VIETNAM MEDICAL JOURNAL N*^ • FEBRUARY • 2017
TAI UEU THAM KHAO
1 . T r i n Thj Mai Oanh, Dam Viet Cu'dng, Du'dng Huy Lutfng va Khydng Anh Tuan (2007), Mpt so phat hi^n chfnh cua nghien ciifU danh j i a tinh hinh chSm soc sut khde cho ngu'di cao tuoi d Vi§t Nam, Vien Chien iude va Oiinh sadi J fia . 2. I r a n V i n Tru'dng, L i m Ngpc An va Trjnh
Dinh Hai (2002), Oieu tra sffc khde rSng mieng toan quoc, Nl)a xuat ban Yhoc, Ha Ngi, 12-18.
3. Ph^m V i n Viet (2004), Nghten cffu tinh trang, nhu (3U chim soc su'c khoe rang mieng va danh gia ket gua hai nam thu'c hien npi dung cham soc rSng mi^ng ban ^ u d ngu'di cao tudi tai Ha Npi, Lu$n van b'en sry hge, Tru&ng Bai hpe Y Ha Ngi,
Slade GD. ( 1 9 9 7 ) , Derivation and validation Q]
short-form oral health impact profile, Commun.
Dent Oral Epidemk}i, 25(4), 284-290.
Petersen PE va cac cong s i ^ ( 2 0 1 0 ) , Glot oral healtii of older people - Call ior public heal action, Community Dent Healtii, 27, 257-268. • Wang N3 Dahl KE, Hoist D, Ohm K (2011 Oral health-related quality of life among adul 68-77 years old in Nord-Trondelag, Norway, Ini Dent Hyg, 9(1), 87-92.
Sumaiya Zabin Eusufzai ( 2 0 1 1 ) , A study ( teeth status and oral health related quality of jjl among elderly in Purbagram village, Narayangi district, Bangladesh, Mahidoi University, ThaiLah
DAC DigM LAM S A N G V A C H A N DOAN HINH A N H C O A ^ BtNH NHAN T H O A T VI DIA DEM COT S 6 N G THAT LU'NG L4L5
TAI BENH VIEN HUTJ NGHI VIET DITC NAM 2 0 1 5
Nguyin Lg Bfio Tiin*, Dinh Ngoc Sffn*, V6 Van Thanh'
D I S C OF T H E LUMBAR S P I N E AT THE VIETNAMESE G E R M A N HOSPITAL I N 2015
Objective: To describe clinical features am imaging of the herniated disc of the lumbar spine l l LS. Method: A prospective study of the d i n l l description. Results: 100% of patients w i simptoms of pain spreading roots style, 100%'3 patients have the legal experience Lasegue (+) 5 wfhich 82.5% had Dejesine ( + ) , 47.5% Lasegue cft^
met at school box. In the study patients witfiol lumbar spine instability before surgery, 1 casell fracture was discovered waist before surgery (2.5%), On MRI: About possible hernia, hernias can primari|
seen betow joints 65%. On the degree of hemiaHohl disc flaking most rommon, witti 85%. On the degr«
of disc degeneration, disc degeneration accounts foi 50% grade 3,* grade 4 accounted for 37.5%;
accounting for 12.5% grade 2, not haWng degenerative disc 1 and Level 5 tfie public Conclusion: The image on the movie disc hemiatior Miy is important in helping us to appreciate the hernia position and can help surgeons make reasonable surgical strategy and determine appropriate points. "^
Keywords: dinicai, diagnose imaging, did hemiation of tiie lumbar spine.
I. D A T V ^ N DE
Ttioat vj dTa dem la s y djch chuyen to chii'c dTa dem vu'dt qua gidi han giai phau sinh ly ciia vdng x d . Khdi thoat vi cd the la: nhan nhay, sun, ban xu'dng sun tham chf ca vdng x d dTa dem.
Benh thu'dng gap d tudi 30 - 50 gay anh hudng tdi ngu'di lao dong.
Dieu tri thoat vi dia dem CSTL tCr tru'dc dai nay chu yeu la dieu trf noi va dieu tri phau thu?t Dieu tri phau thuat du'dc dat ra khi thoat vi da
T6M TAT
Muc tieu: Md ta dac diem lam sang vd di^n doan hinh anh cOa tiioat vj dia dfim CSTL L4L5. Phu'dng phdp: NghiSn cihj hen cOu m& t3 lam sang. Ket qua:
100% benh nhan co trieu chiJng dau lan ki^u re, 100% bgnh nhan cd nghiem phap Lasegue (+) trong do CO 82,5% b§nh nhan cd Dejeane (+), Lasegue cheo g3p d 47,5% tn/dng h ^ . Trong nghien ojitj khong cd benh nhan n i o mat viJhg CSTL tru'dc phau tfiujt, CO 1 trudng hop co gay eo duWc phat hiin triTdc phSu thuat (2,5%). Tren phim cgng hu'dng tCi": Vie the ttio^t vj, chfi yeu g3p ttioat vi the dUdi khdp 65%. Ve mfifc do tiioat vj, bong dia d i m hay gap nhSt vdi 85%.
VS mijt dp tiio^i hda dia a?m, tho^i hda dia dd 3 chiem 50%, d6 4 chiem 37,5%, dd 2 chiSm 12,5%, kiiong gap tholi hda dia dp 1 va dp 5 nao. Ket Iuan:
Hinh anh ttioat vj dia dem tren phim cong hudng tijf rSt quan trong giilip diung ta danh gia diing vj tri va thS ttioat vj giup cho phau ttiuat vien dda ra chien lul?c phau thuat hgfp ly va xic djnh diem v i o phu hdp.
Tifkhoa: lam sang, ch^n doan hinh anh, tholt vj dia dim cot song tiiSt lUhg.
SUMMARY
C L I N I C A L A N D I M A G I N G CHARACTERISTICS OF THE HERNIATED
*BSnh vien HSU Nghi Wet Diji:
2h\u tradi nhiem chtnh: Nguyin Le Bao Tien Email: [email protected]
^gly nh|n b i i : 21.11.2016
^gSy phan bi$n khoa hoc: 28.12.2016
*Jgay duyet bai: 16.01.2017
'A
TAP CHi Y HOC VlfT NAM TAP *S1 - THAHG 2 - S 0 1 - 2017
vd dien ep vao re than Idnh gay trieu chdtig dau
tu'dng uhg va nhuhg tru'dng hdp cd thoat vj diBu tri ndi khoa sau 3 thang khdng ed ket qua. Trong d^u tri phau thuat, md md cd be day Ijch su* va du'dc ap dyng nhieu nhat, tuy nhien md md cd nhieu lian che nhd dddng md dai, 1»n thu'dng phan mCTi Idn, mat mau nhieu, cd the gay mat vChig cot sdng, vi vay ma tai cac nu'dc phat trien phau tiiuat md md chi cdn ap dung trong nhuhg tru'dng hdp thoat vj ^ v3,the thoat vj d vi tri khd hoac thoat vj kem theo mat vGng cot song, hep dng song, hoi chuhg dudi ngda. Trong khi dd phau thuat ndi soi qua lo lien hdp lay nhan thoat vj trong thoat vj dia dem du'dng vao la du'dng ben qua lo li^n lidp, hau nhu* khdng lam thu'dng ton den giai phau cua cot sdng, va seo sd dinh rat it vi du'dng md nhd khoang 0,7 cm, tienh nhan chi ran te tai cho, trong qua trinh phau thuat benh nhan tinh hoan toan do do phau thuat, vien a5 the danh gia ngay du'dc hieu qua cua phau thuat, ngu'di benh chi phai nam vien 1- 2 ngay va cd the tham gia cac hoat ddng xa hoi trong vdng 4 tuan. Tren the gid^ phau thuat noi soi qua Io lien hdp lay nhan thoat vi du'dc u'ng dung rdng rai t?i cac nu'dc phat trien nhu' My, Nhat, Du'c... Tai Viet Nam phau tiiuat noi soi qua lo lien hdp lay nhan thoat vj du'dc lihg dung dau tien tai thanh phd Ho Chi Minh nam 2007, va dau nam 2008 tai benh vien Viet Qdc da trien khai thu'dng quy. Ttf nam 2007 den nay cung cd nhieu cong trinh nghien cu'u lien quan den thoat v| dta dem CSTL nhutig chu^ cd nghien culi nao danh gia rieng nao ve thoat vj dia dem CSTL L4L5 de du^ ra phu'dng thufc phau tiiuat phu hdp.
Vi v$y chung tdi b'en hanh nghien cuXi nay nham muc tieu: "M5 ta dac di&n lam sang va dian doan
hinh anh cua thoat vfdfa d&n CSTL L4L5".II.D6lTir<?NG VA PHUONG PHAP NGHIEN CUU 2.1. Ddi tu'dng nghien ciiru: Gom 40 benh nhan du'dc chan doan thoat vj dia dem L4L5 cd dli dinh phau thuat va du'dc phau thuat bang phu'dng phap NS' qua LLH tif 3/20i4 den
1/4/2015.
2.2. Phu'dng phap nghien dhi: Nghien
cdu tien cull md ta lam sang.2.3. Thu thSp so lieu: Sd lieudu'dc tiiu thap vao benh an da du'dc xay duing sSn. Benh nhan du'dc theo doi va danh gia ket qua trong qua trinh dieu trj tai benh vien Viet Du'c. Kham lai benh nhan sau khi ket thuc nghien CLTU.
2.4. Xiir ly va phan tfch so lieu: Cac sd lieu du'dc nhap va phan ti'ch theo phan man SPSS 16.0.
III. KET QUA NGHIEN CLTU
3.1. Dac diem chung cua ddi tu'dng nghien clhi
Trong 40 benh nhan du'dc nghien culi cho thay tudi trung binh ciia ddi tu'dng nghien cifu la 43,79± 13,09, tudi thap nhat la 18, tudi rao nhat la 64 tudi. Tudi tiy 30-60 bjoi gap nhieu nhat vdi 75%, tren 60 tudi gap 7.5%. Tif 18- 30 tiJOi gap 17,5%. T! le nam/nff la 1,85/1. Tl le bj benh ciia nhdm lao ddng nang/nhdm lao ddng nhe la 1.67/1.
3.2, Dac diem iam sang
Lu'cftig gia mu'c dp han che van ddng CSTL theo thang diem ODI thay 100% tienh nhan anh hu'dng den chii'c nang cot sdng trong dd oo 10%
sd benh nhan mat chifc nang CSTL va diem ODI trung binh tru'dc phau thuat la 66 ± 9,67 diem.
Trong nhdm nghien cifu 100% benh nhan du'dc kham cd trieu chifng Lasegue (+), Lasegue cheo cd 47,5% tienh nhan (+) va 82,5% benh nhan cd trieu chifng Dejesine (+), Diem dau Valleix cd 22% benh nhan (+). Cd 67,5% benh nhan cd roi loan cam giac. Khdng cd tru'dng lidp nao cd x6\ loan van dong. Trong sd 47,5% benh nhan cd Lasegue cheo (+) cd 100% benh nhan cd Vas chan tren 7 diem, va cd 100% benh nhan cd dau hieu Dejesine (+).
Nhu* vay trieu chifng Lasegue la dau hieu rd nhat de chuan doan ve mat lam sang benh nhan cd thoat vi dTa dem CSTL va trieu chifng Lasegue cheo danh gia mii'c do dau ciia benh nhan.
3.3. Sac diem chan doan hinh anh
Bang 3.9. Hinh anhX- Quang CSTL
Cac trieu chu'ng Mat du'dnq conq CSTL
Hep khe LTB Khong mat vu'ng CSTL
Gay eo CSTL
SoliTdng 22 18 -10 1
Tile 55%
45%
100%
3,8%
100% benh nhan trong nghien cifU du'dc cho chup X-Quang CSTL thing nghieng tru'dc phau thuat, cd 55% benh nhan cd mat du'dng cong sinh ly CSTL, trieu chu'ng hep khe LTD tru'dc phau thuat gap 45% so benh nhan, 1 benh nhan gay eo chiem ti le 3,8% va khdng gap benh nhan nao cd
; mat vffrig CSTL.
65
VIETNAM MEDICAL JOURNAL N'l - FEBRUARY - 2017
H m h a n h cong hu'dng tuf CSTL: The thoat vj dTa dem tren phim cdng hu'dng t i f Iat &t ngang Bieu dd 1. The thoat vi tien phim CHT cat ngang
Trong nhdm ngh en cifu thoat vi the du'di khdp gap nhieu nhat vdi 6 5 % thS ngoai lo lien hdp (LLH) khdng gap tru'dng hdp nao va the trung tam la 3 2 , 5 % va the LLH la 2 , 5 % .
- Mifc dp tiioat vi dia dem
Bang 3.11. Mifc dp ttioat vi dia dS/n
So lu'dng Tyle
Bong gra dem 87,2%
Khoi di tru
12,5%Tong
40
Trong nhom nghien cuU bong dTa d^m gap nhieu nhat vdi ti lg 8 7 , 5 % , t i le thoat vi di trii la 12,5%, va khdng gap thoat vj khdi t i f do. Trong sd 5 benh nhan cd thoat vi di trii thi 100% la di tiii gan d v j t r i Zone 3.
- Phan bo thoat vitheo mu'c do tiioai hoa dia dem Bieu do 2. Mu'c do thoai hoa dfa dSm
r
^^r 50% • Thoai hoa dfa do 1• Thoai hoa dTa d6 2
^ TTio^i hoa dia do 3
• Thoai h6a dfa dO 4
• "ThoSi h6a dTa do 5
Trong nhom nghlSn aJu thoat hoa dia d6 3 gap 5 0 % so benh nhan, thoai hoa dTa do 4 gap 7ll,S'h' va thoai hoa d7a do 2 gap 12,5% do 1 va dp 5 i<h6ng gap tru'dng help nao.
IV. BAN LUAN 4 . 2 . Dac diem l a m sang
Ngu'di benh thu'dng den benh vien vdi trieu chffng dau CSTL lan xuong chan theo du'cfng di cua re TK (dau l<ieu re TK). Trong nghiSn ciJu chiing toi co ket qua 100% benh nhan co trieu chu'ng dau l<ieu re than kinh. Nghien ciJu cOa Chung toi cho ket qua dau CSTL gap d 87,5%.
Theo Peng va Yeo [ 2 ] , mot trong nhffng nguyen nhan chu yeu la gay dau luhg do ton thu'dng dTa Aim. Khi bao xd chua rach hoan toan, ap lu'c noi dta^^tang cao tac dong vao cho bao xd b[rach_^, bi ton thu'dng do vi chan thu'dng se tac dong ien thu the cam giac vung bao x d gay nen trieu chuhg dau lu'ng. Khi thoat vi da v8 ra khoi bao thi ap lire noi dTa giam nhanh va dau
luhg vi the cung giam. Ben canh do, khi xuSt hien trieu chuhg chen ep re cung lam giam bdt sif chii y cua benh nhan ve dau lu'ng. Viec giam chffe nang cot s3ng dffdc the hISn ro d bang ODI, trffdc mo. Ve mffc do giam chffe nang cot song;
diem ODI trung binh trffdc phau thuat la 66 i , 9.57 la mu'c can phai can thiep.
_ Trjeu chffng kinh dien trong thoat vi dia dem cot song that luhg la dau kieu re chi phSi va kem theo la vung roi loan cam glae cua re dd. KN khoi thoat v| chen ep nhieu co the gay Uet vSn dong. Tuy nhien, qua cac nghien cu\i tren thut nghierri va tren ngu'di cho thay, neu chi ed die Chen ep ddn thuan se chi tao ra trieu chffng r6l lo^n cam giac va roi loan van dpng, trong khi d6 hien tu'dng dau vung r l chi plioi la do cd che
66
TAP CHl Y HOC WtT NAM TAP 451 - "mANG 2 - S O I - 2017 viem tao ra. Cac nghien culi gan day d i o thay
vai trd cua cac yeu t o cytokines, prostaglandin E2, interleuldn-6 trong nhan nhay ciia dia, khi v d se kidi thich, viem re. Hien b/dng nay giai thich tai sao cd nhuhg tniC^g h ^ rat dau chan nhutig hinh anh cdng hu'dng t i f thoat vj lai nhd, va khdng gay rdi loan van dong cung nhtf cam giac.
Trong nghien cifu cua chting tdi cho ket qua 100% benh nhan cd nghiem phap Lasegue {•*•) va cd dau kieu re TK, benh nhan du'dc lu'dng hda mifc do dau theo thang diem VAS, 4 7 , 5 % benh nhan ( ^ nghiem phap Lasegue cheo ( + ) , 82,5%
benh nhan cd dku hieu E)ejesine ( + ) va 3 0 % b|nh nhan cd an diem dau Valleix ( + ) , trong dd cd 67,5% benh nhan cd trieu chifng t e bi vung da do re TX chi phoi. NghiSn cdu cua d i i i n g tdi dJng tudng t i f nhu nghien cutj cua Vu Quang Bidi [ 3 ] , yd Xuan Sdn [ 4 ] . Trong nghien ciifu gap 90% benh nhan cd trieu chting dau re L5, d ^ u
f
d i ^ c giai thich do tiioat ^^ trong nghien ciifU^ g a p la the du'di khdp, khi do thoat vi chi
^ . v a o 1 re TK va \fl t n tiioat vi d d a L4L5 cung tudng uhg vdi du'dng ra cua re L5, 10% sd benh nhan dau kiai re S l la do thoat vj tmng tam, nen khi do thoat vj se chen ep vao \^ trj o i a re S l .
4 . 2 . S^c diem v e d i a n doan hinh anh Hinh anh X - q u a n g : Trong nghien cifu 100% benh nhan du'dc chup X-Quang CSTL tiiang nghieng va cui u 8 n , khdng cd benh nhan nao cd mat vihig cot sdng, cd 22 benh nhan cd mat du'dng cong sinh ly cdt song chiem 55%.
Nghien cihi cd 26 benh nhan du'dc d i u p X- Quang CSTL chech % tivng d d gap 1 benh nhan cd gay eo chiem 3.8%. Trong nhDhg tru'dng hdp cd gay eo CS kem theo thoat vi va khdng cd d i u hieu mat vuhg thi phau tiiuat ndi soi qua LLH difdC Ida chon, vi it tdn thu'dng cau t i i i c giai phau cua benh nhan, khdng gay mat vuhg CSTL.
Chup cong hifdng tuT: Trong nghien cifu 100% chup cdng hu'dng t i f CSTL trong d d the thoat vj du'di khdp la gap nhieu nhat 26 benh nhan diiem 6 5 % . Nghien cifu cho thay bong dTa dem gap n h ^ u nhat vdi 35 benh nhan chiem 87,5%, sau d d den di t n i gap 5 benh nhan chiem 12,5%. Loi dTa dem va khcn tU do khdng gap t r u ^ g hdp nao. Nghien cdu cua tic gia khac cho ket qua nhu* sau, nghien cifu cua Tran Trung (2008) tren 100 benh nhan cho thay thoat vj mu'c dp bong dTa dem gap 41,7% loi dTa dem gap 33,8%. Nghien cuii cua cho biet Idi dia dem va ti/ do khdng gap tru'dng hdp nao, bong dTa dem gap 93,8%, d i t r i i gap 6,3%.
Hinh anh tiioat vj dia dem tren phim cdng hu'dng tff rat quan trpng giiip chiing ta danh gia
dung vj M va tiie thoat \n giup cho phau thuat vien dda ra chien lu'dc p h i u thuat hdp ly va xac djnh diem vao phu hdp
MuTc dp thoai hda dTa dem tren phim cdng hu'dng tij": Tren Iat cat doc rang hudng tiJf trong n g h i ^ cifu od 20 benh nhan thoai hda dTa dp 3 c h i ^ 5 0 % , 15 benh nhan thoai hda dTa do 4 dhi&n 3 7 , 5 % , 5 b^nh nhan thoai hda dTa dp 2 chiem 12,5% va 0 co benh nhan nao thoai hda dia dp 1 va dp 5. Trong d d thoai hda dia dp 2 va dp 3 khi dd nhan nhay con nhieu n u d t c h i ^ cao dia dem khdng bj giam.
V . K f r LUAN
Thoat vi dTa dem L4L5 thu'dng gap d tudi 30 - 60 tudi vdi 7 5 % , dp tudi trung binh 43,79 ± 13,09, ti le nam/ nu* la 1,85/1 va gap d nhdm lao dpng nang nhieu hdn vdi 62,5%. Trieu chihig thu'dng gap la trieu chihig dau lan kieu re vdi ti le 100% va trieu chuhg dau CSTL vdi ti le 87,5%, lech veo CS it gap hdn vdi ti 1$ 5 5 % , tienh nhan thu'dng dau Ide re L5 vdi ti le 9 0 % . 100% benh nhan cd nghiem phap Lasegue ( + ) trong d d cd 8 2 , 5 % benh nhan cd Dejesine ( + ) , Lasegue cheo gap d 4 7 , 5 % tru'dng hdp
Trong nghien ciili khdng cd benh nhan nao mat vuhg CSTL tru'dc phau t h u a ^ cd 1 tru'dng hdp cd gay eo du'dc phat hien t r i r t k phau thuat (2,5%). Tren phim cdng hirdng tif: Ve ttie thoat vi,chu ySu gap thoat vi ttie du'di khc^ 6 5 % sau dd la the b u n g tam vdi 3 2 , 5 % , the LLH gap d 2,5% va khdng gap tru'dng hdp nao ngoai LLH.
VB mifc dp thoat v i , bong dia dem hay gap nhat vdi 8 5 % , di tru gap 12,5% va ldi dTa dem gap d 2,5% benh nhan. Ve mdc dp thoai hda dTa d | m , thoai hda iSa dp 3 chiem 5 0 % dp 4 diiem 37,5%, dp 2 c h i a n 12,5%, khdng gap thoai hda dTa dp 1 va dp 5 nao.
TAI UEU T H A M KHAO
1 . Nguyen Van Thach, Nguyin Van Chu^iAig , Nguyen Thj Ngoc U n & Va Cong Sif (2011), Bao cao tong hep kit qua i^oa hoc cong nghe rfe tai:" Nghien cuii thu'c bang, eacy&j tor^uy cd ra cae f^udr^ phap dieu lii thoat w dia d0m oaf s&ig-Di tai doc lap dp niia nude". Hanoi.
2. C W. Peng, W. Yeo & S. B. Tari (2009), 'Perojtaneous endosaypic lumbar discectomy:
dinicai and quaiity of life outcomes with a minimum 2 year fdlow-up'. Journal of orthopaedic surgery and research, 4: p. 20.
3. Vu Quang Bich (2006), Phong va chO^ cac chuhg benh dau lutig, Nha xuat ban Y hoc, HN 4. Vo_,Xuan Scfn (2011), "101 euU 100 iiUdng hdp
mo thoat vi dia dmi tiiat Idng bang noi soi qua dtfdng lien ban song". Hoi nghi phau thuat than kinh Viet Nam lan thif XH, Tap d i i Y hoc tiiUc hanh, (779+780), tr 391-398.
