Intervertebral disc protrusion is a partial exit of the disc tissues beyond the space between the vertebrae, the first stage of the development of a vertebral hernia. Protrusion may occur latently. Clinically manifested by radiating pain in the affected segment, initial sensitivity disorders. It is diagnosed according to anamnesis, examination, radiography, MRI/CT, electroneurography. Treatment includes pain relief (anti-inflammatory, painkillers, muscle relaxants), therapeutic gymnastics, massage, spinal traction.
General information
Intervertebral disc protrusion is the initial stage of the formation of an intervertebral hernia. “Protrusion” means displacement of a part of the disk located between the vertebrae beyond the boundaries of the intervertebral space. At the same time, the integrity of the outer part of the fibrous ring is preserved, the pulpous nucleus does not go beyond its limits. Most often, intervertebral disc protrusion is observed in the lumbar region, less often in the cervical or thoracic. The peak incidence occurs in the age period of 35-50 years. Women and men get sick equally often. The risk group for the development of pathology includes people who lead a sedentary lifestyle, have curvature of the spinal column, have suffered spinal injuries, and suffer from dysmetabolic diseases.
Causes
Intervertebral disc protrusion is formed due to degenerative processes leading to loss of elasticity of the fibrous component. Among the factors that cause disc degeneration, there are:
- Physical inactivity. Immobility causes insufficient blood supply to the vertebral tissues, poor development of the muscular corset of the back. As a result, the pressure on the disk increases, and its power deteriorates.
- Posture disorders, spinal column curvature (kyphosis, lordosis, scoliosis). May be associated with congenital anomalies. They lead to an incorrect distribution of the load on various parts of the spinal column, a decrease in the intervertebral distance.
- Spinal injuries. Serious injuries, bruises, repeated microtrauma provoke the growth of connective tissue with loss of elasticity.
- Inadequate loads. They are associated with sports, lifting weights, working in a forced position.
- Dysmetabolic processes. They are a consequence of endocrine pathology (diabetes mellitus, endocrine obesity, hypothyroidism), improper nutrition.
- Old age. Aging of the body is accompanied by dystrophic changes in various organs and tissues, including in the spine.
Pathogenesis
The above factors cause the development of osteochondrosis – degenerative-dystrophic changes in the tissues of the spine, including the intervertebral disc. The elasticity of the fibrous ring surrounding the disc nucleus decreases. Microcracks form in its inner part. The process is facilitated by increased pressure on the disc due to narrowing of the intervertebral space. As a result, the pulpous nucleus shifts to the outer part of the disc. A protrusion is formed. The size of the protruding part ranges from 4 to 6-7 mm. Due to the smaller size of the vertebrae in the cervical region, 2-3 mm protrusions, classified in practical neurology as “prolapse”, may be clinically significant.
Classification
The course and clinic of the disease depend on the direction of prolapse of the disc. According to its location, intervertebral protrusion is classified as follows:
- Anterior (ventral) protrusion is the protrusion of a part of the disc in the direction from the spine to the abdomen. It proceeds latently, without affecting the spinal structures.
- Lateral (lateral) protrusion – located to the side of the spine, adversely affects the nearby spinal root. It can be right- and left-sided, antero- and posterolateral. Separately, there is a foraminal protrusion going in the direction of the intervertebral foramen.
- Posterior (dorsal) protrusion – directed to the back. It includes a median (central) shape going to the center of the spinal canal. With a large size, the median protrusion can affect the spinal tissues directly.
Symptoms
The symptoms depend on the type, location and size of the protrusion. The anterior and anterolateral forms are characterized by an asymptomatic course. The posterior and posterolateral have a hidden period, then manifest signs of irritation of the adjacent spinal root – pain syndrome with irradiation from the spine to the periphery, sensitive disorders in the area innervated by the affected root. Up to a certain size, prolapse of the intervertebral disc is not accompanied by clinical symptoms. Cervical protrusion begins to manifest at sizes from 2 mm, and lumbar protrusion – from 4 mm.
In the cervical region, protrusion is characterized by acute (subacute) pains in the neck, which are burning in nature or resemble a “lumbago”. Pain sensations spread to the shoulder girdle, go along the arm to the fingers. There is numbness, a feeling of “goosebumps”, tingling in the hand. Turns and tilts of the head are limited.
In the thoracic region, pain syndrome can occur with imitation of diseases of internal organs (pain in the epigastrium, in the chest, in the heart). Protrusion is accompanied by tingling, unpleasant sensations along the intercostal space.
In the lumbar region, the pathology of the intervertebral disc occurs most often, which is associated with increased load and a wide range of movements (flexion-extension, torsion). The pains are localized in the lower back, radiate into the buttock on the side of the protrusion, go further to the foot. In the area of pain, there is a feeling of “crawling goosebumps”, discomfort, tingling. Movements in the lower back are limited because they increase the pain syndrome.
Complications
Without medical and security measures, the situation is getting worse. Further progression of degenerative processes, an increase in pressure on the disc with an increasing decrease in the intervertebral distance and inadequate load cause rupture of the outer part of the fibrous ring with the formation of a herniated disc. Compression of the spinal root or spinal cord occurs. In the first case, radiculopathy develops with loss of root function, in the second – discogenic myelopathy. Complications can lead to the formation of persistent neurological deficit and disability. Intervertebral hernia does not respond well to conservative treatment, it is often an indication for surgical intervention.
Diagnostics
The main difficulty lies in the often hidden course of protrusion, the insignificant severity of symptoms, as a result of which patients seek medical help already at the stage of hernia. Comprehensive diagnostics is carried out by the efforts of a neurologist, orthopedist, vertebrologist. Includes:
- Collection of anamnesis. It helps to detect the occurrence of symptoms after exposure to a trigger factor (lifting a heavy object, excessive load, prolonged stay in a bending or twisting position).
- Examination of the patient. It reveals the presence of an antalgic posture, forced restriction of mobility, soreness during paravertebral palpation in the area of the corresponding vertebrae. Neurological status can determine areas of hyper- or hypesthesia, symptoms of tension of nerve roots. The appearance in the status of signs of loss of functions (muscle weakness, decreased reflexes, lack of pain sensitivity) indicates in favor of a hernia.
- Spine x-ray. It helps to assess the distance between the vertebrae, the correctness of the anatomical interposition of bone structures. Radiography is able to confirm the presence of anomalies, curvature, signs of osteochondrosis, suffered spinal injury.
- MRI of the spine. Allows you to visualize the prolapse, assess its size, the degree of compression of the surrounding tissues. CT of the spine is less informative, because it displays soft tissue structures worse.
- Electroneuromyography. It is carried out to assess the degree of functional changes, identify conduction disorders of nerve trunks, and perform differential diagnostics.
Differential diagnosis is performed with mononeuritis, myositis, uncomplicated osteochondrosis. With lesions of the thoracic region, depending on the symptoms, it is necessary to exclude pathology of internal organs (gastritis, pancreatitis, angina pectoris).
Treatment
Therapy of intervertebral disc protrusion is carried out within the framework of conservative methods. Of paramount importance is the elimination of the etiofactor (excessive load, incorrect spine position, metabolic disorders). Treatment has two components:
- Relief of pain syndrome. It is produced by nonsteroidal anti-inflammatory pharmaceuticals. In the presence of pain-enhancing muscle tension, muscle relaxants are prescribed. It is possible to carry out ultraphonophoresis, electrophoresis of painkillers. The patient must observe a protective regime: avoid sudden movements, reduce the load on the spinal column.
- Prevention of the progression of protrusion. It implies strengthening the musculoskeletal system that holds the vertebrae in the correct position, at an adequate distance from each other. Exercise therapy complex allows you to train your muscles, regular classes on special simulators. If necessary, gymnastics is combined with traction therapy — dry or underwater stretching of the spine to increase the intervertebral distance. Massage, physiotherapy enhance blood circulation, nutrition of muscles and paravertebral tissues, contribute to their strengthening.
Prognosis and prevention
Disk prolapse has a favorable prognosis. Timely treatment is effective in 90% of patients. The lack of therapy leads to the progression of the disease with the outcome of a hernia requiring surgical removal. Primary prevention consists in an active lifestyle, rational nutrition, observance of adequate physical activity in the physiological position of the spine, relief of dysmetabolic abnormalities. Secondary prevention is aimed at preventing the development of a herniated disc. It consists in the constant performance of a set of gymnastic exercises to strengthen the muscles of the back, the exclusion of provoking factors, regular observation by a vertebrologist.