伤筋腰椎间盘突出症

1、腰椎间盘突出症the syndromes of lumbar intervertebral disc protrusion定义腰部遭受较重的外力，腰部椎间盘纤维环部分或全部破裂，髓核向外突出，压迫神经根或脊髓，引起腰痛和一系列神经症状。腰突症区别：腰椎间盘突出症与腰椎间盘突出Lumbar pain syndrome caused by degeneration of lumbar intervertebral disc, partially or completely ruptured annular fibrosus, bulged or herniated nucleus due to e

2、xternal force that may irritate the spinal cord and press nerve root.病因病理etiology内因：椎间盘退行性改变，椎间盘发育上的缺陷。外因：外伤（扭、闪、挫），劳损，风寒湿邪气侵袭。The internal cause of the disease is the degeneration of lumbar intervertebral , or development defect of intervertebral discs. The external causes are injury, strain and in

3、vasion of pathogenic wind and cold.椎间盘intervertebral disc椎间盘是连接相邻椎体的屈戌关节，对脊椎起缓冲和吸收振荡的作用。屈戌关节：又名滑车关节，关节头呈滑车状，另一骨有与其相适应的关节窝。通常是只能在冠状轴作屈伸运动，如手指关节。Lumbar intervertebral disc is located between two connective vertebras, forming the weight-bearing joints of the vertebra and serving as the ginglymus of the

4、 spinal column.disc椎间盘的组成：上下是软骨板，周围是纤维环，中央是髓核。纤维环是由坚韧致密的弹性纤维在软骨基质中交织而成，与上下椎体紧密相连。Intervertebral disc consists of annular fibrosus, nucleus pulposus and cartilages.Annular fibrosus is composed of tenacious interlaced elastic fibers in cartilage matrix and are connected tightly with the adjacent verte

5、bras.disc髓核是一种含水分较多的胶状物，纤维环与上下椎体面上的软骨扳，把髓核限制在一个球形腔内。Nucleus pulposus contains hydrous jell.The annular fibrosus and the soft board on the surface of the adjacent vertebras confine the nucleus pulposus in the global cavity.degeneration退变：髓核脱水，椎间盘失去弹性。突出：过度负重，扭、挫、闪使椎间盘受力不均匀，盘内压力过大而发生纤维环破裂，髓核突出。With th

6、e increase of age as well as the influence of pressing, pulling and twisting by external force, the intervertebral discs eventually degenerate, dehydrate, and lose their flexibility, making the intervertebral spaces narrow and the ligaments loose or causing fissures.特点character好发年龄：2040岁。“五十肩、四十腰”好发

7、部位：L4、5 和 L5、S1。因为L4、5是上半身力的支点，而L5、S1的活动度最大，容易引起退变和损伤；后纵韧带从L1开始逐渐变窄，至L5、S1处只有原来的一半。The incidence is high among workers aging from 20 to 40.The most commonly encountered lumbar disc protrusion often happens in the disc L4/L5, and L5/S1.病理分型1根据髓核突出的方向，分为三型：1.向后突出2.向前突出3.向椎体内突出Directions of protrusion

8、of disc:1.Forward protrusion2.backward protrusion3.inward protrusion to vertebral body.病理分型2根据髓核突出的程度，分为三型：1.隐藏型（幼弱型）：纤维环不全破裂，外层保持完整，髓核轻度突出，适当休息可以回纳。2.突出型：纤维环裂隙较大，外层保持完整，髓核突出较大，经手法复位可治愈。3.破裂型：纤维环完全破裂， 髓核向外突出，有的与神经根粘连，有的没有。Degree of nucleus pulposus protrusion1. hidden truded type3.ruptured

9、type病理分型3根据向后突出的部位不同，分三型：1.单侧：髓核从一侧的侧后方突入椎管，压迫神经根。2.双侧：1.少见。2.双下肢症状交替加重3.中央型：髓核由中央向后突出，压迫马尾神经，造成大小便障碍。区别：CT报告的中央型突出与教材的中央型突出的区别。The place of protrusion:1.single side2.double sides3.center诊断（临床表现）腰部有外伤史和积累劳损史。复发则有受寒史。腰痛及下肢放射痛（过膝），不能久坐久站，“坐得太久得坐骨神经”腹压增加，疼痛加重：咳嗽、喷嚏、大便等。Has a history of injury and chron

10、ic strain ,or being attacked by cold evil.Low back pain and the radioactive pain in the lower limb.Coughing , sneezing and pushing hard while defecating may add pressure of abdomen and worse the pain.Clinical manifestations腰背部板滞，活动障碍，腰椎畸形：侧弯，生理曲度消失主观麻木感：小腿后外侧、足跟、或足背麻木。患肢温度下降肌肉萎缩Stiff waist , difficu

11、lty to bend in mild cases , inability to turn the waist in severe cases.Deformity of lumbar vertebra, scoliosis, lordosis, physiology curvature disappear.Numbness in the lower limb,such as crural region, calcar pedis and lateral side of dorsum.Lower temperature of affected low limb.Muscle is atrophy

12、.检查1、直腿抬高试验及直腿抬高加强试验阳性2、屈颈试验阳性3、下肢后伸试验阳性1.leg raising test and foot dorsum flexing test.2.neck bending test3. leg backward extending test4、挺腹试验阳性（腹压增高）5、压痛、放射痛（L4、L5）：坐骨神经通路6、小腿前、后外侧感觉减退4.abdomen straightened test5.Evident tenderness, radioactive pain.6.numbness of crural and calf region.7、趾肌力减退（伸足大

13、趾试验，屈足大趾试验），8.膝、跟腱反射减弱或消失。7.the force is weak of leg , especially big toe flexing upward or downward, 8.knee tendon and ankle tendon reflex are reduced or disappear.X片检查X filmX片：脊柱侧弯，椎间隙变窄，椎体边缘唇样增生。（不能确诊）排除：腰椎结核，骨关节炎，骨折，肿瘤，脊椎滑脱。确诊：CT、MRI、脊髓碘油或碘水造影碘过敏试验The orthograph film sometimes shows lumbar scoli

14、osis, the lateral film shows disappearance of the lumbar anterior protrusion.Narrowed vertebral spaces and hyperosteogeny of the adjacent vertebrao on the margin.Rule out pulmonary tuberculosis , tumor, bone fracture, or congenital deformity of lumbosacral vertebrae.CTUsing CT to test the shape and

15、caliber of lumbar spinal canal is a very significant way to help diagnose lumbar intervertebral disc hernia. It can clearly show the factors responsible for pressure on the lumbar and sacral nerve roots. The stereoscopic display can demonstrate the degree and area of the protrusion of intervertebral

16、 discs.突出程度与症状的关系轻度突出：4MM以下，中度突出：48MM之间，重度突出：8以上在临床工作中，少数患者的临床症状不一定与突出程度成正相关。症状与突出程度、突出物的位置、椎管的大小都有一定的关联。Mild protrusion: below 4mm.Middle protrusion : between 48mm.Serious protrusion: over 8mm.鉴别诊断differentiate diagnosis1.急性腰扭伤：外伤史，剧烈腰痛，脊柱侧弯。CT、MRI 确诊。2.慢性腰肌劳损：病程长、症状轻、痛点广泛。 CT、MRI 确诊。1.acute waist

17、sprain2. chronic strain of low back muscle3.梨状肌综合征：外伤史，臀部疼痛，梨状肌压痛，梨状肌紧张试验阳性。4.增生性脊柱炎：老年人腰痛，晨僵，晨起疼痛加重。X片：脊椎骨质增生。治疗目的：1、增加局部痛域，放松腰肌2、降低盘内压力，增加盘外压力，促使突出物回纳3、改变突出物与神经根位置关系4、加强气血循行，促使神经根炎性水肿的吸收。治疗治则：舒筋通络、松解粘连、解痉止痛、整复减压取穴：阿是穴、腰背部及下肢，肾俞、大肠俞、承扶、殷门、委中、承山、昆仑；居髎、环跳、风市、阳陵泉、绝骨、丘墟。手法：揉、按压、滚、弹拨、运动关节类手法。操作1.循经按揉法：解

18、除背腰臀部肌肉痉挛（滚、按、揉）2.拔伸推压法：拉宽椎间隙，降低盘内压力，扩大椎间孔（手法或机械牵引），拇指或肘尖按压患处。3.理筋整复法：调整后关节，松解粘连（腰椎斜扳或旋转扳法，强制直腿抬高）4.踩跷、背晃法：增加盘外压力（按压、震动腰部，后伸扳法）5.整理手法：使损伤的神经根恢复功能（沿神经根滚、按、揉、点、拿）预后推拿配合功能锻炼效果较好针灸、拔火罐、中药、西药理疗：超短波、磁疗、超激光、电脑中频、红外线、周林频谱、宽频、低周波剧烈疼痛、保守治疗半年效果不明显的建议手术治疗。注意事项1.卧硬板床、带腰围，减少椎间盘承受的压力。2.注意保暖。3.功能锻炼：拱桥势、飞燕势，倒走。4.中央型腰椎间盘突出症不宜推拿治疗坐骨神经痛根性椎间盘突出症、椎管内肿瘤、增生性腰椎炎、腰骶神经根炎腹压增加时疼痛明显加重