腰椎间盘综合征的介绍

腰椎间盘综合征的介绍

　　腰椎间盘位于两个椎体之间，是一个具有流体力学特性的结构，由髓核、纤维环和软骨板三部分构成。接下来小编为大家整理了腰椎间盘综合征的介绍，希望对你有帮助哦!

　　Essentials of Diagnosis

　　诊断要点

　　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.

　　受累区皮肤感觉异常

　　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.

　　下腰背痛复发不一定伴有小腿疼痛。有下腰背及小腿痛的病人常回忆以前在用力后疼痛，其部位限于下腰背部。虽然缺乏特征的证明，继发的腿部疼痛已导致许多临床医生将局限性的下腰背痛的最初发作归咎于纤维环的早期变性，因纤维环变性，髓核向缺失部突出，使应力进一步集中在受损的纤维上。纤维环内有丰富的痛觉神经纤维，进一步变性使疼痛发作更频繁更强烈。无痛期间的特征是固定和僵凝，变性持续下去，纤维环和髓核的胶原结构发生变化并以纤维化及髓核碎裂告终。髓核吸收震荡能力下降，作用力逐渐以不规则的形式传导，受损髓核的碎片被推向外，碰着或突破微弱的纤维环，并使后纵韧带侧缘变得最薄弱。髓核开始在后外侧突出，引起不同程度的神经结构受压和刺激。

　　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.

　　在第一腰椎节段以下的椎管内只有神经根，每个神经根在各自的椎体下方突出。腰4~5及腰5~骶1椎间盘水平面相当于腰脊柱中最大的机械应力区域。此平面的椎间盘突出可累及到下一个椎间隙出口以下的神经根，椎间盘突出影响到腰5及骶190%以上的神经根病变是因此而造成的。

　　Clinical Findings

　　临床表现

　　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.症状及体征：最常出现的是坐骨神经痛，即向下放射至小腿的疼痛。有椎间盘源性的背痛病人，神经根症状是明显的，长期压迫导致神经根炎症及疼痛牵涉到皮节分布区，小腿疼痛常常不知不觉的发作。但伤后的突发椎间盘突出，疼痛也可以急性开始。

　　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.

　　疼痛为刺痛，并典型的的由大腿移至小腿及足部、咳嗽、打喷嚏或用力排便等活动增加腹内压时，压力可直接传导致脊柱内结构，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.

　　由纤维环突出导致的神经根受压时，常常在久坐或久远站后疼痛加重，休息后至少可使疼痛部分缓解，病人更喜欢侧卧。坐时宁愿坐一直背椅，当椎间盘突出发生时，疼痛对休息的反应不显著。

　　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.

　　神经根受压常很早即产生客观的感觉变化，在受影响的皮节区有感觉异常及感觉缺失，神经根持续受压，可发生运动肌无力，若累及腰4神根，可见膝腱反射减弱和轻度股四头肌无力，小腿肌肉感觉减退。当腰5神经根受累时，常表现为 趾背伸无力，小腿前内侧及足出现疼痛和麻木。骶1神经根受累时，影响小腿肌肉。受累侧跟腱反射消失，病人不能反复用足尖踮立，感觉症状包括小腿后外侧和足有疼痛及麻木感。伴随着感觉和运动肌的变化。可出现肌肉萎缩。

　　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.

　　偶尔在腰2~3水平后正中位的椎间盘急性脱出，可使马尾部许多神经根受压。此即解性马尾神经综合征。这是一种外科急症。其症状有一侧或两侧小腿的剧烈疼痛，并有严重的肌肉无力或瘫痪。骶神经根受压导致急性尿潴留。脊造影证实有病变后，可作马尾减压术。

　　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.诊断性试验：没有明确的神经根受压体征时节，几种试验有助于检查腰椎间盘病的存在，直腿拭验高试验的操作方法是：病人在仰卧位时使伤肢伸直抬高。此试验可使腰骶部神经根处产生张力，常使有炎症的或受激惹的腰骶神经根再产生坐骨神经痛。

　　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.

　　在小腿没有症状时亦可作直腿抬高试验，如使受累小腿产生坐骨神经痛，则为阳性。多数临床医生认为，阳性结果果信间盘脱出的有力证据。

　　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试验是在病人仰卧时操作，髋和膝关节曲90度，然后逐渐伸直膝关节，这和直腿抬高方法一样，可以产生坐骨神经牵拉。

　　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线表现：X线检查可显示退行性变化，如椎间隙变狭窄和骨赘病，但结果也可以完全正常。

　　Differential Diagnosis

　　鉴别诊断

　　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.

　　不管有无神经根性症状，涉及到背痛的主要鉴别诊断是脊椎肿瘤。在成人最常见的硬膜外肿瘤是转移性的、多来自妇女乳腺癌和男性的前列腺癌，源于肺、甲状腺及子宫的肿瘤转移较少。多发性骨髓瘤也常累及脊柱，并常导致骨质结构脆弱而产生疼痛，也可以引起病理骨折，成人硬脊肿瘤神经纤维瘤，脑膜瘤和室管膜瘤，较转移肿瘤少见。诊断这些生长缓慢的肿瘤常常是十分困难的，其症状很像椎间盘突出的疼痛，而且经保守治疗后疼痛也可改善。通过常规X线检查可以发现骨的转移性肿瘤。

　　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.

　　病史可提示有脊柱肿瘤的可能，有任何部位的原发件肿瘤病史时，应立即怀疑及此。病人述说夜间疼痛比白天剧烈时，也提示很可能有脊柱肿瘤。这些现象原因不清楚，可能与夜间脑脊液压力增加有关。持续性两侧小腿疼痛而无背痛病史，也提示为脊柱肿瘤，用造影剂作脊髓X线造影或用甲泛影酰胺作CT扫描探查硬膜内或脊内肿瘤是来可少的。

　　Treatment

　　治疗

　　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.

　　对急性腰椎间盘病的处理有分歧的，若症状仅仅是由于纤维环凸出，而非纤维环破裂的髓核突出所引起者，保守疗法如卧床休息，止痛剂及抗炎药物治疗等可使症状完全消失。

　　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.

　　如果疼痛很顽固，或者神经症状有发展，或对保守疗法无反就，可向椎间盘内注射木瓜凝乳蛋白酶(此为一种番木瓜植物的提取物)通过在髓核内对胶原白进行蛋白分解性的降解而减轻症状。此法名为化学核溶解法。较用外科手术摘除椎间盘解除疼痛更有效。病人经木瓜凝乳蛋白酶治疗后，恢复较快，体验到疼痛很快缓解。椎管内有一游离的椎间盘碎片存留时，木瓜凝乳蛋白酶的应用不是绝对禁忌症。如碎片是引起疼痛的主要原因，则需手术摘除椎间盘(椎板切除术)。注射前或手术摘除前的判断，应包括CT扫描或脊髓造影，证明脱了的椎间盘与病人疼痛的分布或神经缺失是相符合的。

　　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，病人可体验到腰部有几天或几周的加重，但小腿疼痛却很快消失。

　　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.

　　化学核溶解法的并发症有椎间盘炎及过敏反应，包括 0.5%的过敏休克的发生率。对番木瓜过敏的病人，或以前曾经注射过木瓜凝乳蛋白酶的人，化学核溶解法是禁忌证。

　　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

　　用椎板切除术摘除椎间盘的并发症有残余椎间盘碎片再脱出。或疤痕形成累及神经根可使疼痛复发;神经根损伤经起神经方面缺陷;硬脊膜撕裂使脑脊液外漏以及椎间盘摘除时穿破纤维环的前侧使脊柱前面的大血管损伤。这种情况引起的出血是灾难性的，因其部位是很难发现及控制。