dau that lung.pdf

BM Y Hc Gia nh. Trng H Y Khoa Phm Ngc Thch

AU THT LNG

1. I CNG

au tht lng (low back pain) l tnh trng au, cng c hay cng c vng di b sn v

trn np gp mng di (c hoc khng km au thn kinh ta). au c th trung tm

(ng gia) hay lin quan n cc cu trc khng nm trn ng gia (bao gm m lin

kt v thn kinh ngoi bin phn b t ty sng). a s cc triu chng au tht lng u

khng c hiu v do vic s dng qu mc hay tn thng cc dy chng v cc c cnh

sng, hoc do thoi ha khp. Cc c ch c hiu gy au lng bao gm:

- Thot v a m

- Hp ng sng

- Gy t sng

- U c tnh ct sng

- Khuyt cung t sng (spondylolysis)

- Trt t sng (spondylolisthesis)

- Nhim trng ct sng

- Bnh l vim nhim

- au cc c quan lin quan n: bnh l mch mu, tiu ha, tit niu sinh dc.


Hnh 1: Cc nguyn nhn ca au lng km au mng v au chn

2. C IM LM SNG CA AU THT LNG

Triu chng v du hiu

Hi bnh s cn thn v thm khm lm sng l iu cn thit xc nh du hiu nghim

trng bnh nhn c biu hin TL cp tnh. Ngi bc s cn phi tm "du hiu bo ng".

Nu cc du hiu bo ng c xc nh, cc bnh nhn cn cp cu nn c t vn trc

tip hoc gii thiu n bc s chuyn khoa thch hp. Bnh nhn khng cp cu m c cc


du hiu bo ng nn c ln k hoch thc hin cc xt nghim chn on thch hp

nhm xc nh xem h c cn gii thiu n bc s chuyn khoa hay khng.

B

Vic khai thc bnh s nn tp trung vo cc c im sau:

- V tr ca cn au

- C ch chn thng (bnh nhn ang lm g khi h thy au ln u tin, cho d l m

thm hoc kt qu ca mt chn thng hoc hot ng c th)

- c tnh ca cn au (c hc, lan to, khp khing, hoc khng c hiu )

- Thi gian ca cn au (cp tnh < 6 tun, hoc mn tnh > 6 tun ) .

- Triu chng thn kinh (triu chng rut hoc bng quang, yu chi, mt cm gic vng

quanh hu mn, hi m) gi hi chng chm ui nga, mt trng hp khn cp phu

thut thn kinh thc s.

- Tnh trng chc nng ca bnh nhn cn lu khi c bt k yu t lm trm trng thm

hoc ci thin tnh trng bnh.

- S hin din ca st, st cn, au v m l mi quan tm c bit nh nhng c th ch ra

mt cn bnh nghim trng hn, chng hn nh ung th tim n .

- Tin cn v mt x hi nn c khai thc, bao gm thng tin v vic s dng hoc lm

dng thuc, tim chch ma tu, s dng thuc l...Tin cn mc cc bnh trc y v phu

thut cng cn c lu , c bit l tin cn phu thut ct sng hoc suy gim min dch

(tin s ung th, s dng steroid, nhim HIV) .

Mt bnh s ton din gip cc nh lm sng xc nh cc du hiu bo ng m i hi

vic khm chuyn su hn loi tr cc bnh nghim trng.

Khm lm sng

-Vic khm lm sng b sung cc thng tin thu c qua vic hi bnh s bng cch gip xc

nh tnh trng bnh nghim trng hoc kh nng tn thng thn kinh nghim trng. Cc

yu t chnh ca vic kha m lm sng l nhn, s, quan st (bao gm c kim tra phm vi

chuyn ng), v nh gi thn kinh-c chuyn bit.


-Vic khm lm sng nn bt u vi vic nh gi cong ct sng, phm vi chuyn ng

ca tht lng. S cc c cnh sng, cc mu chuyn t sng, khp cng chu, cc c hnh

l v v tr ca xng chu (gai chu trc trn v gai chu sau trn). Bi v ct sng tht

lng khp bn ng vi khung xng chu (c bit l vng cng - chu), nn au xng

chu thng c cp nh au ct sng tht lng. gii quyt cc bnh l xng

chu, cc nh lm sng phi xc nh c v tr gai chu trc trn v gai chu sau trn

nhm nh gi ri lon chc nng quay ca xng chu, nguyn nhn gy TL.

-nh gi thn kinh

nh gi thn kinh nn bao gm kim tra phn x gn Achilles (S1) v xng bnh ch (L2-

L4 ), sc gp khp c chn hoc ngn chn ci ( L4- L5 ) v sc c mt lng bn chn (S1),

cng nh v tr phn nn v cm gic (dermatomes lin quan). Th nghim cm gic tinh t

vng gia ( L4 ), mt lng ( L5 ), v mt bn ( S1) ca bn chn cng cn c thc hin.

nhng bnh nhn c biu hin TL cp v khng c than phin c th, mt thm khm thn

kinh phc tp hn thng khng cn thit. Nghim php nng thng chn nn c thc hin

c hai v tr ngi v nm nga nh gi s p r thn kinh. nh gi thn kinh ca chi

di cho php pht hin cc ngha lm sng tn thng r thn kinh cc mc L4- L5 hoc

L5 -S1. Hai v tr ny chim ti hn 90% ca tt c cc bnh l r thn kinh th pht do thot

v a m tht lng. V khm lm sng n gin ny c th tht bi trong chn on mt s

nguyn nhn TL him gp, cho nn bt k bnh nhn khng c ci thin trong 4-6 tun

nn c nh gi li t u.

S phn t g guy c

Tt c cc bnh nhn TL cp nn c phn tng nguy c vi nh gi ban u xc nh

du hiu bo ng. Vic hi bnh s v khm lm sng c kh nng pht hin bnh l trm

trng bn di (v d nh gy xng, ung th, nhim trng, phnh ng mch ch bng, hoc

hi chng chm ui nga. Nhng bng chng lm sng bao gm tin s chn thng nng,

chn thng nh nhng bnh nhn > 50 tui, st dai dng, tin s ung th, ri lon trao i

cht, yu c, ri lon chc nng bng quang hay rut, mt cm gic vng quanh hu mn, hi

m, gim co tht c vng, v m khng ngng au. Khi xut hin du hiu bo ng, cn

nhanh chng hnh ng, chng hn nh thc hin cc phng tin hnh nh hoc cc xt

nghim.


Hnh 2: Du hiu bo ng v nhng hnh ng thch hp BN TL

Bnh l Du hiu bo ng H ng

Ung th Tin cn ung th Nu nghi bnh l c tnh ca ct sng: -Hnh nh hc -CTM, Tc mu lng -Cc CLS tm u nguyn pht: PSA, nh nh, in di protein, in di protein min dch.

St cn CRNN

50 tui

Tht bi iu tr

au 4 6 tun

au v m hay lc ngh

Nhim trng

St Nu nghi nhim trng ct sng: - MRI

-CTM, Tc mu lng -TPTNT

Dng thuc truyn TM

Nhim trng gn y: nhim trng tiu, da, vim phi

Tnh trng c ch MD (dng steroid, ghp tng, T, HIV)

au lc ngh

HC

chm

ui nga

B tiu hay tiu khng t ch Khm chuyn khoa ngoi

Mt cm gic vng quanh hu mn,hi m

Gim co tht c vng/ tiu khng t ch

Yu/t hai chi di hay khim khuyt thn kinh

Gy S Dng Corticosteroid -Hnh nh hc thch hp -Khm chuyn khoa ngoi 70 tui hoc tin cn long

xng

Chn thng nng gn y

Phnh

MCB cp

Khi mch p vng bng -Hnh nh hc thch hp (siu m) -Khm chuyn khoa ngoi Bnh x va M

au v m hay lc ngh

60 tui

Thot v a m

Yu c -Hnh nh hc thch hp -Khm chuyn khoa ngoi

3. VAI TR CA CN LM SNG I VI BN TL:

Xt nghim

Cc bnh nhn nghi ng c biu hin gi mo TL n thun, chng hn nh ung th hoc

nhim trng nn c thc hin cn lm sng. Xt nghim c ngh trong vic nh gi

nhng bnh nhn ny bao gm cng thc mu v tc mu lng (ESR). ESR > 50 mm/h l

gi ca bnh c tnh, nhim trng, hoc bnh vim. BUN, Creatinin, v phn tch nc tiu

(TPTNT) hu ch trong vic xc nh bnh thn hoc bnh ng tiu.


Canxi, phospho v alkaline phosphatase mu cn c kim tra nhng bnh nhn thiu

xng (osteopenia), tn thng ct sng dng hy xng (osteolytic vertebral lesion), hoc

xp thn t sng (vertebral body collapse). Nu nghi ng ung th tuyn tin lit, cn kim

tra PSA (prostate-specific antigen) v nng acid phosphatase. Nu nghi ng a u ty, c

th gip hng dn iu tr da trn in di min dch huyt thanh (IPEP: immunoprotein

electrophoresis).

Hnh nh hc

Chn on hnh nh him khi c ch nh trong TL cp tnh. Sau 4-6 tun u, a s bnh

nhn s t hi phc. Tuy nhin, nu bnh nhn vn hn ch bi cc triu chng xut hin tr

li, hnh nh hc nn c xem xt tm cc bnh l biu hin di triu chng TL.

Nhm bnh nhn nn kho st hnh nh hc bao gm tr em, bnh nhn > 50 tui, bnh nhn

chn thng, hoc bnh nhn m au lng khng ci thin d iu tr bo tn ph hp. Hnh

nh hc lun lun phi c thc hin cn thn, bi v thoi ha a m v li a m

c ghi nhn trong 20-25% ngi khng c triu chng. V vy, pht hin bt thng trn

chn on hnh nh c th c hoc khng i din cho l do au ca bnh nhn.


Hnh 3: Cc CLS c bit v ch nh

Cc CLS c bit Ch nh

Cng thc mu (CBC) Nghi ng u, bnh l ty, nhim trng

Tc mu lng (ESR) Nghi ng u, nhim trng, vim, ri lon chuyn ha

TPTNT (Urinalysis) Nghi ng nhim trng tiu, vim b thn, u ty

in di min dch (IPEP) Nghi ng a u ty

TSH, Cacium, Alkaline

phosphatase

Nghi ng ri lon in gii, ri lon chc nng tuyn

gip, ri lon chuyn ha

X quang Khng khuyn co thng quy trong nh gi TL cp

(tr khi c du hiu bo ng)

Khuyn co loi tr gy xng

X quang chp nghing ch khuyn co khi cc pht hin

gi trt t sng hoc khuyt cung t sng

in c (Electromyelogram),

in di huyt thanh (Serum

electrophoresis)

Nghi ng ri lon chc nng r thn kinh nng vi cc

triu chng chn 6 tun

Khng khuyn khch nu bnh l r thn kinh r rng

MRI hoc CT ty

Triu chng chn lin quan n lng v pht hin trn

lm sng c du hiu p ty

Bnh s c i cch hi do thn kinh nghi hp ng sng

Nghi ng HC chm ui nga, gy S, nhim trng,u

X hnh xng Di cn

Chng ch nh bnh nhn mang thai

4. CC PHNG PHP IU TR AU THT LNG

Nu bnh nhn khng c du hiu bo ng, v bnh s, khm thc th khng gi bt k

nguyn nhn n bn di, c th chn on l TL c hc v c th bt u vic iu tr.

Phng php kim sot triu chng nn tp trung vo vic to s thoi mi v gi cho bnh

nhn hot ng cng nhiu cng tt trong khi ch i phc hi t pht.

Ty thuc vo bnh nhn, iu tr ny c th bao gm iu chnh hot ng, ngh ngi ti

ging (thi gian ngn), iu tr bo tn, tng cng vn ng v tp th dc, vt l tr liu

v gio dc bnh nhn. Vic iu tr ny nn c s dng t 4-6 tun trc khi ch nh

thm cc xt nghim chn on, tr khi cc triu chng ca bnh nhn xu i. Theo di bnh

nhn l rt quan trng gim st v iu chnh iu tr


Gio dc bnh nhn

Gio dc bnh nhn l nn tng iu tr hiu qu ca TL. Bnh nhn n phng khm

chm sc ban u vi TL cp tnh cn c gio dc v cc mong i trong vic hi phc

v kh nng ti pht ca cc triu chng.

Bnh nhn nn c hng dn v cch iu chnh hot ng an ton v hp l, v c

cung cp thng tin lm th no hn ch TL ti pht thng qua k thut nng thch hp,

iu tr bo ph, v cai thuc l.

Nu thuc c s dng, bnh nhn phi c cung cp thng tin v cch s dng v cc tc

dng ph tim tng.

Nu bnh nhn khng ci thin vi iu tr bo tn hoc xut hin cc ri lon chc nng

ng rut, bng quang hoc chc nng thn kinh xu i, bnh nhn cn c hng dn

theo di trong 1-3 tun.

iu chnh hot ng

Bnh nhn TL cp c th c thoi mi hn nu h c th tm thi hn ch hoc trnh cc

hot ng chuyn bit lm tng p lc c hc ln ct sng. Cn phi trnh ngi lu m khng

c ta v nng vt nng, c bit l un cong hoc xon vn. xut hot ng trong cng

vic cho bnh nhn TL cp nn da trn tui ca bnh nhn, sc khe ni chung, v cc

nhu cu th lc ca cng vic.

Ngh gi ti ging

Trong iu tr TL, vic dn dn tr li hot ng bnh thng hiu qu hn l ngh ngi ti

ging ko di. Ngh ngi ti ging lu > 4 ngy c th dn n suy nhc gy teo c do

khng c khuyn khch. Hu ht cc bnh nhn TL cp tnh khng cn ngh ngi ti

ging. Tuy nhin, i vi bnh nhn c cc triu chng ban u nghim trng, ngh ngi ti

ging 2-4 ngy vn l mt la chn.

Thuc

Thuc ung (acetaminophen, thuc khng vim khng steroid, gin c, v nhm opioid) v

phng php iu tr tim c sn iu tr TL.


- Mt nh gi gn y ca th nghim lm sng cho thy NSAIDs c hiu qu hn cho gim

triu chng ngn hn nhng bnh nhn TL cp. NSAID khng c chng minh l c

hiu qu hn na trong vic iu tr TL.

- Gin c khng hiu qu nh NSAIDs trong iu tr TL, v khng tng thm li ch gin

c c s dng kt hp vi NSAID. Gin c c tc dng ph tim tng hn NSAIDs, mt

yu t cn c xem xt khi quyt nh iu tr.

- Opioid c hiu qu hn trong vic lm gim cc triu chng tr li thp hn so vi thuc

gim au khc (aspirin, acetaminophen). V c cc bin chng khc (ph thuc), thuc gim

au opioid, nu c s dng, nn c dng trong mt thi gian ngn.

- Corticosteroid ng ung khng c khuyn khch trong iu tr TL cp.

Liu php tim iu tr cc triu chng TL bao gm cc dy chng, ngoi mng

cngTim l mt la chn iu tr xm ln c th gy nhng bin chng nghim trng cho

bnh nhn. Tuy nhin, tim ngoi mng cng v tim b mt khp c th mang li li ch cho

bnh nhn (nh mt phng tin trnh phu thut).

Vt l tr liu ct sng

C mt s bng chng h tr vic s dng cc liu php VLTL trong iu tr TL cp. K

thut VLTL ct sng gip khi phc chuyn ng ca khp v m mm. C hiu qu sm

sau khi bnh nhn khi pht triu chng TL cp tnh m khng c bnh l r thn kinh. Nu

bnh nhn c biu hin khim khuyt thn kinh tin trin hoc nng, VLTL nn c hon

li trong khi ch i nh gi chn on thch hp. Bnh nhn c cc triu chng ko di hn

4-6 tun, cc thao tc VLTL nn c nh gi li.

Chm cu

Chm cu khng c tm thy l c li cho iu tr bnh nhn TL cp. Tuy nhin, bng

chng gn y cho thy chm cu c truyn Trung Quc v massage tr liu c li trong vic

iu tr TL mn tnh. Khi c b sung vo phng php iu tr thng thng, chm cu

gip ci thin chc nng v gim au tt hn so vi iu tr thng thng mt mnh.

Tp th dc


Bi tp iu tr nn c bt u sm kim sot cn au, v phc hi chc nng. Khng

c bt k mt phng php iu tr hay mt chng trnh tp th dc duy nht no c

chng minh l c hiu qu cho tt c cc bnh nhn TL.

gi li

- i vi nhng bnh nhn c tnh trng TL xu i trong thi gian kim sot triu chng,

ngi thy thuc cn nh gi li v t vn hoc gii thiu n chm sc chuyn khoa. Bnh

nhn TL nn lun lun c nh gi li sau 1-3 tun theo di din tin bnh. Bnh

nhn phi c thng bo theo di sm hn nu tnh trng ca h xu i.

- Trong trng hp iu tr bo tn, cn nh gi li sau 4-6 tun k t ln nh gi ban u.

Ln thm khm tip theo l thi im thch hp xem xt nh gi mi trng lm vic ph

hp cho bnh nhn. Khi bnh nhn ci thin, cn gim liu thuc iu tr v gip bnh nhn

tng bc tr li hot ng bnh thng.

Chuyn khm chuyn khoa

Nu bnh nhn c TL hn 6 tun cho d iu tr bo tn y , bnh nhn cn c nh

gi li. Mt nh gi li ton din, bao gm mt nh gi tm l x hi v khm thc th cn

c thc hin. Trong nhng ln tip theo, cu hi nn c hng vo vic xc nh cc tn

hi ca bnh nhn, bao gm cc triu chng thn kinh mi, tng au, hoc vng lan rng mi

xut hin ca v tr au. Nu cc vn trn c tm thy, bnh nhn cn c nh gi li

cc vn v sc khe v t vn hoc gii thiu khm chuyn khoa..


Hnh 4: T vn cc chuyn khoa khng phu thut

Chuyn gia Ch nh

Phc hi chc

nng

au lng mn tnh > 6 tun

au thn kinh ta > 6 tun

Hi chng au mn tnh

au lng ti pht

Thn kinh au thn kinh ta > 6 tun

au chn mn khng in hnh, nghim php nng chn thng (-)

Khim khuyt thn kinh mi hay tin trin

Y hc v bnh

ngh nghip

Cc tnh hung n b cho cng nhn gp kh khn

Xp mc tn thng hay khuyt tt

Cc vn khi bnh nhn quay v lm vic

Thp khp Loi tr bnh vim khp

Loi tr fibrositis / fibromyalgia

Loi tr bnh xng chuyn ha (v d: long xng)

Y hc th thao au lng mn tnh > 6 tun

au thn kinh ta > 6 tun

au lng ti pht

Nu khng c pht hin bt thng trn mt nh gi li ton din, bao gm c xt nghim

chn on c la chn, cn lp chng trnh k hoch gip bnh nhn tr v hot ng

bnh thng ca h.

5. TIN LNG VN AU THT LNG

Mt nghin cu gn y pht hin ra rng phn ln bnh nhn tip tc bo co au 12 thng

sau ln khi pht ban u. Tuy nhin, 90% bnh nhn s phc hi chc nng vi gim au

sau 6 tun, bt k s can thip ca bc s.


TI LIU THAM KHO

1.. Childs J. D. A clinical prediction rule to identify patients with low back pain most likely

to benefit from spinal manipulation: A validation study. (2004) Annual Internal Medicine.

2. Glenn G. Do NSAIDs help in acute or chronic low back pain? (2002). American Family

Physician.

3. John M. (2011). Low back pain. John Murtagh s General Practice. Mc Graw Hill Lange.

4. Jeanette E. S. Low back pain (2007). Current diagnocsis and treatment Family Medicine.

Mc Graw Hill Lange.

5. Mark B. Low back pain (2009). Family Medicine. Mc Graw Hill Lange.

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