Diffuse herniated intervertebral disc: what is it, differences from others, how to treat

Intervertebral hernias confidently occupy a leading position in the ranking of the most common diseases of the spine and are second only to osteochondrosis. Actually, it is this degenerative-dystrophic disease that is a harbinger of the formation of a spinal hernia.

Due to the fact that the greatest load when walking and performing physical work falls on the lumbar spine, it is the one that is more susceptible to pathological changes in the tissues of the intervertebral discs and ultimately the formation of a hernia.

One of the most commonly affected intervertebral discs is L4–L5. It accounts for about 30% of all cases of hernia of the lumbar spine.

What is an intervertebral disc

Intervertebral discs are cartilaginous formations of a close to round shape, located between the bodies of adjacent vertebrae. Like the vertebrae of different parts of the spine, they have different sizes. Therefore, in the lumbar region the discs are the largest and strongest, which has developed evolutionarily. This allows the spine to withstand daily stress.

Each intervertebral disc has its own internal nucleus, called the pulpous nucleus. It is a viscous, gelatinous mass with high elasticity, which ensures the main shock-absorbing function of the spine.

The nucleus pulposus is surrounded by a special, fairly dense membrane - the fibrous ring. It has a fibrous structure, and the fibers are intertwined in 3 different directions. The last element of the intervertebral disc is the endplates that protect it.

Unlike most other anatomical structures of the human body, discs have a diffuse type of nutrition. In other words, nutrients are not supplied to it directly with the blood through the vessels, but penetrate through the membranes. This is one of the reasons for their gradual destruction over the years, since with age the intensity of blood flow decreases, chronic diseases affect it, and eating habits often leave much to be desired.

The intervertebral discs of the lumbar spine, particularly L4–L5, have a significantly larger diameter than they are tall.

Prevention

To avoid the development of intervertebral hernia, it is recommended:

• monitor posture from childhood;
• exercise to strengthen the back muscles, this will keep the spine in the correct position;
• sit on chairs that are suitable for your height; when working at a desk, your feet should be on the floor;
• sleep on orthopedic mattresses and pillows;
• eat right and lead an active lifestyle, which will maintain normal weight.

The development of herniated intervertebral discs often occurs as a result of a person constantly remaining in one position. Only physical activity will help unload the spine, swimming with measured movements is especially beneficial.

Causes

The main reason for the formation of pathological protrusion of the intervertebral disc is the development of osteochondrosis. This disease tends to progress quite quickly, resulting in a gradual decrease in the height of the disc and an increase in the compressive load on it. The presence of spinal deformity, especially hyperlordosis or scoliosis, greatly predisposes this.

Even minor disturbances in the power supply of the disk lead to changes in it. Moreover, the amount of pressure on it from the vertebral bodies increases in direct proportion to the severity of existing deviations from the norm.

Makes the situation worse:

• presence of excess weight;
• a sedentary lifestyle, leading to weakening of the muscle corset;
• constant, significant physical activity;
• hereditary diseases, including sacralization, lumbolization and weakness of the fibrous ring.

Therefore, initially, under the influence of increased load, changes occur in the structure of the disk. Its symmetry is gradually broken, microscopic breaks appear in the fibers forming the nucleus pulposus, and the structure of the fibrous membrane changes.

If the situation does not change for the better, degenerative changes in the intervertebral disc continue to worsen. Over time, the nucleus pulposus begins to shift from the center and put pressure on the fibers of the fibrous ring in a certain place. They become thinner and rupture, which leads to a decrease in the thickness of the fibrous membrane in this area. Thus, a protrusion is formed.

The nucleus pulposus in this case still remains within the annulus fibrosus, but the shape of the L4–L5 disc changes. On one side, a slight protrusion forms in it, which is already capable of exerting pathological pressure on the structures passing through the spinal canal. In this case, the shock-absorbing function of the disc is disrupted, and the spine begins to experience even greater overloads.

In the absence of intervention at this stage, the pathological process progresses. The vertebrae put even more pressure on the disc and the nucleus pulposus in particular. This, in turn, puts more pressure on the fibrous ring. Therefore, its fibers break one after another, resulting in a local gap through which the nucleus pulposus rushes into the spinal canal. In such situations, they speak first of prolapse of the intervertebral disc, and then of hernia.

Once in the spinal canal, the width of which in most people does not exceed 1.5–2 cm, the nucleus pulposus begins to contact the spinal nerve roots or even compress the spinal cord itself. This cannot go unnoticed by the patient. In this case, a strong pain syndrome immediately occurs, both in the projection of the L4–L5 disc and in the area of ​​the body innervated by the compressed nerve.

This is an important diagnostic difference between intervertebral disc protrusion and hernia. In the first case, pain is also present, but is limited to the site of the lesion, i.e., it is observed in the back in the L4–L5 projection. At the same time, when a hernia occurs, they often spread to the limbs and other parts of the body.

The final stage in the development of a spinal hernia is sequestration. This term means the separation of the part of the nucleus pulposus that has fallen into the spinal canal from the main body. As a result, it gets the opportunity to move both up and down the spinal canal. In this case, nerve fibers are injured, and there is a high risk of severe spinal canal stenosis, which can lead to paralysis and disability.

Operations carried out

• Microsurgical discectomy with installation of a dynamic interspinous implant DIAM
• Puncture endoscopic discectomy
• Laser vaporization of the intervertebral disc

Patient M., 35 years old, was admitted to the spine surgery clinic of the Russian Research Center of Surgery with complaints of nagging pain in the lumbar spine, radiating along the outer surface of the right lower limb, and a periodic feeling of numbness in the right lower limb. From the anamnesis: complaints have been bothering me for 4 months (sharp pain in the lower back occurred while lifting weights). There was no treatment, the attack stopped on its own. Subsequently, I was bothered by minor aching pain in the lumbar spine. Repeated attack - two weeks before hospitalization, irradiation of pain appeared in the right lower limb. On examination: an area of ​​reduced sensitivity on the outer surface of the upper third of the right leg, paresis of the extensor of the first toe of the right foot up to 3 points, a decrease in the Achilles reflex on the right is noted, knee reflexes are preserved. positive Lasegue sign on the right. According to MRI: paramedian right-sided herniation of the L4-L5 intervertebral disc with compression of the L5 root on the right.

The patient underwent surgery: Microsurgical discectomy of L4-L5 on the right with installation of a dynamic interspinous implant DIAM L4-L5

The patient was activated the next day after surgery. Discharged from the hospital on the 4th day. The sutures were removed on the 12th day. After 6 weeks of surgery, all restrictions on physical activity are lifted. The patient is recommended to: breaststroke swimming in the pool at least 3 times a week, a set of exercises to strengthen the back muscles.

Types of L4–L5 disc herniations

Since the intervertebral disc is located strictly between the vertebral bodies and has an approximately round shape, under the influence of increased pressure it can protrude either outward towards the spinous processes or inward into the spinal canal. In the first case, they talk about anterior hernias. They pose virtually no danger and require virtually no treatment.

In the second case, posterior or dorsal intervertebral hernias are diagnosed, which pose a threat to the patient. When they reach a certain size, they can put pressure on the spinal cord and injure it, which causes serious complications. As a result, there may be a decrease in sensitivity from the hips to the knee, up to its complete loss, as well as muscle weakness and other neurological disorders. With dorsal hernias, the situation can develop rapidly and symptoms can progress rapidly.

In turn, dorsal hernias can be divided into 4 more types, depending on in which segment of the posterior surface of the disc the protrusion is formed. This:

• median;
• paramedian;
• circular;
• foraminal.

Depending on the size of the formation, small hernias L4–L5 are distinguished, the size of which does not exceed 5 mm, medium ones – 5–7 mm, and large hernias with sizes more than 8 mm. But the size of the formation does not always have a direct connection with the severity of the manifestations of diseases. The greatest role in the clinical picture of spinal hernia L4–L5 is played by its position in the spinal canal.

Median

A hernia forms in the spinal canal along the central axis of the L4–L5 disc. Often this occurs without significant disturbances until the formation reaches an impressive size.

Subsequently, median hernias can compress the spinal cord and provoke severe neurological symptoms such as paralysis of the legs and impaired control over the processes of urination and defecation.

Median hernias L4–L5 very often occur in athletes.

Paramedian

Unlike median hernias, paramedian hernias are displaced from the center of the disc and spinal canal to the side in the area of ​​​​the branch of the nerve fibers. Thus, left-sided and right-sided hernias are distinguished.

In such situations, pain in the lumbar region occurs almost from the moment the protrusion forms. Over time, they begin to radiate to the buttock, thigh and lower leg of the corresponding half of the body.

One of the first symptoms of a paramedian hernia is a feeling of numbness in the leg. Subsequently, there is a decline in tendon reflexes, as well as a change in gait.

Circular or diffuse

This is one of the most dangerous types of dorsal hernia, since it occupies the entire space of the spinal canal at the L4–L5 level and provokes bilateral neurological symptoms.

Diffuse hernias are more prone to sequestration than others. They provoke severe inflammatory processes that involve muscles, ligaments, tendons and nerves passing at the level of L4–L5.

Most often, circular hernias form against the background of advanced osteochondrosis.

Foraminal

The hernia is located in the area of ​​the natural openings of the spine formed between the bodies of adjacent vertebrae and their arches. These openings, called foraminal openings, are very narrow and are also the site of passage of nerves. Therefore, the growth of a bulging intervertebral disc in them leads to immediate and pronounced compression of the nerve fibers.

This immediately manifests itself as severe pain, both in the affected area and in the hips. The pain is burning in nature and tends to intensify with coughing, laughing, sneezing or defecation. These hernias can be difficult to diagnose, especially without the help of an MRI.

Treatment of circular hernia

Treatment of a circular hernia can be carried out using conservative and surgical methods. In the CELT clinic, the former are practiced, and the latter are resorted to if there are indications or non-surgical treatment did not allow achieving the desired results.

Conservative treatment consists of taking painkillers and anti-inflammatory drugs, as well as performing a number of physical procedures. In addition, epidural blocks can be used, which provide excellent pain relief, lasting from 6 weeks to 6 months. In addition to pain relief, blockades also have a therapeutic effect and are used all over the world to treat pain due to compression of nerve roots. Often, thanks to their implementation, the need for surgery can be avoided.

As for surgical treatment, at the CELT clinic it is carried out using endoscopic intervention technology through an incision not exceeding one and a half centimeters. The operation lasts no more than 40-60 minutes, is accompanied by slight blood loss and minimal risks to the patient’s health, while its effectiveness is quite high, and the recovery period does not exceed 2 weeks.

Symptoms of intervertebral hernia L4–L5

The main manifestations of the disease are the occurrence of pain in the area of ​​the affected spinal motion segment. They can be constant or occur periodically, be sharp or nagging, or be of a different nature.

Pain usually appears or intensifies with sharp turns of the body, bending, prolonged standing, walking or performing physical work. They usually subside when taking a supine position. Also, many patients note that the lower back reacts to straining during bowel movements.

A kind of test for the presence of a L4–L5 hernia is raising a straight leg in a lying position. If the lesion is observed at this level, such an exercise will lead to the immediate appearance of acute pain and its elimination after bending the raised leg at the knee.

With a fully formed hernia, pain can radiate to the lateral surfaces of the thighs and lower legs, since the nerve fibers located at this level are responsible for their innervation. They often become numb, which can affect gait. You may also experience:

• swelling of the legs;
• limitation of movements in the lower back;
• increased sweating;
• dry skin;
• weakness;
• increased fatigue.

We must not forget about vegetative disorders. Since the portion of the spinal cord at the level of the 4th and 5th lumbar vertebrae is responsible for the proper functioning of the prostate gland and lower extremities, if the condition of the spine deviates from the norm, pain in the knees and feet, as well as urination problems, may occur.

If the hernia strongly compresses the nerve, severe neurological symptoms may occur. In such situations, the patient may:

• encounter paresis or paralysis;
• atrophy of the leg muscles;
• decreased sensitivity;
• complete loss of control over the process of urination;
• persistent erectile dysfunction.

Depending on the type of L4–L5 hernia, both legs or only one of them may be affected.

Postoperative management of patients

The duration of strict bed rest is one day from the moment of surgery. As a rule, the very next day after surgery, we allow patients to get out of bed and sit without using corsets on the lumbar spine or any additional means of support. The therapeutic and protective regime lasts 6 weeks from the moment of surgery, during which patients are allowed to walk fully, sit, but without additional load on the lumbar spine. Body bending and twisting are prohibited. At the end of the gentle period, patients begin active rehabilitation - breaststroke swimming in the pool at least 3 times a week, physical therapy aimed at strengthening the back muscles, and massage are recommended. Patients return to a normal physically active life without any restrictions. In particular, sports such as alpine skiing, snowboarding, football, volleyball, rock climbing are allowed.​

Diagnosis of the disease

The main method for diagnosing L4–L5 intervertebral hernias is MRI. This is a highly informative, safe for humans, instrumental study that allows us to give the most accurate assessment of the condition of the intervertebral discs.

The procedure can be carried out in open and closed type devices. The second option is more preferable, since closed devices have greater power, which has a positive effect on the information content of the study and the clarity of the resulting image.

MRI in open devices can be performed only if it is impossible to perform it in a closed one due to the patient’s fear of closed spaces or for other reasons. Such devices generate a magnetic field of up to 1.2 Tesla.

The duration of an MRI is on average 20 minutes. During this entire time, the patient should remain absolutely still so that the resulting images are as clear as possible. If suddenly during the study he feels discomfort, he can call a specialist at any time and interrupt the study by pressing a special button.

Patients are also prescribed CT scans and x-rays of the spine in several projections. These studies are designed to provide information about the condition of bone structures and the position of the vertebrae. Thus, with their help, it is possible to detect concomitant pathologies, often combined with intervertebral hernias of L4–L5. Using CT and X-rays, it is possible to diagnose vertebral instability, the formation of specific bony protrusions at the edges of the vertebral bodies (osteophytes), the degree of curvature of the spine, and also assess the height of the discs.

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

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

Diagnostics

An important diagnostic task is not only to identify a hernia, but also to determine its type and size. The tactics of further treatment directly depend on these factors.

The first stage of diagnosis is an examination by a vertebrologist or neurologist. The doctor collects anamnesis and can make a preliminary diagnosis. To confirm it, instrumental research methods are prescribed.

Neurological examination.

MRI can provide the most comprehensive information. Other diagnostic methods include laboratory examinations, CT scans and x-rays of the spine.

Treatment of L4–L5 disc herniation without surgery

If signs of a L4–L5 hernia occur, you should immediately contact a chiropractor, vertebrologist or neurologist. In this case, it is worth having on hand the results of all the studies performed, so that already at the first consultation the doctor can assess the current situation as fully as possible and immediately prescribe the optimal treatment.

Traditionally, conservative therapy can effectively combat most L4–L5 hernias up to 8 mm in size without surgery. For each patient, the nature of treatment is selected strictly individually, taking into account the concomitant diseases present.

Conservative treatment of L4–L5 disc herniation gives especially good results when its size is no more than 5-6 mm.

But this, unfortunately, is rare in medical practice. Patients have been self-medicating for a long time, relieving lower back pain with ointments or tablets and attributing their occurrence to age. Of course, they are partly right, but such measures only help to temporarily eliminate discomfort, which does a disservice to a person.

He continues to lead his usual lifestyle: lifting weights or sitting at the computer for long periods without breaks. This leads to continued negative effects on already suffering discs and an increase in herniation.

Treatment is always comprehensive, which makes it possible to effectively influence not only the problem itself, but also the causes of its occurrence. Therefore, patients are prescribed:

• drug therapy;
• osteopathy;
• manual therapy;
• massage;
• physiotherapy (phonophoresis, carboxytherapy, ozone therapy);
• individual sessions with a rehabilitation specialist;
• diet.

When diagnosing an intervertebral hernia of L4–L5, it is recommended to optimize physical activity. That is, stop lifting heavy objects, and when working sedentarily, get up and move every hour. Slow walks in the fresh air are also considered beneficial.

If at the time of treatment the patient has acute pain syndrome, and MRI shows the presence of a formation larger than 12 mm, hospitalization and strict bed rest are recommended.

Drug therapy

Without exception, all patients treated for L4-L5 hernia without surgery are prescribed drug therapy. It is aimed at solving a whole range of problems in the presence of a L4–L5 hernia, ranging from eliminating the symptoms of the disease to activating the processes of natural restoration of intervertebral discs. The patient is prescribed a complex of medications from representatives of the following groups:

• NSAIDs – have analgesic and anti-inflammatory properties;
• corticosteroids – give a pronounced anti-inflammatory effect, injected into the epidural space;
• muscle relaxants – eliminate muscle spasms, which often cause severe lower back pain;
• psychotropic drugs – significantly increase the effectiveness of NSAIDs and muscle relaxants, and also help improve the psycho-emotional state of a patient exhausted by constant pain;
• B vitamins – improve nerve conduction and help normalize the functioning of the pelvic organs, which suffer as a result of compression of the spinal roots;
• Vitamin D is a remedy responsible for the condition of bone tissue, as well as for higher brain functions, such as memory, memory, attention, and speech.
• chondroprotectors – saturate cartilage tissue with components important for its effective regeneration, in particular glucosamine and chondroitin. chondroprotectors - contain natural structural elements of cartilage tissue, but the effectiveness of their use for already formed protrusions has not yet been proven. We recommend Mermaids Marine Collagen to our patients. ;
• biostimulants – help increase the intensity of metabolic processes.

All medications are taken in courses, the duration of which can vary within fairly wide limits. The doctor selects specific medications and doses individually, and also describes the specifics of using each of them. This allows you to achieve good results and reduce the likelihood of side effects.

In cases of severe pain, spinal blocks can be performed in a medical facility.

Manual therapy

Manual therapy is prescribed outside the period of exacerbation to each patient in the absence of compelling contraindications. This is an effective method of treating L4–L5 hernias without surgery, since the human spine and intervertebral discs in particular have a natural ability to recover when conditions favorable for this are created. It is this idea that underlies A. Gritsenko’s method. It just allows you to create a positive environment for the spine, in which regeneration processes would occur most pronouncedly.

Also, with the help of this unique proprietary technique, it becomes possible to eliminate the need for surgical intervention. A chiropractor who has fully mastered the method is able to use precise movements to eliminate compression of the nerve and restore the possibility of normal passage of bioelectric impulses through it.

Gritsenko method

Therefore, thanks to the use of Gritsenko’s technique, it is possible to eliminate neurological symptoms without surgery and completely normalize the functioning of the pelvic organs, which so often suffer from a hernia of L4–L5. Most patients note an improvement in their condition after the first session and its increase in the future. They observe:

• reduction of pain in the lower back, knees, hips, ankles and feet;
• normalization of urination processes;
• elimination of swelling of the legs;
• increasing potency without the use of specialized medications;
• increasing the body's adaptive capabilities;
• reducing the severity of inflammatory processes in the prostate gland, which is especially important for men with chronic prostatitis;
• increasing immunity and, accordingly, reducing the frequency of colds.

The method has 95 patents and is recognized as a highly effective means of combating neurological disorders caused by spinal pathologies. At the same time, conducting sessions does not require significant changes in lifestyle. They can be combined with work, business trips and other everyday activities.

Manual therapy has a complex effect on the body and allows not only to effectively combat existing diseases and eliminate existing preconditions for the development of others. After all, the spine is in a very close connection with the work of every organ of the human body, so the slightest changes in it respond by disrupting the functioning of the corresponding systems.

But you can only trust manual therapy to highly qualified specialists who have not only a special medical education, but also a license to practice manual therapy. Otherwise, the patient risks not getting the expected result or even facing the problem of deterioration of the condition and the need for urgent surgery.

Physiotherapy

The main method of physical therapy used for L4-L5 hernia is traction therapy or spinal traction. It is designed to increase the space between the L4 and L5 vertebrae to eliminate increased pressure on the disc lying between them. Thanks to this, not only does the regeneration process improve, but also the pressure on the nerve roots decreases.

The procedure is performed in a medical facility. After it, the patient is usually recommended to lie down for a while and then put on an orthopedic corset. It will help maintain the effect achieved during spinal traction.

Also, for L4–L5 disc herniation, the following courses are indicated:

• electrophoresis;
• laser therapy;
• ultrasound therapy;
• UHF.

Exercise therapy

Physical therapy also plays an important role in the treatment of L4–L5 hernia in a conservative way (without surgery). A set of exercises individually developed by a rehabilitation doctor helps to strengthen the muscular corset that serves as support for the spine and, accordingly, reduce the load on it.

Initially, patients are offered light exercises, gradually the number of repetitions is increased to the optimal level, and then more effective exercises are replaced. Any changes to the exercise therapy complex can only be made by a specialist. If the patient notices the appearance of pain, a repeated consultation with a doctor and correction of the exercise therapy program is required.

Diet

The diet is aimed at normalizing weight and providing the body with the substances necessary to restore cartilage tissue. Therefore, patients are recommended to switch to fractional meals and eat at least 5-6 times a day, but in small portions, and also enrich the diet with fresh vegetables, fruits, and jellies.

Fatty foods, confectionery and bakery products, and alcohol are prohibited. In general, the diet should not undergo significant changes and the majority of products are allowed for consumption.

Conservative treatment methods

Treatment of L4–L5 disc herniation without surgery is possible when its size averages up to 8 mm. Treatment tactics are developed individually for each patient and are largely determined by the size of the protrusion at the time of treatment. But the main goal of conservative treatment in all cases is to reduce the load on this spinal motion segment, which is achieved through strict adherence to bed rest for several days.

Therefore, when the size of the L4–L5 hernia is up to 5 mm, it is usually sufficient to regularly perform a special set of exercises and sometimes traction therapy sessions. If its value exceeds 5 mm, but has not reached 8 mm, a more extensive set of measures will be required, including:

Manual therapy.

• drug treatment;
• exercise therapy;
• massage;
• physiotherapy.

Patients with acute pain syndrome due to a hernia up to 12 mm are subject to hospitalization with strict adherence to bed rest.

As part of drug therapy, patients are prescribed:

• NSAIDs;
• muscle relaxants;
• glucocorticoids;
• vitamins;
• chondroprotectors (do not have convincing evidence of effectiveness).

Many patients are advised to constantly wear an orthopedic corset during the first months in order to reduce the load on the L4–L5 intervertebral disc. In the future, it should be worn when performing heavy physical work, especially when lifting heavy objects.

Semi-rigid lumbar corset.

After eliminating acute pain, treatment is supplemented with sessions of physiotherapy, for example, ultraviolet irradiation or electrophoresis, as well as massage and physical therapy. It is manual therapy and exercise therapy that play one of the most important roles in the conservative treatment of L4–L5 hernia.

The correct impact on the back muscles allows you to relieve excess tension from some, and, on the contrary, tone others. This eliminates pathological imbalance, and regular training helps create reliable support for the spine.

The exercise therapy complex is developed individually, taking into account the patient’s level of physical fitness and the type of intervertebral hernia L4–L5. It usually includes abdominal exercises, push-ups and seated bends. It is recommended to conduct the first classes under the supervision of a specialist, and then daily at home. In this case, it is necessary to avoid sudden movements, and if performing a particular exercise is accompanied by pain, you should immediately stop and consult a vertebrologist.

Sometimes patients are advised to supplement treatment with alternative methods:

• acupuncture;
• traction traction;
• osteopathy;
• kinesiotherapy;
• ozone therapy;
• hirudotherapy.

But such procedures can only be beneficial when performed by a competent specialist.

Complications

Timely initiation of treatment for L4–L5 intervertebral hernia is the key to its success and elimination of the risk of complications. If you do not intervene or ignore the doctor’s recommendations, the disease can lead to:

• spinal canal stenosis;
• paresis and paralysis of the lower extremities;
• loss of control over the process of urination;
• persistent impotence;
• infertility;
• disability.

Therefore, we recommend not to delay contacting a doctor. In the early stages of development, L4–L5 hernia responds well to conservative therapy and does not lead to the development of undesirable consequences.

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Diagnosis of circular hernia

In order to prescribe treatment, doctors at the CELT clinic conduct diagnostic studies to accurately determine the location of the hernia, its size and effect on surrounding tissues. Our clinic is equipped with modern:

• magnetic resonance imaging;
• computed tomograph;
• radiographer.

All of them allow us to conduct the necessary research at a high quality level and provide data for making the correct diagnosis.

Diagnosis of the lumbar region

Only after contacting a specialist and after undergoing appropriate diagnostic measures can the existing diagnosis be accurately established. It is impossible to diagnose a hernia on your own. It is impossible to say exactly which diagnostic method is the best. In each specific case, different examination methods are effective.

Radiography

The primary diagnostic method is radiography. This procedure helps to consider the condition of the spine, whether there are any rough formations, how close the discs are to each other, whether tumors and osteophytes are present. When a person goes to the doctor with primary complaints, he is always sent for an x-ray.

If lower back pain occurs, the patient undergoes an X-ray of the lumbosacral region. Using this study, gross dysfunction of the spine is determined. If there are pathological changes and disc subsidence, the doctor suspects a diagnosis of intervertebral hernia or osteochondrosis.

Spondylography

One type of in-depth study of the spine is spondylography. This type of diagnosis is especially relevant in the presence of osteochondrosis. This type of examination allows you to see each part of the spine separately. Sometimes it is necessary to perform not only direct, oblique and lateral projections, but also to obtain a functional image. It is performed in a bending or bending position.

Studies with contrast

There are also special indications for conducting these types of studies with contrast:

• Pneumomyelography. It involves introducing a certain amount of air into the canal of the spinal column, then an examination is carried out after a preliminary puncture of the spinal cord.
• Angiography. It involves the introduction of contrast into the vertebral arteries and images are taken using X-ray observation.
• Myelography. It involves the introduction of coloring substances into the subarachnoid canal of the spinal column. Next, an x-ray is taken. This type of examination is quite painful and requires the use of anesthesia.
• Discography. A dye is injected into a certain area of ​​the intervertebral disc, then X-rays are taken.

CT scan

After an X-ray, to clarify the diagnosis, the doctor refers the patient to a computed tomography scan. This is a more advanced device, thanks to which you can take pictures from different angles. This procedure helps to determine the presence of atypical types of tissue and establish tissue density. This type of research is more informative.

Complete information about the condition of the spine can be obtained using spiral computed tomography. This procedure makes it possible to determine the most minor changes in internal organs, including arteries and veins.

Magnetic resonance imaging

Often, in order to obtain a comprehensive examination of the spinal column, the patient is prescribed magnetic resonance imaging. It involves the influence of a magnetic field on a specific area, after which an image is displayed on the screen. When performing this study, the condition of the spinal cord, brain, intervertebral discs, joints, and pelvic organs is determined.

Magnetic resonance imaging is more gentle, without radiation exposure. With its help, you can determine the presence of an intervertebral hernia, determine in which area it is located, what its size is. Thanks to this procedure, it is possible to exclude the presence of tumors.

Other examination methods

The spine is also examined using Doppler ultrasound. With its help, they examine how passable the carotid and vertebral arteries are. This is a safe and effective method.

Electromyography allows you to determine the state of peripheral nerve structures and determine the patency of nerve fibers. An ultrasound examination is prescribed if there is swelling in the lumbar region after an injury or bruise.

If there are symptoms of an inflammatory process, the patient is sent for a blood test. Laboratory research makes it possible to evaluate the following indicators:

• erythrocyte sedimentation rate;
• level of leukocytes, monocytes, eosinophils.

Rheumatoid factor is also determined.

If suspicious signs of the disease appear, it is important to visit a doctor as soon as possible. The specialist performs a general examination and collects anamnestic data. If the presence of an intervertebral hernia is suspected, the patient is referred to specialized specialists - a neurologist, orthopedist, traumatologist, rheumatologist or vertebrologist.

Symptoms and pain of lumbar hernia

The key symptom of the presence of an intervertebral hernia in the lumbosacral region is pain in the lower back. The intensity of pain depends on the stage of development of the disease. If there is only a protrusion or a small protrusion, there are no obvious symptoms in most cases.

The development of the disease is accompanied by a slight feeling of stiffness in the morning. Usually people ignore such manifestations and are in no hurry to see a doctor. Over time, as the disease develops, discomfort increases and attacks become more frequent.

The main symptoms of a lumbar hernia include:

• The pain syndrome is constant and is felt over a long period of time. Attacks of intense pain may occur more than once throughout the day.
• When making sudden movements or lifting heavy loads, the symptoms become much more pronounced. The pain can be paroxysmal, acute, and accompanied by muscle spasms.
• Signs characteristic of pathologies such as sciatica or lumbago appear. Shooting sensations are felt in the lower extremities and buttocks. A person becomes susceptible to changes in weather conditions. With hypothermia or drafts, the signs of the disease become more pronounced. Nerve fibers in the spinal cord canal may be pinched.
• The pain syndrome is clearly felt at a specific point, a person can point to the location of the damage.
• Radicular syndrome develops and the sciatic nerve is pinched. This is accompanied by shooting in the lumbar region, unpleasant pain in the sciatic nerve, numbness and pain occurs in the buttock, and spasm often occurs in the thigh.
• Lumbar syndrome occurs - the spine is curved, the lower back muscles are constantly tense, and pain occurs in a specific area.
• Reflex syndrome. The main manifestation is pain in the lumbar region or lower extremities. This symptom may be permanent or become more pronounced after physical exertion. Additionally, disturbances in the functioning of the bladder and intestines appear, and the functions of the pelvic organs are disrupted. Painful sensations interfere with proper sleep, negatively affect the emotional state, and the person becomes irritable.

As the disease gradually progresses, the discomfort increases in intensity. Episodic attacks of pain become constant. Pathological changes affect the legs; due to frequent attacks of lumbago, the gait changes and lameness appears.

Discomfort and attacks of pain intensify when a person begins to move faster, coughs or sneezes. After a while, you can visually see a swollen protrusion at the site where the hernia formed.

Pain in the lower back (lumbar region) is one of the most common causes of disability and seeking medical help [1]. In the structure of the causes of pain in the lumbar region, the leading role is given to musculoskeletal (nonspecific) sources (90-95%) [2]. Discogenic radiculopathy occurs in clinical practice much less frequently (less than 5%) [3], however, patients with radicular syndrome have more intense pain, severe disability and decreased quality of life. In this regard, the volume of therapeutic and diagnostic measures increases, and direct and indirect costs increase [4-6]. For discogenic radiculopathy, both surgical and conservative treatment methods are used, and most patients have a positive effect from conservative therapy [2, 7]. Surgical treatment allows for quicker relief of pain and associated temporary disability, but patients’ condition gradually improves even with conservative management, and after a year of follow-up, the differences between approaches are erased [8, 9]. Improvement in the condition of patients with conservative treatment is often accompanied by natural regression of the disc herniation, which is confirmed by high-quality neuroimaging methods. Over the past 10 years, a number of cases of spontaneous regression of disc herniations have been published in the literature [10–19]. We present a clinical case of regression of a large disc herniation in the lumbar spine against the background of conservative treatment, which we observed at the Clinic of Nervous Diseases named after A.Ya. Kozhevnikova.

The patient, 38 years old, complained of intense pain in the lower back and left gluteal region, radiating along the posterolateral surface of the thigh and lower leg to the fourth and fifth toes of the left foot, a feeling of numbness and tingling in the area where the pain radiated. The patient began to experience episodic pain in the lumbar region about 6 years ago. Exacerbations were observed periodically (up to 3-4 times a year), which could be successfully stopped by taking non-steroidal anti-inflammatory drugs (NSAIDs). It should be noted that the patient’s work involves long periods of sitting at a computer. According to the patient, the real deterioration is caused by lifting heavy objects in an uncomfortable position. In contrast to previous episodes, greater intensity of pain was observed, irradiation into the leg and development of numbness along the posterolateral surface of the leg to the IV-V toes of the left foot. Taking NSAIDs did not bring any significant effect. The pain intensified significantly with movements in the lumbar spine. Due to persistent intense pain and the ineffectiveness of drug therapy, the patient turned to the Clinic for Nervous Diseases named after. AND I. Kozhevnikova.

Upon admission to the clinic, the intensity of pain in the back was up to 8 points on the digital rating scale (DRS), in the leg - up to 6 points, with a pronounced neuropathic component (4 points on the DN4 questionnaire). Severe disability was noted (Oswestry index 68%). Indicators of emotional status corresponded to the norm (according to the Hospital Anxiety and Depression Scale, anxiety was 5 points, depression was 0). The decrease in quality of life was due primarily to the physical component of health (on the SF-12 scale - physical component of health - 36.4, psychological - 61.8 points). According to a special questionnaire (Start Back Screening Tool), the risk of chronic pain was assessed as average (overall score 5 points, subscale score 2 points).

The neurological status revealed hypoesthesia and paresthesia (in the form of a tingling sensation) along the posterolateral surface of the thigh and lower leg to the IV-V toes of the left foot, absence of the left Achilles reflex, positive Lasegue symptom on the left - 45 degrees, pain on deep palpation and percussion in the projection of the spinous processes lower lumbar vertebrae. There are no other neurological disorders, muscle strength is sufficient, pelvic functions are not impaired. Taking into account complaints of intense pain in the lower back with irradiation in the leg to the foot, which developed after heavy lifting, and the presence of signs of radiculopathy (positive Lasegue sign, loss of the Achilles reflex, neuropathic pain and hypoesthesia in the dermatome of the first sacral root), a clinical diagnosis was established: vertebrogenic left-sided lumbar ischialgia , radiculopathy of the first sacral root (against the background of a probable disc-radicular conflict).

Blood tests (general and biochemical), urine analysis without pathology.

MRI confirmed the discogenic nature of the radiculopathy, revealed paramedian sequestered extrusion of the disc between the fifth lumbar vertebra and the sacrum up to 11 mm with lateralization to the left, in the subchondral parts of the adjacent vertebrae there was an increase in the MR signal in T1 and T2 modes, corresponding to the stage of fatty degeneration (Modic II; see picture,

MRI of the patient's lumbosacral region. Upon admission a-c: paramedian sequestered extrusion of the L5-S1 disc up to 11 mm with lateralization to the left is visualized, in the subchondral parts of the adjacent vertebrae (arrows) an increase in the MR signal was noted in T1 and T2 modes, corresponding to the stage of fatty degeneration (Modic II), and after 9 months; d-f: regression of the L5-S1 disc herniation was noted, with preservation of protrusion up to 3 mm, changes (Modic II). a-c).

Due to the absence of emergency indications for surgery, it was decided to use conservative treatment options. The patient was administered steroids in combination with a local anesthetic via the epidural foraminal approach under radiographic guidance. Additionally, NSAIDs were used to reduce pain. The patient's motor mode was corrected: the limitation of heavy lifting during the period of exacerbation and the technique of safer performance of the movement in the future (from a squatting position with a straight back, and not due to bending) were discussed, the need to take breaks during prolonged static loads, the ergonomics of the workplace was adjusted patient (height of the table, chair, location of the computer monitor), therapeutic exercises were selected.

After treatment for 2 weeks, the pain completely regressed in the leg and significantly decreased in the lower back (up to 4 points according to the CRS). The patient returned to normal daily activities, went to work, and continued her professional activities in full. Over the course of 9 months, there were no repeated exacerbations, but periodically I was bothered by lower back pain (up to 3 points according to the CRS) with awkward movements. Indicators of work ability have improved: the Oswestry index decreased to 14%, which corresponds to a minimal limitation of functional status. Indicators of quality of life are normal (physical component of health - 49.6, psychological - 60.7 points), indicators of anxiety and depression on the hospital scale - 0. In the neurological status, only a decrease in the left Achilles reflex, a subjective feeling of numbness along the lateral edge of the foot are noted . Repeated MRI of the lumbosacral spine revealed regression of disc extrusion between the fifth lumbar vertebra and the sacrum, protrusion of up to 3 mm and Modic II type changes remain (see figure, d-f).

Thus, against the background of complex conservative treatment with the use of epidural steroids, the patient with discogenic radiculopathy achieved significant clinical improvement, which allowed her to quickly restore her ability to work. During follow-up, regression of disc extrusion was demonstrated. It should be noted that the decrease in the severity of symptoms significantly outpaced the changes on MRI.

For the first time, regression of a herniated intervertebral disc, confirmed by computed tomography in a 25-year-old patient, was described by F. Guinto et al. in 1984 [20]. Subsequently, with the introduction into widespread practice of MRI, which is highly accurate in assessing changes in soft tissues, including intervertebral disc structures, more publications of both individual clinical cases and their series appeared [10-14, 16-18]. Cases of regression of large hernias have also been described in our country [15, 19].

Currently, three main mechanisms of regression of disc herniations are considered in the literature [12, 16, 21, 22]. The first proposed option, mechanical “reduction” of the hernia, is predominantly speculative in nature and is hypothetically possible only with a intact fibrous ring, for example, with small protrusions. The second mechanism discussed is dehydration, which results in a decrease in the volume of the hernia. This assumption is based on studies that show a higher likelihood of hernia regression in young patients with an increased T2 signal on MRI (due to high fluid content) [21].

The third hypothesis about an immune-mediated reaction against hernia fragments seems to be the most convincing [23-26]. During development, the intervertebral disc is formed as an immune-privileged organ, without interaction with the immune system, which excludes it from the processes of immunological tolerance. During disc degeneration and its extrusion (formation of a hernia), accompanied by a violation of the integrity of the fibrous ring, the nucleus pulposus comes into contact with the immune system, which perceives it as a foreign body and triggers a complex cascade of biochemical and immunological reactions. The autoimmune reaction is realized by the activation of antibody-producing B-lymphocytes and cytotoxic T-lymphocytes. The production of pro-inflammatory cytokines (tumor necrosis factor - TNF, interleukins - IL-1α, IL-1β, IL-6 and IL-17) increases, which contribute to the degradation of the extracellular matrix and increased expression of chemokines. This leads to the penetration of activated immunocytes into the disc and the production of endothelial growth factor, which promotes neovascularization and ensures increased phagocytosis and resorption of disc herniation fragments. Inflammatory cytokines such as TNF further stimulate the production of metalloproteinases (especially metalloproteinase type 7, which causes collagen dissolution).

The development of inflammatory processes in a disc herniation was confirmed by immunohistochemical study of materials obtained during surgery in patients with lumbar ischialgia: high levels of phospholipase A2, inflammatory interleukins, chemokines, and matrix metalloproteinases of various groups were revealed [27]. In the work of M. Yoshida et al. [28] in an experimental model of disc herniation revealed an increase in the level of TNF and IL-1β already on the 1st day. By the 3rd day, the content of monocyte chemoattractant protein type 1 increased, which contributed to active infiltration by macrophages, which led to regression of the hernia after 12 weeks.

The timing and predictors of regression of disc herniation have not been fully studied. The literature presents extremely variable periods of regression (from 3 to 30 months), however, many studies note that regression is more possible in large hernias with sequestration, which probably provokes a maximum immune response. In 2014, M. Macki et al. [29] presented a review of the literature on spontaneous regression of sequestered disc herniations in the lumbar spine. The average time for regression of hernias according to MRI was 9.27±13.32 months, while regression of clinical symptoms was noted much earlier - on average 1.33±1.34 months from the onset of the disease. The authors explain that symptomatic regression, significantly outpacing hernia regression, is likely consistent with the natural history of discogenic radiculopathy. A study of the dynamics of clinical symptoms showed complete resolution of back pain, a decrease in the severity of paresis to 86%, sensory impairment to 68%, and hyporeflexia to 75%. In the case we present, significant clinical improvement during conservative therapy was noted within 10 days, while sensory disorders regressed to a lesser extent. Radiographic changes were noted at 9 months from the onset of the disease.

The influence of the type of disc herniation on the possibility of its regression was studied in a systematic review by S. Chiu et al. in 2015 [21]. The probability of spontaneous reduction of sequestrations reached 96%, extrusions - 70%, protrusions - 41%. The chances of complete regression for sequesters were 43%, and for extrusions - 15%. The authors concluded that the larger the disc herniation, the greater the immune response it provokes, and therefore the greater the likelihood of its regression. In addition, the following features of the hernia were noted that predispose to its reduction. These include migration of disc fragments into the epidural space, usually associated with rupture of the posterior longitudinal ligament, which is consistent with previous studies [30, 31]. Entry of disc fragments into the epidural space makes them more accessible to the immune system and increases the chances of immune-mediated lysis. Contrast enhancement of the peripheral parts of the hernia indicates their vascularization and the possibility of phagocytosis. According to R. Autio et al. [32], the wider the contrast zone, the greater the likelihood of regression. High signal intensity in T2 mode corresponds to a higher fluid content in the disc herniation and predisposes to the dehydration mechanism of its reduction. The authors also noted that the isolated factor of hernia regression does not always correlate with a better outcome of the disease, and on the contrary, clinical improvement is possible without reducing the hernia; thus, once again emphasizing that the reduction of symptoms is determined not only and not so much by radiological changes.

A. el Barzouhi et al. came to a similar conclusion. [33] when studying the relationship between neuroimaging findings and clinical outcome. A year after the onset of the disease, 84% of patients noted a good result of treatment. At the same time, on MRI, disc herniation was detected in 35% of patients with a good outcome and 33% of patients in the group with unsatisfactory treatment results. In the group of patients without a disc herniation, a satisfactory treatment result was observed in 83%, but in the group with a persistent hernia, satisfactory results were observed in 85%. The authors concluded that MRI scans one year after disease onset do not differentiate between patients with different disease outcomes.

The presented clinical case illustrates the effectiveness of multidisciplinary conservative treatment of discogenic radiculopathy using epidural blocks. The possibility of regression of a large sequestered disc herniation was noted. The decrease in the severity of clinical symptoms significantly outpaced neuroimaging changes, which is likely determined by the peculiarities of the course of immunological and biochemical processes in the area of ​​the disc-radicular conflict. It seems promising to study predictors of clinical outcome and hernia regression in patients with discogenic radiculopathy to optimize their management tactics.

The authors declare no conflict of interest.

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Surgery for spinal hernia L5–S1

Surgery for a hernia of the lumbosacral spine is a last resort measure, which is resorted to in strictly defined situations:

• in the absence of positive changes in the patient’s condition after 1–3 months of treatment with conservative methods;
• severe cauda equina syndrome;
• the occurrence of paralysis;
• sequestered hernias.

All operations performed for hernia are minimally invasive and have a high level of safety. Modern neurosurgery offers such ways to solve the problem as:

• nucleoplasty;
• endoscopic surgery;
• microdiscectomy.

The specific surgical tactics for L5–S1 disc herniation are selected based on its size, type, and general health of the patient. If at the stage of preoperative preparation it is assumed that a significant part of the intervertebral disc will be removed, the neurosurgeon will notify the patient of the need to install a special implant to close the resulting defect. Today, a special Barricaid mesh is used for these purposes. It is used to fill the missing part of the annulus fibrosus and prevent the nucleus pulposus from leaking out through the existing defect.

Sometimes the L5–S1 intervertebral hernia reaches such a size that complete removal of the disc is required. In such situations, neurosurgeons may decide to achieve spinal fusion, i.e. fusion of the L5 and S1 vertebrae with each other, but this will lead to limited mobility of the spine, which is not always acceptable for patients.

Another option to solve the problem is to install an M6 endoprosthesis. It is a copy of a natural intervertebral disc, as it has an artificial fibrous ring and nucleus pulposus. Installing an endoprosthesis requires a neurosurgeon to have a thorough knowledge of the technology, but if the doctor has undergone appropriate training, then installing the M6 ​​does not cause any difficulties.

Puncture surgery

Methods of puncture surgery (nucleoplasty) have appeared in the arsenal of neurosurgeons recently, but have already managed to completely revolutionize the idea of ​​operations for intervertebral hernias. They are practically devoid of intraoperative risks, allow you to leave the clinic on the day of surgery, completely free from pain, and avoid the formation of scars.

The essence of nucleoplasty is the introduction, under the control of an image intensifier, of a thin cannula into the nucleus pulposus of the disc through the soft tissue above the affected spinal motion segment. As soon as it reaches the center of the nucleus, an electrode is immersed in it, which creates:

• laser energy (laser nucleoplasty);
• cold plasma (cold plasma);
• radio waves (radio wave).

In the first case, evaporation of part of the nucleus pulposus is carried out using the thermal energy of the laser, but this is associated with the risk of overheating of surrounding tissues, which may include blood vessels and nerves. Therefore, recently preference has been given to other methods of nucleoplasty, especially cold plasma and hydroplasty.

The essence of cold plasma nucleoplasty is the use of cold plasma, which destroys nuclear tissue without causing strong heating. As a result, negative pressure is created in the intervertebral disc, which leads to the retraction of the resulting protrusion back.

Hydroplasty is based on the destruction of the contents of the nucleus by the pressure of a saline solution. It is carried out using a SpineGet device specially created for this procedure. The tip inserted into the body has 2 branches: for injection of liquid supplied under pressure and for suction of waste material. Since the destruction of the nucleus and removal of the resulting particles along with saline solution occurs simultaneously, the neurosurgeon can very accurately control how much of the nucleus pulposus should still be removed.

But puncture therapy methods can only be used for hernias L5–S1, the size of which does not exceed 7 mm.

Endoscopic hernia surgery

Endoscopic operations are indicated for large hernias or their location in narrow areas of the spinal canal. The essence of the method is to create access with a shaver in its projection and insert the endoscope. It is a tube through which special instruments are inserted into the surgical field and the altered tissue is excised. The neurosurgeon controls his every step through a camera inserted into the treatment area using a similar technique.

Endoscopic surgery for intervertebral hernia has a low percentage of intraoperative complications and a short recovery period. But it also cannot be performed in all cases.

Microdiscectomy

One of the classic techniques for removing hernias is microdiscectomy. It involves removal of a protrusion or the entire disc in an open manner through an incision of up to 3 cm. The method is indicated for severe neurological complications, the impossibility of using other techniques, and this operation is also indicated for sequestered hernias L5–S1.