OsteochondrosisOsteochondrosisis a polyfactorial disease that is a polyfactorial disease that

developsdevelopsIn case of two conditions:In case of two conditions: Decompensation of trophic Decompensation of trophic

systemssystems Local excessive load on spinal Local excessive load on spinal

segmentssegments

Pathogenesis of Pathogenesis of osteochondrosisosteochondrosis

The first stage. The first stage. There are There are degenerative changes of pulp nuclei degenerative changes of pulp nuclei

The second stage. The second stage. There are There are degenerative changes in fibrous ring, degenerative changes in fibrous ring, disc protrusion and disc herniadisc protrusion and disc hernia

The third stage.The third stage. There are changes There are changes of hyaline plates - subchondral of hyaline plates - subchondral sclerosissclerosis

X –ray signs of X –ray signs of osteochondrosisosteochondrosis

Low height of between vertebral discsLow height of between vertebral discs Sclerosis of final platesSclerosis of final plates Osteophytes on the edges of vertebras’ Osteophytes on the edges of vertebras’

bodies. They are located perpendicularly to bodies. They are located perpendicularly to the spinal axisthe spinal axis

Local scoliosisLocal scoliosis Spondilolisthesis – dislocation of Spondilolisthesis – dislocation of

neighbouring vertebras’ bodiesneighbouring vertebras’ bodies Local cyphosis (instead of lordosisLocal cyphosis (instead of lordosis))

Vertebral disc’s herniaVertebral disc’s herniaMain positions are:Main positions are: Medial (clinical features of horse tail lesion)Medial (clinical features of horse tail lesion) Paramedial (a little bit out side the medial Paramedial (a little bit out side the medial

position – several radixes are compressed)position – several radixes are compressed) Posterior – medial (much more out side the Posterior – medial (much more out side the

medial position – 1 or 2 radixes are medial position – 1 or 2 radixes are compressed)compressed)

Foraminal - (– 1 radix is compressed)Foraminal - (– 1 radix is compressed)

Pathogenesis of neurological Pathogenesis of neurological signssigns

Irritation of vessels and nerves with Irritation of vessels and nerves with vascular spasm. vascular spasm.

Compression of vascular – nervous Compression of vascular – nervous complex.complex.

Edema (perivascular edema and radicular Edema (perivascular edema and radicular edema)edema)

Reactive process of neibouring structures Reactive process of neibouring structures (straining of muscles)(straining of muscles)

Autoimmune reactions (a part of disc Autoimmune reactions (a part of disc becomes antigenbecomes antigen))

Compressive syndromeCompressive syndrome occurs at occurs at compression and deformation of compression and deformation of radix, vessels and spinal cord.radix, vessels and spinal cord.

Reflex syndromeReflex syndrome occurs at occurs at irritation of different receptors irritation of different receptors (such as Lushka nerve).(such as Lushka nerve).

ClassificationClassification..Reflex syndromesReflex syndromes

Lumbago (backache)Lumbago (backache) LumbalgiaLumbalgia Lumbar ischialgia (muscular – tonic, neuro- Lumbar ischialgia (muscular – tonic, neuro-

dystrophic, autonomic vascular)dystrophic, autonomic vascular)

Compressive radicular syndromes.Compressive radicular syndromes.Compressive vascular radicular – spinalCompressive vascular radicular – spinalsyndromes (radicular ischemia)syndromes (radicular ischemia) AcuteAcute

TransientTransient StrokesStrokes

Chronic ischemic myelopathyChronic ischemic myelopathy

Vertebrogenous syndromeVertebrogenous syndrome

Limitation of movements in lumbar – sacral Limitation of movements in lumbar – sacral part of spinal cord (bending forward, part of spinal cord (bending forward, backward) backward)

Increasing of pain while movements, coughing Increasing of pain while movements, coughing and laughingand laughing

Protective straining of long back musclesProtective straining of long back muscles Extension of lumbar lordosis, cyphosis in Extension of lumbar lordosis, cyphosis in

lumbar – sacral divisionlumbar – sacral division Scoliosis, sometimes with rotationScoliosis, sometimes with rotation Painful paravertebral points and vertebral Painful paravertebral points and vertebral

processes processes

Vertebrogenous Vertebrogenous syndromesyndrome

Discharge – postures and symptomsDischarge – postures and symptomsKnee – elbow positionKnee – elbow positionWhile standing the patient keeps his While standing the patient keeps his

leg aside in order to make the load leg aside in order to make the load less on his legless on his leg

While lying in the bed he bends his leg While lying in the bed he bends his leg in all joints.in all joints.

The symptoms of spinal cord instability The symptoms of spinal cord instability (it is difficult for the patient to stand, to (it is difficult for the patient to stand, to wash himself, but it is much more easier wash himself, but it is much more easier to walk)to walk)

Reflex syndromesReflex syndromes on lumbar – sacral level are divided on lumbar – sacral level are divided

into:into:1. Lumbago 1. Lumbago 2. Lumbalgia2. Lumbalgia3. Lumbar ischialgia3. Lumbar ischialgia- muscular – tonicmuscular – tonic vascularvascular neuro- dystrophicneuro- dystrophic

The points of pain:The points of pain:Pain along the crista iliaca Pain along the crista iliaca The point of iliosacral jointThe point of iliosacral jointThe point of m. gluteus minimus (just The point of m. gluteus minimus (just

under the crista iliaca)under the crista iliaca)The point of m. gluteus medius (1 sm The point of m. gluteus medius (1 sm

lower)lower)The point under the backside foldThe point under the backside foldTrochanter os iliacaTrochanter os iliacaAlong the ischiadic nerve (the posterior Along the ischiadic nerve (the posterior

surface of hip and fossa subpoplitea)surface of hip and fossa subpoplitea)

The symptoms of strainThe symptoms of strain Lasegue’s symptom – in case of straining Lasegue’s symptom – in case of straining

and lifting the leg the low back pain appearsand lifting the leg the low back pain appearsNeri symptom – there is pain in leg at Neri symptom – there is pain in leg at

bending head forwardbending head forwardMatskevych symptom – there is pain in the Matskevych symptom – there is pain in the

anterior surface of the leg at knee bending anterior surface of the leg at knee bending while lying on abdomen while lying on abdomen

Wasserman symptom – the same clinical Wasserman symptom – the same clinical picture at lifting the legpicture at lifting the leg

The symptoms of strainThe symptoms of strainSequar symptom – there is pain on Sequar symptom – there is pain on

posterior surface of leg at foot flexingposterior surface of leg at foot flexingTurin symptom – the same clinical Turin symptom – the same clinical

picture at toe’s flexingpicture at toe’s flexingBechterev’s symptom – there is pain Bechterev’s symptom – there is pain

at knee – flexed leg extensionat knee – flexed leg extensionDejerine’s symptom - there is pain in Dejerine’s symptom - there is pain in

posterior surface of the leg at posterior surface of the leg at coughing, sneezingcoughing, sneezing

Piriformis syndromePiriformis syndrome

Clinical features: Clinical features: Painful palpation of Trochanter majorPainful palpation of Trochanter majorPainful m.PiriformisPainful m.PiriformisSymptom of Soobrase (painful cross-Symptom of Soobrase (painful cross-

legged position)legged position)Symptom of Bone – Bobrovnikova Symptom of Bone – Bobrovnikova

(painful abduction of leg)(painful abduction of leg)

Piriformis syndromePiriformis syndromePopelyansky intermittent claudication Popelyansky intermittent claudication

(while walking the patient is forced to (while walking the patient is forced to sit down because of the pain. That is sit down because of the pain. That is the result of spasm of the vessels. the result of spasm of the vessels.

Sphincter disorders (pause before the Sphincter disorders (pause before the urination) urination)

Signs of n. ischiadicus lesion (muscles Signs of n. ischiadicus lesion (muscles hypotrophy, low Achille reflex, hypotrophy, low Achille reflex, hyposthesia, pain)hyposthesia, pain)

Neurodystrophic form of lumbar Neurodystrophic form of lumbar ischialgiaischialgia

Sacroiliac periartrosis - pain and Sacroiliac periartrosis - pain and limitation of movements in hip joint. limitation of movements in hip joint. The patients cannot run and so on.The patients cannot run and so on.

Knee joint periartrosis– sudden pain in Knee joint periartrosis– sudden pain in knee jointknee joint

Coccygodynia Coccygodynia Neurodystrophic changes of Achille Neurodystrophic changes of Achille

tendon (it is very rare)tendon (it is very rare)

RRadiculopathyadiculopathy Radix L5 ( Disc L4 – L5)Radix L5 ( Disc L4 – L5)

Pain in the external edge of hip, on the Pain in the external edge of hip, on the anterior –external surface of crus until the anterior –external surface of crus until the internal surface of foot and great toe.internal surface of foot and great toe.

Sensory disorders (hypalgesia, analgesia) in Sensory disorders (hypalgesia, analgesia) in the same zonesthe same zones

Paresis of great toe extensors and foot Paresis of great toe extensors and foot extensorsextensors

Hypotonia and hypotrophy on the anterior Hypotonia and hypotrophy on the anterior surface of crussurface of crus

The patient cannot stand on heelsThe patient cannot stand on heels

RRadiculopathyadiculopathyRadix S1 (Disc L5 – S1)Radix S1 (Disc L5 – S1) Pain in external – posterior surface of Pain in external – posterior surface of

hip, crus, foot, the IV –th and Vth toes.hip, crus, foot, the IV –th and Vth toes. Sensory disorders (hypalgesia, Sensory disorders (hypalgesia,

analgesia) in the same zonesanalgesia) in the same zones Paresis of toes flexorsParesis of toes flexors Absent or low Achille reflex Absent or low Achille reflex

RRadiculopathyadiculopathyRadix L4 (Disc L3 – L4)Radix L4 (Disc L3 – L4) Pain in anterior – internal surface of hipPain in anterior – internal surface of hip Sensory disorders (hypalgesia, analgesia) Sensory disorders (hypalgesia, analgesia)

in the same zones prevail over motor onesin the same zones prevail over motor ones Weakness of m. Quadriceps femorisWeakness of m. Quadriceps femoris Hypotrophy of m. Quadriceps femorisHypotrophy of m. Quadriceps femoris Knee reflex is low or sometimes increasedKnee reflex is low or sometimes increased

RRadiculopathyadiculopathyRadix L2 – L3 Radix L2 – L3 Clinical features include pain and sensory Clinical features include pain and sensory

disorders on anterior – medial surface of hip. disorders on anterior – medial surface of hip. Symptoms of Matskevych, WassermanSymptoms of Matskevych, Wasserman Low knee reflexLow knee reflex Weakness of m. Quadriceps femorisWeakness of m. Quadriceps femoris CruralgiaCruralgia Symptoms of lesion of horse tailSymptoms of lesion of horse tail Irradiation of pain into lower part of Irradiation of pain into lower part of

abdomen, genital organsabdomen, genital organs

compression of horse compression of horse tailtail

It is created by radix L2 – S5. It is It is created by radix L2 – S5. It is observed at hernia of discs L4 – L5.observed at hernia of discs L4 – L5.

Clinical features:Clinical features:Significant pain in legsSignificant pain in legsSensory and motor disorders in certain Sensory and motor disorders in certain

zones of innervation zones of innervation Pelvic disorders (incontinence of urine Pelvic disorders (incontinence of urine

and feces)and feces)

Classification on cervical levelClassification on cervical level Reflex symptoms.Reflex symptoms.

Stiff neckStiff neckCervicalgiaCervicalgiaCervical cranialgiaCervical cranialgiaCevical brachialgiaCevical brachialgia

Muscle – tonic syndromeMuscle – tonic syndromeAutonomic – vascular syndromeAutonomic – vascular syndromeNeurodystrophicNeurodystrophic

Compressive radicular syndromeCompressive radicular syndrome

Classification on cervical Classification on cervical levellevel

Compressive – spinal syndromeCompressive – spinal syndrome Compressive vascular radicular – spinal Compressive vascular radicular – spinal

syndromesyndrome AcuteAcute

TransientTransientStrokes Strokes

Chronic ischemic myelopathyChronic ischemic myelopathy A. vertebralis syndrome (radiculopathy of A. vertebralis syndrome (radiculopathy of

C8 radix, disc C7 – C8C8 radix, disc C7 – C8))

Cervical cranialgiaCervical cranialgiaClinical features of posterior cervical Clinical features of posterior cervical

sympathetic syndrome:sympathetic syndrome:Cranialgia – occipital pain with irradiation in Cranialgia – occipital pain with irradiation in

temporal, parietal parts.temporal, parietal parts.Vestibulo – cochlear disturbances – Vestibulo – cochlear disturbances –

dizziness, vomitingdizziness, vomitingEyes symptoms – eyes pain, tears. Eyes symptoms – eyes pain, tears. Autonomic upper quadrant syndrome – Autonomic upper quadrant syndrome –

asymmetry of blood pressure, temperature, asymmetry of blood pressure, temperature, pulse, sensation, cardiac pain and so on. pulse, sensation, cardiac pain and so on.

Cervical brachialgiaCervical brachialgia

Muscle – tonic formMuscle – tonic formNeurodystrophic formNeurodystrophic formAutonomic – vascular oneAutonomic – vascular one

Muscle – tonic formMuscle – tonic form

Muscle – tonic form - Scalenus – Muscle – tonic form - Scalenus – syndrome. syndrome. Clinical features:Clinical features:There are pains above and under There are pains above and under clavicle at the muscle strainingclavicle at the muscle strainingThere are pains at head movements There are pains at head movements with irradiation in the armwith irradiation in the armEdema in above clavicle regionEdema in above clavicle region

Cervical brachialgiaCervical brachialgia

Neurodystrophic form Neurodystrophic form Shoulder – scapula periartrosis Shoulder – scapula periartrosis Shoulder – hand syndromeShoulder – hand syndromeEpicondilosisEpicondilosis

Cervical brachialgiaCervical brachialgia

Shoulder – scapula periartrosis Clinical Shoulder – scapula periartrosis Clinical features:features:

Pain and limitation of movements in shoulderPain and limitation of movements in shoulder Painful palpation of caput os humeriPainful palpation of caput os humeri Limitation of arm movements (the patient Limitation of arm movements (the patient

cannot comb his hair)cannot comb his hair) The symptom of frozen shoulderThe symptom of frozen shoulder M. deltoideus, m. supraspinatus atrophyM. deltoideus, m. supraspinatus atrophy

Shoulder – hand syndromeShoulder – hand syndrome

This syndrome includes clinical This syndrome includes clinical features of shoulder – scapula features of shoulder – scapula periartrosis and autonomic – periartrosis and autonomic – trophic changes of hand.trophic changes of hand.

Clinical features of algic stage:Clinical features of algic stage:Severe hand painSevere hand painEdema, hyperemia and cyanosisEdema, hyperemia and cyanosis

Shoulder – hand syndromeShoulder – hand syndrome

HyperesthesiaHyperesthesiaDecreased muscle strength and Decreased muscle strength and

limitation of movementslimitation of movements

Clinical features of dystrophic stage:Clinical features of dystrophic stage:Muscle atrophyMuscle atrophyOsteoporosis on X – rays examinationsOsteoporosis on X – rays examinations

Compressive radicular Compressive radicular syndromessyndromes

Radiculopathy C6 radix (C5 – C6 Radiculopathy C6 radix (C5 – C6 discs)discs)

Pain, parasthesia and hypalgesia Pain, parasthesia and hypalgesia on anterior external surface of on anterior external surface of armarm

Weakness, hypotrophy of m. Weakness, hypotrophy of m. biceps brachiibiceps brachii

Absent or low flex elbow reflexAbsent or low flex elbow reflex

Compressive radicular Compressive radicular syndromessyndromes

Radiculopathy C7 radix (C6 – C7 Radiculopathy C7 radix (C6 – C7 discs)discs)

Pain, parasthesia and Pain, parasthesia and hypalgesia hypalgesia

Weakness, hypotrophy of m. Weakness, hypotrophy of m. triceps brachiitriceps brachii

Low extensor elbow reflexLow extensor elbow reflex

Compressive radicular Compressive radicular syndromessyndromes

Radiculopathy C8 radix (C7 – C8 Radiculopathy C8 radix (C7 – C8 discs)discs)

Pain, parasthesia and hypalgesiaPain, parasthesia and hypalgesiaLow extensor elbow and carpo – Low extensor elbow and carpo –

radial reflexradial reflex

Additional methods of Additional methods of diagnosticsdiagnostics

Spinal X – ray – Spinal X – ray – examinationexamination

CT of spinal cordCT of spinal cord

TreatmentTreatment Orthopedic Orthopedic Medicines:Medicines:

In edema: Euphyllinum 2.4% 10.0; Lasix 2.0; In edema: Euphyllinum 2.4% 10.0; Lasix 2.0; Dexamethasonum 4 – 8 mg; NaCl 0.9% 200.0 i/v by dropsDexamethasonum 4 – 8 mg; NaCl 0.9% 200.0 i/v by drops

Platiphillinum, No – spa, BaralginumPlatiphillinum, No – spa, Baralginum Analgesics - Reopirini, Voltareni 2.5% 3.0; Tramadol, Analgesics - Reopirini, Voltareni 2.5% 3.0; Tramadol,

AminasiniAminasini Non steroids medicines– Ketanov, Dicloberl, Movalis, Non steroids medicines– Ketanov, Dicloberl, Movalis,

Ranselex, CelecoxibRanselex, Celecoxib Myorelaxants – Midocalm, BaclofenMyorelaxants – Midocalm, Baclofen Chondro- protectors – RumalonChondro- protectors – Rumalon Vitamins and biostimulatorsVitamins and biostimulators Physical methodsPhysical methods

TreatmentTreatmentSurgical methodsSurgical methods (Horse tail (Horse tail

compression, Long lasting (3 – 6 compression, Long lasting (3 – 6 months) pains, Huge hernia (over 15 months) pains, Huge hernia (over 15 mm), Acute compression of radicular mm), Acute compression of radicular – spinal artery)– spinal artery)

SanatoriumSanatorium

PreventionPrevention

Hypokinesia preventionHypokinesia preventionModerate physical activityModerate physical activityTreatment of chronic Treatment of chronic

diseasesdiseases