achein the back it is experienced at least once in a lifetime by 4 out of 5. For the active population, they aremost common cause of disabilitywhich determines their social and economic importance in all countries of the world. Among the diseases that are accompanied by pain in the lumbar spine and limbs, one of the main places is occupied by osteochondrosis.
Osteochondrosis of the spine (OP) is its degenerative-dystrophic lesion, 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 pulpy (gelatinous) elastic nucleus loses its physiological properties: it dries up and sequestered over time. Under the influence of mechanical loads, the fibrous ring of the disc, which has lost its elasticity, protrudes and, subsequently, fragments of the nucleus pulposus fall through its cracks. This leads to the appearance of acute pain (low back pain), 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 the classification proposed by Ya. Yu. Popelyansky and A. I. Osna. In the second period, not only the amortization capacity is lost, but also the fixation function with the development of hypermobility (or instability). In the third period, the formation of a hernia (protrusion) of the disc is observed. According to the degree of their prolapse, the herniated disc is divided intoelastic protrusionwhen there is a uniform protrusion of the intervertebral disc, eboss seized, characterized by irregular and incomplete rupture of the fibrous ring. The pulpus nucleus moves to these places of rupture, creating local protrusions. With a partially prolapsed disc herniation, all layers of the fibrous ring rupture and possibly the posterior longitudinal ligament, but the hernial protrusion itself has not yet lost contact with the central part of the nucleus. A completely prolapsed disc herniation means that not its individual fragments, but the entire nucleus, prolapsed into the lumen of the spinal canal. According to the diameter of the herniated disc, they are divided into foraminal, posterolateral, paramedian and median. The clinical manifestations of a herniated disc are varied, but it is at this stage that various compression syndromes often develop.
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 (induration), so the body increases the support area due to the marginal bone growths around the entire perimeter. Joint overload leads to spondyloarthrosis, which can cause compression of neurovascular formations in the intervertebral foramen. It is these changes that are noted in the fourth period (stage) (OP), when there is a total lesion of the spinal motion segment.
Any schematization of such a complex and clinically diverse disease as OP is, of course, quite arbitrary. However, it allows you to analyze the clinical manifestations in their dependence on morphological changes, which allows not only to make a correct diagnosis, but also to determine specific therapeutic measures.
Depending on which nerve formations the herniated disc, bone growths and other affected structures of the spine have a pathological effect, reflex and compression syndromes are distinguished.
Lumbar osteochondrosis syndromes
Forcompressionthey include syndromes in which a root, vessel or spinal cord is stretched, squeezed and deformed on the indicated vertebral structures. Forreflexthey include syndromes caused by the effect of these structures on the receptors that innervate them, mainly the endings of the recurrent spinal nerves (Lushka's sinovertebral nerve). The impulses that travel along this nerve from the affected spine travel through the posterior root to the posterior horn of the spinal cord. Moving on to the anterior horns, they cause a reflex tension (defense) of the innervated muscles -reflex-tonic disorders.. Moving on to the sympathetic centers of the lateral horn of one's own level or of neighboring ones, they cause reflex vasomotor or dystrophic disturbances. Such neurodystrophic disorders mainly occur in low-vascularized tissues (tendons, ligaments) at the attachment sites to bony prominences. Here the tissues undergo defibration, swelling, become painful, especially if stretched and palpated. In some cases, these neurodystrophic disorders cause pain that occurs not only locally, but also remotely. In the latter case, the pain is reflected, it seems to "shoot" when touching the diseased area. Such zones are called activation zones. Myofascial pain syndromes can occur as part of the reported spondylogen pain.. With prolonged tension of the striated muscle, microcirculation is disturbed in some of its areas. Due to hypoxia and edema in the muscle, zones of seals are formed in the form of nodules and threads (as well as in ligaments). The pain in this case is rarely local, it does not coincide with the innervation zone of some roots. Reflex-myotonic syndromes include piriformis syndrome and popliteal syndrome, the characteristics of which are dealt with in detail in numerous manuals.
Forlocal (local) painful reflex syndromes.in lumbar osteochondrosis, low back pain is attributed to the acute development of the disease and to low back pain in a subacute or chronic course. An important circumstance is the established fact thatlow back pain is a consequence of the intradiscal displacement of the nucleus pulposus. As a rule, this is a sharp, often piercing pain. The patient, as it were, freezes in an uncomfortable position, cannot bend over. An attempt to change the position of the body causes increased pain. There is immobility of the entire lumbar region, flattening of the lordosis, sometimes scoliosis develops.
With low back pain - pain, as a rule, aching, aggravated by movement, with axial loads. The lower back can be deformed, as in low back pain, but to a lesser extent.
Compression syndromes in lumbar osteochondrosis are also different. Among them, radicular compression syndrome, caudal syndrome, lumbosacral discogenic myelopathy syndrome are distinguished.
root compression syndromeit often develops due to a herniated disc at the L levelIV-Lvand Iv-Sone, becauseIt is at this level that disc herniation is most likely to develop. Depending on the type of hernia (foraminal, posterior-lateral, etc. ), one or the other root is affected. As a rule, one level corresponds to a monoradicular lesion. Clinical manifestations of root compression Lvthey are reduced to the appearance of irritation and prolapse in the corresponding dermatome and to the phenomena of hypofunction in the corresponding myotome.
Paresthesias(feeling of numbness, tingling) and throbbing pains spread along the outer surface of the thigh, the front surface of the lower leg up to the I toe area. Hypalgesia can then appear in the corresponding area. In the muscles innervated by the L rootv, especially in the anterior sections of the lower leg, hypotrophy and weakness develop. First of all, weakness is detected in the long extensor of the diseased finger - in the muscle innervated only by the L-rootv. Tendon reflexes with an isolated lesion of this root remain normal.
When compressing the spine Sonethe phenomena of irritation and loss develop in the corresponding dermatome, extending to the area of the fifth finger. Hypotrophy and weakness mainly cover the posterior muscles of the lower leg. The Achilles reflex decreases or disappears. The knee tear is reduced only when the roots of L.2, L3, Lfour. Hypotrophy of the quadriceps, and in particular of the gluteal muscles, also occurs in the pathology of the lumbar caudal discs. Compression root paraesthesia 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, their tension. The most commonly tested symptom isLasegue's symptomwhen there is a sharp increase in pain in the leg when trying to lift it to a straightened state. An unfavorable variant of lumbar vertebrogenic radicular compression syndromes is compression of the cauda equina, the so-calledcaudal syndrome. Most often, it develops with large prolapsed median disc hernias, when all the roots at this level are squeezed. Topical diagnosis is performed on the upper spine. The pains, usually severe, do not spread to one leg, but, as a rule, to both legs, the loss of sensation captures the area of the pilot's pants. With severe variants and the rapid development of the syndrome, sphincter disorders are added. Lumbar caudal myelopathy develops as a result of occlusion of the inferior accessory radiculo-medullary artery (often at the root of Lv, ) and is manifested by weakness of the fibular, tibial and buttock muscle groups, sometimes with segmental sensory disturbances. Often ischemia develops simultaneously in the segments of the epicon (L. 5-Sone) and a cone (S2-S5) of the spinal cord. In these cases, pelvic disorders also join.
In addition to the main identified clinical and neurological manifestations of lumbar osteochondrosis, there are other symptoms that indicate the defeat of this spine. This is especially clearly manifested in the combination of damage to the intervertebral disc against the background of congenital narrowness of the spinal canal, various anomalies in the development of the spine.
Lumbar Osteochondrosis Diagnosis
Lumbar Osteochondrosis Diagnosisis based on the clinical picture of the disease and additional methods of examination, 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 greatly improved. Sagittal and horizontal tomographic sections allow you to see the relationship of the affected intervertebral disc to surrounding tissues, including an assessment of the lumen of the spinal canal. The size, type of disc herniation, which roots are compressed and by which structures they are determined. It is important to establish compliance of the main clinical syndrome with the level and nature of the lesion. As a rule, a patient with radicular compression syndrome develops a monoradicular lesion, and the compression of this root is clearly visible on MRI. This is relevant from a surgical point of view, because. this defines 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 highly informative diagnostic method, especially in conjunction with myelography, but it should be remembered that the scan is performed in a horizontal plane and, therefore, the level of the presumed lesion must be clinically determined very accurately. Routine radiography is used as a screening test and is mandatory in a hospital setting. In functional imaging, instability is better defined. Various abnormalities of bone development are also clearly visible on the spondilograms.
Treatment of lumbar osteochondrosis
With PO, both conservative and surgical treatment is performed. Inconservative treatmentwith osteochondrosis, the following pathological conditions require treatment: orthopedic disorders, pain syndrome, impaired disc fixation capacity, musculo-tonic disorders, circulatory disorders in the roots and spinal cord, nerve conduction disorders, adhesive changes scarring, psychosomatic disorders. Conservative treatment methods (CL) include various orthopedic measures (immobilization, spinal traction, manual therapy), physiotherapy (therapeutic massage and physiotherapy, acupuncture, electrotherapy), prescription of drugs. Treatment should be complex, gradual. Each of the CL methods has its own indications and contraindications, but, as a rule, the general one isprescription of analgesics, non-steroidal anti-inflammatory drugs(NSAIDs),muscle relaxantsAndPhysiotherapy.
The analgesic effect is achieved through the use of diclofenac, paracetamol, tramadol. It has a pronounced analgesic effecta drugcontaining 100 mg of diclofenac sodium.
Gradual (long-term) absorption of diclofenac improves the efficacy of the therapy, prevents possible gastrotoxic effects and makes the therapy as convenient as possible for the patient (only 1-2 tablets per day).
If necessary, increase the daily dose of diclofenac to 150 mg, additionally prescribe painkillers in the form of non-prolonged-acting tablets. In milder forms of the disease, when relatively small doses of the drug are sufficient. In case of a predominance of painful symptoms at night or in the morning, it is recommended to take the drug in the evening.
The substance paracetamol has lower analgesic activity than other NSAIDs and therefore a drug has been developed which, together with paracetamol, includes another non-opioid analgesic, propiphenazone, as well as codeine and caffeine. In patients with ischalgia, when using caffeine, muscle relaxation, a decrease in anxiety and depression are noted. Good results have been observed when using the drug in the clinic to relieve acute pain in myofascial, myotonic and radicular syndromes. According to the researchers, with short-term use, the drug is well tolerated, 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, thromboxane. Treatment should always begin with the appointment of the safest drugs (diclofenac, ketoprofen) at 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 initiate 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 some advantages over standard NSAIDs, which reduces the risk of COX-dependent side effects. Furthermore, misoprostol is able to enhance the analgesic effect of diclofenac.
To eliminate pain associated with increased 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 intramuscular tolperisone 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 the increase in muscle tone. Therefore, it is used in situations where there is no antispasmodic effect of other drugs (in so-called non-responsive 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 a derivative of imidazole, its effect 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 effect and a mild anti-inflammatory effect. The substance tizanidine acts on spinal and cerebral spasticity, reduces strain reflexes and painful muscle spasms. It reduces resistance to passive movements, reduces spasms and clonic convulsions and increases the strength of voluntary contractions of the skeletal muscles. It also has a gastroprotective property, which determines its use in combination with NSAIDs. The drug has practically no side effects.
Surgerywith PO, it occurs with the development of compression syndromes. It should be noted that the presence of the fact of detection of a herniated disc during MRI is not enough for the final decision on the operation. Up to 85% of herniated disc patients among patients with radicular symptoms after conservative treatment do without surgery. CL, with the exception of a number of situations, should be the first step in helping patients with OP. If complex CL is ineffective (within 2-3 weeks), surgical treatment (CL) is indicated in patients with herniated disc and root symptoms.
There are emergency signs for PO. These include the development of caudal syndrome, as a rule, with complete prolapse of the disc in the lumen of the spinal canal, the development of acute radiculomyeloishemia and a pronounced hyperalgic syndrome, when even the appointment of opioids, blockade does not reduce pain. It should be noted that the absolute size of the herniated disc is not decisive for the final decision on the operation and should be considered together with the clinical picture, the specific situation that is observed in the spinal canal according to tomography (for example, there may be a combination of a small hernia against the background of the stenosis of the spinal canal or vice versa - a hernia is large, but of a median position against the background of a wide spinal canal).
In 95% of cases with disc herniation, open access to the spinal canal is used. Various discupuncture techniques have not so far 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 access, the removal of the bony formations of the vertebra is avoided using mainly interlaminar access. However, with narrow canal, hypertrophy of the articular processes, fixed median disc herniation, it is advisable to expand access at the expense of bone structures.
The results of surgical treatment largely depend on the experience of the surgeon and the correctness of the indications for a particular operation. According to the apt expression of the famous neurosurgeon J. Brotchi, who has performed more than a thousand osteochondrosis operations, it is necessary "not to forget that the surgeon must operate on the patient and not on the tomographic image".
In conclusion, I would like to emphasize once again the need for a thorough clinical examination and tomogram analysis in order to make an optimal decision on the choice of treatment tactics for a particular patient.