Selection of lumbocrural pain disease clinical treatment scheme

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Yaotuitong disease through clinical diagnostics and correct diagnosis, clear after thoracolumbar spinal ruled out due to extreme conditions


Yaotuitong disease through clinical diagnostics and correct diagnosis, clear after thoracolumbar spinal ruled out due to extreme conditions or specific lesions (tumors, vascular malformations, spinal cord lesions) caused by pain. After that, it is necessary to make appropriate treatment for various diseases. First of all, to determine whether the surgical indications, it is extremely important, otherwise it will delay the illness, according to the change of the illness and non operative methods and with different treatment methods that different diseases of different stages of the treatment program is different. To achieve targeted, short course of treatment, good curative effect, safe and reliable; for the cause and symptomatic, to achieve the purpose of repair and repair of damaged tissue function.

Theoretical basis of clinical treatment

The pathophysiology of tissue damage in the lumbar spinal canal

The primary factors of lumbar spinal canal were divided into two categories: (1) mechanical factors. Because the intervertebral disc prominent, hypertrophy of yellow ligament degeneration, posterior longitudinal ligament thickening, facet hypertrophy, mechanical compression or irritation of spinal canal stenosis caused by the extrusion can constitute damage to the nerve root, the dural sac or cauda equina. (2) biological factors. Neurogenic neurotransmitter produced by nucleus pulposus protrusion (substance P, vasoactive intestinal peptide, calcitonin gene related peptide and other inflammatory mediators) and immune responses (bradykinin, prostaglandin E1 and leukotriene B4, ACh) in the spinal nerve roots and dural sac by mechanical compression damage dysfunction before fat, connective tissue produced sterile inflammation more intense. In the epidural tissue inflammatory swelling, fibrosis, blood stasis ischemic demyelination pathological changes, thus nerve tissue is stimulated and irritability.

Clinical manifestations of two kinds of symptoms: (1) pain. Super sensitive nerve, ectopic impulses, manifested as back pain, hip pain or low back pain. (2) numbness and / or paralysis of the lower extremities. Loss of sensation or movement, such as weakness, muscle atrophy, tendon reflexes, etc.. And even cause cauda equina injury syndrome (stool dysfunction, lower limb paralysis, perineal sensory disorders). For the pathogenesis of the disease, the main clinical use of spinal reduction techniques (non surgical) or surgical decompression, so that the dural sac and nerve roots from the mechanical relaxation, improve blood supply, restore function. For the biological factors, the main use of epidural nerve block therapy or nucleus pulposus chemical dissolution (such as collagenase injection), to eliminate the pathological changes of aseptic inflammation, blocking the development of lesions. Symptomatic treatment can be used as appropriate, such as the use of anti-inflammatory analgesic drugs, peripheral transcutaneous electrical stimulation and other physical therapy can relieve pain, restore muscle and nerve function.

(two) the pathogenesis of lumbar soft tissue injury

The sequela of acute injury or chronic strain caused by soft tissue pain is the primary factor, the predilection site mainly in skeletal muscle and fascia periosteum in attachment. Due to the damage of tissue inflammatory swelling, blood stasis, necrotic tissue decomposition, the attachment of the nerve endings by aseptic inflammation and pain caused by chemical stimulation. In the local formation of regular soft tissue tenderness points, a three-dimensional area of pain, but also has the characteristics of distance. These lesions are upper respiratory tract infection, infection, fatigue or slight trauma, cold and wet outside stimulation can induce pain.

The pain caused by muscle cramps and muscle contracture with reciprocal causation. Chronic contracture of muscle degeneration can lasting mechanical compression or stretching around blood vessels and nerves, limb radioactivity can also clinically even numbness, weakness and atrophy, blood circulation disorders, such as distal limb cold, hematoma, dark, weak pulse and other disorders like ze. A lesion occurs in spine and pelvis power imbalance. At the same time, the body will cause the corresponding compensation adjustment (left and right, before and after) and series compensation adjustment (up and down), once lost compensation adjustment, one side of the secondary side of lumbago lumbago or abdominal pain, but also to the secondary back, neck, shoulder, upper limb pain or headache, to secondary sacral tail, the sacroiliac and hip, knee and ankle and foot pain like. For the early soft tissue damage, can perform tenderness point massage, drug injection and physical therapy; the median case can be used in spinal loosening techniques, silver needle loosening therapy, combined with traditional Chinese medicine and physical therapy for advanced soft tissue damage; degenerative contracture is serious, can be implemented in various parts of the soft tissue release surgery.

The majority of patients have both internal and external spinal cord tissue damage, treatment should be generally eliminated in the pathogenesis of spinal canal, and then remove the factors outside the spinal canal. If we can only eliminate the factors of spinal canal and not solve the external factors, it will even aggravate the soft tissue pain. The experiment proved that the stimulation of the anterior root of the spinal cord produces the impulse of the retrograde conduction along the motor neurons, which can reduce the excitability of motor neurons. The mechanism is due to motor neuron axon collateral discharge excited inhibitory interneurons in the spinal ventral horn of gray matter in the seventh layer (Renshaw cells) and to inhibit motor neurons caused by. So the single epidural nerve block for eliminating aseptic inflammation, but the return of the inhibition process decreased or disappeared, thereby enhancing the spinal soft tissue damage caused by muscle spasm, exacerbate the pain. On the other hand, modern electrophysiology that stimulation of low threshold myelinated primary afferent fibers, such as muscle I a and I B afferent fibers can reduce spinal dorsal horn nociceptive neuron response, on the contrary, blocking the myelinated fiber conduction can enhance the reaction of pain sensitive neurons of dorsal horn. Therefore, the inhibition of the damage of the fiber to the dorsal horn mainly occurred in the dorsal horn (SG). The use of epidural block is not the only way to treat mixed lesions of the lumbar spine.

Two, clinical treatment ideas

Thoracic and lumbar spinal canal tissue damage. In addition to a variety of diseases such as tumors, vascular malformations, demyelinating diseases, syringomyelia and other diseases, mainly for the treatment of lumbar disc herniation, spinal stenosis and cauda equina nerve damage. Indication of operation: (1) protrusion of intervertebral disc. Huge, ruptured or multiple segmental lesions; (2) severe stenosis of the spinal canal. The sagittal diameter of the main canal was less than 10mm or the diameter of the nerve root canal was less than 2mm (3). Perineal or perianal sensory loss, bladder dysfunction, and lower limb paralysis. Surgical methods: (1) conventional laminectomy. Fenestration, laminectomy, total laminectomy (2) laminectomy. Internal fixation or bone grafting (3) soft tissue of multi segmental intraspinal lysis (4) under diskoscope discectomy (4) percutaneous lumbar discectomy or high power laser surgery. Non operative treatment of lumbar canal lesions: epidural drug injection, spinal decompression technique, collagenase injection. Intravenous drip of mannitol or sodium beta seven leaves on dehydration of detumescence, anti-inflammatory and analgesic, dexamethasone or Lai'anbilin cytoplasmic two choline or nerve with Leping neurotrophic drugs can be used as adjuvant therapy.

(two) soft tissue injury outside the spinal canal. Nonoperative treatment should be used because most patients can be cured. The effective treatment methods are commonly used (1) nerve block therapy (2) soft tissue pain point massage (3) silver needle therapy (4) physical therapy. Surgical indications: (1) intractable symptoms (severe, long duration) (2) (recurrent unprovoked) (3) treatment (non-surgical therapy failed) (4) seriously affect the work and life (disability). Operation method: (1) lumbar soft tissue lysis (2 hips) soft tissue lysis, (3) the pubic symphysis soft tissue lysis (4) thigh adductor lysis (5) infrapatellar fat pad lysis, (6) the tarsal sinus soft tissue release the solution of (7) inner (outer) ankle after soft tissue lysis.

Clinical on the inside and outside of the spinal canal of mixed lesions more common, usually pay attention to the first treatment of spinal diseases, especially to grasp the operation indication, can eliminate the pathogenic factors, will not be adversely affected by illness, and active treatment of spinal soft tissue injury, which should be. The majority of patients should be targeted, highly effective, safe non surgical methods, the formation of sequential treatment programs. Do the internal and external, bones, can be cured.

Three, clinical treatment plan

The following provides only a non-surgical treatment option for lumbocrural pain disease progression according to different condition.

Thoracic and lumbar spinal canal tissue damage. (1) in patients with acute onset of the disease, because of spinal nerve root sheath and epidural fat connective tissue inflammatory reaction, inflammatory swelling, blood stasis ischemic tissue was various, pain caused by the action of substances, the pain was the main signs, not mechanical factors of nerve compression, so in the bed or wear waist aid should be used under epidural injection, or loosening techniques for spine. For the patients with severe pain can not walk, can also be combined with intravenous drip of dehydration detumescence, anti-inflammatory analgesic and neurotrophic drugs. (2) in patients with chronic phase, mechanical factors become the main link of nerve compression, nerve roots and dural sac can suffer from intervertebral disc protrusion or extrusion due to fat connective tissue degeneration, fibrosis and contracture bands caused damage. So you should first take spinal decompression technique after epidural drug injection, intravenous drip of auxiliary neurotrophic drug, traction therapy, can also use collagenase chemonucleolysis combined with epidural drug injection.

(two) external soft tissue injury of thoracolumbar spinal canal. (1) acute onset, nerve block or tenderness point injection; severe illness, severe pain can be treated with nerve block and spinal loosening techniques, quickly relieve pain, relieve muscle spasm; mild cases with various kinds of physical therapy, such as: medium frequency electrotherapy, heat therapy, semiconductor laser or ultrashort wave. (2) in patients with chronic phase, which is characterized by tissue weight, incidence, muscle mechanical compensation function is low, often coexist and intraspinal lesions, so treatment should be to relieve muscle spasm, muscle contracture is the key. The clinical use of spinal loosening techniques and / or silver needle therapy, traditional Chinese medicine, such as heat assisted magnetic method, in order to achieve the soft tissue release and repair purposes. Exercise can also be carried out later, in order to enhance muscle strength, improve physical fitness, in order to promote disease rehabilitation.

For the elderly or young patients, physical weakness, cerebrovascular disease is more serious, at the time of treatment should be treated in different way, selection, selection of drugs, silver needle layout, should be based on individual treatment programs.

Four, commonly used non-surgical therapy

By means of mechanics, it can be used to adjust the anatomical position and functional state of the human body to achieve the purpose of treating pain. Low back pain disease of human body are soft tissue pain, technique has unique curative effect for lumbar disc herniation and the epidural fat connective tissue of chronic inflammation caused by adhesion of the dural sac and nerve root compression stimulation also has good release effect. But because basic research is not deep enough, some osteopathic still has a certain risk, clinical application should be used with human spinal biomechanical principle and standard technique.

1 spinal relaxation technique. For lumbar disc herniation, spinal stenosis (part).

(1) traction manipulation. Applicable to the side or the central character type cervical intervertebral disc herniation, the technique of the biomechanical experimental results show that the tensile and torsional buckling, lumbar disc herniation combined stress the content deviation of nerve root displacement, the main mechanism is loose between solutions between disc herniation and nerve root of both inflammatory adhesion, so as to reduce or eliminate herniated nucleus stimulation and compression of the dural sac and nerve root. Operation method: the patient in the prone position, arms to both sides of the body. With a folding style long wide cloth from the patient back to dig into the armpit respectively, in the chest leads is fixed to the bedside (or by a special chest traction belt fixing). The assistant holds the upper limb of the lower limb of the affected side with both hands for the traction (or in the traction bed, the calf is fixed with the belt to start the traction). The doctor stood on the affected side, with a finger over the lumbar spinous process of small joints, here is the paraspinal tenderness point and scoliosis convex starting point, on the other hand in the contralateral knee hyperextension of the hip. The upper plate. Assistant will gradually lower limb surgery for drafting, refers to being a joint distraction feeling, put hand health leg force to the ipsilateral oblique pulling the lumbar hyperextension and torsion, thumb pressing joint finger under the bony motion and jump with continuous "KaKa" sound, and this is the snapping stick soft tissue release even sound separation. Speed will be healthy limb flat in situ, after the operation to allow patients to rest in bed for a while, after turning over the supine position to maintain 4 hours. Each section of the lesion can only be used once, after each treatment to stay in bed for three days, wearing waist circumference within three weeks. (pictured below)

(2) lumbar traction manipulation: suitable for central protrusion of intervertebral disc.

Patients with abdominal decubitus, shoulder abduction and elbow flexion, arms naturally flat, the chest strap and lower limbs fixed with traction. Patients in patients with ipsilateral trunk, to be assistant to start gradually in patients with lumbar spine traction bed tension, with both hands thumb respectively along the spinous process on both sides about (2cm) spine facet joint connection from upper lumbar to the lumbosacral sliding push, when the thumb push into the lesion gap, the traction force shall be to patients weighing about 1.5 times, usually 90-120 kg, were quick to put pressure on the front, at the moment can feel the zygapophyseal joint was beating, and a clicking sound, and then slowly make the traction to disappear, no person can repeat it again to beat beck. After operation, the attention of the patient supine for 4 hours, the absolute bed rest for three days, three weeks wearing waist. (pictured below)

2 sacroiliac joint reduction maneuver

Anterior dislocation. Patient supine. Patients who stand on the injured side, with a hand thenar distal on the ilium, thumb down, 4 fingers gently in the groin, thumb in the lateral femoral, another hand lower knee, knee to natural hip flexion angle of 90 degrees. The following steps: (1) the hands with steady force vertical to the iliac rear shock pushing; (2) and knees hands full hip flexion, according to iliac hand back at the same time push pressure at the moment, often feel ilium or with mobile "Kacha" sound; (3) according to the hand of the iliac the palm towards the contralateral thumb, close to the iliac front in the hip valgus position above the inward push several discontinuous ilium. (pictured below)

Post dislocation. Patients with contralateral supine or prone position. Patients with palm palm root spine forward hold the injured side after iliac, another hand holding the ankle, hip extension gradually to the maximum, and then push forward under the support of the iliac bone hand force, hip flexion, McGregor iliac movement, completed technique. (pictured below)

(two) nerve block therapy

1 sacral hiatus epidural space nerve block. Suitable for nerve root and epidural inflammation. The patient prone, abdominal pad a thin pillow, slightly lower limbs abduction, convenient for patients to relax hip muscles and patients who touched the sacral hiatus on the edge of the coccygeal tip plug a gauze, prevent the disinfectant to the perineum. The upper edge of the sacral hiatus was touched down along the midline of the spinous process, or from the caudal tip up 4 - 5cm to the hiatus of the sacral hiatus. After routine disinfection for local anesthesia in Pichugin was slightly higher than the two sacral diagonal line. Injection needle with long 4cm, 7.5 or 8 with liquid medicine, and the skin is about 20 degrees (women 30 degrees), directly into the sacral hiatus. When the needle pierced the sacrococcygeal ligament, patients feel a sense of frustration, is the successful puncture, then the needle body inclined clinging to the sacral hiatus mastoideum needle 3 4cm, suction blood no cerebrospinal fluid, then slowly injected into the treatment fluid injection without resistance, about 1 - 2 minutes. The needle, after supine position, breathing and other reactions were observed in patients with pulse. Drug composition: 2% lidocaine 5ml, cytoplasmic two choline 0.5g, vitamin B121mg, dexamethasone (5mg or aspirin dosage: 0.9g); high segment (L1-3) lesions was 25 30ml, lower segment (L4-S1) 16 - 20ml, severe diabetes, cardiovascular disease, ulcer disease or multiple drug allergies with caution.

2 the use of collagenase treatment, must be monitored under imaging (CT or C arm X-ray machine), 16cm long, 18 special disk puncture needle after successful epidural catheter was implanted with core depth within the 5 - wire, lumbar 1 sacral clearance from the skin of 12 - 14cm, 4 - 5 waist gap from the skin of 16 - 18cm. Exit the catheter wire catheter suction, no blood or cerebrospinal fluid, injection of contrast agent 1 - 2ml on the image display under the observation of anteroposterior and lateral contrast display results, especially the lateral contrast agent in the anterior epidural space is linear distribution, indicates that successful intubation, or catheter tip at the desired inner steel wire block or dissolution of the nucleus in the rear CT image monitor. The first injection of 1% lidocaine 4 5ml, 20min did not occur after spinal anesthesia syndrome, can be 1200 2400u collagenase injection (each gap injection 1200u, each no more than 2400u), ipsilateral side down (central HNP prone) 8 10h after getting out of bed. The treatment can also be performed under the supervision of the image monitor using lumbar intervertebral foramen injection.

The other nerve block, such as lumbar paravertebral nerve block, lumbar lateral recess nerve block, nerve block, sciatic nerve block combined with hip pain point regional drug injection, according to the illness and pain as appropriate.

(three) silver needle therapy the silver needle with silver as the main material is made, the needle body length of 6 15cm with different specifications, coarse needle (diameter 1.1mm), is characterized by soft texture, heat transfer effect quickly, the treatment site deep, large range, is a specific therapy in the treatment of soft tissue pain.

1 operating procedures

(1). According to the need of acupuncture treatment to the prone position (waist and back of lower limbs), lateral position (hip), supine (lower side).

(2) to determine the location and scope of acupuncture according to the needs of the disease. Soft tissue pain in the specific lesions in the selection of tenderness points, the general point of tenderness between the needle distance of 1 - 2.0cm. So called "intensive" acupuncture. Most of the tender points were the joints of muscle or fascia and periosteum, which had strict anatomical distribution, consistent with the location and extent of surgical release.

(3). In the sterile operation, in each entry point for the 0.5% lidocaine intradermal injection, forming a diameter of about 5mm Pichugin, the burning moxa needle ball does not produce tingling and burning skin. For large parts of the region such as the tenderness of the waist and hips or the back of the neck has been well used sodium emulsion topical needle points, two hours after the anesthetic effect, the needle area of skin, subcutaneous muscle can be painless.

(4). Choose the suitable length of silver needle high pressure disinfection respectively into Pichugin, aimed at the deep direction or obliquely for piercing the lesion area. Through the subcutaneous muscle or fascia directly attached to the periosteum (tenderness point), lead to a strong acid deposition and expansion of hemp needle sense.

(5). The needle is finished, in each silver needle needle tail is provided with a spherical diameter of about 1.5cm, the ball, ignited slowly burning. At the moment the patient conscious treatment site deep soft tissues appear comfortable warm feeling, pain completely off.

(6). After the quenching of the fire, the residual heat of the needle body still has therapeutic effect. In each of the wound coated with 2% iodine. Let it be exposed (Xia Qiu) or gauze cover (Dong Chun), three days without contact with water, so as to avoid infection into the needle point.

2 note

(1). In the same lesion usually just a acupuncture treatment, treatment of multiple lesions, interval time from 2 to 3 weeks is appropriate. Because the human body soft tissue of silver needle after a stress adjustment, especially the adjacent area shows obvious muscle tension, and acupuncture points are often in muscle relaxation.

(2). Silver needle therapy without acupuncture have diarrhoea, without strong stimulation produced analgesia. Because the intensive acupuncture method can produce significant analgesic effect and muscle relaxation effect.

(3) if the moxa burning heating peak value, because the needle selection will make the skin around the eye of a needle less long have heartburn among available at this time prepared with cold water 20ml water from the syringe needle from the needle handle until the fever of moderate hypothermia.

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