Compression by bone fragments of the spinal cord. Spinal compression syndromes

E.V. Podchufarova

MMA named after I.M. Sechenov Moscow

Among pain syndromes lower back pain occupies a leading position. Acute pain in the back of varying intensity are observed in 80-100% of the population. 20% of adults experience periodic, recurrent pain in the back lasting 3 days or more. Analysis of social, individual and professional factors showed that there is a connection between pain in the back, level of education, disadvantage physical activity, smoking intensity and frequency of bending and lifting heavy objects during work.

Depending on the reason pain distinguish vertebrogenic (pathogenetically associated with changes in the spine) and non-vertebrogenic painful syndromes. In this case, vertebrogenic disorders include lesions lumbar and sacral roots in case of intervertebral disc herniation, stenosis of the central and lateral spinal canal, spondylolisthesis and instability, arthropathic syndrome in case of degenerative lesions of the facet joints. To vertebrogenic causes pain in the back there are also relatively rare malignant neoplasms of the spine (primary tumors and metastases), inflammatory (spondyloarthropathies, including ankylosing spondylitis) and infectious lesions (osteomyelitis, epidural abscess, tuberculosis 0.7, 0.3 and 0, 01% of cases of acute pain in the back, respectively), as well as compression fractures of the vertebral bodies due to osteoporosis (3.10|.
Examples of nonvertebrogenic painful diseases may serve as syndromes internal organs(gynecological, renal and other retroperitoneal pathologies). The main causes of radiculopathy not associated with dystrophic changes in the spine (less than 1% of cases) pain in the back with irradiation to the leg), are primary and metastatic tumors, meningeal carcinomatosis; congenital anomalies(arachnoid and synovial cysts); infections (osteomyelitis, epidural abscess, tuberculosis, herpes zoster, Lyme disease, HIV infection); inflammatory diseases: (sarcoidosis, vasculitis); endocrine and metabolic disorders: ( diabetes, Paget's disease. acromegaly: arteriovenous malformations).
Among the structural damage associated with lower back pain, the following can be distinguished: hernia of the nucleus pulposus; narrow spinal canal (central canal stenosis, lateral canal stenosis); instability due to disc (intervertebral disc degeneration) or extradiscal (facet joints, spondylolisthesis) pathology; myofascial painful syndrome (MFPS). Clinically, the listed factors make it possible to distinguish compression radiculopathy, the progression of which leads to disability. and musculoskeletal painful syndromes (lumbodynia, lumbar ischialgia), mainly worsening the quality of life of patients.
Local pain in the lumbar -sacral region usually referred to as “lumbodynia”; pain, reflected in the leg - “lumboischialgia” and radiating pain associated with vertebrogenic lesions lumbar and/or sacral roots - “compression radiculopathy”.
Compression radiculopathies are most often observed with compression lumbar or sacral root herniated intervertebral disc, as well as lumbar stenosis. Radicular (irradiating) pain differs in greater intensity, distal (peripheral) spread to the corresponding dermatomes and the conditions that cause it. The mechanism of this pain consists of stretching, irritation or compression of the root (spinal nerve). Spreading pain almost always occurs in the direction from the spine to some part of the limb. Coughing, sneezing or exercise are common factors that increase pain. The same effect has any movement that causes stretching of the nerve, or conditions leading to an increase in pressure. cerebrospinal fluid(eg cough, straining).
Compression by a herniated disc

One of the main causes of compression radiculopathy is a herniated disc. When a disc herniation occurs, the dura mater first suffers, then the perineurium of the spinal ganglia and the roots of the cauda equina. Direct relationship between channel sizes and the appearance of signs
there is no compression of the roots. Men over 40 years of age are more likely to get sick. Pain compression related lumbosacral roots of a herniated intervertebral disc, wears
heterogeneous character. The “classical” picture of compression radiculopathy is the appearance of shooting, rolling, and less often burning pain and paresthesia (“pins and needles”, tingling), combined with decreased sensitivity (hypalgesia) in the area of ​​innervation of the affected root. In addition to sensory disorders, the development of weakness in the so-called “indicator” muscles, mainly innervated by the affected root, is characteristic, as well as a decrease (loss) of the corresponding reflex. Characteristic sensory, motor and reflex disorders during
the most common types of compression radiculopathy lumbosacral roots are shown in Table I. In addition, with radicular compression
there is often an increase in pain with increased intra-abdominal pressure (when coughing, sneezing, laughing) in vertical position and a decrease in horizontal position. In approximately half of patients with disc pathology, a tilt of the body to the side (scoliosis) develops, which disappears in the supine position, which is mainly due to contraction of the quadratus muscle lower back. The straight leg raise test (Lasegue's sign) with the lift angle limited to 30 -50″ is practically pathognomonic for disc damage [1]. It is important to keep in mind that the clinical picture of root compression (usually L5) at the level of the corresponding intervertebral foramen is different. In such patients pain It is observed both when walking and at rest, does not increase with coughing and sneezing and is monotonous throughout the day. Forward bends are less limited, and painful sensations are most often provoked by extension and rotation.
Narrow spinal canal
In addition to the presence of disc pathology itself, the occurrence of radicular symptoms is facilitated by the relative narrowness of the spinal canal. Syndrome in which the roots are damaged spinal nerves due to degenerative changes in the bone structures and soft tissues of the spinal canal, it is clinically different from acute protrusion of the intervertebral disc. The main factors for spinal canal stenosis are hypertrophy of the ligamentum flavum, facet joints, and protrusion intervertebral discs, posterior osteophytes and spondylolisthesis. There is stenosis of the central canal of the spine (central lumbar stenosis) and lateral stenosis with a decrease in the size of the root canal or intervertebral foramen (foraminal stenosis). The smallest permissible anteroposterior diameter of the spinal canal at the lumbar level is 10.5 mm. In some cases, the sagittal diameter of the spinal canal remains normal, and narrowing occurs in the radicular canal, which is limited anteriorly by the posterolateral surface of the vertebral body, and posteriorly by the superior articular process. Lateral stenosis is diagnosed when the sagittal size of the root canal decreases to 3 mm. Compression factors in root canal stenosis are hypertrophy of the superior articular process and thickening of the ligamentum flavum. In 20-30% of cases there is a combination of central and lateral lumbar stenosis The L5 root suffers more often than others, which is explained by the significant severity of degenerative changes and the greater length of the lateral canals at the LV-SI level. Root entrapment can also occur in the central canal; this is more likely when it has a small diameter in combination with degenerative changes in the intervertebral discs, joints, and ligaments. The development of radicular compression can be caused not only by degenerative changes, but also by the presence of thickening of the veins (edema or fibrosis), epidural fibrosis (due to trauma, surgery with subsequent hematoma, infectious process, reaction to foreign body). The absolute size of the root ropes cannot indicate the presence or absence of compression: what matters is its relationship with the size spinal ganglion or root

A characteristic manifestation

stenosis is neurogenic (caudogenic) intermittent claudication (claudication). It is most often observed in men aged 40-45 years engaged in physical labor.

occurs in one or both legs when walking, usually located above or below the knee, sometimes spreading to the entire limb. At rest

not expressed. Neurogenic intermittent claudication is characterized by increasing paresis, weakening tendon reflexes and a decrease in somatosensory evoked potentials of the spinal cord and brain from the legs after walking (“march test”). Passed before occurrence

sensations, the distance usually does not exceed 500 m. A decrease in

when leaning forward. Extension and rotation reduce the available space, compressing the root and its vessels, which explains the limitation of both types of movement in patients with this pathology. The basis of the disease is a metabolic disorder in the roots of the cauda equina due to their ischemia during physical activity. The presence of spinal stenosis at one level or narrowing of the lateral canals is not sufficient to cause claudication. More often, multilevel stenosis is observed in combination with a decrease in the size of the root canals. It should be noted that in patients with narrow spinal canal isolated increase in intensity

when walking, often atypical for a radicular lesion of localization, is usually caused by musculoskeletal disorders accompanying lumbar stenosis and degenerative damage to the joints of the spine and legs. Therefore, it is necessary to differentiate caudogenic claudica syndrome from other causes of vertebrogenic

Which may accompany clinically insignificant

stenosis. If a narrowing of the spinal canal is suspected, it is necessary to carry out

(sometimes in combination with myelography)

department of the spine. The presence of a wide spinal canal excludes the diagnosis of neurogenic claudication. Electrophysiological methods - somatosensory evoked potentials and

Most often in clinical practice there are musculoskeletal

syndromes not associated with lesions

roots (about 85% of patients with

in back). They are caused by irritation of the receptors of the fibrous ring, muscle-articular structures of the spine, as a rule, are not accompanied by a neurological defect, but may also be present in the picture of radicular lesions (reflex

syndromes).

In the moment physical stress or with awkward movement, sharp, often shooting lumbago often occurs

lasting from minutes to hours. The patient, as a rule, freezes in an uncomfortable position and cannot change his body position if the attack occurs while lifting something heavy.

the spine remains fixed (natural immobilization) even when trying to passively move the leg (extended at the knee joint) in the hip joint,

may not occur.

Lumbodynia

It is now generally accepted that localized
pain in the back (lumbodynia) is most often caused by damage to muscles, ligaments and degenerative changes in the spine. The cause of localized myogenic
pain in the lumbar and sacral region may be
MFBS of quadratus muscle lower back, muscles. erector spinae, multifidus and rotator cuff muscles lower back. MFBS is characterized by the formation
trigger points (TT) - areas of local pain in the affected muscle, upon palpation of which a tight cord is revealed, an area of ​​local compaction located along the direction muscle fibers. Mechanical pressure on the CT causes not only intense local, but also reflected pain |2|.
MFBS of quadratus muscle lower back often causes deep aching pain in the lower back, which, in the presence of superficially located TTs, irradiates into the area sacro- iliac joints and in the gluteal region, and with TT in the depths of the muscle in the thigh, region ridge ilium and groin region. In the quadratus muscle lower back Most often, active TTs are formed during forced movements, accompanied by bending and turning the body, lifting a load, as well as during postural stress associated with gardening, cleaning premises or driving a car. Pain usually localized in the area bounded above by the costal arch, below by the iliac crest, medial spinous processes of the lumbar vertebrae, and laterally by the posterior axillary line. Painful sensations arise or intensify when walking, bending, turning in bed, getting up from a chair, coughing and sneezing. There is often intense pain at rest, disrupting sleep. Since the quadratus muscle lies under the erector spinae muscle, deep palpation is necessary to identify the TT in it with the patient lying on the healthy side. As a rule, there is a limitation of lateroflexion in lumbar part of the spine in the direction opposite to the localization of the spasmed muscle. MFBS of the erector spinae muscle. Another common myogenic source pain in the back is the MFBS muscle that straightens the spine. Pain associated with it is localized in the paravertebral region and significantly limits movements in lumbar department of the spine. Typically, the TT in this muscle activates the “unprepared” movement with bending and rotation in the lumbar region.
Degenerative spondylolisthesis (displacement of the vertebrae relative to each other) most often occurs at the LIV-LV level. which is due to a weaker ligamentous apparatus, high disc height, predominantly sagittal orientation articular surfaces facet joints. The formation of degenerative spondylolisthesis is also facilitated by: 1) a decrease in the mechanical strength of the subchondral bone (microfractures due to osteoporosis lead to changes in the relationship of the articular surfaces); 2) reducing the resistance to the load of the intervertebral disc, damaged by the degenerative process, and, as a result, increasing the load on the facet joints to withstand the force of the anterior shear; 3) gain lumbar lordosis due to changes in the ligamentous apparatus; 4) weakness of the trunk muscles; 5) obesity. Degenerative spondylolisthesis can be combined with manifestations of segmental instability of the spine. The appearance of neurological disorders in this condition is associated with narrowing and deformation of the central and radicular canals and intervertebral foramina. It is possible to develop symptoms similar to neurogenic claudication, compression of the roots and spinal nerves, more often at the level of I.IV-LV.
Segmental instability of the spine (mixing of the vertebral bodies in relation to each other, the magnitude of which changes with movements of the spine) manifests itself pain in the back, aggravated by prolonged exercise or standing; Often there is a feeling of fatigue, causing the need to rest while lying down. The development of instability is typical in middle-aged women suffering from moderate obesity, with episodes pain in the back in the anamnesis, first noted during pregnancy. The presence of neurological symptoms is not necessary. Flexion is not limited. When extending, patients often resort to using their hands, “climbing up on themselves.” To establish a definitive diagnosis, radiography with functional tests(flexion, extension).

Sciatica

The cause of lumbar ischialgia may be arthropathic disorders (dysfunction of the facet joints and sacral-iliac joints), as well as muscular-tonic and MFBS of the gluteus maximus and gluteus medius, piriformis, iliocostal muscles and ilio- lumbar muscles.
Arthropathic syndrome. Facet (facet, apophyseal) joints can be a source of both local and reflected pain in back. Frequency of facet joint pathology in patients with pain in the lumbosacral region ranges from 15 to 40%. There are no pathognomonic symptoms of their damage. Pain caused by pathology of the facet joints, can radiate to the groin area, along the back and outer surface hips, tailbone. Clinical features, having diagnostic value, are pain in the lumbar department, increasing with extension and rotation with localized pain in the projection of the facet joint, as well as the positive effect of blockades with local anesthetics in the projection of the joint)