Lumbar disc herniation
Introduction
Introduction to lumbar disc herniation Lumbar disc herniation refers to a series of symptoms caused by the lumbar intervertebral disc nucleus protruding from the surrounding nerve tissue. Clinical statistics show that lumbar disc herniation is one of the most common diseases in orthopedic clinics, and it is also the most common cause of low back pain. Tracing back to history, Vesalius described the appearance of the intervertebral disc as early as 1543. In the 1920s, Shmorl of Germany published 11 articles on the dissection and pathology of the intervertebral disc, and made extensive research on the intervertebral disc. In 1932, Barr first proposed that lumbar disc herniation is a possible cause of low back pain. Later, Barr and Mixter first proposed the concept and treatment of lumbar disc herniation. Since then, the basic research on lumbar disc herniation has been gradually deepened, which has improved the clinical diagnosis and treatment of this disease. basic knowledge Sickness ratio: 0.1% Susceptible people: more common in men Mode of infection: non-infectious Complications: vascular injury peripheral nerve injury
Cause
Causes of lumbar disc herniation
Degenerative changes in the lumbar disc (35%):
The degeneration of the nucleus pulposus mainly manifests as the decrease of water content, and can cause small-scale pathological changes such as inferiority and loosening due to water loss; the degeneration of the annulus fibrosis mainly shows the decrease of toughness.
The role of external force (30%):
The slight damage caused by long-term repeated external forces exerts on the lumbar intervertebral disc over time, which increases the degree of degeneration.
The weakness of the disc's own anatomical factors (25%):
The intervertebral disc gradually lacks blood circulation after adulthood and has poor repair ability. On the basis of the above factors, a certain predisposing factor that can cause a sudden increase in the pressure on the intervertebral disc may cause the less nucleus pulposus to pass through the annulus which has become less tough, thereby causing the nucleus pulposus to protrude.
Pathogenesis
First, the main cause
It is well known that lumbar discs are subjected to strong compressive stresses during the loading and movement of the spine. After about 20 years of age, the intervertebral disc begins to degenerate and constitute the underlying cause of lumbar disc herniation. In addition, lumbar disc herniation is related to the following factors:
1. Trauma: Observation of clinical cases shows that trauma is an important factor in the herniation of the intervertebral disc, especially in the incidence of children and adolescents. When the spine is lightly loaded and rapidly rotated, horizontal rupture of the annulus can be caused, and compressive stress mainly causes rupture of the cartilage endplate. It has also been suggested that trauma is only a cause of disc herniation. The original lesion is that the painless nucleus pulposus protrudes into the inner annulus, and the trauma causes the nucleus to protrude further to the outer outer fibrous annulus, which causes pain.
2. Occupation: The relationship between occupation and lumbar disc herniation is very close. For example, the driver of the car and the tractor is in a sitting position and bumpy state for a long time, so that when driving the car, the pressure in the intervertebral disc is relatively high, up to 0.5 kPa/cm2. When the clutch is pressed, the pressure can be increased to 1 kPa/cm2, which is likely to cause lumbar disc herniation. Those who are engaged in heavy physical labor and weightlifting are more likely to cause degeneration of the intervertebral disc due to excessive load. In the case of bending, if the weight of 20kg is raised, the pressure in the intervertebral disc can be increased to more than 30 kPa/cm2.
3. Genetic factors: There are reports of familial morbidity in lumbar disc herniation, and there are fewer materials in China; in addition, statistics show that the incidence of Indians, African blacks and Inuit is more obvious than that of other ethnic groups. The reason for this is low and needs further study.
4, lumbosacral congenital anomalies: lumbosacral deformity can increase the incidence, including lumbar vertebrae, lumbar vertebrae, vertebral deformity, facet joint deformity and axon asymmetry. The above factors can change the stress on the lower lumbar vertebrae, which constitutes one of the factors of increased intravertebral disc pressure and prone to degeneration and injury.
Second, the predisposing factors
In addition to the above-mentioned various main causes, that is, the degeneration of the intervertebral disc, various predisposing factors also play an important role. For example, some factors that slightly increase the abdominal pressure can make the nucleus pulposus prominent. The main reason is that on the basis of the degeneration of the intervertebral disc, a certain factor that can induce a sudden increase in the intervertebral space pressure causes the nucleus pulposus in the free state to pass through the denatured, thinned fiber loop into the spinal canal or through The lamina invades the edge of the vertebral body. There are roughly the following types of predisposing factors:
1, increase abdominal pressure: about one-third of the clinical cases have a clear increase in abdominal pressure before the onset of the disease, such as severe cough, sneezing, breath holding, forced bowel movements, and even "virtual Gong" action, etc. Increased abdominal pressure destroys the balance between the vertebral segments and the spinal canal.
2, the waist position is not correct: whether it is in sleep or in daily life, work, when the waist is in the flexion position, such as suddenly rotating, it is easy to induce the nucleus pulposus. In fact, in this position, the pressure in the intervertebral space is also high, which tends to cause the nucleus to protrude rearward.
3, sudden weight bearing: a well-trained person, do more preparatory activities, or start from a small weight (such as weightlifting, support, etc.) to prevent lumbar sprains or disc herniation, but if suddenly increase the waist load, not only may cause Sprains in the waist can also cause the nucleus pulposus to protrude.
4. Pregnancy: The entire ligament system is in a relaxed state during pregnancy, and the relaxation of the posterior longitudinal ligament is prone to bulging the intervertebral disc. In this regard, the author conducted a related investigation and found that at this time, the incidence of low back pain in pregnant women was significantly higher than that of normal people.
In short, the predisposing factors causing lumbar disc herniation are more complicated. Although various experiments have been carried out at present, due to the inferential nature of animal experiments, the distortion of fresh cadaver specimens, and the limitations of biomechanical testing of tissue surrounding the spine, etc. The exact factors and mechanisms for inducing the disease have not yet been identified, and further research is needed in the future.
5, the waist injury makes the degenerated nucleus pulposus prominent.
6, cold and wet. Cold or wet can cause small blood vessels to contract, muscle spasm, increase the pressure of the intervertebral disc, and may also cause degeneration of intervertebral discs. The external factors are excessive weight or rapid bending, lateral flexion, rotation to form a ring of fiber loops, or lumbar trauma, improper working posture in daily life, lumbar disc herniation may also occur.
Third, the lumbar disc herniation is good for people:
1, from the age point of view: lumbar disc herniation occurs in young adults.
2, from the gender point of view: lumbar disc herniation is more common in men, the incidence of men is higher than women, the ratio of male to female is generally considered to be 4 to 12:1.
3, from the body type: generally too obese or too thin people are prone to lumbar disc herniation.
4. From the professional point of view: more industrial workers with greater labor intensity. But at present, the incidence of mental workers is not very low.
5, from the posture: poor working posture. Employees in the platoons and salesmen and textile workers who are often standing are more common.
6, from the living and working environment: often in a cold or humid environment, are to some extent become the conditions for the induction of lumbar disc herniation.
7, from the different periods of women: prenatal, postpartum and menopause is a dangerous period of lumbar disc herniation in women.
8, congenital lumbar dysplasia or deformity of people, even people with excessive mental stress are prone to low back pain, smokers may cause cough with intervertebral disc pressure and increased pressure in the spinal canal, making it prone to degenerative changes related.
Prevention
Lumbar disc herniation prevention
First, strengthen exercise, keep fit
The basic cause of lumbar protrusion is lumbar disc degeneration, lumbar trauma and accumulated strain. Therefore, through exercise, the bones and the back muscles will be strong, and the nervous system reaction will be agile. Therefore, in various activities, the movements will be accurate and coordinated, and the lumbar vertebrae will not be easily damaged; at the same time, the exercise will help reduce the lumbar load. Delay the degeneration of the lumbar disc to prevent the occurrence of lumbar protrusion. The way of exercising can vary from person to person, depending on local conditions, such as doing radio exercises, aerobics, tai chi and other sports activities.
Second, maintain the correct labor posture
The correct posture can not only improve labor efficiency, but also prevent lumbar muscle strain and delay the degeneration of the intervertebral disc, thus effectively preventing lumbar protrusion.
Here are a few common postures that help protect the lumbar spine:
Standing laborers: hips, knees slightly flexed, about 15 degrees is appropriate, natural abdomen, bilateral hip muscles contracted inward, so that the pelvis forwards, the lumbar vertebrae straight.
Workers seat: Adjust the seat height so just double knee flexion and extension freely, and chairs close to the upper lumbar spine and keep the spine straight. The chair seat should not be too narrow, it should be able to support the two sides of the thigh.
Workers who need to bend halfway due to the nature of their work (such as cooks, hairdressers, etc.): Keep the lower back straight and the feet apart from the shoulders so that gravity falls on the hips and feet. When bending over heavy objects, you should stretch your waist first, then bend your hips and knees, then stretch your hips and knees, and lift your weights. When lifting heavy objects, you should straighten your chest and bend your hips first. Kneeling, then lifting heavy objects at the same time.
Third, do a good job in labor protection and improve working conditions
Those who often bend over the laborer or pick heavy objects can use a wide belt to strengthen the stability of the waist. However, the wide belt can only be applied during labor, and it should be solved normally. Otherwise, the waist strength will be weakened, and even the lumbar muscles will shrink, which will cause low back pain.
No matter what kind of labor or occupation, in a fixed position, work time should not be too long. Especially when you bend over or repeatedly twist your body, you should change your posture regularly to rest your tired muscles.
The driver of the car has been subjected to bumps and vibrations for a long time in the seat. Over time, the pressure on the lumbar intervertebral disc is increased, which may cause degeneration of the intervertebral disc and cause the disc to protrude. Therefore, the driver must have a well-designed seat, pay attention to the correct position, avoid or reduce vibration. Properly let the waist move and rest during driving.
Wind, cold and wet intrusion can reduce the body's immune function, small blood vessels contract and muscle spasm, causing low back pain. Sustained paralysis of the back muscles can lead to increased pressure in the intervertebral disc and induce lumbar protrusion. Therefore, whether in production or in daily life, wind and cold intrusion should be avoided.
During pregnancy and lactation, due to changes in endocrine, the muscles, joint capsules and ligaments of the lower back and pelvis are loose, the load on the lower lumbar spine is increased, and the intravertebral disc pressure is increased, which is prone to lumbar protrusion. Therefore, heavy physical labor should be avoided during pregnancy and lactation.
Fourth, quit smoking
Low back pain can also occur due to excessive smoking. This is because certain chemicals in the tobacco can cause vasoconstriction, ischemia and hypoxia of the blood vessel wall, and deterioration of the nutritional status of the intervertebral disc, thereby accelerating the degeneration of the intervertebral disc. At the same time, smoking can cause cough, and severe cough can cause pressure increase in the intervertebral disc, promote degeneration of the intervertebral disc, leading to lumbar disc herniation, so smoking should be stopped.
The prevention of lumbar disc herniation should start from school, family, work and pre-employment training, so that each staff member understands normal spine physiology, correct labor posture, pay attention to labor protection, avoid acceleration of lumbar disc degeneration and lumbar disc herniation Damage based on change. Preventive measures should start from the following aspects
1. Regular health checkups for adolescents or staff should be carried out at the same time, and publicity and education on prevention of lumbar disc herniation should be widely carried out.
2. The labor department shall stipulate the maximum load of labor, avoid the overload of the spine and accelerate the degeneration.
3, the correct labor posture and work and rest.
4, strengthen the muscles to exercise strong back muscles, so that the balance of spinal strength can prevent soft tissue damage in the lower back and reduce the occurrence of lumbar disc herniation.
Complication
Lumbar disc herniation complications Complications, vascular injury, peripheral nerve injury
First, the central type of prominence often leads to bladder and rectal symptoms (incontinence). Incomplete bilateral lower extremity paralysis.
Second, surgical treatment of lumbar disc herniation, common complications have the following categories:
1, infection: is a more serious complication. In particular, the intervertebral space infection brings great pain to the patient, and the recovery time is long. The general infection rate is about 14%. The main performance is: the original symptoms of neuralgia and low back pain disappeared, after 5 to 14 days, severe low back pain accompanied by pain in the buttocks or lower abdomen and muscle spasm, can not turn over, a lot of pain.
2, vascular injury: vascular injury during lumbar disc herniation, mainly caused by posterior surgery to remove the disc. If the intervertebral disc is removed by intraperitoneal or extraperitoneal anterior approach, these large blood vessels are not easily injured due to exposure of the abdominal aorta and inferior vena cava or iliac crest or vein. The cause of vascular injury is that the intervertebral disc tissue is removed to the front by the pituitary forceps. As a result, the tissue forceps pass through the anterior fiber annulus, and the large blood vessels are clamped to cause a blood vessel laceration.
3, nerve injury: lumbar disc herniation, the compression of the nerve root itself due to the compression of the intervertebral disc tissue, chemical stimulation of the nucleus pulposus and congestion, edema, adhesions, etc. have varying degrees of nerve damage, so after surgery, there may be Neurological symptoms may be worse than before, and some may be nerve damage caused by surgical operations. Nerve damage can be divided into: epidural single or multiple nerve injury, intradural cauda equina or nerve root injury, anesthetic drug damage.
4, organ damage: when the lumbar intervertebral disc is removed, simple organ damage is rare, almost all vascular injury with other organ damage, such as ureter, bladder, ileum, appendix and so on.
5, lumbar instability: in a part of patients undergoing lumbar discectomy, sciatica disappeared and low back pain persisted, some of which are due to lumbar instability, manifested in abnormal activities during lumbar flexion. Therefore, for patients with severe back pain symptoms, in patients with functional spinal lumbar spine, patients with abnormal spinal activity should undergo spinal fusion to resolve low back pain caused by instability of the spine.
6, cerebrospinal fluid fistula or meningeal pseudocyst: mostly due to intradural surgery, dural suture is not strict, or the dural incision is not sutured with a gelatin sponge covering the dural incision. Cerebrospinal fluid sputum occurs on the 3rd to 4th day after surgery. In addition to the application of large doses of antibiotics and keeping the incision dressing clean, the pressure bandaging measures are taken locally, that is, after the dressing is changed, the circumference and the center are pressed and fixed with a wide tape. It can be stopped after about 2 to 3 days. Dural pseudocysts often have low back pain in the first few months after surgery, and there are spherical sacs and dural adhesions in the operation or lumbosacral region. The wall of the mass is thin and shiny, pink, and the edge of the mass is thickened. The tumor has micropores and the spinal canal communicates with the subdural cavity. Compression of a cystic mass can cause sciatica. It is found that the cystic mass of the meninges should prevent the subarachnoid infection caused by the ulceration, and should be repaired by dura mater. After the operation, the bed was taken from the low foot height for 7 to 8 days, and healed at the dural repair site. The operation is good.
Symptom
Lumbar disc herniation symptoms Common symptoms Lower limb numbness low back pain gait instability Electric shock-like painful nerve root stimulation symptoms Intervertebral disc degeneration Toe numbness vertebral ganglion spurs form lumbar painful foot radiation pain
First, the clinical symptoms of lumbar disc herniation
According to the location, size and sagittal diameter of the nucleus pulposus, pathological features, body state and individual sensitivity, the clinical symptoms can vary greatly. Therefore, the understanding and judgment of the symptoms of this disease must be fully understood and inferred from the perspective of pathophysiology and pathological anatomy. The common symptoms of this disease are as follows:
1, low back pain: more than 95% of patients with lumbar disc herniation (de-sex) have this symptom, including vertebral body type.
Mechanism: mainly due to the nucleus pulposus entering the vertebral body or the posterior longitudinal ligament, causing mechanical stimulation and compression of adjacent tissues (mainly nerve root and sinus-vertebral nerve), or due to glycoprotein, - in the nucleus pulposus Protein spillage and histamine (H substance) release cause stimulation of adjacent spinal nerve roots or sinus-vertebral nerves, causing chemical and/or mechanical radiculitis.
Performance: Clinically, it is common to have a dull pain in the lower back. The supine position is relieved, the standing is intensified, and it can be tolerated under normal circumstances, and the waist is moderately active and walks slowly, mainly due to mechanical compression. The duration is as low as 2 weeks, and the elders can last for several months or even years. Another type of pain is the pain in the waist, which is not only sudden and sudden, but also unbearable. This is mainly due to ischemic radiculitis, that is, the nucleus pulposus suddenly protrudes to compress the nerve roots, causing the root blood vessels to be simultaneously compressed and present a series of changes such as ischemia, congestion, hypoxia and edema, and can last for several days. A few weeks (and this can also occur in patients with spinal stenosis, but the duration is very short, only a few minutes). The wooden bed, the closure therapy and various dehydrating agents can alleviate the effects of early relief.
2, lower extremity radiation pain: more than 80% of cases of this disease, of which more than 95% of the latter type.
Mechanism: The same mechanism as the former, mainly due to mechanical and/or chemical stimulation of the spinal nerve roots. In addition, reflex sciatica (or "pseudo-sciatica") can also occur through the sinus nerve of the affected sinus.
Performance: Lighter manifests as a radioactive tingling or numbness from the waist to the thigh and the back of the calf, reaching the bottom of the foot; generally tolerable. In severe cases, it is characterized by severe pain from the waist to the foot, and often accompanied by numbness. Although the pain is still light, the gait is unstable, and the gait is limping; the waist is more inclined or the waist is used to relieve the tensile stress on the sciatic nerve. In severe cases, they rest in bed, and they like to take hips, knees, and lateral positions. Radiation pain is exacerbated by factors that increase abdominal pressure. Because the neck can increase the stimulation of the spinal nerves by pulling on the dural sac (ie, the neck test), the patient's head and neck are more upright.
The limbs of radiation pain are mostly one-sided, and only a few of the central or central parafascicular nucleus are manifested as symptoms of both lower extremities.
3, limb numbness: more with the former accompanied by simple numbness and no pain only accounted for about 5%. This is mainly due to the stimulation of the proprioception and tactile fibers in the spinal nerve roots. The extent and location depend on the number of affected nerve root sequences.
4, limb cold feeling: a small number of cases (about 5% to 10%) consciously limb chills, cold, mainly due to stimulation of the sympathetic nerve fibers in the spinal canal. Clinically, it is often found that the patient complains of limb fever on the day after surgery, and this is the same mechanism.
5, intermittent claudication: its mechanism and clinical manifestations are similar to those of lumbar spinal stenosis, the main reason is that in the case of prominent nucleus pulposus, the pathological and physiological basis of secondary lumbar spinal stenosis may occur; In patients with congenital developmental sagittal diameter of the spinal canal, the nucleus pulposus is more severe and the degree of stenosis of the spinal canal is more serious, so that the symptoms are easily induced.
6, muscle paralysis: due to lumbar disc herniation (de-) caused by the disease is very rare, and many due to root damage caused by the degree of muscles of different degrees of paralysis. The light muscles are weakened, and the muscles lose their function. Clinically, the tibialis anterior muscle, the long and short tibia, the long extensor digitorum and the long extensor muscle of the lumbar 5 spinal nerve are more common, followed by the quadriceps (the waist 3 to 4 spinal nerve innervation). ) and gastrocnemius muscle (1 spinal nerve innervation) and so on.
7, cauda equina symptoms: mainly seen in the posterior central and central parafascicular nucleus process (de-) out of the disease, it is rare in clinical. Its main manifestations are numbness, tingling, defecation and dysuria, impotence (male), and sciatic nerve involvement in both lower extremities. In severe cases, symptoms such as loss of control of the stool and incomplete paralysis of the lower extremities may occur.
8, lower abdominal pain or anterior thigh pain: in the high lumbar disc herniation, when the lumbar 2, 3, 4 nerve roots are involved, there is pain in the lower abdomen groin area of the nerve root dominating area or the anterior medial thigh. In addition, some patients with low lumbar disc herniation may also have pain in the inguinal region or anterior medial thigh. There are 1/3 of the lumbar disc herniation, and one third of them have pain in the groin area or the anterior medial thigh. The incidence of intervertebral disc herniation in the lumbar 4 to 5 and lumbar 5 to 1 gaps is basically equal. This kind of pain is mostly related to pain.
9. The skin temperature of the affected limb is low: similar to the cold feeling of the limb, and also caused by the pain of the affected limb, causing sympathetic vasoconstriction reflexively. Or because of irritating the sympathetic nerve fibers of the paravertebral, causing sciatica and lowering the skin temperature of the calves and toes, especially the toes. This phenomenon of skin temperature reduction is more obvious in people with sacral nerve root compression than those with waist 5 nerve root compression. On the contrary, after the removal of the nucleus pulposus, the limbs have a fever.
10. Others: Depending on the location of the compressed nerve roots and the degree of compression, the extent of involvement of adjacent tissues, and other factors, some rare symptoms such as excessive sweating, swelling, appendix pain, and knee pain may occur. And many other symptoms.
Second, the signs of lumbar disc herniation
1, general signs: mainly refers to the lumbar and spinal signs, is a common manifestation of the disease, including:
Gait: In the acute phase or when the nerve root is stressed, the patient may have limp, one hand or the foot, and the weight of the foot and the jumping gait. Lightweights can be no different from ordinary people.
Lumbar curvature changes: General cases showed that the lumbar vertebral physiology curve disappeared, flat waist or lordosis decreased. In a few cases, there are even kyphosis (multiple patients with lumbar spinal stenosis).
Scoliosis: generally have this sign. The relationship between the prominent part of the nucleus pulposus and the nerve root is different from that of the spine to the healthy side or to the affected side. For example, the prominent part of the nucleus pulposus is located inside the spinal nerve root. Because the curvature of the spine is bent to the affected side, the tension of the spinal nerve root can be reduced, so the lumbar vertebra bends to the affected side; conversely, if the protrusion is located outside the spinal nerve root, the lumbar vertebrae bends toward the healthy side. In fact, this is only a general rule, and there are many factors, including the length of the spinal nerve, the degree of traumatic inflammatory reaction in the spinal canal, the distance of the protrusion from the spinal nerve root, and various other reasons can change the direction of the scoliosis.
Tenderness and pain: The site of tenderness and pain is basically consistent with the vertebral section of the lesion, and is positive in about 80% to 90% of cases. The pain of the spine is obvious at the spinous process, which is caused by the shocking lesion. The tender point is mainly located at the paravertebral equivalent of the iliac spine. Some cases are accompanied by radiation pain in the lower extremities, mainly due to the stimulation of the dorsal branches of the spinal nerve roots. In addition, slamming the bilateral heels can also cause conductive pain. When combined with lumbar spinal stenosis, there may be significant tenderness in the interphalangeal space.
The range of waist activity: depending on whether it is the acute phase, the length of the disease, etc., the extent of the limitation of the waist activity range is also large. The light can be close to normal people, and the lumbar activity can be completely restricted during the acute attack period, and even refuse to test the waist activity. The general cases are mainly lumbar spine flexion, rotation and lateral movement limitation; combined with lumbar spinal stenosis, extension is also affected.
Lower extremity muscle strength and muscle atrophy: depending on the damaged nerve roots, the muscles they control may have weakened muscles and muscle atrophy. Clinically, this group of patients should routinely measure the circumference of the thigh and calf and the muscle strength test of each group, and compare and record with the healthy side, and then compare it after treatment.
Sensory disorder: The mechanism is consistent with the former, and the innervation zone feels abnormal depending on the location of the affected spinal nerve root. The positive rate is over 80%, and the latter type is 95%. Early manifestations of skin allergies, numbness, tingling and feeling fading. It is rare to feel completely disappeared. Because the affected nerve roots are more unilateral and unilateral, the range of sensory disturbances is smaller. However, if the cauda equina is involved (central type and central side type), the range of sensory disturbances is wider.
Reflex changes: also one of the typical signs of the disease. When the lumbar 4 spinal nerve is involved, knee reflex disorder may occur, and the early manifestation is active, and then rapidly becomes a reflex decline, which is more common in the clinic. When the lumbar 5 spinal nerve is damaged, it has no effect on the reflex. When the first iliac nerve is involved, the Achilles tendon reflex disorder. The change in reflex has a greater significance for the location of the affected nerve.
2, special signs: refers to the signs obtained through various special inspections. The main clinical significance is:
The neck test (Lindner sign): also known as the Lindner sign. When the patient is standing, lying on his back or sitting, the examiner places his hand on the top of his head and bends it forward. If there is radiation pain in the affected lower limb, it is positive, and vice versa. The positive rate of spinal canal type is over 95%. The mechanism is mainly due to the fact that the dura mater is displaced upwards at the same time as the neck is bent, so that the spinal nerve roots in contact with the protrusions are pulled. This test is simple, convenient and reliable, especially suitable for outpatient and emergency departments.
Straight leg raising test: The patient is supine, so that the knee is lifted up in the straight state, and the angle of passive elevation is measured and compared with the healthy side. This is called the straight leg raising test. This test has been recognized by everyone since Forst first proposed in 1881. The greater the effect of the test on the lower nerve root, the higher the positive detection rate (the smaller the lifting angle). In addition, the larger the protrusion, the more edema and adhesion of the root sleeve, the smaller the angle of lift.
Under normal circumstances, the lower extremity lifts up to 90°, and the older ones have a slightly lower angle. Therefore, the smaller the angle of lift, the greater the clinical significance, but it must be compared with the healthy side; the bilateral side, generally 60 ° is the normal and abnormal boundary line.
Limb elevation test (also known as Fajcrsztajn sign, Bechterew sign, Radzikowski sign): When the straight leg of the healthy side is raised, the nerve root sleeve of the healthy side can pull the dura mater to the distal end, thereby making the affected side The nerve roots also move down. When the affected disc protrudes at the ankle of the nerve root, the movement of the nerve root to the distal end is restricted, causing pain. If the prominent disc is at the shoulder, it is negative. During the examination, the patient was supine, and when the straight leg was raised, the sciatica was positive on the affected side.
Laseque sign: Some people have combined this with the former, and others have argued. The hip joint and the knee joint are placed under the condition of 90° flexion, and then the knee joint is extended to 180°. In the process, if the patient has radioactive pain behind the lower limb, it is positive. The mechanism of its occurrence is mainly due to the stimulation and pulling of the sensitive sciatic nerve when the knee is stretched.
Straight leg raising and strengthening test: also known as Bragard sign, that is, when the straight leg raising test reaches a positive angle (according to the patient's complaint of limb radiation pain), the affected limb is flexed to the dorsal side to aggravate the sciatic nerve. Pull. The positive person complained of increased radiation pain of the sciatic nerve. The purpose of this trial is primarily to exclude the effects of myogenic factors on the straight leg elevation test.
Supine and abdomen test: The patient takes the supine position and does the lifting of the hips, so that the hips and back are off the bed. At this time, if the main complaint is that the sciatic nerve has radioactive pain, it is positive.
Femoral nerve traction test: The patient was placed in a prone position and the knee joint of the affected limb was fully extended. The examiner lifts the straight lower limbs so that the hip joint is over-extended, and is positive when it reaches a certain degree of pain in the area of the femoral nerve in front of the thigh. This test is mainly used to examine patients with lumbar 2 to 3 and lumbar 3 to 4 disc herniation. However, in recent years, some cases have been used to detect 4 to 5 lumbar disc herniation, and the positive rate can be as high as 85% or more.
Other tests: such as nerve or sacral nerve compression test, lower limb rotation (internal rotation or external rotation) test, etc., mainly used for sciatica caused by other causes.
3, the classification of lumbar disc herniation (de-) out of the nucleus according to the location and direction of the nucleus, can be divided into the following two large.
(1) vertebral body type: refers to the nucleus pulposus of the degenerated nucleus nucleus passing through the lower (more common) or upper (rare) fibrous ring, and then through the cartilage plate vertically or obliquely into the middle of the vertebral body or the nucleus of the vertebral body protruding. In the past, this type was considered rare. In fact, if a comprehensive examination of patients with low back pain can be performed, the patient should not be less than 10%; the autopsy material indicates that the proportion of this type can be as high as 35%. This type can be further divided into:
1 front edge type: refers to the nucleus pulposus penetrating the edge of the vertebral body (the anterior superior edge of the vertebral body is more common), so that a triangular bone-like appearance appears on the edge (so clinically misdiagnosed as a vertebral body edge fracture occur). This type is more common in clinical practice. There are 32 cases of 102 gymnasts in Qumian domain (1982), accounting for 31.3%, which is higher than the average rate of 3% to 9%. It may be related to the training mode of this group of athletes. It is related to the amount of activity. The mechanism of the occurrence is mainly the extension of the lower back, the pressure in the intervertebral space is increased, and the nucleus pulposus is displaced forward and protrudes into the vertebral body.
Different forms appear depending on the course of disease after prolapse, and later can form part of the epiphysis of the vertebral body.
2 medium-sized: refers to the nucleus pulposus vertically or nearly vertically through the cartilage plate into the vertebral body and form Schmorl nodular changes. Because the clinical symptoms are mild or asymptomatic, it is not easy to diagnose. The autopsy is found to be between 15% and 38%.
The protrusions can be large or small, and the larger ones are easily found by X-ray or CT, magnetic resonance examination, and the small ones are often missed. Under normal circumstances, the denatured nucleus is not easy to pass through the small perforation in the cartilage plate, but it can cause this type of damage if it is acquired, the cartilage plate becomes thinner or happens to be worn at the vascular passage.
(2) Spinal canal type: or posterior type, refers to the nucleus pulposus protruding through the fiber ring in the direction of the spinal canal. The prolapsed nucleus pulposus stops in front of the posterior longitudinal ligament and is called "disc herniation"; when the posterior longitudinal ligament reaches the spinal canal, it is called "intervertebral disc prolapse."
According to the anatomical position of the sudden (de-) discharge, it can be divided into the following five types:
1 Central type: refers to the protrusion (de-) of the object located in the center of the front of the spinal canal, mainly caused by stimulation or compression of the cauda equina. In some cases, the nucleus pulposus can pass through the wall of the dural wall into the subarachnoid space. This type of clinical manifestations are mainly bilateral lower limbs and bladder and rectal symptoms. Its incidence is about 2% to 4%.
2 central side type: the fingertip (off) is located in the center, but slightly to one side. Clinically, the symptoms of cauda equina are mainly accompanied by root irritation. Its incidence is slightly higher than the former.
3 side type: refers to the protrusion in the middle of the front of the spinal nerve root, can be slightly offset. The main cause of root stimulation or compression is the most common clinical, accounting for about 80%. Therefore, when referring to the symptoms, diagnosis and treatment of this disease, most of them are described in this type.
4 lateral type: the protrusion is located on the outer side of the spinal nerve root, mostly in the form of "prolapse", so it is not only possible to oppress the same node (inside and below) spinal nerve root, the nucleus pulposus also has the opportunity to move up the anterior wall of the spinal canal and oppress the upper section. Spinal nerve roots. Therefore, if surgical exploration is performed, it should be checked. It is rare in clinical practice, accounting for about 2% to 5%.
5 outermost type: that the nucleus of the nucleus migrated to the anterior side of the spinal canal, even into the root canal or the side wall of the spinal canal. Once adhesions are formed, they are easily missed, and even during intraoperative examination, they may be ignored. Therefore, it is necessary to pay attention to the clinical situation. Fortunately, the incidence rate is only about 1%.
Examine
Lumbar disc herniation
First, laboratory inspection
1, cerebrospinal fluid examination: In addition to the central type caused by complete obstruction of the spinal canal, there may be increased protein content, Pan's test and Quick's test positive, usually normal.
2, other tests: such as erythrocyte sedimentation rate, Kanghua reaction, rheumatoid factor, gelatin gold test and other laboratory tests, mainly used for the differential diagnosis of other diseases.
Second, physical examination
Physical examination: Most patients with lumbar disc herniation can make a correct diagnosis based on clinical symptoms or signs. The main symptoms and signs are:
1, low back pain combined with "sciatica", radiation to the calf or foot, straight leg elevation test positive;
2, there are obvious tender points on the side of the lumbar 4-5 or the waist 51 interspinous ligament, and there is radiation pain to the calf or foot;
3, the anterior or posterior lateral skin of the lower leg feels diminished, the toe muscle strength decreases, and the affected side Achilles tendon reflex declines or disappears. X-ray films can rule out other bone lesions.
Third, imaging examination
In recent years, imaging techniques for the diagnosis of lumbar disc disease have progressed greatly, including X-ray film, discography, CT, ultrasound, magnetic resonance and myelography. Under normal circumstances, ordinary X-ray film can achieve the purpose of diagnosis, and those with difficulty need to use magnetic resonance (or reference ultrasound and CT, but the diagnosis rate is lower). It is not a last resort and it is not easy to use myelography.
1, lumbar X-ray film
(1) posterior anterior lumbar spine (positive position): more lumbar scoliosis, the width of the intervertebral space is unchanged in the early stage of the lesion; if the disease is longer, the intervertebral space is narrow, and there are various forms at the edge of the vertebral body. The bone spurs appear. Although the deviation of the spinous process is more common, it does not necessarily mean anything.
(2) Lumbar lateral radiograph: its diagnostic value is more important than the former.
1 In most cases, the lumbar physiology curve disappears, especially in acute cases.
The leading edge type in the vertebral body type can display a typical triangular bone fracture sign on the lateral position piece.
3 stenosis of the intervertebral space and spur formation at the edge of the vertebral body indicate a longer course
4 intervertebral disc calcification (rare) or prolapsed nucleus pulposus (slightly more common), mainly on the lateral radiograph.
(3) lumbar oblique film: mainly used to exclude lower lumbar vertebral arch fracture and lumbosacral (or sacral) joint lesions. However, there is no special observation in patients with simple disc herniation. Therefore, it is not necessary to take this film if the diagnosis is clear.
2, CT examination: the use of CT examination of the spine and spinal canal lesions has been widely carried out in the clinic, the CT image with relatively high resolution, can clearly show the location, size, morphology and nerve root, dura mater of the herniated disc The image of the capsule under pressure displacement can also show the thickening of the lamina and ligamentum flavum, the hypertrophy of the small joints, the narrowing of the spinal canal and the lateral recess, and the three-dimensional reconstruction of the three-dimensional structure of the spinal canal and the root canal. From the perspective of imaging, the main changes in the CT image are as follows:
(1) Deformation of the posterior margin of the intervertebral disc: Under normal circumstances, the posterior edge of the intervertebral disc is parallel to the edge of the vertebral bone section; in patients with prominent nucleus pulposus, the posterior margin of the intervertebral disc has a partial protrusion. According to the shape and nature of local changes, disc bulging, protrusion or prolapse (rupture) can be distinguished. The former is the early manifestation of degenerative changes, while the latter two are middle and late changes.
(2) Epidural fat disappears: Under normal circumstances, the lumbar region, especially the lumbar 4 to 5 and the lumbar 5 to 1 plane, the dural sac is usually rich in epidural fat, and the epidural translucent area And size is symmetrical. When the disc ruptures, the nucleus pulposus can replace the low-density epidural fat, and the density is asymmetric in the plane of the rupture of the disc.
(3) Increased soft tissue density in the epidural space: the density of protruding or nucleus pulposus is higher than that of dural sac and epidural fat, and the soft tissue density shadow in the epidural space represents prominent debris (size and position). . When the fragments are small and the posterior longitudinal ligaments are attached, the soft tissue shadows are continuous with the intervertebral discs. A separate image can appear when the debris has ruptured outside of the posterior longitudinal ligament and lost continuity with the disc and freed from rupture of the annulus. According to the location of the disc rupture, the soft tissue density may be located in the midline or posterior lateral edge. If the rupture occurs completely at the lateral margin, the soft tissue density is located in the intervertebral foramen. When the protruding fragments are large, the soft tissue density can also be displayed at a level other than the plane of the diseased disc. According to the free direction of the debris, it may be located in the posterior margin of the vertebral body below the intervertebral disc, or in the lateral recess of the pedicle; it may also be located in the vertebral foramen, much like an enlarged ganglion.
(4) Degeneration of the dural capsule: The density of the dura mater and its contents is lower than that of the intervertebral disc. In the upper lumbar region, the entire bony spinal canal is occupied by the meningeal sac. The boundary between the sac and the edge of the disc is clearly defined due to the difference in density. When the disc protrudes, the dural sac can also be deformed. In the lower lumbar region, the dural sac does not fill the entire vertebral canal and does not contact the posterior edge of the disc. It is only smooth when the disc protrudes quite large enough to block the epidural fat and compress the wall of the sac. The shape of the dural sac is deformed, and prominent fragments may compress the nerve roots; there are also a few cases that do not cause deformation of the spinal capsule.
(5) Pressure transposition of nerve root sheath: Under normal circumstances, the nerve root sheath shows soft tissue density under epidural fat contrast, which is located on the posterior side of the osseous spinal canal and the medial aspect of the pedicle, in the vertebra On the plane slightly below the arch, when the debris protrudes toward the posterior side of the bony spinal canal, the root sheath is moved backwards. The root sheath and the protruding fragments are often indistinguishable, which is itself a sign of nerve root compression.
(6) calcification of the nucleus pulposus: the nucleus pulposus (de-) time is longer, calcification can be gradually formed, and consistent changes appear in the CT examination. The debris and the edge of the intervertebral space can be delayed.
(7) CTM examination technique: The diagnostic accuracy of CT examination technique for disc herniation is 80% to 92%. Because CT scans have a small amount of X-ray exposure to patients, they can be classified as a basically harmless diagnostic tool. In addition, the use of water-soluble contrast agents for myelography combined with CT examination (CTM) can improve the accuracy of diagnosis. The above signs are more pronounced during CTM inspection. In most patients with disc herniation, the nerve root and dural sac compressed by the intervertebral disc are in the same plane. Free disc herniation can occur in other parts of the spinal canal.
3, magnetic resonance (MRI) examination: the emergence of MRI, can be said to be a significant advance in imaging, non-invasive and non-radioactive damage can not be compared with any previous inspection methods, its image shows the human tissue structure, More accurate and true than CT examination.
The signals represented on MRI images are roughly classified into three types: high, medium, and low. Generally, under T1 weighting conditions, cortical bone, ligament, cartilage endplate and annulus fibrosus have low signal intensity; bone tissue with adipose tissue and spinous processes have moderate signals (due to a large amount of bone marrow tissue) The intervertebral disc is between the first two. Adipose tissue is a high-intensity signal, followed by spinal cord and cerebrospinal fluid. T2 weighting is more pronounced for intervertebral disc tissue lesions, showing lower signals on T1-weighted images, and T2 weighting is enhanced. Because the T2-weighted cerebrospinal fluid signal is strong and bright, the display of the disc herniation against the dural sac is more clear.
MRI examination is of great significance in the diagnosis of disc herniation. Through the sagittal image of different levels and the transverse image of the intervertebral disc, the morphology of the disc herniation and its relationship with the surrounding tissues such as the dural sac and nerve root can be observed.
MRI examination can not only obtain 3D images for diagnosis (positive rate can reach more than 99%), but more importantly, this technology can be used to locate and distinguish "bulging", "protrusion" and "prolapse", thus facilitating treatment. Method and choice of surgical approach (The authors suggest that posterior enucleation should be performed for out of the box, while extended is preferred for anterior surgery).
4. Ultrasonic technology: Since Porter reported the research in this area twice in the 1970s, this research has also been carried out in China. The technique uses ultrasound to measure the diameter of the lumbar spinal canal, and the size of the canal diameter involves the development of root symptoms. However, there are certain limitations in application, and the trilobal spinal canal of the lumbar spine and lumbosacral region is still difficult to express. At present, MRI and CT technologies have been widely carried out, and few people have chosen this technology.
5. Myelography: Since the application of CT, magnetic resonance and digital subtraction techniques, the clinical application of myelography has been greatly reduced. Although it is helpful for the diagnosis, differential diagnosis and location of the disease, due to its side effects, it is currently recommended to use it carefully. Do not abuse it if it is necessary, and should be based on the choice of non-ionic iodine contrast agent.
The location of the nucleus pulposus (de-extraction) is different, and the imaging can show the lack of root sleeve (more side type), the filling of the root sleeve (in the outer type), and the dural sac compression (central type). Or the dural sac with the root sleeve pressed (central side) and other forms.
6. Intervertebral disc angiography: Because the puncture technique and the drug bring a great response to the patient, and the positive rate is affected by many factors, it is difficult to accurately reflect the objective condition of the lesion. Therefore, it is no longer popular with clinicians, so it is not Narration.
7, epidural angiography: the lumbar anterior and posterior lumbar posterior approach to the contrast agent to the epidural sac observation, inferred sagittal radial diameter, dural sac and root sleeve compression. Its image determination is similar to myelography and is rarely used.
8, other: such as vertebral venography, lumbosacral radiculography and fistula angiography, although each has its own characteristics, but it also has its limitations or due to operational difficulties and more in the exploration stage.
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