Lumbar disc herniation is the protrusion of the intervertebral disc beyond the vertebral bodies in the lumbar spine. Clinically manifests with lumbalgia and vertebral syndrome. It is complicated by discogenic radiculopathy and myelopathy. It is diagnosed mainly according to MRI of the spine. Treatment can be conservative (anti-inflammatory drugs, muscle relaxants, traction, manual therapy, physiotherapy, physical therapy, massage) and surgical (laser vaporization, electrothermal therapy, microdiscectomy, discectomy, installation of a B-Twin implant).
General information
Lumbar disc herniation is a serious complication of osteochondrosis of the spine. Its formation may be due to both reduced motor activity and excessive loads on the spinal column. The most common herniation is localized in the discs located between the last 2 lumbar vertebrae (L4 and L5) or between the last lumbar vertebra (L5) and the first sacral (S1). In some cases, there is a lesion of the discs between the 3rd and 4th lumbar vertebrae (L3 and L4), extremely rarely — in the upper discs of the lumbar region.
The disease affects people in the age category of 30-50 years, more often men. Lumbar disc herniation may manifest a bright clinical picture in the early stages, and may have a long subclinical course up to the development of complications. The prevalence, working age of patients, the likelihood of disabling complications put lumbar hernia in a number of urgent problems of modern vertebrology, neurology and orthopedics.
Causes
Lumbar disc herniation is formed due to degenerative changes occurring in the intervertebral disc, the cause of which is local dysmetabolic disorders. The disorder of the trophic disk is accompanied by a decrease in its hydrophilicity and elasticity. In such conditions, injury or inadequate load on the spine leads to the formation of cracks or tears of the intervertebral disc, as a result of which it protrudes beyond the vertebral bodies between which it is located. A protrusion of the disk is formed. Further development of the disease leads to rupture of the fibrous ring of the disc with loss of the pulpous nucleus. Disk extrusion is formed. It often causes complications of lumbar hernia, such as compression of the spinal root and compression of the spinal cord. In the first case, radicular syndrome (sciatica) develops, in the second — compression myelopathy.
Among the causes of violation of the trophism of the intervertebral disc, the most common are insufficient motor activity and improper load distribution on the spinal column. The latter may be due to abnormalities in the development of the spine, acquired curvature of the spine (excessive lumbar lordosis, scoliosis), static or dynamic load in an uncomfortable position, lifting weights, pelvic distortion (for example, due to hip dysplasia), obesity. The main etiofactors of lumbar hernia also include spinal injuries (fracture of the lumbar spine, spinal contusion, subluxation of the vertebra), dysmetabolic processes in the body, various diseases of the spine (Bekhterev’s disease and other spondyloarthritis, spondyloarthrosis, Calve disease, tuberculosis of the spine, etc.).
Symptoms
In its clinical development, lumbar disc herniation usually goes through several stages. However, a number of patients have a long latent course, and the manifestation of a hernia occurs only at the stage of complications. The main clinical syndromes are pain and vertebral.
The pain syndrome at the beginning of the disease has a non-permanent character. It occurs mainly with physical exertion on the lower back (bending, lifting weights, working in a tilt position, prolonged sitting or standing, sudden movement). The pain is localized in the lower back (lumbalgia), has a dull character, gradually disappears in a comfortable horizontal position. Over time, the intensity of the pain syndrome increases, lumbalgia becomes constant and aching, unloading the spine in a horizontal position brings patients only partial relief. Vertebral syndrome joins, there is a restriction of motor activity.
Spinal syndrome is caused by reflex muscle-tonic changes that occur in response to chronic pain impulses. The paravertebral muscles come into a state of constant tonic contraction, which further aggravates the pain syndrome. Muscle hypertonus, as a rule, is expressed unevenly, as a result of which the torso is skewed, creating conditions for the development of scoliosis. The volume of movements in the lumbar spine decreases. Patients are not able to fully straighten their back, bend over, lift their leg. There are difficulties when walking, if necessary, get up from a sitting position or sit down.
Complications
Radiculopathy manifests when the lumbar disc herniation increases so much that it begins to come into contact with the spinal root. Initially, the root is irritated, which is manifested by the transformation of the pain syndrome from lumbalgia to lumbago with sciatica and the appearance of sensory disorders such as paresthesia (tingling sensation and “crawling goosebumps”). The pain becomes shooting, spreads from the lower back to the buttock and lower down the leg from the side of the root involved in the pathological process. Patients characterize pain syndrome as a lumbago that occurs during movements in the lower back and walking. The most favorable position that relieves pain is to bend the sick leg in a lying position on the healthy side.
As the lumbar hernia increases, it begins to squeeze the spinal root, leading to the appearance and progression of the symptom of prolapse. Along with paresthesia, numbness and decreased sensitivity are noted in the leg of the affected side. There is weakness and hypotension of the leg muscles, as a result of which the patient cannot rise on his toes, sit down, lift his foot on a step. The affected leg becomes thinner, dry skin or hyperhidrosis occurs, trophic disorders, especially pronounced on the foot.
Discogenic myelopathy is observed when a lumbar hernia begins to compress the substance of the spinal cord. Initially, its symptoms affect only the affected side, but in the future they may acquire a bilateral character. The pain syndrome loses its intensity. Motor and sensory neurological deficits come to the fore. Peripheral flaccid paresis of the lower limb develops with loss of tendon reflexes. Pelvic disorders are added. As a result of sensory disturbances, sensitive ataxia is observed.
Diagnostics
It is difficult to suspect the formation of a lumbar hernia in the initial stages, since its clinical picture is similar to the symptoms of uncomplicated osteochondrosis and the onset of other pathological processes (lumbar spondylosis, lumbar spondyloarthrosis, lumbalization, sacralization, etc.). Patients themselves often turn to a neurologist, orthopedist or vertebrologist only at the stage of radicular syndrome.
In the case of a lumbar hernia, spine x-ray is only of auxiliary importance, since it does not allow you to “see” soft tissue formations. It can reveal signs of osteochondrosis, a decrease in the intervertebral distance, the presence of spinal deformity. A lumbar hernia can be visualized using CT or MRI of the spine. Tomography also allows you to determine the presence and degree of spinal compression, which is fundamental to the choice of therapeutic tactics.
Treatment
In the early stages, before the development of complications, and even in the presence of radicular syndrome, conservative treatment of lumbar hernia is possible. The symptoms of discogenic myelopathy are a reason to address the issue of emergency surgery, because the longer they exist, the more irreversible the developing neurological deficit. Minimally invasive methods of surgical treatment of herniated discs are used at earlier stages, before the development of spinal compression. However, they can give some complications (infection, bleeding).
Conservative treatment
Conservative therapy of lumbar hernia is complex. The medicinal component includes anti-inflammatory (ketorolac, meloxicam, diclofenac, nimesulide), muscle relaxants (tolperizone hydrochloride, tizanidine), metabolic (vitamins g. B) pharmaceuticals. To relieve intense pain syndrome, paravertebral blockades are prescribed. Along with this, methods of manual therapy or spinal traction are used to correct the anatomical location of the structures of the lumbar region and increase the distance between the lumbar vertebrae. The use of post-isometric relaxation, reflexotherapy and physiotherapy (UHF, phonophoresis, medicinal electrophoresis) are aimed at relieving pain and tonic syndromes.
Of paramount importance in the treatment of lumbar hernia is individually selected physical therapy. Rest is necessary for the patient only during the period of relief of pain syndrome. After the inflammatory phenomena are on the wane, it is necessary to start special gymnastic exercises, over time allowing you to build up the muscular framework that holds the structures of the spinal column in a normal position. In addition, physical exercises (especially in combination with massage) contribute to the improvement of trophic. Thus, a gymnastics complex with a gradual increase in load, correctly selected with the help of a physical therapy doctor or a rehabilitologist, prevents further hernia prolapse. It should be said that in order to prevent the occurrence of new problems with the spine, the patient will need to perform special gymnastics for the entire subsequent period of life.
Surgical treatment
Surgical treatment of large lumbar hernias is radical in nature: discectomy or microdiscectomy is performed. With a smaller hernia size (no more than 0.6 mm), endoscopic microdiscectomy is possible. After the hernia is removed, a B-Twin implant can be installed to maintain the intervertebral distance and stabilize the spine. At the initial stages of the formation of a lumbar hernia, intradiscal electrothermal therapy and puncture laser vaporization can be used to increase the strength of the disc and prevent its further protrusion.