Spondyloarthrosis - arthrosis of the spine: cervical, thoracic and lumbar regions

Arthrosis of the spine (spondyloarthrosis) is a chronic form of degenerative-dystrophic changes in the articular cartilage of the spinal column, characterized by thinning of the cartilage and proliferation of bone tissue in the vertebral joints. Many people think that the spinal system does not have joints, but consists only of vertebrae and intervertebral discs, which they are greatly mistaken. The central axis of the musculoskeletal system, or the spine, also has so-called facet (facet) joints. They are formed by the ends of the articular processes (facets) of two adjacent vertebrae and are concentrated between the superior process of the lower vertebra and the inferior process of the upper. The articulating surfaces of bones are covered with smooth, slippery and elastic cartilage.

The functional significance of such joints is enormous: they ensure normal flexion and extension of the spine, and also limit the degree of load on the spinal column, protecting it from excessive movements and instability. Degenerative-dystrophic processes that affect the important cartilaginous covering lead to its destruction, thinning and abrasion, as a result, deformations, increased friction of the articular bone elements and overload of the corresponding section. The problem is complicated by osteophytes, which are spine-like bone growths that arise along the edges of the articular area under the influence of heavy mechanical load.

This disease is dangerous because degeneration extends not only to the cartilage, but to all components of the joint: capsule, synovial membrane, ligaments, subchondral bone and even muscles. According to statistics, about 40% of people suffer from spinal arthrosis. Approximately 55% of cases of facet joint degeneration occur in the cervical region, about 30% in the lumbar segment, and the remaining 15% in the thoracic region.

The main category of patients are people over 45 years of age, who are most vulnerable to pathology due to the biological aging of the body. Those who constantly experience heavy physical activity or, on the contrary, lead a sedentary lifestyle are also predisposed to the disease. Excess body weight, a history of autoimmune diseases and injuries, structural anomalies of the spinal structure can also become provocative factors in the initiation and progression of degenerative-dystrophic pathogenesis in the joints of the spine.

There is one pattern: moderately active and not overweight people suffer from such diseases much less often.

Arthrosis phenomena are accompanied by local pain and stiffness of the back or neck, depending on the location of the problem. It is extremely important to promptly detect the development of a dysfunctional process and begin treatment immediately. Otherwise, severe complications will follow, due to which the quality of life will significantly suffer, and the person will become disabled. It is not possible to completely cure the disease conservatively, but well-chosen therapy will slow down or stop negative phenomena. In advanced cases, orthopedic surgery may be required.

Symptoms of spondyloarthrosis

In the early stages, it is quite problematic to determine arthrosis of the facet joints between the sacral and lumbar segments without appropriate diagnostic equipment. Manifestations of early pathogenesis are not constant and pronounced, so a person usually does not perceive the first messages from a problem area as a disease. And the first sign is a feeling of heaviness in the lumbar region.

Heaviness occurs during active physical labor, a long stay in a motionless position, for example, when you have to stand or sit for a long time. As a rule, people attribute such an unpleasant phenomenon at the level of the sacral and lumbar regions to simple fatigue. But it is advisable to start treating the disease right at the stage of its inception. With moderate and severe forms, treatment is by no means an easy task.

Over time, arthrosis deformans begins to progress, new symptoms appear, which are more disturbing and bring a lot of suffering. One of the main signs of lumbosacral arthrosis is pain. It concentrates on a limited area of the lower spinal column. Then the person begins to understand that he is seriously ill, which forces him to seek help from a medical institution. Let's summarize what has been said and add something new regarding the clinical symptoms of lumboarthrosis.

The lumbar type of pathology is expressed:

stiffness, limited motor potential of the lower back;
pain in the sacrolumbar region of varying nature and intensity, most often aching;
increased pain factor during lateral, anterior, posterior bending of the body, turning to the sides, rotation;
pain after prolonged physical activity, a prolonged state of immobility (in case of non-advanced pathology, the pain subsides after rest; in case of serious degeneration, it is persistent, regardless of the load);
local stiffness, while at the initial stage it appears in the morning, as soon as the patient gets out of bed, but after about 30-60 minutes everything goes away;
sometimes a crunch in the lower back at the moment of making any movement;
muscle tension at the location of the problem joint;
local swelling and swelling of soft tissues;
in severe cases, inability to sit down or get up from a sitting position on your own;
fatigue, general malaise, and in rare cases, fever.

It is worth noting that a complicated disease, albeit in rare cases, can affect the sensitivity and strength of the lower extremities. A person may feel numbness, weakness in the feet, legs, pain in the legs or buttocks, although a similar picture is more typical of intervertebral hernias.

As you can see, the list of symptoms is quite extensive, and each of the listed signs can be attributed not only to this disease, but also to many other abnormalities of the musculoskeletal system, including internal organs. For example, the lower back may hurt due to poor functioning of the kidneys, intestines, etc. Therefore, it is important to undergo a high-quality examination to make sure that the problem lies precisely in the intervertebral joints, and not in any other element of the ridge or internal organ.

Instrumental diagnostics

After an oral interview and physical examination, the turn of instrumental diagnostics follows. The following methods are used for studying:

X-ray. Allows you to determine the presence of damage to the spinal column, the presence of malignant neoplasms - osteophytes. If there is an injury, the doctor will assess its extent and take immediate action.
PAT. A complete bone scan to exclude possible inflammatory reactions, malignant tumors and infectious diseases.
CT. It is necessary to assess the condition of the spinal canal and surrounding structures.
MRI. Allows you to see the morphological picture of the spinal cord, assess the condition of the nerve endings, vertebrae and the spinal column itself.

All these measures are optional. PET, CT and MRI are auxiliary instrumental diagnostics that are needed to create a true clinical picture. Symptoms of lumbosacral spondyloarthrosis are very similar to other diseases, so the doctor must be sure that he is making the correct diagnosis.

Thoracic spine (dorsal)

The thoracic spine is loaded to the least extent, which explains the smallest number of cases of arthrosis of the joints in this segment. The presence of pathogenesis may be indicated by symptoms such as stiffness, pain in the chest and ribs, and less often in the area of the shoulder blades. Due to muscle tightness and attacks of pain, it is difficult for the patient to bend over, turn around, and even breathe.

In the initial period, symptoms in the thoracic region predominantly occur during prolonged physical work, prolonged sitting, or after sleep. But as soon as a person rests or disperses, the discomfort stops.
As the disease progresses, breathing becomes impaired; when inhaling/exhaling or coughing, acute pain occurs in the sternum. Attacks with serious deformities are protracted and intense, often permanent.
A person in bed cannot find a comfortable position to ease the severity of severe pain. You can more or less tolerate it lying on your side, but lying on your back or stomach is very difficult.
At the beginning of the pathology, unpleasant symptoms can be muffled by external means and drugs for internal use from the NSAID series. But the further the stage, the stronger the effect of painkillers decreases significantly, as well as any other means of conservative therapy.

The structure of the spine.

It is of paramount importance to clearly establish what is causing the symptoms and recommend treatment only on the basis of reliable diagnostic data.

The point is that such symptoms are common to many diseases. Often people perform treatments that do not correspond to the true diagnosis. The pain syndrome is often localized in the area of the pancreas, stomach, heart, liver, and lungs.

So, someone is unsuccessfully struggling with heart disease, pancreatitis, cholecystitis, gastritis, etc. But in reality, the emphasis should be on restoring the intervertebral joints of the spine. Or, on the contrary, you might think that it’s all about problems with the spinal system, but in fact it’s a pre-infarction condition or pneumonia. Do not joke with any discomfort that appears in the chest, either in the back or in the front, or in the shoulder blade or along the upper line of the abdomen. Go to the hospital immediately, only experienced medical specialists can make the correct diagnosis!

Attention! You should know that the lack of proper therapy for the dorsal form of arthrosis can actually lead to damage to nearby organs. Particularly dangerous is the pathology of the coronary vessels of the heart, as a result of which myocardial infarction can occur.

Diagnostics

If pain or discomfort in the back continues for more than 14 days and becomes chronic, you need to visit the hospital for diagnosis.

The diagnostic stage is divided into two parts: anamnesis collection and instrumental examination. The first part is needed by the doctor in order to have an idea of what he will encounter, the second is to draw up a clinical picture.

The patient’s medical history is fully studied, presenting symptoms, aggressiveness and frequency of pain are collected. It is important for the doctor to know when negative signs first appeared in order to rule out inappropriate diseases.

The specialist will study not only the patient, but also his family. Spondyloarthrosis is a pathology transmitted hereditarily, not necessarily from parents. More distant relatives could have back problems.

The oral interview is followed by a visual inspection. The doctor assesses the patient’s current condition, studies nerve conduction and joint mobility. The examination does not make it possible to establish an accurate diagnosis, but it makes it possible to exclude extraneous diseases.

Costotransverse type of arthrosis

In the thoracic region there are costotransverse and costovertebral joints, which form the connections of the thoracic vertebrae with the ribs. These two types of formations are mechanically interconnected and therefore cannot work without each other. The costovertebral joint and the transverse costal joint perform the same function: raising and lowering the symmetrical arcuate bones that form the rib cage. This specificity of the articular apparatus of the spinal column is characteristic specifically of the thoracic region.

A little anatomy.

Each of the presented joints can suffer from degenerative-dystrophic pathogenesis. Although it is worth noting that articular lesions in this spinal region are very rare, since the thoracic segment is powerfully strengthened by the muscular-ligamentous complex. They develop more often in older people, mainly women.

As for clinical manifestations, in the previous paragraph we have already talked about the nature of the dorsal type of the disease. Let us recall one distinctive feature: pathological signs are predominantly concentrated in the region of the ribs and the upper part of the abdominal wall. If the disease is severely neglected, dangerous complications may follow: severe depression of the respiratory center and serious disorders of the functioning of the cardiovascular system.

Causes of uncovertebral arthrosis

Destruction of cartilage and adjacent bone tissue can occur for congenital and acquired reasons. The development of dystrophic-degenerative processes is triggered by:

developmental anomalies (for example, Oljenik's syndrome - fusion of the 1st cervical vertebra with the occipital bone, congenital underdevelopment of the cervical spine);
foot abnormalities (for example, flat feet) and injuries to the lower extremities (dislocation of the hip joint and others);
postural disorders and other factors causing deviation of the axial load on the spinal column;
professional and sports activities associated with debilitating load on the cervical spine;
sedentary lifestyle and excess weight (especially excess fat deposits in the neck, shoulders, arms);
cervical spine injuries;
metabolic and endocrine disorders, incl. associated with chronic illness or stress;
previous polio and other severe diseases of the nervous system;
dystrophy of paravertebral and other adjacent muscles.

Insufficient load on the cervical spine is no less dangerous than excessive load.

Osteoarthritis of the facet joints

Destruction of the matrix of the cartilaginous surfaces of the cervical joints is the most common type of spinal arthrosis, and one of the most severe. This subtype of the disease is also called uncoarthrosis or cervical osteoarthritis. The pathology develops over a long period of time and may not manifest itself at first. But a progressive osteochondral deformation, causing compression of the cervical-vertebral nerve roots, veins and arteries, and autonomic plexuses, will certainly show itself as a variety of neurological symptoms. So, destructive processes in the articular cartilages of the neck may be indicated by:

limited mobility of the head and painful condition in the cervical region with an uncomfortable posture, prolonged immobility, turns and tilts of the head;
the appearance of a specific sound when moving the head (crunching, clicking);
local muscle tension in the projection of the damaged element;
tinnitus and a feeling of loss of balance;
shooting into the scapuloclavicular triangle;
deterioration of vision, hearing;
feeling of a lump in the throat;
arterial hypertension;
numbness in various parts of the upper extremities and other types of paresthesia;
pain in the neck, head, shoulder girdle, arms, less often in the sternum (sometimes the pain imitates a heart attack).

Naturally, each person will have their own set of symptoms, but all patients will have one common problem - loss of mobility of the cervical segment. The worst thing is that without adequate and timely therapy, the deformed bone bodies can grow together, and the motor abilities of the neck will then be completely blocked. Among other things, due to an illness that affects any level of this department, blood supply and nutrition to the brain can be seriously disrupted.

How it develops

The cervical region includes 7 vertebrae, the most mobile of the entire spinal column. If certain pathological processes occur in the body, the cervical vertebrae, protected by an elastic cartilage “plate” (disc), become covered with osteophytes (bone growths). The cartilage, in turn, becomes thinner and destroyed, and the adjacent soft tissue atrophies.

The intervertebral disc can bulge and put pressure on nearby tissue or nerves. The vertebrae change their shape, which leads to spinal deformities. If they are pronounced, the patient develops deforming cervical arthrosis.

Sometimes the cause of neck arthrosis is... flat feet!

Principles of treatment

Therapeutic goals for spondyloarthrosis of the facet joints include eliminating pain, maintaining cartilage and bone vertebral structures, and normalizing muscle function. Thus, the most important goal will be achieved – improving the patient’s quality of life. Since this disease is chronic, that is, it is impossible to completely get rid of it, a specialist develops a system of treatment and preventive measures that is optimally suitable for a particular case, aimed at achieving remission of the processes of degeneration and dystrophy in the affected segment.

The basic algorithm for the treatment of all joints and the spine is based on the use of medications, physiotherapy and exercise therapy procedures, and diet. All activities must be carried out comprehensively, in regular and complete courses throughout life. This is the only way to achieve lasting positive dynamics in the treatment of a serious illness. If a conservative approach does not help, surgical intervention methods are used. Below we suggest that you familiarize yourself with the table, which clearly presents all the principles of treatment of spondyloarthrosis.

Methods	Examples	Benefit
Drug treatment	Non-steroidal painkillers (external and internal)	They relieve pain, relieve swelling, and eliminate inflammation in the affected area.
	Vasodilators	Improves microcirculation in tissues, blood flow, lymphatic drainage.
	Muscle relaxants	Help relieve muscle spasms and tension (relax tense muscles).
	Chondroprotectors (effective in the early stages)	They provide necessary nutrition to cartilage, resist degeneration of healthy tissues, and increase joint mobility.
	Corticosteroid injections into the spine (only for strict indications)	They have a long-term anti-inflammatory and analgesic effect.
Physiotherapy	Magnetotherapy	Relieves pain, activates blood flow, stimulates interstitial metabolism, fights inflammation.
	Reflexology	Strengthens blood circulation at the local level, normalizes tissue metabolism, reduces pain and inflammation.
	Ultraphonophoresis	Activates blood flow to the diseased area, reduces inflammation, accelerates cell regeneration.
Physiotherapy	A specially selected set of exercises	Strengthens the musculoskeletal corset, increases the endurance of muscles and ligaments, restores motor-support functions, posture and gait, develops the sore area (exercises should not harm the problem area!).
Diet	Increasing the diet of vegetables and fruits, limiting salt and sweets, eliminating harmful fats and alcohol, etc.	It allows you to enrich the body with useful microelements and vitamins, which will help normalize metabolism both in the body as a whole and in osteochondral tissues. It will help you lose weight and relieve the spinal column from increased axial load.
ethnoscience	Natural plant-based tinctures, rubs, ointments, compresses, etc.	Traditional methods serve exclusively as a complement to the main treatment. They act purely symptomatically, giving a superficial, weakly expressed effect.
Surgery	Facet rhizotomy (denevration of the FS)	Causes regression of pain syndrome due to the destruction by high-frequency currents of nerve endings that send pain impulses to the brain.
Surgery	Implant surgery	An artificial implant replaces a worn-out non-viable component of the spine, thereby achieving stabilization and restoration of mobility at a problematic level.

Today, in different parts of the world, there are many clinical and rehabilitation centers that offer treatment for problems of the musculoskeletal system and spine using a variety of productive methods and technologies. But, perhaps, none of the famous countries can compare with the level of development of orthopedics and traumatology with the Czech Republic.

Here, treatment is carried out only by world-famous specialists who have extensive practical experience and a huge store of medical knowledge, who are fluent in all modern tactics of minimally invasive spinal surgery and joint replacement, and conservative therapy for arthrosis. In this country, the prognosis for a favorable outcome after any type of treatment process is the most promising - from 95% to 100%.

Facet syndrome at the lumbar level in elderly patients: diagnosis and treatment

Chronic back pain is an important medical and social problem due to its persistent course, frequent lack of significant effect from therapy, and high costs associated with treatment. The relevance of the problem is also due to the fact that, like any chronic pain syndrome, back pain contributes to excessive stimulation of the sympathoadrenal system, which significantly increases the risk of cardiovascular accidents, and negatively affects not only the quality of life, but also its duration. Modern studies have shown that a decrease in life expectancy in older people depends more on the presence of chronic pain than on the presence or absence of life-threatening diseases [1].

The most common source of chronic back pain, especially in older patients, is the facet joints. Facet joints (synonyms - facet joints, intervertebral joints, articulationes zygapophysiales) are formed at the connection of the lower and upper articular processes of the vertebrae and have a typical structure: articular processes covered with a layer of hyaline cartilage, synovial membrane, synovial fluid and a capsule reinforced by fibers of the multifidus muscle. The orientation of the articular cavities in the cervical region approaches the horizontal plane, in the thoracic region - to the frontal and in the lumbar region - to the sagittal plane. Facet joints have complex and extensive nociceptive and proprioceptive innervation: each joint is innervated from 2-3 segments of the spinal cord, which provides “overlapping” areas of pain. Four mechanisms of irritation of nerve endings in the motor segment have been identified: 1) mechanical or disfixation - due to displacement of the vertebral bodies and articular processes in relation to each other; 2) compression - exostoses, when the joint capsule, meniscoids or free cartilaginous segments in the joint are pinched; 3) dyshemic - due to swelling of periarticular tissues, microcirculation disorders, venous stasis; 4) inflammatory - due to aseptic (reactive) inflammation in the tissues of the motion segment [2].

The incidence of degenerative changes of the facet joints in the population varies widely (from 40% to 85%) due to the use of different diagnostic criteria by different authors and increases with age. For chronic back pain, according to the results of studies conducted using diagnostic blockades, damage to the facet joints is the cause of pain at the lumbar level in 30–60% of cases, at the cervical level in 49–60%, at the thoracic level in 42–48% cases [3].

Facet syndrome, as a rule, refers to painful manifestations of spondyloarthrosis, in which there is no compression of the spinal nerve root or other neurovascular formations by elements of the pathologically altered motion segment. Instead of the term “facet syndrome”, “spondyloarthralgia syndrome”, “small joint inflammation syndrome of the spine” or “mechanical low lumbar syndrome” are also used. Many authors consider the terms “facet syndrome” and “spondyloarthrosis” as synonyms. Spondyloarthrosis, which is the morphological basis of facet syndrome, is a particular form of osteoarthrosis, which is a heterogeneous form of diseases with different clinical presentations and outcomes, which are based on damage to all the constituent elements of the facet joints - cartilage, subchondral bone, ligaments, capsule and periarticular muscles. In lumbar spondyloarthrosis, a sharp decrease in the thickness of the articular cartilage was found, up to its complete disappearance in certain areas where bone tissue proliferation was noted. Spondyloarthrosis can develop in isolation, but much more often it develops against the background of degeneration of the intervertebral discs, leading to increased load on the facet joints and their chronic traumatization. Like disc damage, spondyloarthrosis is more often observed in elderly patients, but can also develop in young people, which is facilitated by hereditary predisposition, congenital anomalies, spinal injuries, hypermobility of spinal motion segments (SMS), and excess body weight. In case of injuries (whiplash type, traction, rotation), facet syndrome can develop acutely.

The development of spondyloarthrosis is associated with disturbances in the functional anatomy of the spinal column, the anterior sections of which (including the intervertebral discs) are intended mainly to resist gravity (compression), and the posterior sections (including facet joints) are intended to stabilize the spine during rotation and displacement of the vertebrae in the anteroposterior direction. Normally, 70–88% of the axial compression load falls on the anterior sections and only 12–30% on the posterior sections. With the development of degenerative changes in the discs, their height decreases, the shock-absorbing function is impaired, and the proportion of the axial compressive load falling on the facet joints gradually increases. Overload of the joints against the background of developing instability of the joint joint leads first to inflammatory changes (synovitis), and then to degeneration of the articular cartilage, deformation of the joint capsules and subluxations in them. This pathological process is asymmetrical in nature, which may be due to uneven load on paired facet joints. Repeated microtraumas, compression and rotatory overloads lead to the progression of degenerative changes in cartilage up to its almost complete loss, the development of periarticular fibrosis and the formation of osteophytes, which leads to an increase in the size of the upper and lower facets, becoming pear-shaped. Under the influence of impulses from the affected PMS, especially from the posterior longitudinal ligament, reflex tension occurs in the intertransverse, interspinous and rotator muscles, which, in the case of their asymmetrical involvement, causes the formation of scoliosis. The combination of changes in the disc, facet joints and muscle-tonic disorders leads to a sharp limitation of movements in the corresponding SMS.

The pain that occurs with facet syndrome is an example of nociceptive pain associated with symptoms of synovitis, direct mechanical irritation of the nociceptors of the joint capsule against the background of instability and muscle-tonic disorders. Most often, spondyloarthrosis develops in the lumbar spine, mainly in the L4-L5 and L5-S1 SDS, which experience the greatest overload. The maximum risk of injury to the facet joints occurs with sudden twisting movements in the lower back. An additional factor contributing to the development of spondyloarthrosis is weakness of the abdominal wall, accompanied by an increase in the severity of lumbar lordosis and compressive load on the facet joints. Much less often, damage to the facet joints is observed in the cervical (mainly at the levels C2-C3 and C5-C6) and thoracic spine. Facet syndrome is characterized by a recurrent course, gradual development and slow regression of each painful episode and a tendency to lengthen and worsen each subsequent exacerbation [4].

The main component of the joint that undergoes degeneration in osteoarthritis is cartilage, consisting of matrix and chondrocytes, in which there is excessive local release of proteolytic enzymes and a progressive slowdown in cartilage repair. This leads to an imbalance between the synthesis and degradation of the extracellular matrix. The matrix contains glycosamines (proteoglycans) and collagen. As the matrix degrades, glycosamines are lost, the resistance of the cartilage matrix to physical stress decreases, and the cartilage surface becomes susceptible to damage. In addition, a wide range of bioactive molecules are synthesized at the chondral level: pro-inflammatory cytokines, free radicals, growth factor, prostaglandin E2, leukotriene B4. This inflammatory component enhances degenerative mechanisms. Inflammation develops primarily in the synovium, leading to impaired filtration of hyaluronic acid through the membrane, its leaching from the joint cavity and the progression of cartilage degeneration. Proinflammatory cytokines are synthesized in the synovium and then diffuse into the articular cartilage through the synovial fluid and are responsible for increased synthesis and expression of matrix metalloproteinases that destroy articular cartilage [5]. Synovial inflammation is directly associated with the occurrence and development of osteoarthritis. Uncontrolled angiogenesis is an important component of synovial inflammation, and these two interdependent processes, angiogenesis and inflammation, are major contributors to the development of osteoarthritis [6]. Thus, the pathophysiological mechanisms of the development of osteoarthritis include not only mechanical damage to the joint and the degenerative process, but also concomitant chronic inflammation, which contributes to the destruction of hyaline cartilage. The structures of the central nervous system associated with the formation of chronic pain syndrome are also involved in the pathological process. Therefore, the leading directions in the pathogenetic treatment of osteoarthritis are modulation of inflammation, regulation of chondrocyte metabolism and stimulation of cartilage synthesis [7].

Features of the clinical picture of facet syndrome at the lumbar level are described in detail [8]. The pain, as a rule, is of moderate intensity, is diffuse, poorly localized, and is described by patients as “deep,” “aching,” “pressing,” “twisting,” “squeezing.” The phenomenon of “morning stiffness” and the maximum severity of pain in the morning (signs reflecting the inflammatory component), as well as after exercise at the end of the day (which is due to the phenomena of instability and disfixation in the area of the affected SMS) are characteristic. The pain is localized paravertebrally and can be bilateral or lateralized. Pain emanating from the facet joints of the lower lumbar level (L4-L5, L5-S1) can be reflected along the sclerotomes in the gluteal region, coccyx area, hip joint, groin, in the thigh (along the posterior surface) and, as a rule, does not “descend” below the knee. Pain from the joints of the upper lumbar level (L1-L2, L2-L3, L3-L4) can spread to the chest area and the lateral surface of the abdomen. Pain with facet syndrome at the cervical level can be reflected in the area of the shoulder girdle and/or upper back and much less often - in the shoulder, forearm, hand (more typical for discogenic radiculopathies). From exacerbation to exacerbation, the pain pattern (its location, nature and intensity) may change. A characteristic feature of facet pain syndrome at the lumbar level is the appearance or intensification of pain during extension and rotation of the lumbar spine, which occurs when moving from a sitting position to a standing position, during prolonged standing, or “twisting” in the lower back. In this case, bending and tilting in the lumbar region can lead to a decrease in pain. The pain decreases while “unloading” the spine - lying down or when bending the spine with support on the hands (stand, railings). Unlike pain syndrome with radiculopathy, referred pain with facet syndrome does not reach the fingers, is poorly localized, does not carry the patterns of neuropathic pain syndrome (sensations of “electric current”, burning, paresthesia, etc.), intensifies with extension (and not flexion) ) of the spine, is not accompanied by the appearance of pronounced symptoms of tension (Laseg, Matskevich, Wasserman), as well as symptoms of loss in the motor, sensory and reflex spheres. A neurological examination reveals smoothness of the lumbar lordosis, scoliosis in the thoracic and lumbar regions, local pain in the Kemp test, local pain on palpation in the projection of the “problem” facet joint, tension in the paravertebral muscles and quadratus dorsi muscle on the affected side, discomfort and limited range of motion during bending back. The muscle tension around the intervertebral joint is determined by palpation. As a rule, there are no neurological sensory, motor or reflex disorders. Unlike radicular syndrome, the symptoms of “tension” are not typical, nor is there any restriction of movement in the legs.

X-ray examination is sufficiently informative, but the detection of degenerative changes in the facet joints does not mean that these changes are the cause of the pain syndrome. In an asymptomatic population, dystrophic changes in the facet joints are detected in 8–12% of cases [9].

The generally accepted standard and the only evidence-based method for confirming the connection of pain with the pathology of the facet joints is the disappearance (or significant reduction) of pain a few minutes after blockade of the medial branch of the posterior primary branch of the spinal nerve under visual control [10]. But diagnostic medial branch blocks are not a widely used method in routine clinical practice.

The main treatment for facet syndrome is the use of painkillers and nonsteroidal anti-inflammatory drugs (NSAIDs), and the issue of treatment safety is of particular relevance. This is due to the chronic recurrent nature of the pain syndrome, requiring repeated, often long courses of therapy, as well as the fact that most patients are elderly and senile, which significantly increases the risk of developing gastrointestinal and cardiovascular side effects. According to existing recommendations, patients at risk of developing such gastrointestinal (GIT) events should be prescribed non-selective NSAIDs together with gastroprotectors (proton pump blockers) or selective NSAIDs. In patients at high risk of developing cardiovascular side effects, parallel administration of low doses of acetylsalicylic acid is recommended. In addition, elderly patients often suffer from diseases requiring the use of indirect anticoagulants (atrial fibrillation, recurrent thrombotic syndrome), which, as a rule, is incompatible with the use of NSAIDs. It is also necessary to take into account that not all drugs of the NSAID group can be used for osteoarthritis - an adverse effect on cartilage tissue of NSAIDs such as indomethacin, piroxicam, and naproxen has been identified.

The participation of the articular component in the formation of back pain suggests the inclusion in therapy of drugs that have a symptom-modifying (chondroprotective) effect - symptomatic slow acting drugs for osteoarthritis - SYSADOA. Outside of exacerbation, monotherapy with SYSADOA is recommended. In case of exacerbation of the process and severe pain, it is recommended to combine SYSADOA with NSAIDs, the analgesic effect of which develops much faster. Combined use allows you to reduce the dose of NSAIDs and thereby prevent a number of unwanted drug reactions. SYSADOA group drugs are biologically active substances consisting of cartilage tissue components necessary for the construction and renewal of articular cartilage. SYSADOA are able to influence the metabolism of bone and cartilage tissue and stimulate its regeneration, have a moderate analgesic and anti-inflammatory effect and are devoid of side effects characteristic of NSAIDs, since their mechanism of action is not associated with suppression of prostaglandin synthesis and blocking cyclooxygenase, but is based on inhibition of nuclear factor kB, stimulating the breakdown of cartilage tissue in the body. Among the drugs belonging to this class, only cartilage-related components - glucosamine (GA) and chondroitin sulfate (CS) - have a high level of evidence (1A) of effectiveness over placebo, and also have high bioavailability and good tolerability (EULAR, 2003). GA and cholesterol are natural metabolites of cartilage tissue. HA is an aminomonosaccharide; in the body it is used by chondrocytes as a starting material for the synthesis of proteoglycans, glycosaminoglycans and hyaluronic acid. CS is a key component of the extracellular matrix of cartilage tissue, responsible for maintaining its elasticity and resistance to stress. The anti-inflammatory properties of cholesterol have been well studied [11], but little is known about its effect on angiogenesis. CS affects the production of pro- and antiangiogenic factors by synovial fibroblasts in the synovial membrane affected by osteoarthritis and is able to restore the balance between them. Since angiogenesis is one of the key processes in the development of osteoarthritis, the beneficial effects of cholesterol can be explained precisely by the antiangiogenic properties of this substance [12].

Studies have shown comparable and even more pronounced anti-inflammatory activity of GA and cholesterol to NSAIDs [13]. CS, GA, and their combination demonstrated a structure-modifying effect [14, 15]. When CS and GA are taken simultaneously, their action is synergistic, since both drugs have anti-inflammatory activity, and also have an anabolic effect on the metabolism of cartilage tissue and inhibit catabolic processes in it, simulating the most important functions of chondrocytes in damaged cartilage. However, there are some peculiarities in the mechanisms of action of these two salts. Thus, cholesterol optimizes the composition of synovial fluid, and GA independently stimulates the production of cholesterol [16]. In this regard, combination drugs containing both cholesterol and GA have become most popular. The most studied, of course, is Teraflex. The advantage of Theraflex is the combination of two active ingredients: chondroitin sulfate (400 mg) and glucosamine hydrochloride (500 mg) in one capsule. There is another form of release of the drug for oral administration: Teraflex Advance, which contains chondroitin sulfate 200 mg, glucosamine sulfate 250 mg and ibuprofen 100 mg. Ibuprofen is a safe standard NSAID with a short half-life (less than 6 hours), which does not accumulate and leads to a rapid analgesic effect [17]. The effect of the combination with ibuprofen is recognized as synergistic, and the analgesic effect of this combination is provided by a 2.4 times lower dose of ibuprofen [18]. The mechanism of action of Theraflex is associated with activation of proteoglycan synthesis, inhibition of the action of enzymes that destroy hyaline cartilage, increased production of synovial fluid, decreased leaching of calcium from bones and improvement of phosphorus-calcium metabolism. The indication for the use of Teraflex is pathology of the musculoskeletal system associated with degenerative changes in cartilage tissue. It is recommended to start treatment with the drug Teraflex Advance, 2 capsules 3 times a day, duration of administration - up to 3 weeks, and then switch to taking the basic drug Teraflex, which does not contain NSAIDs (2-3 capsules per day, course 3 months), for prolonging the analgesic effect and protecting cartilage. We conducted our own clinical observation of the effect of the drug on chronic pain syndrome in the lower back.

Purpose of the study: to study the effectiveness and tolerability of Theraflex Advance for facet syndrome in an outpatient setting in elderly patients.

Materials and research methods

We examined 40 patients (12 men and 28 women) suffering from chronic back pain, aged from 60 to 75 years (old age according to WHO classification). The selection criterion was the presence of chronic pain syndrome in the lower back in the acute stage, the cause of which was arthrosis of the facet joints. The diagnosis was confirmed by a comprehensive examination of patients. The neurological and neuroorthopedic status of patients was assessed and clinical manifestations of facet syndrome were identified. The intensity of the pain syndrome was assessed using a visual analogue scale - VAS (Association for the Study of Pain, 1986). Treatment results were assessed by changes in symptoms and the Oswester Disability Questionnaire for Back Pain [19], before drug use and on the 21st day of the study. Plain radiographs of the lumbar spine were evaluated to exclude specific spinal lesions. To clarify pathological changes in the bone structures of the spine and study structural changes in the intervertebral discs and spinal cord, magnetic resonance imaging (MRI) was performed. For diagnostic purposes, blockades with 0.5% novocaine were performed in the affected area of the facet joint (paravertebral). Exclusion criteria were: the presence of organic diseases of the nervous system, mental illness, a history of spinal injuries, somatic diseases in the stage of decompensation. Additional exclusion criteria: sequestered hernias and disc herniations larger than 8 mm; severe hypermobility, spondylolisthesis more than 5 mm; the presence of destructive changes in the vertebral bodies. The patients were divided into two groups: main (n = 16) and control (n = 14). The groups of patients were comparable in terms of gender, age, duration and severity of chronic pain syndrome (VAS scale). X-ray examination of all patients in the affected area revealed a decrease in the height of the intervertebral discs, subchondral sclerosis of the vertebrae, narrowing of the joint space, incongruence of the articular surfaces, and the formation of osteophytes. All patients were prescribed standard drug therapy, which included muscle relaxants, B vitamins, exercise therapy, massage, and an optimal motor regimen was recommended. Patients in the main group were prescribed Teraflex Advance 2 capsules 3 times a day. Patients in the control group received enteric-coated diclofenac 50 mg twice daily and proton pump inhibitor omeprazole 20 mg daily. Considering that side effects, among which the primary concern should be ulceration of the gastrointestinal mucosa, develop more often in people over 65 years of age, the daily dose of diclofenac did not exceed 100 mg. The course of treatment in both groups was 3 weeks. The criterion for the effectiveness of treatment was the absence of pain or a change in its intensity.

Results and discussion

During the therapy, patients in both groups achieved a good analgesic effect: patients noted a decrease in pain along the spine, a decrease in morning stiffness and an increase in mobility.

The severity of pain according to the VAS scale in patients of the 1st group decreased from 4.3 ± 0.9 points to 1.7 ± 0.6 points, in patients of the 2nd group - from 4.2 ± 0.8 points to 1 .8 ± 0.8 points. In patients of both groups, the greatest dynamics according to the Oswestry questionnaire were noted on the scales “pain intensity”, “ability to walk”, “ability to sit”, “self-care” and “ability to travel”, which is associated with a decrease in pain syndrome, “sleep” was less affected " and "the ability to lift objects." There were no significant differences in the analgesic effect between the groups. The study established that Theraflex Advance was well tolerated; no side effects were observed in patients. In patients of the 2nd group, adverse events were observed much more often, while diclofenac was discontinued in 5 patients: 1 patient developed nausea, 2 - pain in the epigastric region, 2 patients suffering from hypertension and receiving antihypertensive drugs - increased blood pressure. pressure, which required discontinuation of diclofenac.

The results obtained are comparable with studies of the clinical effectiveness of chondroprotectors in patients with nonspecific pain in the lower back. For the first time, cholesterol was used for vertebrogenic pathology by KD Christensen et al. in 1989 [20]. Many authors have shown the feasibility of using chondroprotectors in complex therapy of patients with nonspecific back pain [21, 22]. With long-term course treatment of CS, a decrease in the fragmentation of the fibrous ring of the upper intervertebral discs of the lumbar spine was noted [23], a case of regeneration of the intervertebral disc in a patient suffering from back pain associated with degenerative disc disease was described [24], not only a symptom-modifying, but also structural-modifying effect of cholesterol in degenerative-dystrophic pathology of the spine. The safety of cholesterol in patients with concomitant pathology of the cardiovascular system was studied; no occurrence of anginal pain, arrhythmias, or severity of chronic heart failure was noted, and a decrease in blood pressure was noted in patients with arterial hypertension, which made it possible to reduce the average daily dose of antihypertensive drugs [25]. Considering the synergy in the action of GA and cholesterol, a number of researchers recommend prescribing a combination of these drugs for dorsopathies [26, 27]. The optimal synergistic effect is achieved when using GA and cholesterol in a ratio of 5:4; This is the proportion in which these substances are contained in Theraflex. According to the prognostic model, the maximum effect of Theraflex should be expected in the initial stages of degenerative-dystrophic lesions of the spine; clinically, this means using the drug after the first relapse of nonspecific back pain, especially in the presence of symptoms of spondyloarthrosis. In this case, a course of treatment has a preventive effect regarding the chronicity of pain. There is data [28] on the effectiveness of Theraflex in young patients with degenerative-dystrophic diseases of the cervical, thoracic and lumbar spine with acute and chronic pain of varying intensity, both in combination with NSAIDs and as monotherapy. However, the drug can also be useful in cases of advanced spondyloarthrosis; in this case, one can expect stabilization of the condition and a slowdown in the progression of the process [26].

conclusions

Thus, the combination of chondroitin sulfate, glucosamine and ibuprofen (Teraflex Advance) is effective in the treatment of facet syndrome of the lumbar spine in the acute stage in elderly patients. Teraflex Advance has a significant symptom-modifying effect (reducing pain, reducing stiffness, improving motor activity). Teraflex Advance is well tolerated by patients, which helps improve patient adherence to treatment and makes it possible to recommend switching to Teraflex for a long-term symptom-modifying effect.

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T. L. Vizilo*, 1, Doctor of Medical Sciences, Professor A. D. Vizilo* M. V. Trubitsina** A. G. Chechenin*, Doctor of Medical Sciences, Professor E. A. Polukarova*, Candidate of Medical Sciences

* GBOU DPO "Novokuznetsk GIUV" Ministry of Health of the Russian Federation, Novokuznetsk ** GAUZ KO OKTs OSH, Novokuznetsk

1 Contact information

Spinal gymnastics

Orthopedists and traumatologists emphasize that regular performance of special therapeutic and preventive exercises plays a leading role in spinal arthrosis. An individually developed set of exercises for a particular department can significantly improve blood flow in the affected area, activate the nutrition of depleted tissues, establish the delivery of important substances for reparative and regenerative functions, normalize motor capabilities, and strengthen the muscles responsible for the functioning of the intervertebral joints.

Exercises for the cervical region

Exercise therapy for the cervical region is intended for people who are familiar with the feeling of stiffness in the neck and slight dizziness when moving their head. You cannot work on this part of the body at a time of exacerbation of pain and severe swelling. When you have uncovertebral arthrosis, you need to do exercises especially carefully, gently and calmly, avoiding sudden movements and jerks. This complex is also often recommended for osteochondrosis of the corresponding localization.

Clasp both hands in your fingers. Place the inside of your palms on your forehead. Perform pressure for 5-7 seconds with the frontal surface on the palm, while creating a strong barrier with them, as if preventing the head from moving forward. You should feel the back of your neck muscles tighten. Number of repetitions – 3-5 times.
Now we do the same, but from the back of the head. That is, we apply a closed lock of hands to the back of the head, and apply backward pressure with the head. We create a reliable barrier with our hands, not allowing our head to lean back even a millimeter.
Now we place one palm on the side of the head and carry out the same resistance to the movement of the head, but to the side. We carry out similar actions on the opposite side. For all recommendations on time and frequency of repetitions, see exercise. No. 1.
Slowly lower your head down, trying to reach the jugular fossa with your chin. Pause after reaching your destination for a few seconds, then calmly return back, while throwing your head back to the maximum you can. Don't force anything! Repeat the exercise 5 times.
Press your chin to the front wall of your neck. Make turns to the right and left in this position (slowly!). The total number of turns is 10 times. It is also recommended to make regular right-hand and left-hand turns 5 times on each side, keeping your head level. But make sure it doesn't fall down and keep your shoulders straight.
Tilt your head back, lower it towards your shoulder, trying to touch it with your ear. Do this on the right and left sides for a total of 10 exercises.

It is very important that your physical recovery takes place under the watchful supervision of a professional exercise instructor, orthopedist and physiotherapist. You can’t just take the first example of exercise you come across from the Internet and start doing it; physical therapy is prescribed by a doctor! Along with exercise therapy, the patient’s balanced diet plays a leading role, which will help compensate for mineral and vitamin deficiencies and reduce body weight.

In addition, keep in mind that you are advised to undergo treatment in sanatorium medical institutions 1-2 times a year. Within the Russian Federation, sanatoriums in Karelia have proven themselves well, offering a wide range of procedures for high-quality restoration of the musculoskeletal system.

Arthrosis of the sacrococcygeal joint

The sacrum and coccyx are two sections of the spine, which in an adult are monolithic bone structures. Both initially contain five vertebrae. Until the age of 12 years, the coccygeal vertebrae are independent of each other and are separated by cartilaginous pads. The sacrum is made up of five vertebral bodies that fuse together by the age of 25 years.

There is a joint between the sacrum and coccyx. It ensures minimal mobility of the coccyx and is involved in the distribution of shock-absorbing load throughout the spinal column and pelvic bones.

Sacrococcygeal arthrosis is the destruction of this joint. Arthrosis of the sacrococcygeal joint develops most often after traumatic exposure. This could be a fall on the buttocks, bruises, fractures, sprains of the ligaments and tendons. Instability of the ligaments and muscles surrounding the coccygeal-sacral plexus often provokes displacement of the articular surfaces with damage to the articular capsule. Inside it, the pressure balance of the synovial fluid changes, which causes the onset of degeneration of cartilage tissue.

Deforming arthrosis of the sacrococcygeal joint manifests itself in the form of dull pain in the lower back. They occur at the moment of changing body position after prolonged static tension of the pelvic muscles. For example, if a person sits on a chair for several hours, then after rising to his feet he may experience characteristic pain in the lower back, which spreads throughout the pelvic ring. This is a characteristic sign of destruction of the sacrococcygeal joint. You need to see a doctor as soon as possible.

Exercise therapy for the lumbar region

This is the second most common type of pathology after uncovertebral osteoarthritis. Let us give an approximate complex of exercise therapy used for this type of disease.

Complex No. 1.

Hang on the horizontal bar for 1 minute.
Take a standing position, hands on your belt. Smoothly alternate bending of the body, first to the sides, then forward/backward (8-10 times).
We do not change the IP. We carefully perform alternating movements of the pelvis back and forth (10 times for each direction).
Get on all fours, resting on your forearm. Bend your back up, head down. Stay in this position for 5 seconds, return to i. p. (do up to 10 times).
Lie on your back. Pull your bent knees to your chest one by one, helping with your hands. To do this, you need to grab your knee with both hands and pull it up. Do 10 repetitions for each leg.

We emphasize that in the acute phase, maximum immobilization of the diseased area is necessary, so consult a doctor to receive competent recommendations regarding the mode of physical activity.

Training complex for thoracic localization

Exercise therapy warm-ups will allow you to strengthen this part of the spinal column, increase and maintain its mobility, forget for a long time about excruciating pain in the shoulder blades, sternum and ribs, and restore the functionality of the internal organs.

Stand straight, feet together. As you inhale, raise your arms up and slowly bend back; as you exhale, lower your arms and at the same time bend forward, rounding your back. Repeat 10 times.
Sit on a chair, cross your arms behind your head. Inhaling, bend your back backwards, spreading your elbows as far apart as possible. As you exhale, we return back, relaxing our elbows (8 repetitions).
Kneel down, rest on the palms of your straightened arms. Arch your back downwards, opening your chest as much as possible, and hold in this position for 3 seconds. Then bend your back upward, holding for the same amount of time. Perform alternate bending-bending 7 times for each task.
Lie on your stomach, arms bent, palms at shoulder level. Straightening your upper limbs, raise your body. Standing on straight arms, smoothly arch the spine, pulling your chest forward (5-7 times).
Starting position – lying on your stomach, upper limbs located along the body. We tear our shoulders off the surface, raise them to such a distance from the floor as your physical fitness allows (5-7 repetitions).