第104例 腰_(2.3)椎间盘突出

王××,男性,24岁,病案号46977腰痛双大腿后外侧麻木1个月,左大腿前内侧疼痛半月余。活动后双大腿疼痛加重,卧床休息疼痛缓解,咳嗽时腰痛加重并放射至左小腿外侧。入院前已卧床休息二十天。入院后二十天出现左小腿后外侧麻木。检查:脊柱轻度右侧弯,腰生理前凸消失。腰_3左侧有压痛,腰_(4.5)双侧有压痛无反射性痛。双下肢感觉无明显障碍。后仰背伸试验阳性,仰卧挺腹试验阳性,直腿抬高试验:左30度,右50度均引起疼痛加重,棘突摇摆试验阴性,双下肢膝,踝反射均存在。治疗:经绝对卧床及对症处理,疼痛症状无缓解。腰椎平片示:腰椎骶化,腰_(2.3)退行性变较重,椎间隙变窄。Conray造     

CT引导下盘内椎旁注射臭氧治疗腰椎间盘突出症148例

1临床资料 1．1一般资料 148例患者，男85例，女63例，平均年龄38．6岁，病史1-20年。都有多次疾病发作史，症状加重影响日常生活者107例，剧痛影响睡眠者41例。所有患者查体均有突出间隙深层压痛，直腿抬高试验25^o-65^o（＋）。单侧肢体疼痛136例，     

腰椎间盘突出部位与直腿抬高试验(根性征)关系的研究

目的对直腿抬高试验与腰椎间盘突出部位的关系进行了相关探索,讨论腰腿痛的致病机制,为临床诊断和选择治疗方法提供指导。方法收集102例腰椎间盘突出症的临床资料,根据MRI与神经根关系分为4组,用医学统计软件SPSS13.0进行统计学处理。结果患者腰椎间盘突出症MRI分型和临床分型具有相关性。①直腿抬高试验是否阳性与性别、年龄、病程无关;②患肢出现直腿抬高试验阳性率与椎间盘突出方向密切相关;③直腿抬高试验的出现与疼痛的致病机制密切相关。结论通过本组分析应重新认识直腿抬高试验的临床意义。     

白术脊痛片治疗高原寒湿性腰背痛200例疗效观察

目的:观察该药对寒湿性腰背痛患者疼痛、麻木、功能障碍等症状消除及改善情况.方法:按照中医诊断学及中医筋伤学对寒湿性腰背痛的相关症候诊断标准,选取患者200例,另外选取症候相同患者100例作为对照组,治疗组服用我院自制的白术脊痛片,对照组不用.结果:服用白术脊痛片疗程后腰腿疼痛其奉消失或部分消失,无明显压痛点,直腿抬高试验阴性,基本恢复正常工作、生活、症状体征积分改善在75%以上.有轻度腰背疼痛,直腿抬高试验可疑阴性,部分恢复工作不影响.腰背疼痛改善不明显或无明显改善,直腿抬高试验阳性,不能胜疗程后任工作,影响日常生活,症状体征积分改善小于50%.患者服用后疼痛及由此引起的功能障碍在短期内很快消失或减轻.     

腰椎术后并发细菌性脑膜炎、脑梗塞1例

<正>1病例介绍患者,男,51岁,因"腰痛伴双下肢放射痛、麻木5个月"以"腰椎管狭窄症、腰椎间盘突出症"入院。患者入院检查见:腰痛伴双下肢放射痛,卧床休息后缓解,行走、站立时疼痛加重,右小腿外侧及足背麻木。查体:腰椎曲度正常,活动无受限,L3、4间隙压痛(+),棘突旁无压痛,双侧直腿抬高试验     

注意臀上皮神经损伤的诊断

臀上皮神经损伤是腰腿痛中比较常见的原因疾病,以往常被忽视,或与坐骨神经痛混淆。现举两例谈谈鉴别诊断问题。例1男,40岁。感左臀部及左下肢酸痛、活动受限四天。检查:腰部左侧及左臀部有压痛,直腿抬高试验(一)。以左坐骨神经痛收入内科,经治疗效果不佳。后经外科会诊,发现左臀上皮神经部位压痛最明显,并传导至左小腿外侧,直腿抬高试验(-),确诊为左侧急性臀上皮神经损伤。用分筋、理筋手法复位后,经按摩及超短波治疗,疼痛消失,住院9天,痊愈出院,随访半年未复发。例2男,20岁。左臀部及左下肢后外侧刺痛,久坐,站时疼痛加重一个月。以左坐骨神经痛收入外科,按坐骨神经痛治疗一月余,效果不佳。后来在左臀上皮神经部位触及增粗变硬的臀上皮神经,压痛明显,并沿患肢后外侧传导至足跟部,直腿抬高试验(一),方明确为左侧慢性臀上皮神经损伤。行分筋、理筋、镇定手法及醋酸考的松封闭治疗,疼痛消失,     

髋臼周围部肿瘤的切除与重建1例

1病例资料 患者,男,55岁。左髋部疼痛3个月,加重10余天,于2008年4月9日入院。患者3个月前无明显诱因左髋部疼痛,疼痛呈持续性加重。近10余日左下肢疼痛剧烈,以大腿后侧为重,夜间痛明显。查体：脊柱生理弯曲正常,棘突无压痛及叩击痛：平卧时左臀部因疼痛不敢着床,左侧梨状肌下缘处压痛伴左下肢放射痛。左侧坐骨结节处压痛明显。左侧腹股沟压痛明显,以偏内侧为重。左侧直腿抬高试验及加强试验均阳性。     

双侧椎板开窗髓核切除治疗中央型腰椎间盘突出症

腰椎间盘突出症是骨科的常见病和多发病，采用手术方法治疗腰椎间盘突出症已在各级医院全面展开。我院近3年来选择性地施用双侧椎板开窗髓核切除治疗中央型腰椎间盘突出症18例，随访16例，效果优良，报告如下：1临床资料1．1一般资料本组男12例，女6例。年龄22～54岁，平均年龄35．5岁。病史1个月～6年。临床表现：以单侧下肢疼痛或麻木为主，病变间隙棘旁固定压痛点，直腿抬高试验阳性者6例。腰痛伴双侧下肢疼痛或麻木，直腿抬高试验阳性者8例，其中伴鞍区麻木者3例。腰痛及腰部固定压痛点，耳腿抬高试验明性、股神经牵拉试验阳性者3例。突…     

当归舒筋汤治疗肾虚腰痛98例

我院用自拟的当归舒筋汤治疗肾虚腰痛98例,疗效可靠,现报告如下。1　临床资料98例中男64例,女34例;年龄27～65岁;病程1年以上69例,10年以上29例;其中Ｌ4,5～Ｌ5Ｓ1骨质增生者64例,腰部疼痛者64例,腰腿疼痛或间歇性跛行者26例,伴肌肉萎缩者8例。表现为腰部疼痛、发僵,或下肢放射痛,或伴有麻木感,间歇性跛行,步行、弯腰、伸膝时疼痛加剧,屈髋、屈膝卧床休息时疼痛减轻。检查时有不同程度的脊柱侧弯;腰生理前突减少或消失;在腰骶椎下段棘突和棘突间深压痛,或引起、甚至加重下肢疼痛,直腿抬高试验阳性;部分患者出现下肢肌肉萎缩,小腿下段皮肤感…     

腰椎间盘突出症合并骶丛恶性淋巴瘤1例报告

患者男，70岁。因左臀部、左下肢疼痛、麻木、活动受限，逐渐加重半年余，于2002年9月7日入院。体检：L4／5椎间隙左侧旁有轻度压痛和叩击痛，疼痛向左下肢放射。左小腿外侧、足背及足底部感觉减退，左（足母）趾感觉缺失。左足伸（足母）、伸趾肌及胫前肌肌力0级，左足下垂，不能背伸。左膝反射、跟腱反射较对侧稍差，左下肢直腿抬高试验及     

直腿抬高试验影响因素的逐步回归分析

目的研究直腿抬高试验(straightlegraisingtest,SLR)结果与患者年龄、性别、病程、椎间盘突出率等因素之间的关系。方法对505例腰椎间盘突出病例的SLR影响因素进行逐步回归分析,男281例,女224例;年龄26~69岁,平均42.1岁。单间隙突出(L4-5或L5S1)337例,多间隙突出168例。321例行CT检查,184例行MR检查。结果SLR与急或慢性病程、椎间盘突出率、侧隐窝是否狭窄、椎间盘突出位置(中央型、侧旁型)、间歇性跛行距离等相关;而与年龄、性别、民族(汉族与维吾尔、哈萨克、回族比较)、椎间盘突出大小、单或多间隙突出、侧旁突出的根前、根腋、根肩型不相关;L4-5与L5S1椎间盘突出的SLR结果差异有非常显著性(P<0.01)。结论SLR受诸多因素影响,临床上不能将SLR结果作为判定椎间盘突出严重程度的重要指标。其相关因素为急或慢性病程、椎间盘突出率、侧隐窝是否狭窄、椎间盘突出位置及间歇性跛行距离。     

Objective clinical evaluation of physical impairment in chronic low back pain.

The aim of this study was to investigate physical impairment in patients with chronic low back pain, to develop a method of clinical evaluation suitable for routine use, and to consider the relationship between pain, disability, and physical impairment. Twenty-seven physical tests were investigated. Permanent anatomic and structural impairments of spinal deformities, spinal fractures, surgical scarring, and neurologic deficits were excluded as not relevant to the patient with low back pain in the absence of nerve root involvement or previous surgery. Three consecutive 20-patient reproducibility studies were used to develop reliable methods of examination for 23 of the tests. Only four tests were excluded as unreliable: sacral angle, pelvic tilt, and separate lumbar and pelvic extension, none of which are part of routine clinical examination or have any proven relationship to disability. The remaining 23 physical tests were evaluated in 70 asymptomatic subjects and 120 patients with chronic low back pain. Passive knee flexion, passive hip flexion, hip flexion strength, hip abduction strength, pain reproduction on each of these tests, and the prone extension strength test were excluded because they were too closely related to nonorganic and behavioral responses to examination. Eight tests successfully discriminated patients with low back pain from normal subjects and were significantly related to self-report disability in activities of daily living: pelvic flexion, total flexion, total extension, lateral flexion, straight leg raising, spinal tenderness, bilateral active straight leg raising, and sit-up. Factor analysis failed to demonstrate an underlying statistical dimension of physical impairment. However, an empirical combination of total flexion, total extension, average lateral flexion, average straight leg raising, spinal tenderness, bilateral active straight leg raising, and sit-up provided an equally satisfactory alternative. Simple cut-offs from normal subjects made the scale simple and quick to use. This final scale successfully discriminated 78% of patients and normal subjects and explained 25% of the variance of disability, with a specificity of 86% and sensitivity of 76%. This scale provides an objective clinical evaluation that meets the criteria for evaluating physical impairment, yet is simple, reliable, and suitable for routine clinical use. It should, however, be emphasized that all the tests included in the final scale are measures of current functional limitation rather than of permanent anatomic or structural impairment. This raises questions about the physical basis of permanent disability due to chronic low back pain.     

腰椎间盘突出症术后注射透明质酸钠预防神经根粘连的观察

目的　观察透明质酸钠预防腰椎间盘突出症术后神经根粘连的疗效。方法　 1996年 4月～ 2 0 0 1年 6月 ,对 15 2例腰椎间盘突出症患者 ,采用椎间盘镜下摘除髓核术 ,术后注射透明质酸钠 ,通过临床症状、肢体抬高试验、患者满意程度和腰痛判断标准观察疗效。结果　注射透明质酸钠后 ,随访 1个月～ 3年 ,肢体抬高试验从术前平均 2 6°提高到术后 6 2°,疼痛明显改善 ,临床症状未见反复 ,自觉满意度 86 .8% ,腰痛治疗成绩积分为 2 0～ 2 8分 ,平均 2 5 .4分。结论　透明质酸钠对预防腰椎间盘突出症术后神经根粘连有一定效果。     

Movement coordination of the lumbar spine and hip during a picking up activity in low back pain subjects

The effect of low back pain, with or without nerve root signs, on the joint coordination and kinematics of the lumbar spine and hips during everyday activities, such as picking up an object from the floor, are largely unknown. An experimental study was designed to compare lumbar spine and hip joint kinematics and coordination in subjects with and without sub-acute low back pain, while picking up an object in a sitting position. A three-dimensional real-time electromagnetic tracking device was used to measure movements of the lumbar spine and hips. Sixty participants with subacute low back pain, with or without straight leg raise signs, and twenty healthy asymptomatic participants were recruited. The ranges of motions of lumbar spine and hips were determined. Movement coordination between the two regions was examined by cross-correlation. Results showed that mobility was significantly reduced in subjects with back pain, who compensated for limited motion through various strategies. The contribution of the lumbar spine relative to that of the hip was, however, found to be similar in all groups. The lumbar spine–hip joint coordination was substantially altered in subjects with back pain, in particular, those with a positive straight leg raise sign. We conclude that changes in the lumbar and hip kinematics were related to back pain and limitation in straight leg raise. Lumbar–hip coordination was mainly affected by the presence of positive straight leg raise sign when picking up an object in a sitting position.     

Leg pain and psychological variables predict outcome 2–3?years after lumbar fusion surgery

Prediction studies testing a thorough range of psychological variables in addition to demographic, work-related and clinical variables are lacking in lumbar fusion surgery research. This prospective cohort study aimed at examining predictions of functional disability, back pain and health-related quality of life (HRQOL) 2–3 years after lumbar fusion by regressing nonlinear relations in a multivariate predictive model of pre-surgical variables. Before and 2–3 years after lumbar fusion surgery, patients completed measures investigating demographics, work-related variables, clinical variables, functional self-efficacy, outcome expectancy, fear of movement/(re)injury, mental health and pain coping. Categorical regression with optimal scaling transformation, elastic net regularization and bootstrapping were used to investigate predictor variables and address predictive model validity. The most parsimonious and stable subset of pre-surgical predictor variables explained 41.6, 36.0 and 25.6% of the variance in functional disability, back pain intensity and HRQOL 2–3 years after lumbar fusion. Pre-surgical control over pain significantly predicted functional disability and HRQOL. Pre-surgical catastrophizing and leg pain intensity significantly predicted functional disability and back pain while the pre-surgical straight leg raise significantly predicted back pain. Post-operative psychomotor therapy also significantly predicted functional disability while pre-surgical outcome expectations significantly predicted HRQOL. For the median dichotomised classification of functional disability, back pain intensity and HRQOL levels 2–3 years post-surgery, the discriminative ability of the prediction models was of good quality. The results demonstrate the importance of pre-surgical psychological factors, leg pain intensity, straight leg raise and post-operative psychomotor therapy in the predictions of functional disability, back pain and HRQOL-related outcomes.     

Piriformis syndrome and low back pain: a new classification and review of the literature

Piriformis syndrome is a common cause of low back pain. It is often not included in the differential diagnosis of back, buttock, and leg pain. Additionally it has received minimal recognition because it is often seen as a diagnosis of exclusion. Familiarity with the common elements of the syndrome should increase its recognition and facilitate the appropriate treatment. These include buttock pain and tenderness with or without electrodiagnostic or neurologic signs. Pain is exacerbated in prolonged sitting. Specific physical findings are tenderness in the sciatic notch and buttock pain in flexion, adduction, and internal rotation (FADIR) of the hip. Imaging modalities are rarely helpful, but electrophysiologic studies should confirm the diagnosis, if not immediately, then certainly in a patient re-evaluation and as such should be sought persistently. Physical therapy aims at stretching the muscle and reducing the vicious cycle of pain and spasm. It is a mainstay of conservative treatment, usually enhanced by local injections. Surgery should be reserved as a last resort in case of failure of all conservative modalities. Piriformis syndrome may constitute up to 5% of cases of low back, buttock, and leg pain. Recognition and widespread appreciation of the clinical presentation improves its early detection and accurate treatment.     

Lumbar disc surgery: results of the Prospective Lumbar Discectomy Study of the Joint Section on Disorders of the Spine and Peripheral Nerves of the American Association of Neurological Surgeons and the Congress of Neurological Surgeons

The Prospective Lumbar Discectomy Study enrolled 740 patients in a multiphysician, multicenter, consecutive patient protocol to evaluate the indications and efficacy of lumbar discectomy. Five hundred and thirteen patients could be evaluated at 3 months after surgery. Stepwise logistic regression showed that the factors of fraction of pain referred to the back, work-related injury, absence of back pain on straight leg-raise examination, correspondence of leg pain to typical radicular patterns, leg pain on straight leg-raise examination, and reflex asymmetry were independently predictive of good outcome from surgery. Univariate analysis of the case with different numbers of predictive factors present showed that use of the operating microscope, sensory deficit, central disc bulge, and free disc fragment were correlated with outcome only in subgroups. An analysis of unsatisfactory outcomes showed two patterns: one of failure as a result of mechanical back pain and one of failure as a result of radiculopathy. Factors predictive of outcome did not influence the type of failure. In a stepwise logistic regression analysis, facetectomy and preoperative sensory deficit were associated with increased likelihood of mechanical back pain failure, while preoperative motor deficit was associated with an increased likelihood of radicular failure. The results support several intuitively derived and commonly believed principles of lumbar disc surgery.     

Patient characteristics and patterns of use for lumbar spine radiographs: results from the Veterans Health Study

STUDY DESIGN: Longitudinal data from the Veterans Health Study, an observational study of male patients receiving Veterans Administration ambulatory care, were analyzed. OBJECTIVE: To identify patient characteristics that predict different patterns in the use of lumbar spine radiographs. SUMMARY AND BACKGROUND DATA: In this study, 401 patients with low back pain receiving ambulatory care services in four Veterans Administration outpatient clinics in the greater Boston area were followed for 12 months. METHODS: Participants were mailed the Medical Outcome Study Short Form Health Survey and participated in scheduled interviews that included the completion of a low back questionnaire, a comorbidity index, and a straight leg raising test. Four groups of patients were defined according to the patterns of use for lumbar spine radiographs: prior use, repeat use, no use, and new use of lumbar spine radiographs. These groups were compared in terms of sociodemographics, comorbid conditions, low back pain intensity, radiating leg pain, straight leg raising, Medical Outcome Study Short Form Health Survey scores, and low back disability days. RESULTS: The patients with new lumbar spine radiographs showed worse physical and psychological distress than the participants in the other three groups. In contrast, the patients with no lumbar spine radiographs reported minor physical impairment. Compared with patients who had no repeat radiographs, patients with repeat lumbar spine radiographs had similar scores on physical health, but they showed worse scores of mental health. CONCLUSIONS: Both physical and psychological factors contribute to having new radiographic examinations, whereas psychological factors have increased importance in the repeat use of roentgenographic examinations. Repeat radiographs appear to be overused, judging by the severity of physical impairment as measured by low back pain intensity, the Medical OutcomeStudy Short Form Health Survey, and disability days.     

One-year prognosis in sick-listed low back pain patients with and without radiculopathy. Prognostic factors influencing pain and disability

Background contextPrevious research has documented various psychosocial risk factors with influence on outcome in low back pain (LBP) patients, but the value of clinical predictors has been less well documented.PurposeTo identify clinical and psychosocial risk factors at baseline influencing disability and pain at 1 year in LBP patients sick-listed 3 to 16 weeks, and to look for differences between nonspecific LBP and radiculopathy.Study designCohort study with 1-year follow-up based on a randomized clinical trial.Outcome measuresDisability and change of disability, pain and change in pain at 1 year.MethodsIn a randomized clinical study evaluating multidisciplinary versus brief intervention, 325 patients were followed for 1 year. At baseline, they completed a questionnaire and went through a clinical low back examination, including measure of forward flexion and side flexion as well as tender point examination, a method to estimate diffuse tenderness. Furthermore, degenerative changes on plain X-rays of the lumbar spine were quantified, and sciatica was investigated by magnetic resonance imaging.ResultsRadiculopathy was verified by magnetic resonance imaging in 111 (34%) patients. At 1 year, questions of disability in daily life activities and pain were answered by 60% and 67%, respectively. The intensity of back+leg pain and disability was closely correlated. Statistically significant predictors for both disability and back+leg pain at 1 year were intensity of back+leg pain, worrying and health anxiety, many tender points, and little or moderate exercise in leisure time. Two additional risk factors were identified in patients with radiculopathy: older age and “drinking alcohol less than once per month.” Furthermore, disability at 1 year was associated with initial disability and compensation claim, and back+leg pain at 1 year was associated with fear avoidance about physical activity and the duration of pain. Change in disability was more closely associated with return to work than change in pain. Disc degeneration was not associated with disability or pain at 1 year. General health was not statistically significantly associated with outcome when adjusted for back+leg pain, disability, and worrying and health anxiety.ConclusionsDisability and pain at 1 year were associated with baseline disability and pain, diffuse tenderness, worrying and health anxiety, compensation claim, fear avoidance, and baseline exercise habits. Only in patients with verified nerve root affection, older age, and restrained alcohol seemed to play a role. The multivariate models were insufficient in predicting disability and pain, partly because disability and pain were also strongly associated with return to work.     

Pr?valenz psychischer St?rungen in der multimodalen Therapie des chronifizierten Rückenschmerzes

Because of its biopsychosocial factors chronic back pain is often resistant to unimodal therapy regimes. Multimodal pain programs are a promising therapy option in the management of chronic pain as they focus on functional restoration. The aim of the study was to evaluate the prevalence of psychopathology in patients with chronic back pain. The study included127 patients suffering from chronic back pain in multimodal inpatient pain therapy who were assessed by a psychologist. A retrospective analysis was performed focusing on the psychological diagnoses. Further factors investigated were age, gender, numeric rating scale (NRS) pain intensity at the beginning and end of the program, hospital anxiety and depression scale (HADS), further psychological treatment recommendations and migration background. Fisher??s exact test was performed to calculate the significance in the different subgroups. The results showed that there was a high prevalence of depression, anxiety disorders and adjustment disorders in patients with chronic back pain. In this cohort the prevalence of depression and anxiety disorders was significantly higher than the estimated prevalence of the normal German population.