Paresthesia on the front inner leg
Introduction
Introduction Symptoms of the anterior medial leg are symptoms of lumbar disc herniation. Mainly the waist 4-5: the affected nerve is L5; the pain is the ankle, the thigh and the lateral side of the calf; the tender point is the side of the spine 4 to 5; the anterior and lateral medial area of the lower leg feels abnormal; Extensible, the muscles of the anterior lateral muscles of the calves were atrophied and the nerve reflexes were unchanged.
Cause
Cause
Causes of paresthesia on the medial side of the leg:
1. Degenerative changes of the lumbar 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 water loss; the degeneration of the annulus is mainly tough. The degree is reduced.
2. The role of external force: The slight damage caused by long-term repeated external force, exerting on the lumbar intervertebral disc over time, aggravating the degree of degeneration.
3. The weakness of the disc's own anatomical factors: 1 The intervertebral disc gradually lacks blood circulation after 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.
Examine
an examination
Related inspection
Trace element detection in human body blood routine position bone joint and soft tissue CT examination pain
Examination and diagnosis of paresthesia in the anterior medial leg
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.
Due to the classification of the disease, and the location of the nucleus pulposus in the spinal canal, the type of nucleus pulposus is different, resulting in a large difference in symptoms and signs, so there are more diseases to be identified. Based on clinical experience in the past 50 years, it is recommended that:
In the first step, it is first determined whether the pain characteristic exhibited by the patient is root pain. The pain in patients with lumbar disc herniation should be root pain, not dry or plexus pain.
The second step is to identify other similar diseases according to the nature, characteristics, location and influencing factors of the patient's root pain. In this way, the diagnosis will not be led astray. Of course, for individual types, you will be identified. Identification of root pain, dry pain and plexus pain: 1 positive neck test, may be intraspinal lesions. 2 spinous processes and tenderness and pain in the spine, more common in the spinal canal lesions. 3 is mainly caused by ring-point acupressure and not accompanied by lumbar and femoral nerve tenderness, mostly sciatic nerve exit stenosis. 4 women with a comfortable lower back in the lower abdomen, mostly gynecological diseases. 5 nerve outlets were tender, with pelvic lesions mostly.
The above items can be completed in just a few minutes, plus the sensory area test, the numb area of the foot and the knee and ankle reflex examination, etc., can generally end within 10 minutes, and provide a basis for the identification of the three, which can The letter rate is above 90%. It is supplemented by anal digital examination, gynecological consultation, X-ray film, various tests and treatment tests, etc., which is generally not difficult to identify. For those with obvious symptoms of lower back and accompanied by pyramidal tract sign, neck and neck syndrome should be considered.
Mastering the identification of the three is a basic requirement for each orthopedic surgeon and neurologist, and all need to be taken seriously. Otherwise, blindly relying on modern technologies such as high, precise, and sharp, will inevitably complicate the diagnosis, which is a precedent in clinical practice.
Diagnosis
Differential diagnosis
Differential diagnosis of paresthesia in the anterior medial leg:
The conditions that are clinically confusing with lumbar 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 causing 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) With). 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 adhesive arachnoiditis due to lumbar puncture, subarachnoid block and myelography, the disease has been rare in recent years, and its lesions are quite different, can cause various symptoms and easy to A variety of waist disorders are confused. If the adhesion is located at the spinal nerve root, it can cause symptoms similar to those of disc herniation. This disease can be secondary to disc herniation, especially in elderly patients with severe disease.
5. Lower lumbar instability is a frequently-occurring disease in the elderly, especially in 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 is also 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 diseases are 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, stimulating or oppressing 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. The general case of lumbar sprain 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 is the most common in middle-aged people. 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. Patients with lumbar facet joint disorders are mostly 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 vertebrae tuberculosis is the highest incidence of bone and joint tuberculosis, accounting for 47.28% of the 3587 cases of bone and joint tuberculosis in Tianjin People's Hospital, 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 include various congenital malformations, suppurative spondylitis, lumbar osteoporosis, skeletal fluorosis, facet joint arthritis, lumbar fat prolapse with nerve branch compression, and third lumbar vertebrae Malformations, interspinous ligament injuries, supraspinous ligament injuries, and lumbar symptoms of various systemic disorders should be identified.
In the identification should pay attention to the following characteristics of the disease:
(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.
