Reducing the height of the intervertebral discs of the cervical region. Manifestations of the disease in the thoracic region. Exercises for the treatment and prevention of vertebral hernia

) is quite common. The disease affects more than 80% of the world's population. Often, patients seek medical help when the situation has gone too far. To avoid complications, it is important to detect the problem in time and undergo treatment. You need to know how the decrease in intervertebral discs manifests itself, what it is, what factors provoke it.

To understand what intervertebral osteochondrosis is, you need to understand the human anatomy, find out how the disease occurs, how it develops. The spine is an important part of the human body. It consists of vertebrae and intervertebral discs. The spinal canal runs through the center of the spine. This canal contains the spinal cord. From the spinal cord, a network of spinal nerves diverges, which are responsible for the innervation of various parts of the body.

Intervertebral discs perform the function of a shock absorber (reduce the load on the spine), protect the spinal cord from damage. The disc consists of a central nucleus and an annulus fibrosus surrounding the nucleus. The core has a consistency similar to jelly. It consists of polysaccharides, proteins, hyaluronic acid. The elasticity of the core gives the fibrous ring - a dense tissue surrounding the core.

There are no vessels in the intervertebral discs. All nutrients come to them from nearby tissues.

Causes of intervertebral osteochondrosis

A decrease in the height of the discs develops as a result of circulatory disorders, a slowdown in metabolic processes, and a lack of essential nutrients (for example, in the cervical region). There are many reasons leading to malnutrition.
Risk factors for low disc height:

• Age changes;
• Hypodynamia;
• Excess weight;
• Improper nutrition;
• Heredity;
• Injuries;
• stress;
• Metabolic disease;
• Pregnancy;
• infections;
• Bad habits;
• Individual characteristics;
• Diseases of the musculoskeletal system;
• Wearing shoes with high heels.

Often, negative changes in the intervertebral discs occur under the influence of several factors. For treatment to be beneficial, all causes must be taken into account. Together with therapeutic measures, try to eliminate them.

How it arises and develops

Under the influence of negative factors, the nutrition of the intervertebral disc is disrupted. The result is dehydration. Most often, the process occurs in the lumbar and cervical spine, less often in the thoracic.

Stages of development of intervertebral osteochondrosis:

1. Pathological processes occur in the intervertebral disc itself, without affecting nearby tissues. First, the disk core loses elasticity, then begins to collapse. The fibrous ring becomes fragile, the disk begins to lose height;
2. Parts of the core begin to shift in all directions. This process provokes the protrusion of the fibrous ring. The intervertebral disc is reduced by a quarter. There is an infringement of nerve endings, a violation of the lymph flow and blood circulation;
3. The disk continues to warp and collapse. At this stage, its height is reduced by half, compared with the norm. Against the background of degenerative changes, the spine begins to deform. There is its curvature (scoliosis, lordosis, kyphosis), intervertebral hernia. Intervertebral hernia - rupture of the fibrous ring and the exit of the nucleus beyond its borders;
4. The disk height continues to decrease. Further deformation of the spine is accompanied by a shift of the vertebrae.

Due to degenerative changes, bone growths occur, concomitant diseases appear. Intervertebral osteochondrosis leads to the development of secondary sciatica, and even disability. Therefore, early detection of symptoms, timely diagnosis and treatment are of great importance.

Symptoms of pathology

Symptoms of the disease depend on the stage of its development. The onset of disc height reduction is often asymptomatic. Some patients note stiffness in movements. Further development of the disease is accompanied by pain syndrome.

Depending on the localization of the focus of inflammation, the following symptoms are distinguished:

• Cervical region: headaches, stiffness, numbness in the cervical region, dizziness, paresthesia of the hands, pain in the chest, upper limbs. Often, the defeat of this zone is accompanied by weakness, pressure drops, darkening in the eyes. Symptoms develop as a result of intervertebral discs that have changed their position.
• Thoracic department. Mild pain syndrome in this area (pain is dull, aching). Often there are symptoms similar to gastritis, intercostal neuralgia, angina pectoris. Reducing the height of the discs is accompanied by numbness and pain in the limbs, goosebumps in the chest area, discomfort in the heart, liver and stomach.
• Lumbar. Such localization is manifested by acute pain in the lumbar region, buttocks, lower leg, thighs, stiffness of movements. Reducing the height of the discs leads to paresthesia (impaired sensitivity) and weakness in the legs.
• Degenerative processes in several departments - common osteochondrosis.

If you experience these symptoms, you should immediately consult a doctor. Early initiation of treatment can significantly reduce the risk of developing secondary disorders. If you start the disease, the consequences can be terrible, up to complete immobilization (disability).

Diagnosis of the disease

Often, osteochondrosis is manifested by symptoms similar to other diseases (sciatica, angina pectoris, etc.). Therefore, an accurate diagnosis is made only on the basis of the examination. Diagnosis of lower discs begins with an examination by a neurologist.

After clarifying the complaints and collecting an anamnesis, the doctor, based on the clinical picture, will prescribe additional instrumental diagnostic methods:

• Radiography is an effective method for diagnosing osteochondrosis. It allows you to detect pathological changes (for example, in the cervical region) even at stage 1 of the disease, when there are no symptoms yet. However, the occurrence of an intervertebral hernia at the initial stage of the X-ray examination will not show.
• Magnetic resonance imaging (MRI) allows you to identify intervertebral hernia, evaluate degenerative changes in the spinal cord.
• Electromyography (electroneurography) reveals damage in the nerve pathways.
• Discography allows you to explore all the damage in the structure of the disc.

It is impossible to completely cure the decrease in the height of the disks. You can only stop the development of pathological processes. The procedures are aimed at:

• To relieve pain;
• Improvement of blood circulation and metabolic reactions;
• Restoration of the mobility of the vertebral discs.

In this case, treatment can be conservative or surgical. It all depends on the stage of development of the disease. Treatment methods should be selected by a neuropathologist, based on the results of the examination and the clinical picture. Depending on the symptoms and the stage of development of the disease, various types of drugs are used:

• To relieve swelling and reduce inflammation, non-steroidal anti-inflammatory drugs (Nise, Ketanov, Movalis, etc.) are used;
• To enhance metabolism, vitamin complexes are prescribed (Milgama, Unigama);
• To improve blood flow - Eufilin, Trenetal;
• To relieve spasm, various types of muscle relaxants are used (Mydocalm, Tizanidin).

Medicines and their dosages should be selected only by a specialist. Do not self-medicate. This can lead to serious consequences.

Your doctor may prescribe various pain medications. In especially severe cases, drug blockade is used. During the treatment period, it is necessary to observe a sparing regimen for the back. Any load on the spine is excluded. The doctor may prescribe a course of physiotherapy, physiotherapy exercises, massage, swimming. All these procedures help relieve muscle spasms, improve blood circulation and nutrition in the intervertebral discs.

Surgery is required only if long-term treatment does not work.

Preventive actions

Early diagnosis and proper treatment are important, but preventive measures also play an important role. Methods for preventing a decrease in the height of intervertebral discs:

• Proper nutrition;
• Maintaining the body's water balance (40 ml of liquid per 1 kg of body weight);
• Getting rid of bad habits;
• Weight loss;
• Performing special gymnastics;
• Reduce the impact of stress on the body.

In addition, it is necessary to avoid hypothermia, trauma to the spine, lifting weights. Once a year, you need to undergo a preventive examination, for the timely detection of problems with the spine.

Injuries to the lumbar and thoracic intervertebral discs are much more common than is commonly thought. They arise under the indirect influence of violence. The immediate causes of damage to the lumbar intervertebral discs are heavy lifting, forced rotational movements, flexion movements, sudden sharp straining and, finally, a fall.

Damage to the thoracic intervertebral discs more often occurs with a direct blow or a blow to the region of the vertebral ends of the ribs, transverse processes in combination with muscle tension and forced movements, which is especially often observed in athletes when playing basketball.

Damage to the intervertebral discs is almost not observed in childhood, occurs in adolescence and adolescence, and is especially common in people of the 3rd-4th decade of life. This is explained by the fact that isolated damage to the intervertebral disc often occurs in the presence of degenerative processes in it.

What causes intervertebral disc damage?

The lumbosacral and lumbar spine are the area where degenerative processes most often develop. The IV and V lumbar discs are most often affected by degenerative processes. This is facilitated by the following some anatomical and physiological features of these discs. It is known that the IV lumbar vertebra is the most mobile. The greatest mobility of this vertebra leads to the fact that the IV intervertebral disc experiences a significant load, most often undergoes trauma.

The occurrence of degenerative processes in the fifth intervertebral disc is due to the anatomical features of this intervertebral joint. These features are in the discrepancy between the anterior-posterior diameter of the bodies of the V lumbar and I sacral vertebrae. According to Willis, this difference ranges from 6 to 1.5 mm. Fletcher confirmed this based on an analysis of 600 x-rays of the lumbosacral spine. He believes that this discrepancy in the size of these vertebral bodies is one of the main causes of degenerative processes in the V lumbar disc. This is also facilitated by the frontal or predominantly frontal type of the lower lumbar and upper sacral facets, as well as their posterior-external inclination.

The above anatomical relationships between the articular processes of the I sacral vertebra, V lumbar and I sacral spinal roots can lead to direct or indirect compression of these spinal roots. These spinal roots have a considerable length in the spinal canal and are located in its lateral recesses, formed in front by the posterior surface of the V lumbar intervertebral disc and the body of the V lumbar vertebra, and behind by the articular processes of the sacrum. Often, when degeneration of the 5th lumbar intervertebral disc occurs, due to the inclination of the articular processes, the body of the 5th lumbar vertebra not only descends downwards, but also shifts backwards. This inevitably leads to narrowing of the lateral recesses of the spinal canal. Therefore, so often there is a "disco-radicular conflict" in this area. Therefore, most often there are phenomena of lumboischialgia with the interest of the V lumbar and 1 sacral roots.

Ruptures of the lumbar intervertebral discs are more common in men engaged in physical labor. They are especially common in athletes.

According to V. M. Ugryumov, ruptures of degenerated intervertebral lumbar discs occur in people of middle and old age, starting from 30-35 years. According to our observations, these injuries also occur at a younger age - at 20-25 years old, and in some cases even at 14-16 years old.

Intervertebral discs: anatomical and physiological information

The intervertebral disc, located between two adjacent surfaces of the vertebral bodies, is a rather complex anatomical formation. This complex anatomical structure of the intervertebral disc is due to a peculiar set of functions it performs. The intervertebral disc has three main functions: the function of firmly connecting and holding adjacent vertebral bodies near each other, the function of a semi-joint, which ensures the mobility of the body of one vertebra in relation to the body of another, and, finally, the function of a shock absorber that protects the vertebral bodies from constant trauma. The elasticity and resilience of the spine, its mobility and ability to withstand significant loads are mainly determined by the state of the intervertebral disc. All these functions can only be performed by a full-fledged, unaltered intervertebral disc.

The cranial and caudal surfaces of the bodies of two adjacent vertebrae are covered with cortical bone only in the peripheral regions, where the cortical bone forms a bony edge - the limbus. The rest of the surface of the vertebral bodies is covered with a layer of very dense, peculiar spongy bone, called the endplate of the vertebral body. The bone marginal edging (limbus) rises above the endplate and, as it were, frames it.

The intervertebral disc consists of two hyaline plates, the annulus fibrosus and the nucleus pulposus. Each of the hyaline plates is closely adjacent to the endplate of the vertebral body, equal to it in size and, as it were, inserted into it like a watch glass turned in the opposite direction, the rim of which is the limbus. The surface of the limbus is not covered with cartilage.

It is believed that the nucleus pulposus is a remnant of the dorsal notochord of the embryo. The notochord in the process of evolution is partially reduced, and partially transformed into the nucleus pulposus. Some argue that the nucleus pulposus of the intervertebral disc is not a remnant of the notochord of the embryo, but is a complete functional structure that replaced the notochord in the process of phylogenetic development of higher animals.

The nucleus pulposus is a gelatin-like mass consisting of a small number of cartilaginous and connective tissue cells and fibrous intertwining swollen connective tissue fibers. The peripheral layers of these fibers form a kind of capsule that limits the gelatinous core. This nucleus is enclosed in a kind of cavity containing a small amount of fluid resembling synovial.

The fibrous ring consists of dense connective tissue bundles located around the gelatinous nucleus and intertwined in various directions. It contains a small amount of interstitial substance and single cartilaginous and connective tissue cells. The peripheral bundles of the fibrous ring are closely adjacent to each other and, like Sharpey's fibers, are introduced into the bone edging of the vertebral bodies. The fibers of the fibrous ring, located closer to the center, are located more loosely and gradually pass into the capsule of the gelatinous nucleus. Ventral - the anterior section of the fibrous ring is more durable than the dorsal - posterior.

According to Franceschini (1900), the fibrous ring of the intervertebral disc consists of collagen plates arranged concentrically and undergoing significant structural changes throughout life. In a newborn, the collagen lamellar structure is poorly expressed. Until the 3-4th year of life in the thoracic and lumbar regions and up to 20 years in the cervical region, collagen plates are arranged in the form of quadrangular formations surrounding the nucleus of the disc. In the thoracic and lumbar regions, from the age of 3-4, and in the cervical region, from the age of 20, primitive quadrangular collagen formations are transformed into elliptical ones. Subsequently, by the age of 35, in the thoracic and lumbar regions, simultaneously with a decrease in the size of the disc nucleus, collagen plates gradually acquire a pillow-like configuration and play a significant role in the shock-absorbing function of the disc. These three collagen structures, quadrangular - elliptical and pillow-shaped - replacing each other, are the result of mechanical action on the nucleus pulposus of the disc. Franceschini believes that the core of the disk should be considered as a device designed to convert vertically acting forces into radial ones. These forces are crucial in the formation of collagen structures.

It should be remembered that all elements of the intervertebral disc - hyaline plates, nucleus pulposus and annulus fibrosus - are structurally closely related to each other.

As noted above, the intervertebral disc, in collaboration with the posterior-external intervertebral joints, is involved in the movements carried out by the spine. The total range of motion in all segments of the spine is quite significant. As a result, the intervertebral disc is compared with a semi-joint (Luschka, Schmorl, Junghanns). The nucleus pulposus in this half-joint corresponds to the articular cavity, the hyaline plates correspond to the articular ends, and the fibrous ring corresponds to the articular bag. The nucleus pulposus in different sections of the spine occupies a different position: in the cervical spine it is located in the center of the disc, in the upper thoracic vertebrae - closer to the front, in all other sections - on the border of the middle and posterior thirds of the anterior-posterior diameter of the disc. With movements of the spine, the pulpous nucleus, which is capable of shifting to some extent, changes its shape and position.

The cervical and lumbar discs are higher in the ventral region, while the thoracic discs are higher in the dorsal region. This seems to be due to the presence of appropriate physiological curvature of the spine. Various pathological processes leading to a decrease in the height of the intervertebral discs cause a change in the size and shape of these physiological curves of the spine.

Each intervertebral disc is somewhat wider than the corresponding vertebral body and, in the form of a roller, stands somewhat forward and to the sides. Anteriorly and laterally, the intervertebral disc is covered by the anterior longitudinal ligament, which stretches from the lower surface of the occipital bone along the entire anterolateral surface of the spine to the anterior surface of the sacrum, where it is lost in the pelvic fascia. The anterior longitudinal ligament is firmly fused to the vertebral bodies and freely flips over the intervertebral disc. In the cervical and lumbar - the most mobile sections of the spine, this ligament is somewhat narrower, and in the thoracic - wider and covers the anterior and lateral surfaces of the vertebral bodies.

The posterior surface of the intervertebral disc is covered by the posterior longitudinal ligament, which starts from the cerebral surface of the body of the occipital bone and runs along the entire length of the spinal canal to the sacrum inclusive. Unlike the anterior longitudinal ligament, the posterior longitudinal ligament does not have strong ties with the vertebral bodies, but freely spreads through them, being firmly and intimately connected to the posterior surface of the intervertebral discs. The sections of the posterior longitudinal ligament passing through the vertebral bodies are narrower than the sections associated with the intervertebral discs. In the area of ​​the discs, the posterior longitudinal ligament expands somewhat and is woven into the fibrous ring of the discs.

The gelatinous nucleus of the intervertebral disc, due to its turgor, exerts constant pressure on the hyaline plates of adjacent vertebrae, trying to move them away from each other. At the same time, a powerful ligamentous apparatus and the fibrous ring tend to bring adjacent vertebrae together, counteracting the nucleus pulposus of the intervertebral disc. As a result, the size of each individual intervertebral disc and the entire spine as a whole is not a constant value, but depends on the dynamic balance of the oppositely directed forces of the nucleus pulposus and the ligamentous apparatus of two adjacent vertebrae. So, for example, after a night's rest, when the gelatinous nucleus acquires maximum turgor and largely overcomes the elastic traction of the ligaments, the height of the intervertebral disc increases and the vertebral bodies move apart. In contrast, by the end of the day, especially after a significant back load on the spine, the height of the intervertebral disc decreases due to a decrease in the turgor of the nucleus pulposus. The bodies of adjacent vertebrae approach each other. Thus, throughout the day, the length of the spinal column either increases or decreases. According to A.P. Nikolaev (1950), this daily fluctuation in the size of the spinal column reaches 2 cm. This also explains the decrease in the growth of older people. A decrease in the turgor of the intervertebral discs and a decrease in their height lead to a decrease in the length of the spinal column, and, consequently, to a decrease in human height.

According to modern concepts, the preservation of the nucleus pulposus depends on the degree of polymerization of mucopolysaccharides, in particular hyaluronic acid. Under the influence of certain factors, depolymerization of the main substance of the nucleus occurs. It loses its compactness, condenses, fragments. This is the beginning of degenerative-dystrophic changes in the intervertebral disc. It has been established that in degenerative discs there is a shift in the localization of neutral and pronounced depolymerization of acid mucopolysaccharides. Therefore, subtle histochemical techniques confirm the idea that degenerative-dystrophic processes in the intervertebral disc begin with subtle changes in the structure of the nucleus pulposus.

The intervertebral disc of an adult is in approximately the same conditions as the articular cartilage. Due to the loss of their ability to regenerate, insufficient blood supply (Bohmig) and a large load on the vertebral discs due to the vertical position of a person, aging processes develop in them quite early. The first signs of aging appear already at the age of 20 years in the area of ​​thinned parts of the hyaline plates, where the hyaline cartilage is gradually replaced by connective tissue cartilage with its subsequent defibration. This leads to a decrease in the resistance of hyaline plates. At the same time, the changes mentioned above occur in the nucleus pulposus, leading to a decrease in its shock-absorbing effect. With age, all these phenomena progress. Dystrophic changes in the fibrous ring join, accompanied by tears even under normal loads. Gradually: degenerative changes in the intervertebral and costovertebral joints join this. Moderate osteoporosis of the vertebral bodies develops.

Under pathological conditions, all the described processes in various elements of the intervertebral disc develop unevenly and even in isolation. They show up ahead of time. Unlike age-related changes, they are already degenerative-dystrophic lesions of the spine.

According to the absolute majority of authors, degenerative-dystrophic lesions in the intervertebral disc occur as a result of chronic overload. At the same time, in a number of patients, these lesions are the result of individual acquired or constitutional inferiority of the spine, in which even the usual daily load is excessive.

A more in-depth study of the pathological morphology of degenerative processes in the discs in recent years has not yet introduced fundamentally new facts into the idea of ​​degenerative processes that was described by Hildebrandt (1933). According to Hildebrandt, the essence of the ongoing pathological process is as follows. The degeneration of the nucleus pulposus begins with a decrease in its turgor, it becomes drier, fragments, and loses its elasticity. Biophysical and biochemical studies of the elastic function of the discs made it possible to establish that, in this case, the collagen structure of the nucleus pulposus is replaced by fibrous tissue and the content of polysaccharides decreases. Long before the collapse of the nucleus into separate formations, other elements of the intervertebral disc are also involved in the process. Under the influence of pressure from adjacent vertebrae, the nucleus pulposus that has lost its elasticity is flattened. The height of the intervertebral disc is reduced. Parts of the disintegrated nucleus pulposus are displaced to the sides, they bend outwards the fibers of the fibrous ring. The annulus fibrosus is torn and ruptured. It was found that with a vertical load on the disk, the pressure in the modified disk is much lower than in the normal one. At the same time, the annulus fibrosus of a degenerated disc experiences 4 times more stress than the annulus fibrosus of a normal disc. Hyaline plates and adjacent surfaces of the vertebral bodies are subject to constant trauma. Hyaline cartilage is replaced by fibrous cartilage. Breaks and cracks appear in the hyaline plates, and sometimes entire sections of them are torn off. Defects in the nucleus pulposus, hyaline plates and annulus fibrosus merge into cavities that cross the intervertebral disc in different directions.

Symptoms of damage to the lumbar discs

Symptoms of damage to the lumbar intervertebral discs fit into various syndromes and can vary from minor, sudden onset pain in the lumbar region to a severe picture of complete transverse compression of the elements of the cauda equina with paraplegia and dysfunction of the pelvic organs, as well as a whole range of autonomic symptoms.

The main complaint of victims is sudden onset pain in the lumbar spine after heavy lifting, sudden movement or, more rarely, a fall. The victim cannot take a natural posture, unable to carry out any movements in the lumbar spine. Scoliotic deformity often develops acutely. The slightest attempt to change position causes increased pain. These pains may be local, but may radiate along the spinal roots. In more severe cases, there may be a picture of acute paraparesis, which soon turns into paraplegia. There may be acute urinary retention, stool retention.

An objective examination shows smoothness of the lumbar lordosis up to the formation of angular kyphotic deformity, scoliosis, contracture of the lumbar muscles - a symptom of "reins"; restriction of all types of movements, an attempt to reproduce which increases pain; pain when tapping along the spinous processes of the lower lumbar vertebrae, reflected sciatic pain when tapping along the spinous processes, soreness of the paravertebral points, pain on palpation of the anterior sections of the spine through the anterior abdominal wall; increased pain when coughing, sneezing, sudden laughter, straining, with compression of the jugular veins; inability to stand on toes.

Neurological symptoms of damage to the lumbar discs depend on the level of damage to the disc and the degree of involvement of the elements of the spinal cord. As noted above, with disc ruptures with massive loss of its substance, monoparesis, paraparesis, and even paraplegia, and dysfunction of the pelvic organs can occur. Pronounced bilateral symptomatology indicates massive prolapse of the disc substance. With the interest of the IV lumbar root, hypoesthesia or anesthesia in the buttocks, outer thigh, inner surface of the foot can be detected. In the presence of hypoesthesia or anesthesia on the back of the foot, one should think about the interest of the V lumbar root. Loss or decrease in surface sensitivity on the outer surface of the lower leg, the outer surface of the foot, in the area of ​​​​IV and V fingers suggests the interest of the first sacral segment. Often there are positive symptoms of stretching (symptoms of Kernig, Lasegue). There may be a decrease in Achilles and knee reflexes. With damage to the upper lumbar discs, which is much less common, there may be a decrease in strength or loss of function of the quadriceps femoris, sensitivity disorders on the anterior and inner thighs.

Diagnosis of damage to the lumbar discs

Of great importance in recognizing damage to the intervertebral discs is the X-ray method of examination. X-ray symptomatology of damage to the intervertebral lumbar discs is actually the X-ray symptomatology of lumbar intervertebral osteochondrosis.

In the first stage of intervertebral osteochondrosis ("chondrosis" according to Schmorl), the earliest and most typical x-ray symptom is a decrease in the height of the intervertebral disc. At first, it can be extremely insignificant and is captured only by comparison with neighboring disks. It should be remembered that the IV intervertebral disc is normally the most powerful, the “highest” disc. At the same time, straightening of the lumbar spine is detected - the so-called “string” or “candle” symptom, described by Guntz in 1934.

During this period, the so-called x-ray functional tests are of great diagnostic value. Functional x-ray test is as follows. X-rays are made in two extreme positions - in the position of maximum flexion and maximum extension. With a normal, unaltered disc, at maximum flexion, the disc height decreases in front, and at maximum extension, at the back. The absence of these symptoms indicates the presence of osteochondrosis - it indicates a loss of the depreciation function of the disc, a decrease in turgor and elasticity of the nucleus pulposus. At the moment of extension, the body of the overlying vertebra may be displaced posteriorly. This indicates a decrease in the function of disc retention of one vertebral body relative to another. The posterior displacement of the body should be determined by the posterior contours of the vertebral body.

In some cases, high-quality radiographs and tomograms may show a prolapsed disc.

There may also be a symptom of "strut", which consists in an uneven height of the disc on the anterior-posterior radiograph. This unevenness consists in the presence of a wedge-shaped deformation of the disc - at one edge of the vertebral bodies, the intervertebral gap is wider and gradually narrows wedge-shaped towards the other edge of the bodies.

With a more pronounced x-ray picture (“osteochondrosis” according to Schmorl), sclerosis of the end plates of the vertebral bodies is observed. The appearance of sclerosis zones should be explained by reactive and compensatory phenomena on the part of the corresponding surfaces of the vertebral bodies, resulting from the loss of the depreciation function of the intervertebral disc. As a result, the surfaces of two adjacent vertebrae facing each other are subjected to systematic and constant traumatization. Edge growths appear. Unlike marginal growths in spondylosis, marginal growths in intervertebral osteochondrosis are always located perpendicular to the long axis of the spine, originate from the limbus of the vertebral bodies, can occur in any part of the lnbus, including the back, never merge with each other and occur against the background of reduction in disk height. Often there is a retrograde stepwise spondylolisthesis.

Vollniar (1957) described the "vacuum phenomenon" - an X-ray symptom, which, in his opinion, characterizes degenerative-dystrophic changes in the lumbar intervertebral discs. This "vacuum phenomenon" consists in the fact that at the anterior edge of one of the lumbar vertebrae on the radiograph, a slit-like form of enlightenment the size of a pinhead is determined.

Contrast spondylography. Contrast methods of X-ray examination include pneumomyelography and discography. These methods of research can be useful when, on the basis of clinical and conventional x-ray data, it is not possible to accurately form an idea of ​​the presence or absence of damage to the disc. With fresh injuries of the intervertebral discs, discography is more important.

Discography in the indicated cases provides a number of useful data that complement the clinical diagnosis. Disc puncture allows to clarify the capacity of the disc cavity, to cause provoked pain, reproducing an increased attack of pain, usually experienced by the patient, and, finally, to obtain a contrast discogram.

Puncture of the lower lumbar discs is performed transdurally, according to the method proposed by Lindblom (1948-1951). The patient is seated or placed in a position with the greatest possible correction of the lumbar lordosis. The patient's back is arched. If the disc is punctured in a sitting position, then the forearms bent at the elbows rest on the knees. Carefully determine the interspinous spaces and mark with a solution of methylene blue or brilliant green. The operating field is treated twice with 5% tincture of iodine. Then the iodine is removed with an alcohol wipe. The skin, subcutaneous tissue, interspinous space are anesthetized with 0.25% novocaine solution. The lumbar puncture needle is inserted as in a lumbar puncture. The needle passes through the skin, subcutaneous tissue, superficial fascia, supraspinous and interspinous ligaments, posterior epidural tissue and the posterior wall of the dural sac. Remove the mandrel. Carry out liquorodynamic tests, determine the cerebrospinal fluid pressure. Take for the study of cerebrospinal fluid. Re-introduce the mandrin. The needle is advanced forward. Guided by the sensations of the patient, change the direction of the needle. In case of contact of the needle with the elements of the cauda equina, the patient complains of pain. When pain is felt in the right leg, the needle should be pulled back somewhat and held to the left, and vice versa. The anterior wall of the dural sac, the anterior epidural tissue, the posterior longitudinal ligament, and the posterior section of the annulus fibrosus of the intervertebral disc are pierced. The needle falls into the cavity. The passage of the posterior longitudinal ligament is determined by the patient's reaction - complaints of pain along the spine up to the back of the head. The passage of the fibrous ring is determined by the resistance of the needle. In the process of disc puncture, one should be guided by a profile spondylogram, which helps to navigate in choosing the right direction for the needle.

Determination of the capacity of the disk is carried out by introducing a physiological saline solution through a needle into the cavity of the disk using a syringe. A normal disc allows you to enter into its cavity 0.5-0.75 ml of liquid. A higher number indicates a degenerative disc change. If there are cracks and ruptures of the fibrous ring, then the amount of possible fluid injection is very large, since it flows into the epidural space and spreads in it. By the amount of fluid injected, it is tentatively possible to judge the degree of disc degeneration.

The reproduction of the provoked pains is carried out by a somewhat excessive administration of the solution. By increasing the intradiscal pressure, the injected solution enhances or causes compression of the root or ligaments and reproduces more intense pain characteristic of this patient. These pains are sometimes quite significant - the patient suddenly cries out in pain. Questioning the patient about the nature of the pain allows you to decide whether this disk corresponds to the cause of the patient's suffering.

Contrast discography is carried out by introducing a solution of cardiotrast or gepaka through the same needle. If the contrast agent goes freely, it should not be injected more than 2-3 ml. Similar manipulations are repeated on all questionable disks. It is most difficult to puncture the V disc located between the V lumbar and I sacral vertebrae. This is due to the fact that the bodies of these vertebrae are located at an angle open anteriorly, due to which the gap between them behind is significantly narrowed. Usually more time is spent on the puncture of the V disk than on the puncture of the overlying ones.

It should be borne in mind that radiography is performed no later than 15-20 minutes after the introduction of a contrast agent. After a later period, contrast discography will not work, since the cardiotrast will resolve. Therefore, we recommend that you first puncture all the necessary discs, determine their capacity and the nature of the provoked pain. The needle is left in the disk and the mandrin is introduced into it. Only after the introduction of needles into all the necessary discs, a contrast agent should be quickly injected and a discography should be done immediately. Only in this case discograms of good quality are obtained.

Only the three lower lumbar discs can be punctured transdurally. The spinal cord is already located above, excluding transdural puncture of the II and I lumbar discs. If these discs need to be punctured, the epidural approach suggested by Erlacher should be used. The needle is injected 1.5-2 cm outward from the spinous process on the healthy side. It is directed upward and inward, medially from the posterior-external intervertebral joint into the intervertebral foramen and inserted into the disc through the gap between the root and the dural sac. This disc puncture method is more complex and requires skill.

Finally, the disc can also be punctured using the external approach proposed by de Seze. To do this, a needle 18-20 cm long is injected 8 cm outward from the spinous process and directed inwards and upwards at an angle of 45°. At a depth of 5-8 cm, it abuts against the transverse process. It is bypassed from above and the needle is advanced deeper to the midline. At a depth of 8-12 cm, its tip rests against the lateral surface of the vertebral body. With the help of radiography, the position of the needle is checked and correction is made until the needle enters the disc. The method also requires known skills and takes more time.

There is another possibility to perform a disc puncture during the operation. Since the intervention is performed under anesthesia, in this case it is only possible to determine the capacity of the disc cavity and produce a contrast discography.

The nature of the discogram depends on the changes in the disc. A normal discogram appears as a rounded, square, oval slit-like shadow located in the middle (anterior-posterior projection). On the profile discogram, this shadow is located closer to the back, approximately at the border of the posterior and middle third of the anterior-posterior diameter of the disc. With damage to the intervertebral discs, the nature of the discogram changes. The shadow of the contrast in the area of ​​the intervertebral space can take on the most bizarre forms up to the release of the contrast iodine in the anterior or posterior longitudinal ligaments, depending on where the fibrous ring has ruptured.

We resort to discography relatively rarely, because more often, on the basis of clinical and radiological data, it is possible to make the correct clinical and topical diagnosis.

Conservative treatment of injuries of the lumbar intervertebral discs

In the vast majority of cases, damage to the lumbar intervertebral discs is cured by conservative methods. Conservative treatment of damage to the lumbar discs should be carried out comprehensively. This complex includes orthopedic, medical and physiotherapy treatment. Orthopedic methods include creating rest and unloading the spine.

The victim with damage to the lumbar intervertebral disc is placed in bed. The idea that the victim should be laid on a hard bed in the supine position is erroneous. For many victims, this forced position causes increased pain. On the contrary, in some cases, there is a decrease or disappearance of pain when laying the victims in a soft bed, which allows significant flexion of the spine. Often the pain disappears or decreases in the position on the side with the hips brought to the stomach. Therefore, in bed, the victim must take the position in which the pain disappears or decreases.

Unloading of the spine is achieved by the horizontal position of the victim. Some time later, after the acute effects of the former injury have passed, this unloading can be supplemented by a constant stretching of the spine along an inclined plane with the help of soft rings for the armpits. To increase the tensile strength, additional weights suspended from the victim's pelvis using a special belt can be used. The size of the loads, time and degree of stretching are dictated by the sensations of the victim. Rest and unloading of the damaged spine last for 4-6 weeks. Usually during this period the pain disappears, the gap in the area of ​​the fibrous ring heals with a strong scar. In later periods after a former injury, with a more persistent pain syndrome, and sometimes in recent cases, it is more effective not to constantly stretch, but to intermittent stretching of the spine.

There are several different techniques for intermittent spinal stretching. Their essence boils down to the fact that within a relatively short period of 15-20 minutes, with the help of weights or dosed screw thrust, the tension is brought to 30-40 kg. The magnitude of the stretching force in each individual case is dictated by the physique of the patient, the degree of development of his muscles, as well as his sensations in the process of stretching. The maximum stretch lasts for 30-40 minutes, and then over the next 15-20 minutes it gradually reduces to pet.

Stretching of the spine with the help of metered screw thrust is carried out on a special table, the platforms of which are bred along the length of the table with a screw rod with a wide thread pitch. The victim is fixed at the head end of the table with a special bra worn on the chest, and at the foot end with a belt for the pelvis. With the divergence of the foot and head platforms, the lumbar spine is stretched. In the absence of a special table, intermittent stretching can be carried out on a regular table by hanging weights from the pelvic girdle and a bra on the chest.

Very useful and effective is the underwater stretching of the spine in the pool. This method requires special equipment and equipment.

Medical treatment for lumbar disc injury is oral or topical medication. In the first hours and days after injury, with severe pain syndrome, drug treatment should be aimed at relieving pain. Analgin, promedol, etc. can be used. Large doses (up to 2 g per day) of salicylates have a good therapeutic effect. Salicylates can be administered intravenously. Novocaine blockades in various modifications are also useful. A good analgesic effect is provided by injections of hydrocortisone in the amount of 25-50 mg into the paravertebral tender points. Even more effective is the introduction of the same amount of hydrocortisone into the damaged intervertebral disc.

Intradiscal administration of hydrocortisone (0.5% solution of novocaine with 25-50 mg of hydrocortisone) is performed in the same way as discography is performed according to the method proposed by de Seze. This manipulation requires a certain skill and skill. But even paravertebral administration of hydrocortisone gives a good therapeutic effect.

Of the physiotherapeutic procedures, diadynamic currents are the most effective. Popophoresis with novocaine, thermal procedures can be applied. It should be borne in mind that often thermal procedures cause exacerbation of pain, which appears to be due to an increase in local tissue edema. If the victim's condition worsens, they should be canceled. After 10-12 days, in the absence of pronounced irritation of the spinal roots, massage is very useful.

At a later date, balneotherapy can be recommended to such victims (Pyatigorsk, Saki, Tskhaltubo, Belokurikha, Matsesta, Karachi). In some cases, it can be useful to wear soft semi-corsets, corsets or "grace".

Surgical treatment of injuries of the lumbar intervertebral discs

Indications for surgical treatment of injuries of the lumbar intervertebral discs arise in cases where conservative treatment is ineffective. Usually, these indications occur in the long term after the former injury, and in fact, the intervention is performed on the consequences of the former injury. Such indications are persistent lumbodynia, the phenomena of functional failure of the spine, the syndrome of chronic compression of the spinal roots, which is not inferior to conservative treatment. With fresh injuries of the intervertebral lumbar discs, indications for surgical treatment occur with an acutely developed syndrome of compression of the cauda equina with paraparesis or paraplegia, a disorder in the function of the pelvic organs.

The history of the emergence and development of surgical methods for the treatment of injuries of the lumbar intervertebral discs is essentially the history of the surgical treatment of lumbar intervertebral osteochondrosis.

Surgical treatment of lumbar intervertebral osteochondrosis ("lumbosacral radiculitis") was first carried out by Elsberg in 1916. Taking the fallen disc material when it was damaged for interspinal tumors - "chondromas", Elsberg, Petit, Qutailles, Alajuanine (1928) performed their removal. Mixter, Barr (1934), proving that "chondromas" are nothing more than a prolapsed part of the nucleus pulposus of the intervertebral disc, performed a laminectomy and removed the prolapsed part of the intervertebral disc by trans- or extradural access.

Since then, especially abroad, methods of surgical treatment of lumbar intervertebral osteochondrosis have become widespread. Suffice it to say that individual authors have published hundreds and thousands of observations of patients operated on for lumbar intervertebral osteochondrosis.

Existing surgical methods for the treatment of prolapse of the disc substance in intervertebral osteochondrosis can be divided into palliative, conditionally radical and radical.

Palliative surgery for damaged lumbar discs

Such operations include the operation proposed by Love in 1939. Having undergone some changes and additions, it is widely used in the treatment of herniated discs of the lumbar localization.

The task of this surgical intervention is only the removal of the prolapsed part of the disc and the elimination of compression of the nerve root.

The victim is placed on the operating table in the supine position. To eliminate lumbar lordosis, various authors use different techniques. B. Boychev suggests placing a pillow under the lower abdomen. AI Osna gives the patient "the pose of a praying Buddhist monk." Both of these methods lead to a significant increase in intra-abdominal pressure and, consequently, to venous congestion, causing increased bleeding from the surgical wound. Friberg designed a special "cradle" in which the victim is placed in the desired position without difficulty breathing and increasing intra-abdominal pressure.

Local anesthesia, spinal anesthesia and general anesthesia are recommended. Proponents of local anesthesia consider the advantage of this type of anesthesia the ability to control the course of the operation by compression of the spinal root and the patient's response to this compression.

Lower lumbar disc surgery technique

A paravertebral semi-oval incision is used to dissect the skin, subcutaneous tissue, and superficial fascia in layers. The affected disc should be in the middle of the incision. On the side of the lesion, the lumbar fascia is dissected longitudinally at the edge of the supraspinous ligament. Carefully skeletonize the lateral surface of the spinous processes, semi-arches and articular processes. All soft tissues must be carefully removed from them. With a wide powerful hook, soft tissues are pulled laterally. They expose the semi-arches, the yellow ligaments and articular processes located between them. The area of ​​the yellow ligament is excised at the desired level. Expose the dura mater. If this is not enough, part of the adjacent sections of the semi-arches are bitten off or the adjacent semi-arches are removed completely. Hemilaminectomy is quite acceptable and justified for expanding the operative access, but it is difficult to agree to a wide laminectomy with the removal of 3-5 arches. In addition to the fact that laminectomy significantly weakens the posterior spine, it is believed that it leads to limited movement and pain. Restriction of movements and pain is directly proportional to the size of the lamyectomy. Careful hemostasis is performed throughout the intervention. The dural sac is displaced inside. The spinal root is taken aside. Examine the posterior-lateral surface of the affected intervertebral disc. If the disc herniation is located posterior to the posterior longitudinal ligament, then it is grasped with a spoon and removed. Otherwise, the posterior longitudinal ligament or the posteriorly protruding section of the posterior annulus fibrosus is dissected. After that, part of the dropped disk is removed. Produce hemostasis. Layered sutures are applied to the wounds.

Some surgeons incise the dura mater and use a transdural approach. The disadvantage of transdural access is the need for a wider removal of the posterior vertebrae, opening the posterior and anterior layers of the dura mater, and the possibility of subsequent intradural cicatricial processes.

If necessary, one or two articular processes can be skewed, which makes the operative approach wider. However, this violates the reliability of the stability of the spine at this level.

During the day the patient is in the position on the stomach. Carry out symptomatic drug treatment. From 2 days the patient is allowed to change position. On the 8-10th day he is discharged for outpatient treatment.

The described surgical intervention is purely palliative and eliminates only the compression of the spinal root by a prolapsed disc. This intervention is not aimed at curing the underlying disease, but only at eliminating the complication generated by it. Removal of only part of the prolapsed affected disc does not exclude the possibility of recurrence of the disease.

Conditionally radical surgery for damage to the lumbar discs

These operations are based on the proposal of Dandy (1942) not to be limited to removing only the prolapsed part of the disc, but to remove the entire affected disc with a sharp bone spoon. By doing this, the author tried to solve the problem of preventing relapses and creating conditions for the occurrence of fibrous ankylosis between adjacent bodies. However, this method did not lead to the desired results. The number of relapses and adverse outcomes remained high. This depended on the failure of the proposed surgical intervention. The possibility of complete removal of the disc through a small hole in its fibrous ring is too difficult and problematic, the viability of fibrous ankylosis in this extremely mobile spine is too unlikely. The main disadvantage of this intervention, in our opinion, is the impossibility of restoring the lost height of the intervertebral disc and normalizing the anatomical relationships in the posterior elements of the vertebrae, the impossibility of achieving bone union between the vertebral bodies.

Attempts by some authors to “improve” this operation by introducing separate bone grafts into the defect between the vertebral bodies also did not lead to the desired result. Our experience in the surgical treatment of lumbar intervertebral osteochondrosis allows us to state with some certainty that it is impossible to remove the endplates of the bodies of adjacent vertebrae with a bone spoon or curette so as to expose the spongy bone, without which it is impossible to count on the onset of bone fusion between the vertebral bodies. Naturally, the placement of individual bone grafts in an unprepared bed cannot lead to bone ankylosis. Insertion of these grafts through a small opening is difficult and unsafe. This method does not solve the issues of restoring the height of the intervertebral space and restoring normal relationships in the posterior elements of the vertebrae.

Attempts to combine disc removal with posterior fusion (Ghormley, Love, Joung, Sicard, etc.) should also be considered conditionally radical operations. According to the intention of these authors, the number of unsatisfactory results in the surgical treatment of intervertebral osteochondrosis can be reduced by the addition of surgical intervention with posterior fusion. In addition to the fact that in conditions of violation of the integrity of the posterior sections of the spine, it is extremely difficult to obtain arthrodesis of the posterior sections of the spine, this combined surgical method of treatment is not able to resolve the issue of restoring the normal height of the intervertebral space and normalizing the anatomical relationships in the posterior sections of the vertebrae. However, this method was a significant step forward in the surgical treatment of lumbar intervertebral osteochondrosis. Despite the fact that it did not lead to a significant improvement in the results of surgical treatment of intervertebral osteochondrosis, it nevertheless made it possible to clearly imagine that it is impossible to solve the problem of treating degenerative lesions of the intervertebral discs with a single “neurosurgical” approach.

Radical surgery for damaged lumbar discs

Radical intervention should be understood as an operational benefit, which solves all the main points of the pathology generated by damage to the intervertebral disc. These main points are the removal of the entire affected disc, the creation of conditions for the onset of bone adhesion of the bodies of adjacent vertebrae, the restoration of the normal height of the intervertebral space, and the normalization of the anatomical relationships in the posterior sections of the vertebrae.

The radical surgical interventions used in the treatment of injuries of the lumbar intervertebral discs are based on the operation of V. D. Chaklin, proposed by him in 1931 for the treatment of spondylolisthesis. The main points of this operation are the exposure of the anterior sections of the spine from the anterior-external extraperitoneal access, resection of 2/3 of the intervertebral articulation and placement of the bone graft into the formed defect. Subsequent flexion of the spine contributes to a decrease in lumbar lordosis and the onset of bone adhesion between the bodies of adjacent vertebrae.

With regard to the treatment of intervertebral osteochondrosis, this intervention did not resolve the issue of removing the entire affected disc and normalizing the anatomical relationships of the posterior elements of the vertebrae. Wedge-shaped excision of the anterior sections of the intervertebral articulation and placement of a bone graft corresponding in size and shape into the resulting wedge-shaped defect did not create conditions for restoring the normal height of the intervertebral space and divergence along the length of the articular processes.

In 1958, Hensell reported on 23 patients with intervertebral lumbar osteochondrosis, who were subjected to surgical treatment according to the following method. The position of the patient on the back. The skin, subcutaneous tissue, and superficial fascia are dissected in layers by a paramedian incision. Open the sheath of the rectus abdominis muscle. The rectus abdominis muscle is pulled outwards. The peritoneum is peeled off until the lower lumbar vertebrae and the intervertebral discs lying between them become accessible. Removal of the affected disc is performed through the area of ​​the aortic bifurcation. A bone wedge about 3 cm in size is taken from the iliac wing crest and inserted into the defect between the vertebral bodies. Care must be taken to ensure that the bone graft does not cause pressure on the roots and the dural sac. The author warns of the need to protect the vessels well at the time of wedge insertion. After the operation, a plaster corset is applied for 4 weeks.

The disadvantages of this method include the possibility of intervention only on the two lower lumbar vertebrae, the presence of large blood vessels that limit the surgical field from all sides, the use of a wedge-shaped bone graft to fill the defect between the bodies of adjacent vertebrae.

Total discectomy and wedging corporodesis

This name is understood as a surgical intervention undertaken in case of damage to the lumbar intervertebral discs, during which the entire damaged intervertebral disc is removed, with the exception of the posterior-outer sections of the fibrous ring, conditions are created for the onset of bone fusion between the bodies of adjacent vertebrae, the normal height of the intervertebral space is restored, and there is a wedging - reklpnation - inclined articular processes.

It is known that when the height of the intervertebral disc is lost, the vertical diameter of the intervertebral foramen decreases due to the inevitable subsequent inclination of the articular processes. delimiting for a considerable distance the intervertebral foramen, in which the spinal roots and radicular vessels pass, and also the spinal ganglia lie. Therefore, in the course of the undertaken surgical intervention, it is extremely important to restore the normal vertical diameter of the intervertebral spaces. Normalization of anatomical relationships in the posterior sections of the two vertebrae is achieved by wedging.

Studies have shown that in the process of wedging corporodesis, the vertical diameter of the intervertebral foramen increases to 1 mm.

Preoperative preparation consists in the usual manipulations performed before the intervention in the retroperitoneal space. In addition to general hygiene procedures, they thoroughly cleanse the intestines and empty the bladder. On the morning before the operation, the pubis and the anterior abdominal wall are shaved. On the eve of the operation at night, the patient receives hypnotics and sedatives. For patients with an unstable nervous system, drug preparation is carried out for several days before surgery.

Anesthesia - endotracheal anesthesia with controlled breathing. Relaxation of the muscles greatly facilitates the technical performance of the operation.

The victim is placed on his back. With the help of a roller laid under the lower back, lumbar lordosis is strengthened. This should only be done when the victim is under anesthesia. With increased lumbar lordosis, the spine, as it were, approaches the surface of the wound - its depth becomes smaller.

Technique of total discectomy and wedging corporodesis

The lumbar spine is exposed by the previously described anterior left paramedial extraperitoneal approach. Depending on the level of the affected disc, access is used without resection or with resection of one of the lower ribs. The approach to the intervertebral discs is carried out after the mobilization of the vessels, dissection of the prevertebral fascia and displacement of the vessels to the right. Penetration to the lower lumbar discs through the division of the abdominal aorta seems to us more difficult, and most importantly more dangerous. When using access through the aortic bifurcation, the surgical field is limited on all sides by large arterial and venous trunks. Only the lower valve of a limited space remains free, from the vessels, in which the surgeon has to manipulate. When manipulating the discs, the surgeon must at all times ensure that the surgical instrument does not inadvertently damage nearby vessels. When the vessels are displaced to the right, the entire anterior and left lateral section of the discs and vertebral bodies is free from them. Only the lumboiliac muscle remains adjacent to the spine on the left. The surgeon can safely manipulate the instruments freely from right to left without any risk of damaging the blood vessels. Before proceeding with manipulations on the discs, it is advisable to isolate and shift to the left the left border sympathetic trunk. This greatly increases the scope for manipulation on the disk. After dissection of the prevertebral fascia and displacement of the vessels to the right, the anterolateral surface of the bodies of the lumbar vertebrae and discs, covered by the anterior longitudinal ligament, is widely opened. Before proceeding with the manipulations on the disks, it is necessary to expose the desired disk wide enough. To perform a total discectomy, it is necessary to open the entire length of the desired disc and the adjacent parts of the bodies of adjacent vertebrae. So, for example, to remove the 5th lumbar disc, the upper body of the 1st sacral vertebra, the 5th lumbar disc and the lower body of the 5th lumbar vertebra, should be exposed. Displaced vessels must be securely protected by elevators that protect them from accidental injury.

The anterior longitudinal ligament is dissected either U-shaped or in the form of the letter H, which is in a horizontal position. This is of no fundamental importance and does not affect the subsequent stability of this section of the spine, firstly, because in the area of ​​the removed disk, subsequently, bone fusion occurs between the bodies of adjacent vertebrae, and secondly, because in both in the subsequent case, the anterior longitudinal ligament grows together with a scar at the site of the section.

The dissected anterior longitudinal ligament is separated in the form of two lateral or one apron-shaped flap on the right base and taken to the sides. The anterior longitudinal ligament is separated so that the marginal limbus and the area of ​​the vertebral body adjacent to it are exposed. The fibrous ring of the intervertebral disc is exposed. Affected discs have a peculiar appearance and differ from a healthy disc. They do not have their characteristic turgor and will not stand in the form of a characteristic roller over the vertebral bodies. Instead of the silvery white of a normal disc, they take on a yellowish or ivory color. To the untrained eye, it may seem that the height of the disc is reduced. This false impression is created because the lumbar spine is overextended on the roller, which artificially increases the lumbar lordosis. Stretched anterior annulus and give the false impression of a wide disc. The fibrous ring is separated from the anterior longitudinal ligament along the entire anterior-lateral surface. With a wide chisel using a hammer, the first section is made parallel to the endplate of the vertebral body adjacent to the disc. The width of the bit should be such that the section passes through the entire width of the body, with the exception of the side compact plates. The chisel should penetrate to a depth of 2/3 of the anterior-posterior diameter of the vertebral body, which corresponds to an average of 2.5 cm. The second section is performed in the same way in the region of the second vertebral body adjacent to the disc. These parallel sections are made in such a way that, together with the removed disc, the endplates are separated and the cancellous bone of the bodies of adjacent vertebrae is opened. If the chisel is set incorrectly and the sectional plane in the vertebral body is not near the endplate, venous bleeding from the venous sinuses of the vertebral bodies may occur.

With a narrower bit, two parallel sections are made along the edges of the first in a plane perpendicular to the first two sections. With the help of an osteotome introduced into one of the sections, the selected disk is easily dislocated from its bed and removed. Usually, minor venous bleeding from its bed is stopped by tamponade with a gauze pad moistened with warm saline saline. With the help of bone spoons, the posterior sections of the disc are removed. After removal of the disk, the posterior section of the annulus becomes clearly visible. The “hernial gate” is clearly visible, through which it is possible to extract the prolapsed part of the nucleus pulposus. Particular care should be taken to remove the remnants of the disc in the region of the intervertebral foramina with a small curved bone spoon. At the same time, manipulations must be careful and gentle so as not to damage the roots passing here.

This completes the first stage of the operation - total discectomy. When comparing the masses of the disc removed using the anterior approach with the number of them removed from the posterior-external approach, it becomes quite obvious how palliative the operation is performed through the posterior approach.

The second, no less important and crucial moment of the operation is the “wedging” corporodesis. The graft introduced into the formed defect should contribute to the onset of bone fusion between the bodies of adjacent vertebrae, restore the normal height of the intervertebral space and wedged the posterior sections of the vertebrae so that the anatomical relationships in them normalize. The anterior sections of the vertebral bodies should fold over the anterior edge of the graft placed between them. Then the posterior sections of the vertebrae - the arches and articular processes - fan out. The disturbed normal anatomical relationships in the posterior-external intervertebral joints will be restored, and due to this, the intervertebral foramina, narrowed due to a decrease in the height of the affected disk, will slightly expand.

Therefore, a graft placed between the bodies of adjacent vertebrae must meet two basic requirements: it must contribute to the rapid onset of a bone block between the bodies of adjacent vertebrae, and its anterior section must be so strong. to withstand the great pressure exerted on it by the bodies of the adjacent vertebrae during wedging.

Where to take this transplant? With a well-defined, rather massive iliac crest, the graft should be taken from the crest. You can take it from the upper metaphysis of the tibia. In this latter case, the anterior portion of the graft will consist of a strong cortical bone, a tibial crest, and a cancellous metaphyseal bone that has good osteogenic properties. It is of no fundamental importance. It is important that the graft is taken correctly and of the correct size and shape. True, the structure of the graft from the iliac wing crest is closer to the structure of the vertebral bodies. The graft should have the following dimensions: the height of its anterior section should be 3-4 mm greater than the height of the intervertebral defect, the width of its anterior section should correspond to the width of the defect in the frontal plane, the length of the graft should be equal to 2/3 of the anterior-posterior size of the defect. Its anterior section should be somewhat wider than the posterior one - it narrows somewhat posteriorly. In an intervertebral defect, the graft should be positioned so that its anterior edge does not protrude beyond the anterior surface of the vertebral bodies. Its posterior edge should not be in contact with the posterior annulus of the disc. There should be some space between the posterior edge of the graft and the annulus fibrosus. This is necessary to prevent accidental compression of the posterior edge of the graft on the anterior dural sac or spinal roots.

Before the graft is placed in the intervertebral defect, the height of the roller under the lumbar spine is slightly increased. This further increases the lordosis and the height of the intervertebral defect. Increase the height of the roller should be carefully dosed. The graft is placed in the intervertebral defect so that its front edge enters the defect by 2-3 mm and an appropriate gap is formed between the front edge of the vertebral bodies and the front edge of the graft. The roller of the operating table is lowered to the level of the table plane. Eliminate lordosis. In the wound, it is clearly seen how the vertebral bodies approach each other and the graft placed between them is well wedged. It is firmly and securely held by the bodies of closed vertebrae. Already at this moment, partial wedging of the posterior sections of the vertebrae occurs. Subsequently, when the patient in the postoperative period will be given the position of flexion of the spine, this wedging will increase even more. No additional grafts in the form of bone chips should be introduced into the defect, because they can move backwards and subsequently, during bone formation, cause compression of the anterior part of the dural sac or roots. The graft should be shaped like this. so that it performs an intervertebral defect within the specified boundaries.

Above the graft, flaps of the separated anterior longitudinal ligament are placed. The edges of these flaps are sutured. It should be borne in mind that more often these flaps fail to completely cover the area of ​​the anterior graft section, since due to the restoration of the height of the intervertebral space, the size of these flaps is insufficient.

Careful hemostasis during surgery is essential. The wound of the anterior abdominal wall is sutured in layers. Administer antibiotics. Apply an aseptic bandage. During the operation, blood loss is replenished, it is usually insignificant.

With proper anesthesia, spontaneous breathing is restored by the end of the operation. Perform extubation. With stable blood pressure and replenishment of blood loss, blood transfusion is stopped. Usually, neither during the surgical intervention nor in the postoperative period, significant fluctuations in blood pressure are observed.

The patient is placed in bed on a hard shield in the supine position. The hips and lower legs are bent at the hip and knee joints at an angle of 30° and 45°. To do this, a high roller is placed under the area of ​​\u200b\u200bthe knee joints. This achieves some flexion of the lumbar spine and relaxation of the lumbo-iliac muscles and muscles of the limbs. In this position, the patient remains for the first 6-8 days.

Carry out symptomatic drug treatment. There may be a short delay in urination. To prevent intestinal paresis, a 10% solution of sodium chloride is administered intravenously in an amount of 100 ml, subcutaneously - a solution of prozerin. They are treated with antibiotics. In the early days, an easily digestible diet is prescribed.

On the 7-8th day, the patient is placed in a bed equipped with special devices. The hammock in which the patient sits is made of dense matter. The footrest and back support are made of plastic. These devices are very convenient for the patient and hygienic. The lumbar flexion position further wedged the posterior vertebrae. The patient has been in this position for 4 months. After this period, a plaster corset is applied and the patient is discharged. After 4 months, the corset is removed. By this time, the presence of a bone block between the vertebral bodies is usually noted radiologically, and the treatment is considered complete.

Spinal problems are a concern for many modern people who lead a passive lifestyle. A decrease in the height of the intervertebral discs is observed in 80% of people on the globe who have reached the age of 50-60 years. Pathological changes occur gradually and cause instability of the vertebrae, hernia and curvature of posture.

Intervertebral discs are connective cartilage tissue that fixes the vertebrae of the ridge in one position. It is on their normal state that the mobility and flexibility of the spine, the ability to lead a normal active life depends. Due to the special structure of the fabric, they act as shock absorbers when running, jumping, bending and other movements. Constant exposure to a number of negative factors leads to wear and sagging of the discs.

How does defeat develop?

Intervertebral discs consist of a soft core and a dense shell - the fibrous ring, enclosed in hyaline plates. There are no blood vessels in this cartilage, which means that they are fed from neighboring soft tissues. Normal muscle development, adequate loads on the body and the absence of problems with the circulatory system help keep the discs between the vertebrae healthy.

The appearance of degenerative changes in the body (the development of osteochondrosis), a passive lifestyle, sedentary work, lack of sports - all this leads to stiffness of movements, pain in the back when turning, as well as swelling and spasms.

They, in turn, seriously aggravate blood circulation, which worsens the condition of the pathological area. Over time, discs lose water and cease to be flexible, microcracks appear. As a result, over time, the height of the intervertebral disc decreases.

Reducing the height of the intervertebral discs is the first stage of degenerative-dystrophic changes in the spine

The reasons

The main reason for the appearance of pathology in people of any age is a slowdown in metabolism in the body, impaired blood flow and nutrient deficiency in cartilage tissue. But, besides this, the following factors can affect the malnutrition in the intervertebral discs and reduce their height:

• unbalanced diet;
• obesity;
• changes in tissues with age;
• trauma or stress;
• infectious processes;
• pregnancy;
• stress and metabolic disorders in tissues.

Determining the cause allows you to choose the most effective therapy for the intervertebral disc and achieve improvements in treatment in a short time. The first step to restoring normality is to eliminate the underlying factors that led to the formation of the problem.

Symptoms of the disease

Signs of pathological changes depend largely on the stage and localization. Conditionally, the disease proceeds in several stages:

• Initial . Disk damage is minor, so the appearance of a problem for many goes unnoticed. Patients in this phase complain only of stiffness of movements in the first hours after waking up, as well as the appearance of discomfort in the back during physical exertion.
• Second . Degenerative changes in the disc continue to progress. Characteristic subsidence and defects of the fibrous membrane are observed. At this stage, the appearance of curvature of the thoracic spine, instability of individual vertebrae, as well as severe pain during prolonged stay in an uncomfortable position are noticeable.
• Active . At this stage, cracks appear in the disc, or it begins to go beyond the anatomical limits. The characteristic signs of this stage are swelling, inflammation, muscle spasms, decreased sensitivity of certain areas or limbs.
• Progressive. At this stage, a noticeable decrease in the height of the intervertebral discs, their exit beyond the vertebra and the formation of osteophytes. Signs of pathology are the loss of mobility of the segment, paralysis of the limb and dysfunction of internal organs, often leading to complete disability.

Pain in the affected parts of the spine is the first and constant symptom

It is worth contacting a specialist when the first symptoms appear. The sooner treatment is started, the higher the chance of a favorable outcome.

Diagnostic studies

Today, specialists use a lot of modern technology to carry out diagnostic procedures in order to detect the pathology of the intervertebral disc at an early stage.

When the first signs appear, they turn to a neurologist, who, after a visual examination, questioning the patient and studying the anamnesis, prescribes the following studies:

• X-ray. It allows you to detect violations in the cervical region even at the stage when symptoms are not observed.
• MRI. It is prescribed where X-ray examination is not effective (for the diagnosis of intervertebral hernias at the initial stage). With the help of such a device, you can notice all the degenerative changes in the trunk of the spine.
• Electroneurography. Allows you to detect characteristic processes in the nerve pathways or their damage.
• Discography. Allows you to examine the damage in the disk structure.

The neuropathologist selects the treatment, based on the information after the examination and the clinical picture.

Features of treatment

Reducing the height of the intervertebral discs is treated conservatively, medication or surgery, depending on the patient's condition, the location of the problem, the stage of the disease. In some cases, the progression of the disease and the growth of osteophytes only slow down or stop a little, which improves the condition of the cartilage in general. All actions are aimed at eliminating the pain syndrome, improving blood circulation and metabolic reactions, as well as restoring disc mobility.

Treatment is necessarily complex and includes several of the following activities:

• physiotherapy and manual procedures;
• study of the joint to improve the movement of lymph and blood;
• physiotherapy;
• swimming or yoga;
• massotherapy;
• cryotherapy;
• spinal traction (natural, hardware or water);
• procedures to strengthen muscle, bone and ligament structures of the body.

All this is accompanied by taking painkillers to eliminate discomfort in the area of ​​​​the disks of the cervical region or another area, as well as medicines to relieve inflammation and nourish the cartilage tissue. For some time, the patient is advised to wear a supporting corset, complete rejection of bad habits and diet.

Regular exercise therapy will help to avoid complications of osteochondrosis

Preventive actions

Herniated disc l5 s1 is treated for a long time and is difficult, so every person at risk should take care of high-quality prevention. It will allow to exclude a decrease in the height of discs of other localization, which will protect against possible other complications. The main methods of prevention are:

• regular proper nutrition;
• body weight control, exclusion of the appearance of extra pounds;
• constant maintenance of water balance;
• exclusion of stressful situations;
• performance of special gymnastics;
• quitting smoking and alcohol;
• regular sports.

Such simple actions will strengthen the muscular frame and establish metabolic processes between the lumbar discs and neighboring tissues. This will provide support for their normal height and spine health.

Intervertebral osteochondrosis of any part of the spine has its own characteristics of the course and development. People of working age are susceptible to the disease, many scientists consider pathological changes occurring in the vertebrae and adjacent structures to be the result of a load on the spinal column associated with upright posture.

Terminology of intervertebral osteochondrosis

Initially, the term osteochondrosis denoted a group of diseases of a predominantly inflammatory nature of the subchondral space of long tubular bones of the skeleton and apophyses in short bones.

Intervertebral osteochondrosis means only a degenerative-dystrophic process in the discs of one or more sections of the spinal column. The primary inflammatory process in this case, in the absence of timely treatment and with the continued influence of the provoking factor, also extends to the bone-ligamentous apparatus adjacent to the disk.

The spinal column of each person consists of 33-35 vertebrae. Between these vertebrae are discs that perform mainly the function of a shock absorber. That is, the intervertebral discs do not allow adjacent vertebrae to come into contact with each other, soften the movement, reduce the load.

The anatomy of the disc is represented by the central nucleus and the annulus fibrosus, a dense tissue that surrounds the entire nucleus in a circle. Under the influence of certain causes, the structures of the nucleus and connective tissue of the disc are steadily violated, which leads to a violation of the depreciation function, to a decrease in mobility and to a deterioration in elasticity. This condition manifests itself with different symptoms.

Causes

As the body ages, intervertebral osteochondrosis is observed to some extent in every person. But if the body is constantly under the influence of factors that negatively affect the spinal column, then the bone and cartilage structures are destroyed quickly and all the unpleasant symptoms of the disease occur even at a fairly young age.

Osteochondrosis most often develops under the influence of several causes at once, and all of them must be taken into account in order to achieve the most optimal result in the treatment process.

Intervertebral osteochondrosis develops due to the negative influence of the following factors:

• With constant hypodynamia. That is, degenerative changes occur most often with a sedentary lifestyle.
• Disturbed metabolism.
• infectious diseases.
• Overweight.
• Improper nutrition - the use of fatty, low fortified foods, various food additives.
• Trauma and damage to the vertebral bodies.
• Diseases of the musculoskeletal system, this group includes curvature of the spine, flat feet.
• In women, the load on the spinal column increases significantly during pregnancy and with the constant wearing of high heels.
• Emotional stress.
• Bad habits - smoking, alcohol abuse.

A certain influence on the development of intervertebral osteochondrosis has a hereditary factor. Under the influence of all these provoking causes, blood circulation in the intervertebral structures is significantly disturbed, metabolic processes slow down, insufficient amounts of microelements and vitamins enter tissues and cells. That is, all conditions are created for the occurrence of inflammatory and degenerative changes in the discs.

Degrees

Types of localization

Intervertebral osteochondrosis can affect any part of the spinal column. covers more than one anatomical region of the spine. According to localization, the local pathological process is divided into:

• Cervical osteochondrosis. This type of disease is detected most often and can be in fairly young people.
• Thoracic osteochondrosis is the rarest type of localization of the disease. This is due to the fact that this department is less mobile.
• Lumbar osteochondrosis.
• intervertebral osteochondrosis.

Diagnostics

The diagnosis of intervertebral osteochondrosis is established by a neurologist. Initially, the patient is examined, an anamnesis is taken, and complaints are clarified. To confirm the diagnosis from instrumental examination methods, the following is prescribed:

• spine.
• used to detect intervertebral hernia, assess pathological changes in the spinal cord.
• Discography is prescribed for a complete study of all damaged disc structures.
• or electroneurography are prescribed to determine damage in the nerve pathways.

Symptoms

The clinical picture of intervertebral osteochondrosis depends on the degree of inflammatory and degenerative changes occurring in the discs. The first symptom is pain, usually associated with some movement disorder in the affected segment of the spine.

The pain can be so pronounced that it dramatically reduces a person's performance, disrupts his psycho-emotional state and is removed only after the use of drug blockades. Symptoms of the disease also depend on the type of localization of osteochondrosis.

Symptoms of the disease in the cervical spine

The diagnosis of intervertebral osteochondrosis is exposed most often. Main symptoms:

• Frequent headaches and dizziness.
• Pain in the upper limbs and in the chest.
• Numbness of the cervical region and limitation of its mobility.
• Weakness and decreased sensation in the hands.

Cervical intervertebral osteochondrosis is also often manifested by pressure surges, darkening in the eyes, severe weakness. This is explained by the fact that the vertebral artery that feeds different parts of the brain passes through the vertebrae of this department. Its compression as a result of a change in the anatomical location of the discs leads to various pathological changes in well-being.

Manifestations of the disease in the thoracic region

The spine is less frequently affected by pathological changes than others. The main reason for this type of localization of osteochondrosis is the curvature of the spinal column or its injury.

The symptoms of the ongoing changes are somewhat different from the signs of the disease in other departments. The pain is not so pronounced, it is usually aching, intermittent and dull. Sometimes there are pains and numbness in the limbs, goosebumps are fixed in the chest area.

Compression of the nerve endings involved in the innervation of the internal organs leads to the development of uncomfortable sensations in the liver, stomach and heart.

Due to the fact that the symptoms of thoracic osteochondrosis are identical to other diseases, the diagnosis is often incorrect. It is necessary to distinguish gastritis, angina pectoris, intercostal neuralgia from osteochondrosis of the thoracic region.

Symptoms of lumbar intervertebral osteochondrosis

Intervertebral osteochondrosis affecting the spine is the most common. And most of all, middle-aged male patients are detected with this type of localization. The main symptoms include:

• Severe pain in the lumbar region and marked limitation of mobility.
• Painful sensations are fixed in the buttocks, thighs, legs.
• Patients complain of unexpected lumbago.

This type of intervertebral osteochondrosis is often manifested by a violation of the sensitivity of the skin on the legs, which is explained by pinched nerve endings. Periodically there are paresthesias and weakness in the lower extremities.

Intervertebral osteochondrosis in the last stages of its development is complicated by a number of secondary disorders. Lack of treatment can lead to complete immobility of the patient.

Treatment

Treatment of identified osteochondrosis of the spine is aimed at relieving pain, reducing inflammation, restoring mobility of the vertebrae, improving blood circulation and metabolic reactions.

Fixation of the spine in spondylolisthesis, lowering the height of the intervertebral disc - spinal fusion bone allo- or autografts are neurosurgical operations performed to create immobility between adjacent vertebrae in case of ineffectiveness of conservative treatment of degenerative-dystrophic pathology of the intervertebral disc, instability of the spinal segment, spinal deformity, spondylolisthesis.

The intervertebral disc performs the function of "damping" movements. When it is removed, the biomechanics of the spine is disturbed, there is a risk of developing instability and pain. If the mobility in the segment is more than the permissible value by 5 - 7% - such a segment is unstable and can provoke infringement of the nerve and muscle structures, increase pressure on the joints, leading to degeneration and arthrosis - pain syndrome. Spondylolisthesis- "slipping", displacement of the body of the overlying vertebra.

Spinal fusion stabilizes the vertebrae and discs by creating a connection - fusion of adjacent vertebrae. This excludes any movement between fixed vertebrae. With spinal fusion in one segment, the patient does not feel the restriction of mobility.
Various methods and methods of surgical techniques for performing such operations at different levels of the spine have been developed.
Preparation for operations - standard - general clinical tests, physical examination, X-ray examinations of the spine - radiographs with functional tests, computed and magnetic resonance imaging, discography.
Posterior fusion is performed in case of spinal deformity - scoliosis, kyphosis, spondylolisthesis.

Transforaminal lumbar intercorporeal fusion is performed through the posterior approach, special screws are screwed into the vertebra, the intervertebral disc is removed, a spacer with an implant (possibly taken from the patient's pelvic bone) is inserted in its place, additional bone implants are placed in the lateral grooves of the vertebra. Screws are attached to the rods and the wound is sutured. Over time, the bone implant “takes root” and fusion of the vertebrae occurs - a fixed fusion.

Stay in the hospital - individually - 3-5 days. In the future, corseting, limiting loads, and rehabilitation are recommended - an average of 6 weeks.

For operations with degenerative changes in the intervertebral discs in combination with spondylolisthesis at the levels of the lumbar spine - L2-S1, with prolonged pain and ineffective conservative therapy, it is possible to use the B-Twin implant. This operation can be performed by an open method - through the anterior or posterior approach or through the posterolateral approach percutaneously.

According to the results of the examination, the doctor chooses the method of operation and access, the size of the implant is selected. A discectomy is performed, the folded implant is placed in the intervertebral space and moved apart.

Contraindications to the use of the implant are quite extensive and the possibility of its use is decided by the neurosurgeon. Metabolic bone lesions, neurofibromatosis, osteoporosis, tuberculosis, immunodeficiency, malignant tumors - not the whole list of contraindications. The doctor should be informed about past illnesses, previous treatment (for any reason), the duration of taking hormones, calcitonin, vitamin D ..., the presence of drug allergies and allergies to metals.

Complications - complications of anesthesia - allergic reactions, damage to nerve structures, infectious complications, unsatisfactory fusion of the vertebrae, the need for a second operation, ongoing pain.

Spondyloptosis L5. Two-stage operation - resection of the L5 body and fixation of the lumbosacral region (L3-L4-S1) with the CDI and TSRH system, L4-S1 interbody fusion with Interfix cages.

The Vertex Select reconstructive system is used during operations on the cervical spine to fix the vertebrae and the occipital bone.

An alternative to immobile fusion of the vertebral bodies has been developed by the technique of an artificial intervertebral disc. With this operation, the movement between the vertebrae is restored. The operation is performed through a transabdominal approach, the contents of the abdominal cavity are pushed aside, the affected disc is removed, two plates are installed instead of it and a plastic “support” is installed between them, which ensures the mobility of the vertebrae.

Motion6 Implant - C6 intervertebral disc prosthesis is used to replace the disc at the cervical level - C6 and provides mobility of the cervical spine.

Intradiscal electrothermal therapy (IDET) is a method of electrocoagulation of the disc, its strengthening, “stitching”. A catheter with an electrode is inserted into the damaged disc, an electric current is applied.

Surgical treatment achieves stable fixation of spinal structures, decompression of nerve structures, restoration of spinal biomechanics, prevention of irreversible changes in the affected segment, early activation, shortening of hospital stay and rehabilitation.

Neurologist Kobzeva S.V.