外科学八年制腰椎病

Lumbar Degenerative Diseases Lumbar Degenerative Diseases Epidemiology of Low Back PainEpidemiology of Low Back Pain 25.9 million Americans complain of low back pain a cumulative expense of about $50 billion per year the most common cause of job-related disability the second most common neurologic ailment Five lumbar vertebrae five intervening intervertebral disks (IVDs). vertebra = anterior vertebral body + posterior neural arch neural arch = pedicles+ facet joints + transverse processes + laminae + spinous process 3 A good understanding of the normal anatomy of the spine is of utmost importance for the appreciation of spinal disorders. Physiological Anatomy of Lumbar SpinePhysiological Anatomy of Lumbar Spine 4 1.Cartilaginous end plates for the purpose of nutrition and anchoring 2.Anulus fibrosis made of concentric sheets of collagen for the purpose of containing the pressurized nucleus 3.Nucleus pulposus made of a soft, semigelatinous collagen that can absorb axial compressive loads Anatomy of the disc Physiological Anatomy of Lumbar SpinePhysiological Anatomy of Lumbar Spine 5 Cauda Equina L1 level Physiological Anatomy of Lumbar SpinePhysiological Anatomy of Lumbar Spine Physiological Anatomy of Lumbar SpinePhysiological Anatomy of Lumbar Spine 6 Nerve root contains both motor and sensory components Cross the intervening intervertebral disc space, traveles in the lateral recess, passes underneath the pedicle and through the intervertebral foramen. Biochemical change in the Biochemical change in the degenerative discdegenerative disc 7 Nucleus loses its ability to bear compressive loads Load transfer, shifts to the anulus, that is poorly suited to withstand compression, causes fatigue failure, fissuring, and possibly rupture A herniation of a fragment of the nucleus pulposus follow Load transfer is concentrated at the periphery of the vertebral end plates Lead to osteophyte formation: spondylosis Subsequently, as the degenerating disk becomes less able to resist rotations and shear, Additional stresses are transferred to the posterior elements: facet arthrosis hypertrophy, thickening and buckling of the ligamentum flavum 8 Biochemical change in the Biochemical change in the degenerative discdegenerative disc osteophyte Common DiseasesCommon Diseases Lumbar Disc Herniation Lumbar Canal Stenosis Lumbar Spondylolisthesis 9 A: Lumbar Radiculopathy:Lumbar Radiculopathy: Lumbar Disc Herniation (LDH)Lumbar Disc Herniation (LDH) LDH is a syndrome affecting the nerve root and cauda equina due to degeneration, in which a tear in the outer annulus fibrosus of an intervertebral disc allows nucleus pulposus to bulge out beyond the damaged outer rings. LDH is a common cause of low back pain. It was first described in 1932 by Barr and Mixter. 10 Disk herniations can occur in any direction but most commonly follow a posterolateral direction at the site where the posterior longitudinal ligament is thinnest. Disk material extruded in this location can compress a nerve root, leading to low back pain and radicular symptoms in a specific dermatomal distribution. 11 IntroductionIntroduction Clinical Findings in Common LDH 12 Disc (Incidence%) Root Pain Distribution Muscle Involved Sensory Deficits Reflex Loss L3-L4 (3-10) L4 Anterior thigh Quadriceps femoris Medial malleolus and medial foot Knee jerk L4-L5 (40-45) L5 Posterolateral thigh and leg Tibialis anterior Extensor hallucis longus Large toe web and dorsum of foot None L5-S1 (45-50) S1 Posterolateral thigh and leg down to ankle Gastrocnemius Lateral malleolus Lateral foot Ankle jerk The back pain is usually a minor component. Large, more central disk herniations may compress the cauda equina with resultant cauda equina syndrome, consisting of saddle anesthesia, urinary retention with possible overflow incontinence, and significant motor weakness. In this case, it is advisable to decompress the thecal sac within 24 hours of onset of symptoms. 13 IntroductionIntroduction Etiology of Disc DegenerationEtiology of Disc Degeneration Trauma rotation, compression Occupation driver, weight lifter, heavy labor worker Gestation Genetic Susceptibility family susceptibility, human species Lumbosacral Congenital Malformation Sacralization, Lumbarization, asymmetric zygapophyseal joint 14 SymptomsSymptoms 1.Sciatica and Low back pain pain along the area innervated by sciatic nerve which is composed of L5S1 nerve root, often induced by disc herniation in L45 L5S1. The pain located in posterior and lateral side of thigh, and radiated into calf and foot. 2.Inferior belly pain (L1-2) and anterior lateral thigh pain (L2-4) femoral neuralgia 3.Paraesthesia 4.Intermittent claudicatoin lumbar canal stenosis 5.Cauda equina syndrome central LDH 6. Myoparalysis 16 L1L1- -L2 LDHL2 LDH 17 Inferior belly pain Physical SignsPhysical Signs 18 1.Postural Scoliosis 2.Limitation of lumbar movement 3.Tendern