Osteochondrosis of the spine, herniated disc, disc protrusion

 

Osteochondrosis and intervertebral disk

Vertebral osteochondrosis - a dystrophic pathological process of the spine, starting with the intervertebral disc with subsequent involvement of other parts of the spine. When osteochondrosis primarily affects the cervical and lumbar, like most at overload.

In terms of perergruzok thoracic spine is protected and fixed the chest through the ribs. Therefore, protrusion or herniated disc in the thoracic level in osteochondrosis of the spine occur in clinical practice is rare. In some cases, osteochondrosis clinically manifest various neurological disorders.

Intervertebral disc - a kind of "shock absorber" between the bodies of the vertebrae. Human spine - this is the axial organ that performs the function of providing vertical posture in static and dynamic loads in a wide range.

The structure of the intervertebral disc in cross-section is normal.

As you know, vnutridiskovoe pressure is positive and amounts to 5.6 atmospheres, which in itself excludes the possibility of "reposition the disc has fallen" in the course of manipulation, as alleged by some "experts" on manual therapy.

Distribution vnutridiskovogo pressure of the person doing the work in a sitting position or a small trunk flexion, shows that the posterior segments of the disk are slightly unloaded than the front. This means that vnutridiskovoe pressure is directed toward the spinal canal and has a preferential effect on the rear arc of annulus fibrosus and posterior longitudinal ligament. Obviously, the dystrophic process often develops early in this part of the intervertebral disc, and the possibility of a hernia in the direction of the spinal canal is greatest.

Herniated disc, serving side the spinal canal and compresses the nerve root.

 

This feature of load distribution on the cross section of an intervertebral disc allows you to understand the reason for the high frequency of degenerative disc disease of the intervertebral disc and its complications in patients sedentary occupations compared with men performing dynamic work. During dynamic work, all departments of the intervertebral disc loaded with more or less evenly than the probability of local degenerative lesion of the intervertebral disc decreases.

MRI of the lumbosacral spine is indicated for clinical signs of hernia or protrusion of the disc.

 

In the study of patients with back pain and leg on Tomography (CT or MRI) revealed the following signs of hernial forms of osteochondrosis of the lumbar spine.

 

Changing the status of the contour and size of the disk

This symptom herniated disc can be considered as the main and constant symptom diagnosis. Bulging disc is detected frequently and are often accompanied by a decrease of its height. In these cases, part of the disc supports the borders of neighboring vertebrae. Such changes may have a middle-aged people, and they often do not show pain. Therefore, there is a serious risk of overdiagnosis of intervertebral disc hernia. Are set to the relative size of the disk, the ratio of the edge of the vertebral body and the edge of the adjacent intervertebral disc.

Normally, the edge of the body and the edge of the disc correspond to each other. In the pathology of cartilage disc extends beyond the borders of the vertebral bodies.

Normally, the edge of the body and the edge of the disc correspond to each other.

 

With disc herniation observed local bulging disk of different sizes beyond the vertebral bodies. Terminology that sounds to identify different authors, both local bulging disc or disc protrusion. These two terms are interchangeable, and usually represent different degrees of the same state. In this case, gelatinous nucleus remains within the fibers of the fibrous ring, which weakens and stretches.

Disc prolapse, or otherwise extruded disc, formed by the penetration of nucleus pulposus through the annulus fibrosus, in this case fragments of the nucleus located at the posterior longitudinal ligament. Using CT of the spine is not always possible to distinguish between these types of disc herniation. In these cases it is necessary to carry out a discography.

If sequestration or fragmentation of the disk disc material beyond the intervertebral space, penetrates through the posterior longitudinal ligament in the epidural tissue, migrate to the epidural space. Free fragment can be located on a long distance from the disc, moving as in the cranial and caudal direction, and (very rarely) intradural.

The usual rule is that the hernia compresses the spine, which is under intervertebral disc that is herniated intervertebral disc L4-L5 kompremiruet (squeezes), nerve root L5. With lateral herniation of the intervertebral disc can be kinked nerve root in the intervertebral foramen, and then for a herniated disc L4-L5 is, compressed nerve root L4.

Compression of nerve root herniation of the intervertebral disc with osteochondrosis.

In practice, the neurosurgeon is important to determine what type of disc herniation is available to the patient: protrusion, prolapse or sequestered.

Types of lumbar disc herniation classification based on the location of the disc herniation relative to the facet joint and spinal canal.

 

Radiological classification of hernias of the intervertebral disc:

1. Disc protrusion or bulging of the local - gelatinous nucleus remains within the extended annulus. Intervertebral disc is deformed in the horizontal plane. Protrusion height is less than 1/3 of its width.
2. Disc prolapse - gelatinous nucleus breaks fibrous ring, penetrates through it. Posterior longitudinal ligament remains intact, nucleus pulposus is subglottic. In some cases, there are discontinuities of the longitudinal ligament, do not let the large fragments. Posterior contour of the disk becomes bumpy. Protrusion height exceeds one-third of its length.
3. Sequestered or fragmentation of the herniated disc - the disc material located in the epidural space and migrate freely within it.

Herniated disc are divided by location, depending on their attitude to the front wall of the spinal canal:

• total
• central (median) or median
• paramedian (located between the midline and the line connecting the medial edge of articular processes)
• lateral, foramen (located outside the inner edge of articular processes)
• ekstraforaminalnye (dalnelateralnye)

This classification is most convenient for the operating neurosurgeon. Classification is radiological. It allows you to choose an adequate surgical access. Undoubtedly, the clinical manifestations in different types of hernias of intervertebral discs may not correlate with radiological response. Since the median, according to the radiological methods of examination, disc herniation often manifests itself clinically as lateral or paramedian or even as an extreme option, may be a random finding.

The Pfirrmann classification of lumbar intervertebral disc degeneration graded on MRI T2 weighted images:

Grade I	Grade II	Grade III	Grade IV	Grade V
Homogeneous bright white structure	Inhomogeneous white structure, possible horizontal bands	Clear distinction between annulus and nucleus	Disc height is slightly or moderately decreased	Collapsed disc space

T2-weighted sagittal lumbar MRI images used to evaluate disc degeneration. A. Disc degeneration as described by Pfirrmann: mainly inhomogeneous black discs with no distinction between nucleus and annulus; collapsed disc spaces at L1-L2 and L4-L5. B. Lumbar discs that obtained high reliability for low grade Pfirrmann grades across our evaluators, showing homogeneous structure, with bright hyperintense signal intensity and normal height. .

 

Changing the physical properties of the intervertebral disc

Densitometric study of the disk can reveal in some cases, increase the density of the nucleus pulposus tissue due to calcification, in other cases, the density of the nucleus. By densitometric density can indirectly judge the limitations of education hernia. "Young" disc herniation have a homogeneous structure, density of 60-80 N and not always clear-cut contours. Long-existing hernia have a greater density and heterogeneous structure. Separately, it should be said about the appearance of air pockets in the disk, called a vacuum effect. He is the most striking feature of the nucleus pulposus degeneration.

 

Changes in the tissues around the intervertebral disc

The maximum changes in the epidural tissue can be determined at the last lumbar disks. Epidural space at L5-S1 disk wider and contains a considerable number of vessels that the CT of the spine looks like a soft-tissue component, located symmetrically near the disk. Behind the vertebral body, the midline is located venous plexus Betson, which looks like a soft-tissue formation. This education can be mistaken for a sequestered disc herniation.

Dura mater and roots normally surrounded by fat. Changes in body fat as determined by densitometry. They consist of heterogeneity densitometric density of tissue, demonstrating the adhesive process.

Spinal stenosis with compression of the spinal cord.

 

Obliteration of the epidural space of tissues of higher density or the presence of soft tissue component at the disk level indicates that sequestration of the nucleus pulposus. In addition, it is sometimes possible to determine the increase in epidural fat below the level of disc herniation, which is associated with the expansion of epidural veins below (caudal) level of compression.

 

Changing the contour or position of the dural sac

When the median, paramedian hernias dural sac is shifted back, taking the form of a bean or a crescent. When the lateral hernias dural sac extended to the side. Only when foramen hernia dural sac could be considered intact.

 

Change the position of the nerve roots

Most often roots in the conflict zone with the disc visualized poorly, which is especially characteristic of sequestered hernias. In such cases, the estimated its location can be determined by an imaginary path that connects the "dogryzhevoe" and "poslegryzhevoe" image of the spine. In other cases, herniation of intervertebral disk is asymmetric slip back. For large sequestered hernias and severe adhesions and hernia paradiskalnye tissue did not differentiate and look unified conglomerate.

Isolated as the following CT changes ekstrasakkalnoy portions spine:

• dislocation
• aggregation
• compression
• conglomeration

 

Treatment of osteochondrosis, hernia and protrusion of intervertebral disc

Elimination of pain, tingling and restoration of sensitivity in the leg in the treatment of neuritis of the sciatic nerve in case of compression of the hernia or protrusion disc with osteochondrosis accelerated by the use of physiotherapy.

 

Neurostimulation (physiotherapy) eliminates paresthesias and pain, restores power in the muscles in the treatment of neuritis of the sciatic nerve in case of compression of the hernia or protrusion disc with osteochondrosis.

 

Depending on the severity of symptoms and causes of pain in the neck in a patient, the following therapeutic action

• drug therapy (NSAIDs, analgesics, hormones)
• therapeutic blockade - the injection of drugs into the cavity of the channel
• manual therapy (muscle, joint and radicular technique)
• massage
• physiotherapy (UHF, SMC, etc.)
• acupuncture
• spinal traction (contraindicated in the acute stage)
• medical gymnastics and swimming (after primary treatment)
• surgical treatment

Elimination of swelling, inflammation, pain, restore range of motion in joints and muscles in the treatment of degenerative disc disease lumbar spine, herniation or protrusion of the disc is accelerated by the use of UHF physiotherapy.

Lateral pars interarticularis approach for far lateral disc herniations fragment with exiting nerve root impingement.

 

 

If you have any questions about the diagnosis or treatment of osteochondrosis, hernia and protrusion of the disc, you can specify them with our neurosurgeon or neurologist by phone: (499) 130–08–09