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医学科普

欧洲观点:骶管囊肿被医生严重忽视的十大原因!

发表者:郑学胜 4210人已读

中国腰椎间盘突出的发病率是18%,每个小区、每个村庄里都有很多,所以无怪乎医生们一见腰腿痛,第一反应就是腰椎间盘突出的可能。然而还有一个引起腰腿痛的常见病:骶管囊肿,却长期被医学界所忽视了!上海交通大学医学院附属新华医院神经外科郑学胜

骶管囊肿不是罕见病,而是地地道道的常见病,人群发病率达到5%,在腰骶部核磁共振检查时经常发现,其中大概五分之一是有症状的。

有的医生可能会说,骶管囊肿就是一个水囊,不要紧。固然,骶管囊肿不会恶变、不会危及生命、只是痛苦(到底有多痛苦?)。那么同样的逻辑,人们也可以说,腰椎间盘突出也不是肿瘤、也不会恶变、也不会危及生命、只是痛苦。

骶管囊肿会导致骶尾部、肛周、会阴、下肢疼痛、行走困难,大小便严重障碍、性功能障碍,痛苦程度一点不亚于腰突症——有的病友因此而无法上班工作,辞职在家卧床,部分患者因不明原因严重便秘而行直肠切除术,少数最严重的患者可以出现直肠膀胱功能完全丧失(我们有真实的病例证明以上所述没有夸大)。

同样是给患者带来严重折磨的常见病,骶管囊肿却长期被医学界所漠视,所以很多病友自发组织起来,希望成立中国骶管囊肿协会,以唤起大众、尤其是医学界的关注。

同样的声音也来自欧洲!以下是比利时医生发表在《欧洲脊柱杂志 / Eur Spine J.》的论文,提出了骶管囊肿被医学界严重低估的十大原因: 

(1)骶管囊肿被一些医生认为与临床无关; 

(2)一些医生认为临床上难以确定骶管囊肿是疼痛的原因; 

(3)磁共振或肌电图检查仅针对L1到S1神经,而没有包括大多数骶神经根; 

(4)放射科医生经常不报告骶管囊肿; 

(5)腰椎的退行性改变几乎总是被确定为患者疼痛的原因,而同时存在的骶管病变却被忽视; 

(6)一些医生尚不知道小型骶管囊肿可能是有症状的; 

(7)外科医生常常把骶管囊肿的形态当作致病机制,所以手术都致力于改变骶管囊肿的内部形态;殊不知,从根本上说,骶管囊肿内部静水压的增高才是产生症状的主要机制。因此,骶管囊肿的症状往往在手术后并未改善或短时间缓解后很快复发加重。 

(8)在病史记录中不询问膀胱,肠和括约肌功能障碍。 

(9)因果颠倒:无法解释的疼痛通常归因于抑郁,而抑郁更可能是神经性疼痛的结果。 

(10)骶管囊肿的认知常会伴随着性别偏见(如更年期综合症等)。

结论:

骶管囊肿被忽视的原因有很多,既有主观原因,也有客观原因,但主要是由于持续的误解和偏见。

原文:

Eur Spine J. 2019 Oct;28(10):2237-2248. doi: 10.1007/s00586-019-05996-1.

Symptomatic Tarlov cysts are often overlooked: ten reasons why-a narrative review.

Hulens M, Rasschaert R, Bruyninckx F, Dankaerts W, Stalmans I, De Mulder P, Vansant G.

Author information

Musculoskeletal Rehabilitation Research Unit, Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, University of Leuven, Tervuursevest 101, 3001, Heverlee, Belgium. miekehulens@skynet.be.

, Sint-Joris-Weert, Belgium. miekehulens@skynet.be. 

Department of Neurosurgery, AZ Rivierenland, Kasteelstraat 23, 2880, Bornem, Belgium.

Clinical Electromyography Laboratory, University Hospitals UZ Leuven, Herestraat 49, 3000, Leuven, Belgium.

Musculoskeletal Rehabilitation Research Unit, Department of Rehabilitation Sciences, Faculty of Kinesiology and Rehabilitation Sciences, University of Leuven, Tervuursevest 101, 3001, Heverlee, Belgium.

Ophthalmology Research Group, Department of Neurosciences, University of Leuven, Herestraat 49, 3000 Leuven, Belgium.

Department of Ophthalmology, University Hospitals UZ Leuven, Herestraat 49, 3000, Leuven, Belgium.

Department of Anesthesiology and Pain Therapy, Imelda Hospital, 2820 Bonheiden, Belgium.

Department of Social and Primary Health Care, Public Health Nutrition, University of Leuven, Herestraat 49, 3000, Leuven, Belgium.

Abstract

PURPOSE:

Tarlov cysts (TCs) are dilations of nerve roots arising from pathologically increased hydrostatic pressure (HP) in the spinal canal. There is much controversy regarding whether these cysts are a rare source of pain or often produce symptoms. The aim of this review was to identify the reasons that symptomatic TCs (STCs) are easily overlooked.

METHODS:

The literature was searched for data regarding pathogenesis and symptomatology.

RESULTS:

TCs may be overlooked for the following reasons: 

(1) STCs are considered clinically irrelevant findings; 

(2) it is assumed that it is clinically difficult to ascertain that TCs are the cause of pain; 

(3) MRI or electromyography studies only focus on the L1 to S1 nerves; 

(4) TCs are usually not reported by radiologists; 

(5) degenerative alterations of the lumbosacral spine are almost always identified as the cause of a patient's pain; 

(6) it is not generally known that small TCs can be symptomatic; 

(7) examinations and treatments usually focus on the cysts as an underlying mechanism; however, essentially, increased HP is the main underlying mechanism for producing symptoms. Consequently, STCs may relapse after surgery; 

(8) bladder, bowel and sphincter dysfunction are not inquired about during history taking. 

(9) Unexplained pain is often attributed to depression, whereas depression is more likely the consequence of debilitating neuropathic pain. 

(10) The recognition of STCs is subject to gender bias, confirmation bias and cognitive dissonance and unconscious bias in publishing.

CONCLUSION:

There are several reasons STCs are underdiagnosed, mostly due to persistent misconceptions and biases. These slides can be retrieved under Electronic Supplementary Material.

本文是郑学胜医生版权所有,未经授权请勿转载。

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发表于:2020-01-19 16:01

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  • 默认头像
    d***o 2020-12-15 09:07:44

    骶管囊肿是骶神经功能障碍的重要病因之一。深圳市中医院肛肠科在过去三年,以肛门直肠不适为主要临床表现而就诊的病人中,MRI筛查出骶管囊肿80多例。感谢郑学胜老师对于骶神经的全面讲解及科普,作为同行受益匪浅!

  • 默认头像
    h***3 2020-11-25 11:29:00

    文章很好!但忽视一点如何与脊髓栓系综合征鉴别

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