腰椎关节突关节炎
A Patient’s Guide to Lumbar Facet Joint Arthritis
腰椎关节突关节炎患者指南
Arthritis of the lumbar facet joints can be a source of significant low back pain. Aligned on the back of the spinal column, the facet joints link each vertebra together.Articular cartilage covers the surfaces where these joints meet. Like other joints in the body that are covered with articular cartilage, the lumbar facet joints can be affected by arthritis.
腰椎关节突关节炎可导致显著的下腰痛。关节突整齐排列在脊柱背侧，将每个椎骨连接起来。关节突相到接触的地方有关节软骨在表面覆盖。就如身体上其他覆盖关节软骨的关节一样，腰椎关节突关节也会得关节炎。
This guide will help you understand
本指南将有助于你理解以下几点：
· how the problem develops
· 关节突关节炎如何变化进展？
· how doctors diagnose the condition
· 临床医生如何诊断？
· what treatment options are available
· 可行的治疗有哪些？
What part of the back is involved?
病变发生在腰背部的哪个位置？
The human spine is made up of 24 spinal bones, called vertebrae. Vertebrae are stacked on top of one another to create the spinal column. The spinal column gives the body its form. It is the body’s main upright support.
人体的脊柱是由24块脊柱骨块组成，我们称之为椎骨。椎骨彼此上下堆叠构成脊柱。脊柱塑造了人体的大致形态。脊柱是维持人体直立位的主要支撑。
The back portion of the spinal column forms a bony ring. When the vertebrae are stacked on top of each other, these bony rings create a hollow tube. This tube, called the spinal canal, surrounds the spinal cord as it passes through the spine. Just as the skull protects the brain, the bones of the spinal column protect the spinal cord.
脊柱的背侧部分构成一个骨性环。当椎骨彼此上下堆叠的时候这些骨性环也就组成了一个中空的管道，我们称之为椎管。它围绕贯穿脊柱的脊髓。就好像颅骨保护大脑一样，脊柱的骨性结构保护着脊髓。
Between the vertebrae of each spinal segment are two facet joints. The facet joints are located on the back of the spinal column. There are two facet joints between each pair of vertebrae, one on each side of the spine. A facet joint is made of small, bony knobs that line up along the back of the spine. Where these knobs meet, they form a joint that connects the two vertebrae. The alignment of the facet joints of the lumbar spine allows freedom of movement as you bend forward and back.
在每个脊柱节段的椎骨之间有两个关节突。关节突位于脊柱的背侧。位于每一对椎骨之间的两个关节突各在脊柱的一侧。关节突是由骨性小突起组成，它们排列在脊柱后方。这些突起相接触的地方形成关节突关节，以连接两个椎骨。脊柱关节突的排列使你能都自由的前后弯腰活动。
The surfaces of the facet joints are covered by articular cartilage. Articular cartilage is a smooth, rubbery material that covers the ends of most joints. It allows the bone ends to move against each other smoothly, without friction.
关节突的表面覆盖有关节软骨，关节软骨是覆盖在大部分关节末端的光滑而又弹性的物质。它使得骨端能没有摩擦地相对滑动。
Related Document: A Patient’s Guide to Lumbar Spine Anatomy
相关阅读：腰椎解剖患者指南（翻译招募中，有意者请留言）
精美视频：腰椎解剖（lumbar spine anatomy）
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本视频由张正阳翻译，更多解剖视频，请关注微信公众平台《张正阳Thomas》
Why do I have this problem?
为什么我会患有关节突关节炎？
Normally, the facet joints fit together snugly and glide smoothly, without pressure. If pressure builds where the joint meets, the cartilage on the joint surfaces wears off, or erodes.
正常情况下，关节突紧贴在一起，在没有应力的条件下滑动。一旦在关节突接触点应力增加，关节突表面的软骨就会磨损，侵蚀。
Each segment in the spine has three main points of movement, the intervertebral disc and the two facet joints. Injury or problems in any one of these structures affects the other two. As a disc thins with aging and from daily wear and tear, the space between two spinal vertebrae shrinks. This causes the facet joints to press together.
脊柱的每个节段都有三个主要的活动点，椎间盘以及两侧的关节突。任何一处的损伤会累及另外两个位置。随着年龄增长，椎间盘变薄，以及日常的磨损、撕裂，两个椎骨之间的间隙缩小。这会导致关节突关节的骨头挤压在一起。
Facet joints can also become arthritic due to a back injury earlier in life. Fractures, torn ligaments, and disc problems can all cause abnormal movement and alignment, putting extra stress on the surfaces of the facet joints.
早年的背部损伤也会促使关节突出现炎症。骨折、韧带撕裂以及椎间盘疾病都能引发异常活动以及脊柱排列异常，这会给予关节突表面额外的应力。
The body responds to this extra pressure by developing bone spurs. As the spurs form around the edges of the facet joints, the joints become enlarged. This is called hypertrophy. Eventually, the joint surfaces become arthritic. When the articular cartilage degenerates, or wears away, the bone underneath is uncovered and rubs against bone. The joint becomes inflamed, swollen, and painful.
身体通过形成骨刺来对这些额外的应力做出反应。随着骨刺在关节突周围形成，关节突增大，这就是所谓的关节肥大。最终，关节突表面出现炎症。当关节软骨退变或者磨损，关节下骨就会暴露，骨与骨之间出现摩擦。整个关节突就会出现炎症引发肿胀、疼痛。
View animation of facet arthritis
观看关节突关节炎的动画
Facet joint arthritis develops slowly over a long period of time. This is partly because spinal degeneration in later life is the main cause of facet joint arthritis. Symptoms rarely develop immediately when degeneration is causing the problems. However, rapid movements, heavy twisting, or backward motions in the low back can injure a facet joint, leading to immediate symptoms.
关节突关节炎是在一个漫长的时间里缓慢形成的。这一部分是因为老年脊柱退化是关节突关节炎的主要原因。当退化引发关节炎，症状也很少马上出现。然后下腰部的快速运动、大幅度扭转或者背伸活动会损伤关节突，导致即时的症状。
What does the condition feel like?
关节突关节炎的表现？
Pain from facet joint arthritis is usually worse after resting or sleeping. Also, bending the trunk sideways or backward usually produces pain on the same side as the arthritic facet joint. For example, if you lie on your stomach on a flat surface and raise your upper body, you hyperextend the spine. This increases pressure on the facet joints and can cause pain if there is facet joint arthritis.
关节突关节炎源性的疼痛通常在休息或睡眠时加重。此外，当关节突有炎症时，躯干侧弯或者后伸会引起患侧疼痛。例如，如果你在平板上俯卧，抬起你的上半身体，你的脊柱就处于过伸位。这会增加关节突的应力，如果存在关节突关节炎，就会引发疼痛。
Pain may be felt in the center of the low back and can spread into one or both buttocks. Sometimes the pain spreads into the thighs, but it rarely goes below the knee. Numbness and tingling, the symptoms of nerve compression, are usually not felt because facet arthritis generally causes only mechanical pain. Mechanical pain comes from abnormal movement in the spine.
疼痛可能分布在腰部的中心，向一侧或者双侧臀部放射。有时疼痛放射到大腿，但极少跨越膝盖。通常没有神经压迫症状——麻木和刺痛。这是因为关节突关节炎一般只引起机械性的疼痛。这源于脊柱异常的活动。
However, symptoms of nerve compression can sometimes occur at the same time as the facet joint pain. The arthritis can cause bone spurs at the edges of the facet joint. These bone spurs may form in the opening where the nerve root leaves the spinal canal. This opening is called the neural foramen. If the bone spurs rub against the nerve root, the nerve can become inflamed and irritated. This nerve irritation can cause symptoms where the nerve travels. These symptoms may include numbness, tingling, slowed reflexes, and muscle weakness.
然而，神经压迫症状有时会与关节突疼痛同时发生。关节炎导致关节突边缘的骨刺形成。这些骨刺可能位于神经根离开椎管的开口处，也就是椎间孔。如果骨刺与神经根发生摩擦，神经会激惹发炎。神经激惹会引发神经支配区域的症状。这些症状包括麻木、刺痛、反射减弱以及肌肉无力。
How do doctors diagnose the problem?
医生如何诊断该疾病？
Diagnosis begins with a complete history and physical examination. Your doctor will ask questions about your symptoms and how your problem is affecting your daily activities. This will include questions about where you feel pain and if you have numbness or weakness in your legs. Your doctor will also want to know what positions or activities make your symptoms worse or better.
诊断首先需要完整的病史采集以及体格检查。医生会询问你的症状以及病情对日常生活的影响。这包括疼痛部位，你的下肢是否有麻木或无力。医生还会问你哪些姿势或活动会使症状恶化或者缓解。
Then the doctor performs a physical exam to determine which back movements cause pain or other symptoms. Your skin sensation, muscle strength, and reflexes are also tested.
随后医生会对你进行体格检查来明确哪些腰部活动会引起疼痛或其他症状，并测试皮肤感觉、肌力以及反射。
X-rays can show if there are problems in the bone tissue in and near the facet joints. The images can show if degeneration has caused the space between the vertebrae to collapse and may show if bone spurs have developed near the facet joints.
X线能显示关节突或者周围的骨组织是否有问题。这些影像也能显示是否有退变引起的椎间隙变窄以及是否有骨刺在关节突周围形成。
When more information is needed, your doctor may order magnetic resonance imaging (MRI). The MRI machine uses magnetic waves rather than X-rays to show the soft tissues of the body. This test gives a clear picture of the facet joints to see whether they are enlarged or swollen. This machine creates pictures that look like slices of the area your doctor is interested in. The test does not require dye or a needle.
当需要更多信息时，医生会要求你做磁共振，磁共振运用磁场而不是X线来显示机体软组织，能清晰地显示关节突的图像以观察是否有肥大或者肿胀，还能就医生感兴趣区域提供断层图像。它不需要造影及穿刺。
A computed tomography (CT) scan may be ordered. This is a detailed X-ray that lets your doctor see slices of bone tissue. The image can show whether the surface of the joint has eroded and whether bone spurs have developed.
医生可能会要求你做CT扫描。通过计算机对X线图像进行处理，为医生提供骨组织的断层影像，能显示关节表面是否有侵蚀或者是否有骨刺形成。
A diagnostic injection may be used to locate the source of pain. The doctor uses a long needle to inject a local anesthetic (numbing medication) into either the joint or into the nerve that goes to the joint. The doctor watches the needle on a fluoroscope to make sure it reaches the correct spot. A fluoroscope is a special X-ray television that allows the doctor to see your spine and the needle as it moves. Once the doctor is sure the needle is in the right place, the medicine and a special dye are injected. The doctor watches the dye to make sure the medication is correctly placed. The results from the injection help the doctor make the diagnosis. If pain goes away, it helps confirm the source of pain.
为明确疼痛来源，可采用一种诊断性注射方法。医生用长针在关节突或者支配神经处注射局部麻醉药。医生会在透视下观察针的位置以确保到达正确位置。透视是一种特殊的X线电视，能让医生在穿针时看到脊柱和针的位置。一旦医生确定针已到达正确位置，就会注射药物以及特殊的造影剂。医生观察造影剂来明确药物注射在正确位置。注射后的结果有助于明确诊断。如果注射后疼痛消失，就能证实疼痛来源于关节突关节。
相关视频：关节突关节注射（Facet Joint Injections）
What treatment options are available?
目前可选择的治疗方案有哪些？
Facet joint arthritis is mainly treated nonsurgically. At first, doctors may prescribe a short period of rest, one to two days, to calm inflammation and pain. Patients may find added relief by curling up to sleep on or by lying back with their knees bent and supported. These positions take pressure off the facet joints.
关节突关节炎主要非手术治疗。首先，医生会嘱咐1~2天的短期休息，以缓解炎症以及疼痛。患者会发现蜷曲睡觉或者膝关节屈曲垫起仰卧更能缓解不适，因为这些姿势能消除关节突的应力。
Your doctor may prescribe anti-inflammatory medication, such as a nonsteroidal anti-inflammatory drug (NSAID) or aspirin. Muscle relaxants are occasionally used to calm muscles that are in spasm. Oral steroid medicine in tapering dosages may also be prescribed for pain.
医生会开消炎药，例如非甾体类消炎药物，阿司匹林。肌松药视情况使用来缓解痉挛的肌肉。也会开一些口服类固醇药物来缓解疼痛，但这些药物需要逐渐减少剂量。
Patients often work with a physical therapist. By evaluating a patient’s condition, the therapist can assign positions and exercises to ease symptoms. The therapist may recommend traction. Traction is a common treatment for this condition. It gently stretches the low back and takes pressure off the facet joints. The therapist may also prescribe strengthening and aerobic exercises. Strengthening exercises focus on improving the strength and control of the back and abdominal muscles. Aerobic exercises are used to improve heart and lung health and increase endurance in the spinal muscles. Stationary biking offers a good aerobic treatment and keeps the spine bent slightly forward, a position that gives relief to many patients with lumbar facet joint arthritis.
患者经常可以做做理疗。通过评估患者病情，理疗师可以安排一些姿势以及运动来缓解症状。理疗师也会建议牵引治疗。牵引是针对关节突关节炎的常用治疗方法。它轻柔地牵拉下腰部来解除关节突的应力。运动处方包括力量练习和有氧运动。力量练习主要提升腰背肌以及腹部肌肉的力量和控制。有氧运动则能改善心肺功能，提高脊柱肌肉的耐力。固定单车能提供一个良好的有氧运动治疗方案，它使脊柱保持轻度前伸。这能缓解许多患者的腰椎关节突关节炎。
Patients who still have pain after trying various treatments may require injections into the facet joint or the small nerves that go to the joint. An anesthetic is used to block pain coming from the facet joint. The procedure to inject the medication into the joint is similar to the diagnostic injection described earlier. A steroid medication is occasionally used instead of the anesthetic. There is no strong evidence that these injections work. However, they seem to have some good short-term results with few side effects, so they shouldn’t be abandoned completely. Doctors often have their patients resume physical therapy treatments following an injection.
尝试了各种各样治疗方法仍有疼痛的患者，可能需要进行关节突关节注射或对支配关节的小神经进行阻滞。麻醉药物可阻断来源于关节突关节的疼痛。在关节内注射药物的过程与前面所述的诊断性注射方法相似。常常用类固醇类药物代替麻醉药。没有强有力的证据证明这些注射有效，然而，这些方法似乎有很好的短期疗效，而且副作用很少，因此目前还没完全被摒弃。注射后，医生往往再次给病人做理疗。
Related Document: A Patient’s Guide to Facet Joint Injections
相关阅读：关节突注射的患者指南（翻译招募中，有意者请留言）
腰椎背根内侧支神经阻滞（Medial Branch Block）
People with facet joint arthritis rarely need surgery. However, facet joint arthritis is a primary source of chronic low back pain about 15 percent of the time. After trying other types of treatment, some of these patients may eventually require surgery. There are several types of surgery for facet joint arthritis. The two primary operations are
关节突关节炎患者很少需要外科干预。然而关节突关节炎是慢性下腰痛的主要来源，约占15%。在尝试其他治疗后，一些患者可能最终需要手术。对于关节突关节炎有一些外科方式。主要的两种外科治疗方式如下：
· facet rhizotomy
· 关节突神经切断术
· 后路腰椎融合
Facet Rhizotomy
关节突神经切断术
Rhizotomy describes a surgical procedure in which a nerve is purposely cut or destroyed. Facet rhizotomy involves severing one of the small nerves that goes to the facet joint. The intent of the procedure is to stop the transmission of pain impulses along this nerve. The nerve is identified using a diagnostic injection (described earlier). Then the surgeon inserts a large, hollow needle through the tissues in the low back. A special probe is inserted through the needle, and a fluoroscope is used to guide the probe toward the nerve. The probe is slowly heated until the nerve is severed.
关节突神经切断术讲的是一种将神经有意的切断或破坏的手术方法。关节突神经切断术是切断走行到关节突的神经的一个分支。手术目的是终止神经疼痛信号的传递。所需切断的神经通过诊断性神经阻滞来确定（见前所述）。然后外科医生在腰部组织内插入一个粗而中空的针管，沿针管插入一个特定的探针，用透视辅助引导探针到达神经部位，探针缓慢加热直至神经被离断。
Posterior Lumbar Fusion
后路腰椎融合
Facet joint arthritis mainly causes mechanical pain, the type of pain caused by wear and tear in the parts of the lumbar spine. Posterior lumbar fusion for facet joint arthritis is mainly used to stop movement of the painful joints by joining two or more vertebrae into one solid bone (fusion). This keeps the bones and painful facet joints from moving.
关节突关节炎主要引起机械性疼痛，这是一种由于腰椎骨关节磨损撕裂引发的疼痛。治疗关节突关节炎的后路腰椎融合术主要通过将两个或者更多椎骨融合成一个骨块来阻止病变处关节突的活动。这阻止了椎骨以及引起疼痛的关节突关节的活动。
In this procedure, the surgeon lays small grafts of bone over the back of the spine. Most surgeons will also apply metal plates and screws to prevent the two vertebrae from moving. This protects the graft so it can heal better and faster.
术中，外科医生会将小的骨移植物放置在脊柱后方。大部分外科医生也会应用金属板和螺钉固定来防止椎骨移位。这样可以保护移植物更好更快地融合。
Related Document: A Patient’s Guide to Posterior Lumbar Fusion
相关阅读：后路腰椎融合术患者指南（翻译招募中，有意者请留言）
相关视频：
后外侧植骨术（Posterolateral Gutter Fusion Surgery）
后路腰椎椎体间融合术（Posterior Lumbar Interbody Fusion/PLIF）
非手术治疗的康复
Even if you don’t need surgery, your doctor may recommend that you work with a physical therapist. Patients are normally seen a few times each week for four to six weeks. In severe and chronic cases, patients may need a few additional weeks of care.
即使你不需要手术，医生也会建议你进行物理治疗。正常情况下患者需要进行为期4~6周，每周数次的物理治疗。一些严重的慢性病例，患者需要额外增加治疗周数。
Therapists create programs to help patients regain back movement, strength, endurance, and function. Treatments for facet joint arthritis often include lumbar traction, described earlier. Hands-on treatments such as massage and specialized forms of soft-tissue mobilization may be used initially. They are used to help patients begin moving with less pain and greater ease.
治疗师设定治疗计划来帮助患者恢复背部活动、力量、耐力以及功能。关节突关节炎的治疗一般包括早期腰椎牵引（见前述）。起先会使用一些手法治疗比如按摩以及特定形式的软组织调理。这些有助于患者开始活动时疼痛更轻、更加容易。
Spinal manipulation can sometimes provide short-term relief of pain from facet arthritis. Commonly thought of as an adjustment, spinal manipulation stretches the tissues surrounding the facet joint and helps reset the sensitivity of the spinal nerves and muscles. It involves a high-impulse stretch of the spinal joints and is characterized by the sound of popping as the stretch is done. However, it doesn’t seem to provide effective long-term help when used routinely for chronic conditions.
脊柱推拿有时能短期缓解关节突炎性疼痛。脊柱推拿通常被认为是种调节，能够伸展关节突关节周围的组织，有助于重置脊神经以及肌肉的敏感度。它包括高脉冲的牵拉脊柱关节，以牵拉时爆裂声为特点。然而，当常规用于慢性症状时，并不能带来长期的效果。
Patients are shown how to improve strength and coordination in the abdominal and low back muscles. Therapists can also evaluate their patients’ workstations or the way they use their bodies when they do their activities.
治疗师会指导患者如何提高腰背以及腹部肌肉的力量和协调性。治疗师也会评估患者的工作场所，或患者日常活动时的方式。
Outpatient physical therapy is usually prescribed only for patients who have extra pain or show significant muscle weakness and deconditioning.
出院后物理治疗通常仅限于格外疼痛或者明显肌肉无力不协调的患者。
Patients usually don’t require physical therapy after facet rhizotomy. Surgeons may prescribe a short period of therapy when patients have lost muscle tone in their back and abdominal muscles, when they have problems controlling pain, or when they need guidance about returning to work.
患者一般在关节突神经切断术后不需要物理治疗。当患者背部或腹部肌肉张力低下，或者在缓解疼痛方面有问题，或者需要关于恢复工作的指导，外科医生可能会处方短期物理治疗。
If patients require formal rehabilitation after facet rhizotomy, they will probably only need to attend sessions for two to four weeks. They should expect full recovery to take up to three months.
如果患者在关节突神经切断术后需要正规的康复治疗，他们可能只需要参加2~4周的指导课程。患者完全恢复需要3个月。
Patients who have had lumbar fusion surgery normally need to wait at least six weeks before beginning a rehabilitation program. They typically need to attend therapy sessions for six to eight weeks and should expect full recovery to take up to six months.
腰椎融合术后或者正常需要至少六周休息，之后开展康复。他们一般需要6~8周的康复治疗，完全康复需要6个月。
During therapy after surgery, the therapist may use treatments such as heat or ice,electrical stimulation, massage, and ultrasound to help calm pain and muscle spasm. Then patients begin learning how to move safely with the least strain on the healing back.
在术后治疗期间，治疗师会使用热疗、冷疗、电刺激、按摩以及超声等疗法来缓解疼痛以及肌肉痉挛。然后患者开始学习如何使背部受力最小的情况下进行安全活动。
As the rehabilitation program evolves, patients do more challenging exercises. The goal is to safely advance strength and function.
随着康复进展，患者可以做更具挑战性的锻炼。目标是安全的提升力量和功能。
As the therapy sessions come to an end, the therapist helps patients get back to the activities they enjoy. Ideally, patients are able to resume normal activities. They may need guidance on which activities are safe or how to change the way they go about their activities.
随着治疗到达尾声，治疗师会帮助患者回归到他们热爱的活动，理想情况下，患者能恢复正常活动。这时可以对他们进行关于哪些活动是安全的或者如何改变他们日常活动方式的指导。
When treatment is well under way, regular visits to the therapist’s office will end. The therapist will continue to be a resource. But patients are in charge of doing their exercises as part of an ongoing home program.
当治疗进展顺利，就不用继续定期找治疗师就诊。治疗师仍然是一种资源。但患者出院后必须由自己继续在家进行康复锻炼作为居家计划的一部分。
翻译：郭晓峰，南通大学2016级骨科硕士研究生，目前在南通大学第二附属医院参加规范化培训。
翻译：郭晓峰，南通大学2016级骨科硕士研究生，目前在南通大学第二附属医院参加规范化培训。
校对：保国锋
保国锋，南通市第一人民医院脊柱外科，副主任医师，硕士生导师、医学博士。江苏省“333高层次人才”培育对象、南通市医学重点人才、南通市“226高层次人才”培养对象。社会兼职：江苏省医学会骨科分会创伤学组委员、江苏省中西医结合学会骨科分会委员、北美脊柱外科学会(NASS)会员、南通市中西医结合学会骨科分会委员。擅长颈肩腰腿痛、脊柱脊髓损伤、脑瘫等手术治疗。2011年、2014年、2016年曾在澳大利亚Latrobe大学、德国OberlinHaus医院、德国科隆大学医院和韩国首尔国立大学医院（SNUH）研修脊柱外科。
门诊时间：周五全天
（编辑：胡佰文）
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