Do not be treated for a fictional disease
Professor Shulev: Osteochondrosis is a diagnosis from a pathologist
Irina Baglikova, "Doctor Peter"
If a person comes to the doctor with complaints of back pain, in our country it is difficult to make a mistake with the diagnosis: "osteochondrosis". Manufacturers of corsets and exercise equipment, painkillers and expensive structures earn money from it. And, of course, doctors. Only knowledge will help to distinguish earning money from real treatment, the expert of "Dr. Peter" believes.
– Ostechondrosis is a term denoting natural age–related changes during which cartilage turns into near-bone tissue. As a diagnosis, it is not suitable for clinical practice. In most countries it is used for pathomorphological descriptions. In the clinic, it is better to use clinical terminology: a degenerative cascade. However, our patients perceive this term painfully, they are offended by the word "degenerative", and it means only "changing with age". The word "cascade" means that these changes are natural and consistent, and, like steps in a cascade, they pass one into another. It is not necessary to treat it, moreover, it is impossible. In the West, for example, no one knows the words "osteochondrosis", "degenerative changes" – neither doctors nor patients. They think pragmatically: if the back is sick, the diagnosis is "back pain". And they treat back pain, not osteochondrosis," explains Professor Yuri Shulev, Head of the Department of Neurosurgery at City Hospital No. 2, Vice–Chairman of the Spinal Committee of the World Federation of Neurosurgical Societies (WFNS). He told "Dr. Peter" why it occurs, and whether it always requires surgical treatment
Cascade with drying water
– What is the essence of degeneration or, if you like, osteochondrosis? Our body, especially connective tissue, is made up of protein and water. Water provides turgor of the tissue, the absence of wrinkles on the face, as well as the height of the intervertebral discs, which means human growth. It is retained with the help of salts and protein. You probably noticed how when you ate something salty, puffiness appears. But this is extracellular water, it is retained in the cell not due to salt, but due to protein – collagen. It is he who is the basis of the connective tissue of the body. It is different at different stages: we are born with type 1 collagen, it holds the most water molecules, so children have plump cheeks, handles, and no wrinkles. But the human body cannot produce it all its life. With age, it produces type 2 and type 3 collagen, which no longer retains as much moisture. Many minds are wondering: why is collagen changing? Why do some people have no living space on their spine at 40, while others have a good one at 70? Probably, it is still genetically predetermined.
The degenerative cascade is based on the process of changing collagen with age. Because the intervertebral disc consists of it. It is, conditionally, a washer – a "gasket" between two vertebrae, resembling a "bag of gel" – protein and water. When a person is young, there is a lot of water in the disk, which means that he is tall and copes well with his task – provides free exit of nerve roots from the spinal canal, greater mobility, elasticity.
Of course, young disks can also be damaged. For those who are engaged in traumatic sports (gymnastics, for example), and for anyone – with awkward movement. But this is not at all the suffering that a person experiences at an older age due to a degenerative cascade. Their cause is a disc injury. And its "drying out" in youth, as a rule, is not very problematic, this is the first stage of the degenerative cascade, with which almost no one needs to operate, even with post-traumatic injuries. Therapeutic methods of treatment are needed.
Pain management is an art
The vertebral bodies are difficult to connect with each other. As the collagen changes, the discs become more "dry", their height decreases and the space between the vertebral bodies decreases. They get the opportunity to shift in relation to each other, because the complex ligamentous apparatus becomes free. This is stage II of the degenerative cascade, otherwise it is called the stage of segmental instability, manifested by back pain: on the one hand, the muscles are more tense, on the other – less: muscle-tonic syndrome occurs. The arcuate joints begin to be damaged, because of this, pain also occurs (the so-called facet syndrome). In 99% of cases, surgery is not required. Here we need measures aimed at managing pain so that a person can live without it, but with the spine that he has. At the same time, it is better to do without prescribing a large number of medications. If it's not something catastrophic, the pain will always subside after 5-7 days. A smart attentive neurologist, a physical therapy doctor, or maybe a massage therapist will evaluate and decide what to do when, for example, muscle tension has led to pain on the one hand: warm up, relax... This can be done at home, and if a person wants to do it under control, then there are many useful procedures for this in a good private clinic or a district polyclinic. But before they are prescribed, a competent diagnosis is needed. Because the causes of back pain can be different – tumors, blood diseases, infectious and inflammatory diseases. For them, warming up and massages are dangerous.
However, when a person cannot move, the doctor is forced to prescribe medications. How? According to the principle of the ladder of anesthesia: one after the other in a certain sequence, there should not be many of them, and they should not be taken for a long time. For example, we try not to prescribe medications when we cannot monitor their intake: control is needed in three days, in five.
I always say: "If there is an opportunity to meet with a patient, I will give the medicine, if there is no opportunity, I will not prescribe it." Because, for example, nonsteroidal anti-inflammatory drugs (NSAIDs) are aggressive against the mucous membrane of the gastrointestinal tract, pancreas, violate the blood clotting system. They are assigned uncontrollably, sold – in large-volume packages. The patient got rid of the pain, and when it next appears, he takes a pill out of the first-aid kit and takes it without a doctor's appointment. As a result, patients come to us for surgery, whom we cannot operate on until the pancreas is functioning properly or the ulcer is healed.
Diagnosis: MRI-induced
It is a great happiness for our patients that different diagnostic methods are available. The trouble is when the MRI method, created for the study of the musculoskeletal system and nervous system, is done both when it is necessary and when it is not necessary. This formed a pool of MRI-induced patients – the main "clients" for the installation of expensive metal structures.
If a person over the age of 60 takes a picture in a photo studio and receives a description instead of a photo card, he may confuse it with the conclusion of a pathologist (wrinkles, creases, age spots). In all my medical practice, I have never seen a description of a tomography in which it would be written "age norm". The patient reads: "protrusion, hernia, stenosis, arthrosis." It is induced by the conclusion of an MRI. His back hurts because of segmental instability, these hernias have nothing to do with it. The treatment consists in tying a warm scarf around your back, providing yourself with peace and, possibly, taking light medications. In a few days everything will pass. But when it "passes", you need to go to the gym. And instead he starts to fornicate in different clinics. For private traders who do not treat, but sell medical services, he is just a godsend: medicine is a noble market, but still a market. Everything that is prescribed in these clinics is not prohibited, in general, but it is not allowed either.
How to make a bookcase out of a spine
The patient is treated for a long time, the pain does not go away. They are sent to the surgeon. He says: "It is necessary to fasten the vertebrae" or "It is necessary to replace the disk, it is already black and creaking."
Why is he black? As the amount of water in the disk decreases, the number of hydrogen atoms decreases, the vibrations of which are examined by MRI in a magnetic field. These vibrations create a picture – not a direct image, as on an X-ray, but an image obtained through computational actions. When there is no water in the disk area, there is no glow in the image, it is called an extinct disk or a black disk. That is, the theory of the degenerative cascade is confirmed.
But today huge companies produce expensive products – disk prostheses. They stand as a mid–range car, the operation as a whole - as a luxury car.
A person may not be bothered by anything, but he is told: "The disk is black, it needs to be changed." A person believes because he sees the result of a tomography. This is what I call human MRI induction. A simple defense against it is knowledge.
As I have already said, when the disc loses moisture with age (it turns black on MRI), a larger gap is formed between the vertebral bodies and greater mobility appears, and with it pain. The patient is told: "It is necessary to fasten the vertebral bodies with special screws." This operation also costs like an average car. But after 5 years, the so–called adjacent level syndrome appears: in a chain consisting of several vertebrae, two were connected - for some time the back does not hurt, because there is no segmental instability. The load they were holding will go up and double the mobility there: the adjacent disk will begin to collapse faster by about 15% per year. It is attached to the next one – another piece of iron. Further, the destruction is increasing: in 1.5 – 3 years – another one. As a result, a bookcase is made from the spine. There are already a lot of such patients.
We have to understand a simple thing – no mammal is sitting on a chair. As soon as we sit on a chair, the load on the lumbosacral junction increases by 7 times. Sedentary lifestyle and overweight are the two main factors that lead to back pain. In the country of the most obese people, America, an overweight person says to a doctor: "There is no need for propaganda. As much as I have eaten, I will eat as much. As I have never done sports, I will not do it. I went by car, and I will go. You are a doctor, do it so that it doesn't hurt." Doctor: "Welcome, sign an informed consent agreement: we have warned you." And he is happy to install a construction for him. They are invented to treat spinal injuries. But if the car produces 100 copies, it will be very expensive. In order for the price to be lifting, the volume of sales is needed, then it will be a profitable production, which is what the manufacturer is interested in, who knows how to interest those on whom sales depend (health officials, neurosurgeons). As a result, the constructions are used excessively. And the person who was given the construction thinks that he is cured overnight. But this is not the case.
What kind of surgery is needed to save nerve fibers
A person continues to age: there is even less water, collagen is shorter, the disk is lower. Segmental instability increases, the result is the stage of restabilization, stage III of the degenerative cascade. What we call osteochondrosis is that spikes grow between the vertebral bodies, the joints around the spine become large, they narrow the lumen of the spinal canal. This is a natural process in which muscles stop holding the spine and instead of cartilage, bone–like tissue is formed - the body itself holds the vertebral bodies together. Such patients also manage to put constructions – to break the natural bond and put an iron one. But why operate on the elderly?
At the third stage of the degenerative cascade, three symptoms are distinguished – back pain, leg pain, neurogenically intermittent lameness. The main one is neurogenically intermittent lameness. Back pain manifests segmental instability, pain in the leg indicates that a piece of the disc or a piece of the joint around the spine is located so that it presses on the nerve root, this is sciatica. The ending "-it" indicates inflammation. With radiculopathy, the function of the root changes from compression, these changes go through two stages. The first is irritation: it hurts very much, because it is the sensitive fibers of the nerve root that are squeezed. It's bad, but it's not scary. If compression is not eliminated during treatment, these fibers die. Or they do not die, but cease to fulfill their role – to conduct impulses. Instead of pain, numbness appears in this place. This is the second stage – loss. If pain can be cured by simply releasing the fibers of the root from pressure, then from loss of function (when numb), even if we release the root, the restoration of sensitivity will last six months, and somewhere it will not recover at all. But all the same, compression of sensitive fibers is better than compression of motor fibers, in which a person's foot, knee, hip does not work – depending on which root is squeezed.
Connective tissue, which has grown in the spine, conquers space, occupying the lumen of the spinal canal, in which all the conductors, roots, and spinal cord pass. The diameter of the canal narrows, this is called stenosis. This is manifested by the fact that a person cannot walk. Or it passes 100-200 meters and has to stop, then it overcomes another 100-200 meters. This is neurogenically intermittent lameness.
These patients can and should be operated on effectively. We will not cure the degenerative cascade, but we can expand the lumen of the spinal canal. But. Usually patients with the third stage are elderly people 70-80 years old and older. Traumatic surgery is a high risk for them. Microsurgical surgery can be performed – an accurate and delicate operation. And then no constructions are needed. But this is unprofitable – only intelligence and needlework in our country are worthless. It is advantageous for some expensive construction to be attached to a person's spine - then the clinic will receive a quota, and the state will pay firms for their harmful hardware, and not the doctor – for intelligence and skill. And as a result, everyone is interested in installing metal structures, contrary to biological laws.
And it is difficult for the patient to understand in each specific case. But if he wants to preserve his spine, and with it the ability to move for many years, one should not blindly believe in the appointment of surgical treatment. It is necessary to get a second, third opinion of a specialist. And draw conclusions.
Simple difficult choice: metalwork or physical education
Now doctors in the West are clutching their heads – what are we doing? It was necessary to tell the patient: if you want your back not to hurt, the first thing is to control body weight, the second is to strengthen the gravitational muscles of the back.
When they hear this advice, people go to the gym, swing under the guidance of beautiful young men and women with the inscription "coach" on their backs. But these trainers only know what bodybuilding is, that is, shape. They teach you to train muscles, but not those that hold the spine. It is destroyed by the vertical position and gravity, held by small muscles, which are called gravitational. That is, people who have problems with the spine need to train balance. His simplest workout is walking. To get rid of back pain, a person needs to walk 5 miles a day or at least 5 kilometers.
What is better – to fix all levels of segmental instability with metal or to increase the number of places where a person can meaningfully engage in physical education? Not for the young and beautiful, for whom shape is important, but for ordinary adults who need to maintain a healthy body under the control of smart people. If the state spent half of the money it spends on quotas for the installation of expensive structures on common sense... but it buys them for 300-500 thousand rubles and cannot hire a nurse for a stroke patient for 3 thousand rubles a day. Do not put one construction – and a lot of useful things can be done. But in order to abandon it, it is necessary to teach doctors to work with their hands and use in each case the treatment that will not harm the patient.
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