Postoperative complications and relapses of intervertebral disc herniation

Mechanism of formation of intervertebral hernia

The spine is designed to withstand loads. It supports and stabilizes the body in a standing position, providing complete freedom of movement. When lifting weights, uncomfortable positioning of the body, strong and stressful loads, it takes on the main effort. The load is especially severe when lifting heavy objects with outstretched arms. The heaviest load and, accordingly, wear falls on the lumbar region. When age-related or pathological changes begin in the body, tissues change structure and can no longer fully perform shock absorption functions. Under force, they can become deformed and crumble, which disrupts the functions of the spine and can disrupt the functioning of the entire body.

How does a hernia appear?

The formation of protrusion occurs in several stages:

• Protrusion. The beginning of pathological changes. The fibrous ring becomes less elastic and can shift and become deformed.
• Partial loss of a section of the disc. This is the second stage in which tissue destruction can occur. This process is inevitably followed by displacement of the gel-like core of the disc.
• Prolapse. The nucleus emerges from the disc ring and begins to influence the nerve endings located nearby.
• Sequestration. The process by which a semi-liquid substance from the nucleus penetrates the cavity of the spinal column. This is accompanied by allergic reactions, nerve connections and blood flow in the tissues are disrupted. Due to constant pressure in an area that is not designed for it, there is a loss of sensitivity and the threat of paralysis.

If help is sought in a timely manner, when the process does not involve the nerves and spinal cord, conservative treatment is used and the patient can be completely cured.

Treatment at the Energy of Health clinic

Lower back pain may well be a symptom of a herniated lumbar spine. If you begin to notice discomfort, seek help from the neurologists of the Health Energy clinic. We will conduct a thorough diagnosis to accurately identify the cause of pain and prescribe a comprehensive treatment tailored to the individual characteristics of your body:

• effective drugs to relieve pain and neurological disorders;
• drug blockades;
• injections of prolonged hormonal agents;
• physical therapy with the preparation of an individual set of exercises for home training;
• all types of massage;
• physiotherapy and manual therapy, acupuncture;
• preparation of documents for sanatorium-resort treatment.

How does a hernia manifest?

At the very beginning of the development of the pathological process, the patient does not feel serious pain, symptoms are few. The more tissue protrudes, the more the patient feels it. There are three groups of symptoms for intervertebral hernia:

• The main symptom of a herniated disc is pain. At first it is not sharp, may be aching, and go away with a change in body position. The more serious the stage of the process, the stronger the pain. Shooting sensations appear, it is painful for the patient to turn the body, the sensations intensify with physical activity.
• Spinal syndrome. Constant pain causes spasms in the lower back muscles. The patient cannot move fully and is forced to tilt the body in order to relieve some of the load and reduce pain.
• Damage and death of nerve roots due to constant compression. The compression that occurs due to tissue protrusion constantly affects the nerve fibers. This disrupts blood flow, their functions, and later death occurs altogether. The manifestations of this process are: weakness, decreased tone, loss of sensitivity, the appearance of body asymmetry, decreased sensitivity and tone of the skin.

If the protrusion occurs in the posterior direction, any physical work is highly likely to cause severe compression and paralysis.

Indications for repeated surgery

The main symptom complex that worries the patient and brings him back to the surgeons is chronic, recurrent pain syndrome, which is not relieved within two months by prescribing non-steroidal anti-inflammatory drugs (NSAIDs). The second reason is the progression of neurological deficit. In this case we are talking about:

• about the development of peripheral paresis, inhibition of tendon reflexes, the development of wasting of the muscles of the limbs and a decrease in strength;
• when sensory structures are affected, mainly numbness in the limbs and paresthesia will progress.

Of course, there are also special situations. For example, if an adhesive process develops in the cauda equina area, the patient will be concerned about:

• sharp, shooting pains in the legs;
• numbness of the skin of the perineum;
• urinary urgency or urinary incontinence;
• In men, persistent erectile dysfunction is possible.

Pronounced overlap of the spinal canal. Sequestration.

Therefore, almost all reasons for the formation of FBSS are an indication for repeated surgery, with several exceptions:

• psychogenic pain;
• spondylitis and spondylodiscitis.

In most cases, it is possible to cope with inflammation using conservative methods. But if significant destruction of the vertebral bodies occurs, a deterioration in the quality of life and the development of severe pain with the risk of disability for the patient, emergency surgery is required. However, it must be carried out in the remission phase and always under the guise of antibacterial therapy.

This article will not discuss such highly specialized methods of repeated interventions as transpedicular screw fixation, resection of vertebral bodies, as well as spinal fusion with the formation of a stable bone block from adjacent vertebrae. Let's consider minimally invasive methods used in the case of repeated operations to remove an intervertebral hernia.

Manifestations depending on the location of the hernia

The characteristics of a hernia are determined by its location. In this area, the nerve roots are pinched and a characteristic clinical picture occurs. The nerve that is pinched during the formation of the lumbar protrusion of the spine runs along the inner surface of the leg from the hip to the ankle. The pain is not necessarily localized along the entire length; it can be reflected in the leg, foot, buttock, or outer side of the thigh. The lower back may also hurt at one point. As the situation develops, the pain may move lower - to the lower leg, heel and toes. In intensity, it can be a constant aching pain or lumbago that occurs when moving.

Basically, the pain becomes more intense with prolonged walking, standing, turning the body, and bending. It is also painful to lift your leg, do a number of exercises, and also drive on uneven roads.

At the beginning of the development of a hernia, pain can be relieved by lying down, bending one leg at the chest. This will help relieve tension and pressure on the nerve endings. In a more complex situation, this method will not help. Movements are constrained, their amplitude is greatly reduced, and the leg gets tired.

Basically, the patient feels compression of the spinal cord as tingling, burning, and numbness. It dulls the pain. The main symptom that the specialist will pay attention to during the examination is muscle tension on the side of the back, painful when pressed.

Despite the constant improvement of diagnostic methods and surgical treatment of compression pain syndromes, a pressing problem in the surgical treatment of herniated intervertebral discs is the recurrence of pain in the postoperative period [1, 2]. Some authors attribute this to an increase in the number of operated patients and an expansion of indications for interventions. Indeed, over the past 20 years, the number of patients undergoing surgery has increased sharply in the United States and European countries. But it should also be noted that there has been a qualitative change in the types of interventions performed. According to the US Bureau of Statistics, during the period from 1993 to 2007, the number of microdiscectomies performed decreased by 2 times, with a general increase in surgical interventions for disc herniations from 278 thousand per year to 379 thousand. At the same time, the number of “instrumental” interventions increased sharply, those. using stabilizing systems. And yet, the percentage of unsatisfactory results remains virtually unchanged - 10-35%. In the literature, there are even terms denoting such conditions: these are “unsuccessfully operated spine syndrome”, as well as “post-discectomy syndrome” [3-5]. It is clear that such terms require clarification and a detailed identification of the pathogenesis of pain in each specific case. The number of domestic and foreign works devoted to conservative and surgical methods of treating post-discectomy syndrome is growing. Among the causes are the following: recurrence of disc herniation (regardless of the side and level from the original), post-laminectomy syndrome, spondylodiscitis, instability of the spinal motion segment and spondylolisthesis, epidural fibrosis, spinal stenosis due to various causes (spondyloarthrosis, spondylosis, etc. ) [2, 6, 7]. It should be noted that spinal nerve root compression syndrome in the postoperative period is not the only reason for the formation of post-discectomy syndrome. No less important to us is the development in the patient of reflex pain syndromes of spondyloarthrosis and discogenic non-compression syndromes caused by pathological impulses from intervertebral discs adjacent to the operated one.

Most of the work over the past 15 years has been devoted to improving the methods of surgical treatment of compression syndromes, which cannot but please surgeons, but with such a fairly large number of patients dissatisfied with the results of the operations performed, more and more attention should be paid to the problem of further management of such patients, the development of diagnostic methods, an algorithm not only surgical, but also conservative treatment of “post-discectomy” syndrome.

The purpose of the study is to improve the results of treatment of patients with degenerative-dystrophic diseases in the long-term postoperative period after microdiscectomy by developing a system for diagnosing and treating the causes of pain.

Material and methods

A prospective controlled study of the effectiveness of various treatment methods was conducted in two groups of patients in the long-term period after standard microdiscectomies at the lumbar level. The earliest intervention was performed in 1988. The average postoperative period at the time of the study was 4.4 years. All patients underwent examination: neurological examination, general and functional spondylography, MRI (97%), MSCT (11%) - if MRI was not possible and there was a suspicion of a foraminal recurrence of a disc herniation, which in some cases is better detected by MSCT. In patients with reflex pain syndromes, additional manual testing was performed.

Group 1 included 198 patients (121 women, 77 men) with reflex pain syndromes after removal of a herniated intervertebral disc, and regularly visiting the clinic from year to year. The period from the moment of the operation to the appearance of reflex pain syndromes ranged from 2 to 18 months (7.6±0.9 months). Suspicion of the compressive nature of the pain syndrome was a factor in non-inclusion of the patient in group 1. All patients underwent a course of conservative rehabilitation treatment of osteochondrosis, including epidural blockades with hyaluronidase, physical therapy, exercise therapy, massage, manual therapy as indicated, etc.

Patients of group 1 were divided into two subgroups: main (97 patients) and control (101). The difference was that the patients of the main subgroup were sequentially derecepted (denervation) with an alcohol-novocaine mixture, first of the facet joints (JJ) at the level of the surgical intervention and adjacent to it. Then, in the absence of clinical effect or partial relief of pain, dereception of the above and underlying intervertebral discs was performed. Previously, by introducing a 4% soda solution into the joint area or into the cavity of the intervertebral discs, pain syndromes characteristic of the patient were provoked. This approach makes it possible to clearly prove the dependence of the pain syndrome caused by the DS and/or intervertebral discs. The introduction of an alcohol-novocaine mixture in a 1:2 ratio, in our opinion, is not inferior in effectiveness to methods of radiofrequency destruction, laser coablation, etc. In addition, the solution spreads over a larger area both in the cavity of the intervertebral disc and in the zone of innervation of the joint disc, which increases the effectiveness of the procedure without harming the patient’s health. The subgroups were statistically homogeneous in terms of gender, age, and location of previous surgery.

Group 2 included 64 patients with radicular compression pain syndrome. The period from the moment of surgery to the recurrence of pain ranged from 6 months to 3 years (1.1±0.9 months). Recurrent disc herniation at the LIII-LIV level was detected in 3 patients, at the LIV-LV level in 30, LV-S1 in 31. All patients underwent repeated surgical interventions. Based on the type of intervention, patients were divided into two subgroups. In the main subgroup (34 patients: 15 women and 19 men), recurrent disc herniation was removed from an anterolateral retroperitoneal approach with mandatory anterior foraminotomy and interbody fusion using a metal implant made of porous N-Ti. In the control subgroup, the surgeon performed re-intervention again from the posterior approach—repeat microdiscectomy. All patients had indications for foraminotomy. All surgical interventions were performed using a microscope or binocular loupe with a magnification of at least 4x. However, from the posterior approach, foraminotomy to the required extent could be performed only in 25 (83.3%) patients. Causes: cicatricial adhesive epiduritis (when there is no possibility of normal differentiation of neurovascular structures in scar tissue); epidural bleeding (the lumen of the veins does not collapse in conditions of severe cicatricial adhesive epiduritis). In the presence of impaired fixation ability and, especially, instability of the spinal motion segment, spinal fusion was performed: a combination of transpedicular fixation and PLIF.

Treatment results were assessed using a visual analogue scale (VAS) and the Oswestry scale at 6, 12 and 24 months.

Statistical methods. Spearman's rank correlation method and Pearson's χ2 test, descriptive statistics for quantitative characteristics were calculated using the Biostatistics package, version 4.03 (License LR No. 065635 dated January 19, 1998). In this case, the critical significance level was taken equal to 0.05. The assumptions about the absence of a statistically significant difference in the compared groups (for the χ2 criterion) and the lack of consistency of the studied characteristics (for correlation analysis) were used as null hypotheses. Average values ​​(M) of quantitative traits with a normal distribution are given with a value characterizing the spread of the trait (standard deviation σ): M±σ.

Results and discussion

In patients of group 1, who underwent sequential denervation of the facet joints and intervertebral discs, it was possible not only to provoke reflex pain syndromes, thereby proving their dependence on a particular joint or intervertebral disc, but also to fit these syndromes into a certain scheme.

A similar scheme for localizing referred pain has been developed in almost detail for discogenic reflex syndromes. When performing DS denervation, we obtained the following picture: from the DS LIII-LIV region, the pain syndrome spread to the kidney and anogenital region - in 13 patients; girdle pain, which in some patients was taken as a sign of instability of the lumbar spine, was provoked in 3 patients; from DS LIV-LV, 2 patients received referred pain in the groin area; from DS LV-S1 - pseudoradicular pain along the back of the thigh and lower leg - in 4 patients. Referred pain in the area of ​​the sacrum and coccyx was provoked in 9 patients from LIV-LV DS and in 15 from LV-S1. All patients were provoked by local pain syndromes.

In 84 (86.6%) patients after DS, despite a decrease in pain, certain reflected syndromes persisted, which served as an indication for denervation (dereception) of intervertebral discs on days 4-6, which also made it possible to decipher the syndromes , already dependent on pathological impulses from the damaged annulus fibrosus.

It should be noted that reproducible syndromes from the DS region do not differ from those obtained from intervertebral discs, and may well be combined into a single scheme over time. This phenomenon should be explained by a single innervation of the DS and intervertebral discs.

In this regard, the following becomes clear. In each of our patients, we identified more than one reflex pain syndrome. Most often it was a combination of local and referred pain. We also noticed that in all patients these syndromes were not caused only by the pathology of the DS or only the intervertebral discs - more often there was a combination, i.e. Some of the pain phenomena were reproduced from the DS, and some from the intervertebral discs. Moreover, in 34 (35%) patients the same pain syndrome was reproduced both from the DS and from the intervertebral disc “at the same level” with them. This, in our opinion, is what determines the variation in the effectiveness of denervations of the joint and intervertebral discs performed in different ways described in the literature [7, 8].

The treatment results in the main subgroup differed significantly from those in the control group (Table 1).

Excellent and good results were detected in 88.7% of cases, in the control group - in 45.5% of patients.

In the 2nd group of patients who underwent repeated surgery, the main trigger for the recurrence of radicular compression syndrome was prolapse of the intervertebral disc, which was confirmed by both radiological examination methods and anamnestic data. Isolated recurrence of disc herniation was detected in only 13 of 64 patients. More often there was a combination of several stenotic factors. At the same time, sequestered protrusion in combination with instability of the spinal motion segment was detected in 7 patients, with spondylolisthesis - in 3, a combination of recurrent disc herniation with spondyloarthrosis was diagnosed in 36 patients, a combination of bone growths of the posterior parts of the vertebral bodies, spondyloarthrosis and sequestered protrusion - in 5. Epidural fibrosis was detected to varying degrees in all patients.

Currently, the main treatment method for intervertebral disc herniations is microdiscectomy. The advantage of instrumental surgery for intervertebral disc herniations has not been proven. The same applies to recurrent disc herniations. In our opinion, this intervention has a number of significant disadvantages when used in surgery for recurrent radicular pain syndrome. Firstly, the complexity of the surgical approach due to the need for dissection of scar tissue, which always leads to the progression of epidural fibrosis in the future and the risk of damage to neurovascular structures due to poor visualization. According to C. Bundschuh [9], B. Jonsson [1], the frequency of clinically significant epidural fibrosis after posterior decompressive operations varies from 20.0 to 62.5%, which is confirmed in the domestic literature [3]. Secondly, this is the difficulty of performing foraminotomy in conditions of cicatricial adhesive epiduritis; thirdly, there is no guarantee of preventing relapse in the future; fourthly, an increase in the likelihood of developing instability in the spinal motion segment [10, 11]. Some of these shortcomings can be eliminated with the help of stabilization, which is currently the standard of surgery for recurrent intervertebral disc herniation in most clinics.

But during the time elapsed from the moment of surgical intervention until the onset of relapse of radicular pain syndrome, the clinical and, most importantly, anatomical situation in the affected spinal motion segment most often changes dramatically [12-14]. This is confirmed by data from a survey of patients, which revealed a combination of different stenotic factors, one of which was the leading one. Naturally, most often it was a recurrent sequestration of the remnants of the nucleus pulposus against the background of osteochondral growths of the articular processes. In principle, we can talk about the formation of combined lateral stenosis in the long-term postoperative period.

Considering the described disadvantages of repeated interventions from the posterior approach, we chose a well-proven method for removing herniated intervertebral discs from the anterolateral retroperitoneal approach [15]. In our opinion, this method does not have all the disadvantages previously described for posterior intervention. Performing the access is technically simple; when a groove is formed in adjacent parts of the bodies, a wide view of the epidural space opens, which facilitates the removal of the hernial sequestration; foraminotomy is performed automatically when resection of a sufficiently small area of ​​the posteroinferior edge of the overlying body; the final stage is always stabilization (see description of the operation below). Moreover, work in the anterior epidural space takes place in the absence of epidural fibrosis, which in itself is a big plus. Thus, this approach, in principle, solves all the problems facing a neurosurgeon or vertebrologist: decompression, including foraminotomy, good visibility, the possibility of radical removal of a recurrent disc herniation, reliable stabilization. In addition, it should be noted that due to the total removal of the nucleus pulposus during the approach, the risk of another recurrence of disc herniation at the operated level is eliminated. The disadvantages of this approach are the relative depth of the wound and the surgeon’s work on large arterial and venous trunks; accordingly, there must be a vascular surgeon in the hospital. It should be noted that these disadvantages are significantly reduced if there is such a device as a mini-assistant in the operating room.

The main stages of the operation are: anterolateral retroperitoneal access, which allows wide opening of the anterior surfaces of the LIII-S1 bodies (the most convenient levels for working from this access). In this case, it is better to access the LIV-S1 bodies using transverse skin incisions, which is much more cosmetically advantageous. The iliac vessels at levels LIII-LIV and LIV-LV are carefully shifted in the opposite direction, and at the level LV-S1 the approach to the vertebral bodies passes through their fork. Then, using a crown cutter, a groove with a diameter of 20-24 mm is drilled in adjacent sections of the bodies (the diameter can be selected individually directly during the intervention, depending on the patient’s physique, individual characteristics, and most importantly, the height of the intervertebral disc - the higher the disc and the larger the vertebral bodies, the larger the diameter will be needed). It is better to carefully remove the posterior edges of the formed groove with a bone spoon and pistol pliers, which avoids injuries to the dural sac and spinal nerve roots. After this, the anterior epidural space opens wide together with the already free-lying hernial sequestrum, which in all cases was easily separated from the adjacent dural sac. At the end, a foraminotomy was always performed: using pistol cutters, the posteroinferior edge of the overlying body was resected in the lateral sections of the groove - this automatically expands the anterior wall of the upper floor of the radicular recess, where the spinal nerve root directly passes (see figure).

Figure 1. MSCT of the patient after anterior foraminotomy and interbody fusion with a metal implant made of porous Ni-Ti (foraminotomy is indicated by an arrow). It should be noted that performing foraminotomy using this method is significantly superior to foraminotomy from the posterior approach in its simplicity. Occasional epidural bleeding never interfered with the operation, was easily controlled, and even in the presence of large veins in the anterior epidural space, it was easily stopped by coagulation or application of a hemostatic sponge. The final step was to screw a screw implant made of porous Ni-Ti into the groove, which should exceed the diameter of the hole cutter used to form the groove by 2 mm. The advantages of cylindrical screw implants made of porous Ni-Ti are: ease of installation, reliability of spinal fusion due to an increase in the contact area of ​​the bone-metal area, as well as a wide view of the epidural space after the formation of a groove in the vertebral bodies.

A contraindication to ventral decompression and stabilization surgery is a free-falling migrating hernia with cranial or caudal displacement of the sequester by more than 1/3 of the vertebral body, as well as gross osteochondral growths of the articular processes, which themselves can be the main compressive substrate and require resection, which is only possible using a posterior approach. We were guided by the following principle: when the intervertebral foramen is stenotic by osteochondral growths of the articular processes in the upper 1/3 by more than 50% of the estimated initial value, performing a foraminotomy from the anterior approach is impractical. This category of patients was operated on from the posterior approach.

This method should be used with caution in patients suffering from grade III-IV obesity, as well as those who have undergone extensive abdominal surgery, especially if the surgical approach was on the left, and even more so if the disease was accompanied by infection and was accompanied by prolonged drainage of the abdominal cavity. When planning surgery for this category of patients, one should also lean, in our opinion, in favor of posterior decompressive and stabilizing interventions using transpedicular fixation devices.

The average volume of blood loss in 514 patients operated on for herniated intervertebral discs from the anterolateral retroperitoneal approach in clinics in Kemerovo and Novokuznetsk for the period 2007-2010 was 250±30 ml, the average operation time was 110±15 minutes.

Among the complications of the anterolateral approach, it should be noted thrombosis of the common iliac vein on the left - 2 (0.4%) cases, the formation of metallogranuloma with subsequent suppuration - 1 (0.2%), the formation of ureteral stenosis with scar tissue, requiring the installation of a stent - 1 (0.2%). 2%), hernia of the anterior abdominal wall - 2 (0.4%).

The difference in the results of surgical treatment in the immediate postoperative period in the subgroups is small (Oswestry index was 86±6.4 and 84±5.7, respectively), although one can already note the predominance of excellent and good results in the subgroup of those operated on from the anterolateral retroperitoneal approach. Also noteworthy is the absence in this subgroup of such results as deterioration and no changes (Table 2).

Differences appeared in the long-term period, 1 year or more after surgery (see Table 2)

. The number of patients with excellent results in the control subgroup decreased almost 2-fold, largely due to an increase in the number of patients with satisfactory results, while in the main subgroup during the observation period there were no radical changes in treatment results; there was no relapse of radicular compression syndrome (Oswestry index was 86±5.9 and 78±5.8). In the control subgroup, one patient had a recurrence of disc herniation, and he was operated on for the third time using stabilization.

Conclusion

Recurrence of pain after microdiscectomy is the most pressing problem in surgery for intervertebral disc herniations. Not in all cases this is associated with a recurrence of the intervertebral disc herniation itself. In most patients, reflex pain syndromes of osteochondrosis and spondyloarthrosis predominate, the optimal method of diagnosis and treatment of which is the method of sequential denervation of the facet joints and intervertebral discs (at levels adjacent to the operated level).

Removal of a recurrent intervertebral disc herniation from an anterolateral retroperitoneal approach is a good method of surgical treatment, providing a wide view of the epidural space during intervention, the absence of scar tissue when removing sequesters, decompression of neurovascular formations, including due to the possibility of performing a wide foraminotomy, as well as reliable stabilization after performing the intervention. Thus, this method meets all the tasks facing the surgeon, and, in our opinion, has a number of advantages over posterior “instrumental” (using stabilization) interventions.

Along with the above, one cannot fail to note the availability of anterior surgical interventions. The cost of spinal fusion using a porous Ni-Ti implant is an order of magnitude different from the cost of transpedicular structures and interbody cages. This is an important factor when choosing surgical treatment methods in most clinics in the country.

A comment

The relevance of this work is beyond doubt. In the daily practice of neurosurgeons and orthopedists, relapse of pain after removal of a herniated disc is a common reason for repeated patient visits. This work was carried out by a group of authors representing various leading medical institutions, and includes a large arsenal of solutions to the problem of postoperative pain syndrome - from minimally invasive (denervation of intervertebral joints and discs) to stabilizing operations from an anterior or posterior approach. In our opinion, denervation is an effective method for treating pain, given its minimally invasive nature and low rate of complications. However, a more modern method is the use of radiofrequency denervation in comparison with the use of an alcohol-novocaine mixture. The hypothesis about identical pain symptoms caused by intervertebral joints and a disc of the same level is relevant and requires continued research.

The choice of anterior or posterior approach for recurrent disc herniation, spinal canal stenosis, or development of segment instability is the prerogative of the operating surgeon and in most cases is associated with personal experience. Good results in decompressing nerve structures and stabilizing the spinal segment can be achieved using both anterior and posterior approaches. It is worth noting that the cicatricial adhesive process develops during any surgical operation, and, in our opinion, the genetic factor, minimal trauma of surgical intervention and careful hemostasis are significant. In general, the work is of great interest, given the detailed analysis of the material, and will undoubtedly play a positive role in improving the treatment of this group of patients.

ON THE. Konovalov

(Moscow)

Establishing diagnosis

The diagnosis is made after examination and examination of the patient. First of all, instrumental diagnostics are carried out to help determine whether the tendon reflexes are normal. The patient is asked to raise his straightened leg. Tests are also carried out for sensitivity to vibration, the ability to sense temperature and pain. If there is a hernia, there will be certain manifestations:

• The doctor will determine the sensitivity disorder.
• The patient's movement biomechanics will be changed.
• Tendon reflexes will deviate from normal.

Also, to diagnose protrusion, CT or MRI diagnostics of the spine is performed. These studies will help not only visualize the hernia, but also determine the condition of the surrounding tissues and diagnose narrowing of the spinal canal, if any. If indicated, contrast myelography may be prescribed. After the examination, the degree of pathological changes can be determined and adequate treatment can be prescribed. If the nerves are not affected, the patient complains only of pain, conservative therapy is used.

Diagnostics

Diagnosis of a hernia of the lumbar spine requires consultation with a neurologist. At the first appointment, the doctor finds out the patient’s complaints, the time and circumstances of their occurrence, records information about past diseases and injuries, and chronic pathology. A neurological examination is performed to identify areas of maximum pain, areas of increased or decreased skin sensitivity, changes in muscle strength and reflexes.

Instrumental and laboratory examinations are aimed at confirming the diagnosis and excluding other pathologies with similar symptoms:

• CT or MRI to visualize the protrusion, assess its shape and size, as well as the degree of compression of the nerve roots or spinal cord;
• myelography with contrast: prescribed for suspected spinal cord compression;
• general blood and urine analysis;
• blood chemistry;
• Ultrasound of the abdominal cavity and pelvis (prescribed in the presence of pelvic disorders);
• consultations with a gynecologist, urologist if necessary.

The list of tests and examinations is adjusted depending on the specific situation.

Why is a lumbar hernia dangerous?

Any hernia brings not only pain, but also a serious risk of disruption of the body and paralysis. Vertebral protrusion in the lumbar region has a number of dangerous accompanying manifestations:

• Blood circulation in the pelvis is disrupted, due to which the organs do not receive proper nutrition. This provokes problems with the excretory system and disruption of the internal genital organs.
• The spine is curved due to muscle tone. This causes compression of internal organs and can provoke other pathologies not directly related to the spine.
• Sensitivity decreases, numbness and limited body mobility are observed.
• Shooting appears - severe sharp pain during physical activity or movement.
• Knee reflexes may disappear, and mobility of the ankle and foot may change.
• The most serious consequence is paralysis.

Operation

Radical intervention is used when it is necessary to free the spinal cord and nerves from the pressure of protruding tissues. The most popular methods are:

• Endoscopy is an operation through an incision in the spine using a probe. A camera and instruments are inserted through a small hole, and displaced tissue is removed.
• Disc endoprosthetics. Damaged elements are removed. A prosthetic structure is installed in their place.
• Percutaneous discectomy. Access is made through a puncture, the deformed core is removed and replaced with a special compound.
• Laser reconstruction – the hernia is removed by evaporating moisture from the tissue.

Recovery

Regardless of how the hernia is removed, restoration is required. What is it built on?

• On drug and electrotherapy, aimed at reducing pain after surgery (especially important for patients who have undergone open surgery).
• Wearing special corsets. It helps to consolidate the effect, support the spine in the correct position, relieve stress from the vertebrae, and prevent relapse of the disease. If the hernia was surgically removed and the operation was extensive, then in the first weeks it is recommended to alternate wearing rigid and semi-rigid corsets, and then wear a semi-rigid one for about three months. If the operation is minimally invasive, then sometimes only wearing a semi-rigid corset for two months is enough.
• At therapeutic exercises. Exercise therapy is organized strictly under the supervision of a doctor. The main exercises for the patient are static movements aimed at keeping the back muscles in a contracted state for several seconds.
• On control of being in a vertical position. In the first month after surgery, you can be in an upright position for no more than 1.5 hours at a time.

The exact recovery time after hernia removal depends on age, the presence of concomitant diseases, and the hernia treatment method used.

Preventive measures

Spinal herniation can be prevented. There are a few simple rules for this:

• Nutrition and weight control. Excess weight increases the load on the spine.
• Rejection of bad habits.
• Regular physical activity - morning exercises, warm-up during sedentary work.
• Sleep on a hard mattress, choose the right pillow.
• Preventive examinations with a doctor, timely seeking medical help if alarming symptoms appear.

By contacting a neurologist at the Central Clinical Hospital of the Russian Academy of Sciences in a timely manner, you can avoid complications and return to a normal lifestyle as soon as possible.

Prevention

Prevention of lumbar hernia means caring for your body in general and the spine in particular. Doctors recommend:

• observe the work and rest schedule, get enough sleep;
• adhere to the principles of proper nutrition, ensure the supply of sufficient vitamins and microelements;
• avoid excess body weight;
• regularly engage in sports without striving for records (at the amateur level);
• walk more in the fresh air;
• do gymnastics to strengthen your back;
• avoid lifting heavy objects;
• undergo a timely examination by a doctor and follow all his recommendations.