转：腰椎间盘突出症的诊断与治疗(强烈推荐）

拱腰飞燕

以下内容转自丁香园：

本帖要介绍的是2007年发表在BMJ上的经典文献，BMJ 这个杂志无须多说，虽然不比NEJM牛叉，但也足够权威了。

文中最为重要的内容是，提到了腰椎间盘突出症诊断与治疗的临床指南。翻译过来和大家共享：


BMJ 2007;334:1313-1317 (23 June), doi:10.1136/bmj.39223.428495.BE

Clinical Review
Diagnosis and treatment of sciatica
B W Koes, professor1, M W van Tulder, professor of health technology assessment2, W C Peul, neurosurgeon3

1 Department of General Practice, Erasmus MC, University Medical Center Rotterdam, PO Box 2040, 3000 CA Rotterdam, Netherlands , 2 EMGO Institute, VU University Medical Center, Amsterdam, Netherlands , 3 Department of Neurosurgery, Leiden University Medical Center, Leiden, Netherlands

Correspondence to: B W Koes b.koes@erasmusmc.nl


BMJ 2007;334:1313-1317 (23 June), doi:10.1136/bmj.39223.428495.BE

Clinical Review
Diagnosis and treatment of sciatica
坐骨神经痛的诊断与治疗

译者注：在英文中似乎并没有腰椎间盘突出症这个名词，而“sciatica”（坐骨神经痛）和“lumbar disk herniation”（腰椎间盘突出）这两个词在有关文献中出现频率很高，很多语境中大概类似于中文的“腰椎间盘突出症”。

Sciatica affects many people. The most important symptoms are radiating leg pain and related disabilities. Patients are commonly treated in primary care but a small proportion is referred to secondary care and may eventually have surgery. Many synonyms for sciatica appear in the literature, such as lumbosacral radicular syndrome, ischias, nerve root pain, and nerve root entrapment.
坐骨神经痛在临床上很常见，其最主要的症状是小腿的放射性疼痛和相关的功能障碍。这些患者通常在初级医疗中心接受治疗，但也有少部分需转诊到二级医疗中心，最终甚至可能需进行手术治疗。在文献中坐骨神经痛有很多同义词，如腰骶神经根综合征、坐骨痛、神经根性疼痛、神经根卡压等。

Summary points
Most patients with acute sciatica have a favourable prognosis but about 20%-30% have persisting problems after one or two years
The diagnosis is based on history taking and physical examination
Imaging is indicated only in patients with "red flag" conditions or in whom disc surgery is considered
Passive (bed rest) treatments have been replaced with more active treatments
Consensus is that initial treatment is conservative for about 6-8 weeks
Disc surgery may provide quicker relief of leg pain than conservative care but no clear differences have been found after one or two years
要点概述
大多数急性坐骨神经痛的患者预后良好，但大约20%-30%的患者1或2年后会残留持续性的问题
主要根据病史和体格检查来确定诊断
影像学检查的指征仅限于患者存在“红旗征”或考虑进行椎间盘手术的情况
休息（卧床）治疗已被更为积极的治疗方法所替代
较为统一的意见是初期处理应先进行大约6-8周的保守治疗
椎间盘手术相比保守治疗，可使腿痛的缓解更快，但1或2年后，并没有发现明显的差异。


In about 90% of cases sciatica is caused by a herniated disc with nerve root compression, but lumbar stenoses and (less often) tumours are possible causes. The diagnosis of sciatica and its management varies considerably within and between countries—for example, the surgery rates for lumbar discectomy vary widely between countries.w1 A recent publication confirmed this large variation in disc surgery, even within countries.1 This may in part be caused by a paucity of evidence on the value of diagnostic and therapeutic interventions and a lack of clear clinical guidelines or reflect differences in healthcare and insurance systems. This review presents the current state of science for the diagnosis and treatment of sciatica.
大约90%的患者其坐骨神经痛是由于椎间盘突出压迫神经根所致，而腰椎管狭窄和肿瘤（少见）也是其可能的原因。在同一个国家以及不同的国家之间，坐骨神经痛的诊断和治疗差异相当大。比如，腰椎间盘切除书的手术率在各个国家之间的差别就很大[w1]，最近发表的一项研究证实，椎间盘手术即使在同一个国家，也存在着巨大的差异[1]。这也使得评价诊断和治疗方法的依据相对匮乏，也没有明确的临床指南，并且也使得医疗保健和保险系统也存在很大的差异。本文旨在对当前坐骨神经痛诊断和治疗的现状做一综述。

Sources and selection criteria
We identified systematic reviews in the Cochrane Library evaluating the effectiveness of conservative and surgical interventions for sciatica. Medline searches up to December 2006 were carried out to find other relevant systematic reviews on the diagnosis and treatment of low back pain. Keywords were sciatica, hernia nuclei pulposi, ischias, nerve root entrapment, systematic review, meta-analysis, diagnosis, and treatment. In addition we used our personal files for other references, including publications of recent randomised clinical trials. Finally we checked the availability of clinical guidelines.
文献的入选标准与来源
在Cochrane图书馆查找评价坐骨神经痛手术与保守治疗有效性的系统综述，检索Medline2006年12月之前的文献，找出其他有关腰痛诊断与治疗的系统综述。以坐骨神经痛、髓核突出、坐骨痛、神经根卡压、系统评价、meta分析、诊断和治疗为关键词。此外，应用我们的个人资料作为另外的参考，包括近年发表的随机性临床试验。最后我们还对临床指南的有效性进行了验证。

Who gets sciatica?
Exact data on the incidence and prevalence of sciatica are lacking. In general an estimated 5%-10% of patients with low back pain have sciatica, whereas the reported lifetime prevalence of low back pain ranges from 49% to 70%.w2 The annual prevalence of disc related sciatica in the general population is estimated at 2.2%.2 A few personal and occupational risk factors for sciatica have been reported (box 1), including age, height, mental stress, cigarette smoking, and exposure to vibration from vehicles.2 3w2 Evidence for an association between sciatica and sex or physical fitness is conflicting.2 3w2

哪些人容易患坐骨神经痛？
坐骨神经痛确切的发病率和患病率目前仍缺乏相关的数据。一般估计腰痛的患者中5%-10%患有坐骨神经痛，然而有报道称人的一生中患腰痛的比率占到49%至70%[w2]。据估计，普通人群中椎间盘相关的坐骨神经痛每年的患病率约为2.2%[2]。有研究发现了几项与坐骨神经痛相关的自身和职业风险因素（框1），包括年龄、身高、精神紧张、吸烟，以及经常坐车承受振动等[2, 3,w2]，但没有足够的证据表明坐骨神经痛与性别或体质存在相关性[2, 3, w2]。

Box 1: Risk factors for acute sciatica3w2
Personal factors
Age (peak 45-64 years)
Increasing risk with height
Smoking
Mental stress

Occupational factors
Strenuous physical activity—for example, frequent lifting, especially while bending and twisting
Driving, including vibration of whole body
框 1：急性坐骨神经痛的风险因素[3, w2]
自身因素
年龄（高峰为45-64岁）
身高越高风险越大
吸烟
精神紧张

职业因素
重体力活动——比如频繁地抬举重物，尤其是屈曲扭转时
开车，包括使整个身体振动的工作

How is sciatica diagnosed?
Sciatica is mainly diagnosed by history taking and physical examination. By definition patients mention radiating pain in the leg. They may be asked to report the distribution of the pain and whether it radiates below the knee and drawings may be used to evaluate the distribution. Sciatica is characterised by radiating pain that follows a dermatomal pattern. Patients may also report sensory symptoms.
坐骨神经痛如何诊断？
坐骨神经痛主要通过病史和体格检查来明确诊断，明确患者所诉的下肢放射痛，要求其指出疼痛具体的分布区域，以及疼痛是否放射至膝以下，甚至可以通过描画来评价其具体的分布区域。坐骨神经痛的特征是有明确皮节区域的放射痛。有的患者还可能会有感觉障碍的相关症状。


Physical examination largely depends on neurological testing. The most applied investigation is the straight leg raising test or Lasègue's sign. Patients with sciatica may also have low back pain but this is usually less severe than the leg pain. The diagnostic value of history and physical examination has not been well studied.4 No history items or physical examination tests have both high sensitivity and high specificity. The pooled sensitivity of the straight leg raising test is estimated to be 91%, with a corresponding pooled specificity of 26%.5 The only test with a high specificity is the crossed straight leg raising test, with a pooled specificity of 88% but sensitivity of only 29%.5 Overall, if a patient reports the typical radiating pain in one leg combined with a positive result on one or more neurological tests indicating nerve root tension or neurological deficit the diagnosis of sciatica seems justified. Box 2 shows the signs and symptoms that help to distinguish between sciatica and non-specific low back pain.

体格检查则主要取决于神经病学试验，其中应用得最多的便是直腿抬高试验或称Lasègue征。有坐骨神经痛的患者也可能同时伴有腰痛，但通常不会比腿痛更严重。病史和体格检查的诊断价值并没有进行很好的研究[4]，没有某一项病史或查体试验同时具备较高的敏感性和较高的特异性。据估计直腿抬高试验的累积敏感性为91%，同时其累积特异性为26%[5]。唯一一个具有较高特异性的试验是对侧直腿抬高试验，累积特异性为88%，但其敏感性仅为29%[5]。总的来说，如果患者诉一侧下肢有典型的放射痛，同时伴有一项或多项神经病学试验阳性，提示神经根张力较高或存在神经功能障碍，此时诊断坐骨神经痛则是较为合理的。框2所示为有助于辨别坐骨神经痛和非特异性腰痛的症状和体征。

Box 2: Indicators for sciaticaw5
Unilateral leg pain greater than low back pain
Pain radiating to foot or toes
Numbness and paraesthesia in the same distribution
Straight leg raising test induces more leg pain
Localised neurology—that is, limited to one nerve root
框2：坐骨神经痛的诊断标准
单侧腿痛大于腰痛
疼痛放射至足或足趾
同一区域存在麻木和感觉障碍
直腿抬高试验诱发更为严重的腿痛
局限性的神经病学改变——限于单一神经根

What is the value of imaging?
Diagnostic imaging is only useful if the results influence further management. In acute sciatica the diagnosis is based on history taking and physical examination and treatment is conservative (non-surgical). Imaging may be indicated at this stage only if there are indications or "red flags" that the sciatica may be caused by underlying disease (infections, malignancies) rather than disc herniation.

拱腰飞燕

版主，你好！请帮我把后续的帖子加到我刚发的“转：腰椎间盘突出症的诊断与治疗（强烈推荐）”那个帖子中，以便使文章内容连贯，利于突友阅读。
影像学检查的意义
影像诊断只有在其结果可能影响进一步的治疗时才有必要。对于急性坐骨神经痛而言，诊断主要依据病史和体格检查， 治疗通常都是保守疗法（非手术治疗）。只有当坐骨神经痛有迹象或有“红旗征”表明不是由椎间盘突出所致，而可能源于其他隐匿的疾病时，才有指征进行影像学检查。

Diagnostic imaging may also be indicated in patients with severe symptoms who fail to respond to conservative care for 6-8 weeks. In these cases surgery might be considered and imaging used to identify if a herniated disc with nerve root compression is present and its location and extent. It is important as part of the decision to operate that the clinical findings and symptoms correspond well with the scan findings. This is especially relevant because disc herniations identified by computed tomography or magnetic resonance imaging are highly prevalent (20%-36%) in people without symptoms who do not have sciatica.6w3 In many people with clinical symptoms of sciatica no lumbar disc herniations are present on scans.7 8 At present no one type of imaging method shows a clear advantage over others. Although some authors favour magnetic resonance imaging above other imaging techniques because computed tomography has a higher radiation dose or because soft tissues are better visualised,9 10 evidence shows that both are equally accurate at diagnosing lumbar disc herniation.11 Radiography for the diagnosis of lumbar disc herniation is not recommended because discs cannot be visualised by x rays.11
症状严重的患者，经保守治疗6-8周无效，此时也具备进行影像学检查的指征。这些患者可能需要考虑手术治疗，而是否存在椎间盘突出压迫神经根，及其部位和程度等都需要通过影像学检查来明确。重要的是，临床体征和症状必须与扫描所见必须很好地对应起来，这也是手术决策的一部分。这一点是非常关键的，因为CT或MRI上发现的椎间盘突出，在没有坐骨神经痛相关症状的人群中非常常见（20%-36%）[6,w3]。而很多有坐骨神经痛相关临床症状的患者影像扫描也可能并不存在椎间盘突出[7,8]。目前尚未有某种影像学方法要优于其他方法，不过有些学者相对其他影像学检查更加喜欢MRI，因为CT通常辐射剂量较高，而MRI对软组织显影也更有优势[9,10]。有证据显示，腰椎间盘突出的诊断，两者具有类似的准确性[11]。不主张通过X线片来诊断腰椎间盘突出，因为X线上椎间盘不能显影[11]。

What is the prognosis?
In general the clinical course of acute sciatica is favourable and most pain and related disability resolves within two weeks. For example, in a randomised trial that compared non-steroidal anti-inflammatory drugs with placebo for acute sciatica in primary care 60% of the patients recovered within three months and 70% within 12 months.12 About 50% of patients with acute sciatica included in placebo groups in randomised trials of non-surgical interventions reported improvement within 10 days and about 75% reported improvement after four weeks.13 In most patients therefore the prognosis is good, but at the same time a substantial proportion (up to 30%) continues to have pain for one year or longer.12 13
预后如何？
通常急性坐骨神经痛的临床病程都能得到较好的结果，大部分疼痛和相关的功能障碍2周内都可缓解。例如，在一项随机试验中，对初级医疗中心急性坐骨神经痛的患者，比较非甾体类抗炎药与安慰剂的疗效，60%的患者3个月内回复，70%的患者12个月内恢复[12]。在一项非手术治疗的随机试验中，安慰剂组大约50%的急性坐骨神经痛的患者10天内得到改善，75%的患者称4周后获得改善[13]。因此，对于大多数患者来说预后良好，但同时也有较大比例（30%以上）一年或更长时间内仍有疼痛[12, 13]。

What is the efficacy of conservative treatments for sciatica?
Conservative treatment for sciatica is primarily aimed at pain reduction, either by analgesics or by reducing pressure on the nerve root. A recent systematic review found that conservative treatments do not clearly improve the natural course of sciatica in most patients or reduce symptoms.14 Adequately informing patients about the causes and expected prognosis may be an important part of the management strategy. However, educating patients about sciatica has not been specifically investigated in randomised controlled trials.

拱腰飞燕

拱腰飞燕

尚未纳入系统评价的随机对照试验
另外还有两项已经发表的随机对照试验对椎间盘手术与保守治疗进行了比较。一项试验(n=56)针对坐骨神经痛6-12周的患者，比较小切口椎间盘切除术与保守疗法的治疗结果[19]。总的来看，经过两年多的随访，腿痛，腰背痛以及主观的功能障碍都没有显著的差异。然而，椎间盘切除术的患者腿痛似乎最初的改善更快一些。另外，在美国进行了一项大规模的脊柱患者治疗结果研究试验（随机试验）及其相关的观察性队列研究[20,21]，坐骨神经痛6周以上并经证实存在腰椎间盘突出的患者纳入该研究，可以是随机试验，也可纳入观察性队列研究。在该试验中，患者被随机分配进行椎间盘手术或保守治疗。而队列研究中的患者接受椎间盘手术还是保守治疗主要取决于他们自己的意愿。随机试验(n=501)中两年多以后，无论主要的还是次要的疗效评价指标，两个处理组都有明显的改善。手术治疗组具有轻微的优势，但主要的疗效评价指标上两组的差异没有统计学意义。纳入研究3个月内，仅有50%的患者随机分配到手术组接受了手术治疗，而随机分配到保守治疗组的患者30%进行了手术治疗。经过2年的随访，保守治疗组45%的患者进行了手术治疗，而手术治疗组60%的患者接受了手术。

The observational cohort included 743 patients. Both groups improved substantially over time, but the surgery group showed significantly better results for pain and function compared with the conservative group. The authors did mention caution in interpreting the findings because of potential confounding by indication and because outcome measures were self reported.21
观察性队列研究共纳入743例患者，随着时间延长，两组均有显著的改善，但手术组疼痛和功能的改善相比保守治疗组显示出明显更好的结果。作者解释这一发现时，谨慎地提到，主要是因为治疗的适应证上有混淆，并且疗效评价也都是采用的自我评价[21]。

The results indicate that both conservative care and disc surgery are relevant treatment options for patients with sciatica of at least six weeks' duration. Surgical intervention may provide quicker relief of symptoms compared with conservative care, but no large differences have been found in success rate after one or two years of follow-up. Patients and doctors may thus weigh the benefits and harms of both options to make individual choices. This is especially relevant because patients' preference for treatment may have a direct positive influence on the magnitude of the treatment effect.
这些结果提示，对于坐骨神经痛持续至少6周的患者，无论保守治疗还是椎间盘手术都是合适的治疗选择。与保守治疗相比，手术干预可使症状更快缓解，但经过1或2年的随访后，治疗成功率的比较并没有太大的差异。患者和医生因此可以权衡这两者选择的利弊做出个性化的选择。这样做是非常恰当的，因为患者对于治疗方式的偏好可能对治疗的有效程度产生直接积极的影响。

What are the recommendations in clinical guidelines?
Although in many countries clinical guidelines are available for the management of non-specific low back pain this is not the case for sciatica.22 Box 4 shows the recommendations for sciatica (lumbosacral radicular syndrome) in clinical guidelines recently issued by the Dutch College of General Practice.w4 After excluding specific diseases on the basis of red flags, sciatica is diagnosed on the basis of history taking and physical examination. Initial treatment is conservative, with a strong focus on patient education, advice to stay active, continuing daily activities, and adequate treatment for pain. In this phase imaging has no role. Referral to a medical specialist—for example, neurologist, rheumatologist, spine surgeon—is indicated in patients whose symptoms do not improve after conservative treatment for at least 6-8 weeks. In these referred cases surgery may be considered. Immediate referral is indicated in cases with a cauda equina syndrome. Acute severe paresis or progressive paresis are also reasons for referral (within a few days).
临床指南中有什么样的建议？
虽然在很多国家都有针对非特异性腰痛的临床指南，而坐骨神经痛与其是不相同[22]。框4为Dutch College of General Practice最近发表的坐骨神经痛（腰骶神经综合征）临床指南中的相关建议[w4]。根据红旗征排除掉特殊的疾病后，结合病史和体征确定坐骨神经痛的诊断。初步的治疗为保守疗法，主要集中在患者的健康宣教、建议其保持活动，继续进行日常活动，并充分治疗疼痛。在这一阶段无需进行影像学检查。应将患者安排给内科医师，比如神经科医生，风湿病科医生，而当患者的症状在保守治疗至少6-8周后仍不能缓解时才将其推荐给脊柱外科医生。对于推荐来的这类患者，可以考虑手术治疗。如患者出现马尾综合征时应将其直接安排手术。急性的严重的局部麻痹或进行性的局部麻痹也可考虑直接安排手术（几天内）。

Box 4: Clinical guideline for diagnosis and treatment of sciatica from Dutch College of General Practicew4
Diagnosis
Check for red flag conditions, such as malignancies, osteoporotic fractures, radiculitis, and cauda equina syndrome
Take a history to determine localisation; severity; loss of strength; sensibility disorders; duration; course; influence of coughing, rest, or movement; and consequences for daily activities
Carry out a physical examination, including neurological testing—for example, straight leg raising test (Lasègue's sign)
Carry out the following tests in cases with a dermatomal pattern, or positive result on straight leg raising test, or loss of strength or sensibility disorders: reflexes (Achilles or knee tendon), sensibility of lateral and medial sides of feet and toes, strength of big toe during extension, walking on toes and heel (left-right differences), crossed Lasègue's sign
Imaging or laboratory diagnostic tests are only indicated in red flag conditions but are not useful in cases of suspected disc herniation

Treatment
Explain cause of the symptoms and reassure patients that symptoms usually diminish over time without specific measures
Advise to stay active and continue daily activities; a few hours of bed rest may provide some symptomatic relief but does not result in faster recovery
Prescribe drugs, if necessary, according to four steps: (1) paracetamol; (2) non-steroidal anti-inflammatory drugs; (3) tramadol, paracetamol, or non-steroidal anti-inflammatory drug in combination with codeine; and (4) morphine
Refer to neurosurgeon immediately in cases of cauda equina syndrome or acute severe paresis or progressive paresis (within a few days)
Refer to neurologist, neurosurgeon, or orthopaedic surgeon for consideration of surgery in cases of intractable radicular pain (not responding to morphine) or if pain does not diminish after 6-8 weeks of conservative care
框4：Dutch College of General Practice坐骨神经痛诊断与治疗的临床指南[w4]
诊断
检查红旗征的情况，例如恶性肿瘤、骨质疏松性骨折、脊神经根炎和马尾综合征。
采集病史以确定病变的部位，严重程度，肌力下降的程度，感觉功能障碍，持续时间，发病过程，咳嗽、休息、运动的影响，日常活动的结果等。
进行体格检查，包括神经病学试验，比如直腿抬高试验（Lasègue征）。
对于皮节区感觉异常、直腿抬高试验阳性、肌力下降或感觉功能障碍的患者，进行以下试验：反射（跟腱放射或膝跳反射），足与足趾内侧与外侧的感觉，拇指背伸肌力，足趾和足跟着地行走（比较左右差异），健侧Lasègue征。
影像学和实验室检查只有在发现红旗征时才有指征，对于怀疑椎间盘突出的患者没有意义

治疗
向患者解释出现症状的原因，并使患者确信随着时间的延长不采取特殊的措施症状通常也会减轻
建议患者保持活动，继续进行日常活动；卧床休息几个小时可以使症状缓解一些，但并不会使其更快痊愈
必要时给予药物治疗，通常按照以下四步：（1）对乙酰氨基酚；（2）非甾体类抗炎药；（3）曲马多、对乙酰氨基酚或非甾体类抗炎药联合可待因；（4）吗啡。
对于出现马尾综合征或急性严重的局部麻痹或局部麻痹进行性加重（几天内）应立即转诊给神经外科医生
对于顽固的根性痛（吗啡无效）或保守治疗6-8周后疼痛仍不能缓解的患者，应转诊给神经科医生、神经外科医生或骨科医生，考虑进行手术治疗。

拱腰飞燕

拱腰飞燕

Dutch College of General Practice坐骨神经痛诊断与治疗的临床指南

诊断

⊙检查、排除红旗征的情况，例如恶性肿瘤、骨质疏松性骨折、脊神经根炎和马尾综合征。

⊙采集病史以确定病变的部位，严重程度，肌力下降的程度，感觉功能障碍，持续时间，发病
过程，咳嗽、休息、运动的影响，日常活动的结果等。

⊙进行体格检查，包括神经病学试验，比如直腿抬高试验（Lasègue征）。

⊙对于皮节区感觉异常、直腿抬高试验阳性、肌力下降或感觉功能障碍的患者，进行以下试验：反射（跟腱放射或膝跳反射），足与足趾内侧与外侧的感觉，拇指背伸肌力，足趾和足跟着地行走（比较左右差异），健侧Lasègue征。

⊙影像学和实验室检查只有在发现红旗征时才有指征，对于怀疑椎间盘突出的患者没有意义

治疗

⊙向患者解释出现症状的原因，并使患者确信随着时间的延长不采取特殊的措施症状通常也会减轻

⊙建议患者保持活动，继续进行日常活动；卧床休息几个小时可以使症状缓解一些，但并不会使其更快痊愈

⊙必要时给予药物治疗，通常按照以下四步：（1）对乙酰氨基酚；（2）非甾体类抗炎药；（3）曲马多、对乙酰氨基酚或非甾体类抗炎药联合可待因；（4）吗啡。

⊙对于出现马尾综合征或急性严重的局部麻痹或局部麻痹进行性加重（几天内）应立即转诊给神经外科医生

⊙对于顽固的根性痛（吗啡无效）或保守治疗6-8周后疼痛仍不能缓解的患者，应转诊给神经科医生、神经外科医生或骨科医生，考虑进行手术治疗。

3581

红旗征？

行者无僵

类似的文章内容应该为习惯于草率建议患者手术的临床医生所熟知

yiyishou

这篇文章很有用。

拱腰飞燕

原帖由 3581 于 2010-8-26 11:16 发表
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摘自丁香园的解释：
...[/quote]
摘自丁香园的解释：
“red flag ”红旗征，实际上是在腰痛的诊断与鉴别诊断过程中，提示为严重病情的相关线索，包括既往史、现病史、体征等几个方面的表现。通常为有特异的病因的严重的病变，如果骨折、肿瘤、脊髓神经病变等等。

拱腰飞燕

拱腰飞燕

"对于坐骨神经痛持续至少6周的患者，无论保守治疗还是椎间盘手术都是合适的治疗选择。与保守治疗相比，手术干预可使症状更快缓解，但经过1或2年的随访后，治疗成功率的比较并没有太大的差异。患者和医生因此可以权衡这两者选择的利弊做出个性化的选择。这样做是非常恰当的，因为患者对于治疗方式的偏好可能对治疗的有效程度产生直接积极的影响。"
这个也说明经过6-8周甚至几个月保守无效的患者，医生建议手术是正确的。但是如果患者能够忍受当前的疼痛和不适，可以继续保守治疗。当然，医生只是建议，最终的决定权在于我们自己。

vcvvc

这种东西太多，百家争鸣，各说各的.......