1 Non-surgical treatment
In the past, early surgical treatment of symptomatic lumbar spinal stenosis was advocated because it was considered that the disease was always progressive. However, the research results in recent years show that conservative treatment should be carried out at one stage before determining whether surgery is needed [1].
Non-surgical treatment methods include drug therapy, changing the mode of activity, using braces and epidural hormone blocking. Neither of these methods has been proved to be effective. Non-steroidal anti-inflammatory drugs can not only reduce the inflammatory reaction caused by nerve compression, but also have analgesic effect. These drugs are widely used, but there is no research on the exact effect of treating lumbar spinal stenosis. Paracetamol can affect liver and kidney function. Non-steroidal anti-inflammatory drugs can cause gastric and duodenal ulcers, and also affect liver and kidney function, so attention should be paid when using drugs. The results of double-blind cross-control study showed that intramuscular injection of calcitonin could relieve pain and increase walking distance [1.2.4].
Effective physical therapy methods for lumbar spinal stenosis include stretching therapy, lumbar muscle strength training and anaerobic health training. Riding a stationary bike is very effective for some patients. This kind of exercise is flexion position, which most patients can tolerate. Treadmill walking exercise designed with sling is also very useful for patients with lumbar spinal stenosis because the lumbar spine is not stressed. There are many methods of soft tissue physiotherapy, including hyperthermia, ice therapy, ultrasound, massage, electrical stimulation, traction and so on. Although it is commonly used, its curative effect on lumbar spondylosis has not been confirmed. But it is beneficial to prepare for assisting lumbar movement and carrying out stronger physical therapy. Exercise and physical therapy are safer and can delay surgical treatment. Exercise can improve the patient's general condition, even if it does not relieve symptoms, it is beneficial to better accept surgical treatment [1-3].
Waist protection can increase the stability of lumbar spine to relieve pain, but it should be applied for a short time to avoid lumbar muscle atrophy.
The method of epidural blockade in the treatment of lumbar spinal stenosis is still controversial. It is generally believed that the effect of epidural blockade in the treatment of root pain is poor. Cuckler and others prospectively studied a group of patients who relieved root pain. The results of double-blind cross-control study showed that there was no significant difference between the control group (epidural injection of normal saline) and the experimental group (epidural injection of hormone). Rosen et al. retrospectively studied a group of patients receiving epidural hormone therapy. 60% of the pain symptoms were relieved in the short term, and only 25% of the pain symptoms were relieved in the long term.
Derby et al.' s research results show that the response to epidural hormone blocking therapy is good and its surgical treatment has achieved satisfactory results, but the response to epidural hormone blocking therapy is poor and its surgical treatment has not achieved satisfactory results. For patients with root pain < 1 year, hormone blocking therapy can not predict the surgical effect. Rosen et al. conducted a retrospective study on a group of patients (40 cases) who received epidural hormone therapy. 24 cases (60%) had short-term pain relief, and 10 cases (25%) had long-term pain relief. Ciocon et al. performed epidural block on 30 patients with lumbar spinal stenosis, once a week 1 time, three times in a row, and the pain was relieved 10 months. Although epidural hormone blocking therapy for lumbar spinal stenosis has complications such as epidural hematoma, infection and chemical meningitis, it is still an important non-surgical treatment. Many authors believe that it has the advantages of relative safety, less side effects and easy acceptance by patients [1.2].
2 surgical treatment
2. 1 Indications for operation When the quality of life of patients declines, the pain is unbearable, and conservative treatment is ineffective, surgery should be considered, and the symptoms and signs should be consistent with the results of imaging examination. Simple imaging changes can never be used as surgical indications. It must be emphasized that the purpose of surgical treatment is to relieve the adaptive symptoms of lower limbs, not to relieve low back pain. Although low back pain has also been relieved after surgery, the purpose of surgery is to relieve symptoms rather than cure. After long-term follow-up, it is still possible to grow back to the decompression zone, which will make the symptoms of nerve compression recur. Surgery can't make degenerated intervertebral discs and small joints return to normal. Nor can it prevent the natural development of spinal degeneration [1].
There are many literature reports on decompression of lumbar spinal stenosis, which are basically divided into two types: extensive laminectomy and limited decompression.
2.2 The standard extensive laminectomy decompression method removes laminae and ligamentum flavum from the lateral recess in all transverse planes of the involved spine. Under direct vision, the whole journey of the involved nerve root from the beginning of dura mater to the exit of nerve foramen was completely decompressed, and the lateral recess where the nerve root was embedded was completely decompressed, although the clinical symptoms suggested that there was only one plane stenosis and the unilateral nerve root was compressed. The reason is that spinal stenosis is a multiplanar disease, and the long-term effect of single-plane decompression is not ideal [1.2]
2.3 Reasons for Limited Decompression Methods Degenerative spinal stenosis is mostly staged, which is mainly caused by folding of ligamentum flavum, hypertrophic hypertrophy, hyperplasia of facet joints and joint capsules, and bulging of fibrous rings. On the sagittal plane, the bony spinal canal is usually not narrow. Therefore, selective limited decompression should be performed to preserve more posterior bone and ligament structures, which can theoretically reduce postoperative spinal instability. The operation of oblique laminectomy is to obliquely remove the lateral front of the lamina and selectively perform unilateral or bilateral laminectomy or laminoplasty. Method introduced by mcculloch [5, 6]: Release the posterior median skin incision (5cm in a single plane) to both sides, and then perform bilateral decompression respectively, generally on the left side first. The lumbodorsal fascia was cut at a distance of 65438±0cm from the midline to avoid damaging the supraspinous and interspinous ligaments, and the paravertebral muscles were stripped and separated laterally along the interspinous ligaments and intervertebral spaces. Unilateral laminectomy range: from the starting point of ligamentum flavum to the stopping point of ligamentum flavum (together with 1/4 laminae on the lower vertebral body). The medial facet joint was removed to the inner boundary of the vertebral arch to ensure complete decompression under the articular process. At the same time, intertransverse bone grafting was performed. Then, a similar operation is performed on the other side. This technique of preserving supraspinous ligament, spinous process and interspinous ligament is called micro decompression [6].
This paper reports the prospective randomized study results of multiplanar laminectomy and standard extensive laminectomy and decompression. The two methods were followed up for an average of 3.7 years, and their clinical results were similar. The decompression time of multiplanar laminectomy was long, and nerve injury occurred in 12%. In multiplanar laminectomy and decompression, 26% patients had to change to standard extensive laminectomy and decompression because they were not satisfied with intraoperative decompression.
In recent years, people advocate selective laminectomy for patients with biplanar stenosis, and it is feasible to select one of them as the plane (responsible vertebra) that causes symptoms through nervous system examination, and to check before and after walking or selective nerve block. The symptoms disappeared after nerve root block, indicating that the nerve root was compressed. In a group of reports, among 28 cases of biplane anatomical spinal stenosis, 23 cases (82%) thought that one plane caused symptoms, and 5 cases (18%) thought that two planes caused symptoms. Only the 1 ~ 2 plane thought to cause symptoms was decompressed. Although it is biplanar stenosis, the postoperative effect is similar to that of biplanar stenosis only once [6].
2.4 Bone Graft Fusion In recent years, there have been many discussions about the role of fusion after decompression of lumbar spinal stenosis. Lumbar spondylolisthesis has been reported after decompression without simultaneous bone grafting and fusion. Decompression and total facet joint resection were performed at the same time, and lumbar spondylolisthesis occurred twice after operation, which is one of the reasons for the poor postoperative effect. However, bone grafting and fusion at the same time complicate the operation, prolong the operation time, increase the amount of blood loss, increase postoperative complications and prolong the rehabilitation time. It is generally believed that simultaneous spinal fusion is not conducive to the rehabilitation of patients [1]. The following factors should be considered: simultaneous bone grafting and fusion [1, 2,6 ~11]
2.4. 1 Laus and others with degenerative lumbar spondylolisthesis reported that simple decompression was successful. This shows that natural stability can be obtained at this stage due to the narrowing of intervertebral space and the action of hyperplastic bony spur. However, another data shows that simultaneous fusion during spondylolisthesis is beneficial to improve clinical symptoms. Postachini et al. reported that 16 cases had spondylolisthesis before operation and were followed up for 8.6 years after operation. Among them, 6 cases underwent decompression alone, and the other 10 cases underwent fusion at the same time. The results showed that more bone grew into the spinal canal in patients with non-fusion, and the clinical effect was not as good as that in patients with simultaneous fusion. Literature analysis in recent years shows that satisfactory surgical results can be obtained if fusion is performed at the same time [1.5]. Postacchinit and Cinotti et al. found that postoperative hyperosteogeny was more common in lumbar decompression and fusion period, without spondylolisthesis.
2.4.2 Patients with scoliosis or kyphosis and lumbar spinal stenosis with degenerative scoliosis are extensively decompressed, which may lead to spinal instability or deformity aggravation. Joint fusion is needed at the same time. However, not all patients with spinal stenosis and kyphosis are treated with fusion. Whether to merge at the same time depends on four aspects: ① Flexibility of bending should be considered. If the lateral flexion X-ray film shows that the bending can be partially corrected, simple decompression is in danger of bending development. ② Whether the bending is progressive, and if so, there is evidence of fusion. ③ Lateral spondylolisthesis indicates instability at this stage, and simple decompression will aggravate instability. ④ When there is obvious nerve compression on the convex and concave side, it is difficult to achieve sufficient decompression of the concave side nerve by cutting off the concave side lamina and some small joints, and fusion should be considered to expand decompression [1].
2.4.3 For recurrent spinal stenosis in the same plane, joint fusion should be performed at the same time when reoperation is determined. Because of reoperation, it is necessary to increase facet joint resection to enlarge lateral recess and central spinal canal. More than 50% of facet joint resection will lead to unstable staging, especially when facet joints are inclined to sagittal plane. When recurrent spinal stenosis is accompanied by iatrogenic lumbar spondylolisthesis, bone grafting and fusion must be considered in reoperation to increase the stability of the spine.
2.4.4 Excessive resection of facet joints will cause spinal instability due to facet joint resection or resection > 50%, and spinal fusion should be performed at the same time to prevent postoperative spinal instability or pain. If the integrity of at least one facet joint is preserved, the stability of the spine can be maintained. However, biomechanical research shows that after unilateral facet joint resection (indicating that the horizontal mobility is obviously increased), even if the other side is intact, instability will occur, and unilateral or bilateral medial facet joint resection (< 50%) has little effect on spinal stability [13. 14].
2.5 Whether spinal internal fixation and bone graft fusion are combined with internal fixation instruments is controversial. The purpose of internal fixation is: ① to correct spinal deformity; ② Stabilize the spine; ③ Protecting nerve tissue; ④ Reduce fusion failure or improve fusion rate; ⑤ Shorten the postoperative rehabilitation time. Therefore, its indications are: ① stabilizing or correcting scoliosis or kyphosis; ② Extensive laminectomy in two or more planes; ③ Recurrent spinal stenosis with iatrogenic lumbar spondylolisthesis; ④ X-ray film in flexion and extension position showed that the vertebral translation was greater than 4mm and the angulation was greater than 10. The choice of internal fixation method should be based on short-term fixation and flexible application according to the proficiency of the operator and the actual situation of the patient. More and more data show that internal fixation is beneficial in the fusion of spondylolisthesis [15 ~ 17].
2.6 surgical effect surgical decompression is generally considered to be effective in the treatment of lumbar spinal stenosis [1.5.6438+02]. There is a big difference in the literature (26% ~ 100%). Many authors' research results show that the improvement of clinical symptoms after operation tends to increase with time. In one group of studies, 20% patients achieved satisfactory short-term curative effect after operation, and the symptoms recurred in an average of 8.2 years. In the other group, 27% patients had a good initial postoperative effect, and their symptoms worsened after 5 years. Katz et al. found that 75% patients were satisfied regardless of decompression and fusion. After 7 ~ 10 years, 23% need reoperation. The risk factors of poor long-term curative effect after operation include poor general condition and single-plane laminectomy. The recurrence of symptoms can be the recurrence of the original surgical site stenosis, the development of adjacent plane stenosis and low back pain accompanied by lumbar instability. On the contrary, some authors have reported a group of cases, and the average postoperative clinical effect of 13 years is better than that of 7 years [18 ~ 20].
2.7 Factors affecting the surgical effect
2.7. The effect of1diabetes on the curative effect of lumbar spinal stenosis after decompression is quite different from that reported in the literature. In a group of reports, the proportion of diabetic patients with poor postoperative efficacy is large, and postoperative wound complications are easy to occur. The excellent and good rate was only 42%, while the excellent and good rate of patients without illness was 965438 0%. Another group of reports achieved satisfactory clinical results (72%), and 80% of those without the disease. Some data show that the curative effect of relieving postoperative activity-related symptoms is similar to that of non-patients, but the curative effect of relieving persistent pain and sensory abnormality of lower limbs is uncertain. This is because diabetic neuropathy itself has residual neurological symptoms [1].
2.7.2 Other factors of satisfactory surgical results depend on: ① selecting suitable patients; ② The operation method is correct; ③ Fine operation during operation. Katz et al. reported the results of 194 cases, of which 40 cases were not satisfied with the curative effect. The main reasons are: ① the general condition before operation is poor; ② There are many diseases; ③ Back symptoms are more prominent than lower limb symptoms. ④ The curative effect of lumbar spinal stenosis is influenced by the previous history of lumbar surgery. The available data show that facet joint fracture during lumbar surgery is a potential factor of late low back pain.
3 Conclusion theory
Although the anatomical abnormalities, clinical symptoms and natural development of degenerative lumbar spinal stenosis have been further understood, the scientific nature of many treatment methods has not been fully confirmed. The efficacy of physical therapy, drug therapy and epidural hormone block has not been agreed. Although epidural hormone blocking therapy for lumbar spinal stenosis has complications such as epidural hematoma, infection and chemical meningitis, it is still an important non-surgical treatment. Many authors believe that it has the advantages of relative safety, small side effects and easy acceptance by patients. For most patients, non-surgical treatment is still an effective way to relieve symptoms. The natural development process related to lumbar spinal stenosis still needs to be studied prospectively and randomly, and its method needs to be improved to improve the understanding of its natural development process.
In recent years, limited decompression is the first choice to preserve the stable components of the posterior spine and reduce short-term complications. However, due to the recurrence of stenosis and the development of adjacent plane stenosis, the long-term failure rate is high. For lumbar spinal stenosis with degenerative lumbar scoliosis and spondylolisthesis, there is sufficient evidence that fusion after decompression is appropriate. Short-term pedicle fixation after decompression can improve the fusion rate and avoid long-term fixation. The best way is to choose a surgical method that is beneficial to patients, reduce complications and improve curative effect, which is still a subject to be further studied.
Doing some scientific fitness exercises, such as Tai Ji Chuan, will greatly improve the chances of recovery.