lumbar spinal stenosis
Introduction
Introduction to lumbar spinal stenosis Lumbar spinal stenosis is a disease in which the lumbar spinal canal, nerve root channel and intervertebral foramen are deformed or narrowed, causing the cauda equina or nerve root to be compressed and producing long-term low back pain, leg pain, and intermittent paralysis. According to the location can be divided into central type (main spinal canal) stenosis, lateral type (lateral crypt) stenosis and nerve root canal stenosis, according to the cause can be divided into congenital development and acquired secondary . basic knowledge The proportion of sickness: 0.01% Susceptible people: no special people Mode of infection: non-infectious Complications: lumbar disc herniation
Cause
Causes of lumbar spinal stenosis
(1) Causes of the disease
1. Congenital spinal stenosis is congenital development, the lumbar pedicle is short and the spinal canal is short, which is rare in clinical practice.
2. Degenerative spinal stenosis is the most common clinical manifestation, which is the result of lumbar degeneration. With age, degeneration and degeneration include:
1 lumbar intervertebral disc first degeneration;
2 followed by vertebral lip-like hyperplasia;
3 posterior small joints also hyperplasia, hypertrophy, cohesion, protruding into the spinal canal, upper joint hypertrophy, in the lower lumbar vertebrae (waist 4, waist 5 or waist 3, waist 4, waist 5) from the back of the superior articular process and the posterior vertebral body The lateral crypt formed by the rim is narrowed, where it passes through the nerve root and can be compressed;
4 lamina thickening;
5 yellow ligaments thickened, and even ossified, these occupy a certain space in the spinal canal, together become degenerative lumbar spinal stenosis.
The sagittal diameter of the lumbar spinal canal varies greatly among the various bodies. Like the cervical spinal canal and the thoracic spinal canal, there is a difference in the sagittal diameter. In the case of a wide sagittal diameter of the spinal canal, although there are various degenerative changes, Because of the large space inside the spinal canal, no symptoms of spinal stenosis are produced. In the case of a small sagittal diameter of the spinal canal, degenerative changes can cause symptoms of spinal stenosis, while a relatively narrow spinal canal is not congenital. Sexual spinal stenosis is a difference between individuals.
3. Other causes of spinal stenosis
(1) lumbar spondylolisthesis, the sagittal diameter of the plane canal is reduced.
(2) Central type lumbar disc herniation, occupying the space of the lumbar spinal canal, can produce symptoms of spinal stenosis, both cases have a clear diagnosis, clinically not called lumbar spinal stenosis.
(3) secondary, such as total laminectomy, the formation of scars, and then the spinal canal stenosis, or lamina fusion, the lamina is relatively thick, resulting in local spinal stenosis, this situation is rare.
(4) Lumbar vertebrae burst fracture, vertebral body displacement into the spinal canal, rest in the acute phase, asymptomatic, post-initiation activity or increased activity, spinal canal stenosis symptoms may occur.
(two) pathogenesis
The clinical manifestations are mainly the following three clinical features, and the pathophysiological basis is now described together.
Intermittent cicada
(1) Clinical manifestations: that is, when the patient walks for several hundred meters (several cases only tens of steps), there is side or bilateral backache, leg pain and lower limb numbness, weakness, and even limp, but when a little kneeling or sitting down After a few minutes of rest, you can continue walking. Because of the intermittent period, the name is intermittent.
(2) Basis of pathophysiology: The appearance of the above-mentioned clinical symptoms is mainly due to the relaxation of the muscles of the lower extremities, the physiological congestion of the vascular plexus of the corresponding spinal ganglia in the spinal canal, followed by venous congestion, which causes the microcirculation to be blocked and the ischemia occurs. Sexual radiculitis, when a little squat or sitting, lying down, because the source of stimulation of muscle activity is eliminated, the vascular plexus of the blood is restored to normal, which also restores the normal width of the spinal canal, so the symptoms are also reduced or disappeared. .
2. The contradiction between chief complaint and objective inspection
(1) Clinical manifestations: There are many complaints in each stage of the disease, especially when the patient walks long distances or is in various forced positions that increase the intraspinal pressure, there are more complaints, and even typical sciatic nerves Radioactive pain performance, but no positive findings during the examination, straight leg elevation test is often negative.
(2) Pathophysiology basis: This is mainly due to the short rest before the clinic and the recovery of the pre-flexion position, which increases the internal volume of the spinal canal, and the internal pressure also returns to the original state, and the internal venous plexus is swollen quickly. Recovery also helps to eliminate symptoms. The inconsistency between the main complaint and the physical examination can be mistaken as exaggerating the main complaint or scamping, but in the later stages of the disease, due to various additional factors, such as intervertebral disc prolapse, bone Hyperplasia and intraspinal adhesions, etc., can constitute a persistent space-occupying lesion in the spinal canal with positive signs; however, it is characterized by increased motility.
3. Restriction and pain in the back of the waist
(1) Clinical manifestations: When the lumbar vertebrae are extended backwards, the patient complains of local pain and can radiate to the bilateral or unilateral lower limbs; but as long as the posture is changed, such as the body flexing or kneeling, and walking or cycling On the road, the symptoms disappear immediately. This phenomenon can also be called postural claudication.
(2) Pathophysiology basis: The occurrence of this group of symptoms is mainly due to the reduction or disappearance of the effective space in the lumen, because when the lumbar vertebra changes from the neutral position to the posterior extension, in addition to the small joint capsule behind the spinal canal The ligamentum flavum is squeezed outside the spinal canal and nerve root canal. The length of the spinal canal is also shortened by 2.2 mm. The intervertebral foramen is also narrowed accordingly. The intervertebral disc is enlarged to the spinal canal, and the transverse section of the nerve root is also thickened, so that the intraluminal pressure is increased. Sudden increase, therefore, the patient's extension is bound to be limited, and various symptoms appear, but when the waist is restored to the straight position or slightly forward, the spinal canal is restored to its original width, and the symptoms are immediately Elimination or alleviation, therefore, although these patients can not stand upright, but can bend and walk, can ride (that is, posture type), but if combined with lumbar disc herniation, the waist can not continue to bend or even bend There are also symptoms of low back pain and sciatica.
In addition to causing the above three clinical manifestations, this pathophysiological feature may also have other manifestations in the clinic, mainly including:
1 Lumbar symptoms: manifested as general low back pain, weakness, fatigue and other general lumbar symptoms, this is mainly due to stimulation of the spinal sinus nerve; but the neck test is negative, which is different from lumbar disc herniation.
2 lower extremity root symptoms: mostly bilateral, similar to lumbar disc herniation, characterized by walking, even after rest, relieve or disappear, so the straight leg elevation test is mostly negative, this group of symptoms are also due to The spinal canal and/or root canal is narrow.
3 Abnormal reflection: Achilles tendon reflex is easily affected and weakened. This is mainly due to the lower the lumbar vertebrae, the narrower the spinal canal. Therefore, the 5th and 1st lumbar segments are easily affected and affect the Achilles tendon reflex; normal.
Prevention
Prevention of lumbar spinal stenosis
1. Prevention of overwork: Overloading of the waist will inevitably cause damage to the waist muscles, ligaments and joints, and waist and leg pain.
2. Anti-wind and cold invasive: Chinese medicine believes that: cold wins, pain, cold main stagnation, qi and blood, poor meridians, no pain.
3. Maintain the correct posture: Because the daily standing, sitting, lying, walking and other postures are not scientific, the waist is in an incorrect physiological state, and thus most people suffer from lumbar spondylosis.
4. Protect good living habits: The rightness of the bed directly affects people's health. It is best to add a 5-10 cm cushion to the wooden bed. At the same time, we must also grasp the diet and the degree of sexual intercourse.
Complication
Lumbar spinal stenosis complications Complications lumbar disc herniation
Most of them combined with lumbar intervertebral bulging or lateral stenosis.
Symptom
Lumbar spinal stenosis symptoms common symptoms lumbosacral pain, weakness, spinal physiology, bending, disappearance, sensory disturbance, lumbar disc herniation, intermittent claudication
1. General situation : Although most of the developmental lumbar spinal stenosis is fetal-derived, the true age of onset is mostly after middle age, but the age of the degenerative cause is greater than that of the former 10 to 15 years old. Therefore, more Found in the elderly, the disease more men than women, may be related to male labor intensity and waist load, its incidence is faint, often unconsciously gradually appear symptoms.
2. The main symptoms : As mentioned above, the main symptoms of this disease are lumbosacral pain and intermittent claudication. The lumbosacral pain often involves both sides, standing, aggravating when walking, lying in bed, reducing when sitting, complaining of leg pain Disc herniation is significantly less, the cause of symptoms in addition to spinal stenosis, mostly due to combined disc herniation or lateral recess stenosis.
About 70% to 80% of patients have cauda equine intermittent claudication, which is characterized by asymptomatic when quiet, short leg walking, leg pain, weakness and numbness, standing or squatting for a little time, the symptoms disappear, severely, The chest is stretched, the waist is stretched, and the symptoms can also appear when standing. The difference between the intermittent claudication of the cauda equina and the vascular intermittent claudication of the obliterative vasculitis is that the lower extremity is cold, the dorsal artery pulsation disappears, and the feeling, reflection The barrier is mild, and the cold water induced test is positive (no need to test), the root pain of intervertebral disc herniation and intermittent claudication usually have leg pain, and most of them are unilateral.
Although the patient complained more, in the early quiet, physical examination was often not found, lumbar extension and pain induced more than flexion, straight leg elevation test in patients with simple spinal stenosis can be negative, but in the secondary spinal stenosis The positive rate of the disease can be as high as 80% or more. The leg is weak when walking, and there is numbness. The primary one has no signs of muscle atrophy, but the secondary cases, especially the lumbar disc herniation, are most obvious.
In summary of the above symptoms, it is the above-mentioned intermittent claudication, the main complaints are more than the positive signs and the three major clinical features of stretching.
3. Clinical manifestations of lateral crypt type (root canal) stenosis : similar to those with spinal stenosis, the incidence of lateral recess stenosis is more than that of middle-aged cerebral palsy. Males are more than females, and their symptoms increase with age. Degeneration is aggravated and aggravated. The reason why men are more common is mainly because the male side crypt is narrow and deep, the gap around the nerve is small, and the hyperplasia is heavier and prone to symptoms.
Patients have a long history of low back pain, leg pain is often more serious than spinal stenosis and lumbar disc herniation, can also be caused by fatigue, trauma or aggravation of the disease, nerve root numbness mostly along the waist 5 or 1 The nerve roots travel and the nerve roots are intermittently more obvious than the former. Walking hundreds or even dozens of steps can cause the disease, and the squatting or stopping walking is relieved.
In most cases, there were no positive signs in the examination, and a few had physiological curvature of the spine disappeared or scoliosis, but not as heavy as the former and disc herniation. The extension of the spine can induce or aggravate the numbness of the limb, but the nerve root has paralysis. The presence or absence of sensory impairment varies depending on the severity of the stenosis. In severe cases, the sensation of the damaged innervation zone may occur, and the dyskinesia may be weakened or disappeared.
Examine
Examination of lumbar spinal stenosis
1. Auxiliary examination of spinal stenosis
(1) X-ray plain film: in the developmental or mixed spinal stenosis, mainly manifested as small sagittal diameter of the spinal canal, lamina, articular process and pedicle abnormal hypertrophy, bilateral small joints moved to the midline, vertebra The plate gap is narrow; the degenerative person has obvious bone hyperplasia. The sagittal diameter of the spinal canal can be measured on the lateral radiograph, the spinal canal stenosis is shown in the 14 mm or less, and the stenosis is 14 to 16 mm. The symptoms may appear under additional factors, and the ratio of the spinal canal to the vertebral body may be used to determine whether the stenosis is narrow.
(2) CT, CTM and MRI examination: CT examination can show the morphology of the spinal canal and root canal, but it is not easy to understand the whole appearance of the stenosis; CTM can not only understand the bony structure, but also can confirm the pressure of the dural sac. In addition, MRI examination can show the overall appearance of the lumbar spine, which is currently routinely examined by most orthopaedic surgeons.
(3) vertebral canal angiography: often in the lumbar 2,3 intervertebral space puncture injection angiography, at this time there can be a sharp break, comb-like interruption and bee-waist changes, basically understand the narrow appearance, because this inspection is invasive It is currently used less.
2. Auxiliary examination of lateral recess stenosis
(1) X-ray plain film: There may be laminar space stenosis on the X-ray plain film, small joint hyperplasia, sagittal diameter on the pedicle root becomes shorter, mostly less than 5mm, in the case of less than 3mm, it belongs to lateral recess stenosis In addition, cohesion of the inner edge of the superior articular coronoid also suggests a possible stenosis of the lateral recess.
(2) CT, CTM and MRI examination: CT examination can show the shape of the section of the spinal canal, so it can diagnose the presence or absence of lateral crypt stenosis and the presence or absence of nerve root compression; CTM examination shows more clearly, MRI examination can display three-dimensional The image can simultaneously determine the extent of disc degeneration, the presence or absence of protrusion (or prolapse) and its relationship with the dural sac and spinal nerve roots.
(3) vertebral angiography: non-ionic iodine contrast agent omnipaque, isovist angiography can be seen in the nerve root development interruption, showing side crypt stenosis or nerve root compression, but this examination is not easy to with the oppression caused by disc herniation Differentiate.
Diagnosis
Diagnosis and diagnosis of lumbar spinal stenosis
diagnosis
1. Diagnosis of spinal stenosis The diagnosis of this disease is mainly based on the above three clinical symptoms, especially the long-term lumbosacral pain, bilateral leg discomfort, cauda equina intermittent claudication, no physical examination at rest Positive findings, etc., are the characteristics of the disease. Anyone with middle-aged or above who has the above characteristics should be suspected of this disease and need further examination, including:
(1) X-ray plain film: in the developmental or mixed spinal stenosis, mainly manifested as small sagittal diameter of the spinal canal, lamina, articular process and pedicle abnormal hypertrophy, bilateral small joints moved to the midline, vertebra The plate gap is narrow; the degenerative person has obvious bone hyperplasia.
The sagittal diameter of the spinal canal can be measured on the lateral radiograph, the spinal canal stenosis is shown in the 14 mm or less, and the stenosis is 14 to 16 mm. The symptoms may appear under additional factors, and the ratio of the spinal canal to the vertebral body may be used to determine whether the stenosis is narrow.
(2) CT, CTM and MRI examination: CT examination can show the morphology of the spinal canal and root canal, but it is not easy to understand the whole appearance of the stenosis; CTM can not only understand the bony structure, but also can confirm the pressure of the dural sac. In addition, MRI examination can show the overall appearance of the lumbar spine, which is currently routinely examined by most orthopaedic surgeons.
(3) vertebral canal angiography: often in the lumbar 2,3 intervertebral space puncture injection angiography, at this time there can be a sharp break, comb-like interruption and bee-waist changes, basically understand the narrow appearance, because this inspection is invasive It is currently used less.
2. Diagnosis of lateral recess stenosis Anyone with low back pain, leg pain, intermittent claudication and associated root symptoms should be suspected of lateral recess stenosis and further examination:
(1) X-ray plain film: There may be laminar space stenosis on the X-ray plain film, small joint hyperplasia, sagittal diameter on the pedicle root becomes shorter, mostly less than 5mm, in the case of less than 3mm, it belongs to lateral recess stenosis In addition, cohesion of the inner edge of the superior articular coronoid also suggests a possible stenosis of the lateral recess.
(2) CT, CTM and MR examination: CT examination can show the shape of the section of the spinal canal, so it can diagnose the presence or absence of lateral crypt stenosis and the presence or absence of nerve root compression; CTM examination shows more clearly, MR examination can display three-dimensional The image can simultaneously determine the extent of disc degeneration, the presence or absence of protrusion (or prolapse) and its relationship with the dural sac and spinal nerve roots.
(3) vertebral angiography: non-ionic iodine contrast agent omnipaque, isovist angiography can be seen in the nerve root development interruption, showing side crypt stenosis or nerve root compression, but this examination is not easy to with the oppression caused by disc herniation Differentiate.
Differential diagnosis
1. Lumbar disc herniation is the most confusing disease, and its identification points are:
(1) Simple disc herniation generally does not have three major characteristics.
(2) The root symptoms are very severe and the corresponding signs change.
(3) The neck test and the straight leg raising test were more positive, while the spinal canal stenosis was negative.
(4) Others, if necessary, magnetic resonance or myelography.
However, it should be noted that the two are often accompanied.
2. Sciatic nerve pelvic outlet stenosis The characteristics of this disease are:
(1) The waist is asymptomatic and the lumbar extension is normal.
(2) The tender point is mainly located at the ring jump point.
(3) There are typical symptoms of sciatic nerve dry involvement.
(4) If accompanied by lumbar spinal stenosis, the three characteristics of the disease appear.
3. The horsetail tumor is difficult to identify early, and the main performances in the middle and late stages are:
(1) characterized by persistent lower limbs and bladder, rectal symptoms.
(2) The pain is continuously intensified, especially at night, and non-useful analgesics can not sleep.
(3) lumbar puncture showed more subarachnoid obstruction, protein quantitative increase and Pan test positive.
(4) Others, those with difficulty can use other special detection means, MR examination has the value of diagnosis.
4. Lumbar segment secondary adhesion arachnoiditis This disease has a certain causal relationship with lumbar spinal stenosis, spinal canal, especially the root canal long-term compression can be secondary to this disease, and more from the root sleeve, gradually develop To the full arachnoid space, therefore, for a case of long-term lumbar spinal stenosis, such as surgery, there is no need to identify the disease before surgery, you can decide whether to take a spider web according to the state of the dural sac during surgery. Subcapsular exploration.
5. Others In addition, the disease should be differentiated from lower lumbar instability, proliferative spondylitis, other congenital malformations of the lumbar spine, lumbar infections and chronic lumbar muscle strain.
