Degenerative diseases of the spine

In accordance with the ICD, degenerative-dystrophic diseases of the spine (DDSD) in medicine are understood as a broad group of pathologies of osteochondral tissue, which often cause chronic pain and gradual destruction of the spinal column. Such changes, sometimes with disabling consequences, include: intervertebral hernias, protrusions, osteochondrosis, spondylolisthesis, long-term consequences of spinal fractures and injuries.

Degenerative diseases of the spine may not bother the patient until a certain point, so they are most often “incidental findings” on CT or MRI. However, over time, the situation worsens - stenosis leads to narrowing of the intervertebral foramina and spinal canal, osteoporosis - to increased fragility and degeneration of the vertebrae, osteophytes and hernias - to neuralgia.

Contrary to popular stereotypes, degenerative spinal diseases are not only common in older patients and adults (median age 40 years), but can also be detected in younger patients. Some common DDSDs, such as Schmorl's hernia, do not affect the patient's quality of life and do not require special treatment or surgery. However, their timely diagnosis will help the patient adjust their lifestyle (change motor habits, add exercise therapy, conservative treatment procedures) and thus prevent possible complications.

In this article we will tell you what other diseases belong to the group of DDSD, how they manifest themselves, and what to do if this diagnosis appears in the CT report?

What are the types of degenerative-dystrophic diseases of the spine?

A large group of degenerative-dystrophic diseases of the spine are united by at least three characteristics:

DDSDs are potentially chronic diseases. In the absence of adequate therapeutic and conservative measures, the negative effects increase over time.
Most degenerative diseases of the spine are associated with the natural aging of osteochondral tissue, but its destruction, thinning, and fragility can also be caused by other reasons (sports or household injury, physical inactivity, metabolic disorders, congenital connective tissue dysplasia).
Some DDSDs, such as spinal stenosis, intervertebral hernias, and tumors lead to compression of the nerve endings or roots of the spinal cord. This causes a gross disruption of the biomechanics of the human body, muscle atrophy, weakness of the limbs, lameness, as well as intense pain, which can lead to depression.

Depending on the location, it is customary to distinguish degenerative-dystrophic diseases:

Cervical spine;
Thoracic spine;
Lumbosacral spine.

The localization of DDZP influences treatment tactics.

Degenerative-dystrophic diseases of the spine include:

Osteochondrosis;
Intervertebral hernia;
Protrusion;
Spondylosis;
Spondyloarthrosis;
Spondylolisthesis;
Spinal stenosis;
Spinal cyst;
Osteophytes;
Spondylosis;
Spinal osteoporosis;
Sacroiliitis;
Myofascial syndrome;
Facet syndrome (facet joint syndrome).

Diagnostics

When studying patients with spinal diseases, MRI, CT, X-ray, ultrasound and densitometry are used.

Osteochondrosis is determined by bone mineralization on densitometry.

MRI picture of the cervical spine is normal and with multiple herniated cervical discs

Intervertebral disc degeneration is usually best seen on an MRI.

The initial stages are associated with regression of the blood vessels supplying the discs. Constant pressure when sitting or standing, or playing sports, leads to a displacement of the moving part (core) relative to the fibrous ring, stretching the latter. Prolapse occurs - pushing through the fibrous ring by approximately 0.02 - 0.03 cm.

At the second stage (protrusion), the protrusion increases to 0.08 mm. While the outer shell remains intact, the core can still be retracted.

At the third stage, the fibrous ring ruptures, and the nucleus pulposus breaks out beyond its boundaries. This is clearly shown by the MRI picture, and is also confirmed by the symptoms. The substance of the nucleus irritates the spinal nerve, causing pain syndrome of the lumbar spine (lumbago), chronic discogenic pain (radicular syndrome).

On x-ray, osteochondrosis can be identified by the following signs:

reducing the height of the disk;
subchondral sclerosis;
marginal osteophytes on the anterior and posterior surfaces of the vertebral body;
deformations of the vertebral processes;
subluxations of the vertebral bodies;
calcification of the prolapsed nucleus pulposus of the disc.

Causes of degenerative spine diseases

Among the “triggers” for the development of degenerative-dystrophic diseases of the spine, the following should be mentioned:

Aging of osteochondral tissue , loss of moisture and elasticity by the intervertebral discs (accordingly, a decrease in shock-absorbing properties, as well as the height and density of the disc, higher trauma);
Connective tissue dysplasia (excessive elasticity, fragility, fibrousness);
Physical inactivity or “sedentary” lifestyle: weak back muscles reduce the intensity of local blood circulation, as a result of which the nutrition of the vertebrae is disrupted;
Overweight;
Diabetes; ;
Primary metabolic diseases (gout, mucopolysaccharidosis, pathologies of protein metabolism);
Genetic predisposition to DDSD, congenital anomalies of the structure of the spine;
Infectious and inflammatory processes;;
Systematic overload , violation of biomechanics (work related to heavy lifting, heavy physical labor, professional sports);
Injuries, vertebral displacement.

The causes of these disorders in the lumbar region

Pathological changes in the lumbar region occur due to a number of negative factors.

The main reasons can be identified:

Inactive lifestyle. If there is no load on the lower back, this leads to weakening of the muscles. As a result, the ability to withstand even small loads disappears.
Mechanical and birth injuries.
Professional sports with exorbitant loads. Destructive changes often begin due to lifting excessive weights and sudden movements without warming up the muscles.
Hypothermia of the body.
Inflammatory processes in the spine (arthritis, ankylosing spondylitis).
Aging of the body. The necessary components are washed out from cartilage and bone tissues.
Unhealthy diet. In this case, obesity is often observed, which negatively affects the spine.

There are many other factors that influence the appearance of dystrophic changes. In addition, the spinal column can be affected by several triggers. It follows from this that it is almost impossible to independently identify the cause.

Possible consequences

If you ignore the development of degenerative changes, then serious complications may arise in the lumbar area:

Hernia formation.
Osteochondropathy.
Loss of motor ability and sensation in the legs.
Paralysis of the lower extremities.
Difficulty with bowel movements and urination.
Sexual dysfunction disorder.

Consequences of degenerative-dystrophic changes in the spine

To prevent this from happening, timely and well-chosen treatment is necessary that can stop the destruction of intervertebral discs.

Pain in the spine (dorsopathies)

Dorsopathies in medicine refer to a variety of pain in the back (and limbs) caused by degenerative-dystrophic diseases of the spine.

If the patient experiences pain for longer than 12 weeks, it is called chronic. The causes of dorsopathies are clarified based on the results of MRI of the spine (CT is most often only an auxiliary method). Treatment is carried out by neurologists, osteopaths, algologists or spinal neurosurgeons.

Degenerative-dystrophic diseases of the spine often lead to compression of the nerve endings and roots of the spinal cord, so the pain syndrome can be very intense and spread to other associated parts of the skeleton: arms, feet, chest, etc.

Thus, problems with the spine are indicated not only by dorsopathies localized in the back area, but also by other pains - with irradiation and neuralgic symptoms, for example:

Symptom of intermittent claudication;
“Shooting” pain in the leg;
Numbness in the arms or legs;
Dizziness and headaches;
Weakness of the limbs, marked decrease in muscle tone;
Loss of sensation in limbs.

As a rule, pain becomes more intense after physical activity and goes away during rest, but it also happens the other way around, when it is at rest that the patient begins to experience pain.

DDZD of the cervical spine causes pain in the neck and forearm, paresis of the arms, headaches and dizziness, tinnitus and blurred vision.

DDSD of the thoracic spine can manifest as pain behind the sternum, which intensifies with breathing and coughing. The pain spreads along the ribs with radiation to the back. The symptoms are somewhat reminiscent of angina pectoris.

DDSD of the lumbosacral spine is associated with intense lower back pain radiating to the legs (numbness, weakness, lameness). It becomes difficult for the patient to play sports, walk, bend over, or remain in a static position for a long time.

Treatment

The choice of therapy depends on many factors, in particular, the cause of the disease, the condition and age of the patient, and the presence of concomitant pathologies. If the damaging factor is known (for example, heavy physical activity), then treatment begins with its elimination. All patients are also recommended to sleep on their back on a hard mattress and low pillow. This relieves stress from the spine and unblocks nerve endings and blood vessels. In the acute period, bed rest is prescribed, and wearing a special supporting collar or lumbar corset is recommended to increase the space between the vertebrae.

Positive effect of spinal traction

Conservative methods of therapy are used in the early stages. Treatment includes the use of chondroprotectors, anti-inflammatory drugs and analgesics. Therapeutic exercises are also extremely important, as they help strengthen muscles and create additional support for the spine. To improve tissue trophism, massage, acupuncture, and manual therapy are useful. Also, using methods of traction therapy (traction), it is possible to achieve retraction of hernias, increase the intervertebral space, decompress the nerve endings, and eliminate pain.

Drug treatment

To restore the cartilage tissue of the discs, preparations of chondroitin sulfate and glucosamine (Dona, Artron complex, Osteoartisi), and collagen are used.
For pain syndrome, it is recommended to take analgesics and non-steroidal anti-inflammatory drugs (Diclofenac, Ketorolac, Ibuprofen), preference should be given to selective COX2 inhibitors (Meloxicam, Lornoxicam). They can be taken orally (tablets) or applied pointwise along the spine at the exit points of the nerve roots (ointments with Diclofenac and Chondroxide).
Medicines from the group of muscle relaxants are prescribed in the presence of reflex muscle spasm, pinched sciatic nerve (Mydocalm, Sirdalud).
To relax the nervous system and alleviate the symptoms of DDSP, sedatives and tranquilizers are used at night (Diazepam, Zopiclone). To maintain the function of nerve fibers, vitamin preparations containing group B (Milgama, Neuromultivit) are prescribed.
Restoration of blood circulation around the nerve roots is achieved using peripheral vasodilators (Tental).
Decompression of blood vessels and nerves is helped by dehydration therapy - the removal of excess fluid from the body to relieve swelling (mannitol).
In case of very severe pain, a “blockade” of the nerve roots emerging from the spine is performed. Dexamethasone, Diprospan (corticosteroids that eliminate inflammation and swelling), Metamizole sodium (analgesic), Phenylbutazone, Meloxicam (NSAID), Procaine (local anesthetic) are administered locally.

The operations are most often planned, but can also be performed urgently in cases of strangulation of the cauda equina plexus and myelopathy.

Severe pain and significant dysfunction of the spinal nerves are indications for surgical intervention. During the operation, part of the degeneratively changed vertebrae is removed and the nerve roots are decompressed. Also, if necessary, weakened vertebrae are replaced with artificial ones or several segments are fused to stabilize the spine.

Spinal injuries

Spinal fractures can result from accidents, sports injuries, falls from a height, blows and bruises. Secondarily, they occur against the background of osteoporosis, aggressive growth of hemangiomas or other tumors. It should be noted that not all spinal fractures are visible on x-rays - due to the low resolution and two-dimensional nature of the visualization, the capabilities of this method in diagnosing fractures and injuries are limited. The “gold standard” is considered to be a CT scan of the spine - a high-precision volumetric slice-by-slice scan that allows you to obtain an authentic 3D model of the body area under study.

Spinal injuries are classified into three groups, depending on the severity of the injury:

Vertebral fractures (compression wedge-shaped, comminuted) without distraction and axial torsion - the spinal cord and important neurovascular components are not affected.
Fractures of the vertebral bodies with distraction (rupture) of the anterior and/or posterior segments, there are fracture-dislocations, local compression of the spinal cord is possible.
Vertebral fractures with distraction, displacement (twisting) of the vertebrae, compression of nerve fibers and parts of the spinal cord.

At the moment, computed tomography is the only diagnostic method that provides comprehensive answers about the nature of the bone injury and a complete visual picture.

Osteochondrosis

Behind the term “osteochondrosis” is a large group of pathologies that lead to degenerative processes affecting the intervertebral discs. As a result, they become smaller, delaminate, lose elasticity and ultimately rupture, leading to the formation of a protrusion or intervertebral hernia.

Osteochondrosis is considered to be the starting point for the development of other DDDDs, but in itself it is not their cause. A predisposition to osteochondrosis can be hereditary, but more common causes include metabolic disorders, posture and physical inactivity (weak back muscles, poor circulation and, accordingly, nutrition of the intervertebral discs).

Operation for protrusion

Let us recall that protrusion is the initial form of herniation, when the anatomical integrity of the outer sphere of the fibrous ring is preserved, due to which the nucleus pulposus is still located in the disc. Only such a picture of the disease allows the use of puncture methods of plastic disc surgery. It is advisable to recommend nucleoplasty to a person with a protrusion of the lumbar/lumbosacral location only under the following circumstances:

ineffectiveness of non-surgical treatment for 3-6 weeks;
frequent exacerbations of painful symptoms;
dysfunction of the nerves of the equine ganglion;
chronic reflex and radicular syndrome;
rapidly progressing dynamics of protrusion development.

Puncture nucleoplasty is aimed at reducing the pressure inside the intervertebral disc, which facilitates the return of the latter to its normal shape. The effect of reducing intradiscal pressure and retracting deformation is ensured by direct impact on the core (with the goal of its partial destruction) by a certain physical factor:

cold plasma (cold plasma plastic);
laser (laser vaporization);
electromagnetic waves (radiofrequency ablation);
a pressure jet of isotonic liquid (outdated tactics, hydroplasty).

At their core, all methods of influence “work” and are carried out according to the same principle. They are also approximately equal in effectiveness - the success rate of the procedures is approximately 80%. Access to the intervertebral disc is carried out from the back percutaneously (through a puncture puncture). Anesthesia is used mainly of a local type, but in some situations general anesthesia or epidural anesthesia is not excluded. The intervention is carried out on an empty stomach, before which the patient is given a cleansing enema. The procedure is carried out in the department of minimally invasive neurosurgery, equipped with an intraoperative X-ray machine. Session duration is 15-30 minutes. Let's consider all stages of nucleoplasty.

The patient is placed on the operating table. The classic position is on your side, with your legs tucked towards your stomach.
The skin of the lumbar region is widely treated with antiseptics. Anesthesia is performed.
Under X-ray control, in a safe interval, the surgeon makes a puncture (2-5 mm) with a puncture needle inserted into the disc at the required distance. Usually to the center of the core.
An electrode is installed into the working cannula of the needle, through which the “destruction agent” of the gelatinous substance will be supplied.
By rotating and translational movements of the electrode, emitting, for example, pulses of laser radiation or a flow of low-temperature plasma, the jelly-like component in the disk is partially evaporated.
The denucleation performed ensures inverse retraction of the pulpous mass that has shifted to the periphery of the ring during the course of the disease. The configuration of the lumbar disc is restored, and the pinched nerve root is eliminated.
At the end of the operation, thin working instruments are removed, and an antiseptic patch is applied to the puncture. Usually such a tiny wound does not require stitches.

During the procedure.

If the protrusion is not confirmed by MRI, and a rupture of the fibrous part of the intervertebral lining is diagnosed, the significance of nucleoplasty is completely annulled. The operation of choice for already formed lumbar hernias is microdiscectomy or endoscopy.

Separately, it is worth highlighting the fact that elderly patients (after 50-55 years) do not undergo puncture surgery on lumbar discs. Experts explain this by the fact that, due to age-related aging, the lumbar intervertebral discs at this age are too severely dehydrated. This fact indicates the intractability of the unacceptably dehydrated fibrous ring to reverse retraction in the protrusion zone when using any type of nucleoplasty. And, consequently, the ineffectiveness of such procedures in elderly patients.

Osteophytes of the spine

Osteophytes are hard, abnormal growths on the bone tissue around a vertebra. Such growths have a jagged shape and can painfully compress nerve endings and narrow the lumen of the vertebral foramen. Sometimes osteophytes are formed from the tissues of dead ligaments. In most cases, they do not affect quality of life due to their small size. However, if osteophytes grow over time, they ultimately cause acute compression, damage to surrounding tissue, and inflammation. Symptoms of spinal osteophytes are dull pain in the back or neck, which intensifies when walking or standing (sometimes radiating to the leg or arm) and paresis. In this case, osteophytes require surgical removal. If they are found along with the operated hernia, they can complicate surgical tactics, so in this case they are also removed.

Spinal stenosis

Stenosis is a pathological narrowing of the spinal canal caused by hyperplasia of bone tissue, tumor growth, and the entry of fragments of osteochondral fragments during injury into the space occupied by the roots of the spinal cord or nerve fibers, which leads to their compression. Spinal stenosis manifests itself as pain with neuralgic symptoms. The most common complaint is back pain, which increases with walking and decreases with sitting (flexing the spine). An accompanying symptom is most often numbness and weakness of the legs, pain of a “shooting” nature. The latter is typical for lesions of the lumbosacral segment.

Intervertebral hernia

Intervertebral hernia is a local displacement of disc material (nucleus, cartilaginous nodule, fragments of the fibrous ring) into the spinal canal and intervertebral foramen. Intervertebral hernias can also cause compression of nerve fibers and spinal cord roots.

Depending on the stage of development of the disease, the following types of hernias are distinguished:

Protrusion is a displacement of disc material (nucleus pulposus, annulus fibrosus) towards the spinal canal. Visualized as a small protrusion. The fibrous ring is stretched.
Extrusion is a more pronounced displacement of disc material into the spinal canal. Often leads to damage to the fibrous ring.
Sequestration is the prolapse of the nucleus pulposus and fragments of disc material into the spinal canal with rupture of the fibrous ring. Provokes severe pain.

Schmorl's hernias are cartilaginous nodules that invade the bodies of adjacent vertebrae and deform them. The depression forms at the border of the vertebra and the disc. Large Schmorl's hernias can provoke immune reactions in the body, accompanied by pain. However, the vast majority of such hernias do not affect the quality of life and do not require surgical treatment.

Structural features

The intervertebral disc is a gel-like core surrounded by cartilage tissue and fibers of the fibrous ring. The discs are located between the vertebrae, providing the human body with flexibility. For the spinal column, the discs act as shock absorbers. The discs do not have their own blood supply, so they are restored very slowly, and with age they are completely “erased” (this is why older people become shorter). Therefore, the consequences of any changes in the design of the disc cause pain and can cause illness.

Spinal neoplasms

Spinal tumors can be benign or malignant. The prevalence of the latter is relatively low, and most often it is not bone cancer that is diagnosed, but spinal cord cancer, which paralyzes the entire human body.

As benign tumors grow, they can also have disabling consequences. Neoplasms can compress nerve fibers and roots of the spinal cord, causing pain, neuralgia, and muscle atrophy.

Spinal injuries, bone diseases, and heredity increase the risk of spinal tumors.

Benign tumors of the spine include:

Osteoma - develops from bone cells in the pedicles of the posterior part of the vertebra. It manifests itself as back pain, which bothers you at night. They are poorly visualized on X-ray; the only accurate method of visualizing them is CT.
Bone cyst - a tumor forms on the back of the vertebra or affects it completely. Most often found in the cervical spine. If there are compressions, they are removed surgically.
Giant cell tumors are formed primarily from bone cells and represent a deviation from their normal development. They reach large sizes and therefore cause pain. They are removed surgically and require pre- and postoperative monitoring, as they can degenerate into a malignant tumor of the spine.
Granuloma is a spinal tumor, usually small in size. Accompanying damage to the vertebra, namely the thinning of its body. Vertebral granuloma can be an independent disease, or it can indicate malfunctions and damage to other organs. Treatment is carried out using surgical or radiation methods.

Malignant neoplasms of the spine include:

Metastases are secondary foci of oncology, formed from malignant cells that migrated from other organs, bones and joints through the circulatory system or lymph flow. As a rule, the primary focus is located close, and depending on the segment of the spine, it can be the lungs, abdominal cavity, mammary gland, prostate gland, etc.
Osteogenic sarcoma is a malignant tumor of bone tissue. Common among children (adolescents) and elderly patients.
Myeloma (or multiple myeloma) is a malignant tumor of bone tissue. Multiple myeloma often affects not only the spine, but also other osteochondral structures. The highest prevalence of the disease is among patients over 40 years of age.

Mechanism of development of degenerative joint lesions

The functioning of the joint depends on the condition of the cartilage. In the center the cartilage has a hyaline base; at the periphery it is fibrous. The thickness of the hyaline part is from 1 to 6 mm. Cartilage cells, chondrocytes, produce thin fibrils, threads that intertwine in different directions and form cartilage. The cells also synthesize chondrin, a lubricating fluid.

In a newborn, the tissue fluid of cartilage includes 75-80% water. In an adult, the normal level is 55-65%. During aging, during degenerative changes in the joints, this figure drops below 50%. Under such conditions, primary cartilage lesions develop, which, if nothing is done, spread first to the joint capsule and then further.

The main cause of degenerative changes in joints is moisture deficiency.

Spondylolisthesis of the vertebral segment

Spondylolisthesis is an abnormal displacement or slipping of a vertebra. As a result, the spinal segment loses stability. The consequences can be traumatic and dangerous - sometimes the displacement of one vertebra in relation to another (upper to lower) reaches 75%.

Spondylolisthesis of the spinal segment can be a consequence of injury, surgery, improper bone development, systematic improper loads, and diseases of the osteochondral tissue. Causes pain (passes after rest) with neuralgic symptoms, dysfunction of the pelvic organs.

To stabilize the spinal segment, the patient may be indicated for neurosurgical surgery with the installation of an implant, metal structure, or interbody cage.

Stages of arthritis development

By analogy with arthrosis, arthritis is also diagnosed using an x-ray, which gives an idea of the current stage of the disease:

at the first stage, no abnormalities are visible in the photographs, everything is normal;
at the second stage, the inflammatory process leads to the destruction of bone and cartilage tissue;
at the third stage – joint deformation is noticeable, and the patient complains of limited mobility;
the fourth stage is accompanied by total changes in the joint, and the problem can only be solved surgically.

Despite the similarity with the symptoms of arthrosis, in arthritis the root cause is always inflammation in the joint. Therefore, prevention is not the same as in the case of osteoarthritis, when a person is advised to move more and walk in the fresh air, protect himself from injuries and eat right.

To avoid arthritis, you need to beware of dangerous infectious diseases that can cause bacterial complications. Dangers include, for example, tonsillitis, scarlet fever, gonorrhea and even banal chronic tonsillitis. Routine vaccination can help prevent some of these diseases.

Routine vaccination against dangerous infections is a good prevention of arthritis

A CT scan revealed a degenerative disease of the spine - what to do?

If back pain does not bother you, but the “accidental finding” on a CT or MRI turned out to be “degenerative-dystrophic disease of the spine,” you should clarify what kind of disease it is and assess the possible health risks in the future.

Timely consultation with a neurologist or osteopath will help develop measures for effective treatment of DDSD and prevention of complications. The worst option would be to ignore the problem and “let go” of the situation to the point of traumatic consequences and the need for surgical intervention.

If there is severe pain associated with an intervertebral hernia, stenosis or other type of DDSD, the patient should consult a neurologist, algologist or neurosurgeon. The pain must be relieved, as it makes it difficult to move and provokes the development of depression, thus aggravating the situation. The patient will also be prescribed therapy (NSAIDs, therapeutic blockades, exercise therapy, radiofrequency ablation, physiotherapy, etc.) or surgery will be recommended.

Recovery prognosis

It is possible to say how the disease will develop only after a full examination and an accurate diagnosis. For example, it is impossible to completely get rid of grade 2–4 osteochondrosis . But properly selected therapy can relieve inflammation and stop further development of the disease. With proper treatment, long-term remission can be achieved . It is possible to prevent the occurrence of complications and stop the progression of degenerative-dystrophic changes if you do not forget about prevention.