pain4 out of 5 people live behind at least once in their life. These are for the working populationthe 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 back and limbs, osteochondrosis occupies one of the main places.
Osteochondrosis of the spine (OP) is its degenerative-dystrophic lesion, starting from the nucleus pulposus of the intervertebral disc, extending to the annulus fibrosus and other elements of the spinal segment, often having a secondary effect on adjacent neurovascular formations. Under the influence of unfavorable static-dynamic loads, the elastic pulp (gelatin) nucleus loses its physiological properties - it dries up and becomes sequestered over time. Under the influence of mechanical loads, the fibrous ring of the disc, which has lost its elasticity, comes out, and later pieces of the nucleus pulposus fall out of its cracks. This causes the appearance of acute pain (lumbago) because. The peripheral parts of the annulus fibrosus contain the receptors of Luschka's nerve.
Stages of osteochondrosis
Intradiscal pathological process Ya. It corresponds to the 1st stage (period) (OP) according to the classification proposed by Yu. Popelyansky and A. I. Osna. In the second period, not only the amortization capacity, but also the fixation function is lost 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 dividedelastic protrusionwhen there is a uniform protrusion of the intervertebral disc andsequestered protrusion, characterized by uneven and incomplete breakage of the fibrous ring. The nucleus pulposus moves toward these fracture sites, creating local protrusions. With a partially prolapsed disc herniation, all layers of the annulus fibrosus and possibly the posterior longitudinal ligament are torn, but the herniated disc itself has not yet lost contact with the central part of the nucleus. A completely prolapsed disc herniation means that the entire nucleus has prolapsed into the lumen of the spinal canal, rather than individual fragments. 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 marginal bone growth around 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), during the general damage of the spinal movement segment.
Any scheme for a complex, clinically diverse disease like OP is, of course, highly arbitrary. However, it allows analyzing clinical manifestations in their dependence on morphological changes, which allows not only to make a correct diagnosis, but also to prescribe specific therapeutic measures.
Depending on the nerve formations of disc herniation, bone growth and other affected structures of the spine, reflex and compression syndromes are distinguished.
Lumbar osteochondrosis syndromes
To whomcompressioninclude syndromes in which the root, vessel, or spinal cord is stretched, compressed, or deformed over the specified vertebral structures. To whomreflexinclude syndromes caused by the effect of these structures on the receptors that innervate them, mainly on the ends of recurrent spinal nerves (Lushkan's sinuvertebral nerve). Impulses propagated along this nerve from the affected spine pass from the posterior root to the posterior horn of the spinal cord. Moving to the anterior horns, they cause reflex tension (defense) of the innervated muscles -reflex-tonic disorders.. By moving 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 first of all in low vascularized tissues (tendons, ligaments) in places of attachment to bony protrusions. Here the tissues are subjected to defibration, swelling, they are especially painful when stretched and palpated. In some cases, these neurodystrophic disorders cause not only local but also distant pain. In the latter case, the pain is reflected, when you touch the diseased area, it appears to "throw". Such zones are called trigger zones. Myofascial pain syndromes can occur as part of spondylogenic pain.. With long-term tension of the striated muscle, microcirculation is disturbed in certain areas of it. Due to hypoxia and edema in the muscle, seal zones appear in the form of knots and threads (as well as in ligaments). In this case, the pain is rarely local, does not coincide with the zone of innervation of certain roots. Reflex-myotonic syndromes include piriformis syndrome and popliteal syndrome, the characteristics of which are covered in detail in numerous guidelines.
To whomlocal (local) pain reflex syndromeslumbago in lumbar osteochondrosis is associated with acute development of the disease and lumbago in subacute or chronic course. The important fact is that it is establishedis the result of intradiscal displacement of the nucleus pulposus lumbago. As a rule, this is a sharp pain, often throbbing. The patient seems to freeze in an uncomfortable state, unable to bend. An attempt to change the position of the body leads to an increase in pain. There is immobility of the entire lumbar region, straightening of the lordosis, sometimes scoliosis develops.
With lumbago - the pain, as a rule, is painful, aggravated by movement, axial loads. The lumbar region may be deformed as in lumbago, but to a lesser extent.
Compression syndromes in lumbar osteochondrosis are also different. Radicular compression syndrome, caudal syndrome, lumbosacral discogenic myelopathy syndrome are distinguished among them.
radicular compression syndromeit often develops due to a herniated disc at the L levelIV-LVand LV-Sone, because it is at this level that herniated discs develop more. 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 root compression LVreduced to the appearance of irritation and prolapse in the corresponding dermatome and the phenomenon of hypofunction in the corresponding myotome.
Paresthesia(numbness, tingling sensation) and burning pains spread along the outer surface of the thigh, the front surface of the lower leg to the zone of the first toe. Later, hypoalgesia may appear in the corresponding area. In muscles innervated by the L rootV, hypotrophy and weakness develop, especially in the front parts of the lower leg. First of all, weakness is detected in the long extensor of the diseased finger - the muscle innervated only by root L.V. With isolated damage to this root, tendon reflexes remain normal.
S. while compressing the spineoneirritation and loss phenomena develop in the corresponding dermatome extending to the zone of the fifth toe. Hypotrophy and weakness mainly involve the posterior muscles of the lower leg. The Achilles reflex is reduced or absent. Knee flexion is reduced only when L roots are involved.2, L3, Lfour. Hypotrophy of the quadriceps and especially the gluteal muscles also occurs in the pathology of the caudal lumbar discs. Compression-radicular paresthesia and pain are intensified by coughing and sneezing. The pain intensifies with movement in the lumbar region. There are other clinical symptoms that indicate the development of root compression, their tension. It is the most tested symptomLasegue's symptomwhen there is a sharp increase in leg pain when you try to lift in a straightened position. An unfavorable variant of lumbar vertebrogenic compression radicular syndromes is cauda equina compression, the so-calledcaudal syndrome. Often, when all roots at this level are compressed, large prolapsed median herniated discs develop. Topical diagnosis is performed on the upper spine. Usually, severe pain does not spread to one leg, but, as a rule, the loss of sensation in both legs occupies the area of the breeches. Severe variants and sphincter disorders are added with the rapid development of the syndrome. Caudal lumbar myelopathy develops as a result of obstruction of the lower accessory radiculomedullary artery (often at the root of L).V, ) and weakness of peroneal, tibial and gluteal muscle groups, sometimes manifested by segmental sensory disturbances. Often, ischemia develops simultaneously in the segments of the epicon (L5-Sone) and cone (S2-S5) of the spinal cord. In such cases, pelvic diseases are also combined.
In addition to the established main clinical and neurological manifestations of lumbar osteochondrosis, there are other symptoms that indicate the defeat of this spine. This is especially evident in the combination of congenital narrowing of the spinal canal, damage to the intervertebral disc against the background of various anomalies in the development of the spine.
Diagnosis of lumbar osteochondrosis
Diagnosis of lumbar osteochondrosisbased on the clinical picture of the disease and additional examination methods, which include conventional X-ray 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 (PO) has improved significantly. Sagittal and horizontal tomographic sections allow 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 and type of disc herniation is determined by which roots are compressed and by which structures. It is important to determine the compatibility of the leading clinical syndrome with the level and nature of the lesion. As a rule, 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 defines the transaction input.
Disadvantages of MRI include limitations in screening patients with claustrophobia, as well as the cost of the study itself. CT, especially in combination with myelography, is a highly informative diagnostic method, but it should be remembered that the scan is performed in a horizontal plane, and therefore the level of the alleged lesion must be determined very accurately clinically. Routine radiography is used as a screening examination and is mandatory in a hospital setting. Instability is best identified on functional imaging. Various bone development anomalies are also clearly seen in spondylograms.
Treatment of lumbar osteochondrosis
Both conservative and surgical treatment is performed with PO. Horseconservative treatmentthe following pathological conditions with osteochondrosis require treatment: orthopedic disorders, pain syndrome, disc fixation disorder, muscle-tonic disorders, blood circulation disorders in the roots and spinal cord, nerve conduction disorders, cicatricial adhesive changes, psychosomatic disorders. Conservative treatment methods (CL) include various orthopedic measures (immobilization, traction of the spine, manual therapy), physiotherapy (therapeutic massage and physiotherapy, acupuncture, electrotherapy), prescribing drugs. Treatment should be complex and gradual. Each of the CL methods has its own indications and contraindications, but, as a rule, common onesprescribing analgesics, non-steroidal anti-inflammatory drugs(NSAIDs),muscle relaxantsandphysiotherapy.
Analgesic effect is achieved with the use of diclofenac, paracetamol, tramadol. It has a clear analgesic effectdrugs100 mg of diclofenac contains sodium.
Gradual (long-term) absorption of diclofenac increases 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 long-acting tablets. In milder forms of the disease, relatively small doses of the drug are sufficient. If painful symptoms predominate at night or in the morning, it is recommended to take the medicine in the evening.
Paracetamol substance is inferior to other NSAIDs in terms of analgesic activity, and therefore, together with paracetamol, a drug containing another non-opioid analgesic, propyphenazone, as well as codeine and caffeine, was prepared. In patients with ishalgia, when using caffeine, muscle relaxation, 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 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 related to the suppression of cyclooxygenase (COX-1 and COX-2) - an enzyme that regulates the conversion of arachidonic acid to prostaglandins, prostacyclins, thromboxanes. Treatment should always start with prescribing the safest drugs (diclofenac, ketoprofen) in the lowest effective dose (side effects depend on the dose). It is advisable to start treatment with meloxicam and especially celecoxib or diclofenac/misoprostol in elderly patients and in patients with risk factors for side effects. Alternative routes of administration (parenteral, rectal) do not prevent gastrointestinal and other side effects. The combined drug diclofenac and misoprostol has certain advantages over standard NSAIDs, which reduce the risk of COX-dependent side effects. In addition, misoprostol can enhance the analgesic effect of diclofenac.
To relieve pain associated with increased muscle tone, it is recommended to include central muscle relaxants in complex therapy:tizanidineTolperisone 2-4 mg 3-4 times a day or tolperisone 50-100 mg 3 times a day or 100 mg intramuscular tolperisone 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 cases where other drugs have no antispastic effect (so-called unresponsive cases). The advantage over other muscle relaxants used for the same indications is that there is no decrease in muscle strength with a decrease in muscle tone against the background of the appointment. The drug is an imidazole derivative, its effect is associated with stimulation of the central a2-adrenergic receptors. It selectively inhibits the polysynaptic component of the stretch reflex, has an independent antinociceptive and slight anti-inflammatory effect. Tizanidine substance affects spinal and brain spasticity, reduces stretch reflexes and painful muscle spasms. It reduces resistance to passive movements, reduces spasms and clonic convulsions, increases the strength of voluntary contraction of skeletal muscles. It also has a gastroprotective property that 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 fact of detecting a disc herniation during MRI is not enough to make a final decision about the operation. Among patients with radicular symptoms after conservative treatment, up to 85% of patients with disc herniation are treated without surgery. CL should be the first step in helping patients with PO, except in a few cases. If complex CL is ineffective (within 2-3 weeks), surgical treatment (CL) is indicated in patients with herniated discs and radicular symptoms.
There are urgent instructions for PO. These include, as a rule, the development of caudal syndrome with the complete fall of the disc into the lumen of the spinal canal, the development of acute radiculomyelosemia, and an obvious hyperalgic syndrome, even when the appointment of opioids does not relieve pain. It should be noted that the absolute size of the disc herniation is not decisive for the final decision on the operation, and the clinical picture should be taken into account together with the specific condition observed in the spinal canal according to tomography (for example, the fusion of a small hernia against the background of stenosis of the spinal canal can be the opposite, or vice versa - the hernia is large, but in the middle in the background of the wide spinal canal).
Open access to the spinal canal is used in 95% of cases with disc herniation. Various disopuncture methods have not been widely used to date, although a number of authors report their effectiveness. The operation uses both conventional and microsurgical instruments (with optical magnification). During access, mainly using interlaminar access, the removal of vertebral bony joints is avoided. However, with a narrow channel, hypertrophy of the articular processes, fixed medial disc herniation, it is advisable to expand access due to bony structures.
The results of surgical treatment mainly depend on the experience of the surgeon and the correctness of the instructions for a particular operation. According to the apt statement of the famous neurosurgeon C. Brotchi, who has performed more than a thousand operations related to osteochondrosis, "we must not forget that the surgeon should operate on the patient, not the tomographic image. "
In conclusion, I would like to emphasize once again that in order to make an optimal decision regarding the choice of treatment tactics for a specific patient, a comprehensive clinical examination and analysis of tomograms should be performed.
