外科学教学资料腰椎间盘突出症

腰椎间盘突出症lumbardischerniation,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StructuralsupportandbalanceforuprightpostureFunctionsoftheSpineProtection–SpinalcordandnerverootsFunctionsoftheSpine–InternalorgansFlexibilityofmotioninsixdegreesoffreedomFunctionsoftheSpineLeftandRightSideBendingFlexionandExtensionLeftandRightRotationVertebralStructuresBodyPedicleLaminaSuperiorArticularProcessSpinousProcessTransverseProcessVertebralForamenVertebralStructuresArticularprocessesSuperiorArticularProcessParsinterarticularisInferiorArticularProcessZygapophysealJoint(FacetJoint)LumbarVertebraeBody-L1toL5progressiveincreaseinmassPedicles-longerandwiderthanthoracic;ovalshapedSpinousprocesses-horizontal,squareshapedTransverseprocesses-smallerthaninthoracicregionIntervertebralforamen-large,butwithincreasedincidenceofnerverootcompressionIntervertebralDiscVertebralStructuresEndPlate–Cartilaginous–BonyFibrocartilaginousjointofthemotionsegmentMakesup¼thelengthofthespinalcolumnPresentatlevelsC2-C3toL5-S1Allowscompressive,tensile,androtationalmotionIntervertebralDiscIntervertebralDiscAnnulusFibrosus–OuterportionofthediscLamellaeGreattensilestrength–MadeupoflamellaeAnnulusFibrosus–LayersofcollagenfibersArrangedobliquely30°ReversedcontiguouslayersIntervertebralDiscNucleusPulposusNucleusPulposus–Innerstructure–Gelatinous–Highwatercontent–ResistsaxialforcesTheIntervertebralDiscHastworoles–Shockabsorberofaxialforces–PivotpointinmotionsegmentLPNP--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HerniatedDisc:4degreesNuclearherniation:nucleusruptures.NodisruptionofouterannularfibersDiscprotrusion:rupturednucleuscausesouterfiberstobulgeNuclearextrusion:Completesplitinannulus.MaterialleaksbutremainsattachedtonucleusSequesterednucleus:LeakedsubstancenolongerattachedtonucleusINTRODUCTIONThebackandlegpainsince-Greeksrecognizedit.InthefifthcenturyADAurelianusclearlydescribedthesymptomsofsciatica.Thesciaticaarosefromeitherhiddencausesorobservablecauses-afall,aviolentblow,pulling,orstraining.INTRODUCTIONMixterandBarrintheirclassicpaperpublishedin1934againattributedsciaticatolumbardischerniation.DefinitionRuptureddiscsareamongthemostcommonandpainfulofallbackailments.Theconditionoccurswhentheoutercoverofadiscistornandthesoftinnertissueextrudes.Theextrusionoftenputspressureonthespinalnerves,causingbackandlegpainwhichcanbesevere.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。CIinicaIPresentationThefollowingareriskfactorsforherniateddiscdiseaseinthelumbarspine:smoking,pro-longeddailydrivingofmotorvehicles,andfrequentrepetitiveliftingofheavyobjectsandtwisting.Itismorecommoninmalesthanfemalesandhasamaximalincidenceinthethirdandfourthdecadesoflife.CIinicaIPresentationAsymptom-HNP.Sciaticaispainalongthecourseofthesciaticnerve.Theclassicsymptomislowbackpainwithradiationofseverepaindownthebackofthelegtotheankleandfoot.Itmaybeassociatedwithneurologicalsignssuchasmotorandsensorylossandoccasionallybladderinvolvement.神经根性痛的原因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~~~`ThelevelsoflumbarHNPThemostcommonlevels-L4--L5andL5--Sl.Forthisreason,radicularsymptomsalmostalwaysrefertosymptomsbelowtheleveloftheknee,intheL5orS1dermatome.Legsymptomscanvaryfromnumbnesstodysesthesiatotruepain.TheherniationoftheL4--L5disccancompresstheS5andThelumbosacraldisccausescompressionoftheS1nerveroot.临床表现－症状1腰痛和坐骨神经痛－95％2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）ThemostnotableoftheseistheLasèguesign,orstraight-legraisingtest,describedbyForstin1881butattributedtoLasègue,histeacher.Thistestwasdevisedtodistinguishhipdiseasefromsciatica.ProtrusionoftheL4/5discItmaycauseL5rootpressurewithpainradiatingdownthelegtothedorsumofthefoot.Theremaybenumbnessontheoutersideofthecalfandmedialtwo-thirdsofthedorsumofthefootwithweaknessofdorsiflexion,particularlyofthefootandtoes.ProtrusionoftheL4/5discProtrusionsattheL4/5levelwillthuscompresstheL5root,whileprotrusionsattheL5/S1levelwillcompressthefirstsacralroot.ProtrusionoftheL5/S1discItwillpressontheS1nerverootandmayleadtopainandnumbnessontheoutersideofthefootandundersideoftheheel.ProtrusionoftheL5/S1discTheremaybeweaknessofbotheversionandplantarflexionofthefootwithadiminishedorabsentanklejerk.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.CTCTM3.MRIPlainX-raysPlainX-raysareofverylimitedvalueintheinvestigationofalumbarradiculopathy.BesideMarkedfocaldiscspacenarrowing,plainX-raysareoftennormal.Butitsmostimportantvalueisruleoutthebonydisordersofthelumbarspine,TB,Tumor.腰椎X线平片正位侧位PlainCTCTisrecommendedastheinitialinvestigationfortheevaluationoflumbardiscdisease,Itcanshowmanydisordersofthelevel:解剖结构变化MRIMRIisnowthescreeningtechniqueofchoicefortheaccuratedefinitionoflumbardischerniation.UsingT2-weightedimages,thenucleuspulposusandannulusfibrosuscanbedistinguished