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Youmans:脊椎疼痛鑑別診斷-1

WCH | 2021-12-08 21:39:47 | 巴幣 3216 | 人氣 292


前言

  • Neck and low back pain is one of the most common reasons that people miss work; however, most back or neck pain results from musculoligamentous strain that resolves with conservative therapy. Persistent axial skeletal pain or radicular pain is more likely to result from a surgical lesion and requires a more extensive diagnostic evaluation. Assessment begins with a history and physical examination, followed by appropriate laboratory investigations and diagnostic imaging.
頸部和下背痛是一般人請假的主要原因之一。但多數因為肌肉韌帶緊繃導致的背部或頸部痛都可以透過保守治療來緩解。持續的中軸骨(註:頭和軀幹的骨頭)疼痛或神經根疼痛往往是來自於手術傷害並需要更進一步的評估。可以透過病史、理學檢查、實驗室數據或是影像來進行診斷。
  • The history investigates the onset of pain and its characteristics, location, and aggravating and alleviating factors. Discussion should include similar episodes of pain, associated symptoms, and related systemic complaints. Medical, family, and social histories elucidate conditions associated with spine problems. A comprehensive physical examination of all systems is essential. Anterior neck pathologic conditions, thoracic disease, and abdominal ailments can manifest as visceral pain referred to the neck and back, and systemic disease may first manifest in the spine. Evaluation of the spine includes inspection, palpation, and range-of-motion testing. A detailed neurological examination may document physical evidence of dysfunction of the brain, spinal cord, peripheral nerves, and/or muscles. When a neurological deficit is present, its characteristics help establish the diagnosis.
病史詢問是詢問疼痛的起始時間、特徵、位置以及加重或是緩解因子。需要討論類似的疼痛經驗、額外的症狀以及相關的全身性問題。醫療史、家族史或是社會史可以解釋可能的脊椎原因。另外也要做全方面的理學檢查。前頸病變、胸腔疾病以及腹部疾病都可能會加重頸部或背部的疼痛。同時也有一些全身性的疾病第一時間會出現脊椎疾病。脊椎的檢查包含視診、觸診以及活動度測試。更詳細的神經學檢查是可以記錄腦部、脊髓、周邊神經以及/或肌肉問題。一旦神經學症狀出現,其特徵是可以幫助診斷的。
  • Clinical findings guide laboratory and imaging investigations. Standard laboratory studies include a complete blood count, electrolyte panel, glucose measurement, and coagulation panel. Measurements of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) level, and blood cultures help diagnose an infection; serum and urine studies explore for neoplasia; immunologic markers indicate inflammatory diseases; and endocrine and metabolic studies investigate primary metabolic bone diseases.
實驗室數據和影像學也可以加以診斷。一般實驗室數據會看全血球數量、電解質、血糖含量以及凝血功能。如果想看感染可以額外測ESR、CRP以及血液培養。想看腫瘤則可以多測血漿和尿液。免疫相關的標記分子可以看發炎相關的疾病,同時在內分泌和新陳代線的研究則可以調查初級代謝相關的骨病變。
  • Classically, imaging begins with plain radiographs: anteroposterior, lateral, and flexion-extension views, as well as coned-down views of transitional areas. Magnetic resonance imaging (MRI) or computed tomography (CT) of the spine should follow to further define underlying pathology. MRI is better for imaging soft tissues and changes in tissue hydration, and CT is better for imaging bony detail. CT myelography often better delineates the neural elements in relation to the bony anatomy. Bone scans and bone density determination are occasionally required.
基本上影像學會先看X光:前後照(註:代表X光從前往後打,一般病患會躺著照)、側邊照以及伸展-屈曲照。另外也可以對過度帶(註:胸椎腰椎或尾椎之間的過渡帶)的局部攝影。核磁共振或電腦斷層可以做進一步的檢測。核磁共振適合觀察軟組織或組織水分改變。而電腦斷層則適合用在骨頭細節的觀察。脊髓電腦斷層造影可以看骨頭與神經的關聯。骨攝影與骨密度則偶爾會用到。
  • The laboratory work and radiologic imaging may provide a definitive diagnosis, or pathologic evaluation of abnormal tissue may be required. Once a definitive diagnosis has been obtained, medical or surgical treatment can proceed.
實驗數據和影像檢查可以提共更詳細的診斷,或病理需要。一旦更精確的診斷做出來,就可以考慮開藥或開刀了。

脊椎疼痛合併發燒和體重下降


  • Patients presenting with spine or radicular pain associated with fever and weight loss are at increased risk of having an infectious process. The presentation of patients with neoplastic processes can be similar. The presence of fever with spine or radicular pain should lead the physician to look for an axial skeletal infection first. Neurological deficits can occur, but they usually manifest weeks to months after the onset of pain and systemic symptoms. Vertebral osteomyelitis, discitis, epidural abscess, and granulomatous processes are the most common potential infectious conditions.
這類病患往往有感染的可能性,但有腫瘤的病患也可能有類似的表現。對於脊椎發燒外加神經根疼痛會需要先看中軸骨感染。神經學缺損也可能出現,但通常要到疼痛或全身性症狀出現後數周到數月才會出現。在感染之中,脊椎骨髓炎、椎間盤炎、硬腦膜膿瘍以及肉芽腫是最常見的。

脊髓骨髓炎

  • Vertebral osteomyelitis typically results from a pyogenic infection of the vertebral column. It is the most commonly encountered infection of the axial skeleton, accounting for 2% to 19% of all cases of osteomyelitis. Osteomyelitis may be the result of trauma, extension from adjacent structures, or hematogenous spread. A definitive source of infection is found in less than 50% of cases. The most common foci are genitourinary, soft tissue, and respiratory, or the infection may be traced to intravenous drug abuse. The organisms most commonly isolated are gram-positive cocci, constituting 60% to 70% of all cases. Staphylococcus aureus is the most prevalent, representing up to 60% of all positive culture results. Gram-negative rods are found predominantly in parenteral drug abusers or immunocompromised patients. The lumbar spine is most often involved, followed by the thoracic spine and cervical spine. The vertebral body is involved in more than 95% of cases. Less than 5% of cases involve the posterior elements.
脊椎骨髓炎往往是因為脊椎膿瘍感染所導致,是中軸骨感染後最常遇到的,包含所有骨髓炎的2-19%。骨髓炎可能是因為創傷、從鄰近結構感染來的或是從血液來的感染。確切的感染源只有在不到一半的案例中發現。最常見的來源還是泌尿道、軟組織以及呼吸道。此外也可能是靜脈毒品注射。最常見的病原體是革蘭氏陽性球菌,佔60-70%。其中金黃葡萄球菌最為常見,佔了60%的菌種。格蘭氏陰性桿菌則主要發現於毒品浪用或是免疫缺乏的病患。脊髓骨髓炎多發生在腰椎,接序是胸椎和頸椎。95%發生於脊椎椎體,剩下5%則發生於脊椎的其他地方。
  • Vertebral osteomyelitis has a male predominance. Predisposing conditions include advanced age, diabetes mellitus, steroid therapy, and intravenous drug abuse. The most common symptom is insidious, diffuse back pain, which is seen in about 90% of patients; fever occurs in 50% to 70% of patients. Other symptoms include weight loss, radicular pain, myelopathy, spine deformity, and meningeal irritation. Diagnosis can be delayed owing to the nonspecificity of presenting symptoms. Mean time to diagnosis is 6 to 8 weeks, with a range of 2 weeks to 5 months. Neurological compromise and decreased mobility are late complications. Diagnosis is based on pertinent laboratory findings: elevated ESR and CRP, positive blood and bone culture results, elevated white blood cell count, and radiologic studies. The sensitivity and specificity of MRI make it the “gold standard” for detecting osteomyelitis. Bone scans are useful for diagnosis because of their high sensitivity, but other inflammatory processes or neoplasia can mimic infection on bone scans. CT reveals the extent of bony destruction.
脊椎骨髓炎常常發生於男性。危險因子包含年紀大、糖尿病、類固醇治療以及靜脈毒品濫用。常見的症狀為無症狀、瀰漫性背痛(90%的病患)、發燒(50-70%的病患)。另外也可見體重下降、神經根疼痛、脊髓病變、脊椎結構異常以及刺激到腦膜的疼痛。診斷可能會因為非特異性的症狀而延誤。一般來說約6-8周會被診斷出,範圍可以從2周到5個月。神經功能惡化以及運動能力變差則是之後才會有的併發症。

診斷是基於感染相關的實驗室數據,也就是ESR和CRP升高、血液和骨頭細菌培養成陽性以及白血球升高,另外還有影像學檢查。核磁共振是黃金診斷(註:代表檢查出有就一定有)。骨掃描是有用的檢查因為它高度敏感度(註:代表容易偵測出有異常),但一些腫瘤也可能被骨掃描誤判出來。電腦斷層往往用來看骨頭被破壞的程度。
  • Management is based on biopsy results from percutaneous aspiration and bone biopsy using CT or fluoroscopic guidance. Treatment entails bed rest and broad-spectrum antibiotics, followed by definitive antimicrobial therapy based on culture results. Decompression with or without fixation may be required if there is extensive bony involvement or if neurological sequelae occur from excessive bony destruction or abscess formation.
對於脊椎骨髓炎的處理往往取決於經皮抽取的切片,以及用電腦斷層或螢光染色導引的骨切片。治療則是包括躺床和廣效性抗生素,取決於培養出來的微生物。對於要不要用減壓外加固定脊椎骨,則是考量於有無過度的骨破壞或是膿瘍造成神經學上的後遺症。

脊椎硬腦膜膿瘍

  • A spinal epidural abscess usually results from a pyogenic infection of the epidural space. Although uncommon (reported incidence: 0.2 to 1.2 cases per 10,000 hospital admissions), its clinical importance overshadows its rarity. Approximately 50% of spinal epidural abscesses result from hematogenous spread of infection to the epidural space. Other causes include direct extension of a preexisting osteomyelitis or discitis and direct inoculation from surgical manipulation or trauma. The organisms of spinal epidural abscesses mirror those found in vertebral osteomyelitis. Gram-positive cocci are the most prevalent, with S. aureus isolated in 60% to 65% of cultures with positive results; other staphylococcal and streptococcal species are the next most common organisms isolated. Thoracic involvement is slightly more common than lumbar involvement, followed by cervical involvement. Posterior location predominates in about two thirds of cases. An anterior abscess often results from direct extension of a ventrally located discitis or vertebral osteomyelitis.
脊椎硬腦膜膿瘍往往是因為硬腦膜的膿瘍型感染所造成。雖然很少見(大約每10,000住院病患有0.2-1.2個可見),但臨床意義卻很大。約略50%的病患是因為從血液傳到硬腦膜空間的感染。另外也可能是直接從骨髓炎、椎間盤炎、創傷或是手術造成的感染而來。造成脊椎硬腦膜膿瘍的微生物比脊椎骨髓炎的還來少見。其中最常見的還是格蘭氏陽性球菌。裡面60-65%是金黃葡萄球菌。其他葡萄球菌和鏈球菌則是第二常見的。胸椎比腰椎來得常見,頸椎最不少見。最常發生於脊椎椎體以外的後側,有2/3。前側的往往是從腹側椎間盤炎或是骨髓炎而來。
  • Adults are primarily affected, and there is no sex predominance; spinal epidural abscess is rare in children. Axial skeletal pain is a common initial complaint. The pain may develop a radicular component, and sensory or motor dysfunction of the affected nerve root can occur. If a spinal epidural abscess remains untreated, paraplegia or quadriplegia ensues. The incidence of fever, leukocytosis, and neurological compromise is higher than in vertebral osteomyelitis. Laboratory studies include ESR, CRP concentration, and white blood cell count, which are elevated in most patients. MRI is the diagnostic procedure of choice. T1-weighted images reveal a hypointense epidural mass that enhances with administration of a contrast agent. On T2-weighted images, the mass is hyperintense. Early diagnosis is important because patients with spinal epidural abscess can deteriorate rapidly, even when receiving intravenous antibiotics. Treatment for spinal epidural abscess is surgical evacuation and administration of the appropriate antibiotics.
脊椎硬腦膜膿瘍往往鑑於成人,同時男女比例差不多,並少見於孩童。這疾病最常見的就是中軸骨疼痛,同時這疼痛也可能發展成神經根疼痛,另外也可能造成感覺或運動神經異常。如果脊椎硬腦膜膿瘍沒治療,最後還可能造成偏癱或是全癱。這疾病發生發燒、白血球增多以及神經缺損的比率比脊椎骨髓炎來得高(註:所以前面才會提到臨床意義大)。實驗室數據可見ESR、CRP、白血球數量在多數病患中增加。

核磁共振是個診斷的選擇。其中T1影像會表現出低密度的硬腦膜腫塊,而T2則會形成高密度。早期診斷很重要因為這疾病會急速惡化,即便有用靜脈注射抗生素也一樣。對於脊椎硬腦膜膿瘍的治療主要是手術介入以及住院給予適當的抗生素。

椎間盤炎

  • Discitis represents two entirely different entities in adults and children. Pediatric discitis classically manifests spontaneously. Adult discitis is most often encountered after discectomy, although it can occur spontaneously. Less often, adult discitis results from hematogenous spread secondary to intravenous drug abuse or debilitating disease. Early detection is important to prevent discitis from progressing to vertebral osteomyelitis or epidural abscess.
椎間盤炎在成人和孩童分成兩個不同的樣貌。兒科的椎間盤炎往往是自發性的,而成人的椎間盤炎往往都是在椎間盤切除術後發生,即便也可能是自發的。成人椎間盤炎不常是因為靜脈注射毒品或是衰弱疾病造成的血型性傳播感染。早期的診斷有助於避免椎間盤炎演變成脊椎骨髓炎或是硬腦膜膿瘍。
  • In children, discitis is a relatively benign disease due to a chronic inflammatory disorder, viral infection, or low-grade bacterial infection. The vascular network throughout the cartilaginous end plate and disk predisposes children to discitis. This network functions as a site for bacterial colonization and disappears in late adolescence. Postoperative discitis in adults results from bacterial contamination during surgical manipulation. Gram-positive cocci, staphylococcal and streptococcal species, predominate in both pediatric and adult cultures. Biopsies and blood cultures can be nondiagnostic in 20% to 50% of patients. The lumbar spine is affected more frequently than the thoracic or cervical spine in both children and adults.
在孩童中椎間盤炎是個相對良性的疾病,源自於慢行發炎、病毒感染或低度細菌感染。這些感染會經過軟骨中盤和椎間盤的血管網絡造成椎間盤炎。細菌會在血管網路之中繁殖並於病患青春後期時消失。成人的術後椎間盤炎是因為手術汙染所造成。其中格蘭氏陽性球菌,葡萄球菌和鏈球菌都會造成成人或是小孩的椎間盤炎。在20-50%的病患中的切片和血液培養會沒結果。無論是成人或小孩的椎間盤,腰椎都比胸椎或頸椎來得常見。
  • Patients present with back pain and painful ambulation. In adults, the onset of pain at the surgical level 1 to 3 weeks after surgery signals the possibility of an infection. Typically, ESR and CRP concentration are elevated. MRI is the most sensitive and specific modality for detecting infection and determining the efficacy of treatment. MR images show evidence of the infection sooner than plain radiography does. ESR measurement is a sensitive test for detecting the infection and following the progression of treatment. Management consists of CT- or fluoroscopy-guided biopsy and culture, bed rest, and a course of intravenous and then oral antibiotic therapy. The prognosis of uncomplicated cases is excellent.
椎間盤炎會有背痛或行走疼痛。在成人中在術後1-3周後於手術的位置如果疼痛就可能是感染。典型案例中,ESR和CRP都會上升。核磁共振是最好診斷感染以及評估治療效果的工具,也比X光更快速發覺。ESR測量也是一個很敏感的測試用來偵測感染以及追蹤治療進展。對於椎間盤炎的處置包含用電腦斷層或螢光染色的切片與培養、躺床以及靜脈或口服抗生素。這疾病的預後很好。

肉芽腫感染

  • Granulomatous infections initiate a chronic granulomatous response. Infections with fungal, spirochetal, and other organisms such as Actinomyces, Nocardia , Brucella , and Mycobacterium tuberculosis can produce granulomatous disease of the axial skeleton.
肉芽腫感染是因為慢性肉芽腫所造成,主要是黴菌、螺旋菌以及其他微生物例如放線菌、諾卡氏菌、布氏桿菌或是分枝桿菌感染所造成。
  • Although rare in developed countries, tuberculous spondylitis is globally the most common granulomatous infection affecting the axial skeleton. Historically, tuberculous spondylitis (Pott's disease) is usually caused by M. tuberculosis, but other mycobacteria can also infect the axial spine. Infection results from hematogenous spread of mycobacteria from a pulmonary or genitourinary source. The infection spreads across the disk space, along the posterior or anterior longitudinal ligament, and tends to spare the disk space. The skeleton is affected in about 1% of all cases; of those, 50% to 60% involve the axial skeleton. The thoracolumbar spine is affected most frequently; involvement of the cervical spine and sacrum is rare.
雖然在已開發國家很少見,結核菌造成的脊椎炎在全球中是最常見的肉芽腫發炎成因。歷史上,結核菌脊椎炎常常是結核桿菌所造成。但其他的分枝桿菌也會造成中軸骨的感染。而這些感染通常是血液傳播的。感染會擴散過椎間盤空間,沿著前後縱韌帶移動,最後擴散到整個椎間盤空間。在所有的個案中有1%會影響到骨頭,其中50-60%是中軸骨。胸腰椎最常受到影響,而不常見於頸椎和尾椎。
  • Currently, individuals infected with the human immunodeficiency virus (HIV) account for most tubercular infections in the United States, and drug-resistant strains are being seen more frequently. Clinical presentation involves bone pain over the affected spinal level with fever, malaise, and weight loss. Vertebral collapse, spine deformity, epidural abscess, and subarachnoid seeding after dural erosion are late sequelae. In the progressive stages of the disease, kyphosis and epidural abscesses are common. Neurological sequelae occur in 10% to 50% of patients with active disease. In 20% of cases, tuberculous spondylitis causes paraparesis.
現在在美國,感染HIV的個體最容易造成桿菌感染,同時抗藥性菌株也有增加的趨勢。臨床上可見受影響的脊椎出現疼痛,另外還有發燒、身體不適或是體重下降。脊椎塌陷、結構異常、硬腦膜膿瘍以及膿瘍擴散到蜘蛛膜下腔都是晚期才會見到的。隨著疾病進展,脊柱後凸和硬腦膜膿瘍是很常見的。神經缺損發生於10-50%的病患,在20%的病患可能會導致偏癱。
  • Plain radiography, MRI, and CT myelography evaluate disease progression and guide surgical planning. MRI evaluates the involvement of soft tissue and abscess formation. CT provides bony detail. Treatment is based on positive biopsy or culture results, degree of kyphosis, extent of neurological compromise, and refractoriness of the disease. Decompression and débridement, combined with antibiotic therapy, are the accepted treatment modalities when a neurological deficit evolves. Prognosis relates to patient age, extent of systemic disease, and preoperative neurological status.
X光、核磁共振以及電腦斷層脊髓攝影是可以用來評估病程以及手術計畫。核磁共振可以評估軟組織和膿瘍的生成。電腦斷層可以看骨頭的結構。治療是根據切片和微生物培養的結果、脊柱後凸的程度、神經惡化的程度以及疾病治療的難易度做調整。減壓和清瘡搭配抗生素治療是當病患有神經缺損後可接受的治療。預後跟病患年紀、全身性疾病的嚴重度以及術前神經狀況有關。
  • Actinomyces israelii , an anaerobic gram-positive bacterium, can cause purulent abscesses, external draining sinuses, and characteristic sulfur granules on microscopic examination. Infection is seen mostly in the cervical spine, secondary to direct extension from a preexisting mandible or supraclavicular infection. Nocardia asteroides , a gram-positive bacterium, can be a rare cause of back pain when the spinal column is involved. Nocardia spreads hematogenously from a pulmonary focus, and osteomyelitis due to this agent has occasionally been reported.
以色列放線菌是一個厭氧的格蘭氏陽性俊,或造成化膿性膿瘍、鼻竇過度積液以及顯微鏡可以看到很具代表的硫磺顆粒。感染往往鑑於頸部脊椎,而下顎或鎖骨上感染則是第二常見。星形諾卡氏菌則是革蘭氏陽性菌,可以背痛很罕見的成因。它會透過血液傳播到肺部,偶爾會造成骨髓炎。
  • Fungal infections of the axial skeleton are rare and occur by spore inhalation, with resultant pulmonary seeding and systemic spread. Spinal osseous involvement in patients with disseminated coccidioidomycotic and blastomycotic infection occurs in 10% to 50% of cases. The incidence of axial skeletal involvement with candidiasis or aspergillosis is low. Both fungal infections tend to occur in immunocompromised hosts. Other rare granulomatous diseases of the axial skeleton include parasitic infections such as syphilis and echinococcosis.
黴菌感染很少見,是因為胞子所感染。會到肺部繁殖然後全身性的傳播。10-50%的脊椎骨相關病患是因為球黴菌和芽生菌所造成。因為念珠菌或是麴菌而感染中軸骨是少見的。這兩個黴菌往往都感染到免疫低下的病患。另外很少見的中軸骨肉芽腫疾病也可能是寄生蟲引起,例如梅毒患者可見的包蟲病。

創作回應

淡顏色
椎間盤裝完支架後,上半身某個角度施力都會酸酸的,大概姿勢不良會特別酸。會不會是金屬摩擦到組織關係?
2021-12-08 22:42:41
WCH
有可能,不過通常是因為術後組織附近水腫壓迫所造成。這時候只能等水腫慢慢消掉並給予症狀緩解。
2021-12-08 22:44:13
淡顏色
好的謝謝,已經開完有兩年多,現在就是避免會酸痛姿勢,生活就平常了。
2021-12-08 22:48:01
WCH
辛苦你了,其實這種手術通常滿意度都沒有到很高,約略五六成左右,不過也有報告是說七八成。
2021-12-08 22:49:51
淡顏色
我自己是覺得七成五滿意,至少工作還可以,剛開完當然沒想像中的理想,不過時間久了就習慣,可能支架要取代那軟綿綿的椎間盤還需要在精進
2021-12-08 23:00:16
WCH
就看看未來科技怎麼發展了哈哈
2021-12-08 23:01:07

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