painon the back is experienced at least once in a lifetime by 4 out of 5 people. For the working population,most common cause of disabilitythat determines its 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 sites is occupied by osteochondrosis.
Osteochondrosis of the spine (OP) is a degenerative-dystrophic lesion of the spine, starting in the nucleus pulposus of the intervertebral disc, extending to the annulus fibrosus and other elements of the spinal segment, with a frequent secondary effect on adjacent neurovascular formations. Under the influence of unfavorable static-dynamic loads, the elastic nucleus pulposus (gelatinous) loses its physiological properties - it dries and sequesters with time. Under the influence of mechanical loads, the annulus fibrosus of the disc, which has lost its elasticity, protrudes, and subsequently, fragments of the nucleus pulposus fall through its cracks. This leads to the onset of sharp pain (lumbago) because. the peripheral parts of the annulus fibrosus contain Luschka 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 depreciation 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 its prolapse, the herniated disc is divided intoelastic overhangwhen there is a uniform protrusion of the intervertebral disc, andhijacked bulge, characterized by irregular and incomplete rupture of the fibrous ring. The nucleus pulposus moves to these rupture sites, creating local ridges. With a partially prolapsed herniated disc, all layers of the annulus fibrosus 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 herniated disc means that not its individual fragments, but the entire nucleus, prolapse 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 several compressive syndromes often develop.
Over time, the pathological process can move to other parts of the spinal segment of motion. An increase in load on the vertebral bodies leads to the development of subchondral sclerosis (hardening), so 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 neurovascular formations in the intervertebral foramen. It is these changes that are noticed in the fourth period (stage) (OP), when there is total injury to the movement segment of the spine.
Any schematization of a disease as complex and clinically diverse as OP is, of course, quite arbitrary. However, it allows analyzing the clinical manifestations depending on morphological alterations, 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
Forcompressioninclude syndromes in which a root, vessel, or spinal cord is stretched, compressed, and deformed over the indicated vertebral structures. Forreflectioninclude syndromes caused by the effect of these structures on the receptors that innervate them, mainly the recurrent spinal nerve endings (sinuvertebral nerve of Lushka). Impulses that propagate along this nerve from the affected spine travel through 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 -tonic reflex disorders.. Shifting to lateral horn sympathetic centers from their own or neighboring levels, they cause reflex or dystrophic vasomotor disturbances. Such neurodystrophic disorders occur mainly in poorly vascularized tissues (tendons, ligaments) at the sites of attachment to bony prominences. Here, the tissues undergo defibration, swelling, 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. These zones are called trigger zones. Myofascial pain syndromes can occur as part of referred spondylogenic pain.. With prolonged striated muscle tension, microcirculation is disturbed in certain areas. Due to hypoxia and edema in the muscle, zones of seals are formed in the form of nodules and wires (as well as in ligaments). The pain in this case is rarely local, it does not coincide with the innervation zone of certain roots. Reflex myotonic syndromes include piriformis syndrome and popliteal syndrome, the features of which are covered in detail in several manuals.
Forlocal (local) pain reflex syndromesin lumbar osteochondrosis, low back pain is attributed to the acute development of the disease and low back pain in a subacute or chronic course. An important circumstance is the established fact thatLow back pain is a consequence of intradiscal displacement of the nucleus pulposus. As a rule, this is a sharp pain, often triggered. The patient, so to speak, freezes in an uncomfortable position, cannot let go. An attempt to change the position of the body causes an increase in pain. There is immobility of the entire lumbar region, flattening of lordosis, sometimes scoliosis develops.
With low back pain - pain, as a rule, aching, aggravated by movement, with axial loads. The lower back may be deformed, as in lumbago, but to a lesser extent.
The compression syndromes in lumbar osteochondrosis are also diverse. Among them, the root compression syndrome, the caudal syndrome, the lumbosacral discogenic myelopathy syndrome stand out.
root compression syndromeoften develops due to herniated disc at level L4-IVand IV-S1, because it is at this level that herniated discs are most likely to develop. Depending on the type of hernia (foraminal, posterolateral, etc. ), one or the other root is affected. As a rule, one level corresponds to a single root lesion. Clinical manifestations of root compression LVthey are reduced to the appearance of irritation and prolapse in the corresponding dermatome and to hypofunction phenomena in the corresponding myotome.
paresthesia(sensation of numbness, tingling) and sharp pains spread along the outer surface of the thigh, the front surface of the leg to the area of finger I. Hyalgesia may then appear in the corresponding area. In muscles innervated by the L rootV, especially in the anterior sections of the leg, hypotrophy and weakness develop. First, weakness is detected in the diseased extensor digitorum longus - in the muscle innervated only by the L rootV. Tendon reflexes with isolated injury to this root remain normal.
When compressing the S column1the 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 leg muscles. The Achilles reflex diminishes or disappears. The knee reflex is reduced only when the L roots are involved.two, I3, Ifour. Hypotrophy of the quadriceps, and especially of 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 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 leg pain when you try to lift it in a straight state. An unfavorable variant of lumbar vertebrogenic compression radicular 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 at the top of the spine. The pains, usually severe, do not spread to one leg, but, as a rule, for both legs, the loss of sensation captures the area of the 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 inferior accessory radiculomedullary artery (often at the root of the LV, ) and is manifested by weakness of the peroneal, tibial, and gluteal muscle groups, sometimes with segmental sensory disturbances. Often, ischemia develops simultaneously in the segments of the epiconus (L5-S1) and a cone (Stwo-S5) of the spinal cord. In such cases, pelvic disorders also come together.
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.
Diagnosis of lumbar osteochondrosis
Diagnosis of lumbar osteochondrosisit is based on the clinical picture of the disease and complementary 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 (OP) has significantly improved. Sagittal and horizontal CT sections allow viewing the relationship of the affected intervertebral disc to the surrounding tissues, including an assessment of the lumen of the spinal canal. The size, type of herniated disc, which roots are compressed and by which structures 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 root compression syndrome develops a single root 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.
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 examination is performed in a horizontal plane and therefore the level of the alleged lesion must be determined clinically very accurately. Routine radiography is used as a screening test and is mandatory in a hospital setting. In the functional image, instability is better defined. Various anomalies of bone development are also clearly visible on spondylograms.
Treatment of lumbar osteochondrosis
With PO, conservative and surgical treatment is performed. At theconservative treatmentwith osteochondrosis, the following pathological conditions require treatment: orthopedic disorders, pain syndrome, impaired disc fixation ability, muscle-tonic disorders, circulatory disorders in the roots and spinal cord, nerve conduction disorders, scar adhesive changes, psychosomatic disorders. Conservative treatment methods (CL) include various orthopedic measures (immobilization, spinal traction, manual therapy), physical therapy (therapeutic massage and physical therapy, acupuncture, electrotherapy), medication prescription. Treatment must be complex, staged. Each of the CL methods has its own indications and contraindications, but, as a rule, the general isprescription of analgesics, non-steroidal anti-inflammatory drugs(Ines),muscle relaxantsandphysiotherapy.
The analgesic effect is achieved by the use of diclofenac, paracetamol, tramadol. Has a pronounced analgesic effecta drugcontaining 100 mg of diclofenac sodium.
The 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, in addition to prescribing analgesics in the form of non-long-acting tablets. In milder forms of the disease, when relatively small doses of the drug are sufficient. In case of 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 that, together with paracetamol, includes another non-opioid analgesic, propyphenazone, in addition to codeine and caffeine. In patients with ischialgia, when using caffeine, muscle relaxation, decreased anxiety and depression are observed. 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 suppression of cyclooxygenase (COX-1 and COX-2) - an enzyme that regulates the conversion of arachidonic acid to prostaglandins, prostacyclin, thromboxane. Treatment should always start 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 combination 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 increased muscle tone, it is advisable to include central muscle relaxants in complex therapy:tizanidine2-4 mg 3-4 times a day or tolperisone within 50-100 mg 3 times a day, or intramuscular tolperisone 100 mg 2 times a day. The drug's mechanism of action 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 so-called unresponsive cases). The advantage over other muscle relaxant drugs used for the same indications is that with a decrease in muscle tone at the bottom of the consultation, there is no decrease in muscle strength. The drug is an imidazole derivative, its effect is associated with the stimulation oftwo-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 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 gastroprotective property, which determines its use in combination with NSAIDs. The drug has practically no side effects.
Surgerywith PO, is performed with the development of compressive syndromes. It is noteworthy that the presence of the detection of a herniated disc during MRI is not sufficient for the final decision on the operation. Up to 85% of patients with a herniated disc among patients with radicular symptoms after conservative treatment do not need surgery. LC, with the exception of some situations, should be the first step to help patients with PO. If complex CL is ineffective (within 2 to 3 weeks), surgical treatment (CL) is indicated in patients with a herniated disc and radicular symptoms.
There are emergency indications for PO. These include the development of caudal syndrome, as a rule, with complete disc prolapse into the lumen of the spinal canal, the development of acute radiculomyeloishemia and a pronounced hyperalgic syndrome, when even the appointment of opioids, the blockade does not reduce pain. It is noteworthy that the absolute size of the herniated disc is not decisive for the final decision of the operation and must be considered together with the clinical picture, the specific situation observed in the spinal canal according to the tomography (for example, it can there may be a combination of a small hernia in the context of spinal canal stenosis or vice versa - a hernia is large but of medium location in the context of a wide spinal canal).
In 95% of cases with herniated discs, open access to the spinal canal is used. Several discopuncture techniques have not found wide application to date, although several authors report their effectiveness. The operation is performed with conventional and microsurgical instruments (with optical magnification). During access, removal of bony formations from the vertebra is avoided primarily using interlaminar access. However, with a narrow canal, hypertrophy of joint processes, fixed median disc herniation, it is advisable to widen the access to the detriment of bone structures.
The results of surgical treatment largely depend on the surgeon's experience and the correctness of indications for a given operation. According to the opportune expression of the famous neurosurgeon J. Brotchi, who performed more than a thousand surgeries for osteochondrosis, it is necessary "to remember that the surgeon must operate on the patient, not the tomographic image".
In conclusion, I would like to emphasize once again the need for a thorough clinical examination and analysis of CT scans to make an optimal decision on the choice of treatment tactics for a given patient.