painin the back is experienced at least once in a lifetime by 4 out of 5 people. For the working population, they aremost common cause of disabilitywhich determines their social and economic significance 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 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 frequent secondary effects on adjacent neurovascular formations. Under the influence of unfavorable static-dynamic loads, the elastic pulpous (gelatinous) nucleus loses its physiological properties - it dries up, and sequestrates over time. Under the influence of mechanical loads, the fibrous ring of the disk, which has lost its elasticity, protrudes, and subsequently fragments of the nucleus pulposus fall out through its cracks. This leads to the appearance 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 the classification proposed by Ya. Yu. Popelyansky and A. I. Osna. In the second period, not only the depreciation ability 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, disc herniation is divided intoelastic protrusionwhen there is a uniform protrusion of the intervertebral disc, andsequestered protrusion, characterized by uneven and incomplete rupture of the fibrous ring. The nucleus pulposus moves into these places of ruptures, 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, prolapse into the lumen of the spinal canal. According to the diameter of the disc herniation, it is divided into foraminal, posterolateral, paramedian and median. The clinical manifestations of disc herniation 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 (hardening), then the body increases the area of support due to marginal bone growths around the entire perimeter. Joint overload 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 total lesion of the spinal motion segment.
Any schematization of such a complex, clinically diverse disease as OP, of course, is rather arbitrary. However, it makes it possible to analyze 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 disc herniation, bone growths and other affected structures of the spine have a pathological effect, reflex and compression syndromes are distinguished.
Syndromes of lumbar osteochondrosis
Tocompressioninclude syndromes in which a root, vessel or spinal cord is stretched, squeezed and deformed over the indicated vertebral structures. Toreflexinclude syndromes caused by the effect of these structures on the receptors innervating them, mainly the endings of the recurrent spinal nerves (Lushka's sinuvertebral nerve). Impulses propagating along this nerve from the affected spine travel along the posterior root to the posterior horn of the spinal cord. Switching to the anterior horns, they cause a reflex tension (defense) of the innervated muscles -reflex-tonic disorders.. Switching to the sympathetic centers of the lateral horn of their own or neighboring levels, they cause reflex vasomotor or dystrophic disorders. This kind of neurodystrophic disorders occur primarily in low vascularized tissues (tendons, ligaments) at the sites of attachment to bone prominences. Here, the tissues undergo defibration, swelling, they become painful, especially when stretched and palpated. In some cases, these neurodystrophic disorders cause pain that occurs not only locally, but also at a distance. 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 may occur as part of referred spondylogenic pain.. With prolonged tension of the striated muscle, microcirculation is disturbed in certain areas of it. Due to hypoxia and edema in the muscle, zones of seals are formed in the form of nodules and strands (as well as in ligaments). Pain in this case is rarely local, it does not coincide with the zone of innervation of certain roots. The reflex-myotonic syndromes include piriformis syndrome and popliteal syndrome, the characteristics of which are covered in detail in numerous manuals.
Tolocal (local) pain reflex syndromesin lumbar osteochondrosis, lumbago is attributed to the acute development of the disease and lumbalgia in subacute or chronic course. An important circumstance is the established fact thatlumbago is a consequence of intradiscal displacement of the nucleus pulposus. As a rule, this is a sharp pain, often shooting through. The patient, as it were, freezes in an uncomfortable position, cannot unbend. An attempt to change the position of the body provokes an increase in pain. There is immobility of the entire lumbar region, flattening of the lordosis, sometimes scoliosis develops.
With lumbalgia - pain, as a rule, aching, 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, lumbosacral discogenic myelopathy syndrome are distinguished.
radicular compression syndromeoften develops due to disc herniation at level LIV-LVand LV-Sone, becauseIt is at this level that herniated discs are more likely to develop. Depending on the type of hernia (foraminal, posterior-lateral, etc. ), one or another root is affected. As a rule, one level corresponds to a monoradicular lesion. Clinical manifestations of root compression LVare reduced to the appearance of irritation and prolapse in the corresponding dermatome and to the phenomena of hypofunction in the corresponding myotome.
Paresthesia(feeling of numbness, tingling) and shooting pains spread along the outer surface of the thigh, the front surface of the lower leg to the zone of the I finger. Hypalgesia may then appear in the corresponding zone. In the muscles innervated by the root LV, 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 root LV. Tendon reflexes with an isolated lesion of this root remain normal.
When compressing spine Sonethe phenomena of irritation and loss develop in the corresponding dermatome, extending to the zone of the fifth finger. Hypotrophy and weakness cover mainly 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 involved.2, L3, Lfour. Hypotrophy of the quadriceps, and especially the gluteal muscles, also occurs in the pathology of the caudal lumbar discs. Compression-radicular paresthesia and pain are aggravated by coughing, sneezing. The pain is aggravated by movement in the lower back. There are other clinical symptoms indicating the development of compression of the roots, their tension. The most commonly tested symptom issymptom of Laseguewhen there is a sharp increase in pain in the leg when you try to lift it in a straightened state. An unfavorable variant of lumbar vertebrogenic compression radicular syndromes is cauda equina compression, the so-calledcaudal syndrome. Most often, it develops with large prolapsed median herniated discs, when all the roots at this level are squeezed. Topical diagnosis is carried out on the upper spine. The pains, usually severe, do not spread to one leg, but, as a rule, to both legs, loss of sensitivity captures the area of \u200b\u200bthe rider's pants. With severe variants and the rapid development of the syndrome, sphincter disorders are added. Caudal lumbar myelopathy develops as a result of occlusion of the lower accessory radiculo-medullary artery (often at the root of LV, ) and is manifested by weakness of the peronial, tibial and gluteal muscle groups, sometimes with segmental sensory disturbances. Often, ischemia develops simultaneously in the segments of the epicone (L5-Sone) and a cone (S2-S5) of the spinal cord. In such cases, pelvic disorders also join.
In addition to the identified main 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.
Diagnosis of lumbar osteochondrosis
Diagnosis of lumbar osteochondrosisis based on the clinical picture of the disease and additional methods of examination, which include conventional radiography 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 significantly improved. Sagittal and horizontal tomographic sections allow you to see the relationship of the affected intervertebral disc with the surrounding tissues, including an assessment of the lumen of the spinal canal. The size, type of disc herniation, which roots are compressed and by what structures are determined. It is important to establish the compliance of the leading clinical syndrome with the level and nature of the lesion. As a rule, a patient with compression radicular 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 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 combination with myelography, but it must be remembered that the scanning is carried out in a horizontal plane and, therefore, the level of the alleged lesion must be clinically determined very accurately. Routine radiography is used as a screening examination and is mandatory in a hospital setting. In functional imaging, instability is best defined. Various bone developmental anomalies are also clearly visible on spondylograms.
Treatment of lumbar osteochondrosis
With PO, both conservative and surgical treatment is carried out. Atconservative treatmentwith osteochondrosis, the following pathological conditions require treatment: orthopedic disorders, pain syndrome, impaired fixation ability of the disc, muscular-tonic disorders, circulatory disorders in the roots and spinal cord, nerve conduction disorders, cicatricial adhesive changes, psychosomatic disorders. Methods of conservative treatment (CL) include various orthopedic measures (immobilization, spinal traction, manual therapy), physiotherapy (therapeutic massage and physiotherapy, acupuncture, electrotherapy), prescription of medications. Treatment should be complex, staged. 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 by the use of diclofenac, paracetamol, tramadol. Has a pronounced analgesic effecta drugcontaining 100 mg diclofenac sodium.
Gradual (long-term) absorption of diclofenac improves the effectiveness 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 tablets of non-prolonged action. In milder forms of the disease, when relatively small doses of the drug are sufficient. In the 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 is inferior in analgesic activity to other NSAIDs, and therefore a drug was developed, which, along with paracetamol, includes another non-opioid analgesic, propyphenazone, as well as codeine and caffeine. In patients with ischalgia, 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, with short-term use, the drug is well tolerated, practically does not cause side effects.
NSAIDs are the most widely 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 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, which reduces the risk of COX-dependent side effects. In addition, misoprostol is able to potentiate 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 there is no antispastic effect of other drugs (in the so-called non-responsive cases). The advantage over other muscle relaxant drugs that are used for the same indications is that with a decrease in muscle tone on the background of the appointment, there is no decrease in muscle strength. The drug is an imidazole derivative, its effect is associated with stimulation of central a2-adrenergic receptors. It selectively inhibits the polysynaptic component of the stretch reflex, has an independent antinociceptive and slight anti-inflammatory effect. The substance tizanidine acts on spinal and cerebral spasticity, reduces stretch reflexes and painful muscle spasms. It reduces resistance to passive movements, reduces spasms and clonic convulsions, and increases the strength of voluntary contractions of skeletal muscles. It also has a gastroprotective property, which determines its use in combination with NSAIDs. The drug has practically no side effects.
Surgerywith software, it is carried out with the development of compression syndromes. It should be noted that the presence of the fact of detection of a disc herniation during MRI is not enough for the final decision on the operation. Up to 85% of patients with herniated discs among patients with radicular symptoms after conservative treatment do without surgery. CL, with the exception of a number of situations, should be the first stage of care for patients with PO. If complex CL is ineffective (within 2–3 weeks), surgical treatment (CL) is indicated in patients with herniated discs and radicular symptoms.
There are emergency indications for PO. These include the development of caudal syndrome, as a rule, with complete prolapse of the disc into 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 disc herniation is not decisive for the final decision on the operation and should be considered in conjunction 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 spinal canal stenosisor vice versa - a hernia is large, but of a median location against the background of a wide spinal canal).
In 95% of cases with disc herniation, open access to the spinal canal is used. Various discopuncture techniques have not found wide application to date, although a number of authors report their effectiveness. The operation is performed using both conventional and microsurgical instruments (with optical magnification). During access, removal of bone formations of the vertebra is avoided by using mainly interlaminar access. However, with a narrow canal, hypertrophy of the articular processes, fixed median disc herniation, it is advisable to expand the 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 operations for osteochondrosis, 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 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.