Epidural administration of glucocorticoids in the treatment of vertebral hernias

Epidural administration of glucocorticoids in the treatment of vertebral hernias

Degenerative-dystrophic disorders and herniated intervertebral discs are the most common causes of pain in the lower back (lumbodynia) and pain radiating to the lower extremities (lumbar ischialgia).

At the same time, in approximately half of patients suffering from chronic pain syndromes, the presence of vertebral protrusion or hernia is not always diagnosed. Unpleasant sensations can be caused by disorders of the musculoskeletal system, myofascial or spondyloarthropathic (facet) syndromes, spinal stenosis or vertebral displacement.

Today there is no single and universal method of conservative treatment or surgical intervention that provides a lasting therapeutic effect and leveling of disturbing symptoms. Thus, chronic pain in the lower back and back is a pressing medical problem, especially when it affects young, able-bodied people.

According to statistics, approximately 90% of patients recover almost completely after the first acute attack of the disease thanks to classical therapy. Repeated exacerbations regress more slowly and require special treatment, and only 10-15% of patients require surgery. In this regard, an individual approach in each specific case and a thorough study of the pathophysiological mechanisms of the development of pathology are very important.

The introduction of epidural blocks for chronic pain syndrome made it possible to explore a new direction in the treatment of vertebral hernias. The effectiveness of glucocorticoid injections is assessed ambiguously, since it correlates depending on the duration of the disease, the anatomical features of the body and the pathological factors (genetic, social, professional, psychological, etc.) that provoked it.

For example, epidural administration of glucocorticoids to patients with a disease duration of 3-6 months shows a positive result in more than 90% of cases. If the disease lasts for more than 6 months, the result drops to 70%, and for more than 12 months, the effectiveness of blockades drops to 10-15%.

The occurrence of pain

Osteochondrosis is a disorder of metabolic processes in the body, causing degeneration of the cartilage of the intervertebral discs (primary disease). Over time, it enters the secondary phase - the development of reactive and compensatory pathologies in the osteo-ligamentous apparatus of the skeleton. Then there is protrusion, herniation of intervertebral discs, proliferation of osteophytes, displacement of the vertebrae, compression of the spinal nerve roots and blood vessels.

In most cases, the occurrence of back pain is the result of the combined effects of mechanical stress and damage to the spinal column, as well as the result of the action of chemical mediators. Another confirmation of the presence of a chemical component in the formation of a hernia is the identification of inflammatory mediators in the cartilage tissue of the disc, their immunogenicity and the possibility of unexpected resorption (resorption) of the protrusion.

In addition, a number of studies show that chemical mediators from the nucleus pulposus can penetrate into the epidural space through cracks in the annulus fibrosus of the intervertebral disc. This leads to inflammation of nearby spinal nerve roots, causing localized or referred pain. Thus, pathophysiological mechanisms provoke acute pain in patients in whom a protrusion or hernia has not yet formed.

Pain syndrome, depending on the sources of discomfort, can be divided into:

• Vertebrogenic, associated with degenerative-dystrophic changes in the spine and paravertebral soft tissues. Pain can come from joints, ligaments, muscle fibers, pinched nerve roots, compressed spinal cord, etc.
• Nonvertebrogenic is caused by pathological processes: stress, depression, myofascial pain, diseases of internal organs, infectious lesions, metabolic abnormalities, systemic diseases, osteopenia, tumors, etc.

Referred pain is caused by pain impulses transmitted from the affected internal organs to the corresponding areas of the spinal column. The peculiarity of these pains is the lack of connection between the occurrence of unpleasant sensations and the patient’s motor activity.

Damage and asymmetry of muscle development are observed in more than 85% of patients with protrusions and herniations of intervertebral discs. Musculoskeletal pain is usually characterized by the presence of trigger points - small pockets of local pain located in areas of muscle spasm or tension bundles. On palpation, they can be felt in the form of small balls under the skin; most often they are found in the muscles of the neck, trapezius bundles, under the shoulder blades, quadratus lumbar muscles, and pelvic girdle.

Diagnosis of muscle pain begins with identifying the affected muscle, painful lumps, active trigger points and the area of ​​pain irradiation. For treatment, massages, physiotherapy, exercise therapy, and drug therapy (analgesics, non-steroidal anti-inflammatory drugs, glucocorticoids, muscle relaxants) are initially used. Musculoskeletal pain is associated with physical overload or lack of physical activity, muscle hypothermia or infectious diseases.

Methods of administering glucocorticoids

Glucocorticoids (glucocorticosteroids) are a subclass of corticoid steroid hormones that are produced by the adrenal cortex. They have pronounced anti-inflammatory, metabolic, immunoregulatory, anti-stress, anti-allergic and other properties.

The mechanism of action of steroids during epidural blockades is based on changes in nociceptive signals, reflex impulses in centripetal fibers and the functional state of neurons. They also neutralize the release of phospholipase (an inflammatory mediator) and the synthesis of anti-inflammatory cytokines, providing a secondary analgesic effect.

For myofascial pain syndrome, local injection of a cocktail of steroids (for example, hydrocortisone) and anesthetic (novocaine, lidocaine) into trigger points of the affected muscle fibers is practiced. The course of treatment consists of 3-5 injections with an interval of 2-3 days. After 6-12 months, you can take a second course of therapy. The effectiveness of local muscle blockades is much higher when used in combination with other types of conservative treatment.

Epidural blocks are most often performed in the lumbar spine. They also use a mixture of anesthetics and glucocorticoids (betamethasone, diprospan, prednisolone, etc.). As a rule, they are used to quickly and effectively relieve pain.

Despite the fact that there are numerous groups of patients who respond positively to this type of therapy, many experts cannot recommend epidural administration of glucocorticoids for widespread use. This is associated with a high risk of complications after intervention in the membranes of the spinal cord.

Intra-articular and intraosseous injections, blockades of the median branches of nerve trunks in the treatment of vertebral hernias are used much less frequently. They significantly reduce the intensity of pain and compensate for the functional deficiency of the affected segment, but are more suitable for the treatment of various types of arthrosis, arthritis, osteoporosis, spondylitis and other diseases of the spine.

Epidural blocks

The introduction of fluoroscopes into the practice of minimally invasive surgery has significantly reduced the risks and morbidity of epidural administration of glucocorticoids. In this case, the median intralaminar method of access to the affected spinal motion segment is considered more preferable than the transforaminal one.

Routes of epidural drug administration:

• Caudal (inferior, below the pathological site) access is technically easy to perform, quite safe (the risk of deformation, damage or puncture of the dura mater of the spinal cord is practically absent), but requires the administration of a fairly large volume of drugs (from 10 to 20 ml).
• Intralaminar access (between the vertebral arches) allows you to more accurately reach the pathological area and requires a much smaller dose of the administered drug.
• Transforaminal (through the vertebral foramen) approach is considered the most optimal when accessing a compressed nerve root and requires a small volume of cocktail.

The choice of route of drug administration depends on the individual characteristics of the patient’s spinal structure, the location of the hernia, as well as the experience and preference of the neurosurgeon who performs the intervention.

The disadvantage of treatment with epidural glucocorticosteroid blockades is:

• lack of certain standards and regimens for the use of various drugs and their doses;
• the need to comply with strict patient selection criteria (many patients are contraindicated for this type of intervention);
• lack of appropriate monitoring of the patient's condition, especially if blockades are used in combination with other types of treatment;
• Long-term use of glucocorticoids causes a number of side effects (diabetes mellitus, endocrine system disruptions, persistent increase in blood pressure, osteoporosis, etc.).

Thus, epidural administration of glucocorticoids is a reasonable alternative to other types of treatment (surgery or other minimally invasive interventions), especially in patients in whom the chemical components of hernia formation dominate over the mechanical ones.
Author: K.M.N., Academician of the Russian Academy of Medical Sciences M.A. Bobyr

Hernia resorption

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Resorption is a method of reducing or completely disappearing an intervertebral disc herniation without surgical treatment.

This voluminous article was prepared by our doctor P.D. Kovzelev.

The latest scientific study from 2015 tells us that herniated discs can be reduced without surgery ! Moreover, this is not just an ordinary study, but an entire meta-analysis - this is the highest level of evidence in modern medical science. Literally 10 years ago, if a doctor had said that the hernia had decreased, at least they would not have understood him. There was an opinion that if a disc herniation or protrusion has already appeared, then this is a death sentence and only surgery can help. Now, thanks to science and the ability to look inside the spine using MRI, we can clearly say that resorption is a reality and it is available in St. Petersburg.

Mechanisms of resorption of intervertebral disc herniation:

Loss of water from the disc and its gradual drying out.

Absorption of the hernia by our immunity. An analogy for understanding: a hernia is like a splinter in the finger for the immune system - it is foreign. He “eats” it with his protective macrophage cells.

For those interested, you can read more about the mechanisms of resorption in Wikipedia, article “resorption of intervertebral hernia.” Our article is a little about something else.

Standard picture demonstrating the process of spinal degeneration.

Science does not yet fully understand the mechanisms, the terms of resorption are also blurred, some scientists write about 21 months, which is certainly a long time. But back pain, and even the kind that happens with a real large hernia, is no joke and it’s impossible to endure it for 2 years .

Then, for our patients and adherents of standard medicine, it seems logical to turn to neurosurgeons. The logic is quite simple and understandable: “no hernia, no problem.” But the situation with surgical treatment is more complicated than it might seem to the average person . In a large percentage of cases, patients experience a recurrence of the hernia, the biomechanics of the region changes, and if the intervertebral disc is completely removed and an artificial one is installed, then the chance of damage to the above or underlying discs and joints is 70%. That is why foreign neurosurgeons resort to surgical treatment only in 5% of cases.

Schematic flow of the operation.

By the way, the situation here is not so rosy and operations are performed inadequately often, although over the past 5 years the picture as a whole looks much better. After all, the best operation is the one that was not performed, says medical wisdom.

What are the ways out of the situation and are there any at all?

Of course have.

Treatment of pain syndromes, hernias and disc protrusions is the main focus of our clinic. Looking ahead, we will say that only 2 patients out of 100 require surgery after a course of treatment with us.

How do we achieve such results?

• Specialists . At our clinic, we have formed a team of specialists who are well versed in the problem of pain and spinal injuries. We have gathered young, ambitious and competent doctors. Only a fresh look at the problem and the most current knowledge can help us cure almost every patient with an intervertebral hernia.
• Progressive treatment methods and, in particular, physiotherapy and PRP therapy . When we talk about physical therapy, we usually remember something from the old clinics. But our clinic has the most modern methods and equipment. For example, a healing magnet Super inductive system with a power of 2.5 Tesla, which is almost 2 times more than the standard 1.5 Tesla in MRI scanners! This is the only device in St. Petersburg that is available to anyone ; we purchased it specifically for our patients. We also use the injection method - introducing platelet-rich plasma to the site of the hernia, which greatly accelerates regeneration.
• Patient trust . This is really important, because the treatment process requires full dedication and trust, first of all, from you, the patients. This is a long, labor-intensive process, joint work between the doctor and the patient. Trust in us is reflected in the popular rating of the ProDoctors website and at the time of writing this article, Smart Clinic ranks 1st in St. Petersburg among specialized clinics . We also have only positive reviews on all sites. Thank you for that.

Here are the three main pillars on which our work and your resorption are built.

What does resorption look like?

Clinical case No. 1.

Patient, 33 years old. Long-term medical history of herniated disc removal, disc infection, repeated surgeries, long-term use of antibiotics, and severe pain. At the time of examination, the patient was not sleeping adequately and was clinically depressed.

Clinical picture: severe pain in the legs, constant lumbago to the point of falling, lack of sleep.

Treatment: antibiotics, variation of the resorption protocol, sacroiliac joint blockade, then 1 month once a week PRP injections (plasma therapy).

Only 2 months passed between the MRI before and after , which is surprising even for me. In this case, we see a good result, the main goal was to reduce pain and restore quality of life - it was achieved.

Pay attention to fatty degeneration of muscles. Those. The muscles themselves are of large good volume, but at the same time they have layers of fat. This suggests that at one time a person was actively involved in some type of physical education, and then stopped. Sitting a lot and not experiencing regular physical activity.

Clinical case No. 2.

Patient, 45 years old. He turned to me for help after another shooting in the lower back. Has a long course of back pain. An MRI was performed, which revealed a huge disc herniation with a tendency to sequestration (separation). Neurosurgeons said that surgery was urgently needed, but the patient did not want to rush into making such a decision.

Clinical picture: pain in the right leg, numbness, slight loss of strength.

Treatment: standard for the resorption protocol. 12 days daily, then 1 month once a week PRP injections (plasma therapy).

The pain decreased by more than 2/3 of the initial value after 10 days.

There were 7 months between the before and after MRI. In this case, we see an excellent result, complete resorption of the sequestrum and partial resorption of the hernia. The patient underwent a second course of treatment with the goal of achieving complete resorption, but because... the required deadlines have not passed, then 3 MRIs have not yet been received.

Patient interaction format and treatment.

In-person consultation with a doctor, analysis of all your complaints, detailed neuro-orthopedic examination and examination of MRI images. A comprehensive solution to the question of the effectiveness of treatment and its necessity. We always explain the clinical picture to the patient and show MRI images so that the person is as informed as possible about the state of his health.

Treatment. The treatment format itself consists of daily visits to our clinic, regular examination and questioning by your attending physician, and receipt of direct treatment. Duration of procedures is from 1 to 1.5 hours per day.

The cost of treatment is currently 2990 rubles per day according to the terms of the promotional offer. The duration of therapy is 12-14 days, depending on the severity of your condition.

An MRI is required before and after treatment.

Frequently asked questions and their answers

1. Is there resorption? Yes, sure.

2. What are the chances that the hernia will shrink without surgery? Everything is determined individually. A recent MRI (no older than 1-3 months) and an in-person examination of the patient are required. Sometimes you can tell with certainty even just by looking at an MRI.

3. How long should I wait before the second MRI after treatment with you? Again, everything is decided individually. 3 months, in our opinion, is rapid resorption. 6 – Standard.

4. And all this time I will live with back pain? Of course not. Pain treatment begins from the first day. Typically, after a week, patients experience a 50% reduction in pain, sometimes more.

5. Then why the second MRI only after 3-6 months? Because pain reduction is not resorption. Most often, the cause of pain is muscle spasm, tissue swelling, or damage to the spinal joint. We eliminate these problems and the pain goes away. But the resorption process itself is not so fast.

6. Does it happen that treatment doesn’t help? This also happens, although it is extremely rare. Or there are cases when surgery is clearly needed and conservative treatment is out of the question. Medicine is not mathematics and no one can calculate the result with 100% accuracy. If somewhere you are given guarantees in matters of health, we recommend that you at least be wary.

Comparison with surgical treatment

The table has a horizontal swipe

MRI consultation

Our doctors can look at your MRI for free and tell you whether resorption is possible in your particular case!

To do this, you must send files from a disk or flash drive made no later than 3 months at the time of application. Also briefly state your medical history in a letter: when and how the disease began, how long it lasts, are there any exacerbations, what are the current complaints, etc.

Mail for sending MRI –

Patient Guide

Also, in order to increase understanding of this process, our doctor, Pavel Dmitrievich Kovzelev, wrote a free guide to resorption for our patients. You can download it and read it in detail by clicking on the “download” button. 25 page manual, lots of pictures, MRI, everything is clear and signed. There is also humor. Enjoy it for your health.

Summary of our neurologist Pavel Dmitrievich Kovzelev.

“There is no magic or wizardry in the resorption process itself. The existence of hernias in such quantities was discovered not so long ago, this is due to the widespread introduction and affordable price of MRI. It would not be reasonable to assume that nature and evolution have not built into our bodies mechanisms to heal when a herniated disc occurs. In this case, we only help and speed up this process.”

Sign up for hernia resorption

Osteochondrosis of the lumbosacral spine is one of the most common chronic diseases. In the case of the development of persistent pain syndrome and neurological deficit caused by vertebrogenic compression of neural structures, surgery is often the only treatment method. It can significantly improve the quality of life of patients, returning them to normal activities. The effectiveness of surgical treatment is quite high, which is achieved by improving microsurgical techniques, using new physiological implants, and adjusting the lifestyle of the patient who has undergone surgery. The last factor is no less important than a technically correctly performed intervention, however, even with its high-quality implementation and patients observing a correct lifestyle, surgical treatment is ineffective in 10-20% of them. This category of patients has the so-called operated spine syndrome (SOP: synonymous with “failed spine surgery syndrome”). There is also the term "post-laminectomy syndrome." but it is outdated, since most operations for osteochondrosis of the lumbar spine are performed with preservation of the vertebral arch. SOP is a natural delayed consequence of surgical treatment. It does not include such perioperative complications as damage to neural structures or the dura mater with liquorrhea, massive blood loss, anesthetic complications, etc. It is controversial to include cases of a technically incorrectly performed operation as SOP (failure to perform stabilization in cases of vertebral instability, insufficient sequestrectomy when removing intervertebral disc herniation (IVD), insufficient decompression of the spinal canal due to its stenosis, incorrect installation of implants, error in choosing the level of surgery, etc.).

The spectrum of manifestations of SOP includes 1. Relapse of GMD; 2. Spinal stenosis and instability at the operated level; 3. Adjacent spinal level syndrome; 4. Discitis and wound infection; 5. Facet syndrome; 6. Fibrous muscle atrophy; 7. Cicatricial adhesive epiduritis, arachnoiditis, post-compression isolated radiculopathy; 8. Epidural hematoma; 9. Breakage, displacement of implants, bone resorption in the area of ​​implant installation.

Given that surgical patients at the outpatient level are under the supervision of neurologists, it is necessary that these specialists be widely aware of SOPs.

The purpose of this review is to summarize current data regarding the above-mentioned manifestations of SOP after surgical treatment of osteochondrosis of the lumbar spine.

Relapse of GMD

This complication ranks first among the causes of SOP. A true relapse of GMD is a situation where the patient had a pain-free period for several months after surgery. In its absence, the most likely assumption is non-radical sequestrectomy. Regardless of the correct choice of surgical treatment tactics, the risk of recurrence of GMD is 3.5-7% [1] and depends on the type of operation - with endoscopic removal it is 2 times higher than with open microsurgical surgery [2]. The risk of recurrence after microdiscectomy increases with the size of the anulus fibrosus defect greater than 6 mm [3, 4]. In such cases, the defect can be closed with a special implant [5, 6], and methods are being developed to restore the intervertebral disc using genetic engineering methods [7–9].

The attitude towards obesity as a risk factor for relapse of GMD is ambiguous: according to some data, obesity is a significant risk factor for relapse, but according to others it is not [10-12]. Performing disc curettage in addition to sequestrectomy reduces the risk of recurrent GMD by 3%. Clinically, it is manifested by the resumption of the pain syndrome that occurred before the operation. The diagnosis is confirmed by magnetic resonance imaging (MRI) of the spine. In case of persistent pain syndrome and compression of neural structures, surgical treatment in the form of standard microdiscectomy is indicated. There is evidence that microdiscectomy for recurrent GMD must be supplemented with segment fixation [13]. When performing microdiscectomy without fixation, repeated recurrence of GMD clearly indicates hidden instability of the segment.

Spinal stenosis and vertebral instability at the operated level

After microdiscectomy at the operated level, it is possible to develop true spinal canal stenosis caused by hypertrophy of the joints, arches, and ligamentum flavum, and not by a hypertrophied epidural scar. It is possible to develop both lateral and central stenosis. We were unable to find data on the development of central stenosis in the available literature, although we encountered it from our own experience. It is associated with overload and hypertrophy of the articular-ligamentous apparatus in the operated segment. There is data [14–16] on the development of lateral stenosis after microdiscectomy, including foraminal stenosis; in the acute postoperative period it occurs in 10–30% of patients. During microsurgical decompression of the spinal canal for stenosis, restenosis is possible [17]. It occurs especially often after microsurgical decompression without stabilization of the vertebrae in patients with spondylolisthesis [18, 19]. Therefore, an important aspect of microsurgical decompression of the spinal canal is the preservation of joints, since if they are destroyed, instability and, accordingly, restenosis may develop. Risk factors for the development of spondylolisthesis in this situation are tropism (asymmetry) of the facet joints and paraspinal muscles in the operated segment [20]. Supplementing microsurgical decompression with the installation of an interspinous fixator allows partial unloading of the joints and reduces the risk of restenosis. The treatment tactics are the same as for primary stenosis; in case of significant compression of the neural structures, surgical decompression of the spinal canal is necessary.

Adjacent Spinal Level Syndrome

Adjacent level syndrome is a typical delayed complication of spinal fusion. The provoking factor for its development is an increase in the load on the adjacent segment after turning off mobility in the spinal fusion segment [21, 22]. It has been shown [23] that after spinal fusion, the load on the disc at the upper adjacent level increases by 45%. According to MRI data, 1 year after spinal fusion, 58% of patients experience initial degenerative changes in the overlying disc in the form of dehydration [24]. Complications of adjacent spinal level syndrome include joint hypertrophy with the development of stenosis (in 14–45% of patients), disc damage (in 28–40%), and spondylolisthesis (in 17%) [25–28]. The clinical picture is determined by the type of spinal lesion. The manifestation of the adjacent level syndrome begins 4 years after spinal fusion and, as a rule, involves the upper adjacent segment. Up to 20% of patients with adjacent level syndrome require reoperation. Two main risk factors for its development have been identified. The first is damage to the adjacent segment that existed even before spinal fusion; this primarily concerns joint degeneration [29–32]. The second is the formation of a spinal fusion segment in a position of hypolordosis [33-36]. Currently, there are two ways to prevent adjacent level syndrome: 1) installation of a dynamic fixation system while maintaining mobility at the operated level; 2) simultaneous strengthening of the adjacent segment during spinal fusion; The effectiveness of this technique was proven in a randomized study [37].

Discitis and wound infection

Postoperative discitis is an inflammatory process of the GMD nucleus, cartilaginous endplates, and adjacent cortical layers of the vertebral bodies [38]. Discitis can be either aseptic or infectious [39]. Discitis and wound infection occur in 2–3% of patients undergoing microdiscectomy [40]. Cases [41] of discitis after laser vaporization of the intervertebral disc have been described. Usually its manifestation begins 2-4 weeks after surgery. The main manifestation is lumbodynia with muscular-tonic syndrome; pain may radiate to the buttocks, thigh, and groin. If the root is involved in the inflammatory process, radicular symptoms are possible. Risk factors for the development of discitis are diabetes mellitus and other comorbid diseases that lead to decreased immunity. X-ray computed tomography (CT) visualizes erosion of the endplates and cortical plates; MRI in these areas shows a decrease in the signal on T1 and an increase on T2 [42]. It is impossible to distinguish between aseptic and infectious discitis using neuroimaging methods [43]. Infectious genesis is supported by inflammatory changes in blood tests and a positive bacteriological analysis of intervertebral disc puncture. Prevention of infectious discitis is the perioperative administration of antibiotics. Treatment is usually conservative - a course of broad-spectrum antibiotic therapy for 3-6 weeks. The question of surgical treatment arises in the event of the development and spread of a purulent process with the risk of damage to neural structures (epidural abscess, osteomyelitis with melting of the vertebral bodies, etc.). Discitis and wound infection are usually independent processes and are rarely combined with each other. Wound infection is manifested by typical external inflammatory changes in the wound. In the presence of purulent discharge from the wound, emptying of the purulent focus and its sanitation are indicated. Prevention of infectious discitis and wound infection includes careful adherence to the rules of asepsis during surgery and dressings. An important aspect of prevention is the exclusion of inflammatory foci when planning surgery.

Facet syndrome

It is a complex of symptoms caused by damage to the intervertebral joints. Its development after microdiscectomy is associated with a decrease in the height of the disc in the operated segment and an increase in the axial load on the facet joints. A decrease in disc height is often observed after the so-called “aggressive microdiscectomy,” in which sequestrectomy is supplemented with curettage of the intervertebral disc. The usual clinical manifestation is pain in the lower lumbar spine, often radiating to the gluteal region and thigh; as a rule, the pain does not radiate below the level of the knee. It is most intense in the morning after getting up, increases with extension and decreases with flexion. The diagnosis is confirmed by a test block of the facet joints with an anesthetic. MRI and CT of the spine make it possible to visualize degenerative changes in the facet joints in the form of arthrosis, hypertrophy, and changes in the congruence of the articular surfaces. Facet syndrome develops in 8% of patients undergoing microdiscectomy [44]. An important area of ​​its prevention is a course of conservative postoperative treatment - physiotherapy, exercise therapy, massage. During the operation, it is advisable to limit yourself to sequestrectomy with root revision without disc curettage (so-called non-aggressive microdiscectomy); in this case, there is no significant reduction in the height of the intervertebral disc and there is no risk of developing facet syndrome. In case of a significant decrease in the height of the disc even before surgery or the impossibility of refusing curettage (large defect in the posterior wall of the disc, movable sequesters in its cavity), it is necessary to consider the possibility of implanting an interspinous fixator. Another surgical technique that helps prevent the development of facet syndrome after microdiscectomy is closing the defect in the annulus fibrosus with an implant [45]. Treatment for facet syndrome includes physical therapy, pain medications, and facet joint blockade. If conservative treatment is ineffective, radiofrequency denervation is used. The analgesic effect of this method lasts about 1 year; in case of pain recurrence, repeated intervention is possible, during which it is longer [46, 47]. There are also methods of chemical denervation of facet joints and facetoplasty - the introduction of a special gel into the joint cavity. Surgical treatment of facet syndrome involves implantation of an interspinous fixator, which partially unloads the facets [48].

Fibrous muscle atrophy

Pain in the paraspinal muscles is a common manifestation of reflex muscular-tonic syndrome in GMD, facet syndrome, spinal stenosis, or vertebral instability. In spinal surgery, the paraspinal muscles are separated from the vertebrae and retracted to access the problematic spinal motion segment. At this point, direct injury to the muscle as a result of excessive traction or disruption of its innervation is possible. Intraoperative trauma to the paraspinal muscles significantly increases pain in the immediate postoperative period. Typically, muscles are damaged during more extensive operations, when they are separated from the bone over a significant length - for example, during open transpedicular fixation [49]. Therefore, with minimally invasive techniques, such as endoscopic ones, muscle damage is minimal [50].

One of the methods for preventing muscle damage during surgery is to periodically weaken their traction; during microdiscectomy, this can reduce pain in the postoperative period [51]. We were unable to find data in the literature on whether the atrophied muscle itself could be a source of pain. A study of chronic vertebrogenic lumbar pain with conservative treatment demonstrated a correlation of pain syndrome with the degree of atrophy of the paraspinal muscles [52]. This is due to the direct relationship between the severity of the development of paraspinal muscles and the load on the corresponding spinal motion segment - the better developed the muscle, the less the load. This is an axiom for all patients with lumbar osteochondrosis and requires them to maintain the paraspinal muscles in proper tone through regular training. Atrophy of the paraspinal muscles is easily determined by physical examination. CT and MRI data allow us to determine the degree of fibrosis and fatty degeneration.

Cicatricial adhesive epiduritis, arachnoiditis, post-compression radiculopathy

Cicatricial adhesive epiduritis (epidural fibrosis) is a common (occurs in 10-20% of operated patients) complication after microdiscectomy [53]. Morphologically, it is manifested by the development of a hypertrophied fibrous scar, fused to the dura mater, usually the root is immured in the scar. A risk factor for the development of epidural fibrosis is postoperative epidural hematoma. An individual predisposition to epidural fibrosis has also been established in the form of immune characteristics, for example, in autoimmune diseases [54]. Epidural fibrosis can cause lateral and/or central spinal stenosis with associated neurological symptoms. On native MRI and CT myelography, fibrosis may look like a relapse of GMD. The diagnosis is verified by contrast-enhanced MRI, in which a pronounced accumulation of contrast is noted in the area of ​​fibrosis, which is not observed in GMD. Interestingly, some patients with significant fibrosis at the surgical site may have no neurological symptoms on MRI. If pain occurs, conservative treatment is started. Epidural administration of non-steroidal anti-inflammatory drugs (NSAIDs), glucocorticoids, and enzymes is used [55-58]. Surgical treatment consists of meningoradiculolysis, elimination of the hypertrophied scar. Endoscopic adhesiolysis is also used [59]. Ways to prevent postoperative epiduritis are being actively studied. In the postoperative period, 5 days after surgery, the patient does a special exercise - swing the affected leg in the sagittal plane (if pain allows). The theoretical basis for this exercise is that the movements of the root in the spinal canal during swings prevent the development of adhesions. Various anti-adhesion agents are being developed to apply to the dura mater during primary intervention [60, 61]. Some drugs can reduce the risk of developing epiduritis by 20-30% [62-67]. It is believed that preservation of the ligamentum flavum during microdiscectomy reliably prevents the development of epidural fibrosis [68].

Arachnoiditis can manifest itself by the formation of intradural adhesions with the formation of cysts, adhesion and deformation of the roots, which are detected with high-field MRI [69]. Intradural damage to the roots causes a variety of radicular symptoms. Since neural structures are directly involved in the pathological process, pain syndrome in arachnoiditis is difficult to treat [70]. Treatment begins conservatively, possibly with intradural administration of NSAIDs. Methods for surgical dissection of intradural adhesions are described. If any type of treatment is ineffective, electrical stimulation of the spinal cord is a method of pain relief.

Post-compression isolated radiculopathy manifests itself as radicular symptoms after elimination of the root compressing factor (HMD, hypertrophied articular-ligamentous complex, epidural scar, incorrectly installed implant). Despite a technically correct operation and complete decompression of the root, the patient may continue to experience numbness, weakness and pain in the corresponding area. On postoperative MRI, there is no substrate compressing the root, but it may be swollen and/or deformed [71]. This is due to structural changes that occurred in the root during the period of compression [72, 73]. The most severe manifestation is intense radicular pain. In the available literature, we were unable to find information on the incidence of isolated post-compression radiculopathy, accompanied by pain, the intensity of which did not decrease after surgery. According to our data, this condition is observed in less than 0.5% of patients operated on for spinal osteochondrosis. Treatment is conservative; if it is ineffective, electrical stimulation of the spinal cord may be used.

Epidural hematoma

This rare and severe complication of spinal surgery occurs in 0.1% of cases and is manifested by the development of caudal syndrome in the immediate hours after surgery [74]. Its development requires emergency reoperation to remove the hematoma. Risk factors include coagulopathies and extent of intervention. Delayed hematomas, developing several days or even weeks after surgery, are an even rarer occurrence [75–77]. There is a description of the observation of a patient who underwent decompression and stabilization surgery at the L3-L5 level for spinal stenosis [78]. 14 days after the operation, he acutely developed a clinical picture of isolated damage to the S2-S4 roots with urinary retention. The patient was urgently hospitalized; an MRI revealed an epidural hematoma compressing the dural sac in the area of ​​the operation. After emergency removal of the hematoma, the neurological deficit regressed. There are no descriptions of postoperative chronic spinal epidural hematoma in the literature, but there are corresponding data on idiopathic or post-traumatic chronic spinal epidural hematoma, manifested by radicular symptoms [79].

Breakage, displacement of implants, bone resorption in the area of ​​the implant

In surgery for lumbar osteochondrosis, two types of systems are usually implanted: interspinous fixators and transpeduncular systems with interbody cages. A possible complication is bone resorption in the area of ​​contact with the implant; its incidence reaches 8% [80]. It is determined by the individual characteristics of the reaction of the bone tissue, as a result of which an implant correctly installed during surgery begins to become loose after a few months/years and may move. When using interspinous implants, fractures of the spinous processes are observed in 1–20%, implant migration in 0.5–2%, and breakage in 1% [81–86]. Fractures of beams, screws, loosening of nuts, and displacement of implants in transpeduncular systems occur with a frequency of 1.7–15% [87]. Risk factors for these complications are non-compliance with the orthopedic regimen and osteoporosis. As a rule, in all these cases, removal of the implant is indicated. For transpeduncular fixation due to osteoporosis, self-expanding or cannulated screws with cement injection are used. Bone resorption is determined by radiography and CT. To reduce the risk of its development in the postoperative period, treatment aimed at strengthening bone tissue is possible [88].

Thus, the issue of SOP is currently being widely studied. New data have been obtained, thanks to which it is possible to predict and prevent the development of certain complications. However, many aspects of SOP remain not fully understood. This also applies to relapse of GMD. Treatment of a patient with SOP is a complex and not always completely feasible task. If there is postoperative pain syndrome in a patient with an operated spine, it is necessary to carry out a differential diagnosis, usually within the framework of the SOP itself. Conservative treatment of such patients is carried out by a neurologist; if there is no effect, consultation with a neurosurgeon is necessary.