Overview】 Posterior lumbar joint disorder is a common and frequent disease with a high clinical incidence, and can occur in adolescents, middle-aged and elderly people. The small joints located in the posterior part of the lumbar spine can be caused by acute trauma, chronic strain (stress), degenerative changes and congenital development, resulting in instability of the small joints of the lumbar spine and causing low back pain, limitation of movement and a series of other symptoms; most of them are combined with synovial impingement at this time. However, the name of the disease is not very uniform, some people call it “lumbar small joint misalignment”, some people call it “lumbar posterior joint synovial impaction”, there are differences and similarities, from the pathogenesis and clinical manifestations of both different, but also interconnected In terms of pathogenesis and clinical manifestations, they are different and related to each other, and in terms of treatment, they are basically the same, so they are collectively referred to as posterior lumbar joint disorders. From the anatomical point of view, the small joint of the lumbar spine consists of the inferior articular process of the superior vertebra and the superior articular process of the inferior vertebra. The joint surface is covered by hyaline cartilage and has a small joint cavity surrounded by a small joint capsule. The capsule is loose and thin, and the inner layer is synovial, which secretes synovial fluid to facilitate joint movement. When the lumbar spine is subjected to vertical loading stress or excessive rotational shear of the lumbar spine, the small joint is prone to injurious synovitis, resulting in malnutrition of the articular surface cartilage, thinning of the cartilage surface, fissures and unevenness of the articular surface. The cancellous bone under the cartilage also undergoes degenerative changes and the bone hardens. The joint capsule can tear and form fibrous scarring when subjected to weight bearing and rotational stress. When the intervertebral disc degenerates and the vertebral space narrows, it can cause the small joint capsule to relax and directly cause small joint subluxation. In addition, the waist in the force of activity, but also must be regulated by whistling, such as lifting heavy objects, the first inhalation to fill the abdomen, the abdomen into a solid before the power. The size of the force, to adjust the whistle, whistle and movement disorders, it can hurt small joints and muscles. Therefore, there is no mental preparation for the sudden lifting, turning and splashing, turning and sitting up, lifting and carrying heavy objects, etc., due to whistling and muscle dysfunction, resulting in joint instability and twisting and slipping to the side with the direction of the external force, causing small inter-articular dislocation. (B) Synovial impingement of the small joints The joint capsule of the small joints of the lumbar spine consists of two layers: the fibrous structure and the synovial membrane. The synovial membrane is rich in blood vessels and nerves. The nerves of the small articular synapse are innervated by the posterior branch of the crestal nerve, which is divided into medial and lateral branches, both of which have small branches, and it is a very rich nerve structure, namely the small joint receptors. When the synovium is mechanically or chemically stimulated, it produces significant pain. The articular surface of the lumbar segment is arranged nearly sagittally, reinforced by the ligamentum flavum anteriorly and partly by the intercrural ligament posteriorly, and the rotational activity of the lumbar spine is limited by the small articular synapses. When the small articular processes of the lumbar spine are subjected to rotational violence, injury can easily occur. Crestal flexion of 50o to 60o occurs mainly in the lumbar segment. In anterior lumbar flexion, the small joints separate. In lumbar posterior extension, the small joints converge. When the vertebral body is twisted, the small joints come together on one side and open on the other. When a person reaches adulthood, the intervertebral discs, ligaments and other tissues undergo degenerative changes of varying degrees. If the crest rotates suddenly without adequate preparation, such as lumbar twisting, bending to pick up objects, sweeping the floor, etc., the vertebral body and intervertebral tissues will be subjected to greater force under unstable conditions, and the small joints will be poorly occluded or misaligned. Lumbar 5 has a large range of motion and is prone to small joint opening. When it opens, the negative pressure in the small joint cavity increases, and the synovial membrane of the joint capsule is sucked in, entrapped, and forms small joint synovial impingement. Western diagnosis] 1. Low back pain Patients are mostly young adults. In acute attacks, most patients have unilateral or bilateral lower back pain immediately during the process of twisting or bending into extension, and the pain increases when moving the waist. Patients are often in a forced position, fearing to be touched or moved by others. 2. Nerve root irritation symptoms Early nerve root irritation symptoms can occur, lower limb pain can occur, radiating to the buttocks, thighs and sacrococcygeal region, generally involving a slightly smaller area, and does not spread according to the nerve root distribution area, and mostly does not involve the lower leg. The involvement of lumbar 5 nerve roots may result in weakened or absent Achilles tendon reflex. 3.Signs In acute attack, the physiological bending of the lumbar region disappears, the spinal process is irregularly arranged, there is obvious percussion pain and pressure pain in the small joint area of the lesion, the sacral crest muscle is obviously tense, and the lumbar region is stiff. Local closure of the affected small joints with lidocaine or bupivacaine can reduce the pain. The muscle strength and sensation of the lower limbs are not abnormal. 4.Imaging X-ray examination can show that the physiological curvature of the lumbar spine has changed, with degenerative vertebral joints being the main cause of the change, and it is generally not easy to find small joint displacement. However, the power lateral film can show the loosening sign, and can be found on both sides of the small joint protrusion is asymmetric. CT scan and MR examination can show the bone of the affected vertebral joint and the surrounding soft tissue profile. Basic treatment] I. Manipulation treatment Manual restoration is an effective measure for the treatment of lumbar small joint dislocation, commonly used techniques are oblique trigger method, back method, rotation restoration method, etc.. Before the manual reset, it is advisable to massage the affected area in the lumbar back first to relax the muscles. 1, oblique wrenching method: the patient is lying on his side, the lower side of the hip is straight, the upper side of the hip and knee flexion, in the upper position of the shoulder back up. The operator stands in front of the patient, holding the patient’s upper shoulder with one hand and pressing the iliac crest with the other hand. After the patient’s whole body is relaxed, the patient’s hands are tilted in the opposite direction at the same time, so that the shoulders are pinched and turned backward and the hips are rotated forward, at which time a “clucking” sound can be heard in the lumbar region. The oblique wrenching can make the synovial joint open, which is conducive to the resetting of the embedded synovial membrane and the misaligned joint. Let the patient lie on his side in the opposite direction and use the same method. If the dislocated small joint is reset and the embedded synovial membrane is returned after the oblique traction, the patient can feel relief of back pain at once and turn over freely. If the effect is not good, can also repeat the oblique trigger 2 to 3 times. 2.Lateral back method: Applicable to those who have limited lateral lumbar flexion. The patient stands, the operator stands on the patient’s healthy side, the patient’s healthy hand is held on the operator’s shoulder, the operator holds the patient’s wrist with the far patient’s hand, the other hand is holding the patient’s waist, the side waist back, so that the patient’s foot leaves the ground, the back shakes 4 to 5 times, when the patient is not ready, suddenly the patient pops up, that is, the technique is completed. This technique should be carried out with an assistant on the side of the support, in case the patient inadvertently fluttered. 3, back method: the patient stands, the operator stands behind the patient, the two back to back, and two hands back, to their elbow fossa sat on the patient’s elbow fossa, to their hips top of the patient’s lumbosacral, bend over the patient’s back, so that his feet leave the ground, to wait for the patient’s muscle relaxation, first left and right sway 3 to 5 times, and then tremble 3 to 5 times, that is, the technique is completed. 4.Shake method: patient prone position. An assistant with both elbows holding the patient’s armpit, the operator holds the patient’s double ankle joints for confrontation traction, and after lasting for 1 minute, shake the patient up and down several times with force. This method can make the small joint traction open, can also receive better results. 5.Dorsal extension pressure method: The patient is in prone position. The operator uses the thumbs of both hands to point and press the points of the committee, committee Yang, Chengshan and Chengjian for one minute each, followed by repeated treatment on both sides of the diseased lumbar vertebrae for three times by dividing the tendons, so that the lumbar muscle spasm can be relieved. Then the patient was asked to grasp the head side edge of the examination bed with both hands, the assistant stood on the bed at the end of the examination bed, held the patient’s ankles with both hands, lifted both lower limbs upward and stretched them toward the end of the bed, so that the lumbar region was dorsally extended, at this time the patient’s lower limbs and lumbar region left the bed surface, about 25o~30o with the bed surface, the operator stood on the patient’s healthy side, pressed the palm root of both hands overlapping at the lumbar spine lesion vertebral space, then quickly pressed downward and slightly toward the affected side. And slightly to the affected side of the direction of pressure, repeated 3 to 4 times, sometimes can be heard the sound of popping. Second, traction therapy 1, pelvic traction belt traction lumbar muscle spasm is serious and refuses to be reset by hand, can be the current pelvic traction. Traction weight is 1/3 to 1/2 of the patient’s body weight. 20 minutes after the traction spasm is relieved, the patient is asked to lie prone and perform light pushing and pressing techniques. Generally traction 3 to 5 days, the symptoms can disappear or significantly reduced. 2.Crest traction bed traction method Patients lying prone on the crest traction bed, tighten the traction belt, turn on the traction switch, adjust the traction weight not more than 10kg, maintain traction for 15 minutes, and adjust to the lumbar posterior extension position of about 30o. Third, bed rest Patients with acute attack or manual repositioning should take appropriate bed rest to eliminate the spasm of sacral crest muscle, promote the decreasing of joint edema and reduce pain. And can prevent habitual lumbar disorder. Fourth, closed therapy small synovial joint capsule closure has the effect of antispasmodic and analgesic. Available 2% lidocaine injection 5ml add trimethoprim suspension 1ml or prednisolone acetate (prednisolone) 25mg of suspension, with a No. 7 lumbar puncture needle or intracardiac injection needle, at the small joint pressure pain point 1.5cm next to the spinous process, infiltrate around the small joint. Generally choose lumbar 4 to 5 and lumbar 5 to sacral 1 small joints for multi-site injection. V. External medication 1. Musk and tiger bone ointment, wound and dampness pain relief ointment, and zushi hemp ointment can be applied externally. 2, orthopedic water, safflower oil and other rubbing. 3.Usable external application such as Shujinjin and activating ointment, swelling and pain-relieving ointment, anti-stasis ointment, Kanli Sha and blood circulation and pain-relieving powder. 4.Chinese herbal medicine external support and fumigation: 60g of angelica, 30g of safflower, 30g of frankincense, 30g of myrrh, 60g of catechu, 40g of myrrh, 60g of zingiberis, 60g of wei ling xian, 40g of chuanxiong, 60g of geranium, 60g of stretching grass, 60g of turbinaria, 30g of cao wu, 60g of papaya, 60g of fallen daida, 60g of wu ga pi. 50g~100g, mix well with vinegar and apply to the affected area with infrared light or divine light for 30~40 minutes, once a day for 5~7 days. It can also be sealed with the above medicine in a cloth bag, add 1500ml of water, boil for 20 minutes, and apply hot compress to the affected area, twice a day. Other therapies 1.Physical therapy such as hot compress, ultrashort wave and spectrum can be applied to relax the muscles, subside the edema and improve local blood circulation. 2, acupuncture therapy: acupuncture points: Kidney Yu, Huanjiao, Zhizhong, Yinmen, Yanglingquan, and Aye points. Use diarrhea method, once a day, 10 times for a course of treatment. 3.Chinese medicine iontophoresis therapy: use Chinese medicine that relaxes tendons and blood, reduces swelling and pain, and carries out iontophoresis therapy. When back pain is obvious, oral anti-inflammatory and antispasmodic drugs can be taken, such as ibuprofen, fenbid, intravenous, indomethacin (anti-inflammatory pain), etc. (2) Chinese medicine classification and prescription 1.Qi stagnation and blood stasis type: those with history of trauma, acute onset of pain, and limited lumbar function. The treatment is to regulate the Qi and activate the Blood, and to relax the tendons and activate the collaterals. This formula is based on the following formula: 10g of safflower, 9g of red peony, 12g of angelica, 9g of Chuanxiong, 15g of salvia, 6g of frankincense, 6g of myrrh, 9g of zingiberis, 12g of wei ling xian, 15g of geranium, 15g of elixir, 6g of mucuna pruriens, 9g of lordosis, 6g of sumac, 6g of mucuna pruriens, 12g of green peel, 3g of panax ginseng, 3g of licorice. 2. Wind-cold damp paralysis type: chronic onset, with history of lumbago. The pain is aggravated by cold or climate change, and is reduced by warmth. The treatment is to dispel wind and dampness, relax the tendons and activate the collaterals. Recipe with hemp and gui warm tendon soup: ephedra 9g, cinnamon 12g safflower 6g, dahurica 20g, horsetail 6g, red peony 12g, peach kernel 6g stretching tendon grass 15g, kudzu 15g, wei lingxian 15g, papaya 15g, haitongpi 15g, mulberry 15g, cow knee 12g licorice 3g. 3, liver and kidney deficiency type: usually have soreness of the waist and knees, or often habitual onset, or the elderly and weak. Treatment is to tonify the kidney and strengthen the tendons, soothe the tendons and open the channels. The formula is to tonify the kidneys and strengthen the tendons: Angelica sinensis 12g, rehmannia 12g, cow knee 12g, yam 10g, poria 12g, sequestra 12g, eucommia 12g, white peony 12g, green peel 9g, wujiapi 9, stretching tendon grass 15g, mulberry 15g, safflower 6g, broken old paper 10g, wolfberry 12g. [Prevention and care] 1, waist protection: sleeping bed should be soft and hard, avoid sleeping in a bed too hard or Too soft, so that the waist muscle to get sufficient rest; avoid the waist by wind, cold attack, avoid the waist for a long time in a posture, muscle imbalance, resulting in strain injury of the waist. 2, the waist application: correct use of the waist, lifting heavy objects should first squat, use the waist for too long should change the posture of the waist, more lumbar activities, to prevent the gradual occurrence of strain injury, the nature of the work and excessive use of the waist or has produced a mild strain injury, should be used early lumbar pain Ning capsules and other drugs to avoid further aggravation of strain injury, and eventually cause degenerative changes in the lumbar spine. 3, lumbar health care exercise: adhere to the lumbar health care exercise, often carry out activities in all directions of the lumbar spine, so that the lumbar spine always maintain a state of physiological stress, strengthen the lumbar muscle and abdominal muscle exercises.