脊柱退行性疾病（101页）

1、脊柱退行性疾病脊柱退行性疾病Spinal degenerative diseases What is called degeneration? We also found other phenomenon .Some People are only 40 years old, but looks like 60 years of age or the opposite 。 影响因素影响因素 influence factorsv过度负荷过度负荷 overloadv不良体位不良体位 poor posture v慢性劳损慢性劳损 chronic strainv外伤外伤 injury v慢性炎症慢性炎

2、症 chronic inflammationv先天因素先天因素 congenital factorsAnatomy of the SpineSagittal ViewAP - viewLordosisKyphosisLordosisDevelopment of Disc and Spinal Curvature Newborn25 years4 years- no significant curvature- Disc Height = Vertebral Body Height- Double-S curvature- Disc Height = 40% of VBH- biconcave

3、- biconvex shape of intervertebral space- Disc Height = 25% of VBHIntervertebral discAnulus fibrosusNucleus PulposusNewborn65 yearsNo vascularisation of disc7 years70 years30 yearsWater content in the nucleus pulposus decreased with age Facet JointsCervical vertebrae sloping Thoracic vertebrae coron

4、al Lumbar vertebrae sagittalv9、 人的价值，在招收诱惑的一瞬间被决定。人的价值，在招收诱惑的一瞬间被决定。2022-1-222022-1-22Saturday, January 22, 2022v10、低头要有勇气，抬头要有低气。、低头要有勇气，抬头要有低气。2022-1-222022-1-222022-1-221/22/2022 1:29:06 AMv11、人总是珍惜为得到。、人总是珍惜为得到。2022-1-222022-1-222022-1-22Jan-2222-Jan-22v12、人乱于心，不宽余请。、人乱于心，不宽余请。2022-1-222022-1-22

5、2022-1-22Saturday, January 22, 2022v13、生气是拿别人做错的事来惩罚自己。、生气是拿别人做错的事来惩罚自己。2022-1-222022-1-222022-1-222022-1-221/22/2022v14、抱最大的希望，作最大的努力。、抱最大的希望，作最大的努力。2022年年1月月22日星期六日星期六2022-1-222022-1-222022-1-22v15、一个人炫耀什么，说明他内心缺少什么。、一个人炫耀什么，说明他内心缺少什么。2022年年1月月2022-1-222022-1-222022-1-221/22/2022v16、业余生活要有意义，不要越轨。

6、、业余生活要有意义，不要越轨。2022-1-222022-1-22January 22, 2022v17、一个人即使已登上顶峰，也仍要自强不息。、一个人即使已登上顶峰，也仍要自强不息。2022-1-222022-1-222022-1-222022-1-22LigamentsAnterior longitudinal ligamentPosterior longitudinal ligament Blood SupplyLoad Transfer80%20%vThe FUNCTIONAL UNIT of the spinevComprised of:lTwo adjacent vertebrae

7、lIntervertebral disclConnecting ligamentslTwo facet joints and capsulesIntradiscal PressurevBiomechanics18,31,24,62,75,011,011,023,017,0颈椎退行性疾病颈椎退行性疾病cervical degenerative disease包括：包括：一、颈椎病一、颈椎病二、颈椎管狭窄症二、颈椎管狭窄症三、颈椎间盘突出症三、颈椎间盘突出症四、颈椎后纵韧带骨化四、颈椎后纵韧带骨化 including一、一、Cervical spondylosis二、二、Cervical cana

8、l stenosis三、三、Cervical disc herniation四、四、Ossification of cervical posterior longitudinal ligament一一、颈颈 椎椎 病病 Cervical spondylosisv发病率随着年龄的增加而显著提高发病率随着年龄的增加而显著提高 4050岁的发病率为岁的发病率为20， 60岁以上者达岁以上者达50， 70岁以上则更高。岁以上则更高。v目前发病年龄趋于年轻化目前发病年龄趋于年轻化 定义定义 Conceptv颈椎间盘退变及其继发性改变，刺激或压颈椎间盘退变及其继发性改变，刺激或压迫相邻脊髓、神经、血管等组

9、织，并引起迫相邻脊髓、神经、血管等组织，并引起相应的症状或体征者，称为颈椎病。相应的症状或体征者，称为颈椎病。vCervical spondylosis is a disorder in which there is abnormal wear on the cartilage and bones of the neck.分分 型型 Classification v脊髓型脊髓型 Cervical Spondylotic Myelopathy CSM v神经根型神经根型Cervical Spondylotic Radiculopathy CSR v交感神经型交感神经型Sympathetic Ce

10、rvical Spondylosis SCSv椎动脉型椎动脉型Cervical Spondylosis of Vertebral artery type v其它（食道压迫型、颈型、混合型）其它（食道压迫型、颈型、混合型） CSM以颈脊髓受损为主要临床表现的颈椎病。以颈脊髓受损为主要临床表现的颈椎病。主要表现为走路不稳、四肢麻木、大小主要表现为走路不稳、四肢麻木、大小便困难等。便困难等。Main clinical manifestations:Cervicalspinal cord injury，such as unsteady walk, numbness of limbs, micturit

11、ionand defecation difficulties CSR 1.多见于多见于30岁以上者岁以上者More common in people over 30 years old2.起病缓慢、病程长，反复发作。起病缓慢、病程长，反复发作。Slow onset, long course of disease, recurrent seizures.3.颈肩部疼痛，下颈椎病变可向前臂放射。颈肩部疼痛，下颈椎病变可向前臂放射。 Neck and shoulder pain, some can radiate to the arm SCS 主要表现为头晕、眼花、耳鸣、手麻、心动过速、心主要表现为

12、头晕、眼花、耳鸣、手麻、心动过速、心前区疼痛等一系列症状。前区疼痛等一系列症状。X线片有失稳或退变，椎动线片有失稳或退变，椎动脉造影阴性。脉造影阴性。 Main clinical manifestations: dizziness, tinnitus, numbness of hand, heartbeat tachycardia, precordial pain. X-ray: degeneration of cervical vertebra. Vertebral artery angiography negative.Cervical Spondylosis of Vertebral a

13、rtery type 以椎基底动脉供血不足为主要临床表现的颈椎病。主以椎基底动脉供血不足为主要临床表现的颈椎病。主要表现为头痛，头晕，黑朦等症状，与颈部旋转有关。要表现为头痛，头晕，黑朦等症状，与颈部旋转有关。 Main clinical manifestations: vertebral basilar artery insufficiency，such as headache, dizziness and amaurosis, relate to the neck rotation.食管型颈椎病食管型颈椎病Esophagus type cervical spondylosis vA spe

14、cial type of CS vThroat discomfort, foreign body sensation is an early symptom vLate manifestations is dysphagia vOften accompanied by symptoms of other cervical spondylosis 颈型颈型Neck type cervical spondylosis以颈部酸、痛、麻、僵为主要临床表现或颈以颈部酸、痛、麻、僵为主要临床表现或颈项部压迫感的颈椎病，症状集中在颈部，转项部压迫感的颈椎病，症状集中在颈部，转动不灵活。动不灵活。Main c

15、linical manifestations: acid distention、pain、numbness and stiff in the neck.Mixed type of cervical spondylosis v具备以上两种或两种以上的表现者，具备以上两种或两种以上的表现者，即可确诊。即可确诊。v With two or more than two kinds of performance above.DiagnosisMust be have three conditions: vCervical degenerative changes vRelevant clinical m

16、anifestations vRelevant clinical manifestations are consistent with imaging findings TreatmentIndicatiovMild symptoms vCan not tolerate operation MethodsvCorrect bad posture vTractionvMassagecautiously usevPhysiotherapyvMedications expectant treatment surgical therapy IndicatiovFormal expectant trea

17、tment for 36 months is invalid vSymptom of CSM aggravate progressively or suddenly or MRI showed that the cervical spinal cord signal changes vSymptom of CSR impact quality of life手手术术方方式式手术手术目的目的 surgical purpose 彻底减压彻底减压 Complete decompression 重建脊柱稳定性重建脊柱稳定性 Reconstruction of spinal stability 开放式：

18、开放式：Open operation 前路前路直接减压直接减压Anterior cervical operation Direct decompression 后路后路间接减压间接减压Posterior cervical operation Indirect decompression 微创式：微创式：Microinvasive operationCase 1 颈前路椎间盘摘除、颈前路椎间盘摘除、取自体髂骨椎间植骨融合、内固定术取自体髂骨椎间植骨融合、内固定术Case 2 颈前路椎间盘摘除、颈前路椎间盘摘除、椎间融合器植骨融合、内固定术椎间融合器植骨融合、内固定术Case 3 颈前路椎体次全切

19、除、颈前路椎体次全切除、椎间钛笼植骨融合、内固定术椎间钛笼植骨融合、内固定术Case 4 颈后路单开门椎管扩大成形术颈后路单开门椎管扩大成形术Case 5 颈后路单开门椎管扩大成形颈后路单开门椎管扩大成形后路支撑钢板内固定术后路支撑钢板内固定术Case 5颈颈椎椎人人工工间间盘盘置置换换术术颈椎管狭窄症颈椎管狭窄症 Cervical canal stenosisEtiology and pathology vCongenital developmental CCSvDegenerative or iatrogenic CCS vCCS can be single or multi segmen

20、tal stenosis, common in the C4,5 and C6,7 segments Clinical manifestation vSymptoms are similar to the symptoms of CSvX-rayvCTvMRIA:椎管失状径椎管失状径A13mm 正常正常A13mm 相对狭窄相对狭窄A10MM 绝对狭窄绝对狭窄 B:椎体中失状径椎体中失状径 A:B0.75 狭窄狭窄 椎管正中失状径椎管正中失状径 13mm 正常正常13mm 相对狭窄相对狭窄10mm 绝对狭窄绝对狭窄Cervical intervertebral disc degeneration

21、External force cause rupture of annulus fibrosus and longitudinal ligamentNucleus pulposus protrude into spinal canal The pain of nerve root and signs of spinal compression. 颈椎间盘突出症颈椎间盘突出症Cervical disc herniationRelationship between CDH and CSv颈椎间盘突出症是颈椎病发病过程的病理变化之一颈椎间盘突出症是颈椎病发病过程的病理变化之一 CDH is one

22、of the pathological changes in the pathogenesis of CS v颈椎间盘突出症的致压物只能是突出的髓核，而颈颈椎间盘突出症的致压物只能是突出的髓核，而颈椎病可以是髓核以外的其他组织椎病可以是髓核以外的其他组织 Induced pressure can only be protruding nucleus pulposus，however it can be other tissues except the nucleus pulposus男性，男性，40岁，煤矿工人，既往无四肢麻木、无力病史，岁，煤矿工人，既往无四肢麻木、无力病史，摔伤后出现颈部不

23、适伴双上肢放射性麻木、行走不稳摔伤后出现颈部不适伴双上肢放射性麻木、行走不稳1个个月，经颈围制动、脱水、激素及神经营养治疗效果不佳。月，经颈围制动、脱水、激素及神经营养治疗效果不佳。颈椎后纵韧带骨化症颈椎后纵韧带骨化症 Ossification of cervical posterior longitudinal ligament颈椎后纵韧带异常增殖并骨化，压迫脊髓和神经根，颈椎后纵韧带异常增殖并骨化，压迫脊髓和神经根，产生感觉、运动功能障碍。产生感觉、运动功能障碍。Cervical posterior longitudinal ligament abnormally proliferate

24、and ossify，which can constrict the spinal cord and nerve root ，and then lead to paralysis EtiologyThe exact mechanism is not clear，but there are several hypothesis vTheory of heredityvMechanical damage theory vDisturbance of carbohydrate metabolism theory vThe whole body bone hypertrophy theory Epid

25、emiologyThe incidence of OPLL in East Asia is highervJapan 1.94.3%(over 30 years old.）vKorea 3.6%vTaiwan 2.8%vChina 1.61.8%Clinical characteristicsvA chronic,progressive,spinal cord or nerve root compression symptoms vIts symptoms are very similar to CCS orCSvX-ray,CT andMRI can improve the diagnosi

26、s Classification - - Sagittal SectionTopical typeSegmental type Successive tppeMixed typeClassification - Coronal section图图 点状骨化点状骨化图图 蕈伞状骨化蕈伞状骨化图图 山丘状骨化山丘状骨化图图 偏一侧骨化偏一侧骨化测量椎管狭窄率测量椎管狭窄率Imaging evaluation of OPLL减压不彻底神经功能障碍无改善或加重减压不彻底神经功能障碍无改善或加重Imaging evaluation of OPLLvVery difficultvHigh-riskvMor

27、e complications vPoor prognosis Treatment Operation is the only effective means ChallengeHow to select the reasonable operation?vsuccessive type and Mixed typevossific range 3 vertebral segmentsvCervical canal stenosis 50%Posterior cervical operation /Indirect decompressionLaminectomyLaminoplastyLam

28、inectomy+internal fixationvTopical type and Segmental typevossific range 3 vertebral segmentsvCervical canal stenosis 50%Anterior cervical operation /Direct decompression Discectomy Corpectomy decompression 腰椎退行性疾病腰椎退行性疾病lumbar degenerative disease包括：包括：一、腰椎间盘突出症一、腰椎间盘突出症二、腰椎管狭窄症二、腰椎管狭窄症三、腰椎滑脱症三、腰椎滑

29、脱症 including一、一、Lumbar Disc Herniation二、二、lumbar spinal stenosis三、三、lumbar spondylolisthesis腰椎间盘突出症腰椎间盘突出症 Lumbar Disc Herniation LDHEpidemiologyvSymptomatic LDH are seen in all age groups but have their peak in patients aged between 35 and 45 years.vExcept smoking ,occupational factors include sede

30、ntary work and driver are the main reasons for LDHClassificationDegeneration/BulgingMildsevereCentral Posterlateral Lateral ClassificationProtrusionClassificationExtrusionClassificationSequestrationClassificationSchmorls nodsSymptomsHow can we recognize a herniated disk?vLower back painvSciaticavPai

31、n, weakness, numbness or tingling in the legs, buttocks and feet vProblems with bowel, bladder or erectile function, in severe casesGeneral SignsvChanges of lumbar curvature vCompensatory scoliosis vStraight leg-raising (SLR) testvSLR strengthen testvFemoral nerve stretching test Neurologic signsvSe

32、nsibilityvMuscle forcevDeep tendon reflex vMuscle atrophy We can initially locate the intervertebral discProtrusion of the L3/4 discProtrusion of the L4/5 discProtrusion of the L5/S1 disc Imaging examination vX-rayvCTvMRIvLumbar myelography TreatmentvExpectant treatmentvSurgical treatmentExpectant t

33、reatmentvYoungvFirst attackvShort coursevSymptoms can be relieved by rest vNo spinal stenosis vNo spondylolisthesis Surgical treatmentvThe strict expectant treatment is invalid vCauda equina syndrome Classical -discectomyLumbar arthroscopic discectomyPLDPLDDLumbar tunnel MED discectomyMLDAnterior lu

34、mbar discectomy, interbody fusion Lumber artificial disc replacement腰椎管狭窄症腰椎管狭窄症lumbar spinal stenosisvLSS ，caused by various reasons ，can constrict spinal cord and nerve root and lead to corresponding nerve dysfunction，vOne of the common diseases of lower back and leg pain Etiology and pathology vC

35、ongenital developmental LSSvDegenerative LSSvTraumatic or iatrogenic LSSvBe single or multi segmental stenosis vCommon in the L4/5EpidemiologyvMore common in elderly patients, more than 50 years old vIt is common in L4/5，secondary in L5/S1Clinical manifestationChronic low back painvMild pain or disc

36、omfortvSlowly aggravationvAlleviation after the activity vCough without aggravating Clinical manifestationNeurogenic Intermittent Claudication NICLnCompressionnblood circulatory disordernInflammatory stimulusSymptoms are closely related with lumbar posture vAlleviation in flexion vAggravation in ext

37、ensionvUphill is easier than downhillvCan ride ，hard to walkClinical manifestationLower limb neurological symptoms Clinical manifestationImaging examination X-rayvTransverse diameter 18mmvSagittal diameter 13mmvValuable method vDisplay the location and degree of the disease Imaging examination Lumba

38、r myelography vCoincidence rate is highvTransverse diameter18mmvSagittal diameter13mmvNerve root canal 3mm Imaging examination CT vHigh diagnostic coincidence ratevDifferential diagnosis significance Imaging examination MRI TreatmentvExpectantvSurgicalnDecompressionnFusionnX-Stop腰椎滑脱腰椎滑脱The lumbar s

39、pondylolithesisSpondylo 椎体椎体Lithesis 滑移滑移HistoryvIn 1782, the Belgian Herbinlaux,who is an first described a phenomenon of dystocia caused by L5 spondylolithesisvIn 1854, the German doctor Kilian first proposed the spondylolisthesis and give the descriptionvIn the 1950s, domestic gradually began to

40、report spondylolisthesis.EpidemiologyvThe incidence rate is about 5%vVaring from the age, region and race,occupation,gender Morbidity rate increase with the growth of age More women than men More blacks than whites Common in Hard Physical Labourers, athleteEtiologyCongenital theory Traumatic theoryW

41、iltse classificationMeyerding classification grade 1-4I25%IV100%III75%II50%SymptomvIn the early phase，it often have no symptoms ，and was found accidentally in the X-ray examination v Progress in the follow-up of the disease, often expressed as low back pain、intermittent claudication、sciatica and cauda equina injury，which are si