Reduced height of intervertebral discs. Intervertebral disc - norm and pathology Reduced height of intervertebral discs

Photograph of an anatomical specimen) are the main element connecting the spinal column into a single whole, and make up 1/3 of its height. The main function of intervertebral discs is mechanical (support and shock-absorbing). They provide flexibility to the spinal column during various movements (bending, rotation). In the lumbar spine, the diameter of the discs is on average 4 cm, and the height is 7–10 mm. The intervertebral disc has a complex structure. In its central part there is a nucleus pulposus, which is surrounded by a cartilaginous (fibrous) ring. Above and below the nucleus pulposus are the end plates.

The nucleus pulposus contains well-hydrated collagen (randomly arranged) and elastic (radially arranged) fibers. At the border between the nucleus pulposus and the fibrous ring (which is clearly defined up to 10 years of life), cells resembling chondrocytes are located with a fairly low density.

Fibrous ring consists of 20–25 rings or plates, between which collagen fibers are located, which are directed parallel to the plates and at an angle of 60° to the vertical axis. Elastic fibers are located radially in relation to the rings, which restore the shape of the disc after the movement has taken place. The cells of the annulus fibrosus, located closer to the center, have an oval shape, while at its periphery they elongate and are located parallel to the collagen fibers, resembling fibroblasts. Unlike articular cartilage, disc cells (both the nucleus pulposus and the annulus fibrosus) have long, thin cytoplasmic projections that reach 30 μm or more. The function of these outgrowths remains unknown, but it is assumed that they are capable of sensing mechanical stress in tissues.

End plates They are a thin (less than 1 mm) layer of hyaline cartilage located between the vertebral body and the intervertebral disc. The collagen fibers it contains are arranged horizontally.

Intervertebral disc of a healthy person contains blood vessels and nerves only in the outer plates of the annulus fibrosus. The endplate, like any hyaline cartilage, has no vessels or nerves. Basically, the nerves travel accompanied by vessels, but they can also travel independently of them (branches of the sinuvertebral nerve, anterior and gray communicating branches). The sinuvertebral nerve is the recurrent meningeal branch of the spinal nerve. This nerve leaves the spinal ganglion and enters the intervertebral foramen, where it divides into ascending and descending branches.

As has been shown in animals, the sensory fibers of the sinuvertebral nerve are formed by fibers from both the anterior and posterior roots. It should be noted that the anterior longitudinal ligament is innervated by branches of the spinal ganglion. The posterior longitudinal ligament receives nociceptive innervation from the ascending branches of the sinuvertebral nerve, which also innervates the outer plates of the annulus fibrosus.

With age, there is a gradual blurring of the boundary between the fibrous ring and the nucleus pulposus, which becomes more and more fibrotic. Over time, the disc becomes morphologically less structured - the annular plates of the annulus fibrosus change (merge, bifurcate), collagen and elastic fibers are located more and more chaotically. Cracks often form, especially in the nucleus pulposus. Degeneration processes are also observed in the blood vessels and nerves of the disc. Fragmented cell proliferation occurs (especially in the nucleus pulposus). Over time, intervertebral disc cells die. Thus, in an adult, the number of cellular elements decreases by almost 2 times. It should be noted that degenerative changes in the intervertebral disc (cell death, fragmented cell proliferation, fragmentation of the nucleus pulposus, changes in the annulus fibrosus), the severity of which is determined by a person’s age, is quite difficult to differentiate from those changes that would be interpreted as “pathological”.

The mechanical properties (and accordingly the function) of the intervertebral disc are ensured intercellular matrix, the main components of which are collagen and aggrecan (proteoglycan). The collagen network is formed by type I and type II collagen fibers, which constitute approximately 70% and 20% of the dry weight of the entire disc, respectively. Collagen fibers provide strength to the disc and fix it to the vertebral bodies. Aggrecan (the main disc proteoglycan), composed of chondroitin and keratan sulfate, provides hydration to the disc. Thus, the weight of proteoglycans and water in the annulus fibrosus is 5 and 70%, and in the nucleus pulposus – 15 and 80%, respectively. Synthetic and lytic (proteinases) processes constantly occur in the intercellular matrix. However, it is a histologically constant structure, which provides mechanical strength to the intervertebral disc. Despite the morphological similarity with articular cartilage, the intervertebral disc has a number of differences. Thus, protein glycans (aggrecan) of the disc contain a higher content of keratan sulfate. In addition, in the same person, disc aggrecans are smaller and have more pronounced degenerative changes than articular cartilage aggrecans.

Let us consider in more detail the structure of the nucleus pulposus and the fibrous ring - the main components of the intervertebral disc.

Nucleus pulposus. According to morphological and biochemical analysis, including microscopic and ultramicroscopic studies, the nucleus pulposus of human intervertebral discs belongs to a type of cartilaginous tissue (V.T. Podorozhnaya, 1988; M.N. Pavlova, G.A. Semenova, 1989; A.M. Seidman, 1990). The characteristics of the main substance of the nucleus pulposus correspond to the physical constants of a gel containing 83-85% water. Studies by a number of scientists have determined a decrease in the content of the water fraction of the gel with age. Thus, in newborns the nucleus pulposus contains up to 90% water, in a child of 11 years old - 86%, in an adult - 80%, in people over 70 years old - 60% water (W. Wasilev, W. Kuhnel, 1992; R. Putz , 1993). The gel contains proteoglycans, which, along with water and collagen, are the few components of the nucleus pulposus. Glycosaminoglycans in proteoglycan complexes are chondroitin sulfates and, in smaller quantities, keratan sulfate. The function of the chondroitin sulfate-containing region of a proteoglycan macromolecule is to create pressure associated with the spatial structure of the macromolecule. High imbibitional pressure in the intervertebral disc retains a large number of water molecules. The hydrophilicity of proteoglycan molecules ensures their spatial separation and separation of collagen fibrils. The resistance of the nucleus pulposus to compression is determined by the hydrophilic properties of proteoglycans and is directly proportional to the amount of bound water. Compression forces, acting on the pulpous substance, increase its internal pressure. Water, being incompressible, resists compression. The keratan sulfate region is capable of interacting with collagen fibrils and their glycoprotein sheaths to form cross-links. This enhances the spatial stabilization of proteoglycans and ensures the distribution of negatively charged terminal groups of glycosaminoglycans in the tissue, which is necessary for the transport of metabolites into the nucleus pulposus. The nucleus pulposus, surrounded by a fibrous ring, occupies up to 40% of the area of ​​the intervertebral discs. It is to it that most of the forces transformed in the nucleus pulposus are distributed.

Fibrous ring formed by fibrous plates, which are located concentrically around the nucleus pulposus and are separated by a thin layer of matrix or layers of loose connective tissue. The number of plates varies from 10 to 24 (W.C. Horton, 1958). In the anterior part of the fibrous ring the number of plates reaches 22-24, and in the posterior part it decreases to 8-10 (A.A. Burukhin, 1983; K.L. Markolf, 1974). The plates of the anterior sections of the fibrous ring are located almost vertically, and the rear ones have the form of an arc, the convexity of which is directed posteriorly. The thickness of the anterior plates reaches 600 microns, the rear ones - 40 microns (N.N. Sak, 1991). The plates consist of bundles of densely packed collagen fibers of varying thickness from 70 nm or more (T.I. Pogozheva, 1985). Their arrangement is ordered and strictly oriented. The bundles of collagen fibers in the plates are biaxially oriented relative to the longitudinal axis of the spine at an angle of 120° (A. Peacock, 1952). The collagen fibers of the outer plates of the annulus fibrosus are woven into the deep fibers of the lateral longitudinal ligament of the spine. The fibers of the outer plates of the fibrous ring are attached to the bodies of adjacent vertebrae in the region of the marginal border - the limbus, and are also embedded in the bone tissue in the form of Sharpey fibers and fuse tightly with the bone. The fibrils of the internal plates of the annulus fibrosus are woven into the fibers of hyaline cartilage, separating the tissue of the intervertebral disc from the spongy bone of the vertebral bodies. This is how a “closed package” is formed, which closes the nucleus pulposus into a continuous fibrous frame between the fibrous ring along the periphery and the hyaline plates connected above and below by a single system of fibers. In the plates of the outer layers of the annulus fibrosus, alternating differently oriented fibers with different densities were identified: loosely packed ones alternate with densely packed ones. In dense layers, the fibers split and move into loosely packed layers, thus creating a single system of fibers. The loose layers are filled with tissue fluid and, being an elastic shock-absorbing tissue between dense layers, provide elasticity to the fibrous ring. The loose-fibrous part of the annulus fibrosus is represented by thin, unoriented collagen and elastic fibers and a ground substance consisting predominantly of chondroitin-4-6-sulfate and hyaluronic acid.

The height of the discs and spine is not constant throughout the day. After a night's rest, their height increases, and by the end of the day it decreases. The daily fluctuation in the length of the spine reaches 2 cm. The deformation of the intervertebral discs varies with compression and tension. If, when compressed, the disks flatten by 1-2 mm, then when stretched, their height increases by 3-5 mm.

Normally, there is a physiological protrusion of the disc, which is that the outer edge of the fibrous ring, under the action of an axial load, protrudes beyond the line connecting the edges of adjacent vertebrae. This protrusion of the posterior edge of the disc towards the spinal canal is clearly visible on myelograms and alignment. usually, does not exceed 3 mm . Physiological protrusion of the disc increases with extension of the spine, disappears or decreases with flexion.

Pathological protrusion of the intervertebral disc differs from physiological the fact that widespread or local protrusion of the fibrous ring leads to a narrowing of the spinal canal and does not decrease with movements of the spine. Let's move on to consider the pathology of the intervertebral disc.

PATHOLOGY ( addition)

The main element of intervertebral disc degeneration is decrease in the number of protein glycans. Fragmentation of aggrecans and loss of glycosaminoglycans occur, which leads to a drop in osmotic pressure and, as a consequence, dehydration of the disc. However, even in degenerated discs, cells retain the ability to produce normal aggrecans.

Compared to protein glycans, the collagen composition of the disc changes to a lesser extent. Thus, the absolute amount of collagen in the disc, as a rule, does not change. However, redistribution of different types of collagen fibers is possible. In addition, the process of collagen denaturation occurs. However, by analogy with protein glycans, disc cell elements retain the ability to synthesize healthy collagen even in a degenerated intervertebral disc.

Loss of protein glycans and dehydration of the disc lead to a decrease in their shock-absorbing and supporting functions. The intervertebral discs decrease in height and gradually begin to prolapse into the spinal canal. Thus, improper redistribution of axial load on the endplates and annulus fibrosus can provoke discogenic pain. Degenerative-dystrophic changes are not limited only to the intervertebral disc, since changes in its height lead to pathological processes in neighboring formations. Thus, a decrease in the supporting function of the disc leads to overload in the facet joints, which contributes to the development of osteoarthritis and a decrease in the tension of the yellow ligaments, which leads to a decrease in their elasticity and corrugation. Disc prolapse, arthrosis of the facet joints and thickening (corrugation) of the yellow ligaments lead to spinal stenosis.

It has now been proven that compression of the root by an intervertebral hernia is not the only cause of radicular pain, since about 70% of people do not experience pain when the roots are compressed by a hernial protrusion. It is believed that in some cases, when a herniated disc comes into contact with a root, sensitization of the latter occurs due to aseptic (autoimmune) inflammation, the source of which is the cells of the affected disc.

One of the main causes of intervertebral disc degeneration is violation of adequate nutrition of its cellular elements. In vitro, it was shown that intervertebral disc cells are quite sensitive to oxygen deficiency, glucose and pH changes. Impaired cell function leads to changes in the composition of the intercellular matrix, which triggers and/or accelerates degenerative processes in the disc. Nutrition of the cells of the intervertebral disc occurs indirectly, since the blood vessels are located from them at a distance of up to 8 mm (capillaries of the vertebral bodies and outer plates of the fibrous ring.

Disk power failure can be due to many reasons: various anemias, atherosclerosis. In addition, metabolic disorders are observed with overload and insufficient load on the intervertebral disc. It is believed that in these cases there is a restructuring of the capillaries of the vertebral bodies and/or compaction of the endplates, which impedes the diffusion of nutrients. However, it should be noted that the degenerative process is associated only with incorrect execution of movements during physical activity, while their correct execution increases the intradiscal content of protein glycans.

There are several stages of degenerative-dystrophic changes in the intervertebral disc:
stage 0 - the disk is not modified
stage 1 - small tears of the inner 1/3 of the annular plates of the annulus fibrosus
stage 2 - significant destruction of the disc occurs, but the outer rings of the annulus fibrosus are preserved, which prevent herniation; there is no compression of the roots; at this stage, in addition to back pain, it may radiate to the legs to the level of the knee joint
stage 3 - cracks and tears are observed along the entire radius of the fibrous ring; the disc prolapses, causing tears of the posterior longitudinal ligament

Currently, this classification has been slightly modified, since it did not include compression syndromes.

Attempts to create a real classification, based on computed tomography data, began in 1990 and ended in 1996 (Schellhas):
stage 0 - the contrast agent injected into the center of the disc does not leave the boundaries of the nucleus pulposus
stage 1 - at this stage the contrast penetrates to the inner 1/3 of the annulus fibrosus
stage 2 - contrast extends to 2/3 of the annulus fibrosus
stage 3 - crack along the entire radius of the fibrous ring; the contrast penetrates to the outer plates of the fibrous ring; it is believed that pain occurs at this stage, since only the outer layers of the disc are innervated
stage 4 - there is a spread of contrast around the circumference (reminiscent of an anchor), but no more than 30°; this is due to the fact that radial discontinuities merge with concentric ones
stage 5 - contrast penetration into the epidural space occurs; Apparently, this provokes aseptic (autoimmune) inflammation in nearby soft tissues, which sometimes causes radiculopathy even without obvious signs of compression

Comparative anatomy data allow us to consider the intervertebral disc as articular cartilage, both components of which - the nucleus pulposus (pulpous) and the fibrous ring - are currently classified as fibrous cartilage, and the endplates of the vertebral bodies are likened to articular surfaces. The results of pathomorphological and histochemical studies made it possible to classify degenerative changes in the intervertebral disc as a multifactorial process. Disc degeneration is based on a genetic defect. Several genes responsible for the strength and quality of osteochondral structures have been identified: genes for the synthesis of type 9 collagen, aggrecan, vitamin D receptor, metalloproteinase. Genetic “breakage” is systemic in nature, which is confirmed by the high prevalence of intervertebral disc degeneration in patients with osteoarthritis. The trigger point for the development of degenerative changes in the disc is structural damage to the fibrous ring due to inadequate physical activity. The ineffectiveness of reparative processes in the intervertebral disc leads to an increase in degenerative changes and the appearance of pain. Normally, the posterior outer layers of the annulus fibrosus (1–3 mm) and the adjacent posterior longitudinal ligament are equipped with nociceptors. It has been proven that in a structurally changed disc, nociceptors penetrate the anterior part of the annulus fibrosus and nucleus pulposus, increasing the density of the nociceptive field. In vivo, nociceptor stimulation is supported not only by mechanical stress, but also by inflammation. A degeneratively altered disc produces pro-inflammatory cytokines IL-1, IL-6, IL-8, as well as TNF (tumor necrosis factor). Researchers emphasize that the contact of elements of the nucleus pulposus with nociceptors on the periphery of the annulus fibrosus helps to lower the threshold of excitability of nerve endings and increase their perception of pain. It is believed that the intervertebral disc is most associated with pain - at the stage of disc prolapse, with a decrease in its height, with the appearance of radial cracks in the fibrous ring. When intervertebral disc degeneration leads to herniation, a root or nerve becomes an additional cause of pain. Inflammatory agents produced by hernia cells increase the sensitivity of the root to mechanical pressure. Changes in pain threshold play an important role in the development of chronic pain.

Attempts have been made to identify the mechanisms of discogenic pain using discography. It has been shown that pain occurs with the introduction of substances like glycosaminoglycans and lactic acid, with compression of the roots, with hyperflexion of the facet joints. It has been suggested that the endplates may be the source of pain. Ohnmeiss in 1997 showed that complete rupture of the annulus fibrosus or disc herniation is not necessary for the occurrence of leg pain. He proved that even at stage 2 (when the outer plates of the annulus fibrosus remain intact), pain in the lower back occurs, radiating to the leg. It has now been proven that pain from one level can also come from underlying segments, for example, pathology of the L4–L5 disc can cause pain in the L2 dermatome.

The formation of pain syndrome during intervertebral disc herniation is influenced by:
violation of the biomechanics of the motor act
violation of posture and balance of the muscular-ligamentous-fascial apparatus
imbalance between the anterior and posterior muscle girdle
imbalances in the sacroiliac joints and other pelvic structures

It should be noted that the severity of clinical manifestations of intervertebral disc herniation is also due to the ratio of the size of the intervertebral hernia to the size of the spinal canal where the spinal cord and its roots are located. A favorable ratio is a small hernia (from 4 to 7 mm) and a wide spinal canal (up to 20 mm). And the lower this indicator, the less favorable the course of the disease, requiring a longer course of treatment.

In the case of an association of clinical manifestations of vertebral pathology with degenerative changes in the intervertebral disc, the term used in foreign literature is - "degenerative disc disease"- DBD (degenerative disk disease - DDD). DBD is a component of a single process – osteoarthritis of the spine.

Stages of formation of herniated intervertebral discs according to Decolux A.P. (1984):
protruding disk- bulging of the intervertebral disc, which has lost its elastic properties, into the spinal canal
failed disc- disc masses are located in the intervertebral space and compress the contents of the spinal canal through the intact posterior longitudinal ligament
prolapsed disc - most often detected in acute or traumatic hernia; partial prolapse of intervertebral disc masses into the spinal canal accompanying rupture of the posterior longitudinal ligament; direct compression of the spinal cord and roots
free sequestered disc- a disc lying loosely in the cavity of the spinal canal (in acute cases or as a result of trauma, it may be accompanied by a rupture of the meninges and intradural location of hernial masses

Most often in the lumbosacral spine, hernias occur in the intervertebral discs at the level of L5-S1 (48% of the total number of hernias at the lumbosacral level) and at the level of L4-L5 (46%). Less commonly, they are localized at the level of L3-L4 (5%) and most rarely at the level of L2-L3 (less than 1%).

Anatomical classification of disc herniations:
simple disc herniation , in which the posterior longitudinal ligament is torn, and a larger or smaller portion of the disc, as well as the nucleus pulposus, protrudes into the spinal canal; can be in two forms:
- free disc herniation due to “breaking”: the contents of the disc pass through the posterior longitudinal ligament, but still remain partially attached to areas of the intervertebral disc that have not yet prolapsed or to the corresponding vertebral plane;
- wandering hernia– has no connection with the intervertebral space and moves freely in the spinal canal;
intermittent disc herniation - occurs from an unusually strong mechanical load or from strong compression exerted on the spine, with its subsequent return to its original position after the load is removed, although the nucleus pulposus may remain permanently dislocated.

Topographic classification of disc herniation:
intraspinal disc herniation – completely located in the spinal canal and emanating from the middle part of the disc, this hernia can be in three positions:
- in the dorsal medial(Stukey group I) causes compression of the spinal cord or cauda equina;
- paramdial (group II according to Stukey) causes unilateral or bilateral compression of the spinal cord;
- dosolateral(Stukey group III) compresses the spinal cord or intraspinal nerve roots, or the lateral part of the vertebral plate on one or both sides; this is the most common form, since at this level there is a weak zone in the disc - the posterior longitudinal ligament is reduced to several fibers located on the lateral parts;
disc herniation located inside the intervertebral foramen , comes from the outer part of the disc and compresses the corresponding root towards the articular process;
lateral disc herniation comes from the most lateral part of the disc and can cause various symptoms, provided it is located in the lower part of the cervical segment, compressing the vertebral artery and vertebral nerve;
ventral disc herniation , emanating from the ventral edge, does not give any symptoms and is therefore of no interest.

According to the direction of prolapse of the sequestrum, hernias are divided into (Handbook of Vertebroneurology, Kuznetsov V.F. 2000):
anterolateral, which are located outside the anterior semicircle of the vertebral bodies, peel off or perforate the anterior longitudinal ligament, can cause sympathalgic syndrome when the paravertebral sympathetic chain is involved in the process;
posterolateral, which pierce the posterior half of the fibrous ring:
- median hernias – in the midline;
- paramedian – close to the midline;
- lateral hernias(foraminal) - on the side of the midline (from the posterior longitudinal ligament).

Sometimes two or more types of disc herniations are combined. ABOUT vertebral body hernia (Schmorl's hernia) cm. .

Intervertebral disc degeneration is visualized by magnetic resonance imaging (MRI). The stages of disc degeneration are described (D. Schlenska et al.):
M0 – norm; nucleus pulposus spherical or ovoid in shape
M1 – loal (segmental) decrease in the degree of luminescence
M2 – disc degeneration; disappearance of the glow of the nucleus pulposus

Types (stages) of vertebral body lesions associated with intervertebral disc degeneration, according to MRI data:
Type 1 – a decrease in signal intensity on T1-weighted images and an increase in signal intensity on T2-weighted images indicate inflammatory processes in the bone marrow of the vertebrae
Type 2 - an increase in signal intensity on T1 and T2-weighted images indicates the replacement of normal bone marrow with adipose tissue
Type 3 - a decrease in signal intensity on T1 and T2 - weighted images indicates processes of osteosclerosis

The main diagnostic criteria for intervertebral disc herniation are:
the presence of vertebrogenic syndrome, manifested by pain, limited mobility and deformities (antalgic scoliosis) in the affected part of the spine; tonic tension of the paravertebral muscles
sensory disorders in the area of ​​the neurometamere of the affected root
motor disturbances in the muscles innervated by the affected root
decreased or lost reflexes
the presence of relatively deep biomechanical disturbances in motor compensation
data from computed tomography (CT), magnetic resonance imaging (MRI) or radiographic examination, verifying the pathology of the intervertebral disc, spinal canal and intervertebral foramina
data from electroneurophysiological studies (F-wave, H-reflex, somatosensory evoked potentials, transcranial magnetic stimulation), recording conduction disturbances along the root, as well as the results of needle electromyography with analysis of action potentials of motor units, allowing to establish the presence of denervation changes in the muscles of the affected myotome

Clinical significance of the size of protrusions and herniations of the intervertebral disc:
cervical section of the spinal column:
1-2 mm- small protrusion size
3-4 mm- average protrusion size(urgent outpatient treatment required)
5-6 mm- (outpatient treatment is still possible)
6-7 mm and more- large size of intervertebral hernia(requires surgical treatment)
lumbar and thoracic sections of the spinal column:
1-5 mm- small protrusion size(outpatient treatment is required, treatment at home is possible: spinal traction and special gymnastics)
6-8 mm- average size of intervertebral hernia(outpatient treatment required, surgical treatment not indicated)
9-12 mm- large size of intervertebral hernia(urgent outpatient treatment is required, surgical treatment only for symptoms of compression of the spinal cord and elements of the cauda equina)
more than 12 mm- large prolapse or sequestered hernia(outpatient treatment is possible, but on the condition that if symptoms of compression of the spinal cord and elements of the cauda equina appear, the patient has the opportunity to undergo surgery the next day; with symptoms of spinal cord compression and a number of MRI signs, immediate surgical treatment is required)

Note: when the spinal canal is narrowed, a smaller intervertebral hernia behaves like a larger one.

There is such a rule, What disc bulge is considered severe and clinically significant if it exceeds 25% anteroposterior diameter of the spinal canal (according to other authors - if it exceeds 15% anteroposterior diameter of the spinal canal) or narrows the canal to a critical level 10 mm.

Periodization of compression manifestations of spinal osteochondrosis against the background of intervertebral disc herniation:
acute period (stage of exudative inflammation) - duration 5-7 days; the hernial protrusion swells - the swelling reaches a maximum on days 3-5, increases in size, compressing the contents of the epidural space, including the roots, the vessels that feed them, as well as the vertebral venous plexus; sometimes the hernial sac ruptures and its contents spill into the epidural space, leading to the development of reactive epiduritis or down along the posterior longitudinal ligament; pain gradually increases; any movement causes unbearable suffering; The first night is especially difficult for patients; the main question that needs to be resolved in this situation is whether or not the patient needs urgent surgical intervention; absolute indications for surgery are: myeloschaemia or spinal stroke; reactive epiduritis; compression of two or more roots along the length; pelvic disorders
subacute period(2-3 weeks) - the exudative phase of inflammation is replaced by a productive one; adhesions gradually form around the hernia, which deform the epidural space, compress the roots, and sometimes fix them to the surrounding ligaments and membranes
early recovery period- 4-6 weeks
late recovery period(6 weeks - six months) - the most unpredictable period; the patient feels healthy, but the disc has not yet healed; To avoid unpleasant consequences, during any physical activity it is recommended to wear a fixation belt

To characterize the degree of disc protrusion, contradictory terms are used: “disc herniation”, “ disc protrusion", "disc prolapse". Some authors use them almost as synonyms. Others suggest using the term “disc protrusion” to refer to the initial stage of disc protrusion, when the nucleus pulposus has not yet broken through the outer layers of the annulus fibrosus, the term “disc herniation” only when the nucleus pulposus or its fragments have broken through the outer layers of the annulus fibrosus, and the term “disc prolapse” only refers to the prolapse of hernial material that has lost its connection with the disc into the spinal canal. Still others propose to distinguish between intrusions, in which the outer layers of the annulus fibrosus remain intact, and extrusions, in which the hernial material breaks through the outer layers of the annulus fibrosus and the posterior longitudinal ligament into the spinal canna.

Russian authors(Magomedov M.K., Golovatenko-Abramov K.V., 2003), based on the use of Latin roots in term formation, suggest the use of the following terms:
“protrusion” (prolapse) – protrusion of the intervertebral disc beyond the vertebral bodies due to stretching of the fibrous ring without significant ruptures. At the same time, the authors point out that protrusion and prolapse are identical concepts and can be used as synonyms;
“extrusion” - protrusion of the disc caused by rupture of the FC and the release of part of the nucleus pulposus through the resulting defect, but maintaining the integrity of the posterior longitudinal ligament;
“true hernia”, in which not only the fibrous ring, but also the posterior longitudinal ligament ruptures.

Japanese authors(Matsui Y., Maeda M., Nakagami W. et al., 1998; Takashi I., Takafumi N., Tarou K. et al., 1996) distinguish four types of hernial protrusions, using the following terms to designate them:
“protrusion" (P-type, P-type) - protrusion of the disc in which there is no rupture of the fibrous ring or (if present) does not extend to its outer parts;
« subligamentous extrusion"(SE-type, SE-type) - a hernia in which perforation of the fibrous ring occurs while preserving the posterior longitudinal ligament;
« transligamentous extrusion"(TE-type, TE-type) - a hernia that ruptures not only the fibrous ring, but also the posterior longitudinal ligament;
“sequestration” (C-type, S-type) – a hernia in which part of the nucleus pulposus ruptures the posterior longitudinal ligament and is sequestered in the epidural space.

Swedish authors(Jonsson B., Stromqvist B., 1996; Jonsson B., Jonsson R., Stromqvist B., 1998) there are two main types of hernial protrusions - so-called contained hernias and noncontained hernias. The first group includes: “protrusion” - a protrusion in which ruptures of the fibrous ring are absent or minimally expressed; and “prolapse” - dislocation of the material of the nucleus pulposus to the posterior longitudinal ligament with complete or almost complete rupture of the fibrous ring. The second group of hernial protrusions is represented by extrusion and sequestration. During extrusion, the posterior longitudinal ligament is ruptured, but the fallen fragment of the nucleus pulposus remains connected to the rest of it, in contrast to sequestration, in which this fragment separates and becomes free.

One of the most clear schemes was proposed by J. McCulloch and E. Transfeldt (1997), who distinguish:
1) disc protrusion– as the initial stage of disc herniation, in which all disc structures, including the annulus fibrosus, are displaced beyond the line connecting the edges of two adjacent vertebrae, but the outer layers of the annulus fibrosus remain intact, the material of the nucleus pulposus can penetrate into the inner layers of the annulus fibrosus (intrusion);
2) subannular (subligamentary) extrusion , in which the damaged nucleus plosus or its fragments are squeezed out through a crack in the annulus fibrosus, but do not break through the outermost fibers of the annulus fibrosus and the posterior longitudinal ligament, although they can move up or down in relation to the disc;
3) transannular (transligamentary) extrusion , in which the nucleus pulposus or its fragments break through the outer fibers of the annulus fibrosus and/or the posterior longitudinal ligament, but maintain connection with the disc;
4) prolapse (loss) , characterized by sequestration of the hernia with loss of connection with the remaining disc material and prolapse into the spinal canal.

A review of the terminology of disc herniations would not be complete without noting that, according to a number of authors, the term “ disc herniation» can be used when the displacement of the disc material occupies less than 50% of its circumference. In this case, the hernia can be local (focal), if it occupies up to 25% of the disc circumference, or diffuse, occupying 25-50%. A protrusion of more than 50% of the disc circumference is not a hernia, but is called “ disc bulging"(bulging disk).

To overcome the terminological confusion, they propose (a team of authors from the Department of Neurology of the Russian Medical Academy of Postgraduate Education: Doctor of Medical Sciences, Professor V.N. Shtok; Doctor of Medical Sciences, Professor O.S. Levin; Candidate of Medical Sciences Associate Professor B.A. Borisov, Yu.V. Pavlov; Candidate of Medical Sciences I. G. Smolentseva; Doctor of Medical Sciences, Professor N.V. Fedorova) when formulating a diagnosis, use only one term - “ disc herniation» . In this case, a “disc herniation” can be understood as any protrusion of the edge of the disc beyond the line connecting the edges of adjacent vertebrae, which exceeds physiological limits (normally no more than 2-3 mm).

To clarify the degree of disc herniation, the same team of authors (employees of the Department of Neurology of the Russian Medical Academy of Postgraduate Education: Doctor of Medical Sciences, Professor V.N. Shtok; Doctor of Medical Sciences, Professor O.S. Levin; Candidate of Medical Sciences Scientific Associate Professor B.A. Borisov, Yu.V. Pavlov; Candidate of Medical Sciences I.G. Smolentseva; Doctor of Medical Sciences, Professor N.V. Fedorova) propose the following scheme:
I degree– slight protrusion of the fibrous ring without displacement of the posterior longitudinal ligament;
II degree– medium-sized protrusion of the fibrous ring. occupying no more than two-thirds of the anterior epidural space;
III degree– a large disc herniation that displaces the spinal cord and dural sac posteriorly;
IV degree– massive disc herniation. compressing the spinal cord or dural sac.

!!! It should be emphasized that the presence of tension symptoms, radicular symptoms, and local pain does not necessarily indicate that a disc herniation is the cause of the pain syndrome. Diagnosis of a disc herniation as the cause of a neurological syndrome is possible only when the clinical picture corresponds to the level and degree of disc protrusion.

Due to metabolic disorders and as a result of degenerative-dystrophic processes, dehydration of the intervertebral discs occurs. This condition is characterized in medicine as loss of water in the center of the intervertebral disc; it is recognized as the basis for the development of many spinal diseases.

Dehydration of the intervertebral disc is one of the provoking factors in the development of many vertebral diseases - osteoarthritis, protrusions, hernias and others. Loss of water leads to the loss of the main shock-absorbing function; the disc becomes immobile, simultaneously reducing the amount of motor activity of the spine.

What happens when intervertebral discs dehydrate? If there is a lack of fluid in the intervertebral disc, depreciation is reduced, this leads to the fact that the disc loses its ability to function normally - the spine becomes immobile. The next stage of pathology development is liming.

• Stage zero - no pathological changes.
• The first stage - small tears appear in the internal plates in the fibrous ring.
• The second stage - significant destruction of the intervertebral disc occurs, but the integrity of the outer rings is still preserved.
• The third stage - the integrity of the outer shell of the intervertebral disc is compromised.

A rational and balanced diet will help prevent the progression of pathology and improve human health.

A little about secrets

Have you ever experienced constant back and joint pain? Judging by the fact that you are reading this article, you are already personally familiar with osteochondrosis, arthrosis and arthritis. Surely you have tried a bunch of medications, creams, ointments, injections, doctors and, apparently, none of the above has helped you... And there is an explanation for this: it is simply not profitable for pharmacists to sell a working product, since they will lose customers! Nevertheless, Chinese medicine has known the recipe for getting rid of these diseases for thousands of years, and it is simple and clear. Read more"

• Drink enough liquid. Nutritionists advise drinking at least 2 liters of plain water daily. When intervertebral discs are dehydrated, it is recommended to increase the consumption of the specified volume of fluid to 2.5-3 liters per day. A sufficient amount of water in the body contributes to the accumulation and retention of fluid in the vertebrae. It is important to drink clean, plain water and not carbonated drinks.
• Eat 5-6 times a day in small portions. A balanced diet helps rid the body of extra pounds, which helps to significantly reduce the load on the spine.
• The menu should include protein products. It is important to create a diet so that the bulk of the foods consumed are dairy products, legumes, and low-fat fish. It is recommended to include slow carbohydrates (cereals) in the menu, but high-calorie, sweet and fatty foods should be completely abandoned.
• For strengthening the bone apparatus It is important to eat foods enriched with vitamins A, C, E, B, D, as well as minerals - calcium, magnesium, phosphorus.
• The patient’s diet must contain products that are natural chondroprotectors - jellied meat, fish aspic, jelly.
• It is important to completely eliminate the consumption of any alcohol, as well as strong coffee. Salty, smoked, spicy foods, baked goods, and sweets should be sharply limited.

A lot has been written and said about the principles of a healthy, balanced diet, but it is not easy to correctly create an individual menu. It is necessary to take into account the characteristics of your body and the presence of other chronic pathologies. Therefore, it is better to competently develop a suitable diet with a nutritionist.

Physiotherapy

Performing regular light physical exercise is very useful for various pathologies of the spine. Gymnastics helps strengthen the bone system and connective tissues, improve blood circulation in the spine. For intervertebral disc dehydration, almost any type of therapeutic exercise can be used, a good option is yoga or swimming. Even an ordinary walk at a slow pace in a park or forest will be useful for a person.

In combination with therapeutic exercises, it is useful to use massage procedures; they help relieve tension from the back muscles and improve blood circulation. Back massage should only be performed by a professional.

Surgery

When conservative therapy does not produce adequate results or the disease is in an advanced stage, surgical intervention is used. Most often, during the operation, the intervertebral disc destroyed during dehydration is completely removed.

The combination of a reasonable therapeutic diet, drinking regimen and moderate physical activity with drug therapy is the best option for treating intervertebral disc dehydration.

How to forget about back and joint pain?

We all know what pain and discomfort are. Arthrosis, arthritis, osteochondrosis and back pain seriously spoil life, limiting normal activities - it is impossible to raise an arm, step on a leg, or get out of bed.

A pathological process such as a decrease in the height of intervertebral discs is a fairly common phenomenon. This disease affects the intervertebral discs and the surfaces of other joint parts. Insufficient treatment of the disease can lead to the development of vertebral instability, the formation of hernias or ankylosis.

Causes of decreased intervertebral disc height

Intervertebral discs are a formation of cartilage tissue consisting of an annulus fibrosus and nucleus pulposus. It performs a shock-absorbing function, affects the flexibility of the spine, and maintains normal motor activity of the spinal column. Its supply with nutrients occurs by diffusion with the help of periarticular soft tissues, since the cartilaginous formation itself does not have blood vessels. With insufficient nutrition, the body of the disc becomes dehydrated, decreases in height, and the fibrous ring can spread. In advanced forms of the disease, growths form - osteophytes. This condition greatly reduces the motor activity of the affected area. A decrease in disc height occurs due to the following reasons:

• constantly being in a sitting position;
• poor blood circulation;
• metabolic disease;
• physiological changes;
• diseases of the musculoskeletal system;
• injuries.

Changes in the height of the intervertebral discs can be caused by an unhealthy lifestyle, obesity, constant stress or pregnancy.

Manifestations

The reduction in the height of the intervertebral discs occurs in 4 stages, which are described in the table:

How is it diagnosed?

To make a correct diagnosis, you need to consult a specialist, for example, a neurologist. To begin with, the doctor must collect a reliable medical history and conduct tactile and visual examinations. Then additional diagnostic tests are prescribed to confirm the diagnosis. These include:

• X-ray. It will help to detect small changes occurring in different vertebral structures, for example, cervical discs.
• MRI. It will make it possible to notice pathological abnormalities in the spinal cord or identify the formation of hernias, for example, in the lumbar region.
• EMG. Diagnoses pinched nerve endings and injuries.
• Discography. Shows all manifestations of changes in the intervertebral discs.

Treatment methods

For effective therapy, several complexes of effects are used. The attending physician prescribes physiotherapeutic procedures, massages, spine stretching, exercise therapy, development of the muscular system, and drug treatment. In rare cases, conservative methods of influence do not help, then surgical intervention is performed. It is impossible to completely get rid of changes in the height of the intervertebral discs. Therapy will only help improve the patient’s condition and slow down the progression of the disease. For drug treatment, drugs are prescribed that are presented in the table.

How to restore the loss of intervertebral disc height?

Intervertebral discs are located between the vertebrae and are the connecting element. The main function of intervertebral discs is to ensure flexibility of the spine during various movements. With age, due to various pathological processes, intervertebral discs wear out and their height decreases. When the intervertebral disc wears out, the amount of protein glycans decreases. One of the main reasons for the decrease in the height of the intervertebral disc is a malnutrition of its cellular elements. Intervertebral disc cells have increased sensitivity to oxygen deficiency, glucose and pH changes. Disk malnutrition can be due to several reasons: anemia, atherosclerosis or other diseases. Violations can occur due to overload or, conversely, insufficient load on the intervertebral disc. Rapid restoration of the height of the intervertebral disc is possible only with a surgical method, which is selected based on the physiological characteristics of the patient and the severity of the disease. Also, when the height of the intervertebral disc decreases, it is recommended to perform special exercises aimed at restoring function. However, exercises alone are not enough and special attention to their implementation is required, since an incorrectly performed exercise can contribute to a deterioration in health and lead to irreversible consequences.

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