Herniated disc (hernia of the pulpous core) and back pain
Last reviewed: 25.06.2018
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Herniated disc is the prolapse of the central substance of the disc through the surrounding ring. Pain occurs when the protrusion of the disc causes trauma and inflammation of adjacent tissues (for example, posterior longitudinal ligament). When the disc meets a series of located spinal roots, develops radiculopathy with paresthesias and muscle weakness in the innervation zone of the damaged root. Diagnosis involves mandatory CT or MRI (more informative method). Treatment in mild cases is the administration of NSAIDs (eg, diclofenac, lornoxicam) and other analgesics (tizanidine, baclofen, tramadol), if necessary. Bed rest (long) is rarely shown. With the progression of neurological deficit, non-curable pain or sphincter dysfunction, urgent surgical intervention (discectomy, laminectomy) may be required.
The vertebrae are connected to each other by means of a cartilaginous intervertebral disc consisting of an outer fibrous ring and an internal pulposal core. With degenerative changes (after trauma or without it), a bulging or bursting of the pulpous nucleus occurs through the fibrous ring in the lumbosacral or cervical region. The nucleus is shifted backward or backward and to the side into the extradural space. Radiculopathy occurs when the hernia squeezes or irritates the nerve root. The posterior protrusion may compress the spinal cord or the ponytail, especially when the vertebral canal is congenital (vertebral stenosis). In the lumbar region, more than 80% of herniated discs are squeezed L5 or S1 roots, in the cervical spine most often affected C6 and C7 roots. Often the hernia of the disc does not cause any symptoms and is a finding in the MRI of the spine and spinal cord.
Discogenic pain is much less common than myogenic, but it is not uncommon. And there are several reasons for this: the vascularization of the intervertebral discs decreases during the ontogenesis, at the end of the first decade of life on the fibrous ring of cervical intervertebral discs, tears develop, at the end of the second decade of life, the progressive dehydration of the colloidal nucleus begins. In the future, a rupture of the fibrous ring with the loss of fragments of the pulpous nucleus into the vertebral canal is possible.
Discogenic pain has its clinical features. The first characteristic feature is increased pain during movement, a decrease in rest. This is most clearly seen in the pathology of the lumbar discs. As the walk (movement) continues, the patient observes a progressive increase in pain localized more often along the middle line or with minor lateralization, the appearance of scoliosis (or worsening of the existing scoliosis). The nature of pain is pressing, bursting. But if the horizontal position is optimal for protrusions of the lumbar discs, patients with cervical discogenic pain often experience increased pain in the prone position, which forces them to sleep half sideways.
A characteristic sign can also be sclerotomous irradiation of pain. Sclerotomous pain, described by patients as deep, bursting, localized in the bone is often the cause of diagnostic errors. At the initial stage of disc protrusion, when the clinical signs of radicular compression are absent, and the patient complains of pain in the scapula, or the shoulder or shin, doctors often forget about the possibility of sclerotomous pain having a source in the spinal canal, and concentrate attention and manipulation on the area of projected pain .
Changing the configuration of the spine and forced posture - a frequent sign of discogenic pain. For the lumbar region this is scoliosis, Aggravated with inclinations, for the cervical region - the forced position of the head and neck. A significant limitation of the mobility of the spine because of severe pain in this or that department more often indicates a pathology of the disc than other structures of the vertebral-motor segment. Local soreness and pain enhancement during the thrust palpation of the spinous process or percussion of the vertebral-motor segment are also characteristic signs of the actual protrusion of the disc.
One of the important differential diagnostic criteria of discogenic conflict in the vertebral canal (radiculo-ischemia) is a good effect of Aminophylline (10 ml of a 2.4% solution intravenously slowly or drip).
The only menthol that allows you to assess the condition of the disk. Is magnetic resonance imaging (MRI), so with pain in the back area, MRI should be an obligatory component of the survey standard. In addition to the size of the protrusion, MRI also makes it possible to assess the severity of perifocal changes in the vertebral canal and to perform differential diagnosis with neoplasms in the vertebral canal.
The pathogenesis of discogenic pain does not differ from the pathogenesis of other somatogenic pain. The rupture of the fibrous ring with protrusion of the pulpous nucleus is accompanied by a traumatic injury of the posterior longitudinal ligament or its rupture (clearly defined on the MRI). The irritation of mechanonociceptors and the onset of aseptic inflammation cause the initiation of the nociceptive flow from the protrusion area of the disc. In the event that the disc herniation comes into conflict with the spinal nerves, the spine (rootlets), then neuropathic pain joins the somatogenic pain. In the presence of symptoms of "loss" manifested by the corresponding sensory or motor disorders, the diagnosis of compression of the rootlet presents no difficulties. Difficulties arise in the absence of these symptoms. As a rule, the "radicular" pain irradiates according to the corresponding dermatome or sclerotome. As a rule, the effect on the spine is accompanied by a reflex muscular-tonic reaction, which often leads the doctor's thought away from the spinal canal to the periphery. So the compression of the cervical roots is often complicated by a marked spasm of stair muscles, compression of the lumbar pear-shaped muscle. And these muscular-tonic syndromes can dominate the clinical picture more or less time. The optimal method of instrumental diagnostics of radicular pathology is electromyography, which, unfortunately, has not yet been properly disseminated in everyday clinical practice.
[Diagnosis and treatment of herniated disc
It is necessary to perform MRI (more informative) or CT of the clinically affected area of the spine. Electromyography can help in refining the affected root. Since asymptomatic disc hernias are common enough, the physician should carefully compare the results of the MRI study with the clinical data before considering the issue of invasive procedures.
Since more than 95% of patients with herniated discs recover without surgical treatment for 3 months, treatment should be conservative if the neurologic deficit does not progress or is not severe. Severe or vigorous physical activity is contraindicated, but mild activity (for example, lifting weights from 2 to 4 kg) can be resolved with good tolerability. Prolonged bed rest is contraindicated. NSAIDs (eg, diclofenac, lornoxicam) and other analgesics-adjuvants (eg, tizanidine or tramalol) can be used if necessary to reduce pain. If lumbar radiculopathy leads to a persistent or severe objective neurologic deficit (muscle weakness, sensory disorders) or severe non-curable radicular pain, consideration of invasive treatment is possible. Microdiscectomy and laminectomy with surgical removal of the hernial material are usually the methods of choice. Dissolution of the hernial material by local injection of hemopapin is not recommended. Acute compression of the spinal cord or ponytail (for example, causing urinary retention or incontinence) requires immediate consultation of a neurosurgeon.
In cervical radiculopathy, urgent surgical decompression is required when there is a symptom of compression (the spinal cord, or a surgical method is chosen when the conservative treatment is ineffective.
Myths about the treatment of discogenic pain
"A disk hernia can be corrected." Extremely dangerous delusion. (which some doctors cultivate knowingly or unknowingly.) As early as the end of the 1980s, Professor VN Shevaga in Lviv conducted a series of clinical experiments on the direct digital "correction" of a herniated disc during a neurosurgical operation. Despite the complete relaxation of the patient ( anesthesia, muscle relaxants), the creation of traction for the upper and lower ends of the trunk, the disc herniation did not take place, he reported at vertebro-neurological congresses, however, a misconception is vivid until now, at best for "restoring" the hernia and polzujut traction methods, at worst - the manipulation of the disk.
"The disc hernia can be dissolved." Attempts to lyse the disc hernia with proteolytic enzymes (papain) were made in the second half of the last century by representatives of Novokuznetsk and Kazan schools of vertebro neurologists. However, all of them ended in failure. A person who once saw the intervertebral disc will understand that the proteolytic enzyme introduced for lysis of the hernia must initially lyse all the rest of the contents of the spinal canal, and only then the disk hernia. However, commercial attempts to commit the impossible continue.