Troyanovich S J, Harrison D D, Harrison D E
J Manipulative Physiol Ther. 1999 Feb;22(2):96-104. doi: 10.1016/s0161-4754(99)70114-4.
Low back pain exists in epidemic proportions in the United States. Studies that demonstrate innervation to the intervertebral disk provide evidence that may account for instances of discogenic low back pain encountered in general medical and chiropractic practice. Many patients and health care practitioners believe that intervertebral disk lesions require surgery as the only method of treatment that will result in satisfactory outcome. Surgery rates vary widely across geographic regions. Only one randomized prospective study exists that compares surgical and nonsurgical treatment; it demonstrated essentially equal outcomes in the long run.
To review specific aspects of the examination, history, imaging, and treatment of patients with suspected intervertebral disk lesions and to provide guidelines for conservative management, imaging, and relative and absolute indications for surgical referral.
Review articles, texts, and original articles from indexed refereed sources that discuss the lumbar intervertebral disk in regard to patient history, physical examination, imaging, treatment, and referral for surgery.
Patients with low back pain who do not present with so-called red flags (fever, history of cancer, unexplained weight loss, urinary tract infection, intravenous drug use, saddle anesthesia, or prolonged use of corticosteroids) may be treated initially with conservative methods. Imaging studies are helpful in determining the patient's diagnosis, and computed tomography, magnetic resonance imaging, or other special imaging studies should be ordered judiciously. The only prospective, randomized study of conservative versus surgical management of herniated lumbar intervertebral disk lesions indicates both methods provide adequate outcome in the long run. Little consensus exists on the best method of management for patients with intervertebral disk lesions without absolute indications for surgery.
Patients should be screened for "red flags" to determine whether they are candidates for conservative treatment. Magnetic resonance imaging is perhaps the most practical imaging study for evaluation of lumbar disk lesions because it involves no use of ionizing radiation and because magnetic resonance imaging has other advantages over computed tomographic scanning such as excellent delineation of soft tissue structures, direct multiplanar imaging, and excellent characterization of medullary bone. Provocation computed tomography-diskography is an invasive procedure and should be reserved for patients with normal magnetic resonance imaging findings and continuing severe pain who have not been helped by conservative treatment attempts and for whom surgical intervention is contemplated. Both conservative and surgical interventions have been shown to be effective in the treatment of discogenic and radicular pain syndromes.
在美国，腰痛呈流行态势。证实椎间盘存在神经支配的研究提供了证据，这或许可以解释普通医学和整脊疗法中遇到的椎间盘源性腰痛病例。许多患者和医疗从业者认为，椎间盘病变需要手术治疗，这是唯一能带来满意疗效的治疗方法。手术率在不同地理区域差异很大。仅有一项随机前瞻性研究比较了手术和非手术治疗；从长远来看，其结果基本相同。
回顾疑似椎间盘病变患者的检查、病史、影像学及治疗的具体方面，并为保守治疗、影像学检查以及手术转诊的相对和绝对指征提供指导原则。
来自索引参考来源的综述文章、教科书及原创文章，这些文献讨论了腰椎间盘的患者病史、体格检查、影像学、治疗及手术转诊等方面。
未出现所谓“警示信号”（发热、癌症病史、不明原因体重减轻、尿路感染、静脉药物使用、鞍区感觉缺失或长期使用皮质类固醇）的腰痛患者，可首先采用保守方法治疗。影像学检查有助于确定患者的诊断，应谨慎安排计算机断层扫描、磁共振成像或其他特殊影像学检查。关于腰椎间盘突出症保守治疗与手术治疗的唯一前瞻性随机研究表明，从长远来看，两种方法都能取得足够的疗效。对于没有绝对手术指征的椎间盘病变患者，最佳治疗方法几乎没有共识。
应筛查患者是否有“警示信号”，以确定他们是否适合保守治疗。磁共振成像可能是评估腰椎间盘病变最实用的影像学检查，因为它不使用电离辐射，且与计算机断层扫描相比有其他优势，如能出色地描绘软组织结构、直接进行多平面成像以及对骨髓骨进行出色的特征描述。激发计算机断层扫描 - 椎间盘造影是一种侵入性检查，应仅用于磁共振成像结果正常但持续剧痛且保守治疗无效且考虑手术干预的患者。保守治疗和手术干预在治疗椎间盘源性和神经根性疼痛综合征方面均已被证明是有效的。
