chronic low back pain
Introduction
Introduction to chronic low back pain Low back pain refers to the pain in the back, waist, lumbosacral and ankle, sometimes accompanied by pain or radiation pain in the lower limbs. Most of the low back pain is manifested in the lower lumbar spine and the lower back and the ankle. Low back pain is the most common condition of the human spine and is said to be the price paid by humans crawling from limbs to walking upright. The disease is more common in internal medicine, surgery, gynecology and neurology. The lesions of any tissue in the skin, subcutaneous tissue, muscles, ligaments, spine, ribs, spinal cord and spinal membrane can cause low back pain. basic knowledge The proportion of illness: 0.02% Susceptible people: no special people Mode of infection: non-infectious Complications: spinal deformity
Cause
Causes of chronic low back pain
(1) Causes of the disease
1. Common causes
(1) Spine low back pain:
1 traumatic low back pain: such as vertebral body fractures, muscle sprains, vertebral slippage and so on.
2 congenital malformation low back pain: such as semi-vertebral body, lumbar vertebrae, lumbar vertebrae, spina and so on.
3 inflammatory low back pain: such as ankylosing spondylitis, tuberculous spondylitis, suppurative spondylitis, focal ankle arthritis.
4 degenerative low back pain: such as proliferative spondylitis, disc herniation, spinal stenosis, lumbar posterior joint disorders.
5 nutritional metabolic disorders low back pain: such as osteomalacia, skeletal fluorosis and so on.
6 poor posture low back pain.
7 atrophic low back pain.
8 endocrine abnormal low back pain: such as osteoporosis, primary hyperparathyroidism and so on.
9 bone tumor low back pain.
10 reasons for unclear low back pain.
11 other spinal diseases of low back pain: such as deformity osteitis, young vertebral osteochondritis (youth hunchback) and so on.
(2) Low back pain caused by paravertebral soft tissue disease:
1 lumbar muscle strain.
2 low back muscle myofasciitis (fibromyositis).
3 third lumbar vertebrae transverse process syndrome.
(3) Low back pain caused by stimulation of spinal cord and spinal nerve roots:
1 spinal cord compression: such as epidural abscess, intraspinal tumor, spinal arachnoiditis.
2 acute myelitis.
3 subarachnoid hemorrhage.
4 lumbosacral radiculitis.
5 herpes zoster.
(4) Low back pain caused by visceral diseases:
1 low back pain caused by digestive diseases: such as peptic ulcer, pancreatic cancer, liver cancer, rectal cancer, cholecystitis, posterior appendicitis.
2 urinary, reproductive system caused by low back pain: such as pyelonephritis, kidney stones, kidney tuberculosis, peri-renal abscess, hydronephrosis, kidney cancer, prostatitis, prostate cancer, cervical cancer, uterine posterior tilt, chronic attachment inflammation, Dysmenorrhea and so on.
3 low back pain caused by respiratory diseases: such as pleurisy, pleural thickening or adhesion, tuberculosis, lung cancer and so on.
4 low back pain caused by cardiovascular diseases: such as aortic aneurysm, angina and so on.
5 low back pain caused by retroperitoneal diseases: such as retroperitoneal abscess, retroperitoneal fibroma or fibrosarcoma, as well as the aforementioned kidney disease and pancreatic disease.
(5) Low back pain caused by mental factors:
1 snoring.
2 chronic fatigue syndrome.
3 depression.
4 compensatory neurosis.
2. The relationship between low back pain and occupational factors
(1) The occurrence of low back pain: Buckle et al found that 43% of patients with low back pain were ill at work, and 28% of patients were ill at home. Daniel et al found that about half of the patients (51%) were found by analyzing 100 patients. Onset at work, not all low back pain has predisposing factors.
(2) Relationship with heavy physical work: Many epidemiological survey data indicate that heavy industry, construction industry, miners, and forestry workers have a high incidence of low back pain, which may be related to their large spinal load and vulnerability to injury.
(3) Relationship with bending and twisting: Previous investigations have confirmed that the incidence of low back pain is high in the work of lifting heavy objects and repeating bending and twisting. The authors report that the incidence rate can be 15% to 64%, usually medium weight. The object does not cause damage to the lower back, but it is prone to low back pain when lifting heavy objects frequently. It is generally believed that when bending to extract heavy objects, the trunk flexes to make the intervertebral disc narrow and wide, and when the weight is lifted, the spine is squeezed. Pressing the intervertebral disc, the nucleus pulpus moves backwards to reach the posterior part of the annulus fibrosus, deep in the posterior longitudinal ligament. With the trunk straight, the nucleus pulposus is restricted by the upper and lower cartilage plates, and repeated injury or acute injury can cause The nucleus pulposus is prominent, especially in the posterior extension position. The weight-bearing movement in all directions of the spine can cause different degrees of damage to the posterior intervertebral joint and joint capsule of the spine, interspinous, supraspinous ligament and paravertebral muscle. The cause of low back pain.
(4) Restricted working position and vibration: In recent years, the relationship between restricted working position and low back pain has been paid more and more attention. Long-term sitting work is considered to be a high risk factor for low back pain. Experimental research indicates vibration work (including pneumatic tools) ) easy to produce low back pain, harmful vibration frequency of 3.5 ~ 8.9Hz, most likely to cause damage, can have adverse effects on the musculoskeletal system, cardiovascular system, gastrointestinal tract, the slight stress generated by vibration can accelerate the lumbar intervertebral disc tissue retreat The disc itself has no blood vessels to supply nutrients. The nucleus pulposus nutrient is supplied by the permeation of the cartilage endplate. The slight stress generated by the vibration can affect the intervertebral disc from two aspects. On the one hand, the long-term pressure makes the cartilage endplate and the endplate under the bone. Fatigue and micro-fractures, the repair process reduces the ability of osmotic nutrition, affecting the repair of the nucleus pulposus and the annulus fibrosus; on the other hand, the tiny shear, bending and torsion forces make the fiber ring fatigue and accelerate degeneration, thus making The nucleus pulposus tends to accentuate the nerves and produce low back pain.
(5) Other occupational factors: Bergqnist-Ullmann and Larssonu found that people who are engaged in monotonous repetitive work in the factory assembly line have a high prevalence of low back pain, and another survey found that monotonous repetitive work, less leisure activities, and low back pain Direct relationship, in fact, monotonous and repetitive work has an impact on people's physical strength and psychology. In people who stand, walk and change positions frequently, the prevalence of low back pain is also high. It is also reported that the workplace is uneven or easy. Slip, often susceptible to a sprained waist.
(two) pathogenesis
1. Relationship between individual factors and low back pain: Many authors understand the relationship between low back pain from individual factors such as age, gender, physical and psychosocial and X-ray findings.
(1) Age and gender: Low back pain occurs mostly in young adults. The majority of the onset age is 30 to 40 years old. It is also reported in the literature from 35 to 55 years old. The duration of symptoms is proportional to the age increase. Gender is related to low back pain. The meaning is not very important.
(2) Body posture: Clinically, the scoliosis, hunchback, lumbar lordosis and the length of the lower limbs are often listed as the cause, but there is still insufficient epidemiological data to confirm, some investigations indicate that scoliosis The Cobb angle is greater than 80° or the scoliosis is located in the lumbar region, which is prone to low back pain.
(3) Muscle factors: The strength of the back and abdominal muscles is closely related to the occurrence of low back pain. The stability of the spine is determined by internal and external factors, endogenous stability is provided by the ligaments and intervertebral discs, and exogenous stability is provided by the back and abdominal muscles. In the past, the abdominal muscles were not given enough attention. It is now believed that the abdominal muscles not only control and regulate the spinal movement.
(4) Lumbar motion: Most patients with low back pain have significantly reduced lumbar motion. There is currently insufficient literature to explain the relationship between lumbar motion and low back pain.
(5) History of low back pain: People who have suffered from low back pain in the past have a higher possibility of lower back pain.
(6) Disease factors: Gyntellberg reported that people with chronic bronchitis and atherosclerotic angina pectoris and often have headaches have a high incidence of low back pain. Frymoger reported that people with chronic cough have more onset of low back pain because they can increase waist when coughing Intervertebral disc pressure.
(7) Psychosocial factors: Foreign epidemiological surveys not only involve occupational factors, but also investigate their social and psychological factors. Many survey reports believe that smoking, drug abuse and alcohol abuse are more patients with low back pain, anxiety, nervousness, and dissatisfaction with work. People with low mood, separation and divorce have a high prevalence of low back pain.
2. The etiology and pathogenesis of Chinese medicine: Chinese medicine believes that the cause of lumbosacral disease has many similarities with other rheumatism, and can be roughly divided into two factors: external feeling and internal injury, while righteousness is weak and kidney deficiency is the root cause of lumbosacral failure. .
(1) Exogenous stagnation: lack of righteousness, phlegm and looseness, feeling cold and dampness, cold stagnation, wet turbidity and viscous stagnation, wind, cold and dampness in the meridians, blood line is blocked, blood is not running The lumbosacral stagnation, or the dampness and heat poisoning invades the meridians, or the cold and dampness accumulates in the long-term heat and dampness, or the over-eating fat and spicy products, endogenous damp heat, can also block the meridians, burn blood, blood stasis and waist paralysis.
(2) qi stagnation and blood stasis: falling servant frustration damage meridian qi and blood, stasis internal resistance; or long-term position is not correct, the waist is not properly applied, the breath is frustrated; or anger and anger, liver qi stagnation, blood stasis, obstruction of the meridian; Surgery and prolonged bed rest lead to obstruction of the air machine, blood stasis in the waist meridians, waist loss of blood and support and low back pain.
(3) Kidney deficiency body deficiency: lack of congenital endowment, room labor injury kidney, chronic illness and physical weakness, old and frail, can cause liver and kidney deficiency, kidney essence loss, liver main tendon, kidney main bone, waist for kidney house, Liver and kidney deficiency first affects the waist, causing the meridians to lose their support and pain, kidney yang deficiency, meridians lost in warmth, cold and dampness is easy to invade, yang deficiency and internal cold, cold coagulation meridians, congestion internal resistance and phlegm Pain, chronic illness, spleen and stomach weakness, qi and blood deficiency, meridian dystrophy, external evil stagnation, long-term sputum, women with excessive blood loss after childbirth, kidney loss, can also lead to menstrual dystrophy and lumbosacral.
Prevention
Chronic low back pain prevention
prevention:
1. Health check: For the health check of adolescents or staff, it should be carried out regularly. Check in school should pay attention to the presence or absence of congenital or idiopathic deformity of the spine, such as facet joint deformity or vertebral arch cracking, etc. For sports work, attention should be paid to the occurrence of pedicle fractures, etc. This is more in athletes and acrobats. If there is such a defect in the lumbar structure, the back protection should be strengthened to prevent repeated damage.
2. The labor department should stipulate the maximum load of labor to avoid the overload of the spine and accelerate the degeneration.
3. Correcting bad labor posture: Some labor tasks need to bend over for a long period of time. The pressure on the lumbar intervertebral disc is more than 1 times higher than that in general standing. The long-term sitting worker has a higher incidence of low back pain than the standing worker. However, there is no positive relationship with the incidence of lumbar disc herniation, so it is meaningful to do the work.
4. Correcting bad labor posture: In Xinjiang, China, women in Yanbian area of Jilin often have top-heavy weights. Women in India, North Korea and Jamaica also take this position. According to statistics, the incidence of cervical spondylosis in these women is higher than that of ordinary people, but The incidence of lumbar disc disease is similar.
5. Strengthen muscle exercise: Strong back muscle can prevent soft tissue damage in the lower back, exercise of abdominal muscles and intercostal muscles can increase intra-abdominal pressure and intrapleural pressure, which helps to reduce lumbar load.
6. Prevention in family life: When working in housework, such as ironing the height of the table top should be appropriate, avoid avoiding bending and twisting when taking too much to bend the object. Put the baby into the stroller or bed, should be removed and placed flat. This is the way to prevent the waist from being overloaded and reducing its load.
7. Family education: The purpose is to establish the confidence of patients in treatment, avoid wrong treatment, and reduce the loss of individuals and society.
Complication
Chronic low back pain complications Complications spinal deformity
It can be difficult to walk in parallel, and even dysfunction such as lumbar flexion, extension, and lateral curvature may occur. In severe cases, spinal deformity may occur.
Symptom
Symptoms of chronic low back pain Common symptoms Forced prone position sprain Lumbar disc herniation Lumbar muscle tendon Back tingling Osteoporosis Radioactive pain Buttocks Painful dull pain Lower extremity Induction pain or put...
Low back pain mainly consists of low back, lumbosacral and ankle pain. There are simple low back pain and low back pain accompanied by lower limb induced pain or radiation pain. The pain is mostly dull and dull. Stinging, local tenderness or radiation pain, unfavorable activity, inconvenient pitching, inability to hold weight, difficulty walking, fatigue and limb fatigue, and even dysfunction such as lumbar flexion, extension, and lateral curvature, severe spinal deformity, performance Because the cause of low back pain is more complicated, the disease causes more low back pain in the clinic. Each disease has its special medical history, physical signs and clinical manifestations, so each disease The clinical manifestations of low back pain are not repeated here.
Examine
Chronic low back pain check
The back of the spine is the key examination site for low back pain. It should be checked according to the general examination of body, sputum, movement, quantity and nervous system. In order to avoid multiple flipping of the patient, it can be performed under a certain position.
1. Standing or sitting check should remove the top in a warm room, the examiner faces the back of the patient, and observes the back from the back side combined with the side.
(1) Looking around:
1 Observing the physiological curvature of the spine, whether there is spinal flattening, lumbar kyphosis or lordosis, lumbar deformity pain often manifests as protective lumbar ankylosis, kyphosis is seen in lumbar disc herniation, spinal tuberculosis, lordosis deepening is seen in lumbar spondylolisthesis Symptoms, horizontal atlas.
2 observe the spine with or without round back, hunchback, lateral convex deformity, round back (turtle back) deformity refers to the back segment of the spine with a uniform curved kyphosis, seen in young hunchback, ankylosing spondylitis, senile osteoporosis, etc. Humpback malformation refers to the limited kyphosis of the spine, common in spinal tuberculosis, congenital spinal deformity, spinal fracture, metastatic cancer, etc.; convex deformity refers to the spine to one side or "S" shape, seen in primary or Secondary spine 1 convex, disc herniation, etc.
Look at the diagnosis should also observe whether the shoulders on both sides are equal, whether the thorax is symmetrical; whether there is soft tissue swelling, with or without pigmentation, etc., children should pay attention to the lumbosacral part with or without hair, abnormal protrusion, or step-like change due to slippage And small concave.
(2) Percussion: more in the sitting position, let the patient point out the pain point, so as to narrow the scope of the examination appropriately. If the patient complains of extensive pain, he should check from top to bottom, first touch the spinous process from top to bottom, and have no hemiplegia. High and low changes and tenderness; compression soft tissue pain points: bilateral ribs, ridge ribs, third lumbar vertebrae, posterior superior iliac spine, bilateral gluteal muscles, etc. can simultaneously allow the patient to flex and flex the spine to touch the flexion and extension Symmetrical, especially for spinal pain areas, because of the characteristics of spinal tuberculosis is the protective rigidity of the diseased segment.
(3) examination of thoracolumbar flexion and extension movement: the thoracic vertebrae can only make a little flexion and extension, lateral flexion and rotational movement due to the limitation of the thoracic spine. The main flexion and extension and lateral flexion movement are in the lumbar segment.
Special test
(1) Straight leg raising test and strengthening test: The patient is supine, the legs are straight, the examiner lifts the hand with one hand, and gently presses the knee at the same time to keep the leg straight, causing the radiation pain of the lower extremity to be positive. Stretch the back of the foot. If the pain is aggravated, it is positive for the strengthening test to identify the pain caused by the tension of the hamstring. It is worth noting that the test can also produce ankle joint torque. If the ankle joint lesion can also produce ankle Pain, not radiation pain in the lower extremities, should be identified.
(2) supine and abdomen test: the patient's occipital part and the two feet are the force points to push the abdomen and buttocks up, causing the waist and leg pain to be positive. If it is negative, the patient can be abdomen and take a deep breath and then breathe to blush. At the same time, coughing hard and causing radioactive pain in the affected limb is positive. Shi can be the first to use this method to examine patients with lumbar disc herniation.
(3) flexion neck test: the patient is supine, the limbs are straight and flat, and the neck is slowly raised, and the radiation of the lower limbs is positive.
Diagnosis
Diagnosis and diagnosis of chronic low back pain
Diagnostic criteria
Diagnostic points: Low back pain is caused by a variety of diseases. It is especially important to make a clear diagnosis. In clinical practice, it is necessary to clarify the diagnosis ideas. From the three aspects of medical history, physical examination and auxiliary examination, the following focuses on the medical history and physical examination. Diagnostic ideas.
1. History: First of all, to understand the gender, age and occupation of patients, women should consider whether there is pelvic disease, men pay attention to prostatitis, elderly and postmenopausal women have osteoporosis, young and middle-aged are more common in strain, lumbar disc herniation The disease, occupation and working environment are closely related to the lower back. Workers who are sitting or using the back bend are prone to strain and degeneration. Cold storage and water operators are prone to rheumatism. Long-term exposure to poisons is prone to chronic poisoning and bone metabolism disorders. Chronic onset, gradually worsened, more common in strain, degenerative tumor; sprain and trauma are onset, it is worth noting that cold and weather changes are not the specific cause of rheumatism, many causes and pain of low back pain Aggravation may be related to weather changes and cold. Pain after aggravation is related to chronic strain. Pain after walking is more common in spinal stenosis, spondylolisthesis and lumbar degenerative osteoarthritis, degeneration and pain caused by chronic strain. It is mostly sore, and it is aggravated when you start activities after rest or in the morning. It can be relieved after a little activity, but after a long time of activity Weight, lumbar spinal stenosis and disc herniation are more than walking, but cycling is fine, pain in the back or uphill, and pain in the squat or downhill, tuberculosis and tumor pain often worse at night, vertebrae After the nerve in the tube is stimulated by compression, the intraspinal pressure caused by cough often leads to radiation pain along the nerve. The pain is very important. The simple back pain is mostly from the lower back muscles, ligaments, facet joints, and vertebral bodies. Caused by lesions, low back pain accompanied by radiation pain along the nerve is considered to be caused by embedding nerve stimulation, rheumatism may be accompanied by migratory pain of other joints, early ankylosing spondylitis is ankle Or hip pain, should be carefully asked whether the patient has a history of tumors in other areas, whether the pain is caused by tumor metastasis, whether osteoporosis has a history of diabetes or kidney disease, whether there is a history of endocrine disorders, whether the pain is accompanied by fever or other parts of the Symptoms such as angina cause low back pain, flustered, chest tightness, airlock and other symptoms, urinary stones are often accompanied by abdominal pain and tossing and turning in the bed, kidney tumors are accompanied by Hematuria.
2. Physical examination: the examination should start from the gait at the time of the patient's visit. The gait is stiff and the gait is unstable. It is like drunkenness. It is more common in spinal cord diseases such as cervical spondylotic myelopathy, spinal cord tumors, etc. Waist stiffness or forced to tilt to one side, with the hand to support the waist, gait cautious, more common in lumbar disc herniation, acute lumbar sprain or acute lumbar muscle tissue inflammation, duck step for swinging around when walking, more common in hip disease The patient should be removed from the shirt to observe whether there is a physiological curvature of the back and back, whether there is a side bend, a hunchback, an angular deformity, a mass, a sinus, a scar, and a pigmentation, so that the patient's spine is flexed and stretched. Left and right side flexion, left and right rotation to observe the function of the back, the function of the patients with lumbar back organic lesions is often limited, and the reflex pain caused by visceral diseases is normal, determining the tenderness of the lower back is the most direct search for the lesion. Methods, tenderness can be divided into superficial tenderness and deep tenderness, supraspinous ligament, interspinous ligament, inflammatory lesion of sacral spine muscle with tenderness in the corresponding part of the thumb, if the lower lumbar spine is accompanied by tenderness The radioactive pain in the direction is mostly caused by lumbar disc herniation. The spine bone and spinal canal lesions often have sputum pain. The compression nerve often causes radiation pain. If the tender point is repeated repeatedly, it is fixed. The tenderness point often means that there is an organic lesion in the part. On the contrary, the reflexed lumbar back caused by visceral lesions often has no fixed tenderness point, and then the patient is placed in a supine position. If the lumbar lordosis is straight or the hip joint is flexed and contracted, In the leg straight position, the waist can not be flat, check whether the abdomen is symmetrical, palpate with or without hepatosplenomegaly, with or without a lump and hip fossa abscess. Female patients should pay attention to whether there is deep abdominal tenderness.
3. Several special tests commonly used to check low back pain
(1) Straight leg raising test and strengthening test: The patient is supine, the legs are straight, the examiner lifts the hand with one hand, and gently presses the knee at the same time to keep the leg straight, causing the radiation pain of the lower extremity to be positive. Stretch the back of the foot. If the pain is aggravated, it is positive for the strengthening test to identify the pain caused by the tension of the hamstring. It is worth noting that the test can also produce ankle joint torque. If the ankle joint lesion can also produce ankle Pain, not radiation pain in the lower extremities, should be identified.
(2) supine and abdomen test: the patient's occipital part and the two feet as the force point will force the abdomen and buttocks to rise, causing the waist and leg pain to be positive. If it is negative, the patient can be abdomen while taking a deep breath and then holding his breath to blush. At the same time, coughing hard and causing radioactive pain in the affected limb is positive. Shi can be the first to use this method to examine patients with lumbar disc herniation.
(3) flexion neck test: the patient is supine, the limbs are straight and flat, and the neck is slowly raised, and the radiation of the lower limbs is positive.
(4) oblique shift test: the patient's limbs are straight and supine, the examiner supports the affected side of the knee, so that the hip flexes and bends the knee and receives the hip joint, and the other hand holds the shoulder to fix the upper body, so that the longitudinal axis of the pelvis can be generated. Rotational pressure can cause pain if the ankle has a lesion.
(5) 4 test patient supine: knee flexion puts the ankle and ankle on the contralateral knee, the examiner valgus the knee in one hand, the other side fixes the pelvis opposite, and the ankle pain indicates the ankle There are lesions in the department. If the hip joint is damaged, there is hip pain and the knees cannot be flattened.
In addition, there are neck test, Gaenslen test, Yeomann test, pelvic crush test, etc. Patients with low back pain accompanied by lower extremity pain or numbness should also check the depth and depth of the lower extremities, exercise, Reflex, muscle atrophy, etc., when the back of the waist itself is not able to identify the cause, please consult the relevant departments such as urology, gynecology, abdominal surgery, internal medicine, etc. according to the situation, anal examination of the sacral tumor is necessary, should also Pay attention to the examination of lower extremity lesions such as unequal length of lower limbs, flat feet, internal and external valgus, clubfoot, and toe deformity, etc., which affect the balance of the back and back and cause back pain. Foot lesions such as sputum, spur, synovitis, and toe pain Such as the lower limbs can be imbalanced to cause lumbar muscle strain.
Differential diagnosis
1. Identification with osteophytes: Most of the epiphyses are caused by cold and dampness in the winter. The joints are painful in the joints, the limbs are thin, the cold is cold, the activity is limited, the bones are heavy, the waist and knees are sore. A type of rickety, characterized by lack of kidney yang, feeling cold, dampness and evil as a disease, easy to be confused with lumbosacral, but the disease is in the bone, mainly in the joints of the extremities, accompanied by symptoms of backache Different from lumbosacral.
2. Identification with renal pelvis: Kidney sputum is a bone sputum, combined with kidney qi deficiency and complex external evils, caused by kidney, clinical manifestations of joint pain, limbs are cruel, bones are not lifted, back pain, sputum The song does not stretch, the steps are difficult, and even the " , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , , It is developed from the epiphysis, accompanied by the clinical symptoms of the epiphysis. The onset of the disease begins with the joints of the extremities. It is mainly different from the beginning of the lumbosacral region. The history and initial symptoms are the main points. .
