Lumbar spinal stenosis is a series of low back pain and a series of neurological symptoms caused by various forms of narrowing of the spinal canal, neural canal, and intervertebral foramen, as well as soft tissue-induced changes in the volume of the spinal canal and narrowing of the dural sac itself. This is called lumbar spinal stenosis.
Because of the narrowing of the spinal canal, the cauda equina nerve in the spinal canal is compressed, resulting in symptoms such as low back pain and leg pain. If the spinal canal is narrowed on the lateral side, the nerve roots will also be compressed, causing interruption of the axial pulp due to pressure; obstruction of nerve fluid flow; relative swelling of the nerve sheath; stimulation of nerve endings; tissue hypoxia due to obstruction of blood flow; and local stasis due to restricted venous return, which constitute the causes of low back pain.
Lumbar spinal stenosis
Lumbar spinal stenosis refers to the abnormal structure of the spinal canal caused by primary or secondary factors, narrowing of the spinal canal cavity, and the appearance of low back and leg pain mainly characterized by intermittent claudication.
What are the categories of lumbar spinal stenosis?
According to the international classification, it is divided into the following categories.
(1) Stenosis due to degeneration of the spine: thickening of the vertebral plate and hyperplasia of the vertebral body due to age-related changes and strain, resulting in volumetric reduction of the spinal canal, stenosis, hypertrophy of the small joints and hypertrophy of the ligamentum flavum, etc.
(2) Stenosis due to compound factors: stenosis due to congenital and acquired deformities, stenosis due to disc herniation that reduces the volume of the spinal canal, or stenosis due to a combination of disc herniation and mild stenosis of the spinal canal.
(3) Stenosis due to spondylolisthesis (degenerative) and osteolytic disease.
(4) Stenosis of medical origin: postoperative osteophytes and scar growth adhesions caused by myelin injection, etc.
(5) Injurious stenosis: such as compression fracture and fracture dislocation.
(6) Others: deformational osteitis (Pagets disease) has spinal deformation and the spinal canal can be narrowed; fluorosis can also cause hyperplastic deformation and cause stenosis. What are the causes of lumbar spinal stenosis?
From the perspective of modern medicine, the common etiologies of lumbar spinal stenosis are as follows.
(1) Developmental lumbar spinal stenosis: This spinal stenosis is caused by congenital developmental abnormalities.
(2) Degenerative lumbar spinal stenosis: It is mainly caused by degenerative lesions in the spine.
(3) Spinal slip lumbar spinal stenosis: When spinal slip occurs due to discontinuity or degeneration of the lumbar isthmus, the spinal canal is further narrowed due to anterior and posterior displacement of the upper and lower spinal canal, while the spinal slip can promote degeneration and aggravate spinal stenosis.
(4) Traumatic spinal stenosis: Spinal stenosis is often caused by trauma to the spine, especially when the spine is fractured or dislocated due to severe trauma.
(5) Medically induced spinal stenosis: In addition to surgical errors, it is mostly caused by hypertrophy of the interspinous ligament and ligamentum flavum after spinal fusion or thickening of the vertebral plate in the bone graft, especially after decompression of the posterior vertebral plate and then local bone graft fusion, which results in narrowing of the spinal canal and compression of the cauda equina or nerve roots, causing lumbar spinal stenosis.
(6) Various inflammatory diseases in the lumbar spine: including specific or non-specific inflammation, neoplastic organisms in the spinal canal or on the canal wall can cause spinal stenosis. Various deformities such as senile hunchback, scoliosis, ankylosing spondylitis, fluorosis, Paget’s disease and vertebral joint loosening can all cause spinal stenosis.
From the perspective of Chinese medicine, congenital kidney deficiency, kidney deficiency, and strain injury to the kidney are intrinsic factors in the development of the disease. If repeatedly suffered from trauma, chronic strain, and the attack of wind, cold and dampness as the external factors of its development. The pathological mechanism is kidney deficiency, wind, cold and dampness blocking the ligaments, Qi stagnation and blood stasis, and Ying and Wei not being able to promote the flow, resulting in paralysis and pain in the back and legs.
What are the key points in the diagnosis of lumbar spinal stenosis? The main symptoms of lumbar spinal stenosis are chronic and recurrent lumbar pain and intermittent claudication. The nature of the pain is soreness or burning pain, some of which may radiate to the outer thighs or front, mostly bilaterally, and may alternate between the left and right legs. When standing and walking, lumbar and leg pain or numbness and weakness appear, pain and limp gradually worsen, even can not continue to walk, the symptoms improve after rest, riding a bicycle without hindrance. In severe cases, it may cause urinary urgency or difficulty in urination. Some patients may develop muscle atrophy of the lower limbs, with the most obvious being the tibialis anterior and extensor muscles, hyperalgesia, dull knee or Achilles tendon reflexes, and positive straight leg raise test. However, some patients have more complaints and do not have any positive signs.
Taking frontal, lateral and oblique X-ray of the lumbar spine can help in diagnosis, and changes such as narrowing of the intervertebral space, osteophytes, slipped vertebrae, increased lumbosacral angle and hypertrophy of small articular processes are often seen between lumbar 4 to 5 and lumbar 5 sacral 1. Intradural imaging, CT, and MRI can help clarify the diagnosis.
What is intermittent claudication?
Intermittent claudication is a condition in which the patient starts walking, or after walking a certain distance (usually about several hundred meters), unilateral or bilateral lumbago, numbness and weakness of the lower limbs, or even limping, but after a little squatting or sitting down to rest for a moment, the symptoms can be relieved or disappear quickly, and the patient can continue walking, and then after walking for a period of time, the above symptoms reappear. Because of the intermittent appearance of claudication in this process, it is called intermittent claudication.
The appearance of intermittent claudication is mainly due to the pathological basis of the existing stenosis of the lumbar spinal canal, the increased pressure load on the vertebral body and nerve roots when upright, plus the stretching and contraction activities of the muscles of the lower limbs during walking to further promote the physiological congestion of the blood vessels in the nerve roots of the corresponding spinal ganglia in the spinal canal, followed by venous stasis and ischemic radiculitis due to the blockage of microcirculation in the corresponding areas after the nerve roots are strained, resulting in When the patient squats, sits down or lies down, the pressure load on the nerve root is reduced, the source of stimulation during muscle activity is eliminated, and the ischemic state of the spinal cord and nerve root is improved, so the symptoms are reduced and disappear. When walking again, the above-mentioned symptoms appear again, and then rest, the symptoms are relieved again, and so on, alternately, forming intermittent claudication. It is one of the main clinical features of lumbar spinal stenosis.
How to identify intermittent claudication?
Lumbar spinal stenosis manifests as neurological intermittent claudication, which is different from vascular intermittent claudication (e.g. thrombo-occlusive vasculitis), and is distinguished mainly in the following aspects.
(1) neurogenic intermittent claudication has good dorsalis pedis artery pulsation, while vascular intermittent claudication has diminished or absent dorsalis pedis artery pulsation.
(2) The lower extremity of neurological intermittent claudication may have segmental sensory deficits, while vascular intermittent claudication is a garter-type sensory deficit.
(3) The walking distance of neurological intermittent claudication is gradually shortened with the prolongation of the disease, while vascular intermittent claudication is not obvious.
(4) If necessary, arteriography is feasible; neurogenic intermittent claudication has good arteries, and vascular intermittent claudication can show arterial lumen narrowing areas.
How to treat lumbar spinal stenosis?
Lumbar spinal stenosis is one of the conditions leading to chronic low back pain, and the treatment of this disease mainly includes conservative treatment and surgery.
The commonly used conservative treatments are.
(1) Manipulative treatment: The purpose of manipulative treatment is to activate blood circulation and relax tendons, disperse blood stasis, and loosen adhesions, so that the symptoms can be relieved. Commonly used techniques are pressing and kneading, 扌扌法, 拿法, rubbing, rubbing, and passive movement of lower limb flexion and extension.
(2) Acupuncture and moxibustion treatment: the acupuncture points of lumbar Yangguan, Kidney Yu, Large Intestine Yu, Qihai Yu, Life Gate, Huanjiao, Fengshi, Guizhong, Kunlun, etc. should be taken once a day, 10 times for a course of treatment.
(3) Drug therapy: Analgesic and anti-inflammatory drugs such as Fotarine and Fenbid can be used for aseptic inflammation of nerve roots. Chinese medicine treatment should be warming the meridians, strengthen the tendons and bones, can be used to supplement the kidney and strengthen the tendons soup plus reduction, commonly used drugs such as Shu Di, gun ginger, Du Zhong, cow knee, system dog spine, sequesters, etc.. If there is deficiency of qi and blood, add Astragalus, Radix Codonopsis, Radix Angelicae Sinensis and Radix Paeoniae Alba. For those who have cold pain in the back and legs, add chicken blood vine, douhu, gui zhi, epimedium, etc.
(4) closed treatment: epidural closure can be used to eliminate swelling, loosen adhesions and relieve symptoms, commonly used prednisolone acetate 12.5mg plus 1% procaine 10ml, once a week.
(5) medical sports: can strengthen the back extension muscle, abdominal muscle muscle exercise, so that the stability of the lumbar vertebrae increased, thus delaying the rate of evolution of lumbar joint degeneration. Playing Taijiquan has a better effect on this disease.
(6) Surgery: If the above conservative treatment is invalid or the effect is not obvious, surgery can be considered.
What are the indications for surgery for lumbar spinal stenosis?
The indications for surgery are
(1) Back and leg pain after activity, which affects life and work and is not cured by conservative treatment.
(2) Progressive claudication worsens, or the standing time is gradually shortened.
(3) Nerve function is significantly deficient.
The purpose of surgery is to relieve the compression of nerve tissue and blood vessels in the spinal canal, nerve root canal or intervertebral foramen. The common surgical procedures are laminectomy and nerve root decompression.
What is lumbar spinal canal lateral saphenous stenosis?
In some clinical cases, a lumbar disc herniation is diagnosed before surgery, but intraoperatively there is no herniated disc or only a small protrusion, and the main lesion is lateral stenosis of the spinal canal compressing the nerve roots, which is called lateral saphenous stenosis to distinguish it from main spinal stenosis.
Lateral saphenous fossa refers to the narrowing of the spinal canal extending laterally, mainly in the trilobar spinal canal, most typically in the lower two lumbar vertebrae. The lateral saphenous fossa is generally considered to be narrow if the anterior and posterior diameters are less than 3 mm, normal if they are more than 5 mm, and relatively narrow if they are in between.
So, why is the lateral saphenous fossa narrowed? Congenital factors can cause lateral saphenous stenosis. The deep lateral saphenous fossa and small anterior-posterior diameter of the trilobar spinal canal are developmentally predisposed to stenosis. Another important factor contributing to stenosis is degeneration. Degeneration of the intervertebral disc with calcification of the fibrous annulus, hyperplasia of the posterior superior edge of the vertebral body, which protrudes from anterior to posterior into the lateral saphenous fossa; supra-articular synapse of the inferior vertebrae after disc stenosis; hyperplasia of the isthmus, hypertrophy and calcification of the ligamentum flavum, which protrudes from posterior into the lateral saphenous fossa; and anterior or posterior slippage of the degenerated vertebral body can contribute to lateral saphenous stenosis. The high-tech products jointly developed by the Japanese bone disease expert group, the lumbar spine health combination, comprehensive multi-dimensional approach in the treatment of lumbar spine disease to obtain a world breakthrough, fundamentally solve the problem of lumbar spine disease is difficult to cure and easy to recur, by the world medical community as “no knife surgery”.
What is the manifestation of lumbar lateral saphenous fossa stenosis and how is it treated?
This disease occurs mostly in middle age and above, more men than women, which may be due to the fact that men are heavily burdened, the lower lumbar spinal canal is more clover-shaped, and the gap around the nerve roots is small, which is prone to compression symptoms.
Patients generally have a long history of low back pain and low back and leg pain, leg pain is often heavier than those with disc herniation, and exertion or trauma can induce pain or make symptoms significantly worse. Neurogenic intermittent claudication is progressive, and the claudication distance decreases from hundreds of steps to tens of steps, and is relieved after squatting or sitting down to rest. Lower extremity pain radiates along the lumbar or sacral innervation zone.
Lateral saphenous stenosis is a mechanical compression of the nerve root by adjacent structures and is not amenable to conservative treatment. Traction is only suitable for those with less severe compression. For diagnosed cases, surgical treatment should be chosen to completely relieve the nerve root compression, and surgical techniques should be refined to avoid unnecessary expansion of decompression, which may affect the stability of the spinal segments.
Are lumbar disc herniation and lumbar spinal stenosis the same thing?
Lumbar spinal stenosis refers to any form of narrowing of the spinal canal, nerve root canal, and intervertebral foramen due to congenital developmental causes or various factors of acquired degeneration, causing compression or irritation of the cauda equina or nerve roots and a series of clinical manifestations of the syndrome.
The clinical manifestations of lumbar spinal stenosis are
(1) Intermittent claudication: When the patient stands upright or walks, different sensations such as pain, numbness, heaviness, and weakness occur in the lower extremities that gradually increase, so that they have to change their posture or stop walking, and the symptoms can be alleviated or disappear after squatting or resting for a moment, and continue to stand or walk, and the symptoms reappear and are forced to rest again. Because of repeated walking and resting, the walking distance is gradually shortened. Intermittent claudication may not occur when climbing hills or riding bicycles.
(2) Lower back pain: Most patients with lumbar spinal stenosis have a history of lower back pain or are accompanied by lower back pain. The pain is generally mild and is relieved or disappears with bed rest, and the lumbar forward flexion is not restricted, while the posterior extension is often limited.
(3) Nerve root compression symptoms and signs: Nerve root canal stenosis causes corresponding symptoms and signs of nerve root compression or irritation. Some patients exhibit intermittent claudication, while others exhibit persistent radiological nerve root symptoms, mostly soreness, numbness, swelling, and tingling, with varying degrees of pain. The site of nerve root symptoms is related to the compressed nerve root, and manifests as decreased pinprick sensation, abnormal pain sensation, decreased muscle strength and abnormal tendon reflexes in the corresponding nerve root distribution area.
(4) Cauda equina compression: Lumbar spinal stenosis can lead to compression of the cauda equina nerve, with symptoms and signs in the saddle area and symptoms of the sphincter, and in severe cases, symptoms of urinary and fecal and sexual disorders.
Diagnosis of lumbar spinal stenosis: Appropriate auxiliary examination methods should be selected according to clinical manifestations, such as X-ray plain film, myelography, CT scan, CT myelography, MRI, etc. by various projection methods to make accurate localization, qualitative and quantitative diagnosis. The biggest difference with lumbar disc herniation is that lumbar disc herniation generally does not have the three major symptoms of intermittent claudication, inconsistency between the chief complaint and objective examination, and limitation of lumbar back extension. The flexion neck test and straight leg raising test of lumbar disc herniation are mostly positive, while the lumbar spinal stenosis is negative. In addition, there is a clear difference between lumbar spinal stenosis and lumbar disc herniation in imaging, i.e., lumbar spinal stenosis shows less than normal sagittal signs of the spinal canal on CT, MRI, and myelography, while lumbar disc herniation does not. The two are two separate diseases, but at the same time there is some connection, and they can occur together, and the percentage of concomitant occurrence is quite high, which is the reason why people tend to confuse them. This is because in the later stages of lumbar disc herniation, synovial inflammatory exudative reaction, articular cartilage wear and tear and fragmentation occur in the corresponding small joints, leading to the development of hyperplastic bone flaps at the lateral posterior edge of the vertebral body and at the articular eminence, secondary to lumbar spinal stenosis. When the two diseases occur simultaneously, the patient may show symptoms and signs of both, and clinical diagnosis is not difficult.