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The height of the intervertebral discs is reduced. What are the risks of reducing the height of intervertebral discs?

The spine in the cervical and lumbar region already in early childhood begins to bend slightly forward - this phenomenon is called lordosis.

Let's look at what flattening of lordosis is and what can be done to correct the situation.

Why does hypolordosis occur?

Among the primary factors for flattening physiological lordosis are the period of intrauterine development or the period of early childhood.

At this time, various infections may occur, hereditary diseases, as well as tumors and injuries may influence.

Secondary factors are defects of the spine and/or hip joints, various pathologies of ligaments, joints that develop as a result of injury, diseases (including genetic) or other reasons.

Among the “domestic” reasons are the following:

forced throwing of the head;
uncomfortable furniture;
sitting for a long time in an uncomfortable position;
untrained muscles.

A decrease in physiological lordosis most often occurs due to a degenerative process such as osteochondrosis.

The structure of the intervertebral discs changes, causing the lordosis to become flattened. Sooner or later, the incorrect position of the body becomes habitual, and the spine is “fixed” in the incorrect position.

Some of the factors can be managed early or with effective conservative treatment at almost any age.

Others are sometimes impossible to correct even with surgery. One way or another, any decision regarding therapy can only be made by a doctor.

Manifestations of pathology

When physiological lordosis (angle 150-170°) is flattened (angle 170-172°), this affects the structure of the spine as a whole and its normal functioning.

Even the internal organs begin to experience excessive stress, and overall health deteriorates greatly. For example, when the lumbar lordosis is flattened, the back in this area is visually “leveled”, and in addition, the following appear:

pain, limited mobility and numbness in the lower back, legs;
chronic fatigue while sitting or standing;
dysfunction of internal organs (especially the abdominal cavity, as well as the heart);
metabolic disease.

In the case of flattening of cervical lordosis, the neck visually lengthens, the head moves forward, and becomes more noticeable, which means that sooner or later neurological disorders will begin to occur in the body.

It is difficult for a person to move his head; as the disease progresses, discomfort appears during breathing and swallowing, as well as shortness of breath and coughing. Due to a malnutrition of the brain, the patient sleeps poorly and develops.

How to treat

Diagnosis begins with an external examination, then an instrumental examination is prescribed - this can be radiography or MRI. The specialist will be able to determine the degree of spinal deformation from these images.

If there is a suspicion of other problems that have arisen in connection with the pathology, an ultrasound of internal organs, ECG, MRI or other methods may be recommended.

As soon as it is established that the lordosis of the cervical or lumbar spine is indeed flattened, conservative therapy begins, which, depending on the severity of the disease, includes:

, anti-inflammatory drugs, ;
(the complex must be developed individually);
(, mud therapy, etc.);

Therapeutic gymnastics is recognized as one of the most effective methods, as it allows you to eliminate pain, improve the general condition of the spine, and improve your health in the long term - unlike medications and other methods for relieving symptoms.

Sometimes patients ask the question: is it even worth overcoming the flattening of lumbar or cervical lordosis, because smoothing the natural line of the spinal column is adaptive in nature.

Indeed, it is not necessary to strive for “absolute” normalization, that is, to restore the physiological curve.

The main thing is to restore normal mobility of the corresponding parts of the spine, and only dynamic practices, that is, physical therapy, can do this.

If you want to get more information and similar exercises for the spine and joints from Alexandra Bonina, check out the materials on the links below.

Denial of responsibility

The information in the articles is for general information purposes only and should not be used for self-diagnosis of health problems or for therapeutic purposes. This article is not a substitute for medical advice from a doctor (neurologist, therapist). Please consult your doctor first to know the exact cause of your health problem.

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Intervertebral osteochondrosis of any part of the spine has its own characteristics of course and development. People of working age are susceptible to the disease; many scientists consider the pathological changes occurring in the vertebrae and adjacent structures to be the result of the load on the spinal column associated with upright posture.

Terminology of intervertebral osteochondrosis

Initially, the term osteochondrosis denoted a group of diseases of a predominantly inflammatory nature in the subcartilaginous space of the long tubular bones of the skeleton and apophyses in short bones.

Intervertebral osteochondrosis refers only to a degenerative-dystrophic process in the discs of one or more parts of the spinal column. The primary inflammatory process in this case, in the absence of timely treatment and with the continued influence of the provoking factor, extends to the osseous-ligamentous apparatus adjacent to the disc

The spinal column of each person consists of 33-35 vertebrae. Between these vertebrae are discs that serve primarily as shock absorbers. That is, intervertebral discs prevent neighboring vertebrae from touching each other, soften movement, and reduce the load.

The anatomy of the disc is represented by a central nucleus and the annulus fibrosus, a dense tissue that surrounds the entire nucleus in a circumferential manner. Under the influence of certain reasons, the structures of the core and connective tissue of the disc are steadily disrupted, this leads to disruption of the shock absorption function, decreased mobility and deterioration of elasticity. This condition manifests itself with different symptoms.

Causes

As the body ages, intervertebral osteochondrosis is observed to one degree or another in every person. But if the body is constantly under the influence of factors negatively affecting the spinal column, then the osteochondral structures are destroyed quickly and all the unpleasant symptoms of the disease appear at a fairly young age.

Osteochondrosis most often develops under the influence of several causes at once, and all of them must be taken into account in order to achieve the most optimal result during the treatment process.

Intervertebral osteochondrosis develops due to the negative influence of the following factors:

With constant physical inactivity. That is, degenerative changes most often occur with a sedentary lifestyle.
Disturbed metabolism.
Infectious diseases.
Overweight.
Poor nutrition – consumption of fatty, low-vitamin foods, various food additives.
Injuries and damage to vertebral bodies.
Diseases of the musculoskeletal system, this group also includes curvature of the spine and flat feet.
In women, the load on the spinal column increases significantly during pregnancy and when constantly wearing high heels.
Emotional stress.
Bad habits – smoking, alcohol abuse.

The hereditary factor has a certain influence on the development of intervertebral osteochondrosis. Under the influence of all these provoking causes, blood circulation in the intervertebral structures is significantly disrupted, metabolic processes slow down, and insufficient amounts of microelements and vitamins enter the tissues and cells. That is, all conditions are created for the occurrence of inflammatory and degenerative changes in the discs.

Degrees

Types of localization

Intervertebral osteochondrosis can affect any part of the spinal column. covers more than one anatomical region of the spine. Based on localization, the local pathological process is divided into:

Cervical osteochondrosis. This type of disease is detected most often and can occur in fairly young people.
Thoracic osteochondrosis is the rarest type of localization of the disease. This is due to the fact that this section is less mobile.
Lumbar osteochondrosis.
intervertebral osteochondrosis.

Diagnostics

The diagnosis of intervertebral osteochondrosis is made by a neurologist. First, the patient is examined, anamnesis is collected, and complaints are clarified. To confirm the diagnosis using instrumental examination methods, the following are prescribed:

spine.
used to identify intervertebral hernia and assess pathological changes in the spinal cord.
Discography is prescribed for a complete examination of all damaged disc structures.
or electroneurography are prescribed to determine damage in the nerve pathways.

Symptoms

The clinical picture of intervertebral osteochondrosis depends on the degree of inflammatory and degenerative changes occurring in the discs. The first sign is pain, as a rule, it is combined with some disturbance of movement in the affected segment of the spine.

The pain can be so severe that it sharply reduces a person’s performance, disrupts his psycho-emotional state and is relieved only after the use of drug blockades. Signs of the disease also depend on the type of localization of osteochondrosis.

Symptoms of disease in the cervical spine

The diagnosis of intervertebral osteochondrosis is made most often. Main symptoms:

Frequent headaches and dizziness.
Pain in the upper limbs and chest.
Numbness of the cervical spine and limitation of its mobility.
Weakness and decreased sensitivity in the hands.

Cervical intervertebral osteochondrosis is also often manifested by pressure surges, darkening of the eyes, and severe weakness. This is explained by the fact that the vertebral artery, which supplies different parts of the brain, passes through the vertebrae of this section. Its compression as a result of changes in the anatomical location of the discs leads to various pathological changes in well-being.

Due to metabolic disorders and as a result of degenerative-dystrophic processes, dehydration of the intervertebral discs occurs. This condition is characterized in medicine as loss of water in the center of the intervertebral disc; it is recognized as the basis for the development of many spinal diseases.

Dehydration of the intervertebral disc is one of the provoking factors in the development of many vertebral diseases - osteoarthritis, protrusions, hernias and others. Loss of water leads to the loss of the main shock-absorbing function; the disc becomes immobile, simultaneously reducing the amount of motor activity of the spine.

What happens when intervertebral discs dehydrate? If there is a lack of fluid in the intervertebral disc, depreciation is reduced, this leads to the fact that the disc loses its ability to function normally - the spine becomes immobile. The next stage of pathology development is liming.

There are several stages of dehydration, here they are:

Stage zero - no pathological changes.
The first stage - small tears appear in the internal plates in the fibrous ring.
The second stage - significant destruction of the intervertebral disc occurs, but the integrity of the outer rings is still preserved.
The third stage - the integrity of the outer shell of the intervertebral disc is compromised.

A rational and balanced diet will help prevent the progression of pathology and improve human health.

A little about secrets

Have you ever experienced constant back and joint pain? Judging by the fact that you are reading this article, you are already personally familiar with osteochondrosis, arthrosis and arthritis. Surely you have tried a bunch of medications, creams, ointments, injections, doctors and, apparently, none of the above has helped you... And there is an explanation for this: it is simply not profitable for pharmacists to sell a working product, since they will lose customers! Nevertheless, Chinese medicine has known the recipe for getting rid of these diseases for thousands of years, and it is simple and clear. Read more"

Basics of proper nutrition for dehydration of vertebral discs:

Drink enough liquid. Nutritionists advise drinking at least 2 liters of plain water daily. When intervertebral discs are dehydrated, it is recommended to increase the consumption of the specified volume of fluid to 2.5-3 liters per day. A sufficient amount of water in the body contributes to the accumulation and retention of fluid in the vertebrae. It is important to drink clean, plain water and not carbonated drinks.
Eat 5-6 times a day in small portions. A balanced diet helps rid the body of extra pounds, which helps to significantly reduce the load on the spine.
The menu should include protein products. It is important to create a diet so that the bulk of the foods consumed are dairy products, legumes, and low-fat fish. It is recommended to include slow carbohydrates (cereals) in the menu, but high-calorie, sweet and fatty foods should be completely abandoned.
To strengthen the bone system, it is important to eat foods enriched with vitamins A, C, E, B, D, as well as minerals - calcium, magnesium, phosphorus.
The patient’s diet must contain products that are natural chondroprotectors - jellied meat, fish aspic, jelly.
It is important to completely eliminate the consumption of any alcohol, as well as strong coffee. Salty, smoked, spicy foods, baked goods, and sweets should be sharply limited.

A lot has been written and said about the principles of a healthy, balanced diet, but it is not easy to correctly create an individual menu. It is necessary to take into account the characteristics of your body and the presence of other chronic pathologies. Therefore, it is better to competently develop a suitable diet with a nutritionist.

Physiotherapy

Performing regular light physical exercise is very useful for various pathologies of the spine. Gymnastics helps strengthen the bone system and connective tissues, improve blood circulation in the spine. Almost any type of therapeutic exercise can be used for dehydrated intervertebral discs; yoga or swimming are good options. Even an ordinary walk at a slow pace in a park or forest will be useful for a person.

In combination with therapeutic exercises, it is useful to use massage procedures; they help relieve tension from the back muscles and improve blood circulation. Back massage should only be performed by a professional.

Surgery

When conservative therapy does not produce adequate results or the disease is in an advanced stage, surgical intervention is used. Most often, during the operation, the intervertebral disc destroyed during dehydration is completely removed.

The combination of a reasonable therapeutic diet, drinking regimen and moderate physical activity with drug therapy is the best option for treating intervertebral disc dehydration.

How to forget about back and joint pain?

We all know what pain and discomfort are. Arthrosis, arthritis, osteochondrosis and back pain seriously spoil life, limiting normal activities - it is impossible to raise an arm, step on a leg, or get out of bed.

Intervertebral discs are cartilaginous formations that connect the bony elements of the spine. They provide flexibility and mobility of the spinal column, body rotation, and absorb loads and shocks when running, jumping and other movements. Constant mechanical stress, aging of the body, the harmful influence of external factors and disease gradually lead to the fact that cartilage loses its natural qualities, wears out and sag.

Etiology of the disease

Anatomically, intervertebral discs consist of a dense membrane (annulus fibrosus) and a softer pulpous center (nucleus pulposus), enclosed between hyaline plates that are adjacent to the vertebral bodies.

The discs do not contain blood vessels, so nutrition and water supply to the cartilage fibers occurs diffusely from the surrounding soft tissues. Thus, normal functioning of intervertebral discs is possible only with the normal state of muscle tissue (proper adequate physical activity and active blood circulation).

The development of degenerative-dystrophic changes in the body (osteochondrosis) and a sedentary lifestyle causes deterioration in the nutrition of the back muscles and intervertebral discs. As a result, stiffness of some segments occurs, pain during movement, swelling, spasms, which further complicates blood circulation in the pathological area.

Gradually, the cartilage tissues lose water, their elasticity decreases, the fibrous membrane begins to crack, and the disc itself flattens, becomes lower and sometimes goes beyond anatomically acceptable limits.

The next stage of the disease or stage of osteochondrosis is the development of spondylosis deformans. Subsidence and squeezing out of fibrous fibers of cartilage under the weight of the body and during physical activity leads to the fact that the intervertebral discs pull along the hyaline plates connected to them and the surface of the bone tissue. Thus, bone growths appear on the vertebral bodies - osteophytes.

To some extent, the formation of osteophytes is a protective reaction of the body to the destruction of cartilage and its excess beyond its natural limits. As a result, the discs are limited in the lateral planes and can no longer go beyond the edges of the bone growths (spread even further). Although this condition significantly worsens the mobility of the affected segment, it no longer causes any particular pain.

The further development of the disease is characterized by the degeneration of cartilage tissue into denser tissue, similar in quality to bone, causing the discs to suffer even more.

Stages of pathology and their symptoms

The development of the disease is conventionally divided into several stages:

The initial stage or stage of subtle changes, in which there is slight damage to the membranes of the fibrous ring, but the height of the intervertebral disc itself remains unchanged. The only worrying symptom is some stiffness of movement in the morning and discomfort after unusual and excessive physical activity.
Stage of progression of degenerative disorders, pronounced disc subsidence and damage to the fibrous membrane. At this stage, there is stiffness of the back muscles and ligaments, which are no longer able to support the spine. Curvature of posture (scoliosis, kyphosis, lordosis), vertebral instability and other pathologies may be observed. The patient feels pain after physical exertion and/or prolonged exposure to static and uncomfortable positions.
The stage of active deformation of the disk ring, its cracking, going beyond acceptable limits. The formation of intervertebral protrusions or hernias, which are characterized by local swelling, inflammation, and spasm of muscle tissue, is possible. Disruption of microcirculation of blood and lymph causes severe pain, as well as pinching of blood vessels and nerve roots. May be accompanied by loss of sensitivity, paresis or paralysis of the limbs, and dysfunction of internal organs.
The stage of progression of spondylosis, in which the intervertebral discs significantly lose their height, extend beyond the vertebral bodies, and osteophytes are formed. At this stage of the development of the disease, ankylotic fusions of the joints may occur, which is fraught with a complete loss of mobility of the segment, and, consequently, disability of the patient.

Treatment of the disease

Sagging intervertebral discs, osteochondrosis and spondylosis are conditions that, once they occur, are difficult to treat or restore. Reducing the height of the disc and the growth of osteophytes can only be stopped or slowed down, but it is quite possible to improve the condition of the cartilage tissues of the joints.

Conservative treatment methods involve an integrated approach, which consists of:

relieving pain with medications, physiotherapeutic and manual procedures;
active and passive development of the joint, improving blood circulation and lymph flow in it;
treatment of soft tissues of the whole body and pathological area to restore trophism and metabolic processes;
improving the condition of the cartilage of the spinal column and the whole body with medications, physiotherapy, exercise therapy;
strengthening the bone, muscle and ligament structures of the body;
if necessary, reducing pressure on each other and the soft tissue of bone growths using surgical intervention.

Drug therapy is represented by:

local and general anesthetics to relieve pain;
muscle relaxants to eliminate muscle spasms;
if necessary, NSAIDs to relieve inflammation;
chondroprotectors to improve the condition and nourishment of cartilage tissue;
vasodilating and activating intercellular metabolism drugs to improve blood circulation and metabolic processes.

Physiotherapeutic procedures should be combined with therapeutic exercises, various types of massages, swimming, yoga and other physical activities. Recently, cryotherapy, as well as spinal traction (hardware, natural, water, kinesiological, etc.), have gained wide popularity in the treatment of diseases of the spine.

If necessary, the patient may be advised to rest completely and/or wear a corset for a certain period. An important role in treatment is played by the psychological attitude of the patient himself, giving up bad habits, rethinking his entire lifestyle and an appropriate diet.

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Damage to the lumbar and thoracic intervertebral discs is much more common than is commonly thought. They arise from indirect exposure to violence. The immediate cause of damage to the lumbar intervertebral discs is heavy lifting, forced rotational movements, flexion movements, sudden sharp straining and, finally, a fall.

Damage to the thoracic intervertebral discs most often occurs with a direct blow or impact to the area of the vertebral ends of the ribs, transverse processes in combination with muscle tension and forced movements, which is especially often observed in athletes when playing basketball.

Damage to the intervertebral discs is almost never observed in childhood; it occurs in adolescence and young adulthood, and is especially common in people in the 3rd-4th decade of life. This is explained by the fact that isolated injuries to the intervertebral disc more often occur in the presence of degenerative processes in it.

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What causes intervertebral disc damage?

The lumbosacral and lumbar spine are the areas where degenerative processes most often develop. The IV and V lumbar discs are most often affected by degenerative processes. This is facilitated by the following some anatomical and physiological features of these discs. It is known that the IV lumbar vertebra is the most mobile. The greatest mobility of this vertebra leads to the fact that the IV intervertebral disc experiences significant load and is most often subject to trauma.

The occurrence of degenerative processes in the fifth intervertebral disc is due to the anatomical features of this intervertebral joint. These features consist in the discrepancy between the anteroposterior diameter of the bodies of the V lumbar and I sacral vertebrae. According to Willis, this difference varies from 6 to 1.5 mm. Fletcher confirmed this based on an analysis of 600 radiographs of the lumbosacral spine. He believes that this discrepancy in the sizes of these vertebral bodies is one of the main reasons for the occurrence of degenerative processes in the V lumbar disc. This is also facilitated by the frontal or predominantly frontal type of the lower lumbar and upper sacral facets, as well as their postero-external inclination.

The above anatomical relationships between the articular processes of the 1st sacral vertebra, the 5th lumbar and 1st sacral spinal roots can lead to direct or indirect compression of these spinal roots. These spinal roots have a significant extent in the spinal canal and are located in its lateral recesses, formed in front by the posterior surface of the fifth lumbar intervertebral disc and the body of the fifth lumbar vertebra, and in the back by the articular processes of the sacrum. Often, when degeneration of the fifth lumbar intervertebral disc occurs, due to inclination of the articular processes, the body of the fifth lumbar vertebra not only descends downward, but also moves posteriorly. This inevitably leads to a narrowing of the lateral recesses of the spinal canal. That is why “disco-radicular conflict” so often arises in this area. Therefore, the most common phenomena of lumboischialgia occur with involvement of the 5th lumbar and 1st sacral roots.

Conservative treatment of lumbar intervertebral disc injuries

In the vast majority of cases, damage to the lumbar intervertebral discs is cured using conservative methods. Conservative treatment of lumbar disc damage should be carried out comprehensively. This complex includes orthopedic, medicinal and physiotherapeutic treatment. Orthopedic methods include creating rest and unloading the spine.

A victim with damage to the lumbar intervertebral disc is put to bed. It is a mistaken idea that the victim should be placed on a hard bed in a supine position. For many victims, this forced position causes increased pain. On the contrary, in some cases there is a decrease or disappearance of pain when the victims are placed in a soft bed that allows significant flexion of the spine. Often the pain goes away or decreases in a position on the side with the hips brought to the stomach. Consequently, in bed the victim must take the position in which the pain disappears or decreases.

Unloading of the spine is achieved by placing the victim in a horizontal position. After some time, after the acute effects of the former injury have passed, this unloading can be supplemented by constant stretching of the spine along an inclined plane using soft rings for the armpits. To increase the tensile force, additional weights can be used, suspended from the victim’s pelvis using a special belt. The size of the load, time and degree of stretching are dictated by the sensations of the victim. Rest and unloading of the damaged spine last for 4-6 weeks. Usually during this period the pain disappears, the tear in the area of the fibrous ring heals with a durable scar. In later periods after a previous injury, with more persistent pain, and sometimes in fresh cases, intermittent stretching of the spine, rather than constant traction, is more effective.

There are several different intermittent spinal stretch techniques. Their essence boils down to the fact that over a relatively short period of 15-20 minutes, using weights or dosed screw traction, the tension is increased to 30-40 kg. The magnitude of the stretching force in each individual case is dictated by the patient’s physique, the degree of development of his muscles, as well as his sensations during the stretching process. The maximum stretch lasts for 30-40 minutes, and then over the next 15-20 minutes it is gradually reduced to pet.

Stretching the spine using a dosed screw rod is carried out on a special table, the platforms of which are spread along the length of the table by a screw rod with a wide thread pitch. The victim is secured at the head end of the table with a special bra put on the chest, and at the foot end with a belt around the pelvis. When the foot and head platforms diverge, the lumbar spine is stretched. In the absence of a special table, intermittent stretching can be performed on a regular table by hanging weights from the pelvic girdle and a bra on the chest.

Underwater spinal stretching in the pool is very useful and effective. This method requires special equipment and equipment.

Drug treatment for lumbar disc damage involves taking medications orally or applying them topically. In the first hours and days after injury, with severe pain, drug treatment should be aimed at relieving pain. Analgin, promedol, etc. can be used. Large doses (up to 2 g per day) of salicylates have a good therapeutic effect. Salicylates can be administered intravenously. Novocaine blockades in various modifications are also useful. Injections of hydrocortisone in an amount of 25-50 mg into paravertebral painful points have a good analgesic effect. Even more effective is the injection of the same amount of hydrocortisone into the damaged intervertebral disc.

Intradiscal administration of hydrocortisone (a solution of novocaine 0.5% with 25-50 mg of hydrocortisone) is carried out in the same way as discography is performed using the method proposed by de Seze. This manipulation requires a certain skill and ability. But even paravertebral administration of hydrocortisone gives a good therapeutic effect.

Of the physiotherapeutic procedures, diadynamic currents are the most effective. Popophoresis with novocaine and thermal procedures can be used. It should be borne in mind that thermal procedures often cause an exacerbation of pain, which apparently occurs due to an increase in local tissue swelling. If the victim's health worsens, they should be discontinued. After 10-12 days, in the absence of pronounced phenomena of irritation of the spinal roots, massage is very useful.

At a later date, such victims can be recommended balneotherapy (Pyatigorsk, Saki, Tskhaltubo, Belokurikha, Matsesta, Karachi). In some cases, wearing soft semi-corsets, corsets or “graces” can be useful.

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Surgical treatment of lumbar intervertebral disc injuries

Indications for surgical treatment of lumbar intervertebral disc injuries arise in cases where conservative treatment is ineffective. Typically, these indications occur in the long term after a previous injury and, in fact, the intervention is carried out regarding the consequences of the previous injury. Such indications are persistent lumbalgia, phenomena of functional failure of the spine, syndrome of chronic compression of the spinal roots, which is not inferior to conservative treatment. In case of fresh injuries to the intervertebral lumbar discs, indications for surgical treatment arise in the case of acutely developed cauda equina compression syndrome with paraparesis or paraplegia, and dysfunction of the pelvic organs.

The history of the emergence and development of surgical methods for treating damage to the lumbar intervertebral discs is essentially the history of surgical treatment of lumbar intervertebral osteochondrosis.

Surgical treatment of lumbar intervertebral osteochondrosis (“lumbosacral radiculitis”) was first carried out by Elsberg in 1916. Taking the prolapsed disc substance when it was damaged as interspinal tumors - “chondromas”, Elsberg, Petit, Qutailles, Alajuanine (1928) removed them. Mixter, Barr (1934), having proved that “chondromas” are nothing more than a prolapsed part of the nucleus pulposus of the intervertebral disc, performed a laminectomy and removed the prolapsed part of the intervertebral disc using trans- or extradural access.

Since then, especially abroad, methods of surgical treatment of lumbar intervertebral osteochondrosis have become widespread. Suffice it to say that individual authors have published hundreds and thousands of observations of patients operated on for lumbar intervertebral osteochondrosis.

Existing surgical methods for treating disc prolapse in intervertebral osteochondrosis can be divided into palliative, conditionally radical and radical.

Palliative surgeries for lumbar disc injuries

Such operations include the operation proposed by Love in 1939. Having undergone some changes and additions, it is widely used in the treatment of herniated lumbar intervertebral discs.

The purpose of this surgical intervention is only to remove the prolapsed part of the disc and eliminate compression of the nerve root.

The victim is placed on the operating table in the supine position. To eliminate lumbar lordosis, different authors use different techniques. B. Boychev suggests placing a pillow under the lower abdomen. A.I. Osna gives the patient the “pose of a praying Buddhist monk.” Both of these methods lead to a significant increase in intra-abdominal pressure, and consequently to venous stagnation, causing increased bleeding from the surgical wound. Friberg has designed a special “cradle” in which the victim is placed in the desired position without difficulty breathing or increasing intra-abdominal pressure.

Local anesthesia, spinal anesthesia and general anesthesia are recommended. Proponents of local anesthesia consider the advantage of this type of anesthesia to be the ability to control the progress of the operation by compressing the spinal root and the patient’s reaction to this compression.

Technique of surgery on the lower lumbar discs

A paravertebral semi-oval incision is used to dissect the skin, subcutaneous tissue, and superficial fascia layer by layer. The affected disc should be in the middle of the incision. On the affected side, the lumbar fascia is incised longitudinally at the edge of the supraspinatus ligament. The lateral surface of the spinous processes, semi-arches and articular processes is carefully skeletonized. All soft tissue must be carefully removed from them. A wide powerful hook is used to pull the soft tissues laterally. The semi-arches, the yellow ligaments and articular processes located between them, are exposed. A section of the ligamentum flavum is excised at the desired level. The dura mater is exposed. If this turns out to be insufficient, part of the adjacent sections of the semi-arches is bitten off or the adjacent semi-arches are removed completely. Hemilaminectomy is quite acceptable and justified to expand surgical access, but it is difficult to agree to a wide laminectomy with the removal of 3-5 arches. In addition to the fact that laminectomy significantly weakens the posterior spine, it is believed that it leads to limited movement and pain. Restriction of movement and pain are directly proportional to the size of the lamiectomy. Careful hemostasis is performed throughout the entire intervention. The dural sac is displaced medially. The spinal root is retracted to the side. The posterolateral surface of the affected intervertebral disc is examined. If the disc herniation is located posterior to the posterior longitudinal ligament, it is grasped with a spoon and removed. Otherwise, the posterior longitudinal ligament or the posteriorly protruding portion of the posterior portion of the annulus fibrosus is incised. After this, part of the fallen disc is removed. Produce hemostasis. Layer-by-layer sutures are applied to the wounds.

Some surgeons dissect the dura mater and use a transdural approach. The disadvantage of transdural access is the need for wider removal of the posterior parts of the vertebrae, opening of the posterior and anterior layers of the dura mater, and the possibility of subsequent intradural cicatricial processes.

If necessary, one or two articular processes can be bitten off, which makes surgical access wider. However, this violates the reliability of spinal stability at this level.

During the day the patient is in the prone position. Symptomatic drug treatment is carried out. From the 2nd day the patient is allowed to change position. On the 8-10th day he is discharged for outpatient treatment.

The described surgical intervention is purely palliative and eliminates only the compression of the spinal root by the prolapsed disc. This intervention is not aimed at curing the underlying disease, but only at eliminating the complications caused by it. Removing only part of the prolapsed affected disc does not exclude the possibility of relapse of the disease.

Conditionally radical surgery for damage to the lumbar discs

These operations are based on the proposal of Dandy (1942) not to limit oneself to removing only the prolapsed part of the disc, but to remove the entire affected disc using a sharp bone spoon. By doing this, the author tried to solve the problem of preventing relapses and creating conditions for the occurrence of fibrous ankylosis between adjacent bodies. However, this technique did not lead to the desired results. Relapse rates and adverse outcomes remained high. This depended on the failure of the proposed surgical intervention. The possibility of complete removal of the disc through a small hole in its fibrous ring is too difficult and problematic; fibrous ankylosis in this extremely mobile part of the spine is too unlikely. The main disadvantage of this intervention, in our opinion, is the impossibility of restoring the lost height of the intervertebral disc and normalizing the anatomical relationships in the posterior elements of the vertebrae, and the inability to achieve bone fusion between the vertebral bodies.

Attempts by some authors to “improve” this operation by introducing separate bone grafts into the defect between the vertebral bodies also did not lead to the desired result. Our experience in the surgical treatment of lumbar intervertebral osteochondrosis allows us to state with certain confidence that it is impossible to remove the endplates of the adjacent vertebral bodies with a bone spoon or curette so as to expose the spongy bone, without which we cannot count on the occurrence of bone fusion between the vertebral bodies. Naturally, placing individual bone grafts in an unprepared bed cannot lead to bone ankylosis. Inserting these grafts through a small hole is difficult and unsafe. This method does not solve the problems of restoring the height of the intervertebral space and restoring normal relationships in the posterior elements of the vertebrae.

Conditionally radical operations include attempts to combine disc removal with posterior spinal fusion (Ghormley, Love, Joung, Sicard, etc.). According to the intention of these authors, the number of unsatisfactory results in the surgical treatment of intervertebral osteochondrosis can be reduced by supplementing surgical intervention with posterior spinal fusion. In addition to the fact that in conditions of violation of the integrity of the posterior parts of the spine it is extremely difficult to obtain arthrodesis of the posterior parts of the spine, this combined surgical method of treatment is not able to resolve the issue of restoring the normal height of the intervertebral space and normalizing the anatomical relationships in the posterior parts of the vertebrae. However, this method was a significant step forward in the surgical treatment of lumbar intervertebral osteochondrosis. Despite the fact that it did not lead to a significant improvement in the results of surgical treatment of intervertebral osteochondrosis, it still made it possible to clearly understand that it is impossible to solve the issue of treating degenerative lesions of intervertebral discs with one “neurosurgical” approach.

Radical surgery for damaged lumbar discs

Radical intervention should be understood as a surgical procedure that solves all the main aspects of the pathology generated by damage to the intervertebral disc. These main points are the removal of the entire affected disc, the creation of conditions for the onset of bone fusion of the bodies of adjacent vertebrae, the restoration of the normal height of the intervertebral space and the normalization of the anatomical relationships in the posterior parts of the vertebrae.

Radical surgical interventions used in the treatment of injuries to the lumbar intervertebral discs are based on the operation of V.D. Chaklin, proposed by him in 1931 for the treatment of spondylolisthesis. The main points of this operation are exposure of the anterior parts of the spine from the anterior-external extraperitoneal approach, resection of 2/3 of the intervertebral articulation and placement of a bone graft into the resulting defect. Subsequent flexion of the spine helps to reduce lumbar lordosis and the onset of bone fusion between the bodies of adjacent vertebrae.

When applied to the treatment of intervertebral osteochondrosis, this intervention did not resolve the issue of removing the entire affected disc and normalizing the anatomical relationships of the posterior elements of the vertebrae. Wedge-shaped excision of the anterior sections of the intervertebral joint and placement of a bone graft of appropriate size and shape into the resulting wedge-shaped defect did not create conditions for restoring the normal height of the intervertebral space and the divergence along the length of the articular processes.

In 1958, Hensell reported on 23 patients with intervertebral lumbar osteochondrosis who were subjected to surgical treatment using the following technique. Position the patient on his back. A paramedial incision is used to dissect the skin, subcutaneous tissue, and superficial fascia layer by layer. The sheath of the rectus abdominis muscle is opened. The rectus abdominis muscle is pulled outward. The peritoneum is peeled away until the lower lumbar vertebrae and the intervertebral discs lying between them become accessible. The affected disc is removed through the area of the aortic bifurcation. A bone wedge measuring about 3 cm is taken from the crest of the iliac wing and inserted into the defect between the vertebral bodies. Care must be taken to ensure that the bone graft does not cause pressure on the roots and the dural sac. The author warns about the need to protect the vessels well at the time of insertion of the wedge. After the operation, a plaster corset is applied for 4 weeks.

The disadvantages of this method include the possibility of intervention only on the two lower lumbar vertebrae, the presence of large blood vessels limiting the surgical field on all sides, and the use of a wedge-shaped bone graft to fill the defect between the bodies of adjacent vertebrae.

Total discectomy and wedging corporodesis

This name refers to surgical intervention undertaken in case of damage to the lumbar intervertebral discs, during which the entire damaged intervertebral disc is removed, with the exception of the postero-outer sections of the fibrous ring, conditions are created for the onset of bone fusion between the bodies of adjacent vertebrae, the normal height of the intervertebral space is restored, and wedging occurs - reclination - of the inclinated articular processes.

It is known that with a loss of height of the intervertebral disc, a decrease in the vertical diameter of the intervertebral foramen occurs due to the inclination of the articular processes that inevitably follows. delimiting over a considerable distance the intervertebral foramina, in which the spinal roots and radicular vessels pass, and also the spinal ganglia lie. Therefore, during the surgical intervention, it is extremely important to restore the normal vertical diameter of the intervertebral spaces. Normalization of the anatomical relationships in the posterior sections of the two vertebrae is achieved by wedging.

Studies have shown that during the process of wedging corporodesis, the vertical diameter of the intervertebral foramina increases to 1 mm.

Preoperative preparation consists of the usual manipulations performed before intervention in the retroperitoneal space. In addition to general hygiene procedures, the intestines are thoroughly cleaned and the bladder is emptied. On the morning of the operation, the pubis and anterior abdominal wall are shaved. The night before surgery, the patient receives sleeping pills and sedatives. For patients with an unstable nervous system, drug preparation is carried out for several days before surgery.

Anesthesia - endotracheal anesthesia with controlled breathing. Muscle relaxation greatly facilitates the technical performance of the operation.

The victim is placed on his back. Using a cushion placed under the lower back, lumbar lordosis is strengthened. This should only be done when the victim is under anesthesia. With increased lumbar lordosis, the spine seems to approach the surface of the wound - its depth becomes smaller.

Technique of total discectomy and wedging corporodesis

The lumbar spine is exposed using the previously described left anterior paramedian extraperitoneal approach. Depending on the level of the affected disc, access without resection or with resection of one of the lower ribs is used. The approach to the intervertebral discs is carried out after mobilization of the vessels, dissection of the prevertebral fascia and displacement of the vessels to the right. Penetration to the lower lumbar discs through the area of division of the abdominal aorta seems to us more difficult, and most importantly, more dangerous. When using access through the aortic bifurcation, the surgical field is limited on all sides by large arterial and venous trunks. Only the lower valve of the limited space remains free of vessels, in which the surgeon has to manipulate. When manipulating discs, the surgeon must always ensure that the surgical instrument does not accidentally damage nearby vessels. When the vessels are displaced to the right, the entire anterior and left lateral sections of the discs and vertebral bodies are free from them. Only the lumboiliac muscle remains adjacent to the spine on the left. The surgeon can safely manipulate the instruments freely from right to left without any risk of damaging the blood vessels. Before proceeding with manipulations on the discs, it is advisable to isolate and shift the left border sympathetic trunk to the left. This significantly increases the space for manipulation on the disk. After dissection of the prevertebral fascia and displacement of the vessels to the right, the anterolateral surface of the lumbar vertebral bodies and discs, covered with the anterior longitudinal ligament, widely opens. Before you begin manipulating the disks, you should expose the desired disk quite widely. To perform a total discectomy, the entire length of the desired disc and adjacent parts of the adjacent vertebral bodies must be opened. So, for example, to remove the V lumbar disc, the upper part of the body of the I sacral vertebra, the V lumbar disc, and the lower part of the body of the V lumbar vertebra should be exposed. Displaced vessels must be reliably protected by elevators, protecting them from accidental injury.

The anterior longitudinal ligament is cut either in a U-shape or in the form of the letter H, located in a horizontal position. This is not of fundamental importance and does not affect the subsequent stability of this part of the spine, firstly, because in the area of the removed disc, bone fusion subsequently occurs between the bodies of adjacent vertebrae, and secondly, because in both In subsequent cases, the anterior longitudinal ligament at the site of the section is fused with a scar.

The dissected anterior longitudinal ligament is separated in the form of two lateral or one apron-shaped flaps on the right base and retracted to the sides. The anterior longitudinal ligament is separated so that the marginal limbus and the adjacent area of the vertebral body are exposed. The fibrous ring of the intervertebral disc is exposed. Affected discs have a peculiar appearance and differ from a healthy disc. They do not have their characteristic turgor and will not stand in the form of a characteristic cushion over the vertebral bodies. Instead of the silvery-white color of a normal disc, they become yellowish or ivory in color. To the untrained eye it may seem that the height of the disk is reduced. This false impression is created because the lumbar spine is overextended on the bolster, thereby artificially enhancing the lumbar lordosis. The stretched anterior sections of the annulus fibrosus create the false impression of a wide disc. The fibrous ring is separated from the anterior longitudinal ligament along the entire anterolateral surface. Using a wide chisel and a hammer, make the first section parallel to the end plate of the vertebral body adjacent to the disc. The width of the chisel should be such that the section passes through the entire width of the body, with the exception of the side compact plates. The chisel should penetrate to a depth of 2/3 of the anteroposterior diameter of the vertebral body, which corresponds on average to 2.5 cm. The second section is performed in the same way in the area of the second vertebral body adjacent to the disc. These parallel sections are made in such a way that, together with the removed disc, the end plates are separated and the cancellous bone of the adjacent vertebral bodies is exposed. If the chisel is installed incorrectly and the cutting plane in the vertebral body is not close to the endplate, venous bleeding may occur from the venous sinuses of the vertebral bodies.

Using a narrower chisel, two parallel sections are made along the edges of the first ones in a plane perpendicular to the first two sections. Using an osteotome inserted into one of the sections, the isolated disc is easily dislocated from its bed and removed. Usually, minor venous bleeding from its bed is stopped by tamponade with a gauze pad moistened with warm saline solution. Using bone spoons, the posterior portions of the disc are removed. After removal of the disc, the posterior portion of the annulus fibrosus becomes clearly visible. The “hernial orifice” is clearly visible, through which it is possible to extract the prolapsed part of the nucleus pulposus. Particular care should be taken to remove disc remnants in the area of the intervertebral foramina using a curved small bone spoon. Manipulations must be careful and gentle so as not to damage the roots passing here.

This ends the first stage of the operation - total discectomy. When comparing the disc masses removed using the anterior approach with the amount removed using the posteroexternal approach, it becomes quite obvious how palliative the operation performed through the posterior approach is.

The second, no less important and responsible moment of the operation is the “propping” corporodesis. The graft introduced into the resulting defect should promote the onset of bone fusion between the bodies of adjacent vertebrae, restore the normal height of the intervertebral space and wedge the posterior parts of the vertebrae so that the anatomical relationships in them are normalized. The anterior parts of the vertebral bodies should bend over the anterior edge of the graft placed between them. Then the posterior sections of the vertebrae - the arches and articular processes - will fan out. The disrupted normal anatomical relationships in the posterior-external intervertebral joints will be restored, and thanks to this, the intervertebral foramina, which have narrowed due to a decrease in the height of the affected disc, will somewhat expand.

Consequently, a graft placed between the bodies of adjacent vertebrae must meet two main requirements: it must facilitate the rapid advance of a bone block between the bodies of adjacent vertebrae and its anterior section must be so strong. to withstand the great pressure exerted on it by the bodies of the adjacent vertebrae during wedging.

Where to get this transplant from? If there is a well-defined, fairly massive crest of the iliac wing, the graft should be taken from the crest. You can take it from the upper metaphysis of the tibia. In this latter case, the anterior part of the graft will consist of strong cortical bone, the crest of the tibia and the cancellous bone of the metaphysis, which has good osteogenic properties. This is not of fundamental importance. It is important that the graft is taken correctly and is the correct size and shape. True, the structure of the graft from the iliac wing crest is closer to the structure of the vertebral bodies. The graft should have the following dimensions: the height of its anterior section should be 3-4 mm greater than the height of the intervertebral defect, the width of its anterior section should correspond to the width of the defect in the frontal plane, the length of the graft should be equal to 2/3 of the anteroposterior size of the defect. Its anterior section should be somewhat wider than the posterior one - it narrows somewhat posteriorly. In an intervertebral defect, the graft should be positioned so that its anterior edge does not extend beyond the anterior surface of the vertebral bodies. Its posterior edge should not contact the posterior portion of the annulus fibrosus of the disc. There should be some space between the posterior edge of the graft and the annulus fibrosus. This is necessary to prevent accidental compression of the anterior dural sac or spinal roots by the posterior edge of the graft.

Before placing the graft into the intervertebral defect, the height of the cushion under the lumbar spine is slightly increased. This further increases lordosis and the height of the intervertebral defect. The height of the roller should be increased carefully and in doses. The graft is placed into the intervertebral defect so that its anterior edge enters the defect 2-3 mm and a corresponding gap is formed between the anterior edge of the vertebral bodies and the anterior edge of the graft. The operating table roller is lowered to the level of the table plane. Eliminate lordosis. In the wound, you can clearly see how the vertebral bodies come together and the graft placed between them is well wedged. It is firmly and reliably held by the bodies of the closed vertebrae. Already at this moment, partial wedging of the posterior parts of the vertebrae occurs. Subsequently, when the patient is placed in a position of spinal flexion in the postoperative period, this wedging will increase even more. No additional grafts in the form of bone chips should be introduced into the defect because they can move posteriorly and subsequently, during bone formation, cause compression of the anterior part of the dural sac or roots. The graft should be formed like this. so that he fulfills the intervertebral defect within the specified boundaries.

Flaps of the separated anterior longitudinal ligament are placed over the graft. The edges of these flaps are sewn together. It should be borne in mind that more often these flaps fail to completely cover the area of the anterior part of the graft, since due to the restoration of the height of the intervertebral space, the size of these flaps is insufficient.

Careful hemostasis during surgery is absolutely mandatory. The wound of the anterior abdominal wall is sutured in layers. Antibiotics are administered. Apply an aseptic dressing. During the operation, blood loss is replaced; it is usually insignificant.

With proper administration of anesthesia, spontaneous breathing is restored by the end of the operation. Extubation is performed. When blood pressure is stable and blood loss is replaced, blood transfusion is stopped. Typically, neither during surgery nor in the postoperative period are there significant fluctuations in blood pressure.

The patient is placed in bed on a hard board in the supine position. The thighs and legs are bent at the hip and knee joints at an angle of 30° and 45°. To do this, place a high cushion under the area of the knee joints. This achieves some flexion of the lumbar spine and relaxation of the iliopsoas muscles and muscles of the limbs. The patient remains in this position for the first 6-8 days.

Symptomatic drug treatment is carried out. There may be a short-term urinary retention. To prevent intestinal paresis, a 10% solution of sodium chloride in an amount of 100 ml is administered intravenously, and a solution of proserin is administered subcutaneously. Treated with antibiotics. In the first days, an easily digestible diet is prescribed.

On the 7-8th day, the patient is seated in a bed equipped with special devices. The hammock in which the patient sits is made of dense material. The footrest and back rest are made of plastic. These devices are very convenient for the patient and hygienic. The flexion position of the lumbar spine further wedges the posterior sections of the vertebrae. The patient remains in this position for 4 months. After this period, a plaster corset is applied and the patient is discharged. After 4 months, the corset is removed. By this time, the presence of a bone block between the vertebral bodies is usually radiologically noted, and the treatment is considered complete.