Lumbar spinal stenosis

Introduction Vertebral canal stenosis refers to the general concept of bone or fibrous tissue abnormalities that cause the spinal canal to reduce the effective volume in the spinal canal, so that the nerve tissue located in the pipeline is compressed or Stimulation produces dysfunction and a range of symptoms.

Cause

The cause of lumbar spinal stenosis

(1) Causes of the disease

1. Congenital spinal stenosis is congenital development, the lumbar pedicle is short and the spinal canal diameter is short. This situation is very rare in clinical practice.

2. Degenerative spinal stenosis is the most common clinical manifestation, which is the result of lumbar degeneration. With age, degenerative degeneration includes: 1 lumbar intervertebral disc first degeneration; 2 followed by vertebral lip-like hyperplasia; 3 small posterior The joints also proliferate, hypertrophy, cohesion, and protrude into the spinal canal. When the upper joints are hypertrophied, the lower lumbar vertebrae (waist 4, waist 5 or waist 3, waist 4, and waist 5) are composed of the posterior aspect of the superior articular process and the posterior edge of the vertebral body. The lateral crypt is stenotic, where the nerve root passes, so that it can be compressed; 4 the lamina is thickened; 5 the yellow ligament is thickened, and even ossified, which occupy a certain space in the spinal canal, and together become degenerative Lumbar spinal stenosis. The sagittal diameter of the lumbar spinal canal varies greatly among the various bodies. Like the cervical spinal canal and the thoracic spinal canal, there is a difference in the sagittal diameter. In the case of a wide sagittal diameter of the spinal canal, although there are various degenerative changes, Because of the large space inside the spinal canal, no symptoms of spinal stenosis are produced. In the case of a small sagittal diameter of the spinal canal, degenerative changes can cause symptoms of spinal stenosis, while a relatively narrow spinal canal is not congenital. Sexual spinal stenosis is a difference between individuals.

3. Spinal stenosis caused by other causes (1) Lumbar spondylolisthesis, the sagittal diameter of the plane canal is reduced. (2) The central type of lumbar disc herniation, occupying the space of the lumbar spinal canal, can produce symptoms of spinal stenosis. Both cases have a definite diagnosis, which is not clinically referred to as lumbar spinal stenosis. (3) secondary, such as after the complete laminectomy, the scar formed, and then the spinal canal stenosis, or after the fusion of the lamina, the lamina is relatively thickened, resulting in local spinal stenosis. This situation is rare. (4) Lumbar vertebrae burst fracture, vertebral body displacement into the spinal canal, rest in the acute phase, asymptomatic, post-initiation activity or increased activity, spinal canal stenosis symptoms may occur.

(B) The pathogenesis of the disease is mainly manifested in the following three clinical features, and the pathophysiology basis is now described together.

1. Intermittent claudication (1) Clinical manifestations: that is, when the patient walks for hundreds of meters (several cases only tens of steps), there is side or bilateral backache, leg pain and lower limb numbness, weakness, and even limp. However, when you squat down or sit down for a few minutes, you can continue walking. Because of the intermittent period, the name is intermittent. (2) Basis of pathophysiology: The appearance of the above-mentioned clinical symptoms is mainly due to the relaxation of the muscles of the lower extremities, the physiological congestion of the vascular plexus of the corresponding spinal ganglia in the spinal canal, followed by venous congestion, which causes the microcirculation to be blocked and the ischemia occurs. Sexual radiculitis. When a little kneeling or sitting and lying down, the vascular plexus of the blood stasis returns to normal as the source of stimulation of muscle activity is eliminated, and the spinal canal is restored to the normal width, so the symptoms are also alleviated or disappeared.

2. Contradiction between chief complaint and objective examination (1) Clinical manifestations: There are many complaints in each stage of the disease, especially when the patient walks long distances or is in various forced positions that increase the intraspinal pressure. More, there may even be typical sciatic nerve radiation pain performance, but there is no positive in the examination, the straight leg elevation test is often negative. (2) Pathophysiology basis: This is mainly due to the short rest before the clinic and the restoration of the pre-flexion position, which increases the internal volume of the spinal canal, and the internal pressure also returns to the original state. At the same time, the rapid recovery of venous plexus in the root canal also helps to eliminate the symptoms. The inconsistency between such chief complaints and physical examinations can easily be mistaken as "exaggerating the main complaint" or "scamping." However, in the later stage of the disease, due to various additional factors, such as intervertebral disc prolapse, bone hyperplasia and intraspinal adhesion, it can constitute a persistent space-occupying lesion in the spinal canal and positive signs appear; but the motility is increased. A feature.

3. Limited lumbar extension and pain (1) Clinical manifestations: The patient complains of local pain when the lumbar vertebrae is extended backwards, and can be radiated to both sides or unilateral lower limbs; but as long as the position is changed, such as the body bends forward or squats Next, as well as walking or cycling, the symptoms disappear immediately. This phenomenon can also be called "postural claudication." (2) Pathophysiology basis: The occurrence of symptoms in this group is mainly due to the reduction or disappearance of the effective gap in the lumen. Because, when the lumbar vertebra changes from the neutral position to the posterior extension position, in addition to the small joint capsule and the ligamentum flavum behind the spinal canal, the length of the spinal canal is shortened by 2.2 mm, and the intervertebral foramen also changes accordingly. Narrow, intervertebral disc herniation to the spinal canal, the cross section of the nerve root is also thickened, so that the intraluminal pressure is rapidly increased. Therefore, the patient's extension is inevitably limited, and various symptoms are caused thereby. However, when the waist is restored to the straight position or slightly forward, the symptoms are immediately eliminated or alleviated as the spinal canal returns to its original width. Therefore, although these patients can not stand upright, they can walk and bend, and can ride (ie, position type). However, if the lumbar disc herniation is combined at the same time, the waist can not continue to bend forward or even slightly bend, and there are symptoms of low back pain and sciatica.

In addition to causing the above three clinical manifestations, this pathophysiological feature may also have other manifestations in the clinic, mainly including: 1 Lumbar symptoms: manifested as general lumbar symptoms such as low back pain, weakness, fatigue, etc., mainly due to spinal canal The internal sinus vertebrae are stimulated; however, the neck test is negative, which is different from lumbar disc herniation. 2 lower extremity root symptoms: mostly bilateral, similar to lumbar disc herniation, characterized by walking, even after rest, relieve or disappear, so the straight leg elevation test is mostly negative. This group of symptoms is also due to the narrowing of the spinal canal and/or root canal. 3 Abnormal reflection: Achilles tendon reflex is easily affected and weakened. This is mainly due to the lower the lumbar vertebrae, the narrower the spinal canal. Therefore, the 5th and 1st lumbar segments are easily affected and affect the Achilles tendon reflex; normal.

an examination

Related inspection

Lumbar joints and soft tissue CT examination lumbar back anesthesia test lumbar activity

Examination and diagnosis of lumbar spinal stenosis

1. General Overview Although the developmental lumbar spinal stenosis is mostly fetus-derived, the true age of onset is mostly after middle age. The age of people mainly due to degeneration is greater than that of the former 10 to 15 years old, so it is more common in old age. More men than women in this disease may be related to male labor intensity and waist load. The onset of the disease is faint, and symptoms often appear gradually unconsciously.

2. The main symptoms As mentioned above, the main symptoms of this disease are lumbosacral pain and intermittent claudication. Pain in the lumbosacral region often involves both sides, which is aggravated when standing and walking, and relieved when lying in bed or sitting. The main complaint was that the leg pain was significantly less than that of the disc herniation. In addition to spinal stenosis, most of the causes of symptoms are caused by combined disc herniation or lateral crypt stenosis.

About 70% to 80% of patients have cauda equine intermittent claudication, which is characterized by asymptomatic when quiet, short leg walking, leg pain, weakness and numbness, standing or sitting for a little while the symptoms disappear. If the lesion is severe, symptoms may appear when the chest is chest, stretched, and standing. The difference between the intermittent claudication of cauda equina and the vascular intermittent claudication of occlusive vasculitis is that the lower extremity is cold, the dorsal artery pulsation disappears, and the sensory and reflex dysfunction is light, and the cold water induction test is positive (not necessary) No need to test). Root pain and intermittent claudication of disc herniation usually have leg pain, and most of them are unilateral.

Although the patient complained more, in the early quiet, physical examination was often not found, lumbar extension and pain induced more than flexion, straight leg elevation test in patients with simple spinal stenosis can be negative, but in the secondary spinal stenosis The positive rate of the disease can be as high as 80% or more. The calf is weak and numb when walking. Most patients with primary atrophy have no signs of muscle atrophy, but secondary cases, especially those with lumbar disc herniation, are most obvious.

In summary of the above symptoms, it is the three clinical features of the aforementioned intermittent claudication, multiple complaints, fewer positive signs and limited waist extension.

3. The clinical manifestations of lateral crypt type (root canal) stenosis are similar to those of spinal stenosis. The incidence of lateral crypt stenosis is more than that of middle-aged morbidity, more male than female. The symptoms are also aggravated with age and degeneration. The reason why men are more common is mainly because the male side crypt is narrow and deep, the gap around the nerve is small, and the hyperplasia is heavier and prone to symptoms.

Patients have a longer history of low back pain. Leg pain is often more serious than spinal stenosis and lumbar disc herniation. It can also be caused by fatigue or trauma. The nerve root numbness is mostly radiated along the waist 5 or 1 nerve root. The nerve root intermittent sputum is more common. The former is more obvious, walking hundreds of steps or even dozens of steps can cause the disease, and the squatting or stopping walking is relieved.

In most cases, there were no positive signs in the examination, and a few had physiological curvature of the spine disappeared or scoliosis, but not as heavy as the former and disc herniation. The extension of the spine can induce or aggravate the numbness of the limb, but the nerve root has paralysis. The presence or absence of sensory impairment varies depending on the severity of the stenosis. In severe cases, the sensory and dyskinesia of the damaged innervation zone may appear, and the reflex may be weakened or disappeared.

1. Diagnosis of spinal stenosis The diagnosis of this disease is mainly based on the above three clinical symptoms, especially the long-term lumbosacral pain, bilateral leg discomfort, cauda equina intermittent claudication, and more physical examination at rest. Positive findings, etc., are the characteristics of this disease. Anyone with middle-aged or above who has the above characteristics should be suspected of this disease and need further examination, including:

(1) X-ray plain film: in the developmental or mixed spinal stenosis, the main manifestations are small sagittal diameter of the spinal canal, lamina, articular process and pedicle abnormal hypertrophy, bilateral small joints move to the midline, vertebra The plate gap is narrow; the degenerative person has obvious bone hyperplasia.

The sagittal diameter of the spinal canal can be measured on the lateral radiograph (see Figure 2). The spinal canal stenosis is shown below 14 mm, and the 14 to 16 mm is relatively narrow. Symptoms can occur under additional factors. The ratio of the spinal canal to the vertebral body can also be used to determine whether it is stenosis.

(2) CT, CTM and MRI examination: CT examination can show the morphology of the spinal canal and root canal, but it is not easy to understand the whole appearance of the stenosis; in addition to understanding the bony structure, CTM can still confirm the pressure of the dural sac. many. In addition, the MRI examination can show the whole picture of the lumbar spine, which has been routinely examined by most orthopaedic surgeons.

(3) vertebral angiography: often in the lumbar 2, 3 intervertebral space puncture injection angiography, at this time there may be a sharp break, comb-like interruption and bee-waist changes, basically can understand the stenosis of the whole picture (see Figure 3). Since this inspection is invasive, it is currently used sparingly.

2. Diagnosis of lateral recess stenosis Anyone with low back pain, leg pain, intermittent claudication and associated root symptoms should be suspected of lateral recess stenosis and further examination:

(1) X-ray plain film: There may be laminar space stenosis on the X-ray plain film, small joint hyperplasia, sagittal diameter on the pedicle root becomes shorter, mostly less than 5mm, in the case of less than 3mm, it belongs to lateral recess stenosis disease. In addition, cohesion of the inner edge of the superior articular coronoid also suggests a possible stenosis of the lateral recess.

(2) CT, CTM and MR examination: CT examination can show the shape of the section of the spinal canal, so it can diagnose the presence or absence of lateral crypt stenosis and the presence or absence of nerve root compression; CTM examination shows more clearly. MR examination can display three-dimensional images, which can determine the degree of disc degeneration, the presence or absence of protrusion (or prolapse) and its relationship with the dural sac and spinal nerve root.

(3) vertebral angiography: non-ionic iodine contrast agent omnipaque, isovist angiography can be seen in the nerve root development interruption, showing side crypt stenosis or nerve root compression, but this test is not easy to with the oppression caused by disc herniation Differentiate.

Differential diagnosis

Symptoms of lumbar spinal stenosis

Lumbar hypertrophy: also known as hypertrophic spondylitis or degenerative spondylitis, is a common cause of low back pain in the elderly. When people reach middle age, the lumbar vertebrae begin to proliferate, hypertrophy, and long bone spurs. Almost all the elderly have lumbar hypertrophy. On the X-slice, the sides of the spine are sharply pointed, like the raised lips, so some X-rays are reported as "lip-like hyperplasia."

Lumbar disc herniation: also known as lumbar disc herniation or nucleus pulposus, when the waist of the labor or sports activities suffered from twisting and impacting, lifting heavy objects, excessive force, overwork and other injuries caused by intervertebral disc fiber rupture, The nucleus pulposus tissue emerges from the rupture port, stimulating or compressing the spinal nerve roots and causing pain in the lower back and leg.

Lumbar vertebrae degeneration: refers to the transformation of the fifth lumbar vertebrae into all or part of the atlas, so that it forms part of the humeral mass. It is common to form a wing and a tibia with one or both sides of the fifth lumbar vertebrae. More than the humerus to form a pseudo-articular; and a small number of the fifth lumbar vertebral body (along with the transverse process) and the humerus healed together such deformity is more common. It is one of the classifications of the transitional spine.

1. General Overview Although the developmental lumbar spinal stenosis is mostly fetus-derived, the true age of onset is mostly after middle age. The age of people mainly due to degeneration is greater than that of the former 10 to 15 years old, so it is more common in old age. More men than women in this disease may be related to male labor intensity and waist load. The onset of the disease is faint, and symptoms often appear gradually unconsciously.

2. The main symptoms As mentioned above, the main symptoms of this disease are lumbosacral pain and intermittent claudication. Pain in the lumbosacral region often involves both sides, which is aggravated when standing and walking, and relieved when lying in bed or sitting. The main complaint was that the leg pain was significantly less than that of the disc herniation. In addition to spinal stenosis, most of the causes of symptoms are caused by combined disc herniation or lateral crypt stenosis.

About 70% to 80% of patients have cauda equine intermittent claudication, which is characterized by asymptomatic when quiet, short leg walking, leg pain, weakness and numbness, standing or sitting for a little while the symptoms disappear. If the lesion is severe, symptoms may appear when the chest is chest, stretched, and standing. The difference between the intermittent claudication of cauda equina and the vascular intermittent claudication of occlusive vasculitis is that the lower extremity is cold, the dorsal artery pulsation disappears, and the sensory and reflex dysfunction is light, and the cold water induction test is positive (not necessary) No need to test). Root pain and intermittent claudication of disc herniation usually have leg pain, and most of them are unilateral.

Although the patient complained more, in the early quiet, physical examination was often not found, lumbar extension and pain induced more than flexion, straight leg elevation test in patients with simple spinal stenosis can be negative, but in the secondary spinal stenosis The positive rate of the disease can be as high as 80% or more. The calf is weak and numb when walking. Most patients with primary atrophy have no signs of muscle atrophy, but secondary cases, especially those with lumbar disc herniation, are most obvious. In summary of the above symptoms, it is the three clinical features of the aforementioned intermittent claudication, multiple complaints, fewer positive signs and limited waist extension.

3. The clinical manifestations of lateral crypt type (root canal) stenosis are similar to those of spinal stenosis. The incidence of lateral crypt stenosis is more than that of middle-aged morbidity, more male than female. The symptoms are also aggravated with age and degeneration. The reason why men are more common is mainly because the male side crypt is narrow and deep, the gap around the nerve is small, and the hyperplasia is heavier and prone to symptoms.

Patients have a longer history of low back pain. Leg pain is often more serious than spinal stenosis and lumbar disc herniation. It can also be caused by fatigue or trauma. The nerve root numbness is mostly radiated along the waist 5 or 1 nerve root. The nerve root intermittent sputum is more common. The former is more obvious, walking hundreds of steps or even dozens of steps can cause the disease, and the squatting or stopping walking is relieved.

In most cases, there were no positive signs in the examination, and a few had physiological curvature of the spine disappeared or scoliosis, but not as heavy as the former and disc herniation. The extension of the spine can induce or aggravate the numbness of the limb, but the nerve root has paralysis. The presence or absence of sensory impairment varies depending on the severity of the stenosis. In severe cases, the sensory and dyskinesia of the damaged innervation zone may appear, and the reflex may be weakened or disappeared.

1. Diagnosis of spinal stenosis The diagnosis of this disease is mainly based on the above three clinical symptoms, especially the long-term lumbosacral pain, bilateral leg discomfort, cauda equina intermittent claudication, and more physical examination at rest. Positive findings, etc., are the characteristics of this disease. Anyone with middle-aged or above who has the above characteristics should be suspected of this disease and need further examination, including:

(1) X-ray plain film: in the developmental or mixed spinal stenosis, the main manifestations are small sagittal diameter of the spinal canal, lamina, articular process and pedicle abnormal hypertrophy, bilateral small joints move to the midline, vertebra The plate gap is narrow; the degenerative person has obvious bone hyperplasia. The sagittal diameter of the spinal canal can be measured on the lateral radiograph (see Figure 2). The spinal canal stenosis is shown below 14 mm, and the 14 to 16 mm is relatively narrow. Symptoms can occur under additional factors. The ratio of the spinal canal to the vertebral body can also be used to determine whether it is stenosis.

(2) CT, CTM and MRI examination: CT examination can show the morphology of the spinal canal and root canal, but it is not easy to understand the whole appearance of the stenosis; in addition to understanding the bony structure, CTM can still confirm the pressure of the dural sac. many. In addition, the MRI examination can show the whole picture of the lumbar spine, which has been routinely examined by most orthopaedic surgeons.

(3) vertebral angiography: often in the lumbar 2, 3 intervertebral space puncture injection angiography, at this time there may be a sharp break, comb-like interruption and bee-waist changes, basically can understand the stenosis of the whole picture (see Figure 3). Since this inspection is invasive, it is currently used sparingly.

2. Diagnosis of lateral recess stenosis Anyone with low back pain, leg pain, intermittent claudication and associated root symptoms should be suspected of lateral recess stenosis and further examination:

(1) X-ray plain film: There may be laminar space stenosis on the X-ray plain film, small joint hyperplasia, sagittal diameter on the pedicle root becomes shorter, mostly less than 5mm, in the case of less than 3mm, it belongs to lateral recess stenosis disease. In addition, cohesion of the inner edge of the superior articular coronoid also suggests a possible stenosis of the lateral recess.

(2) CT, CTM and MR examination: CT examination can show the shape of the section of the spinal canal, so it can diagnose the presence or absence of lateral crypt stenosis and the presence or absence of nerve root compression; CTM examination shows more clearly. MR examination can display three-dimensional images, which can determine the degree of disc degeneration, the presence or absence of protrusion (or prolapse) and its relationship with the dural sac and spinal nerve root.

(3) vertebral angiography: non-ionic iodine contrast agent omnipaque, isovist angiography can be seen in the nerve root development interruption, showing side crypt stenosis or nerve root compression, but this test is not easy to with the oppression caused by disc herniation Differentiate.

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