Spondylolysis & Spondylolisthesis椎弓斷裂&脊椎滑脫

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鹭张简
9 years ago
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1 Spondylolysis & Spondylolisthesis 椎弓斷裂 & 脊椎滑脫 Adolescent back pain has been reported to affect more than 50% of school age patients. Parents are often confounded by the severity of the complaints and yet their teenager continues in sports or other extracurricular activities. After months of complaints and minimal relief of symptoms with anti-inflammatory drugs, the family will seek an evaluation. 研究顯示, 青少年的背痛影響著超過 50% 以上的學齡患者家長們常常不清楚孩子們抱怨背痛是否嚴重, 因為孩子們還能繼續運動或進行課外活動然而, 直到好幾個月的背痛, 加上吃了止痛藥也沒什麼幫助時, 家長們開始尋求幫助 Metabolic- Juvenile osteoporosis Inflammatory- Ankylosing Spondylitis Sero-negative Arthritis Neoplasm Osteoid osteoma Congenital L5-S1 facet Hypoplasia Developmental Lumbar Scheurmann's Trauma Pars interarticularis 代謝問題發炎引起腫瘤遺傳性疾病發育疾病創傷造成青少年骨質疏鬆症僵直性脊椎炎血清陰性關節炎類骨質骨瘤第五腰椎與第一薦椎關節面發育不全腰椎舒爾曼氏症椎弓峽部受傷 The adolescent with lumbar back pain may have multiple reasons other than overuse or "growing pains" for the discomfort. (Table 1) 有腰部背痛的青少年可能由各種原因造成, 不一定是過度使用或者生長痛 ( 表一 ) The clinical examination provides information about the location of the pain, muscle spasm, lumbar spine range of motion, hamstring muscle tightness, muscle strength in the legs, reflexes, and sensation in the legs. 經由臨床檢查可以知道痛的位置肌肉是否痙孿腰的可活動範圍後大腿肌肉的緊度腿部的肌力反射與感覺等

2 圖一 : 椎弓峽部 X-ray studies may discount several of the potential diagnoses and direct the physician to propose the diagnosis of a pars interarticularis stress injury or fracture. X 光可看出幾種可能的鑑別診斷, 尤其能知道是否有椎弓峽部 (pars interarticularis)( 圖一 ) 的擠壓受損或斷裂 The pars interarticularis is a portion of the lumbar spine that joins the upper and lower joints together. The pars is normal in the vast majority of children. 椎弓峽部 (pars interarticularis) 是腰椎上下關節面之間的一部分, 大部分的小孩都發育正常 After approximately 8 YOA, certain patients begin to experience abnormal growth and development of this particular region in the bone. A genetic weakness to the bone has only been established in certain ethnic groups such as Alaskan Indians. It does appear that certain athletic activities or injuries (gymnastics, heavy weight lifting) may result in problems in susceptible individuals. 在接近 8 歲時, 有某些特殊病人椎弓峽部開始有不正常的發育有些基因的缺陷會引起此種異常, 目前已在阿拉斯加的印地安人身上證實而特定的運動 ( 如體操舉重 ) 也可能對敏感的族群造成影響 There are three stages of injury to the pars interarticularis - Stress reaction Fracture (Spondylolysis), & Slippage (Spondylolisthesis).

3 關於椎弓峽部受傷有三個階段 : 1. 壓力反應 (Stress reaction) 2. 椎弓斷裂 (Spondylolysis) 3. 脊椎滑脫 (Spondylolisthesis) Stress reaction or injury may occur when the bone experiences excessive wear and tear from activities of daily living, sports, or a fall. The symptoms may include lumbar pain, stiffness, and hamstring muscle tightness. X-rays will not reveal any abnormality. A bone scan will demonstrate the inflammation in the pars. Treatment consists of relieving the pain and restoring spinal flexibility. After several months, the majority of patients resume most activities. 日常生活中運動或摔倒時, 若骨頭受到過多的磨損或撕烈, 會造成壓力反應或者傷害症狀包括腰痛僵硬和大腿後側肌肉緊繃 X 光可能尚未有不正常的表現骨骼掃描則能夠看出峽部發炎 ( 圖二 ) 治療包括疼痛緩解並回復脊椎彈性在數個月後, 病人大多可以恢復大部分的活動圖二 : 在骨骼攝影上顯示的病灶

4 圖三 : 椎弓斷裂 If the pars "cracks" or fractures, the condition is called Spondylolysis. The x-ray confirms the bony abnormality. Treatment is customized based on the severity of symptoms. Anti-inflammatory drugs, physical therapy, brace wear, and activity modifications will be considered. Prior to a release to activities after the pain resolves, a course of truncal core muscle strengthening (pilates or yoga) may be prescribed to condition the muscles and minimize reinjury. 如果傷害造成椎弓斷了, 則稱為椎弓斷裂 (Spondylolysis)( 圖三 ) X 光可以看得出來治療是根據個人的症狀嚴重度來決定, 可使用抗發炎藥物物理治療穿支架 ( 圖四 ) 及適當的運動等, 都可以考慮在疼痛沒解除還不能進行日常活動時, 可先進行中央肌群核心肌力訓練 ( 如皮拉提斯或瑜珈 )( 圖五 ) 來改善肌肉狀況並減少再次受傷的機會圖五 : 中央肌群核心肌力訓練圖四 : 帶支架以保護受壓處或受傷處

5 If the fracture gap at the pars widens, then the condition is called Spondylolisthesis. Widening of the gap leads to the fifth lumbar vertebra shifting forward on the part of the pelvic bone called the sacrum. Standing lateral spine x-rays are measured to determine the amount of forward slippage. 如果椎弓斷裂的缺口變大, 則稱為脊椎滑脫 (Spondylolisthesis)( 圖六 ) 變大的缺口, 將導致第五腰椎向前滑動, 離開原本和薦椎結合的位置側位 X 光片可以測量向前滑動的距離圖六 : 脊椎滑脫 Treatment is prescribed to decrease any acute spasm and restore spinal flexibility. One of the mainstays of physical therapy treatment is to perform truncal core strengthening exercises. The therapist will caution the patient on avoiding hyperextension maneuvers and excessive abdominal "crunches". 治療主要是降低急性的肌肉痙孿並恢復肌肉張力主要的方式還是中央肌群核心肌力訓練物理治療師會提醒病人避免過度伸展和過度仰臥起坐 Prognosis is affected by the amount of slippage. In general, most patients with less than 50% slippage fend to fare well through adolescence. With slippage of 50% or greater, the potential for additional slippage with growth and aging is greater. The small numbers of patients who do not respond to conservative medical management are evaluated for a spinal fusion. 預後則受到滑脫距離多少的影響一般來說, 大部分少於 50% 的滑脫在青少年時期還可以維持, 超過 50% 以上的滑脫隨著發育和年紀成長會越來越嚴重在少部份對一般醫學治療無效的病人, 可能需要手術來融合脊椎

6 圖七 : 用螺絲固定脊圖八 : 用儀器協助脊椎融合術的進行 If the pain, spasm, or slippage increases, then the surgeon will discuss several potential surgical options. For a majority of children, fusing the 5th lumbar vertebra to the sacrum is the first choice. The fusion involves removing the loose bony fragments and placing bone graft in such a manner that will lead to the successful "gluing together" of the two vertebra. 如果疼痛肌肉痙孿或滑脫持續, 醫師會考慮各種手術方法 ( 圖七圖八 ) 對大部分的孩子而言, 融合第五腰椎和薦椎是最佳選擇融合術包括移除掉落的骨碎片並做骨移植來成功的連接這兩個脊錐 The patient is restricted postoperatively with a cast or brace until healing is complete. In older patients the alignment of the two vertebra may benefit from the addition of bone screws during the healing process. 病人在術後必須帶支架直到癒合完全在老年病患身上, 加上骨釘固定可以幫助癒合整齊圖九 : 骨移植術可幫助脊椎融合

7 Bone graft is still added to promote a fusion that may take up to three to six months to heal completely. After a successful fusion most athletic activites can be enjoyed once again. 骨融合需時三至六個月, 而骨移植術 ( 圖九 ) 可以幫助骨骼融合完全在成功的骨融合後, 大部分的運動都能夠再次進行 Reference 參考資料原文出處 : Spondylolysis & Spondylolisthesis - Scoliosis Research Society 譯者 : 台北榮民總醫院骨科部見習醫學生蔡宛蓉 / 住院醫師陳晉瑋 in 2010/1 指導老師 : 台北榮民總醫院骨科部小兒骨科奉季光醫師

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$Microsoft Word - D-2°w¶Ë¬ì¹ï¤U�Iµh®{¤âÀË¬d¬yµ{_¬x°ö�×__P.329-335_.doc$ 針傷科對下背痛徒手檢查流程 329 針傷科對下背痛徒手檢查流程洪培修 1 張晉賢 2 張世良 3 1 嘉義基督教醫院中醫科系 2 長庚紀念醫院中醫醫院基隆分院暨長庚大學醫學院 3 中國醫藥大學中醫院學針灸研究所摘要前言腰痛或下背痛