Lumbar intervertebral disc injuries: causes, symptoms, diagnosis, treatment

Damage to the lumbar and thoracic intervertebral discs is much more common than is commonly believed. It occurs as a result of indirect violence. The immediate cause of damage to the lumbar intervertebral discs is lifting heavy objects, forced rotational movements, flexion movements, sudden sharp straining and, finally, falling.

Damage to the thoracic intervertebral discs most often occurs with a direct blow or a blow 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 playing basketball.

Damage to intervertebral discs is almost never observed in childhood, but occurs in adolescence and youth, and is especially common in people in their 3rd and 4th decades of life. This is explained by the fact that isolated damage to the intervertebral disc often occurs 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 subject to degenerative processes. This is facilitated by the following 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 stress and is most often subject to injury.

The occurrence of degenerative processes in the 5th intervertebral disc is caused by the anatomical features of this intervertebral joint. These features consist of a discrepancy between the anteroposterior diameter of the bodies of the 5th lumbar and 1st 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 causes of degenerative processes in the 5th 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 posterolateral inclination.

The above-mentioned anatomical relationships between the articular processes of the 1 sacral vertebra, the 5 lumbar and the 1 sacral spinal roots can lead to direct or indirect compression of the said spinal roots. These spinal roots have a significant length in the spinal canal and are located in its lateral notches formed in front by the posterior surface of the 5 lumbar intervertebral disc and the body of the 5 lumbar vertebra, and behind - by the articular processes of the sacrum. Often, when degeneration of the 5 lumbar intervertebral disc occurs, due to the inclination of the articular processes, the body of the 5 lumbar vertebra not only descends downwards, but also shifts backwards. This inevitably leads to a narrowing of the lateral notches of the spinal canal. That is why a "disco-radicular conflict" often occurs in this area. Therefore, the most common symptoms of lumbosciatica are those involving the 5th lumbar and 1st sacral roots.

Ruptures of the lumbar intervertebral discs occur more often in men who engage in physical labor. They are especially common among athletes.

According to V. M. Ugryumov, ruptures of degenerated intervertebral lumbar discs occur in middle-aged and elderly people, starting from 30-35 years. According to our observations, these injuries also occur at a younger age - at 20-25 years, and in some cases even at 14-16 years.

Intervertebral discs: anatomical and physiological information

The intervertebral disc, located between two adjacent surfaces of the vertebral bodies, is a rather complex anatomical formation. This complex anatomical structure of the intervertebral disc is due to the unique set of functions it performs. The intervertebral disc has three main functions: the function of a strong connection and retention of adjacent vertebral bodies near each other, the function of a semi-joint, ensuring the mobility of the body of one vertebra in relation to the body of another, and, finally, the function of a shock absorber, protecting the vertebral bodies from constant trauma. The elasticity and resilience of the spine, its mobility and ability to withstand significant loads are mainly determined by the condition of the intervertebral disc. All of these functions can only be performed by a full-fledged, unchanged intervertebral disc.

The cranial and caudal surfaces of the bodies of two adjacent vertebrae are covered with cortical bone only in the peripheral sections, where the cortical bone forms a bone border - the limbus. The remaining surface of the vertebral bodies is covered with a layer of very dense, unique spongy bone, called the endplate of the vertebral body. The bone marginal border (limbus) rises above the endplate and frames it.

The intervertebral disc consists of two hyaline plates, a fibrous ring and a pulpous nucleus. Each of the hyaline plates is tightly adjacent to the endplate of the vertebral body, is equal to it in size and is inserted into it like a watch glass turned in the opposite direction, the rim of which is the limbus. The surface of the limbus is not covered with cartilage.

It is believed that the nucleus pulposus is a remnant of the embryo's spinal chord. The chord is partially reduced in the process of evolution, and partially transformed into the nucleus pulposus. Some argue that the nucleus pulposus of the intervertebral disc is not a remnant of the embryo's chord, but is a full-fledged functional structure that replaced the chord in the process of phylogenetic development of higher animals.

The nucleus pulposus is a gelatinous mass consisting of a small number of cartilaginous and connective tissue cells and fibrously intertwined swollen connective tissue fibers. The peripheral layers of these fibers form a kind of capsule that limits the gelatinous nucleus. This nucleus is enclosed in a kind of cavity containing a small amount of fluid resembling synovial fluid.

The fibrous ring consists of dense connective tissue bundles located around the gelatinous nucleus and intertwined in various directions. It contains a small amount of interstitial substance and single cartilaginous and connective tissue cells. The peripheral bundles of the fibrous ring are closely adjacent to each other and, like Sharpey's fibers, are introduced into the bone edge of the vertebral bodies. The fibers of the fibrous ring located closer to the center are more loosely arranged and gradually pass into the capsule of the gelatinous nucleus. The ventral - anterior part of the fibrous ring is stronger than the dorsal - posterior one.

According to Franceschini (1900), the fibrous ring of the intervertebral disc consists of collagen plates arranged concentrically and subject to significant structural changes during life. In a newborn, the collagen lamellar structure is weakly expressed. Up to 3-4 years of life in the thoracic and lumbar regions and up to 20 years in the cervical region, the collagen plates are arranged in the form of quadrangular formations surrounding the disc core. In the thoracic and lumbar regions from 3-4 years, and in the cervical region from 20 years, the transformation of primitive quadrangular collagen formations into elliptical ones occurs. Subsequently, by the age of 35, in the thoracic and lumbar regions, simultaneously with a decrease in the size of the disc core, the collagen plates gradually acquire a cushion-shaped configuration and play a significant role in the cushioning function of the disc. These three collagen structures, quadrangular - elliptical and cushion-shaped, replacing each other, are the result of mechanical action on the nucleus pulposus of the disc. Franceschini believes that the nucleus of the disc should be considered as a device designed to transform vertically acting forces into radial ones. These forces are of decisive importance in the formation of collagen structures.

It should be remembered that all elements of the intervertebral disc - the hyaline plates, the nucleus pulposus and the fibrous ring - are structurally closely related to each other.

As noted above, the intervertebral disc in collaboration with the posterolateral intervertebral joints participates in the movements performed by the spine. The total amplitude of movements in all segments of the spine is quite significant. As a result, the intervertebral disc is compared to a semi-joint (Luschka, Schmorl, Junghanns). The nucleus pulposus in this semi-joint corresponds to the articular cavity, the hyaline plates correspond to the articular ends, and the fibrous ring corresponds to the articular capsule. The nucleus pulposus occupies different positions in different parts of the spine: in the cervical spine it is located in the center of the disc, in the upper thoracic vertebrae - closer to the front, in all other parts - on the border of the middle and posterior thirds of the anteroposterior diameter of the disc. When the spine moves, the nucleus pulposus, which is capable of shifting to some extent, changes its shape and position.

The cervical and lumbar discs are higher in the ventral region, and the thoracic discs are higher in the dorsal region. This is apparently due to the presence of corresponding physiological curves of the spine. Various pathological processes leading to a decrease in the height of the intervertebral discs cause a change in the size and shape of these physiological curves of the spine.

Each intervertebral disc is somewhat wider than the corresponding vertebral body and protrudes forward and to the sides in the form of a ridge. The intervertebral disc is covered in front and on the sides by the anterior longitudinal ligament, which extends from the lower surface of the occipital bone along the entire anterolateral surface of the spine to the anterior surface of the sacrum, where it is lost in the pelvic fascia. The anterior longitudinal ligament is firmly fused with the vertebral bodies and freely throws over the intervertebral disc. In the cervical and lumbar - the most mobile parts of the spine, this ligament is somewhat narrower, and in the thoracic - it is wider and covers the anterior and lateral surfaces of the vertebral bodies.

The posterior surface of the intervertebral disc is covered by the posterior longitudinal ligament, which starts from the cerebral surface of the body of the occipital bone and runs along the entire length of the spinal canal to the sacrum inclusive. Unlike the anterior longitudinal ligament, the posterior longitudinal ligament does not have strong connections with the vertebral bodies, but is freely thrown over them, being firmly and intimately connected with the posterior surface of the intervertebral discs. The sections of the posterior longitudinal ligament passing through the vertebral bodies are narrower than the sections connected with the intervertebral discs. In the area of the discs, the posterior longitudinal ligament expands somewhat and is woven into the fibrous ring of the discs.

The gelatinous nucleus of the intervertebral disc, due to its turgor, exerts constant pressure on the hyaline plates of adjacent vertebrae, trying to move them apart. At the same time, the powerful ligamentous apparatus and the fibrous ring try to bring adjacent vertebrae closer together, counteracting the pulpous nucleus of the intervertebral disc. As a result, the size of each individual intervertebral disc and the entire spine as a whole is not a constant value, but depends on the dynamic balance of the oppositely directed forces of the pulpous nucleus and the ligamentous apparatus of two adjacent vertebrae. For example, after a night's rest, when the gelatinous nucleus acquires maximum turgor and largely overcomes the elastic traction of the ligaments, the height of the intervertebral disc increases and the vertebral bodies move apart. In contrast, by the end of the day, especially after a significant deadlift load on the spine, the height of the intervertebral disc decreases due to a decrease in the turgor of the pulpous nucleus. The bodies of adjacent vertebrae approach each other. Thus, during the day the length of the spinal column either increases or decreases. According to A. P. Nikolaev (1950), this daily fluctuation in the size of the spinal column reaches 2 cm. This also explains the decrease in height of elderly people. A decrease in the turgor of the intervertebral discs and a decrease in their height lead to a decrease in the length of the spinal column, and consequently to a decrease in human height.

According to modern concepts, the preservation of the nucleus pulposus depends on the degree of polymerization of mucopolysaccharides, in particular hyaluronic acid. Under the influence of certain factors, depolymerization of the main substance of the nucleus occurs. It loses its compactness, becomes denser, and fragments. This is the beginning of degenerative-dystrophic changes in the intervertebral disc. It has been established that in degenerative discs, there is a shift in the localization of neutral and pronounced depolymerization of acidic mucopolysaccharides. Consequently, subtle histochemical methods confirm the idea that degenerative-dystrophic processes in the intervertebral disc begin with subtle changes in the structure of the nucleus pulposus.

The intervertebral disc of an adult is in approximately the same conditions as articular cartilage. Due to the loss of its ability to regenerate, insufficient blood supply (Bohmig) and a large load on the intervertebral discs due to the vertical position of a person, aging processes develop in them quite early. The first signs of aging appear already at the age of up to 20 years in the area of thinned sections of the hyaline plates, where the hyaline cartilage is gradually replaced by connective tissue cartilage with its subsequent fraying. This leads to a decrease in the resistance of the hyaline plates. At the same time, the above-mentioned changes in the nucleus pulposus occur, leading to a decrease in its shock-absorbing effect. With age, all these phenomena progress. Dystrophic changes in the fibrous ring join in, accompanied by its ruptures even under normal loads. Gradually: degenerative changes in the intervertebral and costovertebral joints join in. Moderate osteoporosis of the vertebral bodies develops.

In pathological conditions, all the described processes in various elements of the intervertebral disc develop unevenly and even in isolation. They appear ahead of time. Unlike age-related changes, they already represent degenerative-dystrophic lesions of the spine.

According to the absolute majority of authors, degenerative-dystrophic lesions in the intervertebral disc occur as a result of chronic overload. At the same time, in a number of patients, these lesions are the result of individual acquired or constitutional inferiority of the spine, in which even the usual daily load turns out to be excessive.

A more in-depth study of the pathological morphology of degenerative processes in discs in recent years has not yet brought fundamentally new facts to the concept of degenerative processes described by Hildebrandt (1933). According to Hildebrandt, the essence of the ongoing pathological process is as follows. Degeneration of the nucleus pulposus begins with a decrease in its turgor, it becomes drier, fragments, and loses its elasticity. Biophysical and biochemical studies of the elastic function of discs have established that this involves the replacement of the collagen structure of the nucleus pulposus with fibrous tissue and a decrease in the content of polysaccharides. Long before the disintegration of the nucleus into separate formations, other elements of the intervertebral disc are involved in the process. Under the influence of pressure from adjacent vertebrae, the nucleus pulposus, which has lost its elasticity, flattens. The height of the intervertebral disc decreases. Parts of the disintegrated nucleus pulposus shift to the sides, they bend the fibers of the fibrous ring outward. The fibrous ring becomes frayed and torn. It has been found that with a vertical load on the disc, the pressure in the altered disc is significantly lower than in the normal one. At the same time, the fibrous ring of the degenerated disc experiences a load 4 times greater than the fibrous ring of the normal disc. The hyaline plates and adjacent surfaces of the vertebral bodies are subject to constant trauma. The hyaline cartilage is replaced by fibrous cartilage. Tears and cracks appear in the hyaline plates, and sometimes entire sections of them are rejected. Defects in the nucleus pulposus, hyaline plates and fibrous ring merge into cavities that cross the intervertebral disc in various directions.

Symptoms of Lumbar Disc Damage

Symptoms of damage to the lumbar intervertebral discs fit into various syndromes and can vary from minor, sudden pain in the lumbar region to the most severe picture of complete transverse compression of the elements of the equine tail with paraplegia and dysfunction of the pelvic organs, as well as a whole range of vegetative symptoms.

The main complaint of victims is sudden pain in the lumbar spine after lifting something heavy, making a sudden movement or, less frequently, falling. The victim cannot assume a natural position and is unable to make any movements in the lumbar spine. Scoliotic deformation often develops acutely. The slightest attempt to change position causes increased pain. These pains can be local, but can radiate along the spinal roots. In more severe cases, a picture of acute paraparesis can be observed, soon developing into paraplegia. Acute urinary retention and stool retention can occur.

An objective examination reveals a smoothed lumbar lordosis up to the formation of an angular kyphotic deformity, scoliosis, contracture of the lumbar muscles - the "reins" symptom; limitation of all types of movements, an attempt to reproduce which increases pain; pain when tapping on the spinous processes of the lower lumbar vertebrae, reflected sciatic pain when tapping on the spinous processes, soreness of the paravertebral points, soreness when palpating the anterior sections of the spine through the anterior abdominal wall; increased pain when coughing, sneezing, sudden laughter, straining, with compression of the jugular veins; inability to stand on toes.

Neurological symptoms of lumbar disc damage depend on the level of disc damage and the degree of involvement of the spinal cord elements. As noted above, disc ruptures with massive prolapse of its substance may cause monoparesis, paraparesis and even paraplegia, pelvic organ dysfunction. Expressed bilateral symptoms indicate the massiveness of the disc substance prolapse. With involvement of the fourth lumbar root, hypoesthesia or anesthesia can be detected in the buttock area, outer thigh, inner foot. If there is hypoesthesia or anesthesia on the dorsum of the foot, one should think about involvement of the fifth lumbar root. Prolapse or decreased superficial sensitivity on the outer surface of the shin, outer foot, in the area of the fourth and fifth toes suggests involvement of the first sacral segment. Positive symptoms for stretching are often observed (Kernig's, Lasegue's symptoms). A decrease in the Achilles and knee reflexes may be noted. In case of damage to the upper lumbar discs, which is observed much less frequently, there may be a decrease in strength or loss of function of the quadriceps muscle of the thigh, and disturbances of sensitivity on the anterior and inner surface of the thigh.

Diagnosis of lumbar disc damage

The X-ray method of examination is of great importance in recognizing damage to intervertebral discs. X-ray symptomatology of damage to lumbar intervertebral discs is actually X-ray symptomatology of lumbar intervertebral osteochondrosis.

In the first stage of intervertebral osteochondrosis ('chondrosis' according to Schmorl), the earliest and most typical X-ray symptom is a decrease in the height of the intervertebral disc. At first, it may be extremely insignificant and is detected only by comparative comparison with adjacent discs. It should be remembered that the most powerful, the 'highest' disc is normally the IV intervertebral disc. At the same time, a straightening of the lumbar spine is detected - the so-called 'string' or 'candle' symptom, described by Guntz in 1934.

During this period, the so-called X-ray functional tests are of great diagnostic importance. The functional X-ray test consists of the following. X-rays are taken in two extreme positions - in the position of maximum flexion and maximum extension. With a normal, unchanged disc, with maximum flexion, the height of the disc decreases in the front, with maximum extension - in the back. The absence of these symptoms indicates the presence of osteochondrosis - it indicates the loss of the cushioning function of the disc, a decrease in turgor and elasticity of the nucleus pulposus. At the moment of extension, there may be a posterior displacement of the body of the overlying vertebra. This indicates a decrease in the function of holding one vertebral body relative to another by the disc. The posterior displacement of the body should be determined by the posterior contours of the vertebral body.

In some cases, high-quality X-rays and tomograms may reveal a disc prolapse.

The "spacer" symptom may also be observed, consisting of an uneven disc height on the anteroposterior radiograph. This unevenness consists of the presence of a wedge-shaped deformation of the disc - at one edge of the vertebral bodies, the intervertebral space is wider and gradually narrows in a wedge-shaped manner towards the other edge of the bodies.

With a more pronounced radiographic picture (Schmorl's "osteochondrosis"), sclerosis of the endplates of the vertebral bodies is observed. The appearance of sclerosis zones should be explained by reactive and compensatory phenomena on the part of the corresponding surfaces of the vertebral bodies, arising as a result of the loss of the shock-absorbing function of the intervertebral disc. As a result, the surfaces of two adjacent vertebrae facing each other are subject to systematic and constant trauma. Marginal growths appear. Unlike marginal growths in spondylosis, marginal growths in intervertebral osteochondrosis are always located perpendicular to the long axis of the spine, originate from the limbus of the vertebral bodies, can occur in any part of the limbus, including the back, never merge with each other and occur against the background of a decrease in the height of the disc. Retrograde stepped spondylolisthesis is often observed.

Vollniar (1957) described the "vacuum phenomenon" - an X-ray symptom that, in his opinion, characterizes degenerative-dystrophic changes in the lumbar intervertebral discs. This "vacuum phenomenon" consists of the fact that at the anterior edge of one of the lumbar vertebrae, a slit-shaped clearing the size of a pinhead is determined on the X-ray image.

Contrast spondylography. Contrast X-ray examination methods include pneumomyelography and discography. These examination methods may be useful when clinical and conventional X-ray data do not provide an accurate idea of the presence or absence of disc damage. Discography is more important in the case of fresh intervertebral disc damage.

Discography in the cases shown provides a number of useful data that complement clinical diagnostics. Disc puncture allows us to specify the capacity of the disc cavity, to induce pain that reproduces the increased pain attack usually experienced by the patient, and, finally, to obtain a contrast discogram.

Puncture of the lower lumbar discs is performed transdurally, according to the technique proposed by Lindblom (1948-1951). The patient is seated or laid in a position with the greatest possible correction of lumbar lordosis. The patient's back is arched. If the disc is punctured in a sitting position, the forearms bent at the elbows rest on the knees. The interspinous spaces are carefully determined and marked with a solution of methylene blue or brilliant green. The surgical field is treated twice with 5% iodine tincture. Then the iodine is removed with an alcohol napkin. The skin, subcutaneous tissue, and interspinous space are anesthetized with a 0.25% solution of novocaine. A needle with a stylet for spinal puncture is inserted as for a spinal puncture. The needle passes through the skin, subcutaneous tissue, superficial fascia, supraspinous and interspinous ligaments, posterior epidural tissue and posterior wall of the dural sac. The mandrin is removed. Liquorodynamic tests are performed, cerebrospinal fluid pressure is determined. Cerebrospinal fluid is taken for examination. The mandrin is reinserted. The needle is advanced forward. The direction of the needle is changed based on the patient's sensations. If the needle comes into contact with elements of the equine tail, the patient complains of pain. If pain is felt in the right leg, the needle should be pulled back slightly and passed to the left, and vice versa. The anterior wall of the dural sac, anterior epidural tissue, posterior longitudinal ligament, posterior part of the fibrous ring of the intervertebral disc are pierced. The needle falls into the cavity. The passage of the posterior longitudinal ligament is determined by the patient's reaction - complaints of pain along the spine all the way to the back of the head. The passage of the fibrous ring is determined by the resistance of the needle. During the disc puncture, one should be guided by the profile spondylogram, which helps to navigate in choosing the right direction for the needle.

The capacity of the disc is determined by introducing a physiological solution of table salt into the disc cavity through a needle using a syringe. A normal disc allows 0.5-0.75 ml of liquid to be introduced into its cavity. A larger amount indicates a degenerative change in the disc. If there are cracks and ruptures in the fibrous ring, the amount of possible fluid to be introduced is very large, since it flows into the epidural space and spreads in it. The amount of fluid introduced can be used to roughly judge the degree of disc degeneration.

The reproduction of the provoked pains is carried out by a somewhat excessive introduction of the solution. By increasing the intradiscal pressure, the introduced solution intensifies or causes compression of the root or ligaments and reproduces more intense pains characteristic of the given patient. These pains are sometimes quite significant - the patient suddenly cries out from pain. Questioning the patient about the nature of the pain allows us to resolve the issue of the correspondence of the given disk to the cause of the patient's suffering.

Contrast discography is performed by injecting a solution of cardiotrast or hepaque through the same needle. If the contrast agent flows freely, do not inject more than 2-3 ml. Similar manipulations are repeated on all questionable discs. The most difficult to puncture is the V disc, located between the V lumbar and I sacral vertebrae. This is explained by the fact that the bodies of these vertebrae are located at an angle open to the front, due to which the space between them is significantly narrowed at the back. Usually, more time is spent on the puncture of the V disc than on the puncture of the upper ones.

It should be borne in mind that radiography is performed no later than 15-20 minutes after the introduction of the contrast agent. Contrast discography will not work after a later period, since the cardiotrast will dissolve. Therefore, we recommend that you first puncture all the necessary discs, determine their capacity and the nature of the pain caused. The needle is left in the disc and a mandrin is inserted into it. Only after the needles have been inserted into all the necessary discs should the contrast agent be quickly injected and discography performed immediately. Only in this case will good quality discograms be obtained.

Only the three lower lumbar discs can be punctured transdurally. The spinal cord is located above, which excludes transdural puncture of the second and first lumbar discs. If it is necessary to puncture these discs, the epidural approach proposed by Erlacher should be used. The needle is inserted 1.5-2 cm outward from the spinous process on the healthy side. It is directed upward and outward from the postero-external intervertebral joint into the intervertebral foramen and inserted into the disc through the space between the root and the dural sac. This method of disc puncture is more complex and requires skill.

Finally, the disc can be punctured using the external approach suggested by de Seze. To do this, an 18-20 cm long needle is inserted 8 cm outward from the spinous process and directed inward and upward at an angle of 45°. At a depth of 5-8 cm, it rests against the transverse process. It is bypassed from above and the needle is advanced deeper toward the midline. At a depth of 8-12 cm, its tip rests against the lateral surface of the vertebral body. Using radiography, the position of the needle is checked and corrections are made until the needle enters the disc. The method also requires certain skills and takes more time.

There is another option to perform disc puncture during surgery. Since the intervention is performed under anesthesia, in this case it is only possible to determine the capacity of the disc cavity and perform contrast discography.

The character of the discogram depends on the changes in the disc. A normal discogram appears as a round, square, oval slit-like shadow located in the middle (anteroposterior projection). On a profile discogram, this shadow is located closer to the back, approximately at the border of the posterior and middle third of the anteroposterior diameter of the disc. In case of damage to the intervertebral discs, the character of the discogram changes. The contrast shadow in the area of the intervertebral space can take the most bizarre forms, up to the point of contrast exiting into the anterior or posterior longitudinal ligaments, depending on where the rupture of the fibrous ring occurred.

We resort to discography relatively rarely because more often than not, based on clinical and radiological data, it is possible to make a correct clinical and topical diagnosis.

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Conservative treatment of lumbar intervertebral disc injuries

In the vast majority of cases, damage to the lumbar intervertebral discs is treated with conservative methods. Conservative treatment of damage to the lumbar discs should be comprehensive. This complex includes orthopedic, medicinal and physiotherapeutic treatment. Orthopedic methods include creating rest and unloading the spine.

A victim with a lumbar intervertebral disc injury is placed in bed. It is a mistaken idea that the victim should be placed on a hard bed in a supine position. In many victims, such a forced position causes increased pain. On the contrary, in some cases, pain is reduced or eliminated when the victim is placed in a soft bed that allows significant flexion of the spine. Often, pain disappears or is reduced in a side position with the hips drawn up to the stomach. Therefore, in bed, the victim should assume a position in which the pain disappears or is reduced.

Unloading of the spine is achieved by the horizontal position of the victim. After some time, after the acute effects of the previous injury have passed, this unloading can be supplemented by constant stretching of the spine on an inclined plane using soft rings for the armpits. To increase the stretching force, additional weights can be used, suspended from the victim's pelvis using a special belt. The size of the weights, the 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, pain disappears, the rupture in the area of the fibrous ring heals with a strong scar. In later periods after the previous injury, with a more persistent pain syndrome, and sometimes in fresh cases, intermittent stretching of the spine is more effective than constant traction.

There are several different methods of intermittent spinal stretching. Their essence is that during a relatively short period of 15-20 minutes, using weights or a dosed screw traction, the stretching is brought 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 stretching lasts for 30-40 minutes, and then over the next 15-20 minutes it is gradually reduced to no.

Spinal traction using a dosed screw traction is performed 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, which is 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 by the pelvic belt and a bra on the chest.

Underwater stretching of the spine in a pool is very useful and effective. This method requires special equipment and gear.

Drug treatment of lumbar disc damage involves oral administration of medications or their local application. In the first hours and days after the injury, with severe pain syndrome, 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 can also be useful. A good analgesic effect is provided by injections of hydrocortisone in the amount of 25-50 mg into paravertebral painful points. Even more effective is the introduction of the same amount of hydrocortisone into the damaged intervertebral disc.

Intradiscal injection of hydrocortisone (0.5% novocaine solution with 25-50 mg hydrocortisone) is performed similarly to discography using the method proposed by de Seze. This manipulation requires a certain skill and ability. But even paravertebral injection 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 edema. If the patient's condition worsens, they should be discontinued. After 10-12 days, if there are no pronounced symptoms of irritation of the spinal roots, massage is very useful.

At a later stage, balneotherapy can be recommended to such victims (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 occur in cases where conservative treatment is ineffective. Usually, these indications occur at a late stage after the previous injury, and in fact, the intervention is performed due to the consequences of the previous injury. Such indications include persistent lumbalgia, functional insufficiency of the spine, chronic spinal root compression syndrome that is not inferior to conservative treatment. In case of fresh injuries of the lumbar intervertebral discs, indications for surgical treatment occur in case of acutely developed equine cauda compression syndrome with paraparesis or paraplegia, pelvic organ dysfunction.

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

Surgical treatment of lumbar intervertebral osteochondrosis ("lumbosacral radiculitis") was first performed by Elsberg in 1916. Taking the prolapsed disc material during its damage for interspinal tumors - "chondromas", Elsberg, Petit, Qutailles, Alajuanine (1928) removed them. Mixter, Barr (1934), having proven 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 by trans- or extradural access.

Since then, especially abroad, methods of surgical treatment of lumbar intervertebral osteochondrosis have become widely used. 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 surgery for lumbar disc damage

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 a 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 congestion, causing increased bleeding from the surgical wound. Friberg designed a special "cradle" in which the victim is placed in the desired position without difficulty breathing and increased intra-abdominal pressure.

Local anesthesia, spinal anesthesia, and general anesthesia are recommended. Supporters of local anesthesia consider the advantage of this type of anesthesia to be the ability to control the course of the operation by squeezing the spinal root and the patient's reaction to this compression.

Technique of surgery on lower lumbar discs

The skin, subcutaneous tissue, and superficial fascia are dissected layer by layer with a paravertebral semi-oval incision. The affected disc should be in the middle of the incision. On the affected side, the lumbar fascia is dissected 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 tissues should be removed from them most carefully. The soft tissues are pulled laterally with a wide, powerful hook. The semi-arches, yellow ligaments, and articular processes located between them are exposed. A section of the yellow ligament is excised at the required level. The dura mater is exposed. If this is 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 for expanding 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, there is an opinion that it leads to limited movement and pain. Limited movement and pain are directly proportional to the size of the laminectomy. Careful hemostasis is performed throughout the intervention. The dural sac is displaced inward. The spinal root is moved aside. 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 section of the posterior fibrous ring are dissected. After this, part of the prolapsed disc is removed. Hemostasis is performed. Layered sutures are applied to the wounds.

Some surgeons perform a dissection of the dura mater and use a transdural approach. The disadvantage of the transdural approach is the need for a wider removal of the posterior parts of the vertebrae, opening 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 beveled, which makes the surgical access wider. However, this compromises the reliability of the stability of the spine 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 complication it causes. Removing only part of the prolapsed affected disc does not exclude the possibility of relapse of the disease.

Conditionally radical operations for damage to lumbar discs

These operations are based on Dandy's (1942) proposal not to limit the removal of only the prolapsed part of the disc, but to remove the entire affected disc using a sharp bone spoon. In this way, the author attempted to solve the problem of preventing relapses and creating conditions for the development of fibrous ankylosis between adjacent bodies. However, this method did not lead to the desired results. The number of relapses and unfavorable outcomes remained high. This depended on the failure of the proposed surgical intervention. The possibility of complete removal of the disc through a small opening in its fibrous ring is too difficult and problematic, the viability of fibrous ankylosis in this extremely mobile section 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, the impossibility of achieving bone fusion between the vertebral bodies.

Attempts by some authors to "improve" this operation by introducing individual bone grafts into the defect between the vertebral bodies have also failed to produce the desired result. Our experience in surgical treatment of lumbar intervertebral osteochondrosis allows us to state with some confidence that it is impossible to remove the endplates of adjacent vertebral bodies with a bone spoon or curette to the extent of exposing the spongy bone, without which it is impossible to expect bone fusion between the vertebral bodies. Naturally, placing individual bone grafts into an unprepared bed cannot lead to bone ankylosis. The introduction of these grafts through a small opening 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 also include attempts to combine disc removal with posterior spondylodesis (Ghormley, Love, Joung, Sicard, etc.). According to the authors, the number of unsatisfactory results in surgical treatment of intervertebral osteochondrosis can be reduced by adding posterior spondylodesis to surgical intervention. In addition to the fact that in conditions of impaired integrity of the posterior spine, it is extremely difficult to obtain arthrodesis of the posterior spine, this combined surgical method of treatment is unable to resolve the issue of restoring the normal height of the intervertebral space and normalizing the anatomical relationships in the posterior 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 imagine that it is impossible to resolve the issue of treating degenerative lesions of the intervertebral discs with one "neurosurgical" approach.

[ 9 ], [ 10 ], [ 11 ]

Radical operations for damage to lumbar discs

Radical intervention should be understood as a surgical intervention that resolves all the main aspects of pathology caused by damage to the intervertebral disc. These main aspects 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 anatomical relationships in the posterior sections of the vertebrae.

The basis of radical surgical interventions used in the treatment of lumbar intervertebral disc injuries is the operation of V. D. Chaklin, proposed by him in 1931 for the treatment of spondylolisthesis. The main points of this operation are the exposure of the anterior sections of the spine from the anterior-external extraperitoneal approach, resection of 2/3 of the intervertebral joint 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.

In relation 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 the 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 surgically treated using the following technique. The patient is positioned supine. The skin, subcutaneous tissue, and superficial fascia are dissected layer by layer using a paramedian incision. The sheath of the rectus abdominis muscle is opened. The rectus abdominis muscle is pulled outward. The peritoneum is peeled back until the lower lumbar vertebrae and the intervertebral discs between them become accessible. The affected disc is removed through the aortic bifurcation area. A bone wedge approximately 3 cm in size is taken from the iliac crest 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 dural sac. The author warns of the need to properly protect the vessels when inserting the wedge. A plaster corset is applied for 4 weeks after the operation.

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 a surgical intervention undertaken in cases of damage to the lumbar intervertebral discs, during which the entire damaged intervertebral disc is removed, with the exception of the posterior-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 - reclination - of the inclinated articular processes occurs.

It is known that when the intervertebral disc loses height, the vertical diameter of the intervertebral openings decreases due to the inevitable subsequent inclination of the articular processes. They delimit the intervertebral openings over a considerable distance, in which the spinal roots and radicular vessels pass, and in which the spinal ganglia are located. Therefore, in the process of the undertaken 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 two vertebrae is achieved by wedging.

Studies have shown that during the process of wedging corporodesis, the vertical diameter of the intervertebral openings 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. The morning before the operation, the pubis and the anterior abdominal wall are shaved. The night before the operation, the patient receives sleeping pills and sedatives. Patients with an unstable nervous system undergo drug preparation for several days before the operation.

Anesthesia - endotracheal anesthesia with controlled breathing. Relaxation of muscles significantly facilitates the technical performance of the operation.

The victim is placed on his back. Using a cushion placed under the lower back, the lumbar lordosis is increased. 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 fusion

The lumbar spine is exposed using the previously described anterior left-sided paramedian extraperitoneal approach. Depending on the level of the affected disc, an approach 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 of 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 the approach through the bifurcation of the aorta, the surgical field is limited on all sides by large arterial and venous trunks. Only the lower tap of the limited space remains free of vessels, in which the surgeon has to manipulate. When manipulating the discs, the surgeon must always ensure that the surgical instrument does not accidentally damage the nearby vessels. When displacing the vessels to the right, the entire anterior and left lateral section of the discs and vertebral bodies is free of them. Only the iliopsoas muscle remains adjacent to the spine on the left. The surgeon can safely manipulate the instruments 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 scope for manipulations on the disc. After dissecting the prevertebral fascia and shifting the vessels to the right, the anterolateral surface of the bodies of the lumbar vertebrae and discs, covered by the anterior longitudinal ligament, is widely exposed. Before proceeding with manipulations on the discs, the desired disc should be exposed sufficiently widely. To perform a total discectomy, the desired disc and adjacent parts of the bodies of the adjacent vertebrae should be exposed along their entire length. For example, to remove the 5th lumbar disc, the upper part of the body of the 1st sacral vertebra, the 5th lumbar disc, and the lower part of the body of the 5th lumbar vertebra should be exposed. Displaced vessels must be reliably protected by elevators to protect them from accidental injury.

The anterior longitudinal ligament is dissected 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 section of the spine, firstly, because in the area of the removed disk, bone fusion subsequently occurs between the bodies of adjacent vertebrae, and secondly, because in both cases, the anterior longitudinal ligament subsequently grows together with a scar at the site of the section.

The dissected anterior longitudinal ligament is separated in the form of two lateral or one apron-shaped flap on the right base and moved to the sides. The anterior longitudinal ligament is separated so that the marginal limbus and the adjacent part 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 usual turgor and do not stand out in the form of a characteristic ridge above the vertebral bodies. Instead of the silvery-white color characteristic of a normal disc, they acquire a yellowish or ivory color. To the untrained eye, it may seem that the height of the disc is reduced. This false impression is created because the lumbar spine is hyperextended on the ridge, which artificially increases the lumbar lordosis. The stretched anterior sections of the fibrous ring 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, the first section is made parallel to the endplate of the vertebral body adjacent to the disc. The chisel width should be such that the section passes through the entire width of the body, with the exception of the lateral compact plates. The chisel should penetrate to a depth of 2/3 of the anteroposterior diameter of the vertebral body, which on average corresponds to 2.5 cm. The second section is made 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 the endplates are separated along with the disc being removed and the spongy bone of the adjacent vertebral bodies is exposed. If the chisel is positioned incorrectly and the section plane in the vertebral body does not pass near the endplate, venous bleeding from the venous sinuses of the vertebral bodies may occur.

A narrower chisel is used to make two parallel sections along the edges of the first 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 napkin moistened with a warm physiological solution of table salt. The posterior sections of the disc are removed using bone spoons. After removing the disc, the posterior section of the fibrous ring becomes clearly visible. The "hernial orifice" is clearly visible, through which it is possible to extract the fallen part of the nucleus pulposus. The remains of the disc in the area of the intervertebral openings should be removed especially carefully using a small curved bone spoon. Manipulations should be careful and gentle so as not to damage the roots passing through here.

This completes the first stage of the operation - total discectomy. When comparing the masses of the disc removed using the anterior approach with the amount removed from the postero-external 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 "wedge" corporodesis. The transplant introduced into the resulting defect should promote bone fusion between the bodies of adjacent vertebrae, restore the normal height of the intervertebral space and wedge the posterior sections of the vertebrae so that the anatomical relationships in them are normalized. The anterior sections of the vertebral bodies should bend over the anterior edge of the transplant placed between them. Then the posterior sections of the vertebrae - the arches and articular processes - will fan out. The disturbed normal anatomical relationships in the postero-external intervertebral joints will be restored, and due to this, the intervertebral openings, narrowed due to the decrease in the height of the affected disc, will somewhat widen.

Therefore, the transplant placed between the bodies of adjacent vertebrae must meet two basic requirements: it must facilitate the fastest possible onset of a bone block between the bodies of adjacent vertebrae, and its anterior section must be strong enough to withstand the great pressure exerted on it by the bodies of adjacent vertebrae during wedging.

Where should this transplant be taken from? If the iliac wing crest is well-defined and quite massive, the transplant should be taken from the crest. It can be taken from the upper metaphysis of the tibia. In the latter case, the anterior section of the transplant will consist of strong cortical bone, the crest of the tibia, and the spongy bone of the metaphysis, which has good osteogenic properties. This is not of fundamental importance. It is important that the transplant is taken correctly and corresponds to the required size and shape. True, in terms of structure, a transplant from the iliac wing crest is closer to the structure of the vertebral bodies. The transplant 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 transplant should be equal to 2/3 of the anterior-posterior size of the defect. Its anterior part should be somewhat wider than the posterior part - it narrows somewhat towards the back. In the 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 part of the fibrous ring of the disc. There should be some space between the posterior edge of the graft and the fibrous ring of the disc. This is necessary to prevent accidental compression of the anterior part of the dural sac or spinal roots by the posterior edge of the graft.

Before placing the transplant in the intervertebral defect, the height of the cushion under the lumbar spine is slightly increased. This further increases the lordosis and the height of the intervertebral defect. The height of the cushion should be increased carefully, in doses. The transplant is placed in the intervertebral defect so that its anterior edge enters the defect by 2-3 mm and a corresponding gap is formed between the anterior edge of the vertebral bodies and the anterior edge of the transplant. The cushion of the operating table is lowered to the level of the table plane. Lordosis is eliminated. It is clearly visible in the wound how the vertebral bodies are brought together and the transplant, placed between them, is well wedged. It is firmly and securely held by the bodies of the closed vertebrae. Already at this point, partial wedging of the posterior sections of the vertebrae occurs. Subsequently, when the patient is given 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 may shift posteriorly and subsequently, during bone formation, cause compression of the anterior part of the dural sac or roots. The graft should be formed so that it fills the intervertebral defect within the specified boundaries.

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

Careful hemostasis during the operation is absolutely necessary. The wound of the anterior abdominal wall is sutured layer by layer. Antibiotics are administered. An aseptic bandage is applied. During the operation, blood loss is replenished, it is usually insignificant.

With proper anesthesia, spontaneous breathing is restored by the end of the operation. Extubation is performed. When arterial pressure is stable and blood loss is replenished, blood transfusion is stopped. Usually, there are no significant fluctuations in arterial pressure either during the surgical intervention or in the postoperative period.

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

Symptomatic drug treatment is administered. Short-term urinary retention may be observed. To prevent intestinal paresis, 100 ml of 10% sodium chloride solution is administered intravenously, and proserin solution is administered subcutaneously. Antibiotic treatment is administered. An easily digestible diet is prescribed in the first few days.

On the 7th-8th day, the patient is placed in a bed equipped with special devices. The hammock in which the patient sits is made of thick material. The footrest and backrest are made of plastic. These devices are very comfortable for the patient and hygienic. The lumbar spine flexion position 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 noted radiographically, and the treatment is considered complete.