Neurological symptoms at vertebral osteochondrosis

Neurological signs of lumbar and cervical osteochondrosis.

      Among all the spinal diseases associated with neurological signs the most common are degenerative – dystrophic processes such as osteochondrosis and spondiloarthrosis.

      Osteochondrosis (OC) is one of the most common diseases. About 80% of all people have attacks of low back or cervical pain during their life – time. It takes 68% of all temporary working disability ieurology.

      Spinal osteochondrosis is a degenerative lesion of cartilage – between vertebral disc associated with reactive changes ieighbouring vertebras, between vertebral joints and connecting apparatus.

Etiology of osteochondrosis

According to the main modern theory – osteochondrosis is a polyfactorial disease that develops in case of two conditions:

1.      Decompensation of trophic systems. It is associated with other diseases (those of gastro – intestinal tract, liver, pancreas, and enzyme – associated diseases). All of these diseases lead to the disorders of homeostasis

2.      Local excessive load on spinal segments. They can be explained by inborn peculiarities of spinal cord (sacralization, lumbalization, narrow spinal canal).

 

Pathogenesis of osteochondrosis

    Usually osteochondrosis is developed at the age of 30 – 50. The main pathological process begins in between vertebral discs. Disc consists of pulp nuclei, fibrous ring and hyaline plate. Disc is a natural amortisseur.

The first stage. Because of certain factors (such as dysmetabolism, arthritis and so on) degenerative changes of pulp nuclei develop. That means destruction of chondrocytes with releasing of hyaluronidaze, chondrocakhepsines, and papaini. That causes destruction and depolimerization of muckopolisacharide complex. As a result pulp nuclei looses its hydrophilous properties, becomes small and mobile.

The second stage. There are degenerative changes in fibrous ring. During the movements the main load is on the internal structures of fibrous ring. They broke and cause disc protrusion. The last can be developed later in disc hernia.

The third stage. There are changes of hyaline plates that are called subchondral sclerosis. In this stage reactive process is developed. Disc hernia is vasculated, fibroused and later osteophytes are growing along the bodies of vertebras. In case of spinal segments increased mobility the reactive changes ieighbouring bodies of vertebra and joints are developed. It is known as associated spondiloarthrosis.

X –ray signs of osteochondrosis

1.      Low height of between vertebral discs.

2.      Sclerosis of final plates.

3.      Osteophytes on the edges of vertebras’ bodies. They are located perpendicularly to the spinal axis.

4.      Local scoliosis.

5.      Spondilolisthesis – dislocation of neighbouring vertebras’ bodies.

6.      Local cyphosis  (instead of lordosis)

     At distorted spondilosis (as a result of degenerative – dystrophic changes in long spinal ligaments) there are osteophytes, which are located parallelly to the spinal axis along the spinal cord and there is no changes of vertebral discs height.

    

Between vertebral disc’s hernia can be located in different places according to the spinal canal. These 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 (near the foramina vertebral – 1 radix is compressed)

Pathogenesis of neurological signs 

1.      Irritation of vessels and nerves with vascular spasm

2.      Compression of vascular – nervous complex

3.      Edema (perivascular edema and radicular edema)

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

5.      Autoimmune reactions (a part of disc becomes antigen)

According to the nervous structures that are involved in case of disc’s hernia there are compressive and reflex syndromes.

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). That means reflex muscular – tonic disturbances, extension of muscles, and pain at palpation of muscles. That is usually the reason of local pain and pain in distance. Such zones of pain are called trigger zones. Pathogenetical process in these zones is known as neuroosteofibrosis, the painful nodes in muscles are called nodes of Kornelius, muscular hypertonus – hypertonus of Muller.

 

Neurological signs of osteochondrosis at lumbar – sacral level

 

Classification

I.      Reflex syndromes

·        Lumbago (backache)

·        Lumbalgia

·        Lumbar ischialgia (muscular – tonic, neuro – dystrophic,  autonomic vascular)

II.    Compressive radicular syndromes.

III.  Compressive vascular radicular – spinal syndromes (radicular ischemia)

1.      Acute

A.     Transient

B.     Strokes

2.      Chronic ischemic myelopathy

    

All the neurological signs of osteochondrosis have common symptoms  – the symptoms of vertebrogenous syndrome. 

Vertebrogenous syndrome points that the pathological process is associated with spinal cord.

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

·        Painful vertebral processes

·        Discharge – postures and symptoms

Ø      Knee – elbow position

Ø      While standing the patient keeps his leg aside in order to make the load less on his leg

Ø      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).

I.      Reflex syndromes on lumbar – sacral level are divided into:

·        muscular – tonic

·        vascular

·        neuro- dystrophic

      Clinically all the reflex syndromes at lumbar – sacral level can be divided into:

1. Lumbago

2. Lumbalgia

3. Lumbar ischialgia

1.      Lumbago   It is acute, sudden, attack – like low back pain. It usually begins at lifting something heavy, catching cold or sometimes spontaneously. Pain is very severe and the patient stays in the same position for a long time. At first the pain cannot be localized. Later the patient can localize it and refers the pain to the low back region. It lasts for 1 – 3 up to 6 days.

2.      Lumbalgia The pain is not so severe. It has subacute or chronic character. It lasts for weeks or even months. The pain can be increased or decreased according to different factors.

3.      Lumbar ischalgia The source of pain impulse is receptor. The pain irradiate into hips, leg.

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)

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

·        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

Types of lumbar ischalgia

1.      Muscle – tonic

2.      Neurodystrophic

3.      Autonomic – vascular

 

1.      Muscle – tonic Clinical features are connected with secondary lesion of nerves according to the compressive – ischemic type, the type of tunnel syndrome as a result of muscles spasm and straining.

A. Piriformis syndrome M. Piriformis is located under m. gluteus maximus. It is attached to the internal edge of Trochanter Major and anterior surface of sacroiliac joint.

       Under the muscle sacroilial ligament is situated. Between the muscle and the ligament nervus ischiadicus and a. ischiadica are located. These structures can be irritated or compressed at long – lasted straining of m. Piriformis.

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)

·        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

Except the Popelyansky intermittent claudication there are also:

v     Myelogenic intermittent claudication 

v     Caudal intermittent claudication 

v     Intermittent claudication  at obliterated endarteriitis

• Insignificant sphincter disorders (pause before the urination) as a result of n. pudendus irritation

• Insignificant signs of n. ischiadicus lesion (muscles hypotrophy, low Achille reflex, hyposthesia, pain)

 

2. Neurodystrophic form of lumbar ischialgia is a sign of neuromyofibrosis.There are:

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

 

B. Knee joint periartrosis– sudden pain in knee joint

 

C. Popliteal syndrome It is the result of neuroosteofibrosis in popliteal fossa in the place of m. ischiocrural attachment.

Clinical features:

·        Pain in fossa poplitea while patient’s standing, palpation

·        Cramps – sudden painful tonic straining of m. Triceps surae

Pains in m. soleus

 

D. Coccygodynia Pain is in the coccyx’s region. The last is connected with sacrum via discs. Degenerative changes in disc; straining and painful pelvic muscles cause coccygodynia. Usually it is observed at pregnancy, after childbirth, at long sitting.

Clinical features:

1.      long lasting aching pains

2.      paresthesia in coccyx region, which is increased at sitting, defecation and decreased at standing

3.      that often leads to patients’ depression

 

E. Neurodystrophic changes of Achille tendon (it is very rare)

The peculiarity of neurodystrophic changes is:

·        One side lesion on the side of lumbar ischialgia

·        The lesion of large joints

·        Connection of exacerbation with low back pain

 

3. Autonomic – vascular form of lumbar ischialgia

·        Vasospastic

·        Vasoparetic

·        Mixed

Clinical features: It appears on background of low back pain, freezing and cyanosis, hyperhydrosis, insignificant autonomic – trophic changes of lower extremities (hyperkeratosis, dryness of skin, edema).

II. Compressive radicular syndromes ( radiculopathy)

Hernia of intervertebral discs in lumbar region causes compression of L5 – S1 radixes, sometimes L3 – L4. In compressed radixes there are edema, venous stasis, aseptic inflammation. Clinical features of radiculopathy consist of clinical features of lumbar ischialgia and symptoms of radix’s loss of functions.

 

Clinical features of radiculopathy.

1.      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

2.      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

 

3.      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

4.      Radix L2 – L3

    Compression of these radices is very rare. 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

Syndrome of 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)

 

III. Compressive vascular radicular – spinal syndromes on lumbar level

There are:

1.      Acute vascular – radicular syndromes (transient, strokes)

2.      Chronic (chronic myelopathy)

 

Acute These ones are observed at disc’s hernia, narrow spinal canal, as a result of spondilolisthesis.

Transient

1.      Myelogenic Popelyansky intermittent claudication (transient ischemia of conus and epiconus)

Clinical features:

·        Weakness in legs without pain during long lasting walking

·        Paresthesia

·        Micturition

 

2.      Caudal intermittent claudication of Verbista (transient ischemia of horse tail radices)

Clinical features:

·        Pain in feet, cruses, anal region

·        Weakness in feet

·        Retention of urine

Symptoms last for about 5 – 7 minutes

 

Strokes

They are developed rapidly after long lasting lumbalgia or lumbar ischialgia. There are such forms as:

A. Paralysis ischias (at radix spinal artery L5 – S1 compression)

Clinical features:

·        Foot weakness without sensory disorders

·        Absence of Achille and sole reflex

B. Syndromes of cone ischemia (S3 – S5)

·        Anesthesia of ano-genital zone

·        Pelvic disorders (retention of urine)

C. Syndromes of epicone ischemia (L4 – S2)

·        Flaccid feet paralysis

·        Absence of Achille reflexes

·        Sensory disorders in zones L4 – S2

D. Syndromes of cone and epicone ischemia

·        Paresis and paralysis of lower extremities, much more expressed in distal parts

·        Sensory disorders in zones L4 – S5

·        Pelvic disorders

E. Syndrome of a. Adamkevych

·        Central or peripheral paralysis (paresis) of lower extremities

·        Conductive sensory disorders from umbilicus and downwards

·        Pelvic disorders according to the central type

·        Bed –sores

 

Chronic compressive vascular syndromes – dyscirculative myelopathy.

    It occurs at graduate compression of spinal vessels, hypertrophy of ligamentum flavum.

Lumbar compressive spinal syndromes are very rare. Compressive myelopathy occurs at discs hernia. There are such syndromes:

 

A. Epicone syndrome (It occurs at protrusion of Th10 – L1 discs with lesion of L4 – L5 – S1 – S2 segments).

Clinical features:

·        Low back pain with irradiation in posterior surface of leg

·        Feet paresis

·        Hypotonic and hypotrophic crus’ muscles

·        Absence of Achille and sole reflexes

B. Cone syndrome It occurs at protrusion of L1 – L2 discs with lesion of S3 – S5 segments.

Clinical features:

·        Perineum anesthesia

·        True urine, feces incontinence and sometimes its retention

·        Bed – sores. These signs are dominant

 

Neurological signs of osteochondrosis at cervical level

Anatomical peculiarities of cervical part of the spinal cord

A. C1 and C2 vertebras are joined without between vertebral discs. Rotation is dominating movement in these vertebras.

B.  The body of C3 and the rest cervical vertebras aren’t separated by the disc completely. Disc is only in anterior and posterior part. There are also hook – like processes. Before them artery is located, after them nerve is situated.

C.  Transversal processes of cervical vertebras have transversal holes. These holes are used by vertebral artery to come through.

D.   If there are some changes in between vertebral discs, the main pressure is on hook –like processes, the artery and nerve.

Classification of neurological signs of osteochondrosis on cervical level

1.      Reflex symptoms.

·        Stiff neck

·        Cervicalgia

·        Cervical cranialgia

·        Cevical brachialgia

v     Muscle – tonic syndrome

v     Autonomic – vascular syndrome

v     Neurodystrophic

2.      Compressive radicular syndrome

3.      Compressive – spinal syndrome

4.      Compressive vascular radicular – spinal syndrome

·        Acute

v     Transient

v     Strokes

·        Chronic ischemic myelopathy

5.      A. vertebralis syndrome (radiculopathy of C8 radix, disc C7 – C8)

1.      Reflex syndromes

Stiff neck It is sudden acute pain ieck that lasts from several days up to 1 – 2 weeks.

Cervicalgia It is severe dull pain in cervical part of the spinal cord. Usually it appears in the morning, while coughing. There are signs of vertebrogenous syndrome in cervical level  – limitation of movements in cervical part of the spinal cord, painful paravertebral points and vertebral processes. There are positive symptoms of muscles straining.

 

Cervical cranialgia.

It is the result of:

1.      Irritation of a. vertebralis sympathetic plexus – posterior cervical sympathetic syndrome.

2.      Irritation of cervical muscles, fibrous tissues receptors.

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

 

      Cervical brachialgia.

1.      Muscle – tonic form

2.      Neurodystrophic form

3.      Autonomic – vascular one

 

1.      Muscle – tonic form It can manifest as:

Scalenus – syndrome It is connected with straining of m. scalenus. The muscle starts from transversal processes C3 – C4 and it is attached to the first rib. There are subclavian artery, vein and lower truncus of brachial plexus between the muscle and the rib.

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

·        Positive Adson test – during the arm adduction there is pain over a. subclavia and slow pulsation in a. radialis

·        Weakness of hand

·        Tenar hypotrophy

·        Hypalgesia of the hand ulnar surface

·        Hand edema

·        Paleness of the hand

 

M. pectoralis minor syndrome At this muscle straining the distal part of vascular – nervous trunk is pressed.

Clinical features:

·        Pain in anterior thoracic part and in ulnar surface of hand

·        Hand weakness

·        IV – th – V – th fingers parasthesia

 

2. Neurodystrophic form of cervical brachialgia

·        Shoulder – scapula periartrosis

·        Shoulder – hand syndrome

·        Epicondilosis

 

Shoulder – scapula periartrosis is the result of muscle – tonic and neurodystrophic tissue disorders.

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 and infraspinatus atrophy

    There are two stages of this syndrome – algic and dystrophic. In the dystrophic stage not only active movements are limited but the passive ones also.

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

·        Hyperesthesia

·        Decreased muscle strength and limitation of movements

Clinical features of dystrophic stage:

·        Muscle atrophy

·        Osteoporosis on X – rays examinations

Shoulder epicondilosis It is very common in tennis players.

Clinical features:

·        Elbow pain

·        Insignificant hypalgesia on external surface of hand

 

3. Autonomic – vascular form

Clinical features are the same as in case of lumbar ischialgia.

II.        Compressive radicular syndromes on cervical level

1. 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

 

2. Radiculopathy C7 radix (C6 – C7 discs)

• Pain, parasthesia and hypalgesia

• Weakness, hypotrophy of m. triceps brachii

• Low extensor elbow reflex

3. Radiculopathy C8 radix (C7 – C8 discs)

• Pain, parasthesia and hypalgesia

• Low extensor elbow and carpo – radial reflex

III.      Compressive spinal syndromes

      Clinical features are developed during several months or years, sometimes rapidly, acutely.

Clinical features:

1.      The syndrome of bilateral ventral compression of spinal cord

·        Flaccid upper paralysis

·        Central lower paralysis

·        Conductive sensory disorders

·        Pelvic disturbances

2.      Syndrome of lateral column compression

·        Flaccid upper paralysis

·        Central lower paralysis

·        Conductive sensory disorders on the opposite side

IV.     Compressive vascular radicular – spinal syndromes.

1.      Acute

A.     Transient

B.     Stroke

2.      Chronic

 

1.      A. Transient – Sensory and motor disorders are liquidated in course of 1 – 2 weeks.

 B. Stroke (It is acute ischemia of radix or spinal cord)

·        At radix artery compression radix stroke is developed

·        At anterior spinal artery compression only anterior 2/3 of spinal diameter are injured.

2.      Chronic – cervical myelopathy

·        Anterior horns lesion syndrome

·        Lateral columns syndrome

·        LAS – syndrome

·        Syringomyelia syndrome

V.       Vertebral artery syndrome

1.      Drop – attacks (reticular formation ischemia)

2.      Syncope (pyramidal tract ischemia)

Additional methods of diagnostics

1.      Spinal X – ray – examination

2.      CT of spinal cord

Treatment

1.      Orthopedic

2.      Medicines:

·        At 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

3.      Surgical methods

The main indications:

·        Horse tail compression

·        Long lasting (3 – 6 months) pains

·        Huge hernia (over 15 mm)

·        Acute compression of radicular – spinal artery

4.      Sanatorium

Prevention

1.      Hypokinesia prevention

2.      Moderate physical activity

3.      Treatment of chronic diseases