Causes of the problems of financial accessibility of higher education. Problems of accessibility of higher education

A photograph of an anatomical preparation) are the main element that connects the spinal column into a single whole, and make up 1/3 of its height. The main function of the intervertebral discs is mechanical (support and shock-absorbing). They provide the flexibility of the spinal column during various movements (tilts, rotations). In the lumbar spine, the discs are on average 4 cm in diameter and 7–10 mm high. The intervertebral disc has a complex structure. In its central part is the nucleus pulposus, which is surrounded by a cartilaginous (fibrous) ring. Above and below the nucleus pulposus are the closing (end) plates.

The nucleus pulposus contains well-hydrated collagen (randomly arranged) and elastic (radially arranged) fibers. On the border between the nucleus pulposus and the annulus fibrosus (which is clearly defined up to 10 years of life), cells resembling chondrocytes are located with a fairly low density.

annulus fibrosus consists of 20–25 rings or plates, between which collagen fibers are located, which are directed parallel to the plates and at an angle of 60 ° to the vertical axis. Elastic fibers are located radially with respect to the rings, which restore the shape of the disk after the movement has taken place. The cells of the fibrous ring, located closer to the center, have an oval shape, while on its periphery they elongate and are located parallel to the collagen fibers, resembling fibroblasts. Unlike articular cartilage, disc cells (both nucleus pulposus and annulus fibrosus) have long, thin cytoplasmic outgrowths that reach 30 µm or more. The function of these outgrowths remains unknown, but it is assumed that they are capable of absorbing mechanical stress in tissues.

Closing (end) plates are a thin (less than 1 mm) layer of hyaline cartilage located between the vertebral body and the intervertebral disc. The collagen fibers contained in it are arranged horizontally.

Intervertebral disc of a healthy person contains blood vessels and nerves only in the outer plates of the annulus fibrosus. The endplate, like any hyaline cartilage, does not have vessels and nerves. Basically, the nerves are accompanied by vessels, but they can also go independently of them (branches of the sinuvertebral nerve, anterior and gray communicating branches). The sinuvertebral nerve is the recurrent meningeal branch of the spinal nerve. This nerve emerges from the spinal ganglion and enters the intervertebral foramen, where it divides into ascending and descending branches.

As has been shown in animals, the sensory fibers of the sinuvertebral nerve are formed by fibers from both the anterior and posterior roots. It should be noted that the anterior longitudinal ligament is innervated by branches of the spinal ganglion. The posterior longitudinal ligament receives nociceptive innervation from the ascending branches of the sinuvertebral nerve, which also innervates the outer plates of the annulus fibrosus.

With age, there is a gradual blurring of the boundary between the annulus fibrosus and the nucleus pulposus, which becomes more and more fibrous. Over time, the disc becomes morphologically less structured - the annular plates of the fibrous ring change (merge, bifurcate), collagen and elastic fibers are arranged more and more chaotically. Fissures often form, especially in the nucleus pulposus. Degeneration processes are also observed in the blood vessels and nerves of the disc. Fragmentary cell proliferation occurs (especially in the nucleus pulposus). Over time, cell death of the intervertebral disc is observed. So, in an adult, the number of cellular elements decreases by almost 2 times. It should be noted that degenerative changes in the intervertebral disc (cell death, fragmentary cell proliferation, fragmentation of the nucleus pulposus, changes in the fibrous ring), the severity of which is determined by a person's age, are quite difficult to differentiate from those changes that would be interpreted as "pathological".

The mechanical properties (and, accordingly, the function) of the intervertebral disc are provided intercellular matrix, the main components of which are collagen and aggrecan (proteoglycan). The collagen network is formed by type I and II collagen fibers, which make up approximately 70% and 20% of the dry weight of the entire disc, respectively. Collagen fibers provide strength to the disc and fix it to the vertebral bodies. Aggrecan (the main proteoglycan of the disc), consisting of chondroitin and keratan sulfate, provides the disc with hydration. Thus, the weight of proteoglycans and water in the fibrous ring is 5 and 70%, and in the nucleus pulposus - 15 and 80%, respectively. Synthetic and lytic (proteinases) processes are constantly taking place in the intercellular matrix. However, it is a histologically constant structure, which provides mechanical strength to the intervertebral disc. Despite the morphological similarity with articular cartilage, the intervertebral disc has a number of differences. Thus, in protein glycans (aggrecan) of the disk, a higher content of keratan sulfate is noted. In addition, in the same person, disc aggrecans are smaller and more pronounced degenerative changes than articular cartilage aggrecans.

Let us consider in more detail the structure of the nucleus pulposus and the fibrous ring - the main components of the intervertebral disc.

Pulpous nucleus. According to morphological and biochemical analysis, including microscopic and ultramicroscopic studies, the nucleus pulposus of human intervertebral discs belongs to a type of cartilaginous tissue (V.T. Podorozhnaya, 1988; M.N. Pavlova, G.A. Semenova, 1989; A.M. Zaidman, 1990). Characteristics of the main substance of the nucleus pulposus correspond to physical constants gel containing 83-85% water. Studies by a number of scientists have determined a decrease in the content of the aqueous fraction of the gel with age. So, in newborns, the nucleus pulposus contains up to 90% of water, in a child of 11 years old - 86%, in an adult - 80%, in people over 70 years old - 60% of water (W. Wasilev, W. Kuhnel, 1992; R. Putz , 1993). The gel contains proteoglycans, which, along with water and collagen, are a few components of the nucleus pulposus. Glycosaminoglycans in the composition of proteoglycan complexes are chondroitin sulfates and, to a lesser extent, keratan sulfate. The function of the chondroitin sulfate-containing region of the proteoglycan macromolecule is to create pressure associated with the spatial structure of the macromolecule. High imbibition pressure in the intervertebral disc retains a large number of water molecules. The hydrophilicity of proteoglycan molecules ensures their spatial separation and dissociation of collagen fibrils. The resistance of the nucleus pulposus to compression is determined by the hydrophilic properties of proteoglycans and is directly proportional to the amount of bound water. The forces of compression, acting on the pulpous substance, increase the internal pressure in it. Water, being incompressible, resists compression. The keratan sulfate region is able to interact with collagen fibrils and their glycoprotein sheaths to form cross-links. This enhances the spatial stabilization of proteoglycans and ensures the distribution of negatively charged terminal groups of glycosaminoglycans in the tissue, which is necessary for the transport of metabolites into the nucleus pulposus. The nucleus pulposus, surrounded by the annulus fibrosus, occupies up to 40% of the area of ​​the intervertebral discs. It is distributed to him most of efforts converted in the nucleus pulposus.

annulus fibrosus formed by fibrous plates, which are located concentrically around the nucleus pulposus and are separated by a thin layer of matrix or layers of loose connective tissue. The number of plates varies from 10 to 24 (W.C. Horton, 1958). In the anterior part of the fibrous ring, the number of plates reaches 22-24, and in the posterior part it decreases to 8-10 (A.A. Burukhin, 1983; K.L. Markolf, 1974). The plates of the anterior sections of the fibrous ring are located almost vertically, and the posterior ones have the form of an arc, the bulge of which is directed backwards. The thickness of the anterior plates reaches 600 microns, the posterior ones - 40 microns (N.N. Sak, 1991). The plates consist of bundles of densely packed collagen fibers of different thicknesses from 70 nm or more (T.I. Pogozheva, 1985). Their arrangement is ordered and strictly oriented. The bundles of collagen fibers in the plates are oriented biaxially with respect to the longitudinal axis of the spine at an angle of 120° (A. Peacock, 1952). Collagen fibers of the outer plates of the annulus fibrosus are woven into the deep fibers of the external longitudinal ligament of the spine. The fibers of the outer plates of the fibrous ring are attached to the bodies of adjacent vertebrae in the region of the marginal border - the limbus, and also penetrate into the bone tissue in the form of Sharpey's fibers and fuse tightly with the bone. The fibrils of the inner plates of the fibrous ring are woven into the fibers of the hyaline cartilage, separating the tissue of the intervertebral disc from the spongy bone of the vertebral bodies. Thus, a “closed package” is formed, which closes the pulpous nucleus into a continuous fibrous frame between the fibrous ring along the periphery and hyaline plates connected from above and below by a single system of fibers. In the plates of the outer layers of the fibrous ring, alternating differently oriented fibers with different densities were revealed: loosely packed fibers alternate with densely packed ones. In dense layers, the fibers split and pass into loosely packed layers, thus creating a single system of fibers. Loose layers are filled with tissue fluid and, being an elastic shock-absorbing tissue between dense layers, provide the elasticity of the fibrous ring. The loose fibrous part of the annulus fibrosus is represented by thin non-oriented collagen and elastic fibers and the main substance, consisting mainly of chondroitin-4-6-sulfate and hyaluronic acid.

The height of the discs and spine during the day is not constant. After a night's rest, their height increases, and by the end of the day it decreases. The daily fluctuation in the length of the spine reaches 2 cm. The deformation of the intervertebral discs is different during compression and stretching. If, during compression, the disks flatten by 1–2 mm, then during tension, their height increases by 3–5 mm.

Normally there is a physiological protrusion of the disc, which is. that the outer edge of the fibrous ring under the action of axial load protrudes beyond the line connecting the edges of adjacent vertebrae. This protrusion of the posterior edge of the disc towards the spinal canal is well defined on myelograms, protrusion. usually, does not exceed 3 mm . Physiological protrusion of the disc increases with extension of the spine, disappears or decreases - with flexion.

Pathological protrusion of the intervertebral disc differs from physiological the fact that a widespread or local protrusion of the annulus fibrosus leads to a narrowing of the spinal canal and does not decrease with movements of the spine. Let's move on to the consideration of the pathology of the intervertebral disc.

PATHOLOGY ( addition)

The main element of intervertebral disc degeneration is decrease in the number of protein glycans. Fragmentation of aggrecans occurs, loss of glycosaminoglycans, which leads to a drop in osmotic pressure and, as a result, dehydration of the disc. However, even in degenerated discs, cells retain the ability to produce normal aggrecans.

Compared with protein glycans, the collagen composition of the disc changes to a lesser extent. Thus, the absolute amount of collagen in the disc, as a rule, does not change. However, it is possible to redistribute various types collagen fibers. In addition, there is a process of collagen denaturation. However, by analogy with protein glycans, disc cellular elements retain the ability to synthesize healthy collagen even in a degenerated intervertebral disc.

The loss of protein glycans and disc dehydration lead to a decrease in their depreciation and support functions. Intervertebral discs decrease in height, gradually begin to prolapse into the spinal canal. Thus, improper redistribution of the axial load on the endplates and annulus fibrosus can provoke discogenic pain. Degenerative-dystrophic changes are not limited to the intervertebral disc, since a change in its height leads to pathological processes in neighboring formations. Thus, a decrease in the support function of the disc leads to overloads in the facet joints, which contributes to the development of osteoarthritis and a decrease in the tension of the yellow ligaments, which leads to a decrease in their elasticity, corrugation. Disc prolapse, arthrosis of the facet joints, and thickening (corrugation) of the yellow ligaments leads to spinal stenosis.

Currently proven that root compression by intervertebral hernia is not the only cause of radicular pain, since about 70% of people do not experience pain when roots are compressed by hernial protrusion. It is believed that in some cases, when the disc herniation and the root come into contact, the latter is sensitized due to aseptic (autoimmune) inflammation, the source of which is the cells of the affected disc.

One of the main causes of intervertebral disc degeneration is violation of adequate nutrition of its cellular elements. It has been shown in vitro that the cells of the intervertebral disc are quite sensitive to oxygen deficiency, glucose, and pH changes. Violation of cell function leads to a change in the composition of the intercellular matrix, which triggers and/or accelerates degenerative processes in the disc. The nutrition of the cells of the intervertebral disc occurs indirectly, since the blood vessels are located at a distance of up to 8 mm from them (the capillaries of the vertebral bodies and the outer plates of the fibrous ring.

Disk power failure can be due to many reasons: various anemias, atherosclerosis. In addition, metabolic disorders are observed with overloads and insufficient loads on the intervertebral disc. It is believed that in these cases there is a restructuring of the capillaries of the vertebral bodies and / or compaction of the endplates, which makes it difficult for the diffusion of nutrients. However, it should be noted that the degenerative process is associated only with incorrect performance of movements during physical exertion, while their correct performance increases the intradiscal content of protein glycans.

There are several stages of degenerative-dystrophic changes in the intervertebral disc:
stage 0 - disk not changed
stage 1 - small tears in the inner 1/3 of the annular plates of the annulus
stage 2 - there is a significant destruction of the disc, however, the outer rings of the annulus fibrosus remain, which prevent herniation; no root compression; at this stage, in addition to back pain, it may radiate to the legs to the level of the knee joint
stage 3 - cracks and ruptures are observed along the entire radius of the fibrous ring; the disc prolapses, causing ruptures of the posterior longitudinal ligament

Currently, this classification has been slightly modified, since it did not provide for compression syndromes.

Attempts to create this classification, based on computed tomography data, have been made since 1990 and ended in 1996 (Schellhas):
stage 0 - the contrast agent injected into the center of the disc does not leave the boundaries of the nucleus pulposus
stage 1 - at this stage, the contrast penetrates to the inner 1/3 of the fibrous ring
stage 2 - contrast extends to 2/3 of the annulus
stage 3 - a crack along the entire radius of the fibrous ring; contrast penetrates to the outer plates of the fibrous ring; it is believed that pain occurs at this stage, since only the outer layers of the disc are innervated
stage 4 - there is a distribution of contrast around the circumference (resembles an anchor), but not more than 30 °; this is due to the fact that radial discontinuities merge with concentric
stage 5 - penetration of contrast into the epidural space occurs; apparently, this provokes aseptic (autoimmune) inflammation in the adjacent soft tissues, which sometimes causes radiculopathy even without obvious signs of compression

Comparative anatomy data allow us to consider the intervertebral disc as articular cartilage., both components of which - the nucleus pulposus (jellyfish) and the fibrous ring - are currently referred to as fibrous cartilage, and the endplates of the vertebral bodies are likened to articular surfaces. The results of pathomorphological and histochemical studies made it possible to attribute degenerative changes in the intervertebral disc to a multifactorial process. Disc degeneration is based on a genetic defect. Several genes responsible for the strength and quality of bone and cartilage structures have been identified: genes for the synthesis of type 9 collagen, aggrecan, vitamin D receptor, and metalloproteinase. Genetic "breakdown" is systemic, as evidenced by the high prevalence of intervertebral disc degeneration in patients with osteoarthritis. The starting point for the development of degenerative changes in the disc is structural damage to the fibrous ring against the background of inadequate physical activity. The inefficiency of reparative processes in the intervertebral disc leads to an increase in degenerative changes and the appearance of pain. Normally, the posterior outer layers of the annulus fibrosus (1–3 mm) and the adjacent posterior longitudinal ligament are equipped with nociceptors. It has been proven that in a structurally altered disc, nociceptors penetrate into the anterior part of the annulus fibrosus and nucleus pulposus, increasing the density of the nociceptive field. In vivo, stimulation of nociceptors is supported not only by mechanical action, but also by inflammation. The degeneratively changed disc produces pro-inflammatory cytokines IL-1, IL-6, IL-8, as well as TNF (tumor necrosis factor). The researchers emphasize that the contact of the elements of the nucleus pulposus with nociceptors on the periphery of the fibrous ring helps to reduce the excitability threshold of nerve endings and increase their perception of pain. It is believed that the intervertebral disc is most associated with pain - at the stage of disc prolapse, with a decrease in its height, with the appearance of radial cracks in the fibrous ring. when the degeneration of the intervertebral disc leads to a herniation, the root or nerve becomes an additional cause of pain. Inflammatory agents produced by hernial cells increase the sensitivity of the root to mechanical pressure. Changing the pain threshold plays an important role in the development of chronic pain.

There have been attempts to identify the mechanisms of discogenic pain with the help of discography. It is shown that pain occurs with the introduction of substances like glucosaminoglycans and lactic acid, with compression of the roots, with hyperflexion of the facet joints. It has been suggested that the endplates may be the source of the pain. Ohnmeiss in 1997 showed that complete rupture of the annulus or the occurrence of a herniated disc is not necessary for the occurrence of pain in the leg. He proved that even at the 2nd stage (when the outer plates of the fibrous ring remain intact), there is pain in the lower back with irradiation to the leg. It has now been proven that pain from one level can also come from the underlying segments, for example, the pathology of the L4-L5 disc can cause pain in the L2 dermatome.

The formation of pain syndrome in a herniated intervertebral disc is influenced by:
violation of the biomechanics of the motor act
violation of posture and balance of the muscular-ligamentous-fascial apparatus
imbalance between the anterior and posterior girdle
imbalance in the sacroiliac joints and other pelvic structures

It should be noted that the severity of clinical manifestations of a herniated disc is also due to the ratio of the size of the intervertebral hernia to the size of the spinal canal where the spinal cord and its roots are located. A favorable ratio is a small hernia (from 4 to 7 mm) and a wide spinal canal (up to 20 mm). And the lower this indicator, the less favorable the course of the disease, requiring a longer course of treatment.

In case of association of clinical manifestations of vertebral pathology with degenerative changes in the intervertebral disc in foreign literature the term is used "degenerative disc disease"- DBD (degenerative disk disease - DDD). DBD is a component of a single process - osteoarthritis of the spine.

Stages of formation of herniated intervertebral discs according to Decolux A.P. (1984):
protruding disc- bulging of the intervertebral disc that has lost its elastic properties into the spinal canal
not ejected disk- disc masses are located in the intervertebral space and compress the contents of the spinal canal through the intact posterior longitudinal ligament
prolapsed disc - more often detected in acute or traumatic hernia; partial prolapse of the masses of the intervertebral disc into the spinal canal accompanying a rupture of the posterior longitudinal ligament; direct compression of the spinal cord and roots
free sequestered disk- a disk lying freely in the cavity of the spinal canal (in acute cases or as a result of trauma, it may be accompanied by a rupture of the meninges and intradural location of hernial masses

Most often in the lumbosacral spine, hernias occur in the intervertebral discs at the level of L5-S1 (48% of total number hernia at the lumbosacral level) and at the level of L4-L5 (46%). Less often they are localized at the level at the level of L3-L4 (5%) and most rarely at the level of L2-L3 (less than 1%).

Anatomical classification of disc herniations:
simple disc herniation , in which the posterior longitudinal ligament is torn, and a larger or smaller section of the disk, as well as the nucleus pulposus, protrudes into the spinal canal; can be in two forms:
- free disc herniation due to "hacking": the contents of the disc pass through the posterior longitudinal ligament, but still remain partially attached to areas of the intervertebral disc that has not yet fallen out or to the corresponding vertebral plane;
- wandering hernia- has no connection with the intervertebral space and moves freely in the spinal canal;
intermittent disc herniation - arises from an unusually strong mechanical load or from strong compression exerted on the spine, with its subsequent return to its original position after the load is removed, although the nucleus pulposus may remain completely dislocated.

Topographic classification of disc herniation:
intraspinal disc herniation - completely located in the spinal canal and emanating from the middle section of the disc, this hernia can be in three positions:
- in the dorsal-median(Stukey group I) causes compression of the spinal cord or cauda equina;
- paramdial (group II according to Stukey) causes one- or two-sided compression of the spinal cord;
- dorsal-lateral(group III according to Stukey) compresses the spinal cord or intraspinal nerve roots, or the lateral part of the spinal plate on one or both sides; this is the most common form, since at this level there is a weak zone in the disk - the posterior longitudinal ligament is reduced to several fibers located on the lateral parts;
disc herniation located inside the intervertebral foramen , comes from the outer part of the disk and squeezes the corresponding root towards the articular process;
lateral disc herniation originates from the most lateral part of the disc and may cause various symptoms, provided that it is located in the lower part of the cervical segment, while squeezing the vertebral artery and vertebral nerve;
ventral disc herniation emanating from the ventral edge, does not give any symptoms and therefore is of no interest.

According to the direction of sequestration, hernias are divided into ("Handbook of vertebroneurology" Kuznetsov V.F. 2000):
anterolateral, which are located outside the anterior semicircle of the vertebral bodies, exfoliate or perforate the anterior longitudinal ligament, can cause a sympathetic syndrome when the paravertebral sympathetic chain is involved in the process;
posterolateral that perforate the posterior half of the annulus fibrosus:
- median hernias - along the midline;
- paramedian - near the midline;
- lateral hernias(foraminal) - on the side of the midline (from the posterior longitudinal ligament).

Sometimes two or more types of disc herniation are combined. O hernia of the vertebral body (Schmorl's hernia) cm. .

Degeneration of the intervertebral disc is visualized with magnetic resonance imaging (MRI). The stages of disc degeneration are described (D. Schlenska et al.):
M0 - norm; nucleus pulposus spherical or ovoid
M1 - local (segmental) decrease in the degree of luminescence
M2 - disc degeneration; disappearance of the luminescence of the nucleus pulposus

Types (stages) of lesions of the vertebral bodies associated with degeneration of the intervertebral disc, according to MRI:
Type 1 - a decrease in signal intensity on T1- and an increase in signal intensity on T2-weighted images indicate inflammatory processes in the bone marrow of the vertebrae
Type 2 - an increase in signal intensity on T1 and T2 - weighted images indicates the replacement of normal bone marrow with adipose tissue
Type 3 - a decrease in signal intensity on T1 and T2 - weighted images indicates the processes of osteosclerosis

The main diagnostic criteria for a herniated disc are:
the presence of vertebrogenic syndrome, manifested by pain, limitation of mobility and deformities (antalgic scoliosis) in the affected spine; tonic tension of the paravertebral muscles
sensory disorders in the neurometamer zone of the affected root
movement disorders in the muscles innervated by the affected root
decrease or loss of reflexes
the presence of relatively deep biomechanical disturbances in the compensation of a motor act
data from computed tomography (CT), magnetic resonance imaging (MRI) or radiographic examination, verifying the pathology of the intervertebral disc, spinal canal and intervertebral foramina
data of an electroneurophysiological study (F-wave, H-reflex, somatosensory evoked potentials, transcranial magnetic stimulation), recording a violation of the conduction along the root, as well as the results of needle electromyography with an analysis of the action potentials of motor units, which make it possible to establish the presence of denervation changes in the muscles of the affected myotome

Clinical significance of the size of protrusions and herniated discs:
cervical section of the spinal column:
1-2 mm- small protrusion size
3-4 mm- average protrusion size(requires urgent outpatient treatment)
5-6 mm- (outpatient treatment is still possible)
6-7 mm and more- large intervertebral hernia(requires surgery)
lumbar and thoracic sections of the spinal column:
1-5 mm- small protrusion size(outpatient treatment is required, treatment at home is possible: spinal traction and special gymnastics)
6-8 mm- the average size of the intervertebral hernia(requires outpatient treatment, surgery is not indicated)
9-12 mm- large intervertebral hernia(urgent outpatient treatment is required, surgical treatment is only for symptoms of compression of the spinal cord and elements of the cauda equina)
more than 12 mm- large prolapse or sequestered hernia(outpatient treatment is possible, but on the condition that if symptoms of spinal cord compression and elements of the cauda equina appear, the patient has the opportunity to get surgery the next day; with symptoms of spinal cord compression and a number of MRI signs, immediate surgical treatment is required)

Note: when narrowing the spinal canal, a smaller intervertebral hernia behaves like a larger one.

There is such a rule, what disc protrusion is considered to be significant and clinically significant if it exceeds 25% anteroposterior diameter of the spinal canal (according to other authors - if it exceeds 15% anteroposterior diameter of the spinal canal) or narrows the canal to a critical level 10 mm.

Periodization of compression manifestations of osteochondrosis of the spine against the background of a herniated disc:
acute period (stage of exudative inflammation) - duration 5-7 days; hernial protrusion swells - edema reaches a maximum for 3-5 days, increases in size, squeezing the contents of the epidural space, including the roots, vessels that feed them, as well as the vertebral venous plexus; sometimes there is a rupture of the hernial sac and its contents pour into the epidural space, leading to the development of reactive epiduritis or down along the posterior longitudinal ligament; pain gradually increases; any movement causes unbearable suffering; especially seriously ill patients endure the first night; the main question that needs to be resolved in this situation is whether or not the patient needs urgent surgical intervention; absolute indications for surgery are: myeloischemia or spinal stroke; reactive epiduritis; compression of two or more roots along the length; pelvic disorders
subacute period(2-3 weeks) - the exudative phase of inflammation is replaced by a productive one; adhesions gradually form around the hernia, which deform the epidural space, compress the roots, sometimes fix them to the surrounding ligaments and membranes
early recovery period- 4-6 weeks
late recovery period(6 weeks - half a year) - the most unpredictable period; the patient feels healthy, but the disc has not yet healed; to avoid unpleasant consequences, it is recommended to wear a fixing belt for any physical exertion

To characterize the degree of protrusion of the disc, conflicting terms are used: "herniated disc", " disc protrusion", "gdisk prolapse". Some authors use them practically as synonyms. Others suggest using the term "disc protrusion" to refer to the initial stage of protrusion of the disc, when the nucleus pulposus has not yet broken through the outer layers of the fibrous ring, the term "herniated disc" - only when the nucleus pulposus or its fragments have broken through the outer layers of the fibrous ring, and the term "disc prolapse" - only to refer to the prolapse of hernial material that has lost its connection with the disc into the spinal canal. Other authors propose to distinguish intrusions in which the outer layers of the fibrous ring remain intact, and extrusions in which the hernial material breaks through the outer layers of the fibrous ring and the posterior longitudinal ligament into the vertebral canna.

Russian authors(Magomedov M.K., Golovatenko-Abramov K.V., 2003), based on the use of Latin roots in term formation, they suggest the use of the following terms:
"protrusion" (prolapse) - bulging of the intervertebral disc outside the vertebral bodies due to stretching of the fibrous ring without significant ruptures. At the same time, the authors indicate that protrusion and prolapse are identical concepts and can be used as synonyms;
" extrusion" - protrusion of the disc, due to rupture of the FC and the exit of part of the nucleus pulposus through the formed defect, but maintaining the integrity of the posterior longitudinal ligament;
" True hernia", In which there is a rupture not only of the fibrous ring, but also of the posterior longitudinal ligament.

Japanese authors(Matsui Y., Maeda M., Nakagami W. et al., 1998; Takashi I., Takafumi N., Tarou K. et al., 1996) distinguish four types of hernial protrusions, using the following terms for their designation:
"protrusion" (P-type, P-type) - protrusion of the disc, in which there is no rupture of the fibrous ring or (if any) does not extend to its outer sections;
« subligamentary extrusion"(SE-type, SE-type) - a hernia in which perforation of the fibrous ring occurs with preservation of the posterior longitudinal ligament;
« transligamentary extrusion"(TE-type, TE-type) - a hernia that ruptures not only the fibrous ring, but also the posterior longitudinal ligament;
"sequestration" (C-type, S-type) - a hernia in which part of the nucleus pulposus ruptures the posterior longitudinal ligament and is sequestered in the epidural space.

Swedish authors(Jonsson B., Stromqvist B., 1996; Jonsson B., Johnsson R., Stromqvist B., 1998) distinguish two main types of hernial protrusions - these are the so-called contained and non-contained hernias. The first group includes: "protrusion" - a protrusion in which ruptures of the fibrous ring are absent or minimally expressed; and "prolapse" - dislocation of the material of the nucleus pulposus to the posterior longitudinal ligament with a complete or almost complete rupture of the fibrous ring. The second group of hernial protrusions is represented by extrusion and sequestration. During extrusion, a rupture of the posterior longitudinal ligament occurs, but at the same time, the fallen fragment of the nucleus pulposus retains its connection with the rest of it, in contrast to sequestration, in which this fragment is separated and becomes free.

One of the clearest schemes was proposed by J. McCulloch and E. Transfeldt (1997), who distinguish:
1) disc protrusion- as the initial stage of disc herniation, in which all disc structures, including the annulus fibrosus, are displaced beyond the line connecting the edges of two adjacent vertebrae, but the outer layers of the annulus fibrosus remain intact, the material of the nucleus pulposus can be introduced into the inner layers of the annulus fibrosus (intrusion);
2) subannular (subligamentary) extrusion in which the damaged plous nucleus or its fragments are squeezed out through a crack in the annulus fibrosus, but do not break through the outermost fibers of the fibrous annulus and the posterior longitudinal ligament, although they can move up or down in relation to the disk;
3) transannular (transligamentary) extrusion in which the nucleus pulposus or its fragments break through the outer fibers of the annulus fibrosus and / or the posterior longitudinal ligament, but remain connected to the disc;
4) prolapse (prolapse) , characterized by sequestration of a hernia with loss of connection with the remaining disc material and prolapse into the spinal canal.

A review of the terminology of herniated discs would not be complete without noting that, according to a number of authors, the term " disc herniation» can be used when the displacement of the disk material covers less than 50% of its circumference. In this case, the hernia can be local (focal), if it occupies up to 25% of the disc circumference, or diffuse, occupying 25-50%. A protrusion of more than 50% of the disc circumference is not a hernia, but is called " disc bulge» (bulging disk).

To overcome the terminological confusion, it is proposed (a team of authors from the Department of Neurology of the Russian medical academy postgraduate education: dr honey. Sciences, Professor V.N. Stock; dr med. Sciences. professor O.S. Levin; cand. honey. Sciences. associate professor B.A. Borisov, Yu.V. Pavlov; cand. honey. Sciences I. G. Smolentsev; dr med. Sciences, Professor N.V. Fedorov) when formulating a diagnosis, use only one term - " disc herniation» . At the same time, “herniated disc” can be understood as any protrusion of the edge of the disc beyond the line connecting the edges of adjacent vertebrae, which exceeds the physiological limits (normally no more than 2-3 mm).

To clarify the degree of disc herniation, the same team of authors (employees of the Department of Neurology of the Russian Medical Academy of Postgraduate Education: Doctor of Medical Sciences, Professor V.N. Shtok; Doctor of Medical Sciences. Professor O.S. Levin; Candidate of Medical Sciences Associate Professor B.A. Borisov, Yu.V. Pavlov; Candidate of Medical Sciences I. G. Smolentseva; Doctor of Medical Sciences, Professor N.V. Fedorova) suggest the following scheme:
I degree- slight protrusion of the annulus fibrosus without displacement of the posterior longitudinal ligament;
II degree- medium-sized protrusion of the fibrous ring. occupying no more than two thirds of the anterior epidural space;
III degree- a large disc herniation, displacing the spinal cord and dural sac posteriorly;
IV degree- Massive disc herniation. compressing the spinal cord or dural sac.

!!! It should be emphasized that the presence of symptoms of tension, radicular symptoms, local pain does not necessarily indicate that it is the disc herniation that is the cause of the pain syndrome. Diagnosis of disc herniation as the cause of a neurological syndrome is possible only if the clinical picture corresponds to the level and degree of disc protrusion.

Spinal problems are a concern for many. modern people leading a passive lifestyle. A decrease in the height of the intervertebral discs is observed in 80% of people on the globe who have reached the age of 50-60 years. Pathological changes occur gradually and cause instability of the vertebrae, hernia and curvature of posture.

Intervertebral discs are connective cartilage tissue that fixes the vertebrae of the ridge in one position. It is on their normal state that the mobility and flexibility of the spine, the ability to lead a normal active life depends. Due to the special structure of the fabric, they act as shock absorbers when running, jumping, bending and other movements. Constant exposure to a number of negative factors leads to wear and sagging of the discs.

How does defeat develop?

Intervertebral discs consist of a soft core and a dense shell - the fibrous ring, enclosed in hyaline plates. There are no blood vessels in this cartilage, which means that they are fed from neighboring soft tissues. Normal muscle development, adequate loads on the body and the absence of problems with the circulatory system help keep the discs between the vertebrae healthy.

The appearance of degenerative changes in the body (the development of osteochondrosis), a passive lifestyle, sedentary work, lack of sports - all this leads to stiffness of movements, pain in the back when turning, as well as swelling and spasms.

They, in turn, seriously aggravate blood circulation, which worsens the condition of the pathological area. Over time, discs lose water and cease to be flexible, microcracks appear. As a result, over time, the height of the intervertebral disc decreases.

Reducing the height of the intervertebral discs is the first stage of degenerative-dystrophic changes in the spine

Causes

The main reason for the appearance of pathology in people of any age is a slowdown in metabolism in the body, impaired blood flow and nutrient deficiency in cartilage tissue. But, besides this, the following factors can affect the malnutrition in the intervertebral discs and reduce their height:

  • unbalanced diet;
  • obesity;
  • changes in tissues with age;
  • trauma or stress;
  • infectious processes;
  • pregnancy;
  • stress and metabolic disorders in tissues.

Determination of the cause allows you to choose the most effective therapy for the intervertebral disc and achieve improvements in the treatment for short term. The first step to restoring normality is to eliminate the underlying factors that led to the formation of the problem.

Symptoms of the disease

Signs of pathological changes depend largely on the stage and localization. Conditionally, the disease proceeds in several stages:

  • Initial . Disk damage is minor, so the appearance of a problem for many goes unnoticed. Patients in this phase complain only of stiffness of movements in the first hours after waking up, as well as the appearance of discomfort in the back during physical exertion.
  • Second . Degenerative changes in the disc continue to progress. Characteristic subsidence and defects of the fibrous membrane are observed. At this stage, the appearance of curvature of the thoracic spine, instability of individual vertebrae, as well as severe pain during prolonged stay in an uncomfortable position are noticeable.
  • Active . At this stage, cracks appear in the disc, or it begins to go beyond the anatomical limits. The characteristic signs of this stage are swelling, inflammation, muscle spasms, decreased sensitivity of certain areas or limbs.
  • Progressive. At this stage, a noticeable decrease in the height of the intervertebral discs, their exit beyond the vertebra and the formation of osteophytes. Signs of pathology are loss of segment mobility, limb paralysis and dysfunction. internal organs often resulting in total disability.


Pain in the affected parts of the spine is the first and constant symptom

It is worth contacting a specialist when the first symptoms appear. The sooner treatment is started, the higher the chance of a favorable outcome.

Diagnostic studies

Today, specialists use a lot of modern technology to carry out diagnostic procedures in order to detect the pathology of the intervertebral disc at an early stage.

When the first signs appear, they turn to a neurologist, who, after a visual examination, questioning the patient and studying the anamnesis, prescribes the following studies:

  • X-ray. It allows you to detect violations in the cervical region even at the stage when symptoms are not observed.
  • MRI. It is prescribed where X-ray examination is not effective (for the diagnosis of intervertebral hernias at the initial stage). With the help of such a device, you can notice all the degenerative changes in the trunk of the spine.
  • Electroneurography. Allows you to detect characteristic processes in the nerve pathways or their damage.
  • Discography. Allows you to examine the damage in the disk structure.

The neuropathologist selects the treatment, based on the information after the examination and the clinical picture.

Features of treatment

Reducing the height of the intervertebral discs is treated conservatively, medication or surgery, depending on the patient's condition, the location of the problem, the stage of the disease. In some cases, the progression of the disease and the growth of osteophytes only slow down or stop a little, which improves the condition of the cartilage in general. All actions are aimed at eliminating the pain syndrome, improving blood circulation and metabolic reactions, as well as restoring disc mobility.

Treatment is necessarily complex and includes several of the following activities:

  • physiotherapy and manual procedures;
  • study of the joint to improve the movement of lymph and blood;
  • physiotherapy;
  • swimming or yoga;
  • massotherapy;
  • cryotherapy;
  • spinal traction (natural, hardware or water);
  • procedures to strengthen muscle, bone and ligament structures of the body.

All this is accompanied by taking painkillers to eliminate discomfort in the area of ​​​​the disks of the cervical region or another area, as well as medicines to relieve inflammation and nourish the cartilage tissue. For some time, the patient is recommended to wear a supporting corset, a complete rejection of bad habits and dieting.


Regular exercise therapy will help to avoid complications of osteochondrosis

Preventive actions

Herniated disc l5 s1 is treated for a long time and is difficult, so every person at risk should take care of high-quality prevention. It will allow to exclude a decrease in the height of discs of other localization, which will protect against possible other complications. The main methods of prevention are:

  • regular proper nutrition;
  • body weight control, exclusion of the appearance of extra pounds;
  • constant maintenance of water balance;
  • an exception stressful situations;
  • performance of special gymnastics;
  • quitting smoking and alcohol;
  • regular sports.

Such simple actions will strengthen the muscular frame and establish metabolic processes between the lumbar discs and neighboring tissues. This will provide support for their normal height and spine health.

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