Pain in the thoracolumbar back or buttocks

Introduction Pain in the back or hip of the thoracolumbar segment may be the main symptom of spinal vascular malformation. Spinal vascular malformation is less common, the most common manifestation is subarachnoid hemorrhage or spinal cord hemorrhage. Spinal vascular malformations can occur in any segment of the spinal cord, but the most common are the cervical segments and cones. Spinal vascular malformation is a congenital lesion. Its understanding is based on pathological anatomy, with arterial or venous malformation as the main lesion. In the past, the pathophysiological effects of the vein were emphasized. On the basis of magnetic resonance and selective spinal angiography, combined with gross pathology, spinal cord vascular malformations are now classified into four main types.

Cause

1. Type I

Type I is a dural arteriovenous malformation. The arteriovenous malformation forms a traffic in the dura mater, usually involving the nerve root sleeve or the thoracolumbar spinal canal posterior lateral dura mater, located in the nerve hole. The arteries of the dural arteriovenous malformation are supplied from the dural branches of the segmental arteries of the spine, supplying nerve roots and dura mater. The lower blood flow in the dura is through the lesion, and the venous return to the dura and back to the coronary vein of the spinal cord. This group of veins is located on the dorsolateral side of the spinal cord without venous valves. Thus, an arteriovenous fistula is formed between the segmental artery of the spine and the spinal vein return vein. This sputum is also associated with coronary venous fistulas on the posterior and posterolateral sides of the spinal cord. This sputum also forms a traffic with the coronary plexus of the posterior and posterior aspect of the spinal cord. The blood flow of the coronary venous plexus flows upward toward the occipital foramen. The 15% arteriovenous stenosis of the segmental artery supplies the anterior spinal artery or the posterior spinal artery. There is usually only one nourishing artery in the lesion, but there are more than two nourishing arteries. According to the number of nourishing arteries, Anson and Spetzler further classify type I into subtype Ia as a single nourishing artery, and Ib as multiple nourishing arteries, usually at one or two adjacent segments. The mean static pressure of the dural arteriovenous fistula is about 74% of the systemic arterial pressure. Hemodynamic evidence shows that the pathophysiology of type I dural arteriovenous malformation is mainly due to the increase of venous pressure, which is characterized by coronary venous congestion, dilatation, followed by compression of the spinal cord, but this spinal nerve function The obstacle is reversible damage.

2. Type II

Type II is a vascular globular malformation with an arteriovenous vascular mass in the marrow. These lesions are often found in the cervical spinal cord, but can also occur in any part of the thoracolumbar region. Its characteristics are shown in angiography as high blood flow and sparse venous return vessels. There are often venous tumors and varicose veins.

3. Type III

Spinal vascular malformations, originally called "immature malformations", are characterized by high blood flow and extensive and complex anatomy of the arteries and veins. The lesion can occupy the entire spinal cord, invade the dura mater, and even extend to the vertebral body and paravertebral tissue.

4. Type IV

The spinal vascular malformation is located in the epidural-extraspinal region, and a branch of the anterior spinal artery is a nourishing artery of arteriovenous malformation, which is then returned to the extramedullary veins of varying sizes. The arteriovenous fistula and its return vein are located outside the spinal cord, and the lesion is not in the spinal cord. Such lesions are usually located at the thoracolumbar junction. Anson and Spetzler further classify type IV into subtypes: IVa is relatively small, and extramedullary arteriovenous fistula is supplied by a single nourishing artery, usually on the ventral side and extending over the cone. One or more nourishing arteries of type IVb, usually from the anterior spinal artery and multiple nourishing arteries, are derived from the posterior spinal artery. The blood flow through these lesions is greater than the blood flow through the IVa type. Type IVc is characterized by multiple supply arteries connected to the iliac crest. The venous blood flow of the lesion is often very large, and the ventral varicose veins of the thoracic and lumbar spinal canal often have dilated varicose veins.

Type II, III, and IV spinal vascular malformations were originally caused by intradural vascular malformations. In addition to the above type 4, there are still cavernous vascular malformations.

5. Spongiform vascular malformation

Cavernous vascular malformations can occur in the spinal cord in the form of a single lesion or as part of a cavernous hemangioma of the cranial spinal cord. These low blood flow lesions consist of stratified blood vessels or multi-segment vascular channels in the parenchyma of the spinal cord, which can cause bleeding or compression symptoms within the root canal. Cavernous hemangioma can occur throughout the central nervous system. These lesions are composed of a few vascular blood vessels that have no obvious elastin or smooth muscle wall layers. These thin-walled tubes are lined with endothelial cells and often have old bleeding. There is no visible distribution of normal spinal cord or brain parenchyma between the vessel walls.

an examination

Related inspection

Spinal examination of the spine vertebral body

Examination of pain in the back or hip of the thoracolumbar

The clinical manifestations vary according to the location of the spinal cord vascular malformation located in the epidural and intradural areas. Epidural spinal vascular malformations belong to type I, and intradural vascular malformations are classified into intramedullary and extramedullary, classified as type II, III, and IV, and include cavernous vascular malformations.

1. Type I clinical manifestations

Spinal dural arteriovenous malformations are more common in men than in women. The ratio of male to female is 4:1. The average age of the patients is 40 to 50 years old, and the lesions are mostly in the thoracolumbar region. There is no obvious family morbidity. Demographic data show that spinal dural arteriovenous malformations may be acquired diseases that may be associated with traumatic factors.

Pain is the most common symptom of patients with spinal arteriovenous malformations. Pain in the back or hips of the thoracolumbar may be the main symptom, and sometimes the patient may have radicular pain. Aminoff and Logue reported that 42% of patients complained of pain a pain as their main symptom, 33% of patients had sensory disturbances rather than pain, and some patients often felt hypersensitive in the vicinity of the acupuncture-sensing area. And the lack of positional awareness.

One third of patients with spinal telolithic arteriovenous malformations have motor dysfunction. These patients usually have mixed dysfunction signs of upper motor neurons and lower motor neurons associated with the lumbosacral spinal cord. Atrophy of the gluteal and gastrocnemius muscles often combined with hyperreflexia of the lower extremities. Physical labor, prolonged standing, and various postures such as leaning over, bending over, stretching, or flexing exacerbate the congestion of the veins and exacerbate the symptoms.

Subarachnoid hemorrhage is rare in patients with spinal tread arteriovenous malformation. When acute necrotizing myelopathy can cause sudden paralysis (Foix-Alajouaine syndrome), this may be caused by a sudden onset of venous thrombosis.

One of the typical medical history of patients with spinal dural arteriovenous malformation is a progressive development of mixed sputum with upper motor neurons and lower motor neurons, combined with pain, sensory disturbances, gluteal muscle atrophy, and middle-aged men. Sphincter dysfunction. Although arteriovenous fistula may be above or below the level of the lumbosacral region, symptoms are often associated with the lumbosacral spinal cord. 80% of patients can be a slow-developing myelopathy, and less than 10% to 15% of patients have severe spinal cord dysfunction, and acute onset. The diagnosis of spinal dural arteriovenous malformations is often delayed. Only one-third of patients make a diagnosis within one year, and about two-thirds of patients do not diagnose until three years after symptoms appear.

2. Type II and III clinical manifestations

Spinal vascular malformations that occur in the dura include Types II, III, and IV. Type II (spheroidal vascular malformations) and type III (immature or extensive vascular malformations) are located in the spinal cord.

Intramedullary lesions account for 10% to 15% of all spinal vascular malformations. Compared with spinal dural arteriovenous malformations, intramedullary lesions are similar in gender distribution. Intramedullary lesions can also occur in young patients. Foreign studies report that 75% of patients with intramedullary lesions are younger than 40 years old. 46% of lesions occur in the cervical spinal cord and 44% in the thoracolumbar spinal cord.

The clinical manifestations of patients with intramedullary arteriovenous malformations are significantly different from those of the dural arteriovenous malformations. Intramedullary and subarachnoid hemorrhage often occurs in patients with intramedullary arteriovenous malformations. May be accompanied by or without acute neurological dysfunction. 76% of patients had bleeding at a certain time, and 24% had neurological dysfunction due to bleeding. Intramedullary hemorrhage appears to be more common in cervical venous malformations. Some patients present with progressive progressive development of weakness, sensory disturbances, sphincter dysfunction and impotence, often with intramedullary hemorrhage. Intramedullary aneurysms can occur in approximately 20% of patients with intramedullary arteriovenous malformations. These spinal aneurysms are often located in the main nourishing blood vessels that supply intramedullary arteriovenous malformations. Patients with lesions in the middle thoracic segment have a worse prognosis than patients with lesions in other sites, which may be associated with fewer collateral vessels in the segment. Patients with lesions located in the cervical segment have a better prognosis.

3. Type IV clinical manifestations

Type IV lesions are rare, and Barrow and colleagues report that type IV lesions account for 17% of spinal cord vascular malformations treated at the medical center.

Patients with type IV lesions are usually younger than patients with type I lesions. Symptoms often appear before the age of 40. In the Barrow study, half of the arteriovenous malformations were type IVa lesions. However, Mourier and colleagues noted that 63% of patients had type IVc malformations. Most patients present with progressive development of myelopathy with pain, weakness, sensory and sphincter dysfunction, or subarachnoid hemorrhage. There is no difference between men and women.

Spinal dysfunction in these patients is similar to type I lesions. Angiogenesis is caused by an increase in intradural venous pressure, and the oppression of IVc lesions significantly affects the function of the spinal cord and nerve roots. Barrow speculated that some of these lesions may have occurred the day after tomorrow. There have been several reports of intraspinal surgery and/or cranial spine trauma before symptoms appear, suggesting that in some patients, the onset is due to acquired disease, and other patients are congenital lesions.

4. Clinical manifestations of cavernous vascular malformation

These lesions are estimated to account for 5% to 12% of all spinal vascular malformations, which may be familial or multiple. The incidence of cavernous vascular malformation in the central nervous system is 0.2% to 0.4%, and an estimated 3% to 5% of cerebrospinal cavernous vascular malformations occur in the spinal canal.

The average age of patients with spongiform vascular malformations is 35 years. Patients can present with acute neurological dysfunction, which is often associated with hemorrhage, often due to acute expansion of the blood vessels. Other patients can present with progressive, progressive neurological dysfunction and a trend toward improved neurological function after the onset of more severe dysfunction. Repeated bleeding may also occur, and deterioration of neurological function after bleeding can last for hours or days.

Differential diagnosis

Identification of pain in the back or hip of the thoracolumbar:

1, waist and hip extensive pain and downward radiation: gluteal epithelial nerve dry pain clinical pain manifested as extensive pain in the buttocks, generally more from the middle of the sputum, and radiated downward, up to the posterior thigh. The gluteal epithelium is a group of skin branches consisting of the lateral branches of the posterior branch of the spinal 1, 2, and 3 spinal nerves. When it passes through the fascia of the lower back, it reaches the subcutaneous, and under the skin, it spans the middle of the iliac crest and reaches the buttocks. It is distributed on the outer side of the buttocks and the skin of the large trochanter.

2, back pain: back tingling refers to the pain in the lower back like a needle stab, is one of the painful classification of low back pain. 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 activity, inability to hold weight, difficulty walking, difficulty in walking and fatigue.

3, diffuse low back pain: diffuse low back pain is one of the symptoms of plasma cells. Plasmacytoma is a primary and systemic malignant tumor originating from the bone marrow. It is derived from B lymphocytes and has the property of differentiating into plasma cells. Isolated solitary cell tumors are rare and can be cured. Among them, multiple plasmacytoma is the most common, characterized by osteolytic lesions and plasma cell infiltration of bone marrow. In addition, often associated with anemia, hyperglobulinemia, hypercalcemia, impaired renal function and predisposition to infection. Clinically, patients with over 40 years of age may have skeletal or diffuse low back pain, fatigue, paleness, and mild weight loss. The possibility of myeloma should be suspected.

4, low back pain: low back pain is a common symptom, internal medicine, surgery, neurology, gynecology and other diseases can cause low back pain. It is caused by muscle, bone and visceral diseases.

5, persistent low back pain with morning stiffness: non-ocular clinical manifestations of ankylosing spondylitis scleritis: the most typical early manifestations of persistent low back pain (at least 3 months), unilateral occult, blunt or intermittent Sexuality, accompanied by morning stiffness, reduced after activities. Ankylosing spondylitis (AS) is a chronic systemic disease of unknown cause involving the joints of the spine, ankle, and joints.

diagnosis:

The diagnosis of spinal vascular malformation, in addition to medical history and physical signs, is mainly imaging diagnosis.

1. Type I diagnosis

Abnormal blood vessels can be seen on MRI, but in the lumbosacral spinal cord, abnormal T2-weighted signals are often the only abnormal findings. The diagnosis of spinal dural arteriovenous malformations is often more sensitive and specific in CTM. A larger, curled blood vessel can be seen on the dorsolateral side of the spinal cord on the enhanced CT compared to no contrast. During angiography, the patient should be placed in the supine position to check for venous return in the dura. Intensive CT findings in the dural arteriovenous malformation are very rare. It can be distinguished from intramedullary tumors on MRI. Blood flow can be shown on the MRI, which is consistent with the performance of the tortuous and dilated veins around the spinal cord. MRI in patients with spinal dural arteriovenous malformations is often normal. Myelography should be performed if the patient's MRI results are normal and highly suspected of having a spinal dural arteriovenous malformation. If the angiography is normal, spinal angiography is usually not necessary.

Selective spinal angiography is the method of determining the diagnosis when prompted for this diagnosis on intensive CT or MRI. In the process of angiography, the anterior spinal artery is identifiable, and the blood supply associated with dural arteriovenous malformation can also be determined. All nourishing arteries of the lesion should be clearly defined to prevent recurrence of postoperative arteriovenous fistula. Sometimes, the dural arteriovenous fistula near the skull may have spinal cord venous traffic and can cause spinal venous hypertension and myelopathy. In these patients, in order to diagnose such uncommon diseases, it is necessary to perform selective carotid angiography with selective external carotid artery and internal carotid artery injection.

2. Type II and III diagnosis

Intramedullary arteriovenous malformations can be identified by flow patterns on T1-weighted images. On the T2-weighted image, abnormal signals appear in the spinal cord, and the signs of airflow around the spinal cord suggest the part around the spinal cord lesion. Spinal artery angiography is necessary to determine intramedullary lesions, but it is not always helpful in distinguishing between type II and type III lesions. Selective aortic cannulation and intubation of the vertebral, carotid, and iliac vessels are necessary to determine the nourishing arteries supplied by the intramedullary lesion. The dorsal and ventral root vessels supply arteriovenous malformations through the anterior spinal cord and posterior spinal cord branches. The anterior spinal artery may terminate in an intramedullary arteriovenous malformation or may still act as a segment of the blood vessel to determine spinal aneurysms and varicose veins.

3. Type IV diagnosis

Magnetic resonance imaging sometimes shows large signs of emptiness around the spinal cord, mainly due to the expansion of the apparent epidural venous return, which often occurs at the thoracolumbar junction, near the cone and at the proximal end of the horse's tail. Selective angiography can show the distribution of the anterior spinal artery to the arteriovenous fistula and the reflux vein.

4. Diagnosis of cavernous vascular malformation

Radiographic images of cavernous vascular malformations are characteristic. The center of a mixed signal strength can be seen on T1 weighting, T2 weighting, and proton density imaging. It can be seen on the T1 weighting that the center is surrounded by a low density hemosiderin ring. These lesions are usually not significantly enhanced. Continuous magnetic resonance imaging of patients with fluent symptoms may change the volume of the lesion. Myelography and angiography are rare and often cannot diagnose cavernous vascular malformations. Spinal angiography is sometimes necessary to distinguish cavernous vascular malformations from other types of vascular malformations.

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