Relatives who are proficient in the department of traditional Chinese medicine and wounds will be familiar with the eight big characters of "bone and muscle are soft, qi and blood flow", these eight words are from the "Yellow Emperor's Inner Classic, Su Qing, Anger and Heaven", what does it mean? In layman's terms, the ancients believed that correct bones, soft veins, and smooth qi and blood were important basic conditions for good health. Let's look at the words of these eight words from the text.
"The bones are soft, and the qi and blood flow"
In the Yellow Emperor's Neijing Su Qing And Qi Tongtian Theory, Yun: "It is the reason for the five tastes, the bones are soft, the qi and blood flow, the heart is dense, and if it is, the bone qi is refined." The Word is as it is, and there is a destiny for a long time." Interpret this part of the provisions: Therefore, it is necessary to carefully reconcile the five tastes, so that the bones are strong and upright, the tendons and veins are soft and smooth, the meridians are unobstructed, and the skin is strong and dense, so that the muscles and bones can be strong and powerful. Therefore, paying attention to the way of health and implementing it according to the correct method will maintain strong vitality for a long time.
There is also a passage in the Yellow Emperor's Inner Classic, Su Qing, and Qi Tongtian: "It is the sage Chen Yin and Yang, the tendons and veins and the same, the bone marrow is strong, and the qi and blood are all from it." If so, the inside and outside will be reconciled, the evil cannot be harmed, the ears and eyes will be wise, and the spirit will be as good as ever." Interpretation of the text: Therefore, the saint achieves harmony of muscles and veins, strong bone marrow, and smooth flesh and blood by making yin and yang balanced and invincible. In this way, the inside and outside will be reconciled, the evil qi cannot be infringed, the eyes and ears will be clever, and the gas machine will operate normally.
Through the provisions in the "Yellow Emperor's Inner Classic", we can see that the ancients fully realized as early as 2,000 years ago that only strong and upright bones, soft and smooth veins, smooth meridian qi and blood, and strong and dense texture can be regarded as having a strong physique.
From the perspective of modern medicine, the tendons and veins in the eyes of the ancients should include muscles, ligaments, blood vessels, nerves, intervertebral discs and other soft tissues in modern medicine, the phalagm includes skin, subcutaneous tissue, fascia and other organ tissues, in the author's recent blog post "Waist Pain To Catch the Demon Series", the basic discussion of lumbar muscle lesions ended, iliofascial ligament injury also shared some time ago, no longer repeat, today focus on the supraspinal ligament, interspinal ligament, yellow ligament, posterior longitudinal ligament, anterior longitudinal ligament, transverse inter-process ligament, Anatomical injuries and treatment of lumbar rib ligaments, and discussion of lumbar fascia lesions on a selected date belong to the category of "tendons" in Chinese medicine.
The category of injury treatment in Chinese medicine is roughly divided into two diseases, bone disease and tendon disease, "tendon groove", "bone wrong stitch" is the pathological basis of the cognitive category of Chinese medicine, "bone is soft", "muscle and bone is right", are the same treatment purpose, but the colleagues who are engaged in the technique are more willing to believe, the bone is wrongly sutured, the muscles and flesh will become supple, the kind of patients who carry in and walk out, will often become the capital of our colleagues who engage in techniques, but in fact, in addition to some acute disease patients, Such as small joint disorders, more so-called bone misalignment, subluxation patients, today you give him just right, tomorrow may return to the original position, why is this so? Because the soft tissue of the lesion contracture is still pulling there, only by soothing the muscle bundle of the local spasm, loosening the soft tissue of the adhesion contracture, relieving the nerve stimulation of the jam, eliminating aseptic inflammation, improving the microcirculation disorder, and combining with the regular orthopedic technique, can the chronic pain problem be solved to the greatest extent. Therefore, the author has always adhered to the view of "guarding the tendons in the muscles, guarding the bones in the bones, the same disease in the muscles and bones, and the tendons before the bones". Combining local and overall, treating both symptoms and root causes, treating muscles and bones together, not sticking to a single therapy, and selecting targeted treatment methods or combination treatments, in order to truly achieve the purpose of soft bones and soft muscles.
Get back to the point and keep talking. Before continuing today's ligament topic, let's share the case first, but the protagonist of this case is the author himself!
18 years ago, the author is still working in the grass-roots hospital, the focus of work in addition to traditional Chinese medicine, that is, the treatment of chronic pain diseases, the grass-roots hospital conditions are limited, not even a regular treatment bed, dozens of patients every day acupuncture plus manual treatment, can only be carried out in the ordinary bed, the ordinary bed is very short, long-term bow and waist operation, so that the author appeared in the lower waist in the middle of the continuous soreness symptoms, especially when bending down to work, the pain point is very clear, just between the waist 5 / sacrum 1 spinous process, typical of a "interspinal ligament injury", The cause and diagnosis are very clear, but they can't treat themselves, they can only insist on the disease. In the same year to Beijing to study, Professor Wen Haitao of the Bethune Medical University Affiliated Hospital gave a lecture, Professor Wen brought a "big friend" to help him debug computer projectors and other equipment, this brother said that it is not too much to trim the edges, the clothes are not neat, the oil stains on the clothes are one piece after another, the students in the same class are laughing at how this brother is so sloppy, but the author can see from his learning attitude that this brother is not simple. After private communication, it turned out that this old brother had been doing pain for many years, and had opened several clinics, and lectured around with Professor Wen, just to improve technology. The author's "interspinous ligament injury", I dared to let this buddy treat once, there is no local anesthesia, more than ten seconds of needle and knife treatment, and when the study class is over, the author's waist has been healed, and now it has been 18 years, and there is no feeling. It's just a pity that there weren't so many means of communication now, and I don't know how the old brother who lost contact is now.
To understand lumbar ligament injuries and treatment, or start with anatomy. The author decomposes the supraspinal ligament, interspinous ligament, yellow ligament, posterior longitudinal ligament, anterior longitudinal ligament, interpragmatic ligament, and lumbar rib ligament one by one.
Complex lumbar ligaments.
The supraspinal ligament starts from the 7th cervical spinous process and extends downward to L3 or L5, most people have very few supracous ligament fibers between L4-5, and there is no supraspinal ligament between L5 and S1, and its space is replaced by the left and right cross-attachment of the sacral tendon fibers, and there are elastic fibers between the tendon fiber bundles and are connected horizontally and attached to the spinous process. When the spine is flexed forward, the fibers are straightened and restored when stretched, so the supracupelas supracous ligament has a certain elasticity, but improper overflexion can be damaged.
Supraspinal ligament injuries are mostly caused by tearing or inflammatory degeneration and calcification of the supracian ligament due to trauma or strain. More common in young and middle-aged manual workers, when the treatment is not complete, it will often be extended into chronic strain, causing low back pain, local pain in the injury is more intense, especially when the pain is felt more often when the front flexion is more severe, when leaning back can be reduced, the waist activity is obviously limited, especially the previous lateral bending and rotation restriction is obvious. The examination is locally non-red or swollen, and pain and tenderness are localized at the acanthous process and supracous ligaments.
The interspinous ligament connects the upper and lower spinous processes, along the root of the acanthosis to the tip, in front of the ligament vitis flea, and in the posterior migration to the supraspinal ligament. The interspinous ligament, which is broad, thick and square in the lumbar region, is functioning to strengthen the firmness between the spines and to limit excessive flexion of the spine. If the spine is suddenly hyperflexed, this ligament can be damaged.
Absence of the inferior lumbar supraspinal ligament increases mobility, but creates a structurally weak area. The waist is subjected to a great deal of tension when the waist is bent forward. Muscle tests have shown that the vast majority of people no longer contract when the lumbar anterior flexion is close to the maximum, and the huge tension is borne by the interspinous ligament, the fissure muscle bundle and the joint capsule in turn, so the chance of injury to the interspinous ligament in the lower lumbar segment is relatively large.
The causes of interspinous ligament injury are mainly caused by excessive flexion of the spine due to acute lumbar trauma, resulting in force on the interspinous ligament, resulting in violent interspinous ligament tendon tissue tearing, or long-term repeated bending, chronic stress caused by chronic strain of the interspinous ligament, local tendon tissue degeneration, degeneration and degeneration. Secondly, a small number of scarrings are caused by tissue injuries caused by sharp objects, such as iatrogenic injuries spinal anesthesia puncture injuries to interspinous ligament tissue, the mechanism is similar to acute trauma, but this middle way of needle entry has gradually been replaced by the lateral injection method, and this kind of iatrogenic injury is no longer common.
Common clinical manifestations of interspinous ligament injury are: there is no history of trauma, low back pain does not heal for a long time, is obvious when bending over, but can also cause pain due to squeezing the lesioned interspinous ligament when overextended. Some patients may have pain radiating to the sacral or buttocks. On examination, there is tenderness between the spinous processes at the injured ligament, but there is no redness and swelling. Some interspinous ligament injuries can be confirmed by ultrasound B or MRI.
The pathological basis of injuries to the supraspinal ligament and the interspinous ligament is mostly: the supraspinal and interspinous ligaments are in a tense state, due to trauma or strain, resulting in small tears, bleeding and exudation, and this damaging inflammation stimulates the small branches of the medial branch of the posterior medial branch of the spinal nerve distributed to the ligament, which can cause low back pain. In the elderly, ligaments may be calcified due to degeneration and necrosis. The supraspinal ligament and the spinous junction may slip off the acanthosis due to degeneration and rupture. In addition, the rupture of supraspinal and interspinous ligaments caused by violence, and the formation of more scars due to poor immobilization after injury, are also the causes of chronic low back pain in this type of disease.
Treatment, whether it is supraspinal ligament injury or interspinous ligament injury, the acute phase generally uses conservative treatment, appropriate bed rest, try to avoid bending down to bear weight or repeated bending activities, severe pain can take nonsteroidal anti-inflammatory analgesics, you can also short-term waist circumference fixation to reduce waist activity is conducive to the recovery of interspinous ligament injury. On the basis of the above treatment, it is possible to cooperate clinically with physical therapy.
Small needle knife treatment for chronic supraspinal and interspinous ligament injuries have a good therapeutic effect, according to the theory of needle knife medicine on chronic soft tissue injury, after the injury of supraspine and interspinous ligaments, local adhesions, scars and contractures are formed, resulting in a dynamic balance disorder of the waist, resulting in the above clinical symptoms. According to the above theory, patients with supracupractic and interspinous ligament injuries can receive good treatment effects by using a needle knife to cut the adhesions and scars at the lesion site, so that the local soft tissues can be repaired again and the dynamic balance of the waist can be restored. In severe cases, low-concentration glucocorticoids can also be injected locally, which is conducive to reducing local inflammatory edema and reducing scarring during repair.
The ligament flavum is a ligament tissue structure within the spinal canal that maintains the stability of the spine, and it belongs to one of the supporting structures of the posterior column of the spine. The yellow ligament connects from the lower and inner edges of the upper vertebral pedicle plate to the upper and outer edges of the lower vertebral pedicle plate, participates in the posterior and posterior lateral walls surrounding the spinal canal, thickens sequentially from top to bottom, extends to the intervertebral joint capsule of the lateral ligament of the flavon and extends inward to the spinous process of the midline lamina, leaving a narrow long longitudinal space at the confluence of the midline, and the veins flow back from the spinal canal through this gap to the vertebral plexus posteriorly lateral spine. The sudden loss of resistance when the needle is punctured into the ligament vum and the sense of disappearance after puncture are more significant, and this is often used in clinical practice as a basis for whether to penetrate the epidural space.
From the perspective of tissue structure, the yellow ligament is composed of a large number of elastic fibers, and this histological characteristic of the yellow ligament determines its unique elasticity: that is, it can be extended and become thinner when stretched; when the lamina is close to each other, it can be shortened, and it can not form a fold and protrude into the spinal canal. The adhesion of the yellow ligament can be divided into four zones according to its tissue structure, namely the fibrous zone, the fibrocartilage zone, the mineral-containing zone and the bone zone. From the fibrous region to the bone region can be understood as a process of gradual ossification, which is the intrinsic basis for ossification of the ligament vlacan. Due to the action of various factors that lead to degeneration of the ligament, the bone area eventually expands to the ligament area, so that the yellow ligament loses elasticity due to structural changes and thickens and hardens.
Hypertrophy of the ligament flavum and narrowing of the spinal canal.
Among the diseases associated with the yellow ligament, the most common is the hypertrophy of the yellow ligament. The etiology or pathogenesis of ligament flavum hypertrophy is not well understood and may be related to chronic degeneration, trauma, inflammation, metabolic disorders, and other factors. When the lumbar spine degenerates, the stress of the yellow ligament is abnormally high, and its elastic fibers will degenerate or break, and the long-term injury and repair process will inevitably make the yellow ligament hypertrophy and fibrosis, which will eventually lead to calcification of the yellow ligament.
The standard of yellow ligament hypertrophy is: the cervical spine is generally less than 1.5 mm, the lumbar spine is less than 4 mm, the thoracic spine is less than 2 mm, and the final result of the hypertrophy of the yellow ligament is to cause spinal stenosis, especially the lateral crypt causing the initial stenosis, resulting in compression of the cauda equina and nerve root compression. The elastic fibers of the yellow ligament that have degenerated and hypertrophic are reduced, the compensatory fibers of the collagen fibers are increased, the fibers are arranged disorderly, and the more obvious degeneration and calcification occur; and the collagen content is significantly increased, which is the main reason for the hypertrophy of the yellow ligament.
Hypertrophy of the yellow ligament tends to occur in the elderly, and the course of the disease is long, and there may be an acute exacerbation process. It tends to occur between the lumbar 4 and lumbar 5 lamina, which compresses the cauda equina nerve and nerve roots. Nerve roots can be bilaterally or unilaterally. Clinical symptoms are similar to those of lumbar spinal stenosis. Pain in the lower lower back is usually predominant, which can be relieved or disappeared after rest, and there may be neurogenic intermittent claudication.
There are not many treatment methods for the hypertrophy of the yellow ligament, and the treatment method commonly used by the author is to retreat the No. 16 elbow puncture needle to the dorsal side of the yellow ligament after the end of the epidural nerve block operation, and to shovel and loosen along the edge of the lamina to achieve the purpose of tension reduction and decompression, as long as the operation is standardized, safe and reliable, the specific operation is described in the previous relevant blog post, and will not be repeated. Patients with severe yellow ligament hypertrophy causing spinal stenosis can also be treated surgically
The posterior longitudinal ligament is located behind the vertebral body within the spinal canal and is narrow and tough. It begins from the pivot and continues with the covering of the vertebral body of the pivot, reaching the sacral bone. It is closely connected with the intervertebral disc fiber ring and the upper and lower edges of the vertebral body, and the combination with the vertebral body is more loose, which has the effect of restricting excessive anterior flexion of the spine. It is comparable in length to the anterior longitudinal ligament and is narrower to the vertebral body, but wider at the intervertebral disc, which can limit excessive forward flexion of the spine and prevent the disc from protruding backwards.
Under the action of long-term stress, calcification of the posterior longitudinal ligament may occur to compress the spinal cord, resulting in a series of clinical symptoms. (1) Posterior longitudinal ligament calcification of the cervical spine: can compress the spinal cord, which may lead to symptoms such as limb weakness, numbness of the lower limbs, and walking and stepping on cotton; (2) calcification of the posterior longitudinal ligament of the thoracic spine: symptoms such as weakness of the lower limbs, numbness of the abdomen and lower limbs may occur; (3) calcification of the posterior longitudinal ligament of the lumbar spine: numbness and weakness of one or both limbs may occur. Treatment: If the posterior longitudinal ligament calcification does not compress the spinal cord or nerve roots, there are no clinical symptoms, usually only need to be observed, no treatment is required, but if neurological symptoms appear, conservative treatment is almost ineffective, usually requires surgery.
The anterior longitudinal ligament consists of three layers of juxtaposed fibers. The superficial fibers can span 3 to 4 vertebral bodies; the middle fibers can span 2 to 3 vertebral bodies; and the deep fibers only connect two adjacent vertebral bodies, which are closely connected to the intervertebral disc and the edge of the vertebral body, but are loosely connected with the vertebral body and extend down to the 1st or 2nd sacrum. The inner fibers of the anterior longitudinal ligament are connected to the laminar fiber rings of the intervertebral disc and the epiphyseal rings of the vertebral body, but do not enter the vertebral body. The anterior longitudinal ligament as a whole appears to be a long, wide band of fibers that thickens at the anterior convexity of the vertebral body; it has the effect of limiting the hyperextension of the spine.
Similar to the posterior longitudinal ligament, the anterior longitudinal ligament also often appears calcified, because the degeneration of the vertebral segment begins from dehydration and loosening, which gradually causes relaxation of the anterior longitudinal ligament, and gradually appears ligament-subperiosteal hemorrhage and nucleus pulposus Anterior displacement At the same time as the formation of anterior bone spur of the vertebral segment, the local ligament is also calcified and gradually calcified. This pathological process often lasts for many years and eventually leads to a decrease in the range of motion of the vertebral segments, or even a complete calcification of the vertebral segments and a fusion state. This phenomenon can also be seen as a form of self-defense protective response of the human organism to slow down the continued development of the pathological process of the diseased vertebral segments.
Anterior longitudinal ligament calcification generally does not require treatment, just for now, there is no targeted treatment, can only be symptomatic conservative treatment.
The interverse ligament connection between the transverse process and the adjacent two transverse processes is often absent in the cervical vertebrae, and is thin in the thoracic spine and membranous in the lumbar spine. The main role is to limit excessive curvature of the spine to the contralateral side and to strengthen the function of intervertebral connections. Some spinal injuries can affect this ligament. It is often engaged in people who work in a fixed lumbar spine forward flexion posture, and with force accompanied by rotation and lateral flexion of the lumbar spine, at this time, the interverse ligament on one side is most stressed, if the movement is uncoordinated, it can lead to injury, and will cause more obvious unilateral lower back pain.
Lumbar rib ligament is located in the upper middle layer of the thoracolus lumbar fascia, the thickened part between the 12th rib and the 1st lumbar transverse process, the lumbar rib ligament is often due to frequent flexion and extension of the waist, generally easy to be diagnosed as thoracolumbar fasciitis, in fact, this diagnosis is not unreasonable, lumbar rib ligament is the thickened part of the thoracolumbar fascia. I will break it down in a future blog post about the lower back fascia.
The etiology of low back pain is complex, among which the muscle-derived factors, ligament-derived factors, the author has combined with the summary classification of clinical cases to discuss, of course, the causes of low back pain are far more than these, as well as fascial factors, bone factors, intervertebral disc factors, aseptic inflammatory factors, nerve entrapment factors, etc., in addition, from the perspective of traditional Chinese medicine, there are external causes such as rheumatism and dampness, liver and kidney deficiency and other internal causes, meridian blockage, qi and blood stasis, tendon outflow, bone wrong sutures and other etiological factors exist, The author will continue to discuss and share with personal experience. Waist pain is difficult to get more and more love to repeat, there must be a demon in the waist in the demon catching demon (nine) ------ tendons to pull the bones, bone pulling tendons, loose tendons orthopedic bones only for the bones and tendons soft. The next issue continues.