This disease mainly occurs in young adults aged 20 ~ 40, accounting for about 80% of the total incidence of lumbar disc herniation, with more males than females. Lower lumbar intervertebral disc is the most common part of this disease, especially L4/5 and L5/S 1.
Main etiology and pathogenesis
Lumbar disc herniation is divided into lumbago, lumbago, lumbago and lumbago in TCM.
Huangdi Neijing holds that low back pain is nothing more than deficiency and excess, deficiency syndrome is caused by essence deficiency, and excess syndrome is caused by cold and dampness invasion. Its etiology and pathogenesis, first, feel cold, or sit in the wetland, cold water and damp evil permeate the meridians, meridian qi stagnation and onset; Secondly, it is caused by falling down, accumulation of old injuries, tendon injury and blood stasis; Third, the late stage is accompanied by deficiency of vital qi and deficiency of liver and kidney. Traditional Chinese medicine believes that the dysfunction of qi and blood, meridians and viscera is closely related to the occurrence of low back pain, and the waist is the house of the kidney, so this disease is most closely related to the kidney.
Modern medicine believes that intervertebral disc degeneration is the fundamental cause of nucleus pulposus protrusion caused by the rupture of fibrous ring. Acute or chronic injury is the main external cause of disc herniation. On the basis of intervertebral disc degeneration, some factors that can induce the sudden increase of intervertebral space pressure can cause nucleus pulposus protrusion. Common inducing factors include increased abdominal pressure, improper waist posture, sudden weight bearing, pregnancy, cold and so on. Some patients have no obvious inducement, which may be caused by long-term bad posture and sedentary fatigue.
dialectical thinking
First of all, a clear diagnosis
1. Patients with a medical history often have a history of waist injury or chronic strain.
2. Clinical symptoms Low back pain, lower limb traction pain and numbness are the most important symptoms. In severe cases, dysuria, perineum and perianal paresthesia may occur.
3. Signs: limited movement of lumbar spine, tenderness of tap near the vertebra, radiation of ipsilateral lower limbs, positive straight leg elevation test and strengthening test, abnormal tendon reflex, abnormal skin sensation and weakened muscle strength.
4. Auxiliary examination X-ray examination can show lumbar scoliosis, the intervertebral space is narrowed or left and right, and the affected side space is wider; Lateral radiograph showed that the physiological curvature of lumbar spine decreased or disappeared, and the posterior part of intervertebral space where disc herniation occurred was wider than the anterior part. CT and MRI can clearly show the image of disc herniation, and reflect the compression state of dural sac and nerve root through section, which is the most commonly used examination method to diagnose this disease at present. In addition, according to the distribution range of abnormal electromyography, the damaged nerve roots and their effects on muscles can be judged.
Second, treatment based on syndrome differentiation.
The symptoms of most patients with lumbar disc herniation can be alleviated or even disappeared after regular conservative treatment. If the effect of conservative treatment is not obvious, minimally invasive surgery can be considered, and open surgery is feasible if necessary. In short, the specific plan should be decided according to the patient's condition.
1. Oral Chinese medicine
According to the occurrence and development of diseases, syndrome differentiation and treatment can be divided into three types: qi stagnation and blood stasis, cold-dampness stagnation, damp-heat downward flow, deficiency of both qi and blood, and deficiency of liver and kidney.
2. External treatment of traditional Chinese medicine
External treatment of traditional Chinese medicine includes external application of traditional Chinese medicine, external application of plaster, fumigation and washing, iontophoresis and so on. Drugs can be absorbed through the skin and reach the focus directly, thus alleviating inflammatory reaction and relieving pain symptoms. We often use tricolor ointment for external use while taking Chinese medicine orally, and cooperate with Chinese medicine fumigation and Chinese medicine stains.
Chinese herbal fumigation prescription: Radix Aconiti, Radix Aconiti Kusnezoffii, Rhizoma Arisaematis, angelica tail, Flos Carthami, Ramulus Cinnamomi, Rhizoma Kaempferiae, Songkenote, Radix Arnebiae, Ramulus Mori, Cortex Erythrinae, Radix Clematidis, and lignum sappan. This recipe has the effects of promoting blood circulation, relaxing muscles and tendons, warming meridians and dredging collaterals. Chinese medicine acupoint application can also be used according to the patient's physique.
3. Acupuncture therapy
According to the location of radiation pain, it can be divided into two types: foot-sun syndrome and foot-shaoyang syndrome. Main acupoints: Foot Taiyang Meridian: Yaojiaji, Huantiao, Zhibian, Weizhong, Yanglingquan, Chengshan and Kunlun. Zushaoyang Classic Prescriptions: Yaojiaji, Huantiao, Yanglingquan, Xuanzhong and Xu Qiu. Acupoint matching: ① Mainly cold and dampness, with Yaoyangguan and Shi Feng; (2) Damp-heat is mainly associated with Yinling Spring, Quchi and Interbank; ③ Qi stagnation and blood stasis are mainly matched with Shu Ge and Xue Hai; ④ Deficiency of liver and kidney with Zusanli, Qihai, Guanyuan and Sanyinjiao.
4. Auricular point therapy
Lumbar pain is obvious, lateral movement is limited, and bilateral sacrospinous muscles twitch. First of all, auricular point treatment. Press and pull the upper part of bilateral antihelix with index finger and thumb pulp, and press it properly for 30 seconds each time, so that the patient can feel pain but can bear it, and feel bloated and hot to the helix. The method has the functions of dredging meridian qi and blood, relieving lumbosacral pain and muscle spasm, and improving lumbosacral activity.
5. Needle knife therapy
(1) Body position: The patient is prone, and the abdomen is padded.
(2) The main part is the corresponding lumbar disc herniation, which compresses a nerve root.
(3) Take a point between lumbar spinous processes at a fixed point, take a point 0.5cm on one side of the midline of spinous processes, and take another point 3.4 cm, and disinfect, spread towels, wear sterile gloves and disposable masks and hats according to the requirements of western medicine surgery.
(4) Select No.3 and No.4 acupoints of 65,438+0 for operation, and perform surgical treatments such as needle knife loosening, decompression, peeling, etc. aiming at the above three points in turn. Pay strict attention to the depth and direction of needle insertion and the patient's feeling during the operation. If there is electric shock induction, stop the needle insertion or turn or leave the needle to stop the treatment. Press the band-aid for 5min minutes after operation.
On the one hand, acupotomy can dredge meridians and regulate qi and blood through the role of "needle"; On the other hand, physical stimulation such as loosening the knife can regulate vasoactive substances in the blood, improve local circulatory disorders and metabolism, and thus promote the dissipation and absorption of local pathological edema and hematoma; At the same time, the acupotomy can promote the blood supply around the lumbar intervertebral disc, stimulate and trigger the body's own immune response, that is, natural absorption.
6. Manual therapy
Lumbar chiropractic manipulation is one of the most commonly used manipulations to treat lumbar disc herniation. The mechanism of massage therapy may be to dilate local capillaries, increase blood flow, accelerate metabolism, achieve the purpose of facilitating the repair of diseased tissues, accelerate lymphatic reflux and promote the absorption of edema in lymphatic system.
Indications of manual massage: ① First attack with short course (within 6 months); ② No symptoms of cauda equina nerve compression; ③ Systemic diseases or local skin diseases make the operation impossible; ④ No progressive motor dysfunction of lower limbs; ⑤ TCM syndrome differentiation belongs to qi stagnation and blood stasis. Specific techniques: kneading method, pushing method, pressing method, dialing method, pulling method, pulling method and straight leg lifting method.
However, we should pay attention to the careful choice of heavy manual massage or stilts, which may easily lead to nerve root adhesion, lamina hyperplasia and sclerosis, ligamentum flavum hypertrophy, and even nerve root fibrosis and contusion. Intense massage will lead to rupture of fibrous ring and prolapse of nucleus pulposus, which is manifested as cauda equina nerve injury and aggravated nerve root irritation.
7. Guidance method
The twelve characters of "washing, combing, rubbing, rubbing, loosening, pressing, turning, grinding, squatting, rubbing, spitting and regulating" are used to regulate qi and blood internally, strengthen bones and muscles externally, and strengthen the body resistance and eliminate evil spirits. "Twelve-character health exercises" can adjust the balance of local and systemic muscle strength, improve blood circulation, eliminate facet inflammation, stimulate appetite and adjust patients' mood. It can be used as a daily exercise method to prevent and treat lumbar disc herniation, so as to get rid of the disease and prolong life.
8. Physical therapy
Physical therapy includes ultrashort wave, electrotherapy, magnetic therapy, hyperthermia and laser therapy. It can improve the blood circulation of the affected tissues and promote the absorption of inflammation. High-frequency electrotherapy such as ultrashort wave and microwave was used in acute stage, and low-frequency pulse electrotherapy, meridian leveling and computer intermediate frequency electrotherapy were used in chronic stage.
9. Traction therapy
The role of traction: ① Lumbar traction can widen the intervertebral space, and traction can gradually pull away the adhesion tissue, spasmodic ligament and joint capsule. When the intervertebral space is widened, the volume of lateral recess of spinal canal increases, ligamentum flavum is stretched, and the intervertebral disc space and the relative space between nerve root and dura mater increase. ② Restoring the normal sequence of lumbar spine: the patient's waist was placed in the physiological position during traction, and with the increase of traction time, the abnormal sequence of lumbar spine such as facet joint disorder and scoliosis gradually returned to normal; Under traction, the waist is in a balanced and relatively stable state, which is convenient for alleviating and eliminating inflammatory reactions such as local congestion, exudation and edema. ③ Traction can reduce or eliminate muscle spasm.
10. Sacral canal closure combined with four-step release manipulation
Sacral canal closure is a quick and effective treatment. For patients with obvious symptoms, this method can be used for treatment. Professor Shi Qi pointed out that in order to ensure safety, sacral canal sealing treatment should be completed in the conventional operating room. The patient takes a prone position, and the lower abdomen is slightly lifted. First, find out the location of the sacral canal hiatus, then disinfect and spread the surgical towel. Local infiltration anesthesia was performed with 1% lidocaine solution, and epidural puncture needle was used to puncture. When the ligament that had punctured the sacral canal penetrated into the sacral canal, the sensory resistance disappeared, and then the epidural catheter was slowly inserted through the needle lumen and sent to the epidural space of lumbosacral region. Generally insert 10 15cm, withdraw the bloodless body, observe the pulsation at the end of the catheter and confirm that the catheter is in place. You can slowly inject the prepared mixture, 5ml+ of 2% lidocaine solution+40ml+ of normal saline+20mg of triamcinolone acetonide or 65438+ 0mg of diprospan, ***35 50ml. It is required to inject slowly every 3-4 times and pay close attention to the patient's reaction. Observe for a few minutes after injection, and then do manual treatment without special discomfort. After the sacral canal is closed, we should cooperate with four relaxation methods: stretching and pressing, lateral oblique pulling, straight leg raising hip and knee flexion and extension, and hanging and shaking the waist.
If selective nerve root block combined with four-part release can be used, the effect will be more accurate.
1 1. surgical therapy
Surgical indications should be strictly controlled. The indications for operation mainly include: ① those who have a medical history of more than 3 months and are ineffective or effective after strict conservative treatment, but often relapse and have severe pain; ② The first attack, but the pain is severe, especially the symptoms of lower limbs are obvious. The patient is difficult to move and fall asleep because of the pain, and is in a forced position; ③ Single nerve root paralysis or cauda equina nerve compression paralysis, accompanied by muscle atrophy and decreased muscle strength; ④ Patients with spinal stenosis. Commonly used operations include simple nucleus pulposus removal, intervertebral foramen mirror, posterior lumbar decompression and internal fixation.
This article is selected from Thoughts and Methods of Syndrome Differentiation of Common Bone Injuries in Traditional Chinese Medicine, edited by Mo Wen and presided by Shi Qi, and published by People's Health Publishing House. Editing and finishing of traditional Chinese medicine for human health.