间盘源性腰痛ppt课件

1、间盘源性腰痛间盘源性腰痛-复制疼痛好还是抑制疼痛好？复制疼痛好还是抑制疼痛好？刘宪义北京大学第一医院 DBP DBPdiscogenic back pain discogenic back pain ）：伴）：伴或不伴下肢放射痛的慢性腰痛，起自椎间或不伴下肢放射痛的慢性腰痛，起自椎间盘本身，由椎间盘内部正常结构破坏和生盘本身，由椎间盘内部正常结构破坏和生化改变引起的腰痛或放射痛化改变引起的腰痛或放射痛椎间盘内破裂椎间盘内破裂（IDD Internal Disc Disrupation / Derangement）纤维环放射状撕裂纤维环放射状撕裂 Radial Tear of annulus痛性

2、纤维环撕裂痛性纤维环撕裂 Painful Annulus Tear痛性椎间盘病痛性椎间盘病 Pain Dark Disc Disease 退变性椎间盘疾病退变性椎间盘疾病DDD Degenerative Disc Disease) 腰椎僵硬腰椎僵硬 Lumbar Spondylosis孤立性椎间盘吸收孤立性椎间盘吸收 Isolated Disc Resorption节段不稳节段不稳Segmental Instability) Zdeblick classification:Zdeblick classification:IDDaccountfor39%ofDBPThomas A. Zdebli

3、ck, MD The Spine 4th edition 750The concept of “internal disruptions” was proposed by Crock, in 1970 and 1986.Low back pain may occurred without nerve root compression.IDD(Internal Disc IDD(Internal Disc Disrupation / Disrupation / Derangement)Derangement)0Normal1Contrastagentinfiltratetoinner1/3ofA

4、nnulus2Contrastagentinfiltratetoouter1/3ofAnnulus3ContrastagentinfiltrateacrosstheouterannulusCTDshowsgrade2mayinducingpain!Dallas classification of Dallas classification of Annulus rupture by CTDAnnulus rupture by CTDModified Dallas DiscogramModified Dallas DiscogramPathogenesis：椎间盘造影术后的椎间盘造影术后的CTC

5、T轴向扫描轴向扫描Pathogenesis：Pathogenesis：GranulationtissueSP-Pathogenesis：SP-NF-VIP-Pathogenesis：ExcludeExclude：Back pain but not “back” diseaseBack pain but not “back” disease2%2%）Seldom severe diseaseSeldom severe diseaseinfection,ASinfection,AS）Muscularfasicalradicular painMuscularfasicalradicular pain

6、Acute injuryAcute injuryDiagnosis： ChouR,etal.AnnIntMed2019 DiagnosisandTreatmentofLowBackPain:AJoint ClinicalPracticeGuidelinefromtheAmerican CollegeofPhysiciansandtheAmericanPainSociety. European Guidelines For The Management Of Acute and Chronic Nonspecific Low Back Pain In Primary Care 2019Guide

7、line of LBP:Guideline of LBP:Diagnosis：2. With or without radiating pain. The concept of “HIZ (High Indensity Zone)” was first proposed by Aprill, in 1992.MRIhighindensityareaSaifuddin.Etc:Specificity:96;Sensitivity27.Lam.Etc:Specificity:82,Sensitivity:89.AprillandBogduk：Specificity:89%，Sensitivity:

8、71% provocative pain; Morphological changes of the contrast agent5.Discography: “gold 5.Discography: “gold standard” ?standard” ?5.Discography: “gold 5.Discography: “gold standard” ?standard” ?SPNFVIPLindblom1940propose1950widespreadBlocket&Ohnmeiss：psychologicalproblems-FalsePositiveCarragee：FalseP

9、ositive：50Domestic：FalsePositive：47%5.Discography: “gold 5.Discography: “gold standard” ?standard” ?Doctor-patientSubjective-objective5.Discography:5.Discography:CASEREVIEW:lFemale,44y.lHistory：lowbackpainfor2years.aggravatedfor3months.Cannotsit,stand,walkforalongtimeduetotheseverepain.lPhysicalexam

10、ination：notendernessonlumbarvertebra.Noneuro-signs.X-RAY&MRI:MRI:blackdiscsandHIZHowtoselecttheresponsibledisc?lMulti-disclSeverepain:pain,pain,pain!lPhysicalpainorPsychologicalpain?lProvokeInhibitllidocaineisadministeredintradiscallytoinhibitpain.Isitright?CASEREVIEW:CASEREVIEW:lAfteradministeredin

11、tradiscallyatL4/5-painrelievedobviously.lResidualpainlAfteradministeredintradiscallyatL5/S1-paindisappeared.Research-Method:l2021-8-2019-5l12patientslDiagnosedasDBPbysymptoms,physicalsignandimaginglAverageagewas37.3Research-Method:lAllpatientswasadministereddiscpunctureunderC-armguiding.lMethod:lPro

12、voking:contrastagent(Omnipaque)-administeredintradiscallyatresponsiblediscoradjacentdisc-observethepatientsreactions.Research-Criterion:lInhibting:lidocaine(Concentrationof1%)-administeredintradiscallyatresponsiblelevel-observethepatientsreactions.Research-Criterion:Results:lProvokingpaingroup(6pati

13、ents):l4patientswerepositive.lAverageoperationtime:45minutes.lTheremainingwereadministratedby“inhibitingpain”-painreleasedlInhibitingpaingroup(6patients):lAllpositive-paindisappear,lAverageoperationtime:25minutes.Results:DISSCUSSION:腰痛6个月以上；系统保守治疗无效；神经系统检查正常；直腿抬高试验阴性；椎间盘造影有1-2个椎间盘异常，并有6/10原疼痛强度的诱发疼痛

14、（DerbyR，etal：Neuromodulation，2000，32）：82）间盘源性痛诊断标准间盘源性痛诊断标准Inducethepain-Difficult!lSeverepainlPain:beforeduringafterradiographylFalse-positivelMulti-discpathologicalchanges（atleasttwodiscs）lNotypicalHIZInhibitthepain-?lMoreeffective&efficientlHighreliabilitylAcceptedbypatientsYin XXYin XXM/31 M/31 DBPDBP CASEREVIEW:FalsePositive？Inhibitthepain-?DBP-painreleased!LDH,DLSS,VCF-painreleased?