Low back pain is the most common painful disease in outpatient clinics. Most of them cannot find the exact cause, and the effect of traditional conservative treatment is poor or unsustainable, and all those who have recurrent episodes of low back pain and are not relieved by conservative treatment for more than one month are called intractable low back pain. The authors applied radiofrequency thermal coagulation to destroy the posterior branch of the spinal nerve to treat 116 cases of intractable low back pain and obtained good results, which are reported as follows.
1. Clinical data.
1.1 General data: Among 116 cases, 66 were male and 50 were female, the shortest duration of the disease was 3 months and the longest was 26 years, the youngest was 17 years old and the oldest was 65 years old, 102 cases of unilateral lumbago and 14 cases of bilateral lumbago were diagnosed as acute and chronic sprain, 24 cases of lumbar muscle strain, 16 cases of lumbosacral strain, 6 cases of interspinous ligament strain, 18 cases of third lumbar transverse synovial syndrome, 18 cases of small joint syndrome 22 cases of epiglottic neuritis.
1.2 Clinical manifestations: recurrent episodes of low back pain, conservative treatment for more than one month, difficulty in sitting, turning and walking, aggravation of symptoms with position change, pain area limited or extensive, may be accompanied by ipsilateral hip, hip and posterior and lateral femoral pain, and its characteristic performance is pain over the knee.
1.3 Physical signs: There are pressure pain points in a vertebral body ipsilateral to the painful area of the chief complaint and three segments upward, i.e., pressure pain at three points of the spinous process, the affected small joint and the affected transverse process of the vertebral body, and radiating to the painful area of the chief complaint, among which, the pressure pain at the root of the lateral transverse process of the articular eminence is the most obvious, and this point is the body projection of the main trunk of the posterior branch of the spinal nerve crossing the transverse process of the inferior vertebral body, i.e., the primary pain point.
1.4 X-ray: it is often seen that there are signs of vertebral body rotation at the pressure pain, and the orthopantomograph shows unequal distance of bilateral arch roots from the outer edge of the ipsilateral vertebral body and unequal small joint gaps, and the lateral film shows double shadow signs at the posterior edge of the vertebral body.
1.5 Diagnosis: Based on the medical history, physical signs, x-ray and excluding inflammation, tumor, tuberculosis, disc herniation, spondylolisthesis and other diseases, the diagnosis of intractable low back pain can be made.
1.6 Efficacy evaluation: excellent: pain disappears and normal work and life is resumed; good: pain is significantly reduced and basic work and life is resumed; poor: pain is not significantly reduced and daily work and life is affected.
2.Treatment methods.
2.1 Fixing point: after fixing the large head pin with adhesive tape at the primary pain point, routinely take a positive and lateral lumbar spine film, and on the ortho-x-ray film of equal proportion or converted into equal proportion, set the intersection of the outer edge of the inferior superior lumbar articular process and the upper edge of the transverse process of the posterior spinal nerve branch as point A. After drawing a horizontal line through point A and intersecting the line of the spinous process {mostly at the upper edge of the inferior spinous process}, the intersection point is set as point B, and measure the length of AB.
The patient was placed in a prone position with a pillow under the abdomen, and the position of the superior margin of the inferior lumbar spinous process of the posterior branch of the diseased spinal nerve was repeatedly verified at point B. A horizontal line was drawn to the affected side, and the position of point A was determined according to the length of AB, which was the skin projection of the intersection of the outer margin of the superior articular eminence and the superior margin of the transverse process.
2.2 Anti-inflammatory and analgesic solution preparation: (1) 2% lidocaine 3ml, vitamin B121mg, trimethoprim 20mg (Yunnan Kunming), diluted to 10ml with saline; (2) 2% lidocaine 3ml, vitamin B121mg, Depo-Provera (compound betamethasone sodium phosphate) 7mg, diluted to 10ml with saline.
2.3 Puncture and radiofrequency destruction: through the A point with 0.8*12# radiofrequency needle stabbed vertically, meet the bone that is the base of the transverse process, the needle slightly oblique to the head end with a sense of falling, proving that the needle is in the upper edge of the transverse process, the needle slightly oblique to meet the bone that is the lateral edge of the upper articular process, remove the needle core, connect the radiofrequency instrument, set the radiofrequency parameters for 0.5v-50Hz, 2v -If the patient reported pain in the ipsilateral buttock, hip and posterior and lateral femur and did not radiate below the knee, the puncture was confirmed to be in place. The posterior branch of the spinal nerve was destroyed by radiofrequency at 70°-30″, 80°-30″ and 90°-180″, respectively. After completion of RF, 10 ml of anti-inflammatory and analgesic solution was injected.
3. Results.
A total of 116 cases were treated, including 102 cases unilaterally and 14 cases bilaterally, the pain disappeared in 92 cases after one treatment, and 24 cases were treated twice after one week, with an excellent rate of 100% and no complications such as nerve and blood vessel injury and infection. 98 cases were followed up after 6 months, with an excellent rate of 96%.
4. Discussion.
There are many causes of low back pain, and only 15-20% of them can be found clearly, such as tumor, infection, rheumatism, osteoporosis, intervertebral disc protrusion, spinal stenosis, fracture, etc. The majority of low back pain cannot find a clear cause yet, and there are many traditional diagnoses of these low back pain, such as acute and chronic sprain, lumbar muscle strain, sacroiliac strain, lumbosacral strain, interspinous ligament strain, third lumbar transverse process These diseases are commonly referred to as persistent low back pain because of the poor efficacy and recurrence of traditional conservative treatment.
Traditional treatment for low back pain is to treat which pain, including Chinese massage, acupuncture, physiotherapy, local closure, nerve block, sacral injection, application of painkillers, etc. Traditional conservative therapy is easy but ineffective or not lasting, and the current more advanced treatment is minimally invasive interventional therapy, such as radiofrequency thermal coagulation, freezing, and chemical destruction, etc. Minimally invasive interventions need to be performed under c-arm or cT guidance, while freezing and chemical destruction are not easy to control the extent of destruction. Therefore, the authors explored a new method of radiofrequency thermal coagulation to destroy the posterior branch of the spinal nerve in the treatment of intractable low back pain.
Regarding the etiology of low back pain, recent studies have found that it is related to the anatomical structures outside the spinal canal, among which the posterior spinal nerve branch entrapment has attracted clinical attention. A review of the anatomy shows that the spinal nerve is divided into two branches laterally in the intervertebral foramen, the anterior branch is thick and constitutes the lumbosacral nerve, the posterior branch is small and travels posteriorly through the osteofibular foramen and divides into medial and lateral branches in the intertransverse process ligament, the posterior medial branch is at the root of the transverse process and spans three vertebrae from superior to inferior via the osteofibular canal between the mastoid process and the paraspinal process;
The posterior lateral branch travels downward and posteriorly next to the back of the inferior transverse process and sends many small branches into the adjacent tissues along the way. Therefore, when the posterior branch of the spinal nerve is stuck or inflamed, symptoms may appear in the lumbar, hip, sacral, hip and thigh areas.
Radiofrequency treatment technology has the characteristics of minimally invasive, rapid pain relief, etc. With the function of electrical stimulation test of radiofrequency instrument, the electrode needle is kept away from the motor nerve, and by adjusting the size of radiofrequency output power and setting the action temperature, the scope of destruction can be precisely controlled, so that only the nociceptive fibers are destroyed and not the motor fibers, thus achieving a long-term therapeutic effect. Injection of anti-inflammatory and analgesic solution can reduce local edema and eliminate local sterile inflammation.
The puncture method designed by the authors can be performed on an outpatient basis without the use of c-arm or cT equipment, which has the advantages of avoiding radiation, easy operation, short time, less pain, and high cure rate, and has clinical promotion value.