Surgical treatment of intervertebral disc herniations
Conservative management of patients with disc herniations can last up to 12 weeks. In modern practice, when surgery is necessary, microsurgical interventions are preferred. Unlike traditional laminectomy, such techniques minimize the rehabilitation period, allowing the patient to return to normal life within just a few days.
Treatment of specific spinal pathologies
Various structural changes of the spine have their own management regimens:
- Cervical myelopathy: Conservative management includes limiting neck strain, analgesics, and NSAIDs for pain relief. Surgery (spinal cord decompression) is indicated when medications are ineffective and symptoms progress, such as peripheral paresis of the upper extremities and central paresis of the lower extremities.
- Lumbar stenosis: Initially, patients are advised to avoid provoking postures, take NSAIDs, and use microcirculation-improving drugs. Severe pain is managed with epidural blocks (a mixture of corticosteroids and anesthetics). Surgical removal of compression is performed in cases of severe pain, persistent lower limb paraparesis, or pelvic organ dysfunction.
- Lumbar spondylolisthesis: Conservative strategy involves wearing a brace during exertion, reducing physical activity, and taking painkillers. Surgery is required if conservative measures fail in the presence of severe pain.
Chronic non-specific pain and fibromyalgia
Chronic non-specific back pain requires a comprehensive examination (neurologist, orthopedist, psychologist) and, as a rule, outpatient treatment. Sometimes hospitalization in specialized centers with a multidisciplinary approach is indicated. Main areas:
- Physical rehabilitation and exercise therapy.
- Cognitive behavioral therapy (CBT) to adjust illness perception.
- Pharmacotherapy: tricyclic antidepressants (e.g., amitriptyline) to reduce chronic pain.
- Manual therapy (when strict indications are met).
Fibromyalgia also requires comprehensive measures:
- It is important to explain to the patient that the condition is benign.
- Antidepressants (amitriptyline, duloxetine), NSAIDs, anticonvulsants (pregabalin), and local anesthetic trigger point injections are used.
- Stretching and strengthening therapeutic exercises, as well as psychotherapy, are beneficial.
Non-pharmacological methods and prevention
Physiotherapy (electrotherapy, magnetotherapy, ultrasound), reflexotherapy, and spinal traction are widely used in combination therapy.
For relapse prevention and avoiding the chronic progression of back pain, it is necessary to:
- Avoid heavy lifting, asymmetrical loads (e.g., carrying bags on one shoulder), and prolonged sitting.
- Regularly engage in exercise therapy and swimming to maintain the muscular corset.
Briefly: answers to topical questions
What specific symptoms and indications serve as the basis for surgical treatment of lumbar spondylolisthesis?
The basis for surgical treatment of lumbar spondylolisthesis is the lack of response to conservative therapy in the presence of a pronounced pain syndrome. When spondylolisthesis is combined with spinal stenosis, indications for surgery include:
- Radicular pain syndrome — resistant to conservative therapy.
- Neurological deficit — motor and/or sensory impairments.
- Neurogenic intermittent claudication — a specific symptom of stenosis requiring surgical correction.
What are the classic clinical stages and neurological syndromes associated with lumbar intervertebral disc herniations?
Classic stages of intervertebral disc herniation formation include protrusion, herniation, and extrusion (prolapse).
Stages of the pathological process:
- Protrusion — bulging of the intervertebral disc.
- Herniation — accompanied by spinal nerve root compression.
- Disc extrusion / prolapse — characterized by compression of multiple spinal nerve roots.
The main neurological syndromes in lumbar disc herniation include:
- Discogenic radiculopathy — compression of the spinal nerve root leading to its edema and ischemia.
- Acute cauda equina syndrome (cauda equina) — occurs with massive compression of spinal canal structures, presenting with lower paraparesis, marked reduction of all types of sensation in the anogenital area, and pelvic organ dysfunction (paradoxical ischuria / ischuria paradoxa).
Class and exam questions
What is the advantage of modern surgeries for disc herniations?
The use of microsurgical techniques instead of classical laminectomy significantly shortens the recovery period, allowing the patient to return to daily activities within a few days.
When is surgery indicated for cervical myelopathy?
Surgical intervention is necessary in the absence of effect from conservative treatment and progressive neurological deficit, such as the development of paresis in the arms and legs.
Which medications are effective for chronic back pain and fibromyalgia?
Tricyclic antidepressants (e.g., amitriptyline) have proven high efficacy in reducing chronic pain syndrome. Anticonvulsants such as pregabalin may also be used for fibromyalgia.
How to prevent recurrent back pain?
It is necessary to avoid biomechanical disorders (heavy lifting, asymmetrical and prolonged static loads) and regularly engage in swimming or therapeutic exercises.
What else to study on this topic
- Detailed mechanism of action of epidural blocks in lumbar stenosis.
- Features of the multidisciplinary approach in treating chronic non-specific pain.
- The role of cognitive behavioral therapy in the treatment of chronic pain syndromes.
- Diagnostic criteria and localization of tender points in fibromyalgia.
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