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2011年5月15日 星期日

一個50年腰痛病史的故事

  一位苗條,受過良好教育的77歲女士,身著典雅的洋服和淡妝,優雅地走進了診室。她說她有慢性腰痛,自從她25歲在懷孕第一個孩子到現在 (77-25= 52年)。

(疼痛指數視覺擬量表“ VAS”:0至10分; 0 =無痛,10 =極度痛)

 在她三十幾歲(約 1960年代),(疼痛指數:8至10),她曾一度因持續折騰的背痛臥床不起四年,無法做任何事,除了躺在床上。這一事件
後,背痛下降到一個可容忍程度(疼痛指數:4至6分),她可以恢復正常的日常活動,甚至找到工作,直到她六十幾歲退休。當然,她偶爾會因背痛請病假。
52年 腰痛的盤旋,直到今天,她生活如常(疼痛指數:2至5分):購物,旅遊,家務事,照顧孫兒,等等。 。

問:“在先前那些痛苦的年間,你有沒有考慮過手術,以減輕背痛?

答:“從來沒有。”

問:“為什麼?”

答:“我不敢接受手術。”

問:“你現在感覺如何?”

答:“我很好。背痛已經是我的一部分;它困擾,但我可以應付。”

       她的腰椎正位X光顯示退行性脊柱側彎 15度左右。


腰椎磁共振矢狀 T2的影像顯示 : 顯著的椎間盤退變,從腰1 - 2至腰5 -骶1的椎節,與Modic變化

此案例顯示,遇到一個慢性腰痛病史50年的病人,這是對任何醫生都是一個非常難得的機會與體驗。

 雖然她的病史,有點是逸事性的,但是從影像來看,它確定是一個椎間盤源性下背痛 (discogenic low back pain)的病例。 椎間盤源性腰痛,此醫學術語: 椎間盤源性腰痛(discogenic low back pain),可能是衍生於僅不過25年前從亨利克羅克醫師( HV Crock) 的假設 : 間盤內部破裂(1986年)。在這 25年間,手術治療椎間盤源性下腰痛的蓬勃發展:如椎間盤內電熱療法(IDET),Neulecoplasty(髓核成形術 : 射頻),人工椎間盤置換術(ADR, artificial disc replacement),髓核置換術,經皮激光(雷射) 椎間盤切除,椎體間融合,小關節置換,等等。

 此網頁有非常平衡的關點,值得一看(抱歉,是英文),是關於上述各種侵入性治療下背痛的療效。

我們從這位女士學到了什麼?

1。至目前還沒有針對於椎間盤源性下背痛長期的縱向研究(超過 10年)。一個對疾病自然病史的必要研究;

2。長期使用保守的治療,似乎結果樂觀,至少在一定比例的患者(即:時間可以愈合);

3。我們對椎間盤源性腰痛的本質與病理機轉知道得太少,但手術治療方式卻太多;

4。因此,椎間盤源性腰痛的各種手術治療方式,包括已經淘汰的,目前流行的,還是新發展的,它們都存有許多可以討論空間;

5。這位女士是明智的。

 目前一項動物試驗:以注射方式達成脊柱融合術,這是否是對椎間盤源性腰痛的未來治療方式的選擇之一?我們且拭目以待。


Mozart The Magic Flute Queen of the Night Aria (莫札特 魔笛 夜之后 詠嘆曲, Lucia Popp)

 

2011年5月14日 星期六

A Tale of 50 years' Low Back Pain

A slender, well-educated 77 years old lady, in elegant dress and light make-up, walked gracefully into the clinic room. She said she already had chronic low back pain since 25 years old during pregnancy of her first baby until now. 

(Visual Analog Scale "VAS": 0 to10 points; 0= no pain, 10= extremely painful) 
  At her 30's (around 1960s), due to agonizing persistent backache (VAS: 8 to 10), that she had been bedridden for 4 years and was unable to do anything except lying in bed. After that episode, backache decreased to an extent of tolerable (VAS: 4 to 6) and she could resume normal daily activities, even found a job until retirement at her 60's; of course, she had sick leave once in a while due to backache.  
  Low back pain lingers for 52 years until today, and she is doing well (VAS: 2 to 5): shopping, touring, housekeeping, taking care grand children, and so on. . 

Q: "Did you ever consider surgery to alleviate backache at one time in all those painful years? 
A: "Never."  
Q: " Why?"
A: " I was afraid of surgery."
Q: "How do you feel now?" 
A: " I am doing well. Backache is already part of me, it bothers but I can cope." 

 Her lumbar anteroposterior radiography show degenerative scoliosis about 15 degrees.
Lumbar MRI sagittal T2 image shows significant disc degeneration from L1-2 to L5-S1 levels, and Modic changes.
 
 This case demonstrates that it is a very rare chance for any physician who may encounter a case of chronic low back pain for 50 years
  Although her clinical history may be anecdotal, but from the image findings, it suggests that it is definitely a case of discogenic low back pain.  Amazingly, the terminology of discogenic low back pain (LBP) is possibly derived only 25 years ago from the Henry Crock's hypothesis of Internal disc disruption (1986). In these 25 years, the surgical treatments for discogenic LBP are flourishing: intradiscal electrothermal therapy (IDET), Neulecoplasty (Bipolar RF/”Coblation”), artificial disc replacement (ADR), nucleus replacement, percutaneous laser discectomy, interbody fusion, facet replacement, and so on.    
  
   This web page is very well-balanced and must see, regarding the efficacy of above mentioned interventional treatments for LBP.


 What did we learn from this lady?
1. There is no long-term longitudinal study (more than 10 years) for discogenic LBP. A real regret;

2.  Long-term outcomes using conservative measures seem optimistic, at least for a certain portion of patients (read: time heals);

3. We knew too little about the nature of discogenic LBP but do too much;
4. therefore, various surgical modalities for discogenic LBP, whether the already phased-out ones, currently popular, or the new-comers, they all leave something to be desired;
5. The lady is wise.

  Is this: Injectable spinal fusion, one of the future options? We shall see.
    

2011年5月7日 星期六

母親節

 每個人都在慶祝母親節。它仍然是工作日子偶爾片刻回憶母親的臉,是我的慶祝方式

 想想加護病房病人:
50歲出頭'單身,沒有母親可慶祝她自己也不是,她唯一的兄弟也無視於她(在施行心肺復甦術時,她的哥哥 在電話中回答說:“我兩個晚上沒有,我要去洗澡。“)。她幾乎屬於這個世界:沒有人要她,除了少數的不那麼親密的朋友(或說同情者比較恰當兩位醫生令人驚訝的是她曾被五個醫生拒絕,他們不想處理這個麻煩的病案:胸椎9- 10節化膿性脊椎炎:
 胸十椎體已被破壞,僅剩三分之一 (箭頭);脊髓神經被感染組織壓迫,兩下肢麻木無力。


 
錐心背痛持續3個月,幾近癱瘓腎衰竭接受血液透析洗腎,糖尿病,四根腳趾頭已截肢高血壓名下沒有一分錢,不理她的手足,只剩一個苦痛腐爛的軀殼,一個哭泣的靈魂曾經孤獨的被留置在急診室一個星期。

心痛。

 術後,昏迷,至少曾有30
小時的希望和喜悅,她高興著抬起恢復力量的雙腳,寄望不久後能走路,並成為一名導遊美夢很快變成了無盡的噩夢。 
  不,也許她寧可留住在她甜美的夢裡,不想醒來面對這個殘酷的,不確定的世界。


母親節快樂

Mother's Day

  Everybody's celebrating Mother's day. It is still a working day to me. A short moment of recalling mother's face once in a while is my way of celebration. 
 Think about the patient in ICU: at her early 50s', single, no mother to celebrate not even herself, disregarded by her only sibling (at the moment of CPR, her brother replied "I didn't sleep for two nights and I am going to take a shower."). She was almost not belong to this world: nobody cares about her except a handful of not-so-close friends (sympathizers at best) and two doctors. Amazingly, she had been denied by five surgeons that they didn't want to take care of this troublesome case: T9-10 pyogenic spondylodiscitis, 
T10 vertebral body was destructed and only 1/3 left (arrow); spinal cord was compressed by infected tissues.


near paralyzed, persistent backache for 3 months, renal failure underwent hemodialysis, diabetes, 4 toes had been amputed, hypertension, not a penny to her name but a rotten body with agonizing pain and a weeping soul).  She once had been left alone in ER for one week.

A Heartache. 
 Postoperatively and before comatose, at least, she had 30 hours of hope and joy that she raised her once paralyzed legs, and talked happily about she could walk again and wanted to be a tour guide; but the sweet dream shortly turned into an endless nightmare. 
  No, perhaps she is rather staying in her sweet dream and does not want to wake up to face this cruel and uncertain world.

Happy Mother's Day.

How Many Surgical Options for Degenerative Spondylolisthesis?

1. Decompression: laminectomy, laminotomy (bilateral, or uni-lateral with bilateral decompression), laminoplasty, indirect decompression.
2. Fusion with or w/o instrumentation: posterolateral, PLIF, ALIF, Lateral fusion, TLIF.
3. Non-fusion: dynamic stabilization, inter-spinous process device (IPD).
4. Cage: cylindrical, rectangular (single or pleural); Materials: titanium, PEEK, carbon-fiber, tantalum, ceramic,
5. Graft materials: autograft, allograft, DBM, BMP, 
6. Did I miss anything..

The menu list goes on.