Strangulated hernia according to ICD 10. Standard of medical care for patients with strangulated hernia. Incisional hernia without obstruction or gangrene

The manifestations of ventral hernias depend on their location; the main symptom is the presence of a hernia formation in a certain area. An inguinal hernia of the abdomen can be oblique or straight. An indirect inguinal hernia is a congenital defect when the processus vaginalis of the peritoneum does not heal, thereby maintaining communication between the abdominal cavity and the scrotum through the inguinal canal. With an oblique inguinal hernia of the abdomen, the intestinal loops pass through the internal aperture of the inguinal canal, the canal itself and exit through the external aperture into the scrotum. The hernial sac passes next to the spermatic cord. Usually such a hernia is right-sided (in 7 cases out of 10).
Direct inguinal hernia of the abdomen is an acquired pathology in which weakness of the external inguinal ring is formed, and the intestine, together with the parietal peritoneum, follows from the abdominal cavity directly through the external inguinal ring, it does not pass next to the spermatic cord. Often develops on both sides. A direct inguinal hernia is strangulated much less frequently than an oblique hernia, but more often recurs after surgery. Inguinal hernias account for 90% of all abdominal hernias, with 95-97% of all patients being men over 50 years of age. About 5% of all men suffer from inguinal hernias. A combined inguinal hernia is quite rare - it involves several hernial protrusions, not interconnected, at the level of the inner and outer rings, the inguinal canal itself.
With a femoral hernia, loops of intestine exit the abdominal cavity through the femoral canal onto the anterior surface of the thigh. In the vast majority of cases, this type of hernia affects women 30-60 years old. Femoral hernia accounts for 5-7% of all ventral hernias. The size of such a hernia is usually small, but due to the tightness of the hernial orifice, it is prone to strangulation.
With all of the above types of hernias, patients notice a round elastic formation in the groin area, decreasing in the supine position and increasing in the standing position. When exerting or straining, pain appears in the area of the hernia. With an oblique inguinal hernia, intestinal loops can be identified in the scrotum, then when the hernia is reduced, rumbling of the intestine is felt, peristalsis is heard over the scrotum upon auscultation, and tympanitis is detected upon percussion. These types of hernias should be differentiated from lipomas, inguinal lymphadenitis, inflammatory diseases of the testicles (orchitis, epididymitis), cryptorchidism, and abscesses.
Umbilical hernia - movement of the hernial sac outward through the umbilical ring. In 95% of cases it is diagnosed at an early age; adult women suffer from this disease twice as often as men. In children under 3 years of age, spontaneous strengthening of the umbilical ring with healing of the hernia is possible. In adults, the most common causes of the formation of an umbilical hernia are pregnancy, obesity, and ascites.

Incisional hernia without obstruction or gangrene

Incisional hernia NOS

Parastomal hernia with obstruction without gangrene

strangulated without gangrene
irreducible without gangrene
strangulation without gangrene

Parastomal hernia with gangrene

Parastomal hernia without obstruction and gangrene

Parastomal hernia NOS

Other or unspecified hernias with obstruction without gangrene

epigastric
hypogastric (hypogastric)
midline
Spigelian line (abdomen)

obstructive
disadvantaged
irreducible
strangulation

Other or unspecified anterior abdominal wall hernias with gangrene

HERNIA (K40-K46)

Note. A hernia with gangrene and obstruction is classified as a hernia with gangrene.

Included: hernia:

acquired
congenital [except diaphragmatic or esophageal hiatus]
recurrent

Includes: periumbilical hernia

Included:

hiatal (esophageal) hernia (sliding)
paraesophageal hernia

Excluded: congenital hernia:

diaphragm (Q79.0)
hiatus (Q40.1)

Included: hernia:

abdominal cavity, specified localization NEC
lumbar
obturator
female external genitalia
retroperitoneal
ischial

Included:

enterocele [intestinal hernia]
epiplocele [omental hernia]
hernia:
- NOS
- interstitial
- intestinal
- intra-abdominal

Excludes: vaginal enterocele (N81.5)

The release of a new revision (ICD-11) is planned by WHO in 2017-2018.

Processing and translation of changes © mkb-10.com

Hernia of the anterior abdominal wall (K43)

Incisional hernia (postoperative ventral hernia):

causing obstruction without gangrene
strangulated without gangrene
irreducible without gangrene
strangulation without gangrene

Gangrenous incisional hernia

Incisional hernia NOS

Parastomal (colostomy) hernia:

causing obstruction without gangrene
strangulated without gangrene
irreducible without gangrene
strangulation without gangrene

Gangrenous parastomal hernia

Parastomal hernia NOS

epigastric
hypogastric (hypogastric)
midline
Spigelian line (abdomen)
under the xiphoid process (subxiphoid)

Any conditions listed in K43.6 without gangrene:

obstructive
disadvantaged
irreducible
strangulation

Any variants listed in K43.6 with gangrene

Hernia of the anterior abdominal wall NOS

In Russia, the International Classification of Diseases, 10th revision (ICD-10) has been adopted as a single normative document for recording morbidity, reasons for the population's visits to medical institutions of all departments, and causes of death.

ICD-10 was introduced into healthcare practice throughout the Russian Federation in 1999 by order of the Russian Ministry of Health dated May 27, 1997. No. 170

The release of a new revision of the ICD is planned by WHO in 2017-2018.

With changes and additions from WHO.

Abdominal hernia - description, causes.

Brief description

Abdominal hernias are divided into external and internal. External abdominal hernia is a surgical disease in which, through various openings in the muscular aponeurotic layer of the abdominal walls and pelvic floor, the viscera emerge along with the parietal layer of the peritoneum with the integrity of the skin. An internal abdominal hernia is formed inside the abdominal cavity in the peritoneal pockets and folds or penetrates into the chest cavity through natural or acquired openings and slits of the diaphragm.

Frequency. Observed at any age. Peaks of incidence are preschool age and age after 50 years. It is registered more often in men.

Reasons

Etiology Congenital defects of the abdominal wall (for example, congenital indirect inguinal hernias) Enlargement of the abdominal wall openings. Normally existing but pathologically enlarged openings in the abdominal wall can cause the protrusion of internal organs (for example, the protrusion of the stomach into the chest cavity through the enlarged esophageal opening of the diaphragm during a hiatal hernia) Thinning and loss of elasticity of tissues (especially against the background of general aging of the body or exhaustion ) lead to the formation of inguinal, umbilical hernias and hernias of the white line of the abdomen. Trauma or wound (especially postoperative), when degenerative changes develop in normal tissues along the incision line, which often leads to the formation of postoperative ventral hernias. Suppuration of a postoperative wound increases the risk of hernia formation. Increased intra-abdominal pressure. Factors contributing to increased intra-abdominal pressure: heavy physical labor, cough due to chronic lung diseases, difficulty urinating, prolonged constipation, pregnancy, ascites, abdominal tumors, flatulence, obesity.

Basic concepts. The type of hernia can be determined by objective examination or during surgery. Complete hernia. The hernial sac and its contents exit through a defect in the abdominal wall (for example, a complete inguinal hernia, when the hernial sac with its contents is in the scrotum [inguo-scrotal hernia]) Incomplete hernia. There is a defect in the abdominal wall, but the hernial sac with the contents has not yet gone beyond the abdominal wall (for example, an incomplete inguinal hernia, when the hernial sac with the contents does not extend beyond the external inguinal ring) Reducible hernia. The contents of the hernial sac easily move through the hernial orifice from the abdominal cavity to the hernial sac and back. Irreversible hernia. The contents of the hernial sac cannot be reduced through the hernial orifice due to the formed adhesions or large size of the hernia. Strangulated hernia - compression of the contents of the hernial sac in the hernial orifice. Congenital hernia is associated with developmental anomalies. A sliding hernia contains organs that are partially not covered by the peritoneum (cecum, bladder ), the hernial sac may be absent Richter hernia - a strangulated abdominal hernia. Its peculiarity: infringement of only part of the intestinal wall (without the mesentery). There is no intestinal obstruction (or it is partial) Littre hernia - a hernia of the anterior abdominal wall containing a congenital diverticulum of the ileum.

Complications mainly arise from delays in seeking medical help and late diagnosis. Obstructive intestinal obstruction develops when a loop of intestine protrudes through a defect in the abdominal wall with the appearance of a mechanical obstacle to the passage of intestinal contents as a result of compression or bending of the intestine (the so-called fecal strangulation) Strangulation intestinal obstruction with necrosis and perforation of the intestinal loop develops as a result of compression of the mesenteric vessels with disruption of blood flow in the wall of the strangulated intestine (so-called elastic strangulation). Isolated necrosis with perforation of the strangulated area of the intestinal wall in Richter's hernia.

Indirect inguinal hernia Passes through the deep inguinal ring into the inguinal canal. In some cases, it may descend into the scrotum (complete hernia, inguinal-scrotal hernia). With congenital inguinal hernias, the processus vaginalis of the peritoneum remains completely open and communicates with the abdominal cavity, inguinal canal and scrotum. Partially obliterated processus vaginalis of the peritoneum can cause hydrocele of the spermatic cord. Prevalence. 80–90% of all types of abdominal hernias are inguinal. Among patients with inguinal hernias, 90–97% are men aged 50–60 years. In general, it occurs in 5% of men. In children, there is a significant tendency to infringement. In 75% of cases, a right-sided hernia is observed. It can be combined with undescended testicle into the scrotum, its location in the inguinal canal, the development of hydrocele of the testicular membranes or the vaginal membrane of the spermatic cord. Bilateral nonunion of the processus vaginalis of the peritoneum is observed in more than 10% of patients with an indirect inguinal hernia.

Direct inguinal hernia. The inferior epigastric artery and vein serve as an anatomical landmark for recognizing oblique and direct inguinal hernias. A direct inguinal hernia emerges from the abdominal cavity medially from the lateral umbilical fold. It emerges in the area of the bottom of the inguinal canal through Hesselbach's triangle as a result of thinning and loss of tissue elasticity. Direct inguinal hernia is a direct exit of internal organs through the posterior wall of the inguinal canal posteriorly and inwardly from the spermatic cord; the hernia lies outside the elements of the spermatic cord (unlike an oblique inguinal hernia) and, as a rule, does not descend into the scrotum. The hernial orifice is rarely narrow, so a direct inguinal hernia (as opposed to an oblique one) is less likely to be strangulated. A hernia is not congenital; it is more often observed in old age. In the elderly, it is often bilateral. Recurrent hernias occur more often in patients with direct inguinal hernias than in patients with indirect inguinal hernias. Surgical treatment is aimed at strengthening the posterior wall of the inguinal canal.

Combined inguinal hernias are classified as complex forms of inguinal hernias. The patient has 2 or 3 separate hernial sacs on one side, not communicating with each other, with independent hernial openings leading into the abdominal cavity.

A femoral hernia exits through the femoral canal along the femoral fascia. Prevalence is 5–8% of all abdominal hernias. Most patients (80%) are women aged 30–60 years. They are rarely large and prone to pinching. The contents of the hernial sac are a loop of the small intestine, an omentum. The appearance of hernias is usually associated with heavy physical exertion, chronic constipation and pregnancy.

Diagnostics Patient complaints about a tumor-like protrusion in the groin area and pain of varying intensity (especially during physical stress) Objective examination Inspection. Pay attention to the shape and size of the hernial protrusion in the vertical and horizontal positions of the patient. Palpation. The size of the hernial protrusion, the degree of reducibility, the size of the internal opening of the inguinal canal, the shape and size of the testicles are determined. The symptom of a cough impulse is the jerk-like pressure of the hernial sac on the tip of a finger inserted into the inguinal canal when the patient coughs. Percussion and auscultation of the area of the hernial protrusion. Carry out to identify peristaltic noises and tympanic sound (if there is a loop of intestine in the hernial sac) Differential diagnosis: lipoma, inguinal lymphadenitis, abscess, orchiepididymitis, hydrocele of the testicular membranes, varicocele, cryptorchidism.

Treatment The main stages of hernia repair: Access to the inguinal canal Isolation of the hernial sac, opening its lumen, assessment of the viability of the contents and its reduction into the abdominal cavity Ligation of the neck of the hernial sac, its removal Plastic surgery of the inguinal canal Features of hernia repair for indirect inguinal hernias: Ligation of the hernial sac at the level of the parietal peritoneum Suturing the deep inguinal ring to normal size Strengthening the anterior wall of the inguinal canal with mandatory suturing of the deep inguinal ring is used in young men with small indirect inguinal hernias. For sliding, recurrent and large inguinal hernias, the posterior wall of the inguinal canal is strengthened. For large defects of the abdominal wall, it is strengthened using various grafts. Strengthening the anterior wall of the inguinal canal. Girard's method: the internal oblique and transverse abdominal muscles are sutured to the inguinal ligament above the spermatic cord, and a duplicative aponeurosis of the external oblique abdominal muscle is created. Currently, various modifications of this operation are used - the Spasokukotsky method, the Kimbarovsky suture. Strengthening the posterior wall of the inguinal canal. Bassini's method: the edges of the internal oblique and transverse abdominal muscles, together with the transverse fascia, are sutured to the inguinal ligament under the spermatic cord, on top of which the edges of the previously dissected aponeurosis of the external oblique muscle are sutured. Alloplasty. Used for complex forms of inguinal hernias. Skin autografts, dura mater allografts, and synthetic materials are used. A feature of hernia repair for direct inguinal hernias is the strengthening of the posterior wall of the inguinal canal after reduction of the contents of the hernial sac. The Bassini method is used. Hernia repair for femoral hernias can be performed using the femoral and inguinal methods. Femoral method. The femoral canal is approached from its external opening. Most surgeons use the method proposed in 1894 by Bassini. Access: parallel to and below the inguinal ligament above the hernial protrusion. The hernial orifice is closed by suturing the inguinal and pubic (Cooper) ligaments. The femoral canal is sutured with a second row of sutures between the edge of the lata fascia of the thigh and the pectineal fascia. Unfortunately, the Bassini operation leads to deformation of the inguinal canal and in some cases contributes to the occurrence of indirect inguinal hernias. Rudzhi’s operation, the Rudzhi inguinal method, does not have this drawback. The inguinal canal is opened with an incision above and parallel to the inguinal ligament and (after removal of the hernial sac) the hernial orifice is sutured with sutures connecting the inguinal and Cooper ligaments with the internal oblique and transverse muscles. In this way, the inguinal and femoral canals are simultaneously closed. Relapses after surgical treatment - 3–5% Special situations Incarceration of a section of the intestine with subsequent necrosis. If the diagnosis is established, laparotomy, revision of the abdominal cavity and resection of the non-viable segment of the intestine are performed. Relapses and large defects of the abdominal wall. To eliminate the defect, synthetic prostheses are implanted. Children. Krasnobaev’s method is often used: after removing the hernial sac, 2 sutures are placed on the legs of the external opening of the inguinal canal. In this case, 2 folds of the aponeurosis of the external oblique muscle are formed. They are sewn together with several additional sutures. The hernia bandage is designed to prevent the exit of abdominal organs through the hernial orifice. It is used if there are contraindications to surgical treatment (concomitant somatic diseases) or if the patient refuses surgery Laparoscopic repair for inguinal and femoral hernias Absolute indications: recurrent and bilateral hernias Contraindications: organ strangulation or intestinal infarction within the hernia Accesses - intraperitoneal and extraperitoneal Complications: damage to the external iliac vessels, damage to the ilioinguinal and femoral nerves, and the formation of adhesions during intraperitoneal surgery can cause small intestinal obstruction.

Umbilical hernia is the exit of abdominal organs through a defect in the abdominal wall in the navel area. In women, it is observed 2 times more often. It is most often observed in early childhood, in 5% of cases - in older children and adults. As it develops, self-healing is possible at the age of 6 months to 3 years. Causes of umbilical hernia formation in adults: increased intra-abdominal pressure, ascites, pregnancy. Repair of umbilical hernias in children: Lexer's operation. The umbilical ring is sutured with a purse-string suture. In adults: Mayo operation: the hernial orifice is closed with a duplicate of the aponeurosis sheets stitched one on top of the other. Sapezhko's method. First, the peritoneum is peeled off from the posterior surface of the vagina of one of the rectus abdominis muscles. Then, using separate sutures, capturing on one side the edge of the aponeurosis of the linea alba, and on the other hand, the posteromedial part of the rectus sheath, where the peritoneum is separated, a duplication is created from muscular aponeurotic flaps.

Hernia of the white line of the abdomen can be supra-umbilical, peri-umbilical and sub-umbilical. More often observed in men (3:1). In children, hernias are extremely rare. Hernias can be multiple. Repair by simply suturing the defect in the aponeurosis gives about 10% of relapses. For large hernias, the Sapezhko method is used.

Postoperative ventral hernia is the most commonly observed type of ventral hernia, resulting from complications during the healing of a postoperative wound Predisposing factors: wound infection, hematoma, old age, obesity, high pressure in the abdominal cavity with intestinal obstruction, ascites, pulmonary complications of the postoperative period Surgical treatment is performed after eliminating the reasons that led to their development.

A hernia of the semilunar (Spigelian) line is usually located at its intersection with the line of Douglas. Treatment is surgical. For small hernias, the gate is closed in layers by applying sutures. For large hernias, after suturing the muscles, it is necessary to create a duplicative aponeurosis.

ICD-10 K40 Inguinal hernia K41 Femoral hernia K42 Umbilical hernia K43 Hernia of the anterior abdominal wall K44 Diaphragmatic hernia K45 Other abdominal hernias K46 Abdominal hernia, unspecified

Standard of medical care for patients with strangulated hernia

On November 26, 2007, the Ministry of Health approved protocols for the diagnosis and treatment of strangulated hernia.

Strangulated hernia (ICD - 10 K40.3 - K 45.8) - sudden or gradual compression of the contents of the hernia at its gate.

Strangulation is the most common and dangerous complication of hernia disease. Mortality of patients increases with age, varying between 3.8 and 11%. Necrosis of strangulated organs is observed in at least 10% of cases.

The forms of infringement are different. Among them are:

2) fecal impaction;

3) parietal infringement;

4) retrograde infringement;

5) Litre hernia (strangulation of Meckel's diverticulum).

According to the frequency of occurrence, the following are observed:

1) strangulated inguinal hernia

2) strangulated femoral hernia;

3) strangulated umbilical hernia;

4) strangulated postoperative ventral hernias;

5) strangulated hernia of the white line of the abdomen;

6) strangulated hernias of rare localizations.

A strangulated hernia may be accompanied by acute intestinal obstruction, which occurs through the mechanism of strangulation intestinal obstruction, the severity of which depends on the level of strangulation.

For all types and forms of strangulated hernia, the severity of the disorder is directly dependent on the time factor, which determines the urgent nature of diagnostic and treatment measures.

Protocols for diagnosing strangulated hernias in the emergency department (EMD)

Patients admitted to the emergency department with complaints of abdominal pain and symptoms of acute intestinal obstruction should be specifically examined for the presence of hernial protrusions in typical places.

Based on complaints, clinical history and objective examination data, patients with strangulated hernias should be divided into 4 groups:

Group 1 - uncomplicated strangulated hernia;

Group 2 - complicated strangulated hernia

For complicated strangulated hernia, 2 subgroups are distinguished:

a) strangulated hernia, complicated by acute intestinal obstruction;

b) strangulated hernia, complicated by phlegmon of the hernial sac.

Group 3 - reduced strangulated hernia;

Uncomplicated strangulated hernia;

Criteria for diagnosing an uncomplicated strangulated hernia in the ED:

A strangulated uncomplicated hernia is recognized by:

Sudden onset of pain in the area of a previously reduced hernia, the nature and intensity of which depends on the type of infringement, the affected organ and the age of the patient;

Inability to reduce a previously freely reducible hernia;

An increase in the volume of hernial protrusion;

Tension and pain in the area of the hernial protrusion;

Absence of transmission of the “cough impulse”;

There are no symptoms and signs of acute intestinal obstruction with an uncomplicated strangulated hernia.

Examination protocols in OEMP

Clinical blood test,

Blood type and Rh factor,

Clinical urine analysis.

Protocols for preoperative preparation for uncomplicated strangulated hernia in the EDCU

Protocols of surgical tactics for uncomplicated strangulated hernia.

1. The only method of treatment for patients with a strangulated uncomplicated hernia is emergency surgery, which should be started no later than 2 hours from the moment the patient is admitted to the emergency department. There are no contraindications to surgery for a strangulated hernia.

2. The main objectives of the operation in the treatment of uncomplicated strangulated hernias are:

Inspection of injured organs and appropriate interventions on them;

Plastic surgery of hernial orifices.

3. An incision of sufficient size is made in accordance with the location of the hernia. The hernial sac is opened and the organ strangulated in it is fixed. Dissection of the strangulating ring before opening the hernial sac is unacceptable.

4. If a strangulated organ is spontaneously reduced into the abdominal cavity, it should be removed for inspection and assessment of its blood supply. If it cannot be found and removed, wound expansion (herniolaparotomy) or diagnostic laparoscopy is indicated.

5. After dissection of the strangulated ring, the condition of the strangulated organ is assessed. A viable intestine quickly takes on a normal appearance, its color becomes pink, the serous membrane is shiny, peristalsis is clear, the mesenteric vessels pulsate. Before repositioning the intestine into the abdominal cavity, it is necessary to inject 100 ml of a 0.25% novocaine solution into its mesentery.

6. If there are doubts about the viability of the intestine, ml of 0.25% novocaine solution should be injected into its mesentery and the doubtful area should be warmed with warm tampons soaked in 0.9% NaCl. If doubt about the viability of the bowel remains, the bowel should be resected within healthy tissue.

7. Signs of intestinal non-viability and undisputed indications for its resection are:

Dark coloration of the intestine;

Dull serosa;

Lack of intestinal peristalsis;

Absence of pulsation of the vessels of her mesentery;

8. Resection is subject to, in addition to the strangulated section of the intestine, the entire macroscopically changed part of the afferent and efferent colon plus the unchanged section of the afferent colon and the unchanged section of the efferent colon. The exception is resection near the ileocecal angle, where it is possible to limit these requirements with favorable visual characteristics of the intestine in the area of the intended intersection. In this case, control indicators of bleeding from the vessels of the wall when crossing it and the condition of the mucous membrane are necessarily used. It is also possible to use transillumination or other objective methods for assessing blood supply. During intestinal resection, when the level of anastomosis is at the most distal part of the ileum - less than the cecum, one should resort to ileoascendo - or ileotransverse anastomosis.

9. If there are doubts about the viability of the intestine, especially over a large extent, it is permissible to postpone the decision on resection, using programmed laparoscopy after 12 hours.

10. In cases of parietal strangulation, intestinal resection should be performed. Immersion of a changed area into the intestinal lumen is dangerous and should not be done, since this may cause divergence of the immersing sutures, and immersion of a large area within the unchanged parts of the intestine can create a mechanical obstacle that impairs intestinal patency.

11. Restoring the continuity of the gastrointestinal tract after resection is carried out:

If there is a large difference in the diameters of the lumens of the sections of the intestine to be stitched, a side-to-side anastomosis is performed;

If the diameters of the lumens of the stitched sections of the intestine match, it is possible to use an end-to-end anastomosis.

12. If the omentum is strangulated, indications for its resection are given if it is swollen, has fibrinous deposits or hemorrhages.

13. The surgical intervention ends with plastic surgery of the hernial orifice, depending on the location of the hernia.

Protocols for postoperative management of patients with uncomplicated strangulated hernia

2. All patients are prescribed intramuscular administration of painkillers (analgin, ketarol) 3 times a day for 3 days after surgery; broad-spectrum antibiotics (cefazolin 1 g x 2 times a day) for 5 days after surgery.

Complicated strangulated hernia

Strangulated hernia complicated by acute intestinal obstruction

Criteria for diagnosing a strangulated hernia complicated by intestinal obstruction in the emergency department:

Local symptoms of strangulation are accompanied by symptoms of acute intestinal obstruction:

Cramping pain in the area of the hernial protrusion

Thirst, dry mouth,

Tachycardia > 90 bpm in 1 min.

Periodically recurring vomiting;

Delayed passage of gases;

During the examination, abdominal bloating and increased peristalsis are determined; M.B. “splash noise”;

A plain radiograph reveals Kloiber's cups and small intestinal arches with transverse striations; the presence of an “isolated loop” is possible;

An ultrasound examination reveals dilated intestinal loops and “pendulum-like” peristalsis;

Examination protocols in OEMP

Clinical blood test,

Blood type and Rh factor,

Clinical urine analysis.

Plain radiography of the chest organs

Plain radiography of the abdominal cavity.

Ultrasound of the abdominal cavity.

Protocols for preoperative preparation of strangulated hernia complicated by intestinal obstruction in the emergency department

1. Before the operation, it is mandatory to insert a gastric tube and evacuate the gastric contents.

2. The bladder is emptied and the surgical area and the entire anterior abdominal wall are hygienically prepared.

3. The presence of pronounced clinical signs of general dehydration and endotoxemia serves as an indication for intensive preoperative preparation with placement of a catheter in the main vein and infusion therapy (intravenous 1.5 liters of crystalloid solutions, reamberin 400 ml, cytoflavin 10 ml diluted with 400 ml of 5% solution glucose. Antibiotics in this case are administered intravenously 30 minutes before surgery.

Protocols of surgical tactics for strangulated hernia complicated by intestinal obstruction.

1. Surgery for a complicated strangulated hernia is always performed under anesthesia by a three-medical team with the participation of the most experienced surgeon of the duty team or the responsible surgeon on duty no later than 2 hours from the moment the patient is admitted to the hospital.

2. The main objectives of the operation in the treatment of a strangulated hernia complicated by intestinal obstruction are:

Determination of intestinal viability and determination of indications for its resection;

Establishing the boundaries of resection of the changed intestine and its implementation;

Determination of indications and method of intestinal drainage;

Sanitation and drainage of the abdominal cavity

Plastic surgery of hernial orifices.

3. The initial stages of the operation to eliminate a strangulated hernia complicated by intestinal obstruction correspond to the provisions set out in paragraphs of surgical tactics for an uncomplicated strangulated hernia.

4. The indication for drainage of the small intestine is overflow of the afferent intestinal loops with contents.

5. The preferred method of drainage of the small intestine is nasogastrointestinal intubation from a separate midline laparotomy access.

6. The surgical intervention ends with drainage of the abdominal cavity and plastic surgery of the hernial orifice, depending on the location of the hernia.

Protocols for postoperative management of patients with strangulated hernia complicated by intestinal obstruction

1. Enteral nutrition begins with the appearance of intestinal peristalsis through the introduction of glucose-electrolyte mixtures into the intestinal tube.

2. Removal of the nasogastrointestinal drainage probe is carried out after the restoration of stable peristalsis and independent stool for 3-4 days. The drainage tube, installed in the small intestine through a gastrostomy or retrograde according to Welch-Zhitnyuk, is removed a little later - one day.

3. In order to combat ischemic and reperfusion injuries of the small intestine, infusion therapy is carried out (intravenous 2-2.5 liters of crystalloid solutions, reamberin 400 ml, cytoflavin 10.0 ml diluted with 400 ml of 0.9% sodium chloride solution, trental 5 ,0 - 3 times a day, contricaled/day, ascorbic acid 5% 10 ml/day).

4. Antibacterial therapy in the postoperative period should include either aminoglycosides II-III, cephalosporins of the third generation and metronidozole, or fluoroquinolones of the second generation and metronidozole.

5. To prevent the formation of acute gastrointestinal ulcers, therapy should include antisecretory drugs.

6.Complex therapy should include heparin or low molecular weight heparins to prevent thromboembolic complications and microcirculation disorders.

Laboratory tests are performed as indicated and before discharge. In the case of an uncomplicated course of the postoperative period, discharge is made on the day.

Strangulated hernia, complicated by phlegmon of the hernial sac

Criteria for diagnosing a strangulated hernia complicated by phlegmon of the hernial sac in the emergency department:

Presence of symptoms of severe endotoxicosis;

The hernial protrusion is swollen, hot to the touch;

Hyperemia of the skin and swelling of the subcutaneous tissue, spreading far beyond the hernial protrusion;

There may be crepitation in the tissues surrounding the hernial protrusion.

Examination protocols in OEMP

Clinical blood test,

Blood type and Rh factor,

Clinical urine analysis.

Plain radiography of the chest organs

Plain radiography of the abdominal cavity.

Protocols for preoperative preparation of strangulated hernia complicated by phlegmon of the hernial sac in the ED

1. Before the operation, it is mandatory to insert a gastric tube and evacuate the gastric contents.

2. The bladder is emptied and the surgical area and the entire anterior abdominal wall are hygienically prepared.

3. Intensive preoperative preparation is indicated with insertion of a catheter into the main vein and infusion therapy (intravenous 1.5 liters of crystalloid solutions, reamberin 400 ml, cytoflavin 10 ml diluted with 400 ml of 5% glucose solution) for 1 hour or on the operating table , or in the OCR.

4. It is mandatory to administer broad-spectrum antibiotics (III generation cephalosporins and metronidazole) 30 minutes before surgery intravenously.

Protocols of surgical tactics for strangulated hernia complicated by phlegmon of the hernial sac.

2.Surgery begins with a median laparotomy. If the loops of the small intestine are pinched, resection is performed with anastomosis. The question of how to complete the colon resection is decided individually. The ends of the intestine to be removed are sutured tightly. Then a purse-string suture is placed on the peritoneum around the inner ring of the hernial orifice. The intra-abdominal stage of the operation is temporarily stopped.

3. Herniotomy is performed. The strangulated necrotic part of the intestine is removed through a herniotomy incision with simultaneous tightening of the purse-string suture inside the abdominal cavity. In this case, special attention is paid to preventing the entry of inflammatory purulent-putrefactive exudate of the hernial sac into the abdominal cavity.

4. Primary repair of the hernial orifice is not performed. In the herniotomy wound, necrectomy is performed, followed by loose packing and drainage.

5. According to indications, drainage of the small intestine is performed.

6. The operation ends with drainage of the abdominal cavity.

Protocols for postoperative management of patients with strangulated hernia complicated by phlegmon of the hernial sac.

1. Local treatment of a herniotomy wound is carried out in accordance with the principles of treatment of purulent wounds. Dressings are performed daily.

2. Detoxification therapy includes intravenous administration of 2-2.5 liters of crystalloid solutions, reamberin 400 ml, cytoflavin 10.0 ml diluted with 400 ml of 0.9% sodium chloride solution, trental 5.0 - 3 times a day, contricaled/ day, ascorbic acid 5% 10 ml/day.

3. Antibacterial therapy in the postoperative period should include either aminoglycosides II-III, cephalosporins of the third generation and metronidozole, or fluoroquinolones of the second generation and metronidozole.

4. To prevent the formation of acute gastrointestinal ulcers, therapy should include antisecretory drugs.

5.Complex therapy should include heparin or low molecular weight heparins to prevent thromboembolic complications and microcirculation disorders.

Laboratory tests are performed as indicated and before discharge.

Reduced strangulated hernia.

Criteria for diagnosing a reduced strangulated hernia of the EMP:

The diagnosis of “strangulated hernia, condition after strangulation” can be made when there are clear indications from the patient himself about the fact of strangulation of a previously reduced hernia, the period of time of its non-reduction and the fact of its independent reduction.

A reduced strangulated hernia should also be considered a hernia, the fact of self-reduction of which occurred (and is recorded in medical documents) in the presence of medical personnel (at the prehospital stage - in the presence of emergency medical personnel, after hospitalization - in the presence of the duty surgeon of the EDMC).

Examination protocols in OEMP

Clinical blood test,

Blood type and Rh factor,

Clinical urine analysis.

Plain radiography of the chest organs

Plain radiography of the abdominal cavity.

Protocols for preoperative preparation of reduced strangulated hernia in the EDMP

1. Before the operation, it is mandatory to insert a gastric tube and evacuate the gastric contents.

2. The bladder is emptied and the surgical area and the entire anterior abdominal wall are hygienically prepared.

Protocols of surgical tactics for reduced strangulated hernia.

1. When a strangulated hernia is repaired and the strangulation lasts less than 2 hours, hospitalization in the surgical department is indicated, followed by dynamic observation for 24 hours.

2. If during dynamic observation there are symptoms of deterioration in the general condition of the observed person, as well as peritoneal symptoms, diagnostic laparoscopy is indicated.

3. When self-reducing a strangulated hernia before hospitalization, if the fact of strangulation is beyond doubt, and the duration of strangulation is 2 hours or more, diagnostic laparoscopy is indicated.

Protocols for the management of patients with reduced strangulated hernia.

Postoperative management of patients after diagnostic laparoscopy is determined by diagnostic findings and the extent of surgical intervention for them.

Strangulated postoperative ventral hernia

Criteria for diagnosing a strangulated postoperative ventral hernia of the EMP:

The clinical picture depends on its size, the type of strangulation and the severity of intestinal obstruction. There are fecal and elastic strangulation.

With fecal strangulation, a gradual onset of the disease is observed. Constantly existing pain in the area of the hernial protrusion increases, becomes cramping in nature, and subsequently symptoms of acute intestinal obstruction occur - vomiting, gas retention, lack of stool, and bloating. The hernial protrusion does not decrease in the supine position and acquires clear contours.

Elastic strangulation is typical for hernias with small hernial orifices. There is a sudden onset of pain due to the introduction of a large segment of intestine into the hernial sac through a small defect in the anterior abdominal wall. Subsequently, the pain syndrome intensifies and symptoms of intestinal obstruction appear.

The main symptoms of a strangulated postoperative ventral hernia are:

Pain in the area of hernial protrusion;

Sharp pain on palpation of the hernial protrusion;

With a long period of strangulation, clinical and radiological signs of intestinal obstruction are possible.

Examination protocols in OEMP

Clinical blood test,

Blood type and Rh factor,

Clinical urine analysis.

Plain radiography of the chest organs

Plain radiography of the abdominal cavity.

Protocols for preoperative preparation of strangulated postoperative ventral hernia in the ED.

1. Before the operation, it is mandatory to insert a gastric tube and evacuate the gastric contents.

2. The bladder is emptied and the surgical area and the entire anterior abdominal wall are hygienically prepared.

3. In the presence of intestinal obstruction, intensive preoperative preparation is indicated with the placement of a catheter in the main vein and infusion therapy (intravenous 1.5 liters of crystalloid solutions, reamberin 400 ml, cytoflavin 10 ml diluted with 400 ml of 5% glucose solution) for 1 hour either on the operating table or in the surgical department.

Protocols of surgical tactics for strangulated postoperative ventral hernia.

1. Treatment of a strangulated postoperative ventral hernia consists of performing an emergency laparotomy within 2 hours from the moment of admission to the hospital.

2. Objectives of surgical treatment for strangulated postoperative ventral hernia:

Thorough inspection of the hernial sac, taking into account its multi-chamber nature and elimination of adhesions;

Assessment of the viability of the organ strangulated in the hernia;

If there are signs of non-viability of the strangulated organ, its resection is performed.

3. In case of strangulation of large multi-chamber postoperative ventral hernias of the abdominal wall, the operation is completed by dissecting all fibrous septa and suturing only the skin with subcutaneous tissue.

4. In case of an extensive hernia defect more than 10 cm in diameter, in order to prevent abdominal compartment syndrome, it is possible to close the hernial orifice with a mesh explant.

Protocols for postoperative management of patients with strangulated postoperative ventral hernia.

1. Treatment of patients with a strangulated postoperative ventral hernia until hemodynamics are stabilized and spontaneous breathing is restored is carried out in the medical department.

2. Therapeutic measures in the postoperative period should be aimed at:

Suppressing infection by prescribing antibacterial agents;

Fight against intoxication and metabolic disorders;

Treatment of complications from the respiratory and cardiovascular systems;

Restoration of gastrointestinal function.

Strangulated hernia complicated by peritonitis

Criteria for diagnosing a strangulated hernia complicated by peritonitis in the EMF:

The general condition is serious;

Symptoms of severe endotoxicosis: confusion, dry mouth, tachycardia > 100 beats. in 1 min., hypotension/mm. Hg;

Periodic vomiting of stagnant or intestinal contents;

The examination reveals bloating, lack of peristalsis, and a positive Shetkin-Blumberg sign;

A plain radiograph reveals multiple fluid levels;

Ultrasound examination reveals dilated intestinal loops;

Examination protocols in OEMP

Clinical blood test,

Blood type and Rh factor,

Clinical urine analysis.

Plain radiography of the chest organs

Plain radiography of the abdominal cavity.

Protocols for preoperative preparation of strangulated hernia complicated by peritonitis in the emergency department

1. Preoperative preparation and diagnosis are carried out in a surgical environment.

2. A gastric tube is inserted and the gastric contents are evacuated.

Intensive preoperative preparation is indicated with the placement of a catheter in the main vein and infusion therapy (intravenous 1.5 liters of crystalloid solutions, reamberin 400 ml, cytoflavin 10 ml diluted with 400 ml of 5% glucose solution) for 1 hour either on the operating table or in OHR.

3. It is mandatory to administer broad-spectrum antibiotics (III generation cephalosporins and metronidazole) 30 minutes before surgery intravenously.

4. The bladder is emptied and the surgical area and the entire anterior abdominal wall are hygienically prepared.

Protocols of surgical tactics for strangulated hernia complicated by peritonitis.

2.Surgery begins with a median laparotomy.

Attempts to reduce a strangulated hernia are contraindicated.

The diagnosis of a reduced strangulated hernia can be made when there are clear indications from the patient himself of the fact of strangulation of a previously reduced hernia, the period of time of its non-reduction and the fact of its independent reduction. A reduced strangulated hernia should also be considered a hernia, the fact of self-reduction of which occurred (and is recorded in medical documents) in the presence of medical personnel (at the prehospital stage - in the presence of emergency medical personnel, after hospitalization - in the presence of the duty surgeon of the EDMC).

Group 4 - strangulated postoperative ventral hernia

Strangulation of postoperative ventral hernias is observed in % of cases. The clinical picture depends on its size, the type of strangulation and the severity of intestinal obstruction. There are fecal and elastic strangulation.

Examination protocols in OEMP

Clinical blood test,

Blood type and Rh factor,

Clinical urine analysis.

Plain radiography of the chest organs

Plain radiography of the abdominal cavity.

Ultrasound of the abdominal cavity and hernial protrusion - according to indications

Consultation with an anesthesiologist (if indicated)

Once a diagnosis of strangulated hernia has been established, the patient is immediately sent to the operating room.

Protocols for preoperative preparation in the EDMC

1. Before the operation, it is mandatory to insert a gastric tube and evacuate the gastric contents.

2. The bladder is emptied and the surgical area and the entire anterior abdominal wall are hygienically prepared.

3. If there is a complicated strangulated hernia and a serious condition, the patient is sent to the surgical intensive care unit, where intensive therapy is carried out for 1-2 hours, including active aspiration of gastric contents, infusion therapy aimed at stabilizing hemodynamics and restoring the input-electrolyte balance, as well as or antibiotic therapy. After preoperative preparation, the patient is sent to the operating room.

II. Protocols for anesthetic performance of surgery

1. In case of strangulation of inguinal and femoral hernias with short periods of strangulation, general satisfactory condition, absence of symptoms of acute intestinal obstruction, surgical intervention can be started under local infiltration anesthesia to visually assess the viability of the organ strangulated in the hernia.

2. The method of choice is endotracheal anesthesia.

III. Protocols for differentiated surgical tactics

13. For strangulated hernias complicated by small intestinal obstruction, drainage of the small intestine is performed using a nasogastrointestinal tube

14. For phlegmon of the hernial sac, the operation is performed in 2 stages. The first stage is laparotomy. In the abdominal cavity, resection of the strangulated organ is performed, delimiting the hernial sac and its contents from the abdominal cavity with a purse-string suture. The second stage is herniotomy with removal of the strangulated organ outside the abdominal cavity. Plastic surgery of the hernial orifice for phlegmon of the hernial sac is not performed.

15. The surgical intervention ends with plastic closure of the hernial orifice. The nature of the repair is determined by the location and type of hernia. Hernial orifice repair is not performed for giant multilocular postoperative ventral hernias.

VI. Protocols for postoperative management of patients with uncomplicated course

1. A general blood test is prescribed one day after surgery and before discharge from the hospital.

2. All patients are prescribed intramuscular administration of painkillers (analgin, ketarol) the day after surgery; broad-spectrum antibiotics (cefazolin 1 g x 2 times a day) for 5 days after surgery.

3. Sutures are removed overnight, the day before patients are discharged for treatment at the clinic.

4. Treatment of developing complications is carried out in accordance with their nature

Herniated intervertebral discs are one of the most dangerous pathologies of the musculoskeletal system. This phenomenon is very common, especially among patients 30–50 years of age. In case of spinal hernia, the ICD 10 code is entered in the patient’s medical record. Why is this necessary? When going to the hospital, the doctor will immediately see what the patient’s diagnosis is. Intervertebral disc herniation belongs to the thirteenth class, which contains all pathologies of bones, muscles, tendons, lesions of synovial membranes, osteopathy and chondropathy, dorsopathies and systemic lesions of connective tissue. ICD 10 is a reference network designed for the convenience of physicians. The Medical Information Guide has the following purposes:

creating conditions for the purpose of comfortable exchange and comparison of data acquired in different countries;
to make it more comfortable for doctors and other medical personnel to store information about patients;
comparison of information in one hospital over different periods.

Thanks to the International Classification of Diseases, it is convenient to count deaths and injuries. Also, the ICD 10th revision contains information about the causes of spinal hernia, symptoms, course of the disease and pathogenesis.

Main types of protrusion

A herniated disc is a degenerative pathology that occurs as a result of bulging of the intervertebral disc and pressure on the spinal canal and nerve roots. The following types of hernias are distinguished depending on location:

cervical;
chest;
lumbar;
sacral

The disease most often occurs in the cervical and lumbar region; somewhat less frequently, the pathology affects the thoracic region. The human spine consists of transverse and spinous processes, intervertebral discs, costal articular surfaces, and intervertebral foramina. Each section of the spinal column has a certain number of vertebrae, between which there are intervertebral discs with a nucleus pulposus inside. Let's consider the sections of the spine and the number of segments in each of them

The cervical region consists of the atlas (1st vertebra), axis (2nd vertebra). Then the numbering continues from C3 to C7. There is also a conditionally occipital bone, it is designated C0. The cervical part is very mobile, so hernia often affects it.
The thoracic spine has 12 segments, designated by the letter “T”. Between the vertebrae there are discs that perform a shock-absorbing function. Intervertebral discs distribute the load across the entire spine. ICD 10 states that in the thoracic region, a hernia most often forms between segments T8-T12.
The lumbar part consists of 5 vertebrae. The vertebrae in this area are designated as "L". Often a hernia affects this particular section. Unlike the cervical one, it is more mobile and more often susceptible to injury.

The sacral section is also distinguished, consisting of 5 fused segments. Less commonly, the disease is found in the thoracic and sacral regions. Each part of the spine is connected to different organs of the patient. This should be taken into account; this knowledge will help make a diagnosis.

How is a cervical bulge indicated on the patient's chart? What organs are affected by the disease in this localization?

The ICD 10 code is set according to the type of damage to the cartilaginous intervertebral discs. For a hernia in the cervical spine, code M50 is placed on the patient’s medical card. According to the International Classification of Diseases, damage to intervertebral segments is divided into 6 subclasses:

M50.0;
M50.1;
M50.2;
M50.3;
M50.8;
M50.9.

Such a diagnosis means the patient’s temporary disability. With a hernia in the cervical spine, the patient experiences the following symptoms:

headache;
memory impairment;
hypertension;
blurred vision;
hearing loss;
complete deafness;
pain in the shoulder muscles and joints;
numbness of the face and tingling.

As you can see, a degenerative disease affects the functioning of the eyes, pituitary gland, cerebral circulation, forehead, facial nerves, muscles, and vocal cords. If left untreated, a cervical hernia leads to complete paralysis. The patient remains disabled for life. For diagnosis, pathologists use x-rays, CT or MRI.

Classes for damage to intervertebral discs in the thoracic, lumbar and sacral region

For thoracic, lumbar or sacral hernia of the spine, the ICD classifies it as M51. It refers to damage to the intervertebral discs of other parts with myelopathy (M51.0), radiculopathy (M51.1), lumbago due to displacement of the intervertebral segment (M51.2), as well as specified (M51.8) and unspecified (M51.9) lesions intervertebral disc. There is also a code in ICD 10 M51.3. M51.3 is degeneration of the intervertebral disc, occurring without spinal and neurological symptoms.

This table is usually needed for doctors, nurses and other medical personnel, social security department employees and human resources representatives. Any person can obtain the information; it is in the public domain.

Symptoms of the disease in the thoracic, lumbar and sacral region in table form

The human spine has certain curves; in fact, it is not a column, although in many sources you can find the name “spinal column”. Physiological bends are not a sign of a pathological process in the body; there are certain norms and deviations for various pathologies. A hernia of the spine in the thoracic region causes a person to stoop, so the pain is less pronounced, thus, the appearance of kyphosis or lordosis is possible. To prevent the disease from leading to such complications, you should recognize the symptoms of the pathology in time and consult a doctor. Let's look at the signs of degenerative disease depending on location. Everything is described in detail in the table; even an ignorant person will be able to make a preliminary diagnosis in order to know which doctor to make an appointment with.

A herniated disc in the sacral region most often occurs between segments L5-S1. In this case, there is pain radiating to the buttocks, lower limbs, lumbar region, numbness in the foot, lack of reflexes, changes in sensitivity, sensation of “goosebumps”, tingling, “cough shock” (when coughing or sneezing the patient is struck by a sharp pain).

How are Schmorl nodes designated in official documents?

The International Classification of Diseases designates Schmorl's hernia with code M51.4. Schmorl's nodes are the pushing of the cartilaginous tissue of the end plates into the cancellous bone of the segment. This disease disrupts the density of intervertebral disc cartilage and mineral metabolism. As a result, a decrease in the density of the vertebrae and the elasticity of the intervertebral ligaments may occur. There is a deterioration in shock-absorbing properties, the growth of fibrous tissue at the location of Schmorl's nodes and the formation of intervertebral pathology.

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Includes: periumbilical hernia

Included:

hiatal (esophageal) hernia (sliding)
paraesophageal hernia

Excluded: congenital hernia:

diaphragm (Q79.0)
hiatus (Q40.1)

Included: hernia:

abdominal cavity, specified localization NEC
lumbar
obturator
female external genitalia
retroperitoneal
ischial

Included:

enterocele [intestinal hernia]
epiplocele [omental hernia]
hernia:
- NOS
- interstitial
- intestinal
- intra-abdominal

Excludes: vaginal enterocele (N81.5)

ICD-10 was introduced into healthcare practice throughout the Russian Federation in 1999 by order of the Russian Ministry of Health dated May 27, 1997. No. 170

The release of a new revision (ICD-11) is planned by WHO in 2017-2018.

With changes and additions from WHO.

K40-K46 Hernias

acquired hernia
congenital hernia (except for the diaphragmatic or esophageal opening of the diaphragm)
recurrent hernia

Note: a hernia with gangrene and obstruction is classified as a hernia with gangrene

inguinal hernia (unilateral) without gangrene: causing obstruction, strangulated, irreducible, strangulation

femoral hernia (unilateral) without gangrene: causing obstruction, strangulated, irreducible, strangulation

Hernia of the spine according to ICD 10

Code for intervertebral hernia according to ICD 10

A herniated disc is coded according to ICD 10 in strict accordance with the type of lesion of the cartilaginous intervertebral discs and their location. Thus, pathologies not related to trauma, located in the cervical spine, are placed in a separate department and are designated in the official medical documentation with code M50. This designation can be entered in the diagnosis field on a sheet of temporary incapacity for work, a sheet of statistical reporting, or some types of referrals for instrumental control methods.

An intervertebral hernia located in the thoracic, lumbar and sacral region in ICD 10 is designated by code M51. There is a designation M51.3, which indicates severe degeneration (protrusion of a hernia) of the cartilaginous disc without spinal syndromes and neurological signs. In case of radiculopathy and severe pain during an exacerbation, the hernia can be indicated by code M52.1. Code M52.2 stands for severe degeneration (destruction) of the cartilaginous disc with instability of the position of the bodies of the vertebrae located next to it.

Schmorl's nodes or intervertebral hernia have an ICD code of M51.4. In the event that the diagnosis is not specified and additional differential laboratory diagnostics are required, code M52.9 is entered in official medical documents.

A special table is used to decipher such data. It is usually of interest to employees of medical institutions, employees of the social insurance department and representatives of the human resources department. All necessary information is in the public domain and can be studied by anyone who has an interest in it. If you have any difficulties, you can contact our specialist. He will tell you all about the spinal disease, which is coded as intervertebral hernia according to ICD 10 code.

Trubnikov Vladislav Igorevich

Candidate of Medical Sciences

Neurologist, chiropractor, rehabilitation specialist, specialist in reflexology, physical therapy and therapeutic massage.

Savelyev Mikhail Yurievich

A chiropractor of the highest category, he has more than 25 years of experience.

Proficient in the methods of auriculo and corporal reflexology, pharmacopuncture, hirudotherapy, physiotherapy, exercise therapy. Perfectly applies osteopathy to both adults and children.

Signs of a spinal hernia in the lumbar region

Intervertebral hernia is a degenerative disease of the intervertebral disc, characterized by a violation of its integrity and structure

A hernia of the lumbar spine is the prolapse or protrusion of fragments of the intervertebral disc into the spinal canal. ICD disease code – 10 #8212; M51 (damage to intervertebral discs of other parts). Occurs due to injuries or osteochondrosis, leading to compression of nerve structures.

Hernia in the lumbar region occurs with a frequency of 300:100 thousand of the population, mainly in men from 30 to 50 years old.

Localization of the hernia is L5-S1 (mainly) and L4-L5. In rare cases, a herniated lumbar spine is found at L3-L4 and in severe injuries of the upper lumbar discs.

Systematization (according to the degree of penetration into the spinal canal):

According to the location of the hernia in the frontal plane: lateral, median, paramedian hernia.

Main clinical picture

At the very beginning of the disease, patients complain of lower back pain. Radicular and vertebral syndromes appear much later; in some cases, the “experience” of pain lasts several years.

At this stage, compression of the root occurs and the formation of a disc herniation: lumbodynia (pain in the lumbar region). At first it is fickle and aching. Over time, the severity of pain increases, often due to stretching of the posterior longitudinal ligament and overstrain of the ligamentous apparatus and muscles. The patient feels increased pain with any muscle tension, coughing, sneezing and lifting heavy objects. Lumbodynia is characterized by repeated exacerbations that continue for many years.

A herniated disc can occur on almost any part of the spine

tension of the paravertebral muscles prevents full straightening of the back and causes pain;
limited mobility of the lumbar region;
smoothing of lumbar lordosis (its transition to kyphosis is often observed);

when palpating the paravertebral muscles and interspinous processes, pain is observed;

there is a pronounced change in posture (forced position) to reduce pain;

"call symptom" Tapping the interspinous space, which corresponds to the location of the hernia, leads to shooting pain in the leg;

vegetative manifestations (skin marbling, sweating).

With median and paramedian hernia, scoliosis is observed, open to the painful side (less tension of the posterior longitudinal ligament). With a lateral hernia (reduced compression of the nerve root), scoliosis is observed, open in the opposite direction.

Radicular syndrome (radiculopathy):

pain occurs in the zone of innervation of one or more roots, spreads to the buttock, and below - along the anterior, posterior (posterior) surface of the leg and thigh (sciatica). The nature of the pain is aching or shooting;
pain most often occurs due to injury, when turning the body unsuccessfully or when lifting something heavy;
changes occur in the area of innervation of the nerve root;
the muscles become weak, hypotension is observed, and atrophy (sometimes fasciculations) develops. The patient feels numbness and paresthesia occurs;
"a symptom of a cough impulse." When straining (coughing, sneezing) in the area of innervation of the compressed root, shooting pain appears or its sharp intensification;
loss of proprioceptive reflexes is observed.

pain occurs even with slight lifting of the leg;
pain appears in the lower back and in the dermatome of the affected root. The patient may feel numbness or “pins and needles” when raising the straightened leg up;
the pain weakens (disappears) when the leg is bent at the knee joint, but intensifies when the foot is dorsiflexed.

A hernia of the lumbar spine most often occurs against the background of osteochondrosis

Pathology of the cauda equina (acute compression of the roots):

reason: large median hernia, pain occurs with significant physical effort and heavy load on the spine (sometimes during a manual therapy session). Signs: urinary retention (impaired sensitivity in the anogenital area), lower flaccid paraparesis.

Caudogenic intermittent claudication syndrome:

pain occurs when walking in the lower extremities (due to transient compression of the cauda equina). The patient is forced to stop frequently when moving.

Diagnostic measures

When making a diagnosis, it is important to take into account all the symptoms that indicate the presence of a hernia of the lumbar spine. A spinal hernia is recognized using the following diagnostic methods:

lumbar puncture (moderate increase in protein);
radiography of the spinal column;
MRI and myelography, sometimes followed by high-resolution CT;
electromyography (the ability to differentiate peripheral neuropathy from root compression).

Differential diagnosis

When differentiating from a lumbar hernia, it is important to exclude: tumors and metastases in the spine, ankylosing spondylitis, tuberculous spondylitis, metabolic spondylopathies, circulatory disorders in the accessory spinal artery of Deproge-Gotteron, diabetic neuropathy.

A timely diagnosis and treatment can restore the intervertebral disc completely. With late presentation, all treatment measures, unfortunately, are aimed only at reducing the intensity of symptoms.

Dorsopathy and back pain

2. Degenerative-dystrophic changes in the spine

Degenerative changes in the spine consist of three main options. These are osteochondrosis, spondylosis, spondyloarthrosis. Various pathomorphological options can be combined with each other. Degenerative-dystrophic changes in the spine in old age are observed in almost all people.

Osteochondrosis of the spine

Code according to ICD-10: M42 - Osteochondrosis of the spine.

Spinal osteochondrosis is a decrease in the height of the intervertebral disc as a result of degenerative processes without inflammatory phenomena. As a result, segmental instability develops (excessive degree of flexion and extension, sliding of the vertebrae forward during flexion or backward during extension), and the physiological curvature of the spine changes. The convergence of the vertebrae, and therefore the articular processes, and their excessive friction inevitably lead in the future to local spondyloarthrosis.

Spinal osteochondrosis is an x-ray, but not a clinical diagnosis. In fact, spinal osteochondrosis simply states the fact of aging of the body. Calling back pain osteochondrosis is ignorant.

Spondylosis

ICD-10 code: M47 - Spondylosis.

Spondylosis is characterized by the appearance of marginal bone growths (along the upper and lower edges of the vertebrae), which on radiographs look like vertical spines (osteophytes).

Clinically, spondylosis is of little significance. It is believed that spondylosis is an adaptive process: marginal growths (osteophytes), fibrosis of the discs, ankylosis of the facet joints, thickening of the ligaments - all this leads to immobilization of the problematic spinal motion segment, expansion of the supporting surface of the vertebral bodies.

Spondyloarthrosis

Code according to ICD-10. M47 - Spondylosis. Includes: arthrosis or osteoarthritis of the spine, degeneration of facet joints.

Spondyloarthrosis is arthrosis of the intervertebral joints. It has been proven that the processes of degeneration in intervertebral and peripheral joints are not fundamentally different. That is, in essence, spondyloarthrosis is a type of osteoarthritis (therefore, chondroprotective drugs would be appropriate in treatment).

Spondyloarthrosis is the most common cause of back pain in older people. Unlike discogenic pain in spondyloarthrosis, the pain is bilateral and localized paravertebrally; increases with prolonged standing and extension, decreases with walking and sitting.

3. Disc protrusion and herniation

ICD-10 code: M50 - Damage to the intervertebral discs of the cervical spine; M51 - Damage to intervertebral discs of other parts.

Disc protrusion and herniation are not a sign of osteochondrosis. Moreover, the less pronounced the degenerative changes in the spine, the more active the disc is (that is, the more likely the occurrence of a hernia). This is why disc herniations are more common in young people (and even children) than in older people.

A sign of osteochondrosis is often considered a Schmorl's hernia, which has no clinical significance (there is no back pain). Schmorl's hernia is a displacement of disc fragments into the spongy substance of the vertebral body (intracorporeal hernia) as a result of disruption of the formation of vertebral bodies during growth (that is, in essence, Schmorl's hernia is dysplasia).

The intervertebral disc consists of an outer part - this is the fibrous ring (up to 90 layers of collagen fibers); and the inner part is the nucleus pulposus. In young people, the nucleus pulposus is 90% water; in the elderly, the nucleus pulposus loses water and elasticity, fragmentation is possible. Disc protrusion and herniation occur both as a result of degenerative changes in the disc and as a result of repeated increased loads on the spine (excessive or frequent flexion and extension of the spine, vibration, trauma).

As a result of the transformation of vertical forces into radial forces, the nucleus pulposus (or its fragmented parts) shifts to the side, bending the fibrous ring outward - disc protrusion develops (from the Latin Protrusum - push, push out). The protrusion disappears as soon as the vertical load stops.

Spontaneous recovery is possible if fibrotization processes spread to the nucleus pulposus. Fibrous degeneration occurs and protrusion becomes impossible. If this does not happen, then as protrusions become more frequent and repeated, the fibrous ring becomes more and more unfibered and finally ruptures - this is a disc herniation.

A disc herniation can develop acutely or slowly (when fragments of the nucleus pulposus come out in small portions into the rupture of the fibrous ring). Disc herniations in the posterior and posterolateral direction can cause compression of the spinal root (radiculopathy), spinal cord (myelopathy) or their vessels.

Most often, disc herniation occurs in the lumbar spine (75%), followed by the cervical (20%) and thoracic spine (5%).

The cervical region is the most mobile. The frequency of hernias in the cervical spine is 50 cases per 100 thousand population. Most often, a disc herniation occurs in the C5-C6 or C6-C7 segment.
The lumbar region bears the greatest load, supporting the entire body. The frequency of hernias in the lumbar spine is 300 cases per 100 thousand population. Most often, disc herniation occurs in the L4-L5 segment (40% of all hernias in the lumbar spine) and in the L5-S1 segment (52%).

A disc herniation must have clinical confirmation; asymptomatic disc herniations, according to CT and MRI, occur in 30-40% of cases and do not require any treatment. It should be remembered that the detection of a disc herniation (especially small ones) using CT or MRI does not exclude another cause of back pain and cannot be the basis of a clinical diagnosis.