翻身就腰痛是什么原因？

脊柱的基本解剖单元，常被称为三关节复合体，有成对的关节突关节和椎间盘组成。这些关节共同支持并稳定脊柱，限制其在各个方向上的运动以防止损伤发生。大体观，每个小关节由下位椎体朝向后内侧凹陷的上关节突以及上位椎体朝向前外侧的的下关节突组成。L-z关节的形状及朝向决定了其作用为阻止脊柱过度运动。小关节朝向趋于矢状位可以限制脊柱的轴向旋转但是减少了对剪应力的限制（前后运动时）。而趋于水平的小关节可以更好的保护屈曲和剪切下的应力，但对旋转的抵抗力降低。同济大学附属东方医院疼痛科王祥瑞

he basic anatomical unit of the spine, often referred to as the three-joint complex, consists of the paired zygapophysial joints and the intervertebral disc. Together,these joints function to support and stabilize the spine, and prevent injury by limiting motion in all planes of movement. Macroscopically, each facet joint is composed of a posteromedially facing concave superior articularprocess from the inferior vertebral body, and as maller anterolaterally facing inferior articular processfrom the superior spinal level. The shape and Orientationof the lz joints determine the role each plays in protectingthe spine against excessive motion. Facet joints oriented parallel to the sagittal plane provide substantial resistance to axial rotation but minimal resistance to shearing forces (backward and forward sliding), whereas joints oriented more in a coronal plane tend to protect against flexion and shearing forces but provide minimal protection against rotation .

1、结构

腰椎小关节组成后外侧关节，链接椎体的椎弓和其临近的椎弓。作为真正的滑膜关节，每个小关节包含明显的关节间隙，容纳1到1.5ml关节液。小关节由滑膜，透明软骨表面，和纤维囊组成。纤维囊厚约1mm，大部分有白色纤维组成，横向排列，以在屈曲时提供最大的张力。囊的后部很厚，纤维来源与多裂肌。囊的上部和下部较薄，附着于远离骨软骨边缘的地方，形成了囊下隐窝，正常情况下填充有纤维脂肪性软骨版。囊前部被黄韧带所取代。

The lumbar facet joints form the posterolateral articulations connecting the vertebral arch of one vertebra to the arch of the adjacent vertebra. As true synovial joints,each facet joint contains a distinct joint space capable of accommodating between 1 and 1.5 ml of fluid, a synovial membrane, hyaline cartilage surfaces, and a fibrous capsule.21 The fibrous capsule of the lumbar facet joint is approximately 1 mm thick and composed mostly of collagenous tissue arranged in a more or less transversefashion to provide maximum resistance to flexion.22,23The joint capsule is thick posteriorly, supported by fibers arising from the multifidus muscle. Superiorly and inferiorly, the capsule attaches further away from the osteochondral margins, forming subcapsular recessesthat in the normal joint are filled with fibroadipose menisci.Anteriorly, the fibrous capsule is replaced by the ligamentum flavum.

腰椎小关节不对称对椎间盘突出方向的影响：腰椎小关节特有的定向使得腰椎可以完成较大范围的屈伸活动（约50°～60°）。在腰椎屈曲时，相邻两个椎体的上位椎体相对于下位椎体在横截面上做水平的前滑；同时在横轴上做向前的旋转活动。这种复合运动使得椎体后方的纤维环受到牵拉，推挤前方的髓核。如果椎体后方两侧的小关节倾斜角度相同，则椎体将会在矢状面上移动，同时椎体后方两侧的纤维环、关节囊、韧带、肌肉所受到的牵拉力相同。若两侧关节突倾斜角度不等，则将发生另一种复杂的运动及受力情况。由于在腰椎屈曲时，矢状的小关节比冠状小关节更易使椎体产生向前的滑动，同时也易使相邻椎体在横轴上发生旋转运动。可以认为，如果在一个两侧小关节倾斜角不等的运动节段，当腰椎屈曲时，椎体靠矢状小关节侧较靠冠状小关节侧更易发生向前的滑动和旋转。由于椎体两侧运动不同，所受阻力不等，使上位椎体运动时偏离了原来在矢状面上行走的运动轨迹，靠矢状小关节一侧的纤维环受到更大的牵拉。随着在生活中循环往复不断地使用腰椎屈曲后凸的体位，最终使矢状侧的纤维环先发生劳损、断裂、松弛，以至髓核从该侧突出。

胎儿和婴儿时期，腰椎关节突关节的关节面几近冠状，以后由于关节突关节的外侧缘逐渐向矢状方向生长，使关节面变成弧形且以矢状方向为主。上位腰椎的关节突关节面呈矢状位，而下位的呈冠状位，特别是第5腰椎。腰椎关节突的关节两倾斜度变化较大，两侧常不对称。第5腰椎上关节突的关节面多呈凹形，少数呈平面形；下关节突的关节面变化也较大，以凸面形和平面性为主，其次是凹面形和波浪形(S形)。关节突关节面上覆盖一层软骨，随年龄增长软骨变薄，关节面下部的骨质也变得不规则、增生和硬化。

2、血管和神经关节突关节的血液供应来自腰动脉，走行至椎弓峡部附近穿入椎板发出分支到上、下关节突。上、下关节突的相应静脉则与椎外静脉汇成椎弓静脉，在椎间孔处注入椎内或椎板静脉丛。腰椎关节突关节的神经支配来自腰神经后支的内侧支，向后穿过一骨纤维管，分布予椎间关节及其周围的结构，其整个行程大致为“S”形，以骨纤维管为标志可分为3段：①骨纤维管前段：自起始部至骨纤维管入口，为“S”形的第一个弯曲。②骨纤维管内段：位于骨纤维管内，构成“S”形行程的中间转折部。③骨纤维管后段：自骨纤维管出口至神经分为终末肌支，该段构成“S”段的第二个弯曲，依次分出第一关节支、棘支、第二关节支、棘支和第三关节支。腰神经后内侧支的行程大致为“S”形，这种结构可大大增加其伸缩能力，使神经在运动过程中缓冲牵拉以避免损伤。腰椎关节突关节接受同位或上位甚至上两位神经干前支、后支的分支支配，并有丰富的节段性吻合，为多源双节段分布。

从腰神经的后外侧支的行程来看，有下列易损因索：①骨纤维管入口的边缘与后内侧紧密相贴。②骨性纤维管“S”形转折部最狭窄。③下位节段骨纤维管骨化变窄。④神经穿行骨纤维管时如同绳索在狭窄弯曲的管内滑动、摩擦。因此，当骨纤维管及其周围的结构有炎症或其他病变时，易引起神经损伤而继发腰痛。由于一椎间关节病变可涉及数个节段的腰神经，所以，腰痛的定位不太明确。

3、关节囊

关节突关节囊主要位于关节突的后外侧部，而前内侧的关节囊大部分由黄韧带代替，关节囊的最内层为关节滑膜，滑膜组织向关节间隙内突出形成皱褶。椎间关节囊较紧张，有一定的活动度，囊外有多裂肌附着，内侧与黄韧带相连。关节囊分为纤维层和滑膜层，滑膜层呈光滑半透明状，贴纤维层内面，不易分开。滑膜层约l/3起自关节软骨边缘，滑膜起点与关节软骨缘之间由结缔组织连接，关节腔狭小密闭。滑膜层在相邻关节面之间双层突入形成滑膜皱褶，伸至关节腔内。关节滑膜皱褶出现率为90％，依组织结构分为两类：滑膜脂肪型和纤维软骨型。依滑膜皱褶根部与关节面缘的关系即上、下、内、外四侧缘，分为4型。Ⅰ型：滑膜的皱褶仅出现在关节的一侧缘；Ⅱ型：滑膜皱褶出现在两侧缘，如上、下侧缘；Ⅲ型：滑膜皱褶根部出现三侧缘，如前、后、外侧缘；Ⅳ型：滑膜根部出现四侧(全)缘。

滑膜皱褶的生理功能：填充垫托作用，垫在相邻两关节面之间，或关节软骨表两的凹窝内，使关节面平坦光滑有利关节的滑动；滑膜层和滑膜皱褶能产生和吸收滑液，润滑和营养关节。若关节滑膜皱褶被挤压到相邻的关节面之间，可产生剧烈疼痛，称为关节滑膜嵌顿综合征。正常情况下，关节囊的上、后及外侧有纵行的多裂肌附着，脊柱运动时相应节段的多裂肌纤维收缩，牵拉关节囊带动滑膜皱褶不致嵌于关节面之间；若已有腰椎间盘突出症或腰椎退行性变的患者，在脊柱强烈或不当运动后，突感腰背部剧烈疼痛，可能是滑膜皱褶的炎症、肿胀或移位挤压在相邻关节面的缘故。

关节突关节囊外层纤维组织内包含有丰富的神经末梢，其中以有髓纤维形式存在的机械感受器阈值较低，其对正常生理条件下产生的应力敏感；而另一类以无髓鞘的C纤维形式存在的伤害感受器具有较高的阈值，其受到较强的机械与化学刺激时才反应，这种感受器可能与腰痛的发生过程有关。

每个小关节都受双重神经支配，分别来自同节段及上一临近节段背侧主支的内侧支。例如，L4-L5关节囊的下极接受L4内侧支支配，而其上极接受L3内侧支的支配，分别可在L5和L4的横突处阻滞。L1-L4 脊神经背侧支的内侧支行经各自横突的上端，为同名的下一个阶段脊神经（例如L4穿过L5的横突）。在横突基底部穿越横突间韧带的背侧叶。沿着横突和上关节突下行的神经支穿过乳突副突韧带的基底部，在椎板处分为多支小枝。在一部分病例中，乳突副突韧带骨化，使神经被包埋于其中。这种情况在L5中最常见（将近20%），单也常发生于L4 (10%) 和 L3(4%)。除了l-z关节以外，内侧支还支配多裂肌，棘间肌和韧带以及椎弓处的骨膜。L5神经有所不同，其背侧支本身走行于髂骨翼和髂骨的上关节突。其内侧支在最低关节囊的基底部下外侧角的对面发出。因此阻滞时只能针对背侧支而非内侧支。

Each facet joint receives dual innervation from medial branches arising from posterior primary rami at the same level and one level above the z-joint. For example,the inferior pole of the L4/5 facet joint receives innervation from the L4 medial branch and its superior pole is innervated by the L3 medial branch, L1/L4 dorsal rami course across the top of their respective transverse processes one level below the named spinal nerve (e.g., L4 crosses the transverse process of L5), traversing the dorsal leaf of the intertransverse ligament at the base of the transverse process. Each nerve then runs downward along the junction of the transverse and superior articular processes, passing beneath the mamilloaccessory ligamentand dividing into multiple branches as it crosses the vertebral lamina (fig. 1). In some cases, the mamilloaccessory ligament becomes calcified, which may lead to nerve entrapment.27 This is most common at L5 (approximately 20%) but also occurs at L4 (10%) and L3(4%). In addition to two l-z joints, the medial branches also innervate the multifidus muscle, the interspinous muscle and ligament, and the periosteum of the neural arch.7,28–30 The L5 nerve differs in that it is the dorsal ramus itself that runs along the junction of the sacral ala and superior articular process of the sacrum.29,31 Its medial branch arises opposite the inferolateral corner of the base of the lowest facet joint. At this level, it is the dorsal ramus rather than its medial branch that is am enable to blockade.

4.组织学

腰椎小关节含有丰富的神经支配。包括有包膜（Ruffini型末梢，尼氏小体）、无包膜及游离神经末梢。低阈值，快适应型动力敏感神经元表明，l-z关节囊不仅传导伤害性信号，还起到本体感受器的作用。除了P物质，降钙素基因相关肽，还在一定数量的小关节神经末梢发现了神经肽Y，表明了存在一定比例的交感传出纤维。在软骨下骨及关节囊内也发现了神经纤维。因此小关节介导性疼痛可能是一种结构依赖性而非关节囊依赖性。在腰椎退变的病例中，在小关节软骨及滑膜组织中也发现了炎症介质如PG，炎性细胞因子，白介素1B，白介素6以及肿瘤坏死因子等

Histologic studies have demonstrated that the lumbar facet joints are richly innervated with encapsulated (Ruffini-type endings, pacinian corpuscles), unencapsulated, and free nerve endings.5 The presence of low-threshold, rapidly adapting mechanosensitive neurons suggests that in addition to transmitting nociceptive information, the l-z facet capsule also serves a proprioceptive function. Besides substance P and calcitonin generelated peptide, a substantial percentage of nerve endings in facet capsules have also been found containing neuropeptide Y, indicating the presence of sympathetic efferent fibers.38,39 Nervefibers have also been found in subchondral bone and intraarticular inclusions of l-z joints, that facet-mediated pain may originate in structures besides the joint capsule. In degenerative lumbar spinal disorders, inflammatory mediators such as prostaglandins43 and the inflammatory cytokines interleukin 1B， interleukin 6, and tumor necrosis factor have been found in facet joint cartilage and synovial tissue.

5. 认识过程

1911年，Goldthwaite首次说明小关节的结构特性可以引发腰痛和不稳。16年后在解剖了75例标本以后，Putti认为小关节的局部炎症和退化能刺激神经从而引起坐骨神经痛。1933年，Ghormley创造了“小关节综合征”一词，指腰骶部疼痛伴有或不伴有坐骨神经痛，可能来源于突然的腰部扭转。此后，Mixter and Barr暗示椎间盘破裂时导致腰腿痛的主要原因后，以此为标志，l-z关节作为腰痛的潜在来源的说法开始减弱。1940s，Badgley指出高达80%的腰痛和坐骨神经痛的病人疼痛来源于小关节产生的牵涉痛，而非由直接药品神经根而引起，由此l-z关节源性疼痛的关注有开始得到复苏。1963年，Hirsch用小关节注射的方法复制了患者的腰痛。由于Ree报道小关节射频神经切断术的成功率高达99.8%，1970s这一手术得到广泛开展。此后，Rees的方法被证实在大部分患者中不能有效切断神经。Buoyed报道这种方法并发血肿的概率很高。1970s中期，Shealy又首创了透视引导下射频消融达到小关节去神经化的方法。

In1911, Goldthwaite13 first noted that the peculiarities of the facet joints could be a significant source of back pain and instability. Sixteen years later, after anatomical dissectionsof 75 cadavers, Putti14 suggested that local inflammation and degenerative changes in lumbar facet joints could result in sciatica from irritation of nerveroots. In 1933, Ghormley15 coined the term “facet syndrome,”which he defined as lumbosacral pain, with or without sciatica, that was likely to occur after a sudden rotatory strain. Shortly thereafter, interest in the l-z joints as potential sources of back pain waned after the landmarkarticle by Mixter and Barr16 implicating lumbar discrupture as the major cause of low back and leg pain. The1940s saw a resurgence in the interest of l-z joints as pain generators when Badgley17 suggested that up to 80% of cases of LBP and sciatica are due to referred pain from l-z joint pathology, rather than direct nerve root compression.In 1963, Hirsch et al.7 published the first account whereby the injection of l-z joints reproduced patients’ back pain. Rees,18 who reported a success rate of 99.8%,is generally credited with promoting percutaneous“facet rhizolysis” with his ground-breaking report in the early 1970s. Later, it was shown that the technique advocated by Rees may not have been sufficient to achieve rhizotomy in most patients.3 Buoyed by a high incidence of hemorrhagic complications,

pioneered the use of fluoroscopically guided radiofrequency facet denervation to treat l-z joint pain in the mid-1970s

6. 腰椎小关节病

腰椎小关节病占慢性腰痛的15%，已成为极具挑战性的课题。腰椎小关节源性疼痛常常隐匿起病，伴有既往椎体滑脱、椎间盘退变、和老龄等问题。

Lumbar zygapophysial joint arthropathy is a challenging condition affecting up to 15% of patients with chronic low backpain. The onset of lumbar facet joint pain is usually insidious,with predisposing factors including spondylolisthesis, degenerativedisc pathology, and old age.

小关节囊及其周围结构富含疼痛感受器，当收到拉伸或局部压缩力时，可以被刺激。腰痛患者和志愿者的研究均表明，针对小关节和其支配神经的化学性或机械性刺激均可引发腰痛或腿痛。在局麻（LA）下的腰椎手术中，刺激腰椎小关节囊可以引发近20%患者产生腰痛。最后且最重要的是，局麻不仅阻滞了小关节本身，而且阻滞了内侧支，而阻滞内侧支本可以在部分病人中减轻疼痛。因此，像身体其他的滑膜关节一样，腰椎小关节也是慢性腰痛的发生器。

The facet joint capsule and surrounding structures are richly imbued with nociceptors that fire when the capsule is stretched or subjected to local compressive forces.5,6 In both pain patients and volunteers,chemical or mechanical stimulation of the facet joints and their nerve supply has been shown to elicit back and/or leg pain. During spine surgery performed under local anesthetic (LA), lumbar facet capsule stimulation elicits significant pain in approximately 20% of patients. Last and most significantly, LA blocks of either the facet joints themselves or the medial branches innervating them have been shown to relieve pain in a substantial percentage of patients with chronic LBP.

6.1.病因

除了骨性关节炎，许多其他的疾病亦可影响小关节。包括炎症性关节炎如类风湿性关节炎，强直性脊柱炎及反应性关节炎等，还有滑液撞击，关节软骨版卡压，关节面软骨软化，假性痛风，滑液炎症，绒毛结节性滑膜炎和急慢性感染。小关节内滑囊囊肿可由于拉伸和压缩临近的疼痛发生结构，骨化及不对称关节增生等原因引起疼痛。绝大部分的病例中，l-z关节性疼痛是源于反复的牵拉以及/或低强度的损伤积累的结果。

Aside from osteoarthritis, several other conditions may affect the facet joints. These include inflammatory arthritides such as rheumatoid arthritis, ankylosing spondylitis and reactive arthritis, synovial impingement,meniscoid entrapment, chondromalacia facetae, pseudogout,synovial inflammation, villonodular synovitis, and acute and chronic infection. the overwhelming majority of cases of l-z joint pain are the result of repetitive strain and/or low-grade trauma accumulated over the course of a lifetime.

6.2 诊断性阻滞

在注射1-2ml液体后，小关节很容易破裂导致注射液外渗到其他可能的疼痛发生组织内。由于破裂发生部位不同，注射液可能渗出到硬膜外间隙，椎间孔，黄韧带及椎旁肌等。0.5ml注射量就能扩散到走位6 cm2的组织中。考虑到内侧支和外侧支，中间支的距离接近，即使低剂量的注射仍能阻滞他们。因为这些神经在椎旁肌，筋膜，韧带，骶髂关节及皮肤的支配中占主要地位，因此MBB即使在正常的小关节中也能发挥作用。超声介导下的内侧支关节囊内阻滞被证实较透视介导更精确， 虽然其血管内吸收剂量较低且在肥胖的患者中精确性较差。由于MBB较之关节内注射技术上更简单，且能对受损神经进行麻醉，利用这种阻滞作为神经射频消融前的诊断方法较为合理。

6.3治疗方法

1）卧床休息 一般患者可找到较舒适的姿势使疼痛有所缓解，例如双侧大退下垫枕，侧卧位两腿间垫枕等。急性期应尽量卧床休息1-3天，使肌肉痉挛逐渐缓解。

2）理疗 局部热敷、红外线、频谱等物理治疗，可以使肌肉放松，促进局部血液循环，改善疼痛。

3）药物 腰腿严重时，可使用 非甾体止痛药、以及解痉的药物等等。

4）小关节注射