Osteochondrosis is a chronic degenerative-dystrophic disease that develops under the influence of many rather disparate factors. Initially, pathological changes occur in the nucleus pulposus (the internal contents of the intervertebral disc), and subsequently they spread to the fibrous ring (the outer shell of the disc) and other elements of the spinal motion segment (SDS). This may be a consequence of the natural aging process of the body, or it may occur against the background of injuries, increased loads on the spinal column, and other causes. In any case, osteochondrosis is only the first stage of the destruction of the intervertebral disc, and if it is not treated, protrusions and hernias form, which often require surgical removal.
The intervertebral disc is a cartilage formation that separates the vertebral bodies and acts as a shock absorber.
Osteochondrosis of the lumbar: what is it
From osteochondrosis suffers from 48 to 52% of people. And osteochondrosis of the lumbar spine is most common. The disease can affect any of the intervertebral discs of the lumbosacral spine, several of them, or even all. Most often, the disks L5-S1, L4-L5 suffer, less often L3-L4. The upper lumbar discs (L3-L2 and L2-L1) are affected much less frequently.
The prevalence of lumbar osteochondrosis is due to the fact that the greatest load in the performance of any physical work, especially lifting and carrying weights, walking, running, sitting falls on the lower back. The lumbar spine consists of 5 vertebrae, which are much larger than the thoracic and cervical vertebrae. Accordingly, the intervertebral discs separating them are larger in size. Normally, the lumbar region has a slight anterior curvature (physiological lordosis). It is the last mobile part of the spine and is adjacent to the fixed sacrum, so most often they talk about lumbosacral osteochondrosis.
If previously osteochondrosis was considered an age-related disease, today its first manifestations can already be observed at the age of 15-19. Among thirty-year-olds, already 1. 1% of people suffer from severe symptoms of degenerative-dystrophic changes in the intervertebral discs. And in representatives of the older age group (from 59 years old), clinical manifestations of the disease are already present in 82. 5%. At the same time, the incidence of pathology continues to grow steadily, which is largely due not only to an increase in the average age of the country's population, but also to lifestyle changes that are not for the better.
Reasons for development
Today, there is still no consensus on the etiology of degenerative diseases of the spine. Nevertheless, the main theory of their development is involutive. According to her, osteochondrosis is a consequence of previous damage to the intervertebral disc and bone structures of the spine, as well as the occurrence of inflammatory and other processes. The theory suggests that degenerative changes are genetically predetermined and, in fact, are inevitable. And their clinical manifestation, especially in young and middle-aged people, is due to the influence of various endogenous and exogenous factors.
Thus, the development of osteochondrosis of the lumbar spine is facilitated by:
- heavy physical labor, especially associated with heavy lifting;
- sedentary, sedentary lifestyle;
- any back injury, including bruises;
- overweight;
- metabolic disorders;
- violations of posture, deformation of the spinal column;
- flat feet and other foot pathologies;
- pregnancy, especially multiple pregnancy.
Pathogenesis
Regardless of the causes, degeneration of the intervertebral disc occurs when the intensity of catabolism processes (cleavage and oxidation of molecules) of matrix proteins begins to exceed the rate of their formation. One of the key points in this process is the malnutrition of the intervertebral discs.
Since they, like most cartilage in an adult, do not have a direct blood supply, since they are devoid of blood vessels, the supply of nutrients to them and the removal of metabolic products occurs by diffusion with sequential compression and relaxation of the disk during movement. The main structure that provides power to the disk is the endplates located on its upper and lower surfaces.
By themselves, the endplates are a bilayer formed by cells of cartilage and bone tissue. Accordingly, the cartilaginous side they are adjacent to the disc, and the bone - to the vertebral bodies. They are distinguished by sufficiently good permeability, which ensures the exchange of substances between cells, the intercellular substance of the disc and blood vessels passing in the vertebral bodies. Over the years, especially with the negative impact of external and internal factors, the structure of the endplates changes, and their blood supply decreases, which leads to a decrease in the intensity of metabolism in the intervertebral disc. As a result, its ability to produce new matrix is reduced, which leads to a progressive decrease in its density with age.
At the molecular level, this is accompanied by:
- a decrease in the rate of diffusion of nutrients and metabolic products;
- decrease in cell viability;
- accumulation of cell decay products and altered matrix molecules;
- a decrease in the production of proteoglycans (high-molecular compounds responsible for the formation of new cartilage cells and which are the main sources of synthesis of chondroitin sulfates);
- collagen scaffold damage.
Possible consequences
As a result of the ongoing changes, the intervertebral disc is dehydrated, and the nucleus pulposus loses its ability to adequately distribute the loads that fall on it. Therefore, the pressure inside the disc becomes uneven, and therefore the fibrous ring in several places experiences overload and compression. Since this happens with every movement of a person, the annulus is regularly subjected to mechanical pressure. This leads to adverse changes in it.
Also, often a decrease in the height and elasticity of the disc leads to compensatory changes in the adjacent vertebral bodies. Bone growths called osteophytes form on their surfaces. They tend to increase in size over time and even fuse with each other, excluding the possibility of movements in the affected PDS.
Due to the fact that malnutrition provokes damage to the collagen skeleton, under the influence of the pressure of the nucleus pulposus at certain points, the normal structure of the fibers forming the fibrous ring is disrupted. In the absence of intervention, this eventually leads to cracks and breaks in them. Gradually, more and more fibers of the fibrous ring at the site of application of pressure are torn, which leads to its protrusion. This is especially facilitated by increased loads on the spine. And since the lumbar region takes on the main load during movement and any physical activity, it suffers most often.
The protrusion of the intervertebral disc without the final rupture of the fibrous ring and with the size of its base more than the protruding part is called protrusion. With its complete rupture in one place or another, an intervertebral hernia is diagnosed.
With the destruction of part of the fibers of the fibrous ring, the pressure in the disc gradually decreases, which leads to a decrease in tension and the fibers themselves. This leads to a violation of its fixation and, as a result, pathological mobility of the affected spinal motion segment.
The vertebral motor segment (SMS) is a structural and functional unit of the spine formed by the intervertebral disc, adjacent vertebral bodies, their facet joints, ligaments and muscles attached to these bone structures.
The normal functioning of the spine is possible only with the correct operation of the PDS.
Symptoms of osteochondrosis of the lumbar spine
The disease can be asymptomatic for a long time, and then begin to manifest itself as a slight discomfort in the lumbar region, gradually gaining strength. But in some cases, osteochondrosis of the lumbar begins acutely, immediately provoking a powerful pain syndrome. In most cases, signs of pathology first appear after 35 years.
Back pain is the main symptom of the disease. It can be different in character and be both aching and dull, and acute, constant or episodic. But basically for pathology, especially in the early stages of development, an alternation of periods of exacerbation and remission is characteristic, and both hypothermia or lifting a heavy object, or an unsuccessful, sudden movement can provoke another deterioration in well-being.
Pain is often accompanied by a feeling of numbness and tension in the back muscles. They are aggravated by physical exertion, sudden movements, heavy lifting, bending over, and even coughing and sneezing.
If, due to the instability of the vertebral bodies, the nerve root extending from the spinal cord is clamped by one or another anatomical structure, this will lead to the development of appropriate neurological disorders. Their main manifestations are:
- shooting, severe pain radiating to the sacrum, buttocks, lower limbs or perineum;
- sensitivity disorders of varying severity;
- mobility restrictions, lameness;
- weakness in the muscles innervated by the pinched nerve.
In the lumbar spine, the spinal cord ends at the level of 1-2 vertebrae and passes into the so-called cauda equina, formed by an accumulation of spinal roots. Moreover, each of them is responsible not only for the innervation of the muscles, but also for specific organs of the small pelvis, so prolonged compression can cause disturbances in the work of the corresponding organ. This can lead to the development of impotence, infertility, gynecological diseases, hemorrhoids and other disorders.
The clinical picture of osteochondrosis of the lumbar spine, especially with a long course and the occurrence of compression of the spinal roots, largely depends on the level of the lesion, that is, which particular disk has undergone degenerative-dystrophic changes.
- The defeat of the disk L3-L4 - pain is given to the anterior-internal parts of the thigh, lower leg and inner ankle. This is accompanied by a decrease in the sensitivity of the anterior surface of the thigh, a decrease in the severity or loss of the knee jerk, as well as a decrease in the strength of the quadriceps muscle.
- The defeat of the disk L4-L5 - pain is given from the upper part of the buttocks to the outer parts of the thigh and lower leg. Less commonly, this is accompanied by the spread of pain to the back of the feet, including 1-3 fingers. In these areas, there is a decrease in sensitivity and muscle weakness. Sometimes hypotrophy and incomplete extension of the big toe develops.
- Damage to the L5-S1 disc - pain begins in the middle zone of the buttocks and descends to the heel along the posterior or posterior surface of the thigh and lower leg and can capture the outer edge of the foot, like 4-5 fingers. In these areas of the lower extremities, there is a decrease in sensitivity, and the gastrocnemius and gluteus maximus often decrease in size, which is accompanied by their weakness. If the spinal root passing at the level of this PDS is affected, a decrease or loss of the Achilles and plantar reflexes may be observed.
Discs L1-L2 and L2-L3 are rarely affected.
Accompanying the disease, lower back pain restricts a person and significantly reduces the quality of his life. Since they persist for a long time and regularly recur, if not constantly present, this cannot but affect the psycho-emotional state. As a result, more than half of the patients show signs of chronic emotional stress, depressive disorders, etc.
Diagnostics
If there are signs of osteochondrosis of the lumbar spine, you should contact a neurologist or vertebrologist. First of all, the doctor collects an anamnesis, which consists in clarifying the nature of complaints, the characteristics of pain, the conditions for their occurrence and reduction, the characteristics of a person’s working life, etc.
The second stage of diagnosis, carried out as part of the first consultation with a doctor, is a physical examination. During it, the doctor evaluates the condition of the skin, posture, the depth of the physiological curves of the spine, the presence of its curvature, etc. The condition of the muscles surrounding the spine, called paravertebral, is necessarily assessed, since they are often painful and overly tense, which is a reflex reaction of the body to inflammationand discogenic pain.
Already on the basis of the data obtained during the examination and questioning of the patient, the neurologist may suspect the presence of osteochondrosis of the lumbar spine. But in order to exclude possible concomitant pathologies, as well as confirm the diagnosis and accurately determine the level of damage, the severity of degenerative-dystrophic changes in the intervertebral disc and the involvement of bone structures, laboratory and instrumental diagnostic methods are required.
Laboratory diagnostics
Analyzes of various kinds are not decisive in the diagnosis of osteochondrosis of the lumbar spine. They are more aimed at assessing the degree of the inflammatory process and the detection of concomitant disorders.
Thus, they can be assigned:
- UAC;
- OAM;
- blood test for sugar level;
- blood chemistry.
Instrumental diagnostics
All patients with suspected osteochondrosis of the lumbar spine are shown to have:
- x-ray of the lumbar spine in two projections - allows you to determine the structure of bone structures, detect anomalies, formed osteophytes, changes in the facet joints, etc . ;
- CT - allows you to detect changes in bone structures at earlier stages of development than x-rays, as well as identify indirect signs of osteochondrosis;
- MRI is the best method for diagnosing pathological changes in cartilage formations and other soft tissue structures, which makes it possible to detect the slightest changes in the intervertebral discs, ligaments, blood vessels, and spinal cord and to accurately assess their severity and potential risks.
Additionally, it may be recommended to:
- densitometry - a method for determining bone density, which makes it possible to diagnose osteoporosis, which is especially common in the elderly;
- myelography - allows you to assess the state of the CSF pathways of the spinal cord and the degree of damage to the protruding disc, which is especially important in the presence of an already formed intervertebral hernia of the lumbar spine.
Treatment of lumbar osteochondrosis
When diagnosing osteochondrosis, as a rule, initially all patients are prescribed conservative therapy, provided there is no pronounced and progressive neurological deficit. But her character is selected strictly individually.
Since the disease is chronic, and the regenerative capabilities of the intervertebral discs are extremely limited, especially with pronounced degenerative-dystrophic changes, the main objectives of therapy are to stop their further progression and eliminate the symptoms that disturb the patient. Therefore, treatment is always complex and includes:
- drug therapy;
- manual therapy;
- physiotherapy;
- exercise therapy.
In the acute period, patients are shown to limit physical activity or even adhere to bed rest for 1-2 days. This will help relax the muscles and reduce the pressure inside the disc. If you need to sit, walk or do physical work for a long time, you should wear a stabilizing lumbar corset.
After the end of the acute period and during the remission of the disease, on the contrary, it is important to move as much as possible, but with caution and excluding increased stress on the lower back. Patients will need to acquire the skills of proper sitting, lifting objects from the floor, carrying heavy loads, as all this affects the course of the pathology. It is important to avoid tilting and sudden movements, to lift something from the floor or low surfaces, after bending your knees, and not bending down. You should only sit with a straight back in a chair that supports your back well. In addition, during sedentary work, it is important to regularly take breaks for a short workout. It is important to avoid falls, jumps, fast running and hypothermia.
With osteochondrosis, it is important to maintain body weight within optimal limits, and for obesity, a diet and physical exercises appropriate to the patient's condition are indicated, since excess weight creates an increased load on the lower back and causes faster progression of pathological changes in the discs.
On average, conservative therapy is usually designed for 1-3 months, although it can last longer. But even after completing the main course prescribed by the doctor, it will be necessary to continue taking a number of drugs, exercise therapy and follow recommendations regarding lifestyle.
Medical therapy
The main components of drug therapy are individually selected drugs from the NSAID group. When choosing them, the doctor takes into account not only the severity of the pain syndrome and the course of the inflammatory process, but also the nature of concomitant diseases, especially the digestive tract, since NSAIDs with prolonged use can adversely affect the state of their mucous membranes and provoke an exacerbation of various pathologies of the digestive system.
It is necessary to use NSAIDs for acute pain in the lower back, and immediately after their occurrence. Preferably in 1-2 days. Depending on the severity of the patient's condition, they can be administered intramuscularly, in the form of rectal suppositories, local agents and in oral forms. Duration of admission should not exceed 2 weeks. In the future, an individually selected drug is taken on demand, but trying to avoid frequent use.
Recently, more often preference is given to drugs, as an active ingredient, which include selective inhibitors of cyclooxygenase-2.
Also, patients are prescribed drugs of the following groups:
- muscle relaxants - help to relax overly strained muscles and thereby reduce back pain;
- chondroprotectors - improve the course of metabolic processes in the intervertebral disc (especially effective when started at the earliest stages of development of lumbar osteochondrosis);
- B vitamins - contribute to the improvement of nerve conduction;
- antidepressants and anxiolytics - used for long-term osteochondrosis, which led to depression, chronic fatigue and other psychological disorders.
With very severe pain, especially of neurological origin, therapeutic blockades are performed. They involve the introduction of anesthetics in combination with corticosteroids at points near the compressed nerve, which leads to the rapid elimination of pain. But the procedure can only be carried out in a medical institution by specially trained health workers, since it is associated with a risk of complications.
Manual therapy
Manual therapy allows not only to improve the quality of blood circulation in the area of influence, but also to significantly reduce the severity and duration of pain in osteochondrosis. It effectively relieves muscle tension and allows you to eliminate functional blocks, which significantly increases mobility in the affected SMS.
Also, through well-conducted manual therapy, it is possible not only to increase the distance between the vertebrae, to return them to their anatomically correct position, but also to release the compressed nerve roots. As a result, pain is quickly eliminated and neurological disorders disappear. It also reduces the likelihood of complications and disorders in the work of internal organs.
Additional positive properties of manual therapy are improving mood, strengthening immunity, activating the body's natural recovery mechanisms and increasing efficiency. Usually after the 1st session there is a noticeable improvement in well-being, and in the future the effect becomes more pronounced. As a rule, the course consists of 8-15 sessions, and it is important to complete it to the end, even with complete normalization of well-being.
Physiotherapy
After the subsidence of acute inflammation, courses of physiotherapeutic procedures are indicated, which not only help to reduce pain, but also improve microcirculation, nutrition and the course of reparative processes in the area of degenerative-dystrophic changes. Most often, patients are prescribed:
- electrophoresis with the introduction of drugs;
- electrical neuromyostimulation;
- ultrasound therapy;
- laser therapy;
- magnetotherapy;
- UHF.
What specific methods of physiotherapy will give the best effect, the frequency of their implementation, the duration of the course and the possibility of combining with other types of exposure is determined individually for each patient.
Traction therapy gives very good results in osteochondrosis of the lumbar spine. Thanks to it, it is possible to achieve an increase in the distance between the vertebral bodies, which instantly reduces the load on the affected discs. After the session, to consolidate the results, the patient must wear an orthopedic corset.
exercise therapy
After the elimination of acute pain, the treatment program is necessarily supplemented with exercise therapy. Its main tasks are to stretch the spine and relax the spasmodic muscles of the lower back. Also, therapeutic exercises help to strengthen the muscular corset, create reliable support for the spine and improve posture. In the course of this, blood circulation is inevitably activated and metabolic processes are improved, which has a beneficial effect on the nutrition of the discs.
For each patient, a set of exercises is selected individually in accordance with the degree of degenerative-dystrophic changes, the level of physical development of the patient, the nature of concomitant disorders, age and other factors. Initially, it is recommended to study under the guidance of an experienced exercise therapy instructor.
All patients with degenerative changes in the spinal column are recommended to visit the pool 2-3 times a week, as swimming lessons minimize the load on the spine, but allow you to effectively strengthen the back muscles.
Thus, osteochondrosis of the lumbar spine is one of the most common diseases. At the same time, it is able to deprive a person of working capacity for a long time and even lead to disability due to the development of complications. Therefore, it is important not to ignore the first symptoms of the disease, when it is easiest to deal with it. With the appearance of pain, and even more so numbness, limited mobility, backache, you need to contact a neurologist as soon as possible, undergo the necessary examination and begin treatment. In this case, it will be possible to stop the pathological process and return to a normal, full life without pain and significant restrictions.