|
梨状肌是臀部的深部肌肉，起自第2-4骶椎侧方前面，向外下穿过坐骨大孔而将其分成梨状肌上孔与下孔，肌腱止于股骨大转子上部内侧，是髋关节的外展肌之一。梨状肌综合征是由梨状肌的解剖变异、外伤、劳损、感染等因素导致梨状肌充血、水肿、肥大、痉挛、挛缩、变性从而刺激、压迫坐骨神经及其营养血管引起的一系列症状。症状：臀部、大转子和大腿后侧疼痛、麻木，当晚上平卧，长期坐位，或由起身站立、举重物、弯腰时疼痛加重，某些患者可出现跛行，部分患者存在由大腿后外侧到踝关节的放射痛和坐骨神经分布区的感觉异常。体征 : 1、检查病人的步态和下肢休息时的位置，可提供梨状肌综合征的诊断线索，患者可存在跛行，行走时患侧下肢仿佛较短；2、在仰卧位时患者习惯性保持患肢稍抬高和外旋姿势；3、直腿抬高试验可呈阳性；4、部分患者出现臀肌萎缩5、梨状肌有触痛点并可引起沿坐骨神经的放射痛；6、梨状肌下口处Tinel征阳性；7、梨状肌紧张试验阳性(Freiberg手法)内旋患肢诱发坐骨神经痛8、Pace手法外展患肢诱发坐骨神经痛症状。 超声检查：正常梨状肌位置、大小、回声双侧对称，厚度相差小于2mm。梨状肌综合征患者，患侧梨状肌因充血、水肿、肿胀，超声表现为梨状肌明显增厚，与对侧相比度大于2mm，回声减低，内呈低回声不均匀，梨状肌下孔间隙窄。 治疗：注射疗法:1.有几种不同的注射方法和药物，①在直肠指检找出梨状肌痛点后，进行梨状肌内注射。②在骶骨与大转子中间行梨状肌肌腹封闭治疗，操作中避开坐骨神经。提倡使用25mg醋酸强的松龙或甲基强的松龙，单独或联合局麻药物(10ml1%利多卡因)梨状肌内注射，减轻肌肉应激过高和痉挛，减轻炎症，多数病例报告治疗有效或完全治愈。2.肉毒毒素注射治疗：CT监测下注射肉毒毒素，治疗梨状肌综合征，注射适量的肉毒毒素，可引起局部的化学性去神经支配作用，而注射肌肉出现一过性麻痹，从而迅速消除或缓解肌肉痉挛，改善相关疼痛，而不出现明显的肌力减弱，其是治疗局灶性肌张力增高、痉挛状态、不明原因肌肉肥大等的有效手段。 背景：约6～8％的腰痛，不论是否伴有神经根反射痛，是由梨状肌综合症引起，。临床上采用药物治疗、物理治疗、肌注等方法来治疗梨状肌综合症。肌电图（EMG）、X线透视、计算机断层扫描（CT）或磁共振成像（MRI）等方法被运用在肌注过程中寻找穿刺点。现在超声（US）引导下穿刺注射已经获得令人满意的效果被广泛应用于临床。 目的：本研究的目的是评估梨状肌综合症患者超声引导下进行梨状肌穿刺注射的可靠性。研究设计：可行性研究： 10例梨状肌综合征患者在超声引导下穿刺注射A型肉毒毒素。然后患者被注射2毫升碘剂造影，在CT下进行骨盆和臀部成像来评估碘剂在肌肉内的分布情况。地点：西班牙的多学科疼痛管理中心。 结果：10位患者（8位女性，2位男性），9例有肌肉或筋膜的碘剂分布差异，但碘剂并未进入梨状肌的深层组织中。本组病例碘剂无其他（血管注射）分布差异。 局限性：本研究的主要缺陷是使用电离辐射作为评估手段。 结论：只要操作者受过良好的教育和培训，超声引导下的穿刺可能不失为梨状肌注射简单可靠的方法。超声(US)对医生和病人无辐射及操作简单使得它优于传统的方法。 Computer-Tomographic Verification ofUltrasound-Guided Piriformis Muscle Injection: A Feasibility Study BACKGROUND: Approximately 6% to 8% oflumbar pain cases, whether associated with radicular pain or not, may beattributed to the presence of piriformis muscle syndrome. Available treatments,among others, include pharmacotherapy, physical therapy, and injections ofdifferent substances into the muscle. Various methods have been used to confirmcorrect needle placement during these procedures, including electromyography(EMG), fluoroscopy, computed tomography (CT), or magnetic resonance imaging(MRI). Ultrasonography (US) has now become a widely used technique andtherefore may be an attractive alternative for needle guidance when injectingthis muscle. OBJECTIVE: The objective of this study wasto assess the reliability of US in piriformis injection of patients withpiriformis syndrome. STUDY DESIGN: Feasibility study; 10patients with piriformis muscle syndrome were injected with botulinum toxin Ausing a US-guided procedure. Then patients were administered 2 mL iodinatedcontrast and were then transferred to the CT scanner, where they underwentpelvic and hip imaging to assess intramuscular distribution of the iodinatedcontrast. SETTING: Multidisciplinary Pain ManagementDepartment in Spain. RESULTS: Of all 10 study patients (8 women,2 men), 9 had intramuscular or intrafascial contrast distribution. Distributiondid not go deeper than the piriformis muscle in any of the patients. Theabsence of contrast (intravascular injection) was not observed in any case. LIMITATIONS: The main limitation of our studyis the use of ionizing radiation as confirmation technique. CONCLUSION: Ultrasound-guided puncture maybe a reliable and simple procedure for injection of the piriformis muscle, aslong as good education and training are provided to the operator. US has anumber of advantages over traditional approaches, including accessibility andespecially no ionizing radiation exposure for both health care providers andpatients. |
|
|
