Spinal hernia and back pain

It is known that congenital malformations of the spinal cord (myelodysplasia) are usually combined with some variant of malformation of the spine. The most common and most studied variant of myelodysplasia is spinal hernia.

Spinal hernia is a combined defect of the vertebrae and spinal cord, including a defect of the bone structures forming the spinal canal, the membranes of the spinal cord and its elements bulging into this defect. Spinal hernias have anatomical and clinical-anatomical classifications. In the first case, the localization and contents of the hernial sac are usually taken into account. In the second case, the anatomical variant of the defect, as a rule, is not detailed, and the determining factor is the nature of the clinical manifestations and complications - sensory and / or motor disorders, pelvic dysfunction. In the classification proposed by K. L. Dreyer (1973), two variants of spinal hernias are distinguished: meningeal spinal hernia, not accompanied by dysfunction of the spinal cord, and meningeal-membranous spinal hernia, occurring with paresis or paralysis. The information accumulated to date on the anatomy of spinal hernias has allowed us to identify various anatomical variants of the defect.

RE Lindseth (1996) considers spinal hernias as a special variant of “neural tube defects”, united by the general terms spinal dysraphism, spina bifida aperta, and also provides a classification of neural tube defects and their complications.

The variety of complications of neural tube defects makes it necessary to conduct a targeted search for concomitant anomalies of the vertebrae, spinal canal and spinal cord (including diastematomyelia, various types of spinal cord fixation, Arnold-Chiari syndrome) during the initial examination of a patient with spinal hernia.

We would like to specifically note the fundamental change in views on the treatment of spinal hernia that has occurred over the past twenty years. Previously, the presence of neurological disorders and back pain were considered an absolute contraindication to surgical treatment. From a modern perspective, their presence is not a contraindication to either surgical treatment of the hernia itself or to the treatment of concomitant defects of the spinal cord and spine. In some cases, performing surgery not only facilitates patient care, but also improves the patient's quality of life. The order of operations is dictated by the following principles:

• elimination of concomitant spinal cord defects should be carried out simultaneously with the main plastic intervention for spinal hernia;
• Associated orthopedic defects and complications, including spinal deformity, must be eliminated after the main intervention.

Neural tube defects

Anatomical variants of neural tube defects
Meningocele	A herniated disc without any spinal cord elements included in its contents. As a rule, a purely cosmetic defect, not accompanied by neurological disorders or orthopedic complications.
Myelomeningocele	A spinal hernia containing elements of nervous tissue. Typically, there are peripheral neurological disorders, as well as pathologies of the central nervous system, including hydrocephalus and Arnold-Chiari malformation.
Lipomeningocele	A spinal hernia, the contents of which is a lipoma, intimately fused with elements of nervous tissue. Neurological disorders are often absent at birth, but can develop during growth, without spreading above the lumbosacral level.
Rachischisis (rachischisis)	A defect in the tissues covering the dysplastic spinal cord, typically including the absence of skin, muscle (possibly with a thinned pad), bone structures, and the hernial sac itself.
Complications of neural tube defects
Neurological	Paresis and paralysis (spastic and flaccid), dysfunction of the pelvic organs, sensory disturbances.
Neuroorthopedic:	Spinal deformities Scoliosis. Observed in 100% of cases of paraplegia from the thoracic level. In 85% of cases, the deformation exceeds 45". C-shaped scoliosis is typical for pure neuromuscular deformations. S-shaped scoliosis more often indicates concomitant hydromyelia, syringomyelia or tethered cord syndrome. Lordosis. Rarely observed, often associated with contractures in the hip joints. Kyphosis. It is observed in 8-15% of patients with myelomeningocele, often exceeding 80° already at birth and progressing during growth. Hip dislocations Contractures of the knee joints Foot deformities Charcot arthropathy (progressive neurotrophic degeneration of joints)
Complications from the membranes of spinal hernia	Inflammation of the membranes and ruptures of the membranes
Fractures of the femur and tibia

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