Intervertebral disc herniation, treatment of spinal hernia

Intervertebral hernia has become increasingly common in people of all ages. A disc herniation compresses the nerves and spinal cord, which is accompanied by severe pain and neurological symptoms (numbness, weakness in the limbs). If treatment is not started promptly, the disease can lead to permanent neurological deficits.

To understand how an intervertebral hernia occurs, you need to familiarize yourself with the structure of the spine. The spine is the main supporting structure of the body and consists of a chain of vertebrae (33-34). Between the vertebrae there are intervertebral discs, which are necessary for the flexibility and mobility of the vertebrae. The intervertebral disc in its structure has a core and a fibrous ring. Due to excessive physical exertion or injury, a microcrack may occur in the annulus fibrosus. During life, the crack grows and leads to “protrusion” of the core tissue beyond the spine. Thus, an intervertebral hernia begins to form.

Stages of disc herniation formation

Degenerative-dystrophic changes in the disc . Micro-tears appear in the fibers of the nucleus pulposus, the fibers of the fibrous ring weaken, and in the end plates there is a decrease in the intensity of blood flow and a decrease in the quality of nutrition of the disc. This leads to a deterioration in the shock-absorbing functions of the disc.
Partial disc prolapse. The fibers lose their ability to withstand loads, the magnitude of which can reach 150–300 kg per disc. As a result, the nucleus pulposus is displaced and then protrudes into the spinal canal, i.e., protrusion occurs. Often in this condition no special problems arise, but asymmetrical protrusion can pinch the nerve, which leads to pain.
Disc herniation. Against the background of progressive degenerative changes, the nucleus pulposus extends beyond the fibrous ring and touches the nerve root. The outer shell, which can be called a kind of disc case, can infringe on part of the nucleus pulposus and prevent it from coming out completely. The result is radicular pain that radiates to the leg.
Sequestration. In severe cases, the prolapsed portion of the disc's internal contents becomes detached and can move up or down the spinal canal, causing serious neurological complications.

Interesting Facts:

In a person weighing about 65 kg, bending the torso forward 30° and lifting a load weighing 14 kg creates a load on the L3-L4 and L4-L5 discs of about 150–200 kg each. If you increase the angle of inclination of the body to 70°, the load increases to 300 kg, which can lead to a crack in the fibrous ring, especially with a weakened muscular system and a worn-out disc.
An intervertebral disc can withstand a load of about 5 atmospheres, while for comparison in a car wheel the optimal pressure level is considered to be 2.2 atmospheres.

Features of anatomy

The entire spine is formed by more than 30 vertebrae of different sizes and is divided into 5 sections:

cervical - formed by 7 vertebrae (C1–C2), which are the smallest and most mobile in the body;
thoracic - formed by 12 vertebrae (Th1–Th12), least likely to be susceptible to degenerative-dystrophic changes;
lumbar – consists of the 5 largest vertebrae (L1–L5), which bear the greatest load during physical work;
sacral – has 3 vertebrae (S1–S3);
coccyx – formed by 1–3 fused vertebrae.

Between all the vertebrae there are cartilaginous structures that provide shock absorption when walking and the natural flexibility of the spine. They are called intervertebral discs. Each disc has a pulpous nucleus pulposus and a tough outer shell called fibrous. It is protected on the sides by end plates.

Causes of intervertebral hernias

The spinal canal runs inside the spine and contains the spinal cord. On average, the width of the canal is 1.5–2 cm along its entire length. The section of the spinal cord in the projection of the level of the first vertebrae of the lumbar region L1-L2 and below is called the cauda equina, since in this area all the nerve fibers descend down and branch at each level of the vertebrae to the sides, innervating certain areas of the body.

Thus, the nerve root originating at the level of L3-L4 is responsible for the innervation of the anterior part of the thigh to the knee joint, at the level of L4-L5 - for the lateral sides of the legs, and at the level of L5-S1 - for the back sides of the legs. From the spinal canal, the nerve roots extend into the lateral recess (recessus), i.e., exactly the area where disc protrusion occurs. It is formed on one side by the posterior part of the fibrous ring of the intervertebral disc and the vertebral bodies, and on the other by the ligamentum flavum and the vertebral arches on the sides of the intervertebral joints.

Important! The size of the recession from birth may vary. With a small volume, even a slight protrusion can cause severe compression of the nerve.

There are many factors that contribute to the development of intervertebral hernias. First of all this:

weakness of the musculo-ligamentous apparatus of the spine caused by physical inactivity;
weakness of the annulus fibrosus, which is usually an inherited feature;
excess weight;
lifting weights, professional sports;
regular long-term static loads;
suffering from back injuries;
deformations, as well as pathologies of the spine, in particular sacralization, lumbolization;
characteristics of work (loaders, truck drivers, programmers and representatives of other professions associated with sedentary work are more susceptible to the development of osteochondrosis).

Symptoms and features of manifestation

The main manifestation of a spinal hernia is pain. It can be of a different nature and manifest itself under different circumstances, which depends on the position of the protrusion in the spinal canal, i.e., its type. The pain usually tends to get worse with movement.

Disruption of the functioning of nerve endings connecting the central nervous system and organs over a long period of time will lead to irreversible changes (diseases) of internal organs

Additionally, there may be impaired mobility of the affected spinal motion segment and a feeling of numbness in the limbs. Other symptoms also occur, but their nature is completely determined by the projection of which spinal roots the protrusion is located in.

Cervical hernias

Thus, when an intervertebral hernia forms in the cervical spine, discomfort or obvious pain when turning the head is most often observed, as well as limited mobility of the neck and shoulder girdle. Often the pain radiates to the shoulders, arms and head, and there is a feeling of numbness in them. Patients also often note:

sleep disorders;
deterioration of vision and hearing;
an increase in the incidence of colds, especially manifested by a sore throat;
the occurrence of allergic reactions;
increased irritability, nervousness;
loss of consciousness (especially often occurs when the artery is compressed by a large protrusion);
causeless increase in blood pressure;
the appearance of acne on the skin of the face.

Intervertebral hernias of the cervical spine are the most dangerous, since they are located at the level of the upper parts of the spinal cord and can provoke severe neurological disorders.

Thoracic hernias

The thoracic spine is practically not involved in the extension and flexion movements of the back. It bears little stress when lifting heavy objects or sitting. Therefore, osteochondrosis, as well as spinal hernias, are rarely observed in it. Although they also occur. However, they can be difficult to diagnose, since they occur with a clinical picture characteristic of other diseases. Therefore, sometimes it is impossible to differentiate the pathology of the intervertebral disc from diseases of the heart, lungs or gastrointestinal tract without special instrumental studies.

Often in such situations the following are diagnosed:

asthma;
arrhythmia;
IHD;
Chronical bronchitis;
cholecystitis;
liver diseases;
gastritis;
peptic ulcer of the stomach and duodenum;
diabetes;
colitis;
kidney diseases;
disorders of the pelvic organs, including gynecological and urological diseases, infertility.

One of the symptoms of infringement of the spinal roots at the level of the 8th vertebra may be frequent hiccups.

This often becomes the reason that people are prescribed a whole range of medications that are designed to eliminate disturbances in the functioning of these particular organs. But due to the fact that the cause (spinal hernia) remains, all attempts to improve the functioning of the heart, lungs, and gastrointestinal tract are unsuccessful or, at best, lead to temporary relief. Therefore, it is very important when any deviations in the functioning of any internal organs occur, to pay attention to the condition of the spine, since the quality of the functioning of the whole organism depends on it.

Thus, intervertebral hernias of the thoracic spine can be accompanied not only by acute pain in the area of the affected disc, but by discomfort behind the sternum (with a Th1–Th2 hernia) or abdominal pain (typical of Th5–Th8 lesions). Gait may also suffer, as there is weakness in the legs, a feeling that they do not obey.

When nerves are compressed, deviations in the functioning of their corresponding internal organs appear over time, which may be accompanied by:

frequent cough, especially at night and in the morning;
discomfort in the palms;
increased fatigue;
weakness;
increased frequency of urination;
yellowness of the skin and mucous membranes;
slowing blood clotting;
breathing problems;
disruptions of the menstrual cycle;
problems with potency.

With a Th8–Th9 hernia, a weakening of the immune system may occur, which leads to an increase in the frequency of respiratory infections and the occurrence of allergic reactions.

Lumbar hernias

It is the lumbar spine that experiences maximum stress and is characterized by high mobility. For example, when bending to lift an object weighing about 14 kg, its vertebrae place a load of about 150–200 kg. If a person is overweight, then the spine experiences even greater overload.

In almost 40% of cases, pathological protrusion of the intervertebral disc is formed at the L5–S1 level. This is accompanied by:

pain in the sacrum;
loss of ability to stand on tiptoes;
numbness of the little finger;
nagging pain along the back of the legs;
swelling of the lower extremities.

In 30% of cases, the hernia is located at a higher level (L4–L5), this leads to:

lower back pain;
pain along the sciatic nerve;
inability to stand on your heels;
discomfort in the knees, feet, ankles, mainly along the lateral surface;
numbness of the big toe;
urinary disorders.

Even less commonly, a pathological protrusion forms in the L3–L4 disc, which is characterized by:

pain in the lumbar region, intensifying when raising the legs;
severe nagging pain in the anterior thigh area, often radiating to the knee;
bending your knees while walking;
dysfunction of the bladder and genital organs in men.

In less than 10% of people, spinal hernias form at the L2–L3 and L1–L2 levels. This is accompanied, in addition to lower back pain, discomfort in the inner thighs, digestive disorders and pain in the abdomen and groin.

Diagnosis of the disease

Unfortunately, when symptoms of intervertebral hernia occur, people often delay visiting a doctor and undergoing an examination, look for information on dubious sites and relieve pain with self-selected medications. This helps to temporarily relieve the condition, which creates a false feeling of recovery.

Therefore, patients continue to perform their usual work, which further aggravates the situation and increases the risk of developing neurological complications. Such negative consequences can be avoided if a timely examination is carried out and the cause of the discomfort is determined.

The main method for diagnosing a hernia is MRI. The study is safe for humans and at the same time provides comprehensive, accurate data. It allows you to detect the slightest degenerative changes in the disc, as well as protrusion, the actual hernia and displacement of the vertebrae.

Magnetic resonance imaging can be performed using special large-sized closed or open type devices. In the first, the patient lies down on a couch, which slides into a pipe where a magnetic field is created. It is important to remain completely still to get a clear image. The procedure lasts about 20 minutes, but it is not suitable for people who have older generation metal implants (not titanium), fragments and other objects in their bodies, or those who suffer from claustrophobia.

Open machines are designed for MRI in patients who are afraid of closed spaces. But they create a less powerful magnetic field (up to 0.2–1.2 tesla), which negatively affects the quality of the resulting image. Moreover, in closed-type devices, the magnetic induction power can be 1, 1.5 and 3 Tesla.

If it is impossible to conduct an MRI, for example, if there is metal (except titanium structures) in the body, other diagnostic methods are used:

CT is a highly accurate procedure that allows you to detect deviations in the condition of the bone components of the spine by passing a beam of ionizing radiation through it. With its help, osteoporosis, fractures are diagnosed, and hernias are also detected. The study lasts 5 minutes and has virtually no contraindications.
X-ray – used to diagnose instability of the spinal motion segment. The study is usually carried out in lateral and direct projection. Additionally, it may be prescribed to take images during flexion and extension in a standing position. This helps to increase the load on the spine and obtain objective information. X-ray images allow you to evaluate the height of the discs, determine the presence of bone growths, vertebral anomalies and their displacement.

Deciphering the results of hardware research requires specific knowledge and experience. Therefore, you should not try to diagnose the pathology yourself; it is better to immediately contact a specialist who will correctly assess the nature of the existing changes and be able to select the optimal treatment regimen.

Which doctor should I contact?

Initially, if you have back pain, you should consult a neurologist, or better yet, a vertebrologist. This specialist will conduct a thorough examination, collect anamnesis,, if necessary, prescribe the necessary list of studies and will be able to correctly decipher their results.

If during the examination a protrusion or hernia is detected, the vertebrologist, based on its size and clinical picture, will develop an effective tactic of conservative treatment or refer the patient to a neurosurgeon, spinal surgeon, or orthopedic traumatologist for consultation and surgical removal of the hernia.

Complications and consequences:

If you ignore the problem, increased pain will not be the only consequence of the progression of the hernia. Since it gradually increases, this is fraught with:

spinal canal stenosis;
disruption of the pelvic organs;
paresis or paralysis of the lower extremities.

Kinds

All hernias can be divided into anterior and posterior (dorsal). The former are rare and have a very favorable prognosis, while the latter pose a danger to a person’s physical capabilities because they fall into the lumen of the spinal canal. Depending on their location they are divided into:

central (median) – located in the central part of the spinal canal, so they can provoke the appearance of pain, both on the right side of the body and on the left;
paramedian - formed on the left or right side relative to the central axis of the spine, therefore causing the appearance of characteristic symptoms on the corresponding side of the body;
circular - the entire posterior surface of the disc protrudes, which leads to filling of the entire spinal canal and the development of severe neurological symptoms, as well as severe pain;
foraminal - a hernia forms in the area of very narrow openings of the spine formed by the vertebral body and articular processes, and causes burning, excruciating pain.

Depending on the size of the hernia they are divided into:

small – the size of the protrusion does not exceed 5 mm;
medium – the hernia reaches 5–7 mm;
large - the formation increases to 8 mm or more.

But, unlike popular belief, the size of the intervertebral hernia is not strictly related to the severity of the observed symptoms. Even very large hernias can exist for a long time completely asymptomatically and are discovered by chance, while small ones can so infringe on the spinal root that not only severe pain syndrome occurs, but also serious disruptions in the organ innervated by it. Therefore, treatment tactics for each patient are chosen to a greater extent in accordance with the severity of complaints, rather than the size of the formation.

Conservative treatment

In the absence of severe neurological symptoms (weakness in the limbs, dysfunction of the pelvic organs) and not pronounced compression of the nerve endings, non-surgical treatment of the hernia is possible. Its effectiveness largely depends on the correct selection of each component of conservative therapy, which are:

Drug treatment

It is developed individually and always includes drugs from the NSAID group in oral (tablets), injection form or in the form of ointments for pain relief, B vitamins (Milgamma) to improve nerve trophism. Taking muscle relaxants is also indicated. Additionally, patients may be prescribed chondroprotectors (their cost is quite high, and their effectiveness has not been officially confirmed, but many patients notice positive dynamics).

Blockades

Indicated in cases requiring pain relief. There are several types of blockades depending on the site of drug administration. They can be performed with solutions of corticosteroids or analgesics.

Physiotherapy

A course of magnetic therapy, electrophoresis, phonophoresis and ultrasound therapy procedures increases the effectiveness of treatment and helps accelerate pain relief. In mild cases, physiotherapeutic procedures can be performed at home by purchasing a special device.

Exercise therapy

An obligatory component of conservative therapy. Aimed at improving blood supply in the area of the compressed nerve, due to the flow of blood, regeneration of nerve cells occurs. A set of individually selected exercises should be performed daily, monitoring sensations and avoiding sudden movements. If pain appears or intensifies, you should consult a doctor to understand what caused the discomfort and, if necessary, adjust the set of exercises.

Spinal traction

Traction therapy is an effective method for treating hernias, especially in the cervical region. The essence of the method is to temporarily relieve the pressure on the nerve by the hernia, which allows you to supply the affected area with nutrients, minerals and vitamins. The procedures are carried out using a special apparatus (sometimes in water), which gives a positive result within the first month.

Kinesitherapy

One of the areas of exercise therapy, which involves performing certain passive and active movements. By triggering active muscle contractions, the muscle corset is strengthened, which subsequently takes on the load and relieves the joints of the spine and improves their blood supply. Which helps reduce swelling and eliminate muscle spasms.

Acupuncture

The impact of special needles on specific bioactive points increases the effectiveness of the treatment and helps to quickly eliminate pain.

Reflexology

This involves using, for example, the Kuznetsov applicator, which helps relax spasmodic muscles and eliminate back pain. Its design allows you to simultaneously influence acupuncture points and perform a massage, but the use of the Kuznetsov applicator is possible only as prescribed by a doctor. To treat different areas, different types of applicators have been developed: belt, mat, neck roll.

Osteopathy

It involves the influence of the doctor’s fingers on certain areas in order to return joints and muscles to the physiologically correct position and improve their mobility.

Conclusion about conservative treatment:

If you strictly follow medical recommendations, after completing a course of conservative treatment, pain may disappear. In such cases, they speak of remission of the disease. Its duration depends on how closely the patient adheres to the advice of doctors and the amount of physical activity.

At home, you need to avoid static and physiologically incorrect loads on the spine. To reduce the load, on the recommendation of a doctor, you can wear an orthopedic bandage (corset). It is recommended not to sit in one position for a long time, periodically warm up and do exercises, thereby ensuring the necessary blood flow to all muscles and joints.

Rehabilitation

The main objectives of rehabilitation are the elimination of postoperative pain, the prevention of complications and the restoration of normal functioning of the spine and muscles. For each patient, a set of measures aimed at solving these problems is selected individually. In some cases, it is enough to stop lifting heavy objects and adjust your lifestyle, but after complex open interventions, serious rehabilitation is required.

The main components of a rehabilitation program can be:

Exercise therapy is the basis for proper and rapid recovery. Classes begin under the guidance of a specialist and gradually increase the load. It is important to perform all the exercises regularly, not to make sudden movements and monitor your own sensations.
Wearing a corset - orthopedic structures help to reduce and correctly distribute the load on the spine, which will facilitate rapid recovery.
Drug therapy – treatment is aimed at accelerating tissue regeneration processes and relieving pain. It may include drugs from the NSAID group, chondroprotectors, vitamin complexes,
Kinesitherapy is popular because, unlike exercise therapy, it also involves training on orthopedic simulators. Thanks to individual selection of the level of load on the back muscles, it is possible to quickly develop the back muscles without risks.
Manual therapy is prescribed only by a doctor after the end of the early rehabilitation period. But even after receiving permission, a chiropractor can only use an extremely gentle method of influence - PIR.
Swimming – regular visits to the pool help to gently and without risks strengthen the muscular corset, which will help maintain the spine in the correct position.
Therapeutic massage – helps eliminate swelling and avoid muscle atrophy. But you can begin a course of procedures only a few weeks after the operation, and only with the permission of the doctor.
Physiotherapy – electrophoresis, magnetic therapy, ultrasound therapy, mud baths are used to alleviate the patient’s condition and accelerate reparative processes.

Some patients are additionally recommended to do yoga, stretching exercises, etc. But you can start classes only with the permission of a doctor.

The duration and severity of rehabilitation directly depends not only on the type of surgical intervention performed, but also on the individual characteristics of the patient, the presence of concomitant diseases, etc. After some operations, patients are not allowed to sit, bend over, or perform certain work. If you ignore medical recommendations, patients run the risk of experiencing postoperative complications or relapse of the disease.

Prevention

To reduce the likelihood of a hernia forming or reoccurring, it is important to make lifestyle changes. First of all you should:

stop smoking and minimize the amount of alcohol consumed;
do exercise therapy and stretching exercises daily;
undergo a course of manual therapy twice a year;
avoid stress and change your attitude towards stressful situations;
sleep at least 7–8 hours;
wear high-heeled shoes no more than 2 hours a day;
visit the pool twice a week;
balance your diet, give up unhealthy foods and adhere to a normal drinking regime (at least 1.5 liters of water per day);
take vitamins, especially group B and unsaturated fatty acids (Omega-3).

Pain after microdiscectomy

A rational orthopedic regimen, physiotherapy and adequate drug care ensure a completely tolerable postoperative recovery. It is important to understand that it is normal to feel pain immediately after the procedure, as you have had a full surgery. As a rule, the pain syndrome is significantly reduced by 3-4 days, so be patient, soon you should not be bothered at all. But be sure to immediately notify your doctor if suddenly the pain does not decrease or intensifies, since it is possible that secondary negative reactions have occurred.

When, in addition to removing the hernia, lumbar fixation was performed.

Do not forget about the possibility of relapse, including in the long term. It also signals itself with painful signs, including lumbago, including impaired sensitivity in the legs and arms, which you have already encountered. To protect yourself as much as possible from re-development and exacerbation of the disease, you need to follow simple rules.

This rule is addressed to women who want a child. Plan your pregnancy so that the birth occurs approximately 2 years after surgery. Doctors do not recommend that a woman after microdiscectomy become pregnant earlier than 12 months later.
Do not sit exactly as long as the specialist told you. When you can sit, after 14 days or only after 1.5 months, the doctor will determine based on your progress in recovery. When this ban is lifted, do not stay in a sitting position for long.
Do not ignore wearing a corset - you absolutely need it, strictly adhere to the standards for its use established by your doctor! Moreover, do not carry heavy weights and distribute the load evenly on each hand.
As for sex, intimate life is not allowed for at least 7 days after spinal surgery. Throughout rehabilitation, intimacy should be unforced. In any case, do not hesitate to ask your attending surgeon about this issue; this is one of the temporary restrictions that also requires strict adherence.
The next point is physical education. Let’s answer right away: is it possible to take physical training after microdiscectomy? No! Until your spine is completely restored, don’t even think about taking any sports standards. It is worth considering that intense running, jumping, leg swings, presses, twisting, pull-ups are not allowed after full recovery! People return to normal physical activity that does not involve increased stress after about 2-3 months.
Do not drive a car during the entire recovery period. The same goes for traveling on public transport. Also, during rehabilitation, do not load the spine for more than 30 minutes, take rest breaks, taking a horizontal position. Try to maintain an optimized alternation of activity and rest after recovery.
Every year, ideally 2 times a year, undergo sanatorium-resort treatment in a good sanatorium that specializes in the restoration of the spine and musculoskeletal system.

And the last thing is to regularly, throughout your life, do special exercises for the health of the spine, which qualified methodologists taught you back in the rehabilitation department. Your responsible attitude to what we have talked about will be rewarded with excellent results after surgical treatment, which will not take long to arrive. But most importantly, you will be able to protect yourself as much as possible from re-herniation both in the old place and in other intervertebral levels.

Treatment prognosis

The effectiveness of treatment, both conservative and surgical, directly depends on how accurately the patient follows medical recommendations. Also, the likelihood of relapse depends on the nature of the operation performed. With complete removal of the disc in one way or another, there is no risk of recurrence of the hernia in the same place, but it can form in adjacent spinal motion segments.

On average, the relapse rate after surgical treatment of hernias is 11.5%. But most often they are formed in other PDS.

Endoscopic type of microdiscectomy

This process of microdiscectomy is controlled not with a microscope, but with a light-conducting fiber-optic device called an endoscope. This is the most gentle tactic, which relates to a full ectomy, but it does not require general anesthesia, that is, the session is performed under local anesthesia.

An endoscope tube, at the end of which there is a miniature video camera, is inserted percutaneously into the spinal space, within the desired area, using a posterolateral approach. The incision is 2 times smaller than with a conventional microdiscectomy. It is approximately 1.5 cm.

The operating monitor receives video information in a multiply enlarged format, showing in real time the condition of the disc and adjacent vertebral tissues. Microsurgical instruments are inserted into the endoscopic probe, which is used to pinch off the protruding part of the cartilage. Having seen the free cartilaginous bodies exfoliated from the base of the disc, the surgeon also safely removes it. Pathological tissues are removed through the output section of the endoscope. Thus, the nerve root is freed from compression, and the pain syndrome disappears.

The price for endoscopic surgery is higher; in clinics in the Russian Federation, the price range starts from 100 thousand rubles, the maximum figure is about 300 thousand rubles. Percutaneous technology has similar goals and objectives as standard microdiscectomy. But the consequences and recovery time for endoscopy of a hernia at the lumbar level, as well as in other parts of the spinal axis, are significantly minimized. Moreover, reviews say that walking after such a minimally invasive operation is allowed within 2 hours, and if you feel well, you can leave the hospital the next day. It is worth noting that this method has been introduced into orthopedic practice quite recently, so it has not yet been mastered well enough in our country.