OSTEOCHONDROSIS

From Big Medical Encyclopedia

OSTEOCHONDROSIS (osteochondrosis; Greek osteon a bone + chondros a cartilage + - osis) — a dystrophic disease of a joint cartilage and the subject bone tissue. Earlier this term designated big group of bone and joint diseases. From modern positions often they are considered as osteochondropathy (see), and the term «osteochondrosis» designate only a degenerative and dystrophic disease of a backbone, first of all intervertebral disks, followed by their deformation, reduction of height, stratification. Dystrophic changes in a disk at O. call a disk arthrosis. Most often O. is localized in nizhnesheyny, verkhnegrudny and nizhnepoyasnichny departments of a backbone. O. very widely is widespread and to 40-year age it is found in most of people in a varying degree.

The etiology, a pathogeny

O.'s Aetiology is found insufficiently out. The greatest significance is attached to genetic predisposition, age changes in intervertebral disks, their acute or hron, to an injury, disturbances of segmented blood circulation. In O.'s pathogeny an important role is played by changes of a pulpozny kernel, in particular its dehydration. The last leads to loss by a disk of depreciation functions, to change of conditions of load of a fibrous ring and to its gradual destruction.

The Anatomo-klinichesky periodization

In O.'s development distinguish several periods. Each of them is characterized defined ana-tomo-morfol. changes in a disk, adjacent bodies of vertebrae and in intervertebral joints. In the first period cracks in inner layers of a fibrous ring and in a jellylike kernel are formed. The last begins to get into these cracks and to irritate nerve terminations in peripheral layers of a fibrous ring and in the squeezed back longitudinal sheaf. Clinically this period is shown by pains in the struck department of a backbone, more or less constants (a lyumbalgiya, a tservikalgiya), or a lumbago — lumbago (see). To this period svoystven number of reflexo-painful syndromes: a humeroscapular pain syndrome (see. Periarthritis ), a syndrome of a front scalene (see. Scalene syndrome ), a syndrome of a pear-shaped muscle (see. Piriformis-sindrom ), a syndrome of convulsive tightening of gastrocnemius muscles — kramp, pains in heart etc.

The second period is connected with further destruction of a fibrous ring and deterioration in fixing of vertebrae among themselves. There is a mobility unusual for a backbone — a pseudospondylolisthesis in lumbar department, an incomplete dislocation — in cervical. In general this state is characterized as instability of a backbone. In a wedge, a picture the pains in this or that department of a backbone amplifying at inconvenient prevail or the sensation of discomfort is long the kept poses, a thicket exercise stresses.

Then the period of a rupture of a fibrous ring (the third period) follows. The jellylike kernel is squeezed out (prolabirut) out of limits of a fibrous ring, and hernia of a disk is formed. The prolapse occurs more often towards the vertebral channel, at the same time roots of spinal nerves, vessels, a spinal cord are squeezed (see. Diskosis ), what annoyingly affects receptors of a back longitudinal sheaf. Patol, an impulsation from this zone, as well as at other stages of process, leads to muscular and tonic, neurovascular and dystrophic reflex displays of a disease. They are promoted also by an impulsation from the corresponding intervertebral joints, in to-rykh dystrophic process in the conditions of rapprochement of adjacent vertebrae develops and arises Spondylarthrosis (see). The wedge, syndrome during this period is characterized the expressed fixed deformation of the struck department in the form of a kyphosis, a lordosis or scoliosis, insufficient fixing that is followed by more accurate phenomena of loss from the squeezed roots, vessels or a spinal cord.

The fourth (final) period is characterized by distribution of degenerative process on yellow ligaments, interspinal sheaves and other formations of a backbone. Process of flattening of an intervertebral disk continues, in it scarring begins and eventually there can come its fibrosis. Development of the deforming arthrosis in intervertebral and un-kovertebralny (semi-lunar) joints continues. Epidural fatty tissue turns into the fatty tissue similar to a hypodermic fatty tissue, between yellow ligaments and a firm cover of a spinal cord hems develop. The wedge, a picture during this period can be rather motley as separate disks are struck in different degree. At an uncomplicated current of O. fibrosis of a disk can mean rather permanent remission during a disease. The lake at different stages can be combined with manifestations of deforming spondylosis (see).

Neurologic manifestations to some extent depend on O.'s period, and also develop in connection with a number of other vertebralny and especially ekstravertebralny factors. During a disease distinguish stages of an aggravation and remission. The stage of an aggravation, in turn, is divided into a phase of progressing, a stationary phase and a phase of regressing. In an acute stage there are acute pains with the subsequent irradiation in a hand, a waist or a leg. The compression syndromes forming at the lumbar level are more often at the expense of a rupture of a disk, are caused by a prelum of roots (see. Radiculitis ), additional radikulomedullyarny arteries (see. Spinal cord ). Syndromes of a prelum at the cervical level form due to back and posterolateral unkovertebralny growths more often and are caused by a prelum of roots of spinal nerves and a vertebral artery with its sympathetic vertebral texture (see. Barret — Lyeu a syndrome ).

Pains squeezing, tearing, sometimes burning character, localized in a neck, a nape, in a shoulder and shovels are characteristic of cervical O. Along with it disturbances of sensitivity and motive frustration in a zone of an innervation of the corresponding cervical roots can be observed. Cervical myelipathy (see), arising at disturbance of blood circulation in a spinal cord, it is most often shown by syndromes amyotrophic side sclerosis (see) or spinal gliosis.

At chest O. vertebrogenny, in particular discogenic radicular and spinal, syndromes are observed seldom. Intercostal neuralgia results from others patol, processes more often (shingles, a tumor of a backbone, etc.). At chest as well as at the lower cervical localization of O. there can be pseudo-anginous pains in heart behind a breast with typical irradiation.

At lumbar O. the most frequent nevrol, manifestations are pains (lyumbalgiya), a lumbago (lumbago), radicular pains and disorders of sensitivity in legs, decrease in tendon jerks and vegetative and trophic frustration is frequent. In nek-ry cases syndromes of defeat of an epikonus, a cone, a horse tail are possible.

Reflex manifestations Lakes form in the entire periods of O. and are most often expressed by the following syndromes. 1. Vertebralny syndromes — acute cervical or lumbar pains (lumbago), subacute or hron, pains (a tservikalgiya and a lyum-balgiya) with a frequent contracture of juxtaspinal muscles and change fiziol, bends. Also lumbar and coxofemoral extensive rigidity (the fixed lordosis and restriction of bending in hip joints), and at the cervical level — forced position of the head at the expense of an asymmetric contracture of vertebral muscles, both nizhnesheyny, and verkhnesheyny, especially lower oblique muscle of the head concerns to them. Capsules of intervertebral joints, and at the cervical level — and places of an attachment of scalenes to cross shoots of vertebrae (over-erbovsky points) are painful. 2. Syndromes of a contracture of the muscles which are beginning on a backbone and attached to other bones, napr, a scalenus-anticus syndrome or a piriformis-syndrome. 3. Syndromes of a contracture of muscles of a shoulder girdle, a basin or extremities — muscular and tonic, tser-viko-and pelviomembralny; e.g., a syndrome of a humeroscapular periarthrosis (with kont.raktury the muscles giving a shoulder — chest and big round). 4. Reflex neurovascular syndromes, are more often with a vasospasm and are more rare from a vazodilatation. Are shown by feeling of a chill and paresthesias in an extremity, change of its coloring, puffiness. Here it is necessary to include also a subpear-shaped Charcot's syndrome: the scelalgias amplifying during the walking (at the expense of vasospastic ischemia of a leg at impact of a tight pear-shaped muscle on sympathetic fibers of the lower buttock artery and a sciatic nerve). The syndrome of a vertebral artery mentioned above also concerns to this group. At the chest level discogenic compression syndromes are rare, and vertebrogenny thorax pains (a syndrome of a front chest wall, scapular and costal and other pain syndromes) are caused more often by irritation of capsules of vertebrocostal and cross and costal joints.

The diagnosis

O.'s Diagnosis and its syndromes in typical cases does not present special difficulties, but demands full neurologic, orthopedic and radiological inspection. At inspection of the patient reveal features of a pose, in particular existence of antalgichesky inclinations of a trunk, a muscle tension of a back, painful points at a palpation, restriction of movements. For diagnosis of hernia of a disk it is shown spinal puncture (see), at a syndrome of a vertebral artery and a myelipathy make vertebralny angiography (see) and a venografiya of a vertebral texture (see. Flebografiya ) .

Fig. 1. Side roentgenogram of cervical department of a backbone of the patient with cervical osteochondrosis: small narrowing (1) of an intervertebral cartilaginous disk between VI and VII vertebrae; a sclerosis adjacent for mykayushchy plates (2) bodies of vertebrae; front regional osteophytes (3).
Fig. 2. Side roentgenogram of lumbar department of a backbone of the patient with lumbar osteochondrosis: narrowing (it is specified by an arrow) an intervertebral cartilaginous disk between III and IV vertebrae, the closing plates of bodies of vertebrae are sclerosed.

Rentgenol, a research of a backbone at O. gives the chance to establish localization, character and degree of prevalence patol, process. The degenerative and dystrophic process which is the cornerstone of O. in intervertebral disks radiological is shown by reduction of height of intervertebral space; in this regard but a measure of progressing of O. adjacent surfaces of bodies of vertebrae considerably approach. The changes arising in a disk involve restructuring of adjacent surfaces of bodies of vertebrae; they are condensed and thickened. At the edges of the surfaces of bodies of vertebrae bone growths, shaped fringes, beaks or bridges (fig. 1) are formed. Bone growths develop and on a back surface of bodies of vertebrae, quite often acting towards the vertebral channel. Against the background of the changed closing plate of bodies of vertebrae are defined a semicircular form of impression, formed as a result of a prolapse of fragments of an intervertebral disk — cartilaginous hernias of Shmorl (see. Shmorlya small knots ). Around impressions reaction in the form of a rim of a sclerosis develops. In the expressed O.'s cases the shift of vertebrae which is usually not exceeding 1 cm on the roentgenogram in a direct projection is observed shift aside, and on the roentgenogram in a side projection — in the perednezadny direction (fig. 2) is visible. Unlike true spondylolisthesis (see) a dislocation of the vertebra at O. call a pseudospondylolisthesis.

For definition of degree of dysfunction of an intervertebral disk so-called functional X-ray inspection is shown (in the provision of the greatest possible bending, extension and on average situation). At funkts, a research the shift of 2 — 3 vertebrae on the relation to each other to 2 — 3 mm is normal observed fiziol. Unlike it at O. the pseudospondylolisthesis comes to light within 2 vertebrae. Disturbance of normal function of an intervertebral disk is shown in the form of instability (the raised smeshchayemost — more than 3 mm) vertebrae or, on the contrary, funkts, the block. Pnevmomiyelografiya (see) and miyelografiya (see) allow to reveal protrusions of disks towards the vertebral channel, impression and shift of trunks or roots of spinal nerves. Discography (see) gives the chance to find changes in a jellylike kernel, to specify the direction and degree of its shift.

Radiological differential diagnosis of O. is carried out with those processes, to-rye led to reduction of height of intervertebral spaces — with tubercular and nonspecific spondylitis (see). At O. consolidation and a thickening of the closing plates of bodies of vertebrae, but not their destruction, as is noted at inflammatory processes. Besides, O. needs to be differentiated with tumoral process, a disease to Kalva (see. to Kalva disease ) and effects of damage of disks.

Treatment

Treatment shall be carried out taking into account the period of a disease. In the first period are shown massage, to lay down. physical culture, underwater extension, physical therapy. In the second and third periods the problem of an immobilization of a backbone becomes the main, and in to lay down. a complex include carrying a corset (see. Orthoses ). At the proceeding pains in the second period sometimes make operation of fixing of a backbone — a front or back spondylodesis (see), in the third period — intra disk administration of papain, and sometimes operational removal of hernia of a disk (see. Diskektomiya ). Direct indications to a diskektomiya arise at a prelum of a horse tail or a rough prelum of a spinal cord. Lech. tactics at nevrol. the manifestations connected with a compression, and an ekstravertebralny metastasis ad nervos is defined by a stage of process (remission or an aggravation) and a phase of an aggravation (progressing, stabilization or regressing), and takzhz nevrol, syndromes.

At painful contractures and the vasospastic phenomena appoint heat, analgetics, administration of novocaine in painful zones, applications of novocaine with a dimethyl sulfoxide, impact on biologically active sites by means of an electropuncture (see. Acupuncture ), coherent monochromatic radiation — laser (see). From physiotherapeutic procedures apply local UF-radiation in an erythema and suberythema dose, the harmonic modulated diadynamic currents (see. Impulse currents ), an electrophoresis of novocaine (see. Electrophoresis ) or medicinal anesthetics of mixes with the help galvanic or impulse currents, eufillinelektroforez the harmonic modulated currents, to ultrasounds.) and ultrafonoforez analginum, Euphyllinum, hydrocortisone. At a syndrome of a vertebral artery it is more preferable to apply an electrophoresis, the harmonic modulated and diadynamic currents. In an acute stage of the expressed radicular syndrome dehydration, epidural novocainic blockade are shown, extension (see). At commissural processes appoint a lidaza, biyokhinol, a vitreous, extract of an aloe. Already in a stage of an aggravation (in phases and regressing) appoint stationary to lay down. physical culture and massage (see), and in a stage of remission — to lay down. physical culture and preventive courses of application therapy, various bathtubs (see) — sulphidic, turpentine (at the phenomena of a vasomotor spasm), radonic, chloride sodium; dirt — silt, peat, sapropelic (see. therapeutic muds ). In a stage of incomplete and full remission apply also physiotherapeutic means: an electrophoresis of various pharmaceuticals, constant magnetic field, variation magnetic field of low frequency (see. Magnetotherapy ), decimeter waves (see. Microwave therapy ), inductothermy (see), electric field of UVCh in constant and pulsed operation.

The forecast

the Forecast at timely begun and rational treatment usually favorable. In the started cases it is possible invalidism because of disturbance of an oporosposobnost of a backbone and nevrol, frustration.


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A. I. Kazmin; M. K. Klimova (rents.), Ya. Yu. Popelyansky (not BP.), N. I. Strelkova (fizioter.).

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