How is the spinal cord supplied with blood? Anterior spinal artery.

Before uniting into one artery, the vertebral vessels give off processes to the uppermost part of the cervical spinal cord. The spinal arteries begin from them - one anterior, two posterior. The posterior and anterior spinal artery are vessels giving off anastomoses, which are located longitudinally throughout the entire spinal cord.

The blood supply to the brain is carried out by two systems: carotid (carotid) and vertebral vessels. Admission there's blood coming out through two carotid, two vertebral arteries, and outflow - through two jugular veins. Nutrition of the spinal cord is provided through the spinal arteries and their branches.

Carotid arteries

The common carotid artery branches into the right, left and comes from chest cavity. The right vessel begins from the brachiocephalic trunk, and the left one from the aortic arch. These arteries provide the majority of blood flow to the brain - approximately 75%.

The branch of the common carotid artery is the internal carotid artery. On the left side it originates from the aorta, and on the right it originates from the subclavian artery. This structure of blood vessels allows us to maintain optimal blood supply conditions in the body. However, when a blood clot breaks off from the left side of the heart, it quite often penetrates the branches of the left carotid artery, and not into the system of the right carotid vessel. The internal carotid artery passes into the cranial cavity through the canal of the same name.

The terminal branches of the internal carotid artery are the middle and anterior cerebral vessels. The first of them runs along the lateral sulcus between three parts of the brain: parietal, frontal, temporal.

Spinal arteries

The posterior and anterior spinal vessels receive arterial blood at different levels, and then distribute it among the connecting arteries of the spinal cord. In a calm state, the brain consumes approximately 15% of the blood volume and 20-25% of the inhaled oxygen from these vessels.

The anterior spinal artery is a single continuous vascular trunk on the anterior part of the spinal cord. It reaches down to the conus terminalis, after which it makes a loop and goes to the back of the spinal cord (lumbar region). The vessel then unites with the posterior spinal processes. Thus, the blood supply to the spinal cord is provided by one anterior artery and two posterior spinal vessels.

The path of the vertebrate arteries comes from the subclavian vessels of the thoracic cavity. Then they penetrate the canal of the transverse branches of the cervical vertebrae. In the area of ​​the first cervical vertebra they leave it, after which they penetrate into the cranial cavity through the occipital foramen magnum. They form the vertebrobasilar basin and supply blood to the posterior parts of the brain: the cerebellum, medulla oblongata, and cervical spinal cord.

According to various sources, the vertebral processes provide 15-30% of the blood supply to the brain.

The posterior spinal arteries are located in the grooves of the spinal posterolateral cord and descend down. They are not separate continuous vessels, but chains of small arteries giving anastomyses. Arterial blood in them can function in different directions. Rear cerebellar arteries can give arterial blood into the posterior spinal arteries.

The vessels in the cranial cavity are located in the medulla oblongata. At the site of its border and the pons of the brain, the vertebral processes merge into a single trunk of the basilar artery. At the anterior part of the bridge of the basilar vessel, it bifurcates into two posterior cerebral branches.

The anterior and posterior spinal processes receive blood from the tributaries of the basin, as well as:

• from radicular vessels that arise from one or more vertebral arteries in the neck area;
• from the thyrocostal-cervical trunk of the subclavian artery;
• from segmental intercostal, lumbar vessels.

If there are changes in the cervical spine, if there is an osteophyte, compression of the vertebral artery in this area may be observed.

Connection between the carotid and vertebral arteries

The connection between the internal carotid arteries and the vertebral vessels occurs through the arterial circle of the cerebrum. Its second name is circle of Willis.

The arterial circle of the cerebrum is formed with the help of the following arteries:

• posterior cerebral vessels (from the spinal system);
• connecting posterior vessels (from the internal carotid artery system);
• middle cerebral vessels (from the internal carotid artery system);
• anterior cerebral artery (from the internal carotid artery system);
• anterior communicating artery (from the internal carotid artery system).

The two anterior cerebral arterial processes anastomose thanks to the anterior communicating vessel. The two middle cerebral vessels communicate with the posterior cerebral vessels through the posterior communicating arteries, each of which is a branch of the middle cerebral artery.

Blood supply to the brain

The main purpose of the circle of Willis is to ensure and maintain optimal blood flow in the brain. If disturbances occur in one of the systems, compensation occurs through a system of anastomoses.

Anterior cerebral artery

The anterior cerebral artery is responsible for supplying the following parts of the brain:

• cerebral cortex, a certain part of the white subcortical matter of the frontal, parietal lobes;
• upper parts of the precentral, postcentral gyrus;
• olfactory tract;
• head, outer side of the caudate nucleus;
• anterior parts of the corpus callosum;
• anterior parts of the lenticular (lenticular) nucleus;
• anterior limb of the internal capsule.

The cortical processes of this vessel pass down the outer part of the hemispheres, connecting with the processes of the middle cerebral artery.

Middle cerebral artery

The middle cerebral vessel supplies the following parts of the brain:

• cerebral cortex, white subcortical substance of a significant part of the cerebral hemispheres;
• genu, anterior two-thirds of the limb of the internal capsule;
• some parts of the caudate, lenticular nuclei;
• visual radiance;
• parietal part;
• Wernicke's center of the temporal region;
• middle, inferior frontal gyri;
• rear end frontal region;
• central lobe.

In the area of ​​brain formation, the middle cerebral vessel gives off several branches, which immediately penetrate into the brain mass and supply blood to the knee, the anterior two-thirds of the posterior limb of the internal capsule, certain part lenticular, caudate nuclei.

One of the deepest branches is the vessel of the lenticular nucleus, the striatal body, which belongs to the system of thalamostriatal branches. This is one of the main sources of blood supply to the basal ganglia, the internal capsule.

Another branch is the anterior villous artery. This vessel often departs from the carotid internal artery. The process provides nutrition to the choroid plexuses, can supply blood to the caudate, lenticular nucleus, motor zone of the internal capsule, Graziole's bundle, as well as Wernicke's center of the temporal region.

Several vessels originate from the middle cerebral artery in the lateral sulcus. The anterior, posterior, and intermediate temporal vessels supply the temporal part. The anterior and posterior parietal arteries supply the parietal lobe. The frontal part is fed by a wide common trunk, which splits into several branches: the orbital-frontal, the artery of the precentral sulcus, the artery of the central sulcus.

The middle cerebral vessel provides blood supply not only to the cerebral cortex, but also to the internal capsule, the white matter, in particular under the cortex of the upper part of the central lobule, which belongs to the basin of the anterior cerebral branch.

Posterior cerebral artery

The posterior cerebral artery is responsible for supplying blood to the following parts:

1. cerebral cortex, white subcortical matter of the occipital region, posterior part of the parietal, temporal lobes;
2. hypothalamus;
3. posterior parts of the optic tubercle;
4. body callosum;
5. caudate nucleus;
6. Lewis body;
7. part of visual radiance;
8. peduncles of the brain.

The brainstem and cerebellum are supplied by the vertebral, posterior cerebral vessels, and basilar artery.

Vertebral arteries

The vertebral arteries form the basilar artery. It supplies blood to the cerebellum, the pons of the brain. The first is supplied by three pairs of cerebellar vessels. Two of them are branches of the basilar artery, and one of them is the largest branch of the vertebral artery.

The branches of the vertebral artery unite to form the anterior spinal vessel. The two posterior spinal arteries of the vertebral vessels run separately on the sides, as do the two inferior cerebellar branches.

The vertebral arteries supply:

• posterior and inferior parts of the cerebellum;
• medulla;
• upper parts of the spinal cord.

The posterior inferior cerebellar artery supplies:

1. upper lateral sections of the medulla oblongata;
2. posterior inferior parts of the cerebellum.

Features of blood supply to the brain

A distinctive feature of the blood supply to the brain is the absence of a “gate” system. The branches of the vessels do not penetrate the medulla as in the situation with other organs. They spread over the surface of the medulla, giving off many thin branches at right angles. This allows for a uniform flow of blood throughout the entire plane of the brain, creating optimal conditions for vascularization of the cerebral cortex.

There are no large vessels in the brain matter; small arteries, capillaries, and arterioles predominate. The most extensive network of vessels is present in the hypothalamus region, as well as in the white subcortical matter.

Large vessels of the brain are located deep in the arachnoid membrane between the parietal and visceral layers. They are characterized by a fixed position: suspended on the arachnoid membrane and supported by their own branches at a certain distance from the brain. In case of brain displacement, for example with strong impact, injury may develop hemorrhage as a result of stretching, tearing of the connecting branches.

Blood supply to the spinal cord

The main sources of nutrition for the spinal cord are the arteries, which are located outside the cavity of the skull and spine. Branches of the vertebral, cervical, subclavian arteries, as well as intercostal posterior, lumbar, and sacral lateral vessels depart from the extracranial part. The last of them form spinal processes; they penetrate the intervertebral canal through the intervertebral foramina.

Then, having given branches to the spine, the spinal ganglion, they are divided into terminal radicular arteries. Some of them are depleted, others form a vascular network or provide blood supply to the dura mater. The radicular arteries that reach the spinal cord merge with the anterior and posterior spinal arteries, playing a major role in feeding the spinal cord.

Thus, nutrition of the spinal cord is provided by the anterior, posterior spinal processes and radicular arteries of the back.

The vertebral artery begins from the subclavian artery immediately after it leaves the chest. According to its movement, it is divided into four parts:

1. prevertebral part;
2. neck part;
3. atlas part;
4. intracranial part.

The vertebral artery gives the following branches:

• Muscular vessels. The arteries are directed to the prevertebral cervical muscles.
• Spinal vessels. They depart from the vertebral process, pass through the vertebral cervical foramina into the vertebral canal, and nourish the spinal cord and membrane.
• Posterior spinal artery. A paired vessel, it arises from each side of the vertebral artery in the cranial cavity above the foramen magnum. The spinal vessel descends and, entering the spinal canal, reaches the cauda equina region. Nourishes the spinal cord and membranes. The posterior arteries communicate with each other, as well as with the radicular branches of the lumbar, vertebral, and intercostal processes.
• The anterior spinal artery. It originates from the vertebral artery in the area of ​​the anterior part of the foramen magnum. It goes down, where the pyramids are repainted and is connected with the vessel of the same name on the opposite side. The unpaired vessel descends along the middle fissure of the spinal cord in the anterior region. Provides blood supply to the spinal cord and membranes, is associated with the radicular branches of the vertebral, lumbar, intercostal processes.
• The inferior cerebellar artery is posterior. The vessel branches at the bottom of the posterior part of the cerebellar hemispheres, gives off a number of branches to the choroid plexus of the fifth ventricle, the medulla oblongata, and the cerebellum.
• The inner part of the vertebral artery branches into meningeal branches, they supply blood to the brain hard shell posterior cranial foramen.
• The two posterior spinal processes are connected to each other, with the anterior spinal vessel through a horizontal arterial trunk. Located on the surface of the spinal cord, they form a vascular ring. It has perpendicular branches that penetrate the spinal cord. In it, between the vessels of various segments, processes of the right and left sides, there are multiple anastomoses. They make up a capillary network, and in the gray matter it is noticeably thicker than in the white matter.
• The venous system in the spinal cord is quite developed. The veins of the front and back parts are located approximately where the arteries are. The main venous channels are located longitudinally similar to the arterial vessels. They connect at the top with the veins of the cranial base into a single venous tract. The veins of the spinal cord are connected to the plexus of veins of the spine and, accordingly, to the veins of other parts of the body.

Disease of the spinal vessels

The anterior and posterior spinal vessels, as a rule, are not susceptible to atherosclerosis. Their damage may occur due to arteritis or embolism. Basically, spinal cord infarction is observed in the case of ischemia and blockages of other vessels. Spinal infarction can cause thrombosis, aortic dissection as a result of blockage of the radicular arteries and disruption of direct blood flow to the anterior, spinal branches. The area of ​​the thoracic spinal cord adjacent to the blood supply is susceptible to ischemic stroke.

Spinal cord infarction has a number of causes:

• systemic arteritis;
• immune reactions during serum sickness;
• reactions to the introduction of a contrast agent into the vessels.

In the latter case, the patient experiences severe back pain when contrast serum is administered.

Blockage (occlusion) of the spinal arteries can lead to motor and sensory pathologies.

Spinal cord infarction due to hernia intervertebral discs may be caused by microscopic fragments of the nucleus pulposus as a result minor injury, physical activity. In this case, local acute pain is observed, followed by paraplegia, transverse damage to the spinal cord, which can develop either immediately or up to an hour.

Clinical manifestations Anterior spinal artery occlusion occurs suddenly. In some people, symptoms appear within three days, which makes it difficult to diagnose correct diagnosis. Sudden blockage often occurs due to a blood clot and causes severe pain and loss of sensitivity. Then paralysis of the arm muscles and spastic paralysis of the lower extremities may occur as a result of the participation of the pyramidal tracts of the spinal cord in the process.

It is possible to develop dysfunction of the rectum, bladder, and decreased sensitivity at the segmental level of blockage of this vessel. At the same time, proprioceptive and tactile sensitivity is preserved. In the absence of sweating on the paralyzed part and high temperature around, an increase in body temperature is possible. This condition may be mistaken for the patient having an infection.

Occlusion of the posterior spinal arteries is quite rare. The focus of the infarction involves the posterior tract, the horns of the spinal cord, partially pyramidal side tracks. Sensitivity disorders are observed below the level of the infarction, spastic muscle paralysis and reflex disorders occur.

The blood supply to the spinal cord, its membranes and roots is carried out by numerous vessels extending at the level of the neck from the vertebral, thyroid and subclavian arteries, at the level of the thoracic and lumbar spinal cord - from the branches of the aorta (intercostal and lumbar arteries). More than 60 paired segmental radicular arteries, forming near the intervertebral foramina, have a small diameter (150-200 microns) and supply blood only to the roots and the membranes adjacent to them. The blood supply to the spinal cord itself involves 5-9 unpaired arteries of large caliber (400-800 microns), entering the spinal canal at different levels, either through the left or through the right intervertebral foramen. These arteries are called radiculomedullary, or main, vessels of the spinal cord. Large radiculomedullary arteries are variable in number and are found in cervical spine in the spinal cord from 2 to 5, in the thoracic cord - from 1 to 4 and in the lumbar cord - from 1 to 2.

After entering the subdural space, these arteries reaching the spinal cord are divided into two terminal branches - anterior and posterior.

Presenter functional value have anterior branches of the radiculomedullary arteries. Passing on the ventral surface of the spinal cord to the level of the anterior spinal fissure, each of these branches is divided into ascending and descending branches, forming a trunk, and more often a system of vessels called anterior spinal artery. This artery provides blood supply to the anterior 2/3 of the diameter of the spinal cord due to its branches extending into the depths sulcal arteries, the area of ​​distribution of which is the central zone of the spinal cord. Each half is supplied by an independent artery. There are several sulcal arteries per segment of the spinal cord. The vessels of the intramedullary network are usually functionally terminal. The peripheral region of the spinal cord is supplied by another branch of the anterior spinal artery - circumferential- and its branches. Unlike grooved arteries, they have a rich network of anastomoses with vessels of the same name.

The posterior, usually more numerous (on average 14) and smaller in diameter, branches of the radiculomedullary arteries form the system posterior spinal artery, its short branches supply the posterior (dorsal) third of the spinal cord.

The anterior spinal artery extends caudally to only a few cervical segments. Below it does not represent a single vessel, but is a chain of anastomoses of several large radiculomedullary arteries. It is no coincidence that blood flow in the anterior spinal artery occurs in different directions: in the cervical and upper thoracic sections of the spinal cord from top to bottom, in the middle and lower thoracic - from bottom to top, in the lumbar and sacral - down and up.

Anatomically, the vertical and horizontal arterial basins of the spinal cord are distinguished.

In the vertical plane, there are 3 vascular basins of the spinal cord:

1. Upper (cervicodorsal), supplying the spinal cord in the area of ​​segments C 1 - Th 3.

2. Middle, or intermediate - segments Th 4 - Th 8.

3. Lower, or lumbar - below the Th 9 segment.

The cervical thickening constitutes the functional center of the upper limbs and has autonomous vascularization. In the blood supply cervicothoracic region The spinal cord involves not only the vertebral arteries, but also the occipital artery (a branch of the external carotid artery), as well as the deep and ascending cervical arteries (branches of the subclavian artery). Consequently, the upper vascular system has the best conditions for collateral circulation.

Collaterals at the level of the middle basin are much poorer and the blood supply to the Th 4 - Th 8 segments is significantly worse. This section is extremely vulnerable and is a selective site of ischemic damage. The middle thoracic region of the spinal cord is a transition zone between two thickenings that represent the true functional centers of the spinal cord. Its weak arterial blood supply corresponds to undifferentiated functions.

The lumbar thickening of the spinal cord and its sacral section are sometimes supplied with blood by only one large (up to 2 mm in diameter) artery of Adamkiewicz, which most often enters the spinal canal between the I and II lumbar vertebrae. In some cases (from 4 to 25%), the additional Deproge-Gotteron artery, which enters the canal between the IV and V lumbar vertebrae, participates in the blood supply to the conus of the spinal cord.

Consequently, the conditions of blood supply to different parts of the spinal cord are not the same. The cervical and lumbar regions are better supplied with blood than the thoracic region. Collaterals are more pronounced on the lateral and posterior surfaces of the spinal cord. The blood supply is most unfavorable at the junction of the vascular beds.

Inside the spinal cord (in the transverse plane), 3 relatively discrete (separated) zones of blood supply can be distinguished:

1. The area fed by the central arteries - branches of the anterior spinal artery. It occupies from 2/3 to 4/5 of the diameter of the spinal cord, including most of the gray matter (anterior horns, base of the posterior horns, substantia gelatinosa, lateral horns, Clark's columns) and white matter (anterior cords, deep parts of the lateral and ventral parts of the posterior cords).

2. The area supplied by the artery of the posterior sulcus - a branch of the posterior spinal artery. Includes the outer sections of the posterior horns and the posterior funiculi. In this case, Gaulle's bundle is supplied with blood better than Burdach's bundle - due to anastomotic branches from the opposite posterior spinal artery.

3. The area supplied by the marginal arteries emerging from the perimedullary corona. The latter is formed by small arteries, which are collaterals of the anterior and posterior spinal arteries. It provides blood supply to the superficial parts of the white matter of the spinal cord, as well as collateral communication between the extra- and intramedullary vascular network, that is, the vessels of the pia mater and the central and peripheral arteries of the spinal cord.

Most foci of softening in the spinal cord are almost always localized in the central basin and, as a rule, they are observed in the border zones, i.e. deep in the white matter. The central pool, which is supplied by one source, is more vulnerable than the zones that are fed simultaneously from the central and peripheral arteries.

Venous drainage

The veins entering the venous plexus of the spinal cord are interconnected in the subarachnoid space with the radicular arteries. The outflow from the radicular veins is carried out into the epidural venous plexus, which communicates with the inferior vena cava through the paravertebral venous plexus.

Veins of the spinal cord. Radicular, anterior and posterior spinal veins (Suh Alexander, 1939)

Distinguish anterior and posterior outflow systems. The central and anterior outflow tracts come mainly from the gray commissure, anterior horns, and pyramidal fasciculi. The peripheral and posterior tracts begin from the posterior horn, posterior and lateral columns.

The distribution of venous pools does not correspond to the distribution of arterial pools. The veins of the ventral surface drain blood from one area, occupying the anterior third of the diameter of the spinal cord; from the entire remaining part, blood flows into the veins of the dorsal surface. Thus, the posterior venous pool turns out to be more significant than the posterior arterial pool, and vice versa, the anterior venous pool is smaller in volume than the arterial pool.

The veins of the surface of the spinal cord are united by a significant anastomotic network. Ligation of one or more radicular veins, even large ones, does not cause any spinal damage or impairment.

Intravertebral epidural venous plexus has a surface approximately 20 times larger than the branches of the corresponding arteries. This is a path without valves that extends from the base of the brain to the pelvis; blood can circulate in all directions. The plexuses are constructed in such a way that when one vessel closes, the blood immediately flows out another way without deviations in volume and pressure. Cerebrospinal fluid pressure in physiological limits during breathing, heart contractions, coughing, etc., it is accompanied by varying degrees of filling of the venous plexuses. An increase in internal venous pressure during compression of the jugular veins or abdominal veins, with a complex of the inferior vena cava, is determined by an increase in the volume of the epidural venous plexuses and an increase in cerebrospinal fluid pressure.

Connective tissue, surrounding the epidural plexuses, prevents varicose veins.

Compression of the inferior vena cava through abdominal wall used in spinal intraosseous venography to obtain better visualization of the vertebral venous plexuses.

Although in the clinic it is often necessary to note some dependence of the blood circulation of the spinal cord on the general blood pressure and state of cardio-vascular system, the current level of research allows us to assume autoregulation of spinal blood flow.

Thus, the entire central nervous system, unlike other organs, has protective arterial hemodynamics.

Not established for the spinal cord minimum blood pressure numbers, below which circulatory disturbances occur (for the brain these are figures from 60 to 70 mm Hg (J. Espagno, 1952). It seems that a person cannot have a pressure of 40 to 50 mm Hg without the appearance of spinal ischemic disorders or injuries (S. R. Stephen et coll., 1956)

January 16, 2011

The spine is supplied with blood by paired arterial vessels. In the cervical region these are branches of the vertebral artery, the ascending artery of the neck and the deep artery of the neck. These same arterial vessels give off special branches involved in the blood supply to the cervical spinal cord. In the thoracic region, the tissues of the vertebral segments are supplied with blood by the branches of the intercostal arteries, and in the lumbar region - by paired lumbar arteries. The intercostal and lumbar arteries give off branches along the way to the vertebral bodies. These sources, branching, enter the vertebral bodies through nutrient foramina. At the level of the transverse processes, the lumbar and intercostal arteries give off posterior branches, from which the spinal (radicular) branches immediately separate. Further, the dorsal arteries branch, supplying blood soft fabrics back and vertebral arches.

In the vertebral bodies, the arterial branches divide, forming a dense arterial network. Near the hyaline endplates, it forms vascular lacunae. Due to the expansion of the vascular bed, the speed of blood flow in the lacunae slows down, which is important for the trophism of the central sections of the intervertebral discs, which in adults do not have their own vessels and are nourished by osmosis and diffusion through the hyaline endplates.

The longitudinal ligaments and the outer layers of the fibrous ring have vessels, are well supplied with blood and take part in the trophism of the central sections of the intervertebral discs.

The vertebral arteries of the cervical spine depart from the subclavian, follow cranially in front of the costotransverse processes of the C7 vertebra, enter the canal of the vertebral artery at the level of the transverse foramen of the C6 vertebra and follow upward in the canal. At the level of the supratransverse foramen of the C2 vertebra, the vertebral arteries deviate outward and enter the transverse foramen of the atlas, bend sharply, bypassing the atlantooccipital joint from behind and following the groove of the vertebral artery on the upper surface of the posterior arch of the atlas. Having left it, the arteries bend sharply backwards, bypass the atlantooccipital joints from behind, pierce the posterior atlantooccipital membrane and along the a.vertebralis groove on the upper surface of the posterior arch of the atlas, enter through the foramen magnum into the cranial cavity, where they unite into a. basilaris, which, together with other arteries, forms the circle of Willis.

The vertebral artery is surrounded by a plexus of sympathetic nerves, which together form spinal nerve. The vertebral arteries and the surrounding vertebral nerve pass anterior to the spinal nerves and slightly outward from the lateral surfaces of the cervical vertebral bodies. With uncovertebral arthrosis, the vertebral arteries can become deformed, but the main reason for the disruption of blood flow along the a vertebralis is their spasm due to irritation of the vertebral nerve fibers.

The loop of the vertebral artery at the level of the arch of the atlas is very important, as it creates a certain reserve of length, therefore, during flexion and rotation in the atlanto-occipital joint, the blood supply through the arteries is not disrupted.

The anterior and two posterior spinal arteries depart from the vertebral arteries in the cranial cavity above the anterior edge of the foramen magnum. The anterior spinal artery follows along the anterior fissure of the spinal cord along its entire length, giving branches to the anterior parts of the spinal cord in the circumference of the central canal. The posterior spinal arteries follow along the line of entry of the posterior radicular filaments into the spinal cord throughout the entire length of the spinal cord, anastomosing among themselves and the spinal branches arising from the vertebral, intercostal and lumbar arteries.

Anastomoses between the anterior and posterior spinal arteries give off branches to the spinal cord, which together form a kind of corona of the spinal cord. The vessels of the crown supply blood to the superficial areas of the spinal cord adjacent to the pia mater.

The anterior spinal artery supplies blood to about 80% of the diameter of the spinal cord: the anterior and lateral cords of the white matter, the anterior and lateral horns of the spinal cord, the bases of the posterior horns, the brain substance around the central canal, and partially the posterior cords of the white matter

The posterior spinal arteries supply blood to the posterior horns of the spinal cord, most of the posterior funiculi, and the dorsal portions of the lateral funiculi. Gohl's bundle is supplied with blood from both the right and left posterior spinal arteries, and Burdach's bundle is supplied only from the artery of its side.

The areas of the spinal cord substance that are worst supplied with blood are those located in critical zones between the basins of the anterior and posterior spinal arteries: the bases of the posterior horns, the brain substance around the central canal, including the posterior commissure, as well as Clarke’s nucleus.

Thus, the blood supply to the spinal cord is segmental, but there are additional radiculomedullary arteries: the spinal branch of the fourth intercostal artery, the spinal branch of the 11-12 intercostal artery (Adamkiewicz’s artery) and the inferior additional radiculomedullary artery (Deproge-Getteron’s artery). The latter arises from the internal iliac artery and, together with one of the caudal lumbar spinal nerves and its roots, reaches the conus and epiconus of the spinal cord. These four arterial vessels play a leading role in the blood supply to the spinal cord and its elements. Other spinal branches have an auxiliary role, but under certain conditions, for example, when there is insufficient blood flow in one of the main spinal branches, these arteries participate in compensating for the impaired blood supply.

Along the length of the spinal cord there are also zones of less reliable blood supply, located at the boundaries of the basins of the additional radiculomedullary arteries. Since the number of the latter and the level of their entry into the spinal cord are very variable, the location of the critical zones is not the same in different subjects. Most often, such zones include the upper 5-7 thoracic segments, the area of ​​the brain above the lumbar enlargement and the terminal portion of the spinal cord.

Spinal nerve roots and Nageotte's nerve (part of the spinal nerve from the spinal ganglion to the point where the "cuff" of the nerve originates from the hard meninges) are supplied with blood from two sources: the radicular branches of the anterior and posterior spinal arteries, running in the distal direction.

In the area of ​​the “watershed” of these joints there is a section of the root with depleted arterial blood supply. Disruption of blood flow along any of the radicular arterial branches primarily causes ischemia of this particular area.

In the vertebral bodies, the main part of the venous blood is collected in collectors that go to the posterior surface of the bodies, leaving it and then flowing into the anterior internal vertebral plexus. A smaller part of the veins of the vertebral body exits through the nutrient foramina and flows into the anterior external venous plexus. Likewise, venous blood from the vertebral arches collects in the external and internal posterior venous plexuses of the spine.

The right and left parts of the anterior internal venous plexus are connected by transverse branches, forming venous rings and anastomose with the posterior internal venous plexus. In turn, the internal and external venous plexuses also anastomize with each other and form the lumbar and posterior intercostal branches. The latter flow into the azygos and semi-gypsy veins, but are connected by anastomosis to the system of the inferior and superior vena cava. The upper 2-5 lumbar veins also flow into the azygos and semi-amygos veins, which carry blood to the superior vena cava system, and the lower 2-3 lumbar veins go caudally and form a short and thick iliopsoas trunk, which flows into the common iliac vein. Thus, the venous plexus of the spine is a cava-caval anastomosis. If there is insufficient blood outflow in the inferior vena cava system, the pressure in the lower lumbar part of the vertebral plexuses can increase significantly and lead to varicose veins of the spinal canal, venous stagnation and disruption of the trophism of not only the tissues of the spinal segment, but also the spinal nerves, cauda equina roots and even cone of the spinal cord.

The anastomoses between the internal and external venous plexuses are the veins of the intervertebral foramina. Each intervertebral foramen contains 4 veins, one artery and spinal nerve. Blood from the spinal cord is carried into the radicular veins, which drain into the veins of the vertebral plexuses or directly into the vertebral veins.

It must be remembered that there are arteriovenous anastomoses between the arterial and venous systems. Such arteriovenous shunts are found in all tissues and organs; they play an important role in regulating blood supply. However, in the spinal cord they sometimes transform the nature of vascular malformations. Massive discharge of arterial blood into the venous bed causes insufficiency of venous outflow, varicose veins and edema associated with venous insufficiency, dystrophy, and degenerative changes in the spinal cord.

Arterial blood supply to the spinal cord

Before the vertebral arteries unite to form the basilar artery, they give off branches to the very top of the cervical spinal cord and give rise to one anterior and two posterior spinal arteries. The anterior and posterior spinal arteries are arteries that lie longitudinally along the spinal cord and provide anastomoses. The anterior and posterior spinal arteries receive arterial blood at different levels and distribute it among the spinal cord's own arteries.

The anterior spinal artery (arteria spinalis anterior) runs as a single continuous vascular trunk along the anterior surface (in the median sulcus, fissure) of the spinal cord down to the conus terminalis. It then loops towards the back of the lumbar spinal cord and connects to the posterior spinal arteries (arteriae spinales posterior).

The posterior spinal arteries descend in the posterolateral grooves of the spinal cord near the exit of the dorsal roots. The posterior spinal arteries are not continuous individual vessels, but anastomotic chains of small arteries in which arterial blood can circulate in opposite directions. Sometimes the posterior inferior cerebellar arteries give arterial blood through branches to the posterior spinal arteries.

In addition to tributaries from the vertebral artery basin, the anterior and posterior spinal arteries receive blood from:

• radicular arteries, which arise from one or both vertebral arteries in the neck
• thyrocostocervical trunk of the subclavian artery
• segmental intercostal and lumbar arteries (below the level of the T3 vertebral body)

From birth, each segment of the spinal cord has its own pair of blood supplying radicular arteries. Later, only 5-8 radicular arteries remain, running together with the anterior roots to the anterior spinal artery, and 4-8 arteries, running together with the posterior roots to the posterior spinal arteries, at irregular intervals. The anterior radicular arteries are larger than the posterior ones. The largest among the radicular arteries is called the great radicular artery or artery of Adamkiewicz (arteria radicularis magna). The large radicular artery (artery of Adamkiewicz) usually accompanies the right or left L2 nerve root on its way to the anterior spinal artery. Segmental spinal arteries atrophying after a period initial development humans do not disappear completely. They supply blood to the nerve roots, spinal nodes and dura mater.

1 - vertebral artery, 2 - anterior radicular artery C4-C5, 3 - anterior radicular artery C6-C8, 4 - costocervical trunk, 5 - shield-cervical trunk, 6 - common carotid artery, 7 - brachiocephalic trunk, 8 - aorta, 9 - anterior vertebral artery, 10 - posterior intercostal artery Th4-Th6, 11 - large radicular artery (Adamkiewicz), 12 - posterior intercostal artery Th9-L1.

The anterior spinal artery gives off sulcocommissural (sulcocomissurales) and circumflex (circumflexae) branches at short intervals. Approximately 200 sulcocommissural branches pass horizontally through the anterior median fissure (fissura mediana anterior) of the spinal cord, fan out in front of the anterior commissure (commissura alba) on both sides and supply almost all of the gray matter and the surrounding rim of white matter, including part of the anterior columns. The circumflex branches give anastomoses with the same branches from the posterior spinal arteries, forming the vascular crown (vasocorona). Its anterior branches supply the anterolateral and lateral funiculi of the spinal cord, including most of the lateral pyramidal tracts. The main nerve structures supplied by the posterior spinal arteries are the posterior funiculi and the apices of the dorsal horns of the spinal cord.

Venous drainage of the spinal cord

The capillaries of the spinal cord, which form groups in the gray matter corresponding to the columns of neurons, give blood to the veins of the spinal cord. Most of these veins run radially towards the periphery of the spinal cord. The veins located closer to the center of the spinal cord first spread along and run parallel to the central canal before leaving the spinal cord deep in its anterior or posterior median sulcus. On the surface of the spinal cord, veins form plexuses that supply blood to the winding longitudinal collector veins, the anterior and posterior spinal veins. The posterior spinal collector vein is larger and increases in size towards the lower part of the spinal cord. From the spinal vein collectors, blood flows through the central and posterior radicular veins (there can be from 5 to 11 on each side of the spinal cord) into the internal vertebral venous plexus (plexus venosus vertebralis internus).

1 - arachnoid membrane, 2 - dura mater, 3 - posterior external vertebral venous plexus, 4 - posterior spinal vein, 5 - posterior central vein, 6 - posterolateral spinal veins, 7 - sulcocommissural vein, 8 - vein of the sulcus, 9 – periosteum, 10 - anterior and posterior radicular veins, 11 - anterior internal spinal venous plexus, 12 - intervertebral vein, 13 - vertebral veins, 14 - anterior external spinal venous plexus, 15 - basal vertebral vein, 16 - anterior spinal vein.

The internal vertebral venous plexus, surrounded by loose connective and fatty tissue, is located in the subdural space and is analogous to the venous sinuses of the dura mater of the brain. This venous plexus communicates through the foramen magnum with these sinuses at the base of the skull. The outflow of venous blood also occurs through the intervertebral veins through the intervertebral foramina. Through the intervertebral veins, blood enters the external venous vertebral plexus (plexus venosus vertebralis externus). This plexus, among others, supplies venous blood to the azygos vein, which to the right of the spine connects the superior and inferior vena cava.

Syndromes caused by lesions of the spinal vessels

The anterior and posterior spinal arteries are usually not susceptible to atherosclerosis. The anterior and posterior spinal arteries can be affected by arteritis or embolism. Most often, spinal cord infarction in patients occurs as a result of ischemia with existing blockages (occlusions) of distant arteries. Thrombosis or aortic dissection causes spinal infarction by blocking (occlusion) of the radicular arteries and cutting off direct arterial blood flow to the anterior and posterior spinal arteries. Infarction (ischemic stroke) usually develops in the area of ​​adjacent blood supply to the thoracic spinal cord between the large spinal branch of the aorta, the Adamkiewicz artery below and the anterior spinal artery above.

Causes of spinal cord ischemia and stroke:

• stenosis of the mouth of the segmental artery
• compression of the segmental artery or its branches by anterior, lateral or posterior herniated intervertebral disc
• crura diaphragm syndrome

Spinal cord infarction in patients can occur with systemic arteritis, immune reactions during serum sickness, and after intravascular administration of a contrast agent. With intravascular contrast, a harbinger of spinal cord infarction is severe back pain that occurs in the patient during the administration of contrast.

Spinal cord infarction, caused by microscopic fragments of a herniated intervertebral disc, the contents of which is the nucleus pulposus, can develop in a patient after a minor injury, often received during sports. In this case, patients note acute local pain, followed by rapidly onset paraplegia and transverse spinal cord lesion syndrome, developing within a few minutes to an hour. Pulpous tissue is found in small intramedullary vessels and often within the bone marrow of the adjacent vertebral body. The route of its penetration from the disc material into the bone marrow and from there into the spinal cord remains unclear. This condition should be suspected in young people with transverse spinal cord injury syndromes resulting from an accident.

Blockage (occlusion) of the anterior spinal artery

Clinical manifestations of damage to the anterior spinal artery usually occur suddenly in the patient, like apoplexy. In some patients, symptoms of blockage (occlusion) of the anterior spinal artery increase within 1-3 days, which makes it difficult to diagnose accurate diagnosis. A sudden blockage (occlusion) of the cervical part of the anterior spinal artery, usually due to a blood clot, causes the patient to experience sensory disturbances in the form of paresthesia and severe pain. Following the sensory disorder, the patient develops flaccid paralysis of the arm muscles (peripheral type) and spastic paraparesis of the leg muscles (central type) due to the involvement of the pyramidal tracts of the spinal cord.

There is also dysfunction of the bladder and rectum (function pelvic organs) and a decrease in pain and temperature sensitivity at the segmental level of blockage of the anterior spinal artery. In this case, the patient usually retains proprioceptive and tactile sensitivity. Lack of sweating (anhidrosis) on the paralyzed part of the body can lead to an increase in body temperature, especially when high temperature environment, which simulates a picture of infection in the patient.

Blockage (occlusion) of the posterior spinal artery

Blockage (occlusion) of one or both posterior spinal arteries in patients is extremely rare in clinical practice. The resulting spinal cord infarction involves the posterior tracts and horns of the spinal cord, as well as partially the lateral ones. pyramid paths. Below the level of spinal cord infarction, the patient exhibits sensitivity disorders such as anesthesia and analgesia, spastic muscle paresis and reflex disorders.

The blood supply system of the spinal cord is divided by length and diameter.

1. The blood supply system of the spinal cord along its length.

The blood supply to the spinal cord is carried out by the anterior and paired posterior spinal arteries, as well as the radicular-spinal arteries.

Located on the anterior surface of the spinal cord, the anterior artery arises from two vertebral arteries and branches arising from the intracranial part, called spinal arteries, which soon merge and form a common trunk running down along the anterior groove of the ventral surface of the spinal cord.

The two posterior spinal arteries, arising from the vertebral arteries, run along the dorsal surface of the spinal cord immediately at the dorsal roots; each artery consists of two parallel trunks, one of which is located medial and the other lateral to the dorsal roots. Spinal arteries arising from the vertebral arteries; supply blood to only 2-3 upper cervical segments; throughout the rest of the length, the spinal cord is fed by the radicular-spinal arteries, which in the cervical and upper thoracic regions receive blood from the branches of the vertebral and ascending cervical arteries (subclavian artery system), and below - from the intercostal and lumbar arteries arising from the aorta. The dorsospinal artery departs from the intercostal artery, which divides into the anterior and posterior radicular arteries. The anterior and posterior radicular-spinal arteries, passing through the intervertebral foramen, go along with the nerve roots. Blood from the anterior radicular arteries enters the anterior spinal artery, and from the posterior ones - into the posterior spinal artery.

There are fewer anterior radicular arteries than the posterior ones, but they are larger. The number of arteries varies from 4 to 14 (usually 5-8). In the cervical region there are in most cases 3. The upper and middle parts of the thoracic spinal cord (from TYN to TYUP) are fed by 2-3 thin radicular arteries. The lower thoracic, lumbar and sacral parts of the spinal cord are supplied by 1-3 arteries. The largest of them (2 mm in diameter) is called the artery of the lumbar enlargement or the artery of Adamkiewicz. Disabling the artery of the lumbar enlargement gives a characteristic clinical picture of spinal cord infarction with severe symptoms. Starting from the 10th and sometimes from the 6th thoracic segment, it supplies the entire lower part of the splinal brain. The artery of Adamkiewicz enters the spinal canal usually with one of the roots from TYUS to YU, more often with the THX, THX1 or THXP thoracic root, in 75% of cases - on the left and in 25% - on the right.

In some cases, in addition to the artery of Adamkiewicz, small arteries are found that enter from the TL, TI, or TH roots, and the artery entering from the lumbar or 81 sacral roots, supplying the conus and epiconus of the spinal cord. This is the Deproge-Gutteron artery. There are about 20 posterior radicular arteries; they are of smaller caliber than the front ones.

Thus, three critical levels of blood supply to the spinal cord are distinguished along their length: TIP-TYP; TUSH-THUGH; YU-81.

2. The spinal cord supply system across the diameter. From the previous spinal artery, a large number of central arteries (a.a. cenbaH3) depart at a right angle, which pass along the anterior spinal groove and, near the anterior gray commissure, enter the substance of the spinal cord, either in the right or in the left half. The central arteries supply the anterior horns, base of the dorsal horns, Clark's columns, anterior columns, and most of the lateral columns of the spinal cord. Thus, the anterior spinal artery supplies approximately 4/5 of the diameter of the spinal cord. The branches of the posterior spinal arteries enter the region of the posterior horns and, in addition to them, supply almost the entire posterior columns and a small part of the lateral columns. Thus, the posterior spinal artery supplies approximately 1/5 of the diameter of the spinal cord.

Both posterior spinal arteries are connected to each other and to the anterior spinal artery by means of horizontal arterial trunks, which run along the surface of the spinal cord and form a vascular ring around it - the Oasis sogopa. Multiple trunks extending perpendicularly from this ring enter the spinal cord. Inside the spinal cord, between the vessels of adjacent segments, as well as between the vessels of the right and left sides, there are abundant anastomoses, from which a capillary network is formed, which is denser in the gray matter than in the white matter.

The spinal cord has a highly developed venous system. The veins draining the anterior and posterior parts of the spinal cord have a watershed approximately at the same place as the arteries. The venous canals, which receive venous blood from the substance of the spinal cord, run in a longitudinal direction similar to the arterial trunks. At the top they connect with the veins of the base of the skull, forming a continuous venous tract. The veins of the spinal cord also have a connection with the venous plexuses of the spine, and through them with the veins of the body cavities.

Vertebrogenic vascular myelischemia

Most often, myeloischemia of vertebral origin is caused by osteochondrosis of the cervical and lumbar spine. Spinal vascular disorders can occur both acutely, stroke-like (for example, with disc prolapse), and gradually, chronically (with the “proliferation” of posterior exostoses, hypertrophy of the ligamentum flavum and gradual compression of blood vessels). Vascular pathology often manifests itself as transient disorders of spinal circulation, their mechanism is usually reflex. In the pathogenesis of vascular myeloischemia, a reduction in the size of the intervertebral foramina through which the radiculomedullary arteries pass plays a particularly important role. With osteochondrosis, the discs flatten and settle, which in itself leads to a narrowing of the intervertebral foramen. Compression of blood vessels is promoted by “looseness” of the vertebra, pathological mobility, instability (pseudospondylolisgesis), which is a consequence of weakened fixation ligamentous apparatus spine, especially with cervical osteochondrosis. The accompanying reactive growths of osteochondral tissue with the formation of osteophytes and neoarthrosis make these openings even narrower. Any movement in the affected area (and even if there is insufficient fixation), which entails even a minimal narrowing of the intervertebral foramen, increases the compression of the vessels and roots passing here.

In addition to the direct effect on the vessel with its compression and disruption of blood flow, as a rule, there is also a reflex component - a narrowing of the arteries occurs due to irritation in a narrow bed. it's the same

manifests itself as transient vascular inferiority. Radiculomedullary arteries and veins are compressed most often when the lower lumbar discs prolapse. Thus, in vertebrogenic vascular myeloischemia, medullary pathology depends on the state of the main process - the vertebral one. Vascular pathology in these cases it is necessary to evaluate taking into account the root cause of suffering - spinal pathology. An approach to this complex suffering from such a position will provide adequate pathogenetic therapy.

1. Damage to the radiculomedullary arteries of the cervical thickening. The disease usually develops acutely after injuries with hyperextension of the head (for example, with a “diver’s injury”). Segmental motor and sensory conduction disturbances and dysfunction of the pelvic organs develop. Loss of consciousness is not always observed. Movement disorders may be varying degrees severity: from mild paresis to complete tetraplegia. Mostly superficial types of sensitivity suffer. In most cases, there is good regression of symptoms. Residual effects of the disease are manifested mainly by peripheral paresis of the distal parts of the arm and mild pyramidal signs on the legs. Amyotrophic lateral sclerosis syndrome can also develop with chronic decompensation of the cerebrospinal circulation in the cervical segments.

2. Damage to the great anterior radiculomedullary artery of Adamkiewicz. Development clinical picture depends on the territory of the spinal cord supplied by this artery in a given patient, on the presence or absence of additional radicular arteries (Deprog-Hatteron artery), upper or lower additional radiculomedullary artery. Transient circulatory disorders in this artery have their own characteristic - the syndrome of “intermittent claudication” develops » spinal cord (myelogenous intermittent claudication syndrome), a feeling of heaviness, weakness in the legs, paresthesia that extends to the perineum, lower torso, urinary urgency. All this quickly disappears with rest. Such patients do not have pain in the legs and weakening of the pulsation of peripheral vessels - pathognomonic signs of peripheral intermittent claudication (Charcot's disease). hallmark is a history of indications of recurrent lower back pain. An objective examination, as a rule, reveals vertebral syndrome.

Compression of the Adamkiewicz artery usually develops after heavy lifting, prolonged shaking, or awkward movement. Lower paraparesis develops acutely, up to plegia. The paralysis is flaccid in nature. First, there are features of flaccid paralysis, then symptoms of spastic paralysis may appear. Naru-

There are superficial types of sensitivity of the conductive type, and occasionally in the acute stage deep sensitivity also decreases. Disorders of the function of the pelvic organs of the central or peripheral type are characteristic. Trophic disorders in the form of bedsores appear early. Leg muscle wasting develops quickly. Regression of symptoms is observed slowly, dysfunction of the pelvic organs sphincters is especially stable.

3. Damage to the inferior accessory radiculomedullary artery Deprog-1Btteron. Transient circulatory disorders in the basin of this artery occur as myelogenous or causogenic intermittent claudication (Verbiest syndrome). When walking, painful paresthesia appears in the legs, spreading to the perineal area. Then comes pain in the legs. These complaints are especially common in people with a narrow spinal canal. When an additional artery running with the roots of Ly or 81 is compressed, spinal cord lesion syndrome develops, varying degrees severity: from mild paralysis of individual muscles to severe epiconus syndrome with anesthesia in the anogenital area, severe pelvic and movement disorders - the syndrome of the so-called paralyzing sciatica (de Sez et al.). Usually, against the background of long-term radicular syndrome or phenomena of caudogenic intermittent claudication, paralysis of the muscles of the lower leg and buttock occurs. More often the peroneal muscle group suffers (the patient cannot stand and walk on his heels), less often - the tibial muscle group (he cannot stand and walk on his toes); the foot hangs down or, conversely, takes on the appearance calcaneal foot. Hypotonia affects the muscles of the lower leg, thigh, and buttocks. Achilles reflexes may disappear or remain. Fascicular twitching of the leg muscles is often observed. Characteristic is the development of paresis in symmetrical myotomes (YU Shch 81.811), which occurs after the disappearance of radicular pain. Sensory disturbances develop in the anogenital area. This makes the dynamics and nature of the process different from compression radiculomyelopathies with their asymmetrical lesions and persistence of radicular pain. Therefore, there are two mechanisms of damage to the roots with the development of paresis of the leg muscles: compression radiculopathy and compression-ischemic radiculopathy. At the same time, according to A. A. Skoromets and Z. A. Grigoryan, the syndrome of paralysis of myotomes 1-2 can arise from ischemia of the root only or in combination with ischemia of the corresponding segments of the spinal cord. With the radicular version of paralyzing sciatica, the pathological process is one-sided. With compression-vascular radiculoischemia, symptoms of spinal cord damage with segmental and conduction sensitivity disorders clearly appear. Paresis covers a wider area. There are often bilateral pathological foot signs, even with loss of Achilles reflexes.

4. Damage to the posterior spinal artery. Ischemic disorders in the posterior spinal arteries often develop in the cervical spinal cord, less often in the thoracic, and even less often in the lumbar. The leading symptoms of isolated lesions of the posterior spinal artery are sensory disorders. All types of sensitivity are affected. There are segmental sensitivity disorders, procrioceptive reflexes are lost due to damage to the posterior horn. Sensitive ataxia develops due to a violation of the joint-muscular sense. Signs of damage to the pyramidal tracts are revealed. When the posterior spinal arteries are damaged at the level of the cervical segments, due to the peculiarities of vascularization of the Gaulle and Burdach bundles, a unique symptom complex develops. Clinically, it is characterized by loss of deep sensation in the arms with sensory ataxia while maintaining deep sensation in the legs. This is combined with spastic spinal hemiparesis, sometimes with segmental sensory disturbances. Circulatory disorders in various vascular areas of the spinal cord lead to ischemia of different zones, both original and across. In some cases, only the gray matter is affected, in others, the gray and white matter is affected. Ischemia can spread to one or both halves of the spinal cord, over one or two segments or an entire section of the spinal cord. In each individual case, the localization of the lesion determines the development of certain clinical symptoms. The most common combinations of symptoms of the lesion are combined into separate compression-vascular syndromes:

4.1. Complete transverse lesion syndrome.

4.2.Ventral zone ischemia syndrome. It develops when the anterior spinal artery or the common trunk of the large anterior radiculomedullary artery is damaged. In this case, the softening is localized in the ventral part of the spinal cord. When there is a blockage in the anterior artery at the level of the cervical segments, flaccid paralysis or mixed paresis of the upper extremities with lower spastic paraparesis, impaired superficial types of sensitivity downward from the level of the lesion, and disorders of the pelvic organs occur. Deep sensitivity remains intact. When the artery at the thoracic level is affected, spastic lower paraplegia develops with dissociated paraanesgesia and pelvic disorders such as urinary and fecal retention (Preobrazhensky syndrome). Ischemia of the ventral half of the lumbar enlargement is manifested by lower paraplegia with areflexia, dissociated paraanesthesia and pelvic disorders (Stanislavsky-Tanon syndrome).

4.3.Ischemic syndrome Brown-Sequard. It develops as ischemia in the basin of one of the sulcocommissural arteries. As a rule, complete Brown-Séquard syndrome is not detected, since deep types of sensitivity are not affected.

4.4. Ischemic syndrome ALS (amyotrophic lateral sclerosis). It is more common in chronic lesions of the cervical radiculomedullary arteries. Clinically manifested by mixed paresis of the upper extremities and central paresis of the lower extremities. There are often fascicular muscle twitches and mild segmental sensory disturbances.

4.5. Ischemic anterior horn syndrome (poliomyeloischemia). It develops when the branches of the spinal artery are affected with limited ischemia within the anterior horns. Flaccid paralysis of muscle groups occurs in the corresponding myotome with atony, atrophy and areflexia.

There are signs of changes in muscle electrical excitability, and EMG - anterior horn activity (the “picket fence” rhythm).

4.6. Ischemic pseudosyringomyelia syndrome. Occurs when “distant arterial drives” are damaged and ischemia of the central gray matter. Dissociated segmental sensory disturbances and flaccid paresis of the limbs are detected.

4.7. Posterior funicular vascular syndrome (Ya. Yu. Popelyansky). Develops with severe cervical osteochondrosis with compression of the posterior radicular arteries - damage to the Burdach bundles while the 1st bundles are preserved. Clinically manifested by sensitive ataxia.

4.8. Ischemic Personage-Turner syndrome. With cervical osteochondrosis with damage to the radicular-spinal arteries in the area of ​​the cervical thickening and ischemia of the anterior horns and roots, a clinical symptom complex of neurological amyotrophy of the shoulder girdle occurs. This syndrome also occurs after the introduction of vaccines and serums into the interscapular area. It is characterized by pain in the proximal parts of the upper extremities followed by the development of arm paresis.

5. Damage to the spinal cord caused by impaired venous circulation. The venous system of the spinal cord, like the arterial system, has two structure options: loose and main. Along the anterior and posterior surfaces of the spinal cord there are veins of the same name - anterior and posterior.

Veins of the spinal column, and>. Coliartae verenas, form plexuses on its outer and inner surfaces.

1) External vertebral venous plexuses, p1exm venoy ver- lebga1es ex1em (, are located on the anterior and posterior surfaces of the spinal column:

a) the anterior external vertebral venous plexus, p1exm venoulais velengall exChetis avenor, collects blood from the anterior parts of the vertebral bodies, the anterior longitudinal ligament and adjacent muscles (deep muscles of the neck);

b) posterior external vertebral venous plexus, p1exm vepo-s venebranis ex(ermin romenop, lies on the posterior surface of the arches, transverse and spinous processes; these plexuses receive blood from deep muscles and skin of the back and vertebrae.

2) Internal vertebral venous plexuses, pixm venoy ver- ter-laes Verm, are located in the cavity of the spinal canal and lie on the inner surface of its bone walls, outward from the dura mater of the spinal cord. There are longitudinally located anterior and posterior internal, vertebral venous plexuses, p1exm uepoya vepebga1e$ m (crm an1epog e1 ro1poz), while the anterior one is formed by larger veins. These plexuses are found along the length from the foramen magnum to the lower end of the sacral canal.

The anterior and posterior vertebral venous plexuses are connected by transverse anastomoses, forming venous rings at the level of each vertebra. In addition, the posterior internal vertebral venous plexuses are connected by the posterior external vertebral venous plexuses, and the internal anterior ones are connected to the external anterior ones.

The plexuses collect blood from the vertebrae and internal ligaments and, at the level of the foramen magnum, connect with the occipital venous sinus and the basilar venous plexus.

3) Basal-vertebral veins, y. Lazrebengales, run in the canals of the spongy substances towards the posterior surface of the vertebral bodies and flow into the pexillus veposis ueprebrans cetis ashepor.

The internal vertebral venous plexuses connect to the na-. external anterior vertebral venous plexus through the intervertebral foramina with vertebral veins - in the cervical part, with intercostal veins - in the thoracic part, with lumbar veins - in the lumbar part.

The spinal plexuses connect to the anterior and posterior spinal veins, vy.spr1ua1e5 avenoges e1 pos1poges, which are located in the pia mater of the spinal cord.

The outflow of blood from the spinal cord and the spinal plexuses occurs through the intervertebral veins, yyep.1er1ebga1e5, or directly into the segmental ones: yy. yеnега1ез, уу. 1n1ercos1a1z, yy. 1itbа1ez, yy. zasga1ez 1a1ega1z.

Perimedullary is widely represented vasculature, where blood flows from the intramedullary veins. Further, from the perimedullary network, blood flows through the anterior and posterior radicular veins, which follow the corresponding roots. The number of radicular veins varies from 6 to 35. The posterior radicular veins are larger than the anterior ones: in 90% of cases there is a large radicular vein, which runs with the first or second lumbar root on the left, but can enter the canal with one of the roots from the sixth thoracic to the third sacral. Therefore, vertebrogenic spinal disorders venous circulation with compression of a large radicular vein can develop under the same conditions as arterial radiculomyelopathy and myelopathy.

Most often, the radicular vein is compressed due to a herniated lumbar intervertebral disc. Often patients present only the following complaints: pain in the lower back of a projection nature, a feeling of chilliness in the legs. Pain in both the lower back and leg intensifies when lying down, and with a light warm-up they tend to decrease.

The clinical picture of venous radiculomyelopathy also differs in a number of features: firstly, weakness in the legs increases gradually, gradually, often the patient cannot clearly indicate the time of development of paresis; secondly, with the development of paretic phenomena in the lower extremities in such patients pain syndrome does not disappear for a long time.

The presence of vertebral syndrome is mandatory for vertebrogenic venous radiculomyeloischemia. IN lumbosacral The rhombus often has a pronounced venous network - dilated saphenous veins. This symptom is for the most part a good help in diagnosis, as it indicates stagnation in the epidural venous network. Often this symptom is combined with the presence hemorrhoids. The gait of these patients bears the features of sensitive ataxia (“stamping”, looks at one’s feet) - deep and tactile sensitivity is upset. Superficial types of sensitivity suffer of a segmental type (due to ischemia of the posterior horns and Rolandic substance over several segments). Pyramid signs are revealed. The anterior horns and the function of the pelvic organs are slightly affected.

Consequently, the uniqueness of the complaints of patients and the clinical picture of vertebrogenic lesions of the venous system of the spinal cord make it possible to differentiate compressive venous myelopathy and radiculomyeloischemia from a somewhat similar picture of damage to arterial vessels. And such differentiation is necessary, since therapy in both cases will, naturally, be different.

The consequence of spasm of the radicular arteries and venous congestion is the development of swelling of the root structures and the appearance of a characteristic clinical picture of radicular syndrome. Depending on anatomical feature volumetric ratio of the contents of the intervertebral foramen (1/3 of its volume is occupied by the artery and root, and 2/3 by the venous plexus (p1exi venovis)), as well as the individual severity of vascular reactivity to a decrease in the volume of the intervertebral foramen, two different variants of the clinical picture can be distinguished, corresponding to arterial and venous edema of the root.

Arterial edema of the root is characterized by precise localization of pain, intensification of the pain syndrome towards the end of the day, with warming up and with increasing physical activity (during muscular work, in heat, blood flow in the radicular arteries increases, leading to even greater compression of the radicular structures).

Venous edema is characterized by the absence of precise localization of pain, a decrease in pain when warmed up, with an increase in physical activity (this is due to a decrease in the tone of the venous plexuses under the influence of heat and movement and an improvement in the outflow from venous structures, see table).

Thermal procedures in the treatment and prevention of spinal diseases

Various thermal procedures rightfully occupy an important place in the treatment of spinal diseases. Various options have been used since ancient times bath procedures, various baths, all kinds of local warming agents were used in the area of ​​greatest pain.

However, the use of warming procedures is not always good and can sometimes worsen the condition and increase pain. Therefore, many doctors do not recommend performing them for back pain, and some even categorically prohibit thermal procedures during exacerbation.

What's the matter? Why does the use of heat help in some cases and may even be the main therapeutic factor, while in others it can intensify or cause an exacerbation? Is it worth it or not to use thermal procedures for back pain and what does their effect depend on? Which procedures are better? Bath, bath or

Can I just rub myself with ointment and it will feel better? How to determine the duration and intensity of exposure? How many procedures to perform? How often should I do them?

In order to answer these questions, let's remember what causes back pain and what are the mechanisms of its development. We already discussed these topics at the beginning of the book, now we will only briefly touch on them and list the main factors that cause pain.

Compression of the nerve root by swollen, swollen tissues

The first cause of back pain is compression of the nerve root by swollen and swollen tissues. This is the main reason for the development of pain in radicular syndrome - radiculitis. Does it make sense to use heat treatments to relieve swelling? It would seem that the answer is simple - yes. We are accustomed to the fact that swelling can be easily removed by thermal procedures.

Here it is appropriate to recall the analogy with the treatment of sprains and dislocations. On the first day after the injury, ice should be applied to the sprain site. Why is this being done? Exposure to cold causes a reflex spasm of the arteries and arterioles (the thinnest, microscopic arteries), reduces blood flow to the injured area and prevents swelling. If this was not done, then the damaged tissues swell, and in this case, on the contrary, warming procedures should be applied at the site of damage. This leads to the expansion of small and large veins and improved fluid outflow from damaged tissues.

With radiculitis, both factors act. On the one hand, dilated arteries and arterioles bring blood to the damaged area so that various types of leukocytes and active biochemical substances, the so-called inflammatory mediators, have a healing effect on the damaged area.

On the other hand, contraction of veins and venules leads to the fact that leukocytes and inflammatory mediators remain at the site of damage. The body tries to help heal the affected areas, but this is accompanied by an increase in local edema, pinching of the root and increased pain.

Of these two processes, one always prevails. Naturally, if blood flow predominates, then thermal procedures are contraindicated, since they will only increase swelling. If, on the contrary, the outflow is reduced, then thermal procedures can and should be carried out.

Another cause of pain is mechanical injury to the nerve root due to disc herniation. As a rule, the pain with such a disease is severe. She's very sharp. If the process occurs in the lumbar spine, then usually the pain will radiate to the leg or groin.

First of all, let's decide whether it is possible or not to use thermal procedures for this type of spinal lesion?

Some doctors, if they suspect an intervertebral hernia, oppose the use of any thermal procedures. Others believe that the use of such procedures for herniated discs does not have any effect. Still others adhere to the point of view that thermal procedures can significantly improve the condition of a patient with a hernial protrusion.

Quite contradictory opinions, isn't it? Let's think logically. Pain syndrome with hernial protrusion is caused by mechanical damage to the root intervertebral disc. How can thermal procedures influence this condition? Yes, none. Thermal procedures cannot have any effect on the hernia itself or the root. So, is their use in this case useless?

Not really. As already mentioned, pain can never be caused by one factor. In this case, there are also several factors affecting the nerve root.

Factors affecting the nerve root

First of all, it is, naturally, a hernia. The second is swelling of the tissues surrounding the root. The third factor causing pain is a reflex spasm of the muscles surrounding the root. We have not yet talked about this factor in the occurrence of pain. Can we use thermal procedures to relax cramped muscles? Of course we can.

Thus, although it is not possible to use heating to influence a hernial protrusion, nevertheless, with the help of thermal procedures it is possible to very effectively reduce the severity of the pain syndrome.

Signs of nerve root displacement

What signs may indicate that the cause of the pain syndrome is a displaced root? As a rule, such pain syndrome is very clearly localized. You can always tell where it hurts.