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Youmans:脊椎疼痛鑑別診斷-7(完)

WCH | 2022-01-20 20:56:26 | 巴幣 2320 | 人氣 294


代謝相關疾病

  • Metabolic disorders can affect bone mineralization or density and many predispose affected patients to benign pathologic fractures. Some metabolic disorders, such as Paget's disease, have malignant potential. Frequently, patients with metabolic disorders present with systemic symptoms and signs of the disease before the discovery of any spine pathology. The most common metabolic bone diseases are osteoporosis, osteomalacia, and Paget's disease, and they manifest as localized spine pain, pathologic vertebral column fractures, or symptoms from neural entrapment. Most pathologic vertebral column fractures cause acute localized pain without neurological deficits. External bracing may help relieve pain in the acute phase of a vertebral fracture and should be discontinued when the symptoms resolve. Surgery is reserved for fractures resulting in gross deformity, instability, or neurological impairment. The extensive list of metabolic bone diseases is covered in other chapters; most are managed medically.
代謝疾病可能會影響到骨頭的礦化(註:磷酸鈣的堆積)或是密度。而這些會導致病患出現病理性的骨折。一些代謝疾病,例如柏德氏症,會有癌化的傾向。通常有著代謝疾病的病患往往在出現脊椎疾病前就有全身性的症狀。最常見的代謝性骨病變為骨質疏鬆症、軟骨症以及柏德氏症。這些疾病最大的特點就是局部的脊椎疼痛、病理性脊椎椎體骨折或是神經纏套的症狀。很多的病理性脊椎椎體骨折會導致沒有神經缺損的神經痛。

使用外戴的頸圈可能在急性脊椎骨折時改善疼痛,在不會疼痛的時候也可以拿掉。對於骨折導致的整體變形、不穩定或是神經傷害,都會考慮動手術。而其他的代謝性骨疾病則多數可以靠藥物來處理。
  • Osteoporosis affects 15 to 20 million Americans and is characterized by decreased amounts of bone that is of normal quality, increasing the patient's susceptibility to fractures. Osteoporosis can be primary, which is idiopathic, or secondary, which is a result of endocrinopathies, neoplastic diseases, hematologic disorders, mechanical disorders, biochemical collagen disturbances, or nutritional aberrations. Common causes of secondary osteoporosis include hyperthyroidism, hyperparathyroidism, Cushing's disease, hypothalamic hypogonadism, estrogen deficiency, diabetes mellitus, steroid exposure, multiple myeloma, leukemia, and prolonged bed rest. Osteoporosis results in 1 to 2 million pathologic skeletal fractures each year.
骨質疏鬆影響美國1500-2000萬的人,會減少骨質並增加骨折的風險。骨質疏鬆可以是初級的,通常來源不明。也可能是次級的,來自於內分泌病變、腫瘤、血液疾病、機械性病變、生化的膠原蛋白受影響或是營養師腸。常見的次級骨質疏鬆包含高甲狀腺素、高副甲狀腺素、庫森氏疾病、下視丘性腺功能低下、雌激素缺乏、糖尿病、長期使用類固醇、多發性骨髓瘤、白血病以及臥床太久。骨質疏鬆每年會導致1-2百萬個病理性骨折發生。
  • Osteomalacia and Paget's disease occur less frequently than osteoporosis, although Paget's disease is the second most common metabolic bone disturbance in the United States after osteoporosis. Osteomalacia, a metabolic bone disease characterized by inadequate mineralization of newly formed osteoid, results from a deficiency of or resistance to vitamin D, intestinal malabsorption, acquired or hereditary renal disorders, intoxication with heavy metals (aluminum and iron), and other assorted causes. Paget's disease is characterized by excessive osteoclast and osteoblast activity, which increases bone resorption and promotes marrow replacement by hypervascular fibrous tissue, resulting in a brittle bone matrix susceptible to fracture. The incidence of Paget's disease is 1 per 1000 persons, and the vertebrae, pelvis, and femora are the bones most commonly involved. Malignant degeneration occurs in 1% to 10% of patients with the disease; the most common malignant tumor in pagetic bone is osteogenic sarcoma. The clinical presentation involving the spine includes local pain, vertebral fractures, or entrapment of nerve roots. Treatment is multidisciplinary, with surgery reserved for instability or progressive neurological deficits.
軟骨症以及柏德氏症比骨質疏鬆來得不常見。雖然柏德氏症是美國代謝性骨疾病中僅次於骨質疏鬆還常見的疾病。軟骨症是因為不正常骨質礦化而造成類骨質的形成。是因為維生素D的缺乏或身體對維生素D有耐受性、腸道吸收差、後天或先天的腎臟疾病、重金屬(例如鋁或是鐵)中毒或是其他原因。柏德氏症會表現出過多的蝕骨細胞以及成骨細胞活性。這些都會造成骨頭再吸收增加以及促進骨髓被富含血管的纖維組織所取代。進而造成骨基質脆化而導致骨折。柏德氏症發生於1/1000的病患,同時在脊椎骨、骨盆以及大腿的股骨是最常被侵犯的地方。在1-10%的病患可以看到癌化。柏德氏症最常造成的癌化是變成骨源性肉瘤。臨床表現包含脊椎的局部疼痛、脊椎骨折或是神經根纏套。治療方式很多樣,通常在脊椎不穩定或是有惡化的神經病變會考慮手術。

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