Painsin the back is experienced by 4 out of 5 people at least once in their lives. For working people, they aremost common cause of disabilitywhich determines its social and economic importance in all countries of the world. Among the diseases associated with pain in the lumbar spine and limbs, osteochondrosis occupies one of the main places.
Spinal osteochondrosis (OP) is a degenerative-dystrophic lesion of it, starting from the nucleus pulposus of the intervertebral disc, extending to the fibrous ring and other elements of the spinal segment, with a frequent secondary effect on the adjacent neurovascular formations. Under the influence of unfavorable static-dynamic loads, the elastic pulpy (gelatinous) core loses its physiological properties - it dries up and sequesters over time. Under the influence of mechanical loads, the fibrous ring of the intervertebral disc, which has lost its elasticity, protrudes, and subsequently fragments of the nucleus pulposus fall out through its cracks. This leads to the occurrence of acute pain (lumbago), because. the peripheral parts of the annulus fibrosus contain receptors of the Luschka nerve.
Stages of osteochondrosis
The intradiscal pathological process corresponds to stage 1 (period) (OP) according to that of Ya. Yu proposed classification. Popelyansky and A. I. Osna. In the second period, not only the ability to depreciate is lost, but also the fixation function with the development of hypermobility (or instability). In the third period, the formation of a herniated disc (protrusion) is observed. Depending on the degree of her prolapse, the herniated disc is dividedelastic protrusionif there is a uniform bulging of the intervertebral disc, andsequestered prominence, characterized by an uneven and incomplete rupture of the fibrous ring. The nucleus pulposus moves into these rupture sites and creates local protrusions. In a partially herniated disc, all layers of the annulus rupture and possibly the posterior longitudinal ligament, but the hernial spur itself has not yet lost contact with the central part of the nucleus. A fully herniated disc means that not its individual fragments, but the entire nucleus prolapses into the lumen of the spinal canal. Depending on the diameter of the herniated disc, they are divided into foraminal, posterolateral, paramedian and median. The clinical manifestations of a herniated disc are diverse, but various compression syndromes often develop at this stage.
Over time, the pathological process can move to other parts of the spinal motion segment. An increase in the load on the vertebral bodies leads to the development of subchondral sclerosis (hardening), then the body increases the area of \u200b\u200bsupport due to marginal bone growth around the entire perimeter. Overloading of the joints leads to spondylarthrosis, which can cause compression of the neurovascular formations in the intervertebral foramen. It is these changes that are noted in the fourth period (stage) (OP), when there is a complete lesion of the spinal motion segment.
Any schematization of such a complex, clinically diverse disease as OP is, of course, rather arbitrary. However, it allows to analyze clinical manifestations depending on morphological changes, which allows not only to make a correct diagnosis, but also to establish specific therapeutic measures.
Depending on which nerve formations are pathologically influenced by the herniated disc, bone growths and other affected structures of the spine, a distinction is made between reflex and compression syndromes.
Syndromes of lumbar osteochondrosis
tocompressioninclude syndromes in which a root, vessel, or spinal cord is stretched, pinched, and deformed over the indicated vertebral structures. toreflexinclude syndromes caused by the action of these structures on the receptors they innervate, mainly the endings of the recurrent spinal nerves (Lushka's sinuvertebral nerve). Impulses propagating along this nerve from the affected spine travel through the dorsal root to the dorsal horn of the spinal cord. Switching to the front horns, they cause a reflex tension (defense) of the innervated muscles -reflex tonic disorders.. They switch to the lateral horn sympathetic centers of their own or adjacent levels and cause reflex vasomotor or dystrophic disorders. Such neurodystrophic disorders appear mainly in poorly vascularized tissues (tendons, ligaments) in the places where they attach to bony prominences. Here the tissues undergo defibration, swelling, they become painful, especially when stretched and palpated. In some cases, these neurodystrophic diseases cause pain that is not only local, but also remote. In the latter case, the pain is reflected, it seems to "shoot" when touching the diseased area. Such zones are called trigger zones. Myofascial pain syndromes can occur in the context of referred spondylogenic pain.. With prolonged tension of the striated muscle, the microcirculation in certain areas of it is disturbed. Due to hypoxia and edema in the muscle, sealing zones are formed in the form of nodules and strands (as well as in ligaments). The pain in this case is rarely local, it does not coincide with the zone of innervation of certain roots. Reflex myotonic syndromes include piriformis syndrome and popliteal syndrome, the characteristics of which are discussed in detail in numerous manuals.
tolocal (local) pain reflex syndromesin lumbar osteochondrosis, lumbago is attributed to the acute development of the disease, and lumbago to the subacute or chronic course. An important fact is the established fact thatLumbago is a consequence of the intradiscal displacement of the nucleus pulposus. As a rule, this is a sharp pain that often shoots through. The patient, as it were, freezes in an uncomfortable position and cannot bend. An attempt to change the position of the body leads to an increase in pain. There is immobility of the entire lumbar region, flattening of the lordosis, sometimes scoliosis develops.
With lumbago - pain, as a rule, pain, aggravated by movement, with axial loads. The lumbar region may be deformed as in lumbago, but to a lesser extent.
Compression syndromes in lumbar osteochondrosis are also diverse. Among them, radicular compression syndrome, caudal syndrome and lumbosacral discogenic myelopathy syndrome are distinguished.
Radicular Compression Syndromeoften develops due to a herniated disc at level LIV-Lvand mev-Sone, Because at this level, herniated discs are more likely to develop. Depending on the type of hernia (foraminal, posterior-lateral, etc. ), one or the other root is affected. One level usually corresponds to a monoradicular lesion. Clinical manifestations of root compression Lvreduced to the occurrence of irritation and prolapse in the corresponding dermatome and to hypofunction phenomena in the corresponding myotome.
paresthesias(numbness, tingling) and stabbing pains that spread along the outer thigh, the front surface of the lower leg to the zone of the I finger. Hypoalgesia can then occur in the corresponding zone. In those from the root Lv, especially in the anterior portions of the lower leg, hypotrophy and weakness develop. First, weakness is noted in the long extensor muscle of the diseased finger - the muscle innervated only by the root Lv. Tendon reflexes with an isolated lesion of this root remain normal.
When compressing the spine Sonethe irritation and loss phenomena develop in the corresponding dermatome up to the zone of the fifth finger. Hypotrophy and weakness primarily affect the posterior muscles of the lower leg. The Achilles reflex decreases or disappears. The knee jerk is reduced only when the roots of L are affected.2, l3, lfour. Hypotrophy of the quadriceps, and especially the gluteal muscles, also occurs with the pathology of the caudal discs. Compression radicular paresthesia and pain are aggravated by coughing, sneezing. The pain is made worse by movement in the lower back. There are other clinical symptoms that indicate the development of compression of the roots and their tension. The most commonly tested symptom isSymptom of Lasegueif the pain in the leg sharply increases when you try to lift it in a stretched state. An unfavorable variant of the lumbar vertebrogenic compression root syndrome is the cauda equina compression, the so-calledcaudal syndrome. Most often it develops with large herniated middle disc herniations when all roots at this level are crushed. Topical diagnosis is performed on the upper spine. The usually intense pain does not spread to one leg, but usually to both legs, the loss of sensitivity involves the area of the rider's pants. In the case of severe variants and the rapid development of the syndrome, sphincter disorders are added. Caudal lumbar myelopathy develops as a result of occlusion of the inferior accessory radiculo-medullary artery (often at the root of Lv, ) and manifests as weakness of the peronial, tibial, and gluteal muscle groups, sometimes with segmental sensory disturbances. Often ischemia develops simultaneously in the segments of the epiconus (L5-Sone) and a cone (p2-S5) of the spinal cord. In such cases, pelvic diseases also appear.
In addition to the identified main clinical and neurological manifestations of lumbar osteochondrosis, there are other symptoms that indicate a defeat of this spine. This is especially evident in the combination of disc damage against the background of congenital narrowing of the spinal canal, various anomalies in the development of the spine.
Diagnosis of lumbar osteochondrosis
Diagnosis of lumbar osteochondrosisdepends on the clinical picture and additional examination methods, which include conventional X-ray of the lumbar spine, computed tomography (CT), CT myelography, magnetic resonance imaging (MRI). With the introduction of MRI of the spine into clinical practice, the diagnosis of lumbar osteochondrosis (PO) has improved significantly. Sagittal and horizontal tomography slices allow you to see the relationship of the affected disc to the surrounding tissues, including an assessment of the lumen of the spinal canal. The size, type of disc herniation, which roots are compressed and through which structures are determined. It is important to establish the correspondence of the leading clinical syndrome with the extent and nature of the lesion. Typically, a patient with compression root syndrome develops a monoradicular lesion, and compression of this root is clearly visible on MRI. This is relevant from a surgical point of view because. this defines the operational access.
The disadvantages of MRI include the limitations associated with the examination in patients with claustrophobia, as well as the cost of the study itself. CT is a very powerful diagnostic method, especially when combined with myelography, but it must be remembered thatthat the scan is performed in a horizontal plane and therefore the height of the alleged lesion must be clinically determined very accurately. The routine X-ray serves as a screening examination and is mandatory in a hospital. Instability is best defined in functional imaging. Various bone development anomalies are also clearly visible on spondylograms.
Treatment of lumbar osteochondrosis
Both conservative and surgical treatment are used for PO. atconservative treatmentIn the case of osteochondrosis, the following clinical pictures require treatment: orthopedic diseases, pain syndrome, impaired fixation ability of the intervertebral disc, muscular-tonic disorders, circulatory disorders in the roots and spinal cord, nerve conduction disorders, scarring changes, psychosomatic disorders. Methods of conservative treatment (CL) include various orthopedic measures (immobilisation, spinal traction, manual therapy), physiotherapy (therapeutic massage and physiotherapy, acupuncture, electrotherapy), prescription of medication. Treatment should be complex and staged. Each of the CL methods has its own indications and contraindications, but, as a rule, the general onePrescribing analgesics, nonsteroidal anti-inflammatory drugs(NSAIDs),muscle relaxantsandphysical therapy.
The analgesic effect is achieved with the use of Diclofenac, Paracetamol, Tramadol. Has a pronounced analgesic effecta drugcontains 100 mg diclofenac sodium.
Gradual (long-term) absorption of Diclofenac improves the effectiveness of therapy, prevents possible gastrotoxic effects and makes therapy as comfortable as possible for the patient (only 1-2 tablets per day).
If necessary, increase the daily dose of diclofenac to 150 mg, and additionally prescribe painkillers in the form of tablets of non-prolonged action. In milder forms of the disease, when relatively small doses of the drug are enough. If the painful symptoms predominate at night or in the morning, it is recommended to take the drug in the evening.
The substance paracetamol is inferior to other NSAIDs in its analgesic activity, which is why a drug was developed that, in addition to paracetamol, contains another non-opioid analgesic, propyphenazone, as well as codeine and caffeine. In patients with ischagia, when using caffetin, muscle relaxation, a decrease in anxiety and depression are noted. Good results were noted when using the drug in the clinic to relieve acute pain in myofascial, myotonic and radicular syndromes. According to researchers, the drug is well tolerated with short-term use and practically does not cause side effects.
NSAIDs are the most commonly used drugs for PO. NSAIDs have anti-inflammatory, analgesic and antipyretic effects associated with the suppression of cyclooxygenase (COX-1 and COX-2) - an enzyme that regulates the conversion of arachidonic acid into prostaglandins, prostacyclin and thromboxane. Treatment should always begin with the appointment of the safest drugs (diclofenac, ketoprofen) in the lowest effective dose (side effects are dose-dependent). In elderly patients and in patients with risk factors for side effects, it is advisable to start treatment with meloxicam and especially with celecoxib or diclofenac/misoprostol. Alternative routes of administration (parenteral, rectal) do not prevent gastroenterological and other side effects. The combined drug diclofenac and misoprostol has certain advantages over standard NSAIDs, reducing the risk of COX-related side effects. In addition, misoprostol is able to enhance the analgesic effect of diclofenac.
To eliminate pain associated with an increase in muscle tone, it is advisable to include central muscle relaxants in complex therapy:tizanidine2-4 mg 3-4 times a day, or tolperisone inside 50-100 mg 3 times a day, or tolperisone intramuscularly 100 mg 2 times a day. The mechanism of action of the drug with these substances is significantly different from the mechanisms of action of other drugs used to reduce increased muscle tone. Therefore, it is used in situations where other drugs do not have an antispastic effect (in the so-called unresponsive cases). The advantage over other muscle relaxants used for the same indications is that with a decrease in muscle tone against the background of the appointment, there is no decrease in muscle strength. The drug is an imidazole derivative, its action is associated with the stimulation of the central a2-adrenergic receptors. It selectively inhibits the polysynaptic component of the stretch reflex, has an independent antinociceptive and slightly anti-inflammatory effect. The active ingredient tizanidine works on spinal and cerebral spasticity, reduces stretch reflexes and painful muscle spasms. It reduces resistance to passive movements, reduces spasms and clonic spasms, and increases the strength of voluntary skeletal muscle contractions. It also has a gastroprotective property that dictates its use in combination with NSAIDs. The drug has practically no side effects.
surgeryat PO it is carried out with the development of compression syndromes. It should be noted that the presence of the fact of evidence of a herniated disc during MRI is not enough for the final decision on the operation. Up to 85% of the herniated disc patients among the patients with radicular symptoms after conservative treatment do without an operation. Except in a few situations, CL should be the first step in helping patients with PO. If complex CL is ineffective (within 2–3 weeks), surgical therapy (CL) is indicated in patients with a herniated disc and radicular symptoms.
There are emergency indications for PO. As a rule, these include the development of caudal syndrome with complete herniation of the intervertebral disc into the lumen of the spinal canal, the development of acute radiculomyeloischemia and a pronounced hyperalgic syndrome, when even the appointment of opioids does not relieve the pain of the blockade. It should be noted that the absolute size of the herniated disc is not decisive for the final decision to operate and in connection with the clinical picture, the specific situation observed in the spinal canal according to tomography (for example, there may be a combination of a small herniathe background of spinal canal stenosis or vice versa - a hernia is large, but of medium position against the background of a wide spinal canal).
Open access to the spinal canal is used in 95% of disc herniation cases. Various discopuncture techniques have not yet found wide application, although a number of authors report their effectiveness. The operation is performed using both conventional and microsurgical instruments (with optical magnification). During the approach, the removal of bony formations of the vertebra is avoided by mainly using an interlaminar approach. However, with a narrow canal, hypertrophy of the articular processes and a fixed herniated disc, it is advisable to expand access at the expense of bone structures.
The results of surgical treatment largely depend on the surgeon's experience and the correctness of the indications for a particular operation. According to the apt expression of the famous neurosurgeon J. Brotchi, who performed more than a thousand operations for osteochondrosis, it is necessary "not to forget that the surgeon must operate on the patient, and not the tomographic image".
In conclusion, I would like to once again emphasize the need for a thorough clinical examination and analysis of tomograms in order to make an optimal decision on the choice of treatment tactics for a particular patient.