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1、腰 痛 Low Back PainLow Back Pain 香港大学深圳医院家庭医学科 鲁刚 2015-11-22 全科门诊里最常见的疾病是什么？ 第二常见的是什么？ Katz JNLumbar disc disorders and low back pain：socioeconomic factors and consequences. J Bone Joint Surg Am， 2006，88：2 1-24 感冒感冒！ 腰痛 全世界约全世界约80%80%的成人有腰痛史的成人有腰痛史 概论概论 腰痛最常见原因是什么？ 腰肌劳损 第二常见的是什么？ （约占70%） （约占10%） 腰椎间盘突
2、出 腰椎退行性变 第三？ （约占4%） 腰痛的病因诊断腰痛的病因诊断 腰痛的病因诊断腰痛的病因诊断 机械性腰腿痛 （97%） 1.腰肌劳损扭伤，70%, 2.盘和小关节退行性病变，10% 3.椎间盘突出，4% 4.骨质疏松性压缩性骨折 ，4% 5.椎管狭窄，3% 6.脊椎前移， 2% 7.创伤性骨折，1% 8.先天性， 1% 9.椎骨分离， 10.盘内破裂或盘源性腰痛 11.假定不稳 腰痛的鉴别诊断 非机械性脊椎疾病 （1%） 1.新生物 （0.7%） 2.炎性关节炎 （常伴随HLAb27) （0.3%） 3.感染 （0.01%） 4.schuermanns病 骨软骨病，骨软骨炎 5，Page
3、ts病 内脏疾病 （2%） 1.盆腔疾病 前列腺炎 盆腔炎 子宫内膜异位 2.肾脏疾病 3.主动脉瘤 4.胃肠道疾病 心理疾病 腰痛的病因诊断腰痛的病因诊断 the “red flag” warning signs that suggest serious problems. nrecent major injury n radiation of pain down a leg npain that is constant npain in the upper back or chest nunexplained fever or weight loss npain that increase
4、s at night -转专科治疗 不同国家腰痛的分类 国家分类诊断 Eur Spine J. 2010 Dec;19(12):2075- 94. Australia1.Non-specific LBP 2.Specific LBP Europe 1.Non-specific LBP 2. Specific spinal phathology 3.Nerve root pain/radicular pain Finland 1.Non-specific LBP 2.Possible serious or specific disease 3.Nerve root dysfunction (sc
5、iatic syndrome ,intermittent claudication) Germany 1.Non-specific LBP 2.Specific LBP (based on red flags) 3.Patients at risk for chronicity (based on yellow flags) 3.Radicular pain Italy 1.Non-specific LBP 2.Specific LBP 3.Sciatica USA 1.Non-specific LBP 2.LBP due to specific causes 3.LBP-Radiculopa
6、thy/Spinal Stenosis United Kingdon 1.Non-specific:Mechnical LBP 2.Inflammtory LBP and stiffness 3.Serious pathology The Netherlands 1.Non-specific LBP 2.Specific LBP (based on a list of red flags) 腰痛的分类诊断腰痛的分类诊断 目前最适合全科的腰痛分类法 英美德等13国指南分类法： l非特异性 nonspecific LBP 占所有腰痛的 85% l特异性 specific LBP（肿瘤、感染、风湿、
7、骨折等 ） l坐骨神经/根性疼痛综合征 sciatica 腰痛的分类 非特异性腰痛的临床特征 Clinical features of nonspecific low back pain l绝大部分患者（85%）找不到明确诱 因,X线、CT、MRI检查均无阳性发现,常 靠主诉或压痛点诊断！-特点及定义 腰痛的分类 非特异性腰痛具体包括哪些内容？ What contents included in Nonspecific LBP？ l主要包括：脊柱旁及臀部背伸肌群、棘 上、棘间韧带、 横突间韧带等软组织引 起的腰痛。其发病机理还不十分清楚。 如： 1.腰肌劳损 2.腰椎横突综合征 3.梨状肌综合
8、征 4.心理性腰痛等 非特异性腰痛 的 全科治疗 腰痛的治疗 CountryMedicationExercisesReferral to specialist United States 1.Paracetamol,NSAIS 2.Foracute(4 weeks) antidepressants, benzodiazepines, tramadol, opioids Not effective for acute LBP Recommended for subacute or chronic LBP For interdisciplinary intervention if chronic
9、If suspicion of significant nerve root impingement or spinal stenosis United Kingdom 1.paracetamol (preferred) or NSAID. bine paracetamol and NSAID or add a weak opioid (codeine or tramadol). 3.For non-responders consider benzodiazepine, tricyclic antidepressant Advise patient to stay as active as p
10、ossible. No specific recommendations regarding exercise If progressive neurological deficit If pain or disability remain problematic for more than a week or two consider referral for physio/physical therapy If pain/disability continue to be a problem despite pharmacotherapy and physical therapy cons
11、ider referral to multidisciplinary back pain service or chronic pain clinic 不同国家对腰痛的最新处理比较不同国家对腰痛的最新处理比较 CountryMedicationExercisesReferral to specialist Germany 1.paracetamol, 2.NSAIDs 3.Muscle relaxants (oral or topical), (in cases with muscle spasms, 4.Opioids Acute LBP: exercise therapy not effe
12、ctive Subacute and Chronic LBP: Exercise therapy well supported by evidence Immediate surgery indicated for cauda equina syndrome Optional referral for surgery: therapy resistant (6 weeks) + signs of nerve root compression Surgery may be an option if after 2 years conservative treatment, including b
13、iopsychosocial treatment programme was unsuccessful Australia 1.Paracetamol 2.NSAIDs 3.oral opioids There is conflicting evidence of the effect of exercises but evidence shows that it is no better than usual care When alerting features (red flags) or serious conditions are present 不同国家对腰痛的最新处理比较不同国家
14、对腰痛的最新处理比较 CountryMedicationExercisesReferral to specialist Europe 1.paracetamol, 2.NSAIDs. 3. short course of muscle relaxants on its own or added to NSAIDs Do not advise specific exercises (for example strengthening, stretching, flexion, and extension exercises) for acute low back pain Refer patie
15、nts with neurological symptoms such as cauda equina syndrome Canada NSAIDs, muscle relaxants and analgesics for acute. Low evidence for NSAIDs and analgesics for subacute pain Strengthening exercises, extension exercises and specific exercises are not recommended for acute but recommended for subacu
16、te and chronic with no superior form of exercise Refer patients with neurological signs or symptoms if functional deficits are persistent or deteriorating after 4 weeks 不同国家对腰痛的最新处理比较不同国家对腰痛的最新处理比较 如何正确有效地进行康复运动？ 对康复机制理解的关键是： 腰椎的运动肌与稳定肌的不同 “Global“ muscles“Local“ muscles l腹直肌 l腹内外斜肌 l竖脊肌 l腰方肌 腹横肌 多裂肌 膈肌 The Pelvic floor 锻炼内层局部肌肉只有在 肢体不平衡的情况下锻炼 才能达到效果！ 2015年最新中华运动医学杂志发 表的最新美国康复医学会骨科分 会的下腰痛康复指南 最新指南 错误方法错误方法 错误方法错误方法 有关非特异性腰痛的一些最新研究 最新研究进展最新研究进展 对乙
