The annulus fibrosus is found in 3 places in the human body: intervertebral discs, aortic and pulmonic valves. It is the basis of these valves. Anuli (annuli) fibrosi (cordis), BNA - ring-shaped formations of dense elastic connective tissue surrounding the openings of the aorta and pulmonary trunk. This ring separates the left ventricle and the aorta, and is adjoined by 3 pockets of semilunar valves. They are tightly closed during diastole and do not allow for regurgitation of blood from the aorta. In the area of the fibrous ring, there is some expansion of the aorta into 2 valves, behind each of which are the sinuses of Valsalva (small sinus). They give rise to the coronary arteries - right and left.
Valve mechanism
During systole, the valve leaflets on the ventricular side are pressed against the walls of the aorta, and the passage for blood into the aorta opens. After the passage of blood, its movement slows down in the sinuses. Small whirlpools appear near the walls of the aorta.vortices that push the valves away from the walls to the middle of the aorta. The speed of this process is high; when the lumen into the ventricle closes tightly, it is accompanied by a characteristic sound. It is heard on auscultation as a heart tone.
The aortic valve has a number of ailments of various etiologies, in which a significant role is assigned to various diseases - valve insufficiency is associated with them. The opposite condition, when valve stenosis occurs, is due to thickening of the annulus.
With age (after 50 years), calcium deposits (calcification of the aortic valve) or fatty atherosclerotic plaques appear along the edges of the valve cusps. In this case, it is noted that the fibrous ring is compacted. These are growths, they not only do not give a complete closure of the valves, but also partially block the lumen itself. All this disrupts blood flow and leads to the development of heart failure. Aortic stenosis occurs.
The pulmonic valve (PV) or pulmonary valve (PA) is located between the right ventricle and the pulmonary artery. Its main task is to prevent the reverse flow of blood from the pulmonary trunk to the right ventricle in diastole and to ensure one-way blood flow in the pulmonary circulation. This valve also has 3 leaflets that open only in one direction - into the lumen of the pulmonary trunk. The principle of operation of this valve is identical to that of the aortic valve. The fibrous ring here serves as a supporting frame for the valves. It has a triangular cross section. It contains collagen as the main component, as well as elastin and a littlecartilage tissue. PC disease also manifests itself in the form of its insufficiency or narrowing due to the compaction of the fibrous ring.
But most often this term refers to the ring of the intervertebral disc, since violations occur more often than others in it.
Disc ring
The fibrous ring of the spine is not one, it is located between all the vertebrae - anulus (annulus) fibrosus, PNA, BNA, JNA. It is an annular outer hard layer of collagen fibers surrounding the disc pulp. Where it is located? The vertebrae are separated by discs - these are elastic cartilage tissues that play the role of shock absorbers when exposed to vertical loads on the spine. Such a disc is the annulus fibrosus and the pulp. The pulp is a semi-liquid core located in the center of the disc, and the ring is its retainer.
There are many layers, they are very strong, powerful and densely intertwined in a spiral. The disc itself is attached to the vertebra by hyaline cartilage and provides flexibility to the spine. When a person lifts any weight from an inclined position, the disc is compressed and its core flattens due to the buildup of pressure.
Fibrous ring and makes this pressure uniform. With age and for a number of pathological reasons, changes occur not only in the whole organism, but also in this ring.
Elastic elastic fibers due to malnutrition begin to be very gradually replaced by scar tissue, the strength of joint cells (chondrocytes and chondroblasts) decreases, the elasticity of the connective tissue on the disc surface also. Level dropsprotein glycans, which retain water in the disc and provide its elasticity. The hydrophilicity of the disc becomes noticeably lower. The fibrous ring becomes thinner, and cracks appear on it due to malnutrition, where the pulp of the nucleus begins to shift partially. The structure of the inner fibers of the ring is broken, but the outer one is still preserved. This condition is called disc protrusion, in other words, it precedes herniation.
The pressure inside the disc increases without treatment, and eventually the annulus ruptures. It's a hernia.
A true intervertebral hernia is said when, when the fibrous ring of the intervertebral disc ruptures, prolapse occurs - prolapse of the pulp into the canal of the spinal cord. In this case, the nerve endings are almost always infringed to varying degrees with severe pain, inflammation and swelling of the tissues and a decrease in immunity.
Rupture of the fibrous ring in the future and pathological changes in the cells of the damaged disc can lead to the development of autoimmune processes in the body. This threatens with irreversible consequences for all vital systems. Intervertebral hernia is a rupture of the fibrous ring, which needs to be repaired as soon as possible in order to avoid muscle atrophy, reduced mobility of the spine and subsequent disability.
Disk herniation is also dangerous because a disc that is out of place leads to a narrowing of the spinal cord canal and disruption of blood circulation in it. If the rupture of the annulus of the intervertebral disc compresses the nerve roots of the lumbosacral region, then this is cauda equina syndrome.
All these changes requireimmediate visit to the doctor and treatment. The therapy can be conservative - in 90% it gives good results, but only if you see a doctor in a timely manner. Surgery is indicated when severe neurological symptoms are present.
Violation mechanism
From the point of view of biophysics, an adult middle-aged man in an upright position puts a load on his spine of 30 kg. Even with a slight forward tilt, this load will double, and when tilted to a right angle, the pressure will already be 210 kg. If at the same time a person still lifts the load, what will happen to the spine? The nucleus of the disk will look for a way out due to the strongest compression and will begin to be pushed back - to the weakest point of the vertebra. That is why it is not recommended to lift weights by leaning forward, but to crouch and stand with a straight back.
In case of a single injury, such a pinched flattened fragment of the pulp will grow with fibers, and the hole in the fibrous ring will close. If the loads are constant, then disc protrusion occurs - the first stage of changes. The height of the intervertebral disc decreases, and the vertebral joints begin to experience constant tension.
When the thoracic spine is affected, the changes are not so catastrophic and noticeable, there is no big load here. The lumbar and cervical regions bear the greatest damage. Here the joints wear out the fastest.
As compensation, the body begins to produce osteophytes (bone growths), mobility is limited even more, etc. A vicious circle occurs. As a rule, pathology in the form of a rupture of the fibrous ring of the disc manifests itself after the age of 40 years (more often in men).
Causes of hernia development
Annulus damage occurs for many reasons.
- Heavy lifting and strenuous exercise.
- Congenital hip dislocation.
- Impaired metabolism.
- Kyphosis and scoliosis.
- Regular mechanical spinal injuries due to sports or professional activities.
- Osteochondrosis (discs are compressed by osteophytes).
Predisposing factors for hernia
Provoking factors include the following factors:
- Sedentary lifestyle.
- Seated work with bad posture.
- Hereditary predisposition.
- Age-related changes in the body.
- Infectious diseases.
- Hypercooling.
- Bad habits.
- Long sitting at the computer, desk or driving.
Forms and stages of hernia
According to the type of disk displacement localization, they are distinguished:
- Marginal protrusion of the disc, while damage to the fibrous ring will be in the form of its crack.
- Another option - the disk can bulge up, but it does not go beyond the ring.
- When the ring breaks, the disc is displaced and the pulp simultaneously exits the spinal canal.
- And another option is to split the disk into several fragments.
Stages of development of a herniated disc
There is the following classification by stages:
- The first stage lasts about 3-4 months and is called protrusion of the fibrous rings. Its dimensions can reach no more than 3 mm. The ring just cracked, and only part of the pulp came out. But in the future, the pulp continues to seep and causes inflammation and compression of the nerve endings. The hernia in this period is soft and watery, moderately mobile, and the pain syndrome has a different degree of severity. In acute pain, movement is limited, bed rest is observed. If the pain is moderate, you need to move more, this will allow the hernia to settle down more comfortably so as not to cause pain. This stage allows you to restore the fibrous ring by tightening the crack. It is only forbidden to lean forward, as this contributes to the extrusion of the pulp.
- Second stage (prolapse) - 3-6 months. Without treatment, the nucleus protrudes further outward (extrusion), the disc is deprived of nutrition due to vascular disruption. The result is a rupture of the fibrous ring of the spine, and the nucleus pulposus extends beyond the disc, while maintaining its integrity. Such a hernia has dimensions up to 1.5 cm. This stage of hernia development is complete. But if treatment occurs, by the end of 3 months, the disc herniation will begin to gradually dehydrate and decrease in size - resorption. Often even up to half their size.
- Third stage (sequestration) - 6-12 months. Without treatment, fragments of the nucleus and ring go beyond the disk space. The pinching of the nerves becomes stronger, and the pain often becomes continuous. With the righttreatment, the hernia thickens and the place of ring rupture can be scarred by 60%.
- 4th stage - 12-24 months: the hernia has become firmly fixed. There are no changes, the ability to work returns, but the functional activity of the disk has already been lost. The vertebrae continue their degenerative process - they converge and can grow together. The development of complications is only a matter of time.
And if you remember that the spine after 45 years is not at all the same as it was at 20 years old, you will not torture it with wrong behavior, the more positive the effect on the disc will be, and the risk of going into extrusion will decrease.
Symptoms and signs
The main symptom of the disease is a slowly growing pain syndrome. Very characteristic pain when lifting the leg, which disappears when bending.
With a small hernia, back pain is intermittent, dull or aching (lumbago). With a sharp movement, an uncomfortable posture, sneezing, it can intensify.
Cervical lesion
Dizziness, cephalgia, nausea, tinnitus, weakness and irritability, fatigue and increased pressure may occur - these are manifestations of brain hypoxia. Tingling in the shoulders, poor sleep are also symptoms of this problem.
Thoracic
The defeat of this department is rare. First, there is pain in the shoulder blades with a return to the chest, the sensitivity of the hands may decrease, numbness and paresthesia appear.
Lumbar
It is most common, usually between the 4th and 5th vertebrae or the 5th lumbar and 1st sacral vertebrae. The pain is severe and constant. With an intense load, a backache of pain (lumbago) appears. All unpleasant sensations appear in the legs: irritation of the sciatic nerve, tingling, numbness of the toes, muscle weakness, difficulty walking.
Autonomic disorders: moist edematous skin, redness or pallor of the skin, burning sensation and heat in the legs. From the side of the nervous system, radicular symptoms - paresthesia after prolonged sitting, decreased muscle sensitivity.
As the process progresses, algia becomes pulsating, twitching, the thigh and lower leg hurt. Herniated disc L5 S1 gives pain in the knee, going along the inner surface of the thigh; with strong pressure on the spine - backache in the leg.
Additional features:
- it is difficult to straighten the back, it becomes inactive;
- legs are also difficult to straighten;
- pain on palpation.
To reduce pain, the patient often changes his posture, as a result of which scoliosis gradually develops. In advanced cases, urine outflow is disturbed, stool instability appears, and impotence is often diagnosed in men.
Diagnosis of intervertebral hernia
You need to start with a consultation with a neurologist. There will be an MRI appointment, this examination provides complete information about the size of the protrusions, the degree of narrowing of the spinal canal, the severity of inflammation, the presence of concomitantpathology.
CT of the spine is not so informative: it often distorts the size of protrusions and the results are incorrect.
Also, the doctor may prescribe an x-ray of the spine - he will not give information about a hernia, but will help to exclude diseases similar in symptoms.
Consequences for the patient
A person loses the ability to move. With cauda equina syndrome, the function of the pelvic organs is disturbed - urinary and fecal incontinence occurs, impotence in men.
Treatment
Treatment of any kind of vertebral hernia has one scheme. Includes:
- Glucocorticosteroids are often administered epidurally (Kenalog, Diprospan, Methylprednisolone) - once every 3 months.
- NSAIDs ("Indomethacin", "Ketoprofen", "Diclofenac", "Arcoxia", "Dexalgin", "Meloxicam") - used for less severe inflammation to reduce it and relieve pain. They are also used topically in the form of ointments.
- Novocaine and lidocaine blockades, anesthetics can also act as electrophoresis.
- Drugs to improve microcirculation - angioprotectors ("Pentoxifylline", "Actovegin", "Trental").
- B vitamins in injections to speed up the regeneration process.
- To accelerate the growth of elasticity and rapid healing of disc cracks - "Karipazim", compresses with "Dimexide", "Bishofite".
If there is no improvement within 6 months of conservative treatment, surgery is recommended.
Operation
Basic methods of surgical intervention:
- Discectomy –complete excision of the disc through an incision in the midline of the back. In recent years, this operation has been performed endoscopically.
- Laminectomy - excision of the vertebral arch.
- Ligamentectomy - excision of the ligament of the vertebra with preservation of its arch.
- Chemonucleolysis - drying the leaked pulp with papain preparations.
- When the spinal roots are compressed, an operation is performed to release them. This is especially indicated in cauda equina syndrome.
- Spinal fusion - the disc is replaced with a bone graft from the patient's pelvic bone.
- Laser disc decompression - the laser beam heats the hernia up to 70 degrees, and the protruding pulp evaporates without touching the cartilaginous ring. The laser is applicable if the protrusion has appeared and lasts for about six months, no more.
The success of the operation largely depends on the postoperative period of rehabilitation. First of all, it is wearing a bandage and a minimum of physical activity for 2 months.
Rehabilitation period
It is marked by the elimination of pain and inflammation. Includes:
- physiotherapy;
- IRT;
- massage;
- manual therapy;
- exercise therapy;
- diet;
- UHT.
Physiotherapy is possible only in half of the cases and must be prescribed by a doctor (UHF, magnetotherapy, phonophoresis, hydrotherapy, balneotherapy, thalassotherapy). The last one is the treatment with sea water, algae and seaside climate.
Additional conditions for successful rehabilitation include:
- minimum physical activity;
- rejectionphysical activity;
- alternation of heat and cold on the affected area;
- after 3 weeks - traction (traction of the spine).
Very indicated spa treatment after completion of all procedures. At the same time, it is desirable to carry out balneotherapy (radon, sulfide, turpentine baths), mud therapy.
Lifestyle after an acute period
Your spine must be protected: do not carry heavy things, do not overheat and do not get cold. A long stay in one position adversely affects the spine. Movements cannot be stopped, but twisting of the spine, sudden movements should be excluded. We must not forget about the hardening of the body.
Hernia Prevention
Preventive measures include:
- Moderately active lifestyle with the exception of high loads on the spine.
- Correct posture control.
- No heavy lifting.
- Daily walks.
- Swimming lessons.
- Sleep on orthopedic mattresses.
- Weight normalization.
- Treatment of all chronic diseases.
Pathology of the fibrous ring is a very dangerous phenomenon that can lead to disability. At the first unpleasant symptoms, you should immediately consult a doctor.
