Stages of development of intervertebral hernia of the lumbar spine

December 26, 2019

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The vertebrae of the lumbar spine are the widest and largest, since they bear the main load when turning the body and doing physical labor. Therefore, herniated intervertebral discs most often form in this area. Most often, the L4-L5 and L5-S1 discs are affected, but often, simultaneously with their deformation or in isolation, the degenerative-dystrophic process occurs slightly higher - between the 3rd and 4th vertebrae of the lumbar spine. As a result, an L3–L4 disc herniation is diagnosed.

About 4-5% of all patients with intervertebral hernia know firsthand what it is and where it hurts with a herniated L3-L4 disc.

In the area of ​​the L3–L4 disc there are nerve endings responsible for the innervation of the muscles of the middle part of the anterior surface of the thigh and the lateral area of ​​the knee. Therefore, when they are compressed, there may be a decrease in the sensitivity of the legs in these areas, which also negatively affects motor activity.

Symptoms of L3–L4 disc herniation:

• acute or constant aching pain in the lumbar region, which goes away when resting in a supine position;
• radiating pain in the leg;
• sensation of crawling, tingling in the above-mentioned areas;
• violation of stability;
• stiffness of movements;
• paresis and paralysis.

If there is also a hernia of L4–L5 or L5–S1 of the lumbosacral region, pain will also be present in the buttocks, along the back of the legs, and radiate to the legs and feet.

The main provoking factors for the development of the disease are excess weight, back injuries, as well as such polar working conditions as office work and associated with heavy physical exertion.

Complications and consequences of intervertebral hernia

If there is no timely treatment for a hernia, this is fraught with the development of consequences and complications that negatively affect a person’s life. The most striking complications of intervertebral hernia are:

• paresis of the back or limbs;
• paralysis of limbs;
• chronic pain syndrome;
• dysfunction of the bladder and intestines. This happens when the nerve bundles that are responsible for nerve patency are compressed.

Intervertebral hernia is a serious disease that requires a careful approach to treatment. It is important to consult a doctor on time, undergo appropriate examinations, and follow all medical prescriptions. This is the only way a doctor can prescribe competent therapy. With the right approach to treatment, it is possible to stop the growth and development of the disease and prevent serious consequences and complications.

Kinds

All intervertebral hernias can be divided into anterior and posterior. In the first case, symptoms of L3–L4 disc herniation may be completely absent, since it forms in the direction of growth of the spinous processes. The greatest danger is posed by posterior (dorsal) hernias, since they protrude towards the spinal cord and, when reaching a certain size, can compress the nerve endings and the spinal cord itself.

Depending on the location of the hernia in the spinal canal, there are:

• foraminal;
• median;
• paramedian;
• diffuse.

Each hernia sequentially goes through several stages of development from protrusion to sequestration, i.e. separation of part of the nucleus pulposus from the disc. As a result, it is able to move freely along the spinal canal and can cause significant damage to the dural sac and nerve roots. It is hernias in the sequestration stage that are most dangerous to human health.

Foraminal

When a hernia protrudes into the narrow foraminal openings of the spine, severe pain occurs as the nerves pass through there. They are difficult to detect because the spinal canal remains free.

Paramedian

A fairly common type of hernial protrusion, which is characterized by its formation in the projection of the nerve root cuff, i.e., on the left or right side of the spinal canal. Since this area is the most sensitive, even small hernias can cause severe pain. Paramedian hernias are dangerous due to compression of the dural sac.

Median

Median hernia L3–L4 is extremely rare. It forms clearly in the center of the spinal canal and, when it reaches a large size, can affect the spinal cord.

Diffuse

Such formations occupy the entire space of the spinal canal and are dangerous due to severe compression of the spinal cord. They are accompanied by severe pain even at rest and severe weakness of the leg muscles.

Symptoms

The main sign of the development of the disease is pain. Initially, it is weakly expressed, often dull. Sometimes there is a characteristic crunch in the lower back, which usually precedes the onset of pain. But as the disease progresses, the pain intensifies and can sometimes become unbearable. The pain tends to increase in intensity while walking, moving, after prolonged sitting, or doing physical work.

As the protrusion of L3-L4 increases, the nerves passing at the level of this intervertebral disc may be pinched, which leads to pain that begins to radiate to the buttocks and legs. In this case, lesions of the L3- L4 disc are characterized by irradiation of pain into the outer lateral parts of the buttocks, the front and inner thighs, as well as the knee area and the inner surfaces of the legs up to the ankle .

This is due to the fact that at the level of the L3-L4 disc there are nerves responsible for the innervation of these parts of the legs, as well as:

• genital organs (ovaries, uterus);
• bladder;
• prostate gland.

Therefore, when they are infringed, the quality of transmission of nerve impulses suffers. As a result, the functioning of the internal organs of the small pelvis is disrupted, since the nervous system loses connection with them. Thus, with protrusion of L3-L4 the following may also be observed:

• urinary disorders;
• gynecological diseases;
• impotence;
• problems with conception, infertility.

In severe cases, with protrusion of L3-L4, control over the process of urination may be completely lost, i.e., urinary incontinence may occur.

Also, damage to the nerves at this level of the spine may be accompanied by involvement of the sciatic nerve in the pathological process, resulting in the development of sciatica. Especially often with L3-L4 protrusion, people complain of pain in the knees and feet, as well as other neurological disorders, including:

• crawling sensation, numbness of the buttocks, thighs, ankles and feet in the above areas;
• decreased muscle tone of the lower extremities, impaired stability;
• limited mobility caused by muscle spasms or pain.

With paramedian or foraminal protrusion of L3-L4, such disorders are unilateral, but with diffuse or median protrusion they are usually bilateral.

The fact is that the occurrence of pain in the lumbar region and the inflammatory process caused by the destruction of the intervertebral disc, the body reacts to this by increasing the tone of the lower back muscles. In other words, they spasm, which further intensifies the pain. This is how a vicious circle of “pain - spasm - pain” is formed.

Diagnostics

The first stage of diagnosis is an examination by a neurologist or vertebrologist. During the consultation, the doctor collects data about the patient, lifestyle and working conditions, other existing diseases, etc. Then he conducts an examination, which allows already at this stage to suspect the presence of a protrusion, L3-L4 hernia or perineural cyst. In order to clarify the diagnosis, the following are prescribed:

• MRI;
• CT;
• X-ray examination.

MRI provides the most information about the type, size and other characteristics of a L3–L4 hernia. The results of the study are presented in the form of photographs, which reflect the studied area of ​​the spine in layer-by-layer sections. This allows you to accurately assess the situation and, if surgical intervention is necessary, thoroughly plan the course of the operation.

Methods for diagnosing intervertebral disc pathology

If any of the above symptoms occur, patients are advised to immediately make an appointment with a chiropractor, neurologist or vertebrologist. At the first appointment, the doctor will conduct a thorough interview and examination of the patient, perform a series of neurological tests that will help to accurately determine the cause of pain in the lumbar region and other abnormalities.

A typical sign of L3-L4 protrusion is the appearance or intensification of pain when trying to lift a straight leg.

Often, these data are enough for an experienced specialist to suspect the presence of a protrusion or hernia of L3-L4. But making a final diagnosis, as well as developing the most appropriate treatment tactics for a particular patient, is possible only on the basis of the results of instrumental diagnostic methods.

The main method used to detect protrusions, hernias and other diseases of the spine is MRI or magnetic resonance imaging. With its help, you can thoroughly and in great detail study the features of the soft tissues of the spine and notice the slightest changes in the discs at the earliest stages of development. Therefore, MRI can detect even the smallest protrusions, the size of which does not exceed a millimeter.

The method also makes it possible to detect nerve damage, inflammation in the soft tissues surrounding the spine, their swelling and many other features, knowledge of the presence of which will help develop the most effective treatment tactics.

Patients may also be prescribed other diagnostic methods, in particular:

• X-ray;
• CT;
• electromyography;
• Ultrasound of the pelvic organs (if any disturbances occur in their functioning);

If you have previously had any spinal tests, it is recommended to take their results to your first consultation with a doctor. This will make it possible, if not to refuse to conduct new studies, then at least to provide the specialist with data on the dynamics of progression of L3-L4 protrusion.

In our clinic, you can also learn in more detail about the composition of your body and the state of the vascular system, which is involved in the blood supply to internal organs, skeletal muscles, and the brain. Our experienced doctors will explain the data obtained to you in detail. Bioimpendansometry calculates the ratio of fat, muscle, bone and skeletal mass, total fluid in the body, and basal metabolic rate. The intensity of recommended physical activity depends on the state of muscle mass. Metabolic processes, in turn, affect the body's ability to recover. Based on the indicators of active cell mass, one can judge the level of physical activity and nutritional balance. This simple and quick test helps us identify disturbances in the endocrine system and take the necessary measures. In addition, it is also very important for us to know the condition of blood vessels for the prevention of diseases such as heart attacks, hypertension, heart failure, diabetes and much more. Angioscan allows you to determine such important indicators as the biological age of blood vessels, their stiffness, stress index (which indicates heart rate), and blood oxygen saturation. Such screening will be useful for men and women over 30, athletes, those undergoing long-term and severe treatment, as well as everyone who monitors their health.

In this case, body composition analysis gives us information that adipose tissue predominates in the body, and the bone-muscle component is in relative deficiency. These data will help the rehabilitation doctor competently draw up a physical activity plan, taking into account the individual characteristics of the patient.

Conservative treatment methods

Treatment of L3–L4 disc herniation in the early stages is quite successfully carried out using conservative therapy methods. The choice of tactics depends on the size, type of pathological protrusion and existing symptoms. So, for protrusion and hernia of L3–L4 up to 0.7 cm without severe pain, the following is prescribed:

• drug treatment;
• traction therapy (spinal traction);
• Exercise therapy.

For formations larger than 0.7 cm but less than 11 cm, the following are additionally recommended:

• physiotherapeutic treatment;
• manual therapy;
• wearing an orthopedic corset.

Drug treatment

The goals of drug therapy are to eliminate pain, improve the conduction of nerve impulses, normalize the trophism of the intervertebral discs and create favorable conditions for their independent regeneration. This is achieved by assigning:

• NSAIDs - drugs in this group effectively eliminate pain of moderate severity and additionally have an anti-inflammatory effect;
• muscle relaxants – help relax overly tense back muscles and properly distribute the load on the spinal column;
• B vitamins – necessary to improve nerve conduction, which is the prevention of paresis and paralysis of the lower extremities;
• chondroprotectors are a group of fairly expensive drugs that require long-term use, but do not yet have clinical evidence of effectiveness.

For severe pain, blockades can be performed, which involve injections of glucocorticoid hormones and anesthetics (lidocaine, novocaine) into special points in the L3-L4 disc area. The procedure is performed under completely sterile conditions by a specially trained medical professional. Otherwise, there is a high risk of damage to nerve fibers or infection, which can lead to serious complications.

Traction therapy

Spinal traction is performed using special devices. There are 2 types of procedure:

• dry traction – involves a vibration-mechanical effect on the muscular-ligamentous apparatus due to the work of special rollers and light stretching of the body in opposite directions;
• wet traction – carried out in a special bathroom, which provides a gentle effect and psychological comfort for the patient.

The procedure allows you to increase the space between the vertebral bodies. Thanks to this, it is possible to stop the progression of the disease and reduce the severity of pain.

Exercise therapy

Effective treatment of L3–L4 spinal hernia is impossible without regular performance of a set of special exercises. As a rule, they are selected by a specialist individually for each patient and at first are performed under his supervision.

Once the patient has completely mastered the technique of each exercise, he can begin to perform them independently. But if pain occurs during any of them, you must immediately stop exercising and consult a doctor to identify the causes.

It is recommended to do physical therapy exercises daily. The duration of the lesson usually does not exceed 15–20 minutes. Visiting the pool will help increase their effectiveness.

Physiotherapy

Patients with L3–L4 hernia are prescribed:

• electrophoresis;
• magnetic therapy;
• phonophoresis;
• ultrasound therapy.

These procedures help relieve pain and increase the effectiveness of the treatment.

Manual therapy

Manual therapy sessions help relieve muscle tension from overstrained muscles and tone overly relaxed ones. This helps to equalize the load on the lumbar spine and reduce pressure on the affected disc. Also, an experienced specialist, by performing special manipulation and mobilization techniques, can achieve a reduction in the size of the protrusion.

Orthopedic corsets

Bandages are prescribed to reduce the load on the lumbar spine. This helps stop degenerative-dystrophic changes in cartilage tissue and allows the intervertebral disc to recover.

The size and rigidity of the corset is selected individually by the vertebrologist. In the first months of treatment, it should be worn constantly, and subsequently - put on before physical work.

Alternative methods of conservative therapy

To increase the effectiveness of conservative treatment, patients can resort to:

• reflexology – relaxes tight muscles, eliminates pain, activates blood flow, which improves nutrition of all tissues;
• osteopathy – targeted impact of a specialist’s fingers on specific areas helps restore the normal position of muscles and joints and improve their mobility;
• kinesitherapy - a certain combination of active and passive movements without stress on the affected part of the spine helps eliminate swelling and muscle spasms.

Which doctor should I contact?

For the treatment of median-foraminal, circular-foraminal, paramedian, left-sided, right-sided and other types of hernia of the lumbar or cervical spine, you should contact a neurologist

.
Some of the best specialists in this field work at the Energo clinic and will be happy to help you with your problem. If the disease turns out to be serious enough, then neurologists, in the process of diagnosing and prescribing therapy, can work in tandem with massage therapists
, physiotherapists,
massage therapists
and other specialists who have extensive experience in dealing with pain and its causes.

Surgery for lumbar hernia L3–L4

Surgical intervention is a last resort measure necessary in the absence of positive changes in the patient’s condition during conservative treatment carried out for more than 1–3 months. It is also prescribed to patients whose MRI images show an intervertebral hernia of L3–L4 greater than 12 mm or severe pain, even if the size of the protrusion is small.

In certain situations that threaten serious complications, emergency surgery is required. We are talking about sequestered hernias. But such interventions are the most technically complex and require maximum care and skill from the neurosurgeon.

Removal of L3-L4 disc herniation is possible today by:

• nucleoplasty;
• endoscopic surgery;
• microdiscectomy.

These operations to remove L3–L4 intervertebral hernia differ not only in price. The main difference is the indications for their implementation and the existing limitations. Therefore, the technique is selected separately for each patient.

All types of modern surgical interventions for the removal of intervertebral hernias have in common a low degree of risk, a good cosmetic effect and a short rehabilitation period, but only if an experienced neurosurgeon is selected.

After endoscopic surgery and microdiscectomy, a disc defect occurs and sometimes it is necessary to remove it completely. In the first case, the Barricaid mesh implant is used to prevent relapse. The second requires the use of a transpedicular fixation technique or the installation of an M6 prosthesis.

Nucleoplasty

The most modern technique for removing intervertebral hernia of the lumbar region L3–L4 is nucleoplasty. It can be performed through the use of various techniques, on the basis of which they distinguish:

• laser nucleoplasty;
• cold plasma nucleoplasty;
• radio wave nucleoplasty;
• hydroplastics.

Hydroplasty using the SpineGet device is considered one of the most effective and safe techniques. The essence of the method is to introduce a special thin instrument into the nucleus pulposus through a pinpoint puncture of soft tissue. A saline solution is pumped through it under pressure, which leads to mechanical destruction of part of the gelatinous contents of the disc. At the same time, the liquefied material is pumped out, which creates all the conditions for the protrusion to be retracted and pain eliminated.

Nucleoplasty is possible for uncomplicated hernias up to 7 mm in size. The postoperative wound does not require suturing. It is covered with a sterile bandage.

Relief occurs almost immediately or the patient’s condition gradually improves over 2 weeks. A huge advantage of puncture surgery is the absence of the need for hospitalization and complex rehabilitation, so the patient can independently leave the clinic a few hours after surgery.

Endoscopic surgery

Removal of a hernia using endoscopic equipment is carried out through a pinpoint puncture of soft tissue, up to 1 cm in diameter. A hollow endoscope equipped with a video camera is inserted through it, which transmits the image to the monitor. Through the endoscope, the surgeon inserts a special manipulator with which he can resect the protruding part of the disc.

Endoscopic surgery is possible for large hernias, as well as those located in the foraminal openings or other narrow areas of the spinal canal. Because access to the disc is created using a shaver, the risk of nerve damage is dramatically reduced.

Microdiscectomy

Microdiscectomy is a microsurgical operation performed through an incision of up to 3 cm. It is performed in the presence of neurological disorders or in the diagnosis of a sequestered hernia, since it is impossible to completely remove it in a less traumatic way.

Rehabilitation

How long the rehabilitation will last and how easily it will proceed depends on the type of intervention performed, as well as its volume. Naturally, when several hernias are removed, for example L3–L4 and L4–L5 or L5–S1, the body will take longer to recover.

Patients are almost always prescribed exercise therapy and short-term drug therapy. After nucleoplasty, patients only need to slightly limit physical activity and avoid lifting heavy objects. Performing endoscopic removal of a hernia requires avoiding prolonged sitting; sometimes physical therapy and wearing a corset are additionally prescribed.

After microdiscectomy, recovery is a little more difficult, so patients are discharged from the hospital only after 5–7 days. They also need to adhere to a gentle regime for a longer time.

Thus, modern operations to remove L3–L4 hernia are extremely safe and low-traumatic. They allow you to quickly get rid of debilitating pain and allow you to return to normal life.

What is a foraminal hernia

To understand what a hernia is and how it forms, you should first consider what a healthy segment of the spine with an intervertebral disc looks like. The intervertebral disc consists of a fibrous ring and a nucleus pulposus of a jelly-like consistency. In close proximity to the disc lies the spinal cord in the dura mater. The spinal nerve departing from it with a sensory and motor root lies in the bone bed - the foramen. Under normal conditions, there is enough space for this nerve formation. Foraminal disc herniation l4 l5 is a protrusion of the fibrous contents of the cartilage beyond its normal limits into the foraminal space. As a result of such protrusion, the spinal nerve is pinched, which, of course, causes severe pain and causes disruption of a person’s motor activity and performance. This type of hernia is considered the most dangerous.