painin the back is experienced at least once in a lifetime by 4 out of 5 people. For the working population, it ismost common cause of disabilitywhich determines their social and economic importance in all countries of the world. Among the diseases 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 it, starting from the nucleus pulposus of the intervertebral disc, extending to the annulus fibrosus and other elements of the vertebral segment with a frequent secondary effect on the adjacent neurovascular formations. Under the influence of adverse static-dynamic loads, the elastic pulpy (gelatinous) core loses its normal properties - it dries up and isolates 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 (back pain), becausethe peripheral parts of the annulus fibrosus contain Luschka nerve receptors.
Stages of osteochondrosis
The intradisc 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 capacity 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. Depending on their degree of prolapse, disc herniation is divided intoelastic protrusionwhen there is uniform protrusion of the intervertebral disc, andcommitted ledge, characterized by uneven and incomplete rupture of the annulus fibrosus. The nucleus pulposus moves into these rupture sites, creating local protrusions. With a partial disc herniation, all layers of the annulus fibrosus are ruptured and possibly the posterior longitudinal ligament, but the herniated protrusion itself has not yet lost contact with the central part of the core. A completely prolapsed disc means that not individual fragments of it, but the entire nucleus, fall into the lumen of the spinal canal. Depending on the diameter of the disc herniation, they are divided into foramen, posterior lateral, paramedian and median. The clinical manifestations of a herniated disc vary, but at this stage various compressive syndromes often develop.
Over time, the pathological process can move to other parts of the spine's range of motion. An increase in the load on the vertebral bodies leads to the development of hypochondrial sclerosis (hardening), then the body increases the support area due to the marginal increases of the bones around the entire perimeter. Overloading the joint leads to spondyloarthritis, which can cause compression of the neurovascular formations in the intervertebral foramen. It is these changes that are noted in the fourth period (stage) (EP), when there is total damage to the movement part of the spine.
Any schematization of such a complex, clinically diverse disease as OP is, of course, rather arbitrary. However, it makes it possible to analyze the clinical manifestations in their dependence on morphological changes, which allows not only the correct diagnosis, but also the determination of specific therapeutic measures.
Depending on the formations of the nerves, disc herniation, bony growths and other affected structures of the spine have a pathological effect, reflex and compressive syndromes are distinguished.
Lumbar osteochondrosis syndromes
Tocompressioninclude syndromes in which a root, vessel, or spinal cord is stretched, compressed, and deformed over the indicated vertebral structures. Toreflectioninclude syndromes caused by the effect of these structures on the receptors that innervate them, mainly the endings of the recurrent spinal nerves (vaginal nerve of Lushka). Impulses propagated along this nerve from the affected spine travel through the posterior root to the posterior horn of the spinal cord. Passing to the anterior horns, they cause a reflex tension (defense) 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 vasomotor or dystrophic disorders. Such neurodystrophic disorders occur mainly in tissues with low vascularity (tendons, ligaments) at the sites of attachment to bone projections. Here, the tissues undergo defibrillation, swelling, 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 it touches the affected area. Such zones are called activation zones. Myofascial pain syndromes may occur as part of referred vertebral pain.. With prolonged tension of the striated muscle, the microcirculation is disturbed in some of its areas. Due to hypoxia and swelling in the muscles, seal zones are formed in the form of nodules and strands (as well as in 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 covered in detail in numerous textbooks.
Tolocal (local) reflex pain syndromesin lumbar osteochondrosis, back pain is attributed to the acute development of the disease, and back pain to a subacute or chronic course. An important circumstance is the established fact thatLow back pain is a consequence of intradiscal displacement of the nucleus pulposus. As a rule, this is a sharp pain, often piercing. The patient, as it were, freezes in an uncomfortable position, unable to thaw. 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, pain, aggravated by movement, with axial loads. The lumbar region may be deformed, as in the lumbar spine, but to a lesser extent.
Compressive syndromes in lumbar osteochondrosis are also varied. Among them, the radicular compression syndrome, the caudate syndrome, the lumbosacral discogenic myelopathy syndrome can be distinguished.
root compression syndromeoften develops due to a herniated disc at the L levelIV-LARGEVme tooV-SMALLa, because it is at this level that herniated discs are more likely to develop. Depending on the type of hernia (inguinal, posterior-lateral, etc. ), one or the other root is affected. As a rule, one level corresponds to a monoradial lesion. Clinical manifestations of root compression LVthey decrease in the appearance of irritation and prolapse in the corresponding dermatome and in the hypofunction phenomena in the corresponding myotome.
Paraesthesia(numbness, tingling sensation) and shooting pains spread along the outer surface of the thigh, the front surface of the lower leg to the zone of toe I. Then hypoalgesia may appear in the corresponding zone. In the muscles innervated by the root of LV, especially in the anterior parts of the tibia, scholarship and weakness develop. First of all, the weakness is detected in the long extensor of the diseased finger - the muscle that is innervated only by the L rootV. Tendon reflexes with a single lesion of this root remain normal.
When compressing the spine Sathe effects of irritation and loss develop in the corresponding dermatome, extending to the zone of the fifth finger. Scholarship and weakness mainly covers the posterior tibial muscles. The Achilles reflex decreases or disappears. Knee jerk is only reduced when the roots of L are involved.2, L3, Lfour. Scholarship of the quadriceps and especially the gluteal muscles also occurs in the pathology of the caudal lumbar discs. Compression-radial paresthesia and pain worsen with coughing, sneezing. The pain is aggravated by movement in the lower back. There are other clinical symptoms that indicate the development of compression of the roots, their tension. The most commonly checked symptom isLasegue's symptomwhen there is a sharp increase in pain in the leg when trying to raise it in a straightened state. An adverse variant of the root syndromes of lumbar spondylogenic compression is the compression of the cauda equina, the so-calledcaudal syndrome. Most often, it develops with large prolapsed medial disc herniation, when all the roots at this level are compressed. Local diagnosis is performed on the upper spine. The pains, usually severe, 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 variations and the rapid development of the syndrome, sphincter disorders are added. Caudal lumbar myelopathy develops as a result of occlusion of the inferior accessory radicular 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-SMALLa) and a cone (S2-SMALL5) of the spinal cord. In such cases, pelvic disorders are also associated.
In addition to the recognized 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 in the context 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 methods of examination, which include conventional x-ray of the lumbar spine, computed tomography (CT), computed tomography, 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 the evaluation of the lumen of the spinal canal. The size, type of herniated disc, which roots are compressed and by which structures are determined. It is important to establish the compliance of the leading clinical syndrome with the level and nature of the lesion. As a rule, a patient with root compression syndrome develops a single root lesion, and the compression of this root is clearly visible on MRI. This is relevant from a surgical point of view, becauseThis defines functional access.
The disadvantages of MRI include the limitations associated with examining claustrophobic patients, as well as the cost of the study itself. Computed tomography 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 alleged lesion must be determined clinically with great accuracy. Routine radiography is used as a preventive examination and is mandatory in a hospital setting. In functional imaging, volatility is better defined. Various bone growth abnormalities are also clearly visible on spondylograms.
Treatment of lumbar osteochondrosis
With PO, both conservative and surgical treatment is performed. In theconservative therapywith osteochondrosis, the following pathological conditions require treatment: orthopedic disorders, pain syndrome, reduced ability to fix the disc, myotonic disorders, circulatory disorders in the roots and spinal cord, nerve conduction disorders, snow glue lesions, psychosomatic disorders. Conservative treatment methods (CF) include various orthopedic measures (immobilization, spinal traction, manual therapy), physical therapy (therapeutic massage and physiotherapy, acupuncture, electrotherapy), drug prescription. Treatment should be complex, gradual. Each of the CL methods has its own indications and contraindications, but, as a rule, the general one isprescription of analgesic, non-steroidal anti-inflammatory drugs;(NSAIDs),muscle relaxantsandphysiotherapy.
The analgesic effect is achieved with the use of diclofenac, paracetamol, tramadol. It has a strong analgesic effecta medicinecontaining 100 mg diclofenac sodium.
The gradual (long-term) absorption of diclofenac improves the effectiveness of the treatment, prevents possible gastrotoxic effects and makes the treatment as convenient as possible for the patient (only 1-2 tablets per day).
If necessary, increase the daily dose of diclofenac to 150 mg, prescribe additional 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 prevail at night or in the morning, it is recommended to take the medicine in the evening.
The substance paracetamol is inferior in analgesic effect to other NSAIDs and therefore a drug was developed, which, together with paracetamol, includes another non-opioid analgesic, propyphenazone, as well as codeine and caffeine. In patients with sciatica, when caffeine is used, there is muscle relaxation, a reduction in anxiety and depression. Good results were noted when using the drug in the clinic for the relief of 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 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) at the lowest effective dose (side effects are dose-dependent). In elderly patients and in patients with risk factors for adverse effects, initiation of treatment with meloxicam and especially celecoxib or diclofenac/misoprostol is recommended. Alternative routes of administration (parenteral, rectal) do not prevent gastrointestinal and other side effects. The combined drug diclofenac and misoprostol has some advantages over standard NSAIDs, which reduces the risk of COX-dependent side effects. In addition, misoprostol may enhance the analgesic effect of diclofenac.
To eliminate pain associated with increased muscle tone, it is advisable to include central muscle relaxants in the complex treatment:tizanidine2-4 mg 3-4 times a day or tolperisone intramuscularly 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 anticonvulsant effect of other drugs (in the so-called unresponsive cases). The advantage over other muscle relaxants 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 action is related to the stimulation of the central a2-adrenergic receptors. It selectively inhibits the polysynaptic component of the stretch reflex, has an independent anti-inflammatory and mild anti-inflammatory effect. The substance tizanidine acts on spinal and brain spasticity, reduces stretch reflexes and painful muscle spasms. It reduces resistance to passive movements, reduces convulsions and clonic spasms, 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, occurs with the development of compression syndromes. It should be noted that the presence of the fact of disc herniation during magnetic resonance imaging is not sufficient for the final decision on surgery. Up to 85% of patients with disc herniation among patients with radical symptoms after conservative treatment do without surgery. CL, with the exception of 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 caudal syndrome, as a rule, with complete prolapse of the disc in the lumen of the spinal canal, the development of acute rhizomyeloisemia and severe hyperalgesic syndrome, when even blocking opioids does not reduce pain. It should be noted that the absolute size of the herniated disc is not decisive for the final decision to operate and should be considered in conjunction with the clinical picture, the specific condition observed in the spinal canal according to tomography (e. g. there may bea combination of a small hernia on the background of spinal canal stenosis or vice versa - a hernia is large, but with an average location against the background of a wide spinal canal).
In 95% of cases with a herniated disc, open access to the spinal canal is used. Various dissection techniques have not found widespread application to date, although several authors report their effectiveness. The operation is performed using conventional and microsurgical tools (with optical magnification). During the approach, the removal of bony formations of the vertebra is avoided using mainly an intermediate approach. However, with a narrow channel, hypertrophy of the articular processes, stable medial disc herniation, it is recommended 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 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 thorough clinical examination and tomographic analysis in order to make the optimal decision on the choice of therapeutic tactics for a particular patient.
