Lumbar spinal stenosis (Lumbar spinal stenosis) refers to degenerative changes in the lumbar spinal canal, nerve root canal, lateral saphenous fossa or intervertebral foramen, resulting in abnormal morphology and volume of bony or fibrous structures, causing narrowing of the canal lumen, resulting in nerve root and cauda equina compression and corresponding clinical symptoms. It is a common disease causing back and leg pain, mostly in the middle-aged and elderly, with about 80% occurring between the ages of 40 and 60, more common in men than women, and more common in manual laborers. It belongs to the category of “paralysis” and “back and leg pain” in Chinese medicine. According to Chinese medicine, the main internal causes of this disease are congenital deficiency of kidney qi, deficiency of kidney qi in later life, and strain injury to the kidney. Repeated trauma, chronic strain and injury, as well as the attack of wind, cold and dampness are the common external causes. The main pathological mechanism is kidney deficiency, blocking the meridians and channels, blocking the flow of Qi and blood, resulting in paralysis and pain in the tendons and veins of the lower back and legs. The disease is based on kidney deficiency, phlegm and stasis as the standard, or mixed with wind, cold, dampness and other evils for the subtlety of the evidence of the deficiency. Modern medicine believes that the disease is mainly divided into three types: congenital, secondary, and mixed with two factors, of which lumbar degeneration is the main cause of lumbar spinal stenosis. Due to the degeneration of the lumbar intervertebral disc, the lumbar vertebral body is destabilized, followed by hyperplasia and degeneration of the posterior edge of the vertebral body, narrowing of the intervertebral space, thickening of the ligament and the vertebral plate, hyperplasia and coalescence of the small synapses or degenerative slippage of the vertebral body, etc., all of which reduce the internal diameter of the lumbar spinal canal to varying degrees and cause compression of the cauda equina or nerve roots. In addition, developmental spinal stenosis, such as congenital shortening of the pedicle, and medical spinal stenosis, such as scar tissue proliferation and adhesions in the spinal canal caused by postoperative lumbar spine surgery, can also lead to this disease. Usually, there is a certain buffer space between the fibrous tissue of the spinal canal and the dura mater, and when the stenosis is mild, the cauda equina and nerve roots are not yet compressed, so no clinical symptoms are produced. When the stenosis reaches a certain level, the cauda equina and nerve roots become more ischemic and hypoxic due to the compression, and then neurological dysfunction occurs. The lesions are most common in the lumbar 4 and 5 planes, followed by the lumbar 5-sacral 1 and lumbar 3 and 4 planes. Clinical manifestations and diagnosis The main symptoms are chronic recurrent low back pain and lower extremity paralysis. The pain is relieved or disappears after resting or bending, and worsens when standing, extending back or walking. Patients often complain of difficulty walking with a straight back, often in a forced forward flexion position. Intermittent claudication is the main feature of the disease, often after walking unilateral or bilateral lower limb paralysis, heaviness, weakness, need to squat or sit down to rest for a period of time after the symptom relief, if continue to walk the same symptoms. Patients with milder disease generally do not show signs of neurological dysfunction, such as lower extremity muscle weakness, sensory impairment, and negative straight leg raise test and femoral nerve pull test, so there are many subjective symptoms but few objective signs. In severe cases, incomplete paralysis of both lower extremities, numbness in the saddle area, difficulty in urination, loss of sensation in the limbs and dysfunctional bowel movements may be associated with the disease. The diagnosis of this disease requires a combination of imaging examinations, mainly including the following X-ray examinations Six-position X-ray examination of the lumbar spine is routinely required. Orthopantomographs of the lumbar spine can show different degrees of osteophytes, hypertrophy of the articular processes, or secondary lumbar lateral deformities, etc. Lateral radiographs can show narrowing of the vertebral space in the corresponding segment, shortening of the vertebral arch and slipping of the lumbar spine, etc. Power radiographs can clarify whether there is vertebral body loosening, and double oblique radiographs can clarify whether there is an isthmic fracture of the vertebral arch. The commonly used contrast agent is Amipaque, a non-ionized contrast agent with good water solubility, low toxic side effects, and good neurological and systemic tolerability. In cases of spinal stenosis, the iodine column shows varying degrees of filling deficiency or even complete obstruction. Spinal stenosis can be diagnosed when the anteroposterior diameter of the lower lumbar segment is less than 8 mm on lateral radiographs. CT CT and spiral CT can accurately determine the shape and canal diameter of the spinal canal, and can clearly show the pathological changes such as bony bulge at the posterior edge of the vertebral body, hyperplasia and coalescence of small joints, and stenosis of the lateral saphenous fossa, but they are not satisfactory for soft tissue changes. MRI MRI examination has the advantage of multi-parameter imaging, high contrast, no bone artifacts, through sagittal and horizontal tomography, can clearly show the degree of intervertebral disc degeneration, as well as soft tissue changes such as ligamentum flavum hypertrophy, can also show the extent of long segment or jump lesions, as well as spinal cord pathological changes signal, etc., in which water imaging technology can replace invasive examination spinal canal angiography, but more expensive. The signs and symptoms of lumbar spinal stenosis are inconsistent. Intermittent claudication is the main feature of the disease, and the diagnosis of lumbar spinal stenosis is first considered in patients over 40 years of age with onset of lumbar pain with bilateral lower limb paralysis and normal lumbar forward flexion with intermittent claudication. It is mainly differentiated from lumbar disc herniation and thrombo-occlusive vasculitis. Treatment The vast majority of patients with lumbar spinal stenosis can recover well through conservative treatment, and only 10% to 15% of patients require surgical intervention. Early stage lumbar spinal stenosis, where the stenosis has not yet formed a persistent compression, can be treated non-operatively. If the patient has no obvious effect after conservative treatment and shows progressive lower limb weakness or cauda equina syndrome, early surgical treatment is required. This disease is based on kidney deficiency, and wind, cold and dampness are the symptoms. Chinese medicine treatment is based on tonifying kidney qi, and according to the strength of kidney qi, the strength and weakness of yin and yang, toning and supplementation are given to achieve the effect of strengthening the kidney and fixing the governor. At the same time, according to the characteristics of the long-standing disease, the kidney should be tonified at the same time to invigorate the blood and open the ligaments, so as to balance the symptoms and the root cause. (A) Wind-cold paralysis. Soreness and swelling of the lower back and legs with indefinite pain, sometimes light and sometimes heavy, restrained and uncomfortable, aggravated by cold, relieved by warmth and pain. The tongue is pale, with thin white or white greasy coating and sunken tight pulse. Treatment is to expel wind and remove dampness, relieve paralysis and relieve pain. The formula is Duluxiaosheng Tang with addition and subtraction. If the pain in the lower extremities is severe, add Dioscorea Z and Xian Ling Spleen to strengthen the efficacy of dispelling wind and dampness; if the pain in the lower extremities is severe, add Centipede and Scorpion to open the channels and relieve pain. The Chinese patent medicine is used to stretch the tendon tablets. (2) Damp-heat paralysis Pain in the lower back and legs, with heat sensation in the painful area, or painful redness and swelling in the limbs, thirst, thirst for water, boredom, short urine and red stools, or urgent stools with heavy weight, red tongue, yellow greasy coating, slippery pulse. The treatment is to clear heat and dampness, promote circulation and relieve pain. The formula is Qing Huo Li Damp Tang with addition and subtraction. If the moss is yellow and greasy, add cardamom seeds and bamboo rhizome to aromatize dampness; if the leg paralysis and pain are obvious, add centipede and wuzhu snake to open the channels and relieve pain. If the pain is obvious, add centipede and wuzhu snake to relieve pain. (C) Qi stagnation and blood stasis. Recent history of trauma to the lumbar region, severe pain in the lumbar region, stabbing pain, difficulty in lifting and lowering the lumbar region, refusal to press on the painful area, purple and dark tongue, or petechiae, thin white fur, thin string pulse. This formula is based on Fuyuan Revitalizing Blood Soup with addition and reduction. If the pain is obvious, add Xiang Xiang and Ze Lan to strengthen the flow of Qi and Blood to relieve pain. The Chinese herbal medicine is Yuan Hu pain relief tablets. (D) Kidney Qi deficiency. Recurrent attacks of lumbar and leg pain, weakness of the lumbar and leg, worse in case of exertion, relieved when lying down, short of breath, muscle C-cutting. Pale tongue, thin coating, sunken pulse. The treatment is to nourish kidney yin in favor of yin deficiency. The formula is Zuo Gui Wan plus or minus. If the face is white, the spirit is tired and dull, add Astragalus and Radix Codonopsis to nourish the qi and blood; if the mouth and throat are dry, add Mai Dong and Xuan Shen to nourish the yin and generate fluid. The treatment for those who favor Yang deficiency is to warm the kidney yang, the formula is chosen from the Right Return Pill plus or minus. If the food is low and the stool is loose, add Radix et Rhizoma ginseng and Radix et Rhizoma spp. (later) to tonify the Qi and strengthen the spleen. Chinese herbal medicine is used for Yin deficiency with Liu Wei Di Huang Wan and Yang deficiency with Kidney Qi Wan. Western medicine treatment For the pain and paralysis is more can be used to anti-inflammatory and analgesic, reduce paralysis pain. Commonly used clinical drugs include: non-steroidal drugs, such as Furtalin; Micropoulos for obvious numbness of limbs. When the pain is severe and difficult to relieve, tramadol can be injected intramuscularly, and B to heptaosaponin sodium, mannitol, dexamethasone or methylprednisolone can be given intravenously to reduce neuroedema and relieve paralysis pain. Acupuncture and moxibustion treatment: Take Kidney Yu, Zhi Mou, Qi Hai, Zhen Men, Kun Lun and Huan Yu. The treatment should be carried out daily or every other day, 10 times for a course of treatment. Manual therapy can activate blood circulation and relax tendons, disperse blood stasis and loosen adhesions, so that the symptoms can be relieved or disappeared. Commonly used techniques include waist and hip kneading, point pressure, rolling, lifting and kneading. The manipulation should be gentle, prohibit strong rotational manipulation and lumbar spine posterior extension pressure to prevent aggravation of the disease. V. Lumbar spinal traction is suitable for early lumbar spinal stenosis, only the intervertebral space and nerve root canal stenosis, but not the central spinal stenosis. If the patient’s symptoms worsen after traction, it is not advisable to continue traction. Common traction methods include electric pelvic traction and vertical traction with one’s own body weight. Sixth, physical therapy Clinical methods commonly used include spectral or divine light irradiation, electromagnetic therapy, laser and low-frequency therapy, wax therapy, Chinese medicine ion introduction method, etc. VII. Closure therapy For patients whose clinical symptoms cannot be relieved and whose pain is heavy, epidural closure therapy can be tried to eliminate swelling of nerve roots, loosen adhesions and relieve symptoms. Operated by anesthesiologists, the commonly used drug is Depo-Provera 1mg plus 1% lidocaine 3ml, diluted to 10ml with raw saline, injected into the lumbar epidural cavity once a week for 2 to 3 times. Use with caution if you have hypertension or coronary artery disease. Eight, other therapies can be used depending on the situation, such as hot compresses, fire cans, water acupuncture, etc., all have a certain effect of pain relief. Surgical treatment The fibrous stenosis of the lumbar spinal canal generally does not lift by itself, so surgery is recommended for those with persistent compression and severe symptoms, or those for whom systematic conservative treatment is ineffective. The purpose of surgery is to relieve the compression of the nerve and its feeding vessels in the spinal canal. (A) Indications for surgery 1. severe pain or numbness, shortening walking or standing time, affecting daily life; 2. non-surgical treatment for more than 3 months or aggravation of symptoms, progressive lower limb nerve function changes; 3. with cauda equina syndrome. (2) Contraindications to surgery 1.Poor physical condition, can not tolerate surgery; 2.Severe combined heart, brain, liver, kidney and other important organ function damage, still in the decompensated stage; 3.With mental disorders. (C) Surgical procedures 1.Simple decompression of the vertebral plate is suitable for single or double segmental spinal stenosis, involving unilateral limbs, not combined with disc herniation or lumbar instability; 2.Submerged decompression of the bilateral vertebral plate is suitable for single or multi-segmental spinal stenosis, involving both lower limbs, not suitable for total decompression of the vertebral plate, such as combined with obvious osteoporosis, the elderly and frail. 3.Total decompression of the vertebral plate by laminectomy, internal arch nailing, intervertebral body (or or intervertebral body) fixation 3.Total laminectomy and decompression, internal arch nailing, intervertebral (or intertransverse) bone grafting and fusion are suitable for patients with central spinal stenosis, combined with lumbar instability or degenerative slippage. Most patients with lumbar spinal stenosis are middle-aged and elderly, often combined with hypertension, heart disease, diabetes mellitus and other medical diseases, so attention should be paid to the collection of medical history and detailed physical examination before surgery, and timely consultation with relevant departments should be requested to assist in the treatment. Preoperative blood pressure and coagulation should be controlled within the normal range, and fasting blood glucose should be controlled within 8 mmol/L for diabetes mellitus. Preoperative antibiotics should be applied prophylactically to reduce the chance of infection, and intraoperative attention should be paid to the positioning of surgical segments and monitoring of vital signs. In the early postoperative period, patients are often depleted of vital energy due to blood loss and surgical trauma, resulting in postoperative fatigue syndrome such as deficiency of qi and blood, so attention should be paid to the regulation of the patient’s overall status, as well as the prevention of postoperative nerve root adhesions and edema. During the postoperative recovery period, the patient’s demand for nutrients increases, and the intake and transportation functions of the spleen and stomach are relatively inadequate, so attention should be paid to the use of strengthening the spleen, promoting the flow of qi and resolving dampness to accelerate the patient’s recovery. Prevention and conditioning Patients are mostly combined with different degrees of lumbar degeneration, so pay attention to lumbar maintenance, avoid bending and lifting heavy objects, avoid sitting and walking for a long time, appropriate functional exercises for the lumbar back muscles, stay away from damp and cold places, and encourage patients to swim and exercise in a constant temperature pool. Prognosis and regression The prognosis of patients with lumbar spinal stenosis is good. After systematic conservative treatment, patients with milder lesions will have significantly reduced lumbar pain, improved intermittent claudication, and restored muscle strength and sensation in the innervated area. In patients with more severe lesions, the symptoms of lumbar pain and intermittent claudication will gradually disappear after timely surgical treatment, and they can generally engage in normal physical activities after six months.