1、間盤源性腰痛間盤源性腰痛-復(fù)制疼痛好還是抑制疼痛好？復(fù)制疼痛好還是抑制疼痛好？劉憲義北京大學(xué)第一醫(yī)院 DBP DBPdiscogenic back pain discogenic back pain ）：伴）：伴或不伴下肢放射痛的慢性腰痛，起自椎間或不伴下肢放射痛的慢性腰痛，起自椎間盤本身，由椎間盤內(nèi)部正常結(jié)構(gòu)破壞和生盤本身，由椎間盤內(nèi)部正常結(jié)構(gòu)破壞和生化改變引起的腰痛或放射痛化改變引起的腰痛或放射痛椎間盤內(nèi)破裂椎間盤內(nèi)破裂（IDD Internal Disc Disrupation / Derangement）纖維環(huán)放射狀撕裂纖維環(huán)放射狀撕裂 Radial Tear of annulus痛性

2、纖維環(huán)撕裂痛性纖維環(huán)撕裂 Painful Annulus Tear痛性椎間盤病痛性椎間盤病 Pain Dark Disc Disease 退變性椎間盤疾病退變性椎間盤疾病DDD Degenerative Disc Disease) 腰椎僵硬腰椎僵硬 Lumbar Spondylosis孤立性椎間盤吸收孤立性椎間盤吸收 Isolated Disc Resorption節(jié)段不穩(wěn)節(jié)段不穩(wěn)Segmental Instability) Zdeblick classification:Zdeblick classification:IDDaccountfor39%ofDBPThomas A. Zdebli

3、ck, MD The 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 IDD(Internal Disc Disrupation / Disrupation / Derangement)Derangement)0Normal1Contrastagentinfiltratetoinner1/3ofA

4、nnulus2Contrastagentinfiltratetoouter1/3ofAnnulus3ContrastagentinfiltrateacrosstheouterannulusCTDshowsgrade2mayinducingpain!Dallas classification of Dallas classification of Annulus rupture by CTDAnnulus rupture by CTDModified Dallas DiscogramModified Dallas DiscogramPathogenesis：椎間盤造影術(shù)后的椎間盤造影術(shù)后的CTC

5、T軸向掃描軸向掃描Pathogenesis：Pathogenesis：GranulationtissueSP-Pathogenesis：SP-NF-VIP-Pathogenesis：ExcludeExclude：Back pain but not “back” diseaseBack pain but not “back” disease2%2%）Seldom severe diseaseSeldom severe diseaseinfection,ASinfection,AS）Muscularfasicalradicular painMuscularfasicalradicular pain

6、Acute injuryAcute injuryDiagnosis： ChouR,etal.AnnIntMed2019 DiagnosisandTreatmentofLowBackPain:AJoint ClinicalPracticeGuidelinefromtheAmerican CollegeofPhysiciansandtheAmericanPainSociety. European Guidelines For The Management Of Acute and Chronic Nonspecific Low Back Pain In Primary Care 2019Guide

7、line of LBP:Guideline of LBP:Diagnosis：2. With or without radiating pain. The concept of “HIZ (High Indensity Zone)” was first proposed by Aprill, in 1992.MRIhighindensityareaSaifuddin.Etc:Specificity:96;Sensitivity27.Lam.Etc:Specificity:82,Sensitivity:89.AprillandBogduk：Specificity:89%，Sensitivity:

8、71% provocative pain; Morphological changes of the contrast agent5.Discography: “gold 5.Discography: “gold standard” ?standard” ?5.Discography: “gold 5.Discography: “gold standard” ?standard” ?SPNFVIPLindblom1940propose1950widespreadBlocket&Ohnmeiss：psychologicalproblems-FalsePositiveCarragee：FalseP

9、ositive：50Domestic：FalsePositive：47%5.Discography: “gold 5.Discography: “gold standard” ?standard” ?Doctor-patientSubjective-objective5.Discography:5.Discography:CASEREVIEW:lFemale,44y.lHistory：lowbackpainfor2years.aggravatedfor3months.Cannotsit,stand,walkforalongtimeduetotheseverepain.lPhysicalexam

10、ination：notendernessonlumbarvertebra.Noneuro-signs.X-RAY&MRI:MRI:blackdiscsandHIZHowtoselecttheresponsibledisc?lMulti-disclSeverepain:pain,pain,pain!lPhysicalpainorPsychologicalpain?lProvokeInhibitllidocaineisadministeredintradiscallytoinhibitpain.Isitright?CASEREVIEW:CASEREVIEW:lAfteradministeredin

11、tradiscallyatL4/5-painrelievedobviously.lResidualpainlAfteradministeredintradiscallyatL5/S1-paindisappeared.Research-Method:l2021-8-2019-5l12patientslDiagnosedasDBPbysymptoms,physicalsignandimaginglAverageagewas37.3Research-Method:lAllpatientswasadministereddiscpunctureunderC-armguiding.lMethod:lPro

12、voking:contrastagent(Omnipaque)-administeredintradiscallyatresponsiblediscoradjacentdisc-observethepatientsreactions.Research-Criterion:lInhibting:lidocaine(Concentrationof1%)-administeredintradiscallyatresponsiblelevel-observethepatientsreactions.Research-Criterion:Results:lProvokingpaingroup(6pati

13、ents):l4patientswerepositive.lAverageoperationtime:45minutes.lTheremainingwereadministratedby“inhibitingpain”-painreleasedlInhibitingpaingroup(6patients):lAllpositive-paindisappear,lAverageoperationtime:25minutes.Results:DISSCUSSION:腰痛6個月以上；系統(tǒng)保守治療無效；神經(jīng)系統(tǒng)檢查正常；直腿抬高試驗陰性；椎間盤造影有1-2個椎間盤異常，并有6/10原疼痛強度的誘發(fā)疼痛

14、（DerbyR，etal：Neuromodulation，2000，32）：82）間盤源性痛診斷標(biāo)準(zhǔn)間盤源性痛診斷標(biāo)準(zhǔn)Inducethepain-Difficult!lSeverepainlPain:beforeduringafterradiographylFalse-positivelMulti-discpathologicalchanges（atleasttwodiscs）lNotypicalHIZInhibitthepain-?lMoreeffective&efficientlHighreliabilitylAcceptedbypatientsYin XXYin XXM/31 M/31 DBPDBP CASEREVIEW:FalsePositive？Inhibitthepain-?DBP-painreleased!LDH,DLSS,VCF-painreleased?