The clinical picture in lumbar osteochondrosis consists of vertebral symptoms (changes in the statics and dynamics of the lumbar spine) and symptoms of impaired function of the neurological structures that make up the spinal roots (motor, sensory, vegetative-trophic fibers) and adjacent formations (arteries, veins, etc.). P.). The main complaint is pain.
By the nature of the pain, several of its variants are distinguished:
Local pain in the lumbar region and sacrum (lumbago, lumbalgia);
Dull, aching pain in the lumbar region and deep tissues in the area of the hip, knee and ankle joints – sclerotomic pain (“vegetative”);
Sharp, shooting pain from the lower back to the gluteal region and along the leg to the fingers (along the affected root) – radicular pain.
A pronounced soreness also occurs in the foci of myoosteofibrosis, which are localized mainly in the places of attachment of muscles and ligaments to bone structures.
In order to identify the topics of the lesion and differential diagnosis with other diseases of the musculoskeletal system, it examines the state of muscles and the symptoms of tension of the spinal roots.
During a neurological examination, the condition of the muscles, back and lower extremities (tone, trophism, strength), as well as sensitivity, trophism of the skin, deep reflexes and coordination of movements are assessed in detail. The statics and dynamics of all parts of the spine are studied in detail. Almost all of these indicators need to be quantified (by degrees) for more accurate dynamics under the influence of treatment.
The tone and trophism of the long back muscles vary in all patients. The following degrees of increase in muscle tone are distinguished: I – a slight increase in which the fingers of the doctor’s hands are freely immersed in the muscles; II – the immersion of fingers in the muscle requires a certain effort; III – dense (“stony”) muscle consistency.
Muscle hypotension is determined at the level of the back and lower extremities. It is also characterized by three degrees: I degree – inconstant decline; II degree – a constant decrease; III degree – a sharp decrease in turgor or a complete lack of tensile resistance.
The overwhelming majority of the patients studied by us had irritative-reflex variants of neurological manifestations of lumbar osteochondrosis (the so-called non-radix reflex syndromes).
The characteristics of individual variants of neurological syndromes of lumbar osteochondrosis are given below.
Lumbago and lumbalgia are acute pain in the lumbar spine. The disease develops suddenly, after an awkward movement or when lifting weights (especially if they are combined with hypothermia). Stiffness arises, to which the pain of a bursting, burning, compressive character joins. Any movement, even conversation, reinforce it. At first, the pain radiates widely, spreading to the area of the chest, gluteal region and even the abdomen. Patients are in a forced position. After just a few hours or days, the pain decreases. New relapses of the disease also arise under the influence of certain adverse factors.
The number of exacerbations ranges from 2 to 10 or more. In the intervals between exacerbations, patients feel a severity and a state of discomfort in the lumbar region. After 3-5 years, in almost all patients, lumbalgia syndrome is replaced by lumbar ischalgic or radicular.
Lumbar ischalgic syndrome is observed in more than half of people with heavy physical labor. The duration of the disease (with periods of exacerbations and remissions) ranges from several months to many years.
We diagnosed muscular-tonic (neuromuscular) forms of lumbar ischialgia in 62.3%. The onset of diseases is preceded by a sharp increase in weights, prolonged physical activity, tonic muscle tension, combined loads.
Pain is characterized by lumbar pain spreading to one or both lower limbs.
Different localization of pain in muscle-tonic syndromes is often associated with features of the secondary lesion of nerve trunks at the level of spasmodic muscles. In these areas, nerves are affected by the compression-ischemic type (tunnel syndromes). Most often among our patients were piriform, gluteal and calf syndromes.
Muscular-tonic reflex disorders are a frequent companion of lumbar osteochondrosis. Among such disorders, piriformis syndrome is distinguished,
as one of the most famous, as well as some others, described by the name of the predominantly affected muscle.
The gastrocnemius muscle syndrome is characterized by pain in the calf muscles when walking. Often there are fast and sharp painful tonic cramps in the calf muscles. Their basis, apparently, is the excitation of spinal reflex structures.
Gluteal muscle syndrome is characterized by persistent pain in the lumbosacral region, in the buttocks and on the back surface of the sore leg. They are amplified most often in the position of prolonged sitting, with hypothermia. Significant muscle tension is detected by palpation.
In conclusion, it should be noted that an important diagnostic technique for muscle forms of lumbar ischialgia is the identification of foci of myoosteofibrosis, which are trigger zones of pain – trigger zones. Exposure to them is one of the methods of manual or reflex therapy of lumbar osteochondrosis. An increase in muscle tone often leads to tunnel syndrome with compression and hypoxia of the sciatic nerve or its branches. And in this case, the treatment should also be, first of all, pathogenetic.
The neurodystrophic form of lumboalialgia is formed on the basis of the muscular-tonic syndrome, being its continuation, because along with the foci of neuromyofibrosis, zones of neuroosteofibrosis with an uneven tuberous structure arise. Among patients with this form, sacroiliac periarthrosis or hip periarthrosis and periarthrosis of the knee joint are detected.
Sacroiliac periarthrosis is manifested by the restriction and soreness of movements in the hip joint. Patients complain of increased fatigue in the legs, inability to run fast, climb stairs, spread legs. A sharp pain occurs during palpation under the pupartic ligament and when striking along the greater trochanter.
Periarthrosis of the knee joint at first is characterized only by pain in the lumbar spine (sometimes within 2-3 months), after which the pain gradually moves to the popliteal fossa and to the knee joint. Pain is accompanied by a feeling of constriction in adjacent muscle groups. Often the most painful is the internal epicondyle. All patients are characterized by deep and often nocturnal pain. The main difference from primary gonitis is the absence of pain during palpation of the knee joint,
with pronounced spontaneous pain.
In addition, some patients have coccygodynia – dull, dull, aching, boring pains in the coccyx, making it difficult to sit and walk. Pain often radiates to the gluteal region, external genitalia, anus. Objectively, in the area of the coccyx is determined by sharp pain on palpation and hyperesthesia, in some patients – trophic disorders in the sacrum.
In 1.7% of patients, neurodystrophic changes in the Achilles tendon are detected. 3.5% have a combination of the above manifestations of neurodystrophic syndrome.
The neurovascular form of lumbar ischialga is found in 36.9% of patients in the form of three options: vasospastic, vasodilator and mixed.
It should be borne in mind that in the origin of a number of reflex syndromes, long courses of intramuscular injections are important for the fight against pain syndrome. The foci of myopathy, myosteofibrosis, tension of the upper, middle and lower gluteal muscles due to them, in turn, lead to the defeat of the branches of the sciatic nerve by the mechanism of the tunnel syndrome. This expands the pain zone and creates a vicious circle. Thus, the main clinical feature of the lumbar ischialgic syndrome is the defeat of individual muscle groups (buttock, calf, etc.) or their combination, without clear symptoms of loss of functions of the spinal roots.
Radicular syndromes are detected in 37.4% of patients. Their diagnosis is based on data on the localization of pain and sensitivity disorders, assessment of the muscle strength of certain myotomes, the state of deep segmental reflexes, and the results of additional electrophysiological and radiological research methods. L2 radicular lesion syndrome is rare and is characterized by pain and paresthesia along the anterior-medial thigh surface, a moderate decrease in the knee reflex, and positive symptoms of Matskevich and Wasserman.
L3 radicular lesion syndrome is manifested by pain and paresthesia along the anteromedial surface of the lower third of the thigh and knee area, positive symptoms of Matskevich and Wasserman, moderate hypotension and hypotrophy of the quadriceps femoris muscle without reducing its strength, and inhibition of the knee reflex. Vegetative-vascular disorders in the legs with a feeling of chilliness, cooling of the lower leg and feet are determined.
L4 root lesion syndrome consists of pain on the front-inner surface of the thigh and lower leg,
numbness on the front surface of the upper third of the lower leg, hypofromy of the muscles of the anterior thigh, and a decrease in the knee reflex. A feature of the defeat of the L4 root is a frequent combination with the pathology of other roots (L3, L5).
The syndrome of the affected root L5 develops with osteochondrosis of not only the LIV-LV disk, but also LIII-LIV. Pain and paresthesia are localized on the outer lateral surface of the thigh, lower leg and first two toes. The symptoms of Laseg, Turin, Sikar are positive. Mild hypotrophy is observed in the anterior muscle group of the leg. In 76.3% of cases, weakness of the long extensor of the big toe is revealed. Vegetative-vascular and trophic disorders in the form of cyanosis of limbs, cooling are observed in 1/3 of patients. In 64% of patients there is no reflex from the deep tendon of the long extensor of the big toe, as well as the weakness of this muscle.
Syndrome of the affected root S1: pain on the back surface of the leg with radiation to the heel and on the outer edge of the foot to the V-IV fingers, numbness in this zone; positive symptom of Laseg, Ankylosing spondylitis; hypotension and hypertrophy of the muscles of the posterior tibia, a decrease or loss of Achilles and plantar reflexes; moderate vegetative-vascular disorders on the lower leg and foot with a sensation of chilliness, cooling and changes in the rheographic curve of the spastic type, 82.7% of patients with S1 root lesion experience paresis of individual muscle groups of this myotome.
Often there are signs of a combined lesion of two or more spinal roots: L3-L4; L4-L5; L5-S1.
Thus, the observations of many authors show the existence of a large gamut of clinical options for neurological manifestations of lumbar osteochondrosis. In each of these patients, there are pronounced dysfunction of the spine -.. Changing its configuration to form a hyperlordosis, kyphosis, scoliosis, limited mobility, dystonia, muscle, etc. The clinical picture is often dominated by the vertebral symptoms that have to arrest the various healing methods, including manual therapy, balneophysiotherapy, acupuncture and medications. Therefore, it is necessary in each case to study in detail these vertebral symptoms, because their dynamics can be used to judge the effectiveness of treatment complexes.