What are degenerative diseases of the spine and how are they treated?
Among the patients seeking help from a neurologist, a large place is occupied by a group of patients with various forms of dorsopathies. Latin "dorsum" - back, ridge plus Greek "pato" - suffering, illness, that is, diseases of the spine.
Dorsopathies include manifestations of pathology of the spine at all its levels, from the cervical to the tailbone. Of these, much attention has recently been paid to the most common variant of dorsopathy - pain in the lower back.
The basis of this syndrome is recognized as pain localized between the 12 pair of ribs and the gluteal folds. According to the WHO experts, in developed countries, the prevalence of lower back pain due to degenerative spine disease reaches the size of a non-infectious epidemic.
Short information about degenerative diseases of the spinal cord
Causes of degenerative processes in the back
The main cause of back pain, in most cases, is recognized as degenerative-dystrophic changes in the spine - osteochondrosis and spondyloarthrosis, which are characterized primarily by manifestations of degeneration of intervertebral discs and joints with subsequent involvement in the process of ligaments, muscles, tendons and fascia, and later on spinal roots and spinal nerves.
The destruction of the cartilaginous tissue, which occurs during degenerative processes in the spine, is accompanied by pain syndrome. At the same time, over time, remitting pain syndrome can become chronic and, as a rule, leads to significant biomechanical disorders.
The anatomical complex, consisting of one intervertebral disc, two adjacent vertebrae attached to it, the ligamentous apparatus connecting them and the facet joints, is commonly referred to as the spinal motion segment.
The intervertebral disc consists of a gelatinous nucleus pulposus surrounded by a fibrous ring. The nucleus pulposus has an elliptical shape and consists of an amorphous hydrophilic intercellular substance and cartilage cells - chondrocytes. In newborns, the nucleus pulposus contains up to 88% of water, in an adult - about 70% which manifests in its lower elasticity.
In humans, the spinal column is under great stress. This is due to the fact that most of a person's life is in an upright position, and besides, they lift and carry weights. Particularly pronounced pressure falls on the lumbar (lower back) and cervical (neck) spine, which also have significant mobility.
In the 60s – 90s of the last century, spinal osteochondrosis was recognized as the main cause of pain in the spine and paravertebral (surrounding spine) tissues, as well as radicular syndromes.
The elastic properties of the intervertebral discs normally provide a significant softening of shocks and concussions that occur when walking, jumping and other movements. However, over the years the disc "wears out" and gradually loses its elasticity. This is facilitated by the obliteration of the vessels of the intervertebral disc in people over 20 years of age, after which the disc blood supply is subsequently carried out only due to diffusion from the vessels of the parenchyma of the attached vertebral bodies, while it may be insufficient to ensure regenerative processes in the disc. This leads to dehydration of the nucleus pulposus, a decrease in its turgor, which increases the load on the annulus fibrosus, gradually causes its stretching, the formation of cracks in it and eventually leads to bulging up of the disc tissue beyond the edges of the bodies, adjacent vertebrae. In this case, the next microtrauma or even insignificant additional load on the spinal motion segment may be accompanied by an increase in the severity of disc protrusion.
Intervertebral protrusion (bulging up) is accompanied by tension of the longitudinal ligament. Its stretching is accompanied by irritation and proliferation of the bone tissue of the marginal border of the vertebrae adjacent to the disc. As a result, there is a gradual ossification (hardening) of the ligament, which is manifested by the formation of anterior osteophytes (a bony projection) in the form of coracoid bone growths directed towards each other. This process is usually painless, since the anterior longitudinal ligament is poor in pain receptors. However, its increasing ossification over time increasingly limits the mobility of the spinal column.
The forward extension of the intervertebral hernia and the formation of the anterior coracoid osteophytes usually does not cause pain, while when the disc is displaced backward, the posterior longitudinal ligament rich in pain receptors is irritated, which leads to the onset of pain.
Pain is usually the first sign of spinal osteochondrosis, for which the patient seeks a doctor. At this stage, the examination of the patient reveals soreness of the spinous processes and paravertebral points at the level of discopathy, as well as tension ("defense") of the paravertebral muscles, leading to limitation of the mobility of the spine and to its straightening. All these clinical manifestations not only signal the pathological process, but also help to clarify its localization and nature.
Sometimes in patients with a herniated intervertebral disc during the next exacerbation of the disease, a vascular-radicular conflict occurs, leading to ischemia of the spinal nerve that has undergone compression, with the development of a decrease in sensitivity in the corresponding zone. If radicular artery involved in the blood supply to the spinal cord is affected, then a clinical picture of acute myeloischemia or chronic discirculatory myelopathy may occur, usually at the cervical or lumbosacral level, usually condemning the patient to disability.
For some time now, neurologists have begun to pay more and more attention to the fact that local back pain, radicular syndrome and vascular-radicular disorders can occur even in the absence of a hernia. In such cases, the main cause of local pain syndrome is often the development of deforming spondyloarthrosis, which is based on arthrosis of the intervertebral facet joints. It is believed that spondyloarthrosis is the main cause of pain in 20% of degenerative-dystrophic pathology of the spine, and in people over the age of 65 - in 65%.
Osteochondrosis and spondylosis deformans are provoked by identical factors, first of all, by physical overloads of the posterior parts of the spinal motion segment; at the same time, a possible cause of such an overload may be a disorder of the static spine. Deforming spondyloarthrosis, as a rule, is combined with osteochondrosis and often manifests itself already at an early stage of its development, and sometimes significantly outstrips the clinical manifestations of discopathy. Spondylosis, like osteochondrosis, often develops at the level of the cervical or lumbar spine.
With a degenerative-dystrophic process in the spine, biochemical changes that occur in the facet joint have much in common with similar changes in the intervertebral column caused by osteochondrosis. At the early stage of spondyloarthrosis, the cartilage thickens, and subsequently it becomes thinner, gradually the whole joint is involved in the process, including its synovial membrane, capsule, ligaments, as well as nearby muscles.
In the clinical picture of spondyloarthrosis, local pain and soreness, usually bilateral, mainly along the spine, accompanied by manifestations of muscle spasms at the level of the affected areas of the spine, can be leading for a long time. This syndrome is characterized by pronounced tension and soreness of certain muscle bundles and fascia, especially significant within the trigger zones, the irritation of which provokes pain reactions.
In most cases, the development of deforming spondyloarthrosis is accompanied by a feeling of awkwardness, discomfort in the spine, static disorder, and limited mobility. Characterized by a crunch that occurs when movements in the affected parts of the musculoskeletal system. Exacerbation of pain is often provoked by prolonged standing, as well as by an attempt to stretch the spine, especially if it is combined with its rotation. Changes in the position of the body in spondyloarthrosis can cause temporary dulling of pain, which sometimes prompts the patient to change posture frequently, thus seeking to reduce the feeling of discomfort and pain in the spine. In some cases, the pain subsides when bending forward and walking.
Diagnosis of degenerative diseases of the spine
Imaging methods of examination are very informative in the diagnosis of osteochondrosis and spondyloarthrosis. At the same time, CT you can show the intervertebral disc and the degree of its protrusion into the spinal canal. Especially clear are the results of MRI, which make it possible to judge not only the state of the vertebrae and IVD, but also their relation to other structures by the spinal motion segment, as well as to the spinal nerve roots, spinal nerves and to the dura mater.
Drug treatment of osteochondrosis and deforming spondyloarthrosis and their complications
In the treatment of degenerative spine diseases in the acute period, the main task is to relieve pain and restore the biomechanics of the spine. Carrying out such treatment allows preventing the development of the patient's fixation of the pathological motor stereotype and, if possible, to start rehabilitation measures earlier.
In the process of treating moderate pain syndrome, in most cases, you can use the proposed approximate algorithm:
- 1-2 days of treatment - strict bed rest, the use of analgesics (NSAIDs, such as Nimesulide), which should be administered hourly, without waiting for an aggravation of the severity of pain; the use of muscle relaxants (for example, Tizanidine) is also advisable;
- 2-10 days - semi-bed rest, pharmacotherapy is the same plus moderate exercise, physiotherapy;
- 10-20th days - active movement regimen, possibly with partial restrictions, analgesics - as needed, physiotherapy exercises, massage, in the absence of contraindications - elements of manual therapy;
- 20-40th day - active movement regimen, physiotherapy exercises, restorative physical exercises.
It should be borne in mind that prolonged bed rest can contribute to the transformation of acute pain syndrome into a chronic one, and also increases the likelihood of developing various psychoemotional disorders in the patient. Therefore, if the back pain is moderate and not associated with signs of damage to the spinal roots, radicular vessels and spinal nerve, there is no need to prolong strict bed rest in most cases. Treatment must be accompanied by an explanation to the patient of the essence of the disease and psychotherapeutic influences. The patient should be taught to move, while avoiding provocation of pain and a significant increase in the load on the spine.
Prevention of degenerative spine diseases
Degenerative spine diseases develop more often in individuals with a corresponding genetic predisposition. The development of osteochondrosis and spondyloarthrosis is facilitated by statodynamic overloads that occur not only during hard physical work, but also during prolonged stay in a non-physiological posture, leading to an uneven load on individual fragments of the spinal motion segment. At the same time, the degree of general physical development of a person is very significant, primarily the condition of the muscles of the back and abdomen, which make up the so-called "muscle corset". Muscle weakness as a result of a sedentary lifestyle, muscle detraining, overweight, poor development of the "muscle corset", contribute to the appearance in the spine of manifestations characteristic of osteochondrosis and spodilarthrosis.
In order to prevent premature degenerative-destructive changes in the spine, excessive statodynamic overloads should be avoided, at the same time, systematic, adequate physical activity (morning exercises, jogging, swimming, sports games, etc.) are indicated. At the same time, one must strive to ensure that food is sufficient, but not excessive. Particular attention should be paid to the design of the workplace (the height of the table, chair, workbench, etc.). When walking and during sedentary work, correct posture is required - you must constantly keep your back straight. In the case of work associated with a long stay in a fixed position, breaks are desirable, during which it is desirable to perform at least a few simple physical exercises.
Post by: Samuel Wrangler, M.D., Montgomery, Alabama