Osteochondrosis is a disease that is associated with irreversible changes in the vertebral discs. The neurology of osteochondrosis is manifested by pain radiating to other parts of the body, muscle tension, and numbness of the limbs. It is important to distinguish symptoms and take a comprehensive approach to therapy.
Neurological symptoms may occur with:
- sedentary lifestyle;
- increasing the load on the spine;
- flat feet, excess weight;
- wearing high heels;
- spinal injury;
- hereditary factor.
Most complaints are based on neurological complications of osteochondrosis, which are divided into 4 stages.
Stage 1. The appearance of protrusions of intervertebral discs, increased pain. In medicine, neurological pain syndromes in osteochondrosis are divided into:
- attacks of pain in the cervical region - cervical;
- pain in the sternum - thoracic pain;
- in the lumbar region is called lumbago; frequent attacks of a permanent nature are called lumbodynia.
Stage 2. It is associated with prolapse of intervertebral discs during osteochondrosis, which increases the unpleasant sensations of neurology, pinching of nerve endings - the appearance of radicular syndrome. With changes of a neurological nature, pain appears, which is called radiculitis, it is divided into:
- cervical radiculitis;
- cervicothoracic radiculitis;
- lumbar;
- radiculitis in the lumbosacral region;
Stage 3. Manifestation of pathological changes in the vascular-radicular sections in osteochondrosis. As a result, the blood circulation of the spinal nerve and nerve endings at the roots is disrupted. Pathological processes develop in the motor system, and the sensitivity of some parts of the body disappears.
Stage 4. Blood circulation in the spinal cord is disrupted, which leads to insufficiency of blood in the vessels and ischemic stroke.
When is a neurologist consultation needed?
Often when neurology appears, the patient wonders what caused it and what triggered it. Often the cause of severe pain may not be osteochondrosis, but other diseases:
- intervertebral hernia or radiculitis;
- spinal disc displacement;
- loss of sensation in the limbs, discomfort when turning the neck;
- diseases of internal organs;
- metabolic disease.
The symptoms of such diseases are similar to osteochondrosis. You should pay attention and note the source of pain, take into account whether there is irradiation in the limb. If the following signs appear, you should consult a neurologist.
Chondrosis of the cervical spine has the following neurological symptoms:
- the appearance of migraines, which even strong painkillers cannot cope with;
- severe dizziness may occur when turning the neck;
- pain may radiate to the arm, shoulder girdle;
- vision and hearing deteriorate, “spots” appear before the eyes;
- Loss of tongue sensitivity is common.
Neurological manifestations of thoracic osteochondrosis:
- itching and numbness of the legs;
- feeling of chest tightness, intercostal neuralgia;
- decreased sensitivity of the limbs;
- pain between the shoulder blades when bending sharply;
- When inhaling and exhaling, increased pain in the chest area.
Some symptoms may be confused with angina. If you experience severe pain, you should consult a surgeon or your doctor to confirm the neurological manifestations of osteochondrosis in the spine.
With lumbosacral neurology, it manifests itself as follows:
- aching or increasing pain in the lumbar region in any position, without pressure;
- inability to make any turns or turns;
- pain increases with sneezing and coughing;
- from the sacrum the pain moves to the pelvis or legs.
When contacting a specialist, the patient will be examined using a CT or MRI method. Diagnosis and justification are the initial stage of the fight against pathology. After diagnosis and examination according to the criterion - neurological status for osteochondrosis, the patient will be prescribed appropriate treatment.
Ways to eliminate neurological manifestations
In the acute stage of nervous osteochondrosis, the main goal for eliminating the pain syndrome is bed rest and taking medications that relieve pain.
Physiotherapy courses, which are designed to relieve pain, help to cope well with neurology and inflammation of related factors:
- ultrasound;
- a magnetic field;
- UV irradiation;
- manual therapy;
- use of vasodilators.
When manifestations of neurology occur, osteochondrosis is considered a dangerous disease that can lead to disability. If conservative treatment is delayed, the later stages of this disease will be impossible to cure.
Can emotional nervous tension cause exacerbation of osteochondrosis and how to eliminate it?
The back is an organ that reacts sharply to processes occurring in the body: anxiety, stress, guilt. The source of neurology can tell us about the problems that led to the development of pain.
The main reaction of neurology to a stressful situation is that the body wants to hide from it, the muscles go into a state of tension.
- Neck. Problems in the cervical vertebrae may indicate internal and external flexibility. A person dreams of change, but cannot get out of the routine. Often, with increased stress at work or at home, a person’s cervical spine diseases worsen.
- Thoracic department. Responsible for the emotional state of the body. Often neurology can occur due to mental trauma or loss of a loved one. The occurrence of the disease can provoke shyness and self-doubt.
- Osteochondrosis lumbar region. The main load is placed on this part of the spine. With increasing loads, a person develops a large number of problems and worries, fears arise for yourself and your family.
Neurology in the sacral area can be the cause of dissatisfaction in family or sexual relationships, incompatibility with a partner. A person’s sense of freedom disappears and thoughts of death arise.
To treat such aspects of neurology in osteochondrosis, sedatives should be taken. It could be drugs industrial production, folk remedies. Only a competent specialist can decide which drugs will be most effective for treatment.
What sedatives can you take?
Sedatives for osteochondrosis and emerging neurology have a beneficial effect on humans. With frequent and severe pain, the patient becomes nervous and requires sedatives to subdue it. In modern medicine there are many antidepressant drugs. Doctors prescribe medications:
- Valerian tincture for the neurology of osteochondrosis has a mild calming effect. Admission must be carried out by course methods.
- Motherwort - the principle of action is similar to valerian tincture.
- Elenium - contains chlordiazepoxide, has relaxing and calming properties for neurology.
- Novopassit - this drug is of plant origin. Contains plant extracts. Helps with mental stress, anxiety, and unreasonable fears. Available in syrup and tablet form. Should not be used if you have myasthenia gravis or are allergic to the plant extracts contained in the drug.
- Nozepam is good for calming and fighting insomnia.
- Gidazepam is a neurological sedative that has an anticonvulsant effect and has a mild effect of relaxing the muscular system. Works well for neuroses, migraines, increased irritability, emotional instability.
The main task of taking antidepressants for osteochondrosis is to combat increased nervousness. These medications have their own characteristics:
- sleep improves, when interacting with means that help improve sleep, it enhances their effect;
- the patient's activity decreases during the day;
- the reaction to stimuli from the outside world decreases.
When taking sedatives, doctors advise not to drive a car, it is advisable to take a vacation from work and devote time to your health.
Usually, all antidepressants are well tolerated by patients and do not contribute to addiction; the only negative is that drowsiness may occur.
Contraindications to taking antidepressants are:
- individual intolerance;
- allergy;
- pregnancy and breastfeeding;
- diseases of internal organs.
Osteochondrosis worsens due to nervousness. Sedatives for neurology must be taken as prescribed by the attending physician. If the dose of the drug is increased or incorrectly selected, the following symptoms may occur:
- lethargy;
- inexplicable euphoria;
- violation of movement coordination;
- pupil enlargement;
- decreased muscle tone;
- appearance of pale skin;
- the occurrence of apathy, lethargy.
With such symptoms, the patient should be immediately shown to a specialist.
Neurological manifestations of spinal osteochondrosis are dangerous. In addition to medicines, it is necessary to use courses of massage, physical exercise, and folk methods. If the treatment regimen is incorrectly drawn up, the disease can develop into a form in which it will cause a large number of complications.
The goal of modern medicine is to develop new methodological approaches to solving the problems of medical and social examination for spinal osteochondrosis with neurological syndromes. In this regard, it seems especially relevant to analyze the issues that arise during the examination of temporary disability and the medical and social examination of such patients. Disability due to osteochondrosis is the most pressing issue on this moment. Currently, the ITU does not recognize the disease as a cause of disability. They say that everyone has osteochondrosis!Definition
Neurological manifestations of spinal osteochondrosis are a group of clinical syndromes pathogenetically caused by reflex, compression, myoadaptive factors and manifested by sensory, motor, vegetative-trophic, vascular disorders, and pain.
Epidemiology
Spondylogenic lesions of the nervous system are the most common chronic human diseases. Neurological manifestations of lumbar osteochondrosis account for 60-70% of all diseases of the PNS and are the cause of 70% of cases of temporary disability. The initial visit to the clinic for cervical osteochondrosis syndromes is about 12% of all neurological patients.
Lesions of the lumbosacral spine are diagnosed in 50% of workers at large industrial enterprises, and over 10% of annual labor losses occur among people who have previously suffered exacerbations of lumbar pain with temporary loss of ability to work.
Neurological complications of osteochondrosis occupy 2-3rd place among the causes of all disability due to diseases of the nervous system (about 17%), with discogenic lumbosacral radiculopathy being the leading one. About 45% of patients with posterior cervical sympathetic syndrome have limited ability to work (Gitkina L. S. et al., 1988). Pronounced clinical manifestations, the most frequent and long-term disability are observed during the period of active labor activity (at the age of 25-55 years), more often in men and physical workers. Economic losses due to vertebrogenic diseases are very high in all countries.
Etiology and pathogenesis
According to modern concepts, osteochondrosis is a multifactorial disease with a genetic predisposition and the undoubted significance of a number of additional factors: overload of the lower lumbar and lower cervical spine, especially due to excessive static-dynamic load, autoimmune, endocrine, dysmetabolic and other reasons are important. At the same time, osteochondrosis is a problem of premature aging of discs (Popelyansky Ya. Yu., 1989). Among unfavorable environmental factors, the role of physical overexertion, vibration, and constant movements of large amplitude and frequency is especially important. The early development of osteochondrosis is facilitated by the congenital narrowness of the spinal canal, spinal abnormalities (transitional lumbosacral vertebrae, lumbarization or sacralization, cleft arches, etc.).
Clinically significant morphological degenerative-dystrophic processes: osteochondrosis and spondyloarthrosis. An important period is the outward displacement of parts of the altered disc, its protrusion, the impact on the richly innervated fibrous ring of the disc and the posterior longitudinal ligament. Pathogenetically significant: formation of osteophytes, pseudospondylolisthesis, ossification of the posterior longitudinal ligament. Concomitant spondylosis and Schmorl's hernia have no clinical significance, although they should be considered as components of a single process.
Stages of development of osteochondrosis: 1) relative decrease in disc height, hypermobility; 2) significant reduction in disc height, subchondral sclerosis, marginal growths, instability in the segment; 3) contact of vertebral bodies, increasing sclerosis, pseudospondylolisthesis, fibrous block. In this case, it is necessary to take into account the discrepancy between radiologically detected changes in the spine, in particular disc herniations, and the nature and severity of the clinical manifestations of the disease.
Pathogenesis of compression in the area of the intervertebral foramen: narrowing by osteophytes due to spondyloarthrosis, lateral disc herniation with root compression, impaired blood and lymph circulation with venous stagnation, edema.
Pathogenesis of damage to the vertebral artery: most often compression by exastoses in uncovertebral arthrosis and the articular process in extensor subluxation of the vertebra, stenosis, and more often vasospasm of the artery due to irritation of its sympathetic plexus.
The main pathogenetic variants of vertebrogenic syndromes:
1. Reflex - due to the effect on receptors innervating the affected parts of the spinal segment: muscular-tonic, vasomotor, neurodystrophic disorders.
2. Compression, caused by the impact of pathological structures (hernia, osteophyte, etc.) on the root, vessel, spinal cord, in particular the vertebral artery, with corresponding disorders.
Risk factors for occurrence, progression
1. Hereditary predisposition to osteochondrosis.
2. Congenital anomalies of the spine.
3. Age 25-50 years.
4. Work in professions associated with physical stress (carrying, moving heavy objects), forced position of the head and torso, sudden movements of the hands, vibration, exposure to adverse meteorological (cooling, temperature changes) and toxic factors, etc.
5. Spinal injury.
6. General infections, intoxications.
Classification of vertebrogenic lesions
(Section I of the classification of PNS diseases)
1. Cervical level:
1.1. Reflex syndromes:
1.1.1. Cervicalgia;
1.1.2. Cervicocranialgia (posterior cervical sympathetic syndrome, etc.);
1.1.3. Cervicobrachialgia (muscular-tonic, vegetative-vascular, neurodystrophic manifestations);
1.2. Radicular syndromes:
1.2.1. Discogenic (vertebrogenic) lesion (“radiculitis”) of the roots (specify which ones);
1.3. Radicular-vascular syndromes (radiculoischemia).
2. Thoracic level:
2.1. Reflex syndromes:
2.1.1. Thoracalgia (muscular-tonic, vegetative-visceral, neurodystrophic manifestations);
2.2. Radicular syndromes:
2.2.1. Discogenic (vertebrogenic) lesion (“radiculitis”) of the roots (specify which ones).
3. Lumbosacral level:
3.1. Reflex syndromes:
3.1.1. Lumbago;
3.1.2. Lumbodynia;
3.1.3. Lumboischialgia with muscular-tonic, vegetative-vascular, neurodystrophic manifestations;
3.2. Radicular syndromes:
3.2.1. Discogenic (vertebrogenic) lesion (“radiculitis”) of the roots (specify which ones);
3.3. Radicular-vascular syndromes (radiculoischemia).
The above classification needs certain clarifications, since it does not sufficiently take into account the possibility of vascular complications of osteochondrosis of the cervical and lumbosacral localization - in addition to radiculoischemia, radiculomyeloischemia and myeloischemia naturally occur. It also did not include lesions of the spinal cord caused by its compression by a prolapsed disc. In addition, at present, discogenic damage to the root in osteochondrosis is reasonably designated as radiculopathy.
Clinic and diagnostic criteria
I. General clinical criteria.
1. History: risk factors, including occupational ones; typical development of the disease or exacerbation; previous episodes (reflex, compression), their nature, frequency.
2. Features of neurological symptoms due to localization, pathogenetic variant of vertebrogenic syndrome.
3. Main clinical manifestations:
1) postural myoadaptive syndromes:
a) change in the configuration of the spine - scoliosis, hyperlordosis, kyphosis (severity);
b) disturbance of dynamics - limitation of movements (degree);
c) muscle tension - mild; pronounced - dense muscle; pronounced - the muscle cannot be deformed, the defence is maintained in the supine position;
d) dystrophic changes in muscles - weight loss, hypotension, flabbiness, painful nodules in the area of neuroosteofibrosis;
2) pain syndrome. It is necessary to objectify it and clarify the degree of expression:
a) objectification: general appearance, gait, behavior of the patient; tension symptoms (Lasègue, Neri, Bonnet, Spurling, Wasserman, etc.) with control - the second phase of Lasègue’s symptom, planting symptom, etc.; algic points, tension of paravertebral muscles, limited mobility of the spine; EMG data (decrease in frequency and decrease in the amplitude of potentials at maximum voltage, the appearance of fasciculations during a pain test in the case of severe and moderate pain syndrome);
b) an indicative judgment about the severity of pain:
- with lumbar osteochondrosis: mild - pain occurs when getting out of bed, moving in a standing position; moderate - pain when trying to move in bed, but is absent at rest; severe - pain at rest, intensifies with the slightest movement.
- for cervical and thoracic osteochondrosis: mild - intermittent aching pain that occurs with significant and prolonged physical activity on the muscles of the shoulder girdle and neck; moderate - constant aching, drilling in the area of the shoulder girdle, back, aggravated by forced movements of the head, forced position, active movements are moderately limited; severe - constant sharp pain in the neck, back of the head, thoracic spine, aggravated by minimal movements, antalgic postures;
c) with a long course of the disease, the connection between disorders of the static-dynamic function of the spine and pain syndrome decreases;
3) disturbances of sensitivity (with radicular syndrome, often monodermatomal - hypoesthesia, hyperesthesia in the zone of innervation of the root), with reflex - along the sclerotomes, combined with superficial and deep pain, paresthesia;
4) flaccid muscle paresis in the case of radiculoischemia: more often “paralyzing sciatica” (paresis of the foot); decreased or absent reflexes (depending on the affected root), often remains after regression of the pain syndrome, objective sensory disturbances and does not determine the state of motor functions;
5) vegetative-vascular disorders are obligatory for both reflex and radicular syndromes of osteochondrosis. With the latter, not only arterial, but also venous insufficiency of the root or spinal cord is possible. Skin hypothermia, mild cyanosis, and possible weakened or absent pulsation of the dorsalis pedis artery are typical.
II. Features of the clinical picture due to the localization and pathogenetic variant of osteochondrosis syndrome.
1. At the cervical level:
1.1. Reflex syndromes:
- cervicalgia, cervicobrachialgia. Painful muscular-tonic syndromes are typical, often the first manifestations of cervical osteochondrosis. The clinical picture is represented by burning, arching pain in the deep and superficial parts of the neck, with brachialgia radiating to the shoulder girdle and upper limbs. The pain intensifies when turning the head, coughing, sneezing, usually occurs in the morning after sleep, and is provoked by hypothermia and physical activity, as well as sudden movements in the cervical spine. The muscular-tonic component is manifested by limited mobility of the neck, deflation of the superficial and deep muscles of the neck. The disease occurs chronically or subacutely. At the same time, acute lumbago (“cervicago”) may also be observed;
- syndrome of the inferior oblique muscles of the head with constant aching pain in the cervical-occipital region associated with prolonged stress on the neck muscles, which intensifies when the head is turned to the healthy side;
- syndrome of the anterior scalene and pectoralis minor muscles (described in the group of tunnel neuropathies);
- humeroscapular periarthrosis (periomarthrosis). Develops as a result of dystrophic changes in the joint capsule, tension in the muscles that adduct the shoulder. In addition to osteochondrosis, it occurs in patients who have recently suffered a myocardial infarction. Pain is detected at the point of the coracoid process of the scapula, during rotation and abduction of the arm. Atrophy of the periarticular muscles and increased reflexes due to repercussion are characteristic. Perioarthrosis has a long (2-3 months), sometimes progressive course;
- shoulder-hand syndrome (Steinbrocker) is characterized by a picture of glenohumeral periarthrosis in combination with vegetative-trophic changes in the area of the hand and wrist joint. Its occurrence is facilitated by hand trauma, hemiplegia after a stroke, and myocardial infarction. Clinically, pain in the joints and muscles, swelling and cyanosis of the hand, atrophy of the skin and subcutaneous tissue, osteoporosis of the bones. After the pain subsides (after 5-6 months), stiffness of the fingers and hand often persists. It is one of the manifestations of reflex sympathetic dystrophy syndrome;
- posterior cervical sympathetic Barre-Lew syndrome (cervicocranialgia). Usually forms a single whole with vertebral artery syndrome. Caused by irritation of its sympathetic plexus. The clinical picture consists of burning, bursting pain in the occipital region with irradiation throughout the entire half of the head, into the orbital area and the superciliary region (the so-called “cervical migraine”). The pain is paroxysmal, provoked by sharp turns of the head to the sides. In 90% of cases it is accompanied by cochleo-vestibular, and in 25% by visual disorders, almost always neurotic symptoms. Possible vertebrobasilar insufficiency. Pain points: posterior (Popelyansky) - medially from the apex of the mastoid process, anterior (Ivanova) - along the inner edge of the sternocleidopapillary muscle in the middle third of the neck;
1.2. Radicular syndromes. Usually caused by compression of the root in the intervertebral foramen. They are much less common than reflex ones. The full clinical picture is most often preceded by cervicalgia. Pain and paresthesia are localized in the corresponding dermatome and worsen with active movements. Symptoms of tension (analogs of Lasègue) are of diagnostic importance, Spurling's symptom is an exacerbation of pain with irradiation with a forced passive tilt of the head towards the affected root. In 90% of cases, the roots Cb, C7 are affected, polyradicular syndromes are possible:
- root C6: pain spreads from the neck along the shoulder girdle, the posterolateral edge of the shoulder, the radial edge of the forearm to the thumb. Symptoms of prolapse, in addition to hypoesthesia in the C6 dermatome area, can also be represented by weakness and hypotrophy of the biceps brachii muscle, thenar muscles, and decreased biceps reflex;
- C7 root: pain radiates from the neck under the scapula, along the back of the shoulder and forearm to the II and III fingers. Possible weakness and hypotrophy of the triceps brachii muscle, the posterior muscle group of the forearm; the triceps reflex decreases;
- root C: pain from the neck along the posterior inner surface of the shoulder, the ulnar edge of the forearm to the little finger. Symptoms of prolapse are characterized by hypoesthesia in the area of dermatome C, weakness of the flexors and extensors of the fingers, and flattening of the eminence of the little finger. There is a decrease in the reflex of the triceps muscle, Horner's syndrome.
2. At the thoracic level: compression syndromes are very rare due to the lack of conditions for significant trauma to the discs and the formation of hernial protrusions. Of the reflex symptoms, the most significant is pain in the region of the heart, which occurs with pathology of the cervical and upper thoracic spine. Possible: provocation of an angina attack due to coronary pathology with modification of the clinical picture; vertebrogenic pseudocardialgic pain (pectalgia, anterior chest wall syndrome) - differs in localization, attacks are prolonged, depend on the position of the spine, there are no ECG changes during exercise tests.
3. At the lumbosacral level:
3.1. Reflex syndromes. Observed in 50-60% of patients:
- lumbago (as the first manifestation of lumbar osteochondrosis in 40% of cases). Acute shooting (burning, bursting) pain in the lumbar region, occurring at a moment of physical stress, during awkward movement, after cooling, or for no apparent reason. Flattening of the lumbar lordosis, kyphosis, and sometimes scoliosis. The lumbar spine is fixed due to muscle tension. There are no loss of sensitivity, motor or reflex disorders;
- lumbodynia. The first manifestation of lumbar osteochondrosis in 55-60% of patients. Occurs over several days due to prolonged physical stress and cooling. The pain is aching and worsens with movement, standing or sitting. The spinous processes and interspinous ligaments are painful. Movements in the lumbar spine are possible, but painful, lumbar lordosis is smoothed;
- lumboischialgia. The pain spreads to the gluteal region, leg (does not reach the fingers). Irradiation of pain along the sclerotomes. Painful areas of neuroosteofibrosis, muscle nodules, and vasomotor disorders are identified;
- piriformis syndrome. Can be classified as tunnel;
- coccydynia. Painful manifestations in the coccyx area, muscle-tonic reactions and pain in the pelvic floor muscles. They get worse when lying on your back, sitting, or during defecation. The course is long, neurotization of patients is possible;
3.2. Radicular syndromes (in 40-50% of patients with lesions at the lumbar level). In typical cases, they develop after reflex ones, although with damage to the S1 root, the period of lumbago and lumbodynia may be short or absent. The L5 and S1 roots are most often compressed by a disc herniation. Clinical manifestations: shooting pains, dermatomal hypalgesia, weakening or loss of reflexes, often peripheral paresis. Pain increases with coughing, sneezing, active movements:
- spine L4. It is affected relatively rarely. Pain along the anterior inner surface of the thigh, lower leg, weakness and wasting of the quadriceps muscle. The knee reflex is reduced or absent;
- spine L5. Affected frequently. Pain and paresthesia along the posterior surface of the thigh and lower leg, affecting the back of the foot, fingers, and often only the first finger. There is a decrease in sensitivity in this area. Pain on percussion of the spinous process of the IV lumbar vertebra. Some weakness and hypotrophy of the peroneal group of muscles, extensors of the foot, especially the first toe, is revealed. The Achilles reflex is usually preserved;
- spine S1. Frequent localization. Pain and hypoesthesia radiate along the posterior and posterior-outer surface of the thigh and lower leg, spreading to the heel area, the outer edge of the foot, and the fifth toe. The strength of the gluteus maximus, then the triceps surae muscle and the finger flexors decreases. Achilles and plantar reflexes are reduced or absent;
- compression of the cauda equina. Occurs more often after heavy lifting, with medial disc herniations, usually L2-L3 and L3-L4. Bilateral severe pain, spreading to both legs, paraparesis, pelvic disorders. Surgical treatment is required;
- arterial radiculoischemia syndrome (paralyzing radicular sciatica). Paresis or paralysis of predominantly the distal lower limb develops. Sensitivity is impaired in the area of L5-S1 roots. The process is always one-way;
- radiculomyeloischemia syndromes.
III. Data from additional studies.
1. X-ray of the spine. X-rays in anteroposterior, lateral (if necessary, oblique) projections, and if the tomogram shows, images in the position of maximum flexion and extension in the cervical spine. Spondylography has diagnostic limitations related primarily to the objectification of disc herniation, since it only reveals indirect signs its degeneration.
2. Lumbar puncture, myelography with positive contrast agents. Invasive methods that make it possible to detect deformation of the dural sac hernia (most convincingly only at the L5-S1 level), sometimes a moderate increase in protein content. More often used for differential diagnostic purposes.
3. CT. An objective method for diagnosing herniated intervertebral discs by enhancing image contrast, sometimes in combination with myelography. The method is especially valuable for judgment
about the condition of the bone structures of the spinal segment, osteophytes, calcification of the posterior longitudinal ligament, narrowing of the spinal canal.
4. MRI. Makes it possible, without contrast, to detect a decrease in signal intensity from intervertebral discs, typical for osteochondrosis (on T2-weighted tomograms). The sagittal image visualizes in detail hernias in various parts of the spinal column, their sequestration, and determines the fact of spinal cord compression and its degree. It is possible to clarify the indications for discectomy surgery, making it easier to evaluate its results and the causes of relapses.
5. REG, especially with functional tests (turns, tilts of the head, taking nitroglycerin), helps to objectify the vertebral artery syndrome.
6. RVG clarifies the role of vascular factors in the pathogenesis of some reflex and radicular syndromes of lumbar osteochondrosis.
7. EMG makes it possible to objectify and localize myelischemia along the diameter and length of the spinal cord and thus differentiate the spinal and radicular types of paralyzing sciatica; to clarify the severity of the pain syndrome, to judge the dynamics of the process in patients with radiculomyeloischemia.
8. Thermal imaging. It reveals the focus of hyperthermia in the projection of the affected disc, but the most important data is on the severity of peripheral autonomic-vascular disorders in the extremities.
Differential diagnosis
Some general points:
1. The prevalence of radiologically detectable vertebral osteochondrosis, occurring without clear neurological complications, and also clinically manifested in the past, which can significantly complicate the diagnosis of other vertebrogenic diseases.
2. It is necessary to take into account the locality of discogenic lesions in osteochondrosis, in contrast to many inflammatory and other diseases, and the rarity of neurological manifestations of osteochondrosis of the thoracic spine.
3. In elderly patients, diagnostic errors are especially common in cases of cancer metastases to the spine (breast, thyroid, less often stomach, prostate, hypernephroma). The nature of the pain syndrome is not taken into account (the persistence and severity of pain regardless of the patient’s position, the absence of disturbances in the static-dynamic function of the spine typical of radiculopathy, and other clinical features). The most diagnostically significant are MRI and radioisotope scintigraphy of the pelvic bones and spine, since conventional radiography is often not informative (especially at an early stage of the disease).
4. A differential diagnosis with hormonal spondylopathy, observed in menopausal women, with many endocrine diseases, in particular of hypothalamic origin, multiple myeloma, senile osteoporosis, and with long-term therapy with corticosteroids, is important. Clinically it manifests itself as acute (with a compression fracture of the vertebrae, most often the lower thoracic and lumbar), and then chronic pain syndrome, spinal deformity. X-ray, CT, and biochemical hormonal studies are diagnostically important.
5. There are often difficulties in differential diagnosis with coxarthrosis, especially at an early stage of its development. Characterized by intermittent dull aching pain in the hip joint, spreading to the buttock and groin area, the anterior outer surface of the thigh. The pain intensifies after a long walk, at the beginning of movement. Mobility in the hip joint is limited. Later, vertebral syndrome often occurs. Radiography of the joints is diagnostically significant, but in the initial stage, morphological changes may be minimal.
6. There is reason to take into account the possibility of psychopathological conditions (masked depression) simulating the clinical manifestations of spinal osteochondrosis.
7. The differential diagnostic value of imaging methods of the spine and spinal cord - CT, and especially MRI, which simplifies the identification of bone anomalies and destructive lesions, tumors and vascular malformations of the spinal cord is very great, but their results cannot be absolute.
Differential diagnosis of radicular pain
(according to Shtulman D.R. et al. 1995; as amended)
Diseases that cause pain
Occipital neuralgia, consequences of fracture or displacement of the C1-C4 vertebrae, rheumatoid arthritis, ankylosing spondylitis, Arnold-Chiari anomaly, spinal cord tumors, in particular craniovertebral; myofascial pain.
Consequences of fracture or displacement of the C4-Th1 vertebrae, spinal cord tumor, primary and local static tumors of the spine and surrounding tissues, meningeal carcinomatosis. Ankylosing spondylitis, syringomyelia, Personage-Turner syndrome. myofascial pain, tunnel syndromes of the shoulder girdle and arms.
Consequences of fracture or displacement of the Th5-Th12 vertebrae, spinal cord tumor, primary (hemangiomas) and metastatic tumors of the spine and surrounding tissues, meningeal carcinomatosis, spinal epidural abscess, tuberculous spondylitis, Tietze syndrome, spinal arachnoiditis, hormonal spondylopathy, myeloma.
Spondylolisthesis, sacroiliitis, consequences of fracture or displacement of the L1-L5 vertebrae. primary and metastatic tumors of the cauda equina, spine and surrounding tissues, hormonal spondylopathy, congenital stenosis of the spinal canal in the lumbar region, spinal epidural abscess, spinal arachnoiditis, myofascial pain, tunnel syndromes of the pelvic girdle and legs, coccydynia, coxarthrosis.
Course and prognosis
1. Typically chronic with relapses and remissions.
2. Classic situation: development of radicular and sometimes spinal syndrome after reflex ones (most typical for the lumbosacral level);
3. Remissions can last for many years; they are much shorter if the patient’s working conditions are unfavorable;
4. Exacerbations are provoked by the above risk factors, although they are possible without an apparent reason, they largely determine the severity of the disease as a whole. Criteria for their frequency: frequent (4-5 times a year), medium frequency (2-3 times a year), rare (1-2 times a year). Repeated long-term (3-4 months) exacerbations, especially with massive sequestered hernias, are one of the factors determining the need for surgical treatment of the patient;
5. In case of compression by a herniated disc of the cauda equina, urgent surgical treatment is required. Otherwise, the prognosis is questionable due to persistent pain, motor, and sometimes pelvic disorders.
6. The course and prognosis are complicated by acute radiculomyeloischemia, radiculomyeloischemia, chronic ischemic myelopathy, usually cervical;
7. For those operated on for a disc herniation using the posterior approach, the prognosis is usually favorable: recovery and stable course of the disease, subject to rational employment, in 70-80% of those operated on. Relapses occur in 6-7% of patients, but repeated operations are possible with good results. After a successful anterior spinal fusion operation, patients, as a rule, also return to work, but after prolonged LN or disability.
8. Age-related characteristics during the course of the disease. Variants of changes in the spinal motion segment in dynamics (Ivanichev G. A., 1995): a) herniation with the formation of reflex and compression syndromes (within 3-5 years);
b) fibrosis and drying of the disc without significant clinical manifestations (within 5-8 years). An important role is played by age consolidation in the segment, due, in particular, to the sanogenic effect of concomitant spondylosis. This may explain the significantly lower frequency of severity of exacerbations of radicular osteochondrosis syndrome in old age. At the same time, they are often longer lasting, and there is a tendency for back pain to become chronic, mainly due to lumbodynia, lumbar ischialgia.
Principles of treatment during exacerbation of the disease
1. Complexity of therapeutic measures with minimal use of pharmacological agents.
2. Individualized therapy, taking into account the localization and nature of the neurological syndrome, the possibility of concomitant neurotic disorders. The latter require medication correction and psychotherapy.
3. Rest (bed rest on a shield) on initial stage exacerbations - exclusion of unfavorable static-dynamic loads.
4. The need for specialized assistance. Early hospitalization in a neurological hospital is desirable, especially with repeated and severe exacerbation of radicular syndrome. Late hospitalization, treatment at home with a return visit to the clinic for physiotherapy increases the duration of VL by 20-30%:
a) with severe and severe radicular pain syndrome, strict bed rest - 8-10 days, moderate
- 5 days, in case of exacerbation of cervicalgia - about 3 days, lumbago - at least 3-5 days; analgesics, muscle relaxants (especially sirdalud, which also has an analytical effect), non-steroidal anti-inflammatory drugs: indomethacin, diclofenac (ortofen), piroxicam, etc.; diuretics; antidepressants;
b) after reducing the degree of pain:
- non-pharmacological methods: massage, traction, acupuncture, physical therapy, manual therapy, physiotherapy. Manual therapy should be carried out after a thorough clinical (neurological) and radiological examination. Indications: local pain with lumbago, lumbargia, cervicalgia; sciatica; radicular syndrome in the irritation stage; violations of the statics and dynamics of the spine. Contraindications: severe pain, lack of blockage in the spinal motion segment; radiculoischemia, myeloischemia, spinal cord compression;
- for reflex muscular-tonic syndrome: reducing muscle tension by novocaine blockade (syndrome of the scalene, piriformis, etc.);
- for vegetative-vascular syndrome: physiotherapy, laser therapy, acupressure segmental massage, vasoactive agents;
- for posterior cervical sympathetic syndrome: dosed traction in the cervical spine using a Gleason loop, novocaine infiltration of the vertebral artery, physiotherapy, vasodilators; in case of dizziness - microzer, nootropil.
5. Indications for surgical treatment (determined strictly individually, must be justified): 1) acute compression of the cauda equina (absolute); 2) severe persistent pain in the case of lumbar osteochondrosis, constantly recurring radicular pain when moving to a vertical position, lasting for 3-4 months without a tendency to significantly decrease; 3) acute radiculomyeloischemia; 4) vertebral artery syndrome (severe) with unsuccessful treatment for at least 6 months; 5) pronounced limitation of life activity, disability of the patient. Contraindications: old age, severe concomitant diseases.
Medical and social examination Criteria of VUT
The duration of VN is determined by: a) the clinical features of the neurological syndrome, the level and location of the lesion, the severity of the exacerbation; b) the patient’s profession, working conditions, and other social factors; c) surgical treatment.
Approximate timing for exacerbation:
1. Cervical level: cervicalgia - up to 7 days; radicular syndrome - 2-3 weeks; humeroscapular periarthrosis - 3-
4 months; shoulder-hand syndrome up to 5-6 months (with continuation of treatment on sick leave or referral to BMSE); posterior cervical sympathetic syndrome - with moderate and severe attacks of dizziness from 3 to 7 days.
2. Thoracic level: radicular syndrome in case of moderate exacerbation - up to 10 days, severe - inpatient treatment for 2 weeks, general VL - 18 days.
3. Lumbar level: lumbago, exacerbation of lumbodynia - VL for at least 7-10 days; lumboischialgia - 16-18 days; moderate exacerbation of radicular syndrome - on average 15 days; severe exacerbation of discogenic radiculopathy - inpatient treatment for 2-3 weeks, the total duration of VN is up to 30 days or more, after which, if necessary, easing of working conditions is recommended by the CEC.
Operated patients:
1. Rear access. Inpatient treatment depending on the nature of the operation (hemilaminectomy, interlaminectomy, fenestration and decompression of the disc, etc.) - from 25 days to 1.5 months. The minimum period of VN is 2 months, for persons with physical labor with persistent pain syndrome - continuation of treatment on sick leave for up to 3-4 or more months, temporary restrictions on work on the recommendation of the CEC. If the labor prognosis is unfavorable, a referral to BMSE to determine disability.
2. Anterior approach (discectomy with anterior spinal fusion). Treatment in a hospital is from 1.5 to 2 months. VN due to long-term consolidation (formation of bone ankylosis) - up to 6-8 months or more, according to the decision of the VC. Referral to BMSE after 2-3 months in order to determine disability group II for 1 year (optional).
3. For decompression of the vertebral artery, inpatient treatment is for 1-1.5 months, general VL - up to 2-2.5 months.
Main causes of disability
1. Pain syndrome (even moderately severe, but persistent): a) with lumbar and thoracic osteochondrosis, it limits life activity due to impaired ability to move, stand, and maintain a posture, which reduces the ability to perform daily activities, but mainly the patient’s labor capabilities; b) with cervical osteochondrosis (radicular syndrome, periarthrosis of the shoulder joint, shoulder-hand syndrome), the function of the upper extremities is impaired: decreased manual activity, difficulty and impossibility of movements in the cervical spine, which in general also reduces the ability to perform daily activities at home and work opportunities .
2. Motor deficit is observed in cases of severe impairment of the static-dynamic function of the spine, paresis of the lower limb, lower paraparesis in patients with cauda equina syndrome, radiculomyeloischemia, radiculoischemia. The ability to move and walk up stairs is limited to one degree or another.
3. Periodically occurring cochleo-vestibular disorders, cervicalgia in patients with posterior cervical sympathetic syndrome, provoked by sudden movements in the cervical spine, vibration, sweeping movements of the arms, can significantly limit life activity in everyday life and the ability to work in many professions.
4. The patient’s work opportunities and quality of life are affected by restrictions caused by risk factors for exacerbation of the disease, in particular due to a decrease in endurance to physical stress and exposure to unfavorable climatic conditions (primarily cooling) in Everyday life and in production.
Examples of diagnosis formulation
The diagnosis is formulated in accordance with the requirements of the classification, but in expert practice it is always important to indicate the nosological nature of the disease. In this regard, it should begin with an indication of spinal osteochondrosis and its predominant localization. For example:
- osteochondrosis, unco-vertebral arthrosis C5-C6, C6-C7, moderately severe right-sided radicular syndrome, posterior cervical sympathetic syndrome with rare cervicocranialgic and vestibular attacks in remission, relapsing course;
- lumbar osteochondrosis, lumbago with severe pain;
- lumbar osteochondrosis, discogenic radiculopathy L5 on the right with moderate paresis of the right foot extensors, severe pain, often relapsing. exacerbation.
Contraindicated types and working conditions
1) General: significant physical stress, general and local vibration, forced position of the head, torso, limbs, unfavorable meteorological conditions (cold room, drafts), exposure to neurotropic poisons.
2) Individual - depending on the location of the lesion, the nature and characteristics of work activity, for example, with cervical osteochondrosis, forced head movements, sweeping movements of the arms, etc. Some professions that are contraindicated: miner, driller, tractor driver, heavy vehicle driver, etc.
able-bodied patients
1) With a favorable current disease (mainly with reflex syndromes of osteochondrosis), without a tendency to increase the frequency and severity of exacerbations.
2) Rationally employed patients with discogenic radiculopathy, moderate residual symptoms (loss of reflexes, mild disorders of spinal statics), with rare exacerbations.
3) The same patients employed in their profession with easier working conditions on the recommendation of the VK.
4) Patients who underwent laminectomy for discogenic radiculopathy with a good result, employed in an accessible profession.
5) Patients who were successfully operated on by anterior spinal fusion after a long period of temporary disability, or who were disabled for one year
Group II.
Indications for referral to BMSE
1. Frequent and prolonged exacerbations of radiculopathy (less often reflex syndrome) with insufficient effectiveness of medical rehabilitation measures.
2. Unfavorable course of the disease, repeated exacerbations if it is impossible to continue working in the main profession due to unfavorable factors that cannot be eliminated according to the conclusion of the IC, or if the recommended employment leads to a decrease in qualifications and earnings.
3. Long-term temporarily disabled patients with shoulder-hand syndrome with an unfavorable or questionable prognosis.
4. Severe vestibular disorders, asthenic syndrome, cephalalgia with frequent exacerbations of posterior cervical sympathetic syndrome, contraindicated factors in the work performed and the impossibility of rational employment.
5. Persistent severe pain syndrome, motor disorders after radiculoischemia, radiculomyeloischemia, discogenic compression of the cauda equina.
Minimum required examination when referring to BMSE
1. X-ray of the spine.
2. CT, MRI (if necessary).
3. Lumbar puncture, myelography (if performed).
4. REG (for posterior cervical sympathetic syndrome).
5. RVG (for vascular complications of lumbar osteochondrosis).
6. EMG (for radiculomyeloischemia syndrome).
7. Consultation with a neurosurgeon (in case of indications for surgical treatment).
8. General blood and urine tests.
Group III: moderate limitation of life activity caused by persistent pain, impaired motor, vestibular and other functions, repeated exacerbations that interfere with work performance (according to the criteria of limited ability to work, independent movement of the first degree).
Group II: severe limitation of life activity (frequent long-term exacerbations, unfavorable course of the disease, impossibility or ineffectiveness of surgical treatment) - according to the criteria of limited ability to work and independent movement of the second degree. Sometimes disability group II is established for a year after anterior spinal fusion or complications during laminectomy.
Group I: is rarely determined, as a rule, only in the case of deep lower paraparesis, paraplegia after hernial compression of the cauda equina due to third degree limitation of the ability to move and self-care.
Causes of disability: 1) general disease; 2) occupational disease; a) in patients with reflex syndromes of the cervical and lumbosacral level; b) with cervicobrachial, lumbosacral radiculopathy and radiculomyelopathy. At the same time, the degree of loss of professional ability to work is determined as a percentage; 3) work injury, military reasons (if the role of spinal trauma in the development and progression of osteochondrosis is shown).
Prevention of disability
1. Primary prevention: 1) possible exclusion of factors contributing to the development of spinal osteochondrosis: proper physical education, prevention of sudden overloads and postural disorders from childhood; for workers - a reduction in micro- and macrotraumatization of the spine, forced position of the torso and head and other adverse effects due to the nature and working conditions; 2) identification during dispensary examinations and professional selection of persons with initial manifestations of osteochondrosis, their professional guidance, taking into account contraindications and rational employment; 3) timely and adequate prosthetics for amputations lower limbs, treatment of diseases of the musculoskeletal system, spinal injuries.
2. Secondary prevention: 1) optimal treatment and adherence to VN timing during the first and subsequent exacerbations of the disease; 2) changing working conditions and proper employment on the recommendation of the CEC, taking into account the level of damage and the nature of the neurological syndrome; 3) recommendations for the patient on
prevention of exacerbations of the disease depending on working conditions (change position during work, use rational methods of lifting weights, beware of hypothermia, local overheating, etc.); 4) clinical observation, primarily in relation to patients with exacerbations of reflex, and especially radicular, syndrome (3rd observation group, examinations 2 times a year). After surgical treatment in the first
3 months, once a month, then once every 3 months. Courses of anti-relapse treatment are prescribed.
3. Tertiary prevention: 1) adequate individualized treatment and rehabilitation measures, surgical treatment if necessary; 2) timely determination
III disability group and employment, taking into account contraindications to prevent exacerbations and progression of the disease.
Rehabilitation
An individual rehabilitation program for a patient with neurological complications of osteochondrosis should include:
1. Measures for medical rehabilitation at the final stage of treatment of a patient with exacerbation of the disease and for the purpose of preventing exacerbation. It is advisable to follow the sequence of treatment: in an inpatient rehabilitation department, a clinic (medical unit), a specialized dispensary, or a sanatorium. Predominantly non-pharmacological individualized methods are used: physiotherapy, balneotherapy, massage, physical therapy, etc.
Surgical treatment is an important and effective method of rehabilitation, subject to proper selection of patients, taking into account indications and contraindications for surgery. For example, good and excellent results of laminectomy with the return of patients to work (with follow-up for 5 or more years are observed in 70-80% of cases).
2. Professional and social aspects of rehabilitation include rational employment, taking into account the level of damage and the nature of the neurological syndrome, which is especially important for young patients recognized as having limited ability to work. Often important stage professional rehabilitation is training and retraining of an accessible (depending on the characteristics of neurological disorders) profession. It can be carried out in regular and specialized educational institutions, through individual apprenticeship. The most appropriate training with subsequent employment in professions of the humanitarian, administrative, economic, engineering and technical areas, work in commercial institutions, in trade, manual labor professions (fitter-assembler of small-sized equipment, electrician for repairing household appliances, etc.), medical and technical laboratory assistant, etc. In accordance with the indications, it is necessary to supply means of transportation (motorcycle, bicycle stroller, etc.).
The effectiveness of rehabilitation measures is evidenced by: a decrease in the frequency and duration of VN, positive dynamics of disability and the return to work without restrictions of persons recognized as group III disabled. Thus, according to A.V. Klimenko (1988), the consistent implementation of medical rehabilitation measures for lumbar osteochondrosis syndromes led to a 2-fold reduction in the average duration of LN of patients during the year, which made it possible to achieve a significant economic effect.
Intervertebral discs consist of an annulus fibrosus and a nucleus pulposus located in the center of the disc. The disc is connected to the vertebrae above and below using cartilaginous hyaline plates. The annulus fibrosus consists of concentrically arranged layers of strong connective tissue fibers. The nucleus pulposus is a round elastic formation consisting of connective tissue, characterized by high hydrophilicity. The nucleus pulposus contains 80% water. With age, the water content and elastic properties of the disc decrease significantly. The discs largely determine the height of the spinal column: they account for a total of about 1/4 of the length of the spine.
Powerful longitudinal connective tissue ligaments run along the front and back surfaces of the spine, which make the structure of the spine even stronger. The posterior longitudinal ligament strengthens the surface of the fibrous ring of the intervertebral disc facing the spinal canal, preventing its displacement in this direction. In the same time side surfaces discs, especially in the lumbar region, where the posterior longitudinal ligament narrows, are less durable. This structural feature of the intervertebral discs and ligamentous apparatus allows us to explain some of the features of the manifestation of degenerative changes that the discs undergo.
Strength and Mobility general design The spine is also provided by the joints of adjacent vertebrae and the yellow ligaments located between the vertebral arches. Intervertebral discs act as shock absorbers. With vertical load, the nucleus pulposus flattens and stretches the annulus fibrosus. When the load stops, it returns to its normal position. When turning, bending, or straightening the spine, a corresponding deformation of the nucleus pulposus and the fibrous ring also occurs.
Different parts of the spine experience different loads. Particularly significant load falls on the discs of the lumbar and cervical regions, since these sections are characterized by the greatest mobility. This largely explains the fact that degenerative changes in the vertebrae, discs and ligaments that occur with age are most pronounced in the cervical and lumbar regions. Another feature of intervertebral discs should be noted – their blood supply.
Small vessels supplying blood to the discs are completely empty by the age of 20–30, and metabolic processes in the discs are carried out due to diffusion and osmosis.
All of the above factors (constant mechanical load, changes in metabolic processes and hydrophilicity) inevitably lead to age-related degenerative changes in the discs, the vertebrae themselves and their ligamentous apparatus. Genetic predisposition, significant physical activity associated with life and work, and injuries influence the severity of structural changes in the intervertebral discs and determine the age at which they occur. The fibrous ring loses its elasticity, cracks form in it, into which, with each new load, the nucleus pulposus begins to become more and more invaginated, moving to the periphery of the disc. If the outer layers of the fibrous ring are still preserved, then in the place of its greatest thinning, the disc begins to protrude - a so-called disc protrusion occurs.
When the fibers of the annulus fibrosus are completely ruptured, the contents of the nucleus pulposus extend beyond its boundaries - a herniation of the nucleus pulposus occurs. The prolapsed fragment of the nucleus pulposus can be freely located in the lumen of the spinal canal (disc sequestration).
It is very important in which direction the protrusion or prolapse of the disc occurs. As noted, the posterior and anterior surfaces of the discs are additionally strengthened by the longitudinal ligaments of the spine; therefore, lateral (lateral) displacement of the disc toward the intervertebral foramen through which the spinal root passes occurs more often.
In this regard, the most common manifestation of hernial protrusion (herniation) of the intervertebral disc is compression of the corresponding root with the development of a characteristic pain syndrome (discogenic radiculitis).
Less commonly, the disc can protrude into the spinal canal along the midline (posterior disc herniation). The neurological consequences of posterior hernias depend on the part of the spine in which they occur (posterior, median lumbar hernias can lead to compression of the roots of the cauda equina, while cervical hernias can cause damage to the cervical spinal cord).
When the cartilaginous plates adjacent to the vertebrae are destroyed, the nucleus pulposus can penetrate into the adjacent vertebra, resulting in the development of Schmorl's hernias, which are usually asymptomatic.
Due to the degeneration of the intervertebral discs, their sclerosis occurs, the mobility of the vertebrae is impaired, and the spaces between them decrease, i.e. osteochondrosis develops.
Spondylosis is characterized by a complex of changes in the vertebrae, ligaments, and joints, which can cause radicular symptoms and symptoms of spinal cord damage.
These changes include the formation of bone osteophytes protruding into the spinal canal, the intervertebral foramen, and the vertebral artery canal. These osteophytes form along the edges of the vertebrae, articular surfaces, and the area of the uncovertebral joint. This is often accompanied by thickening and ossification of the longitudinal ligament.
The deformed edges of the vertebrae and the ossifying adjacent parts of the ligaments form bone brackets. All these changes are united by a common name - spondyloarthrosis. With age, signs of spondyloarthrosis are found in most people (90% of men over 50 years of age and 90% of women over 60 years of age). However, in most cases it is asymptomatic or with moderate symptoms. painful sensations, which do not significantly affect activity and ability to work.
Due to weakening of the ligaments and degenerative changes in the discs, spinal instability and displacement of one vertebra relative to another (spondylolisthesis) can occur, which in turn can become an additional cause of injury to the spinal cord and roots.
The impact of all of these factors on the spinal cord and roots can be especially pronounced in patients with a narrow spinal canal.
The clinical manifestations of the mentioned degenerative changes in the spine are largely determined by the level of the lesion. As noted, most often these pathological changes occur in the cervical and lumbar spine, which experience heavy loads.
Lesions of the intervertebral discs and spondylosis of the cervical spine. The greatest dynamic load falls on the lower vertebrae of the cervical spine. It is not surprising that in most cases there is prolapse of the disc between the vertebrae CV and CVI and CVI and CVII. In addition to age-related degenerative changes, trauma, especially “whiplash”, characterized by rapid flexion and extension of the head and neck, is significant in pathological changes in the cervical spine (such an injury can occur in the absence of head restraints in the car during rapid braking or when colliding with an obstacle).
Clinical manifestations of damage to the cervical intervertebral discs. Depending on the location of the prolapsed disc, symptoms of root compression and spinal cord injury (myelopathy) alone or in combination may occur. Diseases often appear in the 3rd–4th decade of life.
The nature of the detected neurological syndrome depends on the level and location of the prolapsed disc.
With lateral disc herniations blocking the intervertebral foramina, the disease begins with acute pain in the neck, shoulder, and arm (corresponding to the area of innervation of the affected root). The pain intensifies with movements in the neck. Weakness of individual muscle groups may be observed, and later signs of their atrophy.
With medial disc prolapse, symptoms of spinal cord damage come to the fore: decreased strength in the upper limbs, uncertainty, awkwardness when walking, dysfunction of the pelvic organs. In rare, severe cases, median disc prolapse can lead to the development of complete spinal cord interruption syndrome.
The neurological symptoms of cervical spondylosis are in many ways similar to the clinical manifestations of herniated intervertebral discs.
Pain in the neck, shoulder girdle, occipital, interscapular areas is one of the most constant and painful manifestations of cervical osteochondrosis. Pain can be caused by irritation of the receptors of the ligamentous apparatus and intervertebral discs, a direct effect on the roots, and an effect on the sympathetic nervous system.
As with herniated cervical intervertebral discs, osteochondrosis (spondylosis) may cause symptoms of damage to the spinal cord and roots - myeloradiculopathy.
Neurodystrophic changes in the form of periarthritis of the shoulder joint, anterior scalene muscle syndrome, and heart pain (cardiac syndrome) are also characteristic.
It is necessary to mention the vertebral artery syndrome, which occurs as a result of the formation of osteophytes in the lumen of the vertebral artery canal, injuring the artery wall and causing its spasm.
Compression of one vertebral artery, even its complete occlusion, may be asymptomatic, but with a bilateral process or hypoplasia of the opposite artery, patients experience symptoms of circulatory disorders in the vertebrobasilar area (dizziness, vomiting, ataxia, blurred vision, and in severe cases, disturbance of vital functions). The disease occurs with remissions and exacerbations.
Diagnostics. X-ray signs of cervical osteochondrosis and spondylosis include narrowing of the intervertebral space, sclerosis of bone tissue, and the presence of osteophytes. Signs of pathological mobility of the vertebrae and spondylolisthesis may be detected.
A more complete and accurate diagnosis, necessary, in particular, to decide on the indications for surgical treatment, requires the use of methods such as myelography, computed tomography and magnetic resonance imaging. Only these methods make it possible to identify prolapsed intervertebral discs and the degree of compression of the spinal cord and its roots.
Herniated intervertebral discs at the lumbar level. More often, posterolateral hernias are observed, compressing the root as it exits the dural sac.
At the lumbar level, the lower edge of the vertebral arch is located above the level of the intervertebral disc, therefore, when a hernia prolapses, the underlying root is compressed (LV SI hernia compresses the SI root).
Central hernias compress not one, but several roots, as they penetrate into the spinal canal at the level of the cauda equina. Discs are most often damaged at the LV–SI and LIV–LV levels; 95% of lumbar intervertebral hernias occur at these levels. In approximately 4% of cases, a hernia prolapses at the LIII–LIV level and only in 1% at the LII–LIII and LI–LII levels.
Clinical manifestations. A prolapsed intervertebral hernia is usually characterized by acute pain in the lumbar region, radiating and often along the sciatic nerve (buttock area, posterior thigh, posterolateral edge of the leg). The pain sharply intensifies with movements, bending the body, and straining. There is a curvature of the spine due to a sharp reflex muscle tension.
The occurrence of an attack can be caused by physical activity - heavy lifting, sudden movement. During the examination, pain is observed when pressing on the spinous processes of the lumbar vertebrae, tension symptoms: Lasegue's symptom, Neri's symptom, pain along the sciatic (less often femoral) nerve. Sensitivity disturbances and loss of tendon reflexes may occur depending on the location of the prolapsed disc, as well as muscle paresis.
Features of neurological symptoms characteristic of lumbar herniated intervertebral discs at various levels.
It should be borne in mind that in some cases, roots that do not correspond to the level of the affected disc may be compressed. This can occur when a prolapsed disc fragment (sequestrum) moves up or down within the spinal canal.
Median disc herniations can only manifest as pain caused by stretching of the posterior longitudinal ligament and dura mater. However, when a large fragment of the disc falls out, symptoms of damage to the roots of the cauda equina may acutely occur in the form of pain in the lumbar region and legs, weakness in the legs, mainly in the feet, sensory disturbances in them, and dysfunction of the pelvic organs.
The disease is usually remitting in nature. Symptoms that arise under the influence of treatment or spontaneously gradually disappear or weaken to a significant extent. This remission is explained by the reposition of the disc when it is incompletely protruded (protrusion), as well as the subsidence of reactive inflammatory changes that are inevitable when the disc prolapses.
Subsequently, painful attacks with signs of compression of the root or roots may be repeated.
Diagnostics. The diagnosis of lumbar intervertebral hernia does not present significant difficulties. A characteristic history and neurological symptoms suggest disc protrusion or prolapse and determine its level. However, final verification of the diagnosis usually requires additional research methods. Spondylography can reveal a narrowing of the space between the vertebrae at the level of the affected disc, and accompanying changes in the vertebrae - spondylosis. In some cases, it is possible to identify the prolapsed disc itself if it has become calcified.
Complete information about the condition of the disc, the location of the prolapsed fragment and the degree of compression of the roots can be obtained using computer and magnetic resonance imaging or myelography.
The consequence of widespread osteochondrosis can be a pronounced narrowing of the spinal canal, leading to compression of the dural sac and the roots located in it. In these cases, canal stenosis syndrome develops. Patients are bothered by pain in the lower back and legs, which intensifies when the spine is extended and weakens when the patient takes a semi-bent position, sits or lies with bent legs.
“Neurogenic intermittent claudication” may occur, characterized by weakness in the legs and increased pain when walking. The reason for the appearance of these symptoms is a violation of blood circulation, primarily venous outflow in the roots of the cauda equina. In contrast to “intermittent claudication” caused by obliterating endarteritis, patients have no signs of impaired peripheral circulation in the legs.
Treatment. Before talking about the treatment of degenerative changes in the spine, accompanied by neurological manifestations, it is worth mentioning the exceptional importance of preventing these changes. A special place among measures to prevent the development of certain vertebrogenic syndromes is occupied by systematic physical exercises aimed at preserving correct posture, mobility of the spine, strengthening its muscles.
As noted earlier, the most common manifestation of spinal osteochondrosis, primarily hernial prolapse of intervertebral discs, is acute radicular syndrome, which is extremely painful for the patient.
Treatment of patients with this syndrome and other neurological complications of spinal osteochondrosis should be comprehensive. Treatment measures are prescribed differentially, taking into account the pathomorphological substrate of the disease, leading clinical manifestations, duration and stage of the disease.
Conventionally, the entire period of the disease can be divided into acute, subacute stages and the remission stage.
In the acute period, rest is indicated (in case of severe pain syndrome, bed rest).
It is advisable to begin treatment with the prescription of non-steroidal anti-inflammatory drugs (piroxicam, indomethacin, voltaren, ibuprofen, reopirin), decongestants (furosemide, diacarb, hypothiazide), painkillers and muscle relaxants, as well as large doses of B vitamins. With this drug combination, the main pathogenetic mechanisms are taken into account diseases, its use reduces the phenomenon of inflammation, swelling, reflex muscle spasm - thereby reducing compression of the nerve root.
For severe pain, intramuscular use of combination drugs, which include dexamethasone, phenylbutazol, lidocaine, cyanocobalamin, as well as radicular and epidural blockades, is effective.
Traction may be indicated to reduce disc protrusion.
If the spine is affected at the cervical level, immobilization using a collar or a special device that fixes the head and neck is advisable (Hallo west).
After the pain subsides (subacute stage of the disease), physical treatment methods are used: gymnastics, manual therapy, physiotherapy, massage.
A set of therapeutic exercises in the subacute stage of the disease is aimed at relaxing muscles, reducing compression of the affected intervertebral discs and decompressing the spinal cord roots, and subsequently at strengthening the muscular corset of the spine. At this stage, vertical loads on the spine should be avoided; exercises that cause rotation in the affected segment are the most traumatic for the intervertebral disc.
Frequently used physiotherapeutic procedures (ultrasonotherapy, sinusoidally modeled and diadynamic currents, drug phonophoresis) provide a significant therapeutic effect based on the antispasmodic, anti-inflammatory, analgesic effect of physiotherapeutic factors that potentiate the effect of drugs. Vascular medications, antispasmodics and muscle relaxants, stimulators of regenerative metabolic processes in the intervertebral discs are prescribed. In some cases, the use of multienzyme drugs (papain, lekozym, karpazim) is effective. Enzymes introduced by electrophoresis have a local selective effect on the connective tissue, including the disc itself and the hernial protrusion. They cause lysis of the tissues of the hernial protrusion, which leads to a decrease in compression of the nerve root.
Complex treatment, including medication and physical therapy, is more effective and allows you to achieve clinical results faster. Manual and reflexotherapy are also used to eliminate radicular pain.
In the remission stage, when a violation of social and everyday adaptation comes to the fore (decreased muscle strength of the affected limb, pain that occurs during physical activity, making it difficult to work in a certain position, etc.), the rehabilitation stage begins. The treatment and rehabilitation measures carried out are aimed primarily at overcoming persistent defects and preventing relapses. The basis of treatment is the constant implementation of a complex of therapeutic exercises and sanatorium-resort treatment.
Surgery. If conservative treatment is ineffective for 2–3 months and computed tomography and myelography detect a prolapsed disc or osteophyte causing pain, surgery is indicated. Surgery is necessary for progressive myelopathy caused by compression of the spinal cord. With the development of cauda equina root compression syndrome, there is a need for urgent surgery, since prolonged compression can cause circulatory disorders and irreversibility of the resulting changes.
For prolapse of cervical intervertebral discs and other described manifestations of cervical osteochondrosis, two approaches are used: posterior with removal of the vertebral arches or their fragments and anterior - through the vertebral bodies.
Most often, especially with prolapsed discs in the middle localization, the anterior approach is used. This approach has advantages because it allows you to remove both the prolapsed disc and osteophytes compressing the spinal cord and roots, as well as, if necessary, stabilize the vertebrae.
The operation is performed through a transverse incision on the anterior surface of the neck corresponding to the affected disc. The soft tissues are dissected layer by layer and an approach is made to the anterior surface of the vertebrae between the carotid artery on one side, the esophagus and trachea on the other. This exposes the corresponding intervertebral space.
There are several methods to remove the disc and stabilize the vertebrae. One of the first to use was the method proposed by A. Cloward. Using a special cutter, part of the disc and adjacent areas of the vertebral bodies are removed. Through the formed bone window, the altered disc is removed, osteophytes and the posterior longitudinal ligament are resected, and thus compression of the spinal cord and roots is eliminated. The vertebrae are stabilized using a bone graft formed with a crown mill from the iliac crest. During the operation, traction of the cervical vertebrae is carried out using a load fixed to the patient’s head with a special bracket for bone traction. Through the empty space between the vertebrae, the disc fragment that has fallen into the spinal canal is removed and the osteophytes are resected. Stabilization is carried out using a bone plate from the ilium. After 3 months, consolidation of bone tissue occurs. If indicated, such an operation can be performed at several levels. In these cases, to more reliably stabilize the vertebrae, special plates are used, attached to the vertebrae with screws.
When there is compression of the vertebral artery, manifested by symptoms of cerebrovascular accident, indications arise for decompression of the vertebral artery canal.
Various methods have been proposed for the removal of herniated intervertebral discs at the lumbar level, including endoscopic discectomy. Nevertheless, the most common and justified are operations with a sufficiently wide exposure of the area of the prolapsed disc, which avoids additional trauma to the compressed root or dural sac with the roots of the cauda equina located in it.
The patient is operated on in the prone or lateral position. In the first case, it is important to position the patient in such a way that the abdominal organs are not compressed, since this leads to increased venous pressure and bleeding from the veins during surgery.
In case of a lateral hernia, from the midline incision of the soft tissues above the spinous processes, the muscles are skeletonized only on the side where the prolapsed disc is located. Fragments of the arches of the upper and lower vertebrae are resected at the level of the disc, and the ligamentum flavum is excised in the space between the arches. This allows the spine and the prolapsed disc to be exposed. If necessary, the resection of the arches can be expanded. The disc itself is removed using a conchotome. Then the prolapsed part of the disc and its fragments located in the intervertebral space are removed.
To remove median disc herniations, in some cases it is necessary to perform a laminectomy (resect the spinous processes and arches on both sides). This allows the dural sac to be widely exposed, moved to the side, and the prolapsed disc removed with less trauma.
If the indications for surgery are correctly determined, disc removal leads to a rapid cessation of pain and the patient can get back on his feet on the first day after surgery.
When disc prolapse is combined with severe spondylosis, the operation is more complex and less effective. The surgeon’s task is to remove as much as possible the affected roots and dural sac from compression. In these cases, wider resection of the arches and removal of not only the disc, but also osteophytes are justified.
For narrow spinal canal syndrome, wide decompression of the dural sac and compressed roots is indicated.
When the spine is unstable at the lumbar level (spondylolisthesis), there is a need to stabilize the vertebrae with the help of special titanium structures.
Osteochondrosis is the development of degenerative processes in the intervertebral discs, but most of complaints with this disease are associated with its neurological complications, which are usually classified into 4 stages:
At the first stage, neurological complications in osteochondrosis are caused by protrusions of intervertebral discs in the posterior region, where many pain receptors are located. As a result, local pain syndromes appear, indicating the presence of osteochondrosis:
- pain syndrome in the cervical spine - cervicago;
- pain syndrome in the lumbar region of the spine - lumbago;
- pain syndrome in the thoracic spine - thoracalgia.
At the second stage, neurological disorders from osteochondrosis are caused by prolapse of intervertebral discs from their natural cavities into the spinal canal, which leads to irritation and pinching of the spinal nerve and spinal roots (development of radicular syndrome). At this stage, neurological disorders are manifested by pain syndromes, designated by the single term radiculitis with different areas of localization:
- cervical radiculitis;
- cervicothoracic radiculitis;
- lumbar radiculitis;
- lumbosacral radiculitis.
At the third stage of the neurological consequences of osteochondrosis, vascular-radicular pathologies develop, which consist of impaired blood supply to the spinal nerve and nerve roots. Pathologies manifest themselves in the form of:
- various movement disorders;
- disturbances in the sensitivity of certain parts of the body.
The fourth stage of the neurological consequences of osteochondrosis is the most severe and often with irreversible consequences. It is characterized by a disruption of the blood supply to the human spinal cord, which leads to:
- cerebrovascular insufficiency of the spinal cord;
- spinal ischemic stroke.
Osteochondrosis is one of the most common diseases of humanity; according to some estimates, more than half of the adult population of the world suffers from back pain associated with osteochondrosis. Osteochondrosis itself is degenerative processes in the intervertebral discs, but the main problems for a person are caused by neurological complications of osteochondrosis. Experts distinguish four stages of neurological complications of spinal osteochondrosis.
The first stage of neurological complications of osteochondrosis is characterized by protrusion of the intervertebral disc back into the area where many pain receptors are located. Therefore, the main manifestations of neurological complications of osteochondrosis at the first stage are local pain syndromes: lumbago (pain syndrome in the lumbar region), cervicago (pain syndrome in the cervical spine) and thoracalgia (pain syndrome in the thoracic spine).
At the second stage of neurological disorders of osteochondrosis, the intervertebral disc falls out of its natural cavity, as a result of which it begins to irritate the spinal roots and spinal nerve (the so-called “radicular syndrome”). The manifestation of osteochondrosis in this case can be various pain syndromes, for which the term “radiculitis” is used: cervical, cervicothoracic, lumbar and lumbosacral radiculitis.
The third stage of neurological complications of osteochondrosis is vascular-radicular, in which the blood supply to the nerve roots and spinal nerves is disrupted. This leads to various movement disorders, as well as disruption of the sensitivity of certain areas of the skin.
Finally, the most severe is the fourth stage of neurological complications of osteochondrosis, in which the blood supply to the spinal cord is disrupted. This can lead to such serious consequences as cerebrovascular insufficiency of the spinal cord and spinal ischemic stroke.
Osteochondrosis is a serious disease of the spine that leads to disability. There are three types of disease: thoracic, cervical, lumbar. Everyone has symptoms.
A degenerative disorder in articular cartilage affects the space between the vertebrae. Osteochondrosis destroys cartilage tissue, causing thinning. Everything around becomes inflamed, including nerve fibers. The vertebrae gradually shift and the nerves become pinched. In each part of the spine it leads to certain symptoms and consequences. Neurological manifestations of osteochondrosis are considered important and serious.
Main symptoms of osteochondrosis
The main symptoms encountered in types of disease:
- Pain at the site of the disease, aggravated by rest.
- Weakness in the body, present on waking, throughout the day. Caused by oxygen starvation.
- Blood pressure surges. Characteristic of cervical osteochondrosis, it occurs in other types of the disease.
The disease has vague, generalized main symptoms, and therefore requires careful diagnosis. Let's consider the neurological side of the symptoms.
Neurology for cervical osteochondrosis
Cervical osteochondrosis is a type of degenerative disorder that affects the vertebrae of the neck. Due to the progressive disease, serious displacement of the vertebrae occurs. The symptoms are pronounced. The disease occurs frequently. Children of adolescence and younger are often susceptible.
Neurological manifestations of dystrophic disorders in the cervical spine:
- Cervicalgia is present at all stages of cervical osteochondrosis. Expressed as a dull pain in the deep tissues of the neck. Patients complain of a feeling of “a stake in the neck.” Discomfort is present throughout the day and worsens at night.
- Inflammation of the anterior scalene muscle is expressed by pain in the side of the neck, noticeably radiating to the corresponding arm. Aching in the fingers after waking up. Caused by inflammation of the nerve fibers, the roots of the C5-C7 vertebrae.
- Cranialgia is characteristic of severe osteochondrosis of the neck. It is expressed by a burning pain syndrome in the crown of the head, above the eyebrows. Often even powerful painkillers are unable to relieve pain.
- Cochlevestibular sensations are expressed by pain in the ears, crackling. Manifestations of cervical osteochondrosis require an urgent visit to a doctor. Oxygen starvation is to blame.
Cervical osteochondrosis has manifestations of neuralgia that require medical supervision. There are many arteries in the neck. The disease reduces blood flow, causing disturbances and disruptions. The main neurological symptoms of the disease are listed.
Manifestations of the disease are not obvious, they concern the initial stage. Most people consult a doctor when the disease is in the second or third stages.
Neurology in thoracic osteochondrosis
Neurological manifestations of thoracic osteochondrosis:
- Aching pain under the shoulder blade – dorsalgia. The person leans forward. There is a feeling of back fatigue, unbearable heaviness in the upper part.
- The plexuses near the collarbone and ribs swell. Causes a feeling of discomfort when turning your back. The swelling is noticeable under the shoulder blade.
- A person experiences pain in the area of the atrium. Often there are no heart pathologies, the problem is in the xiphoid process, which becomes inflamed due to a back disease. The symptom is considered bright and widespread. Neurologists are faced with patient complaints of heart pain. The disease does not affect the functioning of the heart.
These are the main symptoms of thoracic osteochondrosis in terms of neurological changes in the body. Symptoms include serious discomfort and pain. Analgesics, painkillers, and psychotropic drugs used for severe forms of the disease will relieve pain.
The listed symptoms highlight the manifestation of the disease in the thoracic region.
Neurology in lumbar osteochondrosis
Manifestations of spinal osteochondrosis include: general condition, neurology. Osteochondrosis is a neurological disease and is treated by a neurologist. Manifestation of dystrophic disorder in the articular cartilages of the lumbar region from neurology:
- Lumboischialgia is a shooting pain radiating to the leg. It appears after being in an uncomfortable position for a long time. It has chronic and subacute forms. Chronic lumboischialgia is common. A common symptom of lumbar osteochondrosis at the second stage.
- Lumbago is expressed by shooting pain in the lower back, worse at night. There are types of lumbago. Each type differs in the nature of pain.
- Disturbances in the nerve roots. Disease in the lower back is associated with nerve roots in the back, which become inflamed and disrupt the motor activity of the body.
Lumbar osteochondrosis is a common type of osteochondrosis. Every third patient suffers from a dystrophic disorder in articular cartilage. Sometimes it appears in women after childbirth. Associated with injuries in the lumbar and pelvic areas that occurred during pregnancy and childbirth.
Exacerbation of the disease is possible during subsequent births. The treatment is carried out comprehensively and fully. Taking most medications while breastfeeding is contraindicated. The doctor should find a way out of the situation by drawing up a regimen based on suitable medications. Physiotherapy and traditional medicine are often used as a basis. Complete treatment without medications will not work, but the weakening of the effect of the disease on the young mother’s body is guaranteed.
Course of osteochondrosis
Having outlined how osteochondrosis manifests itself, we note the stages of the disease that are characteristic of the varieties of the disease.
The acute course of the disease lasts 4 weeks. The patient feels slight pain in the inflamed area.
Subacute disease lasts up to three months. This is followed by a chronic course that lasts more than one year. Untimely and incomplete treatment can lead to serious problems in motor activity. Osteochondrosis can lead to disability; treatment should be taken seriously.
Therapy for getting rid of osteochondrosis is drawn up by the attending physician - a neurologist. Self-treatment is excluded - the likelihood of positive dynamics without competent self-medication is low.
After the main therapy, the body will need time to recover. The doctor will prescribe a course of physical treatment, the use of methods traditional medicine. Traditional medicine recipes will shorten the recovery period if you use it wisely. There are many plants and natural components that help the body consolidate the results after healing.
The article was written for general educational development. To establish an accurate diagnosis and prescribe treatment, ALWAYS consult a doctor
