nerve root irritation symptoms
Introduction
Introduction Lumbar disc herniation can occur congestion, edema, degeneration, showing signs of nerve root irritation. Lumbar disc herniation is a diagnosis of Western medicine, and Chinese medicine does not have this disease name. Instead, the disease is attributed to the category of low back pain and low back pain. This disease is one of the more common lumbar diseases in the clinic, and it is a common and frequently-occurring disease in orthopedics. Mainly because the lumbar intervertebral disc parts (nucleus pulposus, annulus fibrosus and cartilage plate), especially the nucleus pulposus, have different degrees of degenerative changes, under the action of external factors, the annulus fibrosus ruptures, nucleus pulposus tissue rupture Prominent (or prolapsed) in the posterior or spinal canal, causing adjacent tissues, such as spinal nerve roots, spinal cord, etc. to be stimulated or oppressed, resulting in lumbar pain, numbness, pain and other clinical symptoms of one lower limb or both lower extremities .
Cause
Cause
(1) Causes of the disease
It is due to the degeneration and protrusion of the lumbar intervertebral disc, which stimulates the nerve root and sinus nerve to produce a series of clinical manifestations.
The cause of the disease can be as follows:
(1) Degenerative changes of the lumbar intervertebral disc: the degeneration of the nucleus pulposus is mainly caused by the decrease of water content, and the pathological changes such as inferiority and loosening caused by dehydration; the degeneration of the annulus is mainly manifested as The degree of toughness is reduced.
(2) The role of external force: The slight damage caused by long-term repeated external force exerts on the lumbar intervertebral disc over time, which increases the degree of degeneration.
(3) The weakness of the anatomical factors of the intervertebral disc: 1 The intervertebral disc gradually lacks blood circulation after the adult, and the repair ability is poor. 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.
(two) pathogenesis
1. The main cause: As we all know, the lumbar intervertebral disc bears strong compressive stress during the load 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, car and tractor drivers are in a sitting position and bumpy state for a long time, so that when driving a 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 easy 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: reports of familial morbidity of lumbar disc herniation, less in domestic materials; in addition, statistics show that the incidence of Indians, African blacks and Inuits is higher than that of other ethnic groups. It is obviously low, and the reason is for further study.
(4) congenital anomalies of the lumbosacral lumbosacral 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.
2. Inducing 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 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" action, etc. Increase the abdominal pressure and destroy the balance between the vertebrae and the spinal canal.
(2) Waist posture is not correct: Whether it is during sleep or in daily life or work, when the waist is in the flexion position, if it is suddenly rotated, 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 first, or load weight from small weight (such as weightlifting, support, etc.) to prevent lumbar sprain or disc herniation, but if the waist load is suddenly increased, it is not only possible Caused by a sprained waist, it is also easy to cause the nucleus pulposus to protrude.
(4) Pregnancy: The entire ligament system is in a relaxed state during pregnancy, and the posterior longitudinal ligament relaxation is prone to bulging the 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.
(5) Lumbar trauma causes the degenerated nucleus pulposus to protrude.
(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.
3. Patients with lumbar disc herniation:
(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 that of women, and 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: industrial workers with greater labor intensity are more common. 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 perspective of living and working environment: often in a cold or humid environment, it is a condition that induces lumbar disc herniation to a certain extent.
(7) From different periods of women: prenatal, postpartum and menopause is a dangerous period of lumbar disc herniation in women.
(8) Congenital lumbar dysplasia or deformity, even people with excessive mental stress are prone to low back pain. People who smoke may cause cerebrostatic pressure and increased pressure in the spinal canal, making it prone to degenerative Change related.
Examine
an examination
Related inspection
EMG
[clinical manifestations]
1. 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 described below.
(1) Low back pain: More than 95% of patients with lumbar disc herniation (de-) have this symptom, including those with vertebral body type.
1 mechanism: mainly due to the denatured nucleus into 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 causes stimulation of adjacent spinal nerve roots or sinus-vertebral nerves, etc., causing chemical and/or mechanical radiculitis.
2 performance: clinically, the continuous low back pain is more common, the supine position is relieved, the standing is intensified, can be tolerated under normal circumstances, and allows moderate waist activity and slow walking, mainly caused by 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) Radiation pain in lower extremities: 80% of cases have this disease, of which more than 95% can be post-type.
1 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.
2 performance: lighter manifests from the waist to the thigh and the back of the calf, the radioactive tingling or numbness, reaching the bottom of the foot; generally can be tolerated. 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, only 5% of the numbness and no pain. 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) cold sense of limbs: There are a few cases (about 5% to 10%) consciously chills and chills, mainly due to the stimulation of 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; There is a congenital development of the sagittal diameter of the spinal canal, the nucleus pulposus is more serious than the degree of stenosis of the spinal canal, so that it is easy to induce this symptom.
(6) Muscle paralysis: due to lumbar disc herniation (de-suppression), it is very rare, and many are caused by the damage of the roots 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 syndrome: mainly seen in the posterior central and central parafascicular nucleus (de-suppression), so it is rare in clinical practice. 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 high lumbar disc herniation, when the lumbar 2, 3, and 4 nerve roots are involved, there is pain in the lower abdomen groin area or anterior medial thigh in the nerve root dominating area. 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 spinal nerve root 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 radiation may occur. Pain and other symptoms.
2. Signs of lumbar disc herniation
(1) General signs: mainly refers to the lumbar and spinal signs, which are common features of the disease, including:
1 gait: When the acute phase or nerve root compression is obvious, the patient may have limp, one hand to support the waist or the foot is afraid of weight bearing and jumping gait. Lightweights can be no different from ordinary people.
2 lumbar curvature changes: the general cases showed that the lumbar vertebral physiological curve disappeared, flat waist or lordosis decreased. In a few cases, there are even kyphosis (multiple patients with lumbar spinal stenosis).
3 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. If the prominent part of the nucleus pulposus is located inside the spinal nerve root, the curvature of the spinal nerve root can be reduced due to the curvature of the spine to the affected side, so the lumbar vertebra bends to the affected side; conversely, if the protrusion is located outside the spinal nerve root, the lumbar spine is multi-directionally curved ( figure 1). 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.
4 tenderness and pain: the site of tenderness and pain is basically consistent with the diseased vertebrae, about 80% to 90% of cases are positive. 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.
5 waist activity range: depending on whether it is the acute phase, the length of the disease and other factors, 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.
6 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.
7 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.
8 reflection 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 examinations. The main clinical significance is:
1 flexion test (Lindner sign): also known as 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.
2 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.
3 healthy limb elevation test (also known as Fajcrsztajn sign, Bechterew sign, Radzikowski sign): When the right side of the limb 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.
4Laseque 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.
5 Straight leg raising 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. Pulling. 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.
6 supine and abdomen test: the patient takes the supine position, doing the action of lifting the hips, so that the hips and back leave the bed. At this time, if the main complaint is that the sciatic nerve has radioactive pain, it is positive.
7-strand nerve pull 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.
8 other tests: such as the sacral nerve or sacral nerve compression test, lower limb rotation (internal rotation or external rotation) test, etc., mainly used for sciatica caused by other causes.
The symptoms and signs of localized lumbar disc herniation with localized significance are listed in Table 1. Table 2 shows the clinical manifestations of central lumbar disc herniation.
3. Classification of lumbar disc herniation (dissociation): According to the location and direction of the nucleus nucleus, it 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-) material, 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. It mainly causes root irritation or compression symptoms; it is the most common in clinical practice, 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%.
diagnosis
For the diagnosis of typical cases, there is generally no difficulty, especially in the widespread use of CT and magnetic resonance technology today. However, for atypical cases, or vertebral body type, central type and other cases, it is easy to be misdiagnosed, and should be prevented.
1. Diagnosis of general cases
(1) Detailed medical history.
(2) A careful and comprehensive physical examination and should include a neurological examination.
(3) General symptoms of the waist.
(4) Special signs.
(5) Lumbar X-ray film and other filming.
(6) Magnetic resonance, CT, ultrasound and EMG examinations are used as appropriate.
(7) It is not a last resort, and it is generally inappropriate to use myelography; discography is difficult to lead the diagnosis, and it is not used in principle.
2. Diagnosis of special types of intervertebral disc herniation
(1) Central type: It is not uncommon in clinical practice, but it is easy to be confused with spinal cord tumor at the horsetail. In addition to the above, its diagnostic points are mainly based on the following characteristics:
1 has symptoms of cauda equina involvement: including the feeling of lower limbs, motor function and bladder and rectal dysfunction.
2 When standing and during the day, the symptoms are obvious, and the symptoms are relieved when lying in bed and at night (as opposed to spinal cord tumors).
3 lumbar puncture: It shows that the Queer test is mostly unobstructed or incomplete obstruction, and the cerebrospinal fluid test protein is more normal (and the tumor is more complete obstruction and protein content).
4MRI examination: generally require magnetic resonance or CT examination, all have positive findings.
(2) vertebral body type (leading edge type) lumbar disc herniation: confirmed according to the following characteristics:
1 clinical symptoms: similar to lumbar disc disease (disc source of low back pain), mainly with back pain, vertical compression has aggravating; generally no root symptoms.
The 2X-ray film shows a typical appearance: the leading edge type has a triangular bone on the lateral X-ray film and the Schmorl nodule-like change on the front side of the vertebral body.
3CT and magnetic resonance examination: It is helpful for the diagnosis of this type and should be checked routinely.
(3) High lumbar intervertebral disc herniation (dislocation): refers to the vertebral section above the waist 3, that is, the waist 1 to 2 and the waist 2 to 3, the incidence rate of which accounts for about 1% to 3% of all cases. The main basis for its diagnosis:
1 high lumbar spinal nerve root involvement symptoms: including quadriceps weakness, atrophy, pain in front of the thigh (to knee), numbness and knee reflex disorder, in all cases, this group of symptoms accounted for 60% to 80%.
2 Lumbar symptoms: more than 80% of cases have lumbar symptoms, and there are snoring pain and conduction pain at the spinous processes of the corresponding vertebral nodes. More than half of the cases have tenderness in the paravertebral.
3 paraplegia symptoms: rare, about 10% of cases can suddenly occur paraplegia symptoms. Because of its serious consequences, it must be taken seriously.
4 sciatic nerve symptoms: about 20% of cases occur, mainly due to the spinal nerves of the 3 to 4 lumbar vertebrae.
5 other: generally according to routine magnetic resonance or CT examination to confirm the diagnosis, and should pay attention to the identification of spinal cord tumors.
(4) lumbar intervertebral disc disease (disc source of low back pain): in recent years it is not uncommon, it occurs in patients with a wide sagittal diameter of the lumbar spine, its pathological features are severe degeneration of the vertebral node, with arthritis of injury Features, but few people who stimulate or oppress nerve roots. The main clinical manifestations are:
1 low back pain: also known as discogenic low back pain, generally without the symptoms of lower limb sciatic nerve, the mechanism is caused by the stimulation and compression of local sinus nerve after vertebral degeneration, pathological metabolites are also involved. The fragmented, posterior nucleus pulposus can exacerbate symptoms with lumbar activity, especially during excessive flexion and extension; vertical compression tests can exacerbate pain.
2 lumbar instability: on the dynamic lumbar X-ray film can clearly show the trapezoidal changes of the lumbar vertebrae, and clinical manifestations of limited lumbar activity, but few lower limb neurological symptoms.
3 imaging examination: mainly shows the characteristics of lumbar vertebrae injury arthritis, especially CT and MRI examination is more obvious. Early MRI-T2 weighted images showed a high-intensity zone (HIZ) in the annulus. However, the sagittal diameter of the spinal canal is mostly wide, and there is little root compression.
4 good vertebrae: the most common to see the lumbar 4 ~ 5 vertebrae, followed by the waist 5 ~ 1, waist 3 ~ 4 or more is rare.
(5) Others: refers to the clinically less common for multi-vertebral disc herniation, the most lateral protrusion and adolescent or advanced disc herniation. If you can pay attention to the examination, and routinely perform special examinations such as magnetic resonance, you can generally confirm the diagnosis.
3. Localization diagnosis Through the medical history and detailed physical examination, not only the diagnosis of lumbar intervertebral disc herniation can be made, but also the positioning diagnosis can be basically made. This is mainly based on the unique localization symptoms and signs produced by different nerve roots under the compression of the herniated intervertebral disc tissue. More than 95% of lumbar disc herniation occurs in the lumbar 4 to 5 or lumbar 5 to 1 intervertebral space, oppressing the lumbar 5 or 1 nerve root, mainly producing various symptoms of sciatica; another 1% to 2% lumbar intervertebral disc Prominence occurs in the 3 to 4 intervertebral space of the waist, oppressing the lumbar 4 nerve roots, and symptoms of femoral neuralgia may occur.
Diagnosis
Differential diagnosis
The conditions that are clinically confusing with the lumbar intervertebral disc herniation are identified as follows:
1. Developmental lumbar spinal stenosis: this disease can be associated with lumbar disc herniation (about 50%). Although the basic symptoms of this disease are similar to the latter, its main features are three major clinical symptoms:
(1) Intermittent claudication: that is, due to walking caused by the corresponding vertebral ischemic radiculitis in the spinal canal, resulting in obvious symptoms of lower extremity lameness, pain and numbness, a little rest can rest again after rest; then relapse You need to rest again before you can continue walking. Such recurrent episodes, and intermittent periods, it is called "intermittent claudication", which can occur simultaneously in the case of lumbar disc herniation combined with this disease. Although simple lumbar disc herniation can sometimes occur similarly, it only slightly relieves after rest, and it is difficult to completely disappear.
(2) Subjective and objective contradiction: It means that there are many complaints in this type of patients, and in the physical examination, the symptoms of ischemic nerve root inflammation disappeared due to the rest during the pre-examination waiting for the examination, so that no positive findings were found. This is significantly different from the persistent root symptoms and signs that occur when the lumbar disc is protruding.
(3) Restriction of the back of the lumbar, but can be flexed: because the effective gap between the lumbar spine is further reduced due to the extension of the lumbar spine, the symptoms are aggravated and pain is caused. Therefore, the patient has limited lumbar extension and prefers to take A anterior flexion that increases the internal volume of the spinal canal. For this reason, patients can ride bicycles but are difficult to walk. This is significantly different from those with lumbar disc herniation.
The above points are generally sufficient for identification. For individual atypical or concomitant persons, other auxiliary examination methods, including magnetic resonance and CT examination, may be used for determination.
2. Sciatic nerve pelvic outlet stenosis: This is a common disease that causes sciatic nerve dry pain, and it is more common in patients with low back pain and heavy manipulation. Therefore, it is easy to be confused with lumbar disc herniation. It needs to be identified (but sometimes both Can be accompanied). The main features of this disease are:
(1) tender point: located in the part of the sciatic nerve from the pelvic cavity, that is, the "ring jump" point, and radiated down the sciatic nerve to the bottom of the foot. Sometimes "?" and "" are accompanied by tenderness.
(2) Lower extremity internal rotation test: When the lower extremities are rotated internally, the muscles at the exit of the sciatic nerve can be in a state of tension, so that the stenosis at the exit is intensified and the sciatic nerve is radiated. This phenomenon does not occur in lumbar disc herniation.
(3) Sensory disorder: This disease manifests as a wide range of multiple sensory sensations, and often affects the numbness of the soles. In the case of lumbar disc herniation, a single sensory disturbance is predominant.
(4) Others: The neck test was negative in this disease, and there were no positive signs in the waist. Other special tests are feasible for individuals with different identification difficulties. Piriformis syndrome caused by lesions of the piriformis itself is rare, and the symptoms are similar to the disease, not to mention.
3. The horsetail tumor is a disease that is easily confused with the central type of lumbar disc herniation, and the consequences are serious, so we should pay attention to the identification. The common symptoms of the two are: multiple root or cauda equina damage, lower limbs and bladder, rectal symptoms, severe pain in the lower back and movement disorders. However, the following characteristics of the horsetail tumor can be distinguished from lumbar disc herniation.
(1) low back pain: persistent severe pain, especially at night, even without strong analgesics can not make patients sleep; while lumbar disc herniation, the back pain is relieved after rest, and more obvious at night.
(2) The course of the disease: it is mostly progressive, although it cannot be alleviated or stopped by various treatments.
(3) Lumbar puncture: more indicates that the subarachnoid space is completely obstructed, the protein content in cerebrospinal fluid is increased, and the Pan's test is positive.
(4) Others: If necessary, it is feasible to confirm the diagnosis and determine the location of the lesion by magnetic resonance or CTM; for those with surgical indications, it is feasible to detect the spinal canal.
4. Lumbar segment secondary adhesion arachnoiditis: due to the wide application of lumbar puncture, subarachnoid block and myelography, this disease has been rare in recent years, and its lesions are quite different, can cause various symptoms and easy Confused with a variety of waist disorders. If the adhesion is located at the spinal nerve root, it can cause symptoms similar to those of disc herniation. The following characteristics of the disease should be noted in the identification:
(1) Medical history: There are many medical history such as lumbar puncture.
(2) Pain: It is mostly persistent and gradually intensified.
(3) Signs: The neck test is mostly negative, and the straight leg raising test can be positive, but the lifting range is limited.
(4) X-ray film: those with a history of lipiodol imaging can find candle-shadow or cystic shadow on the X-ray film.
This disease can be secondary to disc herniation, especially in the elderly with the disease, should pay attention.
5. Lower lumbar instability: more common in the elderly, especially women. The characteristics of this disease are as follows:
(1) Root symptoms: Although often accompanied, but most of the root stimulation symptoms. Appeared when standing and walking, relieved or disappeared after lying or resting, and no positive signs were found during physical examination.
(2) Body type: multiple types of obesity and thin body type.
(3) X-ray plain film: dynamic plain film can show vertebral instability and slippage sign (this disease is also called "pseudo-spine spondylolisthesis").
(4) Others: The neck test and the straight leg raising test are mostly negative.
6. Lumbar hyperplasia (hypertrophic) spondylitis: one of the common diseases to be identified. The disease is characterized by:
(1) Age: Patients are more than 55 years old, and lumbar disc herniation is more common in young and middle-aged patients.
(2) Low back pain: Appears in the morning, disappears or alleviates after the activity, and reappears after exertion.
(3) Lumbar activity: It is stiff, but it can still be arbitrarily active without severe pain.
(4) X-ray film: shows typical degeneration changes.
The disease is not difficult to identify, generally do not need special inspection.
7. General pelvic disorders: common diseases of women in middle-aged and above, including attachment inflammation, ovarian cysts, uterine fibroids, etc., resulting in increased pressure in the pelvic cavity, stimulation or compression of the pelvic plexus and multiple dry symptoms. Its characteristics are as follows:
(1) Gender: More than 90% of cases are seen in women after middle age.
(2) Symptoms: multiple nerve trunk involvement symptoms, especially sciatic nerve trunk, femoral nerve trunk and femoral cutaneous nerve trunk are more common, pudendal nerve and obturator nerve can also be involved.
(3) pelvic examination: For female patients, an obstetrics and gynaecology department should be consulted to determine whether there is a gynecological disease.
(4) X-ray film: patients with easy to accompany tibia compact osteitis and other diseases, should be observed.
8. Although pelvic tumors belong to abdominal surgery diseases, orthopedics can often be encountered, especially when compressing the sciatic nerve, it is easy to be confused with this disease. Its characteristics are similar to the former.
(1) Symptoms: mainly dry symptoms of the nerves.
(2) Signs: In the pelvic cavity (anal examination, etc.) can touch the mass.
(3) Others: After cleaning the enema, take a film or a barium enema to determine the location of the mass. If necessary, perform B-mode ultrasound, CT or MRI.
9. Waist sprain: the general case is easy to identify, and it is easy to be confused with reflex sciatica. The main points of identification are:
(1) History of trauma: more specific. However, lumbar disc herniation may also be seen after a sprain in the waist.
(2) tenderness: mostly located at the point of attachment of the lumbar muscles, and more fixed, with limited mobility.
(3) Closure test: After the muscle sprain is closed, not only the local pain is relieved, but also the radiation pain of the lower extremities disappears.
(4) Others: The neck test and the straight leg raising test are mostly negative.
10. Lumbar muscle fasciitis: middle-aged people have the most incidence. It is caused by excessive use of muscles or by sweating and cold after intense activity. Symptoms may also occur after infection with direct cold or upper respiratory tract. The patient mainly feels back pain, and the common site is the muscle group attached to the iliac crest or the posterior superior iliac spine, such as the iliac spine and the gluteal muscle. Other parts of the muscles, myofascial fascia, diaphragm, etc. can also be affected. When the lumbosacral fibrosis occurs, the sinus nerve is stimulated, causing local pain and pain in the lower limbs. Pain is often aggravated by cold and long periods of inactivity, and can be related to weather changes and posture. Exercise helps to alleviate symptoms. Spinal activity is limited by the muscle pain involved. The duration of this low back pain varies from a few days to a few days. The elderly can be several years old and often recurrent after the first onset.
Side bends and limited movement due to muscle-protective tendons during examination. In most patients, it is possible to have a painful nodule or a sense of sling, which is clearer in the prone position. Painful nodules in the lower back are often found in the third lumbar vertebrae, the ankle, and the posterior superior iliac spine. Compression of painful nodules, especially painful nodules in the muscles, can cause local pain and radiate to other parts, such as causing pain in the lower limbs. Pain disappeared with partial closure with 2% procaine. The main manifestations of the reduction of fibrositis are:
(1) Pain that is limited and diffuse with unclear borders.
(2) Localized soft tissue tenderness points.
(3) In soft tissue spasms and nodules or sensations.
11. Lumbar facet joint disorder: Most of the patients are middle-aged, especially women. There was no history of obvious trauma. Most of the sudden onset of illness during normal activities, patients often complained of preparing to bend over to take things or turn to take things, suddenly the waist is very painful, afraid to move. This kind of pain can occur frequently after the first episode, and can occur several times in one year or one month. There are many cases of chronic strain of lumbar strain or history of trauma. Ballet dancers, Peking Opera actors and other regular waist exercises often suffer from lumbar facet joint disorders. Intermittent episodes of some patients can last for many years, and the main complaint is repeated "lumbar dislocation".
During the examination, the spine was bent to the side of the pain side, and the lumbar sacral spine muscle showed painful protective tendon. There are tender points on the waist 4, waist 5 or waist 3, waist 4 spine. If the ankle joint has tenderness, it is a lumbar facet joint disorder caused by asymmetry of the lumbosacral joint. In patients with recurrent episodes, the lumbar spine is unrestricted, and the pain is aggravated when stretching or bending. Straight leg raising test can feel lumbar pain without sciatic nerve radiation pain, this test is negative.
X-ray lumbar spine showed lumbar scoliosis, as well as lumbar or intervertebral disc degeneration, but can not find signs of posterior joint subluxation, posterior joint space widening and other signs. CT examination can show changes in facet joint hyperplasia, osteophyte formation, sclerosis, calcification around the joint capsule and subluxation.
12. Lumbar tuberculosis: The spine is the highest incidence of bone and joint tuberculosis. In the 3587 cases of bone and joint tuberculosis, the Tianjin People's Hospital accounted for 47.28%, half of which occurred in the lumbar spine. Therefore, low back pain is one of the common symptoms; low lumbar tuberculosis can also produce leg pain.
Lumbar tuberculosis patients often have symptoms of systemic tuberculosis, accompanied by longer-term lumbar pain, mostly persistent pain. Lower extremity pain is different due to the location of the lesion. Tuberculosis at the waist 5 and iliac crest can cause pain in the dorsal area of the lumbar 5 and iliac 1 nerves, which is manifested as pain on one side or both sides.
Check the waist for protective rigidity, all activities are limited, and the activity is heavy. Later, the vertebral wedge is compressed, and then kyphosis can occur. A cold abscess can be seen in the concave or lumbar triangle. There are regional sensations, movement disorders, changes in tendon reflexes, muscle atrophy, and only a small number of nerve roots. The test showed that the blood cell sedimentation rate increased. X-ray plain film shows: the adjacent edge of the vertebral body is destroyed, the intervertebral space is narrowed, and the lumbar muscles are widened or the edges are unclear. For patients with difficult identification, MRI should be performed and all cases can be confirmed.
13. Lumbar spondylolisthesis and lumbar spondylolisthesis In addition to congenital cases, lumbar spondylolisthesis due to trauma or degenerative changes will increase with age, more men than women. The site of the disease is most common with lumbar 4 to 5, followed by waist 5 to 1. The disease mainly manifests as low back pain, hip pain or lower limb pain. 50% of patients with lower extremity sciatica and 20% with intermittent limping. However, during the examination, there was no obvious deformity in the lumbar pain, and the lumbar spine flexion was normal and the extension was limited. According to X-ray film and MRI examination is easy to diagnose.
14. Other diseases: including various congenital malformations, suppurative spondylitis, lumbar osteoporosis, skeletal fluorosis, articular arthritis of the joints, lumbar fat prolapse with nerve branch compression, and third lumbar vertebrae Long deformity, interspinous ligament injury, supraspinous ligament injury, and lumbar symptoms of various systemic diseases should be identified.
