Herniated disk is one of the consequences of osteochondrosis, which is a protrusion of the intervertebral disc between the vertebral bodies. Manifests pain, tonic muscle tension and restriction of movement in the affected area of the spine. It can lead to compression of spinal roots, blood vessels and spinal cord. It is visualized using CT, MRI or contrast myelography. Treatment is mainly conservative (medication, physical therapy, massage, traction therapy). Disc removal operations (discectomy, endoscopic discectomy) are performed according to strict indications and can lead to serious complications.
General information
In total, there are 24 intervertebral discs in the spinal column. They have different sizes: the smallest is in the cervical discs, and the largest is in the lumbar discs. In all departments, the discs are characterized by a similar structure: a pulpous nucleus surrounded by a fibrous ring. The core consists of 90% water, its consistency resembles a gel. The fibrous ring is formed by fibers passing in different directions. Together, the components of the disc determine its elasticity, elasticity, resistance to twisting and bending. Intervertebral discs provide movable joints between the vertebral bodies and spinal shock absorption.
The intervertebral (intervertebral) disc is normally located strictly between the bodies of two adjacent vertebrae. When it goes beyond this space, they talk about a herniated disk. Most often hernias are formed in the lumbar region, because it bears the main load during movements and lifting weights. In second place in terms of the frequency of hernia formation is the cervical region, in which complex movements of a large volume (twisting, bending) are carried out. The age of patients diagnosed with a herniated disk usually ranges from 30-50 years. With progression, a herniated disk can cause a number of serious consequences that invalidate the patient. In this regard, its timely detection and diagnosis are urgent tasks of practical vertebrology and neurology.
Causes
The main factor in the development of hernias is osteochondrosis of the spine. As a result of degenerative-dystrophic changes occurring in osteochondrosis, the intervertebral disc loses water and loses its elasticity. The height of the disc decreases, it hardly withstands the pressure of the vertebrae exerted on it and is easily injured by excessive physical exertion. In such a situation, under the influence of various unfavorable factors, a part of the disc is displaced beyond the space between the vertebrae. A herniated disk begins to form.
Earlier, the development of osteochondrosis is observed in individuals with spinal abnormalities (wedge-shaped vertebrae, lumbar fusion, vertebral fusion, Klippel-Feil syndrome, etc.), dysmetabolic diseases (diabetes mellitus, hypothyroidism), previously suffered spinal injuries (spinal fracture, spinal cord injury). The cause of early osteochondrosis may be developmental abnormalities that lead to an uneven load on the spinal column (for example, hip dysplasia). The factors provoking the formation of a hernia are lifting of gravity, spinal contusion, vibration, sudden movements, prolonged stay in a sitting position (for motorists, people working at a computer, etc.), obesity, improper load on the spinal column due to kyphosis, lordosis and other types of curvature of the spine, with impaired posture and work in an uncomfortable position.
Stages of the formation of a herniated disk
- At the initial stage, there is a slight displacement of the disc up to 2-3 mm, called disc prolapse.
- Further displacement (by 4 mm or more) is denoted by the term disk protrusion. In this case, the pulpous nucleus is displaced, but located within the fibrous ring. Clinically manifest symptoms of irritation of the nearby spinal root.
- Further progression of a herniated disk leads to a crack or delamination of the fibrous capsule of the disc and the loss of the pulpous nucleus beyond its limits. This condition is called disk extrusion. At this stage, a herniated disk can compress the spinal root and the blood vessel supplying it, causing radiculopathy and radiculomyeloishemia — radicular syndrome with symptoms of loss of neurological functions.
- Stage, at which the fallen pulpous nucleus hangs like a drop outside the intervertebral fissure, is designated as disc sequestration. As a rule, it leads to the rupture of the fibrous capsule and the complete expiration of the nucleus. At the stage of extrusion and sequestration, the herniated disk reaches such a size that it can cause compression of the spinal cord with the development of compression myelopathy.
Herniated disk symptoms
At the beginning of its formation, a herniated intervertebral disc often has a latent course. Then there are pains in the part of the spine where the hernia is localized. Initially, the pain is of a dull transient nature, increases with static and dynamic load, completely passes in the supine position. The patient tries to spare the diseased area of the spinal column, limiting movement in it. In parallel with the pain syndrome, muscle-tonic tension develops in the corresponding area of the paravertebral region.
As the hernial protrusion increases, there is an increase in pain and muscle-tonic syndromes, restriction of movements. The pain takes on a permanent character, can persist in the supine position. Muscle tension is more pronounced on the part of the location of the hernia and can provoke a misalignment of the spine, which creates an additional load on it and aggravates clinical manifestations. With further progression of a herniated intervertebral disc, complications develop. In some cases, the hernia has a subclinical course and manifests only when the latter occur.
Herniated disk may have a number of clinical features depending on the spine in which it is localized:
- Herniated disk of the cervical spine is accompanied by neck pain and reflex muscular torticollis; it can be complicated by vertebral artery syndrome.
- Herniated disk of the thoracic region often imitates the clinic of somatic diseases (angina pectoris, gastric ulcer, acute pancreatitis); it can provoke dyspepsia, intestinal dyskinesia, difficulty swallowing, enzyme insufficiency of the pancreas.
- Herniated disk of the lumbar region is manifested by symptoms of lumbago and lumboishialgia, makes it difficult to walk and tilt the trunk.
Complications
Radiculopathy occurs when a hernia is exposed to a spinal nerve located next to it. Radiculopathy can have a stage-by-stage development: at first there are symptoms of irritation of the root, and then loss of its functions. In the first case, an intense pain syndrome is characteristic, described by patients as a “lumbago” or “electric shock”, provoked by movements in the affected spine. Paresthesia is noted in the innervation zone of the root. The loss of the functions of the root leads to the appearance of muscle weakness and hypotension in the area of its innervation, and a decrease in sensitivity. Over time, a sluggish paresis develops with muscular atrophy, extinction of tendon reflexes and trophic disorders.
Discogenic myelopathy is formed when a hernia causes narrowing of the spinal canal and compression of the spinal substance. First of all, the motor function suffers. At the level of the lesion, peripheral paresis develops. Then comes the loss of sensitivity and sensitive ataxia. With a lumbar hernia, pelvic disorders are possible. As a rule, at first the manifestations of myelopathy are unilateral. Without appropriate treatment, the changes occurring in the spinal cord become irreversible, and the formed neurological deficit is not subject to reverse development.
Vertebral artery syndrome occurs if a cervical hernia compresses the vertebral artery passing along the lateral surface of the vertebral bodies. It is manifested by dizziness, vestibular ataxia, ear noise, transient scotomas and photopsias, fainting. It can cause transient disorders of cerebral circulation (TIA) in the vertebrobasilar basin.
Diagnostics
The initial manifestations of a herniated intervertebral disc are not very specific and are similar to the clinic of uncomplicated spinal osteochondrosis herniation. Radiography of the spine allows you to diagnose osteochondrosis, curvature of the spine, anomalies of its development, and other pathology of bone structures. However, a herniated disk is not visible on radiographs. It is possible to suspect a hernia in such cases by the persistent nature of the pain syndrome and its progression. During the diagnosis, a neurologist and a vertebrologist need to differentiate a herniated intervertebral disc from myositis, plexitis, Schmorl’s hernia, spondyloarthrosis, hematoma and spinal tumors.
Tomographic methods of examination — MRI and CT of the spine allow to detect a hernia. Moreover, MRI of the spine is more informative, because it gives a better visualization of soft tissue structures. With the help of MRI, it is possible not only to “see” the hernia, to establish its localization and the stage of the process, but also to determine the degree of narrowing of the spinal canal. In the absence of the possibility of tomography, contrast myelography can be used to confirm the diagnosis of “herniated disk”.
Herniated disk of the cervical spine, accompanied by symptoms of compression of the vertebral artery, is an indication for vascular studies: REG, ultrasound of the vertebral arteries. The examination is usually carried out with functional tests (turns and tilts of the head). Patients with a hernia in the thoracic region, depending on the clinical picture, may need to consult a cardiologist, gastroenterologist, pulmonologist with an ECG, an overview chest x-ray, gastroscopy, etc.
Herniated disk treatment
Conservative therapy
It is the most preferred therapeutic tactic for herniated intervertebral disc. It is complex in nature. The medicinal component includes drugs for the relief of pain syndrome (ketoprofen, ibuprofen, diclofenac, naproxen, meloxicam, etc.), muscle relaxants for the removal of muscle-tonic syndrome (tolperizone hydrochloride), vitamin complexes (B1, B6, B12) necessary for the maintenance of nervous tissue, decongestants. In order to relieve intense pain syndrome, local administration of corticosteroids and local anesthetics in the form of paravertebral blockades is used. In the initial stages, chondroprotectors (chondroitin sulfate, glucosamine, etc.) are effective.
Herniated disk in the acute period is an indication for the appointment of UHF, ultraphonophoresis with hydrocortisone, electrophoresis. During the convalescence period, electromyostimulation, reflexotherapy, mud therapy are used to restore paretic muscles. Traction therapy has a good effect, with the help of which there is an increase in the intervertebral distance and a significant reduction in the load on the affected disc, which provides conditions for stopping the progression of herniated protrusion, and in the initial stages can contribute to some recovery of the disc. Manual therapy can replace spinal traction, but, unfortunately, in practice it has a large percentage of complications, so it can only be carried out by an experienced chiropractor.
The most important role in the treatment of herniated disk is assigned to physical therapy. Specially selected exercises can be achieved and stretching of the spine, and strengthening of its muscular frame, and improving blood supply to the affected disc. Regular exercises allow you to strengthen the muscles holding the spine so much that a recurrence of a hernia or its appearance in other parts of the spinal column is practically excluded. Well complements the physical therapy course massage, as well as swimming.
Surgical treatment
It is necessary only for those patients in whom the complex use of conservative therapy has been unsuccessful, and the existing severe complications (uncupable for more than 1-1.5 months. pain syndrome, discogenic myelopathy, vertebral artery syndrome with TIA) tend to progress. Taking into account possible postoperative complications (bleeding, damage or infection of the spinal cord, spinal root injury, development of spinal arachnoiditis, etc.), one should not rush with the operation. Experience has shown that surgical intervention is really necessary in about 10-15% of cases of herniated intervertebral disc. 90% of patients are successfully treated in a conservative way.
The purpose of the operation may be decompression of the spinal canal or removal of a hernia. In the first case, laminectomy is performed, in the second — open or endoscopic discectomy, microdiscectomy. If a complete disc removal (discectomy) is performed during the intervention, then a B-Twin implant or spine fixation is performed to stabilize the spine. New methods of surgical treatment are laser vaporization, intradiscal electrothermal therapy. In the postoperative period, the most important thing is a gradual increase in motor load with anatomically correct execution of all movements. In the recovery period, physical therapy is mandatory.
Forecast
In about half of patients with adequate conservative therapy, the herniated disk ceases to remind of itself after a month. In other cases, this requires a longer period, ranging from 2 to 6 months, and it may take up to 2 years to fully recover. In the “ideal” version, the fallen pulpous nucleus resolves due to resorption processes, and the herniated disk decreases in size. In about a third of cases, this process takes about a year, but can last up to 5-7 years. An unfavorable prognosis occurs in cases of long-term myelopathy. In such conditions, neurological deficit persists even after surgical hernia removal and leads to disability of patients.
Prevention
Since in most cases a herniated disk is a consequence of improper loads on the spine, its main prevention consists in ensuring adequate functioning of the spinal column. Active movements, swimming, regular gymnastics are useful for strengthening muscles. It is necessary to avoid the incorrect position of the spine (slouching, hyperlordosis, etc.), lifting excessive weights, prolonged forced position, gaining excess weight.
