脊柱退行性疾病 英文ppt课件.ppt

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1、脊柱退行性疾病Spinal degenerative diseases,长治医学院附属和平医院骨科 裴卫卫,What is called degeneration?,We also found other phenomenon .Some People are only 40 years old, but looks like 60 years of age or the opposite 。,影响因素 influence factors过度负荷 overload不良体位 poor posture 慢性劳损 chronic strain外伤 injury 慢性炎症 chronic inflam

2、mation先天因素 congenital factors,Anatomy of the Spine,Sagittal View,AP - view,Lordosis,Kyphosis,Lordosis,Development of Disc and Spinal Curvature,Newborn,25 years,4 years,- no significant curvature- Disc Height = Vertebral Body Height,- Double-S curvature- Disc Height = 40% of VBH,- biconcave - biconve

3、x shape of intervertebral space- Disc Height = 25% of VBH,Intervertebral disc,Anulus fibrosus,Nucleus Pulposus,Newborn,65 years,No vascularisation of disc,7 years,70 years,30 years,Water content in the nucleus pulposus decreased with age,Facet JointsCervical vertebrae sloping Thoracic vertebrae coro

4、nal Lumbar vertebrae sagittal,Ligaments,Anterior longitudinal ligament,Posterior longitudinal ligament,Blood Supply,Load Transfer,The FUNCTIONAL UNIT of the spineComprised of:Two adjacent vertebraeIntervertebral discConnecting ligamentsTwo facet joints and capsules,Intradiscal Pressure,Biomechanics,

5、1,8,3,1,2,4,6,2,7,5,0,11,0,11,0,23,0,17,0,颈椎退行性疾病cervical degenerative disease,包括：一、颈椎病二、颈椎管狭窄症三、颈椎间盘突出症四、颈椎后纵韧带骨化,including一、Cervical spondylosis二、Cervical canal stenosis三、Cervical disc herniation四、Ossification of cervical posterior longitudinal ligament,一、颈 椎 病 Cervical spondylosis,发病率随着年龄的增加而显著提高

6、 4050岁的发病率为20， 60岁以上者达50， 70岁以上则更高。目前发病年龄趋于年轻化,定义 Concept,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，并引起相应的症状或体征者，称为颈椎病。Cervical spondylosis is a disorder in which there is abnormal wear on the cartilage and bones of the neck.,分 型 Classification,脊髓型 Cervical Spondylotic Myelopathy CSM 神经根型Cervical Spondylotic

7、 Radiculopathy CSR 交感神经型Sympathetic Cervical Spondylosis SCS椎动脉型Cervical Spondylosis of Vertebral artery type 其它（食道压迫型、颈型、混合型）,CSM,以颈脊髓受损为主要临床表现的颈椎病。主要表现为走路不稳、四肢麻木、大小便困难等。Main clinical manifestations:Cervicalspinal cord injury，such as unsteady walk, numbness of limbs, micturitionand defecation diffi

8、culties,CSR,1.多见于30岁以上者More common in people over 30 years old2.起病缓慢、病程长，反复发作。Slow onset, long course of disease, recurrent seizures.3.颈肩部疼痛，下颈椎病变可向前臂放射。 Neck and shoulder pain, some can radiate to the arm,SCS,主要表现为头晕、眼花、耳鸣、手麻、心动过速、心前区疼痛等一系列症状。X线片有失稳或退变，椎动脉造影阴性。 Main clinical manifestations: dizzine

9、ss, tinnitus, numbness of hand, heartbeat tachycardia, precordial pain. X-ray: degeneration of cervical vertebra. Vertebral artery angiography negative.,Cervical Spondylosis of Vertebral artery type,以椎基底动脉供血不足为主要临床表现的颈椎病。主要表现为头痛，头晕，黑朦等症状，与颈部旋转有关。 Main clinical manifestations: vertebral basilar arter

10、y insufficiency，such as headache, dizziness and amaurosis, relate to the neck rotation.,食管型颈椎病Esophagus type cervical spondylosis,A special type of CS Throat discomfort, foreign body sensation is an early symptom Late manifestations is dysphagia Often accompanied by symptoms of other cervical spondy

11、losis,颈型Neck type cervical spondylosis,以颈部酸、痛、麻、僵为主要临床表现或颈项部压迫感的颈椎病，症状集中在颈部，转动不灵活。Main clinical manifestations: acid distention、pain、numbness and stiff in the neck.,Mixed type of cervical spondylosis,具备以上两种或两种以上的表现者，即可确诊。 With two or more than two kinds of performance above.,Diagnosis,Must be have t

12、hree conditions: Cervical degenerative changes Relevant clinical manifestations Relevant clinical manifestations are consistent with imaging findings,Treatment,IndicatioMild symptoms Can not tolerate operation,MethodsCorrect bad posture TractionMassagecautiously usePhysiotherapyMedications,expectant

13、 treatment,surgical therapy,IndicatioFormal expectant treatment for 36 months is invalid Symptom of CSM aggravate progressively or suddenly or MRI showed that the cervical spinal cord signal changes Symptom of CSR impact quality of life,手术方式,手术目的 surgical purpose 彻底减压 Complete decompression 重建脊柱稳定性

14、Reconstruction of spinal stability,开放式：Open operation 前路直接减压Anterior cervical operation Direct decompression 后路间接减压Posterior cervical operation Indirect decompression,微创式：Microinvasive operation,Case 1 颈前路椎间盘摘除、取自体髂骨椎间植骨融合、内固定术,Case 2 颈前路椎间盘摘除、椎间融合器植骨融合、内固定术,Case 3 颈前路椎体次全切除、椎间钛笼植骨融合、内固定术,Case 4 颈后路

15、单开门椎管扩大成形术,Case 5 颈后路单开门椎管扩大成形后路支撑钢板内固定术,Case 5颈椎人工间盘置换术,颈椎管狭窄症 Cervical canal stenosis,Etiology and pathology Congenital developmental CCSDegenerative or iatrogenic CCS CCS can be single or multi segmental stenosis, common in the C4,5 and C6,7 segments,Clinical manifestation,Symptoms are similar to

16、 the symptoms of CSX-rayCTMRI,A:椎管失状径A13mm 正常A13mm 相对狭窄A10MM 绝对狭窄,B:椎体中失状径 A:B0.75 狭窄,椎管正中失状径 13mm 正常13mm 相对狭窄10mm 绝对狭窄,Cervical intervertebral disc degeneration,External force cause rupture of annulus fibrosus and longitudinal ligament,Nucleus pulposus protrude into spinal canal,The pain of nerve r

17、oot and signs of spinal compression.,颈椎间盘突出症Cervical disc herniation,Relationship between CDH and CS,颈椎间盘突出症是颈椎病发病过程的病理变化之一 CDH is one of the pathological changes in the pathogenesis of CS 颈椎间盘突出症的致压物只能是突出的髓核，而颈椎病可以是髓核以外的其他组织 Induced pressure can only be protruding nucleus pulposus，however it can be

18、 other tissues except the nucleus pulposus,男性，40岁，煤矿工人，既往无四肢麻木、无力病史，摔伤后出现颈部不适伴双上肢放射性麻木、行走不稳1个月，经颈围制动、脱水、激素及神经营养治疗效果不佳。,颈椎后纵韧带骨化症 Ossification of cervical posterior longitudinal ligament,颈椎后纵韧带异常增殖并骨化，压迫脊髓和神经根，产生感觉、运动功能障碍。Cervical posterior longitudinal ligament abnormally proliferate and ossify，whic

19、h can constrict the spinal cord and nerve root ，and then lead to paralysis,Etiology,The exact mechanism is not clear，but there are several hypothesis Theory of heredityMechanical damage theory Disturbance of carbohydrate metabolism theory The whole body bone hypertrophy theory,Epidemiology,The incid

20、ence of OPLL in East Asia is higherJapan 1.94.3%(over 30 years old.）Korea 3.6%Taiwan 2.8%China 1.61.8%,Clinical characteristics,A chronic,progressive,spinal cord or nerve root compression symptoms Its symptoms are very similar to CCS orCSX-ray,CT andMRI can improve the diagnosis,Classification - Sag

21、ittal Section,Topical type,Segmental type,Successive tppe,Mixed type,Classification - Coronal section,图 点状骨化图 蕈伞状骨化图 山丘状骨化图 偏一侧骨化,测量椎管狭窄率,Imaging evaluation of OPLL,减压不彻底神经功能障碍无改善或加重,Imaging evaluation of OPLL,Very difficultHigh-riskMore complications Poor prognosis,Treatment,Operation is the only e

22、ffective means,Challenge,How to select the reasonable operation?,successive type and Mixed typeossific range 3 vertebral segmentsCervical canal stenosis 50%,Posterior cervical operation /Indirect decompression,LaminectomyLaminoplastyLaminectomy+internal fixation,Topical type and Segmental typeossifi

23、c range 3 vertebral segmentsCervical canal stenosis 50%,Anterior cervical operation /Direct decompression,Discectomy Corpectomy decompression,腰椎退行性疾病lumbar degenerative disease,包括：一、腰椎间盘突出症二、腰椎管狭窄症三、腰椎滑脱症,including一、Lumbar Disc Herniation二、lumbar spinal stenosis三、lumbar spondylolisthesis,腰椎间盘突出症 Lum

24、bar Disc Herniation LDH,Epidemiology,Symptomatic LDH are seen in all age groups but have their peak in patients aged between 35 and 45 years.Except smoking ,occupational factors include sedentary work and driver are the main reasons for LDH,ClassificationDegeneration/Bulging,Mild,severe,Central,Post

25、erlateral,Lateral,ClassificationProtrusion,ClassificationExtrusion,ClassificationSequestration,ClassificationSchmorls nods,Symptoms,How can we recognize a herniated disk?,Lower back painSciaticaPain, weakness, numbness or tingling in the legs, buttocks and feet Problems with bowel, bladder or erecti

26、le function, in severe cases,General Signs,Changes of lumbar curvature Compensatory scoliosis Straight leg-raising (SLR) testSLR strengthen testFemoral nerve stretching test,Neurologic signs,SensibilityMuscle forceDeep tendon reflex Muscle atrophy,We can initially locate the intervertebral disc,Prot

27、rusion of the L3/4 disc,Protrusion of the L4/5 disc,Protrusion of the L5/S1 disc,Imaging examination,X-rayCTMRILumbar myelography,Treatment,Expectant treatmentSurgical treatment,Expectant treatment,YoungFirst attackShort courseSymptoms can be relieved by rest No spinal stenosis No spondylolisthesis,

28、Surgical treatment,The strict expectant treatment is invalid Cauda equina syndrome,Classical -discectomy,Lumbar arthroscopic discectomy,PLDPLDD,Lumbar tunnel MED discectomy,MLD,Anterior lumbar discectomy, interbody fusion,Lumber artificial disc replacement,腰椎管狭窄症lumbar spinal stenosis,LSS ，caused by

29、 various reasons ，can constrict spinal cord and nerve root and lead to corresponding nerve dysfunction，One of the common diseases of lower back and leg pain,Etiology and pathology Congenital developmental LSSDegenerative LSSTraumatic or iatrogenic LSSBe single or multi segmental stenosis Common in t

30、he L4/5,Epidemiology,More common in elderly patients, more than 50 years old It is common in L4/5，secondary in L5/S1,Clinical manifestation,Chronic low back painMild pain or discomfortSlowly aggravationAlleviation after the activity Cough without aggravating,Clinical manifestation,Neurogenic Intermi

31、ttent Claudication NICLCompressionblood circulatory disorderInflammatory stimulus,Symptoms are closely related with lumbar posture Alleviation in flexion Aggravation in extensionUphill is easier than downhillCan ride ，hard to walk,Clinical manifestation,Lower limb neurological symptoms,Clinical mani

32、festation,Imaging examination X-ray,Transverse diameter 18mmSagittal diameter 13mm,Valuable method Display the location and degree of the disease,Imaging examination Lumbar myelography,Coincidence rate is highTransverse diameter18mmSagittal diameter13mmNerve root canal 3mm,Imaging examination CT,Hig

33、h diagnostic coincidence rateDifferential diagnosis significance,Imaging examination MRI,Treatment,ExpectantSurgicalDecompressionFusionX-Stop,腰椎滑脱The lumbar spondylolithesis,Spondylo 椎体Lithesis 滑移,History,In 1782, the Belgian Herbinlaux,who is an first described a phenomenon of dystocia caused by L5

34、 spondylolithesisIn 1854, the German doctor Kilian first proposed the spondylolisthesis and give the descriptionIn the 1950s, domestic gradually began to report spondylolisthesis.,Epidemiology,The incidence rate is about 5%Varing from the age, region and race,occupation,gender Morbidity rate increas

35、e with the growth of age More women than men More blacks than whites Common in Hard Physical Labourers, athlete,Etiology,Congenital theory,Traumatic theory,Wiltse classification,Meyerding classification grade 1-4,I25%,IV100%,III75%,II50%,Symptom,In the early phase，it often have no symptoms ，and was

36、found accidentally in the X-ray examination Progress in the follow-up of the disease, often expressed as low back pain、intermittent claudication、sciatica and cauda equina injury，which are similar with LDH or LSS,Tenderness of Lumbar jujube processSidestep of Lumbar jujube processLumbar lordosis incr

37、easedLower limb neurological symptoms,Physical sign,Imaging examination,X-rayAP-view and L-viewDouble oblique-viewHyperextensiond and Hyperflexion-view,Imaging examination CT three dimentional reconstruction,Imaging examination MRI,Can clearly display compressed degree of the dura and caudaequina exclude of other diseases in vertebral canal,Surgical treatment,AgeType of spondylolisthesisDegree of spondylolisthesisSituation of disc and spinal canal,Choose proper operation,Operation procedure,DecompressionReduction and FixationFusion,PLIF,Thank You !,