Photograph of an anatomical specimen) are the main element connecting the spinal column into a single whole, and make up 1/3 of its height. The main function of intervertebral discs is mechanical (support and shock-absorbing). They provide flexibility to the spinal column during various movements (bending, rotation). In the lumbar spine, the diameter of the discs is on average 4 cm, and the height is 7–10 mm. The intervertebral disc has a complex structure. In its central part there is a nucleus pulposus, which is surrounded by a cartilaginous (fibrous) ring. Above and below the nucleus pulposus are the end plates.
The nucleus pulposus contains well-hydrated collagen (randomly arranged) and elastic (radially arranged) fibers. At the border between the nucleus pulposus and the fibrous ring (which is clearly defined up to 10 years of life), cells resembling chondrocytes are located with a fairly low density.
Fibrous ring consists of 20–25 rings or plates, between which collagen fibers are located, which are directed parallel to the plates and at an angle of 60° to the vertical axis. Elastic fibers are located radially in relation to the rings, which restore the shape of the disc after the movement has taken place. The cells of the annulus fibrosus, located closer to the center, have an oval shape, while at its periphery they elongate and are located parallel to the collagen fibers, resembling fibroblasts. Unlike articular cartilage, disc cells (both the nucleus pulposus and the annulus fibrosus) have long, thin cytoplasmic projections that reach 30 μm or more. The function of these outgrowths remains unknown, but it is assumed that they are capable of sensing mechanical stress in tissues.
End plates They are a thin (less than 1 mm) layer of hyaline cartilage located between the vertebral body and the intervertebral disc. The collagen fibers it contains are arranged horizontally.
Intervertebral disc of a healthy person contains blood vessels and nerves only in the outer plates of the annulus fibrosus. The endplate, like any hyaline cartilage, has no vessels or nerves. Basically, the nerves travel accompanied by vessels, but they can also travel independently of them (branches of the sinuvertebral nerve, anterior and gray communicating branches). The sinuvertebral nerve is the recurrent meningeal branch of the spinal nerve. This nerve leaves the spinal ganglion and enters the intervertebral foramen, where it divides into ascending and descending branches.
As has been shown in animals, the sensory fibers of the sinuvertebral nerve are formed by fibers from both the anterior and posterior roots. It should be noted that the anterior longitudinal ligament is innervated by branches of the spinal ganglion. The posterior longitudinal ligament receives nociceptive innervation from the ascending branches of the sinuvertebral nerve, which also innervates the outer plates of the annulus fibrosus.
With age, there is a gradual blurring of the boundary between the fibrous ring and the nucleus pulposus, which becomes more and more fibrotic. Over time, the disc becomes morphologically less structured - the annular plates of the annulus fibrosus change (merge, bifurcate), collagen and elastic fibers are located more and more chaotically. Cracks often form, especially in the nucleus pulposus. Degeneration processes are also observed in the blood vessels and nerves of the disc. Fragmented cell proliferation occurs (especially in the nucleus pulposus). Over time, intervertebral disc cells die. Thus, in an adult, the number of cellular elements decreases by almost 2 times. It should be noted that degenerative changes in the intervertebral disc (cell death, fragmented cell proliferation, fragmentation of the nucleus pulposus, changes in the annulus fibrosus), the severity of which is determined by a person’s age, is quite difficult to differentiate from those changes that would be interpreted as “pathological”.
The mechanical properties (and accordingly the function) of the intervertebral disc are ensured intercellular matrix, the main components of which are collagen and aggrecan (proteoglycan). The collagen network is formed by type I and type II collagen fibers, which constitute approximately 70% and 20% of the dry weight of the entire disc, respectively. Collagen fibers provide strength to the disc and fix it to the vertebral bodies. Aggrecan (the main disc proteoglycan), composed of chondroitin and keratan sulfate, provides hydration to the disc. Thus, the weight of proteoglycans and water in the annulus fibrosus is 5 and 70%, and in the nucleus pulposus – 15 and 80%, respectively. Synthetic and lytic (proteinases) processes constantly occur in the intercellular matrix. However, it is a histologically constant structure, which provides mechanical strength to the intervertebral disc. Despite the morphological similarity with articular cartilage, the intervertebral disc has a number of differences. Thus, protein glycans (aggrecan) of the disc contain a higher content of keratan sulfate. In addition, in the same person, disc aggrecans are smaller and have more pronounced degenerative changes than articular cartilage aggrecans.
Let us consider in more detail the structure of the nucleus pulposus and the fibrous ring - the main components of the intervertebral disc.
Nucleus pulposus. According to morphological and biochemical analysis, including microscopic and ultramicroscopic studies, the nucleus pulposus of human intervertebral discs belongs to a type of cartilaginous tissue (V.T. Podorozhnaya, 1988; M.N. Pavlova, G.A. Semenova, 1989; A.M. Seidman, 1990). The characteristics of the main substance of the nucleus pulposus correspond to the physical constants of a gel containing 83-85% water. Studies by a number of scientists have determined a decrease in the content of the water fraction of the gel with age. Thus, in newborns the nucleus pulposus contains up to 90% water, in a child of 11 years old - 86%, in an adult - 80%, in people over 70 years old - 60% water (W. Wasilev, W. Kuhnel, 1992; R. Putz , 1993). The gel contains proteoglycans, which, along with water and collagen, are the few components of the nucleus pulposus. Glycosaminoglycans in proteoglycan complexes are chondroitin sulfates and, in smaller quantities, keratan sulfate. The function of the chondroitin sulfate-containing region of a proteoglycan macromolecule is to create pressure associated with the spatial structure of the macromolecule. High imbibitional pressure in the intervertebral disc retains a large number of water molecules. The hydrophilicity of proteoglycan molecules ensures their spatial separation and separation of collagen fibrils. The resistance of the nucleus pulposus to compression is determined by the hydrophilic properties of proteoglycans and is directly proportional to the amount of bound water. Compression forces, acting on the pulpous substance, increase its internal pressure. Water, being incompressible, resists compression. The keratan sulfate region is capable of interacting with collagen fibrils and their glycoprotein sheaths to form cross-links. This enhances the spatial stabilization of proteoglycans and ensures the distribution of negatively charged terminal groups of glycosaminoglycans in the tissue, which is necessary for the transport of metabolites into the nucleus pulposus. The nucleus pulposus, surrounded by a fibrous ring, occupies up to 40% of the area of the intervertebral discs. It is to it that most of the forces transformed in the nucleus pulposus are distributed.
Fibrous ring formed by fibrous plates, which are located concentrically around the nucleus pulposus and are separated by a thin layer of matrix or layers of loose connective tissue. The number of plates varies from 10 to 24 (W.C. Horton, 1958). In the anterior part of the fibrous ring the number of plates reaches 22-24, and in the posterior part it decreases to 8-10 (A.A. Burukhin, 1983; K.L. Markolf, 1974). The plates of the anterior sections of the fibrous ring are located almost vertically, and the rear ones have the form of an arc, the convexity of which is directed posteriorly. The thickness of the anterior plates reaches 600 microns, the rear ones - 40 microns (N.N. Sak, 1991). The plates consist of bundles of densely packed collagen fibers of varying thickness from 70 nm or more (T.I. Pogozheva, 1985). Their arrangement is ordered and strictly oriented. The bundles of collagen fibers in the plates are biaxially oriented relative to the longitudinal axis of the spine at an angle of 120° (A. Peacock, 1952). The collagen fibers of the outer plates of the annulus fibrosus are woven into the deep fibers of the lateral longitudinal ligament of the spine. The fibers of the outer plates of the fibrous ring are attached to the bodies of adjacent vertebrae in the region of the marginal border - the limbus, and are also embedded in the bone tissue in the form of Sharpey fibers and fuse tightly with the bone. The fibrils of the internal plates of the annulus fibrosus are woven into the fibers of hyaline cartilage, separating the tissue of the intervertebral disc from the spongy bone of the vertebral bodies. This is how a “closed package” is formed, which closes the nucleus pulposus into a continuous fibrous frame between the fibrous ring along the periphery and the hyaline plates connected above and below by a single system of fibers. In the plates of the outer layers of the annulus fibrosus, alternating differently oriented fibers with different densities were identified: loosely packed ones alternate with densely packed ones. In dense layers, the fibers split and move into loosely packed layers, thus creating a single system of fibers. The loose layers are filled with tissue fluid and, being an elastic shock-absorbing tissue between dense layers, provide elasticity to the fibrous ring. The loose fibrous part of the annulus fibrosus is represented by thin, unoriented collagen and elastic fibers and a ground substance consisting mainly of chondroitin-4-6-sulfate and hyaluronic acid.
The height of the discs and spine is not constant throughout the day. After a night's rest, their height increases, and by the end of the day it decreases. The daily fluctuation in the length of the spine reaches 2 cm. Deformation intervertebral discs different under compression and tension. If, when compressed, the disks flatten by 1-2 mm, then when stretched, their height increases by 3-5 mm.
Normally, there is a physiological protrusion of the disc, which is that the outer edge of the fibrous ring, under the action of an axial load, protrudes beyond the line connecting the edges of adjacent vertebrae. This protrusion of the posterior edge of the disc towards the spinal canal is clearly visible on myelograms and alignment. usually, does not exceed 3 mm . Physiological protrusion of the disc increases with extension of the spine, disappears or decreases with flexion.
Pathological protrusion of the intervertebral disc differs from physiological the fact that widespread or local protrusion of the fibrous ring leads to a narrowing of the spinal canal and does not decrease with movements of the spine. Let's move on to consider the pathology of the intervertebral disc.
PATHOLOGY ( addition)
The main element of intervertebral disc degeneration is decrease in the number of protein glycans. Fragmentation of aggrecans and loss of glycosaminoglycans occur, which leads to a drop in osmotic pressure and, as a consequence, dehydration of the disc. However, even in degenerated discs, cells retain the ability to produce normal aggrecans.
Compared to protein glycans, the collagen composition of the disc changes to a lesser extent. Thus, the absolute amount of collagen in the disc, as a rule, does not change. However, redistribution of different types of collagen fibers is possible. In addition, the process of collagen denaturation occurs. However, by analogy with protein glycans, disc cell elements retain the ability to synthesize healthy collagen even in a degenerated intervertebral disc.
Loss of protein glycans and dehydration of the disc lead to a decrease in their shock-absorbing and supporting functions. The intervertebral discs decrease in height and gradually begin to prolapse into the spinal canal. Thus, improper redistribution of axial load on the endplates and annulus fibrosus can provoke discogenic pain. Degenerative-dystrophic changes are not limited only to the intervertebral disc, since changes in its height lead to pathological processes in neighboring formations. Thus, a decrease in the supporting function of the disc leads to overload in the facet joints, which contributes to the development of osteoarthritis and a decrease in the tension of the yellow ligaments, which leads to a decrease in their elasticity and corrugation. Disc prolapse, arthrosis of the facet joints and thickening (corrugation) of the yellow ligaments lead to spinal stenosis.
It has now been proven that compression of the root by an intervertebral hernia is not the only cause of radicular pain, since about 70% of people do not experience pain when the roots are compressed by a hernial protrusion. It is believed that in some cases, when a herniated disc comes into contact with a root, sensitization of the latter occurs due to aseptic (autoimmune) inflammation, the source of which is the cells of the affected disc.
One of the main causes of intervertebral disc degeneration is violation of adequate nutrition of its cellular elements. In vitro, it was shown that intervertebral disc cells are quite sensitive to oxygen deficiency, glucose and pH changes. Impaired cell function leads to changes in the composition of the intercellular matrix, which triggers and/or accelerates degenerative processes in the disc. Nutrition of the cells of the intervertebral disc occurs indirectly, since the blood vessels are located from them at a distance of up to 8 mm (capillaries of the vertebral bodies and outer plates of the fibrous ring.
Disk power failure can be due to many reasons: various anemias, atherosclerosis. In addition, metabolic disorders are observed with overload and insufficient load on the intervertebral disc. It is believed that in these cases there is a restructuring of the capillaries of the vertebral bodies and/or compaction of the endplates, which impedes the diffusion of nutrients. However, it should be noted that the degenerative process is associated only with incorrect execution of movements during physical activity, while their correct execution increases the intradiscal content of protein glycans.
There are several stages of degenerative-dystrophic changes in the intervertebral disc:
stage 0 - the disk is not modified
stage 1 - small tears of the inner 1/3 of the annular plates of the annulus fibrosus
stage 2 - significant destruction of the disc occurs, but the outer rings of the annulus fibrosus are preserved, which prevent herniation; there is no compression of the roots; at this stage, in addition to back pain, it may radiate to the legs to the level of the knee joint
stage 3 - cracks and tears are observed along the entire radius of the fibrous ring; the disc prolapses, causing tears of the posterior longitudinal ligament
Currently, this classification has been slightly modified, since it did not include compression syndromes.
Attempts to create a real classification, based on computed tomography data, began in 1990 and ended in 1996 (Schellhas):
stage 0 - the contrast agent injected into the center of the disc does not leave the boundaries of the nucleus pulposus
stage 1 - at this stage the contrast penetrates to the inner 1/3 of the annulus fibrosus
stage 2 - contrast extends to 2/3 of the annulus fibrosus
stage 3 - crack along the entire radius of the fibrous ring; the contrast penetrates to the outer plates of the fibrous ring; it is believed that pain occurs at this stage, since only the outer layers of the disc are innervated
stage 4 - there is a spread of contrast around the circumference (reminiscent of an anchor), but no more than 30°; this is due to the fact that radial discontinuities merge with concentric ones
stage 5 - contrast penetration into the epidural space occurs; Apparently, this provokes aseptic (autoimmune) inflammation in nearby soft tissues, which sometimes causes radiculopathy even without obvious signs of compression
Comparative anatomy data allow us to consider the intervertebral disc as articular cartilage, both components of which - the nucleus pulposus (pulpous) and the fibrous ring - are currently classified as fibrous cartilage, and the endplates of the vertebral bodies are likened to articular surfaces. The results of pathomorphological and histochemical studies made it possible to classify degenerative changes in the intervertebral disc as a multifactorial process. Disc degeneration is based on a genetic defect. Several genes responsible for the strength and quality of osteochondral structures have been identified: genes for the synthesis of type 9 collagen, aggrecan, vitamin D receptor, metalloproteinase. Genetic “breakage” is systemic in nature, which is confirmed by the high prevalence of intervertebral disc degeneration in patients with osteoarthritis. The trigger point for the development of degenerative changes in the disc is structural damage to the fibrous ring due to inadequate physical activity. The ineffectiveness of reparative processes in the intervertebral disc leads to an increase in degenerative changes and the appearance of pain. Normally, the posterior outer layers of the annulus fibrosus (1–3 mm) and the adjacent posterior longitudinal ligament are equipped with nociceptors. It has been proven that in a structurally changed disc, nociceptors penetrate the anterior part of the annulus fibrosus and nucleus pulposus, increasing the density of the nociceptive field. In vivo, nociceptor stimulation is supported not only by mechanical stress, but also by inflammation. A degeneratively altered disc produces pro-inflammatory cytokines IL-1, IL-6, IL-8, as well as TNF (tumor necrosis factor). Researchers emphasize that the contact of elements of the nucleus pulposus with nociceptors on the periphery of the annulus fibrosus helps to lower the threshold of excitability of nerve endings and increase their perception of pain. It is believed that the intervertebral disc is most associated with pain - at the stage of disc prolapse, with a decrease in its height, with the appearance of radial cracks in the fibrous ring. When intervertebral disc degeneration leads to herniation, a root or nerve becomes an additional cause of pain. Inflammatory agents produced by hernia cells increase the sensitivity of the root to mechanical pressure. Changing the pain threshold plays a role important role in the development of chronic pain.
Attempts have been made to identify the mechanisms of discogenic pain using discography. It has been shown that pain occurs with the introduction of substances like glycosaminoglycans and lactic acid, with compression of the roots, with hyperflexion of the facet joints. It has been suggested that the endplates may be the source of pain. Ohnmeiss in 1997 showed that complete rupture of the annulus fibrosus or disc herniation is not necessary for the occurrence of leg pain. He proved that even at stage 2 (when the outer plates of the annulus fibrosus remain intact), pain in the lower back occurs, radiating to the leg. It has now been proven that pain from one level can also come from underlying segments, for example, pathology of the L4–L5 disc can cause pain in the L2 dermatome.
The formation of pain syndrome during intervertebral disc herniation is influenced by:
violation of the biomechanics of the motor act
violation of posture and balance of the muscular-ligamentous-fascial apparatus
imbalance between the anterior and posterior muscle girdle
imbalances in the sacroiliac joints and other pelvic structures
It should be noted that the severity of clinical manifestations of intervertebral disc herniation is also due to the ratio of the size of the intervertebral hernia to the size of the spinal canal where the spinal cord and its roots are located. A favorable ratio is a small hernia (from 4 to 7 mm) and a wide spinal canal (up to 20 mm). And the lower this indicator, the less favorable the course of the disease, requiring a longer course of treatment.
In the case of an association of clinical manifestations of vertebral pathology with degenerative changes in the intervertebral disc, the term used in foreign literature is - "degenerative disc disease"- DBD (degenerative disk disease - DDD). DBD is a component of a single process – osteoarthritis of the spine.
Stages of formation of herniated intervertebral discs according to Decolux A.P. (1984):
protruding disk- bulging of the intervertebral disc, which has lost its elastic properties, into the spinal canal
failed disc- disc masses are located in the intervertebral space and compress the contents of the spinal canal through the intact posterior longitudinal ligament
prolapsed disc - most often detected in acute or traumatic hernia; partial prolapse of intervertebral disc masses into the spinal canal accompanying rupture of the posterior longitudinal ligament; direct compression of the spinal cord and roots
free sequestered disc- a disc lying loosely in the cavity of the spinal canal (in acute cases or as a result of trauma, it may be accompanied by a rupture of the meninges and intradural location of hernial masses
Most often in the lumbosacral spine, hernias occur in the intervertebral discs at the level of L5-S1 (48% of the total number of hernias at the lumbosacral level) and at the level of L4-L5 (46%). Less commonly, they are localized at the level of L3-L4 (5%) and most rarely at the level of L2-L3 (less than 1%).
Anatomical classification of disc herniations:
simple disc herniation
, in which the posterior longitudinal ligament is torn, and a larger or smaller portion of the disc, as well as the nucleus pulposus, protrudes into the spinal canal; can be in two forms:
- free disc herniation due to “breaking”: the contents of the disc pass through the posterior longitudinal ligament, but still remain partially attached to areas of the intervertebral disc that have not yet prolapsed or to the corresponding vertebral plane;
- wandering hernia– has no connection with the intervertebral space and moves freely in the spinal canal;
intermittent disc herniation
- occurs from an unusually strong mechanical load or from strong compression exerted on the spine, with its subsequent return to its original position after the load is removed, although the nucleus pulposus may remain permanently dislocated.
Topographic classification of disc herniation:
intraspinal disc herniation
– completely located in the spinal canal and emanating from the middle part of the disc, this hernia can be in three positions:
- in the dorsal medial(Stukey group I) causes compression of the spinal cord or cauda equina;
- paramdial (group II according to Stukey) causes unilateral or bilateral compression of the spinal cord;
- dosolateral(Stukey group III) compresses the spinal cord or intraspinal nerve roots, or the lateral part of the vertebral plate on one or both sides; this is the most common form, since at this level there is a weak zone in the disc - the posterior longitudinal ligament is reduced to several fibers located on the lateral parts;
disc herniation located inside the intervertebral foramen
, comes from the outer part of the disc and compresses the corresponding root towards the articular process;
lateral disc herniation
comes from the most lateral part of the disc and can cause various symptoms, provided it is located in the lower part of the cervical segment, compressing the vertebral artery and vertebral nerve;
ventral disc herniation
, emanating from the ventral edge, does not give any symptoms and is therefore of no interest.
According to the direction of prolapse of the sequestrum, hernias are divided into (Handbook of Vertebroneurology, Kuznetsov V.F. 2000):
anterolateral, which are located outside the anterior semicircle of the vertebral bodies, peel off or perforate the anterior longitudinal ligament, can cause sympathalgic syndrome when the paravertebral sympathetic chain is involved in the process;
posterolateral, which pierce the posterior half of the fibrous ring:
- median hernias – in the midline;
- paramedian – close to the midline;
- lateral hernias(foraminal) - on the side of the midline (from the posterior longitudinal ligament).
Sometimes two or more types of disc herniations are combined. ABOUT vertebral body hernia (Schmorl's hernia) cm. .
Intervertebral disc degeneration is visualized by magnetic resonance imaging (MRI). The stages of disc degeneration are described (D. Schlenska et al.):
M0 – norm; nucleus pulposus spherical or ovoid in shape
M1 – loal (segmental) decrease in the degree of luminescence
M2 – disc degeneration; disappearance of the glow of the nucleus pulposus
Types (stages) of vertebral body lesions associated with intervertebral disc degeneration, according to MRI data:
Type 1 – a decrease in signal intensity on T1-weighted images and an increase in signal intensity on T2-weighted images indicate inflammatory processes in the bone marrow of the vertebrae
Type 2 - an increase in signal intensity on T1 and T2-weighted images indicates the replacement of normal bone marrow with adipose tissue
Type 3 - a decrease in signal intensity on T1 and T2 - weighted images indicates processes of osteosclerosis
The main diagnostic criteria for intervertebral disc herniation are:
the presence of vertebrogenic syndrome, manifested by pain, limited mobility and deformities (antalgic scoliosis) in the affected part of the spine; tonic tension of the paravertebral muscles
sensory disorders in the area of the neurometamere of the affected root
motor disturbances in the muscles innervated by the affected root
decreased or lost reflexes
the presence of relatively deep biomechanical disturbances in motor compensation
data from computed tomography (CT), magnetic resonance imaging (MRI) or radiographic examination, verifying the pathology of the intervertebral disc, spinal canal and intervertebral foramina
data from electroneurophysiological studies (F-wave, H-reflex, somatosensory evoked potentials, transcranial magnetic stimulation), recording conduction disturbances along the root, as well as the results of needle electromyography with analysis of action potentials of motor units, allowing to establish the presence of denervation changes in the muscles of the affected myotome
Clinical significance of the size of protrusions and herniations of the intervertebral disc:
cervical section of the spinal column:
1-2 mm- small protrusion size
3-4 mm- average protrusion size(urgent outpatient treatment required)
5-6 mm- (outpatient treatment is still possible)
6-7 mm and more- large size of intervertebral hernia(requires surgical treatment)
lumbar and thoracic
sections of the spinal column:
1-5 mm- small protrusion size(outpatient treatment is required, treatment at home is possible: spinal traction and special gymnastics)
6-8 mm- average size of intervertebral hernia(outpatient treatment required, surgical treatment not indicated)
9-12 mm- large size of intervertebral hernia(urgent outpatient treatment is required, surgical treatment only for symptoms of compression of the spinal cord and elements of the cauda equina)
more than 12 mm- large prolapse or sequestered hernia(outpatient treatment is possible, but on the condition that if symptoms of compression of the spinal cord and elements of the cauda equina appear, the patient has the opportunity to undergo surgery the next day; with symptoms of spinal cord compression and a number of MRI signs, immediate surgical treatment is required)
Note: when the spinal canal is narrowed, a smaller intervertebral hernia behaves like a larger one.
There is such a rule, What disc bulge is considered severe and clinically significant if it exceeds 25% anteroposterior diameter of the spinal canal (according to other authors - if it exceeds 15% anteroposterior diameter of the spinal canal) or narrows the canal to a critical level 10 mm.
Periodization of compression manifestations of spinal osteochondrosis against the background of intervertebral disc herniation:
acute period (stage of exudative inflammation) - duration 5-7 days; the hernial protrusion swells - the swelling reaches a maximum on days 3-5, increases in size, compressing the contents of the epidural space, including the roots, the vessels that feed them, as well as the vertebral venous plexus; sometimes the hernial sac ruptures and its contents spill into the epidural space, leading to the development of reactive epiduritis or down along the posterior longitudinal ligament; pain gradually increases; any movement causes unbearable suffering; The first night is especially difficult for patients; the main question that needs to be resolved in this situation is whether or not the patient needs urgent surgical intervention; absolute indications for surgery are: myeloschaemia or spinal stroke; reactive epiduritis; compression of two or more roots along the length; pelvic disorders
subacute period(2-3 weeks) - the exudative phase of inflammation is replaced by a productive one; adhesions gradually form around the hernia, which deform the epidural space, compress the roots, and sometimes fix them to the surrounding ligaments and membranes
early recovery period- 4-6 weeks
late recovery period(6 weeks - six months) - the most unpredictable period; the patient feels healthy, but the disc has not yet healed; To avoid unpleasant consequences, during any physical activity it is recommended to wear a fixation belt
To characterize the degree of disc protrusion, contradictory terms are used: “disc herniation”, “ disc protrusion", "disc prolapse". Some authors use them almost as synonyms. Others suggest using the term “disc protrusion” to refer to the initial stage of disc protrusion, when the nucleus pulposus has not yet broken through the outer layers of the annulus fibrosus, the term “disc herniation” only when the nucleus pulposus or its fragments have broken through the outer layers of the annulus fibrosus, and the term “disc prolapse” only refers to the prolapse of hernial material that has lost its connection with the disc into the spinal canal. Still others propose to distinguish between intrusions, in which the outer layers of the annulus fibrosus remain intact, and extrusions, in which the hernial material breaks through the outer layers of the annulus fibrosus and the posterior longitudinal ligament into the spinal canna.
Russian authors(Magomedov M.K., Golovatenko-Abramov K.V., 2003), based on the use of Latin roots in term formation, suggest the use of the following terms:
“protrusion” (prolapse) – protrusion of the intervertebral disc beyond the vertebral bodies due to stretching of the fibrous ring without significant ruptures. At the same time, the authors point out that protrusion and prolapse are identical concepts and can be used as synonyms;
“extrusion” - protrusion of the disc caused by rupture of the FC and the release of part of the nucleus pulposus through the resulting defect, but maintaining the integrity of the posterior longitudinal ligament;
“true hernia”, in which not only the fibrous ring, but also the posterior longitudinal ligament ruptures.
Japanese authors(Matsui Y., Maeda M., Nakagami W. et al., 1998; Takashi I., Takafumi N., Tarou K. et al., 1996) distinguish four types of hernial protrusions, using the following terms to designate them:
“protrusion" (P-type, P-type) - protrusion of the disc in which there is no rupture of the fibrous ring or (if present) does not extend to its outer parts;
« subligamentous extrusion"(SE-type, SE-type) - a hernia in which perforation of the fibrous ring occurs while preserving the posterior longitudinal ligament;
« transligamentous extrusion"(TE-type, TE-type) - a hernia that ruptures not only the fibrous ring, but also the posterior longitudinal ligament;
“sequestration” (C-type, S-type) – a hernia in which part of the nucleus pulposus ruptures the posterior longitudinal ligament and is sequestered in the epidural space.
Swedish authors(Jonsson B., Stromqvist B., 1996; Jonsson B., Jonsson R., Stromqvist B., 1998) there are two main types of hernial protrusions - so-called contained hernias and noncontained hernias. The first group includes: “protrusion” - a protrusion in which ruptures of the fibrous ring are absent or minimally expressed; and “prolapse” - dislocation of the material of the nucleus pulposus to the posterior longitudinal ligament with complete or almost complete rupture of the fibrous ring. The second group of hernial protrusions is represented by extrusion and sequestration. During extrusion, the posterior longitudinal ligament is ruptured, but the fallen fragment of the nucleus pulposus remains connected to the rest of it, in contrast to sequestration, in which this fragment separates and becomes free.
One of the most clear schemes was proposed by J. McCulloch and E. Transfeldt (1997), who distinguish:
1) disc protrusion– as the initial stage of disc herniation, in which all disc structures, including the annulus fibrosus, are displaced beyond the line connecting the edges of two adjacent vertebrae, but the outer layers of the annulus fibrosus remain intact, the material of the nucleus pulposus can penetrate into the inner layers of the annulus fibrosus (intrusion);
2) subannular (subligamentary) extrusion
, in which the damaged nucleus plosus or its fragments are squeezed out through a crack in the annulus fibrosus, but do not break through the outermost fibers of the annulus fibrosus and the posterior longitudinal ligament, although they can move up or down in relation to the disc;
3) transannular (transligamentary) extrusion
, in which the nucleus pulposus or its fragments break through the outer fibers of the annulus fibrosus and/or the posterior longitudinal ligament, but maintain connection with the disc;
4) prolapse (loss)
, characterized by sequestration of the hernia with loss of connection with the remaining disc material and prolapse into the spinal canal.
A review of the terminology of disc herniations would not be complete without noting that, according to a number of authors, the term “ disc herniation» can be used when the displacement of the disc material occupies less than 50% of its circumference. In this case, the hernia can be local (focal), if it occupies up to 25% of the disc circumference, or diffuse, occupying 25-50%. A protrusion of more than 50% of the disc circumference is not a hernia, but is called “ disc bulging"(bulging disk).
To overcome the terminological confusion, they propose (a team of authors from the Department of Neurology of the Russian Medical Academy of Postgraduate Education: dr med. Sciences, Professor V.N. Stock; Dr. med. Sci. Professor O.S. Levin; Ph.D. honey. Sci. Associate Professor B.A. Borisov, Yu.V. Pavlov; Ph.D. honey. Sciences I. G. Smolentseva; Dr. med. Sciences, Professor N.V. Fedorov) when formulating a diagnosis, use only one term - “ disc herniation» . In this case, a “disc herniation” can be understood as any protrusion of the edge of the disc beyond the line connecting the edges of adjacent vertebrae, which exceeds physiological limits (normally no more than 2-3 mm).
To clarify the degree of disc herniation, the same team of authors (employees of the Department of Neurology of the Russian Medical Academy of Postgraduate Education: Doctor of Medical Sciences, Professor V.N. Shtok; Doctor of Medical Sciences, Professor O.S. Levin; Candidate of Medical Sciences Scientific Associate Professor B.A. Borisov, Yu.V. Pavlov; Candidate of Medical Sciences I.G. Smolentseva; Doctor of Medical Sciences, Professor N.V. Fedorova) propose the following scheme:
I degree– slight protrusion of the fibrous ring without displacement of the posterior longitudinal ligament;
II degree– medium-sized protrusion of the fibrous ring. occupying no more than two-thirds of the anterior epidural space;
III degree– a large disc herniation that displaces the spinal cord and dural sac posteriorly;
IV degree– massive disc herniation. compressing the spinal cord or dural sac.
!!! It should be emphasized that the presence of tension symptoms, radicular symptoms, and local pain does not necessarily indicate that a disc herniation is the cause of the pain syndrome. Diagnosis of a disc herniation as the cause of a neurological syndrome is possible only when the clinical picture corresponds to the level and degree of disc protrusion.
Very often, when visiting a therapist with characteristic complaints of pain in the neck and lower back, the patient receives a standard referral for an x-ray. Based on the results of this examination, a professional opinion from a radiologist is given. And it very often includes such a term as reducing the height of the disc in the lumbar or cervical spine. In the thoracic and sacral spine, this pathology is less common. This is due to limited mobility in these departments.
A decrease in the height of the intervertebral discs speaks primarily of severe dehydration (dehydration) of cartilage tissue. Secondly, this is a characteristic sign of disc protrusion. The condition is a complication of long-term osteochondrosis. In turn, protrusion of the fibrous ring is a risk of developing hernial protrusion of the nucleus pulposus. Moreover, a disc rupture can happen at any time. It is impossible to predict the moment of this neurological catastrophe. Therefore, it is necessary to take timely measures to carry out effective and correct treatment.
A decrease in the height of the intervertebral disc is always accompanied by prolapse and protrusion of its boundaries beyond the vertebral bodies. You should not think that this pathology will go away on its own. No, the condition will only get worse in the future. It is possible to restore the shape of the fibrous ring and its shock-absorbing abilities only by normalizing diffuse nutrition. To do this, you need to activate the muscle frame of the back. And first you need to relieve the pain syndrome. This is a treatment regimen using manual therapy methods in our clinic.
Moderate decrease in spinal disc height
A decrease in the height of the spinal disc does not always indicate that a stable protrusion has already formed. In the early stages of the pathological process, this phenomenon may be transient in nature. Those. under the influence of negative factors, such as emotional stress or physical overload, dehydration of cartilage tissue occurs. Then, as the general condition improves, hydration is restored through diffuse exchange, and the height of the disc is restored.
But even a moderate decrease in the height of the discs should be considered as a negative signal to begin the process of restoring the spinal column. In the absence of osteochondrosis and degenerative changes in the cartilage fibers, patients cannot show any pathological signs. Even under the influence of extreme factors. Even after very heavy physical activity, if the cartilage tissue is healthy, the intervertebral discs restore their anatomical shape within 2-5 hours.
Reduced height of lumbar intervertebral discs
Most often modern man An X-ray image shows a decrease in the height of the intervertebral disc in the lumbar spine, and this is far from an accident. There are several reasons for the increased risk of destruction of the fibrous ring in this section:
- sedentary lifestyle and lack of regular physical activity on the muscular frame;
- poor nutrition when the diet is rich in fast carbohydrates and refined foods and does not contain fresh vegetables and fruits, sea fish and omega fatty acids;
- constant injury to cartilage discs during sudden movements, bending, jumping;
- wearing shoes with heels (in women) deforms the entire configuration of the lumbar spine, shifting the physiological center of gravity anteriorly;
- incorrect positioning of the foot in the form of flat feet and club feet;
- curvature of the spine in the associated sections;
- inflammatory processes, rheumatism, etc.
It is worth noting that a decrease in the height of the lumbar discs quite quickly leads to the formation of a hernial protrusion of the nucleus pulposus. Therefore, if there are radiographic signs of decreased intervertebral disc height, effective treatment should be started immediately.
At our manual therapy clinic, patients are offered a free consultation with a leading specialist. During the appointment, the doctor will talk about how the treatment can be carried out and what potential results can be obtained.
Reduced height of intervertebral discs of the cervical spine
Very often, the images reveal a decrease in the height of the cervical discs C4-C5 and C5-C6, since they bear the main static load when performing certain actions during monotonous work. Accordingly, people engaged in sedentary work in offices are susceptible to pathology.
A decrease in the height of the cervical discs is accompanied by serious pain in the collar area. At the end of the working day, the patient experiences severe tension in the neck muscles and an attack of headache localized in the back of the head. There may be sensations of muscle weakness and numbness in the upper extremities.
If the decrease in the height of the intervertebral discs of the cervical spine is not treated, this can lead to the development of vertebral artery syndrome. It will be expressed in impaired blood supply to the posterior cerebral structures. May provoke increased blood pressure, severe headaches, dizziness, decreased mental performance, and depression.
To treat cervical protrusion, it is better to use manual therapy methods. This will allow you to effectively and safely restore the height of the intervertebral disc and eliminate the risk of developing concomitant pathologies.
Osteochondrosis is the most severe form of degenerative-dystrophic lesion of the intervertebral disc. Osteochondrosis of the intervertebral discs most often develops in the lumbar and cervical spine. In each part of the spinal column, osteochondrosis has its own typical localizations and peculiar features.
The high incidence of damage to the caudal lumbar discs is explained by the predominance of load on this segment of the spine during all kinds of rotations and bending of the body, when lifting and carrying heavy objects, as well as in overweight subjects.
In the cervical spine, lesions of several discs develop much more often than in the lumbar spine, which is apparently explained by the high mobility of this section. The vast majority of patients have osteochondrosis of the disc, which is located at the height of cervical lordosis and is most significantly loaded with all movements of the head and neck. This disc is affected in isolation or in combination with neighboring discs, the frequency of which decreases with distance from the C 5 _ b disc. We did not observe any lesions of the first cervical disc, i.e. disc C 2 _ 3. The mobility of the spine in the area of this disc and its load are the least significant.
In the thoracic spine, different relationships are usually observed. Many patients experience damage to several mid-thoracic discs located at the height of kyphosis; often the process is localized in the lower part of the thoracic spine. Analysis of our observations shows that osteochondrosis of the lower thoracic spine occurs most often with static scoliosis and is associated with the characteristics of the resulting load.
Three of the 137 patients in this group developed osteochondrosis of the disc located immediately caudal to the two vertebrae, which were in a state of block due to concrescence. Due to the loss of the corresponding motor segment, the underlying disc found itself in conditions of constant overload and therefore suffered degenerative-dystrophic damage.
The presented data show that osteochondrosis of the intervertebral discs develops, as a rule, in places subject to the most significant load and, therefore, constant exposure to multiple microtraumas.
Causes and symptoms
Osteochondrosis is based on complex biochemical processes that are still poorly understood. The gelatinous core consists of polysaccharides, hyaluronic acid and proteins. With age and under the influence of mechanical factors, the main substance of the core depolymerizes and therefore loses its compactness. This is where degenerative-dystrophic damage to the gelatinous nucleus begins.
Under the name chondrosis, Schmorl identified stage I of the disease, during which the pathological process is limited to the disc, and the term osteochondrosis designated stage II, characterized by changes in the vertebral bodies. The pathomorphological picture of the entire process of development of osteochondrosis was carefully traced by Hildebrand.
First, degeneration of the gelatinous core occurs, it becomes drier, cracks and becomes fiberless, its turgor gradually decreases and finally disappears. With advanced damage, the gelatinous nucleus disintegrates. However, long before this, the remaining elements of the disc and the body of adjacent vertebrae are gradually involved in the pathological process.
The gelatinous nucleus, which has lost its main quality - elasticity, is flattened under the influence of pressure from the bodies of adjacent vertebrae, which are gradually brought closer together due to the prevalence of the influence of the ligamentous apparatus, as well as a decrease or even loss of the disc's resistance to the load constantly falling on the spine. As a result, the height of the intervertebral disc gradually decreases, and parts of the disintegrating gelatinous nucleus evenly shift in all directions and bend the fibers of the fibrous ring outward. The latter also undergo degeneration, become fibrous and rupture, but in some places the cartilaginous cells of the fibrous ring proliferate. Due to the loss of the spring action of the gelatinous nucleus, the hyaline plates and adjacent areas of the vertebral bodies are subject to constant trauma. Therefore, degeneration of hyaline plates begins: in some areas they are replaced by fibrous cartilage, cracks and tears appear in them, and in some places entire pieces of hyaline plates are torn off. Areas of disruption of the integrity of the gelatinous nucleus, fibrous ring and hyaline plates sometimes merge into peculiar cavities that cross the intervertebral disc in different directions.
This stage of the disease is usually asymptomatic for a long time, since the intervertebral discs are devoid of nerve endings. Clinical disorders appear after the pathological process takes into its zone ligaments richly supplied with nerve endings, or causes secondary changes that have an adverse effect on the roots, ganglia, spinal nerves, and very rarely directly on the spinal cord.
At the onset of osteochondrosis, clinical symptoms rarely appear, only when the affected disc prolapses posteriorly and when posterior cartilaginous nodes form.
The degenerated disc gradually flattens and bulges in all directions. It is possible that its prolapse posteriorly is sometimes more significant than in other areas, since the ventral section of the fibrous ring is thicker and denser than the dorsal one and provides greater resistance. The more pliable dorsal section of the annulus fibrosus is strengthened by the posterior longitudinal ligament, but only in the central area. In addition, in the lower cervical and lumbar spine, where osteochondrosis most often develops, the posterior parts of the discs are subject to the greatest load due to lordosis and are therefore affected first. The idea of a greater frequency and severity of posterior disc prolapse may also be due to the fact that it is at such ratios that clinical symptoms appear, leading the patient to, while prolapse of the lateral and anterior parts of the disc does not cause any unpleasant sensations for a long time.
When the substance of the disc prolapses posteriorly, deformation of the anterior wall of the spinal canal occurs due to a kind of transverse ridge protruding from the side of the disc. Depending on its size and the presence or absence of secondary disturbances of venous outflow, cerebrospinal fluid circulation and other similar phenomena, posterior prolapse of the disc substance can be asymptomatic for a long time or cause more or less significant neurological disorders.
Clinical symptoms are often explained not by prolapse of the entire thickness of the disc, but by the appearance of individual cartilaginous nodes resulting from protrusion of the disc substance through tears in the outer fibers of the annulus fibrosus. Schmorl's studies have shown that with a simultaneous rupture of the posterior longitudinal ligament, such a node is embedded in the spinal canal and puts pressure on the dural sac. When the posterior longitudinal ligament is preserved, a local breakthrough of the disc substance occurs outward from it. As a result, a posterolateral node is formed, exerting local pressure on the corresponding root, ganglion or nerve. It is possible that symmetrical posterolateral nodes may appear, breaking through on the sides of the posterior longitudinal ligament and compressing both corresponding roots.
The substance of the disc, which has penetrated beyond the fibrous ring, can proliferate and then the node gradually increases, in other cases it remains unchanged for a long time or gradually shrinks, grows with connective tissue, decreases, sometimes calcifies or even ossifies.
As a result of these protrusions of the disc substance into the spinal canal or intervertebral foramina, clinical symptoms arise, varying depending on the level, location and size of the node, the presence and severity of secondary circulatory disorders, changes in liquor circulation, and involvement of the spinal ganglia in the process.
Diagnostics
X-ray examination of stage I osteochondrosis, in accordance with the above pathomorphological data, reveals a decrease in the disc. At first, it is very insignificant and is detected only when compared with neighboring discs by the violation of the uniform increase in the height of each underlying disc compared with the overlying one, which normally occurs starting from the third thoracic vertebra, and in the cervical spine - starting from the first disc.
At the same time, a violation of the physiological curvature of this part of the spinal column is often detected. According to the most common localization of the lesion in the caudal lumbar or lower cervical discs, the physiological lordosis of these sections decreases, up to complete straightening, or even a slight kyphosis occurs at the level of the affected disc. When the transitional thoracolumbar discs are affected, the so-called string symptom is observed, which consists in straightening the overlying part of the spinal column.
During functional tests, which consist of x-rays of the spine in the position of maximum flexion and full extension, at this stage of the disease the height of the disc ceases to change. Normally, when the spine moves, the disc decreases on the side of greater curvature, i.e., in the concavity region, and its height increases at the height of the arc of lesser curvature, i.e., in the convexity region. The absence of these changes is an indication of the presence of osteochondrosis, as it indicates a loss of function of the gelatinous nucleus, which normally moves during movements. In addition, at the moment of extension, the body of the overlying vertebra with disc chondrosis sometimes moves slightly posteriorly, which normally does not happen.
It is extremely rare that on radiographs of living people, areas of irregularly shaped clearing are detected in the thickness of the affected disc, which are an image of the previously mentioned cavities. Only a few of these have been published. The image of such cavities in the lower cervical discs appeared when the head was thrown back and disappeared when it was tilted anteriorly, i.e., the cavities were discovered during a functional test. This symptom has no practical significance due to its extreme rarity.
Prolapse of the disc substance and its isolated breakthroughs into the spinal canal and intervertebral foramina at the beginning of the pathological process are usually not detected radiographically and can only be suspected when the corresponding neurological symptoms and disc reduction are combined. On high-quality lateral radiographs of the spine with clear differentiation of the image of soft tissues, it is occasionally possible to capture a direct image of the anterior and posterior parts of the disc and detect its posterior prolapse. The same thing is sometimes revealed on sagittal tomograms. Calcified nodes were found in some patients. Myelography and peridurography, as a rule, make it possible to detect these changes in the filling defect, but do not always provide absolutely reliable data and are permissible only in the preoperative period if there are indications for surgical intervention. The best results are obtained by pneumomyelography.
Due to a decrease in the spring function of the affected disc over time, reactive and compensatory phenomena develop in adjacent areas of the vertebral bodies that are subject to constant trauma. More often they occur when the disc is clearly lowered, and sometimes they are detected early, when the height of the disc is slightly changed, but its function is apparently already clearly impaired.
These reactive and compensatory phenomena consist primarily of an increase in the adjacent surfaces of the vertebral bodies due to bone marginal growths formed as a result of proliferation and ossification of Sharpey's fibers of the fibrous ring. The outer fibers of the fibrous ring are, as it were, squeezed out by the disintegrating disc, take a direction perpendicular to the longitudinal axis of the spine, and are gradually transformed into bone tissue, due to which the limbus expands.
Thus, the cranial and caudal surfaces of the adjacent vertebral bodies increase due to the bony marginal growths extending directly from the limbus, continuing it and located perpendicular to the longitudinal axis of the spine. These bone growths, completely typical of osteochondrosis, are clearly visible on appropriate preparations and on radiographs. These bone marginal growths, like those formed during deforming arthrosis, increasing the size of the corresponding surfaces of the vertebral bodies, reduce trauma to bone tissue, since all kinds of forces falling on the corresponding segment are distributed under these conditions over a larger area.
Posterior bony marginal growths are clearly visible on lateral radiographs of the spine. However, the photographs in this projection produce the same image of the bony marginal growths, both spreading along the entire posterior portion of the limbus, and located only in its center or in some lateral section. To clarify the topography, oblique photographs are used, in which the image of the intervertebral foramina is displayed outside the image of the spinal canal. In particular, when radiography of presacral discs, Kovacs placement is used. These images clearly reveal bone growths protruding into the intervertebral foramen.
Even more convincing data are obtained from a layer-by-layer study of the spine. First, a sagittal tomogram of the spine is performed through the median plane, i.e., through the spinous processes and central sections of the vertebral bodies, and then the same tomograms, retreating 5 mm to the right and left from the median plane. Often these 3 tomograms give a clear idea of the topography of the posterior bone growths; sometimes it is necessary to isolate two more layers, located 5 mm outward from each of the previously examined lateral layers.
Bone growths that have arisen along the entire posterior portion of the limbus are clearly visible in this entire series of tomograms and indicate a significant breakthrough of the disc substance into the spinal canal and a relatively long history of this condition. In such patients, bone growths are usually present on the bodies of both adjacent vertebrae. With a more limited breakthrough, formed as a separate node, bone growths more often occur along the edge of the body of one vertebra, apparently, rather the overlying one, are located in a small area and therefore are revealed only by tomography of the corresponding layer. Sometimes they capture one half of the posterior portion of the limbus and penetrate the corresponding intervertebral foramen.
Thus, in these patients we find: a decrease in the height of the affected disc, a decrease in the physiological lordosis of this part of the spine, up to kyphotic curvature, and bone growths in the posterior limbus of one or both adjacent vertebrae.
Such patients complain of constant pain in the area of the affected part of the spine, sometimes sharply aggravated by the lumbago type, especially after any unsuccessful forced turn, strain, or lifting of weight. In some patients, when moving the spine, a distinct crunching sensation is felt in the affected part of the spine. Later, and sometimes from the very beginning of the clinical manifestations of the disease, neurological symptoms appear, forming a picture of persistently recurrent chronic radiculitis. Sometimes, mainly with damage to the cervical discs, other more complex neurological syndromes develop, depending on the addition of various circulatory disorders, involvement of the spinal cord membranes, sympathetic nodes and other formations in the pathological process.
With this course of osteochondrosis, the x-ray picture is usually naturally combined with corresponding neurological symptoms. However, there is no permanent parallelism between them. Due to the mechanisms that have not yet been sufficiently studied, with the same severity of the posterior breakthrough of the intervertebral disc, some patients experience pronounced neurological disorders, while others have significantly lesser ones. Nevertheless, the described x-ray picture always indicates the possibility of the appearance of severe neurological disorders under the influence of any additional burden. Therefore, in order to prevent disability, significant and even moderate deadlifts should be excluded from the work activities of such patients. With severe, persistently recurrent neurological disorders and significant pain, the ability to work of such patients is limited in all professions in which work requires prolonged standing, long walking, and most importantly, lifting and carrying heavy objects. With a sharp severity and duration of these phenomena, patients lose their ability to work, as they are unable to even sit for several hours in a row.
Clinical examples
The following two observations illustrate the points presented.
Patient M., 36 years old, a carpenter by profession, complains of constant pain in the cervical spine, which at times worsens significantly and radiates to both upper limbs. The pain started for no apparent reason about 3 years ago. Neck movements are accompanied by a crunching sound. Neurologically: syndrome of moderately severe chronic bilateral cervical radiculitis. The patient was treated for a long time in neurological and outpatient clinics.
X-ray examination revealed: a moderate decrease in the disc, bone growths in the posterior parts of the limbus of the adjacent surfaces of the bodies and Cb and straightening of the physiological lordosis of the cervical spine with slight kyphosis at the level of the affected disc. To clarify the topography of the bony marginal growths, a layer-by-layer study of the cervical spine in the sagittal plane was performed. Bone marginal growths were revealed both on a tomogram made through the median plane, and on tomograms that identified layers located 5 mm to the right and left of it.
Clinical and radiological diagnosis: osteochondrosis of the C 5 _6 disc with posterior prolapse of its substance along the entire diameter of the anterior wall of the spinal canal at this level and with secondary chronic radicular syndrome with frequent exacerbations.
As a result of the study, it was established that the patient’s ability to work is limited and he cannot continue working as a carpenter. After this, the patient was recognized as a group III disabled person and was sent to a vocational school to acquire the specialty of a standard setter.
Patient G., 51 years old, a draftsman by profession, has not worked for the last 10 years. At the age of 37 years, for the first time, when lifting quite heavy weights, she began to experience pain in the lumbosacral region; they gradually increased and periodically sharply worsened, confining the patient to bed for several months. After 4 years, the patient was recognized as disabled group II. Since then she has not served and cannot do any housework.
Clinically: severe, persistently worsening chronic right-sided lumbosacral radiculitis. The patient was treated many times in neurological clinics and sanatoriums, but no lasting results were obtained.
X-rays revealed: a moderate decrease in the L 4 __ 5 disc and bone marginal growths at the posterior portion of the limbus of the caudal surface. A tomogram highlighting the median plane, as well as a tomogram taken 5 mm to the right of it, revealed significant bone growths, but Tomograms taken to the left of the median plane did not reveal bone growths.
When analyzing a series of radiographs taken over 14 years, it was found that these bone growths appeared 5 years ago and have not changed significantly since then.
During the first 5 years of the disease, the intervertebral joints of this segment were not changed, but later, as the disc decreased, subluxation of the right intervertebral joint occurred, its deforming arthrosis arose and neoarthrosis of the right upper articular process of L 5 with the lower surface of the corresponding arch root and transverse process was formed L 4. Over time, the articular surfaces and neoarthrosis gradually increase.
Bone growths, similar to those formed at the posterior portion of the limbus, are often observed around the circumference of the lateral and anterior parts of the edge. Such small bony marginal growths, located perpendicular to the axis of the spinal column, occur in all localizations of osteochondrosis. However, they are most typical for lesions of the thoracic spine, especially the middle thoracic segments, where the anterior portions of the intervertebral discs are affected. Therefore, with the development of osteochondrosis, it is these areas of the discs that are compressed first and most significantly, and it is in these areas that the first bone marginal growths appear. As a rule, several adjacent segments are simultaneously affected, which leads to a distinct increase in kyphosis. Thus, with osteochondrosis of the thoracic discs, the physiological curvature of the spine increases, in contrast to the cervical and lumbar regions, the physiological curvatures of which decrease with osteochondrosis. Such a mildly expressed degenerative-dystrophic process underlies senile kyphosis.
Due to these local features, osteochondrosis of the thoracic segments, especially the middle ones, often remains asymptomatic for a long time or causes moderate back pain and increased fatigue of the corresponding muscles. Clinical examination reveals only increased physiological kyphosis. The working capacity of such patients, as a rule, is preserved if osteochondrosis does not show a tendency to a significant increase.
Analysis of radiological observations and macerated preparations of the spine shows that as osteochondrosis develops, the anterior longitudinal ligament is gradually involved in the formation of bone marginal growths, under the influence of ongoing load. This occurs because the products of disc decay, protruding beyond its normal boundaries, penetrate under the anterior longitudinal ligament and peel it off. The anterior longitudinal ligament, being the periosteum, responds to constant irritation by the bone formation process. Due to this, new bone layers appear above the limbus of the overlying vertebra and below the limbus of the underlying one. Merging with previously formed bone growths, these new bone masses enlarge them and give them the shape of a wedge, the base of which merges with the vertebral body.
Such bony marginal growths are much larger than those formed due to the fibrous ring; they arise only in the area where the anterior longitudinal ligament is localized, i.e., on the anterior and lateral surfaces of the vertebral bodies, and do not develop near the posterior portion of the limbus. As a rule, they form in any one area of a given segment of the spine, in the direction of which the most massive rejection of the disintegrating substance of the disc occurs. This section corresponds to the area of the highest load of the segment under given static-dynamic conditions.
Despite the participation of the anterior longitudinal ligament in the formation of these bone growths, they still differ significantly from spondylosis, primarily in that they continue to maintain a transverse direction in relation to the length of the spine, while with spondylosis, bone growths, even very significant ones, are directed along the vertebral column. pillar
Thus, bone marginal growths occur in osteochondrosis of the disc as a result of a complex reactive and compensatory process. They are created mainly due to the ossification of the fibers of the annulus fibrosus, moving outward, and therefore are located perpendicular to the spine. Subsequently, the anterior longitudinal ligament is also involved in the pathological process. Due to this source of ossification, the massiveness of bone growths increases, their outer part is created, but their general character does not change. They remain perpendicular to the spine and are shaped like a wedge, the base of which merges with the anterior or lateral surface of the vertebral body, and the apex faces outward.
Bone growths in osteochondrosis are a kind of “functional structures”; they arise as a manifestation of compensatory processes developing in the fibrous ring, vertebral body and in the anterior longitudinal ligament and aimed at strengthening the affected segment of the spine. Their morphological picture has been well studied by pathomorphologists, although some of them considered these bone growths to be a manifestation of spondylosis, that is, changes that, in isolated form, differ significantly from osteochondrosis. These pathomorphological data are largely supplemented by the results of radiological observations.
Bone marginal growths, typical of osteochondrosis, sometimes turn out to be sharply expressed during the period of the disease when the disc is slightly reduced. With a slow torpid course of osteochondrosis, between these wedge-shaped bone growths sometimes an area of calcification appears in the peripheral fibers of the fibrous ring, most significantly pushed outwards.
This condition was discovered, for example, during repeated studies over 10 years of Ms. K., 50 years old, a cleaner, complaining of constant moderate back pain. The pain intensifies after exertion and being in a damp, cold environment. Neurological examination revealed no pathological symptoms. X-ray: slight reduction of the disc, bony marginal growths that expand the anterior parts of the limbus of the adjacent surfaces of the bodies of these vertebrae, and calcification of the anterior portion of the fibrous ring, significantly displaced anteriorly. The bone growths are wedge-shaped.
Clinical and radiological diagnosis: moderate osteochondrosis with no tendency to progress. The patient can continue to work as a cleaner with restrictions on lifting and carrying heavy objects through the VKK.
With osteochondrosis of the cervical discs, bone marginal growths occasionally protrude so significantly anteriorly that they displace the trachea and esophagus, causing corresponding clinical symptoms.
As the disease progresses, the disc is gradually completely destroyed and the bodies of adjacent vertebrae move closer together. Then the adjacent surfaces of bone growths are directly adjacent to one another, between them there are elements of proliferation and decay of cartilaginous tissue.
Due to the pathological mobility of the spine in the area of the destroyed disc, the adjacent surfaces of the bodies of the corresponding vertebrae rub against each other, including their parts that arise due to bone marginal growths. Therefore, bone growths in osteochondrosis usually do not merge into a single formation and do not lead to a block of vertebral bodies, unlike bone growths in spondylosis, which in an advanced stage in the form of peculiar bridges completely connect the corresponding sections of the bodies of adjacent vertebrae.
The described bony marginal growths are sometimes combined with bone growths at the posterior portion of the limbus, which indicates disc prolapse in all directions. As an illustration, we present the following observation.
Mr. G., 50 years old, a grocery store salesman by profession, often lifts and carries heavy weights due to the nature of his work. About 10 years ago, he first felt pain in the lower back, which then gradually intensified and became constant. The pain periodically worsens significantly and spreads to both lower extremities, more to the right. He was treated several times in neurological hospitals and sanatoriums with temporary improvement. Neurologically: chronic lumbosacral radiculitis, prone to exacerbations.
X-ray revealed almost complete destruction of the disc. The bodies of these vertebrae are sharply brought together, especially in the anterior section, where their adjacent surfaces touch and are surrounded by massive wedge-shaped bone growths. Moderate bone growths were also found in the posterior part of the limbus of the body. The adjacent end plates of the bodies of these vertebrae are rearranged, uneven, pitted, directly merging with the flattened limbus and bone marginal growths. The subchondral areas of the bodies of these vertebrae are sclerotic, especially in the anterior sections. Moderate kyphosis at the level of the affected disc and slight posterior displacement of the body. The underlying disk is also modified, but less significantly.
Clinical and radiological diagnosis: pronounced osteochondrosis with secondary chronic lumbosacral radiculitis.
The data obtained indicated that the patient’s ability to work was limited in his profession. He was recognized as a group III disabled person and went to work as a merchandiser.
The process of development of osteochondrosis often proceeds unevenly. When one part of the disk has already been largely destroyed, another may still be preserved. This asymmetrical course is especially typical for lesions of the middle thoracic discs, as well as for osteochondrosis, complicating static scoliosis, when the parts of the discs located on the side of the concavity of the spine are subject to significant overload and therefore are destroyed much faster than the areas located on the convex side. Sometimes such an uneven course is observed in osteochondrosis that occurs after a single significant injury, in which predominantly one part of the disc was damaged. It is often not possible to decipher the cause of the asymmetric course of osteochondrosis.
When predominantly the anterior part of the disc is destroyed, kyphosis develops; when one of the lateral parts is damaged, scoliosis always forms, with a concavity towards the more damaged half of the disc. As a result, conditions are created for further progression of damage to the same area of the disc, since it is this area that finds itself under conditions of constant overload. The affected part of the disc decreases sharply until it touches the vertebral bodies, while its other part sometimes changes slightly. This indicates moderate degeneration of the gelatinous nucleus, but significant destruction of the fibrous ring and hyaline plates in the affected area. With such asymmetric osteochondrosis, bone growths also occur only on the affected side. They retain all previously described features. Usually the anterior longitudinal ligament takes part in the formation of these growths, as a result of which they acquire a typical wedge-shaped shape and a fairly significant size.
Progression of osteochondrosis
As osteochondrosis increases, the hyaline plates are gradually destroyed and the end plates of the vertebral bodies are exposed, first in the most loaded areas, and then throughout. As a result, the disintegrating tissue of the disc is not only squeezed out of its limits, but under the influence of the load it is partially embedded in adjacent areas of the vertebral bodies in the form of so-called Pommer's nodes. Therefore, the end plates of the vertebral bodies become uneven, rough, with multiple depressions. However, true ones are not formed in the vertebral bodies during osteochondrosis due to the disappearance of the turgor of the gelatinous nucleus. Simultaneously with the described changes, a flattening of the bone marginal edge occurs, which appears in the same plane with the end plate.
This restructuring of the vertebral bodies is clearly visible in macerated preparations. On radiographs of the spine of living people, individual cartilaginous nodules, as a rule, are not detected, but it is clearly visible that the corresponding areas of the end plates are no longer smooth, have acquired an irregular shape and an uneven surface with multiple depressions and have merged with the flattened limbus. At the same time, sclerosis of adjacent areas of the spongy bone is revealed and subsequently gradually increases. This restructuring of the structure is completely analogous to the sclerosis of the subchondral parts of the articular ends of the articulating bones in deforming arthrosis. Sclerosis occurs as a reaction to constant trauma to the vertebral bodies and at the same time represents a compensatory phenomenon that prevents the increase in bone tissue damage.
With complete degeneration of all elements of the disc, adjacent surfaces of the vertebral bodies come into contact. Between them there are only traces of disk decay products. In this condition, the boundary between the endplate and the limbus is completely lost; the bony marginal edging undergoes the same restructuring as the end plate, i.e., multiple Pommer's nodules appear in it, in some places it is expanded due to bone marginal growths, in some places it is completely destroyed by the squeezed out products of disc decay.
In the process of restructuring the vertebral bodies, the entire relief of their adjacent surfaces changes significantly. This is especially striking in osteochondrosis of the cervical segments. As the affected disc descends, the body of the overlying vertebra seems to descend onto the body of the underlying one and puts direct pressure on the semilunar processes of Luschka. The latter begin to deviate outward. Nonarthrosis of deformed semilunar processes often occurs with bone growths on the lateral surface of the body of the overlying vertebra and even on the lower surface of the costal part of the transverse process. In this case, the intervertebral foramina and even the canal of the vertebral artery are sharply deformed, which may be reflected in the unique clinical picture of the disease. Gradually, the semilunar processes deviate more and more sharply outward, flatten and, finally, collapse.
The following observation is typical of the clinical and radiological picture of the described changes.
Gr-ka M., 51 years old, a painter by profession with 20 years of experience, has been doing light auxiliary work for the last 5 years, as she is recognized as a group 3 disabled person due to chronic cervical radiculitis and constant pain in the neck, especially when moving. X-ray revealed a significant decrease in the C 4 _ 5 and C 5 _ 6 discs, a moderate decrease in the C 6 _ 7 disc. The adjacent surfaces of the bodies of these vertebrae are surrounded by small bone growths, more significant along the posterior portions of the limbs. The semilunar processes of the bodies of these vertebrae are deflected outward and form non-arthrosis with bone growths on the lateral surfaces of the bodies of the overlying vertebrae, and the semilunar islands of C6, in addition, form with the lower surface of the costal areas of the transverse processes of C5. Changes in the semilunar processes appear especially prominently on the frontal tomogram when compared with the normal semilunar processes C 4 . Cervical lordosis is straightened. The vertebral bodies at the level of the affected discs are slightly displaced in the sagittal plane relative to each other, which is why the anterior wall of the spinal canal is deformed.
Clinical and radiological diagnosis: osteochondrosis of the three lower cervical discs with posterior prolapse, deformation of the intervertebral foramina and spinal canal, and secondary chronic radiculitis.
With severe osteochondrosis, in addition to the semilunar processes, the entire vertebral body is often significantly deformed and rebuilt. It gradually decreases, flattens, and takes on an irregular wedge-shaped shape. Along with sclerosis, small cyst-like formations sometimes appear in the subchondral areas. All these phenomena are usually especially pronounced when the lower cervical segments are affected, but are also observed in other parts of the spinal column.
As osteochondrosis develops and the affected disc decreases, the relationships in the intervertebral joints of this segment are disrupted. Subluxation gradually develops in these joints due to the sliding of the articular surfaces along the longitudinal axis of the spinal column. Due to changes in static-dynamic conditions, deforming arthrosis often develops.
In addition, in the lumbar spine, the upper articular process of the underlying vertebra, due to the convergence of adjacent vertebrae, begins to abut the lower surface of the root of the arch and the base of the transverse process of the overlying vertebra. In this place, nonarthrosis develops, the articular surfaces of which gradually increase. During the development of deforming arthrosis and non-arthrosis, restructuring of the intervertebral joints occurs. It corresponds to the peculiarities of deformation of the spinal column at the level of osteochondrosis and, consequently, to new loading conditions. During this restructuring, the location of the articular processes sometimes changes and the axis of the intervertebral joint deviates anteriorly.
As a result of the destruction of the end plates of the vertebral bodies and the formation of Pommer's nodes, blood vessels from the vertebral bodies sometimes grow into cartilage tissue that penetrates the bone tissue, and then directly along it into the collapsing disc. As a result, connective tissue transformation of the disc occurs and osteochondrosis ends with a fibrous block of adjacent vertebrae. This favorable outcome of osteochondrosis can be considered as a spontaneous cure.
With this course of the disease, local pain gradually disappears, and in the absence of a sharp prolapse of the disc substance posteriorly, neurological disorders can spontaneously disappear.
Radiologically, when osteochondrosis progresses to a fibrous block, the following are revealed: more or less significant reduction of the disc, moderate bone marginal growths and a typical violation of the physiological curvature of the spine, but sclerosis of the subchondral areas gradually disappears and the end plates of the vertebral bodies, being rebuilt, lose their clear outlines. During functional tests, it turns out that the corresponding vertebrae have become a single functional whole, their mutual movements do not occur. Subsequently, the bony marginal growths on these vertebrae sometimes merge, and the fibrously transformed disc spongioses.
We observed such dynamics of osteochondrosis in several patients, including Ms. L., 53 years old, a nurse, who 10 years ago during a car accident received a spinal bruise with a closed compression fracture of the body T 12. After that, for 4 years she experienced constant pain in the cervical spine, especially with movement, and suffered from recurrent cervical radiculitis. Gradually all these phenomena passed. During a clinical examination 10 years after the injury, no deviations from the norm were found. X-ray revealed a significant reduction of the disc with very moderate bone marginal growths, and restructuring of the end plates of the vertebral bodies without their sclerosis. X-rays of the cervical spine with the head tilted forward and backward revealed that these vertebrae function as a single unit, without any changes in their relationships or disc height.
Clinical and radiological diagnosis: fibrosis of the C 5 _ 6 disc after osteochondrosis. The examinee is able to work in her profession as a nurse.
This outcome of the disease is more often observed in the middle thoracic segments, especially with premature senile kyphosis, when, as a result of osteochondrosis, a bone block of the anterior sections of several vertebrae is formed.
However, this favorable outcome of osteochondrosis is rarely observed. More often, as a result of significant destruction of the intervertebral disc and loss of all its functions, including the function of connecting adjacent vertebrae, their pathological mobility occurs, which is facilitated by the above-mentioned restructuring of the intervertebral joints.
A large literature is devoted to the issue of pathological displacements of vertebral bodies, especially lumbar ones.
The basis of all displacements of the vertebral bodies is osteochondrosis. Even spondylolysis, i.e., a local developmental anomaly, which consists in maintaining syndrosis in the interarticular areas of the vertebral arch, can turn into spondylolisthesis, i.e., displacement of the vertebra, only in the presence of osteochondrosis. The latter develops in the area of interarticular synchondrosis and in the underlying disc. As a result, pathological mobility occurs between different parts of the vertebral arch and between the bodies of adjacent vertebrae. This leads to a displacement of the body of this vertebra, together with the roots of its arch and the upper articular processes anterior to the body of the underlying vertebra. At the same time, the lower articular processes and the posterior part of the arch retain their normal position, being connected by the lower intervertebral joints to the underlying vertebra. Spondylolisthesis is one of the diseases studied in detail. Its clinical and radiological symptoms are well known. A detailed analysis of this disease is beyond the scope of this work. We will only point out that spondylolisthesis limits the ability to work in all professions in which work is associated with a dead body load.
In the absence of spondylolysis, osteochondrosis of the disc also leads to pathological displacement of the overlying vertebra posteriorly or anteriorly. If significant deforming arthrosis of the corresponding intervertebral joints has not developed, as the disc decreases, the lower articular processes of the overlying vertebra gradually slide in the caudal direction and somewhat posteriorly along the upper articular processes of the underlying vertebra that articulate with them. This creates conditions for a slight displacement of this entire vertebra posteriorly in relation to the underlying vertebra. This direction of vertebral displacement is most typical for osteochondrosis.
Anterior displacement occurs if osteochondrosis is accompanied by a sharp deforming arthrosis of the corresponding intervertebral joints with deviation of their axes. This phenomenon is known in the literature as pseudospondylolisthesis. Pseudospondylolisthesis develops predominantly in obese women with pronounced compensatory hyperlordosis, in which the direction of the main load of the lumbar spine promotes anterior displacement of the vertebra located above the affected disc. Nevertheless, pseudospondylolisthesis can occur with normal or even low weight of the patient.
According to some authors, changes in the angle of inclination of the axes of the intervertebral joints in relation to the roots of the vertebral arch are sometimes a constitutional feature that creates the preconditions for vertebral displacement in the presence of osteochondrosis of the disc.
The degree of vertebral displacement in osteochondrosis is usually very moderate. Nevertheless, at the same time, the deformation of the intervertebral foramina increases and, thus, the conditions for the occurrence of secondary chronic radiculitis increase.
The most significant pathological displacements of the vertebrae are observed with osteochondrosis of two or more adjacent discs, especially if the bone marginal growths are insignificant or have not developed at all. Then mutual movements of the bodies of several vertebrae occur in the sagittal plane, in the frontal plane, and sometimes, in addition, rotational ones.
As a result of displacements in the sagittal plane, steps-like steps appear between the posterior surfaces of the vertebral bodies, which causes deformation of the anterior wall of the spinal canal. With displacements in the frontal plane, lateral shifts of the vertebral bodies occur. Axial displacements result in rotation of one or two vertebrae in relation to the vertebrae above and below. On the posterior radiographs of the affected part of the spine of such patients, the image of some vertebrae that is usual for this projection is revealed, while the image of others corresponds to radiography in an oblique projection. Clinically, this reveals a straightening of the physiological lordosis, which in the lumbar region is usually combined with rotational scoliosis. With such extensive damage to several discs, osteoporosis of the corresponding vertebrae develops.
As an illustration, we present an x-ray of the lumbar spine of music teacher S., 73 years old. She suffers from osteochondrosis of all lumbar discs. The pathological process began at the age of 18 after being bruised by a board while falling from a swing and, slowly progressing, reached significant severity. Gradually, scoliosis developed to the left. There is a pronounced pain syndrome and a neurological picture of secondary chronic lumbosacral radiculitis. The patient constantly uses a corset, but even in it she cannot sit for more than 3-4 hours, her ability to work is limited.
X-ray examination revealed complete destruction of the right halves of all lumbar discs and significant degeneration of their left halves. There is scoliosis with a convexity to the left. Bone marginal growths did not arise. Rotation also occurred to the right in relation to adjacent vertebrae. At the same time, displacements of the vertebral bodies in the sagittal plane occurred. As a result of pathological mobility, significant deformation of the spinal canal and especially the intervertebral foramina with narrowing of the latter occurred. Osteoporosis of all lumbar vertebrae developed.
All described displacements of the vertebrae sharply increase the deformation and narrowing of the intervertebral foramina and the spinal canal.
Significantly expressed osteochondrosis causes persistent constant pain in the corresponding part of the spine, intensifying after exercise, and is often accompanied by chronic, repeatedly exacerbating radiculitis. The latter is often combined with more complex neurological phenomena, especially with damage to the cervical discs.
The basis of neurological disorders is usually not so much direct pressure on the corresponding spinal nerves, roots or spinal cord, but rather various circulatory disorders leading to roots, their membranes or other formations. Direct compression of certain parts of the nervous system occurs much less frequently with a sharp deformation of the intervertebral foramina or the spinal canal, as well as with the above-mentioned prolapse of the disc substance.
Direct compression of the spinal nerves as a result of deformation of the intervertebral foramina in osteochondrosis of the lumbar discs was observed by A. I. Borisevich and D. I. Fortushnov during anatomical studies. These authors found that the degree of deformation should be very large, since normally the diameter of the lower intervertebral foramina in the lumbar region is 2-3 times greater than the cross-sectional area of the corresponding spinal nerves. The only exceptions are the intervertebral foramina, which in some people are blocked by a non-permanent ligament. With this individual feature, the spinal nerve almost completely fills the corresponding hole and therefore can be easily compressed.
All of the above data show that osteochondrosis of the intervertebral disc is a severe pathological process that develops very slowly, but can lead to complete destruction of the disc and significant secondary changes in all other elements of this segment of the spinal column. This pathological process is usually accompanied by severe pain, and often long-term persistent neurological disorders.
Prevention of osteochondrosis
Prevention of the increase in osteochondrosis is ensured by the correct organization of work activities of patients with the exception of significant and even moderate deadlift. The ability to work of patients suffering from severe osteochondrosis is limited in all professions in which work requires a heavy load. With severe pain syndrome, as well as with significant permanent neurological disorders, patients lose their ability to work. This applies mainly to osteochondrosis of the lumbar, cervical, and less often the lower thoracic segments; Damage to the middle thoracic discs often occurs more benignly and does not impair the ability to work.
In addition to the usual localization of osteochondrosis in the area of intervertebral discs, one should also take into account the possibility of a similar lesion of synchondrosis of the extended transverse process of the lower lumbar vertebra with the lateral mass of the sacrum, i.e. the possibility of osteochondrosis developing in the presence of a transitional lumbosacral vertebra in the form of sacralization or lumbarization.
There are 4 variants of sacralization, i.e., likening the V lumbar vertebra to the sacral ones: 1) bilateral complete or bone sacralization, characterized by the expansion of both transverse processes and their complete fusion with the lateral masses of the sacrum into a single bone formation; 2) unilateral complete or bony sacralization, in which one transverse process L 5 retains its usual structure, and the other expands and merges into a single bone formation with the corresponding lateral section of the sacrum; 3) bilateral incomplete sacralization, in which both transverse processes are expanded and connected to the lateral masses of the sacrum through synchondrosis; 4) unilateral incomplete sacralization, characterized by the same morphological features as unilateral bone sacralization, but with the connection of the expanded transverse process with the lateral part of the sacrum through synchondrosis. Similar options are observed during lumbarization, but they are based not on the fusion of one vertebra with the sacrum, but on its separation from the sacrum.
Bilateral sacralization, or lumbarization, both complete and incomplete, is not detected clinically, is detected only by X-ray examination and is an asymptomatic individual feature. Unilateral complete sacralization (or lumbarization) is often also a variant of the norm that has no clinical significance, but is sometimes accompanied by asymmetry of the body and then becomes the cause of scoliosis. Unilateral incomplete sacralization or lumbarization is the only variant of all forms of transitional lumbosacral vertebra, which can cause severe pain. The latter occurs if osteochondrosis develops in the area of synchondrosis.
Degeneration of the cartilage tissue connecting the transverse process or with the lateral mass of the sacrum is accompanied by a decrease in synchondrosis, bone growths around the corresponding surfaces and pathological mobility. These changes, clearly visible radiographically, cause constant persistent pain that increases after exercise and under the influence of adverse meteorological factors. This clinical and radiological syndrome is called painful sacralization. With unilateral incomplete sacralization, this pathological process develops quite often due to asymmetry of the lumbosacral region, leading to constant overload of synchondrosis.
Painful sacralization in the presence of severe, persistent pain syndrome and in the absence of a positive result of long-term physical therapy limits the ability of patients to work in professions of heavy physical labor, accompanied by significant deadlift.
The article was prepared and edited by: surgeonWhat are the consequences and why the height of the intervertebral discs can be reduced? During an examination of the spine, a diagnosis was made: the height of the intervertebral discs is reduced, what does this mean and how dangerous? What to do next, continue to live ordinary life Or is it better to do something? It is better to know the answers to these questions from childhood, since more than 80% of people in the world, albeit to varying degrees, are related to problems with the spine. In order to understand how and why the height of the intervertebral discs decreases, you need to delve a little deeper into the anatomy. The structure of the spine and the functions of the intervertebral discs The spine is the main support of the human body, consisting of segments (parts), namely the vertebrae. Performs supporting, shock-absorbing (thanks to intervertebral discs) and protective functions (protects the spinal cord from damage). The spinal cord, located in the spinal canal of the spine, is a fairly elastic structure that can adapt to changes in body position. Depending on the part of the spine, spinal nerves branch off from it and innervate certain parts of the body. The head, shoulders and arms are innervated by nerves that branch from the cervical spine. The middle part of the body is correspondingly innervated by nerves branching from the thoracic part of the spine. Lower body and legs - innervated by nerves branching from the lumbosacral segment of the spine. Consequently, if problems arise with the innervation (impaired sensitivity, severe pain reaction, etc.) of any parts of the body, the development of pathology in the corresponding part of the spine can be suspected. From the moment a person began to walk upright, the load on the spinal column increased significantly. Accordingly, the role of intervertebral discs has increased. Intervertebral Discs Fibrous, cartilage-like structures consisting of a nucleus surrounded by a fibrous (tendon-like tissue) ring and shaped like a round plate located between the vertebrae are called intervertebral discs. Their main purpose is depreciation (load softening). How does a decrease in the height of intervertebral discs develop? There is one important point in the structure of intervertebral discs that is related to the development of pathology - they do not contain blood vessels, so nutrients enter them from tissues located nearby. In particular, the latter include the spinal muscles. Therefore, when dystrophy (malnutrition) of the spinal muscles occurs, a malnutrition of the intervertebral discs occurs. The jelly-like, but at the same time quite elastic (thanks to the fibrous ring that limits it) core of the disc provides a reliable and at the same time elastic connection of the vertebrae with each other. As a result of a disruption in the supply of nutrients, the disc begins to dehydrate, lose its height and elasticity, the fibrous ring also loses its flexibility and becomes more fragile. The connection of the vertebrae deteriorates, and instability in the affected motor part of the spine increases. With further development of the process, degeneration (degeneration) and hardening of the cartilage tissue of the disc occurs, it becomes similar to bone. The disc decreases in size even more, loses height, ceases to perform a shock-absorbing function and begins to put pressure on the nerve endings, causing pain. Degenerative-dystrophic (degeneration and malnutrition) processes in which a decrease in the height of the intervertebral discs and rapid growth of osteophytes (bone formations) occur are called osteochondrosis (spondylosis). The terms have Greek roots, meaning joint (spine), the ending -oz characterizes dystrophic (malnutrition) changes. Complicated course of osteochondrosis According to a similar scenario, the pathology occurs not only in diseases that cause disturbances in the trophism of the discs. Most often, with spinal injuries or traumatic loads, compression of the disc occurs, followed by protrusion of the nucleus; if this occurs without violating the integrity of the fibrous ring, it is called protrusion; if prolapse (protrusion) is accompanied by rupture of the ring and the nucleus moving beyond its limits, this is intervertebral disc herniation. At the same time, as a result of compression, the height of the discs also decreases, and with a further increase in pressure, the size of the hernia will increase. What threatens the decrease in the height of intervertebral discs? There are four stages of development of pathology. Each of them has its own characteristic features: I. Initial, still hidden form of flow. Minor discomfort, usually appearing in the morning and disappearing during the day. Most people do not seek help, although they feel limited mobility. The affected disc has the same height as the healthy (adjacent) one. II. Painful sensations appear, deformation of the fibrous ring occurs, the stability of the affected part of the spine is disrupted, pathological mobility develops, and nerve endings are pinched (causing pain). Blood and lymph flows are disrupted. The height of the intervertebral disc is reduced, a quarter less than the neighboring one. III. Further deformation and rupture of the disc ring, the formation of a hernia. Deforming pathology of the affected vertebral sections (scoliosis - deflection of the spine to the side, kyphosis - hump or lordosis - deflection back). The affected disc is half the size of a healthy one. IV. Final. Shift and compaction of the affected vertebrae, accompanied by pain and bone growths. Sharp pain when moving, minimal mobility. Possible disability. An even more significant reduction in disc height. The result of complications of a herniated disc can be: dysfunction of the pelvic organs and loss of sensitivity, paralysis of the leg muscles, movement in a wheelchair. What to do, how to prevent it Eat right, engage in health-improving physical exercises, drink enough fluids (at least 2 liters per day, maintains normal metabolism), do not overload the spine (lifting heavy objects), avoid injuries, stress and hypothermia, during sedentary work – take gymnastic breaks, periodically undergo preventive examinations of the spine, and if problems are detected, immediately seek help.
How to determine the development of a spinal hernia based on symptoms. Spinal diseases are more common than many other diseases. The observations of many specialists allow us to conclude that today osteochondrosis is one of the main enemies of human health. Therefore, the popularity of questions about how to determine a spinal hernia is growing at an alarming rate. Osteochondrosis, which occurred in older people, has now become a frequent companion even in adolescents. The danger lies in the fact that for such a pathology as intervertebral hernia, there is no strict localization zone. It is not always possible to recognize a spinal hernia in time. This is a feature of the body and the spinal column itself: for a long time it can cope with disturbances using its reserves. In fact, a person learns about any disease only in one case: if the body itself cannot stop the deviations. Pain is like a control check, confirmation that a serious disease is developing in the spine. What is an intervertebral hernia? A healthy intervertebral disc has two components: the nucleus and the fibrous ring. Normally, the ring serves as a limiter for the nucleus pulposus. The disc itself acts as a powerful shock absorber for the vertebrae, allowing them to move. However, under the influence of various factors, degenerative processes are triggered in the spine. As a result, the annulus fibrosus weakens and the nucleus begins to protrude beyond the disc. This scenario can have two ends, but more often the negative one is realized: the ring cannot withstand the pressure? and the contents pour into the spine. But all processes in the body are connected, so the outflow of the nucleus pulposus does not hang in the air and does not disappear. The leaked contents start their processes, and a hernia of the spine is formed. Sometimes identifying and diagnosing a herniated disc in the lower back or another part is not easy. In most cases, at first the situation remains invisible to the person. The process of leakage itself is not felt, the general condition has not yet changed. Finding out at this point is often just an accident. Intervertebral formation can be: in the cervical region; in the chest; lumbar or lumbosacral. But more often the formation does not form in the neck or sternum. The favorite location where you can find a lumbar disc hernia is the area of the sacrum and the lower back itself. This frequency is explained by the fact that it is the lower back that takes on the majority of all loads. Due to the ability of the spine to independently align the center of gravity, diseases and the development of pathology from the first stages may simply not be determined. Especially at home and without the necessary examination. However, based on the nature of the pain, persistence and other features, it can be assumed that pathology has started in the spine. It just seems that the pain is the same when any part is affected, that only the locality differs. However, this is not true, because the spine in the acute period and the subacute period may have different sensations. The first signs of formation You need to know that it is not the spinal hernia itself that primarily occurs, but the protrusion. These are small cracks in the annulus fibrosus through which the contents of the nucleus can be squeezed out. Usually this is precisely the stage at which it is already possible to detect pathology. The protrusion stage is completely curable if the patient simply follows all the instructions. But if no action is taken, the crack grows and the contents of the core leak out even more actively. And then the question of whether there is a hernia will become rhetorical. The main and unconditional sign: the appearance of pain. It is born due to pinching of nerve fibers in the vertebrae due to disc destruction. It is from such pinching that a healthy disc protects a person, but how to recognize an intervertebral hernia if there is practically no discomfort? You need to understand that in a healthy body pain simply does not appear, since there are no conditions for its occurrence. There are a number of symptoms for the first phase and how to check the spine: the appearance of headaches; numbness and swelling of tissues; the appearance of muscle spasms; discomfort from certain body positions; lumbago in the spine when turning or bending; aching in the back, and with cervical lesions - aching in the suboccipital region; nausea, dizziness. Then the second phase will come and the nature of the signs will change. The manifestations directly depend on which department is affected. Signs of a cervical hernia Initially, the signs are subtle, the pain is mild and intermittent. Then persistent headaches appear that are difficult to stop. They become especially aggressive in the morning or when sitting at the computer for a long time. A person complains of its birth in the shoulder, the entire arm or both arms. A feeling of dizziness appears, attacks may be accompanied by nausea or vomiting. Vision and hearing are seriously reduced, sometimes pain is felt behind the ears or in the front part of the face. Problems with blood pressure begin, and levels can rise to high levels. Additionally, a full range of neurological signs may be observed. There will be sudden mood swings, sleep disturbances, and growing irritability. The longer the progression of the disease lasts, the more clearly the neurology increases. The manifestation is strong, with a changing character from pulsating under the back of the head to sharp in the temples, above the eyebrows. Symptoms of thoracic nerve damage When a formation develops in the chest area, most often the manifestation boils down to an exacerbation of intercostal neuralgia. This syndrome is characterized by stabbing pain, which intensifies with any attempt to move. The left side is most often affected, and for this reason the symptoms are similar to heart failure. It is important to distinguish one from the other in time, which can only be done by an examination or an “emergency care” team. The symptoms are very similar: acute pain behind the sternum; growing pain when trying to take a breath; radiates to the arm, shoulder, hypochondrium. The pain can last a long time and is caused by pinched nerve roots. This happens especially often if there is pathological kyphosis. Lumbar lordosis can also have an effect. These two sections are connected by aligning the center of gravity. So, if there is severe scoliosis, conditions are already created for pinching in the sternum. Lumbosacral pathology With lumbosacral osteochondrosis and its complications, pain is localized in the lower back, sacrum, and coccyx. Sometimes it shoots, pulsates, as if spreading along the inside of the entire thigh. It can give a strong sensation to the leg and buttock, creating a feeling of nagging suffering. Pinching is characterized by paroxysmal pain, which is clearly felt in the groin and perineum area. It can be similar in nature to contractions, but with periodic decrease in pain. The pain can last a long time, causing gastrointestinal disturbances. Spasmodic nausea, vomiting, and destabilization of the entire tract are possible. This is a dangerous condition in which internal organs can be pinched by a hernia. Often, precisely because of the rupture of hernia formations in this department, the patient is quite capable of becoming an incapacitated disabled person. It is extremely important to try to find out about such an insidious enemy in time. Only early diagnosis can protect against the formation of hernias.
Therapeutic massage for intercostal neuralgia Intercostal neuralgia appears as a consequence of scoliosis, rib injuries, spinal osteochondrosis, deforming spondyloarthrosis, influenza, intoxication, and diseases of internal organs. With intercostal neuralgia, constant or paroxysmal pain is noted on the left side in the back and lateral surface of the chest. At some points the pain can be especially severe, and it spreads in a semicircle along the intercostal nerves (from the spine to the sternum). Massage techniques are recommended for the following areas: Back area. Chest area. BACK MASSAGE Before performing the techniques, you should determine the location of the pain. The massage should first be done on the healthy side, and then on the sore side. If pain spreads over the left and right half of the back, massage should be performed on the half on which the pain is less. Stroking (done along 3 and 4 lines from the sacrum to the shoulder girdle): straight; alternate. Squeeze beak-shaped with the base of the palm along 3 and 4 lines from the sacrum to the shoulder girdle. Kneading on the long back muscles: circular with the pad of the thumb; circular with the pads of four fingers; circular phalanges of bent fingers; circular with the pads of bent fingers; circular base of the palm with a roll. Kneading on the latissimus muscles: ordinary; double neck; double ring; circular with phalanges of bent fingers. Kneading on the fascia of the trapezius muscle and suprascapular region: circular with the pad of the thumb; circular with the pads of four fingers; circular edge of the thumb; “pincer-shaped”; circular tubercle of the thumb; straight with the pad and tubercle of the thumb. Kneading at the intercostal spaces: straight with the pads of four fingers alternately; straight with the pads of the four fingers; straight with the pad of the thumb; circular with the pad of the thumb; straight with the pads of the middle finger; “Stroke-shaped” with the pads of the middle finger. When performing techniques, you should not exceed the pain threshold of the person being massaged. CHEST MASSAGE To perform a massage, the patient should be placed on his back and lubricated chest cream, vegetable oil or warming ointments. Massage of the pectoralis major muscles: Stroking. Squeezing. Kneading: ordinary; double neck; double ring; combined; circular with phalanges of bent fingers. MASSAGE OF THE INTERCOSTAL SPACES OF THE CHEST: Rubbing: straight with the pads of four fingers; circular with the pads of four fingers; straight with the pad of the thumb; circular with the pad of the thumb; straight with the pad of the middle finger; “stroke-shaped” with the pad of the middle finger. MASSAGE OF THE SUBCHESTAL ANGLE: Rubbing (performed in the classical way). The massage session should be carried out for 15-20 minutes. The recommended number of sessions is 8-10.
During an examination of the spine, a diagnosis was made: the height of the intervertebral discs is reduced, what does this mean and how dangerous is it? What to do next, continue to live a normal life or is it better to do something? It is better to know the answers to these questions from childhood, since more than 80% of people in the world, albeit to varying degrees, are related to problems with the spine. In order to understand how and why the height of the intervertebral discs decreases, you need to delve a little deeper into the anatomy.
The spine is the main support of the human body, consisting of segments (parts), namely the vertebrae. Performs supporting, shock-absorbing (thanks to intervertebral discs) and protective functions (protects the spinal cord from damage).
The spinal cord, located in the spinal canal of the spine, is a fairly elastic structure that can adapt to changes in body position. Depending on the part of the spine, spinal nerves branch off from it and innervate certain parts of the body.
- The head, shoulders and arms are innervated by nerves that branch from the cervical spine.
- The middle part of the body is correspondingly innervated by nerves branching from the thoracic part of the spine.
- Lower body and legs - innervated by nerves branching from the lumbosacral segment of the spine.
Consequently, if problems arise with the innervation (impaired sensitivity, severe pain reaction, etc.) of any parts of the body, the development of pathology in the corresponding part of the spine can be suspected.
From the moment a person began to walk upright, the load on the spinal column increased significantly. Accordingly, the role of intervertebral discs has increased.
Intervertebral discs
Fibrous, cartilage-like structures, consisting of a nucleus surrounded by a fibrous (tendon-like tissue) ring and shaped like a round plate, located between the vertebrae are called intervertebral discs. Their main purpose is depreciation (load softening).
How does a decrease in the height of intervertebral discs develop?
There is one important point in the structure of intervertebral discs that is related to the development of pathology - they do not contain blood vessels, so nutrients enter them from tissues located nearby. In particular, the latter include the spinal muscles. Therefore, when dystrophy (malnutrition) of the spinal muscles occurs, a malnutrition of the intervertebral discs occurs.
The jelly-like, but at the same time quite elastic (thanks to the fibrous ring that limits it) core of the disc provides a reliable and at the same time elastic connection of the vertebrae with each other. As a result of a disruption in the supply of nutrients, the disc begins to dehydrate, lose its height and elasticity, the fibrous ring also loses its flexibility and becomes more fragile. The connection of the vertebrae deteriorates, and instability in the affected motor part of the spine increases.
With further development of the process, degeneration (degeneration) and hardening of the cartilage tissue of the disc occurs, it becomes similar to bone. The disc decreases in size even more, loses height, ceases to perform a shock-absorbing function and begins to put pressure on the nerve endings, causing pain.
Degenerative-dystrophic (degeneration and malnutrition) processes in which a decrease in the height of the intervertebral discs and rapid growth of osteophytes (bone formations) occur are called osteochondrosis (spondylosis). The terms have Greek roots, meaning joint (spine), the ending -oz characterizes dystrophic (malnutrition) changes.
Complicated course of osteochondrosis
According to a similar scenario, pathology occurs not only in diseases that cause disturbances in the trophism of the discs. Most often, with spinal injuries or traumatic loads, compression of the disc occurs, followed by protrusion of the nucleus; if this occurs without violating the integrity of the fibrous ring, it is called protrusion; if prolapse (protrusion) is accompanied by rupture of the ring and the nucleus moving beyond its limits, this is intervertebral disc herniation.
At the same time, as a result of compression, the height of the discs also decreases, and with a further increase in pressure, the size of the hernia will increase.
What are the risks of reducing the height of intervertebral discs?
There are four stages of pathology development. Each of them has its own characteristic features:
I. The initial, still hidden form of the flow. Minor discomfort, usually appearing in the morning and disappearing during the day. Most people do not seek help, although they feel limited mobility. The affected disc has the same height as the healthy (adjacent) one.
II. Painful sensations appear, deformation of the fibrous ring occurs, the stability of the affected part of the spine is disrupted, pathological mobility develops, and nerve endings are pinched (causing pain). Blood and lymph flows are disrupted. The height of the intervertebral disc is reduced, a quarter less than the neighboring one.
III. Further deformation and rupture of the disc ring, the formation of a hernia. Deforming pathology of the affected vertebral sections (scoliosis - deflection of the spine to the side, kyphosis - hump or backward deflection). The affected disc is half the size of a healthy one.
IV. Final. Shift and compaction of the affected vertebrae, accompanied by pain and. Sharp pain when moving, minimal mobility. Possible disability. An even more significant reduction in disc height.
The result of complications of a herniated disc can be: dysfunction of the pelvic organs and loss of sensitivity, paralysis of the leg muscles, movement in a wheelchair.
What to do, how to prevent
Eat right, engage in health-improving physical exercises, drink a sufficient amount of fluid (at least 2 liters per day, maintains normal metabolism), do not overload the spine (heavy lifting), avoid injuries, stress and hypothermia, during sedentary work - take gymnastic breaks, periodically undergo preventive examination of the spine, and if problems are detected, immediately seek help.