pain4 out of 5 people experience it at least once in their life. They are for the working populationthe most common cause of disabilitywhich determines their social and economic importance in all countries of the world. One of the main diseases associated with pain in the lumbar spine and limbs is osteochondrosis.
Spinal osteochondrosis (OP) is its degenerative-dystrophic change, which starts from the nucleus pulposus of the intervertebral disc, spreads to the annulus fibrosus and other elements of the spinal segment, with frequent secondary effects on neighboring neurovascular formations. As a result of the unfavorable static-dynamic load, the elastic pulpy (jelly) core loses its physiological properties - it dries out and hardens over time. As a result of mechanical stress, the fibrous ring of the disc, which has lost its elasticity, stretches, and fragments of the nucleus pulposus fall out through its cracks. This leads to the appearance of acute pain (lumbago) because. the peripheral parts of the annulus fibrosus contain the receptors of Luschka's nerve.
Stages of osteochondrosis
The intradiscal pathological process in Ya. According to the classification proposed by Yu, it corresponds to Stage 1 (Period) (OP). Popelyansky and A. I. Osna. In the second period, with the development of hypermobility (or instability), not only the amortization ability is lost, but also the anchoring function. In the third period, the development of the disc herniation (protrusion) can be observed. Disc herniation is divided according to the degree of prolapseflexible protrusionwhen there is an even protrusion of the intervertebral disc andclosed protrusion, which is characterized by uneven and incomplete rupture of the annulus fibrosus. The nucleus pulposus migrates to these rupture sites, creating local protrusions. In the case of a partially prolapsed disc herniation, all layers of the annulus fibrosus are ruptured, possibly the posterior longitudinal ligament, but the hernial protrusion itself has not yet lost contact with the central part of the core. A completely prolapsed disc herniation means that the entire nucleus falls into the lumen of the spinal canal, rather than individual fragments. Disc herniations can be divided into foraminal, posterolateral, paramedian and median parts according to their diameter. The clinical manifestations of disc herniation are varied, but various compression syndromes often develop at this stage.
Over time, the pathological process can move to other parts of the movement segment of the spine. An increase in the load on the vertebral bodies leads to the development of subchondral sclerosis (hardening), and then the body increases the supporting area due to marginal bone growth around the entire circumference. Joint overload leads to spondylarthrosis, which can cause compression of the neurovascular formations in the intervertebral cavity. These changes are observed in the fourth period (stage) (OP), when the complete alteration of the spinal motion segment occurs.
The schematization of such a complex, clinically diverse disease, such as OP, is of course rather arbitrary. However, it allows the analysis of clinical manifestations depending on morphological changes, which allows not only to establish the correct diagnosis, but also to determine specific therapeutic measures.
Depending on which nerve formations in the disc herniation, bone growths and other affected structures of the spine have a pathological effect, reflex and compression syndromes are distinguished.
Syndromes of lumbar osteochondrosis
Tocompressionthese include syndromes in which a root, vessel, or spinal cord is stretched, compressed, and deformed on the indicated vertebral structures. ToreflexThese include the syndromes caused by the effect of these structures on the receptors innervating them, mainly the endings of the recurrent spinal nerves (Lushka's sinuvertebral nerve). Impulses traveling along this nerve from the affected spine reach the posterior horn of the spinal cord through the posterior root. Switching to the front horns, they cause reflex tension (protection) of the innervated muscles -reflex-tonic disorders.. By switching to the sympathetic centers of the lateral horn of their own or neighboring level, they cause reflex vasomotor or dystrophic disorders. Such neurodystrophic disorders occur primarily in low vascularized tissues (tendons, ligaments) at the points of attachment to bony prominences. Here, the tissues undergo fibration, swelling, and become painful, especially when stretched or touched. In some cases, these neurodystrophic disorders cause pain that occurs not only locally, but also remotely. In the latter case, the pain is reflected, it seems to "shoot" when touching the diseased area. Such zones are called trigger zones. Myofascial pain syndromes can occur as part of referred spondylogenic pain.. In case of long-term tension of the striated muscle, the microcirculation is disturbed in certain parts of it. Due to hypoxia and edema of the muscle, zones of seals are formed in the form of knots and fibers (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 myotonia syndromes include piriformis syndrome and popliteal syndrome, the characteristics of which are discussed in detail in many manuals.
Tolocal (local) pain reflex syndromesin lumbar osteochondrosis, lumbago can be attributed to the acute onset of the disease and the subacute or chronic course of lumbago. An important circumstance is the established fact thatLumbago is the result of intradiscal displacement of the nucleus pulposus. This is usually a sharp pain, often piercing. The patient is, so to speak, frozen in an uncomfortable position, unable to bend over. An attempt to change the position of the body causes an increase in pain. Immobility of the entire lumbar region, flattening of the lordosis, and sometimes scoliosis develop.
In case of lumbago - usually aching pain, aggravated by movement, with axial loads. The lumbar region can be deformed, as in lumbago, but to a lesser extent.
Compression syndromes of lumbar osteochondrosis are also diverse. Among these, radicular compression syndrome, caudal syndrome, and lumbosacral discogenic myelopathy syndrome are distinguished.
radicular compression syndromeit is often caused by an L-level disc herniationARC-LVand IV-Sone, because disc herniation is more likely to develop at this level. Depending on the type of hernia (foraminal, posterior-lateral, etc. ), one or the other root is affected. As a general rule, one level corresponds to a monoradicular lesion. Clinical manifestations of root compression in LVthey are reduced 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 on the outer surface of the thigh, on the front surface of the leg extending to the zone of the I. finger. Then, hypalgesia may appear in the corresponding zone. In muscles innervated by the L rootV, hypotrophy and weakness develop, especially in the front sections of the lower leg. First of all, weakness is noticeable in the long extensor of the affected finger - the muscle innervated only by the L rootV. Tendon reflexes associated with an isolated lesion of the root remain normal.
When the spine is compressed, Sonethe phenomena of irritation and loss develop in the corresponding dermatome, extending to the zone of the fifth finger. Hypotrophy and weakness mainly cover the posterior leg muscles. The Achilles reflex decreases or disappears. The knee jerk is reduced only when the roots of L are involved.2, L3, Lfour. In the pathology of the caudal lumbar discs, hypotrophy of the quadriceps muscle, and especially of the gluteal muscles, also occurs. Compression radicular paresthesia and pain are increased by coughing and sneezing. The pain is aggravated by movement of the lower back. There are other clinical symptoms that indicate the development of root compression and tension. The most frequently investigated symptom isLasegue symptomwhen the pain in the leg increases sharply when you try to lift it in an upright position. An unfavorable variant of lumbar vertebrogenic compression radicular syndromes is cauda equina compression, the so-calledcaudal syndrome. Most often, a large prolapse develops with middle disc herniations, when all the roots are compressed at this level. The local diagnosis is carried out in the upper part of the spine. The usually severe pains do not spread to one leg, but usually to both legs, and the loss of sensitivity affects the area of the rider's pants. With severe variants and the rapid development of the syndrome, disorders of the sphincter muscle occur. Caudal lumbar myelopathy develops as a result of occlusion of the inferior accessory radiculomedullary artery (often at the root of LV, ) and manifests itself in weakness of the peroneal, tibial and gluteal muscle groups, sometimes with segmental sensory disorders. Ischemia often develops simultaneously in the segments of the epicone (L5-Sone) and a cone (S2-S5) the spinal cord. In such cases, pelvic disorders are also associated.
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 is especially clearly manifested in the combination of damage to the intervertebral disc against the background of congenital narrowing of the spinal canal, in various anomalies of the development of the spine.
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 MRI of the spine into clinical practice, the diagnosis of lumbar osteochondrosis (PO) has improved significantly. Sagittal and horizontal tomographic sections allow the relationship of the affected intervertebral disc with the surrounding tissues, including the assessment of the lumen of the spinal canal. The size and type of the herniated disc, which roots are compressed and which structures are determined. It is important to determine whether the leading clinical syndrome corresponds to the level and nature of the lesion. Usually, a patient with compression radicular syndrome develops a monoradicular lesion, and compression of this root is clearly visible on MRI. This is surgically relevant because. this determines operational access.
Disadvantages of MRI include limitations in examining claustrophobic patients and the cost of the examination itself. CT is an extremely informative diagnostic method, especially in combination with myelography, but it must not be forgotten that the scanning is done in a horizontal plane, so the extent of the alleged lesion must be determined very accurately clinically. Routine radiography is used as a screening test and is mandatory in a hospital setting. Instability is best defined in functional imaging. Various bone development anomalies are also clearly visible on spondylograms.
Treatment of lumbar osteochondrosis
Both conservative and surgical treatment are performed with PO. Atconservative treatmentin the case of osteochondrosis, the following pathological conditions require treatment: orthopedic disorders, pain syndrome, damage to the disc's ability to fixate, muscle tone disorders, circulation disorders in the roots and spinal cord, nerve conduction disorders, cicatricial adhesion 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. The treatment should be complex and intermittent. Each CL method has its own indications and contraindications, but usually the general oneprescription of painkillers, non-steroidal anti-inflammatory drugs(NSAIDs),muscle relaxantsandphysiotherapy.
The pain-relieving effect is achieved by using diclofenac, paracetamol, tramadol. It has a pronounced pain-relieving effectdrugContains 100 mg diclofenac sodium.
The gradual (long-term) absorption of diclofenac improves the effectiveness of the therapy, prevents possible stomach toxic effects, and makes the 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 and prescribe pain relievers in the form of non-prolonged-acting tablets. In milder forms 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 pain-relieving effect of the substance paracetamol is weaker than other NSAIDs, so a drug was developed that, together with paracetamol, contains another non-opioid pain reliever, propyphenazone, as well as codeine and caffeine. In patients suffering from ischalgia, when caffeine is used, muscle relaxation, anxiety and depression are reduced. Good results have been observed in the clinical use of the drug for the relief of 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 in PO. NSAIDs exert anti-inflammatory, analgesic and antipyretic effects by suppressing cyclooxygenase (COX-1 and COX-2), an enzyme that regulates the conversion of arachidonic acid into prostaglandins, prostacyclin, and thromboxane. Treatment should always be started by prescribing the safest drugs (diclofenac, ketoprofen) in the lowest effective dose (side effects are dose-dependent). In elderly patients and patients with risk factors for side effects, it is advisable to start treatment with meloxicam, especially celecoxib or diclofenac/misoprostol. Alternative administration methods (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 can enhance the analgesic effect of diclofenac.
In order to eliminate the pain associated with the 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 50-100 mg three times a day or tolperisone intramuscularly 100 mg twice 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 other drugs have no anticonvulsant effect (so-called unresponsive cases). Its advantage over other muscle relaxant drugs, which are used for the same indication, is that with a decrease in muscle tone, there is no decrease in muscle strength against the background of the meeting. The drug is an imidazole derivative, its effect is on the central a2-adrenergic receptors. It selectively inhibits the polysynaptic component of the stretch reflex, has an independent antinociceptive and mild anti-inflammatory effect. Tizanidine affects the spasticity of the spine and brain, reduces stretch reflexes and painful muscle spasms. It reduces resistance to passive movements, reduces convulsions and clonic convulsions, and 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.
SurgeryIt is performed with the development of compression syndromes with PO. It should be noted that the fact of detecting a disc herniation during MRI is not sufficient for the final decision on surgery. 85% of patients with disc herniation remain without surgery after conservative treatment in patients with radicular symptoms. CL, except in many situations, should be the first step in helping patients with PO. If complex CL is ineffective (within 2-3 weeks), surgical treatment (CL) is recommended in case of disc herniation and radicular symptoms.
There are emergency signals for the PO. These include the development of the caudal syndrome, usually with the complete prolapse of the disc into the lumen of the spinal canal, the development of acute radiculomyeloischemia and the pronounced hyperalgesic syndrome, when even the appointment of opioids and blockade do not reduce the pain. It should be noted that the absolute size of the disc herniation is not decisive in the final decision on surgery, and it must be taken into account in connection with the clinical picture, the specific situation observed in the spinal canal on the basis of tomography (e. g. a combination of a small hernia may occur in the background of a narrowing of the spinal canal, or vice versa - thehernia is large, but it is moderately located in the background of the wide spinal canal).
Open access to the spinal canal is used in 95% of cases of disc herniation. The various dissection techniques have not been widely used to date, although many authors report their effectiveness. The surgery is performed with traditional and microsurgical instruments (with optical magnification). During the access, the removal of bone formations of the vertebra can be avoided, mainly with interlaminar access. However, in the case of a narrow channel, hypertrophy of the joint processes, or a fixed median disc herniation, it is advisable to expand the access at the expense of the bone structures.
The result of the surgical treatment largely depends on the experience of the surgeon and the correctness of the indications for the given operation. According to the apt expression of the famous neurosurgeon J. Brotchi, who performed more than a thousand operations for osteochondrosis, "one must not forget that the surgeon must operate on the patient, not on the tomographic image. "
In conclusion, I would like to emphasize once again the need for thorough clinical examination and analysis of tomograms in order to be able to make an optimal decision regarding the choice of treatment tactics for a given patient.
