Doporu\u010den\u00fd postup pro praktick\u00e9 l\u00e9ka\u0159e<\/p>\n
Akutn\u00ed bolesti v\u00a0lumbosakr\u00e1ln\u00ed\u00a0oblasti pro praktick\u00e9 l\u00e9ka\u0159e z pohledu neurologa 1. Charakteristika p\u0159edm\u011btu doporu\u010den\u00e9ho postupu Standard se zab\u00fdv\u00e1 problematikou akutn\u00edch, tedy kr\u00e1tkodob\u00fdch (m\u00e9n\u011b ne\u017e 3\u00a0m\u011bs\u00ed-ce trvaj\u00edc\u00edch) bolest\u00ed lokalizovan\u00fdch v bedern\u00ed a k\u0159\u00ed\u017eov\u00e9 (lumbosakr\u00e1ln\u00ed\u00a0– LS) krajin\u011b vymezen\u00e9 doln\u00edm okrajem \u017eeber a h\u00fd\u017ed\u00ed nebo sou\u010dasn\u011b vyza\u0159uj\u00edc\u00ed do doln\u00ed\u00a0kon\u010deti-ny. Standard se nezab\u00fdv\u00e1 chronick\u00fdmi (d\u00e9le ne\u017e 3 m\u011bs\u00edce trvaj\u00edc\u00edmi)\u00a0vertebrogenn\u00ed-mi obt\u00ed\u017eemi v\u00a0lumbosakr\u00e1ln\u00ed\u00a0krajin\u011b pro v\u00fdznamn\u00fd pod\u00edl socioekonomick\u00fdch a psy-chogenn\u00edch\u00a0faktor\u016f a rovn\u011b\u017e obt\u00ed\u017eemi postihuj\u00edc\u00edmi jedince mlad\u0161\u00ed 18 let. 2. Hlavn\u00ed epidemiologick\u00e9 charakteristiky\u00a0Vertebrogenn\u00ed\u00a0onemocn\u011bn\u00ed jsou nej\u010dast\u011bj\u0161\u00ed choroby po nemocech z nachlazen\u00ed, jsou vedouc\u00ed p\u0159\u00ed\u010dinou omezen\u00ed aktivity u lid\u00ed do 45 rok\u016f v\u011bku (10 – 15% prostonan\u00fdch dn\u00ed) a jde o 5. nej\u010dast\u011bj\u0161\u00ed p\u0159\u00ed\u010dinu hospitalizace. Ataku klinicky v\u00fdznamn\u00fdch bolest\u00ed v z\u00e1dech za\u017eije b\u011bhem \u017eivota 60-90% populace; prevalence\u00a0radikul\u00e1rn\u00edch\u00a0syndrom\u016f a\u00a0myelopati\u00ed\u00a0se odhaduje na 2-3%. Nej\u010dast\u011bj\u0161\u00ed jsou obt\u00ed\u017ee z bedern\u00ed oblasti,\u00a0n\u00e1sle-dovan\u00e9 oblast\u00ed kr\u010dn\u00ed a hrudn\u00ed v pom\u011bru p\u0159ibli\u017en\u011b 4:2:1. Ve Spojen\u00fdch st\u00e1tech je ud\u00e1-v\u00e1na\u00a0ro\u010dn\u00ed prevalence bolest\u00ed v\u00a0lumbosakr\u00e1ln\u00ed\u00a0oblasti 15-20% a ve skupin\u011b\u00a0dosp\u011b-l\u00fdch\u00a0v aktivn\u00edm v\u011bku a\u017e 50%. Ekonomick\u00e9 n\u00e1roky na \u0159e\u0161en\u00ed\u00a0vertebrogenn\u00edch\u00a0one-mocn\u011bn\u00ed jsou vysok\u00e9, ve Spojen\u00fdch st\u00e1tech se pohybuj\u00ed kolem 50 mld USD ro\u010dn\u011b (1,2). 3. Podstata struktur\u00e1ln\u00edch a funk\u010dn\u00edch zm\u011bn, etiologie 3.1. Z hlediska patofyziologie a charakteru\u00a0patologicko-anatomick\u00fdch zm\u011bn tvo\u0159\u00ed prvn\u00ed skupinu (malou rozsahem, ale v\u00fdznamnou svoj\u00ed z\u00e1va\u017enost\u00ed)\u00a0vertebrogenn\u00ed\u00a0syndromy, jejich\u017e p\u0159\u00ed\u010dinou jsou dob\u0159e definovan\u00e1 organick\u00e1 onemocn\u011bn\u00ed specific-k\u00e9\u00a0nedegenerativn\u00ed\u00a0povahy: infek\u010dn\u00ed a neinfek\u010dn\u00ed z\u00e1n\u011bty, n\u00e1dory, osteopor\u00f3za, traumata, v\u00fdvojov\u00e9 anom\u00e1lie apod. Do 30 let prob\u00edhaj\u00ed v p\u00e1te\u0159i jen minim\u00e1ln\u00ed\u00a0morfo-logick\u00e9 zm\u011bny a \u010dastou p\u0159\u00ed\u010dinou kompres\u00ed neur\u00e1ln\u00edch struktur jsou v tomto v\u011bku traumatick\u00e9, infek\u010dn\u00ed \u010di n\u00e1dorov\u00e9 procesy, v\u00fdjime\u010dn\u011b se vyskytne\u00a0hernie\u00a0nucleus\u00a0pulposus. 3.2. Druhou, podstatn\u011b v\u011bt\u0161\u00ed skupinu tvo\u0159\u00ed\u00a0vertebrogenn\u00ed\u00a0onemocn\u011bn\u00ed prov\u00e1zen\u00e1 organick\u00fdm posti\u017een\u00edm p\u00e1te\u0159e nespecifick\u00e9 degenerativn\u00ed povahy r\u016fzn\u00e9ho stupn\u011b, typu a lokalizace. Jde o komplex degenerativn\u00edch a\u00a0osteofibroproduktivn\u00edch\u00a0zm\u011bn ozna\u010dovan\u00fd souborn\u00fdm n\u00e1zvem \u201espondyl\u00f3za\u201c; pro degeneraci meziobratlov\u00e9 plot\u00e9nky je pou\u017e\u00edv\u00e1m samostatn\u00fd term\u00edn \u201ediskopatie\u201c. V\u00fdh\u0159ez nucleus\u00a0pulposus, m\u00e9n\u011b \u010dasto sten\u00f3za ko\u0159enov\u00e9ho kan\u00e1lu (samostatnou \u010di v kombinaci s v\u00fdh\u0159ezem) jsou nej\u010dast\u011bj\u0161\u00ed p\u0159\u00ed\u010dinou komprese ko\u0159ene a jeho c\u00e9vn\u00edho z\u00e1soben\u00ed v\u00a0lumbosakr\u00e1ln\u00ed\u00a0oblasti. P\u0159i later\u00e1ln\u00edch v\u00fdh\u0159ezech a later\u00e1ln\u00ed sten\u00f3ze v d\u016fsledku hypertrofie interver-tebr\u00e1ln\u00edch kloub\u016f doch\u00e1z\u00ed k monoradikul\u00e1rn\u00edmu syndromu, zat\u00edmco sten\u00f3za kan\u00e1lu v sagit\u00e1ln\u00edm pr\u016fm\u011bru v d\u016fsledku medi\u00e1ln\u00edho v\u00fdh\u0159ezu disku \u010di spondyl\u00f3zy obvykle v kombinaci s vrozenou sten\u00f3zou vede k pluriradikul\u00e1rn\u00ed symptomatice a\u017e syndromu kauday equiny. Protruze \u010di\u00a0hernie\u00a0disku m\u016f\u017ee b\u00fdt p\u0159\u00ed\u010dinou i prost\u00e9ho lumbaga bez komprese ko\u0159en\u016f. 3.3. Etiologick\u00fd v\u00fdznam v\u00fd\u0161epopsan\u00fdch degenerativn\u00edch zm\u011bn kol\u00eds\u00e1 od kauz\u00e1ln\u00edho \u010dinitele u kompresivn\u00edch neurologick\u00fdch syndrom\u016f (kompresivn\u00ed radikulopatie a mye-lopatie) a\u017e po nejasnou a spornou roli, kterou hraj\u00ed u akutn\u00edch p\u0159echodn\u00fdch poruch funkce, obvykle spont\u00e1nn\u011b reverzibiln\u00edch. Spole\u010dn\u00fdm p\u0159\u00edznakem t\u011bchto akutn\u00edch reverzibiln\u00edch\u00a0vertebrogenn\u00edch\u00a0syndrom\u016f je porucha funkce v jednom \u010di n\u011bkolika pohybov\u00fdch segmentech p\u00e1te\u0159e (tzv. blok\u00e1da, m\u00e9n\u011b \u010dasto hypermobilita). Existuje \u0159ada hypot\u00e9z vysv\u011btluj\u00edc\u00edch vznik blok\u00e1d, jasn\u00fd anatomick\u00fd korel\u00e1t v\u0161ak nen\u00ed zn\u00e1m. Krom\u011b kloubn\u00edch blok\u00e1d m\u016f\u017ee j\u00edt i o poran\u011bn\u00ed kloubn\u00edch pouzder, po\u0161kozen\u00ed liga-ment, odtr\u017een\u00ed \u0161lachov\u00fdch \u00fapon\u016f, rupturu svalov\u00fdch vl\u00e1ken a natr\u017een\u00ed svalov\u00fdch po-chev. Svalstvo m\u016f\u017ee bolet i z pouh\u00e9ho p\u0159et\u00ed\u017een\u00ed. Tato skupina onemocn\u011bn\u00ed je n\u011bkdy nep\u0159esn\u011b ozna\u010dov\u00e1na jako myogenn\u00ed lumbago \u010di \u201efunk\u010dn\u00ed\u00a0vertebrogenn\u00ed\u00a0poruchy\u201c; p\u0159esn\u011bj\u0161\u00ed by bylo ozna\u010den\u00ed\u00a0vertebrogenn\u00ed\u00a0poruchy bez jasn\u00e9ho organick\u00e9ho korel\u00e1tu. Vztah poruch funkce p\u00e1te\u0159e ke spondyl\u00f3ze je komplikovan\u00fd a ne v\u017edy p\u0159esv\u011bd\u010div\u011b definovan\u00fd. Porucha funkce obvykle p\u0159edch\u00e1z\u00ed struktur\u00e1ln\u00ed zm\u011bny a dlouhodob\u00e1 \u010di trval\u00e1 porucha funkce podmi\u0148uje \u010di urychluje vznik a rozvoj degenerativn\u00edch zm\u011bn; p\u0159\u00edtomnost t\u011bchto degenerativn\u00edch zm\u011bn v\u0161ak v n\u011bkter\u00fdch p\u0159\u00edpadech m\u016f\u017ee dispono-vat ke vzniku poruchy funkce p\u00e1te\u0159e. 3.4. Bolesti v\u00a0lumbosakr\u00e1ln\u00ed\u00a0oblasti mohou b\u00fdt vyvol\u00e1ny dysfunkc\u00ed pohybov\u00e9ho \u00fastroj\u00ed mimo oblast p\u00e1te\u0159e: nej\u010dast\u011bji jde o sakroiliak\u00e1ln\u00ed sklouben\u00ed nebo ky\u010deln\u00ed kloub. Do oblasti zad se mohou propagovat i bolesti vznikaj\u00edc\u00ed posti\u017een\u00edm vnit\u0159n\u00edch org\u00e1n\u016f: ledvin a urogenit\u00e1ln\u00edho traktu, tlust\u00e9ho st\u0159eva a kone\u010dn\u00edku, d\u011blohy a vaje\u010d-n\u00edk\u016f, abdomin\u00e1ln\u00ed aorty \u010di ilick\u00fdch tepen. Tyto bolesti b\u00fdvaj\u00ed nep\u0159esn\u011b lokalizov\u00e1ny, mohou i vyza\u0159ovat do p\u0159\u00edslu\u0161n\u00e9ho segmentu doln\u00ed kon\u010detiny mechanismem p\u0159ene-sen\u00e9 bolesti. Ur\u010den\u00ed p\u0159esn\u00e9 etiologie\u00a0vertebrogenn\u00edch\u00a0syndrom\u016f a vztahu klinick\u00fdch p\u0159\u00edznak\u016f k organick\u00fdm, zejm\u00e9na degenerativn\u00edm zm\u011bn\u00e1m je obt\u00ed\u017en\u00e9 a u n\u011bkter\u00fdch typ\u016f posti-\u017een\u00ed a\u017e nemo\u017en\u00e9. Odhaduje se, \u017ee p\u0159esn\u00e1 etiologick\u00e1 diagn\u00f3za odhaluj\u00edc\u00ed patologic-ko-anatomickou p\u0159\u00ed\u010dinu obt\u00ed\u017e\u00ed nen\u00ed mo\u017en\u00e1 a\u017e u 85% nemocn\u00fdch s vertebrogenn\u00edmi obt\u00ed\u017eemi. 4. Klinick\u00fd obraz onemocn\u011bn\u00ed Bolesti v LS oblasti je mo\u017en\u00e9 rozd\u011blit do n\u011bkolika z\u00e1kladn\u00edch klinick\u00fdch obraz\u016f: 4.1. Akutn\u00ed lumbago (akutn\u00ed bedern\u00ed segmentov\u00fd syndrom). Hlavn\u00edm sympto-mem je bolest v\u00a0lumbosakr\u00e1ln\u00ed\u00a0krajin\u011b bez iradiace do doln\u00ed kon\u010detiny trvaj\u00edc\u00ed m\u00e9n\u011b ne\u017e 3 m\u011bs\u00edce. Akutn\u00ed lumbago vznik\u00e1 typicky po zvednut\u00ed t\u011b\u017ek\u00e9ho b\u0159emene z p\u0159edklonu zvl. p\u0159i sou\u010dasn\u00e9 rotaci. N\u011bkdy je p\u016fvod lumbaga m\u00e9n\u011b jasn\u00fd, p\u0159ich\u00e1z\u00ed zd\u00e1nliv\u011b bez p\u0159\u00ed\u010diny, ale p\u0159i pe\u010dliv\u00e9 anamn\u00e9ze je mo\u017eno zjistit dlouhodob\u00fd pobyt v dopravn\u00edch prost\u0159edc\u00edch, prochlazen\u00ed, fyzicky t\u011b\u017ekou pr\u00e1ci nebo uklouznut\u00ed. 4.2. Atypick\u00e9 lumbosakralgie. Bolesti zp\u016fsoben\u00e9 z\u00e1va\u017en\u00fdm organick\u00fdm z\u00edskan\u00fdm a jasn\u011b definovan\u00fdm onemocn\u011bn\u00edm p\u00e1te\u0159e (z\u00e1n\u011bt, n\u00e1dor, trauma, osteopor\u00f3za) jsou obvykle lokalizovan\u00e9 do LS oblasti; oproti akutn\u00edmu lumbagu jsou \u201eatypick\u00e9\u201c t\u00edm, \u017ee nastupuj\u00ed pl\u00ed\u017eiv\u011b, jsou velmi intenzivn\u00ed a progreduj\u00edc\u00ed, vyskytuj\u00ed se i v klidu a zejm\u00e9na v noci. 4.3. Lumboischiadick\u00fd (\u201eischias\u201c) a lumbofemor\u00e1ln\u00ed syndrom je charakteristick\u00fd kombinac\u00ed bolest\u00ed v\u00a0lumbosakr\u00e1ln\u00ed\u00a0oblasti a poruchou funkce lumb\u00e1ln\u00ed p\u00e1te\u0159e s bolest\u00ed vyza\u0159uj\u00edc\u00ed do doln\u00ed kon\u010detiny v distribuci ko\u0159en\u016f L5-S2 (lumboischiadick\u00fd) \u010di L2-4 (lumbofemor\u00e1ln\u00ed syndrom). 4.3.1 Ko\u0159enov\u00fd syndrom vyvolan\u00fd obvykle kompres\u00ed jednoho \u010di v\u00edce ko\u0159en\u016f je charakteristick\u00fd: \uf0e7 poruchou funkce bedern\u00ed p\u00e1te\u0159e, obvykle spojenou s bolest\u00ed v p\u00e1te\u0159i; \uf0e7 bolestmi \u010di parest\u00e9ziemi vyza\u0159uj\u00edc\u00edmi do doln\u00ed kon\u010detiny, obvykle dist\u00e1ln\u011b od ko-lene; \uf0e7 pozitivn\u00edmi nap\u00ednac\u00edmi man\u00e9vry (Lassegueova zkou\u0161ka), zejm\u00e9na u komprese diskogenn\u00edho p\u016fvodu; \uf0e7 svalovou slabost\u00ed s hypotoni\u00ed, hypotrofi\u00ed, zm\u011bnami reflex\u016f a hypest\u00e9zi\u00ed (tyto v\u00fdpa-dov\u00e9 p\u0159\u00edznaky v\u0161ak nemusej\u00ed b\u00fdt p\u0159\u00edtomny). Bolest radikul\u00e1rn\u00edho p\u016fvodu je typicky provokov\u00e1na p\u0159i sezen\u00ed, kdy vzr\u016fst\u00e1 intradis-k\u00e1ln\u00ed tlak. Typick\u00e1 \u00faleva naopak p\u0159ich\u00e1z\u00ed vle\u017ee. P\u0159i existenci trval\u00e9 bolesti nepolevuj\u00ed-c\u00ed vle\u017ee nutno myslet na jinou p\u0159\u00ed\u010dinu ne\u017e v\u00fdh\u0159ez disku. Lok\u00e1ln\u00ed bolest v p\u00e1te\u0159i, porucha funkce p\u00e1te\u0159e i v\u00fdpadov\u00e9 motorick\u00e9 a senzitivn\u00ed p\u0159\u00ed-znaky mohou v\u0161ak b\u00fdt u ko\u0159enov\u00e9ho syndromu vyj\u00e1d\u0159eny minim\u00e1ln\u011b \u010di \u00fapln\u011b chyb\u011bt. I v p\u0159\u00edpad\u011b jejich p\u0159\u00edtomnosti v\u0161ak dominuje bolest v doln\u00ed kon\u010detin\u011b. P\u0159i n\u00e1hle vznikl\u00e9 oboustrann\u00e9 pluriradikul\u00e1rn\u00ed symptomatice charakterizovan\u00e9 bo-lestmi, chab\u00fdmi par\u00e9zami a poruchou citlivosti v obou doln\u00edch kon\u010detin\u00e1ch v\u010detn\u011b poruchy citlivosti v perianogenit\u00e1ln\u00ed oblasti a poruchou sfinkterov\u00fdch funkc\u00ed jde o akutn\u00ed syndrom kaudy equiny. U v\u00edceet\u00e1\u017eov\u00e9 lumb\u00e1ln\u00ed sten\u00f3zy jde typicky o chronick\u00fd pluriradikul\u00e1rn\u00ed syndrom, p\u0159i kter\u00e9m neb\u00fdvaj\u00ed pozitivn\u00ed nap\u00ednac\u00ed man\u00e9vry a bolesti, parest\u00e9zie, par\u00e9zy a poruchy citlivosti se vyskytuj\u00ed typicky v z\u00e1vislosti na vzp\u0159\u00edmen\u00e9m postaven\u00ed bedern\u00ed p\u00e1te\u0159e ve stoje \u010di p\u0159i ch\u016fzi (\u201eneurogenn\u00ed klaudikace\u201c). 4.3.2 U pseudoradikul\u00e1rn\u00edho syndromu doch\u00e1z\u00ed k vyza\u0159ov\u00e1n\u00ed bolesti, napodobu-j\u00edc\u00ed ko\u0159enovou bolest, nikoli v\u0161ak v p\u0159esn\u00e9 dermatom\u00e1ln\u00ed distribuci a obvykle pouze do oblasti stehna, ne dist\u00e1ln\u011b pod koleno a bez p\u0159\u00edtomnosti dal\u0161\u00edch neurologick\u00fdch p\u0159\u00edznak\u016f (par\u00e9z, poruch citlivosti a reflex\u016f); nap\u00ednac\u00ed man\u00e9vry jsou obvykle negativn\u00ed. 5. Postup p\u0159i p\u00e9\u010di poskytovan\u00e9 na po\u010d\u00e1tku a v pr\u016fb\u011bhu onemocn\u011bn\u00ed P\u00e9\u010de poskytovan\u00e1 na po\u010d\u00e1tku bolest\u00ed v\u00a0lumbosakr\u00e1ln\u00ed\u00a0oblasti pat\u0159\u00ed do kompetence praktick\u00e9ho l\u00e9ka\u0159e. Neurologick\u00e1 konzultace je nutn\u00e1 v p\u0159\u00edpad\u011b ko\u0159enov\u00fdch syndro-m\u016f nereaguj\u00edc\u00edch na standardn\u00ed ambulantn\u00ed l\u00e9\u010dbu \u010di v p\u0159\u00edpad\u011b nejasn\u00e9ho n\u00e1lezu, neodkladn\u011b v p\u0159\u00edpad\u011b rozvoje par\u00e9zy a p\u0159\u00edznak\u016f komprese kaudy equiny (3). 6. Diagnostika, diferenci\u00e1ln\u011b diagnostick\u00fd postup Z\u00e1kladn\u00edm v\u00fdchodiskem je fakt, \u017ee v\u011bt\u0161ina p\u0159\u00edpad\u016f akutn\u00edch bolest\u00ed v LS oblasti, tj. akutn\u00ed lumbago, pseudoradikul\u00e1rn\u00ed syndrom i leh\u010d\u00ed formy ko\u0159enov\u00fdch diskogenn\u00edch syndrom\u016f maj\u00ed benign\u00ed pr\u016fb\u011bh a obt\u00ed\u017ee se spont\u00e1nn\u011b \u010di pomoc\u00ed adekv\u00e1tn\u00ed l\u00e9\u010dby uprav\u00ed \u010di v\u00fdrazn\u011b zm\u00edrn\u00ed do 1 m\u011bs\u00edce. 6.1 U v\u0161ech p\u0159\u00edpad\u016f akutn\u00edch bolest\u00ed v LS oblasti je z\u00e1sadn\u00ed klinick\u00e9 vy\u0161et\u0159en\u00ed v\u010detn\u011b anamn\u00e9zy. Toto vy\u0161et\u0159en\u00ed by m\u011blo odli\u0161it n\u00e1sleduj\u00edc\u00ed p\u0159\u00ed\u010diny (viz algoritmus \u201eDiagnostika\u201c). 6.1.1 Z\u00e1va\u017en\u00e1 organick\u00e1 onemocn\u011bn\u00ed p\u00e1te\u0159e, zejm\u00e9na z\u00e1n\u011bt \u010di malignitu; k varovn\u00fdm anamnestick\u00fdm \u010di klinick\u00fdm p\u0159\u00edznak\u016fm vedouc\u00edm k podez\u0159en\u00ed na tuto etiologii pat\u0159\u00ed: v\u011bk nad 50 let, existence prim\u00e1rn\u00edho n\u00e1doru \u010di jin\u00e9ho z\u00e1va\u017en\u00e9ho one-mocn\u011bn\u00ed, dlouhodob\u00e1 l\u00e9\u010dba kortikosteroidy, \u00fabytek v\u00e1hy, nevysv\u011btliteln\u00e9 teploty, existence chronick\u00e9ho z\u00e1n\u011btu (zejm\u00e9na ledvin a plic), trauma v anamn\u00e9ze, bolesti mimo\u0159\u00e1dn\u011b velk\u00e9 intenzity \u010di jejich trv\u00e1n\u00ed po dobu del\u0161\u00ed ne\u017e 1 m\u011bs\u00edc bez \u00falevy, klido-v\u00e9, zejm\u00e9na no\u010dn\u00ed bolesti a bolesti provokovan\u00e9 stojem a m\u00edrn\u00edc\u00ed se vsed\u011b. P\u0159i pode-z\u0159en\u00ed na z\u00e1n\u011bt \u010di malignitu je vhodn\u00e9 doplnit n\u00e1sleduj\u00edc\u00ed vy\u0161et\u0159en\u00ed: sedimentace ery-trocyt\u016f (FW), krevn\u00ed obraz (KO), z\u00e1kladn\u00ed vy\u0161et\u0159en\u00ed mo\u010di, rentgenov\u00e9 (RTG) vy\u0161et\u0159en\u00ed bedern\u00ed p\u00e1te\u0159e a p\u00e1nve a scintigrafii skeletu. 6.1.2 Fraktury obratl\u016f; k podez\u0159en\u00ed vede \u00faraz p\u00e1te\u0159e v anamn\u00e9ze, vy\u0161\u0161\u00ed v\u011bk a l\u00e9\u010d-ba kortikosteroidy (riziko osteopor\u00f3zy). Frakturu vylou\u010d\u00ed RTG vy\u0161et\u0159en\u00ed bedern\u00ed p\u00e1te-\u0159e, sakra a kostr\u010de. 6.1.3 Onemocn\u011bn\u00ed mimop\u00e1te\u0159n\u00edho p\u016fvodu; p\u0159i podez\u0159en\u00ed vhodn\u00e9 prov\u00e9st p\u0159\u00edslu\u0161-n\u00e1 odborn\u00e9 vy\u0161et\u0159en\u00ed ve spolupr\u00e1ci se specialistou (zejm\u00e9na gynekologem, urolo-gem, gastroenterologem, internistou, chirurgem a ortopedem). 6.1.4 Neurologick\u00fd deficit; p\u0159i podez\u0159en\u00ed na par\u00e9zu \u010di v\u00fdrazn\u00e9 ko\u0159enov\u00e9 bolesti spojen\u00e9 s pozitivitou nap\u00ednac\u00edch man\u00e9vr\u016f jak na za\u010d\u00e1tku obt\u00ed\u017e\u00ed, tak v pr\u016fb\u011bhu one-mocn\u011bn\u00ed je vhodn\u00e1 objektivizace deficitu pomoc\u00ed odborn\u00e9ho neurologick\u00e9ho vy\u0161et\u0159e-n\u00ed. P\u0159\u00edznaky nov\u011b vznikl\u00e9 par\u00e9zy a syndromu kaudy equiny kdykoliv v pr\u016fb\u011bhu one-mocn\u011bn\u00ed jsou indikac\u00ed k akutn\u00ed neurologick\u00e9 a neurochirurgick\u00e9 konzultaci. 6.2 U v\u011bt\u0161iny nemocn\u00fdch dojde k \u00fastupu obt\u00ed\u017e\u00ed a dal\u0161\u00edch vy\u0161et\u0159en\u00ed nen\u00ed t\u0159eba. P\u0159i p\u0159etrv\u00e1v\u00e1n\u00ed bolest\u00ed po dobu p\u0159ibli\u017en\u011b 1 m\u011bs\u00edce \u010di jejich progresi, p\u0159i objeven\u00ed varov-n\u00fdch p\u0159\u00edznak\u016f sv\u011bd\u010d\u00edc\u00edch pro z\u00e1n\u011bt, malignitu, mimop\u00e1te\u0159n\u00ed onemocn\u011bn\u00ed \u010di zn\u00e1m-k\u00e1ch neurologick\u00e9ho deficitu (zejm\u00e9na par\u00e9z) je nutn\u00e9 zopakovat a p\u0159ehodnotit kli-nick\u00e9 vy\u0161et\u0159en\u00ed, prov\u00e9st RTG LS p\u00e1te\u0159e a zv\u00e1\u017eit neurologick\u00e9 vy\u0161et\u0159en\u00ed a dal\u0161\u00ed od-born\u00e9 konzultace (rehabilita\u010dn\u00ed l\u00e9ka\u0159, ortoped, neurochirurg). Indikace zobrazovac\u00edch vy\u0161et\u0159en\u00ed p\u00e1te\u0159e (CT, MR, perimyelografie a elektrodiagnostick\u00fdch metod (EMG, evokovan\u00e9 potenci\u00e1ly) nutno prov\u00e1d\u011bt ve spolupr\u00e1ci s neurologem. 7. L\u00e9\u010debn\u00fd postup 7.1 Po proveden\u00ed vstupn\u00edho klinick\u00e9ho vy\u0161et\u0159en\u00ed a p\u0159i chyb\u011bn\u00ed varovn\u00fdch p\u0159\u00edznak\u016f \u010di po vylou\u010den\u00ed z\u00e1va\u017en\u00e9ho organick\u00e9ho onemocn\u011bn\u00ed p\u00e1te\u0159e \u010di mimop\u00e1te\u0159n\u00edho p\u016fvo-du obt\u00ed\u017e\u00ed je vhodn\u00e9 nemocn\u00e9ho informovat o p\u0159\u00edzniv\u00e9m spont\u00e1nn\u00edm pr\u016fb\u011bhu a p\u0159\u00edz-niv\u00e9 progn\u00f3ze onemocn\u011bn\u00ed u v\u011bt\u0161iny nemocn\u00fdch a o pl\u00e1novan\u00e9m diagnostick\u00e9m a l\u00e9\u010debn\u00e9m postupu. 7.2 Modifikace pohybov\u00e9 aktivity. Je vhodn\u00e9 omezit pohybovou aktivitu provoku-j\u00edc\u00ed bolesti. Klid na l\u016f\u017eku je vhodn\u00fd pouze v p\u0159\u00edpad\u011b, \u017ee je vynucen intenzivn\u00edmi obt\u00ed-\u017eemi a nem\u011bl by trvat d\u00e9le ne\u017e 4 dny (nen\u00ed-li vynucen intenzivn\u00edmi bolestmi). V z\u00e1vislosti na rychlosti \u00fastupu bolest\u00ed a intolerance pohybov\u00e9 aktivity je vhodn\u00e9 po-vzbuzovat nemocn\u00e9 k aerobn\u00ed pohybov\u00e9 aktivit\u011b minim\u00e1ln\u011b zat\u011b\u017euj\u00edc\u00ed p\u00e1te\u0159, jako je ch\u016fze, j\u00edzda na kole \u010di plav\u00e1n\u00ed. Po dobu obt\u00ed\u017e\u00ed je t\u0159eba p\u0159eru\u0161it t\u011b\u017ekou fyzickou z\u00e1t\u011b\u017e spojenou se zved\u00e1n\u00edm b\u0159emen, prudk\u00e9 \u0161vihov\u00e9 pohyby a omezit statickou z\u00e1t\u011b\u017e vsed\u011b. 7.3 Analgetick\u00e1 l\u00e9\u010dba. Je nutn\u00e1 v p\u0159\u00edpad\u011b, \u017ee bolest p\u0159etrv\u00e1v\u00e1 i po modifikaci po-hybov\u00e9 aktivity a nen\u00ed nemocn\u00fdm tolerov\u00e1na. Farmakologicky je vhodn\u00e9 ovlivn\u011bn\u00ed bolesti pomoc\u00ed paracetamolu, nesteroidn\u00edch antiflogistik a myorelaxanci\u00ed. Paraceta-mol je l\u00e9kem volby u bolest\u00ed m\u00edrn\u011bj\u0161\u00ed intenzity pro dobrou toleranci a minimum ne\u017e\u00e1-douc\u00edch \u00fa\u010dink\u016f. \u00da\u010dinnost jednotliv\u00fdch antiflogistik a myorelaxanci\u00ed je podobn\u00e1. Vzhledem k potenci\u00e1ln\u011b z\u00e1va\u017en\u00fdm vedlej\u0161\u00edm \u00fa\u010dink\u016fm (zejm\u00e9na gastrointestin\u00e1ln\u00edm) by m\u011bla b\u00fdt l\u00e9\u010dba kr\u00e1tkodob\u00e1, ale v dostate\u010dn\u00e9 d\u00e1vce (optim\u00e1ln\u011b do dvou t\u00fddn\u016f). Pro rychlej\u0161\u00ed n\u00e1stup \u00fa\u010dinku a men\u0161\u00ed riziko ne\u017e\u00e1douc\u00edch gastrointestin\u00e1ln\u00edch \u00fa\u010dink\u016f je mo\u017eno zejm\u00e9na v \u00favodu obt\u00ed\u017e\u00ed pou\u017e\u00edt parenter\u00e1ln\u00ed aplikaci analgetik a nesteroidn\u00edch antiflogistik. L\u00e9\u010dbu kortikosteroidy celkov\u011b a l\u00e9\u010dbu opioidy nelze obecn\u011b doporu\u010dit, i kdy\u017e m\u016f\u017ee b\u00fdt pou\u017eita u refraktern\u00edch ko\u0159enov\u00fdch syndrom\u016f, stejn\u011b jako lok\u00e1ln\u00ed apli-kace lok\u00e1ln\u00edch anestetik a kortikosteroid\u016f (ko\u0159enov\u00e9 \u010di epidur\u00e1ln\u00ed \u201eobst\u0159iky\u201c). 7.4 Manu\u00e1ln\u00ed a fyzik\u00e1ln\u00ed l\u00e9\u010dba. Efekt fyzik\u00e1ln\u00edch metod (aplikace tepla, chladu, ultrazvuku, laseru, transkut\u00e1nn\u00ed elektrick\u00e9 stimulace, mas\u00e1\u017e\u00ed, trakce) nebyl v akutn\u00edm st\u00e1diu onemocn\u011bn\u00ed spolehliv\u011b prok\u00e1z\u00e1n a manipulace m\u016f\u017ee b\u00fdt v akutn\u00edm st\u00e1diu rizi-kov\u00e1. Je vhodn\u00e9 omezit jejich pou\u017eit\u00ed na p\u0159\u00edpady s pomal\u00fdm \u00fastupem obt\u00ed\u017e\u00ed. Pat\u0159\u00ed z\u00e1sadn\u011b do rukou odborn\u00e9ho l\u00e9ka\u0159e \u0161kolen\u00e9ho v t\u00e9to oblasti. 8. Progn\u00f3za Progn\u00f3za je z\u00e1visl\u00e1 na stanoven\u00e9 diagn\u00f3ze a spr\u00e1vn\u00e9 l\u00e9\u010db\u011b. Akutn\u00ed lumbago m\u00e1 dobrou progn\u00f3zu, v\u011bt\u0161inou odezn\u00ed b\u011bhem n\u011bkolika dn\u00ed, 90 % nemocn\u00fdch je bez bo-lest\u00ed do 2-3 m\u011bs\u00edc\u016f, i kdy\u017e asi 50 % nemocn\u00fdch bude m\u00edt pot\u00ed\u017ee opakovan\u011b. Disko-genn\u00ed ko\u0159enov\u00e9 syndromy se uprav\u00ed p\u0159i konzervativn\u00ed l\u00e9\u010db\u011b v 80-90 % p\u0159\u00edpad\u016f, ope-ra\u010dn\u00ed l\u00e9\u010dba indikovan\u00e1 u nemocn\u00fdch nereaguj\u00edc\u00edch na konzervativn\u00ed l\u00e9\u010dbu je \u00fasp\u011b\u0161-n\u00e1 v 70-90 % p\u0159\u00edpad\u016f. V\u00fdjime\u010dn\u011b m\u016f\u017ee u profes\u00ed vy\u017eaduj\u00edc\u00edch manu\u00e1ln\u00ed z\u00e1t\u011b\u017e doj\u00edt k trval\u00e9 a pln\u00e9 invalidizaci nemocn\u00e9ho. Progn\u00f3za bolest\u00ed v LS oblasti vyvolan\u00fdch z\u00e1-va\u017en\u00fdmi onemocn\u011bn\u00edmi p\u00e1te\u0159e \u010di mimo ni je z\u00e1visl\u00e1 na v\u010dasn\u00e9 diagnostice t\u011bchto p\u0159\u00ed\u010din a mo\u017enost\u00ed jejich l\u00e9\u010debn\u00e9ho ovlivn\u011bn\u00ed. 9. Prevence 9.1 Prim\u00e1rn\u00ed prevence. Degenerativn\u00ed zm\u011bny p\u00e1te\u0159e obecn\u011b urychluje jak nad-m\u011brn\u00e1, tak nedostate\u010dn\u00e1 fyzick\u00e1 z\u00e1t\u011b\u017e. Je vhodn\u00e1 osv\u011bta ve smyslu nutnosti p\u0159im\u011b-\u0159en\u00e9ho zat\u00ed\u017een\u00ed p\u00e1te\u0159e (nevhodn\u00e1 nezvykl\u00e1 dlouhodob\u00e1 fyzick\u00e1 z\u00e1t\u011b\u017e, udr\u017eov\u00e1n\u00ed p\u0159im\u011b\u0159en\u00e9 fyzick\u00e9 hmotnosti, vyvarovat se dlouhodob\u00e9 imobilizace p\u00e1te\u0159e). P\u0159i za\u0159a-zov\u00e1n\u00ed do povol\u00e1n\u00ed \u010di \u010dinnost\u00ed spojen\u00fdch s p\u0159et\u011b\u017eov\u00e1n\u00edm p\u00e1te\u0159e (v\u010detn\u011b z\u00e1vodn\u00edho sportu) vhodn\u00e9 prov\u00e9st RTG C a L p\u00e1te\u0159e a nedoporu\u010dit tuto \u010dinnost jedinc\u016fm s prim\u00e1rn\u011b \u00fazk\u00fdm spin\u00e1ln\u00edm kan\u00e1lem, kongenit\u00e1ln\u00edmi deformitami a s hypermobilitou. 9.2 Sekund\u00e1rn\u00ed prevence. U nemocn\u00fdch s klinick\u00fdmi projevy radikulopatie v anamn\u00e9ze se doporu\u010duje \u00faprava pracovn\u00edho a \u017eivotn\u00edho re\u017eimu s c\u00edlem minimali-zovat p\u0159et\u011b\u017eov\u00e1n\u00ed a poran\u011bn\u00ed p\u00e1te\u0159e a upravit t\u011blesnou hmotnost. 10. Posudkov\u00e1 hlediska. Akutn\u00ed lumbago vy\u017eaduje obvykle kr\u00e1tkodobou n\u011bkoli-kadenn\u00ed pracovn\u00ed neschopnost po dobu intolerance pohybov\u00e9 aktivity \u010di statick\u00e9 z\u00e1-t\u011b\u017ee p\u0159i sedu. B\u011bhem akutn\u00ed ataky ko\u0159enov\u00e9ho syndromu je nemocn\u00fd pr\u00e1ce ne-schopn\u00fd a\u017e do odezn\u011bn\u00ed bolest\u00ed a \u00fapravy funkce p\u0159i fyzick\u00e9 z\u00e1t\u011b\u017ei, nutn\u00e9 k vykon\u00e1v\u00e1n\u00ed dan\u00e9 profese. P\u0159i posuzov\u00e1n\u00ed\u00a0vertebrogenn\u00edch\u00a0obt\u00ed\u017e\u00ed je nutno br\u00e1t v \u00favahu \u00fa\u010delovou agravaci obt\u00ed\u017e\u00ed. U nemocn\u00fdch s chronick\u00fdm pr\u016fb\u011bhem \u010di p\u0159etrv\u00e1-vaj\u00edc\u00edm neurologick\u00fdm deficitem nutno ztr\u00e1tu funkce posoudit s ohledem na charakter fyzick\u00e9 z\u00e1t\u011b\u017ee vy\u017eadovan\u00e9 danou profes\u00ed. Liter\u00e1rn\u00ed odkazy 1. Agency for Health Care Policy and Research (AHCPR). Acute low back problems in adults. ACH-PR Publication No. 95-0642. Rockvile: U.S. Department of Health and Human Services, Public Health Service, 1994. 2. Andersson GBJ. The Epidemiology of Spinal Disorders. In: Frymoer JW et al, eds. The Adult Spi-ne. Principles and Practice. 2nd ed. Philadelphia: Lippincot-Raven Publishers, 1997:93-142. 3. Bedna\u0159\u00edk J, Kada\u0148ka Z, Voh\u00e1\u0148ka S. Standard diagnostick\u00fdch a l\u00e9\u010debn\u00fdch v\u00fdkon\u016f. Spondylogenn\u00ed neurologick\u00e9 syndromy: r adikulopatie a myelopatie. \u010ces a Slov Neurol Neurochir 1998;61\/94:50-53. 4. Van Tulder MW, Assendelft JJ, Koes BW, Bouter LM, and the Editorial Board of the Cochrane Col-laboration Back Review Group. Method Guidelines for Systematic Reviews in the Cochrane Collabo-ration Back Review Group for Spinal Disorders. Spine 1997;22:2323-2330. 5. Vroomen PCAJ, de Krom MCTFM, Knotterus JA. Diagnostic value of history and physical exami-nation in patients suspected of sciatica due to disc herniation: a systematic review. J Neurol 1999;246:899-906. DIAGNOSTIKA Akutn\u00ed bolesti v\u00a0lumbosakr\u00e1ln\u00ed\u00a0oblasti Anamn\u00e9za, klinick\u00e9 vy\u0161et\u0159en\u00ed Varovn\u00e9 p\u0159\u00edznaky ? Trauma p\u00e1te\u0159e Bolest v doln\u00ed (z\u00e1n\u011bt, malignita, v anamn\u00e9ze ? kon\u010detin\u011b ? extravertebr\u00e1ln\u00ed onem.) Laboratorn\u00ed testy, RTG LS p\u00e1te\u0159e Lumbago Neurologick\u00e1 RTG LS p\u00e1te\u0159e dysfunkce? (scinti p\u00e1te\u0159e) (neurolog?*) Zn\u00e1mky z\u00e1n\u011btu, Fraktura? Ko\u0159enov\u00e1 iritace? Komprese malignity, extra- Pseudoradikul\u00e1rn\u00ed ko\u0159ene, vertebr.onem.? syndrom? kaudy P\u0159\u00edslu\u0161n\u00e1 Vymizen\u00ed P\u0159etrv\u00e1v\u00e1n\u00ed Progrese P\u0159\u00edslu\u0161n\u00e1 konzultace obt\u00ed\u017e\u00ed obt\u00ed\u017e\u00ed, pomal\u00fd obt\u00ed\u017e\u00ed, konzultace** (onkolog, \u00fastup nov\u00e1 (neurolog, ortoped, neurologick\u00e1 neurochirurg) urolog, dysfunkce gynekolog) \u017d\u00e1dn\u00e9 P\u0159ehodnocen\u00ed anamn\u00e9zy, testy klinick\u00e9ho vy\u0161et\u0159en\u00ed, RTG LS Koment\u00e1\u0159: siln\u011b vyzna\u010den\u00e9 \u0161ipky zna\u010d\u00ed standardn\u00ed diagnosticko-l\u00e9\u010debn\u00fd postup u v\u011bt\u0161iny nemocn\u00fdch s akutn\u00edmi bolestmi v LS oblasti veden\u00fd praktick\u00fdm l\u00e9ka\u0159em a zahrnuj\u00edc\u00ed klinick\u00e9 vy\u0161et\u0159en\u00ed, modifikaci pohybov\u00e9 aktivity a p\u0159\u00edpadn\u011b analgetickou l\u00e9\u010dbu. * Neurologick\u00e1 konzultace v p\u0159\u00edpad\u011b nejasn\u00e9ho n\u00e1lezu ** O indikaci zobrazovac\u00edch metod (CT, MR, PMG) a elektrofyziologick\u00fdch metod (EMG, EP) optim\u00e1l-n\u011b rozhoduje specialista (neurolog, neurochirurg, ortoped); v p\u0159\u00edpad\u011b zn\u00e1mek dysfunkce kaudy (sfink-terov\u00e9 obt\u00ed\u017ee, perianogenit\u00e1ln\u00ed porucha citlivosti, bolesti a par\u00e9zy obou doln\u00edch kon\u010detin) je konzultace urgentn\u00ed! Vypracoval: Doc.MUDr.J.Bedna\u0159\u00edk,CSc., neurologick\u00e1 klinika LFMU a FN Brno Schv\u00e1leno v\u00fdborem \u010cesk\u00e9 neurologick\u00e9 spole\u010dnosti 7.12.2001<\/p>\n","protected":false},"excerpt":{"rendered":"
Doporu\u010den\u00fd postup pro praktick\u00e9 l\u00e9ka\u0159e Akutn\u00ed bolesti v\u00a0lumbosakr\u00e1ln\u00ed\u00a0oblasti pro praktick\u00e9 l\u00e9ka\u0159e z pohledu neurologa 1. Charakteristika p\u0159edm\u011btu doporu\u010den\u00e9ho postupu Standard se…<\/p>\n","protected":false},"author":23,"featured_media":0,"parent":3047,"menu_order":180,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"_searchwp_excluded":"","kia_subtitle":"","footnotes":""},"class_list":["post-3138","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"\n