Osteochondrosis

1. Osteochondrosis is a polyfactorial disease that develops In case of two conditions: Decompensation of trophic systems Local excessive load on spinal segments

2. Pathogenesis of osteochondrosis • The first stage. There are degenerative changes of pulp nuclei • The second stage. There are degenerative changes in fibrous ring, disc protrusion and disc hernia • The third stage. There are changes of hyaline plates - subchondral sclerosis

4. X –ray signs of osteochondrosis • Low height of between vertebral discs • Sclerosis of final plates • Osteophytes on the edges of vertebras’ bodies. They are located perpendicularly to the spinal axis • Local scoliosis • Spondilolisthesis – dislocation of neighbouring vertebras’ bodies • Local cyphosis (instead of lordosis)

6. Vertebral disc’s hernia Main positions are: • Medial (clinical features of horse tail lesion) • Paramedial (a little bit out side the medial position – several radixes are compressed) • Posterior – medial (much more out side the medial position – 1 or 2 radixes are compressed) • Foraminal - (– 1 radix is compressed)

9. Pathogenesis of neurological signs • Irritation of vessels and nerves with vascular spasm. • Compression of vascular – nervous complex. • Edema (perivascular edema and radicular edema) • Reactive process of neibouring structures (straining of muscles) • Autoimmune reactions (a part of disc becomes antigen)

10. Compressive syndrome occurs at compression and deformation of radix, vessels and spinal cord. • Reflex syndrome occurs at irritation of different receptors (such as Lushka nerve).

11. Classification. Reflex syndromes • Lumbago (backache) • Lumbalgia • Lumbar ischialgia (muscular – tonic, neuro- dystrophic, autonomic vascular) Compressive radicular syndromes. Compressive vascular radicular – spinal syndromes (radicular ischemia) • Acute • Transient • Strokes • Chronic ischemic myelopathy

12. Vertebrogenous syndrome • Limitation of movements in lumbar – sacral part of spinal cord (bending forward, backward) • Increasing of pain while movements, coughing and laughing • Protective straining of long back muscles • Extension of lumbar lordosis, cyphosis in lumbar – sacral division • Scoliosis, sometimes with rotation • Painful paravertebral points and vertebral processes

13. Vertebrogenous syndrome • Discharge – postures and symptoms • Knee – elbow position • While standing the patient keeps his leg aside in order to make the load less on his leg • While lying in the bed he bends his leg in all joints. • The symptoms of spinal cord instability (it is difficult for the patient to stand, to wash himself, but it is much more easier to walk)

14. Reflex syndromes • on lumbar – sacral level are divided into: 1. Lumbago 2. Lumbalgia 3. Lumbar ischialgia • muscular – tonic • vascular • neuro- dystrophic

15. The points of pain: • Pain along the crista iliaca • The point of iliosacral joint • The point of m. gluteus minimus (just under the crista iliaca) • The point of m. gluteus medius (1 sm lower) • The point under the backside fold • Trochanter os iliaca • Along the ischiadic nerve (the posterior surface of hip and fossa subpoplitea)

16. The symptoms of strain • Lasegue’s symptom – in case of straining and lifting the leg the low back pain appears • Neri symptom – there is pain in leg at bending head forward • Matskevych symptom – there is pain in the anterior surface of the leg at knee bending while lying on abdomen • Wasserman symptom – the same clinical picture at lifting the leg

17. The symptoms of strain • Sequar symptom – there is pain on posterior surface of leg at foot flexing • Turin symptom – the same clinical picture at toe’s flexing • Bechterev’s symptom – there is pain at knee – flexed leg extension • Dejerine’s symptom - there is pain in posterior surface of the leg at coughing, sneezing

18. Piriformis syndrome Clinical features: • Painful palpation of Trochanter major • Painful m.Piriformis • Symptom of Soobrase (painful cross-legged position) • Symptom of Bone – Bobrovnikova (painful abduction of leg)

20. Piriformis syndrome • Popelyansky intermittent claudication (while walking the patient is forced to sit down because of the pain. That is the result of spasm of the vessels. • Sphincter disorders (pause before the urination) • Signs of n. ischiadicus lesion (muscles hypotrophy, low Achille reflex, hyposthesia, pain)

21. Neurodystrophic form of lumbar ischialgia • Sacroiliac periartrosis - pain and limitation of movements in hip joint. The patients cannot run and so on. • Knee joint periartrosis– sudden pain in knee joint • Coccygodynia • Neurodystrophic changes of Achille tendon (it is very rare)

22. Radiculopathy • Radix L5 ( Disc L4 – L5) • Pain in the external edge of hip, on the anterior –external surface of crus until the internal surface of foot and great toe. • Sensory disorders (hypalgesia, analgesia) in the same zones • Paresis of great toe extensors and foot extensors • Hypotonia and hypotrophy on the anterior surface of crus • The patient cannot stand on heels

24. Radiculopathy Radix S1 (Disc L5 – S1) • Pain in external – posterior surface of hip, crus, foot, the IV –th and Vth toes. • Sensory disorders (hypalgesia, analgesia) in the same zones • Paresis of toes flexors • Absent or low Achille reflex

26. Radiculopathy Radix L4 (Disc L3 – L4) • Pain in anterior – internal surface of hip • Sensory disorders (hypalgesia, analgesia) in the same zones prevail over motor ones • Weakness of m. Quadriceps femoris • Hypotrophy of m. Quadriceps femoris • Knee reflex is low or sometimes increased

27. Radiculopathy Radix L2 – L3 • Clinical features include pain and sensory disorders on anterior – medial surface of hip. • Symptoms of Matskevych, Wasserman • Low knee reflex • Weakness of m. Quadriceps femoris • Cruralgia • Symptoms of lesion of horse tail • Irradiation of pain into lower part of abdomen, genital organs

29. compression of horse tail It is created by radix L2 – S5. It is observed at hernia of discs L4 – L5. Clinical features: • Significant pain in legs • Sensory and motor disorders in certain zones of innervation • Pelvic disorders (incontinence of urine and feces)

32. Classification on cervical level • Reflex symptoms. • Stiff neck • Cervicalgia • Cervical cranialgia • Cevical brachialgia • Muscle – tonic syndrome • Autonomic – vascular syndrome • Neurodystrophic • Compressive radicular syndrome

33. Classification on cervical level • Compressive – spinal syndrome • Compressive vascular radicular – spinal syndrome • Acute • Transient • Strokes • Chronic ischemic myelopathy • A. vertebralis syndrome

34. Cervical cranialgia Clinical features of posterior cervical sympathetic syndrome: • Cranialgia – occipital pain with irradiation in temporal, parietal parts. • Vestibulo – cochlear disturbances – dizziness, vomiting • Eyes symptoms – eyes pain, tears. • Autonomic upper quadrant syndrome – asymmetry of blood pressure, temperature, pulse, sensation, cardiac pain and so on.

36. Cervical brachialgia • Muscle – tonic form • Neurodystrophic form • Autonomic – vascular one

37. Muscle – tonic form Muscle – tonic form - Scalenus – syndrome. Clinical features: There are pains above and under clavicle at the muscle straining There are pains at head movements with irradiation in the arm Edema in above clavicle region

39. Cervical brachialgia Neurodystrophic form • Shoulder – scapula periartrosis • Shoulder – hand syndrome • Epicondilosis

40. Cervical brachialgia Shoulder – scapula periartrosis Clinical features: • Pain and limitation of movements in shoulder • Painful palpation of caput os humeri • Limitation of arm movements (the patient cannot comb his hair) • The symptom of frozen shoulder • M. deltoideus, m. supraspinatus atrophy

41. Shoulder – hand syndrome This syndrome includes clinical features of shoulder – scapula periartrosis and autonomic – trophic changes of hand. Clinical features of algic stage: • Severe hand pain • Edema, hyperemia and cyanosis

42. Shoulder – hand syndrome • Hyperesthesia • Decreased muscle strength and limitation of movements Clinical features of dystrophic stage: • Muscle atrophy • Osteoporosis on X – rays examinations

44. Compressive radicular syndromes Radiculopathy C6 radix (C5 – C6 discs) • Pain, parasthesia and hypalgesia on anterior external surface of arm • Weakness, hypotrophy of m. biceps brachii • Absent or low flex elbow reflex

45. Compressive radicular syndromes Radiculopathy C7 radix (C6 – C7 discs) • Pain, parasthesia and hypalgesia • Weakness, hypotrophy of m. triceps brachii • Low extensor elbow reflex

46. Compressive radicular syndromes Radiculopathy C8 radix (C7 – C8 discs) • Pain, parasthesia and hypalgesia • Low extensor elbow and carpo – radial reflex

47. Additional methods of diagnostics • Spinal X – ray – examination • CT of spinal cord

48. Treatment • Orthopedic • Medicines: • In edema: Euphyllinum 2.4% 10.0; Lasix 2.0; Dexamethasonum 4 – 8 mg; NaCl 0.9% 200.0 i/v by drops • Platiphillinum, No – spa, Baralginum • Analgesics - Reopirini, Voltareni 2.5% 3.0; Tramadol, Aminasini • Non steroids medicines– Ketanov, Dicloberl, Movalis, Ranselex, Celecoxib • Myorelaxants – Midocalm, Baclofen • Chondro- protectors – Rumalon • Vitamins and biostimulators • Physical methods

49. Treatment • Surgical methods (Horse tail compression, Long lasting (3 – 6 months) pains, Huge hernia (over 15 mm), Acute compression of radicular – spinal artery) • Sanatorium

50. Prevention • Hypokinesia prevention • Moderate physical activity • Treatment of chronic diseases