Prevalent groups
The onset of lumbar spinal stenosis occurs mainly after middle age, more in men than in women, probably due to the higher labor intensity and lumbar load in men. Lumbar spinal stenosis can occur in all people as they age, but it is only when symptoms of corresponding neurological dysfunction occur that it is considered “lumbar spinal stenosis”.
Symptoms of the disease
The main symptoms of lumbar spinal stenosis include the following.
1.Lumbar and leg pain
Most patients have long-term pain in the lower back, buttocks, and the back of the thighs. Most of them are soreness, numbness, swelling, scurrying pain, with different degrees of pain, generally mild, with a tendency of chronic aggravation. It is usually mild and tends to increase chronically. It is relieved or disappears with bed rest.
Some patients have pain when they are inactive, but it is relieved after a few hours of activity, but if the activity is too long, it can produce more intense pain.
Some patients have radicular symptoms, with low back and leg pain or increased pain when moving in certain positions, and intermittent claudication does not usually occur, but severe cases may have clinical features similar to lumbar disc herniation, such as abnormal sensation in the lower extremities, radicular pain, weakened muscle force, weakened or absent knee tendon reflex and Achilles tendon reflex, and positive straight leg raise test, which are difficult to distinguish.
Some patients have progressive weakness, numbness and radiating pain in the lower extremities. Perception is abnormal or diminished. Numbness may gradually progress upward from the feet to the calves, thighs and lumbosacral region. When doing lumbar hyperextension movements can cause increased numbness and pain in the lower extremities, this is a positive hyperextension test, which is an important sign for the diagnosis of spinal stenosis.
2.Intermittent claudication of neurogenic origin
Intermittent claudication caused by compression of lumbosacral nerve roots is called neurogenic intermittent claudication, which is the most characteristic symptom. With the aggravation of the lesion, the patient will gradually develop intermittent claudication: walking tens of meters or a hundred meters with lower limb soreness, weakness, pain or even numbness, unstable gait, and difficulty in continuing to walk; the symptoms can be relieved or disappear after sitting or squatting to rest, but the above performance can be repeated after continuing to walk.
Many patients like to lean forward when walking, which is a kind of postural compensation for pain relief. By leaning forward or bending forward, the tissue behind the spinal canal is elongated, the content of the spinal canal is reduced, the prolapsed disc is retracted, etc., and the volume of the spinal canal is relatively increased, the compressed nerves are temporarily decompressed, and the pain can be relieved. Therefore, the patient’s symptoms can be relieved in flexion positions such as walking up hills, riding bicycles, and walking up stairs. The symptoms are aggravated during downhill and posterior extension of the spine. This is because when the lumbar spine is posteriorly extended, the lumbar spinal space widens anteriorly and narrows posteriorly, often causing the lumbar intervertebral disc and the fibrous ring to protrude into the spinal canal, which further narrows the spinal canal and irritates or compresses the nerve roots. When the lumbar spine is posteriorly extended, the nerve roots become shorter and thicker and are easily compressed to produce symptoms of nerve root or cauda equina irritation. The nerve root is easily compressed, resulting in nerve root or cauda equina irritation.
Due to the above characteristics, people suffering from lumbar spinal stenosis tend to have more and heavier self-conscious symptoms, but when they come to the hospital for bedside examination, the clinical signs of the patient have either been relieved or have disappeared. Positive signs are lighter and less frequent.
In addition to a positive posterior extension test, clinical signs often include a positive or negative straight leg raise, often the same on both sides. Tendon reflexes are abnormal, etc.
3. Cauda equina syndrome
When the contents of the spinal canal severely compress the cauda equina nerve, it manifests as numbness and tingling in the perineum, sphincter weakness, urinary and faecal function and sexual dysfunction, etc., which seriously affects the quality of life. Early surgical treatment is required.
Disease treatment
(i) Conservative treatment
Most patients with lumbar spinal stenosis can get significant relief after conservative treatment, which mainly includes
1. Bed rest.
Generally take the flexed hip and knee position to lie on the side, and the symptoms can be relieved or disappear after 3 to 5 weeks of rest. For the elderly, long-term bed rest is likely to cause muscle atrophy, deep vein thrombosis and pneumonia and other complications, it is recommended that it should not exceed 2 to 3 weeks.
2. Drug treatment.
Relaxing and activating the muscles, blood circulation and blood stasis drugs and anti-edema drugs; appropriate amount of non-steroidal anti-inflammatory drugs.
3. Functional exercise.
Straight leg raise exercise: lie on your back, straighten your legs together, raise them upward, 30 degrees, and keep them down for a period of time. Can enhance the abdominal muscle strength, antagonize the mechanical pressure on the spinal canal by the nerve tissue.
Knee-holding pressure knee-holding rolling waist method: the patient lies on his back, fully flexing both knees and both hips, the doctor or family members hold the patient’s sacrococcygeal region with one hand, place one hand on the patient’s calf to fix the lower limb, repeatedly press the calf, so that the lumbar region is rhythmically flexed and relaxed, about 1~3 minutes. Then do the knee rolling method, also lying on the back, fully flexing the knee and hip joints, holding the calf with both hands, the doctor or family members hold the patient’s neck and back with one hand, hold the patient’s sacral area with the other hand or hold the patient’s calf with both hands, so that the patient’s lumbosacral area is repeatedly rolled back and forth on the bed for 1~3 minutes. Or hold the calf, bend the body in a shrimp shape and rock back and forth by oneself. The above functional exercises are done in sequence once a day, five times a week, for 4 weeks for a course of treatment. The mechanism is that the hypertrophied ligamentum flavum is stretched and thinned in the forward flexion position, reducing the degree of projection into the vertebral canal and the lordosis of the upper and lower synapses, and widening the lateral saphenous fossa, increasing the effective volume of the vertebral canal and lateral saphenous fossa, which not only reduces the degree of pressure on the dural sac and nerve roots, but also promotes blood circulation, improves microcirculation, removes venous stasis, and promotes the removal of painful metabolic waste, thus eliminating pain and intermittent It also promotes blood circulation, improves microcirculation, removes venous stasis, and promotes the removal of painful metabolic waste, thus eliminating clinical symptoms such as pain and intermittent claudication.
Straight-leg elevation ankle dorsiflexion exercise: the patient lies on his back, and both lower limbs are alternately elevated to 90 degrees with the best effort, and the ankle is dorsiflexed with force, to the extent of obvious pain. Once a day in the morning and evening, 10~30 strokes each time. This kind of exercise not only can make the nerve root and the pressure-causing object produce relative displacement, make the nerve root detach or reduce the compression, loosen the adhesion of the nerve root, but also can promote the blood circulation of the nerve root itself, and promote the inflammation of the nerve root to subside.
4. Physiotherapy, massage, traction, external application of drugs, etc.
5, brace application: lumbar circumference (or lumbar spine protective brace) can reduce the spinal movement of the joint protrusion and intervertebral disc on the cauda equina nerve root dynamic pull and compression. But should not be applied for a long time, easy to cause muscle atrophy.
6, epidural interstitial injection of steroid drugs can play a local anti-inflammatory effect, is not the ideal method. Some patients temporarily relieve pain, and have seen aggravation and paralysis after intra-sacral canal injection. Multiple injections cause nerve adhesions and increase the difficulty of surgery.
(ii) Surgical treatment
If conservative treatment is ineffective for 3 months, and the self-conscious symptoms are obvious and persistently aggravated, affecting normal life and work; or if there is obvious nerve root pain and clear neurological damage, especially serious damage to the cauda equina, as well as progressive aggravation of lumbar spine slippage and scoliosis with corresponding clinical symptoms, surgery is needed.
1. Indications for surgery.
(1) Restriction of daily activities or unbearable pain, and failure of systematic non-surgical treatment.
(2) Progressive worsening of neurological symptoms, such as weakness of the quadriceps muscle and inability to dorsiflex the ankle joint.
(3) With cauda equina dysfunction.
(4) Most cases of mixed spinal stenosis.
2. Purpose of surgery
To prevent further aggravation of dysfunction, reduce pain and improve the quality of daily activities.
3.Surgical procedure: Minimally invasive decompression or fusion is recommended.