间盘源性腰痛

null间盘源性腰痛- 复制疼痛好还是抑制疼痛好？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DEFINITION：DEFINITION： 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null椎间盘内破裂 （IDD Internal Disc Disrupation / Derangement） 纤维环放射状撕裂 Radial Tear of annulus 痛性纤维环撕裂 Painful Annulus Tear 痛性椎间盘病 　 Pain Dark Disc Disease 退变性椎间盘疾病（DDD Degenerative Disc Disease) 腰椎僵硬　 Lumbar Spondylosis 孤立性椎间盘吸收 Isolated Disc Resorption 节段不稳（Segmental Instability) Zdeblick classification:IDD account for 39% of DBPThomas A. Zdeblick, MD The Spine 4th edition 750nullThe 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)null0—Normal 1—Contrast agent infiltrate to inner 1/3 of Annulus 2—Contrast agent infiltrate to outer 1/3 of Annulus 3—Contrast agent  infiltrate across the outer annulus CTD shows grade 2 may inducing pain!Dallas classification of Annulus rupture by CTDnullModified Dallas DiscogramnullPathogenesis：null椎间盘造影术后的CT轴向扫描Pathogenesis：nullPathogenesis：Granulation tissue nullSP--Pathogenesis：SP--nullNF--VIP--Pathogenesis：nullExclude： Back pain but not “back” disease（2%） Seldom severe disease（infection,AS） Muscular\fasical\radicular pain Acute injuryDiagnosis：nullChou R, et al. Ann Int Med 2007 Diagnosis and Treatment of Low Back Pain: A Joint Clinical Practice Guideline from the American College of Physicians and the American Pain Society. European Guidelines For The Management Of Acute and Chronic Nonspecific Low Back Pain In Primary Care 2004 Guideline of LBP:nullDiagnosis：Clinical charactersCan not sit or walk for a long time.2. With or without radiating pain. nullClinical charactersX ray : negative CT: degenerative changes.MRI:T2-weighted:“black disc”null The concept of “HIZ (High Indensity Zone)” was first proposed by Aprill, in 1992. MRI high indensity areaSaifuddin. Etc : Specificity:96％;Sensitivity27％. Lam. Etc : Specificity:82％, Sensitivity:89％. Aprill and Bogduk：Specificity:89% ，Sensitivity:71% null provocative pain; Morphological changes of the contrast agent5.Discography: “gold standard” ?null5.Discography: “gold standard” ?SP NF VIPnullLindblom 1940 propose 1950 widespread Block et& Ohnmeiss ： psychological problems--- False Positive Carragee： False Positive ：50％ Domestic：False Positive ：47% 5.Discography: “gold standard” ?nullDoctor--------patient Subjective-------objective5.Discography:CASE REVIEW:CASE REVIEW:Female, 44 y. History：low back pain for 2 years . aggravated for 3 months. Can not sit ,stand,walk for a long time due to the severe pain. Physical examination：no tenderness on lumbar vertebra. No neuro-signs.X-RAY&MRI:X-RAY&MRI:MRI:black discs and HIZMRI:black discs and HIZHow to select the responsible disc?How to select the responsible disc?Multi-disc Severe pain:pain,pain,pain!!! Physical pain or Psychological pain?nullProvoke Inhibitlidocaine is administered intradiscally to inhibit pain. Is it right?CASE REVIEW:CASE REVIEW:CASE REVIEW:CASE REVIEW:After administered intradiscally at L4/5 -- pain relieved obviously. Residual pain After administered intradiscally at L5/S1 --pain disappeared.Research-Method:Research-Method:2009-8---- 2011-5 12 patients Diagnosed as DBP by symptoms,physical sign and imaging Average age was 37.3 Research-Method:Research-Method:All patients was administered disc puncture under C-arm guiding. Method:Research-Criterion :Provoking: contrast agent (Omnipaque) ----administered intradiscally at responsible disc or adjacent disc---- observe the patients reactions.Research-Criterion :Research-Criterion :Inhibting: lidocaine(Concentration of 1%) ---- administered intradiscally at responsible level ----observe the patients’ reactions.Research-Criterion :Results:Results:Provoking pain group( 6 patients ): 4 patients were positive. Average operation time :45 minutes. The remaining were administrated by “inhibiting pain”----pain releasedResults:Inhibiting pain group( 6 patients ): All positive ---- pain disappear, Average operation time :25 minutes.Results:DISSCUSSION:DISSCUSSION:null 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!!!Induce the pain----Difficult!!!Severe pain Pain:before– during—after radiography False-positive Multi-disc pathological changes （at least two discs） No typical HIZInhibit the pain-----???Inhibit the pain-----???More effective & efficient High reliability Accepted by patientsCASE REVIEW:Yin XX M/31 DBP CASE REVIEW:nullnullnullAll images are authorized by the patient!False Positive？False Positive？Inhibit the pain-----???DBP----pain released! LDH,DLSS,VCF---- pain released???Case review:Case review:Sciatica-inefficacy Xu XX F/52 PTED Spinal canal decomprression and Disectomy(L4/5 L5/S1) nullnullnullnull Vertebral compression fractures –inefficacy Zhang XX M/53 L1 PVP nullnullnull结论结论间盘注射利多卡因可以帮助判断间盘源性痛，为间盘源性痛的诊断提供了新的选择 当传统的间盘源性痛复制疼痛不可靠时，可以考虑采用抑制疼痛的方法帮助诊断。 nullTHANKS!