A case of thoracic disc protrusion, which is clinically characterized by sciatic nerve pain

Clinicaldatathe patient male, 24 years old, light physical workerThe main complaint is the right lower limb pain numbness for more than 4 months, the pain range from the right hip through the outer side of the thigh, the outer side of the lower leg radiation to the foot back and soles, coughing or sneezing symptoms significantly increasedThere is no clear history of trauma in the pastIn the external hospital, the lumbar mrI examination did not show significant lumbar disc protrusion and nerve root pressure (Figure 1),diagnosisfor unexplained sciatic nerve painConservative treatments such as nonsteroidal anti-inflammatory drug support therapy and bed rest are givenDuring the treatment, the symptoms of lower limb pain gradually worsened, because of the pain can not walk, the appearance of the knee bending hip forcing positionAt this time, has been from the simple right radiation pain progress to the double lower limb radiation pain, and in the last 3 weeks gradually appeared bipedal back stretch and flexor and walking difficultiesHe was treated at the Spinal Surgery Clinic of Beijing Water Tank Hospitala detailed physical examination after admission(1) Double lower limb nerve check: double-sided calves rear outer side, foot back and foot needle sting loss, right long elongation and flexomuscle strength III, left IV level, two-sided straight leg elevation test (-), double-sided knee reflex eschews, Barbinski sign (-), double-sided crucify (-), ankle (-)(2) Torso and vulva body: the torso has no obvious sensory plane, the two-sided abdominal wall reflects symmetrically lead, the vulva feel normal, the anal peripheral reflex exists; Thorta.au and lumbar vertebral positive side X-ray shows the lumbar vertebral physiological curvature is straight, the T11/12 vertebral gap is slightly narrower, and the S1 vertebral lumbarization changes (Figure 2)Lumbar MRI shows lumbar disc signal can, no obvious protruding Thoracic CT and MRI show T11/12 central disc protrusion, combined intervertebral disc bone, spinal cone pressure is obvious (Figure 3) The back circuit thoracic vertebral tube is de-stressed, internally fixed, and bone-implanted fusion is performed Postoperative review of the X-ray show the fixed position is good (Figure 4, 5) 2 weeks after surgery, the lower limb radiation pain significantly reduced, the patient can get out of bed to walk After 3 months of review, the symptoms of radiation pain in the lower extremities completely disappeared, the lower limb muscle strength improved significantly before, has returned to work discussion
about 75% of thoracic disc protrusion (TDH) is located below T8, most commonly at T11/12 If the protruding intervertebral disc encroaches on more than 40% of the vertebral area, it is a large TDH The incidence of TDH is mostly hidden, chronic exacerbation, from the appearance of symptoms to seriously affect the lives of patients for several years Its clinical symptoms are complex and varied, so accurate qualitative diagnosis of TDH and location diagnosis (i.e., the specific relationship between the highlighting segment and the oppressive nerve) requires the attending physician to have a wealth of clinical experience clinical symptoms of TDH and differential diagnosis of key points of back pain: early symptoms of TDH, common lying in the lower part of the thoracic spine TDH, are easily confused with pain caused by cardiopulmonary or other abdominal lesions The key to differential diagnosis is the association between pain and movement The pain caused by TDH is mostly related to exercise and is exacerbated when coughing or sneezing Pain caused by chest and abdominal organs often has corresponding induced and aggravating factors, such as lower temperature, heart-induced pain, overeating and pancreatic diseases If necessary, it is feasible to create an intervertebral disc sciatic aches and weakness estopsy: Common in the thoracic lumbar tDH, similar to lumbar disc protrusion symptoms However, from the anatomical aspect, the thoracic lumbar vertebral tube is the majority of the spinal cord lumbar expansion, the relative distribution of nerves dense, myelin and nerve roots coexist As a result, the clinical manifestations of this segment TDH usually affect multiple neural distribution regions Detailed neurological examination and electromyography examination can help to determine the affected nerve range and carry out differential diagnosis symptoms of spinal cord compression and upper motor neuronal injury: common in the upper middle stage of the thoracic spine TDH, need to be identified with cervical vertebral disease, tumors in the vertebral tube, etc Learn more about the patient's medical history, and carry out nerve function damage location examination, electromyography and other limbs and torso neurological examination, combined with spinal imaging examination clear diagnosis 4 Radiation pain in the ribs or groin area: it needs to be identified with urinary stones, interribal nerve pain, or infection of the shingles virus The key to differential diagnosis is the aggravation and relief of pain Urinary system stones often manifest as "colic", due to some kind of trigger, such as vigorous exercise, labor, etc., suddenly appear one side of the waist severe colic Urine tests and urinary ultrasounds can help identify the diagnosis The nerve pain caused by the virus infection is often characterized by resting pain, and the degree of pain is not directly related to movement Different viral infections have different clinical characteristics, such as shingles virus in the infection of 3 to 7d, the skin in the nerve-dominated areas will appear blisters, to give antiviral treatment is often effective the location diagnosis of TDH is very important, especially multi-section disk prominent, according to the patient's symptoms, signs and imaging test results to clarify the responsibility section to ensure the efficacy of surgery Compared with lumbar disc protrusion, TDH is more complex due to factors such as cone position and lumbar vertebral movement Under normal circumstances, the spinal cone stops at the L1/2 level, T11/12 disc corresponds to L1 to 2 myelin, T12/L1 disc corresponds to L3 to 5 myelin, And L1/2 disc corresponds to S5 myelin The neural positioning of TDH also needs to take into account such factors as the position of the spinal cone and the movement of the lumbar spine If the spinal cone moves up to the T12/L1 level, the T11/12 disc corresponds to L4 to 5 myelin, and the T12/L1 disc corresponds to S1 to 2 myelin In addition, the walking and arrangement of the nerve roots around the spinal cone has certain rules: the nerve roots emitted by the partial side myelin are located on both sides of the spinal cord, and the nerve roots emitted by the side myelin section are located in the center of the spinal cord, where the position of these nerves is fixed by dense complex cobwebs In this case, the positive side X-ray of the spine indicates complete lumbar vertebralization of the spine, and the spinal MRI shows that the spinal cone stops at the lower edge level of the T12 vertebral T11/12 Intervertebral disc protrudes toward the center of the vertebral tube, compressing the L5 myelin and adjacent L4 nerve roots, causing corresponding neurological symptoms and signs Therefore, in the patient's clinical symptoms and signs of unexplained sciatic nerve pain, should consider the next section of TDH compression corresponding myelin and nerve possibilities