Low back pain the lumbosacral spine: diagnosis and treatment.

Back pain lumbar and is a disease that deforms and destroys the cartilage tissue of intervertebral discs in the lumbar region. Without a layer of cartilage, the distance between the vertebrae is reduced significantly. And the minimum bends you can move. The main danger of the disease – the possibility of formation of herniated discs.

Back pain lumbar

You can not bend over to pick up an object that fell on the floor? You suffer from strong pain in the lumbar area of the back and often walk, after you have wrapped your life in a warm shawl? Not worth the effort to bypass the rule that bothers you.

Back pain lumbar may be delayed for the duration of a long time. To nothing the experience of the strength of the body. Love your body. And that parts of his love.

On the lumbar spine represent the largest part of the load of the entire mass of the body than breast and neck departments. Therefore, this subtype of degenerative disc disease – the most often have never seen before.

What are the stages of development of degenerative disc disease?

  • 1 the stage. Preclinical data of. The height of the disk is reduced. In the fibrous ring widths (the outer layer of the intervertebral disc from the cartilage of the fiber to form a crack. The lumbar muscles begin to tire quickly. You feel some discomfort in the back.
  • 2 the stage. Violations of the metabolic processes in a jelly-like kernel (the central part of the intervertebral disc, which consists of a gelatinous tissue cartilage) cells martout or completely destroyed. Collagen structure (structure of protein-based connective tissue) the fibrous ring widths also broken. Local pain, the man can not cope with the physical effort, which first considered quite feasible.
  • 3 the stage. The complete destruction of the fibrous ring widths. Rooms the vertebrae cease to be stable. Any uncomfortable posture gives pain. Because of the experiences of the nerve roots that leave from the spinal cord, the limbs can become less sensitive and mobile.
  • 4 the stage. Intervertebral disc tissue become from. The Vertebra can be in the tubular shell. Clinical description here depends on the physiology of the individual.

The back pain (lumbago) and pain, pain that radiates to the leg when the sciatic nerve (sciatica) are one of the most common complaints with which patients come to the doctor. Due to the fact that these symptoms are quite common in the general population, and also celebrated their constant growth, the diagnosis and treatment of these patients remains one of the main activities of the neurosurgery hospitals. Despite the prevalence of this malocclusion, the surgical removal of herniated intervertebral disc (MTD) is required only 10% of patients with clinical sciatica. The rest of the patients the best effect is a conservative treatment, which includes drug therapy, curative physical education, the use of physiotherapy treatment techniques, but also the return to the previous daily physical activity.

Phase of the disease

Degenerative-dystrophic processes often begin with the deterioration of the cushioning function of intervertebral disc.

  1. The deterioration in the vascularity of the intervertebral disc. In adults, the power supply of the intervertebral discs takes place via diffusion: the blood is delivered only to the vertebrae, and after them “creeps” to the disks. Well, the power supply of the disk occurs during the dynamic loads (e.g., walk), as well as the principle of the pump (flow rate of recycled liquid when squeezed, the flow of nutrients and oxygen during the removal of the load). In this way, the power supply of the intervertebral discs mainly hampered in conditions of stagnation, in the life (idle).
  2. Changes in polipozom nucleus of the disc. With the deterioration of the vasculature interrupted the supply of water, sugars and amino acids in the purposee nucleus. Because of this suffers from the production of carbohydrates, which connects to the water. The nucleus is dehydrated, its gel structure, as becomes a fibrous, worsens the ability to bounce and absorb the impact. This increases the load on the fibrous ring widths and vertebrae, are often subjected to shocks and injuries.
  3. Changes in the ring of the fibrous intervertebral disc. Because of a flattening of the pulposus of the kernel, the greater burden falls on the ring, the fibrous of the disc. In conditions of poor vascularity in the fibrous ring widths loses its strength. The instability occurs in the spine, which can lead to the formation of herniated disc, displacement of the vertebrae and damage the spinal cord or of the nerve roots.
  4. Protrusion of the disc. The formation of herniated disc. Because, as the fibers of the fibrous ring widths weaken, purposee, the nucleus begins to swell, for example, to the side of the channel (disc protrusion). This protrusion may lead to the rupture of the fibrous ring widths and the formation of a hernia. Read more on the process of the formation of the hernia of the disc can be read in a separate article – "an Effective treatment for herniated disc at home".
  5. Spondylosis - the destruction of the joints intervertebral (spondilartroz), the growth of osteophytes, and ossification of the ligaments. In parallel with the formation of herniated disc with osteochondrosis observed the damage of the joints, intervertebral, devastating changes to the vertebrae (the cartilage) and ligaments.

With the progress of the degenerative disc disease and development of complications are increasingly resorting to the purchase of drugs, increase the dosage. This leads to a large financial outlay, but also further deterioration of health due to the side effects of the drugs.

Drug therapy is usually completed by the immobilization of one or two departments of the vertebral column with the help of the orthopaedic corsets of different degrees of stiffness.

The surgical treatment is justified only in cases, when the level of compression of the spinal spine, determined clinically, this corresponds to the survey data, confirmation of the gap-ring fibrous, with "the fall" hernia MTD in the lumen of the spinal canal [3-6]. Results of surgical treatment in patients with small protrusions on the disc, usually disappoint the doctor and the patient. Method that allows you to establish an accurate diagnosis, is magnetic resonance imaging (MRI). About 10% of total population impossible to carry out routine magnetic RESONANCE imaging because of claustrophobia (fear of enclosed spaces). This category of people as possible, the use of the so-called "open" magnetic RESONANCE imaging, it is true, with corresponding loss of quality of the received images. Patient, had previously undergone a surgical treatment, requires the possession of a magnetic RESONANCE imaging with contrast-enhanced to distinguish postoperative scar–adhesive changes from true hernia protrusion of the disc. In patients with suspected hernial diverticulum MTD, when the execution of a magnetic RESONANCE imaging impossible, or the results uninformative, computer–tomographic (CT) myelography is particularly diagnostic value.

Specialists in radiology, in the interpretation of results obtained in research tend to exaggerate the degree of damage to the disk due to the impossibility of mapping the clinical data with the "discoveries" for the tac. These results, as "the changes are in accordance with the age of the patient," almost never meet in research protocols. Despite the improvement of the research methodologies, the responsibility for the correct actions, the diagnosis rests on the shoulders of the clinical, because he alone is able to associate the clinical picture with the data obtained during the computer tomography. The increase of the resolution imagi slightly improved the results of surgical treatment, but were detected deviations from the norm are not asymptomatic patients. The study of the processes that accompany the degenerative–degenerative defeat of the spine, has undergone serious progress in recent years. Arthropathy bhoothnath joints is widespread in the general population and is very often in people of middle age and older group during the course of CT–studies. Degenerative changes MTD, also having a wide spread, very often found, and more specifically to a method for their diagnosis is magnetic RESONANCE imaging. When there are expressed changes MTD, not accompanied by rupture the fibrous ring widths, and only manifests itself insignificant "bulging" disc in the lumen of the spinal canal or the holes intervertebral. In some cases, the degenerative processes that occur in the MTD, can lead to the destruction of the fibrous ring widths with successive interruptions, causing the migration of the part of the pulposus of the nucleus outside of the disc with compression of adjacent roots of the spinal cord. The statement that if there is a pain in the leg, then it must necessarily be a violation of the back of the spinal cord, it is not entirely true. The stomach pains that radiates on the back of the thigh can bring as degeneration of the MTD and bhoothnath joints, intervertebral. For the true attack of sciatica, caused by compression of the nerve root of hernia (MTD), is characterized by pain, radiating to the back part of the thigh and calf. The pain of uncertain nature, limited only thigh part of a hip without the distribution of the movement of the sciatic nerve, and also two-way pain in the buttock area or hip, pain, modify the location (the one on the right, then left), but more often are due arthropathies bhoothnath joints or diffuse degeneration of the MTD. To simulate the clinical picture of compression spine hernia MTD can, and concomitant malocclusion (for example, osteoarthritis of the knee). In patients with pain surgical treatment will not have the desired effect no matter what malocclusion is detected during tomographic research. In other words, the patients only with clinical features of back pain removal of the hernia MTD is ineffective, even if tomograms defined protrusion MTD, as is usually the case. But there are also patients in which the typical model of the sciatica is accompanied by a marked invalidusername pain syndrome, while studies performed with the use of high-resolution imagi, not determined by the compression of the roots of the spinal cord. This category of patients is impractical to run a surgery, as well as with the passage of time rootlet symptoms, and usually disappears.

It is necessary to define the mechanisms that lead to the development of the hernia, the protrusion of the MTD, to recommend to the patients of volume in the allowed movements, without forgetting the work activity. The forces favourable to the formation of hernia protrusion, are the result of degenerative changes in MTD and reduce the vertical dimensions (height) as the fibrous ring widths, and the pulposus of the kernel. Wibehouse fragment MTD 80% moves in the postero–laterally by interfering with this lumen of the spinal canal and the medial departments of the hole in the intervertebral. This shift of hernia MTD to side of the median line, which promotes the retention force of the posterior longitudinal ligament. Up to 10% gruzevich protrusions are located laterally and are distributed in the intervertebral hole (foraminal hernia) or the outer edge of the hole where it exits the spinal the back, thus compressing his.

In the process of life dehydration and degenerative changes lead to the loss of height MTD. These pathological processes involve as a ring of fibrous and purposee nucleus. The most marked destruction of the pulposus of the kernel in the background of the accompanying degeneration of the fibrous ring widths, usually leads only to a loss of height MTD without significant vbuhanii. When prominent changes in the fibrous ring widths of the vertical forces that act on the stored purposee nucleus and are derived your weight, but also the strength of the muscles of the back, that operate on the disk in a lateral direction, or exert excessive pressure on the fragment remaining of the pulposus of the kernel, keeping that in place is not able degenerative changed fiber ring fibrous.

The sum of these two forces leads to an increase of pressure on the MTD, which together with the component of the traction acting on the fiber ring fibrous, which can lead to breakage and swelling in the fragments remaining of the pulposus of the kernel. After that it is formed hernial diverticulum, and "excessive" is a fragment of the nucleus pulposus proved to be outside of the ring of fibrous structure MTD again becomes stable [2]. Consequently, the forces acting on degenerative changed the kernel and ring the fibrous MTD, balanced, and their carrier, thus contributing to further exaggeration of the fragments of the kernel, it switches off. In some cases, partial degenerative changes in the pulposus of the nucleus favor the formation of gas within the MTD, followed by an excess of pressure on the fragment of it remaining. Hernia formation is also accompanied by a process gas to the inside of the disc.

The excess and the intense physical activity, exercised on the patient's back, in the background existing degenerative–injury degenerative diseases of the spine, usually, is only the starting torque, which results in distributed clinical picture of compression to create a syndrome, which is often and wrongly considered to be sick people themselves as the fundamental cause of the sciatica. Clinically hernia MTD may manifest reflex and compression syndromes. Compression refers to the syndromes in the above-mentioned hernia protrusion tense, squeezed and deforms the spine, blood vessels or the spinal cord. The reflection you refer to syndromes induced by the herniated disc on the receptors of the structures, especially the end of the recurrent spinal nerves, which leads to the development of reflex muscle tone of disorders that manifest vasomotor, degenerative, myofascial disorders.

As noted above, the surgical treatment of degenerative diseases–degenerative diseases defeat pozvonocnika it is advisable to only 10% of patients, and the remaining 90% respond well to conservative activities. The basic principles of the use of the most recent are:

  1. relief of pain;
  2. the recovery of a correct posture to maintain fixation capacity of the modified MTD;
  3. liquidation musculo–tonic disorders;
  4. the recovery of the circulation in the back and in the spinal cord;
  5. the normalisation of conductivity to the fiber of bulimia nervosa;
  6. resolution scar–adhesive changes;
  7. relief from psycho–somatic disorders.

Treatment

Today in the treatment of degenerative disc disease and its complications apply preparations the following groups:

  1. Non-steroidal anti-inflammatory drugs (NSAIDS) - in the form of tablets or injections of drugs. These tools have the capacity to reduce pain events, reduce the activity of inflammation. However, the effect of their application does not last long - from a few hours up to two to three days. Therefore, these tools need to take it for a long period of weeks, sometimes months. At the same time, these drugs adversely affect the mucous membranes of the gastrointestinal tract. The long-term use of the full development of gastritis, ulcerative lesions. In addition, they can adversely affect the functioning of the kidneys, the liver, and promote the development of hypertension. And, at the same time, these instruments do not contribute to the cleaning of disks from the dead cells. Therefore, their application is only a way to remove the symptoms, but not solve the main problem.
  2. Steroid (hormone) anti-inflammatory medications. Usually used in case of a strong and annoying pain that accompanies a herniated disc, sciatica, cervical, sciatica, etc Hormones have the capacity to resolve the symptoms of inflammation (because of oppression of the immune system), to relieve the pain. But also have a negative impact on the mucous membranes of the stomach and intestines, promote the leaching of calcium from the bones, inhibit the production of hormones in the body. And do not contribute to purify the hearth of the dead cells.
  3. Antispasmodics - drugs that directly affect the muscles or nerves that go to the muscles and cause relaxation of skeletal muscles. These tools help to remove the muscle terminals, reduce pain and improve blood circulation. But it does help to clean the tissues from cell death. Therefore, do not contribute to the healing of the degenerative disc disease.
  4. Epidural block - introduction of analgesics, and hormonal of the funds in the space between the dura sheath and the periosteum, that covers the vertebrae. Applies, as a general rule, with intense pain, but in a period of acute disc herniation, when expressed radicolite, sciatica. Depending on the composition, this injection helps alleviate the pain for a period of several hours to several days. After the deadline, the manifestations of the disease come back, because the procedure is not conducive to the recovery of the metabolic processes in the discs. In addition, during its course, there is the risk of injury of the blood vessels and nerves.

Methods of conservative treatment include various mattresses and the impact on the spinal column immobilization of the corset, unloading, chiropractic), physiotherapy (therapeutic massage, physiotherapy, acupuncture, electrotherapy, mud, a different type of heating), the periduralna block, and drug therapy. The treatment of degenerative diseases–injuries and degenerative spine must be comprehensive and gradual. Usually, the general principle conservative of the activity is the assignment of analgesics, nonsteroidal anti-inflammatory drugs (NSAIDS), muscle relaxants, and physiotherapy.

The analgesic effect is obtained to the appointment of diclofenac, ketoprofen, lornoxicam, tramadol,. Pronounced analgesic action and anti-inflammatory effect has lornoxicam, existing as the injection, and tablets of forms.

NSAIDS are the most widely used medicines when degenerative diseases–degenerative diseases defeat of the spinal column. Are anti-inflammatory, analgesic, and antipyretic activities, connected with the suppression of the enzyme cyclooxygenase (cox–1 and COX–2), in the matter of the transformation of arachidonic acid to prostaglandins, prostacyclin, thromboxane. In the elderly and in patients with risk factors for side effects of therapy NSAIDS it is appropriate to "cover" the gastroprotection. In such patients, end-of-course injection therapy NSAIDS it is advisable to step to the preformed shape of the COX–2 inhibitors, having less severity of side effects from the gastrointestinal tract.

To eliminate the pain associated with increased muscle tone, in complex therapy it is appropriate to include muscle relaxant action central.

The surgical treatment of degenerative diseases–injuries and degenerative of the spine, justified the ineffectiveness of complex conservative activity (within 2-3 weeks) in patients with hernias MTD (usually larger than 10 mm) and nekupirutayasa symptoms root. There are extra directions to apply the intervention during the "fall" of sequestration in the lumen of the spinal canal and a significant compression of the roots of the spinal cord. The development of the caudal syndrome contributes to acute radiculomyeloischemia linked to the expressed hyperalgebra syndrome, when the appointment of narcotic analgesics, the use of blocks with glucocorticoid and anesthetic agents) does not decrease the severity of the pain. It is important to note that the absolute size of hernia of the disc has no that defines the values for the final decision about the intervention and must be considered in relation with the clinical picture and findings found during the tomographic research. In 95% of cases, when ernie MTD used the open access into the spinal canal. Various discountinue techniques (cold plasma coagulation, laser, reconstruction, etc.) have not found currently, a wide range of applications, and their use is justified only when the protrusions MTD. The classic open microsurgical removal of the herniated disc is performed step by step with the use of microsurgical instrumentation, binoculars, magnifier repair or a surgical microscope. The analysis of remote results of treatment (in terms of more than 2 years old) 13 359 patients who underwent removal of herniated MTD, 6135 of which was performed step by step uninstall seizure, and 7224 has been made, aggressive discectomy, has revealed that the relapse of pain syndrome encountered in 2.5 times (up 27.8% against 11,6%) in patients who underwent aggressive discectomy, while the relapse of hernia formation has been marked 2 times more (7% against 3.5%) in patients in whom it was performed only the removal of the seizure. The quality of life is reduced and more patients experiencing the pain, then as a repeated herniated disc does not always manifest clinically.

In conclusion, once again I would like to emphasize the need for careful clinical examination and analysis of tomograms to make the best decision on the choice of tactics of treatment of the individual patient.