Lülisamba degeneratiivne patoloogia
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1 Lülisamba degeneratiivne patoloogia MRT kool 13& Andres Nurmiste Tallinn
2 Degeneratiivne lülisamba patoloogia seljavalu on väga levinud kaebus väga levinud töövõimetuse põhjus väga palju tehakse MRT uuringuid degen. muutused kaasnevad normaalse vananemisega valu põhjuseid on palju enamasti paraneb vaatamata ravile, v.a. op.ravi
3 Seljavalu Vähemalt 80% inimestest on elu jooksul seljavalu episood(id) Sage perearstile pöördumise põhjus Suur osa kulutustest läheb piltide tegemisele 90% paraneb spontaanselt või vaatamata ravile 4..6 nädalaga Üldiselt ei soovitata kohe piltdiagnostikat, kuid erandiks on punaste ja kollaste lipukestega märgitud asjaolud / sümptomid
4 Punased lipukesed Fraktuur? Liiklusõnnetuses osalemine Kukkumine kõrgusest Kergem trauma osteoporootilisel pt-l. Valu torakaalosas. Tuumor või Infektsioon? Vanus >55a või <20a Ca anamneesis Hiljuti põetud bakteriaalne infektsioon, palavik, kaalulangus Immunosupressioon (kortikosteroidid, HIV,i/v narko.) Öised valud Cauda equina sündroom Progresseeruv neuroloogiline defitsiit
5 Kollased lipukesed Asjaolud mis nö varjutavad kliinilist pilti ja soodustavad vaevuste krooniliseks muutumist Negatiivne suhtumine, kartus, et haigus on pahaloomuline, invaliidistav Passiivsete ravimeetodite eelistamine, kartus ennast liigutada Depressiivsus Sotsiaalsed / materiaalsed probleemid
6 MRT ja degeneratiivne lülisamba Valikmeetod patoloogia : Nomenclature and Classification of Lumbar Disc Pathology (SPINE Volume 26, Number 5, pp E93 E113) Radioloogide ja neuroloogide ühisseminari ettekanded
7 Degeneratiivne haigus Diski degeneratsioon Veesisalduse langus Madaldumine lülide lõpp-plaatides ja subkondraalse luuüdi muutused (Modic et al 1988) I II III Anulaarfissuur Bulging e. väljakummumine Herniatsioon Fassett-liigeste degeneratsioon Artropaatia I II III Sünoviaaltsüstid! Ebastabiilsus? ei ole funktsionaane uuring; tava-mrt-s ainult kaudsed tunnused Degeneratiivne listees
8 MRT leid tervetel vabatahtlikel NEJM
9 Lülisamba MRT Hinnata: vertebra disk fassett-liigesed neuroforaamen spinaalkanal närvijuured seljaaju ümbritsevad pehmed koed
10 Vertebra: Lülisamba MRT lülikeha, lülikaar: kuju, MR signaal, joondumine, asend alumise lüli suhtes Disk küfoos, lordoosi, skolioos listees = nihe alumise lüli suhtes lülikeha madaldumine / kompressioon lõpp-plaatide degen. muutused (Modic 1988) spondüloos MR signaali muutus madaldumine
11 MRT Protokoll vähemalt 2 tasapinnas T2, T1 sag T2 ax (NB! mitte ainult 3 lõiku diski kohal) Soovitav täiendavalt: T2 rasvsupress. sag; MR myelo T2 kor T1 ax post Gd T1 ax, T1 sag (postop., dif dgn.)
12 NEJM
13 NEJM
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15 Vertebra lülide asend üksteise suhtes (listees = nihe alumise lüli suhtes; küfoos, lordoos, skolioos = lateralisatsioon kaare alusel) lülikaar, jätked (sp-lüüs, üleminekulülid) lõpp-plaatide ja subkondraalse luuüdi muutused Modic I, II, III Modic MT, Steinberg PM, Ross JS, et al: Degenerative disk disease: assessment of changes in vertebral body marrow with MR imaging. Radiology 166: , 1988.
16 Nomenclature and Classification of Lumbar Disc Pathology Recommendations of the Combined Task Forces of the North American Spine Society, American Society of Spine Radiology, and American Society of Neuroradiology SPINE Volume 26, Number 5, pp E93 E , Lippincott Williams & Wilkins, Inc.
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20 A- protrusioon B- ekstrusioon migratsiooniga C- sekvester
21 A- protrusioon B ja C- ekstrusioon
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24 Suhe PLL-iga: A- tsentraalne B-paratsentraalne (as- anterior epidural
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35 )
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37 Kontakt närvijuurega Grading of Lumbar Nerve Root Compromise on MR Images Pfirrmann et al; Radiology, February 2004
38 Närvijuure deviatsioon (dislokatsioon)
39 Närvijuure kompressioon
40 MR müelogramm
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47 Sekvester
48 Sekvester T1 ax
49 Sekvester T1+Gd
50 Op?
51 Ei op.-tud
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54 HIZ Anuluse rebend (?) Lumbalgia
55 Väga äge radikulopaatia
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57 Paranenud! Neuroloogilise leiuta
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59 Intervert. osteokondroos Modic
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61 T2 fs
62 Lülisamba kaelaosa ei ole nimmeosa väike koopia Lülisamba kaelaosa
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68 Müelopaatia
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71 Torakaaldiskide herniatsioonid Th8-9>Th7-8>Th5-6
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77 Sünoviaaltsüst
78 Listees
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81 Spondülolistees, spondülolüüs Spondülolistees = lülikeha ettenihe alumise lülikeha suhtes Retrolistees = nihe taha Nihe külgsuunas Degeneratiivne (Spondülo)lüütiline Spondülolüüs Lülikaare pars interarticularis e defekt Diferentsimine Degeneratiivne vs lüütiline
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86 Listees T2 ax
87 Foraminaalne stenoos
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89 Listees?
90 Sp.-lüüs
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92 Epiduraalne lipomatoos Liigne epiduraalne rasvkude, mis deformeerib dura kotti Võib kaasneda steroidraviga Doosi vähendamine, ravi lõpetamine võib anda efekti Seljavalu, müelopaatia, spinaalstenoosi, radikulopaatia sümptomid Kirurgiline ravi?
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95 Postoperatiivne selg Diski herniatsiooni eemaldamine Stenoosi leevendamine Fusioon Segmendi ebastabiilsuse kõrvaldamine Deformatsioonide kõrvaldamine Vertebroplastika Väga palju erinevaid op. tehnikaid Tuumorite eemaldamine
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99 POST-OPERATIIVSED MUUTUSED Operatsioonijärgsete seljavaevuste põhjused: Mehaanilised: residuaal-herniatsioon retsidiiv-herniatsioon stenoos (eri tasandil / operatsioonist põhjustatud) lateraalretsessi või neuroforaameni ahenemine instabiliteet lülidevaheliste liigeste düsfunktsioon ligamendi- või lihasrebend Põletikulised: epiduraalne fibroos arahnoidiit spondülodistsiit epiduraalne abstsess Diagnostilised raskused: valu tõeline allikas on jäänud leidmata disk teises vahemikus kui opereeritud perifeerse närvi- või liigesepatoloogia Kirurgilised: närvijuure kahjustus pseudomeningocele post.op. hematoom paraspinoossete lihaste kahjustus spinaalsete ligamentide rebend
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102 Arahnoidiit
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104 Pseudomeningotseele
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107 Hemilaminektoomia- Järgne listees
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109 Presentatsiooni lõpp Tänan!
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