外科学教学腰椎间盘突出症课件

1、腰椎间盘突出症lumbar disc herniation , LDH 广西医科大学第一临床医学院外科学教研室 杨劲松主讲Structural support and balance for upright postureFunctions of the SpineProtection Spinal cord and nerve rootsFunctions of the SpineInternal organsFlexibility of motion in six degrees of freedomFunctions of the SpineLeft and RightSide Bend

2、ingFlexion and ExtensionLeft and Right RotationVertebral StructuresBodyPedicleLaminaSuperior Articular ProcessSpinousProcessTransverse ProcessVertebral ForamenVertebral StructuresArticular processesSuperior Articular ProcessPars interarticularisInferior Articular ProcessZygapophyseal Joint(Facet Joi

3、nt)Lumbar VertebraeBody - L1 to L5 progressive increase in massPedicles - longer and wider than thoracic; oval shapedSpinous processes - horizontal, square shapedTransverse processes - smaller than in thoracic regionIntervertebral foramen - large, but with increased incidence of nerve root compressi

4、onIntervertebral DiscVertebral StructuresEnd PlateCartilaginousBonyFibrocartilaginous joint of the motion segmentMakes up the length of the spinal columnPresent at levels C2-C3 to L5-S1Allows compressive, tensile, and rotational motionIntervertebral Disc Intervertebral DiscAnnulus FibrosusOuter port

5、ion of the discLamellaeGreat tensile strengthMade up of lamellaeAnnulus FibrosusLayers of collagen fibersArranged obliquely 30 Reversed contiguous layersIntervertebral DiscNucleus PulposusNucleus PulposusInner structureGelatinousHigh water contentResists axial forcesThe Intervertebral DiscHas two ro

6、lesShock absorber of axial forcesPivot point in motion segmentLPNP-病理分型1 纤维环膨出2 纤维环局限性突出3 椎间盘突出4 椎间盘脱出5 游离型椎间盘Herniated Disc: 4 degrees Nuclear herniation: nucleus ruptures. No disruption of outer annular fibersDisc protrusion: ruptured nucleus causes outer fibers to bulgeNuclear extrusion: Complete

7、 split in annulus. Material leaks but remains attached to nucleusSequestered nucleus: Leaked substance no longer attached to nucleusINTRODUCTIONThe back and leg pain since - Greeks recognized it.In the fifth century AD Aurelianus clearly described the symptoms of sciatica. The sciatica arose from ei

8、ther hidden causes or observable causes- a fall, a violent blow, pulling, or straining. INTRODUCTIONMixter and Barr in their classic paper published in 1934 again attributed sciatica to lumbar disc herniation.DefinitionRuptured discs are among the most common and painful of all back ailments. The co

9、ndition occurs when the outer cover of a disc is torn and the soft inner tissue extrudes. The extrusion often puts pressure on the spinal nerves, causing back and leg pain which can be severe.腰椎间盘突出症是因椎间盘变性，纤维环破裂，髓核突出刺激或压迫神经根、马尾神经所表现的一种综合征。CIinicaI Presentation The following are risk factors for her

10、niated disc disease in the lumbar spine: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 decades of life. CIinicaI PresentationA symptom- HNP

11、. 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.It may be associated with neurological signs such as motor and sensory loss and occasionally bladder involvement.神经根性痛的原因压迫改变神经根

12、的传导、营养状态，通过影响局部血运和脑脊液的营养，机械直接损伤神经内部，神经根受压变形，有张力，压迫神经根可引传导性损伤，功能改变。同周围神经一样，单纯压迫不引起根痛，没有炎症和刺激因素压迫只产生感觉缺失，运动无力，反射异常，但无痛。如有化学炎症和代谢因素产生炎性反应存在The levels of lumbar HNPThe most common levels - L4-L5 and L5-Sl. For this reason, radicular symptoms almost always refer to symptoms below the level of the knee, i

13、n 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. 临床表现症状1 腰痛和坐骨神经痛952 下腹痛或大腿前侧痛L2.3.4N根受累3 麻木按受累N区域皮节分布4 间歇性跛行行走时加重对N根压迫5 马尾综合征会阴部麻木 刮约肌功能障碍6

14、 肌瘫痪L5N根 胫前肌.腓骨长短肌 拇.趾长伸肌 S1N根小腿三头肌 但少见临床表现体征1.脊柱外形2.压痛点3.腰椎运动4.肌肉萎缩与肌力改变5.感觉减退6.腱反射改变7特殊试验1直腿抬高试验2直腿抬高加强试验（Bragard 征）The most notable of these is the Lasgue sign, or straight-leg raising test, described by Forst in 1881 but attributed to Lasgue, his teacher. This test was devised to distinguish hip

15、 disease from sciatica.Protrusion of the L4/5 discIt 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 and medial two-thirds of the dorsum of the foot with weakness of dorsiflexion, particularly of the foot and

16、toes.Protrusion of the L4/5 discProtrusions at the L4/5 level will thus compress the L5 root, while protrusions at the L5/S1 level will compress the first sacral root. Protrusion of the L5/S1 discIt will press on the S1 nerve root and may lead to pain and numbness on the outer side of the foot and u

17、nder side of the heel. Protrusion of the L5/S1 discThere may be weakness of both eversion and plantarflexion of thefoot with a diminished or absent ankle jerk.影像学检查注意 1.必须与临床表现相结合 2.不能仅以影像学检查为依据 3.不能片面强调影像学检查1.腰椎X线平片2.CT CTM3.MRIPlain X-raysPlain X-rays are of very limited value in the investigation

18、 of a lumbar radiculopathy. Beside Marked focal disc space narrowing, plain X-rays are often normal. But its most important value is rule out the bony disorders of the lumbar spine, TB, Tumor.腰椎X线平片正位侧位Plain CTCT is recommended as the initial investigation for the evaluation of lumbar disc disease,

19、It can show many disorders of the level: 解剖结构变化MRIMRI 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 Tl and T2 sequences defines the

20、degree of disc protrusion and the extent of any spinal stenosis. MRIAxial views are more valuable in assessing nerve root compression. Even in the absence of disc protrusion, MRI can identify tears in the annulus fibrosus which sometimes enhance with gadolinium.临床表现 流行病学常见于2050岁患者男女比46:1多有弯腰劳动或长期坐位工

21、作史症状腰痛坐骨神经痛马尾神经受压体征腰椎侧突腰部活动受限压痛及骶棘肌痉挛直腿抬高试验及加强实验神经系统表现 神经系统表现感觉异常肌力下降反射异常诊断根据病史、症状、体征及X线平片可作出初步诊断结合CT、MRI，能更准确作出病变间隙、突出方向、突出物大小、神经受压情况及主要引起症状部位的诊断与腰腿痛的其他疾病鉴别治疗非手术治疗适应症 年轻、初次发作者 病程短者 休息后症状可自行缓解者 X线检查无椎管狭窄方法 绝对卧床休息 持续牵引 理疗、推拿、按摩 皮质激素硬膜外注射 髓核化学溶解法手术治疗Indications for operation on prolapsed discsNo improvement in the symptoms and signs after 6 week