Osteochondrosis

Osteochondrosis (osteochondrosis) is a degenerative-dystrophic disease that includes a complex of changes in the intervertebral disc and surrounding tissues and is manifested by polymorphic neurologic syndromes.

Osteochondrosis is the cause of back pain in 80% of cases.

[1], [2], [3], [4], [5], [6], [7], [8]

Causes of the osteochondrosis

The reasons for the development of osteochondrosis, that is, degeneration of the intervertebral disc, are still not accurately established. In fact, osteochondrosis is a polyethological disease. Among the main reasons can be noted the age factor, microtraumatism of discs, metabolic disorders in the body, poor physical development, genetic predisposition, etc.

[9], [10], [11]

Pathogenesis

When osteochondrosis of the intervertebral disk tissue for a number of reasons leading to trophic disturbance, lose moisture, the fibrous ring becomes less elastic, and the pulpous nucleus becomes hypermobile. The intervertebral disc loses its amortization function. In the fibrous ring, cracks may appear, through which a pulpous nucleus can protrude, up to the complete rupture of the fibrous ring with the exit of the pulpous nucleus beyond its limits). Due to anatomical features and biokinetics of the spine, protrusions occur more often in the posterior or posterior-lateral direction, that is, towards the vertebral canal, which leads to compression of the anatomical formations located there (spinal cord, spinal cord, vessels).

In addition to the intervertebral discs with osteochondrosis, hyaline plates suffer, disorders occur in the small joints of the spine, vertebrae change, in which additional growths of bone tissue along the vertebral body edges (osteophytes) are adaptively formed. The latter in turn can also have a compressive effect on both the structures inside the vertebral canal and outside the spine.

The processes of dystrophy of the intervertebral disc during the further development of osteochondrosis entail compensatory changes in the bodies, joints, ligaments with the involvement of the vessels, muscles and nerves in the pathological process.

In some cases, degenerative changes lead to a disruption in the strength of the vertebral joint, and their displacement relative to each other (spondylolisthesis) occurs. Displacement of the disc without breaking the fibrous ring is denoted by the term "protrusion" of the disc. In those cases when the breakthrough of the fibrous ring is accompanied by the exit beyond its part of the degenerate altered jelly nucleus, they speak of prolapse of the disc.

[12], [13], [14], [15], [16], [17], [18]

Symptoms of the osteochondrosis

Most often, osteochondrosis affects the cervical (CV-CVII) and lumbar (LV-SI).

The osteochondrosis of the neck and its symptoms are largely due to the anatomical and physiological features of the cervical spine. Compression-radicular cervical vertebrogenic syndromes are caused by irritation or squeezing of a certain root. This causes pain in the zone of innervation of the corresponding dermatome, sensory and motor disorders. Irritative-reflex syndromes (cervicalgia, cervicocranygia, cervicobrahialgia) are caused by irritation of the sinuvertebral nerve, often with the addition of a vegetative component.

Muscle-tonic syndromes also arise due to the irrigation of pain receptors of the sinuvertebral nerve with the excitation of the segmental apparatus of the spinal cord. They are manifested by prolonged muscle strain, the appearance of pain in them, the development of fibrotic changes. Sometimes this is accompanied by the appearance of reflected pain within segmental vegetative innervation (the Zakharyin-Ged zone). With prolonged irritation of the vegetative-trophic structures of the segmental and supra-segmental apparatus, neurodystrophic syndromes develop (lower oblique muscle syndrome of the head, scapular-rib syndrome, shoulder-scapular periarthrosis, shoulder-brush syndrome, etc.).

One of the most important features of the structure of the cervical spine is the presence of holes in the transverse processes CVI-SII, through which the vertebral artery passes through with the same sympathetic nerve (Frank's nerve). With osteochondrosis of the cervical region, mainly due to the growth of osteophytes, cerebral circulatory insufficiency in the vertebrobasilar basin of compression or reflex genesis can form.

In the case of protrusion or prolapse of the intervertebral disc, a spinal cord compression clinic (compression vertebrogenic myelopathy) with segmental, conductive symptoms, vegetative-trophic disorders and a disorder of pelvic organs may develop.

With lesions of intervertebral discs in the lumbar region, the main complaint of patients is back pain and only in rare cases other disorders appear on the foreground. Usually the pain is localized in the lumbosacral region and irradiates into the lower limbs. In some cases, the disease begins gradually, in others - sharply, with the appearance of sharp pain, which can build up within a few hours, days.

The pathogenesis and character of pain are similar to those in cervical osteochondrosis. When coughing, natuzhivanii pain increases, which is due to increased pressure in the subarachnoid space. In the prone position and in the forced posture, the pain may decrease.

The zones of irradiation of pain in the lower limb have a different topography and almost always have a distinct mono- or biradicular character. On examination, attention is drawn to the presence of a characteristic scoliosis (homo- or goterolateral), more often flattening of physiological lordosis in the lumbar spine. Almost always there is a strain of long back muscles in the lumbar region. With palpation, the soreness of the spinous processes of the vertebrae is determined. A positive Laseg symptom is one of the most constant symptoms with a posterior displacement of the discs of the lower lumbar and first sacral vertebrae.

The second most important symptom of osteochondrosis is a sensitivity disorder in the zones of innervation of the affected roots and the appearance of paresthesia, hypesthesia or anesthesia. Usually the dermatome root for sensitive disorders is defined much more clearly than on irradiation of pain. In addition to sensitive, motor disorders can occur with a decrease in the function of the muscles innervated by the corresponding spine, their atrophy, and a decrease in reflexes.

Occasionally, when the hernia of the LIV or LV root disc is compressed, a spinal cord injury syndrome occurs at the level of the cone and epiconus (acute myeloradiculo-ischemia syndrome). This happens in those cases when this department is supplied with blood by the artery of the root LIV or LV (artery of Deprozh-Gotteron).

Stages

L.I. Osna in 1971 proposed the classification of stages of osteochondrosis.

• I stage - the internal disk displacement of the nucleus is greater than normal, which leads to stretching or tightening of the fibrous ring).
• II stage - the appearance of cracks in the fibrous ring and the stability of the affected vertebral segment.
• III stage - complete rupture of the fibrous ring with disc prolapse, inflammatory process with possible compression of nerves and vessels.
• IV stage - there is a dystrophic lesion of other components of the intervertebral disc with the addition of spondylosis, spondyloarthrosis and other compensatory changes.

[19], [20], [21], [22], [23], [24]

Diagnostics of the osteochondrosis

Radiographic examination of the spine is part of a comprehensive clinical examination of neurological patients, with the help of which they clarify the nature of changes in the vertebrae, discs, vertebral canal, archicular joints. On radiographs, it is possible to detect changes in the axis of the spine - straightening of the cervical and lumbar lordosis or strengthening of the thoracic kyphosis. Radiographs with functional tests help determine the presence of vertebral dislocation (instability). Sometimes a degenerate-altered disk traces the accumulation of gas (a vacuum-symptom) or lime deposition (a direct sign of osteochondrosis).

X-ray signs of osteochondrosis reflect changes in the vertebral bodies that manifest themselves as degenerative-atrophic (destruction of the terminal plates of the vertebral bodies and insertion of the disintegrated disc into the body in the form of small Pommer's nodules) and degenerative-reactive changes (osteophytes - and subchondral sclerosis) . X-ray signs of osteochondrosis also include the slanting of corners of vertebral bodies, narrowing and deformation of intervertebral foramen. Osteochondrosis of intervertebral discs can be complicated by the displacement of the vertebrae (spondylolisthesis).

X-ray diagnosis of herniated discs is rather difficult and is most often based on indirect symptoms: straightening of lordosis, scoliosis, more often expressed in the sick side, a symptom of the spacer, osteoporosis of the posterior-lower corner of the vertebra, and the presence of posterior osteophytes. Of great importance in the diagnosis of osteochondrosis are MRI and CT, which allow not only to assess degenerative-dystrophic processes in the disk, but also to reveal reactive changes in surrounding tissues and to clarify the anatomical and topographic relationships at the level being investigated.

[25], [26], [27], [28]

Treatment of the osteochondrosis

Treatment of pain syndrome in the pathology of discs begins with conservative methods, including the use of medicines, physiotherapy procedures, special medical gymnastics, mechanical unloading, manual therapy, acupuncture, and spa treatment.

The question of surgical treatment is solved individually on the basis of clinical and instrumental data.

Osteochondrosis, whose treatment with conservative methods did not bring relief to the patient and in the case of development of acute compression of the spinal cord or roots of the horse tail should be treated with urgent neurosurgical care.

Planned surgical interventions are performed in the case of prolonged pain syndrome (2-3 to 6 months), identification of syndromes of spine function reduction, chronic compression myelopathy, compression vertebrobasilar insufficiency, the presence of prolapse of the disc or its protrusion of more than 5-8 mm. Among the existing methods of surgical treatment of osteochondrosis, microsurgical removal of disc herniations by flavotomy or interlaminectomy in the lumbar region, partial corpotomy with subsequent corpo- rodeosis in the cervical region, endoscopic removal and puncture laser depolarization of the disc is the most common for today.