Afraid to stand, like to rely on

Introduction Fear of standing, happy relying on: Because of the relaxation of lumbar intervertebral joints, patients are more reluctant to stand for a long time, or rely on the support of the body when standing on the site to reduce the load on the waist. Fear of standing, happy back is a clinical symptom of lower lumbar instability. Low back pain caused by instability of the lower lumbar spine is a common and frequently-occurring disease that affects normal life and work of human beings. Clinical observations show that at least 30% of patients with low back pain have a direct relationship with lumbar instability, and most of the causes are degeneration.

Cause

In addition to the traumatic cases, the disease is a chronic disease that gradually develops and develops. In general, lumbar instability is divided into the following three stages:

(1) Early degeneration period: that is, the initial stage of the disease, which is mainly caused by dynamic instability, so it is also called dysfunction period. At this time, the small joint capsule is slightly slack, and the articular cartilage can exhibit early fibrotic changes. At this time, if an external force is applied, the vertebral body may be displaced; but in this period, the clinical symptoms are generally mild, and even if there is an acute symptom, the body can quickly return to normal.

(2) unstable period: As the lesions intensify, the sagging of the small joint capsules is increased, the articular cartilage and intervertebral discs are degenerated, and various clinical symptoms are prone to occur. The vertebral body is abnormally displaced by dynamic imaging. Biomechanical tests have shown that at this stage, unstable segments are most prone to disc herniation.

(3) Fixed period of deformity: With the further development of the lesion, the segmentation of the spine is stabilized due to the formation of the facet joint and the callus around the intervertebral disc. At this time, a relatively fixed deformity appears. Pathological examination showed that the articular cartilage degeneration had reached the late stage, and there were obvious ruptures and dead bones in the annulus fibrosus and nucleus pulposus, and bone spurs were visible at the edges. Fixed malformation and excessive hyperplasia of the epiphysis often change the caliber of the spinal canal. At this time, because the vertebra is no longer loose, the diagnosis of "vertebral instability" will be replaced by "spinal stenosis".

3. Stimulation and compression symptoms

Degeneration of the intervertebral disc and vertebral pedicle can cause symptoms by directly compressing the cauda equina or stimulating the sinus nerve. Related symptoms manifest as motility in the early stages and are accentuated over time, with the development of pathological changes and various additional factors. However, once converted to vertebral hyperplasia of the vertebral canal, the original symptoms of vertebral instability disappeared and were gradually replaced by symptoms of spinal stenosis.

an examination

Related inspection

Intervertebral foramen compression test laminar space microendoscopic lumbar puncture

The diagnostic criteria of this disease have different opinions. The author believes that the following points are of great significance:

Lumbar interlocking sign

Because lumbar instability is often associated with other lumbar diseases, the clinical symptoms are more complicated and more specific. It is difficult to distinguish from low back pain caused by other causes, and sometimes even without symptoms. When there is repeated acute episodes and severe low back pain for a short period of time, the possibility of lumbar instability may be considered. The unstable interlocking phenomenon at the waist has obvious specificity for the diagnosis of this disease and should be taken seriously.

2. Symptoms disappear after lying down

If the patient's symptoms appear when the patient is active, the test may also have a positive view, but after a slight rest on the supine, the symptoms are significantly reduced or completely disappeared, then this dynamic change has diagnostic significance.

3. Powerful film positive see

At the same time of dynamic imaging, measuring the relative displacement between the vertebral bodies can not only make a clear diagnosis of lumbar instability, but also evaluate the degree of lumbar instability, which is also the main diagnosis of lumbar instability. Means and basis. The authors believe that the relative horizontal displacement of the lumbar vertebrae is greater than 3 mm on the flexion and extension lateral slices and greater than 2 mm on the lateral curvature of the lateral radiographs, which should be considered as an objective performance of instability. The determination of the lumbosacral joint can be increased by 1 mm.

Differential diagnosis

Fear of standing, the differential diagnosis of relying on:

First, primary lumbar instability:

Type I axial rotation instability

Rotational malformation has been known in pathological specimens of degenerative spondylolisthesis. X-ray shows that the anterior segment of the spinous process is not in a straight line. The lateral pedicle can be seen in the pedicle rotation deformity. In addition, the lumbar vertebrae segmentation abnormality and the lumbar 5 transverse process are too long. , indicating that the possibility of instability is increasing. There may be waist 4 or lumbar 5 nerve root damage. The facet joint has asymmetrical stenosis. A CT scan can detect a rotational deformity.

Type II slip instability

Sliding instability is a typical degenerative spondylolisthesis. X-ray films are characterized by intervertebral space stenosis and traction osteophytes. The incidence rate is male: female is 1:4, and the incidence of diabetes is higher. Patients with no neurological symptoms can be treated with anterior interbody fusion or posterior intertransverse fusion plus transpedicular internal fixation. Patients with nerve root irritation were treated with anterior interbody fusion or posterior pedicle internal fixation system plus transverse interbody fusion. The effect is satisfactory.

Type III: post-slip instability

Post-slip instability often occurs at the lumbar 5~1 level, often accompanied by spinal stenosis symptoms that affect the 1 nerve root function. Prone anterior flexion fusion is the most reasonable treatment. We choose to use Jackson rod internal fixation. The reset is excellent and the fusion rate is high.

Type IV: progressive degeneration

Degenerative instability can be a single segment, and progressive lateral bending is often accompanied by multi-segment inter-axis rotational deformity. Damage to the nerve root can also be multi-segment. The extent of the segment that determines the fusion and decompression is designed according to the mechanics and pathological changes. The choice of CD or Zilke instrument fixation is better.

Type V: disc disintegration

Intervertebral disc disintegration also produces segmental instability. At present, the best choice of treatment is anterior interbody fusion, which can restore inter-segment stability.

Second, secondary instability

Type I: secondary instability after discectomy

Follow-up was performed 10 years after discectomy, and 20% of them were unstable. The incidence of female patients is higher, and 3% of patients require reoperation to improve the symptoms of low back pain. Scholars have suggested that these patients should take flexion and extension X-ray films before the first surgery to determine if there is potential instability. The first surgery combined with the fusion is an effective way to prevent secondary instability.

Type II: secondary instability after laminectomy

It is well known that spinal instability can occur after laminectomy and decompression, so a diagnosis must be made before the first operation. In patients with degenerative lumbar spondylolisthesis, progressive instability is more likely to occur after decompression. This progression is related to the patient's age, stability, osteophyte formation, whether the disc is resected, and the number of facet joint resections. In order to prevent secondary instability after laminectomy. Many scholars recommend trying to do fusion at the same time. Some young patients with spinal stenosis have undergone extensive laminectomy and have secondary instability that can involve a single segment or multiple segments. Increase the clinical symptoms of instability. At present, the newer view is that this type of secondary instability is related to the number of small facet joints. Remedial treatment options include anterior or posterior fusion, or transpedicular internal fixation, especially at the waist level of 3-4, and more internal fixation is required.

Type III: secondary instability after spinal fusion

Secondary instability often occurs at the upper and lower ends of the fusion segment. The stress in adjacent segments is increased due to the fusion of the spine. Accelerated adjacent vertebra strain and degeneration, 4% of patients to improve persistent pain and L 3 ~ L 4 instability, need to do fusion. Of the cases that had previously undergone 5 to 1 fusion, 20% needed to have a lumbar 4 to waist 5 level stability surgery to improve persistent lumbar pain. Pseudoarthrosis; low back pain persists in patients undergoing discectomy and spinal fusion. X-ray examination of the flexion and extension showed that there were pseudo-articular activities in 30% of patients. Patients with pseudo-articular formation leading to instability of the spine were followed up and found to be predominantly in cases of extensive facet joint resection. Diagnosis method: Anesthetic can be injected locally in the pseudo joint to observe whether the pain is relieved, so as to confirm whether the X-ray findings are consistent with the symptoms and signs. If the instability of the pseudo-articular joint is indeed achieved, the treatment method may be performed by anterior interbody fusion or posterior pedicle internal fixation plus bone graft fusion.

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