1、山東大學(xué)授課教案（6年制）課程名稱：外科學(xué)本次授課內(nèi)容：頸肩痛、腰腿痛教學(xué)日期：2007,4,3授課教師姓名：宮明智職稱：副主任醫(yī)師授課對(duì)象：臨床醫(yī)學(xué)專業(yè)6年制授課學(xué)時(shí)2教材名稱外科學(xué)6年制授課方式講課本章節(jié)的教學(xué)目的與要求：1、了解腰腿痛的病因分類，了解腰椎間盤突出癥的病因，熟悉分型及病理，掌握臨床表現(xiàn)，熟悉診斷依據(jù)，了解治療方法。2、了解頸椎解剖概要，了解頸肩痛的病因及分類，掌握頸椎病的分型、臨床表現(xiàn)，熟悉診斷依據(jù)，了解鑒別診斷、治療方法。授課內(nèi)容及學(xué)時(shí)分配第一節(jié)腰椎退行性疾病概述：腰腿痛是指下腰、腰舐、舐骼、臀部等處的疼痛，可伴有一側(cè)或兩側(cè)下肢痛、馬尾神經(jīng)癥狀。頸肩痛是指頸、肩、肩胛等處

2、疼痛，有時(shí)伴有一側(cè)或兩側(cè)上肢痛、頸脊髓損害癥狀。臨床表現(xiàn)多樣化，病因復(fù)雜化，故診斷、鑒別診斷困難，“病人腰痛，大夫頭痛”。第一節(jié)腰腿痛1、疼痛容易發(fā)生在活動(dòng)與不活動(dòng)的交界處，如腰椎與舐椎結(jié)合部一下腰痛。腰椎骨折、脊柱結(jié)核易發(fā)生在胸腰椎結(jié)合部一T12,L1處。2、腰椎依靠椎間盤、關(guān)節(jié)突關(guān)節(jié)、前后縱韌帶、黃韌帶、棘上韌帶、棘間韌帶、橫突間韌帶等連接，舐棘肌、腰背肌、腹肌等協(xié)助增加穩(wěn)定性。骨骼、肌肉、筋膜、韌帶、神經(jīng)、血管任何組織的病變（外傷、炎癥、退行性變、腫瘤、結(jié)核、發(fā)育不良等）的排列組合能產(chǎn)生許多疾病。另外內(nèi)臟的疾病向腰部傳到、放射、牽涉痛。3、看書873頁表腰腿痛病因分類。4、注意疼痛性質(zhì)：

3、局部疼痛，牽涉痛，放射痛5、壓痛點(diǎn)：表淺組織壓痛點(diǎn)特定，深部結(jié)構(gòu)（如小關(guān)節(jié)、椎間盤、椎體）深處壓痛，病人往往指不明確。（15分鐘）最多見的原因一一腰椎間盤突出癥（30分鐘）Lumbardiskherniation一、是椎間盤變性，纖維環(huán)破裂，髓核突出刺激或壓迫神經(jīng)根、馬尾神經(jīng)所表現(xiàn)的綜合征，是腰腿痛的最常見原因之一。2050歲多見，男多于女。長期坐位工作（辦公室、汽車司機(jī)等），近年年輕化，增多化。二、病因（簡略講）3、 分型1、膨隆型（膨出）2、突出型3、脫垂游離型（脫出）4、休莫結(jié)節(jié)及經(jīng)骨突出型4、 臨床表現(xiàn)（重要，掌握）（一）癥狀1、 腰痛2、 坐骨神經(jīng)痛（Sciatica）坐骨神經(jīng)（sc

4、iaticnerve）的組成（1,2,3,4,5,的含義），為什么坐骨神經(jīng)痛？（L4,5L5S1）占90%放射痛（radicularpain）3、 馬尾神經(jīng)癥狀大小便障礙，鞍區(qū)感覺異常。（二）體征1、腰椎側(cè)突代償性，為緩解疼痛。2、腰部活動(dòng)受限3、壓痛及舐棘肌痙攣4、直腿抬高試驗(yàn)及加強(qiáng)試驗(yàn)(LaseguesignThestraightleg-raisingtest)positiveabove90%)5.健腿抬高試驗(yàn)(Fajersztajnsign)Thecrossstraightleg-raisingtestpositive5、神經(jīng)系統(tǒng)檢查感覺肌力反射(踝反射(theanklejerkrefl

5、exisdecreasedorabsent)肛門反射，肛門括約肌張力低(三)特殊檢查1、X-RAYplainfilm2、CTcomputedtomography4、 MRI5、 其他肌電圖五、診斷(熟悉)六、鑒別診斷對(duì)口腔專業(yè)只作了解提醒：注意與腰椎腫瘤、結(jié)核鑒別，不要誤診。七、治療(一)非手術(shù)治療1、 臥床休息2、 牽弓3、4、 理療、推拿、按摩5、 椎管注藥6、 化學(xué)溶核（二）手術(shù)僅作了解本次課主要外語詞匯見打印的短文教具：1、腰椎骨骼標(biāo)本，2、腰椎解剖掛圖，3、多媒體幻燈片思考題：（5分鐘）1、什么腰椎間盤突出壓迫坐骨神經(jīng)？2、不作CTMRI如何從查體進(jìn)行定位診斷？參考教材出癥胡有谷主編

6、腰椎間盤突第二節(jié)頸椎退行性疾病（50分鐘）一、頸椎病概念因頸椎間盤退行性變及其繼發(fā)性改變，刺激脊髓、神經(jīng)、血管和食管等組織，并引起癥狀或體征者稱為頸椎病。（Cervicaldegenerativediseaseoccursaspartofthenomalagingprogressandisoftenasymptomatic.Commonlyoccurringsymptomsincludeneckpain,radiculopahy,andmyelopathy）5分（一）復(fù)習(xí)頸部解剖邊講邊提問15分鐘1、7個(gè)頸椎第一頸椎叫第二頸椎叫橫突孔（17有）內(nèi)走的什么（第16）什么是鉤椎關(guān)節(jié)（下一椎體的鉤突

7、與上一椎體的斜坡）2、頸椎之間的連接五個(gè)關(guān)節(jié)后縱韌帶的特點(diǎn)（中部厚，故兩側(cè)突出）項(xiàng)韌帶鈣化3、頸叢：頸14神經(jīng)的前支組成，支配頸部肌肉、膈肌、頸、枕、面部感覺后支組成頸后叢頸2發(fā)出的枕大神經(jīng)（枕下痛，同側(cè)頭皮感覺異常）4、臂叢的組成5,6,7,8,1的含義（二）病因與分類除與腰腿痛相似外，椎動(dòng)脈、交感神經(jīng)受到刺激引起的頭、胸、心、肺、眼、耳等全身癥狀，因此難以區(qū)分。1、病因（Pathogensis）了解退行性變（degenerativechanges）損傷先天性椎管狹窄（12毫米相對(duì)，10毫米絕對(duì)）2.分型及各自的臨床表現(xiàn)掌握15分神經(jīng)根型頸椎病脊髓型頸椎病（重點(diǎn)講授）頸脊髓病功能評(píng)估JOA1

8、7分法交感神經(jīng)型頸椎病椎動(dòng)脈型頸椎病癥狀多，體征少，癥狀不特異，常與其它病的癥狀相似混合型或復(fù)合型頸椎病三.診斷熟悉以下10分四.鑒別診斷了解五治療(Neckpainandradiculopathyusuallyresolvewithnonoperativemodalities.)(一)非手術(shù)治療1 .牽弓2 .頸托、頸圍3 .按摩強(qiáng)調(diào)強(qiáng)行推拿的危害4 .理療5 .自我保健特殊職業(yè)會(huì)計(jì)、伏案、電腦6 .藥物(二)手術(shù)(aims:decompressionandstability)了解1、前路(anteriordiskectomy)2、后路(posteriorsurgicalprocedures

9、)重點(diǎn)頸椎病的分型，各型的臨床表現(xiàn)。了解治療原則主要外語詞匯見復(fù)印短文教具：頸椎骨骼標(biāo)本多媒體幻燈片二、頸椎管狹窄癥(thecervicalcanalstenosis)矢狀徑臨界值13mm,小于13為椎管狹窄三、頸椎間盤突出癥(cervicaldischerniation)四、后縱韌帶骨化(ossificationoftheposteriorlongitudinalligament)思考題：1、脊髓型頸椎病為什么發(fā)生在下頸椎？參考教材如有精力，可閱讀7年制外科學(xué)教材。第三學(xué)時(shí)前20分鐘討論，結(jié)合X線片，CT,MRI片回答同學(xué)提出的問題20分鐘時(shí)間集體閱讀講解英文短文，材料每人1份最后5分鐘，本

10、次課總結(jié)LumbarDiskHerniationSymptomaticdiskherniationsareseeninallagegroupsbuthavetheirpeakinpatientsagedbetween35and45years.Riskfactorsincludesedentaryworkandmotorvehicledriving.Sciatica,characterizedbypainradiatingdowntheleginadermatomaldistribution,isthemostcommonsymptomandisfoundin40%ofpatientswithd

11、iskherniation.PathophysiologyAdiskherniationisusuallyprecededbydegenerativechangesinsidethedisk.Circumferentialtearsintheannulusprogresstoradialtears,andtheseinturnfrequentlycauseinternaldisruptionorfrankherniation.ClinicalfindingsA. SymptomsandSigns:Thetypicalsciaticaiscommonlyprecededbybackpainfor

12、aperiodofdaysorweeks.Themobilityofthelumbarspineisdiminishedmoreinflexionthaninextension.Coughing,sneezing,oravoluntaryValsalvamaneuvercommonlyaggravatestheradiatingpain.Prolongedsittingalsoaccentuatesthepain.Inthemorethan90%ofcases,lumbardiskherniationsarelocalizedatL4-L5andL5-S1.WhentheL4nerveroot

13、isaffected,theremaybeweaknessofthequadricepsmuscle,andthepatellatendonreflexmaybedepressedorabsent.CentralorparacentraldiskherniationsatL4-L5usuallycompromisetheL5nerveroot,wheretheymaycausenumbnessintheL5dermatomeandweaknessofthefootandtoedorsiflexions.AdiskherniationatL5-S1usuallycompromisestheS1n

14、erveroot,causingnumbnessorpainintheS1dermatone,weakplantarflexionofthefoot,lossoftheAchillestendonreflex,ortinglinginthenervedistrbution.Thestraightleg-raisingtestshouldbeperformed.TheLaseguesign（painwhentheaffectedlegiselevated）ispositivein98%ofpatientswithlumbardiskherniation.B. ImagingStudies:MRI

15、isthestandardfordiagnosisofaherniationdisk.28%ofasymptomaticpatientsshowadiskherniationonMRI.CTscanningandmyelographyarefrequentlyusedtoconfirmthediagnosis.TreatmentThegoaloftreatmentistoreturnthepatienttonormalactivitiesasquicklyaspossible.Unnecessarysurgeryshouldbeavoided.A.ConservativeTreatment:T

16、wodaysofbedrestfollowedbyagoodphysicaltherapyprogramwilloftenAnalgesics（止痛劑）epidural（硬膜外）B.SurgeryTreatmentleadtosignificantalleviationofsymptomswithin2or3weeks.nonsteroidalmedicine;corticosteroid（皮質(zhì)醇）chiropractic（按摩療法）adjustment;About10%ofpatientswithlumbardiskherniationwillultimatelyrequiresurgery

17、。Surgeryisrecommendedifthesciaticissevereanddisablingandtentionsignsarepositive,ifsymptomspersistwithoutimprovementforlongerthan1month,oriffindingsonclinicalexaminationandindiagnosictestsareconsistentwithnerverootcompromise。Standarddiskectomy;Microdiskectomy。Chemonucleolysisofherniateddisk（化學(xué)溶核法）Chy

18、mopapain（木瓜凝乳蛋白酶）Risk:duraltear,wronglevelexploration,hemorrhage,infection,nervedeficitGongmingzhiMay5,2006CervicalspondylosisCervicalspondylosisisdefinedasageneralizeddiseaseprocessaffectingtheentirecervicalspineandrelatedtochronicdiskdegeneration.Inabout90%ofmenolderthan50yearsand90%ofwomenolderth

19、an60years,degenerationofthecervicalspinecanbedemonstratedbyradiographys.Initialdiskchangesarefollowedbyfacetarthropathy,osteophyteformation,andligamentousinstability.Myelopathy,radiculopathy(神經(jīng)根病),orbothmaybeseensecondary.Pathophysiologygavethefirstaccountofa“spondyloticbarSubsequentworkrevealedthat

20、diskdegenerationandosteoarthritiscouldleadtocordandrootimpingement.ThemostfrequentlyinvolvedlevelsarethemoremobilesegmentsC5-C6,C6-C7,andC4-C5.Thesagittalcervicalcanaldiameterwasappreciablysmaller(3mmonaverage)inthemyelopathicspodyloticspinethanthenormalspine.ClinicalfindingA. SymptomsandSigns:Heada

21、cheiscommonlylocatedintheoccipitalregionandradiatestowardthefrontalarea.Apainful,stiffneck.1. CervicalspondyloticradiculopathyThechiefcomplaintisradiationofpainintotheinterscapularareaandintothearm.Typically,patientshaveproximalarmpainanddistalparesthesias.2. Cervicalspondyloticmyelopathy-Patientsof

22、tenpresentwithparesthesias,dykinesiasprweaknessofthehand,theentireupperextremity,orthelowerextremity.Deepachingpainoftheextremity,broad-basedgait（步態(tài)）,lossofbalance,lossofhangdexterity（技巧）,andgeneralmusclewastingarefoundinpatientswithadvancedmyelopathy.Impotence（性無能）isnotuncommoninthesepatients.Deept

23、endonreflexescanbeeitherhyporeflexicorhyperreflexicoThepresenceofHoffmannreflexorBabinskireflexindicateanuppermotorneuronlesionHighcervicalspondylosis（C3-C5）leadstocomplaintsofnumbandclumsy（JfB）hands,whilemyelopathyofthelowercervicalspine（C5-C8）presentwithspasticity（痙攣）andlossofproprioception本體感覺inlegs。B. Imagingstudies：X-rayfilmsmayshowsingleormulti