spinal tumor. Myelography with contrast media or CT scan with metrizamide is essential to detect intradural and intramedullary tumors.

　　病史可提示有脊柱腫瘤的可能，有任何部位的原發(fā)件腫瘤病史時，應立即懷疑及此。病人述說夜間疼痛比白天劇烈時，也提示很可能有脊柱腫瘤。這些現(xiàn)象原因不清楚，可能與夜間腦脊液壓力增加有關。持續(xù)性兩側小腿疼痛而無背痛病史，也提示為脊柱腫瘤，用造影劑作脊髓X線造影或用甲泛影酰胺作CT掃描探查硬膜內或脊內腫瘤是來可少的。

　　Treatment

　　治療

　　Management of acute lumbar disk disease is controversial， If symptoms are produced by bulgin rather than extrusion of the herniated disk， conservative measures， such as bed rest， analgesics， and anti-inflammatory medication， often result in complete resolution of symptoms.

　　對急性腰椎間盤病的處理有分歧的，若癥狀僅僅是由于纖維環(huán)凸出，而非纖維環(huán)破裂的髓核突出所引起者，保守療法如臥床休息，止痛劑及抗炎藥物治療等可使癥狀完全消失。

　　If pain becomes intractable or if neurologic symptoms progress or fail to respond despite con servative measures， intraiskal injection of the enzyme chymopapain， an extract of the papaya plant， may diminish symptoms by proteolytic degradation of collagen within the nucleus pulposus. Results with this technique， known as chemonucleolysis， compare favorably with surgical diskectomy for relief of pain. Patients treated with chymopapain recover more quickly and experience more rapid relief of pain. Patients treated with chymopapain recover more quickly and experience more rapid relief from pain. The presence of a free disk fragment in the spinal canal is not an absolute contraindication to the use of chymopapain， but srgical diskectomy (laminectomy) may be necessary if the fragment is a major source of the patient's pain. Preinjection or preoperative evaluation should include CT scan ormyelography showing a protruding disk that corresponds to the patient’s pain distribution or neurologic deficit.

　　如果疼痛很頑固，或者神經癥狀有發(fā)展，或對保守療法無反就，可向椎間盤內注射木瓜凝乳蛋白酶(此為一種番木瓜植物的提取物)通過在髓核內對膠原白進行蛋白分解性的降解而減輕癥狀。此法名為化學核溶解法。較用外科手術摘除椎間盤解除疼痛更有效。病人經木瓜凝乳蛋白酶治療后，恢復較快，體驗到疼痛很快緩解。椎管內有一游離的椎間盤碎片存留時，木瓜凝乳蛋白酶的應用不是絕對禁忌癥。如碎片是引起疼痛的主要原因，則需手術摘除椎間盤(椎板切除術)。注射前或手術摘除前的判斷，應包括CT掃描或脊髓造影，證明脫了的椎間盤與病人疼痛的分布或神經缺失是相符合的。

　　Following the chymopapain injection， the patient may experience increased back pain for several days to several weeks but may have immediate relief of leg pain.

　　注射木瓜凝乳蛋白酶后，病人可體驗到腰部有幾天或幾周的加重，但小腿疼痛卻很快消失。

　　Complications of chemonucleolysis include diskitis and sensitivity reactions， including an 0.5% incidence of anaphylaxis. Chemonucleolysis is contraindicated in patients who are allergic to papaya or who have previously been injected with chymopapain.

　　化學核溶解法的并發(fā)癥有椎間盤炎及過敏反應，包括 0.5%的過敏休克的發(fā)生率。對番木瓜過敏的病人，或以前曾經注射過木瓜凝乳蛋白酶的人，化學核溶解法是禁忌證。

　　Complications of laminectomy for disk removal include recurrence of pain due to reherniation of residual disk fragments or scar formation involving the nerve roots; damage of nerve roots， resulting in neurologic deficit; tear of the dura， with resulting dural leak of cerebrospinal fluid; and penetration of the anterior annulus during diskectomy， with damage of the great vessels lying anterior to the spine. Hemorrhage in this situation may be catastrophic owing to difficulty in detection and control

　　用椎板切除術摘除椎間盤的并發(fā)癥有殘余椎間盤碎片再脫出?；虬毯坌纬衫奂吧窠浉墒固弁磸桶l(fā);神經根損傷經起神經方面缺陷;硬脊膜撕裂使腦脊液外漏以及椎間盤摘除時穿破纖維環(huán)的前側使脊柱前面的大血管損傷。這種情況引起的出血是災難性的，因其部位是很難發(fā)現(xiàn)及控制。