A complex of injections of B vitamins for back pain

Intercostal neuralgia is a pain syndrome: the sensation of pain occurs along one of the intercostal nerves. Acute, “shooting” pain in itself is a rather unpleasant factor, but in the case of intercostal neuralgia it is especially frightening. We usually interpret acute pain in the chest area as cardiac pain. If the nerve running between the lower ribs or the subcostal nerve (running under the lower rib) is affected, we may mistakenly believe that the source of pain is in the abdominal cavity.

What is intercostal neuralgia?

Neuralgia of the intercostal nerves is pain of a different nature that occurs due to various etiological factors. It is more often observed in adult men and women over 30-35 years of age. Symptoms of neuralgia may appear suddenly on one or both sides of the chest, along one or more intercostal nerves. The disease has an ICD code - M.79.2.

To understand what intercostal neuralgia is, you should understand the anatomical features of the thoracic nerves. There are 12 pairs in total. Each intercostal nerve contains motor, sensory and sympathetic fibers. It originates from the anterior roots of the spinal cord of the thoracic spine, passes along the lower edge of each rib, reaching the sternum. The parietal pleura covers the nerve fibers on top.

Thoracic nerves transmit impulses to the skin, the musculo-ligamentous apparatus of the chest and the anterior wall of the abdomen, partly the pleura and peritoneum, and the mammary glands. Sensitive fibers of neighboring nerve trunks actively interact with each other, creating cross innervation.

Diagnostics

Intercostal neuralgia, regardless of the severity of the pain syndrome and its location, requires a full diagnosis. The following examinations will help distinguish it from other pathologies:

• questioning and medical history: identifying the nature of the sensations, the conditions of their occurrence, the duration of the attack, concomitant diseases;
• examination and palpation: the doctor evaluates the appearance of the skin, checks the reaction to movements, pressing, turning, bending, assesses the severity of reflexes;
• laboratory diagnostics: general and biochemical blood tests, general urine tests: allows to identify signs of damage to the heart muscle (tests for troponins, CPK), inflammation, renal pathology, gastrointestinal diseases, etc.; the exact set of tests depends on the location of the source of pain;
• ECG, ultrasound of the heart: allow you to identify or exclude cardiovascular pathology;
• X-ray, CT or MRI of the thoracic spine: helps to identify osteochondrosis, osteoporosis, tumors, hernias and protrusions of intervertebral discs, etc.;
• Chest x-ray: allows you to assess the condition of the lung tissue and identify signs of tumors;
• Ultrasound of the kidneys, abdominal organs (excludes relevant pathology);
• FGDS to exclude pathologies of the esophagus, stomach, duodenum;
• myelography, contrast discography, electrospondylography to assess the condition of the spine, intervertebral discs, spinal cord and its roots.

If necessary, consultations with narrow specialists and additional examinations are prescribed.

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How to distinguish intercostal neuralgia from heart disease?

If neuralgia has acute symptoms in the thoracic region on the left side, differential diagnosis with heart disease must be carried out. You should not look for the cause of the pain syndrome on your own. Thoracalgia on the left side should always be a reason to consult a doctor.

Heart pain and symptoms of intercostal neuralgia on the left have distinctive features:

Symptoms of intercostal neuralgia on the left and right should also be differentiated from other diseases (pleurisy, pneumonia, thoracic aortic aneurysm, pericarditis, acute pancreatitis and others). If there is severe pain in the chest, only a doctor can determine exactly what it is - neuralgia or another pathology.

Symptoms

The main symptom of intercostal neuralgia is severe pain in the chest along the nerve. As a rule, it occurs suddenly and resembles an electric shock, gradually spreading along the ribs. The nature of the sensations can be different: shooting, pulsating, constant, burning or dull.

Deep breathing, turning the head or body, bending, pressing or simply touching the chest causes a pronounced increase in pain. In addition, characteristic signs of neuralgia are:

• persistence of pain at night;
• the ability to determine the epicenter of pain;
• redness or paleness of the skin in the affected area;
• a feeling of tingling, crawling or, conversely, numbness along the affected nerve;
• slight muscle twitching in the affected area.

As a rule, during an attack of neuralgia, a person tries to lie or sit motionless in a position in which the pain becomes slightly less.

If the cause of the pain syndrome is herpes zoster, first redness appears on the skin along the affected nerve, then numerous blisters that burst, forming crusts. After recovery, increased pigmentation remains in this area for some time.

Differences from myocardial infarction

Chest pain, especially on the left, can be a consequence not only of intercostal neuralgia, but also of more serious problems. The most dangerous is myocardial infarction. This condition requires emergency medical attention. The characteristic differences in pain are:

• occurrence against the background of physical, less often psycho-emotional stress;
• spread to the left arm, shoulder, left half of the neck and lower jaw;
• no changes when turning the body, bending, pressing on the sore area;
• decreased intensity when taking nitroglycerin and its analogues.

A heart attack is often accompanied by cold, sticky sweat, pale skin, dizziness, and fear of death.

It is important to remember that the signs of a cardiovascular accident and intercostal neuralgia are not always so radically different. An accurate diagnosis can only be made by a doctor.

Causes of intercostal neuralgia and risk factors

Intercostal neuralgia can develop for a variety of reasons. Among them are:

• injuries to the thoracic nerves, chest and spine;
• surgical interventions, long-term immobilization of a person in a certain position;
• poisoning with chemicals, prolonged use of medications;
• congenital developmental anomalies, hereditary diseases;
• infectious processes (shingles, tuberculosis, brucellosis and others);
• some neurological diseases, such as radiculitis and multiple sclerosis;
• diseases of the spine (osteochondrosis, deforming spondylosis, herniated intervertebral discs);
• compression of nerve branches in the bone-connective sheaths, for example, in the presence of scar changes, benign or malignant neoplasms;
• immunodeficiency (HIV infection, cancer, etc.);
• allergic reactions;
• diabetes;
• various metabolic disorders in nervous tissue and its hypoxia;
• lack of B vitamins in the body;
• alcohol abuse;
• osteoporosis;
• pathology of nearby anatomical structures (aorta, lungs, pleura);
• various systemic diseases (atherosclerosis, rheumatism, anemia, thyrotoxicosis, etc.).

More often, chest neuralgia appears due to several causes. Therefore, it is typical for older patients with vascular, degenerative and metabolic disorders. Sometimes symptoms of neuralgia appear after excessive physical activity, sudden movements or prolonged stay in one position. They can also occur after hypothermia or severe stress.

More often, intercostal neuralgia is observed on the left or right; less often, there is a bilateral lesion. In most cases, the pathogenesis is based on muscle spasm, leading to compression of nerve fibers. Pain occurs in response to nerve damage.

In children, signs of intercostal neuralgia are rare. When they appear, parents should definitely show the child to the doctor, as this may be a signal of the presence of a serious pathology. The doctor will determine the possible causes and explain how to cure intercostal neuralgia in this case.

What vitamins help with osteochondrosis?

One of the contributing factors in the appearance and progression of osteochondrosis is an unbalanced diet and improperly dosed physical activity. And if degenerative changes are already visible on an MRI of the spine or make themselves felt by back pain, a feeling of numbness or tingling in the extremities, a neurologist can prescribe vitamin therapy for you - injection or drip administration of B vitamins. A regimen of vitamin injections is developed individually depending on your needs , complaints and health status of each patient. So, to maintain muscles and muscle corset, injections of vitamin B6 are given. This vitamin is also needed for the normal functioning of the nervous system, so when there is compression of the nerve roots, it is advisable to use drugs containing pyridoxine. Vitamin B1 injections have a positive effect on the functioning of the entire central and peripheral nervous system. Especially injections of this vitamin are beneficial for improving the functioning of the nerves responsible for nutritional processes in tissues. A neurologist will prescribe a course of vitamin B12 injections for the prevention and treatment of demyelination (the process of destruction of nerve cells and damage to the nerve sheath). In addition to B vitamins, vitamin D is sometimes prescribed for degenerative changes in the spine. Vitamin D or calciferol is a vitamin that determines the ratio of calcium and phosphorus in the body. The positive effects of vitamin D are still being studied. Thus, D-vitamin therapy is even used to prevent the development of cerebral atherosclerosis and slow down the aging of the body. The form of taking this vitamin is through the mouth (orally). These vitamins are produced in oil and water solutions. Thus, by undergoing inexpensive complex treatment with vitamins for osteochondrosis, the patient can reduce or completely eliminate symptoms such as:

• numbness in the limbs;
• tingling or nagging pain in the arms and legs.

Forms of the disease

Chest neuralgia can be primary (an independent pathology) and secondary (a symptom of another disease). There are also radicular and reflex forms of the disease. In the first case, symptoms of intercostal neuralgia on the left and right arise due to irritation of the spinal roots. The second type of pathology occurs due to a negative effect on peripheral receptors.

In addition, clinicians distinguish the following types of thoracic neuralgia:

• musculoskeletal;
• vertebrogenic;
• spicy;
• chronic;
• right-sided;
• left-handed;
• psychogenic;
• during pregnancy.

Intercostal neuralgia of a certain type has its own characteristic symptoms and treatment features.

Symptoms of neuralgia on the right and left

Any neuralgia, including intercostal neuralgia, is primarily pain. Painful sensations can be of a different nature (aching, dull, sharp, piercing, burning) and have different intensity. Sometimes the pain is so severe that it forces a person to take a forced position and sharply limit physical activity. Intercostal neuralgia, which has pronounced symptoms, is described by patients as a lumbago or electric current discharge running from the spine to the sternum.

Thoracalgia often begins gradually, with a tingling sensation in the intercostal spaces, then acquires pronounced intensity. Less often it occurs suddenly. The pain can radiate to the scapula, epigastric area, heart, arm and lower back. Sometimes it takes on an encircling character. It intensifies with changes in body position, movements, coughing and deep breathing.

As a rule, painful attacks are constantly repeated, lasting from a few seconds to 2-3 minutes. Therefore, treatment of acute intercostal neuralgia on the right and left, first of all, always begins with the elimination of pain.

In addition to thoracalgia, a person may be bothered by characteristic local signs caused by the influence of sympathetic, sensory and motor nerve fibers. Intercostal neuralgia, depending on the damage to a particular nerve, will have characteristic symptoms on the right, left or both sides of the chest:

• impaired sensitivity, crawling sensation, numbness, tingling;
• muscle twitching;
• increased sweating;
• change in skin color.

If chest neuralgia appears against the background of a herpes infection, it may be accompanied by skin rashes. The latter appear 2-4 days after the onset of thoracalgia. Elements of the rash are located on the skin of the intercostal space in the form of small pink spots, which then turn into vesicles and then into crusts. Subsequently, traces of pigmentation may remain on the skin.

Modern approach to the treatment of trigeminal neuralgia

Trigeminal neuralgia (TN) (synonyms: tic douloureux, or Fothergill's disease) is one of the most common facial pain (prosopalgia) and is one of the most persistent pain syndromes in clinical neurology [1]. TN is a typical example of neuropathic pain (NP) of a paroxysmal nature and is considered the most painful type of prosopalgia. TN most often has a chronic or recurrent course, is accompanied by a large number of comorbid disorders, is much more difficult to treat than many other types of chronic pain and leads to temporary or permanent disability, which makes it a major economic and social problem [2]. Chronic NP has a significant negative impact on the quality of life of patients, causing sleep disturbances, increased anxiety, depression, and decreased daily activity [3]. The high intensity and persistence of TN, its special, often painful nature, and resistance to traditional methods of pain relief give this problem exceptional relevance. Trigeminal neuralgia is a disease characterized by the occurrence of paroxysmal, usually unilateral, short-term, acute, sharp, intense, electric shock-like pain in the area of ​​innervation of one or more branches of the trigeminal nerve [4, 5]. Most often, the lesion occurs in the zone of the II and/or III branch and extremely rarely - in the I branch n. trigeminus [6].

According to WHO, the prevalence of TN is up to 30–50 patients per 100,000 population, and the incidence is 2–4 people per 100,000 population. TN is more common in women than in men, debuts in the fifth decade of life and in 60% of cases has a right-sided localization [7, 8].

According to the International Classification of Headache Disorders (2nd edition), proposed by the International Headache Society (2003), TN is divided into classical, caused by compression of the trigeminal root by tortuous or pathologically altered vessels, without signs of obvious neurological deficit, and symptomatic, caused by proven structural damage to the trigeminal nerve, different from vascular compression [9].

The most common cause of TN is compression of the proximal part of the trigeminal root within a few millimeters of the entrance of the root into the pons (the so-called “root entry zone”). In approximately 80% of cases, compression occurs by an arterial vessel (most often a pathologically tortuous loop of the superior cerebellar artery). This explains the fact that TN occurs in old and senile age and practically does not occur in children. In other cases, such compression is caused by an aneurysm of the basilar artery, space-occupying processes in the posterior cranial fossa, tumors of the cerebellopontine angle and multiple sclerosis plaques [1, 8, 10, 11].

At the extracranial level, the main factors leading to the occurrence of TN are: tunnel syndrome - compression in the bone canal through which the nerve passes (usually in the infraorbital foramen and mandible), associated with its congenital narrowness, the addition of vascular diseases in old age, as well as as a result of a chronic inflammatory process in adjacent areas (caries, sinusitis); local odontogenic or rhinogenic inflammatory processes. The development of TN can be provoked by infectious processes, neuroendocrine and allergic diseases, demyelination of the trigeminal nerve root in multiple sclerosis [7, 12].

Depending on the impact of the pathological process on the corresponding part of the trigeminal system, TN is divided into predominantly central and peripheral genesis. In the occurrence of TN of central origin, neuroendocrine, immunological and vascular factors play an important role, which lead to impaired reactivity of cortical-subcortical structures and the formation of a focus of pathological activity in the central nervous system. In the pathogenesis of peripheral TN, a large role is played by the compression factor, infections, injuries, allergic reactions, and odontogenic processes [7, 8, 12].

Despite the large number of literature reviews and meta-analyses that have appeared in recent years on the problem of treating NB [13], which includes TN, there is no consensus among researchers regarding the basic principles of drug therapy for this disease [14]. Treatment of neuropathic pain is still insufficiently effective: less than half of patients experience significant improvement as a result of pharmacological treatment [15, 16].

The problem of treating trigeminal neuralgia today remains not fully resolved, which is associated with the heterogeneity of this disease in terms of etiology, pathogenetic mechanisms and symptoms, as well as the low effectiveness of conventional analgesics and the development of pharmacoresistant forms of TN that require surgical treatment. In modern conditions, treatment tactics for this disease include medicinal and surgical methods.

The main directions of drug therapy are: eliminating the cause of TN, if it is known (treatment of diseased teeth, inflammatory processes in adjacent areas, etc.), and carrying out symptomatic treatment (relief of pain).

Pathogenetic treatment of patients with TN includes the use of drugs with neurometabolic, neurotrophic, antioxidant, and antihypoxic effects. In recent years, the high effectiveness of the use of metabolic drugs in the complex treatment of NB has been discovered [8, 17]. In the treatment of patients with TN, the high effectiveness of the metabolic drug Actovegin, a deproteinized derivative from the blood of young calves, has been shown. The main effect of this drug is to stabilize the energy potential of cells by increasing intracellular transport and utilization of glucose and oxygen. Actovegin also has an antihypoxic effect, being an indirect antioxidant. In addition, the effect of Actovegin is manifested by indirect vasoactive and rheological effects by increasing capillary blood flow, reducing peripheral vascular resistance and improving the perfusion of organs and tissues [17]. Such a wide spectrum of pharmacological action of Actovegin allows its use in the treatment of TN. During an attack, it is advisable to use Actovegin intravenously in a slow stream or drip for 10 days at a dose of 400–600 mg/day. In the interictal period, the drug is prescribed orally at a dose of 200 mg 3 times a day for 1–3 months [8]. The pathogenetic treatment of patients with TN includes the use of high doses of B vitamins as part of multicomponent preparations, which is due to their multimodal neurotropic effect (impact on metabolism, metabolism of mediators, transmission of excitation in the nervous system), as well as the ability to significantly improve nerve regeneration. In addition, B vitamins have analgesic activity. Such drugs, in particular, include Milgamma, Neuromultivit, Neurobion, containing a balanced combination of thiamine (B1), pyridoxine (B6), cyanocobalamin (B12). Vitamin B1 eliminates acidosis, which reduces the pain threshold; activates ion channels in neuronal membranes, improves endoneurial blood flow, increases the energy supply of neurons and supports axoplasmic transport of proteins. These effects of thiamine promote nerve fiber regeneration [18–20]. Vitamin B6, by activating the synthesis of the myelin sheath of nerve fiber and transport proteins in axons, accelerates the process of regeneration of peripheral nerves, thereby exhibiting a neurotropic effect. Restoration of the synthesis of a number of mediators (serotonin, norepinephrine, dopamine, gamma-aminobutyric acid (GABA) and activation of descending inhibitory serotonergic pathways included in the antinociceptive system leads to a decrease in pain sensitivity (antinociceptive effect of pyridoxine) [18, 21]. Vitamin B12 is involved in processes of regeneration of nervous tissue, activating the synthesis of lipoproteins necessary for the construction of cell membranes and the myelin sheath; reduces the release of excitatory neurotransmitters (glutamate); has an antianemic, hematopoietic and metabolic effect [18, 22]. For rapid relief of pain and pathogenetic neurotropic effects in TN, it is advisable use of the parenteral form of the drug Neurobion - a combined preparation of B vitamins containing the optimal amount of vitamin B12 in both ampoule and tablet form. Neurobion is used in a dose of 3 ml per day intramuscularly 2-3 times a week - 10 injections (for severe pain syndrome can be used daily in the same dosage for 10–15 days). Then, to enhance and prolong the therapeutic effect and prevent relapse of the disease, Neurobion is prescribed in tablet form at a dosage of 1 tablet orally 3 times a day for 1–2 months [8].

Anticonvulsants are also the drugs of choice for the treatment of TN, and carbamazepine was one of the first drugs officially registered for the treatment of this condition [24].

In the early 90s of the last century, a new generation of antiepileptic drugs appeared, and now anticonvulsants are usually divided into first and second generation drugs.

First generation anticonvulsants include phenytoin, phenobarbital, primidone, ethosuximide, carbamazepine, valproic acid, diazepam, lorazepam, clonazepam. First-generation drugs are practically not considered as the first line of treatment for NB (with the exception of carbamazepine for TN) due to the insufficient level of analgesic effect and the high risk of adverse reactions. The most common side effects of first-generation anticonvulsants include: central nervous system reactions (drowsiness, dizziness, ataxia, sedation or increased excitability, diplopia, dysarthria, cognitive impairment, memory and mood impairment), hematological disorders (agranulocytosis, aplastic anemia, thrombocytopenia, leukopenia), hepatotoxicity, decreased bone mineral density, skin rashes, gingival hyperplasia, gastrointestinal symptoms (vomiting, anorexia). Second generation anticonvulsants include pregabalin (Lyrica), gabapentin (Neurontin, Gabagamma, Tebantin), lamotrigine (Lamictal), oxcarbazepine (Trileptal), topiramate (Topamax), levetiracetam (Keppra), tiagabine (Gabitril), zonisamide (Zonegran), vigabatrin (Sabril), felbamate (Taloxa). These drugs have more favorable pharmacokinetic characteristics and safety profiles, as well as a low risk of drug interactions compared to first-generation anticonvulsants [24, 25].

The main mechanisms of action of 1st and 2nd generation anticonvulsants are presented in table [26].

The first anticonvulsant successfully used to treat TN was phenytoin (Difenin) [27]. Diphenin, a derivative of hydantoin, similar in chemical structure to barbituric acid, is contraindicated in severe diseases of the kidneys, liver, and heart failure.

According to the recommendations of the European Federation of Neurological Societies (2009), pharmacotherapy for TN is based primarily on the use of carbamazepine (Finlepsin, Tegretol) proposed by S. Blum in 1962 (200–1200 mg/day), which is the drug of first choice (level of evidence A) [27, 28]. The analgesic effect of this drug is mainly due to its ability to reduce the permeability to sodium of the membranes of neurons involved in nociceptive reactions. The following treatment regimen with carbamazepine is usually prescribed. In the first two days, the daily dose is 200 mg (1/2 tablet in the morning and evening), then within two days the daily dose is increased to 400 mg (morning and evening), and after that - to 600 mg (1 tablet in the morning, at lunchtime and in the evening). If the effect is insufficient, then the total amount of the drug per day can be increased to 800–1000 mg. In some patients with TN (about 15% of the population), carbamazepine does not have an analgesic effect, so in such cases another anticonvulsant, phenytoin, is used.

Three placebo-controlled studies conducted about 40 years ago, which included a total of 150 patients with TN, showed the effectiveness of carbamazepine on both the frequency and intensity of paroxysms [24]. A number of authors have shown that carbamazepine can reduce pain symptoms in approximately 70% of cases. [29]. However, the use of carbamazepine is limited by pharmacokinetic factors and occasional severe side effects (for example, Stevens-Johnson syndrome), especially in elderly patients.

Oxcarbazepine (Trileptal) is structurally similar to carbamazepine, but is much better tolerated by patients and has far fewer side effects. Typically, oxcarbazepine is used at the beginning of treatment for TN at a dose of 600–1800 mg/day (Evidence Level B) [30].

As additional therapy for TN, the effectiveness of lamotrigine (Lamictal) at a dose of 400 mg/day [31] and baclofen at a dose of 40–80 mg/day [32], which are second-line drugs, has been shown (level of evidence: C). Small open studies (class IV) indicate the effectiveness of clonazepam, valproate, and phenytoin [33, 34]. This therapy is most effective in the classical form of TN. For TN of peripheral origin, it is preferable to include non-narcotic analgesics in treatment regimens, and in the case of the development of chronic pain syndrome (more than three months), the prescription of antidepressants (amitriptyline) is indicated [7, 12].

Gabapentin (Neurontin) is the first drug in the world to be registered for the treatment of all types of neuropathic pain. Many studies have shown the effectiveness of gabapentin in patients with TN who do not respond to treatment with other drugs (carbamazepine, phenytoin, valproate, amitriptyline); in most cases, complete relief of pain was observed [35]. The therapeutic dose ranges from 1800 to 3600 mg/day. The drug is taken 3 times a day according to the following regimen: 1st week - 900 mg/day, 2nd week - 1800 mg/day, 3rd week - 2400 mg/day, 4th week - 3600 mg/day.

The results of an open-label, prospective, 12-month study of 53 patients with TN were recently published, evaluating the effectiveness of pregabalin (Lyrica) at a dose of 150–600 mg/day. Treatment with pregabalin resulted in pain relief or at least a 50% reduction in pain intensity in 25% and 49% of patients, respectively [36]. In another multicenter, prospective, 12-week study of 65 patients refractory to prior analgesic therapy, treatment with pregabalin at a mean dose of 196 mg/day (monotherapy subgroup) and 234 mg/day (polytherapy subgroup) resulted in a ≥50% reduction in pain intensity in on average in 60% of patients, and also reduced the severity of anxiety, depression and sleep disorders [37]. When treating TN, the initial dose of pregabalin can be 150 mg/day in 2 divided doses. Depending on the effect and tolerability, the dose can be increased to 300 mg/day after 3–7 days. If necessary, you can increase the dose to the maximum (600 mg/day) after a 7-day interval.

The use of levetiracetam (Keppra) in the treatment of TN was first reported in 2004 by KR Edwards et al. [38]. The mechanism of action of levetiracetam is unknown; There is evidence obtained from animal experiments that it is a selective blocker of N-type calcium channels [39]. The properties of this drug are particularly suitable for the treatment of TN patients with severe pain who require a rapid response to therapy. The pharmacokinetics of levetiracetam are linear and predictable; Plasma concentrations increase proportionally to the dose within the clinically reasonable range of 500 to 5000 mg [40]. Unlike other anticonvulsants, especially carbamazepine, the hepatic cytochrome P450 system is not involved in the metabolism of levetiracetam and the drug is excreted through the kidneys [41]. In addition, this drug is characterized by a favorable therapeutic index and has a small number of adverse side effects (which is the main problem when using drugs to treat TN) [42]. Commonly reported side effects of levetiracetam are asthenia, dizziness, drowsiness, headache and depression. A 10-week, prospective, open-label study showed that higher doses of levetiracetam, ranging from 3000–5000 mg/day (50–60 mg/kg/day), were required for the treatment of TN compared with the treatment of epilepsy, but did not caused significant side effects. This circumstance indicates the prospect of using this drug for the treatment of TN [43].

One domestic study reported positive results with a combination of carbamazepine and gabapentin [44].

Since the 1970s, antidepressants have been used to treat TN [45]. Currently, the effectiveness of the use of tricyclic antidepressants (TCAs) in the treatment of TN has been proven [46].

Until now, the selection of analgesic therapy for NB is more an art than a science, since the choice of drugs is carried out mainly empirically. There are often situations when the use of one drug is not effective enough and there is a need for a combination of drugs. Prescribing “rational polypharmacotherapy” (simultaneous use of drugs with neurotropic, neurometabolic and analgesic mechanisms of action) allows increasing the effectiveness of treatment with lower dosages of drugs and fewer side effects [47].

For patients suffering from unbearable pain for a long time, and if conservative therapy is ineffective in the case of classical TN, surgical treatment is recommended. The following approaches are currently used:

1) surgical microvascular decompression [48]; 2) stereotactic radiation therapy, gamma knife [49]; 3) percutaneous balloon microcompression [50]; 4) percutaneous glycerol rhizolysis [51]; 5) percutaneous radiofrequency treatment of the Gasserian node [52].

The most effective method of surgical treatment of TN is the P. Janetta method, which consists of placing a special gasket between the trigeminal nerve and the irritating vessel; in the long-term period, the effectiveness of treatment is 80% [53–55].

In conclusion, we note that the treatment of TN should be multidisciplinary in nature, and the choice of various treatment methods and the risks of possible complications should be discussed with the patient.

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S. A. Gordeev*, Doctor of Medical Sciences L. G. Turbina**, Doctor of Medical Sciences, Professor A. A. Zusman**, Candidate of Medical Sciences *First Moscow State Medical University named after. I. M. Sechenov, **MONIKI im. M. F. Vladimirsky, Moscow

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Diagnosis of intercostal neuralgia

Make an appointment Shpigel Anna Yakovlevna Neurologist, massage therapist 33 years of experience. The specialist receives: - newborn children and schoolchildren - adults - athletes Reviews from patients Consultation from 3000 rubles.

Acute intercostal neuralgia is a reason to contact a competent, qualified neurologist. Since symptoms in adults with damage to the thoracic nerves can be disguised as other diseases, the patient must undergo a comprehensive examination to exclude possible pathology. The doctor must conduct a survey and examination.

The person’s posture is noteworthy when he leans towards the healthy side, so as not to provoke a painful attack. Palpation of the chest reveals pain. Trigger points are identified at the lower edge of the rib, where the affected nerve passes. If neuralgia affects several nerve branches, which often happens, this leads to a decrease or complete loss of sensitivity in the corresponding area of ​​the body.

First of all, the doctor must distinguish the symptoms of intercostal neuralgia on the left from cardiovascular pathology. For this purpose, the patient undergoes an ECG. If indicated, a cardiologist is consulted. In order to correctly diagnose and treat intercostal neuralgia, the doctor also excludes diseases of the respiratory system, digestive tract, musculoskeletal system, infectious processes and other diseases. He may prescribe a number of additional tests (laboratory tests, x-ray of the lungs, ultrasound of the abdominal organs, MRI of the spine, etc.).

Thoracic neuralgia is an indication for electroneurography. This method allows you to determine the condition of nerve fibers by assessing their structure and functionality.

Chest neuralgia can be a manifestation of benign and malignant tumors. It is often the first symptom of a herniated disc and degenerative changes in the spine. Therefore, early identification of its causes is considered an important task for the neurologist and the patient.

Diagnostic methods

You need to see a general practitioner. After examination and exclusion of other pathologies, the therapist refers to a neurologist who determines the symptoms and treats intercostal neuralgia. The doctor examines the images, prescribes tests and medical examinations.

Instrumental diagnostic methods of examination:

• Radiography. Allows you to examine the bone structure. Makes it possible to determine the presence of non-traumatic or traumatic disorders. X-rays are taken in direct, oblique and lateral projections.
• CT scan. Examines bone and muscle structure in combination. More often used to detect pathological changes in bone structures.
• Myelography. A contrast agent is injected into the spinal canal. This is the main method for diagnosing soft tissue structures (nerve roots and spinal cord).
• Contrasting discography. During the procedure, a contrast agent is injected into the intervertebral disc.
• Magnetic resonance imaging. Allows you to obtain images of organs and tissues. Detects pathological changes in soft tissue structures: nerve tissue, muscles, ligaments, hernias and degenerative changes in intervertebral hernias.
• Electrospondylography. Using the computer diagnostic method, it is possible to assess the condition of the spinal column, identify the disease at an early stage, determine the extent of damage and monitor the course of the disease.

How to treat intercostal neuralgia?

Treatment of any neuralgia, including intercostal neuralgia, is aimed at eliminating the clinical manifestations and causes of the disease. Therapy includes a whole range of activities. If a patient is diagnosed with neuralgia, you can find out how to treat it from the specialists of our clinic. The doctor will select the optimal therapeutic course, taking into account the characteristics of the disease and the individual characteristics of the person.

As a rule, intercostal neuralgia requires long-term treatment and further measures to prevent painful attacks. The doctor prescribes specific methods of therapy, determines the duration of each course, and gives his recommendations on lifestyle and regimen. The treatment plan may include:

• painkillers;
• etiotropic therapy aimed at combating the underlying disease;
• anti-inflammatory drugs;
• neurotropic drugs;
• physiotherapy;
• osteopathy;
• massage;
• Exercise therapy.

The doctor always chooses how to treat neuralgia, based on the clinical picture, the stage of the process, the results of diagnostic examinations and the individual characteristics of the patient.

Treatment methods for intercostal neuralgia

Treatment of intercostal neuralgia is complex. The doctor solves several problems simultaneously.

It is necessary to reduce the severity of the pain, and preferably completely eliminate the pain syndrome. For this purpose, anti-inflammatory therapy is prescribed.

It is important to eliminate the cause of the nerve damage. If the disease is viral in nature, antiviral therapy is carried out. For muscular-tonic syndrome, muscle relaxants are prescribed. If a nerve is pinched at the point where it exits the spinal canal, manual therapy may be prescribed. For tumor processes, surgical treatment is necessary.

Treatment is also carried out to strengthen the nerve tissue.

Treatment during periods of acute pain

During periods of acute pain, bed rest should be observed for at least several days. The bed should be flat and firm. “Dry heat” helps a lot. For example, you can wrap a woolen scarf around your chest. Warm compresses, pepper plaster, and mustard plasters are used (it is necessary to avoid placing mustard plasters directly on the spinal column). Massage with anti-inflammatory and warming ointments is recommended. Sedatives and non-steroidal analgesics are used as prescribed by the doctor.

During this period, it is necessary to avoid physical activity and stress. You can't drink alcohol.

Subsequent treatment

Further treatment includes:

• physiotherapy (methods such as UV therapy, UHF, electrophoresis, darsonvalization, magnetic therapy are used);
• massage;
• reflexology;
• physical therapy.

Make an appointment Do not self-medicate. Contact our specialists who will correctly diagnose and prescribe treatment.

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Is osteopathy effective for intercostal neuralgia?

The causes of neuralgia in the rib area can be different. However, in many cases, a pinched nerve is caused by the consequences of various injuries a person has received in the past. The capabilities of fine diagnostics using hands make it possible to identify and eliminate these disorders, which leads to the elimination of compression of the nerve and the restoration of its normal blood supply. As a result, inflammation and its integral companion – pain – go away. Osteopathy shows high effectiveness in the treatment of both unilateral and bilateral intercostal neuralgia.

Treatment of occipital neuralgia

Without influencing the cause of the disorder, it is impossible to completely eliminate its manifestations. The only case where therapy is purely symptomatic is idiopathic occipital neuralgia.

Until research results are obtained, all patients are prescribed symptomatic therapy. Once the root cause is known, treatment is supplemented with remedies aimed at eliminating it.

In most situations, neuralgia can be dealt with directly using conservative therapy. It assumes:

• drug treatment;
• massage;
• exercise therapy;
• physiotherapy.

If left untreated, occipital neuralgia can lead to destruction of nerve tissue and the development of complications, including hair loss and depressive disorders.

Drug therapy

Depending on the nature of the clinical manifestations and causes of nerve irritation, patients may be prescribed:

• muscle relaxants - a group of drugs that help eliminate muscle spasms;
• NSAIDs are drugs that have anti-inflammatory and analgesic properties;
• corticosteroids – have powerful anti-inflammatory properties, prescribed in short courses when NSAIDs are insufficiently effective;
• anticonvulsants – help reduce muscle tone;
• antidepressants – necessary to normalize the psycho-emotional state of patients;
• B vitamins - necessary to improve the condition of nervous tissue and impulse conduction.

In case of a severe attack of pain, a blockade can be performed, which involves pinpoint injections of anesthetics at certain points along the affected nerve.

Physiotherapy

To increase the effectiveness of drug therapy, patients are recommended to undergo courses of physiotherapeutic procedures:

• UVR method involves exposure to mid-wave ultraviolet rays. This leads to an intensification of the release of specific neurotransmitters, which has a beneficial effect on the transmission of nerve impulses. Typically, the course of treatment includes 10 procedures.
• UHF - the procedure is based on the action of high frequency currents, which provoke an improvement in the quality of blood circulation and restoration of the sodium-potassium membranes of nerve cells. Treatment duration is from 15 to 20 sessions of 15 minutes each.
• Electrophoresis is a procedure during which painkillers or other drugs are injected directly into the affected area using an electric current. Traditionally, 10 procedures are prescribed, performed every other day.
• inductometry;
• Laser therapy is a method based on the positive effect of the thermal energy of laser beams on nerve fibers. This effect reduces their sensitivity, which reduces the degree of their irritation and the frequency of attacks. Patients are recommended 10 procedures of 4 minutes each.
• Diadynamic currents - the procedure involves fixing electrodes on trigger points and passing Bernard current through them. This is an ultra-high frequency current, the impact of which provides a rapid decrease in the pain threshold and inhibition of the transmission of nerve impulses. The duration of the treatment course is 5 sessions, performed every other day.
• Spinal traction is a procedure aimed at increasing the size of intervertebral discs and normalizing the position of the vertebrae. It can be performed using dry or underwater methods. Its duration ranges from several minutes to an hour, and the course of treatment includes about 15 sessions. With the dry method, traction is carried out under the influence of its own weight in a vertical or horizontal position. When underwater, the procedure is carried out after the patient is immersed in water. The second method has a more gentle effect on the spine.

Additionally, patients may be recommended reflexology sessions. It has long been noted that targeted effects on biologically active points provoke increased blood circulation, improved lymph flow and a decrease in the severity of pain.

Massage

A properly performed massage helps eliminate pressure on nerve endings, improve blood circulation in the head, and eliminate muscle spasms. The mastoid process and the area under it are exposed to manual intervention. It is important that the procedure is carried out by a qualified specialist. Otherwise, you may accidentally hit trigger points, which will provoke a new attack of pain.

Traditionally, a course consisting of 12–14 procedures is prescribed. The duration of each of them is about a quarter of an hour.

Therapeutic exercise (physical therapy)

Regular exercise therapy classes according to individually designed programs will help normalize the functioning of the cervical spine. They are especially important for osteochondrosis, as they allow you to accelerate the processes of natural restoration of cartilage tissue and eliminate the prerequisites for compression of nerves.

For each patient, a set of exercises is selected separately, taking into account the characteristics of existing diseases. They should be performed daily at least once a day. On average, one physical therapy session takes about 20–30 minutes.

All exercises are performed carefully, without sudden movements. If a new attack of neuralgic pain or discomfort in the cervical spine occurs, you should immediately stop exercising and consult a doctor as soon as possible to understand the causes of pain and change the nature of the exercises to a more gentle one.

Possible complications and consequences

Any neuralgia, in particular intercostal neuralgia, that does not respond to treatment, may be a sign of a serious illness. Most of the complications that arise with thoracalgia are precisely a manifestation of the underlying pathology, which worsens against the background of constant pain.

Chest neuralgia itself, with a long-term severe course, can provoke the development of a hypertensive crisis or an attack of angina (less often, myocardial infarction). Severe, constant pain affects a person’s physical and mental state in different ways. Often severe symptoms of intercostal neuralgia on the left or right significantly complicate the patient’s life. He sleeps poorly, is nervous, cannot move normally and do his usual work.

Pain in the intercostal spaces does not allow the patient to perform full breathing movements, which leads to a decrease in oxygen supply to the body and the development of hypoxia. Sometimes neuralgia is accompanied by such debilitating pain that it contributes to emotional exhaustion, and this is a serious complication, since this condition causes depression.

Neuralgia during pregnancy

If intercostal neuralgia appears in a pregnant woman, how to diagnose it and how to treat it is decided by a neurologist together with a gynecologist. Therapy is selected taking into account possible negative effects on the fetus. Self-medication in this situation is considered unacceptable, as this can have a negative impact on the health of the expectant mother and child.

To prevent chest neuralgia from appearing during pregnancy, it is advisable to follow preventive measures. If a woman has previously had attacks of thoracalgia, then at the stage of preconception preparation she should visit a neurologist and osteopath. The doctor will conduct a diagnosis, and then the neurologist will give a number of recommendations on how to treat intercostal neuralgia. An osteopath will identify possible causes of neuralgia and conduct a treatment session aimed at eliminating them.

Surgical treatment of occipital neuralgia

For idiopathic neuralgia, as well as when conservative treatment is ineffective, patients may be offered surgical treatment. It may consist of:

• microvascular decompression;
• radiofrequency ablation;
• neurostimulation.

Patients may also be recommended surgeries aimed at eliminating the cause of neuralgia. Most often, they lie in disturbances in the structure of the cervical spine, which is why surgical interventions are performed in this same area with high frequency.

Microvascular decompression

Microvascular decompression allows complete preservation of the nerve. It can be used when a nerve fiber is compressed by a nearby passing blood vessel, from which blood pulsations are transmitted to it, which causes pain.

The operation is performed openly under general anesthesia. Its essence is to separate the vessel from the nerve at its junction and install a Teflon gasket between them. This is a reliable means of eliminating pain and leads to complete recovery, provided that neuralgia was a consequence of irritation of the occipital nerve by pulsation of a blood vessel.

But this method of surgical treatment requires great caution from the operating neurosurgeon, since it can easily damage the nerve fiber. This will result in loss of sensation in the entire area it innervates. Therefore, you can trust its implementation only to a highly qualified neurosurgeon.

Radiofrequency ablation

The procedure is characterized by minimal trauma and a high level of safety. Its essence consists in introducing a thin needle through the skin under the control of an image intensifier. It is brought directly to the nerve, after which the active or damaging electrode is immersed through the cavity in it. It is connected to a generator, due to which, after turning on the device, current is supplied to the non-insulated end of the electrode. By acting on the nerve fiber, it is destroyed, which leads to the elimination of pain.

For neuralgia of the occipital nerve, the use of current with a frequency of 100 Hz is indicated. This leads to heating of the tissue around the bare end of the electrode to 42°C. The ablation itself lasts about 2 minutes, and the extremely low temperature effect eliminates the risk of thermal damage to surrounding tissues.

Because the procedure does not require significant tissue damage, the patient can move and return to daily activities almost immediately afterward. No hospitalization required.

Radiofrequency ablation is performed under local anesthesia, so choosing it completely avoids the risks associated with general anesthesia. The duration of the procedure is about half an hour. Almost always it leads to complete recovery and immediate pain relief.

The method is also used if the cause of pain is spondyloarthrosis, which is not amenable to conservative treatment. In this case, the essence of the procedure is the same, but the damaging electrode is immersed under the control of the image intensifier into the soft tissue in the immediate vicinity of the affected joint.

Neurostimulation

The essence of the procedure is to implant electrodes under the skin that generate electrical impulses, which helps reduce pain. A total of one or two 8-pin electrodes are installed. The quantity depends on whether the process is one-sided or two-way.

Electrodes are installed in the area of ​​the greater and lesser occipital nerves. They are connected to a generator with the ability to recharge and are equipped with a remote control. Patients can independently turn on the supply of electrical impulses when an attack occurs, which allows them to completely get rid of the painful sensations.

Operations aimed at eliminating pathologies of the cervical spine

Since one of the causes of the development of occipital neuralgia is degenerative-dystrophic diseases of the cervical spine, patients may be prescribed surgical interventions aimed at eliminating them. The type of operation depends on the nature of the detected deviations. It can be:

• Microsurgical methods for the treatment of intervertebral disc protrusions (cold plasma, radio wave, laser nucleoplasty) - make it possible to reduce the size of the disc protrusion by sclerosing part of the nucleus pulposus with cold plasma, thermal laser energy or high-frequency current. They are not performed under local anesthesia, allow you to immediately return home and do not leave scars on the skin, since all the necessary instruments are inserted into the patient’s body through a thin cannula.
• Microdiscectomy is an operation to remove a herniated intervertebral disc, performed under general anesthesia through an incision, usually on the side of the neck, up to 3 cm in size. It requires a short hospitalization and compliance with a number of restrictions during the recovery period, but has a significantly lower risk of relapse. At the same time, with the help of microdiscectomy, hernias of almost any size can be removed.
• Endoscopic surgery is performed for herniated intervertebral discs, but is carried out through a pinpoint puncture of soft tissue up to 1 cm in size. It has a more gentle effect on the body, which facilitates the rehabilitation period. It is also indicated for severe spondylosis. In such cases, excess bone tissue is removed, the intervertebral disc is moved or removed, and, if necessary, implants are installed.

Forecast and prevention of intercostal neuralgia

In most patients, intercostal neuralgia can be completely cured. If thoracalgia occurs against the background of a herpetic infection, relapses are possible.

If adequate treatment of neuralgia does not bring the desired result, a more “deep” diagnosis is carried out to search for the possible cause of this condition. First of all, spinal hernias, benign and malignant tumors are excluded.

To prevent neuralgia of the intercostal branches from recurring, and its symptoms in adults to manifest themselves less painfully, doctors recommend the following preventive measures:

• follow the canons of a healthy lifestyle: give the body adequate physical activity, eat right, actively relax in the fresh air, give up bad habits, etc.;
• maintain normal functioning of the immune system;
• monitor posture and spinal health;
• promptly treat chronic diseases and infectious processes;
• if possible, visit the pool and harden yourself;
• undergo preventive examinations on time;
• undergo regular scheduled examinations by an osteopath approximately once every six months.

If a person has previously had thoracic neuralgia, he should not be overcooled, be in a draft, expose the body to excessive physical stress, perform sudden movements or remain in an uncomfortable position for a long time. In addition, it is necessary to eliminate or minimize as much as possible stress and any unfavorable factors that can cause symptoms of intercostal neuralgia on the left, right or both sides.

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