On the basis of the degeneration of intervertebral disc tissue, if it is subjected to unbalanced pressure again, the annulus fibrosus can rupture at the weak point, and the nucleus pulposus will bulge from the rupture point, which is called swelling clinically. If it protrudes further, it is called hernia and prolapse. The protruding part of the nucleus pulposus and the ruptured fibrous ring protrude into the spinal canal, compressing the corresponding nerve roots and nerve cones, which will produce serious symptoms.
Protrusion occurs when the lumbar intervertebral disc is suddenly or continuously compressed. Such as bending down to carry heavy objects, not cooperating well with others when lifting heavy objects, twisting the waist too much, sitting on the ground when falling, etc. It is rare that it is really caused by direct trauma to the waist, but it is not uncommon to wash your face, wash your clothes, and even cough and sneeze. About 30% of patients have unknown causes. When the nucleus pulposus of young people is in a semi-liquid state, the protruding tissue can be absorbed and the symptoms will be alleviated. However, if the prominent tissue is the degenerated nucleus pulposus of existing hyaline cartilage or fibrocartilage, it can not be absorbed, which will cause the nerve root to be compressed for a long time, and the symptoms will persist, and then adhesion will occur around the nerve root (Figure 100-27). At this time, even if the protrusion is finally absorbed, the pain often still exists. The degeneration of intervertebral disc, the instability of intervertebral joint itself and the relaxation of anterior and posterior longitudinal ligaments caused by the decrease of intervertebral disc height also change the structure of posterior joint. When the waist is active, the vertebral body will often move back and forth, and osteophyte and ligamentum flavum hypertrophy will appear at the edge of the vertebral body and small joints. These changes themselves will also compress the nerve roots, so the reasons for the symptoms of patients in the later stage are not single. Lumbar disc herniation is mostly unilateral, but there are also a few people who are bilateral, and sometimes central protrusion compresses bilateral nerve roots at the same time. The clinical symptoms are different because of the different positions of the protrusion. Because the nerve root has to descend for a while after it is emitted from the dural sac and before it passes through the intervertebral foramen, the protrusion of lumbar intervertebral disc 4 and 5 presses the nerve root of lumbar 5, while the protrusion of lumbar 5 and sacral 1 intervertebral disc presses the sacral 1 nerve root.
Diagnostic description
Diagnosis and differential diagnosis According to the history, signs and X-ray manifestations, the diagnosis of lumbar disc herniation is not difficult. Especially through angiography or CT and MRI examination, the diagnostic rate is quite high. But it should be differentiated from the following diseases.
1. Lumbar tuberculosis: It can cause low back pain and lower limb pain. Early X-ray films showed intervertebral space stenosis, sometimes mixed with lumbar disc herniation. Generally, lumbar tuberculosis is more common in teenagers, with low fever, accelerated erythrocyte sedimentation rate, and sometimes cold abscess, and bone destruction can be seen after the course of the disease progresses.
2. Lumbar tumors: including primary and secondary tumors, generally with bone destruction, which can be distinguished by isotope examination.
3, cauda equina tumor: must be differentiated, because the two diseases are sometimes confused with each other. However, cauda equina tumors often have no obvious low back pain, and their symptoms are gradually aggravated (non-intermittent), and the pain is prominent at night, but the symptoms of bed rest are aggravated. Hypoesthesia in sellar region, dysuria, and increased cerebrospinal fluid protein. Myelography can make a definite diagnosis with high MRI resolution.
4. Pedicle fracture and spondylolisthesis can be distinguished by X-ray plain film, but sometimes the two diseases can coexist.
5. Lumbar spinal stenosis: Sometimes lumbar disc herniation is the cause of spinal stenosis, but the real lumbar spinal stenosis should not include lumbar disc herniation (see the chapter on lumbar spinal stenosis). It is difficult to distinguish spinal canal stenosis with sciatica as the main manifestation, but the sagittal and transverse diameters of spinal canal can be known by measuring spinal canal on plain film, myelography, CT or MRI.
6, ankylosing spondylitis: the disease is progressive, and there may be low back pain and sciatica in the early stage. But at first, it often appears in bilateral sacroiliac joints, and the erythrocyte sedimentation rate is fast. After the disease develops, the facet joints will blur or fuse. There are bamboo-like changes in the spine in the later stage.
7. Interdiscitis: It mostly occurs in children and is rare in adults. Adults often have a history of surgery and systemic inflammation. X-ray film showed early intervertebral space stenosis, but in the later stage, the relative edges of the two vertebral bodies widened and finally the vertebral bodies fused.
clinical picture
Clinically, this disease is a disease of young adults, generally occurring between 30 and 50 years old. This is because the activity intensity of this age group is high and the intervertebral disc has degenerated. Men are about10:1more than women; The left side is more than the right side, probably because most people like to exert force on the right side, which makes the muscles of the right back more developed, and the tension and pressure on the intervertebral disc spread to the left side and protrude on the left side. The lower lumbar spine is the most common protruding part, which can reach 98% according to some statistics, while the lumbar vertebrae 4 and 5 account for 60%.
Common signs of lumbar disc herniation
(1) Low back pain and radiation pain of lower limbs. This is the most common symptom of lumbar disc herniation. Low back pain usually occurs first, and leg pain occurs after a period of time. Some people also have low back pain and leg pain immediately after trauma. Pain is generally severe, affecting life and work. In severe cases, bedridden, bending, coughing, sneezing and defecation will aggravate the pain. Symptoms are mostly unilateral, sometimes turning to the opposite side, that is, both sides have symptoms. In severe cases, dysuria, loss of sensation in the saddle area and paralysis of both feet may occur. Symptoms are often relieved after rest, sometimes light and sometimes heavy, but the interval of relief is gradually shortened and the pain is aggravated. A few patients have leg pain from the beginning without low back pain.
(2) Limiting waist movement The lumbar muscles have protective spasms, which make the waist stiff, inconvenient to move in all directions, and difficult to get on and off the bed and sit up. The pain is more serious when the lumbar spine is extended, which can be explained as that the extension pushes the protrusion to the spinal canal, and the ligamentum flavum relaxes the protrusion and increases the compression on the nerve root.
(3) Scoliosis is called "sciatica scoliosis" (Figure 100-28). Most patients are biased towards the healthy side and a few are biased towards the affected side. It is generally believed that this is related to the relative position of the protuberance and the nerve root. For example, the protuberance bends to the healthy side when it is above the lateral part of the nerve root, and bends to the affected side when it is below the medial part. The reason is that the body tries to avoid the compression of nerve roots by protrusions.
(4) Lumbar tenderness and radiation pain The tenderness points of this disease are often located on both sides of the midline. Characterized by tenderness and radiation to lower limbs, the positive rate can reach about 90%, which can be used as a powerful basis for diagnosis and localization.
(5) Straight leg elevation test (Lasegue sign), etc. This is an important test to diagnose this disease. Make the patient lie on his back, straighten his knees and slowly lift his lower limbs, which can reach about 90 normally. Generally, the healthy side is lifted first to prepare the patient, and then the affected side is lifted, which often does not reach 90 degrees, depending on the severity of the protrusion pressing the nerve root. In severe cases, it hurts if you can't lift it to 30. Then the examiner bends the instep with his hand before the lower limbs are raised to pain, which will cause pain. This is called Bragade's sign or enhancement test. In the past, the straight leg elevation test was considered negative, but now it is found that in rare cases, the straight leg elevation test can be positive. Sometimes when the healthy side is lifted, the affected side will be painful, which is called positive for Lewin sign. Another examination method is called sitting nerve root test, that is, the patient sits, straightens his knee, gradually lifts it, observes the degree of lifting, and also pulls the sciatic nerve. Femoral nerve traction test, also known as heel-hip test, the patient pushes his heel to the hip joint on his stomach. If the femoral nerve is compressed, the patient will feel pain. In addition, you can also do a neck flexion test. The patient lies on his back, and the examiner holds his chest with one hand and raises his head with the other. The lower limb pain of the positive person is also the reason why the nerve root is pulled. Compression of jugular vein can increase the pressure in dura mater, aggravate the compression of nerve root by protuberance, and also aggravate the pain, which is called Naffziger sign.
(6) The skin segment innervated by the compressed nerve root will have sensory changes. First I feel allergic, then I feel dull or disappear. The sensory changes of lumbar nerve root 5 are on the outside of calf and instep, and sacral nerve root 1 is on the outside of toe and foot when compressed, which has certain reference value for the location of protrusion, but it is uncertain.
(VII) Hypomyodynamia Femoral nerve involvement affects the muscle strength of quadriceps femoris. The compression of lumbar nerve root 5 indicates that the muscle strength of extensor pollicis decreases, and it can also affect extensor dorsi pedis in severe cases, which also has positioning value.
(8) Tendon reflex changes femoral nerve compression, knee reflex decreases, and Achilles tendon reflex caused by sacral nerve root compression decreases 1, which also has localization value.
(9) There is generally no abnormality in laboratory examination, and the cerebrospinal fluid protein of a few patients is slightly increased.
Experimental examination
X-ray manifestations are routine X-ray examination, aiming at excluding tuberculosis, tumors and other spinal diseases, and observing whether there are indirect signs of intervertebral disc diseases, such as scoliosis, narrowing of intervertebral space, degeneration of vertebral bodies and small processes, spondylolisthesis, etc. Because the intervertebral disc is underdeveloped, it is impossible to diagnose whether there is disc rupture and nucleus pulposus protrusion from plain film, and angiography or other methods are needed.
(1) There are many imaging methods, such as: ① myelography: inject iodine-containing contrast agent into the subarachnoid space of spiders to observe their blood flow and whether there is filling defect (Figure 100-32), and the diagnostic rate is quite high (60-95%). However, there are some problems such as caking, contrast agent stimulation and nerve root adhesion (see the chapter on cervical spondylosis). ② Nucleography: The diagnostic rate of direct injection of contrast agent into nucleus pulposus is also high (68.9 ~ 9 1%), but it is difficult to operate, and the injection of contrast agent often produces severe sciatica, so it is rarely used at present. ③ Epidural contrast: The contrast agent is injected into the epidural space in the form of dotted line, just like the snow hanging on the branches, which can describe the outline of the epidural space and the direction of nerve roots. In the hands of experienced doctors, the diagnostic rate can reach (98.2 ~ 100%), the contrast agent is absorbed quickly, and there will be no adhesion in the arachnoid membrane. , but it is not easy to operate, and it is quite difficult to reasonably explain the contrast performance. ④ Venography: There are two methods, one is injecting contrast agent into spinous process, and the other is injecting contrast agent into lumbar vein through intubation. The disadvantage is that the X-ray equipment is special and the development is unclear.
(2) CT and magnetic resonance imaging have been widely used in spinal surgery, with the advantages of painless, clear development, prominent intervertebral disc and nucleus pulposus, and clear view of the relationship with nerve roots, with high accuracy. However, these two methods are complicated in equipment and expensive in inspection. Therefore, the way of special inspection should be based on the specific situation.
Treatment instructions
After the treatment of nucleus pulposus protrusion, it can gradually shrink and absorb, and the damaged part of fibrous ring can also be replaced by fibrous tissue repair, which reduces the pressure on nerve roots and gradually relieves symptoms, so the first author can often be cured by non-surgical treatment. However, although the defect on the fiber ring has been repaired, it is always a weak link. Once it is damaged again, the pressure in the intervertebral disc increases and it can protrude again, so the symptoms are repeated and the circulation is getting heavier and heavier. Some patients with severe initial protrusion have great pressure on nerve roots, and the symptoms will be unbearable for patients. There are also cases where the epidural space adheres to the nerve root due to protrusion, which cannot completely disappear. All these changes.
(1) Non-surgical treatment
1, absolute bed rest is the simplest and most effective therapy, and the word absolute is emphasized, that is, never leave the hospital bed for eating or defecating, and the hip and knee joint can be slightly flexed to reduce the pressure in the intervertebral disc and the pressure on the nerve root. Most patients with the first attack can relieve their symptoms within 3 weeks.
2. Pelvic traction. The purpose of traction is to widen the ruptured intervertebral disc and restore the prominent nucleus pulposus. But in fact, the rupture is small and irregular, and the nucleus pulposus is broken and cannot be returned. So its therapeutic effect is probably due to bed rest.
3. Massage and massage therapy are generally considered to be a very effective method, especially for patients who are visiting a doctor for the first time. The therapeutic mechanism may be to retract the nucleus pulposus or change the position relationship between the protrusion and the nerve root, which can reduce or eliminate the compression on the nerve root, but it has not been confirmed. The method is that the patient lies on his side. The doctor puts one hand on the patient's shoulder and the other hand on the iliac crest, pulls the shoulder backward, pushes the iliac bone forward at the same time, and suddenly twists the waist firmly, so that a noise can often be heard at the waist, and the symptoms can often be dramatically relieved (Figure 100-34). For acute patients, massage can be performed. Recently, it has been reported that the so-called big massage under general anesthesia has a certain effect, but because anesthesia completely relaxes muscles, improper exertion will cause unnecessary injuries, aggravate symptoms, and even cause cauda equina paralysis, which has serious consequences and is not suitable for use.
After the symptoms are relieved by non-surgical treatment, the waist line should be worn to protect the waist from further injury. But it is the most important thing to do lumbar muscle exercise.
(2) chemical nuclear dissolution
The enzyme that can dissolve cartilage is directly injected into the intervertebral disc to destroy the hydrophilicity of nucleus pulposus, and mucopolysaccharide acid produced by cartilage mucin decomposition is excreted with urine, which reduces the pressure in the intervertebral disc. Chymosin is commonly used. Because of its simple operation, it has been widely used abroad, and the curative effect can reach 70 ~ 80%. If nucleus pulposus dissolution fails, surgery can still be performed, which is also suitable for cases of failed surgery. However, it was banned in the United States because of reports that a few patients died of allergic reaction, arachnoiditis and paraplegia.