Osteochondrosis of the lumbosacral spine: diagnosis and treatment.

Osteochondrosis of the lumbar spine is a disease that deforms and destroys the cartilage of the intervertebral discs in the lumbar region. Without the cartilage layer the distance between the vertebrae is greatly reduced. And at the slightest sharp turns they can move. The main danger of the disease – the possibility of formation of herniated discs.

Osteochondrosis of the lumbar

You can't bend over to lift the object that had fallen on the floor? You suffer sharp pain in the lumbar region of the back, and often go under the waist in a warm shawl? Do not ignore a condition that bothers you.

Osteochondrosis of the lumbar may be delayed in its duration for a long time. No need to test the organism for durability. Love your body. And it will love you back.

On the lumbar region accounts for a large part of the burden of entire body mass compared to thoracic and cervical departments. Therefore, this subspecies of osteochondrosis most common.

What are the stages of development of an osteochondrosis?

  • Stage 1. Preclinical. The height of the disc decreases. In the fibrous ring (the outer layer of the intervertebral disc of cartilage fibers) is formed crack. The lumbar muscles are quick to tire yourself. You feel some discomfort in the back.
  • Stage 2. Violations of metabolic processes in gelatinous nucleus (the Central part of the intervertebral disc, which consists of gelatinous cartilage): its cells meltout or completely destroyed. Collagen structure (protein structure is the basis of connective tissue) fibrous ring is also impaired. Local pain, people can not cope with the physical strains that were previously considered quite feasible.
  • Stage 3. The complete destruction of the fibrous ring. Adjacent vertebrae cease to be stable. Any uncomfortable posture gives pain. Because of the experiences of the nerve roots, which branch off from the spinal cord, the limbs may become less sensitive and moving.
  • Stage 4. Tissue of the intervertebral disc becomes scarring. Vertebrae can be like tortoise shell. Clinical description depends on the individual physiology.

Lower back pain (lumbago) and pain radiating to the leg along the course of the sciatic nerve (sciatica) is one of the most common complaints with which patients seek medical help. Due to the fact that these symptoms are quite common in the General population, and noted their steady growth, diagnosis and treatment of such patients will remain one of the main activities of neurosurgical hospitals. Despite the wide spread of this disease, surgical removal of a herniated intervertebral disc (MTD) requires only 10% of patients with a clinical picture of sciatica. The remaining portion of patients best effect of conservative treatment, including drug therapy, physiotherapy, the use of physiotherapeutic methods of treatment and the return to the old everyday physical activity.

The stage of the disease

Degenerative processes often begin with the deterioration of the cushioning function of intervertebral disc.

  1. The deterioration of blood supply of the intervertebral disc. In adults, the nutrition of the intervertebral discs is carried out by means of the diffusion: blood is delivered only to the vertebrae, and in which she “leaks” to the disks. Best food drive takes place during dynamic activity (eg, walking), as the principle of the pump (the outflow of the processed fluid when compressed, the flow of nutrients and oxygen when the load is removed). Thus, nutrition of the intervertebral discs is difficult especially in conditions of a sedentary lifestyle (inactivity).
  2. Changes in polipozom the nucleus of the disc. With the deterioration of the blood supply is disturbed the supply of water, sugars and amino acids in purposee core. This affects the production of carbohydrates to bound water. The core is dehydrated, the structure of the gel becomes fibrous, impair the ability to bounce and absorb shocks. This increases the load on the annulus and the vertebrae, they are more exposed to shocks and injuries.
  3. Changes in the fibrous ring of the intervertebral disc. Due to the flattening of the nucleus pulposus to bear high load on the fibrous ring of the disc. In conditions of poor vascularity of the fibrous ring loses its strength. There is instability of the spine, which can lead to the formation of intervertebral hernia, displacement of the vertebrae and damage the spinal cord or nerve roots.
  4. Disc protrusion. The formation of a herniated disc. Inasmuch as the fibers of the annulus weaken, purposee the core begins to protrude, for example, in the intervertebral canal (a disc protrusion). Further, such bulging can cause rupture of the fibrous ring and the formation of a hernia. Read more about the process of formation of herniated discs can be read in a separate article – "Effective treatment of intervertebral hernia in the home".
  5. Spondylosis - the destruction of the intervertebral joints (spondylarthrosis), the growth of osteophytes and calcification of ligaments. In parallel with formation of herniated discs degenerative disc disease occurs when damage to the intervertebral joints, destructive changes of the vertebrae (cartilage) and ligaments.

Progression of degenerative disc disease and development of complications has had to resort to medication, increase the dosage. This leads to big financial expenses, as well as further deterioration in health due to side effects of drugs.

Drug therapy usually is complemented by immobilization of one or both of the spine by using orthopedic corsets of different hardness.

Surgical treatment is justified only in cases when the level of compression of spinal roots, defined clinically, corresponds to the data survey, confirming rupture of the fibrous ring with the "loss" of discal hernias in the lumen of the spinal canal [3-6]. The results of surgical treatment in patients with a small protrusion of the disk usually disappoint the doctor and the patient. This method allows us to establish an accurate diagnosis, is magnetic resonance imaging (MRI). Approximately 10% of people the General population it is impossible to conduct a routine MRI because of claustrophobia (fear of enclosed spaces). This category of persons may use the so-called "open" MRI, but with a corresponding loss of quality of the obtained images. Patients previously underwent surgical treatment requires a contrast enhanced MRI for distinguishing postoperative scar–commissural changes from true hernia protrusion of the disc. In patients with suspected hernial protrusion of the MPD, when performing an MRI is not possible, or the obtained results are uninformative, computed tomography (CT) myelography acquires a special diagnostic value.

Experts of beam diagnostics, interpreting results of research, as a rule, exaggerate the degree of damage of the disc due to the inability of the Association of clinical data with findings at imaging. Such conclusions like "changes correspond to the age of the patient," rarely found in research protocols. Despite improvements in neuroimaging techniques, the responsibility for right actions, the diagnosis rests with the Clinician, as only he can correlate the clinical picture with the data obtained by tomography. Higher resolution scanners significantly improved the outcomes of surgical treatment, but began to detect abnormalities in symptom-free patients. The study of the processes involved in degenerative–dystrophic lesions of the spine, has undergone serious progress in recent years. Arthropathy bootastic joints is widespread in the General population and is found quite often in persons of middle and older age groups when performing a CT–scan. Degenerative changes of the IPOA, also widespread, fairly often found, and more specific method for their diagnosis is an MRI. With frequent significant changes of the IPOA is not accompanied by the rupture of the fibrous ring, but only manifested a slight "bulging" of the disc into the lumen of the spinal canal or intervertebral foramen. In some cases, degenerative processes in the MPD, can lead to the destruction of the fibrous ring with subsequent ruptures, which causes migration of the nucleus pulposus outside the disc with compression of the adjacent spinal roots. The statement that if there is pain in the leg, it must necessarily be infringement of the nerve root of the spinal cord, is not quite true. The pain in the buttock radiating along the back of the thigh can lead to the degeneration of the IPOA and bootastic intervertebral joints. For a true attack of sciatica, caused by compression of the nerve root hernia discal, characterized by pain radiating in the back of the thigh and lower leg. The pain of an uncertain nature, limited gluteal region or thigh area without the spreading in the course of the sciatic nerve, and bilateral pain in the gluteal region or hips, and pain that changes its location (the right and to the left), often caused by arthropathy bootastic joints or diffuse degeneration of the IPOA. To simulate the clinical picture of compression of the spine hernia discal can and associated pathology (e.g., osteoarthritis of knee joints). Patients with such pain surgical treatment will not have the desired effect no matter what the pathology will be detected with CT. In other words, patients only clinic back pain removal of discal hernias will be ineffective, even if the tomograms are determined by the protrusion of the MPD, as it usually happens. But there are those patients in whom the typical pattern of invalidusername sciatica is accompanied by severe pain syndrome, while studies performed using high-resolution scanners, is not determined by compression of the spinal roots. This category of patients is not performing surgical intervention, as over time radicular symptoms they have, as a rule, subsides.

Need to clarify the mechanisms leading to the development of hernial protrusion of the IPOA is to recommend to patients the scope of permissible movements, not forgetting the work activities. Forces contributing to the formation of hernial protrusion, are a result of degenerative changes in the MPD and reducing the vertical size (height) as the fibrous ring and nucleus pulposus. Wibehouse the MPD fragment in 80% shifted in the rear–lateral direction, penetrating the lumen of the spinal canal and the medial divisions of the intervertebral foramen. Such displacement of the discal hernias in the direction away from the midline contributes to the retention forces of the posterior longitudinal ligament. Up to 10% gruzevich protrusions are localized and distributed in the lateral intervertebral foramen (foraminal hernia) or at the outer edge of the hole where it leaves the spinal root, thereby squeezing it.

In the process of life dehydration and degenerative changes lead to loss of height of the IPOA. These pathological processes are involved as the fibrous ring, and purposee core. More pronounced destruction of nucleus pulposus on the background of concomitant degeneration of the fibrous ring, as a rule, only leads to loss of height MTD without significant vbuhanii. When the predominant changes in the fibrous ring of the vertical forces acting on the remaining purposee the core and which is derived from its own weight and forces of muscles acting on the disc in the lateral direction, exert excessive pressure on the remaining fragment of the nucleus pulposus, hold that not in a state of degenerative changes of the fibers of the fibrous ring.

The summation of these two forces leads to an increase of the centrifugal pressure on the MPD, which in conjunction with the tensile component acting on the fibers of the fibrous ring can cause it to tear and bulging of the remaining fragments of the nucleus pulposus. After formed a hernial protrusion, and "redundant" fragment of nucleus pulposus were outside fibrous ring, the structure of the IPOA is once again becoming stable [2]. As a result of force acting on the degenerative changes of the nucleus and the fibrous ring MTD, balanced, and vector contributing to the further protrusion of the fragments of the core, is declining. In some cases, partial degenerative changes in the nucleus pulposus contribute to gassing within MPD with subsequent pressure on its remaining fragment. The formation of the hernia is also accompanied by a process of gas formation within the disc.

Excessive and sudden physical strain exerted on the patient's back, on the background of the current degenerative–dystrophic lesions of the spine, as a rule, is only the starting point, which leads to expanded clinical compression radicular syndrome, which often and erroneously regarded by patients as the root cause of sciatica. Clinically hernia discal can manifest reflex and compression syndromes. To include compression syndromes, which over the herniation protrusion is stretched, squeezed and deformed spine, blood vessels or the spinal cord. To reflex include syndromes caused by disc herniation on the receptors of these structures, mainly the end of the recurrent spinal nerves that leads to the development of reflex–tonic disorders, manifested vasomotor, degenerative, myofascial disorders.

As noted above, surgical treatment of degenerative–dystrophic lesions of pozvonocnika is appropriate only in 10% of patients, the remaining 90% respond well to conservative measures. The basic principles of using the latter are:

  1. the relief of pain;
  2. restore proper posture to maintain fixation ability of the modified MTD;
  3. elimination of muscular–tonic disorders;
  4. restoration of blood circulation in the spine and spinal cord;
  5. normalization of conductivity in the nerve fiber;
  6. elimination of scar–commissural changes;
  7. relief of psycho–somatic disorders.

Treatment

Today in the treatment of osteochondrosis and its complications used drugs of the following groups:

  1. Nonsteroidal anti-inflammatory drugs (NSAIDs) in the form of tablets or injection preparations. These funds have the ability to reduce pain symptoms, to reduce inflammation. However, their effect is short - from several hours to two-three days. Therefore, such means must be taken for a long time - weeks and sometimes months. At the same time, these drugs have a negative impact on the mucous membranes of the gastrointestinal tract. Their long reception can lead to the development of gastritis, ulcers. In addition, they may have an adverse effect on kidney, liver, contribute to the development of hypertension. And at the same time, these funds do not contribute to the cleaning of disks from dead cells. Therefore, their application is just a way to relieve the symptoms but do not eliminate the main problem.
  2. Steroid (hormone) anti-inflammatory drugs. Usually they are used when strong and persistent pains that accompany a hernia, radiculitis, sciatica, etc. Hormones have the ability to remove symptoms of inflammation (because of the oppression of the immune system), relieve pain. But they also affect the mucous membranes of the stomach and intestines, promote leaching of calcium from bones, depress the secretion of endogenous hormones. And do not contribute to the cleansing of the hearth from dead cells.
  3. Antispasmodics - drugs that have a direct effect on the muscles or nerves going to the muscles, and causing skeletal muscle relaxation. These tools help to remove muscular clips, reduce pain and improve blood flow. But it does not help to clear the tissue of dead cells. Therefore, do not contribute to healing from degenerative disc disease.
  4. Epidural blockade was the introduction of painkillers and hormonal means in the space between the dural sheath and the periosteum covering the vertebrae. Used, as a rule, intense pain in the acute phase of intervertebral hernia in patients with severe sciatica, sciatica. Depending on composition, this injection helps to relieve pain for a period of from several hours to several days. After expiration, the manifestation of the disease returning, as the procedure helps to restore metabolic processes in the disks. In addition, in its conducting there is a risk of injury to vessels and nerves.

Conservative methods of treatment include various orthopedic effect on the spine (corset immobilization, traction, manual therapy), physiotherapy (therapeutic massage, physiotherapy, acupuncture, electrotherapy, mud therapy, various kinds of heating), paravertebral periduralna blockade, and drug therapy. Treatment of degenerative–dystrophic lesions of the spine should be integrated and phased. As a rule, a General principle of conservative measures is the appointment of analgesics, nonsteroidal anti-inflammatory drugs (NSAIDs), muscle relaxants, and physiotherapy.

Analgesic effect is achieved by the assignment of diclofenac, Ketoprofen, lornoxicam, tramadol. A pronounced analgesic and anti-inflammatory effect has lornoxicam, existing both in injectable and tablet form.

NSAIDs are the most widely used drugs in degenerative lesions of the spine. They have anti-inflammatory, analgesic and antipyretic effect associated with the inhibition of the enzyme cyclooxygenase (COX–1 and COX–2), which regulates the conversion of arachidonic acid to prostaglandins, prostacyclin, thromboxane. In elderly and patients with risk factors for side effects of the treatment with NSAIDs is advantageously carried out under the "cover" of gastroprotection. Such patients upon completion of the course of injection of NSAID therapy is appropriate, the transition to a tablet form of the COX–2 inhibitors with less side effects from the gastrointestinal tract.

To eliminate the pain associated with increased muscle tone, in the comprehensive therapy should include the muscle relaxants of Central action.

Surgical treatment of degenerative–dystrophic lesions of the spine is justified when failure of comprehensive conservative measures (within 2-3 weeks) in patients with hernias MTD (typically larger than 10 mm) and nekupirutayasa root symptoms. There are urgent indications for surgical intervention in "fallen" sequestration into the lumen of the spinal canal and marked compression of the spinal roots. Development of caudal syndrome contributes to acute radiculomyeloischemia that leads to the expressed hyperalgesia syndrome, when even the appointment of narcotic analgesics, the use of blockades (with glucocorticoid produces the anasthetic and drugs) does not reduce the severity of pain. It is important to note that the absolute size of the disc herniation is not decisive for the final decision about surgical intervention should be considered in connection with the clinical picture and findings detected by CT. In 95% of cases of hernia MPD is used open access into the spinal canal. Discountinue various methods (cold plasma coagulation, laser reconstruction etc.) are not found in present widespread use, and their use is justified only when the protrusion of the IPOA. The classic open microsurgical removal of disc herniation is carried out using microsurgical instruments, binocular loupes or an operating microscope. Analysis of remote results of treatment (in terms of more than 2 years old) 13 359 patients after removal of discal hernias, 6135 of which have been the removal of the sequestration, and 7224 conducted aggressive discectomy, showed that the relapse of pain syndrome was found 2.5 times more often (27.8% and 11.6%) patients after aggressive discectomy, whereas recurrence of hernia formation was noted in 2 times more often (7% vs 3.5%) in patients who underwent only removal of the sequestration. Quality of life is reduced more in patients experiencing pain, whereas repeated disc herniation is not always evident clinically.

In conclusion, I would like to emphasize the need for careful clinical examination and analysis of images to make the optimum decision on choice of treatment for a particular patient.