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1、脊柱退行性疾病脊柱退行性疾病Spinal degenerative diseases 长治医学院附属和平医院骨科长治医学院附属和平医院骨科 裴卫卫裴卫卫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。影响因素影响因素 influence factorsv过度负荷过度负荷 overloadv不良体位不良体位 poor posture v慢性劳损慢性劳损 chronic
2、 strainv外伤外伤 injury v慢性炎症慢性炎症 chronic inflammationv先天因素先天因素 congenital factorsAnatomy of the SpineSagittal ViewAP-viewLordosisKyphosisLordosisDevelopment of Disc and Spinal Curvature Newborn25 years4 years-no significant curvature-Disc Height=Vertebral Body Height-Double-S curvature-Disc Height=40%o
3、f VBH-biconcave-biconvex shape of intervertebral space-Disc Height=25%of VBHIntervertebral discAnulus fibrosusNucleus PulposusNewborn65 yearsNo vascularisation of disc7 years70 years30 yearsWater content in the nucleus pulposus decreased with age Facet JointsCervical vertebrae sloping Thoracic verte
4、brae coronal Lumbar vertebrae sagittalLigamentsAnterior longitudinal ligamentPosterior longitudinal ligament Blood SupplyLoad Transfer80%20%vThe FUNCTIONAL UNIT of the spinevComprised of:lTwo adjacent vertebraelIntervertebral disclConnecting ligamentslTwo facet joints and capsulesIntradiscal Pressur
5、evBiomechanics18,31,24,62,75,011,011,023,017,0颈椎退行性疾病颈椎退行性疾病cervical degenerative disease包括：包括：一、颈椎病一、颈椎病二、颈椎管狭窄症二、颈椎管狭窄症三、颈椎间盘突出症三、颈椎间盘突出症四、颈椎后纵韧带骨化四、颈椎后纵韧带骨化 including一、一、Cervical spondylosis二、二、Cervical canal stenosis三、三、Cervical disc herniation四、四、Ossification of cervical posterior longitudinal
6、ligament一一、颈颈 椎椎 病病 Cervical spondylosisv发病率随着年龄的增加而显著提高发病率随着年龄的增加而显著提高 4050岁的发病率为岁的发病率为20，60岁以上者达岁以上者达50，70岁以上则更高。岁以上则更高。v目前发病年龄趋于年轻化目前发病年龄趋于年轻化 定义定义 Conceptv颈椎间盘退变及其继发性改变，刺激或压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。相应的症状或体征者，称为颈椎病。vCervical spondylosis is a disorder i
7、n which there is abnormal wear on the cartilage and bones of the neck.分分 型型 Classification v脊髓型脊髓型 Cervical Spondylotic Myelopathy CSM v神经根型神经根型Cervical Spondylotic Radiculopathy CSR v交感神经型交感神经型Sympathetic Cervical Spondylosis SCSv椎动脉型椎动脉型Cervical Spondylosis of Vertebral artery type v其它（食道压迫型、颈型、混合
8、型）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。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、大小主要表现为走路不稳、四肢麻木、大小便困难等。便困难等。Main clinical manifestations:Cervicalspinal cord injury，such as unsteady walk,numbness of limbs,micturitionand defecation difficulties CSR 1.多见于多见于30岁以上者岁以上者More common in people over 30 years old2.起
9、病缓慢、病程长，反复发作。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。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 主要主要表现为头晕、眼花、耳鸣、手麻、心动过速、心表现为头晕、眼花、耳鸣、手麻、心动过速、心前区疼痛等一系列症状前区疼痛等一系列症状。X线片有失稳或退变，椎动线片有失稳或退变，椎动脉造影阴性。脉造影阴性。Main clinical manifestati
10、ons:dizziness,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。表现为头痛，头晕，黑朦等症状，与颈部旋转有关。Main
11、 clinical manifestations:vertebral basilar artery insufficiency，such as headache,dizziness and amaurosis,relate to the neck rotation.食管型颈椎病食管型颈椎病Esophagus type cervical spondylosis vA special type of CS vThroat discomfort,foreign body sensation is an early symptom vLate manifestations is dysphagia v
12、Often accompanied by symptoms of other cervical spondylosis 颈型颈型Neck type cervical spondylosis以颈部酸、痛、麻、僵为主要临床表现或颈以颈部酸、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，转项部压迫感的颈椎病，症状集中在颈部，转动不灵活。动不灵活。Main clinical manifestations:acid distention、pain、numbness and stiff in the neck.Mixed type of cervical spondylosis v具备以
13、上两种或两种以上的表现者，具备以上两种或两种以上的表现者，即可确诊。即可确诊。v With two or more than two kinds of performance above.DiagnosisMust be have three conditions:vCervical degenerative changes vRelevant clinical manifestations vRelevant clinical manifestations are consistent with imaging findings TreatmentIndicatiovMild symptom
14、s vCan not tolerate operation MethodsvCorrect bad posture vTractionvMassagecautiously usevPhysiotherapyvMedications expectant treatment surgical therapy IndicatiovFormal expectant treatment for 36 months is invalid vSymptom of CSM aggravate progressively or suddenly or MRI showed that the cervical s
15、pinal cord signal changes vSymptom of CSR impact quality of life手手术术方方式式手术手术目的目的 surgical purpose 彻底减压彻底减压 Complete decompression 重建脊柱稳定性重建脊柱稳定性 Reconstruction of spinal stability 开放式：开放式：Open operation 前路前路直接减压直接减压Anterior cervical operation Direct decompression 后路后路间接减压间接减压Posterior cervical opera
16、tion Indirect decompression 微创式：微创式：Microinvasive operationCase 1 颈前路椎间盘摘除、颈前路椎间盘摘除、取自体髂骨椎间植骨融合、内固定术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、颈前路椎间盘摘除、椎间融合器植骨融合、内固定术椎间融合器植骨融合、内固定术Case 3 颈前路椎体次全切除、颈前路椎体次全切除、椎间钛笼植骨融合、内固定术椎间钛笼植骨融合、内固定术Case 4 颈后路单开门椎管扩大成形术颈后路单开门椎管扩大成形术Case 5 颈后路单开门椎管扩大成形颈后路单开门椎管扩大成形后路支撑钢板内固定术后路支撑
17、钢板内固定术Case 5颈颈椎椎人人工工间间盘盘置置换换术术颈椎管狭窄症颈椎管狭窄症 Cervical canal stenosisEtiology and pathology vCongenital developmental CCSvDegenerative or iatrogenic CCS vCCS can be single or multi segmental stenosis,common in the C4,5 and C6,7 segments Clinical manifestation vSymptoms are similar to the symptoms of CS
18、vX-rayvCTvMRIA:椎管失状径椎管失状径A13mm 正常正常A13mm 相对狭窄相对狭窄A10MM 绝对狭窄绝对狭窄 B:椎体中失状径椎体中失状径 A:B0.75 狭窄狭窄 椎管正中失状径椎管正中失状径 13mm 正常正常13mm 相对狭窄相对狭窄10mm 绝对狭窄绝对狭窄Cervical intervertebral disc degenerationExternal force cause rupture of annulus fibrosus and longitudinal ligamentNucleus pulposus protrude into spinal canal
19、 The pain of nerve root and signs of spinal compression.颈椎间盘突出症颈椎间盘突出症Cervical disc herniationRelationship between CDH and CSv颈椎间盘突出症是颈椎病发病过程的病理变化之一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 v颈椎间盘突出症的致压物只能是突出的髓核，而颈椎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病可以是
20、髓核以外的其他组织 Induced pressure can only be protruding nucleus pulposus，however it can be other tissues except the nucleus pulposus男性，男性，40岁，煤矿工人，既往无四肢麻木、无力病史，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、行走不稳摔伤后出现颈部不适伴双上肢放射性麻木、行走不稳1个个月，经颈围制动、脱水、激素及神经营养治疗效果不佳。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颈椎后纵韧带骨化症 Ossifica
21、tion 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，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。产生感觉、运动功能障碍。Cervical posterior longitudinal ligament abnormally proliferate and ossify，which can constrict the spinal cord and nerve root，and then lead to paralysis EtiologyThe exact mechanism i
22、s not clear，but there are several hypothesis vTheory of heredityvMechanical damage theory vDisturbance of carbohydrate metabolism theory vThe whole body bone hypertrophy theory EpidemiologyThe incidence of OPLL in East Asia is highervJapan 1.94.3%(over 30 years old.）vKorea 3.6%vTaiwan 2.8%vChina 1.6
23、1.8%Clinical characteristicsvA chronic,progressive,spinal cord or nerve root compression symptoms vIts symptoms are very similar to CCS orCSvX-ray,CT andMRI can improve the diagnosis Classification-Sagittal SectionTopical typeSegmental type Successive tppeMixed typeClassification-Coronal section图图 点
24、状骨化点状骨化图图 蕈伞状骨化蕈伞状骨化图图 山丘状骨化山丘状骨化图图 偏一侧骨化偏一侧骨化测量椎管狭窄率测量椎管狭窄率Imaging evaluation of OPLL减压不彻底神经功能障碍无改善或加重减压不彻底神经功能障碍无改善或加重Imaging evaluation of OPLLvVery difficultvHigh-riskvMore complications vPoor prognosis Treatment Operation is the only effective means ChallengeHow to select the reasonable operati
25、on?vsuccessive type and Mixed typevossific range 3 vertebral segmentsvCervical canal stenosis 50%Posterior cervical operation/Indirect decompressionLaminectomyLaminoplastyLaminectomy+internal fixationvTopical type and Segmental typevossific range 3 vertebral segmentsvCervical canal stenosis 50%Anter
26、ior cervical operation/Direct decompression Discectomy Corpectomy decompression 腰椎退行性疾病腰椎退行性疾病lumbar degenerative disease包括：包括：一、腰椎间盘突出症一、腰椎间盘突出症二、腰椎管狭窄症二、腰椎管狭窄症三、腰椎滑脱症三、腰椎滑脱症 including一、一、Lumbar Disc Herniation二、二、lumbar spinal stenosis三、三、lumbar spondylolisthesis腰椎间盘突出症腰椎间盘突出症 Lumbar Disc Herniati
27、on LDHEpidemiologyvSymptomatic LDH are seen in all age groups but have their peak in patients aged between 35 and 45 years.vExcept smoking,occupational factors include sedentary work and driver are the main reasons for LDHClassificationDegeneration/BulgingMildsevereCentral Posterlateral Lateral Clas
28、sificationProtrusionClassificationExtrusionClassificationSequestrationClassificationSchmorls nodsSymptomsSymptomsHow can we recognize a herniated disk?How can we recognize a herniated disk?vLower back painvSciaticavPain,weakness,numbness or tingling in the legs,buttocks and feet vProblems with bowel
29、,bladder or erectile function,in severe casesG Generaleneral Signs SignsvChanges of lumbar curvature vCompensatory scoliosis vStraight leg-raising(SLR)testvSLR strengthen testvFemoral nerve stretching test Neurologic signsvSensibilityvMuscle forcevDeep tendon reflex vMuscle atrophy We can initially
30、locate the intervertebral discProtrusion of the L3/4 discProtrusion of the L4/5 discProtrusion of the L5/S1 disc Imaging examination vX-rayvCTvMRIvLumbar myelography TreatmentvExpectant treatmentvSurgical treatmentExpectant treatmentvYoungvFirst attackvShort coursevSymptoms can be relieved by rest v
31、No spinal stenosis vNo spondylolisthesis Surgical treatmentvThe strict expectant treatment is invalid vCauda equina syndrome Classical-Classical-discectomydiscectomyLumbar arthroscopic Lumbar arthroscopic discectomydiscectomyPLDPLDDLumbar tunnel MED Lumbar tunnel MED discectomydiscectomyMLDAnterior
32、lumbar discectomy,interbody fusion Lumber artificial disc replacement腰椎管狭窄症腰椎管狭窄症lumbar spinal stenosisvLSS，caused by various reasons，can constrict spinal cord and nerve root and lead to corresponding nerve dysfunction，vOne of the common diseases of lower back and leg pain Etiology and pathology vCo
33、ngenital developmental LSSvDegenerative LSSvTraumatic or iatrogenic LSSvBe single or multi segmental stenosis vCommon in the L4/5EpidemiologyvMore common in elderly patients,more than 50 years old vIt is common in L4/5，secondary in L5/S1Clinical manifestationChronic low back painvMild pain or discom
34、fortvSlowly aggravationvAlleviation after the activity vCough without aggravating Clinical manifestationNeurogenic Intermittent Claudication NICLnCompressionnblood circulatory disordernInflammatory stimulusSymptoms are closely related with lumbar posture vAlleviation in flexion vAggravation in exten
35、sionvUphill is easier than downhillvCan ride，hard to walkClinical manifestationLower limb neurological symptoms Clinical manifestationImaging examination X-rayvTransverse diameter 18mmvSagittal diameter 13mmvValuable method vDisplay the location and degree of the disease Imaging examination Lumbar m
36、yelography vCoincidence rate is highvTransverse diameter18mmvSagittal diameter13mmvNerve root canal 3mm Imaging examination CT vHigh diagnostic coincidence ratevDifferential diagnosis significance Imaging examination MRI TreatmentTreatmentvExpectantvSurgicalnDecompressionnFusionnX-Stop腰椎滑脱腰椎滑脱The lu
37、mbar spondylolithesisSpondylo 椎体椎体Lithesis 滑移滑移HistoryvIn 1782,the Belgian Herbinlaux,who is an first described a phenomenon of dystocia caused by L5 spondylolithesisvIn 1854,the German doctor Kilian first proposed the spondylolisthesis and give the descriptionvIn the 1950s,domestic gradually began
38、to report spondylolisthesis.EpidemiologyvThe incidence rate is about 5%vVaring from the age,region and race,occupation,gender Morbidity rate increase with the growth of age More women than men More blacks than whites Common in Hard Physical Labourers,athleteEtiologyCongenital theory Traumatic theory
39、Wiltse classificationMeyerding classification grade 1-4I25%IV100%III75%II50%SymptomvIn the early phase，it often have no symptoms，and was found accidentally in the X-ray examination v Progress in the follow-up of the disease,often expressed as low back pain、intermittent claudication、sciatica and caud
40、a equina injury，which are similar with LDH or LSSvTenderness of Lumbar jujube processvSidestep of Lumbar jujube processvLumbar lordosis increasedvLower limb neurological symptomsPhysical sign Imaging examination X-rayvAP-view and L-viewvDouble oblique-viewvHyperextensiond and Hyperflexion-view Imagi
41、ng examination CT three dimentional reconstruction Imaging examination MRIvCan clearly display compressed degree of the dura and caudaequina vexclude of other diseases in vertebral canalSurgical treatmentvAgevType of spondylolisthesisvDegree of spondylolisthesisvSituation of disc and spinal canalChoose proper operation Operation procedure vDecompressionvReduction and FixationvFusionPLIF