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1、间盘源性腰痛- 复制疼痛好还是抑制疼痛好？刘宪义 北京大学第一医院DEFINITIONDEFINITION：DBP（discogenic back pain ）：伴或不伴下肢放射痛的慢性腰痛，起自椎间盘本身，由椎间盘内部正常结构破坏和生化改变引起的腰痛或放射痛椎间盘内破裂 （IDD Internal Disc Disrupation / Derangement） 纤维环放射状撕裂纤维环放射状撕裂 Radial Tear of annulusRadial Tear of annulus 痛性纤维环撕裂痛性纤维环撕裂 Painful Annulus TearPainful Annulus Tear
2、 痛性椎间盘病痛性椎间盘病 Pain Dark Disc Disease Pain Dark Disc Disease 退变性椎间盘疾病（DDD Degenerative Disc Disease) 腰椎僵硬 腰椎僵硬 Lumbar Lumbar SpondylosisSpondylosis 孤立性椎间盘吸收孤立性椎间盘吸收 Isolated Disc Isolated Disc ResorptionResorption节段不稳（Segmental Instability)Zdeblick classification:IDD account for 39% of DBPThomas A. Z
3、deblick, MDThe Spine 4th edition 750The concept of “internal disruptions” was proposed by Crock, in 1970 and 1986.Low back pain may occurred without nerve root compression.IDD(Internal Disc Disrupation / Derangement)0Normal1Contrast agent infiltrate to inner 1/3 of Annulus 2Contrast agent infiltrate
4、 to outer 1/3 of Annulus 3Contrast agent infiltrate across the outer annulusCTD shows grade 2 may inducing pain!Dallas classification of Annulus rupture by CTDModified Dallas DiscogramPathogenesis：椎间盘造影术后的CT轴向扫描Pathogenesis：Pathogenesis：Granulation tissue SP-Pathogenesis：SP-NF-VIP-Pathogenesis：Exclu
5、de：1.Back pain but not “back” disease（2% ）2.Seldom severe disease（infection,AS）3.Muscularfasicalradicular pain4.Acute injuryDiagnosis： Chou R, et al. Ann Int Med 2007Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American
6、 Pain Society.European Guidelines For The Management Of Acute and Chronic Nonspecific Low Back Pain In Primary Care 2004Guideline of LBP:Diagnosis： Clinical charactersClinical characters1.1. Can not sit or walk Can not sit or walk for a long time.for a long time.2. With or without radiating pain. ad
7、iating pain. Clinical charactersClinical characters3.3. X ray : X ray : negativeCT: CT: degenerative changes.4.4. MRI:T2-MRI:T2- weighted:weighted:“ “black disc” The concept of “HIZ (High HIZ (High IndensityIndensity Zone) Zone)” was first proposed by Aprill, in 1992.MRI high indensity areaSaifuddin
8、. Etc : Specificity:96 ;Sensitivity27.Lam. Etc : Specificity:82, Sensitivity:89.Aprill and Bogduk： Specificity:89% ， Sensitivity:71%provocative pain; Morphological changes of the contrast agent5.Discography: “gold standard” ?5.Discography: “gold standard” ?SPNFVIPLindblom 1940 propose1950 widespread
9、 Block et& Ohnmeiss ： psychological problems- False Positive Carragee： False Positive ：50Domestic：False Positive ：47%5.Discography: “gold standard” ?Doctor-patientSubjective-objective5.Discography:CASE REVIEW:lFemale, 44 y. lHistory：low back pain for 2 years . aggravated for 3 months. Can not sit ,s
10、tand,walk for a long time due to the severe pain.lPhysical examination：no tenderness on lumbar vertebra. No neuro-signs.X-RAY&MRI:MRI:black discs and HIZHow to select the responsible disc?lMulti-disclSevere pain:pain,pain,pain!lPhysical pain or Psychological pain?lProvoke Inhibitllidocaine is admini
11、stered intradiscally to inhibit pain. Is it right?CASE REVIEW:CASE REVIEW:lAfter administered intradiscally at L4/5 - pain relieved obviously.lResidual painlAfter administered intradiscally at L5/S1 - pain disappeared.Research-Method:l2009-8- 2011-5l12 patients lDiagnosed as DBP by symptoms,physical
12、 sign and imaging lAverage age was 37.3 Research-Method:lAll patients was administered disc puncture under C-arm guiding. lMethod:lProvoking: contrast agent (Omnipaque) -administered intradiscally at responsible disc or adjacent disc- observe the patients reactions.Research-Criterion :lInhibting: li
13、docaine(Concentration of 1%) - administered intradiscally at responsible level -observe the patients reactions.Research-Criterion :Results:lProvoking pain group( 6 patients ): l4 patients were positive. lAverage operation time :45 minutes. lThe remaining were administrated by “inhibiting pain”-pain
14、releasedlInhibiting pain group( 6 patients ): lAll positive - pain disappear,lAverage operation time :25 minutes.Results:DISSCUSSION:腰痛6个月以上；系统保守治疗无效；神经系统检查正常；直腿抬高试验阴性；椎间盘造影有1-2个椎间盘异常，并有6/10原疼 痛强度的诱发疼痛（Derby R，et al：Neuromodulation，2000，3（2）：82）间盘源性痛诊断标准Induce the pain-Difficult!lSevere painlPain:be
15、fore during after radiographylFalse-positivelMulti-disc pathological changes （at least two discs）lNo typical HIZInhibit the pain-?lMore effective & efficient lHigh reliability lAccepted by patientsYin XX M/31 DBPCASE REVIEW:All images are authorized by the patient!All images are authorized by the patient!False Positive？Inhibit the pain-?DBP-pain released!LDH,DLSS,VCF- pain released?Case review:lSciatica-inefficacy Xu XX F/52 PTED Spinal canal decomprression and Disectomy(L4/5 L5/S1)lVertebral compression fractures inefficacyZha
