ca lÂm sÀng 3/11/2014 - thuchanhthankinh.com lam sang... · ankylosing spondylitis, psoriatic...
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![Page 1: CA LÂM SÀNG 3/11/2014 - thuchanhthankinh.com lam sang... · Ankylosing spondylitis, psoriatic spondylitis, Reiter’s syndrome (0.3%) 4.Osteochondrosis(bệnh hư sụn xương)](https://reader030.vdocuments.mx/reader030/viewer/2022041122/5d13790688c993b5158b9113/html5/thumbnails/1.jpg)
CA LÂM SÀNG3/11/2014
Nội trú và chuyên khoa thần kinh(For interns, residents)
PGS.TS Cao Phi Phong
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Ca lâm sàng
Bn nam 68 tuổi nhập viện vì đau lưng thấp cấp
Bệnh sử
Tư 17 ngay trươc, bệnh nhân sôt lanh run (?0C), sôt liên
tuc ca ngay kem đau thăt lưng, không lan chân kem bon,
tiêu chậm, phai răn. BN vân đi lai bình thương, không tê,
yêu chân. BN tư mua paracetamol uông, giam sôt, đau co
giam luc đâu, sau đau tăng dân.
Ngay NV, BN bươc đi đôt ngôt đau thăt lưng dư dôi lan
măt sau mông -> sau đui -> 2 ban chân, bệnh nhân không
tư bươc đi -> BVĐHYD
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Tiền căn
Ban thân:
Chưa ghi nhận TC đôt quy, tăng huyêt ap, ĐTĐ,
bệnh tim, lao
Không tiên căn chấn thương côt sông
Gia đình:
Chưa ghi nhận bất thương
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Thăm khám
Huyêt ap 130/80 mmHg, M: 92 l/ph, NT: 22l/p, T º:
38,5ºC
Nôi khoa: âm thổi tâm thu dang tran ơ mom lan nach,
cương đô 4/6.
Thân kinh:
Côt sông:
Ân đau đôt sông L4, L5
Lasegue (+) P 400, T 800
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Tóm tắt
BN nam, 68 tuổi, NV vì đau thăt lưng
Bệnh 2 tuân
Sôt, lanh run
Đau lưng lan 2 chân, Lasegue (+) P 400, T
800, giam PXGC gôi, mất PXGC got 2 bên
Rôi loan cơ vong
Âm thổi hơ 2 la
Chẩn đoan : hôi chứng đau lưng thấp cấp
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Tiếp cận bn đau lưng thấp(Low Back Pain- LBP )
Định nghĩa
1. Cấp LBP: đau lưng <6 tuân2. Bán cấp LBP: đau lưng >6 tuân nhưng <3 tháng3. Mãn LBP: bn đau lưng anh hương hoat đông > 3 tháng4. Tái phát LBP: cấp LBP ơ bn có cơn trươc đo cùng vị trí
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Nguồn gốc LBP
Đau qui chiêu tư tư nôi tang (Referred pain)
ĐAU KHÔNG LIÊN QUAN HOẠT ĐỘNG:
Viêm nhiễm (Inflammation)
Infectious/rheumatic
Xương (Osseous)
Thiêu sót măc phai
Tổn thương trong tủy
Rôi loan biên dưỡng
LIÊN HỆ HOẠT ĐÔNG:
Disco dural hay disco radicular
Capsuloligamentous
Stenotic
Đau không do nguyên nhân thưc thê (Non-organic causes)
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Đánh giá đầu tiên bn LBP
Bệnh sử, tiên sử, thăm kham thưc thê
Nhận thức “Red Flags”
Không có Red Flags, chẩn đoan hình anh,
xét nghiệm không giup ích trong 4 tuân đâu
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Red Flags(dấu hiệu nguy hiểm) Tuổi > 70
Sốt, ớn lạnh, viêm đường hô hấp trên/nhiễm trùng da, vết thương xuyênthấu gần cột sống
Chấn thương quan trọng hay trung bình >50 tuổi
Đau liên tục vè đêm hay lúc nghĩ)
Thiếu sót vận động hay cảm giác tiến triển
Mất cảm giác kiểu yên ngực(Saddle anesthesia), đau tk tọa 2 bên hay yếuchân, đi tiểu khó khăn, đi tiêu không kiểm soát
Mất cân không giải thích
Tiền sử ung thư hay nghi ngờ ung thư
Tiền sử osteoporosis
Immunosuppression
Dùng oral steroid lâu dài
IV drug use, substance abuse
Không cải thiện sau 6 tuần điều trị bảo tồn
Có điểm đau (Point tenderness)
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LBP: yếu tố nguy cơ
Làm năng(nhấc và xoắn)
Béo phì
Ít vận động
Tiền sử đau lưng do chấnthương
Tiền sử tâm thần (Psychiatric history)(chronic LBP)
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Chẩn đoán phân biệt
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Phân biệt: Cơ chế LBP
1. Tổn thương cơ học tủy sông
(Mechanical Spinal Condition (97%))
2. Không cơ học
(Non-mechanical Spinal Condition (1%))
3. Không tủy sông/nôi tang
(Non-spinal/Visceral Disease (2%))
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Đau lưng thấp hay đau châncơ học (97%)
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Phân biệt: Cơ chế LBP
Đau lưng do kéo căng hay bong gân (Strain or Sprain) (70%)
Thoai hoa dĩa đệm va măt khơp (10%)
Herniated disc (4%)
Osteoporotic gãy chèn ép(4%)
Spinal Stenosis (3%)
Spondylolisthesis (2%)
Gãy chấn thương (<1%)
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Phân biệt: Cơ chế LBP
Bệnh bẩm sinh(<1%)Severe Kyphosis or ScoliosisTransitional Vertebrae
Spondylolysis* Pha vỡ dĩa liên đôt/đau lưngdo dĩa đêm
( 2%)
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Spondylosis: thoái hóa cột sống
Hình ảnh giải phẫu thoái hóa hẹp tủy sống lưng
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Giải phẫu bệnh cột sống lưng thường gặp
Liên khơp Lệch ra trươc
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Spondylolysis
Spondylos (spine or vertebra)
lysis (a break or loosening) pha vỡ hay rơi ra
Loosening of the pars interarticularis fracture
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Spondylolysthesis
Spondylos (spine or vertebra)listhesis (to slip or slide) trượt a condition where one bone slips forward on another
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Disc Herniation – sinh lý
• Rách vòng bao(annulus)
• Thoát vị nhân đệm (pulposus)
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Disc Herniation – sinh lý
• Chèn ép rễ thần kinh gây đau
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Lumbrosacral Dermatones
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Axial T2-weighted image at L4 shows large paracentral
disk extrusion extending into the right lateral recess and
neuroforamen
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Disc Degeneration – sinh lý
• Theo tuổi và lập lại gắng sức, dĩa đệm mất độ cao và nước (“bone on bone”)
• Cử động bất thường giữa xương gây đau
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Disc Degeneration – điều trị
Bảo tồn(Conservative Tx)
– Moderate bed rest
– Spinal manipulation
– Physical therapy
– Medication
• NSAIDs
• Muscle relaxants
• Rarely narcotics
Phẫu thuật(Surgical Tx)
• Lumbar fusion
OR
• Replacement with
artificial disc
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lumbosacral spinal stenosis
Tư thê khom
lưng, côt sông
cổ, hông, gôi
gập
Dĩa đệm xẹp, trật khơp, xâm lấn vao trong
ông sông trung tâm hẹp
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Nguyên nhân không cơ học ơ tủy (1%)
1.U: multiple myeloma, metastatic CA, lymphoma,
leukemia, spinal cord tumors, retroperitoneal
tumors, primary vertebral tumors (0.7%)
2.Nhiễm trung: osteomyelitis, septic diskitis,
paraspinous abscess, epidural abscess, shingles
(0.01%)
3.Viêm nhiễm khơp (Inflammatory arthritis):
Ankylosing spondylitis, psoriatic spondylitis,
Reiter’s syndrome (0.3%)
4.Osteochondrosis(bệnh hư sun xương)
5.Paget Disease
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PAGET’S DISEASE
Rôi loan xương khu trú
Là rôi loan mãn tính hậu qua xương to ra và méo mó.
Nguyên nhân sư thất bai và cấu thành xương, theo
sau là tu sủa tổ chức xương bị phá hoai. Nguyên
nhân làm xương yêu đi, đau, méo mó, gãy vá viêm
khơp gân vùng xương bị anh hương
Siêu vi hay di truyền?
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Nguyên nhân nội tạng
Visceral Disease : 2% TÂT CẢ ĐAU LƯNG
1. Disease of pelvic organs: prostatitis,
endometriosis……
2. Renal Disease: nephrolithiasis,
pyelonephritis, perinephric abscess
3. Aortic aneurysm
4. GI disease: pancreatitis, cholecystitis,
penetrating ulcer
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Ca lâm sàng
Đau lưng thấp hay đau chân cấp
Red flag(+)
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Đánh giá người lớn tuổi
Khả năng có thể xảy ra
• Cancer, compression fractures, spinal stenosis, aortic aneurysms more common
• Osteoporotic fractures without trauma
• Spinal Stenosis secondary to degenerative processes and spondylolisthesis more common
• Khuyến cáo chẩn đoán xq sớm
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Nếu không có red flags?
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1. Sau khi hoi bệnh sử và thăm khám loai trư đau lưngnguy hiêm, chúng ta có thê điêu trị, phân lơn rơi vàophân loai này.
2. Không cân x quang hay cận lâm sàng
3. Có thê cam đoan rằng 90% trương hợp khoi trongmôt tháng vơi điêu trị bao tồn
.
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11/10/2014
LBP xấu
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Khi LBP xấu, chỉ định cậnlâm sàng nào?
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Xquang quy ước(Plain films)
Đanh gia cấu truc côt sông: chấn thương ,
ung thư, nhiễm trung, thoai hoa.
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MRI
• Shows tumors and soft tissues (e.g., herniated discs) much better than CT scan
• Almost never an emergency
– Exception: Cauda equina syndrome
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CT Scan
• Shows bone (e.g., fractures) very well
• Good in acute situations (trauma)
• Sagittal reconstruction is mandatory
• Soft tissues (discs, spinal cord) are poorly visualized
• CT-myelogram adds contrast in the CSF and shows the spinal cord and nerves contour better
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Cauda Equina:
Neurosurgeon STAT
Plain films, MRI
Fracture: plain films, +/- MR/CT
Cancer: plain films; CRP, ESR, CBC
Infection: plain films +/- MRI; CRP, ESR, CBC
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11/10/2014 S. Matin MD
Radiculopathy, Spinal Stenosis
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Làm gì khi nghi ngờ bệnh lýrễ hay hẹp ống sống ?(Suspected Radiculopathy or Spinal Stenosis)
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Refer to Physical Therapy
Follow in 2-4 weeks for progress
If no improvement by 6-12 weeks
Plain films, MRI, +/- EMG/NCV
Refer for interventions
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Osteomyelitis
Phân loại:
• Thời gian Acute, Subacute or Chronic
• Đường nhiễm trùng Hematogenous or Exogenous
• Đáp ứng ký chủ Pyogenic or Granulomatous
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1. Bệnh lý gãy xương (Pathological fracture)
2. Nhiễm trung lan rông: Arthritis (joint inflammation), myositis (muscle inflammation) neuritis (nerve inflammation)
3. Nhiễm trung mau
4. Chronic suppurative osteomyelitis( viêm tủy xương nung mủ mãn)
5. Tổn thương growth plate gây biên dang phat triên
Biến chứng osteomyelitis:
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Vertebral osteomyelitis
Osteomyelitis liên hệ côt sông thương găp qua đương
mau, (ngươi lơn lan tư dĩa đêm không thấy)
(Blood vessels in the paediatric spine pass through the physeal
cartilage and terminate within the intervertebral disc, allowing for
seeding of infection from the osseous vasculature (Tay, et al., 2002).
This results in a direct extension of infection into the disc that is not
seen in adult patients. For this reason, this condition is referred to by
some authors as paediatric discitis rather than osteomyelitis.)
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Tiêu chuẩn chẩn đoan vertebral osteomyelitis (VO)
A Biopsy with a picture of osteomyelitis (sinh thiêt)
B Positive bacterial culture from biopsy (cấy mô)
C Blood culture in at least bottles (cấy máu)
D Local or radiating pain andor neurological deficiencies (dấu tk khu trú)
E Morphological examinations indicating VO on at least one of
Plain X-ray, MRI, CT, Skeletal scintigraphy (hình anh học)
F Signs of acute inflammatory reaction with at least one of the following:
CRP>30mg/l, ESR>30mm/h, Temperature>38 C (viêm nhiễm)
Definition
Definition VO A+B or
E and at least one of A, B or C (ha+st+vt mô hay vt
máu)
Definition VO A or B or E+F (ha+viêm nhiễm)
Definition VO D and either C or E (ls tk+cấy máu+hình anh)
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Pott’s Disease
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Pott's disease
• Pott's disease is a presentation of extra pulmonary tuberculosis that affects the spine, a kind of tuberculous arthritis of the intervertebral joints.
• The lower thoracic and upper lumbar vertebrae are the areas of the spine most often affected.
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Pott’s Disease; X-ray Pott’s Disease; MRI
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Biến chứng
• Vertebral collapse resulting in kyphosis
• Spinal cord compression
• Sinus formation
• Paraplegia (called Pott's paraplegia)
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Một vài nguyên nhân không điểnhình LBP”
Spondylosis (Osteoarthritis of facet/disk)
Spondylolysis/-listhesis
Acute lumbar strain
Facet pain
Discogenic pain
Ligamentous pain
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Chúng ta làm gì Non-specific Low Back Pain ?
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Hương dân bn mong chơ dư hậu tôt
Khuyên vân hoat đông khi dung nap được
Giam đau và tư chăm sóc
Hồi phuc 2-4 tuân, điêu chỉnh điêu trị khi cân thiêt
Không x quang trư khi chuyên qua mãn tính
Không cai thiện: nhập viện
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Ca lâm sàng
CTM: BC 11,34 G/L, Neu 81,2%, Hb 11,3 g/dL, INR 0,96
VS 1h 105mm, VS 2h 121mm
Sinh hoa: CRP 1414 nmol/L, Procalcitonin 6,24 ng/ml,
CEA 3.5ng/ml, CA 19.9 9,6 u/ml, AFP 2,4 ng/ml
TPTNT bình thương
Cấy mau: Staphylococci coagulase (+)
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Ca lâm sàng
Nôi soi đai trang: polyp ĐT chậu hông, ĐT ngang -> căt
polyp
SA tim: hơ 2 la 3/4, EF 64%, không RL vận đông vung
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Khi nào chỉ định can thiệp ngoai?
Sciatica and probable herniated discs
Cauda equina syndrome
Progressive or severe neurological deficit
Persistent neuromotor deficit after 4-6 weeks conservative treatment
Persistent sciatica with consistent neurologic and clinical findings
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Khi nào chỉ định can thiệp ngoai ?
Spinal Stenosis
Progressive or severe neurological deficit
Persistent back and leg pain improving with flexion and associated with spinal stenosis on imaging
Spondylolisthesis
Progressive or severe neurological deficit
Severe back pain/ sciatica with functional impairment that persists > 1 year
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Điểm then chốt trong LBP
>90% are due to mechanical causes and will resolve spontaneously within 6 weeks to 6 mths
Pursue diagnostic workup if any red flags found during initial evaluation
If ESR elevated, evaluate for malignancy or infection
In older patients initial Xray useful to diagnose compression fracture or tumor
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ĐIỀU TRỊ
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Viêm thân sống, dĩa đệm, ngoài màng cứng
Vertebral body, disc space, epidural
• Risk factors
– Postop, IVDU, DM, haemodialysis, immunosupression,
endocarditis
• Bacterial ( Staph, E.Coli, Salmonella ) / Mycobacterium
• Clinical presentation : Pain ++, neurological symptoms,
pyrexia
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Áp-xengoai mang cứng
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Điều trị
• Urgent decompression if cord compression ( esp.
bacterial abscess)
• Appropriate antibiotics
– Length of time – ask the microbiologists ( and add or
subtract 3 months depending on answer! )
– Monitor inflammatory markers
– If no response consider diagnosis – tissue and
bacteriological, ?pt taking treatment
– Response to treatment - CRP, ESR
• Surveillance imaging
– Deformity
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Thank you for not sleepingNow you can ask your questions
???