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【临床医学】颈腰椎退行性变.ppt课件

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腰椎退行性变 颈腰椎退行性 ppt课件】颈部 颈腰椎退行性变 腰椎退行性改变
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颈腰椎退行性变 •颈 肩 痛 •腰 腿 痛 2/57 2 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 颈 椎 病 • 颈椎间盘退变及其继发性改变,刺激或 压迫相邻脊髓、神经、血管等组织,引 起症状和体征,称为颈椎病。 • The cervical spondylosis • 好发部位:颈5­6、颈4­5、颈6­7 3/57 3 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 病因及病理 • 颈椎由两个相邻椎骨、椎间盘、关节突关节和钩椎关 节(或钩突)构成。颈椎最小,运动度最大,因而易发 生退变。 • 颈椎间盘退行性变。早期为椎间盘髓核中蛋白多糖减 少,使椎间盘水分丢失,纤维环的胶原纤维变性,出 现裂隙,外力诱发髓核从此裂隙向后方突出。椎体反 应性骨组织修复,使骨赘形成。骨赘以钩椎关节为多 ,其次为椎体后缘及前缘。颈椎间盘退变进展到—定 程度,可影响脊髓、神经和椎动脉等,产生相应的症 状。 • 颈椎外伤。 • 先天性颈椎管狭窄。 4/57 4 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 临床表现和诊断:有四型 • 神经根型 • 发病率最高。是椎间盘向后外侧突山,或因钩 椎关书或关节突关节的增生、肥大,压迫或刺 激颈神经根所致。 • 主要临床表现为上肢放射痛和感觉障碍。 • 上肢放射痛:颈痛向上臂、前臂和手指放射, 当仰头、咳嗽、喷嚏时,可使疼痛加重。 • 感觉障碍:有手指麻木、过敏和异样感。 5/57 5 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 神经根型 • 臂丛牵拉试验(Eaton试验)阳性:术者站病人身后,一 下托患者头部,另一手握患侧前臂,将其外展90°, 两手对抗牵拉,引出患肢放射痛和麻木者。 • 压头试验(Spurling试验)阳性:病人端坐,头后仰偏患 侧,术者手掌在其头顶加压,诱发颈痛及上肢放射痛 。 • X线:颈椎生理曲度消失,椎间隙狭窄,椎体前后缘骨 赘增生,钩椎关节增生,椎间孔狭窄等。 6/57 6 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 脊髓型 • 中央型髓核突出、推体后缘骨赘、骨化的后纵韧带、 肥厚的黄韧带等压迫颈髓。 • 临床以侧束、椎体束受损明显。表现: • 早期单侧或双侧下肢发麻(踩棉花感),以后四肢肌无 力,行走困难和大小便功能障碍。 • 自下而上的上运动神经原性瘫痪。 • X线:大体同神经根型。 • 脊髓造影:显示完全或部分梗阻。 • 脑脊液:蛋白增加,动力试验也表现有梗阻。 7/57 7 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 椎动脉型 • 椎间隙狭窄、钩椎关节骨赘增生或转头 活动压迫或刺激横突孔中的椎动脉,或 因颈交感神经兴奋,反射性引起椎动脉 痉挛而致椎动脉供血不足。 • 表现:眩晕、头痛、视觉障碍、猝倒。 8/57 8 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 交感神经型 • 反射性交感神经症状: • 头部:有头痛、头晕、偏头痛、颈后痛等。 • 眼部:有视物模糊,甚至失明,彩视。双例瞳孔 或脸裂大小不等。 • 心脏:如心跳加速,心动徐缓,心前区疼痛等。 • 其他:如耳鸣、耳聋,一侧面部无汗或多汗,可 有肢体发凉,肢体、头面、颈部发麻或疼痛等 。 • 有颈神经根刺激征。 9/57 9 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 治疗原则:减压、止痛、稳定颈椎 • 非手术疗法 • 颌枕吊带牵引:适用于神经根型,椎 动脉型及交感型颈椎间盘突出症。 作用为制动、解除颈肌痉挛和缓解 推间盘内压力。 • 理疗:对加速消除炎性水肿和改善神 经的血供有利。 • 药物:神经营养药物、非甾体抗炎药 物、舒张血管药物、肌松剂 、镇静 止痛剂、醋酸强地松龙痛点封闭。 • 围领和颈托使颈椎处于制动状态。 • 推拿按摩:脊髓型除外。 10/57 10 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 手术治疗 • 手术指征: • ①脊髓型颈椎间盘突出症。 • ②椎动脉型对非手术疗法无效者。 • ②神经根型反复发作者。 • 手术有前路和后路两种。 • 目的是切除退变和突出的椎间盘,以及椎体后 缘的骨赘,以解除对脊髓和神经根的压迫,同 时行椎间植骨融合术。 11/57 11 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 肩关节周围炎 • Adhesive capsulitis of the shoulder joint • 又称冻结肩、粘连性肩关节囊炎,俗称凝肩, 简称肩周炎。以长期肩部疼痛、关节功能障碍 和肌肉萎缩为特征的肩关节囊、滑囊、肌腱、 肩周肌肉的慢性损伤性炎症。50岁女性。 • 病因:外伤、慢性劳损、感受风寒、肩部长期固 定或退行性变。 • 病理:肩周组织充血、水肿、渗出、粘连等。 12/57 12 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 临床表现 • 50岁左右的中老年人多见; • 起病慢、病程长、患肩隐痛或刺痛,常向上臂 及前臂放射; • 患肩常处于下垂略内旋位,肩的活动受限,抬 肩及摸背困难; • 患肩肌肉萎缩,在喙突、肩峰下、大小圆肌和 肩胛骨内侧缘有明显的压痛点; • X线见肩部骨质疏松。 13/57 13 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 治疗 • 坚持肩关节的功能锻炼是治疗本病的关键。 锻炼方式包抱:前后、左右摆动上臂、爬墙摸 高,患肩外展及环转运动,内旋屈肘摸背等主 动活动,每日3汰,每次不少于30分钟。 • 最好能配合按摩,在压痛点处运用分筋、理筋 、弹筋拔络等手法,并加用电按摩,每日或隔 日一次。 • 加服消炎痛、强筋松或在压痛点用泼尼松龙封 闭,可缩短疗程。 14/57 14 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 腰 腿 痛 • 腰腿痛(lumbag and sciatica)不是一种病 ,而是一组症候群,是指下腰、腰骶、 骶髂、臀部等处的疼痛,有时伴有一侧 或两侧下肢痛和马尾神经症状。 • 第5腰椎和骶椎构成腰骶关节,负重量大 ,是活动度大的腰椎与固定的骶椎相交 处,承受的压力较大,易患劳损。 15/57 15 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 椎间盘 • 椎间盘由髓核、纤维环和软骨板三部分构成。 • 软骨板在椎体和髓核之间彼此相联系。纤维环由胶原 纤维、弹力纤维和纤维软骨形成,呈层状排列,各层 纤维的方向彼此交错牢固地附着在椎体上,这样可以 限制髓核在负重压力下产生的移位,也可限制椎体的 过度扭转和滑移活动。髓核是粘液样胶体物质,为纤 维和软骨板所包绕,其中含有大量水份和粘多糖复合 物,有极强的吸水性能,使椎间盘具有一定的弹性, 其主要功能为传递压力和吸收震荡。 • 后关节突关节即椎间小关节,是滑膜关节,在腰部关 节面呈矢状排列。 16/57 16 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 脊椎体间横断面 17/57 17 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 脊柱韧带 • 前纵韧带上自枕骨,下至骶骨; • 后纵韧带上起枢椎,下达骶骨,较前纵韧带薄弱; • 黄韧带位于相邻二椎板之间,构成椎管后壁的一部分 ; • 棘上韧带、棘间韧带。 • 韧带的共同作用是联系和稳定脊椎。 18/57 18 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 脊柱肌肉 • 三组肌肉维持脊柱的稳定并协调活动。 • 背侧组:背阔肌、骶棘肌等,可使脊柱背伸、侧屈,并 保持脊柱的直立位。 • 前侧组:腹内、外斜肌和腹直肌,是脊柱的屈肌。 • 外侧组:包括腰大肌和腰方肌,腰大肌和骼肌是屈髋的 主要肌肉,当下肢固定时,其收缩可使脊柱前屈。腰 方肌的作用为使脊柱侧屈。脊柱的旋转活动则是各组 肌肉协调作用的结果。 19/57 19 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 病因 • 损伤性:脊椎骨折与脱位、韧带劳损、肌肉劳损、黄 韧带增厚、后关节突紊乱综合征。 • 退行性:腰椎间盘突出症、腰椎管狭窄症。 • 结构性缺陷:隐性脊椎裂、第5腰椎骶化。 • 功能性缺陷:脊柱侧凸、腰前凸增加、驼背。 • 炎症:脊柱结核,脊柱化脓性骨髓炎。 • 肿瘤:转移癌,原发性的骨巨细胞瘤和脊索瘤。 • 其它:代谢性、内分泌失调、血管及精神因素。 • 以损伤和退行性变所致腰痛最为常见原因;腰椎间盘 突出症、腰椎管狭窄症为常见疾病。 20/57 20 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 检查及鉴别诊断 • 年龄:青壮年易患损伤性腰痛;对老年人应想 到转移肿瘤;儿童则以脊柱结核及脊柱畸形为 多见。 • 创伤史:可有明确的扭伤、摔伤史,也可无创 伤史。 • 疼痛部位:①局部痛:常反映病变所在。如一侧 骶髂劳损,疼痛多在骶髂关节处。②转移痛: 骶髂关节感觉由骶1~2神经根支配,疼痛可转 移至臀部和股后部。③肌肉痉挛痛:肌肉保护 性痉挛及牵拉骨膜可引起疼痛。急性腰痛常有 骶棘肌痉挛。 21/57 21 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. • 疼痛性质:是锐痛还是钝痛,与受伤有无关系 ;持续性疼痛多见于炎症、肿瘤等,间歇性 或放射性痛多见于椎间盘突出症。 • 疼痛与活动、劳累、姿势、体位、气候与时 间(日、夜)等关系:劳累引起疼痛,卧床后即 好转;类风湿性关节炎患者常诉说阴雨寒冷 时节症状加重;癌症疼痛夜间加剧;椎管狭 窄多伴有间歇性跛行。 • 过去治疗情况:应查明曾作何治疗,效果如何 。 • 其它情况:有无胃肠系、泌尿系和妇科疾患等 。 22/57 22 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 一般检查 • 步态:观察患者步态,双下肢是否对称,有无跛行。 • 立位检查 – 观察脊柱有无后凸、前凸、侧弯畸形,背肌是否 痉挛。后凸分两种:弧形后凸亦称圆背,见于椎体 骨骺炎、姿势性后凸、类风湿性脊柱炎等;角状 后凸见于脊柱结核、椎体压缩性骨折等(图)。 – 自主运动范围:嘱患者作腰部前屈、后伸、侧弯及 左右旋转活动。腰椎间盘突出时,常出现一两个 方向的运动受限;而脊柱结核时,脊柱各方向的 活动均受限制。 – 拾物试验:腰椎有病变时,拾物须屈曲双膝及髋关 节而腰部挺直。脊柱结核患者多为阳性。 23/57 23 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 仰卧位检查 • 腹部触诊:有无肾下垂、腹膜后肿物、腰大肌寒性脓肿 。 • 直腿抬高试验:检查者一手握病人足跖部,使踝关节背 屈,另手保持膝关节于伸直位,将下肢抬高,一般能 举高70度左右。注意两侧对比。如一侧明显低于对侧 ,即为阳性(图)。腰椎间盘突出症患者常有患侧直腿抬 高试验阳性,疼痛可沿大腿后侧放射到足趾。 • 骨盆摇摆试验:强屈髋膝二关节,使腰骶关节屈曲,作 左右摇摆活动。摇摆时如肌肉有阻力和腰骶关节处疼 痛,说明病变在腰骶部(图)。 直腿抬 高试验 骨盆摇 摆试验 24/57 24 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. • “4”字试验:患侧髋膝关节屈曲并外旋 ,将足外踝部置于另侧伸直位的膝部 ,状如“4”字。检查者一手按住健侧 髂前上棘处,另一手将屈曲的膝部下 压。骶髂关节疾患时有疼痛(图)。 • 唧筒柄试验:检查者一手按患侧肩部, 稳定上身,另手扶患肢膝部,使屈肢 屈髋屈膝,然后向下按压膝部,强使 髋关节屈曲内收。骶髂关节病变时该 部位出现疼痛(图)。 • 周围神经检查:检查下肢和会阴部的皮 肤感觉、肌力、膝腱、跟腱反射和病 理反射等。 • “4”字试验 唧筒柄试验 25/57 25 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 俯卧位检查 • 去枕头,头偏一侧,两上肢伸直平放于身体两旁。 • 压痛点:先以手掌,自颈椎至骶椎依次按压,在有压 痛的部位,再以拇指仔细检查,确定主要压痛点的位 置。同时注意疼痛的程度和范围,是否放射及放射的 部位。腰椎间盘突出症患者,压痛点多在棘旁约2cm 处,且常伴有向下肢后外侧的放射痛,可直达足跟或 足趾。常见腰痛压痛点如图所示。 26/57 26 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. • 股神经牵拉试验:一侧下肢伸直,使患侧下肢向 后过度伸展。在腰3~4椎间盘突出时,沿股神 经有放射性痛,是为阳性(图)。应注意除外骶髂 关节、股四头肌及腰大肌脓肿等病变。 • 普鲁卡因试验:痛点注射10~20毫升,若系肌肉 、韧带劳损,疼痛暂时消失,而骨髂病变或椎 间盘突出症引起的腰痛则无效。 27/57 27 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 影象检查 • X线平片:一般包括前后位和侧位,据需要拍照左、右 斜位片。对疑有骨性病变的患者,如骨折、结核、肿 瘤、椎弓峡部不连与脊柱滑脱等,则应进行平片检查 。 • 体层摄影:又称断层摄影。腰椎的矢状面断层片可较清 楚地显示椎管的矢状径,有助于椎管狭窄症的诊断。 • 脊髓造影:须严格掌握适应证。一般用于诊断椎管内肿 瘤、高位椎间盘突出和严重的椎管狭窄症等。 • CT:可发现结核、肿瘤的早期病灶,并有助于腰椎管 狭窄症和腰椎间盘突出症的诊断。 • 磁共振(MRI):是利用强磁场的作用,使体内氢原子核 发生旋转和定向排列,取消磁场后,这些氢原子回复 到原来位置。 28/57 28 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 腰椎间盘突出症 herniation of lumbar intervertebral disk • 病因及病理 • 椎间盘的退行性变、外伤、遗传、妊娠等,造成纤维 环软弱或破裂,髓核即由该处突出。 • 髓核多从一侧(少数两侧) 突入椎管,压迫神经根;也 可由中央向后突出,压迫马尾神经,造成大小便障碍 。 • 多发生于腰4­5与腰5­骶1间隙。 腰椎间盘突出症是指 腰椎间盘变性、纤维 环破裂,髓核突出,刺 激和压迫马尾神经根 所引起的一种综合征 。 29/57 29 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 分四型 • 膨隆型:纤维环部分破裂、隆起,但表层完整 。 • 突出型:纤维环完全破裂,髓核突向椎管,突 出的髓核有薄层纤维环膜覆盖。 • 脱垂游离型:破裂突出的椎间盘组织游离于椎 管内。 • Schmorl结节及经骨突出型:髓核经上、下软骨 板裂隙突入椎体松质骨内,或髓核沿椎体之间 的血管通道向前纵韧带方向突出,形成椎体前 缘的游离骨块。 30/57 30 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 临床表现及诊断 • 腰痛和一侧下肢放射痛是主要症状。 • 坐骨神经痛:放射痛沿坐骨神经传导,直达小 腿外侧、足背或足趾。 • 一切使脑脊液压力增高的动作,如咳嗽、喷嚏 和排便等,都可加重腰痛和放射痛。 • 活动时疼痛加剧,休息后减轻。 • 体位:多数患者采用侧卧位,并屈曲患肢。 • 马尾神经受压时表现为双侧大小腿、足跟后侧 及会阴部感觉迟钝,大小便障碍。 31/57 31 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 脊柱侧弯畸形 • 侧弯的方向取决于突出髓核与神经根的关系。 左:髓核突出位于神经根内前 方,脊柱向患侧弯,如向健 侧的弯则疼痛加剧 右:髓核突出位于神经根外前 方,脊柱向健侧弯,如向患 侧的弯则疼痛加剧 32/57 32 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. • 脊柱活动受限 髓核突出,压迫神经根,使腰 肌保护性紧张,可发生于单侧或双侧。由于腰 肌紧张,腰椎生理性前凸消失。脊柱前屈后伸 活动受限制,前屈受限明显。侧弯受限往往只 有一侧,据此可与腰椎结核或肿瘤鉴别。 • 腰部压痛伴放射痛 患侧棘突间、棘突旁有局 限的压痛点,并向下肢放射,对诊断有意义。 • 直腿抬高试验阳性 由于个人体质的差异,无 统一的度数标准,应注意两侧对比。患侧直腿 抬高受限,并感到向小腿或足的放射痛即为阳 性。有时抬高健肢而患侧腿发生麻痛,系因患 侧神经受牵拉引起,此点对诊断有较大价值。 33/57 33 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and operators to safeguard the legitimate rights and interests, to ensure that our City's tourism sustainable, healthy and coordinated Development. 神经系统检查 • 腰3­4突出(腰4神经根受压)时,可有膝反射减 退或消失,小腿内侧感觉减退。 • 腰4­5突出(腰5神经根受压)时,小腿前外侧足 背内侧感觉减退,第1趾肌力常有减退。 • 腰5骶1间突出(骶1神经根受压)时,小腿外后及 足外侧感觉减退,第3、4、5趾肌力减退,跟 腱反射减退或消失。神经压迫症状严重者患肢 可有肌肉萎缩。 34/57 34 Through this publicity campaign, further improve the sense of business integrity of tourism enterprises to help tourism consumers and oper
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