One of the most effective methods for eliminating pain and treating the spine is paravertebral blockade. It is aimed at a specific segment and, in addition to pain relief, performs a therapeutic function. The most important thing is the right choice of a specialist who will carry out the procedure. You should also pay attention to the equipment used in the clinic. In most cases, the injection is well tolerated by patients and adverse reactions are possible if the injection technique is violated.
What is a blockade?
This type of injection involves blocking acute pain in the spine by injecting medications into the site of inflammation. The injection is carried out at the point where the nerve roots exit the spine; the guideline is the paravertebral line, located 3-4 cm lateral from the line of the spinous processes of the vertebrae. This allows you to disable the mechanisms responsible for pain in this area, block the nerve, and also eliminate pain radiating to the leg. Additionally, swelling and irritation of the nerve root are reduced, and metabolism is improved.
The main goal of the procedure is to quickly eliminate pain. But the blockade also helps to achieve other results - by dilating blood vessels, blood flow improves and swelling of the nerve ending decreases.
It is worth noting the speed of the body’s reaction to such treatment. The pain subsides within a few minutes after administration of the drug. In this case, the medicine immediately reaches the site of inflammation. This reduces the likelihood of side effects to the drug.
Advantages
Paravertebral blockade, in addition to pain, relieves swelling and spasm. The main advantages of the technique are:
- speed of action, since the medicine is injected directly into the affected area;
- minimal side effects, which is due to the introduction of the drug into the lesion, bypassing the bloodstream;
- more noticeable effect;
- the possibility of repeated administration of the drug;
- using a lower dosage of the drug;
- complex impact.
Paravertebral blockade lasts about 12 hours. After this time, the pain may return, but it will be less severe.
If a paravertebral blockade is used during surgery, patients are less likely to experience nausea, vomiting, and urinary retention. This speeds up their discharge from the medical facility.
Indications for use
Paravertebral blockade is recommended for pathologies of the spine and muscular system, when other methods of pain relief have not shown results.
This method of treating the spine is prescribed to patients diagnosed with the following diseases:
- spinal injuries;
- intercostal neuralgia;
- pinched nerve;
- rib fracture;
- shootings in the back;
- arthrosis;
- spinal hernia;
- radiculitis;
- lower back pain;
- osteochondrosis;
- muscle inflammation;
- renal and hepatic colic;
- chronic pain.
Paravertebral blockade is used after surgical interventions on the mammary gland or chest. The procedure is also performed for postoperative pain relief.
This pain relief technique is used during childbirth instead of epidural analgesia.
Indications and contraindications
| Indications | Contraindications |
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It is not recommended to carry out treatment for low blood pressure, epilepsy, and mental illness; in any case, if there are concomitant diseases, it is recommended to consult with your doctor.
Mechanism of action
When pathological changes occur in the spine, the spinal nerves are pinched, which provokes severe pain. Depending on which nerve is pinched, the pain can radiate to the neck, shoulders, buttocks, hips, etc. If it becomes unbearable, the only way to help the person is to perform a blockade.
Due to the targeted administration of the anesthetic, the conduction of impulses along the nerve fibers is temporarily blocked. This leads to the elimination or at least a significant reduction in pain intensity within a couple of minutes. Therefore, the patient can almost immediately return to abandoned activities and move fully.
If the manipulation is performed correctly, there are no negative consequences, which allows you to repeat it as many times as required. An additional advantage is the presence in the injected solution, in addition to the anesthetic, of anti-inflammatory substances. They contribute to the rapid elimination of the inflammatory process in the affected segment of the spine and increase the effectiveness of conservative therapy.
The procedure is carried out exclusively under completely sterile conditions (usually in an operating room or dressing room). This is extremely important, since when viruses or bacteria penetrate the spinal cord, life-threatening complications can develop: meningitis, encephalitis, myelitis.
In the first few days after the manipulation, there may be undesirable consequences in the form of numbness of a part of the body. This does not require correction and goes away on its own in a few days.
Methodology for paravertebral blockade: Preparations
At its core, the blockade is a regular injection. But since the manipulation is performed in the spine area, the injection site should be as accurate as possible. Therefore, only an experienced specialist should carry out this procedure.
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The Stoparthrosis clinic provides:
- blockade of the lumbosacral region;
- blockade of the cervical spine;
- blockade of the thoracic spine.
Orthopedic doctor Andrey Sergeevich Litvinenko comments:
When selecting medications, the doctor proceeds individually in each case. The work mainly uses anesthetics, corticosteroids, vitamins and additional drugs.
Drugs for blockades
Local anesthetics
- use novocaine or lidocaine in an amount of 5-10 ml, these drugs are used to eliminate pain and to painlessly carry out the blockade.
Corticosteroids
- prescribed to relieve inflammation of the nerve root and long-term relief of pain. Diprospan, dexamethasone, and Kenalog are often used for paravertebral blockade.
Vitamins
- The most commonly used vitamins are B vitamins - B6 and B12.
Vasodilators and antiallergic medications may also be added.
Complications
Complications with paravertebral blockade are rare and are practically impossible when using ultrasound during manipulation. Studies show that this is possible in only 10% of patients. Several cases of nerve damage, puncture of the inferior vena cava and aorta have been recorded.
A slight swelling and hematoma may appear at the injection site. During an injection, the doctor may accidentally damage surrounding tissue if he moves the needle too much. An unqualified specialist may accidentally touch muscles, ligaments, tendons, and periosteum.
As with any procedure that involves puncturing tissue, the patient may experience bleeding. It poses a danger if blood enters a confined space, compressing neighboring structures.
When performing a paravertebral block, tissue infection is unlikely, since the procedure takes place under sterile conditions and the injection is administered into an area treated with an antiseptic. If the rules of asepsis are violated, patients experience suppuration of the joint and epidural abscess.
Anesthetics used for paravertebral blockade are sometimes difficult to tolerate by patients. Convulsions, breathing problems, loss of consciousness, and epileptic seizures are possible. There is also a chance of death, especially if injected in the neck. Cases of anaphylactic shock and malignant hypertension have been recorded.
Treatment with glucocorticosteroids is accompanied by problems with sleep, metabolic disorders, and increased blood pressure. A high dosage of the drug aggravates the ulcer, and long-term treatment leads to adrenal insufficiency.
In 10% of adult patients, paravertebral blockade was not effective. In children this figure is 6%.
Prices for blockades for back pain
| Services | Price | Sign up |
| Piriformis muscle block | 3000 rub | Sign up |
| Block of the sacroiliac joint | 3000 rub | Sign up |
| Blockade at home + doctor visit | 6000 rub | Sign up |
| Blockade of the lumbar region | 3000 rub | Sign up |
| Blockade for lumbar hernia | 3000 rub | Sign up |
| Paravertebral spinal block | 3000 rub | Sign up |
Spinal block at SL Clinic
At SL Clinic, blockades are performed by fully trained medical professionals, which guarantees absolutely precise adherence to the manipulation technique and the absence of complications. With us you can make any type of blockade. The doctor will individually select the most effective method of eliminating pain. Each procedure is indicated in the price list.
Prices
The cost of the blockade is from 1000 to 5000 rubles and depends on: - The cost of the drugs that we administer; — Clinics where the blockade will be carried out. - Number of blockades. — Type of blockade (paravertebral, epidural, etc.) The price includes: — Medicine; - Syringes with a needle. — The clinic where the blockade will be carried out; — Type of blockade administration (paravertebral, epidural, etc.) — Number of blockade sessions; — Observation and consultation during the rehabilitation period.
We also suggest that you not only fight the manifestations of the existing disease, but also the disease itself. Qualified vertebrologist-surgeons and doctors of other specialties will be able to thoroughly understand the causes of pain and select the optimal treatment tactics.
Diagnostics at the SL Clinic are carried out using modern equipment of the latest generations, which makes it possible to detect the slightest deviations from the norm and effectively treat them with conservative therapy. If it is ineffective or in advanced cases, we can offer you rapid surgical treatment of existing diseases using the latest methods, characterized by low invasiveness and a high level of safety. With us you will not find queues, careless and inattentive attitude towards patients. We sincerely care about your health and are ready to go with you on the long path to spinal health. Make an appointment with the right specialist now by calling.
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Add a comment
Artem 03/18/2021 02:22:53
Tell me, does this injection correct the problem itself or can it only temporarily relieve pain? Will it be necessary to undergo a full examination and continue treatment after this procedure?
Show answer
LITVINENKO Andrey Sergeevich 03/22/2021 11:31:33
Hello Artem! the blockade helps reduce pain, the course may include from 1 to 5 injections with different drugs, in some cases this is the only way to help the patient. The effectiveness and need for follow-up treatment, as well as the prescription of additional medications, depend on the severity of the patient’s pain. If the pain has decreased but not completely disappeared, additional appointments will be required.
Lily 03/17/2021 12:06:35
I would like to ask, what methods are used for patients with low blood pressure and diseases of the central nervous system for urgent relief of pain when the sciatic nerve is pinched?
Show answer
MOISEENKO Alexey Yurievich 03/22/2021 11:26:14
Good afternoon Lily! All treatment methods are selected based on indications and contraindications. If some method is contraindicated, then it can be replaced with another, there is always a way out).
Valeria 03/13/2021 22:58:57
Good afternoon Please tell me how to alleviate the condition. I have osteochondrosis of the lumbar region in the acute stage. I experience severe discomfort and pain while moving. Treatment with non-steroidal anti-inflammatory drugs does not help much, or for a short period of time.
Show answer
LITVINENKO Andrey Sergeevich 03/17/2021 09:35:33
Good afternoon Valeria! If the pain is severe, we recommend doing an MRI of the lumbar region and consulting a doctor. It may be necessary to take a drug blockade to relieve severe pain.
Technique
A paravertebral block is performed by a specialist neurologist or neurosurgeon, since it requires complex technical skills. The room where the injection will be given must be sterile. The injection technique depends on the part of the spine where the disease is localized. The main landmark is the midline running along the spinous processes. The paravertebral line runs 25 mm to the side.
Paravertebral blockade occurs in several stages. First, the patient's skin is treated with an antiseptic, then anesthesia is administered. Only after this the blockade is placed directly, using a thick needle. The administered drugs help relieve swelling and inflammation and dilate blood vessels.
Repeated introduction of the blockade is allowed for 3-4 days. It is recommended to prescribe the patient no more than 3 injections for 4-6 months.
To carry out paravertebral blockade, prepare the following instrument:
- syringes 20 ml;
- puncture needle;
- needle for local anesthesia of the skin;
- marker;
- sterile wipes;
- sterile gloves.
There are several methods for carrying out this blockade. Sometimes the needle is inserted blindly, and the doctor focuses on the loss of resistance. It is taken into account that a distance of 25-30 mm should remain between the midline and the injection site. This method leads to complications in 13% of cases. In addition, there is no exact data on how to calculate the injection site for a child from the midline.
Another blind method is to focus on the contact of the needle with the transverse process, after which it is bypassed by 15-20 mm from above and below. This does not take into account the characteristics of the patient’s build and anatomical structure, which leads to complications.
Doctors have come to the conclusion that the most successful outcome of paravertebral blockade is possible if during the procedure the doctor controls the exact position of the needle tip.
For this, it is recommended to use radiological methods or ultrasound. The sensor in relation to the transverse processes is installed along the midline or laterally. The direction is chosen oblique, transverse or sagittal. The needle is positioned longitudinally or transversely in relation to the sensor.
The most difficult technique is the transverse position of the needle relative to the sensor, when the sensor is placed parallel to the vertebra directly above the transverse processes. In this case, there is a risk of puncture of the pleural cavity, since the doctor cannot visualize the entire length of the needle. The safest method, in which you can completely follow the movement of the needle, is transverse insertion, when the sensor is positioned perpendicular to the spine. The puncture is made slightly to the side of the transverse process. In this case, the likelihood of the drug entering the epidural space is reduced.
A method that relies on pressure at the tip of a needle is also common. During its passage, it is higher when the patient inhales, and lower when he exhales. Once in the paravertebral space, the tip of the needle records a lower pressure during inhalation and a higher pressure during exhalation.
In some cases, it is practiced to introduce a blockade through a catheter, but even with the use of ultrasound, adverse reactions in the patient are possible. This is due to the twisting of the catheter in the paravertebral space. The procedure is successful only in half of the cases. The likelihood of complications is reduced with the use of flexible catheters.
The infusion rate for adults should be 0.1 ml per kg body weight per hour. For catheterization, the needle is most often inserted at an angle of 45 degrees, its movement is fully visible on the monitor. In this case, the puncture is made between the transverse processes.
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Contraindications to the procedure
A back block, even with severe pain, cannot be done if:
- bleeding disorders, in particular with hemophilia or the patient taking anticoagulants;
- infectious disease;
- myasthenia gravis;
- sick sinus angle syndrome;
- severe cardiovascular diseases;
- severe bradycardia, arterial hypotension;
- disruption of hematopoietic processes;
- allergies to novocaine or lidocaine;
- epilepsy;
- increased vascular tone;
- pregnancy and lactation;
- serious kidney disease;
- liver failure;
- mental disorders.
Also, the procedure is not performed on patients who are unconscious. Even if the patient has not previously experienced an allergic reaction to the drugs used, allergy tests are performed immediately before the blockade to determine sensitivity to them. For this purpose, the skin is lightly scratched with a scarifier and a drop of the drug is applied to this area. In the absence of redness, swelling and other signs of allergy, blockade injections using it are allowed.
Preparatory stage
To perform paravertebral blockade, the patient is placed on the couch on his stomach. The doctor gently palpates your back to determine the most painful areas. Having found them, the specialist treats the suspected injection sites with an antiseptic solution.
Then 4 injections are made with a thin needle to numb the skin. These injections are given at targeted points on the sides of the spinous process. When this anesthesia takes effect, the administration of blockade drugs begins directly.
Intravascular and periarticular blockades
Intravascular block is a type of local anesthesia. It is injected directly into the area of the body where it is necessary to reduce pain sensitivity.
There are also periarticular blockades.
Causes of pain in periarticular joints:
- Injuries.
- Great physical activity.
- Congenital developmental problems.
- Disorders of the musculoskeletal system.
The most effective treatment method is injections into the affected area, as they act instantly. The choice of medication and its dosage is influenced by the severity of the pathology, its volume/size, which reduces the risk of side effects.
Regional blockades in complex therapy of acute radicular pain syndrome
Gnezdilov A.V., Syrovegin A.V., Medvedeva L.A., Zagorulko O.I. Scientific Center of Surgery RAMS, Moscow
In modern conditions, the need to quickly restore working capacity is often one of the main requirements of the patient for the treatment program carried out by specialists. Acute pain syndromes of various origins are one of the most common causes of disability in patients of the most socially active age from 20 to 45 years. Among them, the leading ones are muscular-tonic, including “back pain”, among which the leading role is played by radicular pain syndromes (RPS) of a discogenic nature, due to the significant intensity of pain and the duration of the treatment period. The emergence of new technologies, drugs and special means of their delivery in some cases makes it possible to reconsider the principles of treatment of acute pain syndromes. The treatment tactics developed over the years - rest, immobilization, prescription of non-steroidal anti-inflammatory drugs (NSAIDs) - often require long-term hospitalization of the patient and does not in all cases guarantee rapid pain relief, which, in turn, does not allow the full use of physical rehabilitation methods for the purpose of complete restoration of normal motor activity. At the same time, the assessment of neuromotor disorders, as well as monitoring the effectiveness of therapy, as a rule, is carried out only on the basis of clinical data, which does not meet modern requirements. Therefore, in our practice, we actively use the electrophysiological monitoring methods we have developed at all stages of treatment.
Our experience in the active use of conduction anesthesia methods allows us to recommend their use in clinical practice for rapid pain relief. In our opinion, treatment of acute CAD with pain intensity over 6–7 points on a 10-point visual analogue scale (VAS) should begin with a therapeutic epidural block with the administration of corticosteroids (CS) (Gnezdilov A.V. et al., 1998, 1999,2000). We believe that this method is pathogenetically substantiated, effective and can be considered as a leading method in the treatment of acute CAD, which will be discussed below.
Materials and methods. We analyzed 200 cases of treatment of patients with CAD caused by protrusions or herniations of intervertebral discs at the level of the lumbar spine, confirmed by MRI or CT data (in the early stages of the study). The average age of the patients was 35 ± 5 years, of which 112 were men, 88 were women. Neurological symptoms in 57% of cases were determined by changes at the L 5 - S 1 level, in 40% of cases - at the L 4 - L 5 level (changes in the discs at these two levels were observed in 32% of patients) and only in 3% of cases the leading neurological symptoms were caused by damage to the disc at the L 3 - L 4 level. As a rule, patients complained of intense pain spreading from the lumbosacral region down to the distal parts of the leg ( depending on the anatomical location of the hernia), a sharp limitation of independent movement and the presence of pain even in a lying position. The intensity of pain often reached 8 - 9 points on the VAS. In cases where the pain intensity was below 6 points, we did not use therapeutic blockades and used only reflexology methods and pharmacotherapy.
In 43% of cases, the pain syndrome was accompanied by motor disorders, mainly signs of peroneal nerve paresis (weakness of the lower leg muscles) were identified.
For the purpose of pain relief, therapeutic epidural blockades were performed at the levels L3 - L4 - L5 - S1 with the introduction of 4 - 6 ml of 0.5% marcaine solution or 0.75% naropin in combination with 1 - 2 ml of CS solution (depending on body weight) . All patients used the drug diprospan. All procedures were performed on an outpatient basis in a treatment room, observing aseptic rules using disposable epidural needles or “V. Brown." Puncture of the epidural space was carried out according to the standard technique, with the patient lying on his side on the affected side. After the injection, the patient remained in the indicated position for 7 - 10 minutes, then turned on his stomach and remained in this position for 30 - 40 minutes, after which he left the clinic. From one to 4 therapeutic blockades were carried out with intervals between them from 3 to 7 days. Additionally, in the acute period, NSAIDs were used - diclofenac 75-150 mg / day or xefocam 8-16 mg per day for 7 - 10 days, multivitamins (usually milgamma - 2.0 ml 1 time per day IM No. 5 - 10) , acupuncture, it was recommended to wear a rigid orthopedic belt.
Based on the methodology of using electromyography in the diagnosis of lesions in neuropathic pain conditions (Gnezdilov A.V. et al., 2002, 2003), we tried to study the mechanisms of formation of vertebrogenic pain syndromes in patients with intervertebral hernias, using methods of recording voluntary and electrically evoked EMG of individual limb muscles.
Results. The research results showed that the formation of CAD of a discogenic nature is accompanied by muscle weakness, mainly in the distal muscle groups of the leg on the affected side. Analysis of the EMG activity of weakened muscles of the diseased side revealed a decrease in the amplitude of electrical potentials and the area of the overall power spectrum, when compared with the same indicators of homogeneous muscles of the healthy side. The frequency characteristics of the EMG muscles of the diseased and healthy sides did not differ. In such cases, no significant bilateral differences were found in the latency and amplitude of the M-response of the muscles of the sick and healthy side. Figure 1 illustrates the analysis of voluntary and evoked EMG activity m. abductor hallucis in one of the patients with complaints of pain in the right lumbar region radiating to the foot.
| Fig.1. Patient (L., 55 years old) with radicular pain syndrome on the right at the level of L4-L5, “shooting” pain along the sciatic nerve and decreased sensitivity in the right foot. A -samples of recordings of arbitrary EMG m. |
The positive effect of a single epidural blockade, noted immediately after the injection, was clinically manifested by a decrease in the intensity of pain to 0 - 2 points on a 10-point scale in 45% of patients and to 3 - 4 points in 53% of patients. In 2% of patients, the intensity of pain after the blockade decreased by only 2 - 3 points, and the effect was regarded as unsatisfactory. After the end of the action of MA (on average, after 6 - 8 hours), the intensity of pain, in some cases, returned to its original value and remained unchanged for 12 - 24 hours, only after which its significant decrease was observed.
At the same time, thanks to the use of long-acting MA, in most patients, pain was significantly reduced after injection until the onset of the anti-inflammatory effect of the CS.
When analyzing the duration of the pain syndrome, a persistent improvement in the condition was noted in 62% of patients with a disease duration of no more than 6–8 weeks, manifested by a decrease in the intensity of pain to 0–2 points according to the NRS and positive neurological dynamics. At the same time, among patients suffering from pain for 2-6 months, significant improvement after a single injection of a steroid drug and local anesthetic was achieved only in 33% of cases, and with a disease duration of more than 6 months - in only 22% of cases .
7 days after the repeated blockade (if the effect of the first procedure was insufficient), a positive effect was noted in the remaining 38% of patients with a pain syndrome duration of 6 - 8 weeks, in 33% of patients with a pain syndrome duration from 2 to 6 months and in 28% of patients with pain lasting more than 6 months. Thus, at this stage, radicular pain syndrome was relieved in almost 100% of patients with a disease duration of 6 - 8 weeks, 66% of patients suffering from pain for 2 - 6 months and 50% of patients with a disease duration of more than six months. It should be noted that in the latter group the highest percentage of patients with spinal canal stenosis or signs of intervertebral disc sequestration was noted. In other cases, slight improvement or no effect was noted.
In some patients with persistent radicular pain, 3rd and 4th epidural blocks were indicated using the same doses of drugs as with the second injection. This procedure was effective in 28% of patients in the group with a disease duration of 2 to 6 months and in 23% of patients with a pain syndrome duration of more than 6 months (i.e., in 94% and 73% of cases, respectively).
In patients with ineffectiveness of 3 or 4 times epidural analgesia and refusal of surgical treatment, we used paravertebral intraradicular blockade at the same level. Retreating 2-3 cm from the spinous process at the level of L 4-L 5 with a needle for spinal anesthesia perpendicular to the surface of the body, the needle was passed to the level of the transverse process of the vertebra and, changing the angle of inclination, the needle was passed under it. After reaching the nerve root, which was accompanied by a sensation of “electric shock,” 10 ml of a 0.125% solution of marcaine or naropin was administered in combination with 1 ml of diprospan or dexamethasone. Anesthesia of the lower limb developed within 10 minutes, accompanied by motor block, which persisted for 4-7 hours after the blockade. If necessary, from 1 to 4 procedures were performed. This technique made it possible to achieve an effect in 50% of patients with ineffective epidural analgesia.
It should be noted that one of the main clinical criteria for the effectiveness of pain relief is the symptom of “shortening” of pain. With effective therapy, the pain “fragmented” and persisted only in the lower back and lower leg area. If pain persisted in the lower back, a blockade was used in the area of 2-3 sacral foramina (sacral blockade), which was achieved with an intramuscular needle at a depth of 2-4 cm from the skin surface, followed by injection of 20 ml of a 0.125% solution of marcaine or naropin with 2 ml of milgamma and 1 ml of diprospan or dexazone. The patient remained in the prone position for 10-15 minutes. From 2 to 5 procedures were performed. If pain in the lower leg area persisted, a local anesthetic solution (0.125-0.25% solution of marcaine or naropin) was administered in combination with milgamma into the trigger points of the lower leg at the rate of 1-2 ml of solution per zone. This tactic provided effective pain relief in 90% of patients.
After relief of the acute pain syndrome, the patients underwent active rehabilitation, which included courses of acupuncture, artificial correction of movements using multichannel electromyostimulation, exercises in the pool, physical therapy, and massage.
Successful treatment led to a relative normalization of EMG parameters, accompanied, first of all, by an increase in the areas of the spectral power of EMG signals, and, consequently, an increase in muscle strength. In connection with such observations, it was assumed that when muscle activity normalized after therapy, a greater number of alpha motor neurons began to function, which were blocked in the initial recording at the time the patient sought medical help.
Discussion of clinical results.
Discussing the results obtained, it is necessary to emphasize the leading role of inflammation in the pathogenesis of radicular pain syndrome. Studies of nerve roots during laminectomy in the vast majority of cases reveal their inflammation and swelling (Rydevic B., Brown M.D., Ludborg G. ,
1984).
The disappearance of negative pressure in the epidural space is considered as a manifestation of an exudative inflammatory process with a corresponding increase in capillary permeability and is considered significant in the genesis of pain (Kepes E. R., Duncalf D., 1985) The positive effect of GCS is largely due to the effect on perineural hemodynamics, the result of which is to reduce swelling of the root without changing the size of the herniated part of the disc. At the same time, the exudation of protein and other macromolecules decreases, which is important for preventing the development of accompanying adhesive processes (Rydevic B., Brown M.D., Ludborg G. ,
1984, McCarron R., Wimpee M., 1987). It is known that radicular pain syndrome in 30% of cases is accompanied by the presence of an extradural adhesive process (Johansson A., Hao J., Sjolund B.1990 Kirkaldy - Willis W. H.1984), which contributes to pinching of the spinal nerve due to fixation of the hard shell and impairment of free movement nerve in the intervertebral foramen. At the same time, the positive effect of GCS has been shown in experimentally induced adhesive processes (adhesive arachnoiditis) - prevention of adhesion in the acute period due to inhibition of giant cell granulomas and the growth of fibrous tissue (Kepes E. R., Duncalf D., 1985).
The effect of corticosteroids (mostly suspension forms) in this pathology is direct and pronounced when applied topically. Local therapeutic concentrations often persist for two weeks after injection (Burn J.M., Langdon L.1974 )
. Epidurally administered corticosteroids (with the exception of hydrocortisone) do not have a damaging or irritating effect on nervous tissue, which is confirmed by experimental and clinical studies (Abram S.E., Marsala M., Yaksh T.L.1994, Van Zundert J., Van Buyten J P., Vueghs P. et al.1999,2000). It is obvious that the elimination of pain immediately after the injection is due to the direct action of the local anesthetic and is associated with the development of sensory epidural blockade, suppressing afferentation with corresponding relaxation of the muscles and ligaments of the lumbar spine, which breaks the vicious circle of pain - muscle spasm - pain. However, this effect in patients with herniated intervertebral discs is temporary, which is confirmed by the resumption of pain in patients who were administered only local anesthetics to reduce pain (in the early stages of our studies). At the same time, we must not forget that breaking the vicious circle, in parallel with the anti-inflammatory effect of GCS, reduces compression of the intervertebral disc, and this, in turn, reduces the size of the hernia by reducing intradiscal pressure and fluid loss from damaged disc tissue, i.e. leads to its “drying out”.
As shown above, epidural administration of steroids to patients with radicular pain syndrome is pathogenetically justified. It is obvious that the effect of this therapy and the rate of regression of pathological symptoms directly depend on the stage of the pathological process. Thus, in the early stages of root compression (6–8 weeks), when the pain syndrome is apparently associated with perineural edema due to stasis and increased permeability of the epineural vessels, a persistent positive effect after a single injection was achieved in 62% of patients. In this case, in the absence of degenerative neuronal changes (fibrosis, adhesions), diffusion of drugs to the nerve fibers and relief of edema due to the normalization of microcirculatory processes are easily achieved. In cases where a single injection of GCS does not improve the patient’s condition, one should assume the transition of the pathological process to the next stage - intraneural edema due to prolonged (more than 7 - 8 weeks) and (or) intense compression (Rydevic B., Brown M.D., Ludborg G ,
1984).
In this case, the nerve reacts to injury with demyelination and axonal degeneration, reactive inflammation caused by the irritating effect of degeneration products of the nucleus pulposus of the disc and a sharp increase in the permeability of intra- and epineural vessels (Rydevic B., Brown M.D., Ludborg G. ,
1984, McCarron R. , Wimpee M., 1987). Impaired conduction of nerve impulses through the affected area of the nerve, combined with hypersensitivity to mechanical stimuli, creates the possibility of generating ectopic neuronal activity (Devor M. 1989,1991).
Obviously, the positive effect of the drugs used is due to both a decrease in microvascular permeability and suppression of the activity of ectopic foci, characteristic of local anesthetics even in subtherapeutic concentrations (Devor M. 1989), as well as a decrease in conductivity along nerve fibers, achieved by exposure to both local anesthetics and GKS (Johansson A., Hao J., Sjolund B. 1990). Changes in the nature of the pathological process determine the need to perform a repeated epidural block. At the same time, at the next stage the effectiveness of using this treatment technique decreases. Apparently, it depends on the intensity of the development of adhesive processes in the affected root and the effectiveness of their prevention with the help of the drugs used. The development of intra- and extraneural fibrosis prevents the diffusion of active agents to nerve fibers. We do not consider it advisable to perform more than four numbers of therapeutic epidural blockades, since this increases the risk of complications and the likelihood of improvement is low.
The absence of a therapeutic effect after a four-time epidural injection of a steroid drug and local anesthetic in combination with acupuncture and drug therapy can be considered an indication for surgical intervention. However, the patient’s refusal to undergo surgery is the main indication for the use of other methods of regional analgesia - paravertebral intraradicular blocks, which are often effective in patients with adhesions in the epidural space. The use of sacral blockade and blockade of trigger zones of the lower leg aims to completely relieve pain, increase the patient’s motor activity and open up opportunities for his complete physical rehabilitation.
LITERATURE
- Gnezdilov A.V., Ovechkin A.M., Kukushkin M.L. et al. Modern principles of multidisciplinary pain treatment in an orthopedic clinic. // Anest. and resuscitator. – 1998. – N.5. – P.46-51.
- Gnezdilov A.V. Diagnosis and treatment of phantom and vertebrogenic pain syndromes: abstract. diss. doc. honey. Sci. – M., 1999. – 43 p.
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