● 但脊柱在轴向上主动伸长时,终板平面出现分离,椎间盘的厚度增加。同时,椎间盘的宽度缩小,纤维环的张力增加。在休息状态下呈偏平状的髓核,趋向于圆球状。椎间盘高度的增加减少了椎间盘的内压。● 脊柱受轴向压缩时,椎间盘受挤压而变宽,髓核变扁平,导致内压增加,增加的压力横向传递至纤维环的最内层。● 脊柱后伸时,上位椎体向后移动,椎间隙减小,驱动髓核前移。髓核随后压迫纤维环中位于前方的纤维,并使它们的张力增加,使得上位椎体回复至其初始位置。● 脊柱屈曲时,上位椎体向前移动,前方椎间隙减小,髓核向后移位,压迫纤维环中位于后方的纤维,增加了其张力,实现脊柱的自我稳定。● 脊柱侧屈时,上方椎体像屈侧倾斜,驱动髓核向反方向移动,,实现脊柱的自我稳定。● 脊柱轴向旋转时,与运动方向相反的斜向纤维被拉伸,与旋转方向相反的中间部位纤维则松弛。纤维环中央的纤维受张力最大,倾斜最明显。相应地,髓核受压加大,内压增加,内压增加程度与旋转度成正比。● 但静态压力稍微倾斜地作用于椎体时,这个垂向作用力可分解为: -垂直于下位终板表面的分力 -平行于下位终板表面的分力白天,当躯体直立位承受压力时,髓核的水分通过微孔溢至椎体,导致髓核高度降低。夜晚,当平卧休息时,椎体不再承受轴向重力的作用,髓核的亲水性发挥作用,将椎体中的水分重新吸收回髓核,椎间盘可回复至初始高度。本文系郭刚医生授权好大夫在线(www.haodf.com)发布,未经授权请勿转载。
1.保护性跛行:走路时,患侧足刚一点地则健侧足就赶快起步前移;健足触地时间长,患足点地时间短;患腿迈步小,健腿跨步大;患腿负重小,健腿负重大。这种保护性患足点地跛行,多见下肢受伤者。2.拖腿性跛行:走路时,健腿在前面患腿拖后,患肢前足着地,足跟提起表现为拖腿蹭地跛行。可见于儿童急性髋关节扭伤、早期髋关节结核或髋关节骨膜炎等。3.间歇性跛行:开始走路时步态正常,但走不了多远(严重者不到百米)患者就因小腿后外侧及足底胀麻疼痛而被近停步,需蹲下休息片刻,待症状缓解后再重新起步。走走歇歇,因此称为间歇性跛行。常见于腰椎管狭窄症、坐骨神经受累以及血栓闭塞性脉管炎局部供血不足患者。4.摇摆步态:走路时患者靠躯干两侧摇摆。使对侧骨盆抬高,来带动下肢提足前进。所以每前走一步,躯干要向对侧摆动一下,看上去好像鸭子行走,所以又称"鸭行步"。常见于小儿先天性髋关节双侧脱位、进行性肌营养不良、严重的"O"型腿,以及臀上神经损害患者。5.高抬腿步态:走路时,患腿高抬,而患足下垂,小跨步跛行,如跨越门槛之状,所以又称"跨越步态"。主要是由于小腿伸肌瘫痪,足不能背伸而成下垂状态。为避免走路时足尖蹭地而有意识将腿抬高,常见于坐骨神经、腓总神经麻痹或外伤等。6.足跟步态:走路时以足跟着地,步态不稳,表现躯体轻轻左右晃动,足背伸、足弓高。可见于胫神经麻痹、跟腱断裂、遗传性共济失调等患者。7.划圈步态:走路时表现为患腿膝僵直,足轻度内旋及下垂,足趾下勾。起步时,先向健侧转身,将患侧骨盆抬高以提起患肢,再以患侧髋关节为轴心,直腿蹭地并向外侧划一半圆前走一步。由于多见于下肢痉挛性偏瘫患者,所以又称"偏瘫步态"。此外,还有慌乱步态:多见于脑动脉硬化、脑肿瘤、头部陈旧性外伤等;醉汉步态:主要见于小脑或前庭疾患;踏地步态:常见于多发性神经炎、髓型颈椎病以及脊髓痨等患者;交叉步态:多见于大脑瘫、截瘫等患者。
“大多数的错误源自缺乏充分的体检”“医师会因怕弄脏受而懒做必要的体检”本文的目的是对腰背痛患者的常规临床检查进行一个概述。在以后的文章中常见临床症状的检查及治疗时特别的临床表现会被再次提到。精确的病史询问及检查是必须重视的。这就意味着必须提供准确的描述而不是含糊的如“好的”“差的”“受限的”等。好的记录对于病例的分析及比较是必需的,并且在回顾病例及辅助会诊医师,甚至在提供可靠法律依据方面都起到很大作用。腰背部检查应该有计划地进行。患者的检查不应该由完全通过病史中得到的特殊疾病的体征所主导,也不能完全依赖于个体化的一系列体征如:神经体征、腹部体征、血管体征等。检查必须按程序,这样才可获得所有的阳性体征。当完成对患者的检查后,你必须对已经检查过的或将检查的患者的身体状况有尽可能多的了解。检查的先决条件是患者脱去衣服。对于许多检查,患者脱去衣服是常规,但是在门诊的时候,由于各种条件所限,患者脱衣是不合适的。粗略的检查不如不检查,因为这样往往会误导我们认为损害比较轻。第1步 步态检查观察患者走路是否存在避免疼痛的步态,如髋关节或膝关节疼痛步态?是否存在提示神经损伤的步态,僵硬或痉挛?患者弯腰,提示椎管狭窄?步态观察可以发现许多疾病的细节。通常较难区别患者的腰腿痛是由于背部疾病还是由髋关节疾病引起的,然而通过观察患者较长时间的行走可以帮助诊断,特别是患者表现出由于脊髓病变引起的僵硬步态或是髋部疼痛引起的跛行。第2步 脊椎外形从后方及侧方观察患者,脊椎整体外形的异常是很明显的。最好是从矢状位以及冠状位或额状位上来观察脊椎外形上的异常。冠状位不对称有3种原因导致冠状面上的不对称。可以通过一下几点来鉴别结构性脊柱侧弯或是坐骨神经痛性脊柱侧弯。1.结构性脊柱侧弯(1)曲线固定且不随着身体前屈而改变。(2)右胸段原发性的曲线通常存在肋骨隆起,在屈曲时更明显。(3)斜卧时曲线不复原。2.坐骨神经痛性脊柱侧弯(1)坐骨神经痛性脊柱侧弯的曲线较弥散,没有肋骨隆起的表现。(2)前屈时,曲线改变,多表现位侧弯更明显,并可改变侧弯的方向。(3)坐骨神经痛性脊柱侧弯的前屈活动较结构性脊柱侧弯受到更大的限制。(4)斜卧时侧弯消失。从后方检查患者时应主要观察以下几点:(1)腰骶部皮肤皱褶改变提示可能存在脊椎滑脱。(2)皮肤标志:皮肤色素沉着斑是神经纤维瘤的标志。其他位于腰骶部的脂肪瘤或多毛斑等肿块提示可能存在深部的骨性畸形如脊椎裂伴随或不伴随神经性肿瘤。第3步 活动范围及节奏接下来检查脊椎活动范围及节奏。前屈活动范围测量:嘱患者前屈,双手伸直下垂,记录指尖离开地面的距离。前屈活动节奏测量:将指尖置于相邻棘突间,感觉屈曲时相邻棘突分离的距离大小。伸展能力测量:让患者后仰,记录骨盆倾斜前患者能够后仰的最大限度。侧屈能力测量:让患者一侧手掌在同侧大腿向膝部滑动,记录最大滑动距离。旋转能力测量:让患者分腿站立,双手置于髋部并旋转。通过这些测试来观察一些特殊的畸形,如:在腰部僵直的情况下脊柱前屈活动明显受限常见于椎间盘突出所致的根性疼痛。此类患者脊柱前屈活动时多偏向疼痛侧。全脊椎退变的特征性表现。为了避免小关节的伸展,患者旋转骨盆以恢复直立位置。当从前屈的位置起身时,患者将伸展脊柱,但这种活动是非常不舒服的。为避免这类不适,患者将轻微地屈髋屈膝,旋转骨盆,然后伸直双腿恢复直立。当患者保持站立时,腓肠肌肌力是通过用趾尖站立的能力来测定的。反复做踮足尖的动作(疲劳试验)可以带来早起病变。与腰椎间盘突出压迫S1神经根有关的损伤可以导致足趾屈肌力及踝反射减弱,我们可以让患者跪在椅子上以做检查。测试者必须记住如果患者股四头肌力减弱,踮足尖时会出现小腿屈曲。这是在诊断时容易被忽略的。第4步有两种床边检查。第1个膝反射和踝反射。疼痛会影响检查结果,因为我们采用对于腰背痛患者而言相对舒适的坐位。患者因坐骨神经痛卧床时无法抬腿,这样会错误地掩盖膝反射。患者能直接看到反射检查过程也会影响过程也会影响检查结果,强化试验可避免此影响。第2个检查是跖浅屈肌反射。该反射的一个特点是伴随阔筋膜张肌收缩。S!神经根受损时可使该撤回反射部分消失。可顺便检查坐位Babinsiki征。第5步仰卧位是检查肌力的最佳体位。一些病损如L4-5椎间盘突出导致L5神经根损伤时踝内翻能力会减弱。检查踝背伸肌力时膝关节不能伸直,因为如果患者有明显的坐骨神经痛时做任何对抗踝关节跖屈的动作会加重疼痛,导致检查出肌力下降的假阳性结果。检查时取仰卧位,膝关节保持屈曲。L5神经损伤时最早表现的是拇长伸肌肌力减弱。相同的,S1神经损伤时最早表现的是拇长屈肌肌力减弱。比较患者双足可以发现一侧拇趾可以屈曲但另一侧不能。许多检查者通过让患者用足尖及足跟走路来检查L5及S1神经根。第3及第4神经根损伤可导致股四头肌肌力减弱。检查股四头肌肌力时患者仰卧位,髋关节略屈,膝部置于检查者前臂。患者用力伸膝对抗检查者手的阻力。广泛肌力减弱,特别是腰背肌,是患者情感低落的暗示。功能或是情感导致肌力减弱可以表现为无论多大外力作用下肌肉的松弛。通常此类患者的关节可以维持固定姿势,但是启动活动关节时则无法感受弱阻力。这被称为差异动力减弱。严重情感障碍时,会出现弥漫的,不合理的许多肌群肌力减退。典型的表现为,这些患者伸直拇趾远端指间关节时无法对抗最轻阻力,并且但检查者推开患者眼睑时,患者无法紧闭双眼。肌力按标准的0~5级标准来评价。第4级肌力又可分为以下3个等级:4+明显减弱4++中等程度减弱4+++减弱但基本接近正常肌力的分级0——肌肉完全瘫痪,没有收缩能力1——肌肉稍有轻微收缩表现2——肢体仅能在平面上移动,不能抗重力活动3——肢体可以抗重力和部分抗阻力活动4——能够抗重力及正常范围下的阻力活动,但较正常肌力差5——正常肌力以前,疼痛是通过患者肌力测试来评价的。一些患者腰腿痛过于明显,尽管尝试着配合检查,他们仍然不能完成许多动作。一些患者出现这些表现是因为疼痛与不合作,但通过病史与体格检查可以判断是否为非器质性反应。第6步神经根刺激常伴有特殊肌肉的过敏。S1神经根受刺激,腓肠肌变得敏感;L5神经根受刺激,胫前肌变得敏感;L4神经根受刺激,股四头肌变得敏感。胫骨表面压痛过敏,情感因素起到很大作用。特定的肌肉敏感性增高是相应神经根受刺激的重要体征。患者保持仰卧位,检查并比较双下肢向对应部位针刺感。S1支配足底、小腿及足外侧边缘的皮肤感觉,L5支配小腿前方及足背皮肤感觉,L4支配胫前内侧皮肤,L3支配膝部皮肤,L2支配大腿近端皮肤。感觉坚定的正确评估,是一个精细的技术。草率的针刺检查只能检查出明显的感觉变化。当变化轻微时,感觉坚定依赖于整体刺激。因为这种生理现象,失神经支配部位的10次针刺相当于对侧相应部位1~2次针刺。为了精确评估,应在双侧对称的部位进行刺激以比较。最使患者厌烦和不适的是针刺觉检查(确认这不是曾经刺伤过患者的同一类征)。患者会为了快点结束检查而同意检查者的任何暗示。对于50岁以上的患者而言,温度觉和震动觉是不敏感的。必须记住的是“长袜”类型的感觉减退并不能完全说明疼痛是异常兴奋来源的。这可能仅意味着患者异常神经兴奋表现是由于特定器官损伤而夸大的。证明这种感觉缺损的重要点在于评价患者其他伴随的症状及体征。第7步现在评价神经根体征。牵拉周围神经可以引起神经根疼痛。检查坐骨神经,握住足跟抬腿时不能过快,这样会引起明显疼痛而掩盖其他症状。抬腿要缓慢,检查者一手按住患者膝关节保持伸直。当腿或臀部感到疼痛时记住此时抬起的角度。腰背痛的再现并不能说明神经根受牵拉。任何背部损伤疼痛伴随膕绳肌腱痉挛,直退抬高会旋转骨盆并损伤腰骶区,加重疼痛。踝关节背伸疼痛加重,高度提示神经根受牵拉,屈膝疼痛缓解可以更加证实这一点。如果患者屈膝后疼痛依然存在,屈髋后疼痛进一步增加(屈腿抬高),检查这应考虑是否存在情感障碍,或者是髋关节损伤表现为坐骨神经痛症状。直腿抬高另一侧无症状的肢体,患者疼痛加重,提示突出的椎间盘位于神经根的腋部或是内侧。最可信的神经根牵拉检查是弓弦征。在该检查中,症状出现后再进行直退抬高检查。在此基础上,慢慢屈膝直到疼痛减轻。检查者将患者下肢抵于自己肩上并用拇指按住膕窝坐骨神经处。突然加压背部疼痛加重或出现下肢放射痛,患者受根性牵拉出现明显疼痛。试验意义通过膕绳肌腱来校验。存在两种情况:①按压膕绳肌腱内侧不引发疼痛;按压膕绳肌腱外侧不引发疼痛;按压外侧腓神经引发疼痛; ②按压膕绳肌腱内侧引发疼痛;按压胫神经引发疼痛;按压膕绳肌腱外侧引发疼痛;按压外侧腓神经引发疼痛;按压外侧腓神经引发疼痛。第1种情况的患者有明显的器质性综合征;而出现第2种情况的患者可能为精神问题所致。对于腹肌减弱及椎间盘退变的患者,尝试做双侧直退抬高试验导致疼痛,因为腿的重量导致骨盆旋转,导致腰椎的过伸。屈髋、屈膝不会加剧机械性的腰背痛,但是存在障碍的患者多在做此动作时主诉疼痛。在损伤涉及L3-4神经根,伸展股神经时出现疼痛。该检查时患者取俯卧位;髋关节后伸,膝关节微屈。如果患肢疼痛但健肢无疼痛,该试验结果更肯定。注意不要把股神经牵拉与Ely征相混淆。Ely征检查用于描述股直肌缩短及挛缩。股直肌跨越髋、膝关节,作用为屈髋及伸膝。膝关节完全屈曲,股直肌伸展。如果存在肌肉挛缩,按此动作被动伸展将导致髋关节屈曲。当患者俯卧并完全屈膝时可以表现该体征。此时屈髋表现为患者臀部离开床面。这便是Ely征,多在正力型患者中表现阳性。对于L4神经根受损伤的患者,这种体位可以导致严重股四头肌疼痛。第8步在这一阶段的检查,涉及在髋关节的整个活动范围。髋关节骨关节炎可能导致与L4受压相似症状:疼痛放射到下肢远端,四头肌减弱萎缩,四头肌触痛,股神经牵拉疼痛。在检查中很易混淆。检查髋关节方法:①观察患者行走; ②内旋功能;③是否存在屈曲畸形。第9步接下来,检查动脉血管搏动。体毛脱落及其他萎缩表现,如指甲萎缩,可以提示供血不足。静脉回流障碍也值得注意。患者保持仰卧,腹部触诊是否有腹部包快,触诊周围脉搏了解是否存在充盈不足。第10步患者侧卧位,检查下肢对抗阻力下的外展能力。检查时,臀肌强烈收缩使骶骨与骨盆分离。有骶髂关节劳损或任何骶髂关节疾病的患者在做此动作时会感到疼痛。骶髂关节也可以通过过度旋转来检查。健侧髋关节屈曲,大腿紧贴前胸部使腰椎紧张。上位髋关节极度伸展时,骶髂关节过度旋转,骶髂关节疾病患者此时会感到疼痛。骶髂关节损伤的患者侧卧时骨盆受压会导致疼痛。其他检查患者侧卧位时,可以顺便行肛门指检。患者俯卧时,可以在臀部及大腿部触诊坐骨神经来源的肿瘤。检查时有时还需测量下肢长度。比较双侧小腿的最长周径,比较双侧大腿在离开胫骨结节固定距离处的周径。患者坐于床边检查胸廓的扩张度。强直性脊柱炎患者胸廓的扩张度明显改变。患者下床俯于床边缘,腹下垫枕。这样的体位可以充分暴露整个脊柱走行,且患者比价舒适。从无疼痛处开始检查。集中按压脊椎会导致不舒适。患者必须区别正常按压带来的不适以及按压病变节段带来的不适感。分别触诊每个棘突,从后向前按压棘突。背部触诊可能是最难的,主要因为检查者无法通过表面触诊及骶骨触诊来评估患者。总结结束体检后阅读患者影像学资料前(好的脊柱外科医师在体检之前不会看患者的影像学资料),以下工作是否完成?1.“听懂”了患者病史,并作出初步诊断;2.体检不但证实了诊断,而且明确病理定位;3.全面把握了下肢的神经系统以及相关的骨骼肌肉、血管等病变。在上述基础上,可以通过阅片进行疾病的定性和定位,并且核查临床表现与影像学是否一致,定性或定位的不一致均可导致错误:可能源于病史和体检的不准确,或者影像学解释的错误。接下来需要疾病复习,重新采集病史和体格检查。
医师:琼斯太太,今天我能帮你做点什么?Doctor: Well, Mrs. Jones, what can I do to help you today?患者:我恳求您能救救我。Patient: I sure hope you can cure it.医师:哦,我会尽力的,您是觉得哪里疼吗?Doctor: Well, I’ll try. Have you any pain?患者:那是当然啦,否则我就不会在这里了。我可不是那种没什么事还老爱往医师那里跑的人!我知道您很忙而且如果……Patient: Of curse I have, I wouldn’t be here if I didn’t have any pain. I’m not the sort of person that keeps running to docers with nothing wrong with them. I know you’re all very busy and if…医师:您哪儿疼?Doctor: Where is the pain?患者:您没看过我的X线片吗?Patient: Haven’t you looked at my radiographs?医师:我先询问一下您的病史,然后再做一次全面的体格检查,在那之后我会看您的X线片的,请告诉我您觉得疼痛的位置。Doctor: I will look at your radiographs after I have taken your history and completed an examination. Please tell me where your pain is located.患者:就是以前一直痛的位置。Patient: The same place it’s always been.医师:哪里?Doctor: Where is that?患者:当然是我的背啦。Patient: In my back, of course.医师:是背部的哪里?腰背部吗?Doctor: Where in your back-in the low back?患者:我可不知道您管那儿叫什么,我只知道它真的非常疼。Patient: I don’t know whether you would call it low or high. All I can say is it’s sure a bad pain.医师:能把疼的地方指给我看吗?啊!我知道了。疼了多久了?Doctor: Could you point to the pain? Ah, I see. How long have you had this?患者:自从我在楼梯上跌倒以后就开始疼了。Patient: Ever since I tripped on the stairs.医师:您什么时候摔的?Doctor: When was that?患者:我的医师没把我的病史寄给您吗?他的护士答应我要寄给您的。哦,这太糟糕了,如果您对我什么都不了解,我来这里就毫无意义了。我想知道为什么……Patient: Didn’t my doctor send you my history? His nurse promised me she’d mail it to you. Oh, this is terrible. I don’t see any point in coming here if you don’t know anything about me. I wonder why …医师:您是什么时候在楼梯上跌倒的?Doctor: When did you have the accident on the stairs?患者:6月份。Patient: In June.医师:那年?Doctor: What year?患者:当然是今年。真的很遗憾我的医师没把我的病史寄给您!Patient: Why, this year of douse. I’m so sorry my doctor didn’t send you my history!医师:从那以后您觉得每天都疼痛吗?Doctor: Have you had pain every day since then?患者:有时候吧Patient: Sometimes.医师:您是说疼痛是间歇性的吗?Doctor: You mean the pain is intermittent?患者:不,我是说有时候觉得疼,有时候不疼。Patient: No. I mean sometimes I have the pain, and sometimes I don’t.医师:什么时候您觉得疼痛会加剧?Doctor: When you have the pain, what aggravates it?患者:您说的“加剧”是什么意思?Patient: How do you mean aggravates?医师:就是您觉得什么情况下疼痛会加重?Doctor: Does anything make the pain worse?患者:没有,它一直非常非常痛。Patient: No, it’s worse all the time.医师:提东西的时候疼痛会变厉害吗?Doctor: Does lifting make the pain more severe?患者:不会.Patient: No.医师:您是说您不管提起什么东西的时候背都不疼吗?Doctor: You can lift anything you want without hurting your back?患者:不,我不能提起任何东西。Patient: No, I can’t lift anything.医师:为什么?Doctor: Why?患者:因为我的背痛。Patient: Because of my back.医师:让我们来想一想您在家里都做些什么事吧。用吸尘器清洁、整理床铺、洗熨衣服,但您做这些事情的时候背痛会加剧吗?Doctor: Let’s just think of some things you do in your house. Vacuum cleaning, bed making, doing the laundry; do any of these things make it worse?患者:如果我能做这些事我就不会在这里了。我不会为了一点点小事就跑来看医师的,我比绝大多数人都能忍受疼痛。您可以去问我丈夫,我甚至痛的坐不下来。Patient: If I could do all of those things I wouldn’t be here. I don’t believe in running to the doctor with the least little thing. I can take a lot of pain, more than most people. You ask my husband. I can’t even sit down because of the pain.医师:有什么能让您的背痛缓解一点吗?Doctor: Does anything relieve your back pain?患者:没有。Patient: No.医师:那您觉得痛得厉害得时候怎么办的呢?Doctor: What do you do when the pain is bad?患者:我就躺下来。Patient: I lie down.医师:那您躺下来您觉得好一点没有?Doctor: Does lying down make the pain better?患者:没有,但我起来时还是一样疼。 Patient: No. It’s just as bad when I get up. 医师:那么当您躺着的时候,背痛是不是好一些呢?Doctor: When you are actually lying down, is the pain any easier?患者:是的,可我总不能一辈子都躺在床上。Patient: Yes, but I can’t spend my life lying down.医师:背痛影响您做什么事情了吗?Doctor: Does the pain stop you from doing anything you want to do?患者:我不能陪我丈夫打高尔夫球了。Patient: I can’t play golf with my husband.医师:那您每次打高尔夫球的时候背都会非常疼痛吗?Doctor: Do you get a lot of pain in your back every time you play golf?患者:是的。Patient: Yes.医师:您最后一次打高尔夫是什么时候?Doctor: When did you last play golf?患者:8年前.Patient: Eight years ago.医师:那您为什么没再试着打高尔夫呢?Doctor: Why haven’t you tried to play golf again?患者:因为我的医师让我别再打了。Patient: My doctor told me not to.
椎间孔镜与脊柱内窥镜类似,是一个配备有灯光的管子,它从病人身体侧方或者侧后方(可以平可以斜的方式)进入椎间孔,在安全工作三角区实施手术。在椎间盘纤维环之外做手术,在内窥镜直视下可以清楚的看到突出的髓核
一般原则:尽可能作立时,双膝高过双髋。最好双足踏在凳子的搁脚上如无搁脚凳,则双腿交叉坐,双腿不要伸直不要做伸展动作不要俯身提重物或高举过头不要弯腰取物不要向前推家具不要向上推窗户不要提重物不要同一姿势下过长时间睡觉:床垫应硬,如床垫过软应在其下方电硬板,尽量膝关节微弯、侧卧坐:驾车时,把坐位尽量调近方向盘以使髋膝关节屈曲。在坐车时则应该在腰部后方垫一枕头以便更坐得前一点。髋膝关节也要屈曲,在全天应尽量保持使膝高于髋得所谓“懒男孩姿势”由坐位到站位:由坐位到站位时应尽量不要弯腰,保持腰部直立很重要,必要时用手支撑协助站起来站立:在站立时尽量一足着地。另一足踩在物体上,如桌腿或椅座上,千万别保持前倾姿势提物:3个月内尽量不要提重量超过超过15磅重物,原则上6个月内不要提50磅以上得重物。提物时保持腰部直立,通过屈曲髋和膝关节晚餐。别在膝关节伸直状态下从地上提重物别搬离躯干1米远得15磅以上重物别举20磅以上重物过肩家务劳动:设施:所有家务设施均应用长手柄吸尘器:吸尘器手柄宁长勿短,不要一次完成整个房间得吸尘厨房:不要从高架上取物,重新布置厨房将所有得常用物品放在灶台上得第一排橱柜,如果需要站着长时间操作则应将一只脚放在9英寸高物体上。如需取超过肩膀高得物品则应踩一脚凳。需要从灶台下面取物时应屈髋屈膝,保持腰直立,不要在膝关节伸直位弯腰取物品。洗衣:在洗衣时,将用小篮子盛衣服于躯体得一侧,不要提重洗衣篮于躯体前方,如许洗衣服应多次提拿,避免一次过重提拿。楼梯:上下楼梯都要特别小心,将楼上楼下得家务分两天来完成收拾床铺:在抖床单时弯腰,容易诱发腰痛。在严重腰痛时,尽量让其他家庭成员做这一家务。如非得自己做尽量利用手和膝得活动而避免用腰。
Safeguards to Prevent Neurologic Complications after Epidural Steroid InjectionsConsensus Opinions from a Multidisciplinary Working Group and National OrganizationsABSTRACTBackground:Epidural corticosteroid injections are a common treatment for radicular pain caused by intervertebral disc herniations, spinal stenosis, and other disorders. Although rare, catastrophic neurologic injuries, including stroke and spinal cord injury, have occurred with these injections.Methods:A collaboration was undertaken between the U.S. Food and Drug Administration Safe Use Initiative, an expert multidisciplinary working group, and 13 specialty stakeholder societies. The goal of this collaboration was to review the existing evidence regarding neurologic complications associated with epidural corticosteroid injections and produce consensus procedural clinical considerations aimed at enhancing the safety of these injections. U.S. Food and Drug Administration Safe Use Initiative representa- tives helped convene and facilitate meetings without actively participating in the deliberations or decisionmaking process.Results:Seventeen clinical considerations aimed at improving safety were produced by the stakeholder societies. Specific clinical considerations for performing transforaminal and interlaminar injections, including the use of nonparticulate steroid, anatomic considerations, and use of radiographic guidance are given along with the existing scientific evidence for each clinical consideration.Conclusion:Adherence to specific recommended practices when performing epidural corticosteroid injections should lead to a reduction in the incidence of neurologic injuries.Epidural injections of corticosteroids are widely used as a treatment for radicular pain caused by disc herniation and other conditions that affect spinal nerves. These injections are associated with a number of minor complications and side effects, such as exacerbation of pain, vasovagal reaction, headache, and unintentional dural puncture,that do not involve any permanent impairment. Of great concern, however, are rare injuries to the central nervous system that occur as a result of epiduralcorticosteroid injections. These rare neurologic injuries can be catastrophic and include stroke and spinal cord injury that can result in increased pain, severe permanent disability, or death. An expert working group with facilitation from the U.S. Food and Drug Administration’s Safe Use Initiative (SUI) and representatives from leading specialty societies reviewed the existing scientific evidence and assembled consensus clinical considerations aimed at reducing the risk of severe neurologic complications.BackgroundThe evidence that neurologic injury is associated with epidural injection of steroids is limited to case reports and reports of closed malpractice claims, and this evidence will be reviewed in the paragraphs that follow. The incidence of these rare complications cannot be calculated from the limited data because there is little information on the numbers of patients undergoing the procedures. The reports show us that these cata- strophic injuries do occur, and the number of cases reported in the literature suggests that the risk is not negligible. The most commonly used routes of administration are the interlaminar route, in which the needle is placed between adjacent spinal laminae into the posterior epidural space (figs. 1 and 2), and the transforaminal route, in which the needle is placed in an intervertebral foramen (figs. 3 and 4).The cardinal neurologic complication ofcervical interlaminarinjections is direct needle injury to the spinal cord (fig. 1). Case reports of such injuries are few in the literature; additional evidence is available from reviews of closed malpracticeclaims. An earlier review of malpractice claims identified 14 cases of spinal cord injury after epidural injection of steroids, among 276 claims relating to chronic pain management between 1970 and 1999.A more recent review looked at malpractice claims between January 1, 2005 and December 31, 2008.Of 294 claims relating to chronic pain management, 64 involved cervical interventions, with 20 cases of direct spi- nal cord injury. There has also been one report of indirect spinal cord injury, ostensibly due to a transient increase in pressure within the epidural space during injection causing ischemia.Direct spinal cord injury has been reported once aftercervical transforaminalinjections,but the cardinal neu- rologic complications of this procedure are infarctions of the spinal cord, brainstem, cerebrum, or cerebellum. These have been described in several case reportsand extended by a survey of 1,340 physicians.A review of closed claims iden- tified nine instances of spinal cord infarction although the overlap with the published case reports could not be deter- mined.Circumstantial evidence, and some direct evidence,implicates a variety of possible mechanisms for these com- plications, involving either the vertebral artery or a radicular arterymore precisely termed a radiculomedullary or spinal medullary arteryan artery that reinforces the anterior or posterior spinal artery (fig. 3).For thoracic and lumbar injections, reports of injuries have been fewer although no less devastating. One case of paraplegia has been reported after a thoracic interlaminar injection of steroids (fig. 2), ostensibly due to direct injury of the spinal cord.In the four cases after lumbar injections,the mechanisms of neurologic injury are unclear, but variously may have involved swelling of an unrecognized epidural spaceoccupying lesion, injury to a radiculomedullary artery, or hematoma.More extensive is the literature reporting paraplegia afterlumbar transforaminalinjections (fig. 4).In all cases, particulate steroids were used, and the suspected mechanism of injury is either injection of steroids into a radiculomedullary artery or spasm of such an artery when perturbed by the needle.Anatomy, Laboratory, and Animal StudiesAnatomic studies have shown that the vertebral artery lies in close proximity to needles inserted into the cervical intervertebral foramen, along with other arteries, such as the ascending cervical and deep cervical arteries, which can contribute to the supply of the central nervous system (fig. 3).The diameter of those arteries is sufficient to admit the tip of a needle. In the case of radicular arteries, investigators have captured images of contrast medium injected into cervical radicular arteries in the course of transforaminal injections, showing that it is possible to cannulate these small vessels unintentionally.Laboratory studies have shown that certain steroid preparations contain particles and form aggregates. Methylprednisolone has the largest particles, triamcinolone is intermediate, and betamethasone has the smallest.These particles or their aggregates can act as emboli if injected into an artery and are of sufficient size to block small terminal arterioles supplying the brain or spinal cord. Dexamethasone does not form particles or aggregates.Animal studies have shown that injection of particulate methylprednisolone into the vertebral artery or internal carotid artery can lead to severe neurologic injuries (strokes) similar to those seen in published human case reports.Such injuries did not occur after the injection of dexamethasone.Possible Mechanisms of InjuryCollectively, these studies suggest that intraarterial injection of particulate steroids is a likely mechanism of spinal or cerebrovascular complications of cervical transforaminal injections. In this regard, it is conspicuous that in virtually all case reports of infarction after cervical transforaminal injection of steroids, particulate steroids were used. In cases where nonparticulate medication was injected, such as lidocaine or contrast (iopamidol), paralysis of the extremities or blindness was temporary.Other potential mechanisms of injury involving the ver- tebral artery include perforationand traumatic aneurysm caused by penetration with the needle.Direct contactbetween an advancing needle and a small artery could theoretically cause spasm of that vessel or create an intimal flap (i.e., dissection).Direct evidence is lacking for these alternate mechanisms for neurologic injury.Animal studies have shown that the carrier used in some steroid preparations might be directly toxic to the central nervous system, resulting in injury.A review of the animal studies showed that the concentrations of the preservatives polyethylene glycol and myristyl-gamma-picolinium chloride needed to cause morphologic or nerve conduction changes must be 2 to 10 times the concentrations found in these commercial drug preparations, thus toxicity resulting directly from the low concentrations of preservative appears to be unlikely.reduce harm resulting from one or more putative mechanisms of injury.Once clinical considerations were drafted, representatives from a number of national pain organizations were invited to review and vote on them. After an initial vote, newer studies were published that provided further guidance on key issues.The working group presented findings from these studies to the consulting organizations, which revoted on the clinical considerations based on the new information.ResultsThe representatives of the national organizations overwhelmingly approved all the clinical considerations of the working group, with board approval from their respective societies before rendering their final votes (table 1).The working group and the advising national organizations unanimously agreed that epidural injections of steroids were rarely associated with serious complications due to injuries of the central nervous system. They agreed that transforaminal injections are associated with a risk of catastrophic neurovascular complications and that particulate steroids appear to be inordinately represented in case reports of these complications.The representatives unanimously approved the clinical consideration that only nonparticulate steroids should be used intherapeutic cervicaltransforaminal injections. Although the initial use of nonparticulate steroid dexamethasone inlumbartransforaminal injections was recommended (11 of 13 votes), the representatives unanimously agreed that there might be instances where particulate steroids could be used in this set- ting, for example, consideration to use of a particulate steroid might be given if a given patient had failed to improve after an initial treatment with nonparticulate steroid.Clinical considerations involving technical aspects of the procedures included use of appropriate imageguided views, injection of contrast under realtime fluoroscopy, review of prior imaging studies, use of face mask and sterile gloves, use of extension tubing, and avoidance of heavy sedation.Three clinical considerations received votes against adop- tion. Two clinical considerations involved the measures needed to prevent intravascular injection, the representative of one organization felt that digital subtraction imaging (DSI) should be made mandatory when injecting a potentially hazardous substance transforaminally. One clinical consideration that received a negative vote involves the use of extension tubing for transforaminal injections.Three clinical considerations receive votes of “unable to reach consensus” among the officers, board of directors, or representatives of the organizations. One organization could not reach consensus on the issue of injection of contrast medium under realtime fluoroscopy and/or DSI before cervical transforaminal injections. Two organizations could not reach consensus on two clinical considerations: the initial use of nonparticulate steroid dexamethasone in lumbar transforaminal injections and the performance ofinter laminarinjections without contrast in patients with a significant history of contrast allergy or anaphylactic reaction.Image guidance for all cervical interlaminar injections was recommended to avoid penetration of the spinal cord as a result of improper insertion of the needle. Appropriate lateral or oblique views are essential to gauge depth of needle insertion (fig. 5).Relying on loss-of-resistance or on antero- posterior views alone does not protect patients from excessivedepth of needle insertion, resulting in the risk that air, saline,or contrast medium might be injected into the spinal cord.Similar precautions apply for lumbar interlaminar injections. Appropriate lateral or oblique views are required to ensure correct depth of needle insertion, lest the injection be into the subarachnoid space; contrast medium should be used to ensure injection correctly into the epidural space; and particulate steroids are acceptable because there is little risk ofintraarterial injection.The clinical consideration that needle entry for cervicalinterlaminar injections be performed at C7-T1 was based on reports that at other segmental levels the cervical epidural space is often narrow, making the dural sac and spinal cord more susceptible to penetration and injury.Based on similar rationale about the close anatomic proximity of the dura mater and spinal cord to the point of needle entry, the clinical consideration was adopted that cervical interlami- nar injections should not be undertaken unless inspection of imaging taken before the procedure demonstrates that the epidural space at the segmental level at which the injec- tion will be undertaken is sufficient in size to admit a needle safely. A recent studyfound that magnetic resonance imag- ing did not improve treatment outcomes for epidural steroid injections done in patients with a wide range of painful spi- nal disorders, yet suggested that magnetic resonance imaging may improve outcomes in the subset of patients with radicu- lopathy. This study did not examine the impact of imaging on safety, nonetheless the authors do emphasize that mag- netic resonance imaging can detect rare contraindications to epidural injection, such as spinal metastases and infection.For cervical procedures in general, irrespective of whether interlaminar or transforaminal injections were performed, analy- sis of closed claims reveals that having the patient heavily sedated during the procedure or being unresponsive at the time of injec- tion are each significantly associated with an increased risk of spinal cord injury.Furthermore, some 45% of spinal cord injuries were deemed avoidable had suitable precautions been used. There was agreement by all societies that if sedation is used, it should be light enough to allow the patient to communicate pain or other adverse sensations or events during the procedure.For cervical and lumbartransforaminalinjections, the cardinal risk is intraarterial injection. Therefore, a test dose of con- trast medium is essential to identify unintended entry into an arterybeforeany other agent is injected (figs. 6 and 7). Dexamethasone was recommended as the first-line agent for lumbartransforaminal injections on two grounds. The first was to avoid particulate steroids, which have been implicated in all cases of severe neurologic complications from this procedure. Thesecond was that studies have now shown that the effectiveness of dexamethasone is not significantly less than that of particulate steroids.Use of dexamethasone as a firstline agent forlumbar transforaminal is the most controversial clinical consideration the group is putting forward. We acknowledge that there is no direct evidence that nonparticulate steroids are superior to sham injections, and studies that show no difference between particulate and nonparticulate steroids are underpowered.Digital subtraction imaging was endorsed for transforaminal injections on the grounds that it significantly increases thedetection of vascular uptake of contrast mediumand requires less contrast medium to detect vessels (figs. 6 and 7). One study showed the sensitivity of DSI to be 60% compared with 20% with aspiration.However, the working group acknowledged that DSI was not widely available, not necessarily essential for safety, and increases radiation exposure.Physicians who do not use DSI and rely instead on real-time fluoroscopy must carefullyview the images during the injection of contrast medium, lest the fleeting appearance of a small artery escapes notice.Extension tubing was recommended so that once a needle had been placed, it would no longer be touched, and risk being dislodged when syringes for successive agents are connected. This practice guards against a needle, shown to be in a safe location by a test dose of contrast medium, being dislodged to an unsafe location when the syringe for steroids is connected. Face masks and gloves were recommended to comply with generally accepted guidelines for aseptic technique.Topics that have been discussed by some experts but were not considered by the working group include the use of a local anesthetic test dose,placement of the needle at the inferior aspect of the intervertebral foramina instead of the superior “safe triangle,”and use of specific needle tip types.The working group felt that there were not enough quality publications to discuss these logical but largely untested safeguards. The use of chlorhexidine in alcohol for antisepsiswas also omitted in view of the controversy surrounding possible neurotoxicity of the antiseptic solution.Finally, the issue of neuraxial injections in the anticoagulated patient was omitted because the American Society of Regional Anesthesia and Pain Medicine, in collaboration with some national and international organizations, is finalizing guidelines on interventional pain procedures for patients on anticoagulants (Honorio T. Benzon, M.D., Professor of Anesthesiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, written communication, December 2014).We acknowledge that catastrophic neurologic injuries can and do occur during epidural steroid injections. The actual incidence is unknown, but epidural steroid injections are common, and reports of these neurologic injuries are uncommon. The purpose of this multidisciplinary effort was to review the available evidence and assemble the best clinical considerations for reducing or eliminating these injuries. Although it is beyond the scope of this effort, it is equally important to closely examine the need for epidural injection in each patient who receives this treatment. The clinical considerations put forth herein are broadly supported by experts from many disciplines and stakeholder national medi- cal organizations. We acknowledge that many of the clinical considerations are nothing more than the logical opinions of a group of experts and many remain untested through rigorous scientific research. Many, if not most of the clinical considerations will never be tested, as the incidence of these rare complications is so low that even large studies including thousands of patients are unlikely to detect meaningful differences after the implementation of the clinical considerations. For now, our hope is that these clinical considerations will help every practitioner who performs epidural injections of steroids to become familiar with the risk of neurologic complications and to adopt the best safeguards to avoid complications and provide the safest care for their patients.
解剖学分类解剖学区域 解剖部位(局部节段)颈椎 中央型 椎间孔型胸椎 中央型腰椎 中央型 侧隐窝型 椎间孔型 椎间孔外型(远侧出口型)病理学分类先天性 软骨发育异常 先天性脊椎滑脱 脊柱侧凸 脊柱后凸特发性退变和炎症 骨性关节炎 炎性关节炎 弥漫性特发性骨骼肥厚症 脊柱侧凸 脊柱后凸 退行性脊椎滑脱代谢性疾病 Paget病 氟中毒
脊柱的轴向运动,在未受载荷的休息体位下,纤维环的纤维已经在髓核的作用下受到了牵拉,因此它处于预负荷状态。1. 当脊柱在轴向上主动伸长时,终板平面出现分离,由此增加椎间盘的厚度。同时,椎间盘的宽度缩小,纤维环的张力增加。在休息状态下呈扁平状的髓核,此时趋向于圆球状。椎间盘高度的增加减少了椎间盘的内压。通过脊柱牵引治疗椎间盘突出的原理即在于此。当脊柱被拉伸时,突出椎间盘的胶冻状物质回到其初始的髓核位置内。但是,这个结果并不一定能实现,因为纤维环中央绷紧的纤维,实际上可能会增加髓核的内压。2.脊柱受轴向压缩时,椎间盘受挤压而变宽,髓核变扁平,导致内压增加,增加的压力横向传递至纤维环的最内层。因此,一个轴向的作用力被转化为横向作用力,并拉伸了纤维环中的纤维。3.脊柱后伸时,上位椎体向后移动,椎间隙减小,驱动髓核前移。髓核随后压迫纤维环中位于前方的纤维,并使它们的张力增加,其结果使得上位椎体回复至其初始位置。4.脊柱屈曲时,上位椎体向前移动,前方椎间隙减小,髓核向后移位,压迫纤维环中位于后方的纤维,增加了其张力。这种髓核-纤维环的协同作用再一次实现了脊柱的自我稳定功能。5.脊柱侧屈时,上方椎体向屈侧倾斜,驱动髓核向反方向移位,同样实现了脊柱的自我稳定。6.脊柱轴向旋转时,与运动方向相反的斜向纤维被拉伸,与旋转方向相反的中间部位纤维则松弛。纤维环中央的纤维受张力最大,倾斜最明显。相应地,髓核受压加大,内压增加,内压增加程度与旋转度成正比。这也解释了为何在合并屈曲和旋转运动时,髓核压力会增加,进而导致纤维环撕裂,并驱动其沿着纤维环潜在的裂隙向后移动。7.当静态压力稍微倾斜地作用于椎体时,这个垂直作用力可分解为:(1)垂直于下位终板表面的分力(2)平行于下位终板表面的分力这个垂直作用力压迫上下两个椎体,切向分力使上位椎体向前移动,导致每一层纤维环中的斜行纤维逐渐被拉伸。总体来说,有一点可以明确,无论何种应力作用于椎间盘,它总是引起髓核内压增加,并拉伸纤维环中的纤维。但是,由于髓核的相对运动,被拉伸的纤维环中的纤维具有相反方向的趋势,因此,整个脊柱系统也具有恢复至其初始状态的趋势。
概述腰椎间盘突出症是在腰椎神经孔部位神经根受压和炎症反应的病理过程。病因/分型*病因包括机械负荷过重,反复劳损或创伤流行病学*最常见于年龄3-~50岁的人群,但是也可以发生于年龄更大的人群发病机制*90%的损害发生于L5~S1椎间节段,继而是L4~L5椎间节段*中央型突出会侵犯下一节段穿出的神经根,而极外侧型突出会侵犯同一节段穿出的神经根*较大的椎间盘突出比较小的突出更容易被吸收*椎间盘突出相关的疼痛与椎间盘受压和/或炎症介质的释放有关危险因素*屈曲伴旋转*遗传素质临床特征*之前腰痛的病史*腰痛,放射至腿部*直腿抬高试验阳性,并有与单神经根相关的深反射丧失、肌肉运动无力和麻木自然病程*椎间盘突出可能是自限性的,但是其可能伴随有疼痛和活动受限,这将导致废用诊断鉴别诊断*髋关节病变*骶髂关节功能障碍*椎管狭窄*脊柱骨关节病病史*轻度或重度锐痛,可沿受累神经的分布区放射至腿部*患者可能仅有放射至双侧臀部的腰痛体格检查*功能性脊柱侧弯*减痛步态*腰部关节活动度减少*直腿抬高试验阳性*椎旁肌和臀中肌压痛*L5神经根病表现为趾长伸肌无力、踝反射丧失,以及第1和第2足趾间趾蹼部位感觉减退*S1神经根病表现为小腿三头肌无力,体现为不能用脚尖步行或不能进行连续10次提踵;踝反射丧失;以及外踝或小腿后侧感觉丧失*表现可能各异,往往没有客观的反射、运动或感觉检查结果辅助检查*电生理诊断检查确诊神经受侵,在某些病例确诊慢性神经根损伤*CT可以显示椎间盘突出*磁共振成像提供椎间盘突出和神经根受累的图像潜在危险*因为无症状人群中有20%~57%在磁共振成像中发现椎间盘突出,应予以注意红色信号*严重肌肉运动无力*马尾综合征治疗一般临床处理*非甾体抗炎药(NSAIDs)*镇痛药*抗惊厥药*肌肉松弛药*口服皮质类固醇逐渐减量运动治疗*卧床休息不超过2天*应鼓励步行*逐渐牵伸练习和肌力练习*基于伸展体位的McKenzie疗法物理疗法*热疗、冷疗、超声波和经皮神经电刺激已用于缓解疼痛和肌肉痉挛症状注射*触痛点注射,用于肌筋膜痛症状*可以使用硬膜外类固醇注射用于控制症状,使患者重返无痛状态,并使康复治疗获得进展*与触痛点注射48%的成功率相比,已证实经椎间孔类固醇注射成功率为84% ——效果可以持续长达16周 ——症状也可能不再复发外科*对保守治疗失败,或显示进行性神经系统受损及马尾综合征的患者,进行椎板切除术或显微椎间盘摘除术会诊*物理医学与康复科*神经外科或脊柱外科治疗并发症*持久的神经系统缺陷*慢性疼痛*硬膜外类固醇注射相关并发症预后*80%的患者保守治疗有效*已发现在年轻患者手术摘除椎间盘是成功的,85%的病例腿痛减少,75%腰痛减少*6%的患者出现复发性椎间盘突出症注意*尚未发现磁共振成像能够对椎间盘突出相关的将来出现的症状有预测作用。