Radiculopathy cervical, thoracic and lumbosacral

Radiculopathy (radicular syndrome) is a neurological syndrome caused by irritation of the spinal roots. Each root corresponds to the body of its vertebra and is located at the same level with it. It passes through the narrow intervertebral foramen and is surrounded by muscles, ligaments and choroid plexuses. Problems with any of these formations can cause irritation and/or compression of the root.

Thus, the origin of radiculopathy and the occurrence of pain is determined by the position of the roots.

Definition

Radiculopathy is a symptom, not an independent disease, a symptom of a disease of the peripheral nervous system, the cause of which in most cases is protrusion or herniation of the intervertebral disc and arthrosis of the vertebral joints. And before continuing, I would like to start with the anatomy of the spine and the structure of the nervous system.

According to the classification of vertebrae, free vertebrae are distinguished:

• cervical vertebrae – 7 pcs.
• thoracic vertebrae – 12 pcs.
• lumbar vertebrae – 5 pcs.

and fused:

• sacral vertebrae – 5 pcs.
• coccygeal vertebrae – 3-5 pcs.

A distinctive feature of the cervical vertebrae is the presence of an opening in the transverse process - the vertebral arteries pass through it. Another distinctive feature is the atlas and axial vertebrae (1st and 2nd vertebrae), they are atypical, they lack a body, spinous and articular processes. 3 - 7 cervical vertebrae - typical.

In any typical vertebra, the body, arch and process are distinguished, and their connections are distinguished according to the parts of the vertebra.

The vertebral bodies are connected to each other through intervertebral discs, anterior and posterior longitudinal ligaments.

The arches are connected by the ligamentum flavum.

Among the processes, spinous, transverse and articular (upper and lower) are distinguished. The spinous processes are connected by the interspinous ligament, the transverse ones by the intertransverse ligament, and the articular processes by the intervertebral joints.

All vertebrae form the spinal column among themselves, and when the vertebrae connect, intervertebral foramina are formed (right and left), through which spinal nerves and vessels pass.

The spinal column does not occupy a strictly vertical position; it has physiological curves. The curve facing backward is called kyphosis, and the curve facing forward is called lordosis.

The spinal cord located inside the spinal canal begins from the foramen magnum and ends to the first lumbar vertebra (LI) in men, 2 lumbar vertebra (LII) in women.

There are 124 roots extending along the spinal cord. 62 posterior and 62 anterior, from which 31 pairs of spinal nerves are formed.

Having understood the anatomy of the spine and the formation of nerve roots, you can move on to the disease.

All back pain can be divided into specific, nonspecific and radicular.

So, radiculopathy is a disease caused by compression (damage) of a nerve root, causing radicular pain in the back. Compression occurs due to the fact that the intervertebral disc, which performs a shock-absorbing function in the spine, begins to protrude under external loads and a non-functioning muscle corset. Thus forming a protrusion, and subsequently a herniation of the intervertebral disc.

For understanding, here are statistics on the prevalence of back pain:

• specific – 85% (due to muscles, ligaments, tendons, small joints),
• nonspecific – 10% (vertebral fracture, tuberculosis, osteomyelitis, abscess, spinal stenosis, neoplasm, ankylosing spondylitis, etc.)
• radicular up to 4%.

In other words, the prevalence of radiculopathy is 4% of all back pain syndromes.

Thoracic radiculopathy

Radiculopathy of the thoracic spine is characterized by acute or chronic painful sensations of varying intensity, having various qualitative and subjective characteristics from acute piercing, unbearable pain to the sensation of a blow of wind and depends on the disease causing radiculopathy. Painful sensations can change depending on the position of the body, head, movements, time, day, climatic phenomena, the menstrual cycle in women, psycho-emotional status and many other reasons that a doctor can find out by carefully collecting an anamnesis. In addition, the following clinical manifestations can be objectively observed:

• muscle weakness of the arms and back;
• impaired sensitivity of the skin of the back, upper limbs, sternum, abdomen;
• shortness of breath, rapid heartbeat;
• increased muscle tone on the side of the affected nerve.
• discoloration of the skin on the body;
• skin rashes on the body;
• hypotrophy, weight loss of body muscles;

Symptoms of radiculopathy

On the torso, areas of the skin with increased pain sensitivity are divided into certain areas - dermatomes, or they are also called Zakharyin-Ged zones, after the names of the clinical researchers who discovered this phenomenon - Russian therapist G.A. Zakharyin and the English neuropathologist G. Ged.

With radiculopathy, a peripheral version of sensitivity disorder occurs. It is characterized by disorders that occur when sensory pathways are damaged (peripheral nerves, plexuses, roots). And peripheral paralysis or paresis, which is a disorder of voluntary movements. As a result, a sensitivity disorder occurs in the corresponding dermatome. And the muscles innervated by the affected root become weak and hypotonic, which contributes to their atrophy.

Clinical manifestations of radiculopathy are characterized by a sudden onset, with constant or periodic shooting, piercing, intense pain, which at least occasionally radiates to the distal zone of the dermatome, the corresponding affected nerve root.

The pain syndrome can appear and intensify with movement, straining, lifting weights, sitting in a deep chair, staying in one position for a long time, coughing and sneezing and weakens with rest, especially if the patient lies on his healthy side, bending the affected leg at the knee and hip joints. Initially, the pain may be dull and aching, but it gradually increases, and sometimes it can immediately reach its maximum.

During the examination, the patient often takes a forced position. Movement in the affected segment of the spine and the limb innervated by it is sharply limited. On palpation, pronounced tension of the paravertebral muscles is noted.

In differential diagnosis, a neurological examination of the patient is of great importance. Due to damage to the nerve root, its function is impaired, therefore, radiculopathy is characterized by a violation of pain, temperature, vibration and other sensitivity (including in the form of paresthesia, hyper- or hypoalgesia, allodynia, hyperpathia) in the corresponding dermatome, a decrease or loss of tendon reflexes, closing through the corresponding segment of the spinal cord, hypotension and weakness of the muscles innervated by this root.

Symptoms

Each type of radiculopathy is characterized by the presence of a specific set of symptoms.

The general symptom is pain of varying severity. The pain can range from not too intense to quite significant. Acute pain often limits the mobility of the limbs and body and makes it impossible to lead a normal lifestyle, which affects the patient's quality of life.

Symptoms of cervical radiculopathy

Most often, acute pain occurs in the morning. It could be:

• pain in the neck
• headache (sometimes very intense)
• shoulder pain
• arm pain
• soreness and/or stiffness of the neck muscles
• paresthesia (impaired sensitivity, accompanied by a feeling of burning, tingling, numbness, coldness)
• metabolic disorders (dry skin, peeling, coldness of the skin when touching the affected area)

Important! If you find yourself with similar symptoms, treatment should be started without delay. You should not rely on “home” methods. They can only give a temporary effect and will not eliminate the cause of the disease.

Only a qualified neurologist will accurately determine the type of disease, prescribe an examination and adequate treatment.

Symptoms of thoracic radiculopathy

Along with the general symptoms characteristic of all types of radiculopathy, the following are observed in the chest form:

• girdle pain, pain between the shoulder blades, behind the sternum and in the area of ​​the lower ribs
• pain radiating to the shoulder and armpit
• pain radiating to the middle finger
• triceps weakness
• During a medical examination, a decrease in the tricepital reflex is detected

It is difficult to diagnose the disease yourself. It should be borne in mind that the symptoms of thoracic radiculopathy resemble the symptoms of angina pectoris and other dangerous diseases.

Self-treatment can cause irreparable harm!

Symptoms of lumbosacral radiculopathy

Lumbosacral neurological syndrome is characterized (along with similar symptoms in other types of radiculopathy):

• intense pain in the foot, hip and buttock
• acute pain in the lower back, radiating to the limbs
• impaired motor function due to awkward bending or sudden movement
• loss of sensation in the lower limb, weakening of the muscles of the lower limbs

Pathogenesis

The onset of the development of the disease is two factors that are related to each other: mechanical irritation of the root and/or spinal ganglion and inflammatory changes in the perineural tissue that occur as a result of penetration of the disc into the epidural space.

In this case, factors of root compression can be both disc herniations and bone growths (uncovertebral, spondyloarthritic). Compression can also be caused by hypertrophied ligaments and periarticular tissues, vascular structures (epi- and subdural hematomas, arteriovenous malformations, epidural hemangiomas).

Until now, “blank spots” remain in the pathophysiological concept of radicular pain. It is assumed that the basis of radicular pain is axonal dysfunction caused by various etiological factors, including neural compression, ischemia, damage by inflammatory and other biologically active substances. Spinal roots (unlike peripheral nerves) have a weak blood-neural barrier, making the axon more susceptible to compression injury.

Increased vascular permeability due to mechanical compression of the root leads to endoneurial edema. As a result, a precedent arises that prevents full capillary blood supply and the formation of interneural fibrosis. The spinal root receives up to 58% of its nutrition from the surrounding cerebrospinal fluid (CSF). Perineural fibrosis prevents the complete supply of axonal tissue with nutrients due to diffusion from the CSF, which also contributes to increased sensitivity of the fiber to pressure.

Studies using experimental root compression have shown that even at minimal pressure (5–10 mm Hg) venous blood flow ceases.

The occlusion pressure of the radicular arterioles is significantly higher (approximately corresponds to mean blood pressure), but depends on the potential for venous stasis. Ischemia of nerve fibers or venous congestion leads to biochemical changes that can maintain pain sensations.

Work with experimental root compression demonstrates that compensatory diffusion of nutrients from the CSF is impaired in the setting of epidural inflammation or in the presence of fibrosis.

Recent studies have shown that degenerative changes in the nucleus pulposus and annulus fibrosus can lead to local neural changes and the synthesis of algogenic agents such as metalloproteinases, tumor necrosis factor (TNF), interleukin (IL)-6 and prostaglandin E2. Pathogenetically, the pain syndrome in radiculopathy is of a mixed nature, including nociceptive and neuropathic components.

Chronic radiculopathy: new treatment options

Danilov A.B., Zharkova T.R.

Nerve root compression (radiculopathy) accounts for 8 to 10% of other causes of back pain [1-4,9]. Up to 90% of radiculopathies are caused by herniated intervertebral discs, and in more than 80% of cases, pathology is detected in the lumbar region. In 48% of cases, hernias are localized at the level of L5-S1 of the lumbosacral region, in 46% of cases - at the level of L4-L5; the remaining 6% at other levels or at several levels of the lumbosacral region. In 80% of patients, pain goes away under the influence of treatment in a fairly short period of time - from several weeks to a month, but in the remaining 20% ​​of patients it becomes chronic and relapsing [14]. This disease most often occurs between the ages of 45 and 64 years.

From the point of view of pain mechanisms, radiculopathy is today considered as a mixed pain syndrome, where both nociceptive and neuropathic components are present [2,5,8]. This approach allows for differentiated pharmacotherapy of pain depending on the severity of a particular component. For the treatment of the nociceptive component, it is recommended to use simple analgesics or nonsteroidal anti-inflammatory drugs (NSAIDs), which are known to relieve nociceptive pain well. In the pharmacotherapy of neuropathic pain, anticonvulsants, antidepressants and opioid analgesics are most often used [2]. Anticonvulsants are more often used to relieve neuropathic pain of a burning and “shooting” nature. One of these anticonvulsants, the most recognized and tested in the world, is gabapentin [6,12,13,16]. The mechanism of its action is associated with the influence on the central mechanisms of pain at the level of the posterior horn. Acting on a special alpha-2 subunit of calcium channels on the presynaptic membrane in the terminals of a sensory neuron, gabapentin blocks the entry of calcium into the cell and thereby impedes the release of pain mediators (glutamate, substance P) into the synaptic cleft. This disrupts the transmission of pain signals from the peripheral neuron to the central one. As a result, there is a decrease in central sensitization, an improvement in the neurotransmitter balance towards increased analgesic GABAergic effects and a reduction in the effects of glutamate, the main neurotransmitter of pain [16].

In order to differentiate the treatment of pain in radiculopathy, it is very important to assess the representation of nociceptive and neuropathic pain mechanisms in each specific case. A number of questionnaires have been developed to assess the reliability of the presence of neuropathic pain. The DN4 questionnaire consists of 10 items regarding the characteristic clinical characteristics of neuropathic pain [7]. As a result of the questionnaire and neurological analysis, the total score is determined (from 0 to 10). Pain is assessed as neuropathic with a score of at least 4. The PainDETECT questionnaire combines a diagram of the distribution of pain disorders in the form of a picture with a VAS scale and a questionnaire aimed at identifying spontaneous and evoked symptoms of neuropathic pain [11]. Also, using the drawing, the nature of the pain is assessed. The questionnaire most fully reflects all possible pain parameters and allows you to visually monitor the dynamics of the pain syndrome. A score greater than 19 indicates that the patient likely has a neuropathic component of pain. From 13 to 18 points - the indications are ambiguous, but a pain component may occur.

The purpose of this study was to evaluate the pain syndrome in chronic radiculopathy from the point of view of the severity of the neuropathic component of pain and to evaluate the clinical effectiveness of the drug Tebantin (gabapentin) for targeted therapy of this component.

Research material

The group of patients consisted of 37 people with chronic lumbosacral radiculopathy (women - 59%, men - 41%). Inclusion criteria were: chronic pain syndrome due to discogenic radiculopathy L4-L5, L5-S1 (lasting at least 3 months). Each patient was informed about the purpose of taking the drug, possible side effects of therapy, and signed an informed consent. The average age of patients receiving therapy was 47.62±13.36 years.

Research methods

Clinical and neurological examination included collection of anamnesis of the disease, general somatic and neurological examination. To confirm the presence of intervertebral disc herniation at the L4-L5 and/or L5-S1 level, all patients underwent magnetic resonance imaging.

For each patient, a clinical questionnaire was filled out, including a passport part, a description of the subjective characteristics (descriptors) of the pain syndrome, the intensity of each descriptor was assessed on a visual analogue scale, the localization of pain, the duration of the pain syndrome, the number of exacerbations in the history, the course of the disease, provoking factors and communication with physical activity, accompanying symptoms, pain relief measures, as well as complaints during the interictal period and concomitant diseases. The localization and nature of sensory disorders were assessed in the neurological status. The presence or absence of phenomena of stimulus-dependent pain symptoms was also taken into account: allodynia, hyperalgesia, paresthesia and dysesthesia. Sensory disorders were recorded on a picture in the patient's questionnaire. Tendon reflexes and strength in the limbs were assessed. According to Khabirov’s questionnaire, the index of muscular-tonic syndrome was calculated [4].

Psychometric testing included an assessment of the severity of depression using the Beck Questionnaire, an assessment of the level of reactive and personal anxiety according to Spielberger, and an assessment of the quality of life using the SF36 questionnaire.

Treatment was carried out according to the following scheme. Tebantin monotherapy at a dose of 1800 mg per day (600 mg 3 times) for 6 weeks with preliminary titration: on the first day - 300 mg/day; on the 2nd - 600, on the 3rd - 900, on the 4th-6th - 1200, on the 7th-10th - 1500 and from the 11th day - 1800 mg/day. in three doses of 600 mg. The intensity of the pain syndrome was assessed on a visual analogue scale (from 0 to 10) at each week of treatment, as well as the reliability of the presence of a neuropathic component of the pain syndrome was assessed using the DN4 and PainDetect questionnaires before and after treatment.

results

The average duration of the disease in the group was 3.4±3.9 years and ranged from 6 months to 18 years. The average age of onset of the disease was 44.1±12.7, in men the pain syndrome was first detected at the age of 40.3±11.5 years, in women - at the age of 46.6±13.1 years. The number of exacerbations in the group examined during the period of the disease was 2.9±2.3.

Four types of pain syndrome were identified among patients. Continuous pain, slightly varying in intensity, was noted in 8 patients (21.6%). Continuous pain with periodic, rare attacks was detected in 6 patients (16.2%). 9 patients (24.4%) characterized the course of their pain syndrome as attacks of pain without pain between them. Most often, 14 patients (37.8%) experienced frequent attacks of pain, accompanied by pain in the intervals between them.

All examined patients noted the occurrence of pain attacks at different times of the day. 7 patients (19%) indicated that pain attacks occur exclusively at night, 18 patients (49%) complained of pain that occurs only during the day, and 12 patients (32%) noted the occurrence of pain both during the day and during the day. at night.

A significant group of patients - 26 people (70.2%) indicated that physical activity increases the severity of pain. 4 patients (10.8%) considered hypothermia to be a factor provoking pain. 16 patients (43.2%) noted pain when walking, 11 people (29.8%) - while sitting.

According to clinical neurological examination and based on subjective complaints of patients, it was revealed: 23 patients (62%) complained of shooting pain, 20 patients (54%) had burning pain, 24 patients (65%) had compressive pain, 12 patients had aching pain. (62%), allodynia was detected in 16 (43.2%), paresthesia - in 29 patients (78%).

Table 1 shows the characteristics of the pain syndrome before and after treatment with Tebantin. There was a significant decrease in the intensity of burning, squeezing, pressing, aching pain, pain like electric shocks, and a significant decrease in the frequency of burning pain during treatment. A decrease in the intensity of allodynia, frequency and intensity of paresthesia was noted.

26 patients (70%) complained of numbness. Hypalgesia was detected in 23 patients (62%), 11 patients had a decrease in pain sensitivity in the zone of innervation of the L5-S1 root, in 11 patients - in the zone of innervation of the L4-L5 root, in 1 patient - in the zone of innervation of the L4-L5 and L5 roots -S1. Hyperalgesia was observed in 9 patients (24%), in 4 people - in the zone of innervation of the L5-S1 root, in 5 - in the zone of innervation of the L4-L5 root.

A positive Lasegue test was detected in 67% of patients, a Lasegue cross-test was detected in 40%. Table 2 shows the data of the neurological examination of patients before and after treatment. There was a significant decrease in the frequency of hyperesthesia, the frequency of occurrence of the Lasègue test and the cross-Lasègue test during treatment.

A decrease in the knee reflex was noted in 6 patients (16.2%), the knee reflex was absent in 3 patients (8%). A decrease in the Achilles reflex was detected in 5 patients (13.5%), its absence in 25 patients (67.5%).

Among the examined group of patients, an analysis of the tension of the multifidus muscles of the back and the erector spinae muscle was carried out. The muscles were palpated at the lumbar level with the patient tilted forward by 10-15°. During palpation, the severity of spontaneous pain, tone, muscle soreness, duration of pain and the degree of pain irradiation during palpation were assessed. According to Khabirov's questionnaire, the index of muscular-tonic syndrome was calculated. 12 patients (32.4%) had the first degree of muscular-tonic syndrome, and 25 patients (67.6%) had the second degree of muscular-tonic syndrome. No pronounced manifestations of muscular-tonic syndrome were found in patients with chronic pain due to lumbosacral radiculopathy.

According to the DN4 questionnaire, the average score was 5.45±1.57, 90% of patients were ?4; according to PainDETECT - 13.78±3.10, in 65% of patients ?13 (Fig. 1). The severity of pain according to VAS among patients in the examined group was 7.45±1.83. The dynamics of VAS during treatment with Tebantin by week are shown in Figure 2. A significant decrease in pain according to VAS was noted already in the 3rd week of treatment.

The dynamics of clinical and psychological characteristics of patients before and after treatment with Tebantin are presented in Table 3.

There was a significant decrease in the severity of depression and a significant improvement in the quality of life of patients during treatment.

Tolerability of the drug in most patients was satisfactory; 5 patients experienced mild drowsiness and slight dizziness during the first 4-5 days of use.

To analyze predictors of treatment effectiveness, two polar groups of patients were assessed: with low treatment effectiveness and high treatment effectiveness relative to VAS data (Table 4).

Treatment with Tebantin was most effective in patients with a longer disease duration and a greater history of exacerbations. In patients in this group, pain more often occurred at night; along the way, these were frequent attacks of pain, accompanied by painful intervals between them. Patients with higher treatment effectiveness initially significantly more often complained of shooting, burning pain; they more often had symptoms such as allodynia, paresthesia, numbness, and a positive Lasegue symptom. More effective treatment was observed in patients with initially higher scores according to the DN4 and PainDETECT questionnaires.

Discussion

Currently, several mechanisms of pain formation in compression radiculopathy are being considered [10]. In addition to direct mechanical compression of the root, damage to the nociceptors of the intervertebral disc itself can be a source of pain. In addition, the inflammatory process plays a certain role, when inflammatory mediators, locally acting on nerve endings in tissues, are also involved in the generation of pain. Thus, pain in radiculopathy is considered to be mixed, with nociceptive and neuropathic components present [8,10]. Large epidemiological studies indicate that in 20-35% of patients with discogenic radiculopathy, the neuropathic component predominates [10]. The cause of the formation of the neuropathic component may be mechanical compression of the nerve root (mechanical neuropathy) and/or its irritation under the influence of inflammatory mediators (inflammatory neuropathy) [10]. Specific characteristics of the neuropathic component in back pain are complaints of shooting, deep excruciating, pulling, aching, boring pain, burning, allodynia, Lasegue's symptom, painful numbness [15].

According to our study, the neuropathic component was identified in 90% of patients according to the DN4 questionnaire and in 65% of patients according to the PainDETECT questionnaire, which confirms the data that the pain syndrome in radiculopathy is mixed, with the leading role of the neuropathic component. It should be noted that in our study, the DN4 questionnaire turned out to be more informative and sensitive in diagnosing the neuropathic component of pain than the PainDETECT questionnaire.

The use of the drug Tebantin in our study was aimed at clarifying the mechanisms of pain in radiculopathy and the possibility of targeted therapeutic effects on it.

The results of the work showed the high effectiveness of gabapentin (Tebantine) in reducing the neuropathic component of pain. This, on the one hand, indicates that the neuropathic component plays a significant role in the formation of pain in radiculopathy, and on the other hand, indicates the possibility of effectively influencing this component with the help of gabapentin (Tebantin). It should be emphasized that as a result of pain reduction, a significant improvement in psychological status was noted (decreased depression and anxiety).

Thus, the diagnosis of the neuropathic component in back pain is important from the point of view of differentiated pharmacotherapy. The drug Tebantin has a clear positive effect predominantly on the neuropathic component in the structure of mixed pain syndrome in chronic radiculopathy and to a lesser extent affects the characteristics of the nociceptive component.

The results of the study allow us to conclude that it is advisable to clarify the severity of the nociceptive and neuropathic components in back pain in order to select an adequate drug from the group of NSAIDs to influence the nociceptive component and gabapentin to treat the neuropathic component. It is likely that in most cases of chronic radiculopathy, simultaneous administration of NSAIDs and gabapentin in an adequate ratio is necessary to influence both components of the pain syndrome, which can positively affect the effectiveness and timing of pharmacotherapy and rehabilitation.

Literature

1. Pain syndromes in neurological practice//Ed. Veina A.M. - M.: MEDpress-inform, 2001. 2. Danilov A.B., Davydov O.S. Neuropathic pain, 2007 3. Podchufarova E.V., Chronic back pain: pathogenesis, diagnosis, treatment.// RMZh.- 2003. - T. 11.- No. 25.- P. 32-37 4. Khabirov F.A. . Guide to clinical spinal neurology. Kazan, 2006. 5. Baron R., Binder A. How neuropathic is sciatica? The mixed pain concept. Orthopade., 2004 May; 33(5):568-75. 6. Birklein F. Mechanism-based treatment principles of neuropathic pain. Fortschr Neurol Psychiatr., 2002 Feb; 70(2):88-94. 7. Bouhassira D, Attal N, Alchaar H, Boureau F, Brochet B, Bruxelle J, Cunin G, Fermanian J, Ginies P, Grun-Overdyking A, Jafari-Schluep H, Lanteri-Minet M, Laurent B, Mick G, Serrie A, Valade D, Vicaut E. Comparison of pain syndromes associated with nervous or somatic lesions and development of a new neuropathic pain diagnostic questionnaire (DN4). Pain. 2005 Mar; 114(1-2):29-36. 8. Brisby H. Pathology and possible mechanisms of nervous system response to disc degeneration. J Bone Joint Surg Am. 2006 Apr; 88 Suppl 2:68-71. 9. Deyo RA, Tsui-Wu YJ. Descriptive epidemiology of low-back pain and its related medical care in the United States. Spine (Phila Pa 1976). 1987 Apr; 12(3):264-8. 10. Freynhagen R, Baron R. The evaluation of neuropathic components in low back pain. Curr Pain Headache Rep. 2009 Jun; 13(3):185-90. 11. Freynhagen R, Baron R, Gockel U, Tolle TR. painDETECT: a new screening questionnaire to identify neuropathic components in patients with back pain. Curr Med Res Opin. 2006 Oct; 22(10):1911-20. 12. Hansson P., Fields H., Hill R., Marchettini P., eds. Neuropathic Pain: Pathophysiology and Treatment, Progress in Pain Research and Management. Vol. 21. Seattle, WA: IASP Press; 2001: 151-167. 13. Junker U., Brunnmuller U. Efficacy and tolerability of gabapentin in the treatment of patients with neuropathic pain. Results of an observational study involving 5620 patients. MMW Fortschr Med., 2003; 145:37. 14. Manchikanti L, Singh V, Datta S, Cohen SP, Hirsch JA; Comprehensive review of epidemiology, scope, and impact of spinal pain. 2009 Jul-Aug;12(4):E35-70. 2005 Mar; 114(1-2):29-36. 15. Oostdam EM, Duivenvoorden HJ Description of pain and the degree to which the complaints fit the organic diagnosis of low back pain. Pain. 1984 Jan; 18(1):71-82. 16. Wiffen PJ, Collins S. Anticonvulsant drugs for acute and chronic pain (Review). The Cochrane Collaboration, 2008; 1-35. Key words of the article: Chronic, radiculopathy, new, possibilities, therapies

Source RMJ January 26, 2010, volume 18, no. special

Classification of the disease

Over the years, changes occur in our body, for example, a baby’s skin is soft and elastic, but at 30 years old it is no longer so. The same thing The same thing happens with our spine. Degenerative and dystrophic processes in the spine contribute to the formation of protrusions and hernias, which can and do lead to radiculopathy in the future.

There are discogenic and vertebrogenic forms of the disease. Vertebrogenic radiculopathy is a secondary type of disease in which the spinal cord root is compressed in a kind of tunnel formed by various pathological processes. This may be soft tissue swelling, tumor, osteophytes, disc herniation.

As the degenerative inflammatory process develops, the tunnel narrows, indentation and severe pain appear.

Depending on the location, the following forms of radiculopathy are distinguished:

• cervical;
• lumbosacral;
• mixed.

The disease can occur in adults of any age; if left untreated, the disease can lead to disability. Another name for this disease is radicular syndrome. Complex names have not caught on among the people, so you can often hear that a person suffers from radiculitis. Although this name is not entirely correct.

The most common type is lumbosacral radiculopathy. It affects the vertebrae L5, L4, S1. To understand which vertebrae are involved in the process of inflammation, you need to remember that all parts of the spine are designated by Latin names. The sacral region is Os Sacrum, therefore, the vertebrae are designated by the letter S from 1 to 5. The lumbar region is Pars Lumbalis (L1-L5). Cervical region - Pars Cervicalis (C1-C7). Thoracic spine - Pars Thoracalis (Th1-12).

Having familiarized yourself with this classification, it is easy to understand that Th3 means damage to the third vertebra in the thoracic region, and C2 means damage to the second cervical vertebra. The level of damage is determined using an x-ray.

There is an international classification of diseases - ICD 10. It is generally accepted for coding all medical diagnoses. According to the ICD, radiculotherapy is assigned code M 54.1.

Causes

Possible causes of radicular syndrome:

• mechanical injuries
• weak back muscles
• metabolic disorders
• hormonal disorders
• age-related degenerative changes
• chronic inflammatory process
• consequences of surgical interventions
• postural disorders (scoliosis, etc.)
• heavy physical (dynamic and static) loads
• gravity loads
• spinal abnormalities
• tumor processes
• narrowing of the spinal canal (due to displacement of the vertebrae)
• narrowing of the foraminal (intervertebral) foramina

• protrusion and herniation of intervertebral discs

The development of degenerative-dystrophic changes in intervertebral discs occurs over time as a result of a combination of factors. Changes in the intervertebral discs are manifested by thinning and loss of elasticity. In the absence of adequate treatment, their destruction occurs.

Thus, the conditions for disc protrusion are created. The process is carried out in the thinnest area of ​​the outer fibrous ring.

When the fibrous membrane ruptures, the core of the disc protrudes.

The initial stage is characterized by the formation of intervertebral disc protrusion. In this case, rupture of the fibrous ring does not occur.

Both in the case of rupture of the fibrous ring, and in the case of protrusion formation, when the ring remains intact, the vertebral disc acts on the nerve roots, which are located on the sides of the spinal column. At the initial stage of the process, irritation affects only the membranes. Subsequently, if the process is not stopped, compression of the roots occurs. This process is called discogenic radiculopathy.

Radicular syndrome occurs in two stages:

• at the first, neurological stage, there is an increase in sensitivity, sharp and unexpected acute pain, characteristic muscle tension, pain in the paravertebral points when pressed
• in the second, neurotic stage, there is a decrease in sensitivity in the area of ​​innervation of nerve bundles formed from damaged roots; During a medical examination, the extinction of the periosteal reflex is revealed and partial malnutrition is diagnosed. The muscle tension and intense pain characteristic of the first stage are preserved.

Complications of radiculopathy

In the absence of a proper approach to the treatment and prevention of this disease, radicular syndrome quickly becomes chronic. As a result, changes such as sudden movement, exposure to cold, or stress can trigger an attack of pain.

Another complication may be a persistent impairment of the motor and sensory function of the affected limb and lead to disability. For example, a hernia in the lumbar spine without timely treatment causes peripheral paresis and parylysis of the lower limb, and disrupts the function of the pelvic organs.

Prevention and recommendations

Recommendations are general in nature and cannot be used for self-medication.

Psychotherapy, massage, physical therapy, swimming, physiotherapeutic procedures, sanatorium treatment (balneological resorts) are indicated. Galvanization, phonophoresis, amplipulse therapy, magnetotherapy, laser therapy, laser magnetic therapy give good results.

For follow-up treatment and prevention of recurrent attacks, radon, mineral and pearl baths are prescribed.

There are currently many modern and effective methods. Only a qualified neurologist can determine the advisability of prescribing them.

Don't risk your health!

Diagnostics

To establish the level of damage, topical diagnosis is of great importance. The main radicular syndromes are presented in the table: [6]

Radiculopathy requires a CT or MRI scan of the affected level of the spine. In order to assess the level of research, it is necessary to find out the symptoms of the disease, neurological status during admission. If the level of the lesion cannot be determined, electromyography is prescribed, which helps to target the affected root, but does not allow the cause to be determined.

If neuroimaging does not reveal atomic changes, it is necessary to study the cerebrospinal fluid to exclude infectious and inflammatory causes, as well as determine the level of glucose in the blood to exclude diabetes.

Vertebrogenic cervical radiculopathy - etiology and pathogenesis

The etiology of vertebrogenic cervical radiculopathy includes disc herniation, spinal stenosis, osteophyte formation in the vertebrae, cervical spondylosis and spondyloarthrosis. The immediate cause of the entire complex of pain syndromes in cervical radiculopathy is compression (compression) of the spinal roots, blood vessels, as well as the spinal cord and choroid plexuses. Compression can be caused by a herniated disc, less commonly by protrusion, osteophytes in the vertebrae and facet joints. Spondylolisthesis can cause the same consequences. There are other possible causes of radiculopathy, including spinal injuries, infectious diseases and cancer.

Intervertebral hernias can be medial (middle) - they occur quite rarely and can lead to compression of the spinal cord (myelopathy), but practically do not cause pain. Compression of the spinal roots and intense pain are characteristic of lateral (side) hernias. More often, disc herniations are detected at the level of vertebral motor segments (VMS) C5-C6 and C6-C7, leading to damage to the C6 and C7 roots, respectively.

The most commonly affected cervical root is C7 (60% of cases), less commonly C6 (up to 20% of cases), which is explained by the higher load on the lower joints of the cervical spine.

The direct cause of pain in windbrogenic cervical radiculopathy is two factors: irritation of pain receptors (nociceptors) in the outer layers of the damaged disc and surrounding tissues, and damage to the nerve fibers of the root as a result of compression, inflammation and swelling, and nutritional disturbances in the surrounding tissues.

Radicular syndrome in cervical radiculopathy is often accompanied by the formation of painful trigger points in the muscles of the neck, shoulder girdle, and arms, which can further increase the pain syndrome.

Treatment of radiculopathy

A neurologist treats herniated discs. Medical specialists have extensive experience in treating such diseases. You can go through all stages of treatment under the supervision of your attending physician, who will answer all your questions.

In most patients with radicular pain, conservative treatment is effective; however, in 2% of patients there are absolute indications (progression of sensory and motor disorders, cauda equina syndrome) for surgical treatment.

In general, we can say that conservative tactics for managing patients with this disease are favorable in most cases and should be considered as a priority in the absence of a verified compressing substrate.

The first stage of treatment is non-steroidal anti-inflammatory drugs (NSAIDs). They have analgesic and anti-inflammatory effects. Corticosteroid (CS) injections may be considered as an alternative to NSAIDs for the treatment of radicular pain. Perineural injections (translaminar, epidural, transforaminal or selective root block) should be performed only after neuroimaging (MRI) of a clinical topical diagnosis. To influence the neuropathic component of radicular pain, some drugs from the group of anticonvulsants (carbamazepine, gabapeptin, pregabalin, lamotrigine) can be used.

According to studies conducted to evaluate the effectiveness of systemic local analgesic drugs lidocaine, mexiletine, tocainide and flecainide showed good results.

Treatment stories

Case No. 1

Patient S., 25 years old, after skiing and falling, felt a sharp pain in the lower back and numbness in the right foot. Started taking painkillers. However, due to the appearance of abdominal pain and heartburn, I was forced to give them up. On the second day I went to see a neurologist at the EXPERT Polyclinic. The patient was prescribed treatment and consultation with a gastroenterologist. The patient underwent a course of intramuscular and intravenous drip injections at the day hospital of the EXPERT Polyclinic. The pain syndrome has completely regressed, the numbness in the right foot has disappeared. Patient S. was consulted by a gastroenterologist. She underwent fibrogastroduodenoscopy (FGDS), which revealed an acute ulcer of the duodenal bulb. A gastroenterologist prescribed treatment for this issue.

Forecast and prevention of the disease

It is necessary to recommend that the patient return to normal daily activities as quickly as possible, since maladaptive pain behavior is the main barrier to recovery. In addition, comorbid depression also negatively affects treatment outcomes. If pain persists for >4–6 weeks, it is advisable to add antidepressants to analgesic therapy. Pathogenetically, it is most justified to use antidepressants that act on both neurotransmitter systems (serotonin and noradrenergic) for the treatment of pain symptoms. Tricyclic antidepressants (TCAs), which block the reuptake of serotonin and norepinephrine, have greater potential than selective antidepressants. TCAs are more successful in treating pain symptoms and leading to more complete remission of depression. A new class of drugs, dual-action antidepressants that block the reuptake of serotonin and norepinephrine, have high analgesic efficacy and a more favorable spectrum of side effects than TCAs. The effectiveness/safety ratio is optimal for dual-acting antidepressants (duloxetine, venlafaxine). During the recovery period, active exercises are recommended to strengthen the muscle corset.

Compression syndromes in cervical radiculopathy of various locations

Depending on the location of the pinched or irritated nerve root, the symptoms of cervical radiculopathy vary somewhat. Based on clinical signs, the following radiculopathies can be distinguished depending on the location of the source of pain.

Radiculopathies C2-C4

When the upper cervical roots are affected, spondylosis is most often diagnosed. Motor disturbances are rare. The pain is localized:

• if the C2 root is affected - in the occipital region from the foramen magnum to the vertex
• if the C3 root is affected - in the area of ​​the auricle, mastoid process, angle of the lower jaw, outer part of the back of the head
• when the C4 root is affected - mainly in the neck and shoulder girdle

Radiculopathy C5

C5 root involvement occurs in approximately 5% of cases of cervical radiculopathy and is usually caused by C4-C5 disc herniation. Radiculopathy C5 is manifested by the following clinical signs:

• pain is localized in the neck, shoulder girdle and along the front surface of the upper shoulder
• sensory disturbances are detected on the outer surface of the shoulder
• possible paresis of muscles in the shoulder region, weakening of the reflexes of the biceps brachii and brachioradialis muscles

Symptoms and diagnostic methods

The most characteristic symptom of radiculopathy is pain in the lumbar region.

Pain may also be accompanied by the following symptoms::

• 
  Radiculitis is characterized by acute and shooting pain. Girdle pain from the spine to the middle of the peritoneum;

• Shooting pains in the lower back;
• Painful sensations mistakenly taken for inflammation of adjacent organs;
• Paleness or, conversely, hyperpigmentation of the skin in the sacral area;
• Hypertonicity of the lumbar muscles;
• Swelling;
• Convulsions affecting the muscle in the anterior zone of the peritoneum;
• Pain in the pelvic area, radiating to the lower extremities.

All these symptoms can occur on both the right side and the left. With minor physical exertion, as well as palpation, the symptoms intensify.

In addition, the patient has one or more neurological symptoms:

• Allodynia (pain that occurs even with slight touch);
• Paresthesia (numbness, tingling, goosebumps);
• Hyperalgesia (increased sensitivity);
• Hyperpathy (partial tactile insensitivity to external stimuli);
• Changes in tendon reflexes.

Diagnosis of radiculopathy

First of all, the doctor will conduct a general examination, talk with you, and then prescribe additional diagnostic measures if, after a general examination, the suspicion of radiculopathy remains:

• X-ray diagnostics;
• MRI;
• ;
• Lumbar punctures;
• General blood analysis;
• General urine analysis.

In addition to general diagnostic measures, the patient may be prescribed individual examination methods (this depends on the specific symptoms that may manifest in a given patient).

Video: “Back pain: causes and what to do?”

Therapeutic patch NANOPLAST forte - increasing the effectiveness and quality of treatment of radiculopathy

It should be noted that NSAIDs are characterized by a relatively high risk of side effects such as dyspepsia, gastrointestinal bleeding, liver dysfunction, headache, kidney dysfunction, etc. Therefore, modern drugs that, when used in combination, make it possible to reduce the dosage of NSAIDs, shorten the time of their use, increase the effectiveness of treatment and do not cause side effects are of great interest to patients and specialists. One of these drugs is the new therapeutic anti-inflammatory patch NANOPLAST forte.

The therapeutic plaster NANOPLAST forte has shown high effectiveness in the treatment of various diseases of the spine. It allows you to relieve pain and inflammation, improve blood circulation in the affected area, reduce the dose of painkillers and anti-inflammatory drugs, and increase the effectiveness of their action.

To relieve acute symptoms in the treatment of vertebrogenic cervical radiculopathy, a therapeutic patch is used for 3 to 5 days. The duration of the course of treatment for chronic disease is from 9 days. It is usually recommended to use the treatment patch in the morning for 12 hours, but it can also be used at night.

When treating cervical radiculopathy, the therapeutic plaster NANOPLAST forte is applied to the disturbing area of ​​the neck, avoiding the anterior surface, especially the area of ​​the carotid arteries and lymph nodes. A course of treatment of 9 days or more is recommended. It is usually recommended to use the patch in the morning for 12 hours, but it can also be used at night.

High efficiency, unique composition, long-term (up to 12 hours!) therapeutic effects, ease of use and affordable price make NANOPLAST forte the drug of choice in the treatment of various forms of radiculopathy.

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