Diagnosis Experience of Patients with Cervical, Thoracic and Lumbar Multi-Segment Spinal Stenosis: A Case Report and Literature Review

Background: The incidence of cervical, thoracic and lumbar spinal canal stenosis is low. It is difficult to identify the main focus and responsible segment, and it is also difficult to select the sequence of staging surgery. We report a patient with triple stenosis. Case Presentation: In this paper, we introduced a 61-year-old female patient with cervical, thoracic and lumbar spinal canal stenosis who had previously undergone “lumbar discectomy” in the outer hospital. The postoperative effect was not good and the symptoms were poor. The diagnosis was “cervical spinal stenosis and lumbar postoperative surgery”. The staged spinal canal decompression operation and Duhuo Jisheng Decoction (DHJSD) treatment were conducted in our hospital. After three months of follow-up, the functional and imaging results were satisfactory. Conclusions: The main focus and responsible spinal segment should be determined by the comprehensive analysis of medical history, signs, and images. Surgery combined with Chinese herbal medicine DHJSD therapy may be an effective treatment for this kind of disease.


Background
Spinal canal stenosis, which refers to the progressive narrowing of the spinal *Guosen Du and Longbiao Xu have equally contributed to this work as co-first authors. canal due to degeneration, is general in aged patients. The symptoms of spinal canal stenosis vary by the segment and severity of the stenosis, including radiculopathy, claudication, and myelopathy. Among all segments, the stenosis of the cervical and lumbar canal is most common due to more spinal activity [1]. Multisegmental stenosis is less common than single segmental stenosis, which can create confusion in the diagnosis and treatment. Teng et al. first reported concurrent cervical and lumbar stenosis. Dagi et al. first invent the word "tandem spinal stenosis" to describe combined stenosis, whose triad is intermittent neurogenic claudication, progressive gait disturbance, and findings of mixed myelopathy and polyradiculopathy in both the upper and lower extremities. Cervical, thoracic, and lumbar spinal canal stenosis may occur due to developmental, metabolic, or degenerative reasons. However, the diagnosis and definition of multiple spinal stenosis have not been clearly defined.
The incidence rate of multi-segment triple spinal stenosis of cervical, thoracic and lumbar vertebrae is low. At present, relevant literature reports on diagnosis and treatment are relatively rare. Park et al. analyzed the clinical data of 460 patients with lumbar stenosis, of which only 18 patients were complicated with triple stenosis. Japanese scholars found through autopsy of 1072 patients with lumbar stenosis that lumbar stenosis and thoracic stenosis are not caused by tandem stenosis, and the incidence rate of triple stenosis is relatively low [2] [3] [4]. In the following case, we presented a case of a triple spinal stenosis patient and describe our diagnosis and treatment experience in this disease.

Case Presentation
The patient, a 61-year-old woman, was admitted to the hospital for "weakness of both lower limbs for one year that aggravated with walking instability for half a year". One year ago, the patient suffered from fatigue of both lower limbs without inducement, accompanied with numbness below the plane of both knees, and could not walk for a long distance, while both upper limbs were not affected. No palpitation, chest tightness, dizziness, nausea and other discomforts. In the following six months, the symptoms gradually worsened that the patient had the feeling of stepping on cotton and walked unstably. The patient was diagnosed with "lumbar disc herniation and lumbar spinal canal stenosis" in the outer hospital and underwent lumbar discectomy (Figure 1(a) and Figure 1(b)). The above symptoms did not ease after operation. In the past six months, the patients felt that the appeal symptoms were further aggravated and accompanied by walking difficulties. Therefore, she turned to our hospital for further treatment and was admitted to our department as "cervical spinal stenosis and lumbar postoperative surgery".
The patient had the past history of "left knee arthroplasty" and "left femoral internal fixation" for the left femoral fracture (Figure 1

Discussion
Most patients with cervical, thoracic and lumbar multi-segment spinal stenosis have a long course of the disease and often have experienced various treatment experiences. It is difficult to verify the development and changes of the diseases.
The patient in our case had undergone two previous surgical treatments for her symptoms, and neither of them had achieved expected results nor gotten worse.
The decision-making process of diagnosis and treatment is worthy of our consideration.
Such patients mostly have both upper and lower motor neuron symptoms, and the symptoms are interwoven with each other, which is easy to be missed and misdiagnosed [5]. In the process of diagnosis and treatment, the medical history should be inquired in detail to guide patients to provide valuable information for diagnosis. It is particularly important to carry out a careful physical examination, which can identify the main focus and responsible segment by  [11]. In our country, whole spine examination is sometimes limited by financial elements, and patients are hardly followed by the same doctor in the outpatient.
These make it difficult for an exact diagnosis and probable treatment. This phenomenon is also an important factor that causes clinical misdiagnosis.  [22]. Basic research shows that it has the effects of anti-inflammatory, analgesia, immune regulation, cartilage promotion, and fibrous ring repair [23]. DHJSD has been widely used in the treatment of lumbar disc herniation [24] [25], and other orthopedic diseases, such as knee arthritis and osteoporosis [26] [27]. A systematic review and meta-analysis for DHJSD in the treatment of lumbar disc herniation also showed good effectiveness and safety [23]. In our case, after surgery, this patient was treated with DHJSD, with the dosage of 100 ml per day for three months. With the follow-up, the patient's symptoms improved significantly. It is proved that surgery combined with Chinese herbal medicine DHJSD therapy is an effective treatment for this patient.

Conclusion
We should pay more attention to patients with spinal degenerative diseases, and must pursue the unity of medical history, signs, and images. In case of difficult patients, more comprehensive examinations are required, and the main focus and responsible segment are determined through comprehensive analysis. Further exploration is needed when the manifestation could not be reasonably explained by the acquired information, especially when some focal lesions exist while some potential coexisted problems are ignored due to incomplete examinations.

Availability of Data and Materials
Data sharing not applicable to this article as no datasets were generated or analysed during the current study.

Authors' Contributions
This case report was designed by XL and ZY, case materials were collected by TY, this article was written by XL and TY. YG and ZY participated in discussion development, reviewed the article, and provided expert guidance. All authors read and approved the final manuscript.