Posterior spinal nerve syndrome is a syndrome caused by mechanical stimulation of the posterior spinal nerve branches, such as kaya, and is characterized by low back pain, posterior lateral hip and thigh pain, lumbar muscle spasm, and dyskinesia. The mechanism is that when the posterior branch of the spinal nerve and its branching medial and lateral branches travel through a small and inflexible orifice such as a bone fiber foramen, a bone fiber canal, or through a thoracolumbar fascial fissure, they are prone to mechanical strain due to the high mobility of the lumbar region; or the orifice is deformed and narrowed due to osteophytes and ossification of the ligaments, and the symptoms are caused by compression of the vascular nerves.
[Application anatomy]
The posterior branch of the spinal nerve has a diameter of about 1 mm and emanates from the lateral side of the spinal ganglion at the external opening of the intervertebral foramen. It travels posteriorly through the bony fiber pore between the vertebral papillae and the pars interarticularis, at the junction of the inferior superior articular eminence and the superior border of the transverse process root, and divides into the medial and lateral branches at the internal border of the intertransverse process muscle, with anastomoses between the posterior branches of the spinal nerve.
1. The posterior medial branch is located on the posterior side of the root of the superior articular process of the inferior lumbar vertebrae, behind the transverse process obliquely directed posteriorly, and turns downward through the fibrous canal to the back of the arch plate, spanning 1~3 vertebral bodies, overlapping the joint capsule, ligaments and dorsal extensor muscles on the medial side of the joint line. The medial branch of lumbar 4 to 5 crosses downward across 2 to 3 vertebral bodies to reach the back of the sacrum and also distributes to the sacroiliac joint. The posterior medial branch connects with the branches in the upper and lower planes within the muscles of the lumbar back and abuts the vertebral plate immediately to the inferior edge of the spinous process, and the supraspinous ligament is innervated by the posterior medial branch in the upper plane.
2. The posterior lateral branch accompanies the blood vessels, runs along the back of the transverse process obliquely outward, passes through the sacrospinous muscle, penetrates the thoracolumbar fascia to the subcutis, and innervates the tissue structures beyond the line of the intervertebral joint. The lateral branches of lumbar 1~3 are longer and form the gluteal epineurium.
3, spinal branch Mostly the posterior branch of the spinal nerve or the branch of the general trunk of the lumbar nerve, through the intervertebral foramen back into the spinal canal (return nerve), distributed in the fibrous ring, posterior longitudinal ligament, dural connective tissue, blood vessels and spinal cord peritoneum (spinal branch), its confluence with sympathetic nerve fibers to form the sinus vertebral nerve. The sinus vertebral nerve has extensive anastomoses between adjacent segments, so stimuli may be transmitted across segments and laterally to the center, causing back and leg pain.
The fibrous foramen is located posteriorly to the external opening of the intervertebral foramen and opens posteriorly, perpendicular to the intervertebral foramen. Its upper boundary is the sickle edge of the intertransverse ligament, the lower boundary is the upper edge of the transverse process of the inferior vertebral body, the inner boundary is the outer edge of the superior articular process of the inferior vertebral body, and the outer boundary is the medial edge of the intertransverse ligament
5, the bone fiber canal is located in the bone groove between the lumbar papillae and the parapophysis. The anterior wall is the sulcus between the mastoid process and the paraxial process, and the posterior wall is the ligament of the superior articular process and the paraxial process.
Symptoms】Lower back pain, hip pain, posterior lateral thigh pain, not exceeding the knee joint.
Signs] Complaint of pressure pain at the upper edge of the root of the transverse process of the segment 1-2 above the painful area, accompanied by discharge pain to the complaining painful area.
Differential diagnosis】1. lumbar disc herniation: leg pain mostly spreads to the lower leg and high level spreads to the anterolateral thigh.
2, osteoporosis: mostly seen in elderly women, with widespread pressure pain in the spine and reduced bone density seen on x-ray.
3, discogenic low back pain: pressure pain points are located in the interspinous process. The symptoms are aggravated by prolonged sitting and standing.
【Treatment methods
(a) Closed treatment.
1. prone position. 2. use a marker such as a needle or a large-headed needle to stick to the pressure pain point and take a film or C-arm X-ray machine fluoroscopy. Take the upper edge of the transverse process root as the target point.
3. After routine disinfection of the skin, use a No. 7 8 cm intracardiac needle to first draw 2 ml of 2% lidocaine hydrochloride, hit the mound and then stab vertically into the target point, encounter bone that is the base of the transverse process, slightly retreat the needle, then slightly tilt the head end into the needle to reach the original depth to encounter no bone or a feeling of sliding down from the bone surface, then prove that the tip of the needle is exactly at the upper edge of the transverse process, then slightly retreat the needle, depress the tail of the needle obliquely into the needle medially, encounter bone That is, the outer edge of the upper articular process, slightly lifting and inserting the puncture needle, and the tip of the needle at the intersection of the upper articular process and the transverse process, the patient has a tingling or electric shock sensation, indicating that the needle has reached the lumbar nerve after the expenditure of the bone fiber hole, back to draw no blood after the injection of 2% of lidocaine 1ml + tretinoin acetate 1ml.
(B) Needle knife release.
1. Position Same as before.
2. Puncture point positioning Same as before.
3. Operation steps First perform the block according to the previous method, then pierce the small needle knife No. 3 according to the original approach, cut and peel 2~3 cuts from the upper edge of the transverse process along the outer edge of the superior articular process in the superior and inferior directions, and exit the needle knife when there is a sense of loosening under the hand.
(c) Other therapies: freezing, radiofrequency, chemical ablation and other methods are basically the same as the closure method, but with different means to achieve the purpose of blocking the posterior branch of the spinal nerve. 1. The posterior branch of the lumbar nerve and the medial and lateral branches are accompanied by blood vessels, so when performing needle and knife release must make the blade parallel to the outer edge of the upper joint and close to avoid damage to the blood vessels.
Because the posterior branch of the lumbar nerve has extensive anastomosis, the best result can be achieved by involving 2~3 adjacent nerve roots at the same time when releasing.
Patients with a long history or those whose effect cannot be consolidated by 2 blocks need to be released by needle and knife.