Injury of lumbar intervertebral disks: causes, symptoms, diagnosis, treatment

Damage to the lumbar and thoracic intervertebral discs is much more common than commonly thought. They arise with the indirect effects of violence. The immediate cause of damage to the lumbar intervertebral discs are weight lifting, forced rotational movements, flexion movements, sudden sharp straining and, finally, a fall.

Damage to the thoracic intervertebral discs often occurs with a direct impact or impact on the vertebral end of the ribs, transverse processes in combination with muscular tension and forced movements, which is especially often observed in sportsmen when playing basketball.

Damage to the intervertebral discs is almost not observed in childhood, occur in adolescence and adolescence and especially in people 3-4 years of life. It is explained by the fact that isolated lesions of the intervertebral disc often arise in the presence of degenerative processes in it.

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What causes intervertebral disc damage?

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

The appearance of degenerative processes in the V intervertebral disk is due to the anatomical features of this intervertebral articulation. These features consist in the inconsistency of the anterior-posterior diameter of the bodies of the V lumbar and I sacral vertebrae. According to Willis, this difference varies from 6 to 1.5 mm. Fletcher confirmed this on the basis of an analysis of 600 roentgenograms of the lumbosacral spine. He believes that this discrepancy in the sizes of these vertebral bodies is one of the main causes of the onset of degenerative processes in the V lumbar disc. This is also facilitated by the frontal or predominantly frontal type of the lower lumbar and upper sacral facets, as well as their posterior-external incline.

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

Lacerations of the lumbar intervertebral discs are more common in men who are engaged in manual labor. They are especially frequent among athletes.

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

Intervertebral discs: anatomical and physiological information

The intervertebral disc, located between two adjacent surfaces of vertebral bodies, is a rather complex anatomical formation. This complex anatomical structure of the intervertebral disc is due to a peculiar complex of functions performed by it. The intervertebral disc has three main functions: the function of strong connection and holding adjacent vertebral bodies adjacent to each other, the function of the half joint, which ensures the mobility of the body of one vertebra in relation to the other's body, and, finally, the function of a shock absorber protecting the vertebral bodies from permanent traumatization. Elasticity and elasticity of the spine, its mobility and ability to withstand significant loads are mainly determined by the state of the intervertebral disc. All these functions can only perform a full, unchanged intervertebral disc.

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

The intervertebral disc consists of two hyaline plates, a fibrous ring and a pulpous core. Each of the hyaline plates densely belongs to the terminal plate of the body of the vertebra, is equal in size and is inserted into it like a clock-glass turned in the opposite direction, with the limb being the rim. The surface of the limbus is not covered with cartilage.

It is believed that the pulpous nucleus is the remainder of the dorsal chord of the embryo. Chord in the process of evolution is partially reduced, and partially transformed into a pulpous nucleus. Some argue that the pulpous nucleus of the intervertebral disc is not the remainder of the chord of the embryo, but represents a full functional structure that has replaced the chord in the process of phylogenetic development of higher animals.

Pulpoid nucleus is a gelatinous mass consisting of a small number of cartilaginous and connective tissue cells and fiber-like interwoven swollen connective tissue fibers. The peripheral layers of these fibers form a kind of capsule, bounding the gelatinous core. This nucleus turns out to be enclosed in a kind of cavity containing a small amount of fluid resembling synovial.

Fibrous ring consists of dense connective tissue bundles, located around the gelatinous nucleus and intertwined in different directions. It contains a small amount of interstitial substance and single cartilaginous and connective tissue cells. Peripheral bundles of the fibrous ring, closely adjacent to each other and similar to the Sharpei fibers are introduced into the bone edge of the vertebral bodies. The fibers of the fibrous ring, located closer to the center, are located more friable and gradually pass into the capsule of the gelatinous nucleus. Ventral - anterior section of the fibrous ring is more durable than the dorsal - posterior.

According to the data of Franceschini (1900), the fibrous ring of the intervertebral disc consists of collagen plates located concentrically and undergoing significant structural changes during their lifetime. In a newborn, the collagen lamellar structure is poorly expressed. Up to 3-4 years of life in the thoracic and lumbar regions and up to 20 years in the cervical region, the collagen plates are arranged in the form of quadrangular formations surrounding the nucleus of the disc. In the thoracic and lumbar regions from 3-4 years old, and to the cervical - from the age of 20, the primitive quadrangular collagen formations transform into elliptical formations. Subsequently, by the age of 35 in the thoracic and lumbar regions, while the size of the disk nucleus decreases, the collagen plates gradually acquire a pillow-like configuration and play a significant role in the damping function of the disc. These three collagen structures are quadrangular - elliptical and pillow-shaped, - replacing each other, are the result of mechanical action on the pulpous nucleus of the disc. Franceschini believes that the core of the disk should be seen as an adaptation designed to convert vertically acting forces into radial forces. These forces are crucial in the formation of collagen structures.

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

As noted above, the intervertebral disc in conjunction with the posterior-external intervertebral joints participates in the movements performed by the spine. The total amplitude of movements in all segments of the spine is quite significant. As a result, the intervertebral disc is compared with the semi-joint (Luschka, Schmorl, Junghanns). The pelvic nucleus in this hemisphere corresponds to the articular cavity, the hyaline plates to the articular ends, and the fibrous ring to the articular pouch. The pelvic nucleus in different parts of the spine occupies a different position: in the cervical spine it is located in the center of the disc, in the upper thoracic vertebrae - closer to the front, in all other sections - at the border of the middle and posterior third of the anteroposterior diameter of the disc. When the spinal column moves, the pulpous nucleus, capable of shifting to some extent, changes its shape and position.

Cervical and lumbar discs are higher in the ventral area, and pectorals are in the dorsal. This, apparently, is due to the presence of appropriate physiological curves of the spine. Various pathological processes leading to a decrease in the height of the intervertebral discs cause a change in the magnitude and shape of these physiological curves of the spine.

Each intervertebral disc is somewhat wider than the corresponding body of the vertebra and, in the form of a roller, stands somewhat forward and sideways. Front and sides of the intervertebral disc is covered with anterior longitudinal ligament that extends from the lower surface of the occipital bone along the entire anterior-lateral surface of the spine to the front surface of the sacrum, where it is lost in the pelvic fascia. The anterior longitudinal ligament is firmly fused to the bodies of the vertebrae and freely spreads through the intervertebral disc. In the cervical and lumbar - the most mobile parts of the spine, this ligament is somewhat narrower, and in the thoracic - wider and covers the anterior and lateral surfaces of the vertebral bodies.

The posterior surface of the intervertebral disc is covered by the posterior longitudinal ligament, which starts from the cerebral surface of the occipital bone and extends all the way through the spinal canal to the sacrum inclusive. Unlike the anterior longitudinal ligament, the posterior longitudinal ligament does not have strong connections with the vertebral bodies, but freely flows through them, being firmly and intimately connected to the posterior surface of intervertebral discs. The sites of the posterior longitudinal ligament passing through the vertebral bodies are narrower than those connected with the intervertebral discs. In the region of the discs, the posterior longitudinal ligament is somewhat widened and intertwined into the fibrous ring of the discs.

The gelatinous core of the intervertebral disc, due to its turgor, exerts constant pressure on the hyaline plates of the adjacent vertebrae, seeking to separate them from each other. At the same time, a powerful ligamentous apparatus and a fibrous ring tend to bring together adjacent vertebrae, counteracting the pulpous nucleus of the intervertebral disc. Because of this, the size of each individual intervertebral disc and the entire spine as a whole is not a constant value, but depends on the dynamic equilibrium of the oppositely directed forces of the pulpous nucleus and the ligamentous apparatus of two adjacent vertebrae. So, for example, after an overnight rest, when the gelatinous core acquires the maximum turgor and largely overcomes the elastic traction of the ligaments, the height of the intervertebral disc increases and the bodies of the vertebrae part. In contrast, by the end of the day, especially after a significant stanial load on the spine, the height of the intervertebral disc is reduced due to a decrease in the turgor of the pulpous nucleus. The bodies of adjacent vertebrae approach each other. Thus, throughout the day the length of the spine increases or decreases. According to AP Nikolaev (1950), this daily fluctuation of the spinal column reaches 2 cm. This also explains the decrease in the growth of elderly people. A decrease in the turgor of the intervertebral discs and a decrease in their height lead to a decrease in the length of the spinal column, and consequently, to a decrease in the growth of a person.

According to modern concepts, the safety of the pulpous core depends on the degree of polymerization of mucopolysaccharides, in particular hyaluronic acid. Under the influence of certain factors, depolymerization of the basic substance of the nucleus takes place. It loses its compactness, compacted, fragmented. This is the beginning of degenerative-dystrophic changes in the intervertebral disc. It is established that in the degenerate discs there is a shift in the localization of neutral and marked depolymerization of acidic mucopolysaccharides. Therefore, thin histochemical methods support the notion that degenerative-dystrophic processes in the intervertebral disc begin with subtle changes in the structure of the pulpous nucleus.

The intervertebral disc of an adult is approximately in the same conditions as the articular cartilage. Due to the loss of ability to regenerate, insufficient blood supply (Bohmig), and a large load on the mozveropnovkovye disks due to the vertical position of the person in them, the aging processes develop quite early. The first signs of aging occur already at the age of 20 years in the area of thinned sections of hyaline plates, where the hyaline cartilage is gradually replaced by connective tissue cartilage and its subsequent disintegration. This leads to a decrease in the resistance of hyaline plates. At the same time, the above-mentioned changes in the pulpous nucleus leading to a decrease in its damping effect occur. With age, all these phenomena are progressing. Dystrophic changes in the fibrous ring are associated with tearing it even under normal loads. Gradually: degenerative changes in the intervertebral and costal-vertebral joints join this. A moderate osteoporosis of vertebral bodies develops.

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

According to the absolute majority of authors, lesions of a degenerative-dystrophic nature in the intervertebral disk arise as a consequence of chronic overload. At the same time, in a number of patients, these lesions are the result of an individual acquired or constitutional inferiority of the spine, in which even the usual daily load turns out to be excessive.

A more in-depth study of the pathological morphology of degenerative processes in discs in recent years has not yet made fundamentally new facts in the notion of degenerative processes that was described by Hildebrandt (1933). According to Hildebrandt, the essence of the ongoing pathological process boils down to the following. Degeneration of the pulpous nucleus begins with a decrease in its turgor, it becomes more dry, fragmented, and loses its elasticity. Biophysical and biochemical studies of the elastic function of the discs made it possible to establish that in this case the collagen structure of the pulpous core is replaced by a fibrous tissue and the content of polysaccharides decreases. Long before the nucleus decays, other elements of the intervertebral disk are involved in separate processes. Under the influence of the pressure of adjacent vertebrae, the pulpous nucleus that has lost its elasticity is flattened. The height of the intervertebral disc is reduced. Parts of the decomposed pulpous nucleus are displaced to the sides, they flex to the outside of the fiber of the fibrous ring. Fibrous ring is broken, torn. It was revealed that, under vertical load on the disk in the modified disk, the pressure is much lower than in the normal one. At the same time, the fibrous ring of the degenerate disc undergoes a 4-fold greater load than the fibrous ring of the normal disc. Hyaline plates and adjacent surfaces of vertebral bodies undergo permanent traumatization. Hyaline cartilage is replaced by fibrous. In the hyaline plates, discontinuities and cracks appear, and at times entire sections of them are torn away. Defects in the pulpous nucleus, hyaline plates and fibrous ring merge in the cavity, intersecting the intervertebral disc in various directions.

Symptoms of lumbar disc injuries

Symptoms of lesions of the lumbar intervertebral discs fit into various syndromes and can range from minor, sudden pains in the lumbar region to a severe picture of complete transverse compression of the cauda equina with paraplegia and a disorder of the pelvic organs, as well as a whole gamut of vegetative symptoms.

The main complaint of the victims is the sudden pain in the lumbar spine after lifting gravity, sudden movement or, more rarely, falling. The victim can not take a natural posture, unable to carry out any movement in the lumbar spine. Scoliotic deformations are often acute. The slightest attempt to change the position causes an increase in pain. These pain can be local, but can radiate along the spinal roots. In more severe cases, there can be a picture of acute paraparesis, which soon turns into paraplegia. There may be an acute delay in urination, stool retention.

In an objective study, the lumbar lordosis is flattened down to the formation of angular kyphotic deformation, scoliosis, contracture of the lumbar muscles is a symptom of the "reins"; the restriction of all kinds of movements, the attempt to reproduce which intensifies the pain; pain during flicking along the spinous processes of the lower lumbar vertebrae, reflected ischialgic pain during effleurage along the spinous processes, soreness of the paravertebral points, soreness in the palpation of the anterior sections of the spine through the anterior abdominal wall; intensification of pain during coughing, sneezing, sudden laughter, straining, with compression of the jugular veins; impossibility of standing on toes.

Neurological symptoms of lumbar disc damage depend on the level of damage to the disc and the degree of interest in the elements of the spinal cord. As noted above, with rupture of the disc with a massive loss of its substance, monoparesis, paraparesis, and even paraplegia may occur, a disorder of the pelvic organs. The expressed bilateral symptomatology specifies massiveness of abaissement of a substance of a disk. With the interest of the IV lumbar spine, hypostasis or anesthesia can be detected in the buttocks, the external surface of the thigh, and the inner surface of the foot. In the presence of hypostension or anesthesia on the rear of the foot, one should think about the interest of the V lumbar spine. Falling or reduction of surface sensitivity along the outer surface of the shin, the external surface of the foot, in the region of the IV and V fingers suggests the interest of the first sacral segment. Often there are positive symptoms of tension (symptoms of Kernig, Lasega). There may be a decrease in Achilles and knee reflexes. If the upper lumbar discs are damaged, which is observed much less often, there may be a decrease in strength or loss of function of the quadriceps femoris, a sensitivity disorder on the front and inner surface of the thigh.

Diagnosis of lumbar disc damage

The x-ray method of investigation is of great importance in the recognition of intervertebral disc injuries. X-ray symsymptomatology of lesions of intervertebral lumbar disks is actually an x-ray-symptomatology of lumbar intervertebral osteochondrosis.

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

During this period, the so-called x-ray functional tests are of great diagnostic importance. The functional X-ray test is as follows. X-ray images are produced in two extreme positions - in the position of maximum flexion and maximum extension. With a normal unchanged disc, with maximum bending, the disc height is reduced from the front, while the maximum extension is at the rear. The absence of these symptoms indicates the presence of osteochondrosis - it indicates loss of cushioning function of the disc, a decrease in turgor and elasticity of the pulpous nucleus. At the moment of extension, the body of the overlying vertebra may be displaced posteriorly. This indicates a decrease in the function of holding the disc of one vertebral body relative to the other. The displacement of the body to the posterior should be determined from the posterior contours of the vertebral body.

In some cases, high-quality radiographs and tomograms may reveal a discoloration.

There may also be a symptom of the "strut", consisting of an uneven height of the disc and an anteroposterior radiograph. This unevenness consists in the presence of wedge-shaped deformation of the disc - the intervertebral crevice is wider at one edge of the vertebral bodies and gradually tapering toward the other edge of the bodies.

With a more pronounced radiologic picture ("osteochondrosis" according to Schmorl), there are phenomena of sclerosis of the closing plates of vertebral bodies. The appearance of sclerosis zones should be explained by reactive and compensatory phenomena from the side of the corresponding surfaces of the vertebral bodies, arising from the loss of the amortization function of the intervertebral disc. As a consequence, the surfaces of two adjacent vertebrae facing each other are systematically and permanently traumatized. Appearance of marginal growths. In contrast to the marginal growths in spondylosis, marginal growths with intervertebral osteochondrosis always located perpendicular to the long axis of the spine, proceed from the vertebral limbus of the vertebral bodies, can occur in any part of the lumbus, including the posterior, never merge with each other and arise against the background reduce the height of the disc. Retrograde stepped spondylolisthesis is often observed.

Vollniar (1957) described a "vacuum phenomenon" - an x-ray symptom, which, in his opinion, characterizes degenerative-dystrophic changes in the lumbar intervertebral discs. This "vacuumfenomenon" consists in the fact that at the anterior edge of one of the lumbar vertebrae on the roentgenogram, a slick-like bleaching-like shape is defined with a pinhead.

Contrast spondylography. Contrast methods of X-ray study include pionmomielography and discography. These research methods can be useful when, based on clinical and conventional radiographic data, it is not possible to accurately comprehend the presence or absence of damage to the disc. With new lesions of intervertebral discs, discography is more important.

Discography in the cases shown provides a number of useful data supplementing clinical diagnostics. The puncture of the disc allows you to clarify the capacity of the disc cavity, cause provoked pain, which reproduces the intensified attack of pains usually experienced by the patient, and, finally, get a contrast discogram.

The puncture of the lower lumbar discs is performed transdulally, according to the procedure proposed by Lindblom (1948-1951). The patient is seated or placed in a position with the maximum possible correction of the lumbar lordosis. The back of the patient is arched. If the puncture of the disc is made in the sitting position, the forearms bent in the elbows rest on their knees. Carefully determine the interstitial spaces and denote a solution of methylene blue or brilliant green. The operating field is treated twice with 5% tincture of iodine. Then iodine is removed with an alcoholic napkin. Skin, subcutaneous fat, interstitial space is anesthetized with 0.25% solution of novocaine. The needle with the mandrel for spinal puncture is administered, as with spinal puncture. The needle undergoes the skin, subcutaneous tissue, superficial fascia, the interstitial and interstitial ligament, the posterior epidural fiber and the back wall of the dural sac. Remove the mandril. Conduct liquorodynamic tests, determine liquor pressure. Take for examination cerebrospinal fluid. Again introduce the mandrake. The needle is advanced anteriorly. Guided by the feelings of the patient, change the direction of the needle. In the case of needle contact with the elements of the horse's tail, the patient complains of pain. When you feel pain in your right leg, you should pull the needle a little and hold it to the left, and vice versa. Puncture the front wall of the dural sac, the anterior epidural fiber, the posterior longitudinal ligament, the posterior section of the fibrous ring of the intervertebral disc. The needle falls into the cavity. Passage of the posterior longitudinal ligament is determined by the reaction of the patient - complaints of pain along the course of the spine until the occiput. The passage of the fibrous ring is determined by the resistance of the needle. During the process of puncture the disc should focus on a profile spondylogram, which helps to navigate in choosing the right direction for the needle.

Determination of the capacity of the disk is carried out by injecting a physiological saline solution through a needle into the disk cavity using a syringe. Normal disk allows you to enter into its cavity 0,5-0,75 ml of liquid. A larger amount indicates a degenerate disc change. If there are cracks and ruptures of the fibrous ring, then the amount of possible introduction of fluid is very large, since it flows into the epidural space and spreads in it. By the amount of fluid introduced, it is roughly possible to judge the degree of degeneration of the disc.

Reproduction of the provoked pains is carried out by a little excessive introduction of a solution. Increasing the internal disk pressure, the injected solution intensifies or causes compression of the spine or ligaments and reproduces the more intense pain inherent in the patient. These pains are sometimes quite significant - the patient suddenly screams from pain. The patient's questioning about the nature of the pains makes it possible to solve the question of the correspondence of this disk to the cause of the patient's suffering.

Contrastive discography is carried out by introducing a solution of cardiotrial or hepak through the same needle. If the contrast material is free, do not inject more than 2-3 ml. Similar manipulations are repeated on all questionable disks. It is most difficult to puncture the V disk located between the V lumbar and I sacral vertebrae. This is due to the fact that the bodies of these vertebrae are located at an angle open anteriorly, so that the gap between them is considerably narrowed from behind. Usually more time is spent on the puncture of the V disk than on the puncture of the overlying ones.

It should be borne in mind that the radiography is produced no later than 15-20 minutes after the administration of contrast medium. After a later period, the contrast discography will not work, as cardiotrast will resolve. Therefore, we recommend first to puncture all the necessary disks, determine their capacity and the nature of provoked pain. The needle is left in the disk and the mandrl is introduced into it. Only after the introduction of needles in all the necessary disks should you quickly enter a contrast agent and immediately make a discography. Only in this case are discographs of good quality.

Trduralnym way you can puncture only the three lower lumbar discs. Above is already the spinal cord, excluding transduralpuyu puncture II and I lumbar discs. If you need to puncture these discs, you should use the epidural access suggested by Erlacher. The needle is injected 1.5-2 cm outward from the spinous process on the healthy side. It is directed upward and koutri, from the posterior-external intervertebral joint to the intervertebral foramen and inserted into the disk through the gap between the spine and the dural sac. This method of puncturing the disc is more complicated and requires skill.

Finally, the disk can also be punctured with external access, offered by de Seze. To do this, a needle 18-20 cm long is inserted 8 cm outward from the spinous process and directed to the inside and upward at an angle of 45 °. At a depth of 5-8 cm, it rests against a transverse process. He is circumvented from above and moves the needle deeper to the middle line. At a depth of 8-12 cm, its tip rests against the lateral surface of the vertebral body. By means of roentgenography, check the position of the needle and make correction until the needle enters the disk. The method also requires known skills and takes longer.

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

The nature of the discography depends on the changes in the disc. A normal discogram is a rounded, square, oval slit-shaped shadow located in the middle (anteroposterior projection). On the profile discogram this shadow is located closer to the back, approximately on the border of the back and middle third of the anteroposterior diameter of the disc. In case of intervertebral disc injuries, the character of the discogram changes, the shadow of contrast in the intervertebral space can take the most bizarre forms up to the emergence of contrast iodine anterior or posterior longitudinal ligaments, depending on where the fibrous ring ruptured.

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

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Conservative treatment of lesions of lumbar intervertebral discs

In the vast majority of cases, lesions of the lumbar intervertebral discs are cured by conservative methods. Conservative treatment of lesions of lumbar discs should be carried out in a complex manner. This complex includes orthopedic, medicamental and physiotherapeutic treatment. Among the orthopedic methods are the creation of rest and unloading of the spine.

The injured person with a lumbar intervertebral disc is placed in bed. It is a mistake to imagine that the victim should be laid on a hard bed in the position on the back. In many affected, such a forced situation causes an increase in pain. On the contrary, in some cases there is a decrease or disappearance of pain when laying the victims in a soft bed, allowing a significant flexion of the spine. Often the pain passes or decreases in the position on the side with the hips brought to the stomach. Consequently, in bed, the victim must accept the position in which pain disappears or diminishes.

Discharge of the spine is achieved by the horizontal position of the victim. After some time, after passing the acute phenomena of the former damage, this unloading can be supplemented by a constant spinal extension along the inclined plane with the help of soft rings for axillary cavities. To increase the strength of stretching, additional weights can be used, suspended from the pelvis by means of a special belt. The magnitude of the cargo, time and degree of stretching are dictated by the feelings of the victim. Rest and unloading of the damaged spine last for 4-6 weeks. Usually pain disappears in this period, the rupture in the area of the fibrous ring heals with a strong scar. In later periods after the former damage, with more persistent pain syndrome, and sometimes even in fresh cases, it is more effective not to permanently stretch, but intermittently stretch the spine.

There are several different techniques for intermittent spinal distension. Their essence boils down to the fact that during a relatively short period of 15-20 minutes, with the help of cargoes or dosed screw traction, the tension is increased to 30-40 kg. The magnitude of the tension force in each individual case is dictated by the physique of the patient, the degree of development of his musculature, and also by his sensations in the process of stretching. The maximum stretching lasts for 30-40 minutes, and then during the next 15-20 minutes it gradually reduces to pet.

Stretching of the spine with the help of a dosage screw rod is carried out on a special table, the platforms of which are spread along the length of the table by a screw rod with a wide thread pitch. The victim is fixed on the head end of the table with a special bra worn on the chest, and on the foot - by the belt behind the pelvis. With the divergence of the foot and head platforms, the lumbar spine extends. In the absence of a special table, intermittent stretching can be performed on an ordinary table by hanging loads behind the pelvic girdle and a bra on the chest.

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

Medicamentous treatment of lesions of lumbar disks consists in oral intake of medicinal substances or their local application. In the first hours and days after injury, with a pronounced pain syndrome, medication should be aimed at relieving pain. Analgin, promedol, etc. Can be used. A good therapeutic effect is provided by large doses (up to 2 g per day) of salicylates. Salicylates can be administered intravenously. Novocaine blockades are also useful in various modifications. A good analgesic effect is injected with hydrocortisone in the amount of 25-50 mg into the paravertebral painful points. Even more effective is the administration of the same amount of hydrocortisone to the damaged intervertebral disc.

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

Of the physiotherapeutic procedures, diadynamic currents are most effective. Can be applied povoporez novocaine, thermal procedures. It should be borne in mind that often thermal procedures cause exacerbation of pain, which appears, apparently, due to increased local edema of tissues. If the victim's state of health worsens, they should be canceled. After 10-12 days in the absence of pronounced phenomena of stimulation of the spinal roots, massage is very useful.

In later terms, such victims can recommend balneotherapy (Pyatigorsk, Saki, Tskhaltubo, Belokurikha, Matsesta, Karachi). In some cases, it is useful to wear soft semi-corsets, corsets or "graces."

[3], [4], [5], [6], [7], [8]

Operative treatment of injuries of lumbar intervertebral discs

Indications for surgical treatment of lesions of lumbar intervertebral discs arise in those cases when conservative treatment is ineffective. Usually these indications occur in the long term after the former damage and in fact the intervention is made about the consequences of the former damage. Such indications are persistent lumbalgia, phenomena of functional inconsistency of the spine, syndrome of chronic compression of the spinal roots, not inferior to conservative treatment. With fresh lesions of the intervertebral lumbar disks, indications for surgical treatment arise with acute development of the horse tail syndrome with paraparesis or paraplegia, a disorder of the pelvic organs.

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

The operative treatment of lumbar intervertebral osteochondrosis ("lumbosacral radiculitis") was first performed by Elsberg in 1916. Taking the dropped out matter of the disc when it was damaged for intespinal tumors - the chondromas, Elsberg, Petit, Qutailles, Alajuanine (1928) removed them. Mixter, Barr (1934), proving that the "chondromas" are nothing more than a fallen part of the pulpous core of the intervertebral disc, produced a laminectomy and removed the fallen part of the intervertebral disc by trans- or extradural access.

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

The existing surgical methods for treating the deposition of disc substance in intervertebral osteochondrosis can be divided into palliative, conditionally radical and radical ones.

Palliative surgery in case of damage to lumbar discs

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

The task of this surgery is only to remove the fallen out part of the disc and to eliminate the compression of the nerve root.

The victim is placed on the operating table in the position on the back. To eliminate lumbar lordosis, different authors use different techniques. B. Boychev proposes to lay a pillow under the lower abdomen. AI Osna gives the patient "the pose of a praying Buddhist monk." Both of these methods lead to a significant increase in intraluminal pressure, and consequently, to venous stasis, which causes increased bleeding from the operating wound. Friberg constructed a special "cradle" in which the victim is placed in the right position without difficulty breathing and increasing intra-abdominal pressure.

Local anesthesia, spinal anesthesia and general anesthesia are recommended. Supporters of local anesthesia consider the advantage of this type of anesthesia the ability to monitor the course of the operation by squeezing the spinal root and the patient's reaction to this compression.

Technique of operation on the lower lumbar discs

A paravertebral semi-ovoid incision is layered through the skin, subcutaneous tissue, superficial fascia. The middle of the incision should have an affected disc. On the side of the lesion, the lumbar fascia is dissected longitudinally at the edge of the bunched ligament. The lateral surface of the spinous processes, half-arches and articular processes carefully skeletonize. From them, all soft tissues must be carefully removed. A wide powerful crochet soft tissues are pulled laterally. They expose the half-arcs, which are between them yellow ligaments and articular processes. Dissect the site of the yellow ligament at the desired level. They expose the dura mater. If this turns out to be inadequate, the part of the adjacent parts of the half-bows or the adjacent half-bows are completely bored. Gemilaminectomy is completely permissible and justified for the expansion of operative access, but it is difficult to agree to a wide laminectomy with removal of 3-5 arches. In addition to the fact that laminectomy significantly weakens the posterior part of the spine, it is believed that it leads to a reduction in movement and pain. The limitation of movements and pain is directly proportional to the size of the lamiaectomy. Careful hemostasis is performed throughout the intervention. The dural sack is shifted to the inside. Spread aside the spinal root. Inspect the posterolateral side of the affected intervertebral disc. If the disc herniation is located posteriorly from the posterior longitudinal ligament, then it is grasped with a spoon and removed. Otherwise, the posterior longitudinal ligament or protruded posterior portion of the posterior section of the fibrous ring is dissected. After that, remove part of the disc. Produce a hemostasis. On the wounds are layered sutures.

Some surgeons produce a dissection of the dura mater and use triodural access. The disadvantage of transdulal access is the need for a wider removal of the posterior parts of the vertebrae, dissection of the posterior and anterior plates of the dura mater, the possibility of subsequent intradural cicatricial processes.

If necessary, one or two articular processes can be eaten, which makes operative access more extensive. However, this breaks the reliability of the stability of the spine at this level.

Within 24 hours the patient is in the position on the abdomen. Conduct symptomatic medication. From 2 days a patient is allowed to change position. On the 8-10th day he is discharged for outpatient treatment.

The described surgical intervention is purely palliative and eliminates only the compression of the spinal root by the dropped disc. This intervention is not aimed at curing the underlying disease, but only at eliminating the complication that results from it. Removing only a portion of the affected lesion does not preclude the possibility of recurrence of the disease.

Conditionally radical surgery for damage to lumbar discs

The basis of these operations is the proposal of Dandy (1942) not to be limited to removing only the fallen part of the disk, but using an acute bone spoon to remove the entire affected disc. In this way, the author tried to solve the problem of preventing relapses and create conditions for the emergence of fibrous ankylosis between adjacent bodies. However, this method did not lead to the desired results. The number of relapses and adverse outcomes remained high. This depended on the insolvency of the proposed operative intervention. Too difficult and problematic is the possibility of completely removing the disc through a small hole in its fibrous ring, the availability of fibrous ankylosis in this highly mobile spine is too unlikely. The main disadvantage of this intervention, in our opinion, is the impossibility of restoring the lost height of the intervertebral disc and normalizing anatomical relationships in the posterior vertebral elements, the inability to achieve bone fusion between the vertebral bodies.

Attempts by individual authors to "improve" this operation by introducing separate bone grafts into the defect between vertebral bodies also did not lead to the desired result. Our experience in the surgical treatment of lumbar intervertebral osteochondroses allows us to state with certain certainty that it is impossible to remove the end plates of adjacent vertebral bodies with the bone spoon or curette so as to expose the spongy bone, without which it is impossible to count on the onset of bone fusion between the vertebral bodies. Naturally, placing individual bone grafts in an unprepared bed can not lead to bone ankylosis. The introduction of these grafts through a small hole is difficult and unsafe. This method does not solve the problems of restoring the height of the intervertebral space and restoring normal relationships in the posterior elements of the vertebrae.

The number of conditionally radical operations includes attempts to combine removal of the disc with posterior spondylodesis (Ghormley, Love, Joung, Sicard, etc.). According to the authors' intention, the number of unsatisfactory results in surgical treatment of intervertebral osteochondroses can be reduced by supplementing the operative intervention with posterior spondylodesis. In addition to the fact that it is extremely difficult to get arthrodesis of the posterior parts of the spine in conditions of disruption of the integrity of the posterior parts of the spine, this combined surgical method of treatment is not able to resolve the issue of restoring the normal height of the intervertebral space and normalizing anatomical relationships in the posterior parts of the vertebrae. However, this method was a significant step forward on the path of operative treatment of lumbar intervertebral osteochondrosis. Despite the fact that he did not lead to a significant improvement in the results of surgical treatment of intervertebral osteochondrosis, he nevertheless made it clear that it is impossible to solve the problem of treating degenerative lesions of intervertebral disks with one "neurosurgical" approach.

[9], [10], [11]

Radical operations in case of damage to lumbar discs

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

The operation of VD Chaklin, proposed by him in 1931 for the treatment of spondylolisthesis, is based on the radical surgical interventions used to treat lesions of the lumbar intervertebral discs. The main points of this operation are exposure of the anterior spine from anterior-external extraperitoneal access, resection of 2/3 of the intervertebral articulation and placement in the resulting defect of the bone graft. Subsequent flexion of the spine helps reduce lumbar lordosis and the onset of bone adhesion between the bodies of adjacent vertebrae.

With regard to the treatment of intervertebral osteochondrosis, this intervention did not resolve the issue of the removal of the entire affected disc and the normalization of anatomical interrelations of posterior vertebral elements. Wedge-shaped excision of the anterior sections of the intervertebral articulation and placement in the resulting wedge-shaped defect of the corresponding in magnitude and shape of the bone graft did not create conditions for restoring the normal height of the intervertebral space and diverging along the length of the articular processes.

In 1958, Hensell reported 23 patients with intervertebral lumbar osteochondrosis, who were promptly treated according to the following procedure. The position of the patient on his back. Paramedic dissection cuts the skin, subcutaneous tissue, superficial fascia. Open the vagina of the rectus abdominis muscle. The rectus abdominis is pulled outward. The peritoneum is exfoliated until the lower lumbar vertebrae and the intervertebral discs that lie between them become accessible. Removal of the affected disc is performed through the aortic bifurcation area. A bone wedge about 3 cm in size is taken from the crest of the wing of the ilium and inserted into the defect between the vertebral bodies. It is necessary to ensure that the bone graft does not cause pressure of the roots and dural sac. The author warns of the need to protect the vessels well at the time of insertion. After the operation, a plaster corset is applied for 4 weeks.

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

Total discectomy and wedging corporodesis

This name is understood as the surgical intervention undertaken in the case of lesions of the lumbar intervertebral discs, during which the entire damaged intervertebral disc is removed, with the exception of the posterior-external parts of the fibrous ring, conditions for the onset of bone fusion between the bodies of adjacent vertebrae, restore the normal height of the intervertebral space, and there is a wedging - rekklnatsiya - inclinated articular processes.

It is known that when the height of the intervertebral disc is lost, the vertical diameter of the intervertebral foramen decreases, due to the inevitable subsequent incision of the articular processes. Separating the intervertebral foramen, in which the spinal roots and radicular vessels pass, and also the spinal ganglions. Therefore, it is extremely important to restore the normal vertical diameter of the intervertebral spaces during the operative intervention. Normalization of anatomical relationships in the posterior regions of two vertebrae is achieved by wedging.

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

Preoperative preparation consists in the usual manipulations performed before the intervention on the retroperitoneal space. In addition to general hygiene procedures, carefully clean the intestines, empty the bladder. In the morning on the eve of surgery, the pubis and the anterior abdominal wall are shaved. On the eve of surgery for the night, the patient receives sleeping pills and sedatives. Patients with an unstable nervous system are given medication for several days before the operation.

Anesthesia is endotracheal anesthesia with controlled breathing. Relaxation of the musculature greatly facilitates the technical performance of the operation.

The victim is laid on his back. Using a roller, laid under the waist, strengthen the lumbar lordosis. This should be done only when the victim is in a state of anesthesia. Increased lumbar lordosis spine as it approaches the surface of the wound - its depth becomes smaller.

The technique of total discectomy and wedge-shaped corporeodesis

The lumbar spine is exposed by the previously described anterior left-sided paramedial extraperitoneal access. Depending on the level of the affected disc, access is used without resection or resection of one of the lower ribs. The approach to the intervertebral discs is realized after mobilization of vessels, dissection of the prevertebral fascia and displacement of the vessels to the right. Penetration to the lower lumbar discs through the area of division of the abdominal aorta seems to us more difficult, and most importantly more dangerous. When using access through aortic bifurcation, the operating field is confined to all sides by large arterial and venous trunks. Free, from the vessels there is only the lower crane of the limited space in which it is necessary to manipulate the surgeon. When manipulating the discs, the surgeon should always ensure that the surgical instrument does not accidentally damage nearby vessels. With the displacement of the vessels to the right, the entire front and left lateral part of the discs and vertebral bodies is free of them. Only the lumbosacral muscle remains attached to the spine to the left. The surgeon can freely manipulate instruments from the right to the left without any risk of damaging the blood vessels. Before proceeding to manipulations on the disks, it is advisable to select and shift left the left border sympathetic trunk. This greatly increases the scope for manipulation on the disk. After the dissection of the prevertebral fascia and the displacement of the vessels to the right, the anterior-lateral surface of the bodies of the lumbar vertebrae and discs, covered with anterior longitudinal ligament, is widely opened. Before you begin to manipulate the disks, you need to disclose the disk you need. To carry out a total discectomy, you should open the entire disk and the adjacent parts of the adjacent vertebral bodies along the entire length. For example, to remove the V lumbar disc, the upper part of the body I of the sacral vertebra V, the lumbar disc and the lower body of the lumbar vertebra V, should be exposed. Displaced vessels should be reliably protected by elevators, which protect them from accidental injury.

The anterior longitudinal ligament is dissected either U-shaped or in the form of the letter H, which is in a horizontal position. This is of no fundamental importance and does not affect the subsequent stability of this part of the spine, firstly, because in the region of the distant disk, later, bone fusion occurs between the bodies of adjacent vertebrae, and secondly, because both of them In the following case, the anterior longitudinal ligament fuses with the scar at the site of the cut.

The dissected anterior longitudinal ligament is cut off in the form of two lateral or one apron flap on the right base and taken to the sides. The anterior longitudinal ligament is cut off enough to expose the marginal limb and the adjacent area of the vertebral body. Expose the fibrous ring of the intervertebral disc. Affected discs have a peculiar appearance and differ from a healthy disc. They do not have a characteristic turgor and will not stand in the form of a characteristic cushion over the bodies of the vertebrae. Instead of a silvery-white color, characteristic of a normal disc, they acquire a yellowish color or ivory. Unsuspecting eyes may seem that the height of the disc is reduced. This false impression is created because the lumbar spine overdrawn on the platen, than the lumbar lordosis is artificially strengthened. Stretched anterior sections of the fibrous ring and create a false impression of a wide disc. The fibrous ring is separated from the anterior longitudinal ligament along the entire anterior-lateral surface. A wide chisel with a hammer produces the first section parallel to the plate of the vertebral body adjacent to the disk. The width of the chisel should be such that the cross section passes through the entire width of the body, except for the side compact plates. The chisel must penetrate to a depth of 2/3 of the anterior-posterior diameter of the vertebral body, which on average corresponds to 2.5 cm. The second section is performed in the same way in the region of the second body of the vertebra adjacent to the disc. These parallel sections are made in such a way that, together with the disc being removed, the end plates are separated and the spongy bone of the adjacent vertebral bodies is opened. If the chisel is not installed correctly and the plane of the section in the body of the vertebra passed not near the closure plate, venous bleeding from the venous sinuses of the vertebral bodies may occur.

A narrower bit produces two parallel sections along the edges of the first in a plane perpendicular to the first two sections. With the aid of an osteotome inserted into one of the sections, the isolated disc is easily dislocated from its bed and removed. Usually, a slight venous bleeding from his bed is stopped by a tamponade with a gauze pad moistened with a warm saline solution. With the help of bone spoons, remove the posterior parts of the disc. After removing the disc, the posterior compartment of the fibrous ring becomes visible. The "hernial gates" are clearly visible, through which it is possible to remove the fallen part of the pulpous nucleus. Especially carefully remove with the help of a curved little bone spoon the remains of the disc in the area of the intervertebral foramen. Manipulation in this case must be careful and gentle, so as not to damage the roots passing here.

This concludes the first stage of the operation - total discectomy. When comparing the masses of the disk deleted when using the front access, with the number of them removed from the rear-outdoor access, it becomes quite obvious how palliative the operation performed through the rear access is.

The second, not less important and responsible moment of the operation is a "wedging" corpodrose. The transplant introduced into the formed defect should promote the onset of bone fusion between the bodies of adjacent vertebrae, restore the normal height of the intervertebral space and prop up the posterior parts of the vertebrae so that the anatomical relationships in them will normalize. The anterior sections of the vertebral bodies should bend over the front edge of the graft placed between them. Then the posterior parts of the vertebrae - the arches and articular processes - will fan out in a fanlike manner. The disturbed normal anatomical relationships in the posterior-external intervertebral joints will be restored, and due to this the intervertebral foramen, which narrowed due to the decrease in the height of the affected disc, is somewhat widened.

Consequently, the graft placed between the bodies of adjacent vertebrae should meet two basic requirements: it should promote the fastest onset of the bone block between the bodies of adjacent vertebrae and its anterior section should be so strong. To withstand the great pressure exerted on him by the bodies of the adjacent vertebrae during the wedging.

Whence to take this transplant? With a well expressed, sufficiently massive crest of the iliac wing, the graft should be taken from the ridge. You can take it from the upper metaphysis of the tibia. In this latter case, the anterior section of the transplant will consist of a strong cortical bone, a crest of the tibia and a spongy bone of the metaphysis, which has good osteogenic properties. This is of no fundamental importance. It is important that the transplant be taken correctly and fit the right size and shape. However, the structure of the graft from the crest of the iliac wing is more similar to the structure of vertebral bodies. The transplant should have the following dimensions: the height of its anterior section should be 3-4 mm greater than the height of the intervertebral defect, its width in front should correspond to the width of the defect in the frontal plane, the length of the graft should be equal to 2/3 of the anterior-posterior size of the defect. Its anterior section should be somewhat wider than the posterior one - posteriorly it narrows somewhat. In the intervertebral defect, the graft should be positioned so that its anterior margin does not survive beyond the front surface of the vertebral bodies. Its posterior edge should not contact the posterior section of the fibrous disc ring. There should be some space between the posterior edge of the transplant and the fibrous disc ring. This is necessary to prevent accidental compression of the posterior margin of the graft of the anterior section of the dural sac or spinal roots.

Before placing the transplant in the intervertebral defect, slightly increase the height of the bead under the lumbar spine. This increases the lordosis and the height of the intervertebral defect further. Increase the height of the roller should be carefully, dosed. The transplant is placed in the intervertebral defect so that its anterior margin of 2-3 mm enters the defect and a corresponding gap forms between the anterior edge of the vertebral bodies and the anterior edge of the graft. The roller of the operating table is lowered to the level of the plane of the table. Eliminate lordosis. In the wound, one can clearly see how the bodies of the vertebrae converge and the graft placed between them is well wedged. It is firmly and reliably restrained by the bodies of closed vertebrae. At this point, partial wedging of the posterior parts of the vertebrae occurs. Later, when the patient in the postoperative period is given the position of flexion of the spine, this wedging will increase even more. No additional grafts in the form of bone crushed stone should be introduced into the defect because they can move posteriorly and subsequently cause bone compression in the anterior section of the dural sac or roots. The transplant should be formed as follows. That he performed an intervertebral defect in the specified boundaries.

Above the transplant, the flaps of the severed anterior longitudinal ligament are placed. The edges of these flaps are sewn together. It should be borne in mind that more often these flaps can not completely close the area of the anterior part of the transplant, because due to the restoration of the height of the intervertebral space the size of these flaps is insufficient.

Careful hemostasis during the operation is absolutely mandatory. The wound of the anterior abdominal wall is sutured layer by layer. Enter antibiotics. Apply an aseptic bandage. In the process of surgery, blood loss is compensated, it usually is insignificant.

With proper management of anesthesia, spontaneous breathing is restored by the end of the operation. Extubation is performed. With stable indices of blood pressure and replenishment of blood loss, blood transfusion is stopped. Usually, neither during operative intervention, nor in the postoperative period, there are significant fluctuations in blood pressure.

The patient is placed in bed on a hard shield in the position on the back. Hips and tibia are bent in the hip and knee joints at an angle of 30 ° and 45 °. For this, a high roller is placed under the area of the knee joints. This achieves some flexion of the lumbar spine and relaxation of the lumbosacral muscles and muscles of the limbs. In this position the patient remains for the first 6-8 days.

Conduct symptomatic medication. There may be a brief delay in urination. To prevent intestinal paresis, intravenously inject 10% sodium chloride solution in the amount of 100 ml, subcutaneously - a solution of prosirin. Antibiotics are administered. In the early days, an easily digestible diet is prescribed.

On the 7th-8th day the patient is seated in bed, equipped with special appliances. The hammock in which the patient sits is made of dense matter. The footrest and backrest are made of plastic. These devices are very convenient for the patient and hygienic. The flexion position of the lumbar spine further wedges the posterior parts of the vertebrae. In this position the patient is 4 months old. After this period, a plaster corset is applied and the patient is discharged. After 4 months, the corset is removed. By this time, usually there is a roentgenologic presence of the bone block between the vertebral bodies, and the treatment is considered complete.