Vertebral Motion Segment Research Articles

Perspective on Intradiscal Therapies for Lumbar Discogenic Pain: State of the Science, Knowledge Gaps, and Imperatives for Clinical Adoption.

Specific clinical diagnostic criteria have established a consensus for defining patients with lumbar discogenic pain. However, if conservative medical management fails, these patients have few treatment options short of surgery involving discectomy often coupled with fusion or arthroplasty. There is a rapidly-emerging research effort to fill this treatment gap with intradiscal therapies that can be delivered minimally-invasively via fluoroscopically guided injection without altering the normal anatomy of the affected vertebral motion segment. Viable candidate products to date have included mesenchymal stromal cells, platelet-rich plasma, nucleus pulposus structural allograft, and other cell-based compositions. The objective of these products is to repair, supplement, and restore the damaged intervertebral disc as well as retard further degeneration. In doing so, the intervention is meant to eliminate the source of discogenic pain and avoid surgery. Methodologically rigorous studies are rare, however, and based on the best clinical evidence, the safety as well as the magnitude and duration of clinical efficacy remain difficult to estimate. Further, we summarize the US Food and Drug Administration's (FDA) guidance regarding the interpretation of the minimal manipulation and homologous use criteria, which is central to designating these products as a tissue or as a drug/device/biologic. We also provide perspectives on the core evidence and knowledge gaps associated with intradiscal therapies, propose imperatives for evaluating effectiveness of these treatments and highlight several new technologies on the horizon.

Патология шейного отдела позвоночника и головная больу пациентов с синдромом дисплазии соединительной ткани

This study aimed at evaluating the role of pathologic changes in the vertebral motor segment (VMS) of the cervical spine in the development of headache in patients with connective tissue dysplasia (CTD). 
 Materials and methods. The study involved 130 patients, aged 18-59, with complaints of headache. 100 patients (76.9 %) had clinical manifestations of CTD (main group). The control group consisted of 30 patients (23.1 %) without CTD manifestations. The presence of CTD was confirmed by phenotyping according to T.I. Kadurina’s tables. The headache nature, frequency, and intensity were analyzed in all patients, and standard neurological examination, manual testing, and neuroimaging studies of all patients were performed.
 In the study presented, it was found that chronic migraine, headache associated with temporomandibular joint dysfunction (TMJD) was more common in the group of patients with CTD. Patients with headache on the background of CTD had pathological changes in the cervical spine in the vast majority of cases. Functional blockade of the VMS of the cervical spine with the formation of myofascial trigger zones in the trapezius and pericranial muscles is detected significantly more often in patients with CTD.
 Thus, it is necessary to take into account the presence of functional disorders in the VMS of the cervical spine when diagnosing and treating headache in patients with CTD.

Anterior transcorporeal approach combined with posterior translaminar approach in percutaneous endoscopic cervical discectomy for two-segment cervical disc herniation treatment: a technical report and early follow-up

ObjectiveFull endoscopic techniques are being gradually introduced from single-segment cervical disc herniation surgery to two-segment cervical disc herniation surgery. However, there is no suitable full endoscopic treatment for mixed-type two-segment cervical disc herniation (MTCDH) in which one segment herniates in front of the spinal cord and the other segment herniates behind the spinal cord. Therefore, we introduce a new full endoscopic technique by combining an anterior transcorporeal approach and a posterior translaminar approach. In addition, we provide a brief description of its safety, efficacy, feasibility, and surgical points.MethodsThirty patients with MTCDH were given full endoscopic surgical treatment by a combined transcorporeal and transforaminal approach and were followed up for at least 12 months.ResultsClinical assessment scales showed that the patient’s symptoms and pain were significantly reduced postoperatively. Imaging results showed bony repair of the surgically induced bone defect and the cervical Cobb angle was increased. No serious complications occurred.ConclusionThis technique enables minimally invasive surgery to relieve the compression of the spinal cord by MTCDH. It avoids the fusion of the vertebral body for internal fixation, preserves the vertebral motion segments, avoids medical destruction of the cervical disc to the greatest extent possible, and expands the scope of adaptation of full endoscopic technology in cervical surgery.

Evaluation of hemodynamics in vertebral arteries in case of herniated cervical intervertebral discs using functional tests

Background. Degenerative changes of the vertebral-motor segment occupy an important place among the causes of cervicogenic headache, neck pain with radiation to the shoulder and arm, noise in the head, dizziness. The same symptoms are often found in vertebral artery syndrome, which is a set of disorders of vertebral-basilar dynamics. Dopplerography makes it possible to obtain quantitative parameters of blood flow in the vertebral arteries, thereby assessing the level of pathological changes in blood flow.
 Purpose. Dopplerographic assessment of blood flow parameters in vertebral arteries in patients with herniated cervical intervertebral discs using functional tests.
 Materials and methods. An analysis of the results of dopplerography of the vertebral arteries in 42 young patients with herniated cervical intervertebral discs was carried out. Peak systolic velocity (Vs), end-diastolic velocity (Vd), indices of peripheral resistance (RI) and pulsatility (PI), minute volume of blood flow (HOK – Vvol) in the second segment of the VA at the C2-C3 level were determined at functional prob.
 Results and discussion. With a left-sided hernia, the value of Vs in the left VA during contralateral head rotation was 34.1 ± 2.9 cm/s, RI – 0.71 ± 0.03, PI – 1.04 ± 0.06, HOC – 85 ± 9 ml/min, and in the comparison group – 45.3 ± 3.8 cm/s, 0.59 ± 0.02, 0.85 ± 0.04, 118±13 ml/min, respectively. In patients with a right-sided hernia, Vs in the right VA during contralateral head rotation was 32.6 ± 3.2 cm/s, RI – 0.72 ± 0.03, PI – 1.03 ± 0.06, COC – 83 ± 8 ml/min, and in the comparison group – 44.8 ± 4.1 cm/s, 0.60 ± 0.02, 0.87 ± 0.04, 117 ± 12 ml/min, respectively. The difference between Doppler blood flow parameters obtained during contralateral head rotation in patients with disc herniation and the comparison group (persons without disc herniation) was significant (P < 0.05).
 Conclusion.Hemodynamically significant disruption of blood flow in the vertebral artery occurs when the paramedian and posterolateral hernia is localized on the side of the same name during head rotation to the opposite side. These violations consist in a significant decrease in systolic speed and minute volume of blood flow, in an increase in indices of resistance and pulsatility compared to persons without disc herniation.

Treatment and Companion Diagnostics of Lower Back Pain Using Self-Controlled Energo-Neuroadaptive Regulator (SCENAR) and Passive Microwave Radiometry (MWR).

Evaluation of the effectiveness of treatment of nonspecific lower back pain (LBP) is currently largely based on the patient’s subjective feelings. The purpose of this study was to use passive microwave radiometry (MWR) as a tool for assessing the effectiveness of various treatment methods in patients with acute and subacute nonspecific LBP. Patients with a pain assessment on a visual analogue scale (VAS) of 6 to 10 points were divided into two groups: Group I included patients with pharmacological, syndrome-oriented treatment (n = 30, age 54.9 ± 2.3 years); Group II included a combination of pharmacotherapy with self-controlled energy-neuroadaptive regulation (SCENAR) (n = 25, age 52.8 ± 2.5 years). The analysis showed that the addition of SCENAR therapy (Group II) significantly potentiated the analgesic effect at the stages of treatment, and after 3 weeks, this had increased by more than two times, by 1.3 points on the VAS. There was also a significant decrease in the maximum internal temperature and normalization of the gradient of internal and skin temperatures, and a decrease in thermo-asymmetry, as assessed by temperature fields. Thermal asymmetry visualization allows the identification of the area of pathological muscle spasm and/or inflammation in the projection of the vertebral-motor segment for the possible targeted use of treatment methods such as percutaneous electro neurostimulation, massage, manual therapy, diagnostic and treatment blocks, etc. The MWR method also avoids unnecessary radiation exposure.

Нестабильность пояснично-крестцового отдела позвоночника

The instability of the lumbosacral spine is determined by a disability to maintain the connections between vertebrae, to prevent their displacement depending on the load and physiological position of the body, which from the standpoint of biomechanics leads to a violation of the proper functioning of the spine. Depending on the violation of the constituent element of the vertebral-motor segment, there are three types of instability: discogenic, discartrogenic (retrolisthetic type) and discartroosteogenic (antelisthetic type). The clinical picture of spinal instability is characterized by a violation of the supporting function and the failure of the supporting complexes, the formation of spinal deformities, which causes irritation of the spinal cord and is accompanied by pain syndrome, muscle tension, movement restriction and neurological disorders. The clinical symptoms of instability in the lumbosacral spine include: the «tightrope walker» gait, with pronounced deformities accompanied by a «duck» gait; the «step» symptom; the «reins» symptom; increased pain syndrome during movements in the spine; an increase in lumbar lordosis; horizontal location of the sacrum; hypotrophy of the gluteal muscle. The main tools for diagnosing instability are functional radiographs, spiral computed tomography, magnetic resonance imaging and the use of the scoring method. Treatment of instability in the lumbosacral spine depends on the underlying disease. The main method of surgical treatment of instability in the spinal-motor segment is decompressive-stabilizing surgical interventions, taking into account the correction of the vertebral-pelvic relationships using modern interbody implants.

The role of epidural steroid injections in the treatment of pain in patients with degenerative changes in the lumbar spine

Epidural steroid injections of the lumbar spine are a common interventional procedure that is used to alleviate radicular pain resulting from degenerative changes in the spine. Although several studies have compared epidural steroid injections with placebo with favorable outcomes, randomized controlled trials in this direction are needed. The purpose of the study was to evaluate the effectiveness of the use of epidural steroid injections in the treatment of pain in patients with degenerative lesions of the lumbar spine. During the study, 262 patients with degenerative lesions of the spine at one or two levels of the vertebral-motor segment (VMS) were selected. Epidurally transforaminally under fluoroscopic control all patients received steroid injections at the appropriate level (s) of VMS on the basis of the rehabilitation department of the Institute of Traumatology and Orthopedics of the National Academy of Medical Sciences of Ukraine during 2017-2019. Of the 262 patients who received epidural steroid injections, 204 were able to reduce pain and avoid surgery within one year. However, 58 patients experienced only slight pain relief and were recommended surgical treatment. In our study, patients with negative results were offered surgery after 1.98 ESI procedures with an interval of 3.7 months. In the group of operated patients, the preliminary use of steroid injections did not bring relief by the results of Oswestry Disability Index (ODI) and Visual Analog scale (VAS), however, the condition of these patients improved significantly after surgery (p<0.05). The use of epidural injections is possible as a first-line therapy in patients with moderate functional limitations, which can subsequently be directed to surgery in the absence of a positive result.

Rotational stability of thoracolumbar junction fixation systems

Objective To compare the rotational stability of fusion constructs using bisegmental fixation of Th12-L2 vertebrae with anterior stabilization or pedicle screw fixation.Material and Methods The strength, rigidity and limit of elasticity in the “injured vertebral motion segments (VMS) – bisegmental anterior stabilization” system under dislocating rotational loads were estimated. The data obtained were compared with the similar characteristics of the “injured VMS – bisegmental 4-screw transpedicular metal construction” system and intact spine segments.Results Under rotational loads the limits of elasticity of injured spine segments of Th12-L2 with anterior stabilization and transpedicular screw fixation (TSF) is 45.5 and 41.7%, respectively, and the general strength is 66.4% and 80%, respectively, as compared with those intact VMS. Rigidity parameters of anterior-stabilized and pedicle screw fixated VMS with unstable damage of L1 are 60.2 and 93.9%, accordingly, in comparison with those intact VMS.Conclusion No significant differences were observed between bisegmental anterior stabilization and bisegmental pedicle screw fixation of thoracolumbar junction in terms of the key mechanical properties. When treating patients with unstable thoracolumbar spine injuries using bisegmental anterior stabilization or transpedicular fixation with 4-screw spinal system possible rotation motion amplitude of operated segments must not exceed 50% of maximum physiological limits.

Analysis of the structure of revision interventions in elderly and senile patients with degenerative pathology of the lumbar spine

The study objective is to study the causes of repeated surgical treatment in patients of an older age group with degenerative pathology of the lumbar spine.Materials and methods. A retrospective analysis of the treatment of 962 patients who underwent surgical treatment of degenerative pathology on the basis of the FCN of Novosibirsk from 2013 to 2017. A total of 360 men, 602 women; average age 66 years. 624 (64.9 %) patients underwent decompression, 338 patients (35.1 %) underwent stabilizing intervention in combination with decompression. The study group consisted of 98 (10.2 %) patients who underwent repeated operations taking into account the inclusion and exclusion criteria. On average, the period after the previous intervention is 17 months (from 1 day to 6 year). 68 patients (69.4 %) previously underwent decompression interventions, 30 (30.6 %) rigid stabilization. The indication for revision treatment was the presence of pain and (or) neurological deficiency, resistant to treatment for at least 6 weeks. Evaluation criteria are described, and the structure of complications is analyzed. The minimum follow-up period after repeated surgery was 1 year, the maximum 6 years.Results. Iatrogenic factors were detected in 39 patients (39.8 %). Progression of degenerative pathology in 59 (60.2 %) patients. More often, repeated intervention was performed at the level of L4–L5 (36.1 %), the cranial adjacent segment was 76.5 %, and the caudal segment was 23.5 %. The minimum period of manifestation of continued degeneration is 3 months. The development of the disease of the adjacent segment after fixation is higher in the period of 3–4 years (p = 0.015). Patients with repeated surgical treatment after decompression for continued degeneration had a higher BMI of 32.3 (p = 0.12), as well as patients with damage to the adjacent segment 32.5 (p = 0.10), compared with the group of primary patients (BMI 30.6 on average). The similar dependance is registered for patients after stabilization: BMI of patients with repeated interventions is 34.5 that is higher than BMI of primary interventions group (on average 33.2, р = 0.13).Conclusions. The main reason for repeated interventions in patients of an older age group is the progression of degenerative pathology on the segments on the segment operated as as well as the adjacent segments (60.2 % repeated interventions, 46.9 % at the adjacent level including).Repeated surgical treatment of patients of an older age group in the early period (for up to 1 year) is most often due to insufficiently effective primary surgical intervention with prevailing early recurrence of disk herniation (1.6 % patients of total number of primarily operated). In the long term (more than 3 years), the reason for repeated surgical treatment is due to the development of an adjacent segment disease where the number of operations of patients with primarily made rigid fixation is increasing progressively in the course of time.High BMI is a predictor of the development of instability of the vertebral motor segment and continued degeneration of the operated one as well as the adjacent level in the long follow-up time.

COMPARATIVE ANALYSIS OF RADIOLOGIC ASPECTS OF FACET JOINTS IN SURGICAL TREATMENT OF PATIENTS WITH DEGENERATIVE DISEASES OF THE LUMBAR SPINE

Objective To study the radiologic characteristics of facet joints at different stages of the degenerative process in the lumbar spine to determine the indications for various methods of fixing the affected segment and to evaluate the results of treatment.Material and Methods To determine the radiologic aspects of facet joints in the affected area and in adjacent segments of the lumbar spine, two groups were formed, including 136 patients who underwent multispiral computed tomography in two-energy mode before surgery and 12 months after surgery. Group I included patients who underwent rigid fixation of the spine (360°), and group II included patients who underwent dynamic fixation using nitinol rods (180°).Results Based on a comprehensive instrumental study, it was found that the degeneration of the intervertebral disc according to Pfirrmann II and III revealed an increase in the density of the cartilaginous plate in facet joints (HU). These digital indicators confirm the preservation of joint functionality, both in the affected area and in adjacent segments. With severe degrees of disk degeneration in Pfirrmann IV and V and facet joints, deep pathological changes occurred, directed towards the loss of facet joints functionality.Conclusion The obtained digital indicators of dual-energy computed tomography for the state of facet joints in combination with the results of magnetic resonance imaging can be used as criteria in a complex of patient studies to assess the degree of degeneration of the vertebral motion segment in the affected area and adjacent segments. We recommend using these criteria as a diagnostic component for finding optimal methods of surgical treatment.

Experience in the use of dynamic interspinous fixation in the treatment of lumbar spine stenosis

The results of surgical treatment of lumbar stenosis using the dynamic intercostal fixator Coflex in the period from September 2016 to February 2019 were analyzed in 36 patients, 25 of them with monosegmental stenosis, 11 with two levels. Caudogenic intermittent claudication was observed in 27 patients. Dynamic interspinous fixation was performed on38 vertebral-motor segments of the lumbar. Assessment of the quality of life and the intensity of pain in the back and leg before and after the operation, as well as the outcome of the operation in the distant period after the operation, was carried out by validated scales and questionnaires. There were no intraoperative complications. In the distant period after surgery, the results of control functional spondylography of the lumbar revealed a direct dependence of the mobility of the operated vertebral-motor segment on the value of the disk height index. In all observations, a decrease in the mobility of the operated level was noted, which indicated the high-quality functioning of the interspinous implant. An increase in the height of the intervertebral foramen additionally provided indirect decompression of the spinal nerve in all cases. Syndrome of caudogenic intermittent claudication by the time of discharge regressed in all cases. For the period of observation of cases of development of postoperative instability and restenosis at the operated level was not noted. Satisfactory outcomes were obtained in 33 (91,7%), and unsatisfactory outcomes in 3 (8,3%) cases. Unsatisfactory outcomes in two cases were due to chronic pain in the lower back due to symptomatic stenosis of the spinal canal at an adjacent level, and in one observation, severe pain in the right leg due to the formation of sequestered herniated discs at an adjacent level. In general, interspinous dynamic stabilization has proven itself in the treatment of spinal stenosis of the lumbar spine, as the completion of the operation after the decompression phase.

The Value of Functional Multislice Computed Tomography in the Diagnosis of Instability of the Cervical Spinal Motion Segments

Objective. Instability of the vertebral motion segments is a very urgent problem of medicine, since it has very serious consequences. Today, search for optimal diagnostic methods continues. The authors propose a new diagnostic technique - functional multislice computed tomography (fMSCT). The objective of the study was to investigate the efficiency of the technique versus radiography. Material and methods . The new technique was used to examine 35 patients with a referral diagnosis of cervical spinal instability, who had previously undergone cervical spine radiography in the frontal and lateral projections. Results. Instability of the spinal motion joints in its clinical manifestations is similar to the hypermobility of the cervical spine. According to the results of fMSCT, the occurrence of signs of instability and hypermobility was assessed. When performing fMSCT, compression of the spinal canal was detected in 48.6% of patients, compression of the spinal roots was revealed in 85.7%. Violation of the integrity of the anterior and posterior support complexes was registered in 11.4% and 97.1% of patients, respectively. Conclusion . The developed fMSCT technique allows to accurately assess both the statics and dynamics of the spine and, unlike radiography, to diagnose ventral and dorsal vertebral displacements. The technique is recommended for widespread use in clinical practice.

Cellular and molecular aspects of degenerative disc disease and potential strategies of biological therapy

Back pain is one of the main global health problems with a high level of prevalence and patients’ disability. In most cases, it is associated with degenerative spine damage (degenerative disc disease), dorsopathy, discopathy (M51 and M53 according to the International Classification of Diseases, 10th revision), affecting all levels of the intervertebral disc (IVD) (cytological, chemical and biochemical) as a whole as well as biological molecules that regulate homeostasis of the disc intercellular substance (growth factors, pro-inflammatory cytokines, enzymes). A key point in IVD dehydration is that catabolic processes predominate over anabolic ones due to changed gene expression in the corresponding biologically active molecules, disc angiogenesis and neoinnervation of the structures of the fibrous ring and pulpous nucleus. The latter is responsible for chronic pain in patients.Cells supporting homeostasis in nucleus pulpous, chondrocytes, continuously synthesize and restore proteoglycans and hyaluronic acid in nucleus pulpous, restoring shock-absorbing functions of the vertebral-motor segment. Decreased activity and death of chondrocytes in the avascular disc structure is a serious problem for reparative medicine. In accordance with IVD molecular-cellular mechanisms, numerous approaches to treat degenerative disc disease are being developed, each of which, influencing one of the links in the pathogenesis, has a direct or indirect effect on IVD repair.The article describes morphology, pathogenesis and genetics of degenerative disc disease, as well as main modern strategies of biological therapy: tissue engineering, biologically active substances locally used in IVD matrix, including PRP therapy (Platelet Rich Plasma therapy), methods of gene (using the viral vector) and cell therapy, as well as experience in the local use of genetically engineered biological products. Most successful studies are a combination of cell and gene therapy with the use of synthesized matrices.

Pre-operative planning in surgical treatment of patients with lumbar spinal stenosis of degenerative etiology

Aim. Develop a pre-operative planning algorithm to treat patients with lumbar spinal stenosis of degenerative etiology.Material and methods. The results of surgical treatment of 522 patients at the age of 23-78 years with degenerative lumbar stenosis were analyzed. Patients with osteoporosis, with a sagittal spinal profile disorder or deviations in the frontal plane of more than 20 degrees, with spondylolistesis of more than 1 Meyerding degree, with accompanying pathology aggravating the Charlson Commorbidity Index of more than 8 points, were not included in this group. All patients underwent decompressive-stabilizing operations using TPF for 1 to 8 vertebral-motor segments (PDS). Decompression and interbody stabilization were performed by the method PLIF, TLIF, or by the method of reconstruction of the lumbar vertebral-motor segment (patent #2527150), or the ventral fusion was performed.Results. Immediate and distant results over a period of 24-36 months were studied by regression in major clinical manifestations. The VAS, McCulloch and Young scales, the Oswestry questionnaire, and the modified Macnab scale were applied. The quality of decompression, correction in operated PDS and intertose splicing were evaluated. The effect of the initial state of patients on the obtained results and the number of complications were studied as well. For this purpose, the correlation analysis was carried out between clinical parameters characterizing initial condition of patients (length of lumbar spinal stenosis, degree of functional maladaptation, duration of anamnesis and severity of premorbid background) and achieved results of treatment, as well as number of complications. A correlation analysis was also performed between the technique of performed operations and surgical tactics on the one hand and the achieved results and the number of complications on the other.Discussion. Differences in results and number of complications depending on the applied technical and tactical treatment options and statistical treatment with determination of the correlation coefficient of Spirman and Fisher's criterion determined clinical and spondylometric signs in the pre-operative state of patients, that influenced the probability of complications when using the specified technical and tactical treatment options. It has been found that the state of the premorbid background reliably affects the probability of the most dangerous intraoperative and early complications. The length of decompressive stabilizing operations affects the probability of evidence for audits in the distant period. When performing TLIF, the spondylolistesis presence increases the likelihood of intraoperative liquvorea. The method of lumbar vertebral-motor segment reconstruction in lumbar lordosis deficiency improves the possibility of correction in operated PDS in comparison with TLIF technique.Conclusion. Taking into account the revealed statistically confirmed effect of a number of clinical and spondylometric signs of the pre-operative condition in patients on the probability of complications using various technical and tactical versions of treatment, an algorithm of pre-operative planning of surgical intervention in patients with lumbar stenosis of degenerative etiology is presented.

DEGENERATIVE DISC DISEASE IN YOUNG PEOPLE. MEDICAL IMAGING TECHNIQUES

Degenerative changes of intervertebral discs is a very complicated process as a result of interaction of many factors: genetic, environmental, physical activity. Abnormalities in the vertebrae structure create the preconditions for the overload of the vertebral motor segment, which contributes to the spread of degenerative lesions and increases the risk of spinal injuries. Degenerative disc disease is one of the most common causes of back pain. The process of degeneration begins at a young age and in adulthood it often becomes widespread with a predominance of one or another localization. Methods of medical imaging occupy an important place in diagnosis of musculoskeletal pathologies. Radiography assesses the changes only in bone structures, but does not allow the visualization of soft tissues, which include not only the ligaments of the vertebral motor segment, but also the intervertebral discs. Magnetic resonance imaging is the most effective method for diagnosing degenerative changes in intervertebral discs. Possibilities of ultrasound examination in the diagnosis of early stage degenerative disc disease have not been studied enough. There were examined 147 patients aged 18−27 years with clinical and neurological signs of degenerative disease of cervical and lumbar spinal discs. Ultrasonic semiotics showed changes within the pulpal nucleus as an increased echogenicity and displacement back towards the fibrous ring, fibrous ring thinning, which indicated the disc protrusion. In patients with pain in neck and lower back, fragmentary imaging of the fibrous ring and prolapse of the disc contents into the lumen of spinal canal, indicating the development of hernias was found. The presence of herniated discs of cervical and lumbar spine in all cases coincided with the results of magnetic resonance imaging, and protrusion did in 91,4 % of cases. Thus, among medical imaging the ultrasonography is the most accessible and informative method for diagnosing degenerative changes in intervertebral discs of cervical and lumbar spine. Key words: degenerative disc disease, ultrasonography, cervical and lumbar intervertebral discs.

Role of radiologic imaging complex in morpho-pathogenetic approach to sanatorium resort intensity regimen selection in patients with dorsopathies

At the present time for sanatorium treatment of dorsopathies no morpho-pathogenetic principles are based on severity of degenerative spine changes. The choice of treatment modalities is provided according only to clinical signs and the fact of degenerative spine disease presence, in spite of limitations and contradictions to some resort procedures because of their mechanisms and peculiarities of therapeutic effects. Materials and methods. Comparison of complex imaging examination and sanatorium resort intensity regimen medical appointments of 952 patients with dorsopathies was provided depending on morphological pattern and severity of degenerative spine changes. Case histories, sanatorium medical outpatient cards and the results of radiologic imaging (computed tomography, magnetic resonance imaging, spondylography and osteodensitom-etry) were analyzed. Results. Three groups of sanatorium resort therapeutic action intensity (maximal, 376 patients; limited, 493 patients; and minimal, 83 patients) for patients with dorsopathies were established. The most significant morphological criteria of patient distribution into appropriate groups were established, such as bone mineral density state, the presence and severity of spinal osteoarthrosis and spondylolisthesis, vertebral-motor segment stability or instability, vertebral body hemangiomas. The size of intervertebral disc extrusions and grade of disc height decreasing played a secondary role. The value of spondylography, computed tomography, magnetic resonance imaging and dual-energy radioabsorptiometry in determination of these criteria is presented, as far as in imaging algorithm of examination of patients with dorsopathies on the pre-sanatorium stage, with calculation of computed tomography and magnetic resonance imaging sensitivity, specificity and accuracy. Discussion. Forming morpho-pathogenetic approach to sanatorium resort treatment of dorsopathy demands essential application of modern radiologic imaging modalities. The presence, type and severity of degenerative spine morphological changes must be as fundamental as clinical and neurological pattern, affecting sanatorium resort intensity regimen selection and treatment modalities and schemes. In basic cases most advisable radiologic imaging pre-sanatorium examination modality should be computed tomography, but others are also necessary to use when concretely indicated.

ROLE OF DOPPLEROGRAPHY IN DIAGNOSIS OF HEMODYNAMIC DISORDERS IN VERTEBRAL ARTERIES WITH INSTABILITY AND ARTHROSIS OF ATLANTO-AXIAL JOINTS

Biomechanical dysfunction of the cervical vertebral motor segment is one of the most common causes of cervicogenic headache. Cervical pain syndrome of vertebrogenic genesis is often observed against the background of congenital anomalies of bone and soft tissue structures. It has been established that anatomical variation of the place of junction, the level of entry into the bone canal, as well as doubling of the vertebral arteries create prerequisites for pathological changes of hemodynamics in them at different functional loads, therefore, timely diagnosis is important to prevent these disorders. Due to the fact that the vertebral arteries are contained in the vertebral canal, which is formed by the transverse processes of the cervical vertebrae, they are normally protected against rotational movements. The development of osteoarthritis with the appearance of osteophytes leads to compression of the vertebral artery or irritation of the cervical nerve plexuses located on the walls of blood vessels. This, in turn, leads to a spasm of the vertebral arteries during rotational movements. To develop informative hemodynamic parameters in the vertebral and basal arteries in case of pathologies of the cervical spine, an analysis of the Doppler sonography results was performed in patients with instability and arthrosis of the atlanto−axial junction. The maximum systolic velocity (Vs), end diastolic velocity (Vd), resistance index (RI) in the second and third segments of the vertebral arteries in neutral position of the head and during rotational movements were determined. Thus, hemodynamic disturbances in the vertebral arteries in patients with instability and arthrosis of the atlanto−axial articulation are manifested by a decrease in Vs, an increase in RI. These changes are most pronounced with functional loads in the form of rotational movements of the head. Key words: dopplerography, atlanto−axial joints, third segment of the vertebral artery.

DIAGNOSTIC RADIOLOGY METHODS OF DEGENERATIVE CHANGES IN LUMBAR INTERVERTEBRAL DISCS IN YOUNG PEOPLE

In recent years, the number of scientific studies investigating the prevalence of low back pain among schoolchildren has been significantly increased. Degenerative disease of the discs is often accompanied by a low back pain with irradiation into the legs in representatives of different age groups, in particular, in older children. The main factors of its development are genetic predisposition, trauma, obesity, lack of exercise. Most of the components of the vertebral motor segment have the nerve endings and reflex influences, accompanied by inflammation, microcirculatory disorders, and their combination contributes to an appearance of back pain. Diagnosis of degenerative disc disease includes the study of the patient's medical history, analysis of clinical symptoms, use of functional tests and various types of imaging to clarify the degree of macrostructural changes in disks, among which the main place is taken by the magnetic resonance imaging. The development of degenerative changes in intervertebral discs as early as childhood, which requires a further study using non−invasive, accessible and informative methods, especially ultrasound ones. The results of ultrasonography of lumbar intervertebral discs were analyzed in 36 adolescents aged 16−18 years, diagnosed for the protrusion when the MRI was applied. Paramedian protrusion was found to be significantly more frequent than posterolateral, median, and circular ones. Due to its non−invasiveness, low price and information value, the ultrasound can be the most popular method not only as a screening one but also for the expert evaluation of lumbar intervertebral disc protrusion in schoolchildren. Key words: diagnostic radiology, lumbar intervertebral discs, adolescents.

The Experience of Using the Implantable Interspinous System COFLEX in the Surgical Treatment of Compression Forms of Lumbosacral Radiculitis

The paper presents the experience of surgical treatment of 58 patients with discogenic lumbosacral radiculitis. The aim of the surgical treatment was to eliminate the compression of the spinal roots of the herniated disc with the subsequent stabilization of the spinal-motor segment with implantable interspinous system COFLEX. Indications for surgical treatment were persistent radicular pain syndrome, which was not stopped by conservative methods of treatment, and disco-radicular conflict in the area of the interested vertebral-motor segment, confirmed by radiation research methods. In the diagnosis, the following research methods were used: clinical and neurological examination, survey and functional spondylography of the lumbar spine, computed tomography with contrast myelography, morphometric and statistical methods. The effectiveness of treatment was evaluated in 49 patients (84 % of operated) one and a half years after surgery. All patients showed complete regression of neurological deficit and satisfactory standing of the implanted interstitial dynamic system COFLEX in the operated vertebral-motor segment. Thus, the use of the implantable COFLEX dynamic system for the above indications is the choice method for operating surgeons, in which it is assumed that the function of the interested vertebral-motor segment is preserved.

Radiological and Functional Research Methods in the Diagnosis of Segmental Instability in Cervical Osteochondrosis and of Cervicobrachial Syndrome

This paper presents the analysis of diagnostic policy of 72 patients with cervical osteochondrosis and cervicobrachial syndrome. All patients were examined according to a single program, which included a specially designed questionnaire containing address data, diagnosis, history of life and illness, patient complaints, with a mandatory examination by a neurologist for the presence of compression of neural structures of the cervical spine with a detailed description of the local status and clinical and neurological syndromes. Patients underwent general spondylography of the cervical spine in the anteroposterior and lateral projections. For the diagnosis of segmental instability, functional spondylography was performed in the position of maximum flexion and extension and functional spondylography with burdening, which is based on mathematical modeling of the distribution of the vector force load system in the cervical spine under conditions of inclination of the head at an angle of 45° (flexion) and 15° (extension) with the weight on the head weighing up to 500 grams (putting a special device on the head). A mathematical formula for calculating the index of instability of the vertebral motor segment in the cervical spine is proposed. Sagittal balance of the cervical spine was studied with the correlative dependence of its indicators with the intensity of the pain syndrome according to standard spondylography and magnetic resonance imaging. Identified marker indicator of electroneuromyographic studies of the upper extremities - F-wave. Based on the obtained fundamental knowledge, an algorithm for diagnosing osteochondrosis of the cervical spine and cervicobrachial syndrome has been developed and scientifically substantiated.