（12）颈肩痛与颈椎病CBL.ppt

1、颈肩痛与颈椎病CBL Cervical & shoulder pain and cervical spondylosis-CBL,北京大学第一医院骨科,刘 洪,颈肩痛,18,PRECISION DIAGNOSIS AND TREATMENT OF BACK AND NECK PAIN. Bogduk, et al. CONTINUUM: Lifelong Learning in Neurology. Pain and Palliative Care. 11(6):94-136, December 2005.,FIGURE 4 -10 Segmental patterns of referred

2、 pain from the cervical zygapophysial joints or intervertebral discs.,Neck Pain Distribution Area,Case 1,男，56岁，因“颈肩痛伴右上肢疼痛麻木2月余”就诊,Case 1,低头时左颈后部伴右上肢针刺样疼痛2月余，阵发性发作， 牵引颈部后可缓解,典型颈肩痛症状,部位：颈后或枕骨区，肩胛骨内侧，向上肢放射 性质：锐痛或钝痛 诱因：低头/或头部转动时 持续时间：持续或阵发性 缓解方式：上肢上举放于头部或牵引颈部时 伴随症状：上肢麻木无力等 危险因素：长期伏案工作,Case 1,既往发现心脏病3年余

3、。会计工作10余年，无外伤史颈部肌肉紧张，C56棘突压痛，右肩胛骨内侧压痛，右侧椎间孔挤压试验阳性,8,9,10,11,12,13,14,颈肩痛的常见临床体征,椎间孔挤压试验（Spurlings test） 臂丛牵拉试验（Etons test） Hoffmanns sign Rossolimos sign,颈肩痛常见疾患,颈部筋膜炎 肩周炎 肩袖损伤 颈部炎症结核等 带状疱疹 颈部肿瘤 肩部肿瘤 心脏疾患 肺Pancoast 肿瘤,18,颈椎病,由颈椎间盘退行性变，继发椎间关节退行性变，压迫神经根、脊髓或椎动脉产生的临床综合征。,Cervical spondylosis should be r

4、egarded as a clinical syndrome resulting from degeneration of the intervertebral disc and intervertebral joints, consequent pressure on the cervical nerve roots , cervical spinal cord or vertebral artery.,颈椎病的分型,脊髓型（Cervical Spondylosis Myelopathy) 神经根型(Cervical Spondylosis Radiculopathy) 椎动脉型？ 交感神经

5、型？(Sympathetic Cervical Spondylosis),20,Cross-sectional view of cervical spine at level of disc (D). Uncinate process (U) forms ventral wall of foramen. Root (N) exits dorsal to vertebral artery (A).,21,临床表现 clinical features,神经根型颈椎病 servical spinal nerve root pressure or radiculopathy 1) 颈肩疼痛，上肢放射疼

6、，手指麻木 或过敏，肌力减低，腱反射低。 2）颈僵硬，活动受限。臂丛神经牵 拉试验（Eaton）、压头试验（Spurling） 阳性.,22,X线片 roentgenograms,神经根型颈椎病 1） 生理前凸消失；loss of the normal cervical lordosis. 2）椎间隙变窄；Disc space narrowing. 3）骨增生。Hypertrophic changes, lipping of the vertelral bodies and ostrophytes from the posterior spinal joints. CT, MRI和Cervic

7、al discography,23,C5 nerve root compression (Indicative of C4-5 disc rupture or other pathological condition at that level) Sensory deficit Upper lateral arm and elbow Motor weakness Deltoid Biceps (variable) Reflex change Biceps (variable),24,C6 nerve root compression (Indicative of C5-6 disc herni

8、ation or other local pathological condition) Sensory deficit Lateral forearm, thumb, and index finger Motor weakness Biceps Extensor carpi radialis longus and brevis Reflex change Biceps Brachioradialis,25,C7 nerve root compression (Indicative of C6-7 disc rupture or other pathological condition at

9、that level) Sensory deficit Middle finger (variable because of overlap) Motor weakness Triceps Wrist flexors (flexor carpi radialis) Finger flexors (variable) Reflex change Triceps,26,C8 nerve root compression (Indicative of C7-T1 disc rupture or other pathological condition at that level) Sensory d

10、eficit Ring finger, little finger, and ulnar border of palm Motor weakness Interossei Finger flexors (variable) Flexor carpi ulnaris (variable) Reflex change None,27,临床表现 Clinical features,2.脊髓型颈椎病 servical spinal cord pressure or myelopathy 1）颈痛不明显； 2）四肢乏力，胸、腹束带感，行走困难，大小便功能障碍visceral disturbances o

11、f bladder and bowel, incontinence； 3）感觉异常，肌张力增高spasticity， 腱反射亢进hyperactive reflexes, 踝阵挛ankle clonus, 病理反射阳性Babinski sign。,28,X线片 roentgenograms,所见与神经根型颈椎病相同。 颈脊髓造影（Cervical myelography）、CT、CTM和MRI检查可确定病变部位和程度。,29,临床表现 Clinical features,交感神经型颈椎病 头疼、偏头疼、头晕、视物不清、耳鸣、听力下降、心动过速或过缓、心率不齐等等。 椎动脉型颈椎病 旋转性眩晕为

12、主要症状，头疼（枕部、颞部），视物障碍，等等。,交感型颈椎病的诊断,CSSS的定义：颈椎间盘退行性变刺激或压迫 交感神经纤维，引起的一系列反射性症状。 CSSS的诊断标准：1 交感神经症状 2 神经受压-影像学 3 排除其他疾患,Case 2,患者，男，69岁，双上肢麻木，行走不稳2年余，加重3个月,Case 2,双上肢感觉减退，双下肢肌张力增高，双侧Hoffmanns sign(+),双侧踝阵挛（+），双侧膝腱反射活跃,Case 2,颈椎X线：C45C56C67节段椎间隙狭窄，钩椎关节增生 颈椎MRI：C3-C7多节段椎间盘突出，椎管狭窄，脊髓明显受压,35,诊断 diagnosis,中老年

13、； 病史和症状； 体征和神经系统检查； 影象学表现。,36,鉴别诊断 differential diagnosis,神经根型颈椎病 1）肩周炎和腕管综合征； 2）胸出口综合征； 3）肌萎缩型侧索硬化症 脊髓型颈椎病 1）骨折、脱位、结核、肿瘤脊髓压迫 2）后纵韧带骨化 OPLL Ossification of the Posterior Longitudinal Ligament,37,治疗 treatment,非手术治疗 conservative treatment 1）颌枕带牵引； 2）颈托和围领； 3）推拿和按摩； 4）理疗； 5）自我保健疗法； 6）药物治疗。,38,治疗 treatm

14、ent,2. 手术治疗 surgical treatment 1）前路及前外侧手术-骨赘和间盘切除 +植骨融合 Anterior approach 2）后路手术-椎板切除或椎板成形 Posterior approach,颈椎病的手术适应证,脊髓型颈椎病，一旦确诊，积极手术；神经根型颈椎病，症状严重影响生活工作，保守治疗无效；反复发作的其他各型前路：方式及适应证：1-3个节段椎间盘突出或骨赘致脊髓神经根腹侧受压者；孤立型OPLL；局限型椎管狭窄后路: 方式及适应证：脊髓型颈椎病多节段椎管狭窄或OPLL；颈椎黄韧带骨化致脊髓背侧受压者,颈椎病的预防,避免长期低头伏案工作 睡眠时枕头应垫在颈部 颈部

15、功能锻炼 避免颈部外伤,41,Types (configurations) of grafts used in anterior arthrodesis of cervical spine. Type I, Robinson and Smith; Type II, Cloward; Type III, Bailey and Badgley. Numbers are means for load-bearing capacity for each.,42,Placement of keystone graft shown in lined area.,43,Anterior fusion of

16、cervical spine. Trough has been cut in anterior aspect of vertebral bodies, intervertebral disc spaces have been cleared and filled with iliac bone chips, and iliac graft has been mortised into trough.,44,v,45,46,47,48,49,ORION anterior cervical plate system. A, Bone graft and plate position. B, Cep

17、halad/caudad screw angulation. C, Standard cranial and caudal angulation of screws. D, Plate holder locked into plate.,50,51,52,Case 7-唐 *,63,C34间盘突出 头晕（5分）,（4分）,Case 1,相红 F/44 前路C4肿瘤切除，人工椎体植入，钢板内固定,Awl,Pusher,Perforator,Bone blocks from spinous processes,Free fat graft,Nylon thread,A 52-year-old ma

18、le with OPLL,Pre Op.,Post Op.,Enlargement of spinal canal following En Bloc Laminoplasty,Pre. Op.,1M after Op.,2 Y after Op.,Case 3 兰淑 *,79ys,头痛，头晕，耳鸣，耳聋，心慌（16 分）,C56,Postop,（3 分）,Case 4-李国*， 女,58,C56 C67（18分）,Postop &follow-up,（4 分）,个人简介,Nothing is imposssible!,颈椎病的预防,避免长期低头伏案工作 睡眠时枕头应垫在颈部 颈部功能锻炼 避免颈部外伤,常用评分方法,JOA评分 VAS评分,思考题：,神经根型颈椎病的常见鉴别诊断 脊髓颈椎病的常见鉴别诊断 脊髓颈椎病的临床表现及治疗原则 神经根型颈椎病的临床表现及治疗原则,参考资料,【外科学】北京大学医学出版社，主编：郭应禄，祝学光 2、Campells operative surgery,tenth edition,Thank you for your attention,