painin the back is experienced at least once in life by 4 out of 5 people. For the working population they arethe most 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 vertebrae 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, reaching the fibrous ring and other elements of the spinal segment with frequent secondary effects on the neighboring neurovascular formations. Under the influence of unfavorable static-dynamic loads, the elastic pulpous (gelatinous) core loses its physiological properties - it dries up and, over time, is sequestered. 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 out through its cracks. This leads to the appearance of acute pain (lumbago), becausethe 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. Popelyanski and A. I. Osna. In the second period, not only the ability to amortize, but also the function of fixation is lost 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 an even protrusion of the intervertebral disc andsequestered protrusion, characterized by uneven and incomplete rupture of the annulus fibrosus. The nucleus pulposus moves into these tear sites, creating local protrusions. In a partially prolapsing disc herniation, all layers of the annulus fibrosus and possibly the posterior longitudinal ligament are torn, but the hernial protrusion itself has not yet lost contact with the central part of the nucleus. A complete prolapsed disc herniation means that not its individual fragments, but the entire nucleus prolapses into the lumen of the spinal canal. According to the diameter of the disc herniation, they are divided into foraminal, posterolateral, paramedian and median. The clinical manifestations of disc herniation are diverse, but various compression syndromes often develop at this stage.
Over time, the pathological process can move to other parts of the spinal motor segment. Increasing the load on the vertebral bodies leads to the development of subchondral sclerosis (hardening), after which the body increases the bearing area due to marginal bone growths along the entire perimeter. Overloading 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 total lesion of the motion segment of the spine.
Any schematization of such a complex, clinically diverse disease as OP is, of course, quite arbitrary. However, it allows to analyze the clinical manifestations depending on the morphological changes, which allows not only to make a correct diagnosis, but also to determine specific therapeutic measures.
Depending on which nerve formations are pathologically affected by disc herniation, bone growths and other affected structures of the spine, reflex and compression syndromes are distinguished.
Lumbar osteochondrosis syndromes
Tocompressioninclude syndromes in which a root, vessel, or spinal cord is stretched, compressed, and deformed on the specified spinal structures. Toreflexinclude syndromes caused by the effect of these structures on the receptors that innervate them, mainly the endings of the recurrent spinal nerves (Lushka's synuvertebral nerve). Impulses propagating along this nerve from the affected spinal column pass through the posterior root to the posterior horn of the spinal cord. Passing to the front horns, they cause reflex tension (protection) of the innervated muscles -reflex-tonic disorders.. Passing to the sympathetic centers of the lateral horn at their own or neighboring levels, they cause reflex vasomotor or dystrophic disorders. Such neurodystrophic disorders occur primarily 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 from a distance. In the latter case, the pain is reflected, it seems to "shoot" when touching the painful area. Such areas are called trigger zones. Myofascial pain syndromes can occur as part of the mentioned spondylogenic pain.. With prolonged tension of the striated muscle, the microcirculation is disturbed in certain areas of it. Due to hypoxia and edema, areas of seals are formed in the muscles in the form of knots and threads (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 popliteus syndrome, the characteristics of which are discussed in detail in numerous manuals.
Tolocal (local) pain reflex syndromesin lumbar osteochondrosis, lumbago is due to the acute development of the disease and lumbago in a 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 piercing. The patient seems to freeze in an uncomfortable position, cannot bend. 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 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 degree.
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 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 L. root compressionVare reduced to the appearance of irritation and prolapse in the corresponding dermatome and to phenomena of hypofunction in the corresponding myotome.
Paresthesia(sensation of numbness, tingling) and shooting pains spreading on the outer surface of the thigh, the front surface of the lower leg to the area of the I finger. Hypoalgesia may then appear in the respective area. In the muscles innervated by the root LV, especially in the front parts 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 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 involve the posterior muscles of the lower leg. The Achilles reflex decreases or disappears. The knee is reduced only when the roots of L are involved.2, L3, Lfour. In the pathology of the caudal lumbar discs, there is hypotrophy of the quadriceps and especially the gluteal muscles. Compression-radicular paresthesia and pain worsen when coughing, sneezing. The pain increases with movement in the lower back. There are other clinical symptoms indicating the development of compression of the roots, their tension. The most frequently tested symptom isLasegue's symptomwhen there is a sharp increase in pain in the leg when you try to raise it in an upright position. An unfavorable variant of the radicular syndromes of the lumbar vertebrogenic compression is the compression of the cauda equina, the so-called.caudal syndrome. It most often develops in large prolapsed middle disc herniations, when all roots at this level are compressed. Local diagnosis is performed on the upper part of the spine. Pains, usually severe, do not spread in one leg, but, as a rule, in both legs, the loss of sensitivity captures the area of the rider's pants. In severe variants and rapid development of the syndrome, sphincter disorders are added. Caudal lumbar myelopathy develops as a result of occlusion of the lower accessory radiculomedullary artery (often at the root of 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 epiconus segments (L5-Sone) and cone (S2-S5) of the spinal cord. In such cases, pelvic disorders are also added.
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 manifests itself especially clearly 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 research methods, which include conventional radiography of the lumbar spine, computed tomography (CT), CT myelography, nuclear magnetic resonance (MRI). With the introduction of MRI of the spine into clinical practice, the diagnosis of lumbar osteochondrosis (LO) 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 and type of disc herniation, which roots are pressed and by which structures are determined. It is important to establish the correspondence 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 the compression of this root is clearly visible on MRI. This is relevant from a surgical point of view, becausethis determines operational access.
Disadvantages of MRI include the limitations associated with the study in claustrophobic patients, 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 scan is performed in a horizontal plane, and therefore the level of the suspected 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 best defined. Various abnormalities in bone development are also clearly visible on spondylograms.
Treatment of lumbar osteochondrosis
In PO, both conservative and surgical treatment is carried out. Atconservative treatmentin osteochondrosis, the following pathological conditions require treatment: orthopedic disorders, pain syndrome, 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), prescription of drugs. Treatment should be complex, phased. Each of the CL methods has its own indications and contraindications, but as a rule, the general one isprescribing analgesics, nonsteroidal anti-inflammatory drugs(NSAIDs),muscle relaxantsandphysiotherapy.
The analgesic effect is achieved by using diclofenac, paracetamol, tramadol. It has a pronounced analgesic effectmedicinecontaining 100 mg diclofenac sodium.
Gradual (prolonged) absorption of diclofenac improves the effectiveness of therapy, prevents possible gastrotoxic effects and makes 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 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 medicine in the evening.
The substance paracetamol is lower in the analgesic activity of other NSAIDs, and therefore a drug has been developed that, together with paracetamol, includes another non-opioid analgesic, propifenazone, as well as codeine and caffeine. In patients with ischalgia, when caffeine is used, muscle relaxation, reduction of 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 the researchers, with short-term use, the drug is well tolerated, practically does not cause side effects.
NSAIDs are the most widely used medications 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) in the lowest effective dose (side effects are dose-dependent). In elderly patients and in patients with risk factors for adverse reactions, it is recommended to start treatment with meloxicam and especially with celecoxib or diclofenac/misoprostol. Alternative ways 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 may potentiate the analgesic effect of diclofenac.
To eliminate the pain associated with an increase in muscle tone, it is recommended to include central muscle relaxants in the 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 unresponsive cases). The advantage over other muscle relaxants, which are 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 related to stimulation of the central a2- adrenergic receptors. It selectively inhibits the polysynaptic component of the stretch reflex, has an independent antinociceptive and 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, 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 PO is carried out with the development of compression syndromes. It should be noted that the presence of the fact of disc herniation during MRI is not sufficient for the final decision on the operation. Up to 85% of patients with disc herniation among patients with radicular symptoms after conservative treatment manage without surgery. CL, except in a number of 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 disc herniation and radicular symptoms.
There are urgent indications for PO. These include the development of a caudal syndrome, as a rule, with a complete prolapse of the disc in the lumen of the spinal canal, the development of acute radiculomyeloischemia and a pronounced hyperalgesic 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 for surgery and should be considered in conjunction with the clinical picture, the specific situation observed in the spinal canal according to the tomography (e. g. there may be a combination of smallhernia on the background of stenosis of the spinal canal or vice versa - the hernia is large, but with an average location on the background of a wide spinal canal).
Open access to the spinal canal is used in 95% of herniated disc cases. Various discopuncture techniques have so far not been widely used, although a number of authors have reported their effectiveness. The operation is performed with both conventional and microsurgical instruments (with optical magnification). During access, removal of vertebral bony formations is avoided, using primarily an interlaminar approach. But with a narrow channel, hypertrophy of the joint processes, a 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 performed more than a thousand operations for osteochondrosis, it is necessary "not to forget that the surgeon must operate on the patient, 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.
