Waist pain

Introduction Low back pain refers to pain in the back, waist, lumbosacral and ankle, sometimes accompanied by pain or radiation pain in the lower extremities. Most of the low back pain is manifested in the lower lumbar spine and lumbosacral and ankle. Low back pain is the most common condition of the human spine and is said to be the price paid by humans crawling from limbs to walking upright. The disease is more common in internal medicine, surgery, gynecology, and neurology. The lesions of any of the tissues of the lower back skin, subcutaneous tissue, muscle, ligament, spine, ribs, spinal cord, and spinal cord can cause low back pain.

Cause

Classification of causes:

(1) Acute and chronic injuries:

1, acute injuries such as spinal fractures, ligaments, muscles, joint capsule tear, acute disc herniation.

2, chronic injuries such as ligament inflammation, muscle strain, proliferation and degeneration of the spine and joints, spine slip and so on.

(two) inflammatory lesions:

Inflammatory lesions are divided into bacterial inflammation and non-bacterial inflammation.

1, bacterial inflammation:

Can be divided into suppurative and specific infections such as spinal tuberculosis. Suppurative infections are more common in intervertebral space infections, epidural abscesses, and vertebral osteomyelitis.

2, non-bacterial inflammation:

Rheumatoid muscle fibrositis, rheumatoid arthritis, third lumbar vertebrae transverse process syndrome, ankylosing spondylitis, can store joint tight osteitis.

(3) Degenerative changes of the spine:

Such as intervertebral disc degeneration, small joint degeneration osteoarthritis, secondary spinal stenosis, senile osteoporosis, pseudo-sliding and spinal instability.

(4) Abnormal bone development:

Scoliosis, hemivertebra, narrow-necked porpoise, hunchback, lumbosacral or lumbar vertebrae, spina bifida and hook-like spinous processes, horizontal humerus, lower limbs, unequal length, flat feet.

(5) Poor posture:

Long-term work at the desk or bent over, pregnancy, obesity caused by the abdomen.

(6) Tumors:

Bone and soft tissue tumors, bone marrow or nerve tumors.

(7) Involved pain caused by visceral diseases:

Gynecological pelvic disease, prostate disease, etc. can cause low back pain, kidney diseases such as stone J tumor, kidney ptosis, pyelonephritis and retroperitoneal diseases such as abscess, hematoma, etc. can cause back pain, liver and heart disease can cause back pain.

(8) Mental factors:

With the progress of society and the acceleration of the rhythm, such diseases gradually increase, such as chronic fatigue syndrome, psychosis spondylitis, neurasthenia, rickets, depression.

Mechanism

First, acute injury:

Acute injury can cause small blood vessels to rupture, tissue edema, and exudation. Hematoma can cause a sterile inflammatory response. H, K, prostaglandins, histamine, and osmotic pressure are considered to be the main causes of pain. In the hematoma of the fracture, the pH value can reach below the young, is acidic, has a high H concentration, and thus causes pain. The edema and exudation of the tissue can cause the tissue to infiltrate, and the ruptured cells of the tissue cells release the acidic lysozyme with the grain, causing pain. Acute injury can tear the ligaments and muscles, damage the joint capsule and lead to pain in the damaged area, fracture and dislocation. The hematoma can compress the spinal cord or nerve and produce compression symptoms causing distal pain or numbness. In severe cases, it can cause paralysis.

Second, chronic strain and degenerative changes:

Chronic strain and degeneration can cause a series of changes in the disc, facet joints, ligaments and muscles and cause pain.

1. Changes in the intervertebral disc:

The blood supply to the adult intervertebral disc is only a small amount of blood supply on the surface of the annulus fibrosus. The nutrition depends mainly on the penetration of lymph, and because of the strain on the lower lumbar intervertebral disc, the load is heavy, and it is located at the junction of the active segment and the fixed segment. change. Nachemson's study showed that if the lumbar intervertebral disc pressure is 100% in the standing position, 150% in the sitting position, if it is tilted forward, it will increase to 180%, and if the standing position is slightly forwarded to 150%, this indicates the long-term sitting position or People who have a forward tilting position are more prone to intervertebral disc degeneration. Because the posterior annulus degeneration is most obvious, it is easy to rupture and cause disc herniation. This first stimulates the branch of the sinus nerve behind the disc, causing low back pain. If compression causes nerve roots, it will cause venous return obstruction, nerve root edema, and aseptic inflammation. It is also believed that glycoproteins in the nucleus pulposus can cause chemical inflammation of nerve roots in proteins and histamine, which all increase pain. Sensitivity, causing radioactive sciatica.

2. Degeneration of small facet joints:

This joint is a typical synovial joint. Due to the degeneration of the intervertebral disc, the internal water is reduced, the intervertebral space is narrowed, and the pressure of the spine is borne by the articular joint. Due to the super-physiologically resistive compressive stress, the cartilage gradually turns yellow. It is opaque, and then rough and uneven, wear and fall off, compressing the branches of the sinus nerve around it and causing low back pain. Synovial inflammation of the facet joints can also cause lumbar pain.

Third, inflammation caused by low back pain:

Some substances in inflammation such as H+, prostaglandins, histamine, bradykinin and other pain receptors that act on the nerve cause pain, and an increase in tissue osmotic pressure can also cause pain. Tissue ischemia can accumulate acidic metabolites in local tissues, and the concentration of H+ in tissues increases and causes pain. Both rheumatoid and trauma can cause cell damage and cell disintegration, releasing acidic lysosomal enzymes to produce pain. The purulent pus juice caused by bacterial infection is acidic, while the painless tuberculous abscess is neutral. Inflammation can also cause tissue congestion, edema, and elevated tissue pressure causing pain.

Fourth, the pain caused by lacrimal tumor:

The expansive growth of a tumor can cause pain or stimulation of surrounding nerve endings or nerve trunks, and the interior of the tumor is acidic and can cause pain. Spinal tumors can also squeeze nerve roots and cause radiation pain along the nerve. Compression of the spinal cord can cause spinal cord compression and cause sensory dyskinesia below the pressure plane.

5. Low back pain caused by osteoporosis:

The relationship between osteoporosis and pain is not well understood. Osteoporosis may cause a vertebral compression fracture that causes low back pain.

an examination

Related inspection

Low back pain physical examination leg lift test waist back examination

Physical examination :

The examination should start from the gait at the time of the patient's visit. The stagnation of the two legs is unstable and it is drunk, and it is more common in spinal cord lesions such as cervical spondylotic myelopathy and dorsal marrow tumor. Cautious gait, waist stiffness or forced to tilt to one side, with the hand to support the waist, gait cautious, more common in lumbar disc herniation, acute lumbar sprain or acute lumbar muscle fibrosis. The duck step swings around when walking, and is more common in myelopathy. Patients should be removed from the top, to observe the presence of physiological curvature of the lower back, with or without lateral curvature, hunchback, (angular deformity, with or without mass, sinus, extreme marks, pigmentation. The patient's spine is flexed. Left and right side flexion, left and right rotation to observe the function of the back. Patients with lumbar back organic lesions are often limited in 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 supraspinous ligament, the interspinous ligament, and the inflammatory lesion of the spinous muscle have tenderness in the corresponding part with the thumb. If the lower lumbar spinous process is accompanied by radioactive pain along the nerve, it 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 a giant organic lesion in the site. Conversely, there is often no fixed tenderness in the reflexed lower back caused by visceral lesions. Then let the patient supine position, if the lumbar lordosis is straight or the flexion of the medullary joint is contracted, the leg can not be flat in the straight position. Check whether the abdomen is symmetrical, palpation with hepatosplenomegaly, with or without lumps and osteocytes abscess. Female patients should pay attention to whether there is deep abdominal tenderness.

Several special tests commonly used to check low back pain are:

1. Straight leg raising test and strengthening test: The patient is supine and 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. If the pain is aggravated, the test is positive to identify the pain caused by the tension of the hamstring. It is worth noting that the test can also produce the axillary joint torsion. If the sacroiliac joint lesion can also produce ankle pain, rather than the lower extremity radiation pain, it should be identified.

2, supine and abdomen test: the patient with the occipital and two heels as the force point to the abdomen and buttocks force up another! The back and leg pain is positive. If it is negative, the patient can be abdomen while taking a deep breath and then holding his breath to blush, or coughing at the same time, causing the radiation pain of the affected limb to be positive. Shi can be the first to use this method to check patients with lumbar disc herniation.

3, the neck test: the patient is supine, the limbs are straight and flat, slowly raising the head and bending the neck, resulting in lower limb radiation pain 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 flexion of the pulp bends the knee and the internal pulp joint, and the other hand supports the fixed part of the upper body, so that the vertical axis of the pelvis can produce rotational pressure If the sacroiliac joint has a lesion, it can cause pain.

5, "4" word test: the patient supine, knee flexion put the ankle and foot on the opposite knee, the examiner presses the knee to the bed surface with one hand, and the other hand fixes the pelvis to the opposite side. There is a lesion in the joint. If the myelopathy is a lesion, there is pain in the myelopathy and the knee cannot be flattened.

In addition, there are neck press test, Gaen-slen test, and Yaoman test (Yeomann) pelvic squeeze test.

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. It is necessary to perform anal examination on the sacral tumor. Should also pay attention to the examination of lower extremity lesions such as unequal length of lower limbs, flat feet, intra-abdominal valgus, horseshoe foot, toe deformity, etc. affecting the back and back balance and stability caused by low back pain, foot lesions such as clothing, bone spurs, synovium Inflammation, toe pain, etc. can cause weakness in the lower limbs and cause lumbar muscle strain.

Laboratory and equipment inspection:

1, erythrocyte sedimentation: tuberculosis, rheumatism active period and malignant tumors can accelerate the erythrocyte sedimentation rate, it should be noted that pregnancy or abortion can also accelerate the erythrocyte sedimentation rate.

2, blood, urine routine: rheumatoid, malignant tumors can cause anemia, infection, the use of adrenal cortical hormone drugs and leukemia can increase leukocytosis, tuberculosis during the recovery period of lymphocytes. Increased urinary protein in the week means multiple myeloma, red blood cells, protein and cast in the urine are considered for urinary system diseases, and urine glucose should be considered for diabetes.

3, Streptococci hemolysin "O", rheumatoid latex test and HLA-B27 anti-chain "O" increased indicates rheumatic activity, rheumatoid latex test positive may have rheumatoid.

4. Acid phosphatase and alkaline phosphatase: Acid phosphatase can be elevated when prostate cancer is metastasized. Alkaline phosphatase is elevated. It reflects an increase in bone remodeling activity, which is increased in diseases such as bone metastases, hyperparathyroidism, and multiple fibrositis.

5, x-ray examination: X-ray is an important means of checking low back pain, often first positive side film, if necessary, can be added oblique position and function position. It can show changes in the lumbar spine physiological curve, vertebral body alignment, bone changes, and good display of lumbar spine fractures, tuberculosis tumors and deformities.

6, spinal canal angiography: spinal canal imaging is helpful for the diagnosis and differential diagnosis of various injuries or diseases involving the spinal canal. Because the current contrast agents Omnipaque and Isovist are non-ionic iodine contrast agents, their side effects are minimal, with excellent neurological and local tolerance. The disadvantage is that they need to be imported from abroad and are more expensive.

7, CT: is a computer-controlled X-ray transverse scan. It is localized for lumbar disc herniation, spinal stenosis, extent of spinal tuberculosis, spinal tumors, and epidural hematoma. Qualitative diagnosis provides good information.

8. MRI: It is based on the principle of magnetic resonance to determine the difference in density of moving protons in various tissues. It has high force on soft tissues, especially spinal cord, brain tissue, kidney cortex and medulla. The image is very clear, but for bone tissue. Not as clear as CT. The emergence of MRI is an epoch-making advancement in the diagnosis and treatment of spinal cord injury and disease.

Differential diagnosis

Symptoms of low back pain that are easily confused:

First, simple low back pain:

Simple low back pain refers to low back pain without lower limb pain or numbness. The main points of its differential diagnosis are as follows.

1. Age and gender: Age and gender are closely related to the cause of low back pain. Adolescents are prone to tuberculosis. Long-term sitting can lead to ligament inflammation or muscle fibroinitis. If adolescent males have a history of cold, they are prone to ankylosing spondylitis. Young women have lower back pain. Most of them are dense iliac bones due to pregnancy and strain. inflammation. Young and middle-aged household chores and work are more arduous, and the intervertebral disc. The ligaments and muscles have begun to degenerate, resulting in lumbar disc herniation, myofasthesia, ligament inflammation, and spondylolisthesis. In middle-aged and elderly patients, spine degenerative osteoarthritis and ligamentitis should be considered first. If women should pay attention to osteoporosis and Menopausal syndrome.

2, medical history: the back of the spinous process on both sides of the sore, bent or sitting a long time after aggravation, bed rest or a little activity can be alleviated by muscle fiber inflammation. Pain in the back of the back, painless or relieved in the upright position, pain increased during flexion, waist weakness can not be bent for a long time to work, chest and lumbar segments are mostly supraspinous ligament inflammation, mainly lumbosacral segments For interspinous ligament inflammation. If the low back pain suddenly occurs after bending, and it is rapidly aggravated, and the waist is stiff and does not dare to move, it is mostly the incarceration of the lumbar facet joint synovial membrane. If the pain is mainly caused by the sacroiliac joint, sometimes accompanied by pain in the knee or myelopathy, cold or cloudy, the back pain is gradually developing upward, the spine is stiff, and may be accompanied by fatigue, low fever, loss of appetite, etc. Spondylitis. If the back pain gradually worsens, the nighttime pain will pay attention to the spinal tumor. If it is gradually aggravated, it will become a horn deformity, accompanied by low heat and weakness, night sweats, etc. may be vertebral tuberculosis, and some vertebral tuberculosis patients with low back pain There is a painless cold abscess. Lumbar disc herniation, nucleus pulposus removal after a few days to several weeks after the occurrence of severe deep pain in the waist, first consider the intervertebral space infection. Patients with fluorosis-prone areas or long-term drinking industrial pollution should be excluded from fluorosis caused by fluorosis.

3, physical examination and examination: tenderness and tenderness is the primary method to find the lesion. Thumb tenderness is shallow tenderness, and snoring pain is deep tenderness. The superficial tenderness point is mostly supraspinous ligament inflammation in the spinous process, interspinous ligament inflammation in the interspinous process, muscle fibrositis in the muscles on both sides of the spinous process, and the third lumbar transverse process in the third lumbar vertebrae Syndrome, shallow tenderness lesions are mostly in superficial ligament muscles, so no positive findings on X-ray examination, deep tenderness should be examined in patients with no tenderness, and X-ray or CT examination should be performed on deep tenderness. If there is a history of traumatic fractures, the vertebral body should be considered for vertebral tumors. If the flattened vertebral body is fishtail and the bone density is generally reduced, osteoporosis should be considered. The spine has an angular deformity X-ray showing that the vertebral body has bone destruction, the intervertebral space is narrowed, or the paraspinal abscess is visible. It is characterized by vertebral tuberculosis, limited lumbar stiffness, and can cause joint pain, "4" test or The positive waterline of the oblique pull test shows the specific expression of the sacroiliac joint. The early joint space is blurred and widened, the edge is unclear and the bite is broken, and the gap is narrowed. The marginal bone is dense and even fusion can be ankylosing spondylitis. Performance, late X-ray showed that the spine showed a bamboo-like change, and there was osteoporosis. Spinal spondylolisthesis caused by a narrow stenosis can be seen in the lumbosacral region with a kyphosis X-ray lateral radiograph showing spine slippage, double oblique position It is shown that there is no exact relationship between the hyperplasia of the lumbar vertebrae and the low back pain. If the degeneration is obvious and the tenderness is deep, lumbar vertebrae stiffness can be considered for lumbar hyperplastic osteoarthritis. Reflex low back pain has no obvious pain, and lumbar motion is normal.

Second, low back pain accompanied by lower limb pain or numbness

Low back pain associated with numbness or pain in the lower extremities is mostly caused by compression of the thoracolumbar spinal cord or cauda equina or nerve roots and stems. The first lumbar vertebrae level above the spinal cord, patients may have intercostal neuralgia, high limb tension, femoral reflexes and lower extremity pathological signs positive, the second lumbar vertebrae oppression of the cauda equina or nerve roots, more occurrence of ponytail intermittent break, shares Nerve or sciatic nerve pain or numbness, corresponding femoral reflexes weakened or disappeared, no pathological signs.

Thoracic vertebrae compression is more common in thoracic tuberculosis tumors, intraspinal tumors, severe thoracic scoliosis, thoracic spinal stenosis, thoracic disc herniation and trauma. It should be noted that the thoracic and thoracic joints are roughly upper thoracic. The segment is different from the same number of vertebral bodies, the lower thoracic segment is about two different, the lumbar pith is 1~5 knots in the chest 11~waist 1~the waist is 1~2; between the middle, the pith is located at the waist 1~the waist 1~2 In the meantime, the cause of traumatic thoracic spinal cord compression is clear. There are often complete or incomplete lower extremity paralysis. The J line can show the fracture and displacement of the vertebral body. MR can clearly show the compression of the spinal cord and whether it is completely broken. Patients with thoracic tuberculosis first consciously have back pain, or found that the thoracic spine is deformed into an angular deformity, necrotic intervertebral disc tissue, cheese-like substance, and dead bone can compress the spinal cord backwards. First, there is paralysis of the lower extremity. If not treated, it can be converted into flaccidity. The water line can be seen narrowing the intervertebral space, bone destruction, dead bone, paraspinal abscess, CT can clearly show the dead bone and abscess that is not easy to find in the spinal canal and X-ray. Thoracic spine tumors are more common in middle and old age, with metastatic tumors being the most common, followed by giant cell tumors and hemangioma. Sustained back pain, patients with pain at night or rest, gradually worsening, compression of nerve roots can cause severe intercostal neuralgia, easily misdiagnosed as abdominal organ diseases such as appendicitis, cholecystitis. Tumor compression of the spinal cord can cause paraplegia. X-ray can be expressed as osteolytic and osteogenesis. The main line of osteolytic destruction is S-line. The vertebral body is discoidally flattened, and the left and right can be widened. However, the intervertebral space is normal. CT examination is helpful for early detection of lesions. The vertebral hemangioma has a "fence-like" shadow on the X-ray film because the vertical and rough trabecular bone is clearly visible. The tumor in the spinal canal first stimulates the nerve root, causing radiation pain, and the upper thoracic segment is radiated to the chest. The lower thoracic segment radiates to the abdomen and is easily misdiagnosed as visceral disease. When the spinal cord is compressed, it first appears to be numb under the pressure plane, the lower limbs are weak, and then the sensation and movement that develops below the plane gradually loses. Spinal angiography can determine the diagnosis and localization. After CT, the size of the tumor and intramedullary or extramedullary can be observed. MR can show the shape, size and exact location of the tumor and the compression of the spinal cord, with or without trauma. Thoracic spinal stenosis and thoracic disc herniation are rare, and the symptoms are similar to those in the spinal canal. However, CT and MR examinations of the vertebral canal can be clearly diagnosed.

Medical history:

First of all, to understand the gender, age and occupation of patients, women should consider whether there is pelvic disease, men should pay attention to prostatitis, elderly and postmenopausal women have osteoporosis, young and middle-aged are more common in strain, lumbar disc herniation. The occupational and working environment is closely related to the lower back. Long-term sitting or bending workers are prone to strain and degeneration. Cold storage and water workers are prone to rheumatism. Long-term exposure to poisons is prone to chronic poisoning and bone metabolism disorders/chronic onset, and gradually worsens in strain and retreat. Older 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. Pain after exertion. Pain is associated with chronic strain. Pain after walking is more common in lumbar 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 when backing or uphill, and pain 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, and the low back pain is mostly caused by the back and back muscles and ligaments. Small facet joints, caused by 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 energy or myelopathy. Patients should be carefully asked if there is any history of tumors 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 parts of the symptoms such as angina causes low back pain, flustered, 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.

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