Low back pain with sensory or radiating pain in the lower extremities
Introduction
Introduction Chronic low back pain is mainly caused by pain in the back, lumbosacral and ankle, and there is simple low back pain and low back pain associated with lower limb induction pain or radiation pain.
Cause
Cause
(1) Causes of the disease
1. Common causes
(1) Spine low back pain:
1 traumatic low back pain: such as vertebral fractures, muscle sprains, vertebral spondylolisthesis.
2 congenital malformation low back pain: such as semi-vertebral body, lumbar vertebrae, lumbar vertebrae, spina and so on.
3 inflammatory low back pain: such as ankylosing spondylitis, tuberculous spondylitis, suppurative spondylitis, focal ankle arthritis.
4 degenerative low back pain: such as proliferative spondylitis, disc herniation, spinal stenosis, lumbar posterior joint disorders.
5 nutritional metabolic low back pain: such as osteomalacia, skeletal fluorosis and so on.
6 poor posture low back pain.
7 atrophic low back pain.
8 endocrine abnormal low back pain: such as osteoporosis, primary hyperparathyroidism and so on.
9 bone tumor low back pain.
10 reasons for unclear low back pain.
11 other low back pain in spinal diseases: such as deformity osteitis, young vertebrae osteochondritis (young hunchback).
(2) Low back pain caused by paravertebral soft tissue disease:
1 lumbar muscle strain.
2 low back muscle myofasciitis (fibromyositis).
3 third lumbar vertebrae transverse process syndrome.
(3) Low back pain caused by stimulation of spinal cord and spinal nerve roots:
1 spinal cord compression: such as epidural abscess, intraspinal tumor, spinal arachnoiditis.
2 acute myelitis.
3 subarachnoid hemorrhage.
4 lumbosacral radiculitis.
5 herpes zoster.
(4) Low back pain caused by visceral diseases:
1 low back pain caused by digestive diseases: such as peptic ulcer, pancreatic cancer, liver cancer, rectal cancer, cholecystitis, posterior appendicitis.
2 low back pain caused by urinary and reproductive system: such as pyelonephritis, kidney stones, renal tuberculosis, peri-renal abscess, hydronephrosis, kidney cancer, prostatitis, prostate cancer, cervical cancer, uterine posterior tilt, chronic attachment inflammation, Dysmenorrhea and so on.
3 low back pain caused by respiratory diseases: such as pleurisy, pleural thickening or adhesions, tuberculosis, lung cancer and so on.
4 low back pain caused by cardiovascular diseases: such as aortic aneurysm, angina and so on.
5 low back pain caused by retroperitoneal diseases: such as retroperitoneal abscess, retroperitoneal fibroma or fibrosarcoma, as well as the aforementioned kidney disease and pancreatic disease.
(5) Low back pain caused by mental factors:
1 snoring.
2 chronic fatigue syndrome.
3 depression.
4 compensatory neurosis.
2. The relationship between low back pain and occupational factors
(1) The occurrence of low back pain: Buckle et al found that 43% of patients with low back pain developed symptoms at work and 28% of patients developed symptoms at home. Daniel et al. found that about half of the patients (51%) developed symptoms at work by analyzing 100 patients. Not all low back pain has predisposing factors.
(2) Relationship with heavy physical work: Many epidemiological survey data indicate that the incidence of low back pain in heavy industry, construction industry, miners and forestry workers is high, which may be related to the large load of the spine and the damage.
(3) Relationship with bending and twisting: Previous investigations have confirmed that the incidence of low back pain is high in the work of carrying heavy loads and repeated bending and twisting. The authors report that the incidence rate can be 15% to 64%. Usually a medium-weight object does not cause damage to the lower back, but it is prone to low back pain when lifting heavy objects frequently. It is generally believed that when the weight is bent to extract the weight, the trunk flexes to make the intervertebral disc narrow and wide. When the weight is lifted, the spine load presses the intervertebral disc, and the nucleus pulpus moves backward to reach the posterior part of the annulus fibrosus and the deep ligament of the posterior longitudinal ligament. The trunk is straight and the nucleus pulposus is restricted to the posterior part by the pressure of the upper and lower cartilage plates. Repeated injury or acute injury can cause the nucleus pulposus to protrude. Especially in the posterior extension position, the weight-bearing movement in all directions of the spine can cause different degrees of damage to the posterior intervertebral joints and joint capsules of the spine, interspinous, supraspinous ligaments and paravertebral muscles, and become low back pain. the reason.
(4) Restricted working position and vibration: In recent years, the relationship between restrictive working position and low back pain has been paid more and more attention. Long-term sitting work is considered to be a high risk factor for low back pain. Experimental studies have shown that shocking work (including pneumatic tools) is prone to low back pain, and the harmful vibration frequency is 3.5-8.9 Hz, which is the most likely to cause damage and can have adverse effects on the musculoskeletal system, cardiovascular system and gastrointestinal tract. The slight stress generated by the vibration accelerates the degeneration of the lumbar disc tissue. The intervertebral disc itself has no blood vessels to supply nutrients, and its nucleus pulposus is supplied by the permeation of the cartilage endplate. The slight stress caused by the vibration can affect the intervertebral disc from two aspects. On the one hand, the long-term pressure causes the cartilage endplate and the endplate bone to be slightly fractured due to fatigue. The repair process reduces the osmotic capacity and affects the nucleus pulposus and the annulus fibrosus. Repair; on the other hand, the tiny shear, bending and torsion forces make the fiber ring fatigue and accelerate degeneration. Thereby, the nucleus pulposus is easy to protrude and compress the nerve to produce low back pain.
(5) Other occupational factors: Bergqnist-Ullmann and Larssonu found that people with monotonous repetitive work in the factory assembly line had a high prevalence of low back pain. Another survey found that monotonous work, less leisure activities, is directly related to low back pain. In fact, monotonous and repetitive work has an impact on both physical strength and psychology. The prevalence of low back pain is also higher in people who stand, walk, and change positions frequently. It has also been reported that the workplace is uneven or slippery, often suffering from a sprained waist.
(two) pathogenesis
The relationship between individual factors and low back pain Many authors understand the relationship between low back pain from individual factors such as age, gender, physical and psychosocial and X-ray findings.
(1) Age and gender: Low back pain occurs mostly in young adults. The majority of the onset age is 30 to 40 years old. It is also reported in the literature from 35 to 55 years old. The duration of symptoms is proportional to the increase in age. Gender is less important for low back pain.
(2) Body posture: Clinically, the scoliosis, hunchback, lumbar lordosis and the length of the lower limbs are often listed as the cause, but there is still insufficient epidemiological data to confirm. Some investigations have pointed out that the Cobb angle of scoliosis is greater than 80° or the scoliosis is located in the lumbar region, which is prone to low back pain.
(3) Muscle factors: The weakness of the back and abdominal muscles is closely related to the occurrence of low back pain. Spinal stability is determined by internal and external factors, endogenous stability is provided by ligaments and intervertebral discs, and exogenous stability is provided by the back and abdominal muscles. In the past, the abdominal muscles were not given enough attention. It is now believed that the abdominal muscles not only control and regulate the spinal movement.
(4) Lumbar motion: Most patients with low back pain have significantly reduced lumbar motion. There is currently insufficient literature to explain the relationship between lumbar motion and low back pain.
(5) History of low back pain: People who have suffered from low back pain in the past have a higher possibility of lower back pain.
(6) Disease factors: Gyntellberg reported that people with chronic bronchitis and atherosclerotic angina and often have headaches have a high incidence of low back pain. Frymoger reports that people with chronic cough have a high incidence of low back pain. Because of cough, it can increase lumbar disc pressure.
(7) Social psychological factors: Foreign epidemiological investigations not only involve occupational factors, but also investigate their social psychological factors. Many surveys report that people who smoke, drug, and alcohol abuse have more patients with low back pain. People with anxiety, nervousness, dissatisfaction with work, depression, separation and divorce also have a high prevalence of low back pain.
Examine
an examination
Related inspection
Neurological examination, supine and abdominal test, parathyroid hormone, parathyroid hormone (PTH), bone and joint, soft tissue, CT examination
Low back pain is mainly caused by pain in the back, lumbosacral and ankle, and there is simple low back pain and low back pain associated with lower limb induction pain or radiation pain. The nature of pain is mostly dull pain, dull pain, tingling, local tenderness or radiation pain, unfavorable activities, inconvenient pitching, inability to hold weight, difficulty walking, fatigue and limb fatigue, and even the functions of lumbar flexion, extension, and lateral bending. Obstacles, severe cases of spinal deformity, manifested as: " . Because the cause of low back pain is more complicated, there are more diseases that cause low back pain in the clinic. Each disease has its own specific history, signs and clinical manifestations. Therefore, the clinical manifestations of low back pain caused by each disease are not repeated here.
Diagnostic points: Low back pain is caused by a variety of diseases, and a clear diagnosis is especially important. In clinical practice, it is necessary to clarify the diagnosis ideas. Starting from three aspects: medical history, physical examination and auxiliary examination. The following focuses on the diagnosis of medical history and physical examination.
1. History: First of all, to understand the gender, age and occupation of patients, women should consider whether there is pelvic disease, men pay attention to prostatitis, elderly and postmenopausal women have osteoporosis, young and middle-aged are more common in strain, lumbar disc herniation disease. The occupational and working environment is closely related to the lower back. Long-term sitting or bending workers can easily cause strain and degeneration. Cold storage and water operators are prone to rheumatism. Long-term exposure to poisons is prone to chronic poisoning and bone metabolism disorders. Chronic onset, gradually worsening is more common in strained and degenerative tumors; sprains and traumas are onset. It is worth noting that cold and weather changes are not specific causes of rheumatism. Many causes of low back pain and increased pain may be related to weather changes and cold. Aggravation of pain after exertion is associated with chronic strain.
Pain worsening after walking is more common in spinal stenosis, spondylolisthesis and lumbar degenerative osteoarthritis. The pain caused by degeneration and chronic strain is mostly sore. The pain is aggravated after the break or when the activity starts in the morning. It can be relieved after a little activity, but it is aggravated again after a long time. Lumbar spinal stenosis and disc herniation are more serious than walking, but there is nothing to do with cycling, pain in the back or uphill, and aggravation when lifting or downhill. Tuberculosis and tumor pain often worsen at night. After the spinal nerve is compressed and stimulated, the intraspinal pressure caused by cough often causes radiation pain along the nerve. The location of the pain is very important. The simple back pain is caused by the muscles of the lower back, ligaments, facet joints, and vertebral lesions. Low back pain accompanied by radiation pain along the nerve is considered to be caused by embedding nerve stimulation, and rheumatism may be accompanied by migratory pain of other joints. Early ankylosing spondylitis is pain in the ankle or hip joint. Patients should be carefully asked if they have a history of cancer in other areas. Whether the pain is caused by tumor metastasis, whether osteoporosis has a history of diabetes or kidney disease, and whether there is a history of endocrine disorders. Whether the pain is accompanied by fever or other symptoms such as angina causes low back pain, such as palpitation, chest tightness, airlock and other symptoms, urinary stones are often accompanied by abdominal pain and tossing and turning in the bed, kidney tumors are accompanied by hematuria.
2. Physical examination: the examination should start from the gait at the time of the patient's visit. The gait-like person's legs are stiff and the gait is unstable. It is drunk-like. It is more common in spinal cord lesions such as cervical spondylotic myelopathy and spinal cord tumors. Cautious gait, waist stiffness or forced to lean to one side, with hands on the waist, gait cautious, more common in lumbar disc herniation, acute lumbar sprain or acute lumbar muscle fibrosis. Duck steps swing around when walking, more common in hip disease. The patient should be removed from the top to see if there is a physiological curvature of the back and back, with or without side bends, hunchbacks, and angular deformities. There are no masses, sinus, scars, pigmentation. The patient's spine is flexed, stretched, flexed left and right, and rotated left and right to observe the function of the back. Patients with lumbar back organic lesions often have limited function, while reflex pain caused by visceral diseases is normal. Determining the tenderness of the lower back is the most direct way to find the lesion. The tenderness can be divided into superficial tenderness and deep tenderness. The inflammatory lesions of the supraspinous ligament, interspinous ligament, and sacral spine are tendered with the thumb in the corresponding part. If the lower lumbar spine is tender, the radioactive pain along the nerve is mostly Caused by lumbar disc herniation. Spinal bones and intraspinal lesions often have sputum pain, and those who oppress the nerve often cause radiation pain. If the tender point is not changed repeatedly, it is a fixed tender point, which often means that there is an organic lesion in the part. Conversely, there is often no fixed tenderness in the reflexed lower back caused by visceral lesions. Then let the patient supine, if the lumbar lordosis is straight or the hip flexes and contracture, the leg can not be flat in the straight position. Check whether the abdomen is symmetrical, palpate with or without hepatosplenomegaly, with or without a lump and hip socket abscess. Female patients should pay attention to whether there is deep abdominal tenderness.
3. Several special tests commonly used to check low back pain
(1) Straight leg raising test and strengthening test: The patient is supine, the legs are straight, the examiner lifts the hand with one hand, and gently presses the knee at the same time to keep the leg straight, causing the radiation pain of the lower extremity to be positive. The back of the foot is stretched, and if the pain is aggravated, the test is positive to identify the pain caused by the tension of the rope muscle. It is worth noting that the test can also produce ankle joint torsion. If the ankle joint lesion can also produce ankle pain, rather than the lower extremity radiation pain, it should be noted.
(2) supine and abdomen test: the patient's occipital part and the two feet are the force points to push the abdomen and buttocks up, causing the waist and leg pain to be positive. If it is negative, the patient can be abdomen and breathe deeply to blush after deep inhalation. At the same time, coughing hard and causing radioactive pain in the affected limb is positive. Shi can be the first to use this method to check patients with lumbar disc herniation. (3) flexion neck test: the patient is supine, the limbs are straight and flat, and the neck is slowly raised, and the radiation of the lower limbs is positive.
(4) oblique shift test: the patient's limbs are straight and supine, the examiner supports the affected side of the knee, so that the hip flexes and bends the knee and receives the hip joint, and the other hand holds the shoulder to fix the upper body, so that the longitudinal axis of the pelvis can be generated. Rotational pressure can cause pain if the ankle has a lesion.
(5) 4 test patient supine: knee flexion puts the ankle and ankle on the contralateral knee, the examiner valgus the knee in one hand, the other side fixes the pelvis opposite, and the ankle pain indicates the ankle There are lesions in the department. If the hip joint is damaged, there is hip pain and the knees cannot be flattened.
In addition, there are a neck test, a Gaenslen test, a Yeomann test, a pelvic squeeze test, and the like. Patients with low back pain accompanied by pain or numbness of the lower extremities should also check the depth and depth of the lower extremities, exercise, reflexes, and muscle atrophy. When the back of the lower back itself fails to find out the cause, the relevant departments should be consulted according to the situation, such as urology, gynecology, abdominal surgery, internal medicine, etc. An anal examination of the sacral tumor is necessary. Should also pay attention to the examination of lower extremity lesions such as unequal length of lower limbs, flat feet, internal and external valgus, horseshoe foot, toe deformity, etc. affecting the back and back balance and stability caused by low back pain, foot lesions such as sputum, bone spur, synovitis, Toe pain and the like can cause the lower limbs to be dysfunctional and cause lumbar muscle strain.
Diagnosis
Differential diagnosis
The clinical diagnosis of the diagnosis of low back pain caused by each disease is a differential diagnosis.
1. Distinguish from the epiphysis. The epiphysis is mostly caused by the cold, dampness and deep invasion of the injured bones in the winter. The clinical joint pain is the limbs, the limbs are thin, the cold is cold, the activity is limited, the bones are heavy, and the waist and knees are sore. A type of rickets that are characterized by kidney yang deficiency, feeling cold, dampness and evil as a disease, easy to be confused with lumbosacral, but the disease is in the bone, mainly in the joints of the extremities, accompanied by symptoms of backache and soft The waist is different.
2. Identification of renal pelvis with the renal pelvis as a bone sputum, coupled with kidney qi deficiency and complex external evil, caused by the kidney, clinical manifestations of joint pain, limbs, the bones are heavy, the back is sore. If you dont bend it, youre struggling, and you can even see it. The disease is located in the kidney and in the bone, and has the same symptoms as the lumbosacral symptoms and the disease. But the renal pelvis is developed from the epiphysis. It is accompanied by the clinical symptoms of the epiphysis. The onset of the disease begins with the joints of the extremities. It is mainly different from the beginning of the lumbosacral spine. The medical history and initial symptoms are the main points of identification.
Low back pain is mainly caused by pain in the back, lumbosacral and ankle, and there is simple low back pain and low back pain associated with lower limb induction pain or radiation pain. The nature of pain is mostly dull pain, dull pain, tingling, local tenderness or radiation pain, unfavorable activities, inconvenient pitching, inability to hold weight, difficulty walking, fatigue and limb fatigue, and even the functions of lumbar flexion, extension, and lateral bending. Obstacles, severe cases of spinal deformity, manifested as: " . Because the cause of low back pain is more complicated, there are more diseases that cause low back pain in the clinic. Each disease has its own specific history, signs and clinical manifestations. Therefore, the clinical manifestations of low back pain caused by each disease are not repeated here.
Diagnostic points: Low back pain is caused by a variety of diseases, and a clear diagnosis is especially important. In clinical practice, it is necessary to clarify the diagnosis ideas. Starting from three aspects: medical history, physical examination and auxiliary examination. The following focuses on the diagnosis of medical history and physical examination.
1. History: First of all, to understand the gender, age and occupation of patients, women should consider whether there is pelvic disease, men pay attention to prostatitis, elderly and postmenopausal women have osteoporosis, young and middle-aged are more common in strain, lumbar disc herniation disease. The occupational and working environment is closely related to the lower back. Long-term sitting or bending workers can easily cause strain and degeneration. Cold storage and water operators are prone to rheumatism. Long-term exposure to poisons is prone to chronic poisoning and bone metabolism disorders. Chronic onset, gradually worsening is more common in strained and degenerative tumors; sprains and traumas are onset. It is worth noting that cold and weather changes are not specific causes of rheumatism. Many causes of low back pain and increased pain may be related to weather changes and cold. Aggravation of pain after exertion is associated with chronic strain.
Pain worsening after walking is more common in spinal stenosis, spondylolisthesis and lumbar degenerative osteoarthritis. The pain caused by degeneration and chronic strain is mostly sore. The pain is aggravated after the break or when the activity starts in the morning. It can be relieved after a little activity, but it is aggravated again after a long time. Lumbar spinal stenosis and disc herniation are more serious than walking, but there is nothing to do with cycling, pain in the back or uphill, and aggravation when lifting or downhill. Tuberculosis and tumor pain often worsen at night. After the spinal nerve is compressed and stimulated, the intraspinal pressure caused by cough often causes radiation pain along the nerve. The location of the pain is very important. The simple back pain is caused by the muscles of the lower back, ligaments, facet joints, and vertebral lesions. Low back pain accompanied by radiation pain along the nerve is considered to be caused by embedding nerve stimulation, and rheumatism may be accompanied by migratory pain of other joints. Early ankylosing spondylitis is pain in the ankle or hip joint. Patients should be carefully asked if they have a history of cancer in other areas. Whether the pain is caused by tumor metastasis, whether osteoporosis has a history of diabetes or kidney disease, and whether there is a history of endocrine disorders. Whether the pain is accompanied by fever or other symptoms such as angina causes low back pain, such as palpitation, chest tightness, airlock and other symptoms, urinary stones are often accompanied by abdominal pain and tossing and turning in the bed, kidney tumors are accompanied by hematuria.
2. Physical examination: the examination should start from the gait at the time of the patient's visit. The gait-like person's legs are stiff and the gait is unstable. It is drunk-like. It is more common in spinal cord lesions such as cervical spondylotic myelopathy and spinal cord tumors. Cautious gait, waist stiffness or forced to lean to one side, with hands on the waist, gait cautious, more common in lumbar disc herniation, acute lumbar sprain or acute lumbar muscle fibrosis. Duck steps swing around when walking, more common in hip disease. The patient should be removed from the top to see if there is a physiological curvature of the back and back, with or without side bends, hunchbacks, and angular deformities. There are no masses, sinus, scars, pigmentation. The patient's spine is flexed, stretched, flexed left and right, and rotated left and right to observe the function of the back. Patients with lumbar back organic lesions often have limited function, while reflex pain caused by visceral diseases is normal. Determining the tenderness of the lower back is the most direct way to find the lesion. The tenderness can be divided into superficial tenderness and deep tenderness. The inflammatory lesions of the supraspinous ligament, interspinous ligament, and sacral spine are tendered with the thumb in the corresponding part. If the lower lumbar spine is tender, the radioactive pain along the nerve is mostly Caused by lumbar disc herniation. Spinal bones and intraspinal lesions often have sputum pain, and those who oppress the nerve often cause radiation pain. If the tender point is not changed repeatedly, it is a fixed tender point, which often means that there is an organic lesion in the part. Conversely, there is often no fixed tenderness in the reflexed lower back caused by visceral lesions. Then let the patient supine, if the lumbar lordosis is straight or the hip flexes and contracture, the leg can not be flat in the straight position. Check whether the abdomen is symmetrical, palpate with or without hepatosplenomegaly, with or without a lump and hip socket abscess. Female patients should pay attention to whether there is deep abdominal tenderness.
3. Several special tests commonly used to check low back pain
(1) Straight leg raising test and strengthening test: The patient is supine, the legs are straight, the examiner lifts the hand with one hand, and gently presses the knee at the same time to keep the leg straight, causing the radiation pain of the lower extremity to be positive. The back of the foot is stretched, and if the pain is aggravated, the test is positive to identify the pain caused by the tension of the rope muscle. It is worth noting that the test can also produce ankle joint torsion. If the ankle joint lesion can also produce ankle pain, rather than the lower extremity radiation pain, it should be noted.
(2) supine and abdomen test: the patient's occipital part and the two feet are the force points to push the abdomen and buttocks up, causing the waist and leg pain to be positive. If it is negative, the patient can be abdomen and breathe deeply to blush after deep inhalation. At the same time, coughing hard and causing radioactive pain in the affected limb is positive. Shi can be the first to use this method to check patients with lumbar disc herniation. (3) flexion neck test: the patient is supine, the limbs are straight and flat, and the neck is slowly raised, and the radiation of the lower limbs is positive.
(4) oblique shift test: the patient's limbs are straight and supine, the examiner supports the affected side of the knee, so that the hip flexes and bends the knee and receives the hip joint, and the other hand holds the shoulder to fix the upper body, so that the longitudinal axis of the pelvis can be generated. Rotational pressure can cause pain if the ankle has a lesion.
(5) 4 test patient supine: knee flexion puts the ankle and ankle on the contralateral knee, the examiner valgus the knee in one hand, the other side fixes the pelvis opposite, and the ankle pain indicates the ankle There are lesions in the department. If the hip joint is damaged, there is hip pain and the knees cannot be flattened.
In addition, there are a neck test, a Gaenslen test, a Yeomann test, a pelvic squeeze test, and the like. Patients with low back pain accompanied by pain or numbness of the lower extremities should also check the depth and depth of the lower extremities, exercise, reflexes, and muscle atrophy. When the back of the lower back itself fails to find out the cause, the relevant departments should be consulted according to the situation, such as urology, gynecology, abdominal surgery, internal medicine, etc. An anal examination of the sacral tumor is necessary. Should also pay attention to the examination of lower extremity lesions such as unequal length of lower limbs, flat feet, internal and external valgus, horseshoe foot, toe deformity, etc. affecting the back and back balance and stability caused by low back pain, foot lesions such as sputum, bone spur, synovitis, Toe pain and the like can cause the lower limbs to be dysfunctional and cause lumbar muscle strain.
