Thoracic osteochondrosis symptoms

Spinous processes, arches and articular processes of thoracic vertebrae tile cover each other;articular processes articulate in the frontal plane. The ribs connect all the parts of the skeleton of the thorax into a relatively rigid system. The intervertebral disc in the thoracic part is covered by the rib-vertebral joints. The exception is XII, and sometimes XI pair, where the articulation does not occur at the disc level, but directly on the body of the vertebra. Limited mobility of the thoracic spine plays a positive role, since the intervertebral disks are less injured. How to treat this ailment with folk remedies, look here.

Important in the anatomical and physiological aspect is the presence of physiological thoracic kyphosis. If in the cervical and lumbar parts of the physiological lordosis leads to a maximum load on the posterior parts of the disc, then in the thoracic part most of the load falls on the front parts of the spine, therefore for the chest osteochondrosis the front and lateral osteophytes are more characteristic, which in general proceed asymptomatically. The posterior osteophytes and large disc herniation in the thoracic region are rare.

The incidence of intervertebral disc lesions in the thoracic region increases from the top down. According to our data, the lesion of the three lower thoracic discs Th10-12 accounted for more than half of all cases of chest osteochondrosis. Approximately the same pattern is observed in compression fractures.

The height of intervertebral discs in the thoracic region is insignificant;if in the cervical region the total height of the disks is 40%, then in the thoracic region this figure is only 20%.The obliquely arranged lateral processes and rib-vertebra articulations severely restrict inflexion in this part of the spine-up to 3-7 ° in each segment.

The area of ​​the spinal canal in the thoracic region is smaller than in the cervical and lumbar regions and is 2.3-2.5 cm2.The dura mater does not adhere directly to the inner surface of the spinal canal. They are separated by an epidural space filled with loose fatty tissue containing a rich network of venous plexuses. The spinal roots, which extend at an acute angle, lie in their vaginas, which are protrusions of the dura mater, almost to the intervertebral ganglion. Distal from the intervertebral ganglion, the sensory and motor roots form a mixed nerve( funiculus).The length of the roots increases in the caudal direction. At the Th12 level, it is 81 mm.

In adults, the spinal cord, with an average length of 40-50 cm, ends in men at the level of the L1 disc, and in women - approximately at the mid-body level of L2.Below this vertebra lie the lumbosacral roots that form the ponytail. In the lateral horns of the spinal cord and the lateral parts of the anterior horns, sympathetic cells are located, the axons of which leave the spinal cord in the anterior roots. Sympathetic cells in the spinal cord are concentrated mainly in the thoracic region: from the VIII cervical to the I-IV lumbar segments. Outgoing from the spinal cord 6 the composition of the front roots sympathetic fibers form rr.communicantes albi, which enter the borderline sympathetic trunks. These fibers, originating in the gray matter of the spinal cord, are called preganglionic. Upon exiting from the intervertebral foramen, the sinuvertebral nerve connects to a single trunk with a sympathetic branch that extends from the border sympathetic trunk. Most of the fibers from the sympathetic nodes form bundles of sympathetic fibers that have a certain relation to the internal organs, is part of the visceral plexus or ganglion located in the organs themselves( heart, gastrointestinal tract, etc.).

In the thoracic region, the borderline trunk consists of 10-12 sympathetic nodes, located at the level of the articular lines in front of the head of the ribs. Osteoarthritis in the region of the vertebral-rib and transverse-rib joints often accompanies the osteochondrosis of the thoracic region and is its consequence. The intimate connection of the spinal nerves and the sympathetic trunk with the capsules of these joints under these conditions leads not only to shingles of the type of intercostal neuralgia, but also to autonomic syndromes.

The connection between the thoracic and cervical nodes is carried out by a rich network of anastomoses. The lower jug ​​and the upper thoracic nodes, joining, form a stellate node( gangl. Stellatum), from which the main cardiac branch n.cardialis, branches to the spine, esophagus, bronchi, to the recurrent nerve and carotid arteries. In the innervation of the heart, there are also branches from the four upper thoracic sympathetic ganglia, the wandering and pharyngeal nerves. The ventral nerve, formed by sympathetic fibers from Th5 to Th10 nodes, passes through the diaphragm and enters the solar plexus.

Vegetative fibers either approach directly to the innervated tissues and affect them chemically( diffusion synapses), or to intramural ganglia located already in the organs themselves( heart, gastrointestinal tract, etc.).

The vasomotor nerves of the lower extremities originate from the three lower pectoral and two upper lumbar segments, which are in connection with the lower lumbar and the three upper sacral nodes.

Lesion of thoracic discs, in addition to static disorders, leads both to direct signs of compression of roots and spinal cord, and to irritation of the mass of efferent fibers manifested by vasomotor, vegetative and trophic responses.

A study of recent literature shows that a certain number of cases of acute and chronic ischemia of the spinal cord is associated with the pathology of the intervertebral disc. Of the 52 radicular arteries penetrating through the intervertebral openings into the vertebral canal, the blood supply to the spinal cord is mainly carried out by the anterior spinal artery, which is formed from 6-8 radicular arteries with their anastomoses. From the basin of the anterior spinal artery is supplied 4/5, from the back - 1/5 of the substance of the spinal cord. The posterior spinal artery is rich in anastomoses, so its occlusion usually does not lead to circulatory disorders. Some departments are always supplied with a single radicular artery. Pressing it with an osteophyte or a hernia can lead to a marked shortage of blood supply or ischemia of the area of ​​the spinal cord. The arterial blood supply of the spinal cord is divided into several zones. In particular, the root artery entering the Th10 spine and L1, the Adamkiewic artery, which feeds the whole segment of the spinal cord lying below the Th8 segment, is of great importance.

Thoracic osteochondrosis develops sharply. Usually, after trauma, sometimes insignificant, and depending on localization, the clinical picture is characterized by tetra- or paraparesis with conductive loss of sensitivity and pelvic disorders, then a cone syndrome with saddle anesthesia of the perineum and urogenital organs, then mild paralysis of certain muscle groups. These cases resemble "paralytic sciatica", caused by compression of the roots of the horse's tail by the prolapse of the disc. And although in most cases for acute vascular myelopathy is characterized by a relatively rapid regression of symptoms, their severity is quite high. In this aspect I would like to emphasize the danger of rhizotomy of the roots( naturally, together with their artery), undertaken to relieve the pain syndrome in patients with herniated discs. Cases of gross pelvic disorders that develop after this, and anesthesia of the anogenital region after crossing the roots of L5 or Si are described. To this closely adjoins the Corbin( 1960) report on 13 cases of myelomalations that developed after thoracolumbal sympathectomy. The author considers them to be the result of accidental damage to one or several thoracic intercostal arteries feeding the thoracic radicular arteries. In his opinion, special danger is represented by manipulations in the root zone of Th8-L2 on the left.

Arseni and Nash( 1963) observed and operated on a patient with transient attacks of lower paraparesis, caused by a small calcified hernia compressing the anterior spinal artery in the thoracic region. The presence of some compression symptoms is much higher than the level of discoloration most often indicates secondary disorders of the spinal circulation.

These anatomical features of the thoracic spine and mainly complex interaction of vegetative innervation impose imprint on the clinic of chest osteochondrosis. First of all, we are talking about symptoms from the internal organs, sometimes simulating organic diseases( for example, abdominal syndrome).

Along with the topical principle, innervation of internal organs is carried out simultaneously from a number of adjacent segments, and some organs,( small intestine, rectum) have bilateral innervation. The liver, the gallbladder, the blind and ascending colon are innervated by the right sympathetic trunk, while the heart, spleen, pancreas, stomach, descending colon and sigmoid colon are left.

The number of patients with chest osteochondrosis appears to be much larger than can be assumed from the frequency of diagnosed cases. The reason is that the main complaints of patients are accentuated on visceral disorders. It is this circumstance that explains the long-term treatment of such patients in therapists.

The clinical picture of chest osteochondrosis is extremely diverse, but none of the symptoms is strictly specific. In general, they depend on the localization of the process and the degree of its expression. Often, the attention of clinicians is directed to the posterior hernia of the disc and, if it is not found on the operation, the diagnosis is considered erroneous. However, a herniated disc is only one of the manifestations of osteochondrosis. In addition, it is very rare in the thoracic region. When examining 202 patients with osteochondrosis of the thoracic spine, only 4 posterior hernias and 26 protrusions were found. A significant frequency of detection of a rare pathology is probably related to the target selection of our patients.

It is characteristic that the pain from the very beginning is localized in the spine and only eventually radiates to another place. However, the pains of new localization are sometimes so strong that they fix the main attention of the patient and the doctor. Irradiation of pain and vegetative disorders proceed according to the type of radicular disorders or compression or ischemic myelopathies.

Pain in the thoracic spine is the main symptom that was noted in all patients. After physical exertion or a long stay in one position, the pain intensified, which made the patients often change their position even at night. Very characteristic is the so-called inter-shoulder sympathy, manifested by burning, aching or blunt pain in the scapula and interlobular space. Patients complain of the feeling of "iron mites" squeezing their back, more often at night. This peculiar phenomenon is caused by the disappearance of the reflex tension of the muscles and the ligamentous apparatus in a dream.

However, not all authors recognize the priority of pectoral osteochondrosis in the syndrome of interscapular sympathy. Based on the fact that the innervation of the muscles of the upper parts of the trunk( in particular, the rhomboideus) in contrast to the skin of this region is carried out by the cervical segments C5-C8, some authors consider the interlobular dorsalgia a sign of cervical osteochondrosis. But this symptom was observed when both the cervical and upper thoracic parts of the spine were affected. It is known that with cervical myelopathy the lower border of the affected dermatosis is projected into 5-6 segments below.

Morbidity with percussion of spinous processes was revealed in 188 patients. Sometimes the pains were very intense and radiated to other parts of the spine and internal organs.

Restriction of mobility of the thoracic spine( mainly extension) was established in 156 examined. In some of them, any sharp turn, tremor, or cough increased pain;some patients could not use the city transport. In cases of acute exacerbation, local soreness( sometimes with irradiation) with an axial load of the spine was detected in 20 patients, in 78, a moderately expressed scoliosis was detected. Protective defensiveness of paravertebral muscles in chest osteochondrosis was found in only 37 patients. The rarity of this symptom, as well as mild scoliosis even with severe pain, seems to be explained in the immobilizing role of the rib cage.

Compared to cervical and lumbar localization, sensitivity disorders in chest osteochondrosis are more clearly defined. This circumstance is caused not only by metameric segmentation, but also by the widespread nature of the lesion. Sensitivity was impaired in 137( 68%) patients;of them hyperesthesia was found in 41, and hypesthesia in 96. Paresthesias were observed in patients with a combined form of osteochondrosis( often with cervical spine).

Changing tendon reflexes is characteristic for chest osteochondrosis, since the lumbar and sacral segments of the spinal cord, in which arches of the knee and Achilles reflexes are closed, is at the level of the inferior thoracic vertebrae. Degenerated disks can affect both the spines passing here, and the spinal cord. The defeat of the anterior roots can cause segmental abaissement of the function of the abdominal musculature. In the patients we observed, the knee( in 45) and the Achilles( in 21), the reflexes were most often elevated. Six patients had a clonus of feet. Reduction of reflexes( mainly Achilles and abdominal) was detected in 33 patients. There are often bilateral violations. In 3 patients with a hernia at the level of Th11-12, pathological reflexes( symptoms of Babinski and Rossolimo) were observed. Although the violation of reflexes occurs quite often, for topical diagnosis this symptom, unlike the violation of sensitivity, is of little value.

A study of cerebrospinal fluid showed that an increase in the level of protein in the cerebrospinal fluid in the presence of a hernia or( more rarely) protrusion is associated with venous congestion. IM Irgier( 1965) described a rare case of posterior disc herniation in the thoracic region with a sharp increase in the protein content to 26 g / l. We studied spinal fluid in 52 patients. An increase in the protein content( up to 0.99 g / l) was found only in 13. This study has a differential diagnostic significance. In contrast to the extramedullary tumor, protein-cell dissociation is rare.

Vasomotor disorders of the lower limbs under the influence of a prolonged spasm on the basis of pain impulses - a frequent manifestation of chest osteochondrosis. Oscillator index was reduced in half of our patients. In some, along with a decrease in the oscillatory index, a decrease in skin temperature of the extremities, chilliness, skin peeling and fragility of the nails were revealed.

Four patients( and subsequently operated) had a typical thoracic myelopathy clinic due to the posterior hernias of the discs( two medial and two paramedic).Clinically, the disease was of the type of extramedullary tumor compression. However, a typical anamnesis( acute or subacute onset of the disease after trauma), as well as contrast study data( epidurography and myelography) suggested a herniated disc. The clinic of thoracic myelopathy, and with simultaneous compression of the roots - radiculophelopathy, consisted of four main symptoms: pain, motor, sensory and pelvic disorders. Pain, except for vertebral localization, is most often dermatomic in type of intercostal and abdominal neuralgia or irradiated to the lower extremities. Motor disorders are manifested by the paresis of one or both legs( often spastic) with muscle atrophy. Characteristic is a decrease in not only superficial, but also deep sensitivity, as well as paresthesia. Disorders of the function of the pelvic organs are expressed in the absence of a feeling of passing the urine, delayed urination and constipation, and subsequently - incontinence. Violations of sexual functions are common.

According to Abbott and Retter( 1956), depending on the location of the prolapse, three clinical forms are distinguished:

Visceral syndromes. Pains in the heart( pseudo-anginal syndrome) are often noted in patients with chest osteochondrosis. IS Berlyand et al.(1964) observed 25 patients admitted to the hospital with suspicion of myocardial infarction who had a posterolateral syndrome due to osteochondrosis of the inferior and upper thoracic spine.

Recognizing the true cause of pain is often difficult. In the presence of carefully collected history, it can be shown that pain in the region of the heart occurs simultaneously with pain in the spine, sometimes after lifting the weight( lumbago), with an uncomfortable position of the body, intensify with coughing, sneezing and abrupt movements. Pseudoangiogenic pain can be pressing, compressing, girdling, localized in the chest and in the heart, more often at the top, irradiate to the left humerus. Pain almost does not respond to nitroglycerin and Validol;Their intensity usually decreases in 15-20 minutes, but often they last a long time( several days), and after the disappearance there is soreness in the left arm and ribs( from II to V).Unlike angina, radicular pain is less painful, but if the pain begins with a lumbago, there is a feeling of stiffness of the entire thorax, the patients froze, not daring to move. Breathing in such cases is superficial. Often, these attacks are taken for asthma or neurotic reactions. ECG is not detectable.

Davis( 1957) considers the most important diagnostic evidence of radicular syndrome the renewal of cardiac pain when pressing on the spinous processes of Th2-Th7.This symptom was revealed by us in 18 patients. In 74 patients, pain in the heart area was accompanied by a heartbeat. At times they had the character of real seizures. No focal changes were detected on the ECG in any case. These patients were treated for a long time about vegetoneurosis and angina pectoris. Pain in the heart often combined with headaches.

Reports on developing abdominal pain in osteochondrosis of the inferior thoracic localization are noted by a number of authors. Often there is a need to differentiate abdominalgic syndrome, caused by vegetative pain, from the syndrome of an acute abdomen, requiring urgent surgical care. Cases of erroneous diagnoses of an acute abdomen, which led to unnecessary laparotomy, are described.

Various disorders of the gastrointestinal tract were observed in 26 patients. Characteristic painful heartburn, not depending on acid indicators, and constipation. Pain syndrome can be pronounced. Five of these patients after a thorough investigation were transferred to us from the surgical department as having arrived with an erroneous diagnosis of acute appendicitis. Apparently, residual pain after appendectomy is often due to improper diagnosis.

The abdominalgic syndrome may be due to irritation of the solar plexus, which includes nn.splan-chnici, vagus and phrenicus dextra. The clinical picture is characterized by pain in the navel and back( "solar nail"), increased arterial pressure due to spasm of the vessels of the abdominal cavity and inhibition of peristalsis.

Pain in the right upper quadrant often depends on the lesion of the lower thoracic segments. Such patients are periodically treated for the diagnosis of cholecystopathy.

Indications for the possibility of a disorder of the function of the urinary tract in chest osteochondrosis are found in the works of Love and Schorn( 1965), which lead to 22 cases of bladder dysfunction.25 patients with osteochondrosis with typical attacks of renal colic and dysuric disorders were observed. Four of them previously suffered an uncomplicated compression fracture of the spine. A thorough urological examination( review radiographs, excretory urograms, urinalysis, etc.) made it possible to completely exclude urological diseases. The degenerative process of the spine was localized at the level of Th9-L1.One of these patients had a Th11-12 disc rupture on the discs. Sexual weakness is possible with chest osteochondrosis;in women loss or weakening of libido, in men a decrease in potency. This symptom was registered by us in 19 patients. In 1 patient Arseni and Nash, priapism and satyriasis were observed: in this case, a 21-year-old male with 18 years of age had elevated sexual desire, and at age 19, persistent priapism developed without disrupting ejaculation. In the operation, the calcified central hernia of the Th12 disk was removed, and the patient completely got rid of abnormalities in the genital area.

Thus, for chest osteochondrosis, along with static and neurological disorders and the corresponding radiographic data, visceral disorders are constantly characterized.

Often, cases of overdiagnosis of chest osteochondrosis. We repeatedly advised patients suffering from organic lung diseases, the gastrointestinal tract, diaphragmatic hernia, in which reflected back pains were typical irritation of sympathetic formations in the thoracic and abdominal cavity( Geda-Zakharyin zone).These symptoms were unreasonably interpreted as visceral and were supported by roentgenological data, which had the nature of spondylosis, which occurs in almost all individuals over 40-50 years of age. As Matzen( 1968) rightly points out, "we would go far, explaining every vague pain syndrome in the thoracic or abdominal cavity as vertebrogenic."

The diagnosis of chest osteochondrosis has not yet been fully developed. In the degeneration of the disc in this department, along with rooting disorders, a number of symptoms occur, characteristic of diseases of internal organs. This often obscures the underlying cause of the disease, forcing patients to contact therapists, surgeons, urologists and other specialists. Out of 202 patients with thoracic osteochondrosis, trauma of the spine as a direct cause of the development of clinical syndromes or exacerbation of the disease was noted in 53, and 40 of them had uncomplicated compression fractures of vertebral bodies. Most patients had a history of spinal congestion or no traumatic moments. Thoracic osteochondrosis in 38 patients was the result of the transferred Sheyurmann disease - May. Preventive measures were not carried out: 17 patients for a long time performed heavy physical work, despite the progression of thoracic kyphosis.

Given the projection distortions associated with the presence of ribs and physiological kyphosis, spondylograms in the direct and lateral projections are removed during inspiration, separately for the upper and middle chest thoracic spine. The overwhelming majority of patients with chest osteochondrosis can detect certain radiologic signs of a dual kind;dependent on the degeneration of the disc and associated with changes in the vertebrae themselves.

We detected the symptoms of disk degeneration in all 202 examined subjects, each of which had several radiographic signs indicating changes in the intervertebral discs. The frequency of various radiologic symptoms in patients with osteochondrosis of the thoracic localization is as follows: scoliosis, an increase in physiological kyphosis, a decrease in the height of the discs, sclerosis of the closure plates, anterior and lateral otiotrophy, posterior osteophytes, cartilaginous depressions in the vertebral bodies, calcification of the discs, a decrease in the height of the vertebral bodies and wedge deformation,rotation of vertebral bodies, consolidated fractures of vertebral bodies. Such radiologic signs of osteochondrosis, as a decrease in the height of the disc, sclerosis of the closure plates and osteophytes, were found in the thoracic region as often as in other parts of the spine, but usually more segments were captured.

Scoliosis, as a rule, is not clearly expressed and has a local character. The increase in physiological kyphosis was also noted. Apparently, minor static changes in the thoracic region are due to its low mobility. The decrease in the height of the vertebral bodies due to their compaction, especially the areas adjacent to the end plates, was noted in patients. Destructive changes were not detected. For osteochondrosis of thoracic localization, cartilaginous impressions in the body of the vertebrae( true Schmorl hernia) are characteristic, which are better revealed on the tomograms. This symptom is found in half of the patients. Quite often and multiple calcifications of disks. Strengthening of kyphosis in combination with wedge deformation on the soil of the transferred Sheyerman-May disease was noted in 40 people.

Most patients had anterior and lateral osteophytes of various shapes, sizes and directions. Rear osteophytes are very rare. Better they are revealed on the tomograms and on the radiographs with direct magnification.

In many patients, chest osteochondrosis is combined with osteochondrosis of other parts of the spine. In this section, "pure" lesions of the thoracic spine are subjected to analysis;this is of great practical importance for the prognosis and especially the treatment technique. Since several sections are usually affected in the thoracic region, a non-contrasting spondylography( of course, along with clinical data) plays a decisive role. If the results of spondylography are questionable, especially if there is a discrepancy with the clinical picture, contrast methods of research are shown.

Contrast methods of research. Pneumomielography - contrasting the contents of the spinal canal by introducing air or oxygen into the subarachnoid space.

Its methodology is as follows. The night before the patient is made with a cleansing enema and inside give 1 g of carboline. In the morning the patient is not fed. The study is performed on the table of the X-ray apparatus in the position of the patient on its side. Lumbar puncture and liquorodynamic samples are made at the level of L3-L4.Remove 10 ml of CSF( for analysis).The leg end of the table is raised by 15-30 °( the head end of the table should be fixed).Through the puncture needle slowly( 3-4 minutes) inject 20 ml of air or oxygen with a syringe. Then let out another 10 ml of CSF and again inject 20 ml of air. Thus, 30 ml of CSF are withdrawn in fractional portions and 40 ml are injected into the lumbar region and 60 ml of air( or oxygen) for the thoracic or cervical region. It is most convenient to use a special switch with a switch. The needle is extracted and X-rayed. However, to study the lumbar or lower thoracic spine, without changing the position of the table, take pictures in the lateral and posterior, and sometimes oblique projections. If necessary, examine the overlying parts of the spine, which are elevated by changing and tilting the table and position of the patient. To prevent the penetration of air into the ventricles of the brain;at the end of the examination the patient is placed in a position with an elevated pelvis, transported to the ward and placed on the bed with a 15-20 ° raised leg at an angle lying down on the abdomen. After 2-3 days, the endolumbelled air is absorbed and the patient is transferred to normal mode.

For hernial protrusion on the pneumomyelogram in the lateral projection, displacement posteriorly or stopping the gas column is characteristic. The advantage of pneumomyelography in its relative safety is due to the complete spontaneous resorption of air, the possibility of repeating this study, and a slight irritation of the neural elements. However, the method has a number of disadvantages: weak contrast of the gas( therefore the quality of the radiograph should be ideal);the inability to detect posterolateral hernias in the cervical region, small protrusions in the thoracic and even large hernias at the level of L5-S1, due to the lack of pressure on the dural sac;headache, sometimes vomiting, within a few days noted in some patients after the study. Only in 18 of 25 patients, the results obtained did not cause doubt. According to MV Tsyvkin, the use of a horizontal ray path during radiography can increase the number of positive findings( more than 50%).

Myelography with X-ray contrast agents for the diagnosis of breast osteochondrosis has not been widely used due to the possibility of complications and the difficulty of determining small hernial protrusions. Large prolapses in the thoracic area are extremely rare. As a contrast solution, we used majodil, which clearly reveals tumor-like formations, as well as large hernial protrusions.

More reliable information about the condition of the disc is given by discography. However, if it is relatively easy to perform in the lumbar and cervical spine( transural for the lower lumbar region and anterior access for the cervical spine), then in the thoracic department there are serious obstacles to the implementation of this study. Not to mention the multiple lesions of the discs in chest osteochondrosis, the transural approach due to the danger of damage to the spinal cord is naturally excluded. In the lateral access, we examined 18 lower thoracic and upper lumbar disks( Th9-L1) in 10 patients. The intervertebral spaces could not be studied because of the anatomical relationship between the discs and the ribs. For the reasons listed, the discography in the thoracic department has not become widespread.

Peridurography - introduction of contrast medium in the epidural space for diagnosis of posterior disc hernias and reactive periduritis

Epidural space is a narrow cylindrical receptacle located between the dura mater and the wall of the spinal canal and extending from the large occipital opening to the sacrum and sacral canal. The epidural space is filled with fatty tissue, which surrounds the nerve roots and venous plexuses. The dura mater is tightly fused to the margins of the large occipital opening and reliably isolates the epidural space from the cranial cavity and the subarachnoid space of the spinal cord.

Water-soluble iodine preparations are used as contrast agents: 20% solution of Conrey( Congray-280), hypac, urografine or verohrafine.

Method of peridurography: in the patient's position on the side( as with lumbar puncture), after the skin treatment and local anesthesia, puncture needle with mandrlum is inserted into the interstitial space( usually at the level of L3-L4) strictly along the midline. After the needle has entered a depth of 2-2.5 cm, the mandrene is removed and a 5-gram syringe with a solution of novocaine and an air bubble under the syringe plunger are attached to it. Further movement of the needle occurs under the control of the air bubble and resistance sensations at the pressure on the piston rod. As long as the tip of the needle is in the thickness of the ligaments, the piston "springs", the air bubble in the syringe is compressed and the solution does not leak out. As soon as the tip of the needle penetrates into the epidural space( usually at a depth of 4-6 cm), the sense of resistance stops( the piston no longer springs), the air bubble ceases to contract, and the solution starts to flow freely from the syringe. In order to make sure that the needle did not penetrate through the dura mater into the subarachnoid space( dangerous!), Take the syringe away from the needle and observe if the liquid does not come from it. It is known that in epidural space the pressure is always negative: 50-100 ml of water. Art.

On this basis, the symptom of "swallowing a drop" is used. A syringe with a drop of solution on its tip is brought to the pavilion of the needle;if it really is in the epidural space, then due to the difference in pressure, the drop of solution rushes into the lumen of the needle and, as it were, swallows it.

The method described by MD Nudel( 1963) is based on the same principle.

After removal of the mandrel, a glass tube used for the investigation of liquor pressure is added to the needle, previously filled with sterile isotonic sodium chloride solution to a level of 100 mm of water. Art.

Moving the needle to a depth of 4-6 cm, it is usually noted that the level of liquid in the tube begins to fall. This indicates that the end of the needle is in the epidural space. Disconnect the syringe( or glass tube) and check to see if the liquor flows out of the needle.

Produce a trial injection of contrast medium( no more than 2-4 ml) followed by radiography. If the needle is in the epidural space, then on the roentgenogram two narrow strips of contrast solution are visible, extending along the dural sac. These features prevent unwanted needle insertion into the dural sac. Only then the rest of the contrast medium( 40-60 ml) is administered. The patient feels a slowly increasing severity, which immediately disappears after the cessation of the introduction.

The first image( in the lateral projection) is done in -7 minutes in the patient's position on the abdomen with a horizontal lateral ray, then they are taken in half-and anteroposterior projections. On the peridurogram, two contrasting posts are found in the lateral projection - anterior and posterior. The rear post is much wider than the front. Normally, the anterior post column is even and uniform throughout. With protrusion of the disc, even minor, it deflects posteriorly or is generally interrupted at the level of the affected intervertebral disc. Normally, after 20-30 minutes after peridourography, a contrast agent can not be detected in the vertebral canal. Deceleration of its resorption for more than 1-2 hours suggests stagnant phenomena.

The advantage of this method is that even a slight protrusion( 1-2 mm in size) is quite satisfactorily indicated on the peridourogram. In addition, the condition of the spinal canal can be traced immediately over a considerable length.

The main method of treatment of patients with chest osteochondrosis is conservative, as there are many reasons for refraining from this surgery from osteochondrosis. First of all, this is anatomical and physiological features of this department of the spine;the prevalence of the process, which seizes many segments of the thoracic, and often other parts of the spine, the predominance of visceral clinical syndromes, especially with neurological stratifications. The posterior hernial protrusions of large size, leading to spinal disorders, are very rare in this section of the spine.

All patients with chest osteochondrosis, who were under our supervision, underwent complex conservative therapy: orthopedic measures, physiotherapy, medical treatment, therapeutic gymnastics and massage. During the exacerbation, bed rest was prescribed for 8-10 days in the position on the shield.

Due to the fixed thoracic vertebrae, stretching does not allow achieving the required discharge. The method of traction depended on the level of damage. In osteochondrosis of the lower thoracic region( Th4-Th12), as well as in its combination with lumbar osteochondrosis, passive traction was carried out, that is, the patient's body weight, on an inclined plane. The duration of the procedure is 3-4 hours per day with two intervals. The stretching was achieved by two soft rings, supporting the patient for axillary cavities and fixed to the bed at the level of the trunk. The stretch can also be made in the horizontal plane with a gradual daily increase from 10 to 20 kg( 2 kg each), and then by reducing the load for 2 hours every day. In case of osteochondrosis of the upper thoracic region( Th1-Th4), as well as its combination with cervical osteochondrosis, the traction was performed in two ways-passive traction along the inclined plane by the Glisson loop with sharply expressed symptoms of functional deficiency of the spine and active vertical traction on the special device used for cervical osteochondrosis. The duration of passive traction was 2 hours a day( with one interval), active - according to the scheme specified in the section "Cervical osteochondrosis", but no more than 15 minutes with a load of up to 10-12 kg. The course of traction therapy is designed for 3 weeks.

We give indications and contraindications to traction treatment of chest osteochondrosis.

Contraindications:

The use of unloading corsets for the thoracic spine is less effective than for the lumbar spine, but with functional spine deficiency we recommend wearing these corsets during work.

At the same time, daily massage and medical gymnastics are mandatory. Massage of the muscles of the back and lower extremities is applied after the acute pain is suppressed for 10-15 minutes daily with a constant increase in intensity. We attach great importance to swimming in the pool with the implementation of a special complex of gymnastics in the water. Medication for breast osteochondrosis is given the proper place. Widely used sedatives( trioksazin, elenium, meprobamate, etc.) for 3-4 weeks in the usual dosage. The combination of them with ganglioblokatorami( pahikarpin, platifillin, padutin) and dimedrol significantly reduces the manifestation of visceral disorders in most patients. Within 15-20 days, patients are prescribed injections of prozerin, a complex of B vitamins and nicotinic acid. Analgesics( rheopyrine, analgin) we use only in an acute period, usually 5-8 days.

Paravertebral novocain blockades are effective, but their analgesic effect does not last long. A longer-lasting effect in chest osteochondrosis is given by spirituous-new-blockade by Friedland. The most effective in chest osteochondrosis were paravertebral spirituonokainovye blockades. After treatment of the skin at a distance of 3-4 cm to the outside of the interstitial gap, a thin needle is injected intradermally with novocaine until a "lemon crust" is formed. The second, longer needle( put on a 5-gram syringe with the indicated solution) is injected in the sagittal plane until it comes into contact with the transverse process;then, bypassing the process( from above or below) in the direction of the spine at an angle of 30 °, advance the needle to a total depth of 5-6 cm. Introduce 5 ml of the solution. Usually block 2-3 gaps on both sides.

From the physiotherapy procedures during the exacerbation period, it is preferable to use Bernard currents, as well as quartz or UHF( 6-8 sessions).Some pain intensification after 2-3 sessions should not serve as an excuse for their cancellation. After passing through the acute period depending on the patient's condition, it is best to use ultrasound, "Luch-58" or inductothermy for 10-12 sessions, alternating them with radon or coniferous-salty baths( every other day).With contraindications to the appointment of radon baths, they can be replaced with salvia.

We do not apply hormonal and x-ray therapy for chest osteochondrosis. In patients previously treated with these methods in other medical institutions, no effect was noted. Significant improvement comes after the sanatorium-resort balneological treatment in combination with, underwater traction and massage. However, in most patients, remission lasted an average of 6-8 months. Some patients were treated at the resorts 2-3 times. The duration of inpatient treatment of the patients we observed was 30-45 days. As a result of complex conservative therapy, many patients achieved a practical recovery, and they were able to immediately return to their previous work. In some patients, there was a significant improvement: sharp pains decreased, and painful visceral disorders disappeared. To a lesser extent, neurological and static symptoms regressed.

Those who have been treated conservatively perform the former work, and the rest are transferred to a facilitated job. An unsatisfactory result of the treatment was also noted, and half of them were invalids of the II group. All patients of this group were subjected to surgical treatment. Thus, the immediate results of complex conservative treatment of the majority of patients with chest osteochondrosis are positive. Not always, however, the effect of conservative therapy was persistent, so the course of treatment had to be repeated. The duration of remission after conservative treatment of patients with osteochondrosis of thoracic localization was significantly less than with cervical osteochondrosis.

Very few publications are devoted to the problems of surgical intervention in chest osteochondrosis. Until 1960, only one operation was used: the removal of a disc herniation by means of a laminectomy. Unlike the lumbar in the thoracic region, fixed ribs, there are no strict indications for economical access. The main task of operative access is to avoid damage to the spinal cord. Love and Kiefer( 1950) with laterally located hernias were limited to hemilaminectomy, with central-complete laminectomy with mandatory crossing of the tooth-like ligaments and opening of the dura mater. The results obtained left much to be desired. One of the main causes of unsatisfactory results is irreversible changes in the spinal cord( hematomelia, myelomalacia, etc.) occurring with delayed surgical intervention.

In 1960, Hulme proposed an operation to remove a disc herniation by a side extrapleural access with a resection of the heads of two adjacent ribs and an expansion of the intervertebral foramen. Of the six operated, recovery occurred in 4. Perot and Munro( 1969) modified lateral access to hernia, using instead of a paramedial tissue cut with conventional transpleural thoracotomy. Hernia is removed through the drilled hole behind the intervertebral foramen. The authors operated on patients with excellent results.

Technique of operation for Tsivyan. Right-sided Crespleural access, corresponding to the level of lesion, reveals the affected disc. With the help of a thin bit, a total resection of the affected disc is made together with the end plates of the adjacent vertebral bodies. The posterior parts of the disc are removed with a bone spoon. In the intervertebral defect insert a spongy autograft, taken from the crest of the wing of the ilium. Apply a gypsum corset for 3-6 months. Indication for this operation, the author considers a single lesion of the thoracic disk with compression or without compression of the elements of the spinal cord. With multiple lesions of thoracic discos, L. Tsivyan suggests anterior spondylodesis with the removal of the contents of the discs from the formed groove. In this case, use a solid autotransplant from the tibia, which is placed in a common bed.

Although total discectomy with anterior spondylodesis is the most radical operation in osteochondrosis of the spine, in the thoracic department this operation, in our opinion, is shown only in single and, rarely, multiple lesions of the disc, but without compression of the spinal cord elements. The most common compression of the spinal cord is caused by extensive posterior prolapse of the disc. It was then that the laminectomy with the removal of the hernia and the scraping of the disc is shown. In addition, the operation should be urgent. Proof of this is the example above. Due to the technical difficulties of removing all affected discs, transplural access can indeed be limited to stabilization, but without discectomy it is a palliative agent and therefore there is no need to operate anterior transpleural access. The simplest in these cases is the low-traumatic posterior bone fixation of the spine according to the known Henle-Whitman or Chaklin methods used in scoliosis( placing a solid graft in the bed between the spinous processes and the arches after the preliminary exposure of the spongy surface).

Any of these operations( with the exception of disc herniation) should be performed in the absence of the effect of persistent conservative treatment. We are talking about severe pain symptoms and functional deficiency of the thoracic spine in the form of fast fatigue of the back, the inability to sit for long, to stand, the need to take a horizontal position several times a day, radicular and visceral( thoracic and abdominal) syndromes.

Usually, stabilization was performed on both sides or on the side of a more pronounced pain syndrome. Autologous( from tibial), lyophilized or formalized allogeneity was used as transplants. The disadvantage of the method in the need for a re-operation after 1 - I1 / 2 years for the removal of metal structures. Wearing a corset before the onset of ankylosis( usually within 9-12 months) was mandatory.

Technique of operation of posterior osteoplastic fixation according to Henle-Whitman. Under endotracheal anesthesia, in the position of the patient on the abdomen, a linear cut along the middle line of the back divides the soft tissues layer by layer into the apex of the spinous processes. A wide vertebral raspator( not to fall into the vertebral canal) subperiosteally separates the soft tissues from the lateral surface of the spinous processes and half-arches to the articular processes. The wound is swabbed with gauze napkins moistened with hot isotonic sodium chloride solution. Larger vascular branches coagulate. With two-sided fixing, similar actions are performed on the opposite side. From the exposed spinous processes and half-bows, a cortical layer is removed to a spongy tissue with a broad, slightly grooved, sharp chisel.

In a carefully prepared bone bed, large bone grafts are laid, previously having modeled them in the presence of pronounced kyphosis. The spontaneous surface of the transplant should be directed towards the spongy tissue of the receptive bed, and on the sides an autostrake is laid to stimulate osteogenesis. Fixation is carried out with nylon sutures, conducted through spinous processes and pre-drilled in several places grafts. The number of stitches corresponds to the number of stabilized vertebrae. After additional fixation with Kaplan plates( in the usual way), grafts are covered with paravergebral muscles, which are not stitched. The layers are superimposed on the fascia and skin leaving the rubber graduates for a day.

The method of postoperative administration was the same as in the remaining patients with cervical osteochondrosis. Four patients with discectomy with anterior "terminal" spondylodesis in the middle and lower thoracic spine were transplural.

The above data indicate that in severe forms of chest osteochondrosis, which are not amenable to conservative therapy, surgical intervention is indicated. The results of treatment largely depend on the severity of the selection of patients, the duration of the disease and the procedure of operations.