painin the back is experienced at least once in life by 4 out of 5 people. For the working population, they aremost 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 spine and limbs, one of the main places is occupied by osteochondrosis.
Osteochondrosis of the spine (OP) is a degenerative-dystrophic lesion of the spine, starting from the pulpy nucleus of the intervertebral disc, extending to the fibrous ring and other elements of the spinal segment with a side effectfrequent on adjacent neurovascular formations. Under the influence of unfavorable static-dynamic loads, the elastic (gelatinous) pulpy nucleus loses its physiological properties - it dries out and sequesters over time. Under the influence of mechanical loads, the fibrous ring of the disc, which has lost its elasticity, protrudes, and subsequently fragments of the pulpy nucleus fall through its cracks. This leads to the appearance of sharp pains (lumbago), because. the peripheral parts of the annulus fibrosus contain 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 damping ability is lost, but also the fixation function with the development of hypermobility (or instability). In the third period, the formation of a herniation (protrusion) of the disc is observed. According to the degree of their prolapse, the herniated disc is divided intoelastic protrusionwhen there is a uniform protrusion of the intervertebral disc, andsequestered protrusion, characterized by uneven and incomplete rupture of the annulus fibrosus. The nucleus pulposus moves in these places of ruptures, creating local projections. 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, prolapses into the lumen of the spinal canal. According to the diameter of the disc herniation, they are divided into foraminal, posterolateral, paramedian and medial. The clinical manifestations of herniated disc are varied, but it is at this stage that various compression syndromes often develop.
Over time, the pathological process may move to other parts of the motion segment of the spine. An increase in the load on the vertebral bodies leads to the development of subchondral sclerosis (hardening), then the body increases the bearing area due to marginal bone growth along 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 noted in the fourth period (stage) (OP), when there is a total lesion of the motion segment of the spine.
Any mapping of such a complex and clinically diverse disease as OP, of course, is rather arbitrary. However, it allows 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 the nerve formations, herniated disc, 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, compressed, and deformed over the indicated 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 (sinovertebral nerve of Lushka). Impulses traveling along this nerve from the affected spine pass through the posterior root to the posterior horn of the spinal cord. Passing to the anterior horns, they cause reflex tension (defense) of innervated muscles -reflexo-tonic disorders.. Passing to the sympathetic centers of the lateral horn of their own level or neighboring levels, they cause vasomotor or dystrophic reflex disorders. These neurodystrophic disorders occur mainly in poorly vascularized tissues (tendons, ligaments) at the sites of attachment to bony prominences. Here the tissues undergo defibration, swelling, they become painful, especially when stretched and palpated. In some cases, these neurodystrophic disorders cause pain that is not only local, but also distant. In the latter case, the pain is reflected, it seems to "pull" when touching the diseased area. These areas are called trigger zones. Myofascial pain syndromes can 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, seal areas are formed in the form of nodules and strands (as well as in the ligaments). The pain in this case is rarely local, it does not coincide with the zone of innervation of certain roots. Reflex-myotonic syndromes include piriformis syndrome and popliteal syndrome, the features of which are described in detail in many textbooks.
Tolocal (local) pain reflex syndromesin lumbar osteochondrosis, lumbago is attributed to the acute development of the disease, and low back pain to the 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, it is a sharp, often traversing pain. The patient, as it were, freezes in an uncomfortable position, cannot relax. An attempt to change the position of the body causes an increase in pain. There is immobility of the entire lumbar region, flattening of the lordosis, sometimes scoliosis develops.
With low back pain - 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, the root compression syndrome, the caudal syndrome, the lumbosacral discogenic myelopathy syndrome are distinguished.
root compression syndromeoften develops due to L-level disc herniationIV-LVand meV-Sa, becauseIt 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 general 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(sensation of numbness, tingling) and shooting pains distributed along the outer surface of the thigh, from the front surface of the lower leg to the area of the finger I. Hypogesia may then appear in the areacorresponding. In muscles innervated by the L rootV, especially in the front parts of the lower leg, hypotrophy and weakness develop. First, weakness is detected in the extensor digitorum longus 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 Sathe phenomena of irritation and loss develop in the corresponding dermatome, extending to the zone of the fifth finger. The hypotrophy and weakness mainly cover the posterior muscles of the lower leg. The Achilles reflex decreases or disappears. The patellar reflex is reduced only when the roots of L are involved.2, L3, Lfour. Hypotrophy of the quadriceps, and in particular of the gluteal muscles, also occurs in the pathology of the caudal lumbar discs. Compressive root paresthesias 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 symptom most often tested for isLasègue symptomwhen there is a sharp increase in pain in the leg when trying to lift it into a straightened state. An unfavorable variant of lumbar vertebrogenic compression radicular syndromes is cauda equina compression, known ascaudal syndrome. Most often it develops with large prolapsed median herniated discs, when all the roots at this level are pressed. Topical diagnosis is performed on the upper spine. The pains, usually intense, do not spread to one leg, but, as a rule, to both legs, the loss of feeling captures the area of the rider's pants. In addition to severe variants and the rapid development of the syndrome, there are sphincter disorders. Caudal lumbar myelopathy develops as a result of occlusion of the inferior accessory radiculomedullary artery (often at the root of LV, ) and is manifested by weakness of the peroneal, tibial and gluteal muscle groups, sometimes accompanied by segmental sensory disturbances. Often, ischemia develops simultaneously in the segments of the epicon (L5-Sa) and a cone (S2-S5) of the spinal cord. In such cases, pelvic disorders also join.
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 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 x-ray 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 (OP) has improved significantly. Sagittal and horizontal tomographic slices allow you to see the relationship of the affected intervertebral disc with surrounding tissues, including an assessment of the spinal canal lumen. The size, type of herniated disc, which roots are compressed and by which structures are determined. It is important to establish the conformity of the reference clinical syndrome with the level and nature of the lesion. Typically, a patient with root compression syndrome develops a single-root lesion, and the compression of this root is clearly visible on MRI. This is surgically relevant, 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. Computed tomography is a very informative diagnostic method, especially in combination with myelography, but it must be remembered that scanning is performed in a horizontal plane and therefore the level of the presumed lesion must be clinically determined veryprecise. Routine X-rays are used as a screening test and are mandatory in hospitals. In functional imaging, the instability is better defined. Various abnormalities of bone development are also clearly visible on spondylograms.
Treatment of lumbar osteochondrosis
With PO, conservative and surgical treatment is carried out. Toconservative treatmentwith osteochondrosis, the following pathological conditions require treatment: orthopedic disorders, pain syndrome, impaired disc fixation ability, musculo-tonic disorders, circulatory disorders of the roots and spinal cord, nerve conduction disorders, adhesive scar 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 drugs. Treatment should be complex, phased. Each of the CL methods has its own indications and contraindications, but, as a rule, the general method isprescription of analgesics, nonsteroidal 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 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 tablets of non-prolonged action. In milder forms of the disease, when relatively small doses of the drug are sufficient. If painful symptoms predominate at night or in the morning, it is recommended to take the drug in the evening.
The substance paracetamol has a lower analgesic activity than other NSAIDs, and therefore a drug has been developed which, together with paracetamol, includes another non-opioid analgesic, propyphenazone, as well as codeine and caffeine. In patients with ischalgia, when using caffeine, 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 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 OPs. 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 effects, it is advisable to start treatment with meloxicam and especially with celecoxib or diclofenac/misoprostol. Other routes of administration (parenteral, rectal) do not prevent gastroenterological and other side effects. The combination drug diclofenac and misoprostol has some advantages over standard NSAIDs, reducing 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 core 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 so-called non-reactive cases). The advantage over other muscle relaxant drugs used for the same indications is that with a decrease in muscle tone in 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 a central2- adrenergic receptors. It selectively inhibits the polysynaptic component of the stretch reflex, has an independent antinociceptive and mildly 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 skeletal muscle contractions. It also has a gastroprotective property, which determines its use in combination with NSAIDs. The drug has practically no side effects.
Operationwith PO it is carried out with the development of compression syndromes. It should be noted that the presence of the fact of the detection of a herniated disc during MRI is not enough for the final decision on the operation. Up to 85% of patients with herniated disc among patients with radicular symptoms after conservative treatment go without surgery. CA, with the exception of a number of situations, should be the first step in helping patients with OP. If complex CL is ineffective (within 2-3 weeks), surgical treatment (CL) is indicated in patients with disc herniation and root symptoms.
There are emergency indications for PO. These include the development of caudal syndrome, as a rule, with a complete prolapse of the disc in the lumen of the spinal canal, the development of acute radiculomyeloishemia and a pronounced hyperalgesic syndrome, even when the appointment of opioids, theblocking does not reduce pain. It should be noted that the absolute size of the herniated disc is not decisive for the final decision on the operation and should be considered in conjunction with the clinical picture, the specific situation observed in the spinal canal according to tomography (eg, there may be a combination of a small hernia on the background of spinal stenosis or vice versa - a hernia is large, but of a midline location on the background of a wide spinal canal).
In 95% of herniated disc cases, open access to the spinal canal is used. Various depuncture techniques have not found wide application to date, although a number of authors report their effectiveness. The operation is performed using conventional and microsurgical instruments (with optical magnification). During access, the removal of bone formations from the vertebra is avoided by mainly using interlaminar access. However, with a narrow channel, hypertrophy of the articular processes, a fixed medial disc herniation, access should be expanded to the detriment 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, one should "not forget that the surgeon must operate on the patient, and 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.