Intervertebral hernia is a prolapse (protrusion) of the intervertebral disc beyond the boundaries of the vertebral bodies. Most often it is located between the 4th and 5th lumbar vertebrae or between the last 5th lumbar and first sacral vertebrae. It manifests itself as lower back pain and spinal syndromes (torso distortion, limited range of motion, difficulty walking and changing body position).
When treating intervertebral hernias, an integrated approach is used, aimed at various pathological parts of the disease. Drug therapy, physical therapy, physiotherapy, massages and even innovative non-surgical methods are used. If treatment methods are ineffective, the question of surgical intervention arises. Minimally invasive techniques have been developed, but classic full-fledged radical operations can also be used.
NSAIDs
Treatment of intervertebral hernias always begins with the prescription of NSAIDs (non-steroidal anti-inflammatory drugs). These drugs act on cyclooxygenase (COX), thereby reducing the activity of the inflammatory response and suppressing the transmission of pain impulses.
NSAIDs are divided into two large groups: non-selective and selective. The difference between them lies in the mechanism of action. Non-selective ones affect both isoforms of COX, which leads to a high risk of complications from the gastrointestinal tract - peptic ulcer, gastrointestinal bleeding. Selective ones are more aimed at COX-2 (the second isoform of the molecule), which reduces the likelihood of complications from the gastrointestinal tract, but increases the risks regarding the cardiovascular system (heart attacks and strokes). Therefore, the choice of drugs should be made by a doctor based on the patient’s medical history. Non-selective NSAIDs include Ibuprofen, Diclofenac, Indomethacin. Selective ones include Meloxicam, Naproxen.
Herniated lumbar intervertebral discs (l4-l5 and l5-s1). Symptoms and treatment
A herniated intervertebral disc is a rather unpleasant disease of the spine, characterized by the release of a gelatinous substance (nucleus pulposus) through a crack formed in the dense shell of the disc (annulus fibrosus). Of course, such a pathology rarely forms at one moment and is preceded by a long period of weakening of the spine, metabolic disorders, wear of cartilaginous structures and protrusion of the spinal discs. Protrusion or prolapse is a change in the anatomical shape of the fibrous ring of the disc and its protrusion beyond the natural dimensions of the spine.
In some cases, all of the above diseases develop practically asymptomatically, disturbing the person only occasionally with dull or weak aching pain in the lower back after unusual physical activity. Therefore, the need to treat the lumbar spine comes as a surprise to many patients.
Lumbar spine and its weak points
According to statistics, many more patients come to Dr. Bobyr’s clinic with complaints of lower back pain than with pain syndromes in the neck or chest. Most often, this is a herniated disc at the level of the l5-s1 spinal segment; damage at the l4-l5 level is slightly less common.
The lumbar spine is the most mobile, experiences the maximum load when supporting the entire body, and it is in it that the center of gravity of the body is located. A sufficiently large amplitude of movements (tilts, turns, rotations) and the connection of the vertebrae only with each other (the thoracic segment has, for example, a more rigid connection with the ribs) leads to gradual wear and damage to the cartilaginous tissue of the intervertebral discs.
Quite often, a person simply does not think about the load on the lumbar segment, performs sudden movements, lifts weights incorrectly (bending forward and putting stress on the back instead of squatting a little and doing a leg press). Even during sleep, the lower back does not rest, as it is constantly in a curved state. You can relax and free up the lumbar discs a little by placing a small cushion under them.
Causes of intervertebral hernia formation
The causes of herniated intervertebral discs can be very diverse, and doctors have not yet established clear criteria. Most often, disc damage is a consequence of osteochondrosis (age-related degenerative processes in the body). As a result of metabolic disturbances, the gelatinous substance filling the disc begins to gradually lose moisture, dry out and crack the dense shell covering it, shift in one direction or another, and therefore lose its shock-absorbing qualities.
Intervertebral discs do not contain blood vessels and receive water and nutrients diffusely from adjacent soft tissues. A decrease in metabolic processes and a slowdown in blood flow accelerates dehydration and “starvation” of the cartilage fibers of the disc. Bad habits, an inactive lifestyle, and increasing body weight also add stress to the spine and provoke the progression of the disease.
The gradual destruction of disc structures, a decrease in their properties and increasing tension lead to protrusion of the nucleus pulposus beyond the dense walls of the fibrous ring. Ignoring treatment of protrusion at this stage will sooner or later lead to rupture of the membrane and the formation of a herniated disc. The cause of rupture of the fibrous ring can be excessive hard work, sudden movement, household trauma (fall, blow), physical overexertion in professional athletes, viral infections, emotional and mental breakdowns, etc.
Main symptoms of the disease and their consequences
The main symptom of the disease is local pain in the pathologically affected area. Painful sensations may intensify with sudden movements, turns of the body, or slight physical activity. The body's response to pain is spasm of muscle tissue, swelling of soft structures, and limited body mobility. In some cases, pain may spread to the buttocks and leg (back of the thigh and lower leg), pinching of the sciatic nerve, decreased sensitivity of the limbs, muscle weakness, etc.
Treatment of numbness in the legs, decreased reflex reactions of the lower extremities (knee and Achilles), pinched nerve roots almost always accompany an intervertebral hernia at the level of the l5-s1 segment. The situation is much more complicated when the disc core moves towards the spinal cord and provokes its compression. This leads to the development of cauda equina syndrome, serious disruption of the internal organs of the pelvis (urinary incontinence, uncontrolled defecation, potency disorder, etc.), and complete paralysis of the lower extremities.
Another unpleasant and dangerous type of disease is considered to be a sequestered hernia of the lumbar spine. In this variant, part of the protruded nucleus is torn off from the total mass and forms a foreign body. The separated part, not connected to living tissues, quickly begins to become inflamed, forming suppuration, swelling, fistulas, causing acute pain. The progression of such a disease leads to the same consequences as the previous case. Many vertebrologists believe that treatment of the two previous cases is only possible with surgery. The cost of herniated disc surgery is quite high and involves some risks, so it is considered a last resort.
Treatment of spinal hernia
Conservative treatment. Initially, they try to overcome the disease using traditional methods and use conservative treatment for a spinal hernia. In most cases, it is sufficient and after two to three months patients feel relief, and after six months to a year approximately 90% of patients recover. Urgent surgery is performed only when the pain syndrome cannot be relieved, there is a threat to life and/or it is necessary to restore the mobility of the patient’s lower extremities, or the functioning of the internal organs is seriously impaired.
Treatment of lumbar intervertebral hernia begins with a complete examination (x-ray, MRI or CT scan, general blood and urine tests, ECG, and other diagnostic procedures if necessary) and establishing an accurate diagnosis. Initially, the patient is prescribed bed rest, minimal physical activity and drug treatment:
- Analgesic drugs to relieve pain, if necessary, local novocaine (lidocaine) blockades.
- Non-steroidal anti-inflammatory drugs to eliminate inflammatory processes and swelling of soft tissues.
- Muscle relaxants (substances that relieve muscle spasms) to relax muscles and release pinched blood vessels or nerve roots.
- Sedatives, B vitamins, vitamin and microelement complexes to relieve psychological stress and provide general support to the body.
After the pain has subsided, a set of physiotherapeutic procedures (warming, massages, manual therapy treatment methods, etc.) and gradually therapeutic exercises are introduced. If necessary, the patient may be prescribed to wear a rigid corset or traction (traction) of the spine.
Further therapy is based on properly selected and balanced physical activity (physical therapy, swimming, yoga, aerobics), restoration of mobility and flexibility of the spine itself, muscle structures, cartilage, ligaments and general strengthening of the body. This will help stop the progression of the disease, prevent the development of pathologies in other segments of the spine and get rid of relapses.
Surgery. As mentioned earlier, surgical treatment of herniated intervertebral discs is used as an emergency and last resort measure. The invention and use of the endoscope, as well as digital microscopes in surgery, has made it possible to significantly secure operations on the spine, and specifically the removal of intervertebral hernia. Microdiscectomy and endoscopy are neurosurgical types of surgery and make it possible to reduce the burr hole to 2-3 cm, which significantly reduces the risk of relapses, the likelihood of inflammation, damage to soft tissues (blood vessels, nerve clusters, spinal cord, etc.) and speeds up the patient’s recovery.
With endoscopic intervention, the trepanation incision can be even smaller, but there are restrictions on the size and placement of hernial protrusions.
After surgical manipulations, treatment is largely the same and resembles traditional conservative methods. In both cases, restoration of the skeletal muscles is required, preferably annual specialized sanatorium-resort treatment. Author: K.M.N., Academician of the Russian Academy of Medical Sciences M.A. Bobyr
Muscle relaxants and antispasmodics
One of the mechanisms for the development of pain in intervertebral hernias is muscle spasm. This creates a vicious circle: pain leads to local spasm of the muscles, and spasm leads to even greater pain. To break this cycle, muscle relaxants are prescribed. In addition to the analgesic effect, these drugs help increase the range of motion in the affected part of the spine, help reduce the dosage of NSAIDs and thereby reduce the risk of adverse reactions. Drugs in this group include Mydocalm, Diazepam, and Tetrazepam.
Drugs that improve microcirculation of blood and lymph
This group of drugs includes Pentoxifylline, Actovegin, Berlition. The drugs improve microcirculation of fluid in the area of inflammation, which reduces swelling and reduces the severity of the inflammatory reaction.
Drug treatment
Anesthetic agents. Oral or injectable preparations can be used.
Novocaine blockades, if the use of anesthetics does not have an effect.
Drugs from the group of muscle relaxants. Designed to reduce muscle tone, eliminate tension and spasms. Spasms are a protective reaction of the body necessary to maintain the correct position of the spine and reduce pain.
Vitamin therapy, in particular B vitamins.
Chondroitin and glucosamine. Used as a prophylaxis against further destructive process.
At the initial stage, the patient is recommended to adhere to bed rest for several days. After this, you need to move on to limited physical activity. When taking anesthetics, the patient must remember that they do not eliminate the root cause of the pain, but only relieve it. Therefore, physical activity, even in the absence of pain, can significantly worsen the condition of the spine.
Chemonucleolysis
This method of treatment involves the destruction of the nucleus pulposus of the intervertebral disc. For this purpose, a special enzymatic drug, chymopapain, is introduced into its thickness. After the core “melts,” it is aspirated, which leads to a decrease in the size of the intervertebral hernia. Carrying out such a procedure is possible only if the integrity of the disc membrane is maintained.
Treatment of intervertebral hernias is a long, labor-intensive process, and it requires some effort from the patient. But in general, the earlier the activities are started, the more successful they are. If you develop back pain, do not delay visiting your doctor. With timely treatment, the problem can be solved without resorting to the prescription of strong drugs with serious side effects. In addition, timely treatment will significantly slow down the progression of the pathology and preserve the patient’s health for a long time.
Surgical intervention
The operation is performed in advanced cases, and also if all other methods have failed.
Indications for surgical intervention are:
- numbness of the perineal area;
- inability to move the lower limbs;
- uncontrolled passage of feces and urine;
- sexual dysfunction;
- hernia size exceeding 7mm.
During the operation, different methods can be used. In one case, the entire disc may be removed, in others, only the hernia. The decision on the optimal method is made by the surgeon in each individual case based on diagnostic data.