A. Acute lumbar sprain Most have a history of acute lumbar sprain, which can present with a variety of different symptoms and dysfunctions, as well as sudden onset of acute pain, often in a forced position, with pain radiating to the buttocks due to protective muscle tension causing spinal tonicity or lateral convexity. When flexing the hip and knee, it can cause lumbar pain. The straight leg raise test can be positive, but there is no sciatic nerve pulling pain, and the straight leg raise strengthening test is negative. Chronic lumbar strain injury can be caused by acute lumbar sprain without timely and reasonable treatment or long-term accumulative lumbar tissue injury. It often manifests as soreness or dull pain in the lumbosacral region, and the pain is aggravated after exertion, and the symptoms are alleviated after resting, changing position and local pounding and massage, and it cannot insist on bending work, and when the pain is serious, it can be involved in the buttocks and the back side of the thigh. The most common pressure point is at the attachment point of the erector spinae muscle in the lumbosacral region, and there are deep pressure points at the paravertebral, interspinous and transverse processes of the 3rd lumbar vertebra, and pressure points at the starting point of the gluteal muscle and the buttocks. There is no radiating pain in the straight leg raising test. Degenerative degenerative lumbar osteoarthropathy is dominated by degenerative changes in the lumbar spine, with extensive bone and joint proliferative changes in the lumbar spine, and a series of clinical symptoms and signs. The clinical manifestations are stiffness or soreness of the lumbar region in the morning, and the symptoms are gradually reduced after activities, but the lumbar pain can be aggravated after longer activities, and can be relieved after bed rest and local massage. There is often no obvious pressure point in the lumbar region, and there is a comfortable feeling after local pressure. In patients with more serious degeneration, the small joints are asymmetrical, and the incidence of lumbar disc degeneration in this segment is significantly higher, resulting in osteophytes and backward compression of nerve roots, or stimulation of nerve roots due to instability of the lumbar spine and hyperplasia of the small joints, and radiating pain in the lower extremities, with pain mainly in the anterolateral part of the femur, sometimes manifesting as radicular pain, at which time attention should be paid to differentiate from lumbar disc herniation, combined with imaging examination when necessary. Fourth, the third lumbar transverse process syndrome is a lesion outside the lumbar spinal canal, the soft tissue at the tip of the transverse process causes a series of pathological changes due to injury, and leads to lumbar pain or lumbar hip pain. It mostly occurs in young and strong people with weak lumbar back muscles, and is more common in men with a history of trauma and long-term poor work posture. The main symptom is pain in the lumbar region and buttocks, which is aggravated by activity. When examined in prone position, mild spasm and pressure pain of one or both erector spinae muscles can be detected. The straight leg raise test is negative, no nerve root irritation symptoms, and no special abnormalities in laboratory and imaging examinations. V. Disintegration and slippage of the lumbar vertebral arch The isthmus between the upper and lower synapses of the lumbar vertebral arch is defective or broken, resulting in the loss of the complete bony connection of the vertebral arch, also known as isthmus discontinuity. The vertebral body slips forward on the basis of the arch breakdown, also known as true slippage. If the intact vertebral body of the vertebral arch slips, it is called pseudoslip. When the isthmus of the vertebral arch is broken, the broken end of the vertebral arch moves and forms a pseudo-union. The repeated activity and friction cause the broken end to produce a large number of fibrocartilage-like crusts, and these proliferating fibrocartilage-like tissues can cause nerve root adhesions to produce lumbar and leg pain and can cause radicular compression of nerves to produce radicular pain. Differentiation points with lumbar disc herniation: ① collapse of the vertebral arch and collapsed slippage generally have a long course, without significant exacerbation or remission period. ②The effect on nerve roots is not as obvious as disc herniation. ③X-ray examination can clarify the diagnosis and determine the degree of slippage, which can be combined with lumbar spine power position X-ray to clarify the stability of the vertebral body structure and, if necessary, CT and MRI examination to make a judgment. Lumbar spinal stenosis ① Central spinal stenosis is mainly caused by degeneration of the intervertebral disc, diffuse posterior bulging of the fibrous ring, resulting in a smaller intervertebral space, backward overlap of the vertebral plates, folding of the ligamentum flavum, coupled with degenerative hyperplasia of the articular prominence, coalescence invasion to the midline, resulting in a reduction of the mid-sagittal diameter of the spinal canal and compression of the cauda equina nerve in the spinal canal. Clinical manifestations mostly include long-term lower back, hip and posterior thigh pain, with symptoms gradually worsening, aggravated by standing and stretching, followed by gradual appearance of intermittent claudication. The pain gradually expands, and abnormal sensation, weak dorsiflexion of the toes, weakened or absent Achilles tendon reflex, and even sensory loss in the saddle area and sphincter dysfunction may occur. ②Nerve root type spinal stenosis (lateral saphenous fossa stenosis) The lumbar nerve root canal refers to the nerve roots emanating from the dural sac and sloping downward to the external mouth of the intervertebral foramen, and the distance through which the nerve roots pass is called the nerve root canal, containing the nerve root sleeve and the arterioles of the nerve roots and nerves. The nerve roots have little room for movement in the canal, so it is easy to produce nerve root compression in the lower lumbar trigeminal canal, resulting in lower back pain and sciatica, which is very similar to lumbar disc herniation. However, the symptoms of radicular pain are generally not as sudden and intense as those of lumbar disc herniation, and the history of the disease is longer, the age of onset is older, and posterior lumbar extension can induce aggravation of symptoms, and straight leg raising is less restricted. (iii) Mixed spinal stenosis Narrowing of both the central canal and the nerve root canal. Clinical manifestations include both intermittent claudication and nerve root pain symptoms. This type is mostly seen in older patients with a long history of chronic low back pain. The epiglottic neuritis refers to the jamming of the epiglottic nerve at the exit of the bony fiber canal or at the exit of the fascia, which causes pain in the lumbar and hip areas and leg pain. When the nerve penetrates the thoracolumbar fascia or enters the buttock through the bone fiber duct at the iliac crest, it is easy to cause injury, or the duct is narrowed and compresses the nerve, resulting in lumbar and hip pain and leg pain to the back of the thigh up to the N fossa. Lower lumbar spine surgery can also cause epiglottic neuralgia, which appears on the 3rd to 5th postoperative day, similar to the symptoms of lumbar disc herniation, and the symptoms can usually disappear with closure and acupuncture treatment. Analysis of the causes: ① Intraoperative stripping is too large, damaging the muscles and tendon membranes attached to the transverse process and causing injury to the lateral branch of the posterior branch of the spinal nerve. (ii) Intraoperative bleeding and inflammatory reaction can stimulate compression of the nerve. (③) Edema and ischemia of the nerve itself. The pear-shaped muscle starts from the inner surface of the pelvis on both sides of the 2~4 sacral foramina and is attached to the inner wall of the pelvis through the large sciatic foramen tied to the greater trochanter. Most of the sciatic nerve penetrates from the lower edge of the pear-shaped muscle, and the other part is the tibial or common peroneal nerve, which penetrates through the belly of the pear-shaped muscle or its upper and lower edges. Severe injury to the pear-shaped muscle without proper treatment can produce sciatic nerve entrapment symptoms, similar to lumbar disc herniation. Differentiation points: ① Difference between dry pain and radicular pain. ②The pain range is different. ③Difference in pressure pain points. ④ Combine with CT and MRI examination. 9. Lumbar spine tuberculosis and sacroiliac joint tuberculosis Some patients may have symptoms similar to lumbar spine nerve root compression, which is a contraindication to massage. It can be differentiated by combining the characteristics of medical history, physical signs, and auxiliary examinations (blood sedimentation, X-ray, CT, MRI). The onset of the disease is slow, the history is long, the symptoms are progressively aggravated, the spine generally has no scoliosis deformity, no limitation of lumbar activities, and most of them show symptoms of cauda equina compression, which is easy to be missed. If the tumor invades the spinal canal, it can be accompanied by radiating pain in the hip and leg, which is similar to lumbar disc herniation and is a contraindication to massage. It can be differentiated by medical history characteristics, laboratory examination and imaging examination. Spinal arachnoiditis is a disorder characterized by thickening, adhesions and cyst formation in the spinal arachnoid membrane due to plasma inflammation, resulting in compression of nerve tissue and blood flow disorders. It may manifest as thoracic and abdominal girdle-like pain with or without radiating pain in the lower extremities. Weakness in both lower extremities and dysfunction of urination and defecation. It can generally be caused by infection, trauma, chemical irritation, and lesions of the spinal nerve itself. The differential diagnosis can be made by medical history, neurology specialist examination, lumbar puncture cerebrospinal fluid examination, MRI examination, etc. Myelitis is mostly an autoimmune reaction caused by viral infection, or inflammation of the spinal cord due to poisoning or allergy. Clinically, transverse myelitis is the most common, with lesions in the thoracic segment, followed by the cervical segment, and lesions in the lumbar and sacral segments are less common. It manifests as limb paralysis, sensory loss, and bladder and rectal dysfunction below the level of the spinal cord lesion. Clinical signs may include ① Motor impairment: mainly upper motor neuron palsy below the lesioned segment. However, in acute cases, the early phase may be a transient flaccid paralysis, called spinal shock. After a few days to weeks, typical signs such as hyperactive tendon reflexes, increased muscle tone and pathological reflexes gradually appear. (2) Sensory impairment: hypoesthesia or loss of sensation below the lesioned segment. Both superficial and deep senses are involved to varying degrees, but the severity is not necessarily symmetrical bilaterally. If only one side of the spinal cord is involved, it will show the absence of pain and temperature sensation in the contralateral limb below the level of the lesion, and the absence of ipsilateral deep sensation. There is often a nociceptive hypersensitivity zone at the junction of normal sensation and sensory deficit. (③) Vegetative symptoms: urinary retention or constipation in the acute phase, urinary incontinence gradually appears in those who have passed the spinal shock period, and some cases eventually become autonomic bladder. Other vegetative nerve dysfunction may occur with different segments of the damage. Herpes zoster is an acute inflammatory skin disease caused by the varicella zoster virus, known in traditional Chinese medicine as “tangle waist fire dragon” and “tangle waist fire dan”. It is also commonly known as “snake sores” and “spider sores”. It is characterized by clusters of blisters that are distributed in clusters along one side of the peripheral nerve, often accompanied by significant neuralgia. Occasionally, sciatica may be involved, manifesting as pain in the buttocks and legs in the area innervated by the sciatic nerve. The differential diagnosis can be made by fully exposing the painful area during the examination, but the diagnosis can be easily missed in the early stage of the disease and when the herpes is not typical.