Spinal stenosis, spinal osteophytes - Causes, Symptoms and Treatment .MF .
Spinal Canal Stenosis - to chronic process characterized by an abnormal narrowing of the central spinal canal, lateral pocket or intervertebral foramen bone, cartilage and soft tissue structures, with the invasion of the spaces occupied by the nerve roots and spinal cord.The narrowing of the spinal canal caused by a herniated disc, which lead generally does not apply to acute compression of neurovascular structures to the stenosis.
spinal canal stenosis is a disease that involves a combination of the narrowing of the spinal canal according to a computed tomography (CT) or magnetic resonance imaging (MRI) or X-ray of the spine (spondylography) and typical clinical symptoms.During the MRI persons over 60 years noted that 21% of them had radiographic signs of narrowing of the spinal canal in the lumbar level.Only one-third (33%) have the characteristic of the stenosis complaints
classification of spinal stenosis
anatomical criteria distinguish
- central stenosis - reducing the distance from th
- lateral stenosis - narrowing of the radicular canal and intervertebral foramen to 4 mmAt least
- congenital or idiopathic stenosis;achondroplasia
- acquired stenosis
- combined stenosis - any combination of congenital and acquired stenosis
reasons for spinal canal stenosis
spinal canal formed by arches and vertebral bodies, as well as the tight ligaments that connect the vertebrae together.Between the walls of the spinal cord and the spinal canal is located a space filled with loose fatty tissue and cerebrospinal fluid.The presence of this space allows the body to compensate for a slight narrowing of the spinal canal without the development of neurological complications.However, progressive stenosis of the spinal canal will inevitably lead to spinal cord compression, and (or) the nerve roots, which is accompanied by the appearance of neurological symptoms.
spinal canal stenosis is most often noted on the lumbar level.The narrowing of the lumen of the spinal canal can be caused by the development of a herniated disc, tumors, traumatic injury, thickening of the yellow ligaments, facet arthrosis, growth of osteophytes, disc protrusion, spondylolisthesis, and some other reasons.
Congenital stenosis due to anatomic features of the spine in the human structure and manifests itself:
vertebrae arc - achondroplasia (increase in thickness of the vertebral arch, the shortening of the legs and reducing the height of the vertebral body)
- cartilage and fibrous diastematomieliey
In this case, the stenosis symptomsspinal canal appear at a younger age.
Causes of acquired stenosis different.The main ones are:
- deforming spondyloarthrosis with hypertrophy of intervertebral joints, formation of marginal osteophytes
- ossified hernia of intervertebral discs
- hypertrophy and ossification of yellow
ligament - a disease Forestier (diffuse idiopathic hyperostosis rheumatoid nature)
- ankylosing spondylitis
- spondylolisthesis degenerativegenesis
- iatrogenic stenosis - education subarachnoid adhesions and / or scars
- «steel stenosis" - the introduction of metal structures in the lumen of the vertebral or radicular channel
Central stenosis arises due to pathological processes in the anatomic structures form the spinal canal (in particularintervertebral discs, intervertebral joints, yellow ligament, the posterior longitudinal ligament), which contains the cerebrospinal bag incorporating the nerve roots.
lateral stenosis may occur in one or more of the three anatomical regions: the entrance area (lateral retsessuse), the middle zone and exit zone (intervertebral foramen).
Lateral retsessus limited:
- behind - the superior articular process vertebra
- medially - bag Dura
- laterally - foot vertebra
- caudal - vertebral body
- rostral - intervertebral disc
Normally, the height of the lateral retsessusa of 5mm.Reducing its size to 3.4 mm is defined as a stenosis.In most cases, the stenosis is caused by the lateral retsessusa or hypertrophy of the superior articular process of the vertebra or posterolateral herniated disc.
middle zone is limited:
- behind - intervertebral joints
- top - foot vertebra
- front - vertebral body
- medially - actually the spinal canal.
narrowing of the middle zone and accordingly root compression can occur with spondylolisthesis and rotational deformities.
intervertebral foramen limited
- top and bottom - legs of adjacent vertebrae
- front - the bodies of adjacent vertebrae located between the intervertebral disc
- behind - intervertebral joints and the lateral part of the yellow ligament
Normally, the height of the intervertebral foramen 20-30mm, width of 8-10 mm, the area from 40 to 160 mm².Reducing the height of the intervertebral foramen at least 15 mm is treated as its stenosis (in conjunction with clinical signs of nerve root)
intervertebral foramen stenosis is more common in the lower lumbar region, ingda common spinal stenosis in the cervical or thoracic spine.
pathogenesis of spinal canal stenosis
pathophysiological mechanisms that cause the development of specific complaints, due to a combination of three groups of factors - increasing the epidural pressure, aseptic inflammation and ischemia.
The appearance of each of them due to chronic compression of the neurovascular structures of the spinal canal.
Due to chronic compression of a mismatch of blood flow to the nerve structures of the spinal canal.The level of incoming blood is reduced and, accordingly, there is ischemia of the nerve root (with lateral stenosis) and horse tail (cauda equina) (at the center).When combined stenosis there is a combination of ischemia as the cauda equina or nerve root.It is noted that the phenomenon of ischemic cause demiedinizatsii processes, the formation of adhesions between the soft and arachnoid meninges, the development of interstitial fibrosis and scar-adhesions epidurita need for oxygen increases the amplification of biochemical processes.This explains the fact that complaints of pain in the back and / or legs, weakness of the spinal canal stenosis occur during walking.
mismatch volume neurovascular structures of the volume of the spinal canal causes an increase in the epidural pressure and as a result gives rise to inflammation.Epidural pressure increases when walking, causing ectopic production of nerve impulses and the occurrence of pain is manifested.
A feature of the pathogenesis of the spinal canal is the dependence of its volume from the position of the body.When a man kneels, lumbar lordosis is straightened or kifoziruetsya, articular processes differ, increases clearance of the intervertebral foramen, freeing up choking the blood vessels, which leads to the restoration of normal blood flow, and hence the supply of ischemic neural elements.At the height of the intervertebral foramen flexion increased by 12%, while extension is reduced by 15%.This explains the typical complaint, which is in regression of pain until the complete disappearance when sitting down, stooping.Moreover, on the basis of this symptom is carried out differential diagnosis between neurogenic (spinal canal stenosis) and vascular claudication.Thus, in neurogenic intermittent claudication, unlike vascular person can work for a long time on a stationary bike, do not experience complaints during prolonged driving.
spinal canal stenosis as a consequence of osteochondrosis
most commonly acquired spinal stenosis is the last of the 4th stage of osteochondrosis.Its occurrence is characterized by the fact that against the background of instability of the vertebral-motor segment (3rd stage osteoarthritis) develop compensatory processes aimed at its stabilization.These include the proliferation of bone osteophytes intervertebral joint arthrosis.Intervertebral joints limit as the spinal canal and nerve root entry zone, an intermediate zone and the intervertebral foramen.Accordingly, the expansion of the intervertebral joints leads to the narrowing of the anatomical structures of the above and, accordingly, the development of stenosis.
Symptoms of spinal stenosis
narrowing of the spinal canal leads to compression and irritation of the nerve roots.This can cause pain and impaired nerve function.When stenosis decreased delivery of oxygen and nutrients to the spinal cord.During physical activity, such as walking or running, the nerve cells of the spinal cord need to be increased delivery of oxygen and nutrients.However, spinal canal stenosis, this does not happen, as the volumetric rate of blood flow can not increase in proportion to the needs of nerve cells due to the increased interstitial pressure in the spinal canal, causing compression of the blood vessels.spinal cord ischemia leads to weakness and pain in the limbs.
most often with spinal canal stenosis, patients complain of pain, heaviness and weakness in the legs and lumbar region, arising from walking or prolonged standing.After the rest, these symptoms usually disappear.This simpatokompleks called neurogenic claudication, by analogy with intermittent claudication vascular diseases of the lower extremities.
In the study group of patients with stenosis of the spinal canal in the lumbar level, noted that major complaints are:
- back pain and lower back - lumbodynia (95%)
- syndrome of neurogenic intermittent claudication (91%)
- radicular pain in oneand two legs (71%)
- tension symptoms (Lassega, Wasserman et al.) 75%
- a weakness in one or two legs (33%)
- Sensory impairment in the legs 63%
- Paresis in the legs 59%
-sciatica (pain in the leg) 54%
- Wasting lower limbs 43%
- sensory disturbances in the anogenital area 21%
- Crump 20%
calf muscles - Violation of the pelvic organs 14%
patients who noted the combination of painleg and waist 70% noted the same intensity of leg pain and back pain, 25% dominated by the pain in his legs.In 58% of cases there was a pain in one leg and in 42% it was bilateral.The majority of patients had multiple nerve roots radiculopathy.Generally pain in the spinal canal stenosis is distributed in dermatomes L5 (91%) and SI (63%), at least in dermatomes L1-L4 (28%).
Neurogenic claudication is a pathognomonic symptom of spinal stenosis, before allowing additional methods of examination suggest the presence of spinal stenosis.For her characterized by the appearance of pain when walking, which regresses when sitting down or forward inclination of the trunk.After that people can once again go through a certain distance before the pain.In the sitting position the patient can perform any work (exercise bike, driving a car) without causing pain.The intensity of neurogenic intermittent claudication otsenivaaetsya in distance (meters) that can pass before the person in pain.
diagnosis of spinal stenosis
diagnosis of spinal stenosis can be set based on a combination of clinical complaints and luminal narrowing of the spinal canal, respectively, according to other research methods.
narrowing of the spinal canal (anteroposterior size of less than 12 mm) can be identified according to the magnetic resonance imaging, computed tomography and radiography (spondylography) lumbosacral spine.
Radiography - a painless method of investigation that allows to visualize the formation of bone using X-rays.When spinal canal stenosis caused by degenerative changes, X-ray examination can be identified symptoms such as a decrease in the height of the intervertebral gap, osteophytes, hypertrophy of the facet joints, the instability of the vertebral-motor segment during functional tests (flexion and extension).Rentgegnografiya can also identify vertebral fractures, vertebral tumors, some infections of the spine.However, this method of investigation is not rendered soft tissue, so an accurate diagnosis is necessary to conduct magnetic resonance imaging.
Magnetic resonance imaging - a painless, completely safe method of research based on the use of radio-magnetic waves to produce images of internal body structures.MRI image is represented as a series of longitudinal and transverse sections.With this method any easily diagnosed study pathological changes in soft tissue, including the spinal cord and nerves.Using MRI can also reveal degenerative changes in the intervertebral discs, facet hypertrophy, spinal stenosis, disc herniation.
When computed tomography study is conducted with the help of X-rays, and the information data are processed by a computer.The images are presented in a series of cuts, as well as MRI.This study is to identify the optimal conditions such as hypertrophy of the facet joints, bone spurs, degenerative bone changes.To facilitate the visualization of soft tissue Computed tomography is often combined with a myelogram.
Treatment of spinal stenosis
Treatment of spinal stenosis can be conservative and surgical.
Conservative treatment of spinal canal stenosis
Conservative treatment includes the appointment of antalgic, cardiovascular, anti-inflammatory drugs.In patients with moderate symptoms of spinal stenosis effective conservative treatment, which includes medication, physical therapy, massage, and epidural steroid injection.The latter method is the introduction of solutions of glucocorticoid hormones (kenalog, diprospan) in the epidural space in the spinal canal stenosis.The effect of glucocorticoids is based on reducing pain by reducing inflammation and local edema in the area of compression of neural structures.Glucocorticoid hormones often used in combination with local anesthetics are rapidly relieve pain, but are sufficiently short.Conversely, the effect of glucocorticoid hormones develops slowly enough, and the duration of action is 2-4 weeks.Epidural steroid injection is effective in only 50% of patients.At the same time, this method of treatment complications can occur, so it is used only after failure of other methods of conservative therapy.
Conservative treatment of spinal canal stenosis is not sufficiently effective in the treatment of spinal canal stenosis, since it leads to an improvement in well-being only 32-45% of patients.
Surgical treatment of spinal canal stenosis
Surgical treatment of spinal stenosis has a number of features.
Firstly, there are several types of operations used in the stenosis.