LOWERBACKPAIN

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HERNIAOFINTERVERTEBRALDISC腰痛和腰椎間盤突出癥..LOWERBACKPAINANDHERNIAOF1StructuralsupportandbalanceforuprightpostureFunctionsoftheSpine..Structuralsupportandbalance2ProtectionSpinalcordandnerverootsFunctionsoftheSpineInternalorgans..ProtectionFunctionsoftheSp3FlexibilityofmotioninsixdegreesoffreedomFunctionsoftheSpineLeftandRightSideBendingFlexionandExtensionLeftandRightRotation..Flexibilityofmotioninsixd4Cranial-theheadortowardstheheadCaudal-thetailortowardsthetailAnterior-thefrontsectionortowardsthefrontPosterior-thebacksectionortowardsthebackVentral-thefrontoranteriorsurfaceDorsal-thebackorposteriorsurfaceBasicTerminologyCranialCaudalAnteriorPosteriorDorsalVentral..Cranial-theheadortowards5VertebralStructuresPediclenotchesSlightNotchDeepNotchIntervertebralForamenIntervertebralforamenNerverootsexit..VertebralStructuresPedicleno6VertebralStructuresBodyPedicleLaminaSuperiorArticularProcessSpinousProcessTransverseProcessVertebralForamen..VertebralStructuresBodyPedicl7AnteriorArchVertebralbodyAnterior1/3pediclesVertebralArchesPosteriorArchPosterior2/3pediclesandposteriorelementsArchesformthevertebralforamen..AnteriorArchVertebralArchesP8VertebralStructuresArticularprocessesSuperiorArticularProcessParsinterarticularisInferiorArticularProcessZygapophysealJoint(FacetJoint)Pars..VertebralStructuresArticular9LumbarVertebraeBody-

L1toL5progressiveincreaseinmassPedicles-

longerandwiderthanthoracic;ovalshapedSpinousprocesses-

horizontal,squareshapedTransverseprocesses-

smallerthaninthoracicregionSpinalforamen-largetoallowforcaudaequinaandnerverootsIntervertebralforamen-large,butwithincreasedincidenceofnerverootcompression..LumbarVertebraeBody-L1toL10IntervertebralDiscVertebralStructuresEndPlateApophysealRingCartilaginousBony..IntervertebralDiscVertebralS11TheFUNCTIONALUNITofthespineComprisedof:TwoadjacentvertebraeIntervertebraldiscConnectingligamentsTwofacetjointsandcapsulesTheMotionSegment..TheFUNCTIONALUNITofthespi12FibrocartilaginousjointofthemotionsegmentMakesup?thelengthofthespinalcolumnPresentatlevelsC2-C3toL5-S1Allowscompressive,tensile,androtationalmotionLargestavascularstructuresinthebodyIntervertebralDisc..Fibrocartilaginousjointofth13....14IntervertebralDiscAnnulusFibrosusOuterportionofthediscLamellaeGreattensilestrengthMadeupoflamellaeAnnulusFibrosusLayersofcollagenfibersArrangedobliquely30°Reversedcontiguouslayers..IntervertebralDiscAnnulusFib15....16IntervertebralDiscNucleusPulposusNucleusPulposusInnerstructureGelatinousHighwatercontentResistsaxialforces..IntervertebralDiscNucleusPul17IntervertebralDiscLargestavascularstructureBloodsupplybydiffusionthroughendplatesDamagetothebloodsupplyleadstodegradationofthedisc..IntervertebralDiscLargestava18AnatomyandDegenerativeChangeTheVertebralBody(VB)KeyRolesCarry80%oftheaxialloadsthroughVBanddiscEndplatesenablenutritiontodiffusetodisc..AnatomyandDegenerativeChang19IntervertebralDisc..IntervertebralDisc..20TheIntervertebralDiscHastworolesShockabsorberofaxialforcesPivotpointinmotionsegment..TheIntervertebralDiscHastwo21IntervertebralDisc..IntervertebralDisc..22LigamentsLigamentumflavumPosteriorlongitudinalligamentAnteriorlongitudinalligament..LigamentsLigamentumflavumPost23SpinalLigamentsBandsorsheetsoftough,fibroustissuethatconnectbones,cartilage,orotherstructuresBecomeactivewhenstressedtomaximumrangeofmotionProtectthejointsfrombeinghyperflexed..SpinalLigamentsBandsorsheet24TheIntervertebralDiscandDegenerativeChangeTwomajorcomponentsofIVDAnnulusfibrosis:thick,fibrous“radialtire”LamellaeNucleuspulposus:ball-likegel..TheIntervertebralDiscandDe25TheIntervertebralDisc(IVD)andDegenerativeChangeByage50,95%ofpeopleshowlumbardiscdegenerationNotallhavesymptomsSignificantchangestoIVDare:WaterandproteoglycancontentdecreasesCollagenfibersofAFbecomedistortedTearsmayoccurinthelamellaeResultsin:DisclosesheightandvolumeLosesresistancetoloadingforcesNolongeractsasashockabsorber..TheIntervertebralDisc(IVD)26Overview-cont.ThemotionsegmentisthefunctionalunitofthespineandconsistsofMuscle(activators)Ligaments(passiverestraints)AdjacentvertebralbodiesA3-jointcomplexoftwofacetjointsandadisc(pivots)Degenerationcanbegininoneormoreofthesejoints,butultimatelyallthreewillbeaffected..Overview-cont.Themotionseg27DegenerativeConditionsProvideanoverviewofdegenerativeconditionsDegenerativeDiseaseSpinalStenosisHerniatedDisc..DegenerativeConditionsProvide28DegenerativeDisease-OverviewLossofnormaltissuestructureandfunctionduetoagingprocessChangesareusuallygradual,traumasometimesacceleratesDegenerativechangesdonotalwaysleadtoclinicalsymptomsWhenchangescausesymptoms(oftenpain),theprocessisreferredtoasosteoarthritisSpondylosisisdegenerativechangesinthespine..DegenerativeDisease-Overvie29AnatomyandDegenerativeChangeTheVertebralBody(VB)DegenerativeChangesSclerosis:IncreasedboneformationadjacenttoendplatesReducesnutritiondiffusingtodiscStiffensendplate,andreducesabilitytoabsorbloadsOsteophytes:FormationofsmallbonyspursCanprojectintoneurostructures..AnatomyandDegenerativeChang30FacetJointsandDegenerativeChangeKeyRolesCarry20%ofcompressiveloadsHelpstabilizespineDegenerativeChangesCartilageliningloseswatercontentCartilagewearsawayFacetsoverrideeachotherLeadstoabnormalfunctionofmotionsegment..FacetJointsandDegenerative31AnatomyandDegenerativeChangeLigamentsandMusclesLigamentsattachbonetoboneProvidestability,enablenormalmotionDegenerativeChangesPartialruptures,necrosisandcalcificationsNegativelyimpactfunctionofmotionsegment..AnatomyandDegenerativeChang32DegenerativeDiscDiseaseChangesinclude:DisclosesheightandvolumeCompressiveloadstransferawayfromnucleustomarginsSclerosisofendplatereducesdiscnutritionFacetjointswearawaycartilage,begintooverrideMotionsegmentbecomeshypermobileOsteophytesdeveloptoattempttostabilizemotionsegmentOsteophytesmayencroachonneurostructures..DegenerativeDiscDiseaseChang33SpinalStenosisNarrowingofthespinalcanaland/orlateralforamenthroughwhichthenervestravelThreetypes:Centralstenosis:incentralspinalcanalwherecordorcaudaequinaarelocatedLateralrecessstenosis:inthetractwherenerverootsexitcanalAcquired:inlateralforamenwherenerverootsexittobodyMostfrequentinlowercervicalandlowerlumbarspine..SpinalStenosisNarrowingofth34HerniatedDiscOftencalled“ruptureddisc”VerycommonpathologyL3-4,L4-5,L5-S1commonlocationsThoughttobeaculminationofacutetraumaticeventstothedisc..HerniatedDiscOftencalled“ru35HerniatedDisc:4degrees

Nuclearherniation:nucleusruptures.NodisruptionofouterannularfibersDiscprotrusion:rupturednucleuscausesouterfiberstobulgeNuclearextrusion:Completesplitinannulus.MaterialleaksbutremainsattachedtonucleusSequesterednucleus:Leakedsubstancenolongerattachedtonucleus..HerniatedDisc:4degreesN36INTRODUCTIONThebackandlegpainsince-Greeksrecognizedit.InthefifthcenturyADAurelianusclearlydescribedthesymptomsofsciatica.Thesciaticaarosefromeitherhiddencausesorobservablecauses-afall,aviolentblow,pulling,orstraining...INTRODUCTIONThebackandlegp37....38

ThemostnotableoftheseistheLasèguesign,orstraight-legraisingtest,describedbyForstin1881butattributedtoLasègue,histeacher.Thistestwasdevisedtodistinguishhipdiseasefromsciatica...

Themostnotableoftheseis39Biomechanicsofthelumbarspine..Biomechanicsofthelumbarspi40....41Biomechanicsofthelumbarspine..Biomechanicsofthelumbarspi42Biomechanicsofthelumbarspine..Biomechanicsofthelumbarspi43Biomechanicsofthelumbarspine..Biomechanicsofthelumbarspi44Biomechanicsofthelumbarspine..Biomechanicsofthelumbarspi45Biomechanicsofthelumbarspine..Biomechanicsofthelumbarspi46INTRODUCTIONMixterandBarrintheirclassicpaperpublishedin1934againattributedsciaticatolumbardischerniation...INTRODUCTIONMixterandBarrin47DefinitionRuptureddiscsareamongthemostcommonandpainfulofallbackailments.Theconditionoccurswhentheoutercoverofadiscistornandthesoftinnertissueextrudes.Theextrusionoftenputspressure

onthespinalnerves,causingbackandleg

painwhichcanbesevere.

腰椎間盤突出癥是因椎間盤變性，纖維環破裂，髓核突出刺激或壓迫神經根、馬尾神經所表現的一種綜合征。..DefinitionRuptureddiscsarea48ProlapsedintervertebraldiscItusuallyoccursintheL4/5orL5/S1intervertebraldiscregionsandismostoftenseenononlyonesidebutmaybebilateral.Itmayoccurinotherregions,especiallyattheL3/4level,andoccasionallydiscprotrusionmayoccuratmorethanonelevelsimultaneously.Itisoftenduetodegenerationofthediscandthereforeoccursmostcommonlyinmiddleoroldage.Degenerationoftheannulusfibrosusallowsthenucleuspulposustoherniatethrough..ProlapsedintervertebraldiscI49壓迫對神經根的作用壓迫改變神經根的傳導、營養狀態，通過影響局部血運和腦脊液的營養，機械直接損傷神經內部，神經根受壓變形，有張力，壓迫神經根可引傳導性損傷，功能改變。同周圍神經一樣，單純壓迫不引起根痛，沒有炎癥和刺激因素壓迫只產生感覺缺失，運動無力，反射異常，但無痛。如有化學炎癥和代謝因素產生炎性反應存在~~~`..壓迫對神經根的作用壓迫改變神經根的傳導、營養狀態，通過影響局50壓迫對神經根的作用壓力從10～13.33kPa引起了神經傳導功能的逐漸減弱。其中，傳入神經傳導功能的減弱更加明顯，而去壓迫后，運動神經能更加容易和迅速地恢復到幾乎正常的CMAP水平。壓迫在26.67kPa時，引起了神經傳導功能的迅速減弱，而且去壓迫后傳入神經幾乎沒有恢復，傳出神經仍有30%～40%的恢復。將壓迫時間從2h延長到4h，對神經恢復能力的影響更加明顯〔3〕。..壓迫對神經根的作用壓力從10～13.33kPa引起了神經傳導51產生腰痛的組織--背根節Howe發現背根節對中度壓迫極度敏感，當壓力解除后感覺神經釋放的信號可持續25分鐘。從神經生理學角度背根節是特有的、“搗鬼”的疼痛源，突出椎間盤能擠壓它對于周圍神經來說，當刺激解除后，神經沖動馬上停止...產生腰痛的組織--背根節Howe發現背根節對中度壓迫極度敏52產生腰痛的組織-背根節實驗結果背根節在尼龍線牽拉產生60秒的發電，而玻璃棒壓迫會產生4分鐘的沖動..產生腰痛的組織-背根節實驗結果背根節在尼龍線牽拉產生60秒的53產生腰痛的組織--背根節背根節的神經細胞與突觸相交處的細胞膜上有高密度的鈉通道，使其對機械壓力特別敏感。這種高密度的鈉通道可能是導致神經沖動持續，在背根節受壓時產生生骨神經痛...產生腰痛的組織--背根節背根節的神經細胞與突觸相交處的細胞膜54產生腰痛的組織--神經根Olmarker等應用不同的化學標記物來研究壓力的大小和壓迫發生的速度與水腫形成和營養障礙的關系。結果提示，壓迫產生越迅速，神經根水腫的形成和營養供給障礙越明顯。..產生腰痛的組織--神經根Olmarker等應用不同的化學標記55產生腰痛的組織-脊神經背根與DRG不同，背根對機械壓力不是始終有反應，除非神經根有炎性或處可易惹狀態。Howe在被鉻腸線結扎神經根后可以引出多次發電的情況，單一壓迫刺激即可引Aα、β、d神經纖維放電5-30秒。被刺激的神經根是有鞘神位由可能含有神經末梢。Jang發現了貓的S1背根中有點狀直接受刺激區..產生腰痛的組織-脊神經背根與DRG不同，背根對機械壓力不是始56產生腰痛的組織-脊神經背根最有效的機械刺激是輕度牽拉，與臨床情況相吻合。有病間盤水平的神經根比鄰近正常的神經根更敏感Kuslich在局麻下椎間盤手術中，對有炎癥或壓迫的神經根壓迫特別敏感，壓迫它再現坐骨神經痛Smyth用尼龍線繞過受累神經根，輕拉即再現坐骨神經痛的..產生腰痛的組織-脊神經背根最有效的機械刺激是輕度牽拉，與臨床57神經源的化學介質損傷和炎癥的組織釋放的化學介質使神經末梢致敏。這些神經致敏物質包括由C纖維釋放出的P物質、11氨基酸神經肽。P物質導致血管擴張，血漿外滲，肥大細胞釋放組胺。這些炎性介質的持續釋放引起了疼痛。..神經源的化學介質損傷和炎癥的組織釋放的化學介質使神經58神經源的化學介質雖然原因還不清楚，P物質可能直接作用神經末梢或間接通過血管擴張，釋放組胺、血漿外滲起作用。P物質在神經致敏中起重要作用，這有重臨床意義，脊柱的運動正常是無痛的，但在炎癥條件下引起疼痛..神經源的化學介質雖然原因還不清楚，P物質可能直接作用神經末梢59腰痛癥狀持續的原因

非神經源的化學介質在組織損傷中產生的可以激活和致敏神經末梢的化學介質包括：緩激肽、血清素(5-HT)、組織胺、鉀離子、前列腺素。已在椎小關節及鄰近組織中發現了P物質，使用10-μg即能同時興奮低痛閾和高痛閾神經纖維，30分鐘后這些神經對機械刺激的痛閾明顯降低..腰痛癥狀持續的原因

非神經源的化學介質在組織損傷中產生的可以60非神經源的化學介質當將角叉菱膠或陶土注入關節后，神經纖維致敏興奮性增加，1-2mm的各方關節活動即可導致關節支配神經的持續釋放沖動電位。最近的研究表現在神經感受器對機械壓力敏感的部位，注入角叉菱膠，會導致神經元放電達3小時..非神經源的化學介質當將角叉菱膠或陶土注入關節后，神經纖維致敏61非神經源的化學介質這些研究的臨床意義：如果關節囊、韌帶、肌肉受牽拉，例如脊柱滑脫和椎間盤突出癥，引起組織損傷會導致持久的傷害性刺激，并可以導致一種循環狀態，肌肉痙攣，痛覺過敏，以致持續性疼痛..非神經源的化學介質這些研究的臨床意義：如果關節囊、韌帶、肌肉62椎間盤及神經根周圍的炎癥有關椎間盤的神經生理學研究是有限的。Cavanaugh報告了椎間盤受機械刺激時只偶有少量沖動，只有腹側硬膜受牽拉才有持續沖動。只有電刺激椎間盤和后縱韌帶引起A-d纖維沖動，同椎管內注入致痛物質，像組胺作用一樣..椎間盤及神經根周圍的炎癥有關椎間盤的神經生理學研究是有限的。63椎間盤及神經根周圍的炎癥Yamashita報告了椎間盤對機械壓力大部分情況是沒有反應。椎間盤內只有靜止傷害感受器，它只對損傷或炎癥產生的致痛電學物質有反應。McCarron向狗硬膜外腔注入自體的髓核，表現出它的致炎作用。Olmarker發現身體髓核在神經組織中產生炎性和退行性改變..椎間盤及神經根周圍的炎癥Yamashita報告了椎間盤對機械64免疫和炎癥反應腰腿痛當中，原因很復雜，椎間盤突出的大小與疼痛程度不一，生化和機械因素交互作用。有很多證據表明髓核有致免疫原性，自體髓核與血液接觸，對髓核自身抗體已發現，雖然很多證據表明介導免疫炎性，絕大多數以前的研究都注意到椎間盤退變和疼痛的產生中的免疫現象標志物。Saal證明突出間盤邊緣有免疫細胞，發現了T淋巴細胞IL-1、2，據細胞。浸潤的不同程度分級與癥狀相關。反應程度與術前癥狀時間相關但病人沒有全身的自身免疫性疾病表現,疼痛直接原因不清。..免疫和炎癥反應腰腿痛當中，原因很復雜，椎間盤突出..65磷脂酶A2---PLA2在風濕性關節炎、急性胰腺炎、血清單陰性關節炎、膿毒癥表現出明顯的炎癥作用。它在體內的源性：表1PLA2activiyu

PMN~~~~~~~~~~~~~~~~~~~~3,2Platelet~~~~~~~~~~~~~~~~~~1.4

Plasma~~~~~~~~~~~~~~~~0.006Sperm~~~~~~~~~~~~~~~~~~28.0inflammatorysynovialfluid~~12.1herniatedlumbardisc~~~~~1212.0正常椎間盤內PLA2就有致水腫作用..磷脂酶A2---PLA2在風濕性關節炎、急性胰腺炎、血清單66PLA2的神經毒性Steroid局部應用非常有效，在沒有免疫反應的生化炎癥，作為疼痛發生機制的另一個原因髓核有介導炎性的能力，含有高濃度的PLA2。Saal在有腰痛病人病變節段的椎間盤組織內會有不正常高濃度的磷酸激酶A2-PLA2。髓核、PLA2及別的致炎物質作用到椎間盤的傷害感覺受器，它激活痛感纖維的作用比單純壓力更大PLA2進入神經根后→神經水腫，髓鞘軸突損傷，同注射蛇毒PLA2，但作用程度輕，支持了PLA2的神經毒性硬腰外使用自體髓核，發生傳導阻滯，神經周圍組織炎癥。..PLA2的神經毒性Steroid局部應用非常有效，在沒有免疫67Leakageofnucleuspulposusmaterialtonerveroots,isapathophysiologicmechanisminLBPandsciatica

Incisionoftheanulusfibrosusinducesnerverootmorphologic,vascular,andfunctionalchanges.Anexperimentalstudy.Kayama--Japan:Spine1996Thenerveconductionvelocitywassignificantlylowerintheincisiongroup(1314m/sec)comparedwiththenonincisiongroup(735m/sec).Theobvioussignsofcapillarystasiswithanincreasednumberanddiameteroftheintraneuralcapillariesintheincisiongroup.

..Leakageofnucleuspulposusma68Cultured,autologousnucleuspulposuscellsinducefunctionalchangesinspinalnerveroots

Kayama--Sweden:Spine1998Nucleuspulposuscellsandfibroblastswereculturedfor3weeks,andvariouspreparationswereappliedtothecaudaequinain29pigs.After1week,nerveconductionvelocitywasdeterminedbylocalelectricalstimulation.Applicationofnucleuspulposuscellsreproducedthepreviouslyseenreductioninnerveconductionvelocityinduced...Cultured,autologousnucleusp69腰痛癥狀持續的原因

椎間盤及神經根周圍的炎癥Kuslich在144例椎間盤手術中，在病變椎間盤外側檢查刺激或電刺激產生中度疼痛占70%，重度占30%。突出椎間盤或狹窄的椎間只對DRG或突炎神經根的機械壓迫是持續的，就能導致持續性疼痛，或DRG或炎性神經根內壓增加這種持續性疼痛就會變為進行性加重。Cavanaugh將自體髓核注入DRG引起1-3分鐘的神經釋放..腰痛癥狀持續的原因

椎間盤及神經根周圍的炎癥Kuslich在70PLA2致痛原因①致炎因素；②直接作用傷害感受器；③磷脂酶本身的直接造成神經損傷。炎癥介定導致源發性神經根壞死，體外證實PLA2直接刺激纖維環傷害感受器。這些化學物質可直接刺激纖維環和周圍神細胞中的細小的無髓纖維C或Adeltal。致病物質作用后，傷害感受器的痛域下降。（對機械刺激）正常的生理活動就可以導致腰痛、障礙痛、根性痛（在纖維環外1/3后縱韌帶）...PLA2致痛原因①致炎因素；②直接作用傷害感受器；③磷脂酶本71第二部分：腰痛癥狀持續的原因

椎間盤及神經根周圍的炎癥臨床、組織化學、生理化學、神經組織學研究，髓核含有化學性致炎、神經退變，急性期有神經興奮的作用。同樣化學物質有氫離子、PLA2免疫球蛋白G等，在椎間盤性疼痛中，增加炎性神經根的敏感性起重要作用..第二部分：腰痛癥狀持續的原因

椎間盤及神經根周圍的炎癥臨床、72PhospholipaseA2sensitivityofthedorsalrootanddorsalrootganglion

OzaktayUSA

：Spine1998JunPhospholipaseA2appearedtobeneurotoxicwhendosesrangingfrom100to400Uwereappliedonthemechanicallysensitivesegmentsofthedorsalrootganglia.PLA2dosescomparabletoserumconcentrationsinhumanrheumatoidarthritiswhenappliedtodorsalrootganglia.TheseresultssuggestthatdorsalrootsanddorsalrootganglionmaybeimpairedbyphospholipaseA2,leadingtosciaticaandlowbackpain...PhospholipaseA2sensitivityo73脊髓水平

中樞致敏組織損傷可能導致連續的神經沖動至脊髓，這使后角神經元致敏致敏的神經元痛閾下降，對傳入沖動的反應增強，對重復刺激的反應也增強，接受刺激的閾值變寬。惡性刺激導致中樞致敏時，有明確證據后角釋放了興奮性胺基酸和神經肽..脊髓水平

中樞致敏..74脊髓水平---中樞致敏在中樞致敏狀態下，機械刺激的致痛閾值已下降，使很低的機械刺激就可以讓后角發出疼痛信號。變寬的接受閾能把損傷處及附近正常組織的傳入信號變為疼痛信號向上傳遞，這就解釋了腰疼痛位不清和持久、及牽涉痛的原因..脊髓水平---中樞致敏在中樞致敏狀態下，..75脊髓水平---中樞致敏Gilleffe發現了后角單個神經元可接受從各種脊柱組織傳入的信號，呈一種高度會聚接收狀態。脊髓后角的神經元可以由壓迫皮膚、椎小關節、韌帶、及肌肉而興奮，這種高度會聚功能也是腰痛不易定位的原因..脊髓水平---中樞致敏Gilleffe發現了后角單個神經元可76ChronicCompressionofDorsalRootGanglionProducedbyIntervertebralForamenStenosis

HuSJ-Xi'an,PRChinaPain1998JulAnexperimentalmodelintherat.Asmallstainlesssteelrod(0.5-0.8mmindiameter)wasinsertedintotheL5intervertebralforamenTheseneuronshadagreatlyenhancedsensitivitytomechanicalstimulationoftheinjuredDRGandaprolongedafterdischarge.apersistentheathyperalgesia5-35daysTheexcitatoryresponseswereevokedintheinjured,butnottheuninjured,DRGneurons...ChronicCompressionofDorsal77EPIDEMIOLOGY-riskfactors

Multiplefactorsaffectthedevelopmentofbackpain.smoking,pro-longeddailydrivingofmotorvehicles,jobsrequiringfrequentrepetitiveliftingofheavyobjectsandtwisting,theuseofjackhammersandmachinetools,andtheoperationofmotorvehicles

episodesofanxietyanddepression.Itismorecommoninmalesthanfemalesandhasamaximalincidenceinthethirdandfourthdecadesoflife...EPIDEMIOLOGY-riskfactorsMult78LUMBARDlSCHERNlATIONBackpainmaybecausedbystimulationofthepainfibersintheouterlayersoftheannulusfibrosus.Alternatively,distortionoftheposteriorlongitudinalligament,whichisrichlyinnervatedbypainfibers,mayresultinbackpain.LegpaincanresultfromcompressionofanerverootbyanHNP..LUMBARDlSCHERNlATIONBackpai79腰痛可以起自于椎間盤、椎小關節、肌肉的神經末梢。化學炎性介質釋放，使正常無痛的運動變為疼痛性的。髓核是強列的神經根和神經末梢致炎和刺激物質椎間盤與神經根的位置、DRG的特殊神經生理特點、神經根和DRG易被壓迫而出現坐骨種經痛。系列惡性沖動使后角感覺神經元致敏，導致的慢性疼痛狀態..腰痛可以起自于椎間盤、椎小關節、肌肉的神經末梢。..80CIinicaIPresentationThefollowingareriskfactorsforherniateddiscdiseaseinthelumbarspine:smoking,pro-longeddailydrivingofmotorvehicles,andfrequentrepetitiveliftingofheavyobjectsandtwisting.Itismorecommoninmalesthanfemalesandhasamaximalincidenceinthethirdandfourthdecadesoflife...CIinicaIPresentationThefoll81Theclinicianmustruleoutacompressivelesionofthesciaticnerveperipherallybeforeascribingthepaintoaherniateddisc.Theremaybeahistoryofapreviousinjury...Theclinicianmustruleouta82CIinicaIPresentationAsymptom-HNP.Sciaticaispainalongthecourseofthesciaticnerve.Theclassicsymptomislowbackpainwithradiationofseverepaindownthebackofthelegtotheankleandfoot.Itmaybeassociatedwithneurologicalsignssuchasmotorandsensorylossandoccasionallybladderinvolvement...CIinicaIPresentationAsymptom83ThelevelsoflumbarHNPThemostcommonlevels-L4--L5andL5--Sl.Forthisreason,radicularsymptomsalmostalwaysrefertosymptomsbelowtheleveloftheknee,intheL5orS1dermatome.Legsymptomscanvaryfromnumbnesstodysesthesiatotruepain.TheherniationoftheL4--L5disccancompresstheS5andThelumbosacraldisccausescompressionoftheS1nerveroot.

..ThelevelsoflumbarHNPThemo84SymptomsandsignsofthelumbarspineThereisoftenassociatedspasmofthespinalmuscleswithtendernessoverthelowerlumbarspineonthesideofthelesion.Themuscularspasmmayproduceascoliosis.Limitationoflateralflexionofthelumbarspinetothesamesidewillbemostmarkedwithaprotrusionlateraltothenerveroot,whilelimitationoflateralflexiontotheoppositesidewillbemostmarkedwithaprotrusionmedialtothenerveroot...Symptomsandsignsofthelumb85FocalsignsFocalsignsaredependentonthedistributionoftheaffectednerveroot.WithL4compressionthereisweaknessofquadricepsandtibialisanterior,withsensorychangeoverthemedialaspectoftheshinanddepressionofthekneejerk.L5rootcompressionmaysolelydeclareitselfbyweaknessofextensorhallucislongus.Anysensorychangeisfoundoverthemedialaspectofthedorsumofthefootandthelateralshin.InanSlrootsyndromeweaknesscanoccurinthebuttockmuscles,thehamstringsorthecalfmuscles.Theanklejerkislikelytobedepressedorabsent.Sensorychangeparticularlyoccursoverthelateralaspectofthefootandthecalf...FocalsignsFocalsignsaredep86ProtrusionoftheL4/5discItmaycauseL5rootpressurewithpainradiatingdownthelegtothedorsumofthefoot.Theremaybenumbnessontheoutersideofthecalfandmedialtwo-thirdsofthedorsumofthefootwithweaknessofdorsiflexion,particularlyofthefootandtoes...ProtrusionoftheL4/5discIt87ProtrusionoftheL4/5disc..ProtrusionoftheL4/5disc..88ProtrusionsattheL4/5levelwillthuscompresstheL5root,whileprotrusionsattheL5/S1levelwillcompressthefirstsacralroot...ProtrusionsattheL4/5level89ProtrusionoftheL5/S1discItwillpressontheS1nerverootandmayleadtopainandnumbnessontheoutersideofthefootandundersideoftheheel.

..ProtrusionoftheL5/S1discIt90ProtrusionoftheL5/S1discTheremaybeweaknessofbotheversionandplantarflexionofthefootwithadiminishedorabsentanklejerk...ProtrusionoftheL5/S1discTh91....92....93ProtrusionoftheL3/4discItmaycausepressureontheL4nerveroot

mayleadtonumbnessoverthefrontofthekneeandlegwithdiminutionofthekneejerkandweaknessofthekneeextensors...ProtrusionoftheL3/4discIt94ProtrusionoftheL3/4discFemoralnervetractiontest..ProtrusionoftheL3/4discFem95CentralprotrusionofalowerlumbardiscItcanpressonthecaudaequinaleadtourinaryretention.Onexaminationthereisusuallyperianalnumbnessandapatulousanus.Emergencydecompressionisessentialtoavoidpermanentdamagetosphincterinnervation...Centralprotrusionofalower96CentraldiscprotrusionFollowingacentraldiscprotrusion,whichcanoccurwithoutanantecedenthistoryofbackpain,caudaequinacompressionoccurs,ofteninanabruptfashion.Severepainresults,withparavertebrallocalizationorwithradiationintobothlowerlimbs.Typically,thereisseveredistallowerlimbweaknesswithfootdrop,depressionoftheanklereflexesandimpairedsphincterfunction.Saddleanaesthesiaiscommon.

..CentraldiscprotrusionFollowi97中央型Occasionallytheprotrusioniscentral,pressingonthecaudaequinaandaffectingautonomiccontrolofthebladderleadingtourinaryretention.Urgentsurgicaldecompressionofthecaudaequinaisrequiredasanemergency...中央型Occasionallytheprotrusion98CIinicaIPresentationAnymaneuverthatincreasesintraspinalpressure,suchasstrainingatstool,coughing,orsneezing,mayexacerbatesymptoms.InoverhalfthepatientswithsciaticafromanHNP,aspecificnerverootcanbeidentified,simplybyhistory.Weakness:

thetibialisanterior---godownstairs,thegastrocnemiussoleusmusclegroup---goingupstairsdifficult...CIinicaIPresentationAnymaneu99臨床表現

流行病學常見于20～50歲患者男女比4～6:1多有彎腰勞動或長期坐位工作史..臨床表現100癥狀腰痛坐骨神經痛馬尾神經受壓體征腰椎側突腰部活動受限壓痛及骶棘肌痙攣直腿抬高試驗及加強實驗神經系統表現..癥狀..101TreatmentNotallpatientssufferpainAsouterdiscdistorts,mayprotrudeintospinalcanalMayleadtosciatica(paindownbackofleg)Oftenstartwithconservative,non-operativecareSpontaneousresolutionofsciaticaoftenoccursPatientswithcaudaequinasyndromerequiresurgicalattentionCommonsurgicalproceduresinclude:Laminectomy,discectomy,microdiscectomy,endoscopicdiscectomy,ablationprocedure..TreatmentNotallpatientssuff102PhysicalExaminationTheposture:OftenthereisafunctionalscoliosisRangeofmotionofthelumbarspinemaybelimitedduetoparavertebralmusclespasmorguarding.Forwardflexionmayincreasethesymptomsofsciatica.Palpationmayshowtendernessinthesciaticnotchduetoirritationofthenerve...PhysicalExaminationThepostu103PhysicalExaminationStraight-legraisingisperformedbygentlyelevatingtheoutstretchedlegfromthehorizontalwiththepatientlyingsupine.Thedegreeofmovementisrecorded.Themostspecificsignforlumbardischerniationisacontralaterallypositivestraightlegraisingexamination,alsocalledcross-legtest.AfemoralstretchtestusuallyindicatesadischerniationattheL3--L4levelorabove.Ameticulousneurologicexaminationisnecessarytodetectmotorweakness,sensorychanges,anddeeptendonreflexasymmetry...PhysicalExaminationStraight-104PlainX-raysPlainX-raysareofverylimitedvalueintheinvestigationofalumbarradiculopathy.BesideMarkedfocaldiscspacenarrowing,plainX-raysareoftennormal.Butitsmostimportantvalueisruleoutthebonydisordersofthelumbarspine,TB,Tumor...PlainX-raysPlainX-raysareo105MyelographyPurpose:ShowcompressionordisplacementofneuralelementsMethod:RadiopaquematerialinjectedintothethecalsacStandardx-raysand/orfluoroscopyReading:NeuralstructuresaredarkContrastmaterialwhiteSpecialRadiographicStudies..MyelographySpecialRadiographi106SpecialRadiographicStudiesDiscographyPurpose:EvaluatepatencyofdiscEstablishwhetherdisciscausingback/radicularpainMethod:PlaceneedleintodiscunderfluoroInjectdyeintothediscReading:Dyeleaksoutofnucleus=incompetentdiscInjectionreproducespain=discassourceofpain(Provocativediscogram)..SpecialRadiographicStudiesDi107SpecialRadiographicStudiesComputedTomography(CT/CAT)Purpose:DetectbonytissuepathologiesMethod:Multipleslicesofaxialx-rayimages(1-4mm)ComputerconstructsintopermanentimageHighradiationexposure..SpecialRadiographicStudiesCo108SpecialRadiographicStudiesMagneticResonanceImaging(MRI)Purpose:DetectsofttissuepathologiesMethod:UsesmagneticandradiowaveenergyShowsatwo-dimensionalsliceCoronal,sagittaloraxialviewNoradiation..SpecialRadiographicStudiesMa109SpecialRadiographicStudiesBoneScanPurpose:Detectinflammation,infection,tumorMethod:InjectradioisotopeintothebloodstreamIsotopeabsorbedbybonetissueGammascandetectsradiationReading:Darkareas=increasedactivity (hotspot)..SpecialRadiographicStudiesBo110RadiologyOverview..RadiologyOverview..111PlainCTCTisrecommendedastheinitialinvestigationfortheevaluationoflumbardiscdisease,Itcanshowmanydisordersofthelevel:

lumbarcanalstenosisthelateralrecesssyndromecalcificationofthedisc...PlainCTCTisrecommendedast112雙側根管狹窄，椎管狹窄嚴重

..雙側根管狹窄，椎管狹窄嚴重

..113....114解剖結構變化..解剖結構變化..115CTmyelographyCTmyelographycomplementsmyelographyintheinvestigationofsuspectedlumbardiscprotrusion.Myelographyachie