painin the back is experienced at least once in a lifetime by 4 out of 5 people. For the working population, they arethe most common cause of disabilitythat determines their social and economic importance in all countries of the world. Among the diseases associated with 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 it, starting from the nucleus pulposus of the intervertebral disc, extending to the fibrous ring and other elements of the spinal segment with a frequent secondary effect on the adjacent neurovascular formations. Under the influence of unfavorable static-dynamic loads, the pulpy (gelatinous) elastic core loses its physiological properties - it dries up and sequesters over time. Under the influence of mechanical loads, the fibrous ring of the disc, which has lost its elasticity, protrudes, and then fragments of the nucleus pulposus fall through its cracks. This leads to the appearance of acute 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 cushioning ability is lost, but also the fixation function with the development of hypermobility (or instability). In the third period, the formation of a disc herniation (protrusion) is observed. According to the degree of their prolapse, disc herniation is divided intoelastic elongationwhen there is a uniform protrusion of the intervertebral disc andextension seized, characterized by uneven and incomplete rupture of the annulus fibrosus. The nucleus pulposus moves to these rupture sites, creating local protrusions. With a partially prolapsed disc herniation, all layers of the fibrous ring are torn, and perhaps the posterior longitudinal ligament, but the hernial protrusion itself has not yet lost contact with the central part of the nucleus. A fully 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 different, but it is at this stage that various compression syndromes often develop.
Over time, the pathological process can move to other parts of the spinal movement segment. 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 marginal growth of the bones around the entire circumference. Joint overload leads to spondylarthrosis, which can cause compression of neurovascular formations in the intervertebral foramen. It is these changes that are observed in the fourth period (phase) (OP), when there is a total lesion of the spinal motion segment.
Any schematization of such a complex, clinically diverse disease as OP is, of course, quite arbitrary. However, this makes it possible to analyze clinical manifestations in their dependence on morphological changes, which allows not only to establish an accurate diagnosis, but also to determine specific therapeutic measures.
Depending on the nerve formations, disc herniation, bone growths and other affected structures of the spine have a pathological effect, reflex and compression syndromes are distinguished.
Lumbar osteochondrosis syndromes
for hercompactinginclude syndromes in which a root, vessel, or spinal cord is stretched, compressed, and deformed over the indicated vertebral structures. for herreflexinclude the syndromes caused by the effect of these structures on the receptors that innervate them, mainly the endings of recurrent spinal nerves (Lushka's sinuvertebral nerve). Impulses that propagate along this nerve from the affected spinal column travel through the posterior root to the posterior horn of the spinal cord. Passing to the front horns, they cause a reflex tension (protection) of the innervated muscles -reflex-tonic disorders.. Passing to the sympathetic centers of the lateral horn of their own or neighboring levels, they cause reflex or dystrophic vasomotor disorders. Such neurodystrophic disorders occur mainly in low vascularized tissues (tendons, ligaments) in the places of connection with bone prominences. Here, the tissues undergo defibration, swelling, they 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. Such 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, areas of seals are formed in the form of joints and threads (as well as in ligaments). The pain in this case is rarely local, it does not coincide with the area of innervation of certain roots. Reflex-myotonic syndromes include piriformis syndrome and popliteal syndrome, the characteristics of which are covered in detail in numerous manuals.
for herlocal (local) pain reflex syndromes.in lumbar osteochondrosis, lumbago is attributed to the acute development of the disease, and lumbago to the subacute or chronic course. An important circumstance is the proven fact thatlumbago is a consequence of intradiscal displacement of the nucleus pulposus. As a rule, this is a sharp pain, which often passes. The patient, so to speak, freezes in an uncomfortable position, cannot bend over. 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 extent.
Compression syndromes in lumbar osteochondrosis are also different. Among them are radicular compression syndrome, caudal syndrome, lumbosacral discogenic myelopathy syndrome.
radicular compression syndromeoften develops due to disc herniation at the L levelIV-LVand LV-SA, because it is precisely at this level that the disc herniation 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 occurrence of irritation and prolapse in the relevant dermatome and hypofunction phenomena in the relevant myotome.
Paresthesia(sensation of numbness, tingling) and shooting pains spread along the outer surface of the thigh, the front surface of the lower part of the leg to the area of toe I. Hypalgesia may then appear in the corresponding 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 extension of the diseased finger - in the muscle innervated only by the L root.V. Tendon reflexes with an isolated lesion of this root remain normal.
During spinal compression SAThe 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 muscles of the lower leg. The Achilles reflex decreases or disappears. Knee stiffness is reduced only when L roots are involved.2, L3, Lfour. In the pathology of the middle caudal discs, hypotrophy of the quadriceps and especially of the gluteal muscles is also present. Paresthesia and compressive radicular pain are aggravated by coughing, 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. The most 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 radicular syndromes of lumbar vertebrogenic compression is compression of the cauda equina, the so-calledcaudal syndrome. It most often develops with large medial prolapsed disc herniations, when all the roots at this level are squeezed. Local diagnosis is performed in the upper part of the spine. The pains, usually strong, do not spread to one leg, but, as a rule, to both legs, the loss of sensitivity 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 LV, ) and is manifested by weakness of the peroneal, tibial and gluteal muscle groups, sometimes with segmental sensorial disorders. 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 are also associated.
In addition to the identified main clinical and neurological manifestations of lumbar osteochondrosis, there are other symptoms that indicate the loss of this spine. This is especially clearly manifested in the combination of intervertebral disc damage against the background of congenital narrowness of the spinal canal, various abnormalities in 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 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 (LO) has improved significantly. 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. Size, type of disc herniation, which roots are compressed and by which structures are determined. It is important to determine the compatibility of the main clinical syndrome with the level and nature of the lesion. As a rule, a patient with radicular compression syndrome develops a monoradicular lesion and the compression of this root is clearly visible on MRI. This is important from a surgical point of view, because. this determines operational access.
The disadvantages of MRI include the limitations associated with the examination in claustrophobic patients, as well as the cost of the study itself. CT is a very 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 supposed lesion must be clinically determined very accurately. Routine radiography is used as a screening examination and is mandatory in a hospital setting. In functional imaging, instability is best defined. Various abnormalities of bone development are also visible on the spondylogram.
Treatment of lumbar osteochondrosis
With PO, conservative and surgical treatment is performed. INconservative treatmentwith osteochondrosis, the following pathological conditions require treatment: orthopedic disorders, pain syndrome, impaired disc fixation ability, muscle-tonic disorders, blood circulation disorders in the roots and spinal cord, nerve conduction disorders, cicatricial adhesive 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 medications. The treatment should be complex, with stages. Each of the CL methods has its own indications and contraindications, but, as a rule, the general one isprescription of analgesics, non-steroidal anti-inflammatory drugs(NSAIDs),muscle relaxantsANDphysiotherapy.
The analgesic effect is achieved with the use of diclofenac, paracetamol, tramadol. It 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, also prescribe pain relievers in the form of non-long-acting tablets. In the mildest forms of the disease, when relatively small doses of the drug are enough. 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 inferior in analgesic activity to other NSAIDs, and therefore a drug was created, which, together with paracetamol, includes another non-opioid analgesic, propyphenazone, as well as codeine and caffeine. In patients with sciatica, during the use of caffeine, muscle relaxation, a decrease in anxiety and depression is observed. Good results were observed during the use of the drug in the clinic to relieve acute pain in myofascial, myotonic and radicular syndromes. According to 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 into prostaglandin, prostacyclin, thromboxane. Treatment should always start with the appointment of the safest drugs (diclofenac, ketoprofen) in the lowest effective dose (side effects depend on the dose). In elderly patients and in patients with risk factors for side effects, it is advisable to start 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 combined drug diclofenac and misoprostol has several 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 the pain associated with an increase in 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 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-responsive cases). The advantage over other muscle relaxant drugs 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 an imidazole derivative, its effect is associated with the stimulation of the a center2-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 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.
Surgerywith 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 sufficient for the final decision on surgery. Up to 85% of patients with disc herniation among patients with radicular symptoms after conservative treatment do 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 emergency indications for PO. These include the development of the caudal syndrome, as a rule, with the complete prolapse of the disc in the lumen of the spinal canal, the development of acute radiculomyelosemia and a pronounced hyperalgesic syndrome, when even the appointment of opioids, the blockade does not reduce the 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 considered in relation to the clinical picture, the specific situation observed in the spinal canal according to tomography (eg there may be a combination of asmall hernia on the background of stenosis of the spinal canal or vice versa - a hernia is large, but of an average location on the background of a wide spinal canal).
In 95% of cases with disc herniation, open access to the spinal canal is used. Various discopuncture 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 the bony formations of the vertebra is avoided by mainly using interlaminar access. However, with a narrow channel, hypertrophy of the articular processes, fixed medial disc herniation, it is advisable to expand the access at the expense of bony structures.
The results of surgical treatment depend mainly 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 has performed more than a thousand operations for osteochondrosis, it is necessary "not to 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 clinical examination and complete analysis of tomograms in order to make an optimal decision on the choice of treatment tactics for a particular patient.
