Foraminal protrusion and hernia: what are the features, symptoms and treatment

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Disc protrusion is a pathology associated with degenerative changes in the intervertebral discs located between the vertebrae of the cervical, thoracic and lumbar spine.
Intervertebral discs, due to their structure, impart elastic properties to the spine, which allows it to achieve a wide range of movements and alleviate the pressure placed on the spine in everyday life. This is due to the special structure of the discs, which include the annulus fibrosus and the nucleus.

The basis of the core is the pulp, a gelatinous substance consisting of proteoglycan with a high concentration of water. Around the nucleus pulposus there is a cartilaginous ring with a concentric layered structure - the fibrous ring, which holds the nucleus in a stable position.

With age, the water concentration decreases, structural changes occur in the pulp - it becomes harder due to dehydration, more susceptible to deformation.

The fibrous ring loses its elasticity and can gradually be pressed outward, forming a bulge - a protrusion.

Degenerative changes in the intervertebral discs can be aggravated by loads along the axis of the spine, which in turn leads to the development of microtraumas in it and the appearance of prerequisites for the formation of hernias. In some cases, the annulus fibrosus bursts, the pulp is squeezed out of the nucleus, and sometimes beyond the disc (sequestration).

Due to the pressure of deformed intervertebral discs, inflammation and swelling of the surrounding tissues occur. All this, along with the existing hernia, often leads to compression of the nerve roots or spinal cord. This, in very general terms, is the mechanism of pathogenesis of many complications of spinal diseases.

Classifications of protrusions

Protrusions are classified depending on the location of deformation changes:

• central protrusion - the bulge occurs at the back, towards the center of the spinal canal, where the spinal cord is located;
• paracentral, paramedian disc protrusion (“mid-right-sided” or “mid-left-sided”) - the bulge occurs towards the center with a shift to the right or towards the center with a shift to the left from the midline of the spinal canal, where the spinal cord and nerve roots are located;
• foraminal - protrusion occurs in the left or right side of the spinal canal, where the bases of the nerve roots are located;
• extraforaminal (lateral) - protrusion occurs to the left or right of the spinal canal, where the nerve roots extend from the spinal cord.

Compression of a spinal nerve root can result in symptoms known collectively as radiculopathy. Central (median) and paramedian disc protrusions that compress nerve roots may include symptoms such as:

• muscle weakness;
• pain radiating to the arm, leg, neck;
• numbness or tingling in the arms, one arm, or one or two legs;
• Urinary incontinence.

What it is?

First of all, let's understand the structure of the lesion - the disc itself.

Intervertebral disc “layers” make up a total of 25% of all spinal segments. In the center of the disc there is a pulpous nucleus pulposus, surrounded by the so-called fibrous ring .

With excessive load on the musculoskeletal system, as well as when the body turns, the core is flattened, and the fibrous ring is subsequently stretched. When a person assumes a normal position, the elements of the system take on a standard shape. Prolonged curvature of the back and regular overloads lead to deterioration of disc recovery, which ultimately leads to protrusion.

Protrusion (or prolapse ) is a violation of the position of the intervertebral disc relative to the vertical of the spinal column: the disc moves, “bulges out.” At the same time, it can be difficult to notice the protrusion visually: as a rule, the displacement does not exceed 6 mm.

The pathology of intervertebral formations is a direct prerequisite for the development of a hernia: the diagnosis of protrusion is made when the disc is deformed without rupture of the peripheral fibrous ring, while a hernia is disc prolapse with the destruction of this ring, which will happen in the absence of treatment for the protrusion.

Clinical picture

In total, when classifying protrusions, 7 types of displacement are distinguished depending on the site of development of the pathology and the direction of displacement . The foraminal type of the disease usually affects the lumbosacral spine.

Along the fronts of the spine, reinforcing ligaments run vertically, bringing the segments of the column together and supporting them. By regularly taking the wrong position and overloading the spine, you weaken these ligaments, which increases the risk of deformity.

Foraminal protrusion is characterized by displacement of the disc backwards towards the intervertebral canal. The main danger of the disease is that foraminal protrusion affects the spinal nerve root, and therefore can directly affect the health of the nervous system.

The main danger of foraminal protrusion is that it is directed towards the spinal canal

Let us consider the main stages of development of pathology and variants of its manifestation.

Video: “Structure of the spinal column”

Stages of prolapse development

1. Violation of metabolic processes. Deformation of the disc contributes to its exclusion from the supply chain of the vertebral segments: the disc gradually becomes dehydrated, loses its shape and elasticity, the fibrous ring cracks, and the process of protrusion of the disc nucleus begins.
2. Active displacement progress.
3. Thinning of the fibrous membrane. The nucleus pulposus begins to protrude beyond the boundaries of the ring, but the integrity of the fibers of the periphery of the disc is still preserved.

Types of foraminal protrusion

• Foraminal . Completely covers the intervertebral canal.
• Intraforaminal . The prolapse is located inside the intervertebral foramen.
• Extraforaminal . Displacement to the outer edge of the intervertebral canal.
• Circular-foraminal . Characterized by uniform protrusion of the disc in all directions; the disk, as it were, expands comprehensively, going beyond its own normal boundaries. This type of protrusion occurs most often.

Above are the most common classification options for foraminal protrusion, however, individual diagnosis can reveal another form of the disease: for example, there is a right-sided or left-sided variety, a dorsal form (in which the displacement occurs towards the spinal canal) and others. Only a doctor can give you an accurate diagnosis.

As with most diseases, the earlier a patient is diagnosed with protrusion, the easier and more effective subsequent therapy will be. And in order to contact a doctor in a timely manner, you should know the prerequisites for the development of the disease and its symptoms.

Protrusion and herniation of intervertebral discs

The protrusion process begins with a point bulging of the ring: a protrusion from 1 to 8 mm is formed from its fibrous plates. At the same time, the internal structure of the fibrous ring has already been destroyed, and, most likely, significantly - by the time protrusion appears, usually more than half of the outer shell of the disc is cracked and has lost its functionality. But the outer, stronger layer of the disk still holds the core.

In the scientific literature, especially foreign, a herniated disc is considered to be a localized displacement of part of the disc (nucleus pulposus, cartilage, collagen rings in various combinations) outside the intervertebral disc space, generally speaking, both when the fibrous ring is ruptured (prolapse) and when the integrity of the outer, more durable layers of the fibrous ring (protrusion). In popular scientific literature and in everyday life, a hernia is most often understood as prolapse - loss of the internal tissues of the ring through a rupture of its outer shell.

Thus, protrusion in a simplified view is the initial stage of the formation of a hernia, but at the same time it can lead to consequences no less serious than a developed disc herniation. In the diagram you can see that the main threat is not so much the rupture of the fibrous ring, and not the bulge of the disc itself, but its size and location in relation to the nerve roots and spinal cord, compression of which will inevitably lead to the occurrence of pain and other consequences.

Not every protrusion causes concern and threatens health, just as not every protrusion will inevitably turn into prolapse. But the presence of protrusions of any type and size in the intervertebral discs indicates the development of degenerative processes in the spine and should be an incentive to begin timely treatment of osteochondrosis in order to avoid severe stages of the disease and complex surgical intervention.

Causes

There are many reasons why you will have to find out what it is, L4-L5 disc protrusion. These include:

• osteochondrosis – lack of nutrition leads to a decrease in elasticity, and the end result of “starvation” is protrusion;
• spinal column injury;
• unbearable stress on the spine;
• Bekhterev's disease, spondylitis of tuberculosis nature and other pathologies;
• the patient is overweight;
• genetic diseases affecting connective tissue;
• underdeveloped back muscles;
• incorrect posture;
• age-related changes.

One of these causes or a combination of several causes protrusion, but the pathology does not appear at once.

Prerequisites for the occurrence of intervertebral disc protrusion

The occurrence of protrusions depends on a number of circumstances, ranging from preventable causes (for example, injury, inadequate physical activity, improper lifting and moving objects) to inevitable (genetics, aging).

In addition to degenerative processes in the spine (osteochondrosis), there are other predisposing factors, such as:

• constitutional weakness of the ligaments,
• congenital pathology of the spine;
• incorrect posture during work;
• pregnancy;
• obesity;
• falls on the buttocks, legs, injuries, weightlifting;
• bending, torsion of the spine;
• weakness of the abdominal muscles and muscles that support correct posture.

These and other reasons can lead to protrusion of the annulus fibrosus, usually on the posterior side, where the annulus fibrosus is thinner, up to rupture of the nucleus pulposus and the formation of a prolapse (hernia) into the epidural space of the spinal canal with the appearance of symptoms of compression of nerve tissue.

Causes and risk factors

First of all, it is worth noting that protrusion is not a disease, but a symptom. The basis for the development of displacement is usually a pre-existing spinal ailment.

Intervertebral disc prolapse begins with:

• osteochondrosis;
• scoliosis (curvature of the spine);
• spondylosis (appearance of bone intervertebral growths);
• spondylitis (inflammatory processes in the spinal column).

These diseases are the direct cause of disc deformation, however, they also have their own prerequisites and risk factors:

• 
  Pay attention to the main reasons for the appearance of protrusions in the spine; poor posture;

• weak muscle corset;
• overload of the spinal muscles;
• prolonged static muscle tension (for example, sitting in an uncomfortable position);
• spinal injuries;
• genetic disorders of the musculoskeletal system;
• maintaining an unhealthy lifestyle;
• obesity

A separate risk group includes elderly people (due to a higher likelihood of progression of age-related osteochondrosis) and people with impaired calcification of the spine.

Reference! Calcification is the process of deposition of calcium salts. With the normal functioning of all body systems, calcium salts are concentrated in the vertebrae; disturbances in metabolic processes lead to bone osteoporosis. Another possible pathology associated with calcification is the accumulation of salts not only in the vertebrae, but also in the ligaments of the musculoskeletal system: this usually occurs during the development of spondylitis.

What are the symptoms of the disease?

Affected discs may not cause any clinical manifestations, but more often present with pain. It happens that intervertebral disc protrusion is not diagnosed immediately, as patients come with vague pain in the hips, knees or legs. Although it is theoretically possible for a hernia to appear in any part of the spine, in practice, as a rule, patients are faced with damage to the intervertebral discs in the cervical and lumbar regions. The onset of protrusion formation can be acute, due to injury or sudden movement, or develop slowly, progressively, without visible external causes.

Symptoms of intervertebral disc protrusion may vary depending on the location of the hernia and the type of soft tissue that is affected by it. They can range from a pain-free existence, where a bulging disc is the only change, to severe and unrelenting pain in the neck or lower back that radiates to adjacent areas. Other symptoms may include sensory changes such as numbness, tingling, or a crawling sensation; Muscle weakness, paralysis, and changes in reflexes may occur.

For example, in the case of a disc protrusion in the lumbar region, the patient may experience pain along the outer or back surface of the leg, a feeling of “muscle spasm,” numbness or tingling in these areas.

Damage to the nerves in the lumbosacral region can lead to loss of bowel and bladder control, as well as sexual dysfunction (cauda equina syndrome).

After the appearance of protrusions of the cervical intervertebral discs, pain occurs, localized in the neck and sometimes in the arms. Typically, symptoms are experienced on only one side of the body.

If the bulge is very large in shape and volume, pressure on the spinal cord can cause pain on both sides of the body, often with serious consequences, which can lead to permanent nerve damage or paralysis.

Protrusions can cause secondary changes in the spine, such as:

• intervertebral disc herniation - rupture of the fibrous ring.
• Spinal stenosis is a narrowing of the spinal cord canal, which leads to compression of the spinal cord and the nerve roots emerging from it. Stenosis can also be the result of thickening of the ligaments, the presence of posterior marginal growths, and other reasons.
• Osteoarthritis of the intervertebral joints is the result of wear and tear of the articular cartilage in the intervertebral joints. In this case, the distance between the vertebrae decreases, which changes the relationship of the articular surfaces to each other, as well as the mechanics of the joint itself.

Treatment

Foraminal protrusion requires complex therapy. The primary goal of treatment is to stop the progress of intervertebral disc destruction.

General recommendations:

• exclusion of heavy physical labor;
• maintaining a daily routine;
• no strain on the back

Physiotherapy plays a special place in the treatment of intervertebral disc protrusion Mechanical methods

• daily gymnastics;
• physical therapy (often includes swimming);
• massage;
• physiotherapy;
• spinal traction (in a traction chair or on a plane)

Drug treatment

Medications for foraminal protrusion are prescribed to relieve swelling, reduce inflammation and block pain.

Several groups of drugs are used:

• non-steroidal anti-inflammatory drugs;
• antispasmodics and muscle relaxants (for severe muscle spasms);
• analgesics.

Initially, the patient is given intramuscular injections for several days; as the clinical picture improves, the patient switches to oral medications (tablets) and external medications (gels and ointments for external use).

Alternative techniques

In cases where traditional treatment methods do not produce tangible results, the doctor may prescribe another method to the patient.

Today they are actively used:

• "Bone block" method. It involves administering an injection directly into the affected area of ​​the spinal column.

Method of blocking pain syndrome in case of pinched nerve

• Laser vaporization of the disc . The nucleus pulposus is “cauterized,” stopping its further growth. This technique is effective only at the early stage of protrusion development.
• Hydroplastics . Solves the problem of dehydration of the affected disc: under pressure, a special liquid is injected into the affected segment of the spine, which moisturizes the areas of the disc that have escaped destruction.
• Cold plasma nucleoplasty . It is expected that cooled plasma will be injected into the lesion. The method is aimed at reducing disc pressure and, as a result, reducing pain.

Technique for cold plasma disc nucleoplasty

As you can see, there are many methods for treating foraminal protrusion of the intervertebral disc and their combinations. Modern medicine has managed to achieve the most favorable prognosis for treatment (about 93%), but everything always depends on the specific case.

Diagnosis of intervertebral disc protrusions

If you experience back pain in the lumbar region, neck, sensory disturbances in the limbs and other symptoms described above, you should consult a neurologist and undergo an examination.

To diagnose degenerative changes in the spine, the doctor usually finds out the presence of typical painful symptoms, concomitant rheumatic diseases, sensory and motor disorders, and deterioration of reflex activity. In addition, MRI plays a decisive role in forming an objective diagnosis.

Diagnostic methods

Protrusion of the L4-L5 parts of the spine does not reveal its presence for a long time. However, as soon as nerve tissue is pinched, characteristic symptoms appear. After a survey and examination, a neurologist

will prescribe several procedures for you that will allow you to obtain the necessary amount of information.

Plain X-ray of the spine

Allows you to obtain a lot of information about the patient’s health status. Namely:

• identifies curvatures that could cause dorsal protrusion of the L4-L5 disc;
• what condition are the vertebrae in, are there any damages;
• at what distance are the vertebrae from each other - if the distance is reduced, the protrusion will make itself felt over time.

However, at the same time, radiography does not allow us to evaluate the whole picture as a whole, since only the bone structures of the spinal column can be examined.

MRI

Magnetic resonance imaging allows you to exhaust all questions regarding the condition of the vertebrae and fibrous membrane. MRI is performed in two projections; it can also be used to assess the condition of the tissues around the spine.

CT scan

Dorsal disc protrusion L4-L5 can also be diagnosed using CT, but it is prescribed less frequently than MRI. The thing is that such a procedure involves the need to irradiate the body. The final decision regarding the method of diagnosing the disease is made by a neurologist or vertebrologist

.

Characteristic features of retrusion

This pathology occurs when some teeth deepen towards the inside of the mouth. The reasons for such tooth growth are of the same nature as for protrusion. The culprit here is overnumeration, displacement of large adjacent teeth, pathologies with milk teeth, and bad habits.

The consequences of the disease may be other pathological conditions. First of all, there is a crowding of the row and a trapezoidal formation of the jaw, the teeth in which are retruded. The bite becomes deeper, causing injury to the opposite gum. Speech disorders appear, the smile becomes unsightly.

Types of retrusion are divided into: occurring on both jaws and separately on one of the arches. Depending on its location, it can be on different teeth.

Prevention of retrusion

This type of disease can be treated, but it is best not to lead to complications and carry out prevention in advance. The most common cause of this pathology is the habit of thumb sucking in childhood. To avoid consequences, parents are advised to wean their children quickly and without delay.

The second most popular reason is considered to be the habit of breathing through the mouth. In this case, children should be weaned more gently and first check what exactly is preventing the baby from breathing correctly through his nose. These may be adenoids, sinusitis and many other symptoms.

The habit of chewing pens, pencils and any other objects, which occurs in both children and adults, has a very bad effect on teeth. Parents of schoolchildren should be especially attentive to this problem. In this way, a person usually seeks to cope with negative emotions or resolve difficult situations. The solution to the problem is simple - find another way to calm down.