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下腰背痛
Essentials of Diagnosis
診斷要點(diǎn)
Paraspinous low back pain aggravated by exertion.
用力可使下腰脊柱旁疼痛加重
Radiation of pain into the buttock or thigh.
疼痛放射至臀部或大腿
General Considerations
概述
Low back pain is the cause of much time lost from work in the USA， with about 400，000 workers disabled by back pain each year. It has been estimated that 80% of the population suffers low back pain at some time. All physicians are called on at least occasional to advise patients with this complanint， and a systematic approach is necessary to differentiate the numerous possible causes. Diagnosis and management can be frustrating， because the exact cause of most low back pain is uncertain and no cure is known. The first task is to identify the relatively few cases with specific causes that can be treated. The less rewarding and more demanding task is to provide long-term guidance and management for patients for whom specific remedies are unavailable.
在美國(guó)，下腰背痛是損失許多工作時(shí)間的原因，大約每年有400 000名工人因下腰背痛而失去工作能力。某一時(shí)期曾有人估計(jì)，在人群中患下腰痛者達(dá)80%，幾乎所有的醫(yī)生，至少有一、兩次被請(qǐng)求提出對(duì)腰背痛的咨詢(xún)，要鑒別可能產(chǎn)生腰背痛的各種原因，需進(jìn)行系統(tǒng)的探討。由于多數(shù)下腰背痛的確切原因不能肯定，且未聞?dòng)兄斡姆椒ǎ适紫鹊娜蝿?wù)是查出相對(duì)為數(shù)不多的特殊病因并可以治療的病人。對(duì)那些無(wú)特異治療的病人來(lái)說(shuō)得益少，但需要的任務(wù)則是提供長(zhǎng)期的指導(dǎo)和處理。
Clinical Findings
臨床表現(xiàn)
a. Symptoms and Signs： The most common cause of low back pain is mechanical strain. Patients complain of pain related to overexertion. Pain may immediately follow lifting or other forms of exertion or may have a more insidious onset after prolonged physical activity. Many patients in this group demonstrate generally poor conditioning， with poor abdominal muscle tone and poor posture.
a.癥狀和體征：下腰背痛最常見(jiàn)的原因是機(jī)械性勞損。病人主訴有用力過(guò)度相關(guān)聯(lián)的疼痛。在舉重或其它形式用力后立即產(chǎn)生疼痛，或在長(zhǎng)時(shí)間體力活動(dòng)后不知不覺(jué)中發(fā)作疼痛。這類(lèi)病人一般情況顯得較差。腹部肌肉張力較弱和姿勢(shì)不正。
Pain from lumbar strain is exacerbated by bending or lifting and relieved by rest. Pain is often described as a deep-seated aching that is dull and somewhat diffuse. Pain is most severe in the lumbosacral area and may radiate into the buttocks. Palpation reveals tenderness in the paraspinous area， with “trigger points” or “knots” in the erector spinae. Spasm of the paraspinous muscles is a common finding， and the patient may have a slight list toward the nonpainful side. Motion is limited by pain.
起因于腰部勞損的疼痛可因彎腰或舉重加重，休息后可緩解，病人描述為深部印性及少許彌漫性疼痛。腰骶部疼痛最重，并可放射至臀部。觸診時(shí)在脊柱旁有壓痛，豎脊肌內(nèi)有觸發(fā)點(diǎn)或結(jié)，常發(fā)現(xiàn)脊柱旁肌肉痙攣，病人可向非疼痛側(cè)輕度傾斜，活動(dòng)因疼痛而受限。
Physical examination is remarkable for the lack of neurologic involvement. Deep tendon reflexes are present and symmetric. Motor power and sensation in the lower extremities are normal. Rectal tone is normal. The straight leg-raising test is normal. This test is performed with the patient lying supine on the examining table. The examiner lifts the patient's leg， which is extended at the hip and knee. This maneuver passively stretches the sciatic nerve and results in transmission of tension to the lumbosacral roots that contribute to the nerve. The lack of radicular leg pain associated with straight leg raising diminishes the likelihood of spinal nerve compression as the source or symptoms.
物理檢查值得注意的是無(wú)神經(jīng)受累。深部腱反射存在，且對(duì)稱(chēng)。下肢運(yùn)動(dòng)與感覺(jué)正常。直腸的張力正常，直腿抬高試驗(yàn)正常。作此試驗(yàn)時(shí)，應(yīng)讓病人平臥在檢查臺(tái)上，檢查者將病人伸直的髖及膝關(guān)節(jié)的腿抬高，此法使坐骨神經(jīng)受到牽拉，導(dǎo)致張力傳送至腰骶神經(jīng)根部。隨著直腿抬高而無(wú)神經(jīng)根性腿痛者，說(shuō)明胃脊神經(jīng)受壓而引起癥狀的可能性小。
b. X-Ray Findings： X-ray examination may reveal changes such as lumbar disk space narrowing and osteophytosis or may be entirely normal. Because x-ray signs are nonspecific， many clinicians avoid x-ray studies during the initial evaluation. X-rays should be obtained for persons over age 50， in whom metastatic tumors are more likely， and those under age 20， in whom symptomatic congenital or developmental anomalies may be present. For other patients， x-rays may be obtained during subsequent ivsits if symptoms do not resolve within weeks.
b.X線(xiàn)所見(jiàn)：X線(xiàn)檢查可顯示一些變化如腰椎間隙狹窄，有骨贅形成或完全正常。由于X線(xiàn)顯示是非特異性的。許多臨床醫(yī)生開(kāi)始時(shí)避免作X線(xiàn)檢查。年齡超過(guò)50歲，很可能是轉(zhuǎn)移性腫瘤，而年齡在20歲以下者同可能有閏狀性的先天性或發(fā)育性異常常存在，故應(yīng)作X線(xiàn)檢查。對(duì)其它病人來(lái)說(shuō)，就診后數(shù)周內(nèi)癥狀不消失時(shí)，復(fù)診時(shí)可作X線(xiàn)檢查。
Treatment
治療
Management of lumbar strain includes analgesics and rest during the acute phase. A firm board beneath the patient's mattress provides support for tender spinal muscles. Abdominal conditioning and spinal muscle strengthening exercises are prescribed only when pain subsides. Typical exercises include bent-knee sit-ups and hamstring and spinal muscle stretching. Lumbosacral corsets with steel stays provide mechanical support for the spine by compresing and reinforcing the flaccid abdominal wall proper body mechanics should be discussed with the patient， especially the proper manner of lifting objects while bending the legs rather than the spine. Postural exercises may be useful and most effectively taught by trained physical therapists.
在急性期，腰部勞損的處理包括用止痛劑及休息，在床墊下面放置硬板。可為有觸痛的脊柱肌肉提供支撐。只有當(dāng)疼痛消失后，方可作腹部適應(yīng)性的及脊柱旁肌肉增強(qiáng)性的鍛煉，包括屈膝、仰臥起坐及國(guó)繩肌，脊柱旁肌肉的伸曲展活動(dòng)。腰鶻部鋼架腰圍，通過(guò)緊壓和增強(qiáng)松弛的腹壁，對(duì)脊柱起機(jī)械機(jī)撐作用。和病人共同商量適合其軀體的力學(xué)。特別是當(dāng)病人屈腿而不是屈曲脊柱，舉重物時(shí)的最恰當(dāng)姿勢(shì)。由經(jīng)過(guò)訓(xùn)練的物理治療人員教病人作姿勢(shì)性鍛煉是有益和有效的。
Course & Progsis
病程及預(yù)后
The usual course of lumbar strain is spontaneous remission with time. Relapses of pain are commonly precipitated by stressful activity， though months may pass without symptoms. Some patients complain of constant pain without real remission. Probing inquiry frequently reveals profound depression in these individuals， for whom illness and disability have become dominant elements in their lives. When strain is attributed to working conditions， the clinical course may be complicated by considerations of secondary gain.
腰部勞損的通常病程隨時(shí)間而自行緩解。雖然幾個(gè)月在無(wú)癥狀中度過(guò)，又常因腰部用力活動(dòng)促使疼痛復(fù)發(fā)。有些病人自述疼痛持續(xù)而無(wú)真正緩解。經(jīng)調(diào)查詢(xún)問(wèn)表明這些病人有嚴(yán)重意志消沉現(xiàn)象，對(duì)他們來(lái)說(shuō)，疾病和傷殘成為生活中的主要組成部分。當(dāng)勞損是由于工作條件引起時(shí)，要考慮到再次勞損可使得病程復(fù)雜化。
Patients who fail to respond to rest and supportive measures must be carefully reexamined to rule out development of neurologic compromise. Those who remain neurologically normal must be encouraged to return to normal activities as rapidly as possible. Prolonged reliance upon analgesics must be discourage.
當(dāng)休息及支撐療法對(duì)病人無(wú)效時(shí)，必須仔細(xì)再檢查，以排除發(fā)生神經(jīng)損傷的可能性。對(duì)那些一直是神經(jīng)正常的病人，應(yīng)盡快地鼓勵(lì)他恢復(fù)正?；顒?dòng)，對(duì)長(zhǎng)期依賴(lài)止痛藥的病人一定要進(jìn)行勸阻。
Essentials of Diagnosis
診斷要點(diǎn)
Paraspinous low back pain aggravated by exertion.
用力可使下腰脊柱旁疼痛加重
Radiation of pain into the buttock or thigh.
疼痛放射至臀部或大腿
General Considerations
概述
Low back pain is the cause of much time lost from work in the USA， with about 400，000 workers disabled by back pain each year. It has been estimated that 80% of the population suffers low back pain at some time. All physicians are called on at least occasional to advise patients with this complanint， and a systematic approach is necessary to differentiate the numerous possible causes. Diagnosis and management can be frustrating， because the exact cause of most low back pain is uncertain and no cure is known. The first task is to identify the relatively few cases with specific causes that can be treated. The less rewarding and more demanding task is to provide long-term guidance and management for patients for whom specific remedies are unavailable.
在美國(guó)，下腰背痛是損失許多工作時(shí)間的原因，大約每年有400 000名工人因下腰背痛而失去工作能力。某一時(shí)期曾有人估計(jì)，在人群中患下腰痛者達(dá)80%，幾乎所有的醫(yī)生，至少有一、兩次被請(qǐng)求提出對(duì)腰背痛的咨詢(xún)，要鑒別可能產(chǎn)生腰背痛的各種原因，需進(jìn)行系統(tǒng)的探討。由于多數(shù)下腰背痛的確切原因不能肯定，且未聞?dòng)兄斡姆椒ǎ适紫鹊娜蝿?wù)是查出相對(duì)為數(shù)不多的特殊病因并可以治療的病人。對(duì)那些無(wú)特異治療的病人來(lái)說(shuō)得益少，但需要的任務(wù)則是提供長(zhǎng)期的指導(dǎo)和處理。
Clinical Findings
臨床表現(xiàn)
a. Symptoms and Signs： The most common cause of low back pain is mechanical strain. Patients complain of pain related to overexertion. Pain may immediately follow lifting or other forms of exertion or may have a more insidious onset after prolonged physical activity. Many patients in this group demonstrate generally poor conditioning， with poor abdominal muscle tone and poor posture.
a.癥狀和體征：下腰背痛最常見(jiàn)的原因是機(jī)械性勞損。病人主訴有用力過(guò)度相關(guān)聯(lián)的疼痛。在舉重或其它形式用力后立即產(chǎn)生疼痛，或在長(zhǎng)時(shí)間體力活動(dòng)后不知不覺(jué)中發(fā)作疼痛。這類(lèi)病人一般情況顯得較差。腹部肌肉張力較弱和姿勢(shì)不正。
Pain from lumbar strain is exacerbated by bending or lifting and relieved by rest. Pain is often described as a deep-seated aching that is dull and somewhat diffuse. Pain is most severe in the lumbosacral area and may radiate into the buttocks. Palpation reveals tenderness in the paraspinous area， with “trigger points” or “knots” in the erector spinae. Spasm of the paraspinous muscles is a common finding， and the patient may have a slight list toward the nonpainful side. Motion is limited by pain.
起因于腰部勞損的疼痛可因彎腰或舉重加重，休息后可緩解，病人描述為深部印性及少許彌漫性疼痛。腰骶部疼痛最重，并可放射至臀部。觸診時(shí)在脊柱旁有壓痛，豎脊肌內(nèi)有觸發(fā)點(diǎn)或結(jié)，常發(fā)現(xiàn)脊柱旁肌肉痙攣，病人可向非疼痛側(cè)輕度傾斜，活動(dòng)因疼痛而受限。
Physical examination is remarkable for the lack of neurologic involvement. Deep tendon reflexes are present and symmetric. Motor power and sensation in the lower extremities are normal. Rectal tone is normal. The straight leg-raising test is normal. This test is performed with the patient lying supine on the examining table. The examiner lifts the patient's leg， which is extended at the hip and knee. This maneuver passively stretches the sciatic nerve and results in transmission of tension to the lumbosacral roots that contribute to the nerve. The lack of radicular leg pain associated with straight leg raising diminishes the likelihood of spinal nerve compression as the source or symptoms.
物理檢查值得注意的是無(wú)神經(jīng)受累。深部腱反射存在，且對(duì)稱(chēng)。下肢運(yùn)動(dòng)與感覺(jué)正常。直腸的張力正常，直腿抬高試驗(yàn)正常。作此試驗(yàn)時(shí)，應(yīng)讓病人平臥在檢查臺(tái)上，檢查者將病人伸直的髖及膝關(guān)節(jié)的腿抬高，此法使坐骨神經(jīng)受到牽拉，導(dǎo)致張力傳送至腰骶神經(jīng)根部。隨著直腿抬高而無(wú)神經(jīng)根性腿痛者，說(shuō)明胃脊神經(jīng)受壓而引起癥狀的可能性小。
b. X-Ray Findings： X-ray examination may reveal changes such as lumbar disk space narrowing and osteophytosis or may be entirely normal. Because x-ray signs are nonspecific， many clinicians avoid x-ray studies during the initial evaluation. X-rays should be obtained for persons over age 50， in whom metastatic tumors are more likely， and those under age 20， in whom symptomatic congenital or developmental anomalies may be present. For other patients， x-rays may be obtained during subsequent ivsits if symptoms do not resolve within weeks.
b.X線(xiàn)所見(jiàn)：X線(xiàn)檢查可顯示一些變化如腰椎間隙狹窄，有骨贅形成或完全正常。由于X線(xiàn)顯示是非特異性的。許多臨床醫(yī)生開(kāi)始時(shí)避免作X線(xiàn)檢查。年齡超過(guò)50歲，很可能是轉(zhuǎn)移性腫瘤，而年齡在20歲以下者同可能有閏狀性的先天性或發(fā)育性異常常存在，故應(yīng)作X線(xiàn)檢查。對(duì)其它病人來(lái)說(shuō)，就診后數(shù)周內(nèi)癥狀不消失時(shí)，復(fù)診時(shí)可作X線(xiàn)檢查。
Treatment
治療
Management of lumbar strain includes analgesics and rest during the acute phase. A firm board beneath the patient's mattress provides support for tender spinal muscles. Abdominal conditioning and spinal muscle strengthening exercises are prescribed only when pain subsides. Typical exercises include bent-knee sit-ups and hamstring and spinal muscle stretching. Lumbosacral corsets with steel stays provide mechanical support for the spine by compresing and reinforcing the flaccid abdominal wall proper body mechanics should be discussed with the patient， especially the proper manner of lifting objects while bending the legs rather than the spine. Postural exercises may be useful and most effectively taught by trained physical therapists.
在急性期，腰部勞損的處理包括用止痛劑及休息，在床墊下面放置硬板。可為有觸痛的脊柱肌肉提供支撐。只有當(dāng)疼痛消失后，方可作腹部適應(yīng)性的及脊柱旁肌肉增強(qiáng)性的鍛煉，包括屈膝、仰臥起坐及國(guó)繩肌，脊柱旁肌肉的伸曲展活動(dòng)。腰鶻部鋼架腰圍，通過(guò)緊壓和增強(qiáng)松弛的腹壁，對(duì)脊柱起機(jī)械機(jī)撐作用。和病人共同商量適合其軀體的力學(xué)。特別是當(dāng)病人屈腿而不是屈曲脊柱，舉重物時(shí)的最恰當(dāng)姿勢(shì)。由經(jīng)過(guò)訓(xùn)練的物理治療人員教病人作姿勢(shì)性鍛煉是有益和有效的。
Course & Progsis
病程及預(yù)后
The usual course of lumbar strain is spontaneous remission with time. Relapses of pain are commonly precipitated by stressful activity， though months may pass without symptoms. Some patients complain of constant pain without real remission. Probing inquiry frequently reveals profound depression in these individuals， for whom illness and disability have become dominant elements in their lives. When strain is attributed to working conditions， the clinical course may be complicated by considerations of secondary gain.
腰部勞損的通常病程隨時(shí)間而自行緩解。雖然幾個(gè)月在無(wú)癥狀中度過(guò)，又常因腰部用力活動(dòng)促使疼痛復(fù)發(fā)。有些病人自述疼痛持續(xù)而無(wú)真正緩解。經(jīng)調(diào)查詢(xún)問(wèn)表明這些病人有嚴(yán)重意志消沉現(xiàn)象，對(duì)他們來(lái)說(shuō)，疾病和傷殘成為生活中的主要組成部分。當(dāng)勞損是由于工作條件引起時(shí)，要考慮到再次勞損可使得病程復(fù)雜化。
Patients who fail to respond to rest and supportive measures must be carefully reexamined to rule out development of neurologic compromise. Those who remain neurologically normal must be encouraged to return to normal activities as rapidly as possible. Prolonged reliance upon analgesics must be discourage.
當(dāng)休息及支撐療法對(duì)病人無(wú)效時(shí)，必須仔細(xì)再檢查，以排除發(fā)生神經(jīng)損傷的可能性。對(duì)那些一直是神經(jīng)正常的病人，應(yīng)盡快地鼓勵(lì)他恢復(fù)正?；顒?dòng)，對(duì)長(zhǎng)期依賴(lài)止痛藥的病人一定要進(jìn)行勸阻。