Radiologic diagnosis of osteochondrosis

In recent years, the role of X-ray examination in osteochondrosis of the spine has increased significantly. It is undertaken primarily to clarify the possibility of secondary effects of changes in the vertebral segment on the spinal cord, roots and vessels, as well as to exclude primary bone changes and lesions of various etiologies (developmental anomalies, tumors, etc.). At the same time, when analyzing X-ray data, certain difficulties often arise in their correct interpretation, in the specific correlation of the nature and level of X-ray findings and clinical manifestations. There are mainly two reasons for this. Firstly, changes in the bone-ligamentous apparatus of the spinal PDS, arising as a result of degeneration of the intervertebral disc, often become available for X-ray control later than the appearance of clinical signs. Secondly, degenerative-dystrophic changes in the spine that are clearly defined on X-ray images are far from always accompanied by corresponding clinical pathology or occur with minimal clinical manifestations. In this regard, radiological signs of osteochondrosis, which cause certain neurological or vascular disorders, are of decisive importance.

When analyzing radiographs, the location of the greatest manifestation of osteochondrosis in the spinal column should be taken into account first. For example, if radiographic signs of osteochondrosis are determined only on the anterior or anterolateral surfaces of the vertebral bodies, no effect on the nerve formations should be expected. On the contrary, if changes are present in the posterior and posterolateral parts of the spine, clinical symptoms may occur.

In the thoracic spine, due to the presence of physiological kyphosis and the associated distribution of force stresses, the formation of osteophytes, as a rule, occurs in the anterolateral parts of the spine and does not cause pain syndrome.

Pronounced lordosis in the cervical and lumbar spine with a predominant load on the posterior sections of the intervertebral discs leads to more frequent protrusion of the latter in the posterior and posterolateral directions with the subsequent formation of posterior and posterolateral hernias and osteophytes, which often cause one or another clinical symptomatology.

It should be noted that the cervical spine radiographs must necessarily show the area of the skull base and the first two thoracic vertebrae. In the C7-Th region _, the detection of cervical ribs and hypertrophied transverse processes of the vertebral bodies is often of clinical significance.

Radiographs of the lumbar spine should include the sacrum, iliosacral joints, and iliac wings.

The course and direction of the X-ray examination of the patient depend on the clinical picture. It is only necessary to emphasize the importance of performing X-rays in a number of cases with the patient standing and sitting, which allows the examination to be carried out under physiological stress.

The following signs are revealed on the lateral radiograph.

Narrowing of the intervertebral space between the vertebrae, indicating a decrease in the height of the intervertebral disc as a result of disintegration, resorption, or extrusion of its degenerated masses.

ATTENTION! A pronounced narrowing of the intervertebral space is a late symptom of osteochondrosis.

The clinical significance of the decrease in the height of the intervertebral space, even without the presence of posterolateral hernias or osteophytes, may be due to the displacement of the oblique articular processes of the spinal joint such that the processes of the underlying vertebra are pressed into the intervertebral openings, which narrow in both the craniocaudal and oblique dimensions. A slight displacement of the adjacent vertebral bodies relative to each other is also possible. This is often accompanied by the development of degenerative-dystrophic changes in the small joints - spondyloarthrosis and reactive changes in the yellow ligament with secondary effects on the spinal cord.

• In severe cases of osteochondrosis, sclerosis of the subchondral bone tissue occurs, which is revealed on radiographs as marginal sclerosis of the vertebral bodies. This radiological symptom of osteochondrosis has no independent clinical significance and can only be an indication of the presence of a degenerative-dystrophic process.
• Cartilaginous hernias of the vertebral bodies (Schmorl's nodes) also have no clinical significance. They often develop in the thoracic and lumbar spine during the aging process and are rarely observed in the cervical spine.
• Of clinical importance is the detection of posterior or posterolateral osteophytes, which are often the cause of spinal cord or root compression, especially at the cervical level, where the relative narrowness of the spinal canal and intervertebral foramina means that even a small osteophyte or dorsal disc protrusion can affect the spinal cord or roots. It has been clearly established that in the cervical spine, the cause of compression is more often posterior and posterolateral osteophytes than intervertebral disc herniations. At the lumbar level, compression of the cauda equina roots is more often due to posterior disc protrusion or prolapse. It is known that the spinal canal is wider here than in the cervical spine, and under the influence of heavy loads, a degenerated intervertebral disc apparently has a greater potential for rapid posterior prolapse.
• Anterior osteophytes are also detected, and the reaction of the anterior longitudinal ligament in the form of its calcification is also visible.

On the frontal radiographs:

1. In the thoracic and lumbar spine, osteophytes can also be detected on the lateral surfaces of the vertebral bodies, often multiple. The clinical significance of the former is minimal and only indicates the presence of a degenerative process at this level. The ratio of lateral osteophytes to the anterior parts of the vertebral body sharply reduces their clinical significance (N.S. Kosinskaya);
2. cervical spine, uncovertebral arthrosis is most often detected, which is one of the early signs of osteochondrosis, often being determined in the initial stages, when only a functional X-ray examination confirms the presence of changes in the intervertebral discs. This is due to the increased load on them in the area of Lushka's joints. Radiologically determined manifestations of uncovertebral arthrosis often also affect the vertebral artery and vertebral nerve.

• Of certain clinical significance is the detection of displacement of the vertebral bodies, which can affect the spinal cord and roots even in the absence of posterolateral osteophytes or hernias. It should be remembered that displacement of the vertebrae in the lumbar region can also occur in the absence of osteochondrosis with anomalies in the development of the vertebrae, changes in statics, etc. Moreover, osteochondrosis of the spine can often develop secondarily.
• The smoothing of the lordosis in the cervical and lumbar spine in middle and old age, especially its straightening at the level of individual segments, is an early symptom of osteochondrosis.
• Angular kyphosis of the cervical or lumbar spine in the physiological position of the patient is always an indication of the presence of pathology of the intervertebral disc.
• Arthrosis of small joints of the spine (spondyloarthrosis) is most often detected at the same level as degenerative-dystrophic changes in the intervertebral discs. At the same time, there is no coincidence in the degree of damage to the intervertebral joints and discs (I.L. Tager); sometimes with pronounced osteochondrosis, the symptoms of spondyloarthrosis are small, often absent,
  and vice versa.

Spondyloarthrosis is characterized by changes in the form of newly formed osteophytes, narrowing of the joint space, increasing its length, the presence of sclerosis of the subchondral bone layer. Neoarthrosis with the base of the arches, Pommer's nodes in the form of small defects in the endplates with clear contours and a sclerotic reaction around are often formed.

The clinical significance of spondyloarthrosis is that it almost always causes reactive changes in the yellow ligament, narrowing of the spinal canal with an effect on the spinal cord. Changes in the articular processes of the vertebrae also cause a decrease in the anteroposterior size of the intervertebral openings with an effect on the nerve roots; osteophytes formed during spondyloarthrosis can also directly affect them. The latter may also affect the vertebral arteries.

• The intervertebral foramen in osteochondrosis can be narrowed due to the convergence of the vertebral bodies, posterolateral osteophytes, osteophytes in uncovertebral arthrosis in the cervical spine and spondyloarthrosis. In the lumbar spine, the intervertebral foramen is often narrowed by a posterolateral disc herniation. Narrowing of the intervertebral foramen in the cervical spine directly by a disc herniation is a rare phenomenon, since its advancement is impeded by the ligaments of the uncovertebral joints.

Typical features in the radiographic picture of deforming spondylosis are the following:

1. Systemicity of the lesion - osteophytes develop on several vertebrae (can be detected on face X-rays). Large osteophytes developing in only one vertebra indicate against a purely degenerative and static-degenerative origin of the deformation and are more common in post-traumatic spondylosis.
2. Disorder and unevenness of the lesion. In deforming spondylosis, osteophytes on different vertebrae have different sizes.
3. Damage to both (caudal and cranial) halves of the vertebrae. Osteophytes develop both towards the cranial and caudal disc. This feature is often detected on radiographs only in both (direct and lateral) projections.
4. Fusion of the vertebrae in deforming spondylosis develops as a result of the fusion of osteophytes. This fusion occurs asymmetrically and not necessarily at the level of the disc. Often, two "beaks" growing towards each other form a kind of joint (nonarthrosis of osteophytes), on which secondary osteophytes develop in turn.
5. The discs (intervertebral spaces) in "pure" forms of deforming spondylosis without combination with osteochondrosis are not narrowed. On the contrary, projectionally the intervertebral spaces seem even somewhat widened and have a distinctly expressed appearance of biconvex lenses. This is explained by the fact that the vertebral bodies are enlarged in diameter and stretched in the area of X-ray "angles" due to bone growths.
6. The vertebral bodies in deforming spondylosis are usually not porotic. The absence of osteoporosis is partly explained by the fact that the spine is, as it were, enclosed in a "cover" of ossifications, and also by the fact that the function of the spine is preserved until the development of osteophyte fusion.

Variations in the structure of the spine should primarily include quantitative deviations. However, the total number of vertebrae in humans varies only within small limits and mainly in the sacrum and coccyx area. The so-called transitional sections are most susceptible to such variations: craniocervical, cervicothoracic, thoracic-lumbar and lumbosacral.

In this case, such changes in shape (mainly of the arches and their processes) occur that give the last cervical vertebra the shape of a thoracic vertebra (development of the cervical ribs). Similarly, the last thoracic vertebra may have only rudimentary ribs, not much different from the transverse processes of the 1st lumbar vertebra, or the 1st lumbar vertebra may have a rudiment of a rib. In the transitional lumbosacral region, partial or complete transformation of the last vertebra according to the sacral type or the 1st sacral according to the lumbar type may be observed. The following terms are used for such variants: dorsalization, sacralization and lumbarization.

Cervical ribs. It is known that almost 7% of all people have some type of cervical ribs, usually at the 7th cervical vertebra, and more often bilateral than unilateral. It is observed, although quite rare, that cervical ribs develop on several cervical vertebrae.

Lumbosacral region. Of all the regions of the spine, the transitional lumbosacral region is undoubtedly the most variable. Variations are observed here in the number of vertebrae (instead of the normal number of 5, 4 and 6 may be observed), the shape of the transverse processes, mainly in the lumbar vertebra, in the posterior part of the vertebral arches (non-fusions and fusion variants of the L5 _and sacral vertebrae) and, finally, in the articular processes of the lumbar vertebrae and the 1st sacral.

At the same time, it should be emphasized that the analysis of anomalies and variants of the spine on radiographs should be comprehensive. For example, it is impossible, having identified a non-fusion of the arch of the 1st sacral vertebra, not to pay any attention to the condition of the bodies of the lumbar vertebrae, discs and processes of the arches, firstly, because the variants of the arches are often accompanied by variants of the processes; secondly, because along with the variant of the arch, such changes as, for example, osteochondrosis, arthrosis of the intervertebral joints, etc. can be detected. Experience shows that the detection of easily detectable, but insignificant variants leads to the overlooking of other difficult to detect, but clinically more important acquired changes.

In severe, recurrent, and resistant to conventional treatment ischialgia, in which X-ray examination indicates sacralization, spina bifida, spondylolisthesis, osteophytes, or rheumatic changes, one should not conclude that they are the cause of ischialgia. Intraspongy disc herniations indicate the possibility of a general disease of the intervertebral discs.

Of all these combined signs, some are random, while others may only emphasize congenital anomalies, thereby indicating the place of least resistance of the lumbar segment of the spine.

A number of authors (Lascasas, Pison, Junghans) turned all their attention to the angle formed by the L4 vertebra, and accordingly L5, with the sacrum.

The sacrovertebral angle does not exceed 118°. The Junghans angle, determined by the median axis of the vertebral bodies L5-S1, is open at 143°, and the vertebral-sacral disc is open at 20°.

Cranio-cervical border. In the area of the transitional craniocervical region, several types of anomalies and variants are observed, among them: a) assimilation of the atlas and b) "manifestation" of the atlas.

In assimilation, the first cervical vertebra fuses with the occipital bone in the area of both or one lateral mass. Fusion of the atlas arches may also be observed with partially free lateral masses. Along with assimilation, crack formations are often found in the posterior arch of the atlas and very rarely in the anterior arch (V.A. Dyachenko). The opposite condition is "manifestation of the atlas", i.e. the appearance of unusual protrusions along the edges of the occipital foramen, resembling a rudimentary atlas. This variant has no practical significance.

Anomalies and variants of the articular processes of the spine are mainly reduced to the following points.

• Variable position of the articular facet in relation to the sagittal plane of the body is what Putti called "tropism anomalies" of the articular facets. For example, normally the articular facets of the lumbar vertebrae are in a plane close to the sagittal plane, but in the case of "tropism anomalies" we find that the facets on one or both sides are in a more frontal plane. The opposite relationship is observed in the joints between L5 and S1, where the facets are normally located in the frontal plane.

"Tropism" refers to a morphological variant of the lumbar spine in which the plane of the intervertebral articulation on the right is located asymmetrically in relation to the plane of the intervertebral articulation on the left.

Tropism phenomena are most often observed in the lumbosacral spine. Imperfectly constructed intervertebral joints with additional trauma or static overloads of the spine can serve as a place for the development of deforming arthrosis and cause pain in the lumbar spine.

• Rotation of the long axis of the facet relative to the longitudinal axis of the body.
• Anomaly in the size of the articular process or only the articular facet.
• Cuneiform joint.
• A transverse fissure dividing the process into the base and the apex (accessory ossification nucleus).
• Absence of articular processes.
• Spondylosis.
• Hypoplastic articulations of the transitional vertebra with the sacrum. It should be noted that all the described isolated anomalies and variants of the articular processes of the sx relate mainly to the lumbar spine.

Transitional sacrococcygeal border

The sacrum usually consists of 5 vertebrae, which contain four pairs of sacral openings. At the lower end of the sacrum there are peculiar bays, which, with the appropriate adjacency of the 1st coccygeal vertebra, form the fifth pair of openings; thus, the sacrum includes another vertebra.

Mostly, the first and second coccygeal vertebrae are connected by a joint, and the first coccygeal and the last sacral vertebra may be connected by bone. On radiographs, it is often possible to determine the bone fusion between the last sacral and the first coccygeal vertebra.

X-ray studies have made it possible to identify the following morphological forms of the coccyx (I.L. Tager): a) perfect; b) unilaterally assimilated; c) bilaterally assimilated.

Clinical classification of lumbar vertebral displacements

Offset type	Stability of the spinal segment	Compression neurological syndrome	Treatment tactics
A	Stable displacement	None or moderate	Conservative treatment
IN	Stable displacement	Expressed	Spinal canal decompression
WITH	Unstable bias	None or moderate	Stabilization
D	Unstable bias	Expressed	Decompression and stabilization

The perfect form of the coccyx is characterized primarily by the presence of a separate 1st coccygeal vertebra with horns and transverse processes and separate, decreasing in size, other vertebrae. In this case, the last vertebrae can be deformed and fused together.

Unilateral assimilation - when the 1st coccygeal vertebra has taken the form of a sacral vertebra only on one side, only on one side it is fused with the sacrum with the formation of the fifth sacral opening on the side of fusion. Various degrees of fusion are observed: either complete bone fusion with complete bone closure of the sacral opening and with the formation of the lateral parts of the coccygeal vertebra like the lower edge of the sacrum, or the lateral parts of the coccygeal vertebra are adjacent to the lateral part of the sacrum, but are separated by a gap of several millimeters, a linear gap, or even a trace of a gap.

In case of bilateral assimilation, the 1st coccygeal vertebra completely passes into the sacrum, forming the fifth pair of sacral openings. The coccyx in this case consists of one or two vertebrae in the form of oval fragments. In these cases, different degrees of assimilation are also observed: along with complete bone fusion, there are forms of the coccyx with not yet completely fused lateral parts of the 1st coccygeal vertebra with the sacrum, separated by a narrow gap or even its trace.

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Displacement of vertebrae

Spondylolisthesis was studied clinically, radiologically and experimentally by G.I. Turner (1926). It is known that the displacement of a vertebra cannot occur without disruption of its fixation in the intervertebral disc. In essence, each case of displacement should be considered as "looseness" of the disc, and spondylolisthesis - as "disease of the intervertebral disc". Three degrees of spondylolisthesis are distinguished:

• 1st degree - the displaced vertebra has slid forward moderately, partial exposure of the surface of the 1st sacral vertebra;
• 2nd degree - significant exposure of the upper surface of the sacrum, the 5th vertebra is strongly tilted forward;
• 3rd degree - the entire upper facet of the sacrum is exposed;
• 4th degree - the vertebra is displaced into the pelvis.

Since the first studies on spondylolisthesis appeared, numerous attempts have been made to systematize it. The most widely used classification was that of Meyerding (1932), who distinguished 4 degrees of vertebral displacement based on spondylography. Displacement up to the j-part of the vertebra corresponded to degree I, from j to S - to degree II, from S to s - to degree III, and from s and further - to degree IV. Junge and Kuhl (1956) proposed adding degree V to Meyerding's classification - complete displacement of the vertebra relative to the underlying one. Newman, Wiltse, Macnab (1976) proposed a classification based on the etiopathogenetic factor (dysplastic spondylolytic degenerative traumatic pathological spondylolisthesis).

The clinical classification of spondylolisthesis proposed by V.V. Dotsenko et al. (2002) can serve as a supplement to the existing radiological and etiopathogenetic classifications.

Stable offset:

• lumbago is absent or not constant;
• the patient's activity is slightly reduced or normal;
• there is no need to take analgesics;
• the patient does not require external immobilization;
• there are no radiographic signs of instability.

Unstable bias:

• constant lumbago;
• the patient's activity is reduced;
• severe drug dependence;
• need for external immobilization;
• radiographic signs of instability.

Compression neurological syndrome (moderate):

• intermittent radicular syndrome amenable to conservative treatment;
• there are no signs of “loss” of root function;
• the patient's activity is normal or slightly reduced.

Compression neurological syndrome (pronounced):

• persistent radiculopathy at the level of the displaced vertebra, not amenable to conservative treatment;
• increasing syndrome of "loss" of function of the root or roots;
• the patient's activity is reduced.

Spondylolysis is a gap in the vertebral arch between the articular processes, and not at the junction of the arch with the vertebral body, as some authors mistakenly interpret (normally, up to the age of 8, there is a cartilaginous layer between the bodies and arches of the vertebrae). Spondylolytic gaps are located, as shown by observations of V.A. Dyachenko, just under the articular facet of the superior articular process and most often have a transverse-oblique direction - from the inside and from above, outward and downward. In other cases, the gap crosses the arch transversely, under the base of the superior articular process and its facet. The surfaces of the gaps have an ear-shaped, triangular shape; they are smooth, without spines, the surfaces of the gaps are usually symmetrical, bilateral.

Spondylolysis is in most cases detected in only one vertebra, rarely in two, and is detected in radiological practice in patients aged 20-30 years.

Spondylolisthesis in combination with spondylolysis occurs in men 5-6 times more often than in women and is usually detected after the age of 30.

In case of pronounced degrees of displacement, the diagnosis of spondylolisthesis of the first degree is made on the basis of a clinical examination: the trunk is shortened in the lumbar region, the ribs are close to the iliac crests, the spinous process of the 5th lumbar vertebra is palpated above the sacrum, above which a deep depression is determined. At the same time, the sacrum maintains a vertical position. Transverse folds of skin (especially in women) hang over the abdomen and in the lumbar region. Tension of the long muscles is determined. In the presence of increased lumbar lordosis, the trunk is slightly tilted backward. According to V.D. Chaklin, the most severe forms of spondylolisthesis are also accompanied by scoliosis.

In severe cases of spondylolisthesis, clinical examination often reveals a shortened waist with transverse folds in the lumbar region above the iliac crests. This shortening is not due to the displacement of the vertebra, but rather to the straightening of the pelvis, bringing the iliac crests closer to the lower ribs.

Often, with spondylolisthesis, a decrease in the mobility of the spine in the lower lumbar region is detected, which is explained by both the loss of the mobile segment of the spine due to damage to the intervertebral disc, and contracture of the muscles of the lumbar region.

From the neurological side, patients' complaints come down to pain in the lumbar region, manifested in the form of lumbar radiculitis (lumbago) or lumboschialgia. Pain sometimes occurs suddenly after overload or sudden movements.

Pseudospondylolisthesis is observed in the vast majority of cases in elderly obese women and much less frequently in men (10:1). The displacement of the vertebra is moderate. As a rule, the IV lumbar vertebra is displaced to the V. During clinical examination, sharp hyperlordosis and tension of the lumbar muscles are noticeable.

ATTENTION! Based on clinical data alone, without X-ray examination, diagnosis of this type of spondylolisthesis is practically impossible, as, incidentally, it is impossible with mild degrees of spondylolisthesis.

Currently, a distinction is made between:

• fixed (functional) spondylolisthesis, i.e. such an anterior displacement of the vertebra, which is “fixed” by the presence of a spondylolysis gap in combination with osteochondrosis or, in the absence of spondylolysis, by an elongation of the interarticular part of the arch in combination with osteochondrosis;
• fixed or non-fixed spondylolisthesis, which is osteochondrosis of the spine in combination with local deforming arthrosis of the articular pair corresponding to this disc;
• functional displacement due to the presence of osteochondrosis, but without radiologically noticeable deformation of the arch and its joints.

The posterior displacement of the vertebrae is known under different names - retrospondylolisthesis, retroposition. Most specialists consider degenerative disc disease to be the cause of posterior displacement of the vertebrae. Traumatic and inflammatory etiology of displacement is not excluded.

In the mechanism of posterior displacements, Brocher assigns the main role to significant posterior traction from the yellow ligaments and the powerful extensor of the back, which are antagonists of the anterior longitudinal ligament.

There are no objective signs during clinical examination that would allow the detection of posterior displacement of the vertebrae. Only X-ray examination allows a final diagnosis. The details of such displacements are not revealed in the images in the posterior projection; for this, lateral images are absolutely necessary, where a step-like violation of the line drawn through the dorsal contours of the vertebrae is determined at the level of displacement.

Unlike "pseudospondylolisthesis", arthrosis in the joints of the arches is not detected with posterior displacements. Posterior displacements of the vertebrae are a severe form of pathological displacements and give the highest percentage of disability.

Posterior displacements are most often located in the zone of II-III lumbar vertebrae. Functional radiography is of invaluable help, making it possible to objectively document not only the presence of posterior displacement, but also the degree of "looseness" in the corresponding spinal PDS.

Consequently, as with anterior displacements, posterior displacements can occur at any level of the lumbar spine, but the ratios of the statics of the spine and the level of posterior displacements are opposite to those in "pseudospondylolisthesis". Thus, with hyperlordosis, the lower lumbar vertebrae are displaced forward, and the upper lumbar vertebrae are displaced backward; with hypolordosis, the ratios are reversed. This allows us to conclude that the level of vertebral displacement and the direction of displacement (forward or backward) depend entirely on the statics of the thoracolumbar spine.

A study of radiographs shows that the posterior displacement of the vertebrae occurs in the transition zone of kypholordosis: it is here that the point of greatest vertical load is the posterior sections of the discs, in which degenerative changes (osteochondrosis) occur due to prolonged compression. But since the discs and vertebrae in the transition zone are located in such a way that their ventral sections are higher than the dorsal ones, then, naturally, the sliding of the vertebrae at this level can only occur posteriorly. This applies to both hyperlordosis and hypolordosis.

From the point of view of the mechanism of slippage, it should also be noted that the articular processes, due to their position at a certain angle to the back, cannot resist the posterior displacement of the vertebra, which is further enhanced by the constant traction experienced by the vertebra from the yellow ligaments during extension movements.

When assessing the presence of posterior displacement, the possibility of so-called false retroposition should be taken into account. In such cases, we are talking about an increase in the anteroposterior size of the vertebra in relation to the underlying one. Such an increase can be observed in turn as true (for example, after consolidation of a compression fracture, with Paget's disease, hemangioma, etc.) or false - due to marginal posterior osteophytes.

ATTENTION! False retropositions can cause a pronounced neurological syndrome, since they are always accompanied by degenerative changes in the disc.

Clinical and radiological observations allow us to distinguish two more groups of vertebral displacements: ladder and combined displacements.

With scalene spondylolisthesis, two (possibly more) vertebrae are simultaneously displaced in one direction - forward or backward.

Combined displacements are characterized by the simultaneous displacement of two vertebrae in opposite directions.

The diagnosis of osteochondrosis is made based on the presence of several of the above-mentioned radiographic signs. In the clinic, for a comprehensive assessment of the identified radiographic changes, it is advisable to use the following criteria.

Criteria reflecting disorders of the cushioning function of the disc: narrowing of the intervertebral space, compaction of the endplates of the vertebral bodies, the presence of anterior or posterior growths (osteophytes), slanting of the vertebral bodies in the area of the anterior part of the marginal border, calcification of the fibrous ring, development of arthrosis and neoarthrosis. For the cervical spine, a very pathognomonic sign of osteochondrosis is a change in the uncinate processes, their deformation, the formation of uncovertebral arthrosis.

Criteria reflecting the impairment of the motor function of the vertebral segment, which are most clearly revealed and specified during functional tests: pathological mobility or immobility ("block") of one or more segments. Signs of fixation on radiographs are straightening of physiological curvatures or local angular kyphosis, lordosis, scoliosis, displacement of the spinous processes, and in advanced cases - convergence of the transverse processes of the vertebral bodies, local "block" (symptom of "strut"), as well as areas of calcification of the disc of a triangular shape, facing the apex into the intervertebral space. Signs of immobility are often noted in combination with signs of hypermobility in the PDS (pseudospondylolisthesis, subluxation according to Kovacs, etc.).

To assess the stages and severity of osteochondrosis, the Zeker classification can be recommended:

• Stage 1 - minor changes in lordosis in one or more segments;
• Stage 2 - moderate changes: straightening of the lordosis, slight thickening of the disc, moderately pronounced anterior and posterior exostoses or deformation of the uncinate processes in the cervical spine;
• Stage 3 - pronounced changes, i.e. the same, but with a significant narrowing of the intervertebral openings;
• Stage 4 - significantly pronounced osteochondrosis with narrowing of the intervertebral openings and spinal canal, massive exostoses directed backwards - towards the spinal canal.

ATTENTION! Clinical symptoms may not always be caused by radiologically detected bone changes in the spinal vertebral column.

In the clinical practice of radiologists, neurologists, orthopedic traumatologists, rheumatologists and other specialists working with this category of patients, there are often cases of discrepancy between the radiological symptoms of spinal damage and the severity of clinical manifestations.