What is the L4-L5 spinal segment. How does it support the body. What are its key anatomical structures. Which common problems affect this area. How can L4-L5 issues be treated.

Anatomy and Function of the L4-L5 Spinal Segment

The L4-L5 spinal segment comprises the two lowest vertebrae of the lumbar spine. This crucial area plays a vital role in supporting the upper body and enabling various trunk movements. Let’s explore its key components and functions:

L4 and L5 Vertebrae

The L4 and L5 vertebrae are the foundational bones of this spinal segment. Each vertebra consists of:

• A vertebral body at the front
• A vertebral arch at the back
• Three bony protrusions: one spinous process and two transverse processes
• Facet joints connecting the vertebrae

These vertebrae are taller in front than behind, contributing to the natural inward curvature (lordosis) of the lumbar spine. Their endplates help resist compressive forces acting on the spine.

L4-L5 Intervertebral Disc

Between the L4 and L5 vertebral bodies lies the intervertebral disc. This structure consists of:

• A gel-like nucleus pulposus at the center
• A tough, fibrous annulus fibrosus surrounding it

The disc acts as a cushion and shock absorber, preventing the vertebrae from grinding against each other during spinal movements. Its height is crucial for maintaining the lumbar lordosis.

L4 Spinal Nerve

The L4 spinal nerve roots exit the spinal cord through small openings called intervertebral foramina. These nerve roots join with others to form larger nerves that extend down the spine and legs. The L4 nerve is responsible for:

• Sensations in the L4 dermatome (an area of skin including parts of the thigh, knee, leg, and foot)
• Control of the L4 myotome (a group of muscles in the back, pelvis, thigh, leg, and foot)

Importance of the L4-L5 Spinal Segment

Why is the L4-L5 segment so crucial? This area bears significant responsibility in our daily lives:

• It supports the weight of the upper body
• Allows for a wide range of trunk motions
• Provides protection for the cauda equina (bundle of spinal nerves)
• Plays a key role in maintaining proper posture

Due to its heavy load-bearing function and flexibility, the L4-L5 segment is more susceptible to injury and degenerative changes compared to other lumbar segments.

Common Problems Affecting the L4-L5 Segment

Given its critical role and constant stress, the L4-L5 segment is prone to various issues. What are the most frequent problems encountered in this area?

Facet Joint Problems

The high mobility of the L4-L5 segment makes it susceptible to facet joint issues, including:

• Osteoarthritis
• Synovial cyst formation
• Facet joint instability

Disc Problems

The L4-L5 disc is at high risk of degeneration due to increased loads. Common disc-related issues include:

• Herniated disc
• Degenerative disc disease
• Disc bulge or protrusion

Spinal Stenosis

Narrowing of the spinal canal or neural foramina at L4-L5 can lead to spinal stenosis, potentially compressing nerves and causing pain or neurological symptoms.

Spondylolisthesis

This condition occurs when one vertebra slips forward over the one below it, often affecting the L4-L5 segment. It can lead to instability and nerve compression.

Symptoms of L4-L5 Spinal Problems

How do issues in the L4-L5 segment manifest? Common symptoms include:

• Lower back pain
• Sciatica (pain radiating down the leg)
• Numbness or tingling in the legs or feet
• Weakness in the lower extremities
• Difficulty walking or standing for extended periods

The specific symptoms can vary depending on the underlying condition and the extent of nerve involvement.

Diagnosis of L4-L5 Spinal Issues

How are problems in the L4-L5 segment diagnosed? The process typically involves:

1. Physical examination: Assessing range of motion, reflexes, and muscle strength
2. Medical history review: Understanding the patient’s symptoms and any relevant past conditions
3. Imaging studies: May include X-rays, CT scans, or MRI to visualize the spinal structures
4. Nerve conduction studies: To evaluate nerve function if neurological symptoms are present

Accurate diagnosis is crucial for determining the most appropriate treatment approach.

Treatment Options for L4-L5 Spinal Problems

What treatments are available for issues affecting the L4-L5 segment? The approach depends on the specific condition and its severity, but may include:

Conservative Treatments

• Physical therapy to improve strength and flexibility
• Pain management techniques, including medication and injections
• Chiropractic care or osteopathic manipulation
• Lifestyle modifications to reduce stress on the spine

Surgical Interventions

In cases where conservative treatments are ineffective, surgical options may be considered:

• Microdiscectomy for herniated discs
• Laminectomy to relieve spinal stenosis
• Spinal fusion for instability or severe degenerative changes
• Artificial disc replacement in select cases

The choice of treatment is individualized based on the patient’s specific condition, overall health, and personal preferences.

Preventing L4-L5 Spinal Problems

Can issues in the L4-L5 segment be prevented? While some factors like age and genetics are beyond our control, several strategies can help maintain spinal health:

• Regular exercise to strengthen core and back muscles
• Maintaining proper posture during daily activities
• Using ergonomic furniture and equipment
• Practicing safe lifting techniques
• Maintaining a healthy weight to reduce stress on the spine
• Quitting smoking, which can accelerate disc degeneration

By adopting these preventive measures, individuals can reduce their risk of developing L4-L5 spinal problems and maintain better overall spinal health.

Living with L4-L5 Spinal Issues

For those diagnosed with L4-L5 spinal problems, how can they manage their condition and improve their quality of life?

• Adhering to prescribed treatment plans
• Engaging in regular, low-impact exercise as recommended by healthcare providers
• Using assistive devices when necessary to reduce strain on the spine
• Practicing stress-reduction techniques like meditation or yoga
• Making necessary workplace modifications to accommodate spinal health needs
• Joining support groups to connect with others facing similar challenges

With proper management and support, many individuals with L4-L5 spinal issues can lead active, fulfilling lives while minimizing pain and discomfort.

Understanding the anatomy, function, and potential problems of the L4-L5 spinal segment is crucial for maintaining spinal health and addressing issues when they arise. By staying informed and proactive, individuals can work effectively with healthcare providers to manage and prevent spinal problems, ensuring better overall health and well-being.

All About the L4-L5 Spinal Segment

The L4 and L5 are the two lowest vertebrae of the lumbar spine. Together with the intervertebral disc, joints, nerves, and soft tissues, the L4-L5 spinal motion segment provides a variety of functions, including supporting the upper body and allowing trunk motion in multiple directions.

¹
Waldman SD. Functional Anatomy of the Lumbar Spine. In: Pain Review. Elsevier; 2009:65-66. doi:10.1016/b978-1-4160-5893-9.00029-0

The L4-L5 segment supports the weight of the upper body and allows movement, making this spinal motion segment prone to injury. Watch: Lumbar Spine Anatomy Video

Due to its heavy load-bearing function and wide range of flexibility, the L4-L5 motion segment may be more susceptible to developing pain from injury and/or degenerative changes compared to other lumbar segments.

²
Cramer GD. The Lumbar Region. In: Clinical Anatomy of the Spine, Spinal Cord, and Ans. Elsevier; 2014:246-311. doi:10.1016/b978-0-323-07954-9.00007-4

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Anatomy of the L4-L5 Spinal Motion Segment

The L4-L5 motion segment includes the following structures:

• L4 and L5 vertebrae. Each vertebra consists of a vertebral body in front and a vertebral arch at the back. The vertebral arch has 3 bony protrusions: a prominent spinous process in the middle and two transverse processes on either side. The region between the spinous process and the transverse process is called the lamina. The region between the transverse process and the vertebral body is called the pedicle. The vertebrae are joined by facet joints (zygapophyseal joints), which are covered by articulating cartilage to provide smooth movements between the joint surfaces.

   

  The L4 and L5 vertebral bodies are taller in front than behind. The upper and lower ends of each vertebral body are covered by bony endplates that help resist compressive loads placed on the spine.

  ²
  Cramer GD. The Lumbar Region. In: Clinical Anatomy of the Spine, Spinal Cord, and Ans. Elsevier; 2014:246-311. doi:10.1016/b978-0-323-07954-9.00007-4

• L4-L5 intervertebral disc. A disc made of a gel-like material (nucleus pulposus) surrounded by a thick fibrous ring (annulus fibrosus) is situated between the vertebral bodies of L4 and L5. This disc provides cushioning and shock-absorbing functions to protect the vertebrae from grinding against each other during spinal movements.

   

  Read more about Spinal Discs

  The height of the L4-L5 disc plays an important role in maintaining the lordosis (inward curvature) of the lumbar spine.

  ²
  Cramer GD. The Lumbar Region. In: Clinical Anatomy of the Spine, Spinal Cord, and Ans. Elsevier; 2014:246-311. doi:10.1016/b978-0-323-07954-9.00007-4

• L4 spinal nerve. The L4 spinal nerve roots exit the spinal cord through small bony openings (intervertebral foramina) on the left and right sides of the spinal canal. These nerve roots join with other nerves to form bigger nerves that extend down the spine and travel down each leg.
  • The L4 dermatome is an area of skin that receives sensations through the L4 spinal nerve and includes parts of the thigh, knee, leg, and foot.
  • The L4 myotome is a group of muscles controlled by the L4 spinal nerve and includes parts of several muscles in the back, pelvis, thigh, leg, and foot.

    ³
    Kayalioglu G. The Spinal Nerves. In: The Spinal Cord. Elsevier; 2009:37-56. doi:10.1016/b978-0-12-374247-6.50008-0

The L4-L5 motion segment provides a bony enclosure for the cauda equina (nerves that continue down from the spinal cord) and other delicate structures.

¹
Waldman SD. Functional Anatomy of the Lumbar Spine. In: Pain Review. Elsevier; 2009:65-66. doi:10.1016/b978-1-4160-5893-9.00029-0

See Lumbar Spine Anatomy and Pain

In This Article:

• All About the L4-L5 Spinal Segment

• L4-L5 Treatment

• Lumbar Spine Anatomy Video

Common Problems at L4-L5

Some of the more common injuries and disorders that may occur at the L4-L5 motion segment include:

• Facet joint problems. The high degree of mobility at L4-L5 makes this motion segment prone to facet joint related problems, such as osteoarthritis

  ²
  Cramer GD. The Lumbar Region. In: Clinical Anatomy of the Spine, Spinal Cord, and Ans. Elsevier; 2014:246-311. doi:10.1016/b978-0-323-07954-9.00007-4
  , synovial cyst (fluid-filled sac) formation, and instability of the facets.

  See Facet Joint Disorders and Back Pain

• Disc problems. The L4-L5 disc is at a high risk of degeneration. This risk may be due to increased loads at the L4-L5 motion segment and decreased movement in the segments below this level. A change in disc height due to degeneration may affect the lordosis of the lumbar spine.

  ²
  Cramer GD. The Lumbar Region. In: Clinical Anatomy of the Spine, Spinal Cord, and Ans. Elsevier; 2014:246-311. doi:10.1016/b978-0-323-07954-9.00007-4
  The disc may also herniate due to degeneration or injury.

  ⁴
  Amin RM, Andrade NS, Neuman BJ. Lumbar Disc Herniation. Curr Rev Musculoskelet Med. 2017;10(4):507–516. doi:10.1007/s12178-017-9441-4

  See Lumbar Herniated Disc: What You Should Know

• Spondylolysis. A fracture of the pars interarticularis (a small segment of bone from the vertebral arch joining the facet joints) can occur at the L4-L5 level due to concentration of compressive loads in this region.

  ²
  Cramer GD. The Lumbar Region. In: Clinical Anatomy of the Spine, Spinal Cord, and Ans. Elsevier; 2014:246-311. doi:10.1016/b978-0-323-07954-9.00007-4
  It can occur on one or both sides. Frequently, the bone does not break, but becomes stressed and this condition is called a pars stress reaction.

  Watch Lumbar Spondylolysis Video

• Degenerative spondylolisthesis. The angle of the L4-L5 facet joint changes with age, making this level susceptible to spondylolisthesis (forward slippage of L4 on L5) due to degenerative changes in individuals over 60 years of age.

  ²
  Cramer GD. The Lumbar Region. In: Clinical Anatomy of the Spine, Spinal Cord, and Ans. Elsevier; 2014:246-311. doi:10.1016/b978-0-323-07954-9.00007-4

  See Degenerative Spondylolisthesis

• Spinal stenosis. Narrowing (stenosis) of bony openings for nerves due to the presence of bone spurs (abnormal bone growth) or other degenerative changes may cause compression of the nerve roots in the area of stenosis.

  See Lumbar Spinal Stenosis

External trauma from falls or motor vehicle accidents may cause facet joint dislocation, fracture, and/or damage to the cauda equina at this level. Rarely, tumors and infections may affect the L4-L5 vertebrae and spinal segment.

The L4-L5 motion segment may cause referred pain from the joints and/or muscles or radicular symptoms that travel through nerves. Referred pain from L4-L5 usually stays within the lower back and is typically felt as a dull ache. The back may also feel stiff.

Depending on the type and severity of the underlying cause, the L4-L5 motion segment may cause lumbar radicular pain of the L4 and/or L5 spinal nerves, also called sciatica. Common symptoms and signs include:

• Sharp pain, typically felt as a shooting and/or burning feeling that originates in the lower back and travels down the leg in the distribution of a specific nerve, sometimes affecting the foot.
• Numbness in different parts of the thigh, leg, foot, and/or toes.
• Weakness while moving the thigh, knee, or foot in different directions.
• Abnormal sensations, such as a feeling of pins-and-needles and/or tingling.

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It is also possible for a stabbing pain or ache to be isolated to any of these (dermatomal) areas. While lumbar radiculopathy typically affects one leg at a time, sometimes, both legs may be affected together.

See Lumbar Radiculopathy

An injury to the cauda equina may cause severe pain, weakness, numbness, tingling, or paralysis in both legs. There may also be a reduction or complete loss of bowel and/or bladder control. This condition, called cauda equina syndrome, is a medical emergency and requires urgent treatment to preserve leg function and restore bowel and/or bladder function.

See Cauda Equina Syndrome

Nonsurgical treatments are often tried first for symptoms that stem from L4-L5. In rare cases, surgery may be considered.

See Non-Surgical Treatments for Lower Back Pain

Dr. David DeWitt is an orthopedic surgeon practicing at the NeuroSpine Center of Wisconsin, where he specializes in spine surgery. He has more than 15 years of experience evaluating and treating spine diseases and trauma.

• 1
  Waldman SD. Functional Anatomy of the Lumbar Spine. In: Pain Review. Elsevier; 2009:65-66. doi:10.1016/b978-1-4160-5893-9.00029-0
• 2
  Cramer GD. The Lumbar Region. In: Clinical Anatomy of the Spine, Spinal Cord, and Ans. Elsevier; 2014:246-311. doi:10.1016/b978-0-323-07954-9.00007-4
• 3
  Kayalioglu G. The Spinal Nerves. In: The Spinal Cord. Elsevier; 2009:37-56. doi:10.1016/b978-0-12-374247-6.50008-0
• 4
  Amin RM, Andrade NS, Neuman BJ. Lumbar Disc Herniation. Curr Rev Musculoskelet Med. 2017;10(4):507–516. doi:10.1007/s12178-017-9441-4

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Dermatomes Diagram: Spinal Nerves and Locations

A dermatome is an area of skin supplied by a single spinal nerve. There are 31 pairs of spinal nerves, forming nerve roots that branch from your spinal cord.

Your spinal nerves help to relay sensory, motor, and autonomic information between the rest of your body and your central nervous system (CNS).

So why are dermatomes important? How many are there? And where can they be found? Continue reading as we answer these questions and more.

Each of your dermatomes is supplied by a single spinal nerve. Let’s take a closer look at both of these components of the body.

Your spinal nerves

Spinal nerves are part of your peripheral nervous system (PNS). Your PNS works to connect the rest of your body with your CNS, which is made up of your brain and spinal cord.

You have 31 pairs of spinal nerves. They form nerve roots that branch from your spinal cord. Spinal nerves are named and grouped by the region of the spine that they’re associated with.

The five groups of spinal nerves are:

• Cervical nerves. There are eight pairs of these cervical nerves, numbered C1 through C8. They originate from your neck.
• Thoracic nerves. You have 12 pairs of thoracic nerves that are numbered T1 through T12. They originate in the part of your spine that makes up your torso.
• Lumbar nerves. There are five pairs of lumbar spinal nerves, designated L1 through L5. They come from the part of your spine that makes up your lower back.
• Sacral nerves. Like the lumbar spinal nerves, you also have five pairs of sacral spinal nerves. They’re associated with your sacrum, which is one of the bones found in your pelvis.
• Coccygeal nerves. You only have a single pair of coccygeal spinal nerves. This pair of nerves originates from the area of your coccyx, or tailbone.

Your dermatomes

Each of your dermatomes is associated with a single spinal nerve. These nerves transmit sensations, such as pain, from a specific area of your skin to your CNS.

Your body has 30 dermatomes. You may have noticed that this is one less than the number of spinal nerves. This is because the C1 spinal nerve typically doesn’t have a sensory root. As a result, dermatomes begin with spinal nerve C2.

Dermatomes have a segmented distribution throughout your body. The exact dermatome pattern can actually vary from person to person. Some overlap between neighboring dermatomes may also occur.

Because your spinal nerves exit your spine laterally, dermatomes associated with your torso and core are distributed horizontally. When viewed on a body map, they appear very much like stacked discs.

The dermatome pattern in the limbs is slightly different. This is due to the shape of the limbs as compared with the rest of the body. In general, dermatomes associated with your limbs run vertically along the long axis of the limbs, such as down your leg.

Your dermatomes are numbered based on which spinal nerve they correspond to. Below, we’ll outline each dermatome and the area of the body that it’s associated with.

Remember that the exact area that a dermatome may cover can vary by individual. Some overlap is also possible. As such, consider the outline below to be a general guide.

Cervical spinal nerves

• C2: lower jaw, back of the head
• C3: upper neck, back of the head
• C4: lower neck, upper shoulders
• C5: area of the collarbones, upper shoulders
• C6: shoulders, outside of arm, thumb
• C7: upper back, back of arm, pointer and middle finger
• C8: upper back, inside of arm, ring and little finger

Thoracic spinal nerves

• T1: upper chest and back, armpit, front of arm
• T2: upper chest and back
• T3: upper chest and back
• T4: upper chest (area of nipples) and back
• T5: mid-chest and back
• T6: mid-chest and back
• T7: mid-chest and back
• T8: upper abdomen and mid-back
• T9: upper abdomen and mid-back
• T10: abdomen (area of belly button) and mid-back
• T11: abdomen and mid-back
• T12: lower abdomen and mid-back

Lumbar spinal nerves

• L1: lower back, hips, groin
• L2: lower back, front and inside of thigh
• L3: lower back, front and inside of thigh
• L4: lower back, front of thigh and calf, area of knee, inside of ankle
• L5: lower back, front and outside of calf, top and bottom of foot, first four toes

Sacral spinal nerves

• S1: lower back, back of thigh, back and inside of calf, last toe
• S2: buttocks, genitals, back of thigh and calf
• S3: buttocks, genitals
• S4: buttocks
• S5: buttocks

Coccygeal spinal nerves

buttocks, area of tailbone

Dermatomes are important because they can help to assess and diagnose a variety of conditions. For instance, symptoms that occur along a specific dermatome may indicate a problem with a specific nerve root in the spine.

Examples of this include:

• Radiculopathies. This refers to conditions in which a nerve root in the spine is compressed or pinched. Symptoms can include pain, weakness, and tingling sensations. Pain from radiculopathies can follow one or more dermatomes. One form of a radiculopathy is sciatica.
• Shingles. Shingles is a reactivation of the varicella zoster (chickenpox) virus that lies dormant in the nerve roots of your body. Symptoms of shingles, such as pain and a rash, occur along dermatomes associated with the affected nerve root.

Dermatomes are areas of skin that are connected to a single spinal nerve. You have 31 spinal nerves and 30 dermatomes. The exact area that each dermatome covers can be different from person to person.

Spinal nerves help to relay information from other parts of your body to your central nervous system. As such, each dermatome transmits sensory details from a particular area of skin back to your brain.

Dermatomes can be helpful in evaluating and diagnosing conditions affecting the spine or nerve roots. Experiencing symptoms along a specific dermatome can help inform doctors about which area of the spine may be affected.

Radiculopathy – symptoms, diagnosis, treatment.

Definition

Radiculopathy is a symptom, not an independent disease, a symptom of a disease of the peripheral nervous system, the cause of which in most cases is protrusion or herniation of the intervertebral disc and arthrosis of the vertebral joints. And before continuing, I would like to start with the anatomy of the spine and the structure of the nervous system.

According to classification
vertebrae secrete free vertebrae:

• cervical vertebrae – 7 pcs.
• thoracic vertebrae – 12 pcs.
• lumbar vertebrae – 5 pcs.

and fused:

• sacral vertebrae – 5 pcs.
• coccygeal vertebrae – 3-5 pcs.

A distinctive feature of the cervical vertebrae is the presence of a hole in the transverse process through which the vertebral arteries pass. Another distinguishing feature is the atlas and the axial vertebra (1 and 2 vertebrae), they are atypical, they lack a body, spinous and articular processes. 3 – 7 cervical vertebrae – typical.

In any typical vertebra, the body, arch and process are distinguished, and their connections are distinguished according to the parts of the vertebra.

The vertebral bodies are interconnected by means of intervertebral discs, anterior and posterior longitudinal ligaments.

The arches are connected by a yellow ligament.

Among the processes, spinous, transverse and articular (upper and lower) are distinguished. The spinous processes are connected by the interspinous ligament, the transverse processes by the intertransverse ligament, and the articular processes by the intervertebral joints.

All vertebrae form the vertebral column, and when the vertebrae are connected, intervertebral foramina (right and left) are formed through which the spinal nerves and blood vessels pass.

The spinal column does not occupy a strictly vertical position, it has physiological curves. The bend facing backwards is called kyphosis, and anteriorly – lordosis.

The spinal cord located inside the spinal canal starts from the foramen magnum and ends up to the first lumbar vertebra (L _I ) in men, 2 lumbar vertebrae (L _II ) in women.

There are 124 roots throughout the spinal cord. 62 posterior and 62 anterior, of which 31 pairs of spinal nerves are formed.

Having dealt with
the anatomy of the spine and the formation of nerve roots, you can go to
disease.

All back pain can be
divided into specific, non-specific and radicular.

So, radiculopathy
is a disease caused by compression (damage) of the nerve root,
causing back pain. Compression occurs due to the fact that the intervertebral
disk, which performs a shock-absorbing function in the spine, under the influence of loads
from the outside and a non-functioning muscular corset, begins to protrude. Forming
thus, protrusion, and further herniation of the intervertebral disc.

For understanding, we present
back pain prevalence statistics:

• specific – 85% (due to muscles, ligaments, tendons, small joints),
• non-specific – 10% (vertebral fracture, tuberculosis, osteomyelitis, abscess, spinal canal stenosis, neoplasm, ankylosing spondylitis, etc.)
• radicular up to 4%.

In other words,
the prevalence of radiculopathy is 4% of all pain syndromes in
back.

Causes of radiculopathy

Causes of disease formation:

• sedentary lifestyle
• sedentary work
• excessive physical activity
• age-related changes in the spine
• injuries
• neoplasms
• genetic predisposition.

Symptoms Radiculopathy

On the torso area
skin with increased pain sensitivity is divided into certain areas –
dermatomes, or they are also called Zakharyin-Ged zones, by surnames
clinical researchers who discovered this phenomenon – the Russian therapist G.A.
Zakharyin and the English neuropathologist G. Ged.

In radiculopathy, a peripheral variant of sensory disturbance occurs. It is characterized by disorders that occur when sensory pathways (peripheral nerves, plexuses, roots) are affected. And peripheral paralysis or paresis, which is a disorder of voluntary movements. As a result, there is a violation of sensitivity in the corresponding dermatome. And the muscles innervated by the affected root become weak and hypotonic, which contributes to their atrophy.

Clinical
manifestations of radiculopathy are characterized by a sudden onset, with constant or
periodic shooting, piercing, intense pain, which, at least
occasionally radiates to the distal zone of the dermatome corresponding to
damaged nerve root.

Pain syndrome may appear and intensify when moving, straining, lifting weights, sitting in a deep chair, staying in one position for a long time, coughing and sneezing, and weakens at rest, especially if the patient lies on a healthy side, bending the affected leg at the knee and hip joints . Initially, the pain may be dull, aching, but it gradually increases, and sometimes it can immediately reach its maximum.

During inspection
the patient often takes a forced position. Movement in the affected segment
of the spine and the limb innervated by it is sharply limited. On palpation
marked tension of the paravertebral muscles.

Neurological examination of the patient is of great importance in differential diagnosis. Due to damage to the nerve root, its function is impaired, therefore, radiculopathy is characterized by a violation of pain, temperature, vibration and other sensitivity (including in the form of paresthesia, hyper- or hypoalgesia, allodynia, hyperpathy) in the corresponding dermatome, a decrease or loss of tendon reflexes, closing through the corresponding segment of the spinal cord, hypotension and weakness of the muscles innervated by this root.

Pathogenesis

Onset of disease development
are two factors that are related to each other: mechanical irritation
root and / or spinal ganglion and inflammatory changes in
perineural tissue, which arise due to the penetration of the disc into the epidural
space.

At the same time, factors
root compression can be both herniated discs and bone growths (uncovertebral,
spondylarthrosis). Also, compression can be carried out by hypertrophied
ligaments and periarticular tissues, vascular structures (epi- and
subdural hematomas, arteriovenous malformations, epidural
hemangiomas).

So far in
The pathophysiological concept of radicular pain remains “blank spots”.
It is assumed that the basis of radicular pain is axonal dysfunction,
due to various etiological factors, including neural
compression, ischemia, damage by inflammatory and other biologically active
substances. Spinal roots (unlike peripheral nerves) have
weak blood-brain barrier, which makes the axon more susceptible to
compression damage.

Increased vascular permeability due to mechanical compression of the root leads to endoneural edema. As a result, a precedent arises that prevents a full-fledged capillary blood supply and the formation of interneural fibrosis. The spinal root receives up to 58% of its nutrition from the surrounding cerebrospinal fluid (CSF). Perineural fibrosis prevents the full supply of axonal tissue with nutrients due to diffusion from the CSF, which also contributes to increased pressure sensitivity of the fiber.

Research with
experimental compression of the root showed that already at a minimum pressure
(5–10 mm Hg) venous blood flow stops.

Occlusal pressure
radicular arterioles is significantly higher (approximately corresponds to the average
BP), but depends on potential venous congestion. Nerve ischemia or
venous stasis lead to biochemical changes that are able to maintain
pain sensations.

Works with
experimental root compression demonstrate that the compensatory
diffusion of nutrients from the CSF
worsens in conditions of epidural inflammation or in the presence of fibrosis.

Recent studies have shown that degenerative changes in the nucleus pulposus and anulus fibrosus can lead to local neural changes and the synthesis of algogenic agents such as metalloproteinases, tumor necrosis factor (TNF), interleukin (IL)-6 and prostaglandin E2. Pathogenetically, the pain syndrome in radiculopathy is mixed, including nociceptive and neuropathic components.

Disease classification

Over the years, changes occur in our body, for example, the skin of a baby is tender and elastic, but at the age of 30 it is no longer the same. The same thing happens with our spine. Degenerative and dystrophic processes in the spine contribute to the formation of protrusions and hernias, which in the future can and lead to radiculopathy.

There are discogenic and vertebrogenic forms of the disease. Vertebrogenic radiculopathy is a disease of a secondary type, in which the spinal cord root is compressed in a kind of tunnel formed by various pathological processes. It can be soft tissue edema, tumor, osteophytes, disc herniation.

As development progresses
degenerative inflammatory process, the tunnel narrows, appears
indentation and severe pain.

Depending on
localization distinguish the following forms of radiculopathy:

• cervical;
• lumbosacral;
• mixed.

The disease may
occur in adults of any age, if you start the disease, it can
lead to disability. Another name for this disease is radicular
syndrome. Among the people, complex names did not take root, so you can often hear
that the person is suffering from sciatica. Although this name is not entirely correct.

Lumbosacral radiculopathy is more common than others. It affects the vertebrae L5, L4, S1. To understand which vertebrae are involved in the process of inflammation, it is necessary to remember that all parts of the spine are designated by Latin names. Sacrum – Os Sacrum, therefore, the vertebrae are denoted by the letter S from 1 to 5. Lumbar – Pars Lumbalis (L1-L5). Cervical region – Pars Cervicalis (C1-C7). Thoracic spine – Pars Thoracalis (Th2-12).

After reviewing this
classification, it is easy to understand that Th4 means damage to the third vertebra in
thoracic region, and C2 – damage to the second cervical vertebra. Damage level
determined by X-ray.

Exists
international classification of diseases – ICD 10. It is generally accepted for
coding of all medical diagnoses. According to the ICD, radiculotherapy is assigned
code M 54.1.

In the absence of due
approach to the treatment and prevention of this disease, radicular syndrome quickly
turns into a chronic form. As a result, changes such as drastic
movement, hypothermia, or stress can trigger an attack of pain.

Other complication
there may be a persistent violation of the motor and sensory function of the affected
limbs and lead to disability. For example, a hernia in the lumbar region
spine without timely treatment causes peripheral paresis and parilich
lower limb, disrupts the function of the pelvic organs.

Diagnostics

For leveling
lesions, topical diagnosis is of great importance. Basic radicular
syndromes are presented in the table: ^[6]

Radiculopathy requires
CT or MRI of the affected level of the spine. In order to evaluate
the level of research is necessary to find out the symptoms of the disease neurological
status at the time of admission. If the level of damage cannot be determined,
electromyography is prescribed, which helps to top the affected root,
but fails to determine the cause.

If neuroimaging does not reveal atomic changes, examination of the cerebrospinal fluid is necessary to exclude infectious and inflammatory causes, as well as the determination of blood glucose levels to exclude diabetes.

Treatment Radiculopathy

A neurologist treats herniated discs. Specialists of the medical center “I’m healthy” have extensive experience in the treatment of such diseases. You can go through all the stages of treatment under the supervision of the attending physician, who will answer all your questions.

In most patients with radicular pain, conservative treatment is effective, however, 2% of patients have absolute indications (progression of sensory and motor disorders, cauda equina syndrome) for surgical treatment.

On the whole, it can be said
that the conservative management of patients with this disease in most
cases is favorable and should be considered as a priority in
the absence of a verified compressing substrate.

Non-steroidal anti-inflammatory drugs (NSAIDs) are the first line of treatment. They have analgesic and anti-inflammatory effects. Corticosteroid injections (CS) can be considered as an alternative to the use of NSAIDs for the treatment of radicular pain. Perineural injections (translaminar, epidural, transforaminal, or selective root block) should be given only after neuroimaging (MRI) of the clinical topical diagnosis. To influence the neuropathic component of radicular pain, some drugs from the group of anticonvulsants (carbamazepine, gabapeptin, pregabalin, lamotrigine) can be used.

Studies conducted to evaluate the efficacy of systemic local analgesics such as lidocaine, mexiletine, tocainide and flecainide showed good results.

Prognosis and prevention of disease

It is necessary to advise the patient to return to the usual daily activities as soon as possible, since maladaptive pain behavior is the main barrier to recovery. In addition, comorbid depression also negatively affects treatment outcomes. If pain persists for >4–6 weeks, it is advisable to add antidepressants to analgesic therapy. Pathogenetically, it is most justified to use antidepressants that act on both neurotransmitter systems (serotonin and noradrenergic) for the treatment of pain symptoms. Tricyclic antidepressants (TCAs), which block the reuptake of serotonin and norepinephrine, have greater potential than selective antidepressants. TCAs have a more successful effect on pain symptoms and lead to a more complete remission of depression. A new class of drugs – dual-acting antidepressants that block the reuptake of serotonin and norepinephrine, have high analgesic efficacy and a more favorable spectrum of side effects than TCAs. The efficacy / safety ratio is optimal for dual-acting antidepressants (duloxetine, venlafaxine). In the recovery period, active exercises are recommended to strengthen the muscular corset.

Acute back pain – Insight Medical Kyiv Poznyaki

Acute back pain of varying intensity is observed in 80-100% of the population, but only 40% seek medical help. It is known that after 30 years, every fifth person in the world suffers from sciatica. Why the back hurts, how to prevent the problem and how to avoid surgical intervention – is discussed in article of the head physician of the Insight Medical clinic, a neurologist of the highest category, candidate of medical sciences, psychoneurologist, reflexologist Slynko Anna Alekseevna

The clinical picture of intervertebral disc pathology consists of the pressure factors of the altered disc on the spinal cord, spinal nerve roots, vessels that accompany the roots, as well as complex changes that occur due to venous stasis with swelling of the roots and adjacent tissues.

• Mechanical factor – heavy lifting, uncomfortable movements, body position, sharp turn of the body, inclination, weight transfer, inadequate physical load;
• Consequence of past infectious diseases or hypothermia;
• Weakening of the abdominals due to operations on the abdominal organs, consequences of pregnancy;
• Statodynamic disorders during pregnancy, injuries of large joints, limb amputation, when the posture, posture and motor stereotype are disturbed.

The most common division of osteochondrosis syndromes is the division into reflex and compression syndromes.

First there are reflex, and then compression (squeezing syndromes).

Reflex syndromes include syndromes of irritation of the sinuvertebral nerve Luschka. It innervates bones, ligaments, annulus fibrosus, vessels. In case of injury or compression of these structures, a signal goes along the nerve to the spinal cord and a reflex adaptive mechanism occurs. A muscular-tonic syndrome is formed, which also contributes to the pain syndrome, switching to the sympathetic centers and lateral horns of the spinal cord, vasomotor and dystrophic disorders occur.

Low-vascularized tissues (tendons, ligaments) are especially prone to dystrophic changes, especially to attachment sites. In some cases, these neurodystrophic changes cause intense pain, not only locally, but also at a distance, manifesting as “shoots”.

Autonomic disturbances are possible in the trigger zones, the so-called pain of muscular-fascial dysfunction – myofascial pain.

Reflex syndromes include lumbago in the acute development of the disease, lumbago, subacute and chronic course. There is a formation of muscular-tonic syndrome, antalgic posture, flattening of the lumbar lordosis.

Of the compression syndromes, radiculopathy is the most common – about 40% of all extravertebral syndromes. Due to the physiological characteristics of the structure of the spine, the lumbar region most often suffers.

The next radicular stage, or the stage of discogenic sciatica, is due to the protrusion of the disc and the penetration of the disc tissue into the epidural space, where the spinal roots are located. Radicular symptoms correspond to the level of the pathological process in a certain segment.

The vascular-radicular stage of neurological disorders is caused by prolonged compression of the hernia on the root and the radicular artery, which runs next to it. In such a situation, the so-called “paralytic sciatica” may occur – when peripheral paresis or paralysis of the extensor muscles of the foot develops. In such cases, the appearance of motor disorders is accompanied by a decrease in pain.

The next, fourth stage is caused by a violation of the blood supply to the spinal cord due to damage to the vascular radicular arteries.

Most often, blood circulation is disturbed in the basin of the Adamkevich artery and the accessory arteries of Desproges-Gotteron. As a result, the syndrome of intermittent claudication of the cauda equina develops. When a median hernia prolapses at the lumbar level, all roots are compressed at the level of the affected segment and a caudal syndrome develops, that is, compression of the roots of the cauda equina.

Osteochondrosis and prolapse, protrusion of disc herniation leads to segmental stenosis of the spinal and root canals. The most common cause of narrowing of the spinal canal is a combination of a progressive degenerative process in the discs, ligaments, and joints. The most mobile, and as a result, the most injured and worn discs are at the level of L4-L5. Therefore, roots L5-S1 are most often affected. Edema and venous congestion occur in the compressed root, which can lead to the development of aseptic inflammation.

L3 root lesion syndrome includes pain and paresthesia in the L3 dermatome, paresis of the quadriceps muscle, decreased or loss of the tendon reflex from the quadriceps muscle, i.e. knee reflex. The pain radiates to the lumbar region and further to the front surface of the thigh. Pain in the anterior-inner thigh is more common. In the future, it spreads to the anterior-internal part of the lower leg and the inner surface of the foot. Characteristic is hypersensitivity, hypesthesia and hyperpathy on the thigh, often atrophy of the thigh muscles.

If the L4 root is affected, the pain is localized in the upper gluteal region, spreading to the outer surface of the thigh and lower leg, the back of the foot and 2-3 fingers.

Sensitivity disturbances, paresthesias, weakness of the leg muscles develop in the same zone, which turn into atrophy and loss of function: it is impossible to stand on the heels. However, knee and Achilles reflexes are preserved.

When the S1 root is affected, the pain is localized in the mid-gluteal region along the posterior outer region of the thigh, lower leg, outer side of the heel, with the transition to the outer edge of the foot, the fourth and fifth fingers. Movement disorders begin with paresis of the gluteal muscles. Muscles gradually atrophy and later the gluteal fold disappears, then the weakness of the calf muscle, the Achilles reflex decreases and may completely disappear. Can’t stand on toes.

Also, the symptoms of root damage include Lasegue’s symptom (pain in the lumbosacral region and along the leg when it is raised in a straight position, the patient lies on his back). Inclinations are difficult, especially back and to the side, from the side of the pathology. Soreness of the spinous processes of the vertebrae and paravertebral in the affected area.

The complexity of the interaction of pathogenic compensatory mechanisms often contributes to the lack of clear criteria for the severity of the process.

Sometimes, with a severe pain syndrome, we observe minor morphological changes and often the absence of pain and minor pain sensations, which are accompanied by serious morphological disorders: foot paresis, lack of reflexes, etc., tell us about the seriousness of the ongoing violations.

Here it is important to have complete information on additional instrumental methods: MRI, CT, Rӧ, electroneuromyography, in order to have an idea about the level and localization of the lesion, the nature of the process.

However, it is important to note that not all cases require surgical intervention. The urgency (urgency) of this manipulation is decided by a neurologist or neurosurgeon. Only in some cases – with a syndrome of compression of the supplying arteries, dysfunction of the pelvic organs, unbearable pain that does not stop within 3 months, critical narrowing of the spinal canal with impaired walking, etc. – are indications for surgical intervention. Our and foreign colleagues studied groups of patients operated on and treated conservatively within 5 years after the development of acute lumbosacral sciatica. It is noteworthy that there was no significant difference in the well-being of these 2 groups of patients. Therefore, the conclusion suggests itself that if it is possible to treat this pathology conservatively, using the entire arsenal of methods of traditional and non-traditional therapy, it is possible not to operate. It is important to help the compensatory and regenerative processes in the body to restore the disturbed balance.

The compressed spine must be freed from swelling and pressure. For this, anti-edematous measures are carried out, decompression – traction, removal of muscle spasm – with muscle relaxants, acupuncture, massage, post-isometric relaxation, physical methods (UHF, diadynamic therapy).