下腰痛影像诊断的临床综合评估

[目的]探索下腰痛各种影像学检查方法的合理选择，避免资源浪费，减少病人支出，使其发挥互补作用。[方法]对61例下腰痛患者包括腰椎间盘突出症（38例）、椎管狭窄（4例）、滑脱（10例）、感染（4例）和肿瘤（5例）的影像学资料进行分析。[结果]临床症状和体征是引导正确诊断的基础，影像学检查结果只有建立于其上才有意义。常规X线摄片对骨性结构具有较高的分辨率，可为进一步影像学检查提供依据。脊髓造影根据硬膜囊及神经根管的影像学改变来判断下腰段的病变，对较小的L5S1椎间盘突出和极外侧椎间盘突出不易诊断。计算机体层摄影（CT）从横断面观察脊柱的病变，但较局限，不易观察椎管内CT值相似的软组织病变。脊髓造影后CT扫描（CTM）则提高了诊断的阳性率。磁共振成像（MRI）从多平面显示多节段的病变，对软组织具有很高的分辨率，但对骨性结构的分辨率较CT差。[结论]常规X线摄片是最基础且重要的常规检查方法，脊髓造影、CT、CTM、MRI对下腰痛的诊断各有其特点，不能相互替代，而是起相互补充的作用。     

椎间盘源性腰痛的诊断及手术治疗

目的:分析和总结椎间盘源性腰痛的诊断及手术疗效。方法:对50例腰痛患者应用MRI及椎间盘造影进行术前检查,并对确诊患者行后路病变节段的椎间盘切除、椎间融合、椎弓根螺钉内固定术手术治疗,对治疗结果作回顾性分析。结果:39例确诊患者经治疗后,效果确切,优良率92.3%。统计学结果显示,术前MRI信号改变,包括高信号(HIZ)现象以及终板信号改变,与椎间盘造影阳性的结果在本组患者中显示有较高相关性。结论:MRI、椎间盘造影可为椎间盘源性腰痛的诊断提供重要的依据;后路椎间盘切除、椎体间融合、椎弓根螺钉内固定术治疗椎间盘源性腰痛疗效确切。     

MRI终板异常的下腰痛患者的临床表现探讨

目的：探讨MRI检查有终板异常的下腰痛患者的临床表现特征。方法：对10例MRI检查表现终板异常的下腰痛患者系统地询问下腰痛症状，并与10例MRI检查无终板异常者进行比较。结果：终板异常组的10例下腰痛患者中有8例表现为持续性疼痛；7例表现为站立、行走位加重。而对照组10例下腰痛患者中只有3例表现为持续性疼痛；2例表现为站立、行走位加重。结论：终板异常的患者更多地表现为持续性疼痛以及站立、行走位加重，终板及其下方骨组织在MRI上的改变应该引起重视。     

Aetiology,diagnosis and treatment of low back pain

Summary A total of 274 patients complaining of low back pain following injury was reviewed. Impact injuries were associated with soft-tissue strain, which was seen less often after twisting injuries. Twisting injuries were associated with disc prolapse more often than falls. Discogenic pain followed lifting injuries more often than jerking injuries. Slipping and jerking injuries were associated with poor outcomes, but the diagnosis was of no prognostic significance. The response to treatment was markedly influenced by the presence of a compensation claim. Only educational classes could be shown to have a significant effect on outcome.     

Thermography in the diagnosis of low back pain.

The basic premises of thermographic analysis for low back problems are that variations in skin temperature signify certain and specific underlying disease processes. The newer technologic advances for monitoring skin temperature raise the questions of whether thermography is an adequate substitute for invasive diagnostic tools such as electromyography and myelography or computed tomography and magnetic resonance imaging. This article discusses the basic concepts, procedures, clinical experiences, postoperative studies and chronic low back syndromes, and thermograms.     

The current approach to the medical diagnosis of low back pain.

A small number of patients who present with low back pain will have an underlying medical disorder as the source of their pain. Patients who fail to respond to conservative management with controlled physical activity and nonnarcotic analgesics should have a thorough re-evaluation to detect possible sources of nonmechanical pain. Symptoms of fever, weight loss, recumbency pain, morning stiffness, acute severe pain, or colicky back pain represent specific entry points into the algorithm for diagnosis of back pain from underlying systemic illnesses. These patients will generally require a plain roentgenographic examination with subsequent scintography, MRI, CT, laboratory work, and biopsy as indicated by any positive findings during the diagnostic work-up. Therapy for individuals with nonmechanical low back pain is directed at the specific medical disorder that is the cause of their symptoms.     

腰痛的诊疗进展

背景 腰痛,又称下背痛,是引起功能障碍的主要原因.目的 在众多腰痛的诊断和治疗方法中,提供基于循征医学的腰痛诊断和治疗进展.内容 临床医生应该首先把腰痛患者归类为机械性、神经性或继发性腰痛,进而给予相应的检查和治疗.趋向 机械性腰痛不应该常规使用影像学检查.腰痛患者的一线药物治疗是对乙酰氨基酚或非类固醇类抗炎药.腰痛的...     

Nerve blocks in the diagnosis of low back pain.

The use of diagnostic injection techniques in the evaluation of low back pain disorders is a clinical judgment skill, based on applied anatomy, pharmacology of the agents employed, and the neurophysiology of pain. In earlier years, the focus was primarily on the anatomic basis of pain, with sometimes oversimplistic interpretations of the results obtained. Although an anatomic correlation of a subjective complaint remains the same diagnostic objective today, a clearer understanding of pain concepts has also given these injection techniques a greater sensitivity but narrower spectrum in their application. Local anesthetic injections can readily identify sources of pain in soft tissues, scar tissue, nerve injury, and ligaments. They have particular application in this regard in postsurgical and postinjury back pain states in which the normal anatomy or function may be distorted. Local anesthetic blocks can also corroborate or define sites of pain in dorsal facet joints and in torsional disc capsule tears, where sites of multiple imaging or negative imaging findings make for difficult clinical diagnosis. In this context, they can also allow additional injection of deposteroid preparations, extending the procedure to a longer term therapeutic measure. Less specific anatomic information can be developed with respect to contributions from afferent and efferent responses, and in peripheral as compared with central mechanisms subserving the total clinical pain. For disorders of neuropathic and sensitization pain states, the spinal segmental level of signal processing from which conscious projection is derived can be well defined. Planned use of diagnostic blocking techniques is not a shortcut to sophisticated imaging or neurophysiologic studies but readily complements such investigations when conclusions are equivocal. Diagnostic blocks are only as good as the detailed clinical examinations which precede and follow the block itself.     

Manual-medical differential diagnosis of low back pain including osteopathic procedures

The differential diagnostic evaluation of painful functional disorders of the lumbosacral and lumbopelvic region, i. e. the so-called “low back pain” is very extensive, but is often reduced to the question of chronicity. The manual medical diagnosis can make a valuable contribution in such cases for determination of structural and functional pathology. Early application of manual medical therapies seems to be effective for peracute complaints. The mobilization of restrictions of the pelvic visceral attachments should be included. In the following review manual medical syndromes are presented that summarize the findings from the musculoskeletal and visceral system. This is intended to facilitate the primary differential diagnostic evaluation, as well as treatment planning. The combination with osteopathic methods is very profitable. A necessary specialist differential diagnosis remains essential.     

Artificial intelligence in the diagnosis of low back pain.

Computerized methods are used to recognize the characteristics of patient pain drawings. Artificial neural network (ANN) models are compared with expert predictions and traditional statistical classification methods when placing the pain drawings of low back pain patients into one of five clinically significant categories. A discussion is undertaken outlining the differences in these classifiers and the potential benefits of the ANN model as an artificial intelligence technique.     

The role of HLA-B27 in the diagnosis of low back pain.

The HLA-B27 antigen was determined in 652 patients with low back pain which had lasted for more than 3 months. A clinical and roentgenological examination of the sacroiliac joints and the thoraco-lumbar spine was performed in all the patients. The control group consisted of 302 unrelated persons who did not show signs of low back pain. Antigen HLA-B27 was found in 276 of these 652 patients attending the ward for rheumatic diseases (42.4 per cent) and in 37 of the 302 unrelated persons in the control group (12.2 per cent). The difference is statistically highly significant (P less than 0.001). Ankylosing spondylitis was found in 128 out of the 276 patients with low back pain and antigen HLA-B27. This demonstrates the importance of this antigen in the differential diagnosis of low back pain.     

椎间盘源性下腰痛的发病机制

目的探讨椎间盘源性下腰痛的发病机制。方法收集腰椎后路切除的17例椎间盘源性下腰痛患者的19个经腰椎间盘造影术证实的疼痛腰椎间盘;同时收集12个在MRI T2加权像上信号强度明显减弱、无腰痛症状的生理老化椎间盘和10个正常对照椎间盘,行组织学检查和P物质、神经丝蛋白和血管活性肠肽的免疫组织化学染色检查。结果椎间盘源性下腰痛患者的疼痛椎间盘在组织学上的显著特征表现为,一条从髓核至纤维环外层的血管化肉芽组织条带区,其间伴有1个或多个裂隙;肉芽组织条带区与椎间盘造影术后CT上显示的纤维环裂隙一致,肉芽组织之外的纤维环结构基本正常。生理老化椎间盘和正常对照椎间盘表现为与年龄相关的改变。免疫组织化学染色显示,疼痛椎间盘中P物质、神经丝蛋白和血管活性肠肽3种神经肽阳性神经纤维分布数量和比例,较正常对照椎间盘和生理老化椎间盘明显增多;神经纤维主要沿伴有裂隙的肉芽组织条带区分布;疼痛椎间盘髓核中可见P物质和神经丝蛋白的阳性神经纤维分布。结论椎间盘后方神经分布广泛的肉芽组织条带区是椎间盘造影术疼痛和椎间盘源性下腰痛的起源部位。肉芽组织条带可能起源于椎间盘的创伤修复过程。生理老化椎间盘和疼痛椎间盘的差异是后者形成组织学上的肉芽组织条带区。     

The pathogenesis of discogenic low back pain

Discogenic low back pain is a common cause of disability, but its pathogenesis is poorly understood. We collected 19 specimens of lumbar intervertebral discs from 17 patients with discogenic low back pain during posterior lumbar interbody fusion, 12 from physiologically ageing discs and ten from normal control discs. We investigated the histological features and assessed the immunoreactive activity of neurofilament (NF200) and neuropeptides such as substance P (SP) and vasoactive-intestinal peptide (VIP) in the nerve fibres. The distinct histological characteristic of the painful disc was the formation of a zone of vascularised granulation tissue from the nucleus pulposus to the outer part of the annulus fibrosus along the edges of the fissures. SP-, NF- and VIP-immunoreactive nerve fibres in the painful discs were more extensive than in the control discs. Growth of nerves deep into the annulus fibrosus and nucleus pulposus was observed mainly along the zone of granulation tissue in the painful discs. This suggests that the zone of granulation tissue with extensive innervation along the tears in the posterior part of the painful disc may be responsible for causing the pain of discography and of discogenic low back pain.