Orthopedics - Oleksa A.P. 2006

Spinal conditions causing pain
Spinal stenosis

The spinal canal is formed by anatomical structures that protect the Spinal Cord and its elements. Its cross-sectional diameter and shape vary across different sections of THE Vertebral Column and differ individually from person to person.

According to O.O. Korzh, A.I. Prodan, and H.H. Hruntovskyi (1986), who measured the diameter of the lumbar spinal canal in patients with various spinal pathologies, the sagittal diameter of the canal is of primary importance. For instance, in lumbar osteochondrosis and lateral displacement of a damaged disc fragment, the canal diameter in most patients was 13-14 mm or greater, whereas posterior disc displacement narrowed the canal to 12 mm or less.

Morris (Morris J.M., 1990) points out that congenital narrowing of the spinal canal can occur, and its normal shape is typically rounded, and sometimes nearly triangular.

Secondary narrowing of the spinal canal is most commonly caused by posterior displacement of a damaged intervertebral disc fragment, spondylolisthesis and spinal instability, spondyloarthritis, Bechterew's disease (Ankylosing spondylitis), and osteophytes. These pathological factors can lead to the compression of the neurovascular structures of the spine, manifesting as spinal stenosis syndrome.

However, as Morris notes, certain narrowings of the triangular canal do not always compress the cauda equina, because the nerve roots are located in the lateral recesses of the canal. For a long time, such narrowing may remain clinically asymptomatic.

Spinal stenosis is typically characterized by bilateral or unilateral pain in the lower back and buttock regions during walking, rotational Movements of the spine, or even in a standing position. This discomfort arises when the patient remains standing for a prolonged period (even without walking).

O.O. Korzh and co-authors point out that in 75% of patients, this syndrome, In addition to neurogenic manifestations, causes intermittent claudication. As a rule, this occurs in patients over 45 years of age with signs of venous insufficiency in the INFERIOR VENA CAVA system (VARICOSE Veins OF the lower extremities, post-thrombotic syndrome, hemorrhoids). They explain the onset of claudication by impaired venous outflow from the internal vertebral venous plexuses, which serve as a cavo-caval anastomosis. The authors confirmed this by a sharp decrease in the optical density of epidurograms performed immediately after contrast administration and 15 minutes later. According to densitometry, in the control group, the optical density of epidurograms decreases by 70-80%, whereas in patients with neurogenic intermittent claudication, The rate of contrast resorption is markedly delayed—by only 10-30% 15 minutes after administration. A significantly elevated pressure in the iliolumbar vein was also detected, which hinders Blood outflow from the internal plexuses and radicular veins, causes their edema, and impairs nerve conduction.

The Diagnosis of spinal stenosis is based on the patient's history and complementary examinations.

A middle-aged patient experiences pain after 15–20 minutes of walking. The pain is dull and aching in one or both lower extremities, compelling the patient to sit down. The same occurs during prolonged standing. The patient finds relief in a sitting position and can resume standing or walking after just 5 minutes. Significant relief is achieved by lying supine with the hips and knees elevated and flexed.

Radiological examinations may reveal a narrower-than-normal spinal canal, marginal osteophytes on the vertebral bodies, and degenerative Changes in the intervertebral joints. Contrast examinations demonstrate canal block (Fig. 295) and impaired CEREBROSPINAL FLUID Circulation. Radiculography provides a more precise indication of spinal canal narrowing.

Computed tomography makes it possible to visualize cross-sections of the affected spinal segment, the walls and narrowing of the canal, as well as the underlying causes (bone spurs, displaced disc, ligamentous hypertrophy and ossification, etc.) (Naylor A., 1979) (Fig. 296).

Magnetic Resonance imaging detects not only osseous and cartilaginous changes but also soft tissue abnormalities, which significantly facilitates diagnosis.

Spinal stenosis must be differentiated from lower extremity vascular pathology, which is frequently a cause of pain and intermittent claudication. For this purpose, oscillography, angiography, and other studies are performed. Vascular pathology does not cause pain in the standing position, whereas spinal canal narrowing presents without signs of vascular disease.

Treatment. To alleviate the patient's condition, cycling can be recommended as an alternative to prolonged walking. Furthermore, the patient should avoid prolonged standing and sudden rotational movements of the torso. Once the exact cause of spinal stenosis has been established, surgical intervention is indicated to relieve compression (remove osteophytes or a posteriorly displaced intervertebral disc, enlarge the lateral recesses at the site of stenosis, etc.).

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Fig. 295. Contrast myelogram in a narrowed spinal canal.

Fig. 296. Tomogram of a narrowed spinal canal caused by a displaced ossified intervertebral disc of the C₅-C₆ vertebral bodies.

Decompression is a necessary and effective surgical Procedure. Sometimes it is necessary to operate on multiple spinal segments, depending on the extent of the spinal lesions identified through radiography and tomography.