illin the back is experienced at least once in a lifetime by 4 out of 5 people. For the working population, they arethe most common cause of disabilitywhich determines their social and economic interests in all countries of the world. Among diseases 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 the adjacent neurovascular formation. Under the influence of unfavorable static-dynamic loads, the elastic (gelatinous) pulpous nucleus loses its physiological properties - it dries up, and is isolated over time. Under the influence of mechanical load, 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 (lumbago), because. the peripheral portion of the annulus fibrosus contains Luschka's nerve receptors.
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 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 hernia (protrusion) of the disc is observed. According to the degree of their prolapse, disc herniations are divided intoelastic protrusionwhen there is a uniform protrusion of the intervertebral disc, andisolated protrusions, characterized by uneven and incomplete rupture of the fibrous ring. The nucleus pulposus moves to these rupture sites, creating a local protrusion. With a partially prolapsed disc herniation, all layers of the fibrous ring are ruptured, and possibly the posterior longitudinal ligament, but the herniated protrusion itself has not yet lost contact with the central part of the nucleus. A fully prolapsed disc herniation means that not individual fragments, but the entire nucleus, prolapses into the lumen of the spinal canal. According to the diameter of disc herniation, they are divided into foraminal, posterolateral, paramedian and median. The clinical manifestations of disc herniation are varied, but at this stage various compression syndromes often develop.
Over time, the pathological process can move to other parts of the spinal motion segment. Increased load on the vertebral body leads to the development of subchondral sclerosis (hardening), then the body increases the support area due to the growth of marginal bone around the entire perimeter. Excess joint load leads to spondylarthrosis, which can cause compression of the neurovascular formation in the intervertebral foramen. These changes are noted in the fourth period (stage) (OP), when there is a total lesion of the spinal motion segment.
Any schema of a clinically complex and diverse disease like OP is, of course, somewhat 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 formation the disc herniation, bone growth and other structures of the affected spine have pathological effects, reflex and compression syndromes are distinguished.
Lumbar osteochondrosis syndrome
Tocompressionincluding syndromes in which roots, vessels or spinal cord are stretched, compressed and deformed above the indicated vertebral structures. Toreflexincluding syndromes caused by the effects of these structures on the receptors surrounding them, especially the recurrent spinal nerve endings (Lushka's sinuvertebral nerve). Impulses that propagate along this nerve from the affected spine travel through the posterior root to the posterior horn of the spinal cord. Moving to the anterior horn, they cause reflex tension (defense) of the absorbed muscles -reflex-tonic disorder.. Moving to the sympathetic center of the lateral horn of their own or neighboring levels, they cause vasomotor reflexes or dystrophic disorders. Such neurodystrophic disorders occur mainly in the lower vascular tissues (tendons, ligaments) at the attachment site to bony prominences. Here, the tissues undergo defibration, swelling, they become painful, especially when stretched and palpated. In some cases, this neurodystrophic disorder causes pain that occurs not only locally, but also at a distance. In the second case, the pain is reflected, it seems to "shoot" when touching the diseased area. Such a zone is called a trigger zone. Myofascial pain syndrome may occur as part of referred spondylogenic pain.. With prolonged tension of striated muscles, microcirculation is disturbed in certain areas. Due to hypoxia and edema in the muscles, the seal zone is 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 a specific root conservation zone. Reflex-myotonic syndrome includes piriformis syndrome and popliteal syndrome, the characteristics of which are discussed in detail in many manuals.
Tolocal (local) pain reflex syndrome.in lumbar osteochondrosis, lumbago is associated with the acute development of the disease and lumbalgia in a subacute or chronic course. An important condition is the established fact thatlumbago is the result of intradiscal displacement of the nucleus pulposus. As a rule, this is a sharp, often shooting pain. The patient, as it were, froze in an uncomfortable position, unable to bend. Attempts to change the position of the body cause increased pain. There is immobility of the entire lumbar region, flattening of the lordosis, sometimes scoliosis develops.
With lumbalgia - pain, as a rule, pain, aggravated by movement, with axial load. The lumbar region may be deformed, as in lumbago, but to a lesser degree.
Compression syndrome in lumbar osteochondrosis is also diverse. Among them, radicular compression syndrome, tail syndrome, lumbosacral discogenic myelopathy syndrome are distinguished.
radicular compression syndromeoften develops as a result of disc herniation at the L levelIV-LVand LV-Sone, because it is at this level that a herniated disc is 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 of LVreduced to the appearance of irritation and prolapse in the corresponding dermatome and to the phenomenon of hypofunction in the corresponding myotome.
Paresthesia(numbness, tingling) and shooting pain spread along the outer surface of the thigh, the front surface of the lower leg to the zone of fingers I. Hypalgesia may then appear in the corresponding zone. In the muscles innervated by the roots of LV, especially in the anterior part 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 root.V. Tendon reflexes with isolated lesions of this root remain normal.
When compressing the spine Sonethe phenomenon of irritation and loss develops in the corresponding dermatome, extending to the zone of the fifth finger. Hypotrophy and weakness covers mainly the posterior muscles of the lower leg. The Achilles reflex is reduced or absent. The knee jerk is reduced only when the L root is involved.2, L3, Lfour. Hypotrophy of the quadriceps, and especially the gluteal muscles, also occurs in caudal lumbar disc pathology. Paresthesia and compressive radicular pain aggravated by coughing, sneezing. The pain worsens with movement in the lower back. There are other clinical symptoms that indicate the development of root compression, their tension. The most common symptoms tested areLasegue symptomswhen there is a sudden increase in pain in the leg when you try to lift it in a straight position. An unfavorable variant of radicular syndrome of lumbar vertebrogenic compression is cauda equina compression, so-calledcaudal syndrome. Most often, it develops with a large prolapsed median herniated disc, when all the roots at this level are squeezed. Topical diagnosis is carried out on the upper spine. Pain, usually severe, does not spread to one leg, but, as a rule, to both legs, loss of sensitivity captures the area of the rider's pants. With severe variants and rapid development of the syndrome, sphincter disorders are added. Caudal lumbar myelopathy develops due to blockage of the inferior accessory radiculo-medullary artery (often at the root of LV, ) and manifested by weakness of the peroneal, tibial and gluteal muscle groups, sometimes with segmental sensory disturbances. Often, ischemia develops simultaneously in the epiconal segment (L5-Sone) and a cone (S2-S5) spinal cord. In such cases, pelvic disorders also join.
In addition to the main clinical and neurological manifestations of lumbar osteochondrosis identified, there are other symptoms that indicate the defeat of this spine. This is especially evident in the combination of damage to the intervertebral disc 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 osteochondrosisis based on the clinical picture of the disease and additional examination methods, which include conventional radiography of the lumbar spine, computed tomography (CT), CT myelography, magnetic resonance imaging (MRI). With the introduction of spinal MRI into clinical practice, the diagnosis of lumbar osteochondrosis (PO) has improved significantly. Sagittal and horizontal tomographic sections allow you to see the relationship of the affected intervertebral disc with the surrounding tissue, including the assessment of the lumen of the spinal canal. The size, type of disc herniation, which root is compressed and by what structure is determined. It is important to establish the compliance of the leading clinical syndrome with the extent and nature of the lesion. As a rule, patients with compressed radicular syndrome develop monoradicular lesions, and this root compression 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 very informative diagnostic method, especially in combination with myelography, but it should be remembered that scanning is performed in a horizontal plane and, therefore, the extent of the alleged lesion must be clinically determined very accurately. Routine radiography is used as a screening examination and is mandatory in the hospital setting. In functional imaging, instability is best defined. Various anomalies of bone development are also clearly visible on spondylograms.
Treatment of lumbar osteochondrosis
With PO, both conservative and surgical treatment is carried out. Onconservative treatmentwith osteochondrosis, the following pathological conditions require treatment: orthopedic disorders, pain syndromes, impaired fixation ability of the disc, muscle-tonic disorders, blood circulation disorders in the roots and spinal cord, nerve conduction disorders, cicatricial adhesive changes, psychosomatic disorders. Conservative treatment methods (CL) include various orthopedic measures (immobilization, spinal traction, manual therapy), physiotherapy (therapeutic massage and physiotherapy, acupuncture, electrotherapy), drug prescription. Treatment should be complex, phased. Each CL method has its own indications and contraindications, but, as a rule, the general ones areprescription analgesics, non-steroidal anti-inflammatory drugs(NSAIDs),muscle relaxantandphysiotherapy.
An analgesic effect is achieved with the use of diclofenac, paracetamol, tramadol. Has a pronounced analgesic effectdrugscontains 100 mg diclofenac sodium.
Gradual (long-term) absorption of diclofenac increases the effectiveness of therapy, prevents possible gastrotoxic effects, and makes therapy as easy as possible for patients (only 1-2 tablets per day).
If necessary, increase the daily dose of diclofenac to 150 mg, additionally prescribe painkillers in the form of short-acting tablets. In a milder form of the disease, when a relatively small dose of the drug is sufficient. In case of predominance of painful symptoms at night or in the morning, it is recommended to take the medicine in the evening.
The substance paracetamol is lower in analgesic activity than other NSAIDs, and therefore a drug has been developed, which, together with paracetamol, includes other non-opioid analgesics, propyphenazone, as well as codeine and caffeine. In patients with ischalgia, when using caffeine, muscle relaxation, decreased 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 researchers, with short-term use, this 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 related to the suppression of cyclooxygenase (COX-1 and COX-2) - enzymes that control the conversion of arachidonic acid to prostaglandins, prostacyclin, thromboxane. Treatment should always start with the appointment of the safest drug (diclofenac, ketoprofen) at the lowest effective dose (side effects depend on the dose). 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 gastroenterology and other side effects. The combination of diclofenac and misoprostol has certain advantages over standard NSAIDs, which reduce the risk of COX-dependent side effects. In addition, misoprostol is able to increase the analgesic effect of diclofenac.
To eliminate the pain associated with an increase in muscle tone, it is advisable to include central muscle relaxants in the complex therapy:tizanidine2-4 mg 3-4 times a day or tolperisone in 50-100 mg 3 times a day, or intramuscular tolperisone 100 mg 2 times a day. The mechanism of action of drugs with these substances differs significantly from the mechanism 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 cases of so-called unresponsiveness). The advantage over other muscle relaxant drugs used for the same indication is that with a decrease in muscle tone on the background of the appointment, there is no decrease in muscle strength. This drug is an imidazole derivative, its effect is associated with central stimulation a2-adrenergic receptors. It selectively inhibits the polysynaptic component of the stretch reflex, has an independent antinociceptive effect and is slightly anti-inflammatory. The substance tizanidine acts on spinal and cerebral spasticity, reducing stretch reflexes and painful muscle spasms. It reduces resistance to passive movements, reduces spasms and clonic convulsions, and increases the strength of voluntary contraction of skeletal muscles. It also has gastroprotective properties, which determines its use in combination with NSAIDs. This medicine has almost no side effects.
Surgerywith PO, it is carried out with the development of compression syndrome. It should be noted that the presence of the fact of detection of disc herniation during MRI is not sufficient for the final decision about the operation. Up to 85% of patients with a herniated disc among patients who experience radicular symptoms after conservative treatment do without surgery. CL, with the exception of a few situations, should be the first step in helping 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 signs 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 radiculomyeloischemia and a clear hyperalgic syndrome, despite the appointment of opioids, restrictions do not reduce pain. It should be noted that the absolute size of the disc herniation does not determine the final decision on the operation and should be considered in conjunction with the clinical picture, specific conditions observed in the spinal canal according to tomography (for example, there may be a combination of a small hernia with a background of stenosis of the spinal canal or vice versa - a herniais large, but the median location against the background of the wide spinal canal).
In 95% of cases with disc herniation, open access to the spinal canal is used. Various discopuncture techniques have not found widespread application to date, although some authors report their effectiveness. Operations are performed using both conventional and microsurgical instruments (with optical magnification). During access, removal of vertebral bone formation is avoided by using mainly interlaminar access. However, with a narrow channel, hypertrophy of the articular process, herniation of the median disc, it is advisable to expand the access at the expense of the bone structure.
The results of surgical treatment largely depend on the experience of the surgeon and the accuracy of the indications for a particular operation. According to the exact expression of the famous neurosurgeon J. Brotchi, who has performed more than a thousand operations for osteochondrosis, it is necessary "do not 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 tomogram analysis to make an optimal decision regarding the choice of treatment tactics for a particular patient.
