Posterior central herniated intervertebral disc l3 4. Causes, symptoms and treatment of herniated intervertebral discs l3-l4, l4-l5, l4-s1, l5-s1. Clinical manifestations of L4 L5 disc protrusion

Pain syndrome Until the hernia has reached medium size, the pain syndrome will manifest itself weakly. As it grows, pressure on the spinal nerves increases.

As a result, any movement: raising a leg, changing body position - all this will be accompanied by excruciating acute pain. In advanced cases, patients are not even able to cough without experiencing pain.

It usually radiates to the area of ​​the buttocks and thighs.

Sequestration of a hernia with disruption of the integrity of the disc and release of the nucleus pulposus into the lumen of the spinal canal. The person suffers from severe pain, which is explained by compression of the spinal nerves and spinal cord.

As a result, the patient loses the ability to self-care, as he becomes unable to move.

As the hernia grows, the patient may become completely or partially paralyzed and assigned a disability group.

Formation of an autoimmune inflammatory process. The reason for its manifestation is the protein content of cartilage and fibrin fibers, which trigger an autoimmune reaction.

Compression of the bundle of spinal nerve roots. In medicine, this complication is called the cauda equina symptom.

Disturbances in the act of urination and defecation due to malfunction of the pelvic organs.

Atrophy of the tissues of the lower extremities associated with loss of sensitivity.

So, a dorsal hernia located at the l4-l5 level can lead to paralysis of the legs and complete loss of sensation in the feet with all the ensuing consequences from this condition.

A dorsal hernia located at the l5-s1 level can provoke serious disturbances in the functioning of the internal organs of the pelvis. Therefore, if the first symptoms of the disease appear, you should immediately seek medical help.

If you suspect the presence of a dorsal hernia in the lumbar region, instrumental diagnostic methods are necessary. The most informative method in this case will be MRI. The image will show the direction of the protrusion, its size, and the degree of compression of the spinal canal.

If a hernia has already formed, then it can only be removed through surgery. However, doctors are in no hurry to send the patient to the operating table, since there are clear indications for this.

Conservative treatment of dorsal hernia l5-s1 and l4-l5

In order to relieve the patient of pain, he is prescribed painkillers and anti-inflammatory drugs, including: Diclofenac sodium, Ibuprofen.

To relieve muscle spasms, taking muscle relaxants is indicated, for example, Baclofen, Sirdalud, Mydocalm.

Non-narcotic analgesics - Ketanol, Baralgin, Ketanov.

Treatment

Treatment of the pathology is selected in accordance with where the prolapsed part is directed, the type of hernia, and its size. Computer or magnetic resonance imaging helps in their precise determination.

To treat the pathology, conservative therapy and surgery can be used.

Conservative treatment

The most important symptom of the disease is severe back pain, which gets worse with any body movement. But besides this, there are other signs that indicate a problem such as a dorsal disc herniation. These include:

• Stiffness of movements and adoption of an unnatural posture.
• Pain in the lumbar region.
• Pain radiating to the buttocks and thighs.
• Sharp pain in the lower extremities when sneezing or coughing.

Despite the fact that a sequestered hernia has quite pronounced neurological symptoms, it, like any other disease in the body, requires careful diagnosis.

First of all, in order to prescribe the correct treatment, the specialist must conduct a general examination of the patient and determine the necessary examination procedures.

Basically, to clarify the diagnosis, doctors use examination methods such as:

• Magnetic resonance imaging;
• radiography;
• general and biochemical analysis.

Once the diagnosis is confirmed, treatment begins.

Use of medications

A median hernia that affects the sacral vertebra at the initial stage of development is treated with conservative therapy. First of all, it is important to relieve pain, relieve muscle spasms and swelling.

Muscle relaxants are used to relax the muscle frame. After the acute symptoms have been relieved, the patient is advised to perform a set of physical exercises that will help strengthen the muscle corset and prevent the disc from moving.

As with any disease, treatment of a herniated disc should be carried out comprehensively and include both drug therapy and surgical intervention. In some cases, it is acceptable to use alternative treatments.

A herniated disc L4 L5 is a herniation between the fourth and fifth lumbar vertebrae.

About half of intervertebral hernia diseases are associated with the fourth and fifth vertebrae. The essence of this disease is that the lumbar root from the 5th vertebra, emerging between this vertebra and the sacrum, is subject to compression.

Causes of hernia formation

The X-ray image shows a disc herniation at L4-L5.

Surgical treatment of the disease requires only 5% of cases. When prescribing treatment for a hernia, a doctor looks not only at the size of the hernia, but also at a number of other factors: the width of the spinal canal, the location of the hernia relative to the spinal root.

First, the nerve roots of the spinal cord are treated. Several options are offered:

1. Delete;
2. Nucleoplasty (surgery);
3. Nucleoplasty (cold plasma);
4. Endoscopic transformation (for sequestered hernias);
5. Implants, structures.

Physical exercises treat both paramedian disc herniation of the 4th and 5th vertebrae, as well as other types of hernias. Physical exercise helps completely eliminate the disease.

Physical exercises consist of:

1. Abdominal exercises to strengthen your abdominal muscles. This reduces stress on the back;
2. Push-ups. This involves strengthening the spinal muscles, as well as helping to return the intervertebral disc to its correct state.
3. Exercise "Knees-chest". This exercise gives elasticity to the lower back muscles. By bending over while sitting on a chair, the patient can alleviate his condition in cases of median and other types of hernias.

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The doctor prescribes the exercises, otherwise the hernia may be strangulated and the patient’s condition may worsen.

If absolutely necessary, dorsal and other types of hernias are treated surgically.

The positive features of the operation are that:

1. The pain goes away quickly. The next day after surgery, the patient feels pain only at the operation site;
2. A radical way to get rid of the disease. Relief occurs for a very long time (years).

Negative traits:

1. In 5 percent, the disease recurs. In this case, the patient lies down on the operating table again;
2. Threat of inflammatory processes. The use of antibiotics for a short period of time, up to 3 days, helps.

Treating a patient will relieve him of pain and breathe new life into him. There is an opinion that during the operation the patient’s spinal cord may be damaged. The fact is that this is unrealistic due to the location of the 4th and 5th lumbar vertebrae below the spinal cord.

An intervertebral hernia in the lumbar spine appears after a previous pathological condition called protrusion.

The disease consists of displacement of the nucleus pulposus, which is cartilaginous tissue between the vertebral bodies. In this case, the fibrous ring along the perimeter of the nucleus remains intact and restrains further movement of the intervertebral disc in one direction or another from the physiological position.

Detection of the disease at the stage of protrusion formation is not always possible, because the pathology may be asymptomatic or not cause clinical manifestations at all.

Diffuse herniation of the intervertebral disc is one of the types of hernias in which the integrity of the fibrous ring is not compromised, but uneven displacement of the disc is observed.

The difference from other types of hernias is the absence of a hernial sac and the presence of a bulge similar to a hernia. It is worth noting that with this disease the disc is partially affected - however, if the process is started and is more than 50%, it can lead to rupture of the fibrous ring.

The most dangerous subtype of this pathology is posterior diffuse disc herniation, which is directed inside the spinal canal and can lead to compression of the spinal cord and spinal nerves, especially with the simultaneous presence of stenosis and narrowing of the spinal canal.

The most common is diffuse L4-L5 disc herniation, along with diffuse L5-S1 disc herniation. This is due to the fact that the lumbar region bears the greatest load.

It is worth noting that in the stage of formation of a dorsal hernia, symptoms are practically not manifested, so patients often seek medical help much later, when treating the disease is much more difficult. Clinical manifestations of diffuse hernias are as follows:

• the appearance of pain of a different nature, from pulling to stabbing;
• radiating pain to other parts of the body in the limbs, arms, legs;
• decreased sensitivity, and often its loss;
• decreased muscle tone in those parts of the body for which the nerves compressed by the hernia are responsible for the innervation.

If the lumbosacral region is affected, pain symptoms are accompanied by disturbances in the functioning of the sphincters of the rectum and bladder.

Treatment of diffuse hernia is carried out by conservative and surgical methods. The latter, as a rule, are used only if there are indications for this, or if conservative treatment has not achieved the desired effect.

Conservative treatment involves taking painkillers and anti-inflammatory drugs, and performing a number of physical procedures. Epidural blocks are often used.

Which provide excellent pain relief, lasting from six weeks to six months. They also have a therapeutic purpose, allowing them to relieve swelling and inflammation, and often allow them to completely avoid surgery.

Posterior displacement of hernias is dangerous because, as a rule, it causes severe pain. And all due to the fact that the nerve endings of the spinal cord are clamped.

Intervertebral hernial formations can be divided into several groups depending on their location and methods of manifestation. So, they differ:

1. 1. Dorsal diffuse disc herniation l5-S1 - no significant tissue deformation. Destruction is observed over the entire surface of the disk.
2. 2. Dorsal medial hernia l4-l5 - the center of the spinal cord is affected.
3. 3. Foraminal hernia - goes into the canals of the same name. This damages the nerve endings of the spinal cord.
4. 4. Paramedian hernia - the formation is displaced to the side. A specific part of the spinal cord is affected.

Depending on the stage of the disease, the type of hernia and other factors, treatment is carried out.

Disc herniation at the L4-L5 level occurs in almost half of the cases of instrumentally confirmed (by MRI) lumbar hernias. The L5-S1 level is approximately equally often affected.

Hernias of other locations (in the lumbar region) are statistically rare and much less likely to reach clinically significant sizes.
.

The process of herniation involves the loss of substance from the nucleus pulposus of the intervertebral disc through micro-tears in the fibrous ring that surrounds this very nucleus.

In practice, this is a long process, and suddenly developing pain syndrome against the background of physical activity is only a manifestation of the aggravation of a long-developing disease.

The most dangerous is a sequestered disc herniation. Theoretically, it is possible to unlace the sequester and move it.

However, very often the process of sequestration (necrosis of the hernia) ends successfully after 2-3 months and on the control MRI we observe a decrease in the size of the hernial protrusion.

But in the process, the sequestration of the hernia has an impressive protrusion size, the pressure on the nerve roots increases, and the clinical picture worsens. This may necessitate surgery so that the person does not remain disabled (lower paraplegia, peroneal nerve palsy).

Very often, a paramedian protrusion occurs in the L4-L5 disc. This means that the nucleus pulposus protrudes posteriorly, closer to the midline. Median, paramedian disc herniation L4-L5 compresses the nerve roots only in cases of large size or in a narrow spinal canal.

A lateral hernia (looking towards the nerve roots) requires immediate treatment, since even small ones often cause pain and various complications.

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Consultation on treatment using traditional oriental medicine methods (acupressure, manual therapy, acupuncture, herbal medicine, Taoist psychotherapy and other non-drug treatment methods) is carried out at the address: St. Petersburg, st.

Lomonosova 14, K. 1 (7-10 minutes walk from the Vladimirskaya/Dostoevskaya metro station), from 9.

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Patients with L4 L5 disc herniation consult a doctor with the following complaints:

1. Periodic back pain that worsens during physical activity or prolonged rest;
2. Increased sweating, change in skin color;
3. As the pathological process develops, the pain intensifies, the patient feels lumbago in the back, constant aching pain;
4. Lasegue's symptom is observed - discomfort appears when raising the leg in a supine position;
5. Numbness of the limbs, crawling sensation, pain in the leg;
6. Changing posture, forced body position to relieve pain.

In the case of an intervertebral hernia located in the lumbar region, the symptom that most worries a person is pain, which slowly increases as the disease progresses.

Intervertebral hernia of the lumbar region can be treated both therapeutically and surgically. It all depends on the specific situation, the stage of development of the process, the presence of concomitant diseases and contraindications.

Therefore, when treating a hernia of the lumbosacral region, it is important not to miss the moment when you can still help in conservative ways and avoid surgery with all the ensuing consequences. If you consult a specialist in a timely manner, you can stop the progression and prevent possible complications.

Conservative treatment aims to relieve pain during the acute period of the disease, and at its end - to prevent relapses.

1. Anti-inflammatory therapy. Appointed non-steroidal anti-inflammatory drugs: How ibuprofen, diclofenac, Nise and naproxen can help manage pain, reduce inflammatory swelling and temporarily restore freedom of movement. Paravertebral and epidural blockades with glucocorticosteroid drugs have a good analgesic effect.
2. Bed rest for several days. Perform all movements slowly and confidently. It's worth changing your daily routine. Avoid movements that increase pain: bending forward, lifting heavy things.

After the pain syndrome has subsided, the number of drugs used is reduced, and the emphasis is on therapeutic exercises, massages and physiotherapeutic procedures. The main goal is to improve the condition of the muscular corset and ligamentous apparatus.

It is advisable to continue conservative methods for 4-8 weeks. If during this time they turn out to be completely ineffective, it is necessary to either change the treatment tactics or consider the issue of surgical intervention.

A hernia with this location manifests itself as follows:

1. There are periodic intermittent pain in the lumbago area (i.e. lower back). The pain is aching, shooting in nature.
2. As the disease progresses, there is an increase in pain due to compression of the root, as well as due to the formation of a hernia in the intervertebral disc.
3. The patient's posture changes: the lumbar lordosis is smoothed out (with a possible transition to kyphosis). This occurs due to the body's desire to reduce the intensity of pain.
4. When the interspinous spaces and paravertebral muscles are palpated, a patient with a disc herniation l4 5 experiences pain.
5. A vertebral symptom appears: when the interspinous space is tapped, the patient experiences shooting pain in the leg.
6. A clear manifestation of Lasegue's symptom: a patient with this type of hernia, lying on his back, cannot lift his straightened leg without experiencing pain. In this case, lumbar pain appears, as well as pain in the dermatome of the root. Some patients feel numbness or have a crawling sensation on their skin. When the leg bends at the knee, the symptom immediately disappears.
7. Marbling of the skin and excessive sweating are vegetative symptoms.

Firstly, pain in the leg and lower back.

Secondly, leg numbness.

When prescribing treatment, the doctor is guided not only by the size of the hernia, but also by the width of the spinal canal, the location of the hernia relative to the spinal root, as well as numerous other factors. Surgery is used only in 5% of cases.

First of all, when treating such a hernia, it is necessary to cure the nerve roots of the spinal cord. There are several methods:

1. Hernia removal, that is, microdiscectomy;
2. Nucleoplasty (minimally invasive surgical method);
3. Cold plasma nucleoplasty;
4. Endoscopic transformation with sequestered hernias;
5. Installation of implants and special structures.

Paramedian disc herniation l4 l5 (bulging to the right or left of the spinal column), like other types, can be treated with physical therapy. Thanks to exercise therapy, symptoms become less pronounced, and in some cases, complete relief of symptoms is observed.

The exercise therapy complex includes abdominal exercises that strengthen the abdominal muscles. Such exercises are prescribed to reduce the load on the back by moving it to the abdominal area.

Push-ups for such a hernia strengthen the spinal muscles and help keep the intervertebral disc in the correct position. The “Knees - Chest” exercise is prescribed to give elasticity to the lumbar muscles.

Median disc herniation l4 l5 (like other types), oriented to the center of the dural sac, causes less problems when performing bends when the patient performs them from the starting position, sitting on a chair.

Treatment of each type occurs therapeutically, and in case of ring rupture, surgical treatment is used, followed by restorative measures.

Today there are several effective ways to treat lumbar hernia at an early and advanced stage. Treatment with nonsteroidal anti-inflammatory drugs, antispasmodics, and, in parallel, physiotherapeutic treatment is used.

First of all, the patient is provided with complete rest - bed rest for a week from the moment the acute stage begins to develop. Rest allows you to reduce the pain syndrome of the pathology, by relieving pressure on the nerve endings.

Then drug treatment is used to relieve tissue swelling and inflammation, which is provoked by a median and paramedian hernia. And as a consolidating method, physiotherapeutic treatment is included - manual, gymnastic, as well as acupuncture.

Today there is practically not a single person who does not complain of periodic lower back pain. They can be a consequence of banal physical fatigue, prolonged exposure to a static sitting position. But such a symptom often indicates the development of serious problems with the spine. Protrusion of the l5 s1 disc is a lesion of the lumbar region. If left untreated, it can lead to the development of a hernia, requiring surgical intervention. But here the consequences can be completely different.

L5 s1 protrusion is when the specified disc extends beyond the spine. In this case, the fibrous ring remains intact. If it ruptures, an intervertebral hernia appears. The protrusion can vary in size - from 1 to 5 mm. If it is not pinched, then symptoms do not appear. A person may not even be aware of the problem of l5 s1 protrusion for a long time.

Most often, this pathology is a complication of osteochondrosis, in which destruction of cartilage tissue occurs, and then the vertebrae themselves. The lumbar region suffers most often, as it experiences the maximum load.

Causes

Disc protrusion l5 s1 does not occur on its own. Often the pathology is a consequence of an incorrect lifestyle or delayed treatment of osteochondrosis. There are other reasons for the development of pathology:

• Deformation of the spinal column (congenital or acquired).
• Back injury.
• Changes in the l4-l5 vertebrae due to age-related degenerative processes.
• Congenital skeletal pathologies.
• Osteoporosis.

• Weak activity, constant sitting position.
• Too much body weight.
• Chronic diseases of bones or muscle structures.
• Poor blood circulation in the lumbar region, as a result of which the vertebral discs do not receive proper nutrition.

The pathological process can be triggered by severe local or general hypothermia of the body, constant exposure to stressful situations, poor nutrition, and excessive drinking and smoking.

How does a bulge form?

Protrusion of the l4-l5 discs develops gradually. Along this path, the disease goes through several stages:

1. Microscopic cracks appear on the fibrous ring, however, it continues to remain intact. No protrusion has yet been observed. At this stage, symptoms may not appear, although sometimes flashes of pain are felt, which go away on their own within a short time.

Neurologist Ignatiev Radion Gennadievich will tell you more about protrusions:

1. A small protrusion appears (1-2 mm). At the same time, the fibrous ring continues to deteriorate. The pain syndrome becomes long-lasting and medications are required to relieve it. The patient's physical activity is limited. Discomfort is felt not only in the l5-s1 disc area, but also spreads to other areas of the body.
2. The third stage of protrusion is characterized by rupture of the fibrous ring. The disc bulges even more. The pain syndrome becomes very intense, and it is not always possible to relieve it with standard analgesics. If nothing is done at this stage, the patient will develop a hernia. If it becomes pinched, partial or complete paralysis of the lower extremities may occur.

There is no need to put off treating the disease for too long. It is better to play it safe and get tested as early as possible, especially if there is a genetic predisposition to diseases of the musculoskeletal system.

Forms of pathology

Protrusion of the L5 intervertebral disc varies. It all depends on which direction it moves.

Table 1. Forms of pathology

Depending on what form of pathology is observed in the patient, he is prescribed appropriate treatment. Posteromedian protrusion is considered quite complex, as it poses a threat to the spinal cord.

Symptoms of protrusion

Regardless of what form of pathology develops in a person, it must be treated. In the later stages of development of disc protrusion l4-l5, l5-s1, the following symptoms appear:

• , which becomes more intense when moving or making sharp turns.
• Discomfort spreads to the legs, hip, intercostal spaces.
• Muscle tissue spasms.
• Numbness of toes and hands.
• Change in blood pressure.

As the pathology develops, a person may experience dizziness

• Muscle weakness.
• Head pain, dizziness.
• If the pathology is too advanced, then a person may have difficulty urinating.
• Pain that appears after raising a straight leg.
• After the onset of pain, the patient may hear a crunching sound in the spine.

The symptoms of l4-l5 disc protrusion cannot be called specific, since they can also be caused by other pathologies. That is why the diagnosis of the disease must be differential. It is better to start treatment as quickly as possible in order to prevent the development of complications of disc protrusion l4-l5 and l5-s1.

Diagnostic features

What l4-l5 disc protrusion is is already clear, but it should be correctly distinguished from other pathological processes occurring in the spine. This will require a thorough diagnosis.

The examination involves performing the following procedures:

• External examination of the patient, as well as recording of his complaints. Palpation will allow you to feel the protrusion.
• Radiography. It will detect changes in the vertebrae: the proliferation of osteophytes, damage to the surface of the vertebrae.

Ultrasound of the vessels of the affected area of ​​the spine

• MRI or CT. This study will provide maximum information about the condition of the vertebrae, discs, soft tissues, nerves and blood vessels.
• Ultrasound. Ultrasound will make it possible to assess the condition of blood vessels and soft tissues.

The pathology must be diagnosed as early as possible. Otherwise, large areas of the spine will be involved in the pathological process, and the innervation of internal organs will be disrupted. The result of inaction or improper therapy will be a person’s disability, loss of ability to work, and deterioration in the quality of life.

Treatment

If you do not pay attention to the protrusion in a timely manner, then in its place in the area of ​​the l5-s1 vertebra a hernia will form, which already poses a danger to human health. The type of therapy and its intensity largely depend on the size of the protrusion.

Traditional and physiotherapy

Medications for l4 protrusion are used only to eliminate pain and possible inflammation. Otherwise, preference is given to massage, physical therapy, and physiotherapeutic procedures.

As for medications, treatment will require analgesics (Ketanov), NSAIDs (Diclofenac), vitamin complexes (based on B vitamins), muscle relaxants (Sirdalud, Mydocalm). Medicines can only eliminate symptoms. But without physical activity and following the doctor’s instructions, they will not get rid of the very cause of the symptoms.

Diclofenac is a drug with analgesic and anti-inflammatory effects. The average price in pharmacies is 50 rubles.

Massage helps restore lost muscle tone and relieve pain. Manual therapy techniques allow you to use not only bone structures, but also soft tissues. An experienced specialist will be able to correct the location of the vertebrae relative to each other. The therapist will realign the displaced parts of the spine. This procedure is not safe, so you should make sure that the person working on the patient’s body is qualified. This type of treatment is not used in an acute condition, or if the diagnosis is not clearly established.

Table 2. Physiotherapeutic procedures

Folk remedies to get rid of protrusion of the l4-l5 and l5-s1 discs do not bring serious benefits, although in some cases they help to somewhat reduce the intensity of pain.

Physiotherapy

Gymnastics is the main method in complex therapy, which allows you to strengthen the spinal muscles and reduce protrusion. The mobility of the lumbar region is also restored. However, some exercises cannot be used if the l4-l5 and l5-s1 discs are affected. Performing movements should not be accompanied by pain. It’s better not to put unnecessary strain on your lower back.

If a person has already started doing gymnastics, then it needs to be continued. There should be a break of 1-1.5 minutes between each exercise, especially in the first days. During physical exercise, the corset or bandage must be removed.

A set of exercises that can significantly improve the patient’s health:

The following complex will be useful:

1. In the position on your stomach, you need to alternately bend your knees and lift them. Next, the foot is covered by the hand and pulled forward.
2. Now you can roll over onto your back. One leg should be bent at the knee and pulled towards the torso. After this, an exercise is done that is similar to pumping up the abs, only the tension is applied not to the abdominal muscles, but to the back muscles.
3. The last exercise is performed in a side position. The limb must be bent and pulled towards the body. The movement is repeated 4-5 times.

Gymnastics is done on a soft mat. If the patient feels even slight discomfort, then the exercises should be stopped. You can perform the exercises at home, but the complex is selected by a specialist individually for each patient.

When is surgery necessary?

Median (discs l4-l5 and l5-s1), as well as other types of pathology presented, are not always amenable to conservative and physiotherapeutic treatment. In particularly difficult cases, in the presence of a hernia or severe deformation of the spinal column, surgery may be prescribed. It is indicated if the protrusion has developed to such an extent that changes in the spine are irreversible.

Laser vaporization burns out a herniated disc with minimal intervention

In general, the affected disc can be removed using a scalpel. But there are gentle types of operations that do not require a long recovery period. Among such operations are:

1. Hydroplasty (the affected vertebra is exposed to a high-pressure water jet, which washes away all parts of the destroyed disc).
2. Laser burning of the damaged part. But the procedure will be effective only in the early stages of pathology development.
3. Vaporization of the affected disc with cooled plasma.

No matter how safe the operation may seem, it is better not to go through with it.

Disease prevention

Dorsal disc protrusions l5-s1 can develop in any person. Even a child can be affected if he or she is seriously involved in sports and exercises excessively. However, if you monitor your health, this pathology can be prevented. To do this, it is better to follow these preventive measures:

• Eat properly.
• Move more: ride a bike, swim, walk, do morning exercises. If a person has a sedentary job, then he should warm up every hour.

• Watch your posture.
• Periodically undergo preventive examinations, as well as attend massage courses.

Protrusion can be cured without resorting to medications or surgery. But for this it must be detected at an early stage of development.

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GPA levels L4-5 and L5-S1 make up the majority of GPDs (up to 98%). 24% of patients with hernias at the L3-4 level have a history of hernias at the L4-5 and L5-S1 levels, which suggests a generalized tendency to form disc herniations. In a series of 1,395 HPDs, there were 4 L1-2 hernias (incidence 0.28%), 18 L2-3 hernias (1.3%), and 51 L3-4 hernias (3.6%).

Clinical manifestations

The typical presentation is BE; in 51% of cases, the onset is associated with injury or stress. Subsequently, paresthesia and pain are observed in the anterior surface of the thigh, and then complaints of leg weakness appear (especially up the stairs).

Symptoms

The quadriceps femoris muscle most often suffers, which is manifested by its weakness and sometimes atrophy.

Tests: raising a straight leg is positive only in 40% of cases; psoas muscle tension - in 27% of cases; hip stretching can be positive.

In 50% of cases, there is a decrease or absence of the knee reflex; Achilles reflex disorders are present in 18% of cases. Reflex disorders are observed more often in L3-4 hernias (81%), followed by hernias at the L1-2 level (none) or L2-3 (44%).

Extremely lateral lumbar disc herniation

GPD in the area of ​​the facet joint (foraminal) or distal to it (extraforaminal), although some authors do not classify foraminal hernias as “extreme lateral”. Frequency (see Table 11-11): 3-10% of all GPDs (in a series with a large number of observations, some included GPDs were not actually extremely lateral).

Table 11-11. Frequency of extremely lateral lumbar vertebral hernias according to level (138 patients)

Differences from the more common more medial GPA:

Usually the root that emerges at this level is affected (as opposed to the root at the next level)

The straight leg raising test is negative in 85-90% of cases ≥1 week after the onset of the disease (with the exception of double hernias; if double hernias are also taken into account, it will be negative in ≈65% of cases); hip stretch test may be positive

Leaning to the painful side leads to pain reproduction in 75% of cases

Myelography by itself rarely provides sufficient diagnostic information (CT or MRI is usually required)

Higher frequency of extruded fragments (60%)

Higher incidence of double hernias on the same side and at the same level (15%)

Pain greater than with conventional HDP (possibly as a result of direct compression of the dorsal root ganglion)

Most often observed at the level of L4-5, and then L3-4 (see Table 11-11), so the most commonly damaged roots are L4, and then L3. In the presence of a clinical picture of upper lumbar root compression (ie, radiculopathy with a negative straight leg raise test), the odds of having an extreme lateral hernia rather than an upper lumbar disc herniation are ≈3:1.

Clinical manifestations

The most common symptoms observed are quadriceps weakness, decreased patellar reflex, and decreased sensation in the L3 or L4 dermatomes.

Differential diagnosis includes:

1. stenosis of the lateral recess or hypertrophy of the superior articular facet
2. retroperitoneal hematoma or tumor
3. diabetic neuropathy (amyotrophy)
4. spinal tumor
5. benign (schwannoma or neurofibroma)
6. malignant
7. lymphoma
8. infection
9. localized (spinal epidural abscess)
10. psoas muscle abscess
11. granulomatous disease
12. spondylolisthesis (with a defect of the interarticular part)
13. compression of the united nerve root
14. On MRI, enlarged foraminal veins can be mistaken for extremely lateral GPD

X-ray diagnostics can be difficult and in some cases the diagnosis is not initially established. However, if this pathology is actively sought, then many asymptomatic extremely lateral hernias can be detected on CT and MRI.

Myelography: in 87% of cases, the diagnosis cannot be made even when using water-soluble CV due to the fact that compression of the root occurs distal to the dural cuff (and, accordingly, outside the contrast zone).

CT: indicates the presence of a formation that displaces the epidural fat and affects the intervertebral foramen or lateral recess, causing compression of the root passing there. The formation may be located lateral to the hole. Sensitivity ≈50% and equivalent to CT/myelography. A more sensitive test may be CT after discography (94%).

MRI: sensitivity corresponds to CT/myelography. Sagittal images through the intervertebral foramina may show prolapsed disc herniation. False-positive results occur in ≈8% of cases due to the fact that enlarged foraminal veins may resemble an extremely lateral GPD.

Surgery

Foraminal hernias

A mesial facetectomy is usually required to access the area lateral to the dural sac without undue traction on the root or cauda equina. Caution: Total facetectomy combined with discectomy is associated with a high rate of instability (total facetectomy alone is associated with ≈10% spondylolisthesis). However, in other series of observations this risk was less significant (≈1 case in 33 patients). Another option would be to remove only the lateral portion of the underlying articular process. For GPD in this location, endoscopic removal techniques may be appropriate.

Disc herniations located lateral to the intervertebral foramen

Various accesses are offered, including:

1. traditional median laminectomy: you can partially or completely remove the articular process on your side. The safest way to identify the exiting nerve root is to perform a sufficiently high laminectomy of the lower part of the overlying vertebra (eg, L4 in L4-5 GPD) to expose the origin of the root from the dural sac, and then trace its path laterally through the intervertebral foramen by removing articular process until a hernia can be identified

2. lateral (i.e. extracanal) access through a paramedian incision. Advantages: the facet joint is preserved (removal of the facet joint together with discectomy can lead to instability), muscle separation is easier. Disadvantages: Most surgeons are not familiar with this approach and the root cannot be followed in a medial-lateral direction. (A 4 cm skin incision is made 3 cm lateral to the midline. Above L4, the multifidus (medially) and longissimus (lateral) muscles can be dissected and separated to approach the lateral facet joint. The position of the transverse process should be determined, after which the muscle and fascia are divided, located between the transverse processes. Determine the location of the radicular artery, vein and root, usually slightly medial to this position. If desired, the lateral facet joint can be resected and then the GPD removed)

Herniated discs in young people

Less than 1% of surgeries for GPD are performed in individuals aged 10–20 years (in one series from the Mayo Clinic, 0.4% of patients operated on for GPD were<17 лет). У этих больных редко находятся какие-либо другие симптомы за исключением положительного теста поднимания выпрямленной ноги. Вещество грыжи диска у молодых обычно плотное, фиброзное, крепко спаяно с хрящевыми замыкательными пластинками в отличие от такого у лиц зрелого возраста. На обзорных спондилограммах с необычно высокой частотой встречаются врожденные аномалии позвоночника (переходные позвонки, гиперлордоз, спондилолистез, расщепление позвонков и т.д.). Хороший результат после первой операции наблюдается в 78% случаев.

Intradural disc herniation

The incidence of prolapse of a disc fragment into the dural sac and dural cuff of the root (the latter is sometimes called an “intraradicular” disc herniation) is 0.04-1.1% of all GPDs. Although such a hernia may be suspected on the basis of preoperative myelography or MRI, diagnosis can rarely be made preoperatively. During surgery, it can be suspected on the basis of the presence of a solid mass inside the nerve root cuff or in the absence of a mass suspected by clear clinical data or radiological signs at the appropriate level (after confirming the correctness of the intraoperative determination of the level).

Surgery: To remove the fallen fragment, the dura mater can be opened, however, a number of authors believe that this is rarely necessary.

Greenberg. Neurosurgery

Foraminal herniation of intervertebral discs is fraught with rapid progression of the disease and pronounced pain that affects a person’s quality of life. In 4-10 cases out of a hundred in people diagnosed with intervertebral hernia, a violation of the integrity of the fibrous ring occurs in the area of ​​the foraminal opening. The spinal cord is located along the spine and is securely covered by the dura mater, from which two spinal nerves with a sensitive flexible root arise.

The bone bed is the foraminal opening in which the roots of the spinal nerves lie. It is formed in the lateral parts of the spine and is located between the articular processes of the vertebrae. The channel itself is 1.5 centimeters long. When the fibrous ring protrudes, creating pressure on it, compression of the endings occurs, as a result of which the brain receives an acute signal about the formation of pathology.

Foraminal hernias can occur in several places, and therefore four types of such protrusions are distinguished:

• Interforaminal or dorsal location - inside the opening;
• Foraminal medial - at the entrance between the vertebrae;
• Lateral – directly at the exit;
• Estraforaminal lateral - the protrusion is located outside the intervertebral foramen, or at the root of the vertebral arches.

Hernia pathologies are usually classified as left-sided or right-sided. They are also divided into cervical, thoracic and lumbar, depending on the location.

The complex structure of the musculoskeletal system sometimes malfunctions. Certain segments of the spine experience increased loads, as a result of which they begin to wear out. This can cause a crack to appear, which begins to irritate and pinch the roots.

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Among the main prerequisites for the formation of a hernia in the area of ​​the foraminal opening, leading to deformation of the fibrous ring, the following should be highlighted:

• Uneven distribution of load on the back skeleton during physical work or sports;
• Spinal injuries;
• Regularly staying in one position with a sedentary lifestyle;
• Poor nutrition, bad habits (smoking, alcohol abuse) and insufficient water consumption;
• Genetic predisposition due to mutation of collagen fibers that form the fibrous ring, which helps to reduce its strength;
• Age-related changes with worsening blood circulation and the appearance of protrusions;
• Excess weight, which creates additional stress on the vertebrae;
• Wearing uncomfortable shoes or flat feet.

Characteristic symptoms

Foraminal disc herniation differs from other similar pathologies in that during the development of the disease a person experiences sharp and very acute pain, since the nerve endings directly connected to the spinal cord are affected

Damage to the nerve roots in the neck

Cervical foraminal hernias are the least common. They are formed in discs c5, c6 and c7. They are manifested by headaches of varying intensity, dizziness, decreased hearing and vision (floaters before the eyes), muscle weakness, numbness of the fingers, as well as a feeling of discomfort in the affected area. Speech disturbances and changes in gait are rarely observed. Injuries to the neck that can lead to such pathologies may be the result of a direct blow (for example, injury from car accidents or during sudden immersion in water upside down).

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For pinched nerves in the lumbosacral region

The most common are protrusions in the lumbar and sacrolumbar spine, since it is in this area that the maximum load is created. Experts designate the areas of the back skeleton under consideration with the abbreviations l5-s1. Depending on which vertebrae there is a violation of the integrity of the area of ​​the fibrous ring, such a disease is accompanied by a digital designation. For example, a hernia l3-l4 is characterized by the presence of pathology in the lumbar region between the third and fourth vertebrae.

Among the symptoms, patients note:

• Sudden intense pain in the affected area, which can only be relieved, in some cases even with a narcotic drug. Changing body position does not bring relief;
• A sharp decrease in sensation in the legs. With protrusion, the patient cannot stand on his toes or heels. When the ring extends beyond the disc, complete immobilization of the lower extremities is possible;
• Decreased activity as a result of loss or weakening of tendon reflexes.

It should be noted that foraminal disc herniation has an acute onset and is poorly responsive to analgesic therapy. The pain does not stop for a long period. Conservative treatment methods are ineffective. Hernias l5-s1, l3-l4 and l4-l5 are eliminated exclusively by surgery.

Diagnostic methods

Only a highly qualified specialist can visually determine the presence of the disease after a thorough examination and interview of the patient. To confirm the diagnosis, the following diagnostic methods may be prescribed:

• Ultrasound and X-ray. These techniques make it possible to exclude the presence of concomitant spinal diseases. It is impossible to determine the size of the protrusion;
• MRI and CT. Computed tomography and magnetic resonance imaging allow you to see the damage in 3D format with an accurate assessment of the location, size of the hernial sac and the condition of the nerve endings.

MRI is considered to be the gold standard for diagnosis, since the patient is not exposed to X-rays, but the specialist can obtain complete information about the destruction of cartilage tissue, the localization of the site of swelling, the condition of the nerve roots, as a result of which further treatment is prescribed and a prognosis is made about the possible development and course of the disease.

Treatment

With such a diagnosis, there are two options for the development of events. For minor injuries, the patient may benefit from treatment with conservative methods. If such methods do not bring the expected effect, surgical intervention will be prescribed.

Conservative therapy

In the first stages, the patient will be offered conservative therapy, including analgesics and non-steroidal anti-inflammatory drugs. All medications will reduce muscle tension, relieve pain and swelling, and improve tissue nutrition in the damaged area. As an auxiliary therapy, the specialist will prescribe massages, consultation with a chiropractor and physical therapy.

All activities will be aimed at stretching the spine to release nerve endings and reduce the pain threshold. Wearing a special bandage helps. It is advisable to sleep on a hard surface. If possible, it is better to purchase an orthopedic mattress.

To reduce the size of the tumor, electrophoresis with injections of medications is used.

Surgery

Surgical intervention is indicated if one hundred days of traditional procedures have not brought significant relief, and the pain has become chronic. Surgery is also prescribed if the tumor is more than 10 mm in size and paralysis of the limbs is present.

The procedure is performed by neurosurgeons in a clinical setting. There are four intervention methods:

• Microdiscectomy. The intervertebral disc is removed, eliminating pressure on the nerve endings;
• Laminectomy. Sections of the intervertebral disc and part of the bone in the area of ​​the damaged area are eliminated;
• Interspinous spacers. The technique involves installing implants that help reduce pressure on the pinched roots;
• Transforminal endoscopy. It is carried out by puncture with the introduction of a needle and subsequent removal of a small part of the disc and sequestration. This allows you to restore the shock-absorbing functions of the vertebra with the elimination of pain.

Rehabilitation

After the procedures or surgery, the patient will need to undergo a course of rehabilitation aimed at restoring physical activity, strengthening the muscle corset and minimizing the risk of relapse. It is recommended to engage in physical therapy, visit the pool under the supervision of a trainer, reduce the time spent working at the computer, eliminate physical activity and driving for the first two months. You should not delay going to the doctor, since untimely treatment can lead to negative consequences, including paralysis of the limbs.

About 80% of the population experience pain in the back and lower back, often these symptoms are associated with the development of an intervertebral hernia. The human spine can withstand heavy loads, and over time, the lumbar discs can wear out. A bulging intervertebral disc is a hernia.

Note. Most often, a hernia occurs in the skeletal segments L4-L5 and L5-S1. Disc protrusion is observed between the 4th and 5th lumbar vertebrae and between the sacrum and the last vertebra. Median and sequestered hernias are common.

Manifestation of the disease

Intervertebral hernias may not manifest themselves in any way at the initial stages of development. A slight protrusion of the disc does not cause severe pain or discomfort. However, as the tumor grows, the symptoms of the disease intensify.

Symptoms such as lumbago, lower back pain, potency disorder and numbness of the lower extremities may indicate the development of a lumbosacral hernia. This disease is very dangerous and requires timely treatment. How not to miss the development of a hernia and what methods are used in its treatment - this and much more will be discussed in this article.

The main symptom of an intervertebral hernia is pain in the lumbar region. It can change its character, strength and even location. As a rule, pain increases with heavy lifting and sudden movements. In a horizontal position, the discomfort goes away. As the hernia increases, the pain syndrome changes its manifestation. The sensations may become aching and piercing. The pain may radiate to the leg, heel, foot or head.

In addition to pain, patients with intervertebral hernia experience:

• muscle spasm;
• loss of stability;
• numbness of the limbs;
• slouch;
• stiffness of movements;
• compression of the spinal cord roots;
• dryness or sweating of the skin near the damaged nerve root;
• paralysis, etc.

Causes of hernia

Lumbar disc herniation is most often observed in adults 30-60 years old. The disease can be caused by a number of reasons, most often the following factors contribute to disc protrusion:

• Excess weight.
• Prolonged sitting position.
• Improper lifting of weights, heavy loads.
• Sharp turns.
• Impacts or injuries to the spinal column.

How to treat?

It is possible to cure a herniated disc using conservative methods. Many patients who consulted a doctor in the early stages of the disease successfully completed the therapeutic course and returned to a normal healthy life. In advanced cases, patients are recommended to use a surgical treatment method, but it does not guarantee complete recovery and the absence of the likelihood of relapse.

Treated using the following methods:

• A complex of therapeutic exercises and spinal stretching. Physical exercises strengthen the muscle corset and eliminate disc protrusion. Many doctors recommend that patients spend more time in the pool.

Important! Swimming helps to eliminate the symptoms of pathology in a short time.

• Physiotherapy - electrophoresis, laser therapy, magnetic puncture, etc. Procedures help relieve pain, get rid of swelling, inflammation, and prevent the manifestation of the disease.
• A complex of manual therapy, massage, kinesiology, etc. These procedures restore the disturbed anatomical relationships of the spinal structures.
• Wearing special corsets, etc.

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Depending on the stage of development of the disease and the patient’s condition, the attending physician prescribes anti-inflammatory drugs. Steroid injections can help relieve pain when symptoms are severe. Some patients are advised to take dosed rest.

Most patients return to everyday life after successful treatment, but in 5% of cases there is a chance of relapse of the disease.