下腰背痛
essentials of diagnosis
诊断要点
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.
在美国，下腰背痛是损失许多工作时间的原因，大约每年有400 000名工人因下腰背痛而失去工作能力。某一时期曾有人估计，在人群中患下腰痛者达80%，几乎所有的医生，至少有一、两次被请求提出对腰背痛的咨询，要鉴别可能产生腰背痛的各种原因，需进行系统的探讨。由于多数下腰背痛的确切原因不能肯定，且未闻有治愈的方法，故首先的任务是查出相对为数不多的特殊病因并可以治疗的病人。对那些无特异治疗的病人来说得益少，但需要的任务则是提供长期的指导和处理。
clinical findings
临床表现
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.症状和体征：下腰背痛最常见的原因是机械性劳损。病人主诉有用力过度相关联的疼痛。在举重或其它形式用力后立即产生疼痛，或在长时间体力活动后不知不觉中发作疼痛。这类病人一般情况显得较差。腹部肌肉张力较弱和姿势不正。
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.
起因于腰部劳损的疼痛可因弯腰或举重加重，休息后可缓解，病人描述为深部印性及少许弥漫性疼痛。腰骶部疼痛最重，并可放射至臀部。触诊时在脊柱旁有压痛，竖脊肌内有触发点或结，常发现脊柱旁肌肉痉挛，病人可向非疼痛侧轻度倾斜，活动因疼痛而受限。
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.
物理检查值得注意的是无神经受累。深部腱反射存在，且对称。下肢运动与感觉正常。直肠的张力正常，直腿抬高试验正常。作此试验时，应让病人平卧在检查台上，检查者将病人伸直的髋及膝关节的腿抬高，此法使坐骨神经受到牵拉，导致张力传送至腰骶神经根部。随着直腿抬高而无神经根性腿痛者，说明胃脊神经受压而引起症状的可能性小。
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线所见：x线检查可显示一些变化如腰椎间隙狭窄，有骨赘形成或完全正常。由于x线显示是非特异性的。许多临床医生开始时避免作x线检查。年龄超过50岁，很可能是转移性肿瘤，而年龄在20岁以下者同可能有闰状性的先天性或发育性异常常存在，故应作x线检查。对其它病人来说，就诊后数周内症状不消失时，复诊时可作x线检查。
treatment
治疗
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，腰部劳损的处理包括用止痛剂及休息，在床垫下面放置硬板。可为有触痛的脊柱肌肉提供支撑。只有当疼痛消失后，方可作腹部适应性的及脊柱旁肌肉增强性的锻炼，包括屈膝、仰卧起坐及国绳肌，脊柱旁肌肉的伸曲展活动。腰鹘部钢架腰围，通过紧压和增强松弛的腹壁，对脊柱起机械机撑作用。和病人共同商量适合其躯体的力学。特别是当病人屈腿而不是屈曲脊柱，举重物时的最恰当姿势。由经过训练的物理治疗人员教病人作姿势性锻炼是有益和有效的。
course & progsis
病程及预后
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.
腰部劳损的通常病程随时间而自行缓解。虽然几个月在无症状中度过，又常因腰部用力活动促使疼痛复发。有些病人自述疼痛持续而无真正缓解。经调查询问表明这些病人有严重意志消沉现象，对他们来说，疾病和伤残成为生活中的主要组成部分。当劳损是由于工作条件引起时，要考虑到再次劳损可使得病程复杂化。
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.
当休息及支撑疗法对病人无效时，必须仔细再检查，以排除发生神经损伤的可能性。对那些一直是神经正常的病人，应尽快地鼓励他恢复正常活动，对长期依赖止痛药的病人一定要进行劝阻。