腰痛和腰椎间盘突出症(英文)课件

1、 LOWER BACK PAIN AND HERNIA OF INTERVERTEBRAL DISC腰痛和腰椎间盘突出症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 Bendi

2、ngFlexion and ExtensionLeft and Right RotationCranial - the head or towards the headCaudal - the tail or towards the tailAnterior - the front section or towards the frontPosterior - the back section or towards the backVentral - the front or anterior surfaceDorsal - the back or posterior surfaceBasic

3、 TerminologyCranialCaudalAnteriorPosteriorDorsal VentralVertebral StructuresPedicle notchesSlight NotchDeep NotchIntervertebral ForamenIntervertebral foramenNerve roots exitVertebral StructuresBodyPedicleLaminaSuperior Articular ProcessSpinousProcessTransverse ProcessVertebral ForamenLumbar Vertebra

4、eBody - L1 to L5 progressive increase in massPedicles - longer and wider than thoracic; oval shapedSpinous processes - horizontal, square shapedTransverse processes - smaller than in thoracic regionSpinal foramen- large to allow for cauda equina and nerve rootsIntervertebral foramen - large, but wit

5、h increased incidence of nerve root compressionIntervertebral DiscVertebral StructuresEnd PlateApophyseal RingCartilaginousBonyThe FUNCTIONAL UNIT of the spineComprised of:Two adjacent vertebraeIntervertebral discConnecting ligamentsTwo facet joints and capsulesThe Motion SegmentIntervertebral DiscN

6、ucleus PulposusNucleus PulposusInner structureGelatinousHigh water contentResists axial forcesIntervertebral DiscLargest avascular structureBlood supply by diffusion through end platesDamage to the blood supply leads to degradation of the discAnatomy and Degenerative ChangeThe Vertebral Body (VB)Key

7、 RolesCarry 80% of the axial loads through VB and discEndplates enable nutrition to diffuse to discLigamentsLigamentum flavumPosterior longitudinal ligamentAnterior longitudinal ligamentSpinal LigamentsBands or sheets of tough, fibrous tissue that connect bones, cartilage, or other structuresBecome

8、active when stressed to maximum range of motionProtect the joints from being hyperflexedThe Intervertebral Disc and Degenerative ChangeTwo major components of IVDAnnulus fibrosis: thick, fibrous “radial tire”LamellaeNucleus pulposus: ball-like gelThe Intervertebral Disc (IVD) and Degenerative Change

9、By age 50, 95% of people show lumbar disc degenerationNot all have symptomsSignificant changes to IVD are:Water and proteoglycan content decreasesCollagen fibers of AF become distortedTears may occur in the lamellaeResults in:Disc loses height and volumeLoses resistance to loading forcesNo longer ac

10、ts as a shock absorberOverview - cont.The motion segment is the functional unit of the spine and consists ofMuscle (activators)Ligaments (passive restraints)Adjacent vertebral bodies A 3-joint complex of two facet joints and a disc (pivots)Degeneration can begin in one or more of these joints, but u

11、ltimately all three will be affectedDegenerative ConditionsProvide an overview of degenerative conditionsDegenerative DiseaseSpinal StenosisHerniated DiscDegenerative Disease - OverviewLoss of normal tissue structure and function due to aging processChanges are usually gradual, trauma sometimes acce

12、leratesDegenerative changes do not always lead to clinical symptomsWhen changes cause symptoms (often pain), the process is referred to as osteoarthritisSpondylosis is degenerative changes in the spineAnatomy and Degenerative ChangeThe Vertebral Body (VB)Degenerative ChangesSclerosis: Increased bone

13、 formation adjacent to endplatesReduces nutrition diffusing to discStiffens endplate, and reduces ability to absorb loadsOsteophytes: Formation of small bony spursCan project into neuro structuresFacet Joints and Degenerative ChangeKey RolesCarry 20% of compressive loadsHelp stabilize spineDegenerat

14、ive ChangesCartilage lining loses water contentCartilage wears awayFacets override each otherLeads to abnormal function of motion segmentSpinal StenosisNarrowing of the spinal canal and/or lateral foramen through which the nerves travelThree types:Central stenosis: in central spinal canal where cord

15、 or cauda equina are locatedLateral recess stenosis: in the tract where nerve roots exit canalAcquired: in lateral foramen where nerve roots exit to bodyMost frequent in lower cervical and lower lumbar spineHerniated DiscOften called “ruptured disc”Very common pathologyL3-4, L4-5, L5-S1 common locat

16、ionsThought to be a culmination of acute traumatic events to the discHerniated Disc: 4 degrees Nuclear herniation: nucleus ruptures. No disruption of outer annular fibersDisc protrusion: ruptured nucleus causes outer fibers to bulgeNuclear extrusion: Complete split in annulus. Material leaks but rem

17、ains 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 either hidden causes or observable causes-

18、a fall, a violent blow, pulling, or straining. 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 disease from sciatica.Biomechanics of the lumbar spineBiomechanics of

19、the lumbar spineBiomechanics of the lumbar spineBiomechanics of the lumbar spineBiomechanics of the lumbar spineBiomechanics of the lumbar spineINTRODUCTIONMixter and Barr in their classic paper published in 1934 again attributed sciatica to lumbar disc herniation.DefinitionRuptured discs are among

20、the most common and painful of all back ailments. The condition 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。Prol

21、apsed intervertebral discIt usually occurs in the L4/5 or L5/S1 intervertebral disc regions and is most often seen on only one side but may be bilateral. It may occur in other regions, especially at the L3/4 level, and occasionally disc protrusion may occur at more than one level simultaneously.It i

22、s often due to degeneration of the disc and therefore occurs most commonly in middle or old age.Degeneration of the annulus fibrosus allows the nucleus pulposus to herniate through压迫对神经根的作用压迫改变神经根的传导、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

23、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压迫对神经根的作用压力从1013.33kPa引起了神经传导功能的逐渐减弱。其中，传入神经传导功能的减弱更加明显，而去压迫后，运动神经能更加容易和迅速地恢复到几乎正常的CMAP水平。压迫在26.67kPa时，引起了神经传导功能的迅速减弱，而且去压迫后传入神经几乎没有恢复，传出神经仍有30%40%的恢复。将压迫时间从2h延长到4h，对神经恢复能力的影响更加明显3。产生腰痛的组织 -背根节Howe发现背根节对中度压迫极度敏感，当压力解除后感觉神经释放的信号可持续25分钟。从神经生理学角度背根节是特有的、“捣鬼”的疼痛源，突出椎间盘能挤压

24、它对于周围神经来说，当刺激解除后，神经冲动马上停止.产生腰痛的组织-背根节实验结果背根节在尼龙线牵拉产生60秒的发电，而玻璃棒压迫会产生4分钟的冲动产生腰痛的组织-背根节背根节的神经细胞与突触相交处的细胞膜上有高密度的钠通道，使其对机械压力特别敏感。这种高密度的钠通道可能是导致神经冲动持续，在背根节受压时产生生骨神经痛.产生腰痛的组织-神经根Olmarker等应用不同的化学标记物来研究压力的大小和压迫发生的速度与水肿形成和营养障碍的关系。结果提示，压迫产生越迅速，神经根水肿的形成和营养供给障碍越明显。产生腰痛的组织-脊神经背根与DRG不同，背根对机械压力不是始终有反应，除非神经根有炎性或处可易

25、惹状态。Howe在被铬肠线结扎神经根后可以引出多次发电的情况，单一压迫刺激即可引A、d神经纤维放电5-30秒。被刺激的神经根是有鞘神位由可能含有神经末梢。Jang发现了猫的S1背根中有点状直接受刺激区产生腰痛的组织-脊神经背根最有效的机械刺激是轻度牵拉，与临床情况相吻合。有病间盘水平的神经根比邻近正常的神经根更敏感Kuslich在局麻下椎间盘手术中，对有炎症或压迫的神经根压迫特别敏感，压迫它再现坐骨神经痛Smyth用尼龙线绕过受累神经根，轻拉即再现坐骨神经痛的神经源的化学介质 损伤和炎症的组织释放的化学介质使神经末梢致敏。这些神经致敏物质包括由C纤维释放出的P物质、11氨基酸神经肽。P物质导致

26、血管扩张，血浆外渗，肥大细胞释放组胺。这些炎性介质的持续释放引起了疼痛。神经源的化学介质虽然原因还不清楚，P物质可能直接作用神经末梢或间接通过血管扩张，释放组胺、血浆外渗起作用。P物质在神经致敏中起重要作用，这有重临床意义，脊柱的运动正常是无痛的，但在炎症条件下引起疼痛腰痛症状持续的原因非神经源的化学介质在组织损伤中产生的可以激活和致敏神经末梢的化学介质包括：缓激肽、血清素(5-HT)、组织胺、钾离子、前列腺素。已在椎小关节及邻近组织中发现了P物质，使用10-g即能同时兴奋低痛阈和高痛阈神经纤维，30分钟后这些神经对机械刺激的痛阈明显降低非神经源的化学介质当将角叉菱胶或陶土注入关节后，神经纤维

27、致敏兴奋性增加，1-2mm的各方关节活动即可导致关节支配神经的持续释放冲动电位。最近的研究表现在神经感受器对机械压力敏感的部位，注入角叉菱胶，会导致神经元放电达3小时非神经源的化学介质这些研究的临床意义：如果关节囊、韧带、肌肉受牵拉，例如脊柱滑脱和椎间盘突出症，引起组织损伤会导致持久的伤害性刺激，并可以导致一种循环状态，肌肉痉挛，痛觉过敏，以致持续性疼痛椎间盘及神经根周围的炎症有关椎间盘的神经生理学研究是有限的。Cavanaugh报告了椎间盘受机械刺激时只偶有少量冲动，只有腹侧硬膜受牵拉才有持续冲动。只有电刺激椎间盘和后纵韧带引起A-d纤维冲动，同椎管内注入致痛物质，像组胺作用一样椎间盘及神经

28、根周围的炎症Yamashita报告了椎间盘对机械压力大部分情况是没有反应。椎间盘内只有静止伤害感受器，它只对损伤或炎症产生的致痛电学物质有反应。McCarron向狗硬膜外腔注入自体的髓核，表现出它的致炎作用。Olmarker 发现身体髓核在神经组织中产生炎性和退行性改变免疫和炎症反应腰腿痛当中，原因很复杂，椎间盘突出的大小与疼痛程度不一，生化和机械因素交互作用。有很多证据表明髓核有致免疫原性，自体髓核与血液接触，对髓核自身抗体已发现，虽然很多证据表明介导免疫炎性，绝大多数以前的研究都注意到椎间盘退变和疼痛的产生中的免疫现象标志物。Saal证明突出间盘边缘有免疫细胞，发现了T淋巴细胞IL-1、2

29、，据细胞。浸润的不同程度分级与症状相关。反应程度与术前症状时间相关但病人没有全身的自身免疫性疾病表现, 疼痛直接原因不清。磷脂酶A2 -PLA2在风湿性关节炎、急性胰腺炎、血清单阴性关节炎、脓毒症表现出明显的炎症作用。它在体内的源性：表1 PLA2 activiyu PMN3,2 Platelet1.4 Plasma0.006 Sperm28.0 inflammatory synovial fluid 12.1 herniated lumbar disc1212.0正常椎间盘内PLA2就有致水肿作用PLA2的神经毒性Steroid局部应用非常有效，在没有免疫反应的生化炎症，作为疼痛发生机制的另

30、一个原因髓核有介导炎性的能力，含有高浓度的PLA2。 Saal在有腰痛病人病变节段的椎间盘组织内会有不正常高浓度的磷酸激酶A2-PLA2。髓核、PLA2及别的致炎物质作用到椎间盘的伤害感觉受器，它激活痛感纤维的作用比单纯压力更大PLA2进入神经根后神经水肿，髓鞘轴突损伤，同注射蛇毒 PLA2，但作用程度轻，支持了PLA2的神经毒性硬腰外使用自体髓核，发生传导阻滞，神经周围组织炎症 。 Leakage of nucleus pulposus material to nerve roots, is a pathophysiologic mechanism in LBP and sciatica I

31、ncision of the anulus fibrosus induces nerve root morphologic, vascular, and functional changes. An experimental study.Kayama -Japan: Spine 1996 The nerve conduction velocity was significantly lower in the incision group (13 14 m/sec) compared with the nonincision group (73 5 m/sec). The obvious sig

32、ns of capillary stasis with an increased number and diameter of the intraneural capillaries in the incision group. Cultured, autologous nucleus pulposus cells induce functional changes in spinal nerve roots Kayama -Sweden : Spine 1998 Nucleus pulposus cells and fibroblasts were cultured for 3 weeks,

33、 and various preparations were applied to the cauda equina in 29 pigs. After 1 week, nerve conduction velocity was determined by local electrical stimulation. Application of nucleus pulposus cells reproduced the previously seen reduction in nerve conduction velocity induced.腰痛症状持续的原因椎间盘及神经根周围的炎症Kusl

34、ich在144例椎间盘手术中，在病变椎间盘外侧检查刺激或电刺激产生中度疼痛占70%，重度占30%。突出椎间盘或狭窄的椎间只对DRG或突炎神经根的机械压迫是持续的，就能导致持续性疼痛，或DRG或炎性神经根内压增加这种持续性疼痛就会变为进行性加重。Cavanaugh将自体髓核注入DRG引起1-3分钟的神经释放PLA2致痛原因致炎因素；直接作用伤害感受器；磷脂酶本身的直接造成神经损伤。炎症介定导致源发性神经根坏死，体外证实PLA2直接刺激纤维环伤害感受器。这些化学物质可直接刺激纤维环和周围神细胞中的细小的无髓纤维C或Adeltal。致病物质作用后，伤害感受器的痛域下降。（对机械刺激）正常的生理活动就

35、可以导致腰痛、障碍痛、根性痛（在纤维环外1/3后纵韧带）.第二部分：腰痛症状持续的原因椎间盘及神经根周围的炎症临床、组织化学、生理化学、神经组织学研究，髓核含有化学性致炎、神经退变，急性期有神经兴奋的作用。同样化学物质有氢离子、PLA2免疫球蛋白G等，在椎间盘性疼痛中，增加炎性神经根的敏感性起重要作用Phospholipase A2 sensitivity of the dorsal root and dorsal root ganglion Ozaktay USA ：Spine 1998 JunPhospholipase A2 appeared to be neurotoxic when d

36、oses ranging from 100 to 400 U were applied on the mechanically sensitive segments of the dorsal root ganglia. PLA2 doses comparable to serum concentrations in human rheumatoid arthritis when applied to dorsal root ganglia. These results suggest that dorsal roots and dorsal root ganglion may be impa

37、ired by phospholipase A2, leading to sciatica and low back pain. 脊髓水平中枢致敏组织损伤可能导致连续的神经冲动至脊髓，这使后角神经元致敏致敏的神经元痛阈下降，对传入冲动的反应增强，对重复刺激的反应也增强，接受刺激的阈值变宽。恶性刺激导致中枢致敏时，有明确证据后角释放了兴奋性胺基酸和神经肽脊髓水平-中枢致敏在中枢致敏状态下，机械刺激的致痛阈值已下降，使很低的机械刺激就可以让后角发出疼痛信号。变宽的接受阈能把损伤处及附近正常组织的传入信号变为疼痛信号向上传递，这就解释了腰疼痛位不清和持久、及牵涉痛的原因脊髓水平-中枢致敏Gillef

38、fe发现了后角单个神经元可接受从各种脊柱组织传入的信号，呈一种高度会聚接收状态。脊髓后角的神经元可以由压迫皮肤、椎小关节、韧带、及肌肉而兴奋，这种高度会聚功能也是腰痛不易定位的原因Chronic Compression of Dorsal Root Ganglion Produced by Intervertebral Foramen Stenosis Hu SJ- Xian, PR China Pain 1998 JulAn experimental model in the rat.A small stainless steel rod (0.5-0.8 mm in diameter) w

39、as inserted into the L5 intervertebral foramenThese neurons had a greatly enhanced sensitivity to mechanical stimulation of the injured DRG and a prolonged after discharge. a persistent heat hyperalgesia 5-35 days The excitatory responses were evoked in the injured, but not the uninjured, DRG neuron

40、s. EPIDEMIOLOGY-risk factors Multiple factors affect the development of back pain. smoking, pro-longed daily driving of motor vehicles, jobs requiring frequent repetitive lifting of heavy objects and twisting, the use of jackhammers and machine tools, and the operation of motor vehicles episodes of

41、anxiety and depression.It is more common in males than females and has a maximal incidence in the third and fourth decades of life.LUMBAR DlSC HERNlATIONBack pain may be caused by stimulation of the pain fibers in the outer layers of the annulus fibrosus. Alternatively, distortion of the posterior l

42、ongitudinal ligament, which is richly innervated by pain fibers, may result in back pain. Leg pain can result from compression of a nerve root by an HNP腰痛可以起自于椎间盘、椎小关节、肌肉的神经末梢。化学炎性介质释放，使正常无痛的运动变为疼痛性的。髓核是强列的神经根和神经末梢致炎和刺激物质椎间盘与神经根的位置、 DRG的特殊神经生理特点、神经根和DRG易被压迫而出现坐骨种经痛。系列恶性冲动使后角感觉神经元致敏，导致的慢性疼痛状态CIinicaI

43、 Presentation The following are risk factors for herniated 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

44、decades of life. The clinician must rule out a compressive lesion of the sciatic nerve peripherally before ascribing the pain to a herniated disc.There may be a history of a previous injury.CIinicaI PresentationA symptom- HNP. Sciatica is pain along the course of the sciatic nerve. The classic sympt

45、om 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.The levels of lumbar HNPThe most common levels - L4-L5 and L5-Sl. For this reason, radicul

46、ar symptoms almost always refer to symptoms below the level of the knee, in 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. Symptoms and sign

47、s of the lumbar spineThere is often associated spasm of the spinal muscles with tenderness over the lower lumbar spine on the side of the lesion. The muscular spasm may produce a scoliosis. Limitation of lateral flexion of the lumbar spine to the same side will be most marked with a protrusion later

48、al to the nerve root, while limitation of lateral flexion to the opposite side will be most marked with a protrusion medial to the nerve root.Focal signsFocal signs are dependent on the distribution of the affected nerve root. With L4 compression there is weakness of quadriceps and tibialis anterior

49、, with sensory change over the medial aspect of the shin and depression of the knee jerk. L5 root compression may solely declare itself by weakness of extensor hallucis longus. Any sensory change is found over the medial aspect of the dorsum of the foot and the lateral shin.In an Sl root syndrome we

50、akness can occur in the buttock muscles, the hamstrings or the calf muscles. The ankle jerk is likely to be depressed or absent. Sensory change particularly occurs over the lateral aspect of the foot and the calf. Protrusion of the L4/5 discIt may cause L5 root pressure with pain radiating down the

51、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 toes.Protrusion of the L4/5 discProtrusions at the L4/5 level will thus compress the L5 root, while protrusio

52、ns 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 under side of the heel. Protrusion of the L5/S1 discThere may be weakness of both eversion and plantarflexion

53、of thefoot with a diminished or absent ankle jerk.Protrusion of the L3/4 discIt may cause pressure on the L4 nerve root may lead to numbness over the front of the knee and legwith diminution of the knee jerk and weakness of the knee extensors.Protrusion of the L3/4 discFemoral nerve traction testCen

54、tral protrusion of a lower lumbar discIt can press on the cauda equina lead to urinary retention. On examination there is usually perianal numbness and a patulous anus.Emergency decompression is essential to avoid permanent damage to sphincter innervation.Central disc protrusionFollowing a central d

55、isc protrusion, which can occur without an antecedent history of back pain, cauda equina compression occurs, often in an abrupt fashion. Severe pain results, with paravertebral localization or with radiation into both lower limbs. Typically, there is severe distal lower limb weakness with foot drop,

56、 depression of the ankle reflexes and impaired sphincter function. Saddle anaesthesia is common. 中央型Occasionally the protrusion is central, pressing on the cauda equina and affecting autonomic control of the bladder leading to urinary retention. Urgent surgical decompression of the cauda equina is r

57、equired as an emergency.CIinicaI PresentationAny maneuver that increases intraspinal pressure, such as straining at stool, coughing, or sneezing, may exacerbate symptoms. In over half the patients with sciatica from an HNP, a specific nerve root can be identified, simply by history. Weakness: the ti

58、bialis anterior-go downstairs, the gastrocnemius soleus muscle group - going upstairs difficult. 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TreatmentNot all patients suffer painAs outer disc distorts, may protrude into spinal canalMay lead to sciatica

59、 (pain down back of leg) Often start with conservative, non-operative careSpontaneous resolution of sciatica often occursPatients with cauda equina syndrome require surgical attentionCommon surgical procedures include:Laminectomy, discectomy, microdiscectomy, endoscopic discectomy, ablation procedur

60、ePhysical Examination The posture: Often there is a functional scoliosisRange of motion of the lumbar spine may be limited due to paravertebral muscle spasm or guarding. Forward flexion may increase the symptoms of sciatica. Palpation may show tenderness in the sciatic notch due to irritation of the