pain4 out of 5 people experience it at least once in their life. 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 accompanied by pain in the lower back and limbs, one of the main places is occupied by osteochondrosis.
Osteochondrosis of the spine (OP) is its degenerative-dystrophic damage, starting from the nucleus pulposus of the intervertebral disc, spreading to the fibrous ring and other elements of the vertebral segment with frequent secondary effects on the surrounding neurovascular formations. Under the influence of unfavorable static-dynamic loads, the elastic pulpy (gelatinous) core loses its physiological properties - it dries up and breaks down over time. Under the influence of mechanical load, the fibrous ring of the disc, which has lost its elasticity, is exhausted, and subsequently, fragments of the nucleus pulposus fall out through its cracks. This causes acute pain (lumbago) because. The peripheral parts of the annulus fibrosus contain receptors of the Lushka nerve.
Stages of osteochondrosis
Intradiscal pathological process corresponds to stage 1 (period) (OP) Ya. According to the classification proposed by Yu. Popeliansky and A. i. Osna. In the second period, not only the cushioning ability is lost, but also the fixation function with the development of hypermobility (or instability). In the third period, disc herniation (protrusion) is observed. Disc herniations are divided according to the degree of their prolapseElastic protrusionWhen there is a uniform protrusion of the intervertebral disc andSequestered protrusion, is characterized by uneven and incomplete rupture of the fibrous ring. The nucleus pulposus migrates to these rupture sites, forming local outgrowths. With a partially prolapsed disc herniation, all layers of the annulus fibrosus are torn and possibly the posterior longitudinal ligament, but the protrusion of the herniation 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, it is divided into foraminal, posterolateral, paramedian and median. The clinical manifestations of disc herniation are diverse, but it is at this stage that various compression syndromes often develop.
Over time, the pathological process can move to other parts of the segment of the vertebral movement. An increase in the load on the vertebral bodies leads to the development of subchondral sclerosis (hardening), then the body increases the support area due to the growth of the marginal bone around the entire perimeter. Overloading of the joints causes spondylarthrosis, which can cause compression of neurovascular formations in the intervertebral foramen. It is these changes that are observed in the fourth period (stage) (OP), when there is a total damage to the segment of spinal movement.
Any schematization of such a complex, clinically diverse disease as OP is, of course, quite arbitrary. However, it makes it possible 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 have disc herniation, bone formations and other damaged structures of the spine, reflex and compression syndromes are distinguished.
Lumbar osteochondrosis syndromes
thatcompressionIncludes syndromes in which the root, vessel, or spinal cord is stretched, compressed, and deformed on specified spinal structures. thatreflexIncludes syndromes caused by the effects of these structures on their innervated receptors, mainly the endings of recurrent spinal nerves (Lushka's sinuvertebral nerve). Impulses traveling along this nerve travel from the injured vertebra through the posterior root to the posterior horn of the spinal cord. By switching to the front horns, they cause reflex tension (defense) of the innervated muscles. Reflex-tonic disorders.. Switching to the sympathetic centers of the lateral horn of its own or neighboring levels causes reflex vasomotor or dystrophic disorders. Such neurodystrophic disorders are mainly found in low vascular tissues (tendons, ligaments) in places of attachment to bone spurs. Here the tissues experience defibration, swelling, become painful, especially during stretching and palpation. In some cases, these neurodystrophic disorders cause pain that occurs not only locally, but also remotely. In the latter case, the pain is reflected as if it "shoots" when touching the affected area. Such zones are called trigger zones. Myofascial pain syndromes can develop as part of referred spondylogenic pain.. During prolonged tension of the striated muscle, microcirculation is disturbed in certain areas of it. Due to hypoxia and swelling in the muscle, ring zones are formed in the form of knots and threads (as in ligaments). 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 characteristics of which are covered in detail in many textbooks.
thatLocal pain reflex syndromesIn the case of lumbar osteochondrosis, lumbago belongs to the acute development of the disease and lumbago in the subacute or chronic course. An important circumstance is the established fact thatLumbago is the result of intradiscal displacement of the nucleus pulposus. As a rule, it is a sharp pain that often cuts. As it turned out, the patient freezes in an uncomfortable position, unable to bend down. Attempting to change the position of the body leads to an increase in pain. There is immobility of the whole waist, flattening of lordosis, sometimes scoliosis develops.
During lumbago - the pain is usually aching, aggravated by movement, axial load. The lumbar region may be deformed as in lumbago, but to a lesser extent.
Compression syndromes in lumbar osteochondrosis are also diverse. Radical compression syndrome, caudal syndrome, lumbosacral discogenic myelopathy syndrome are distinguished among them.
Radical compression syndromeIt often develops due to a herniated disc at the L levelIV- LVand LVsone, because it is at this level that the probability of developing herniated discs is. Depending on the type of hernia (forminal, posterior-lateral, etc. ), one or the other root is damaged. As a rule, one level corresponds to a monoradicular lesion. Clinical manifestations of root compression 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 sensation) and shooting pains spread along the outer surface of the thigh, the front surface of the lower leg to the area of the first toe. After that, hypoalgesia may appear in the corresponding area. In the muscles innervated by the root LVHypotrophy and weakness develop especially in the front parts of the lower leg. First of all, weakness is manifested in the long extensor of the affected finger - in the muscle innervated only by the L root. V. Tendon reflexes remain normal with isolated lesions of this root.
During the compression of the spine soneThe phenomenon of irritation and loss develops in the corresponding dermatome, which extends 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 jerk is only reduced when the roots of the L are involved.2, L3, Lfour. Hypotrophy of the quadriceps and especially the gluteal muscles is also found in pathology of the caudal lumbar discs. Compressive-radicular paresthesia and pain are aggravated by coughing and sneezing. The pain is aggravated by movements in the lower back. There are other clinical symptoms that indicate the development of compression of the roots, their tension. It is the most frequently checked symptomLaseg symptomWhen there is a sharp increase in pain in the leg when you try to lift in a straight position. An unfavorable variant of radicular syndromes of lumbar vertebrogenic compression is cauda equina compression, i. e. yearCaudal syndrome. Most often, it develops during large medial herniated discs, when all the roots at this level are compressed. Local diagnosis is performed on the upper part of the spine. The pains are usually severe, do not extend to one leg, but usually to both legs, loss of sensation covers the area of the rider's pants. With 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 base of LV, ) and is manifested by weakness of peroneal, tibial and gluteal muscle groups, sometimes with segmental sensory disturbances. Often, ischemia develops simultaneously in epicon segments (L5sone) and cone (S2s5) of the spinal cord. In such cases, pelvic disorders are also associated.
In addition to the main clinical and neurological manifestations of lumbar osteochondrosis, there are other symptoms that indicate the defeat of this vertebra. This is especially clearly manifested in the background of congenital narrowness of the spinal canal, various anomalies of the spine development, combined with damage to the intervertebral disc.
Diagnosis of lumbar osteochondrosis
Diagnosis of lumbar osteochondrosisIt is 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 in 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 tissues, including the evaluation of the lumen of the spinal canal. Disc herniation size, type, which roots are compressed and by what structures are determined. It is important to determine the relevance of the leading clinical syndrome to the level and nature of the lesion. Typically, a patient with compressed 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 determines operational access.
Disadvantages of MRI include limitations associated with examination in claustrophobic patients, as well as the cost of the examination itself. CT is a highly informative diagnostic method, especially in combination with myelography, but it must be remembered that the scan is carried out in a horizontal plane, and therefore the level of the probable damage must be determined very accurately clinically. Routine radiography is used as a screening examination and is mandatory in the hospital. Instability is best defined by functional imaging. Spondylograms also clearly show various abnormalities of bone development.
Treatment of lumbar osteochondrosis
Both conservative and surgical treatment are performed with PO. onconservative treatmentThe following pathological conditions require treatment with osteochondrosis: orthopedic disorders, pain syndrome, decreased ability to fix the disc, muscle-tonic disorders, blood circulation disorders in the roots and spinal cord, nerve conduction disorders, adhesive changes, psychosomatic disorders. Conservative treatment methods (CL) include various orthopedic measures (immobilization, spinal traction, manual therapy), physiotherapy (therapeutic massage and physiotherapy, acupuncture, electrotherapy), medication. Treatment should be complex, gradual. Each method of CL has its own indications and contraindications, but, as a rule, they are generalPrescribing analgesics, non-steroidal anti-inflammatory drugs(nonsteroidal anti-inflammatory drugs),Muscle relaxantsandPhysiotherapy.
Analgesic effect is achieved using diclofenac, paracetamol, tramadol. has a pronounced pain-relieving effectdrugContains 100 mg diclofenac sodium.
Gradual (long-term) absorption of diclofenac improves the effectiveness of therapy, prevents possible gastrotoxic effects and makes therapy as comfortable 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-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 to other non-steroidal anti-inflammatory drugs in terms of pain-relieving activity, and therefore, a preparation was created that, together with paracetamol, contains another non-opioid analgesic, propifenazone, as well as codeine and caffeine. In patients with ischalgia, when using caffeine, muscle relaxation, anxiety and depression decrease are noted. Good results were observed when using the drug in the clinic to relieve acute pain in myofascial, myotonic and radicular syndromes. According to the researchers, the drug is well tolerated with short-term use and practically does not cause side effects.
NSAIDs are the most widely used drugs for PO. Nonsteroidal drugs have anti-inflammatory, analgesic and antipyretic effects associated with inhibition of cyclooxygenase (COX-1 and COX-2) - an enzyme that regulates the conversion of arachidonic acid into prostaglandins, prostacyclin, thromboxane. Treatment should always start with the safest medication (diclofenac, ketoprofen) at the lowest effective dose (side effects depend on the dose). In elderly patients and patients with risk factors for side effects, it is advisable to start treatment with meloxicam and especially 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, reducing the risk of COX-dependent side effects. In addition, misoprostol can 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 tolperisone intramuscularly 100 mg 2 times a day. The mechanism of action of the drug with these substances is significantly different 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 (so-called unresponsive cases). The advantage over other muscle relaxants, which are used for the same indications, is that there is no decrease in muscle strength due to the decrease in muscle tone. The drug is an imidazole derivative, its action is related to the stimulation of central a2-adrenergic receptors. It selectively suppresses 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. Reduces resistance to passive movements, reduces spasms and clonic convulsions and increases voluntary contraction of skeletal muscles. It also has a gastroprotective property, which determines its use in combination with non-steroidal drugs. The drug has practically no side effects.
surgeryTogether with PO, it is carried out with the development of compression syndromes. It should be noted that the presence of the fact of detecting a disc herniation during MRI is not enough to make the final decision for surgery. After conservative treatment, among patients with radicular symptoms, up to 85% of patients with herniated disc do without surgery. CL, except in a number of situations, should be the first step in helping PO sufferers. 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, usually with a complete prolapse of the disc in the lumen of the spinal canal, the development of acute radiculomyelosemia and a pronounced hyperalgesic syndrome, when even with the appointment of opioids, the blockade does not reduce pain. It should be noted that the absolute size of the disc herniation is not decisive for the final decision of the operation and should be taken into account together with the clinical picture, the specific situation observed in the spinal canal according to tomography (for example, there may be a combination of a small hernia on the background of spinal canal stenosis or vice versa - the hernia is large, but medianlocation on the background of the wide spinal canal).
Open access to the spinal canal is used in 95% of cases of disc herniation. Various discopuncture techniques have not been widely used to date, although many authors note their effectiveness. The operation is performed using both conventional and microsurgical instruments (with optical magnification). During access, the removal of bone formations of the spine is avoided mainly by using interlaminar access. However, in the case of a narrow channel, hypertrophy of the articular processes, fixed median disc herniation, it is advisable to expand access at the expense of bony structures.
The results of surgical treatment largely depend on the experience of the surgeon and the correctness of the indications for a specific operation. Famous neurosurgeon J. According to the appropriate expression of Broch, who performed more than a thousand osteochondrosis operations, it is necessary "to remember that the surgeon should operate on the patient, not on the tomographic image".
In conclusion, I would like to emphasize once again 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.
