Spinal bone marrow edema: what is it and how to relieve swelling

Magnetic resonance imaging shows pathological changes in internal structures without invasive manipulation. The method is more informative in relation to loose tissues containing a significant amount of liquid. Hydrogen atoms in water molecules respond to a directed electromagnetic pulse, providing a stable signal. Trabecular (from the Latin trabeculae - plates of spongy substance) edema is clearly visible on MRI of the spine due to the accumulation of fluid in the bone marrow tissue.

Lumbar spondylodiscitis with hyperhydration (increased fluid volume) of the spongy substance

The tomograph sensors record the signal generated by the resonance of charged atoms. Using complex algorithms, information is converted into a series of monochrome images and transmitted to a computer monitor. Layer-by-layer scanning is carried out in increments of 1 mm, which allows you to visualize the slightest changes in the substance in the area of interest.

In some cases, contrast-enhanced MRI is performed. The method involves intravenous injection of a “coloring” solution based on gadolinium chelates. The drug does not cause allergies and is eliminated from the body naturally.

Characteristics of the disease

Spinal cord edema occurs due to excess fluid accumulation in the spinal cavity. This happens due to damage to the ridge, blood vessels, or a failure in the natural process of removing cerebrospinal fluid. Usually this is the body’s reaction to negative external influences, but the process can begin due to the entry of dangerous bacteria and pathogenic microorganisms into the circulatory system. In this case, it is they who increase the volume of tissue due to the onset of local inflammation.

This condition is dangerous for humans, and without medical help a variety of complications develop. If swelling is suspected, the doctor will prescribe tests and an MRI. They allow you to make an accurate diagnosis and take the necessary measures.

Varieties

Swelling of the spinal cord has its own classification, which simplifies the process of choosing treatment tactics when determining the type at the diagnostic stage. Each type has its own characteristics and features.

Trabecular. Occurs when the spine is injured and vertebrae are destroyed. Against the background of deformed cartilage, an accumulation of fluid appears, which causes severe pain to the person, nausea, dizziness and other characteristic symptoms are observed.
Subchondral. A process occurs as a result of the destruction of cartilage in the vertebrae. The degree of danger depends on the size of the edema.
Aseptic. Swelling affects the neck and head of the femoral bone. Against the background of the report, a high body temperature, swelling at the site of localization, and acute pain when pressed appear. Inflammation gradually develops, and functional damage to the area occurs.
Reactive. Usually occurs after surgery, as it is characterized by the ingestion of pathogenic microflora. Swelling is accompanied by acute pain.
Perifocal. It is formed when the white matter of the brain enters the plasma proteins. Swelling can be small or extensive and usually does not require surgery.
Infectious. The cause of the damage is the entry of dangerous pathogens into the body. In rare cases, swelling is caused by helminths or infestations.

Treatment at home after confirmation of the diagnosis is unacceptable, as the risk of complications is high. Therefore, a patient with any form of the disease must be hospitalized in the inpatient department of the hospital.

Spinal cord swelling most often occurs as a result of tissue damage

Intramedullary tumor of the spinal cord

Intramedullary (intracerebral) tumors in the general classification of OSM account for an average of 18%. They are predominantly represented by primary neoplasms from the structural components of the nervous tissue of the brain (gliomas). This variant of origin, the occurrence of which, according to some data, is approximately 95%, is called glial. Let's consider the most common neoplasms of the intramedullary series.

Ependymoma (63%) is often a benign intradural tumor formed due to abnormal cell division of the ependymal epithelium of the central canal of the spinal cord. It is mostly located at the level of the cauda equina or in the neck, and has a clearly demarcated structure, which allows it to be successfully operated on (radically) with positive functional results for the patient. As reviews and clinical observations show, it is more often found in people over 30 years of age. Despite the predominance of benignity, after its total removal, consequences in the form of relapses or the appearance of metastases along the cerebrospinal fluid ducts can sometimes occur. Relapses occur in an average of 16% of cases.
Astrocytoma (30%) is a benign (in 75% of cases) or cancerous (in 25%) tumor that develops from neuroglial cells (astrocytes). As a rule, this type of oncology is observed in the cervical segments in adults, and in the thoracic region in children. In children, astrocytoma occurs more often; they are usually detected before the age of 10. Intratumoral cysts are often found with this diagnosis, which grow slowly, but can reach impressive sizes. Its characteristic feature is expansive-destructive growth.
Hemangioblastoma (7.5%) is a slowly growing non-malignant pathogenesis, which is a collection of thin-walled vascular formations. In 50% the lesion is thoracic, in 40% it is cervical. Men are 2 times more susceptible to this pathology than women. Predisposing age is 40-60 years. After high-quality surgical treatment, solitary hemangioblastoma almost never recurs. The situation is much more complicated with Hippel-Lindau disease, which in 25% of patients is combined with this type of tumor. With such a clinical picture, even complete removal of pathological tissue is not able to prevent the re-activation of a process of a similar nature in various parts of the central nervous system.
Oligodendroglioma (3%) is a rare glial OSM of 2-3 degrees of malignancy, developing from mutated oligodendrocytes, that is, cells that form the myelin sheath of nerve fibers of the SM. It is detected with a high frequency in 30-45 years, the male sex is most vulnerable to it. After surgery, which is a necessary treatment measure, the pathological crisis often returns after 1-2 years.

Intramedullary type.

The first clinical signs of an intramedullary tumor in 70% are expressed by local pain, then it radiates to the lower or upper extremities. Over time, the atypical formation leads to severe neurological deficits: lack of mobility, muscle and joint weakness of the legs or arms, increased or decreased tactile sensations, numbness and other disorders associated with spinal cord damage. Without proper therapy, progression of neurological abnormalities and significant deterioration in a person’s quality of life are observed.

Important information! Today, surgical treatment is the generally accepted standard in the treatment of intramedullary tumors, which for the most part are potentially curable. Modern neuroimaging tools and surgical tactics make it possible to clearly plan the course of the operation and perform manipulations on the principle of the safest radical removal of such a neoplasm - while preserving areas of high functional significance. It is known that the earlier the intervention is implemented, the greater the patient’s chances of successful physical recovery and a significant increase in life expectancy.

Today, few clinics undertake to operate on an intramedullary tumor, considering it to be poorly located, and therefore offer only non-surgical treatment and standard decompression, which is often not justified. Although countries where modern high technologies in the field of neurosurgery are excellently developed, have an excellent command of productive, proven effective methods for removing even such a complex type of tumor.

Among the most successful countries in terms of productive treatment of vertebral oncopathologies of any type and severity, it is worth highlighting the Czech Republic. Why don't we talk about Germany or Israel? Of course, these two countries carry out high-tech operations at the highest level, but the cost is high.

Czech clinics are known everywhere for their specialization in this area, no less than German and Israeli medical institutions, but only in the Czech Republic the prices for surgical interventions for spinal tumors are 2 times lower. Moreover, clinical centers in the Czech Republic always include in this reasonable price (50% lower) full rehabilitation care after the removal procedure, and not just the services of a surgeon, as most medical institutions in Germany or Israel do.

Causes of edema

Fluid begins to accumulate in the bone marrow for a variety of reasons. But determining the etiology is extremely important for choosing the most effective treatment tactics, because both the rate of progression and the nature of tissue damage will differ. The most common prerequisites for the appearance of pathology are:

What is cervical myelopathy

Inflammatory process. An infection in the body, regardless of location, can easily reach any place through the blood. The waste products of pathogenic microflora provoke an increase in capillaries in size. The immune system responds appropriately and attacks the infection. The wall of the blood vessels is damaged and swelling occurs in the spinal cord.
Injury. One of the most common causes of the disease. As a result of injury, fracture or severe bruise, fluid accumulation occurs very rapidly. If help is not provided in time, it can be fatal.
Osteochondrosis. Degenerative processes in the body gradually destroy cartilage and bone tissue, impair the mobility of the vertebrae, and provoke the appearance of hernias. This, in turn, leads to the body attempting to repair the damaged area, which increases swelling. This is one of the most likely complications of the disease.
Malignant formations. Sometimes the appearance of a pathological process is explained by a tumor. Computer or magnetic resonance imaging can detect this condition.

Important information! Bone marrow edema can be provoked not only by infections occurring in the spine, but also by any processes in the body that easily “migrate” through the bloodstream.

It is easy to detect clinically only swelling of the bone marrow, which is formed as a result of injury. The person requires immediate help, as the condition progresses rapidly and in most cases, medical workers do not have time to conduct studies to clarify the diagnosis.

Acute pain is one of the characteristic signs; it is observed several centimeters above the lesion itself

Extramedullary type

Such neoplasms, which in medicine are given the name “extramedullary,” are concentrated not inside the spinal component, but in close proximity to it. Simply put, they originate in the structures that surround the SC (developing from the meninges, nerve roots, fatty tissue and other tissues passing nearby).

This category of harmful process is the most common; it develops 4 times more often than true intracerebral pathogenesis, and, fortunately, is more represented by pathologies of benign origin. But this does not mean at all that a non-malignant disease cannot portend anything terrible. In the absence of the necessary treatment, it threatens severe disability due to compression of the spinal cord and its elements, up to the complete loss of the ability to move and self-care. Sudden death cannot be ruled out. This is not to mention the fact that due to such neoplasia, irreversible destruction of the bone and cartilaginous units of the spinal column often occurs. Therefore, both extra- and intramedullary tumors equally require timely diagnosis, as well as the rapid involvement of adequate methods of therapy.

MRI.

Extramedullary OSM can have extradural (31.5%) or intradural (68.5%) localization. The extramedullary-extradural type is distinguished by its large size and the predominance of malignant forms; in turn, the malignant focus progresses at a fairly intensive pace and is predominantly recognized as a secondary (metastatic) formation. The extramedullary-intradural type of pathology, which is also the most common, is characterized by a predominance of primary neuromas (40%) and meningiomas (25%).

Meningioma (arachnoidendothelioma) is a benign tumor that grows slowly and gradually. Formed from cells of the arachnoid meninges. Diagnosed over the age of 50 years, and in predominant numbers in women (80%). With a high frequency it affects the spinal membrane in the thoracic region. Rarely, but can recur and produce multiple growths, causing transverse damage to the spinal column. Although the size of this neoplasia, which externally resembles a small dense node, rarely increases by more than 1.5 cm, such a tumor even a few millimeters in size can directly put pressure on the nerve structures, provoking a severe neurological clinical picture of symptoms.
Neuroma (schwannoma) is a round-shaped benign OSM with clear boundaries and a dense structure, which develops as a result of metaplasia of lemmocytes (Schwann cells), namely auxiliary cells of the peripheral nerve fiber involved in the formation of the myelin sheath. Female patients are more likely to experience this disease; people of middle age and older have the greatest predisposition. At first, the disease proceeds latently, and later it is expressed by severe radicular pain, paresis and paralysis of the muscles in the area of innervation, loss of sensitivity according to the conduction type. The neck and thoracic region are common areas that neuromas affect.

Other extramedullary neoplasms with intradural concentration (angiomas, lipomas, metastases, etc.) are much less common.

Symptoms

Pain in the vertebrae can be attributed to almost any ailment of the musculoskeletal system, which in turn makes it difficult to make a diagnosis. But without timely consultation with a doctor, there is a risk of death, especially if there is swelling of the cervical spine, which is the most dangerous.

The pathological process is accompanied by the following symptoms:

Impaired functioning of the respiratory system.
Decreased vision.
Neurological disorders.
Irregularities in heart rhythm.
Paralysis of the upper or lower limbs.
Acute pain in the back, in the affected area.
Disruption of the senses.
Dysfunction of the pelvic organs (problems with urination or bowel movements, constipation, bladder pain).
Loss of skin sensitivity.
Cramps and spasms in the legs or arms.

Pain syndrome can be observed not at the location of the pathology, but several centimeters higher, this is explained by the accumulation of a large amount of fluid and compression of the nerve endings. When the cervical spine is affected, the pressure inside the skull increases, hydrocephalus appears, and nerves are pinched.

Patients with bone marrow edema often develop allergies, exacerbation of radiculitis or intestinal infections. This occurs due to a sharp decrease in the body’s immunity due to the appearance of pathology.

Important! One of the key symptoms is anemia, bleeding gums and frequent nosebleeds. This is due to the loss of functionality of the organ responsible for hematopoiesis.

Musculoskeletal disorders in internist practice - diagnosis, treatment approaches

Musculoskeletal disorders are widespread and occur in all age groups of the population. The vast majority of patients are middle-aged and elderly. The leading complaint is pain in the joints and back associated with physical activity, appearing and/or intensifying in the second half of the day/first half of the night, decreasing with rest, while local and systemic signs of inflammation are slightly expressed.

Typical representatives of the group of musculoskeletal diseases are osteoarthritis (OA), periarticular pathology (enthesitis, bursitis, tendonitis, etc.), and nonspecific low back pain (LBP).

OA is a multifactorial disease, the development of which is facilitated by genetic factors, obesity, physical inactivity, microtrauma of the joints, excessive physical effort, as well as “major” joint injuries [1]. As defined by The Osteoarthritis Research Society International (OARSI) 2005, OA is a disorder involving mobile joints characterized by cellular stress and extracellular matrix degradation initiated by micro- and macro-injury that activate inappropriate repair responses, including pro-inflammatory pathways of the immune system [2].

Currently, several OA phenotypes have been described [3].

OA phenotypes:

obesity-induced phenotype (oxidative stress, leptin dysregulation, endothelial dysfunction) - OA of the spine and supporting joints;
phenotype associated with sports loads - microtraumatization of supporting joints (shoulder, elbow, hip, knee), including against the background of torsional loads;
hypodynamic phenotype - OA of the spine (spondyloarthrosis), shoulder, wrist and hand joints (due to the use of smartphones and a computer mouse);
a phenotype associated with nutritional deficiency (including hypovitaminosis D, C) - characterized by damage to more than three groups of joints (generalized OA).

OA represents a heterogeneous group of diseases of various etiologies, in which the process involves not only articular cartilage, but also subchondral bone, ligaments, joint capsule, synovium and periarticular muscles.

The progression of OA is a consequence of the interaction of mechanical, biological, biochemical and molecular factors that disrupt the normal cycle of synthesis and degradation of articular cartilage chondrocytes, extracellular matrix (ECM) components and subchondral bone. In normal cartilage, there is a balance between the synthesis and degradation of CM constituents, whereas in OA, the dynamic balance is disrupted as a result of loss of type II collagen. In addition to disorders of cartilage metabolism and changes in subchondral bone, inflammation plays a large role in the pathogenesis of OA. The inflammatory process affects almost all structures of the joint with the formation of chondritis, synovitis and osteitis [4].

The interactions of cytokines, enzymes, and matrix breakdown products lead to a decrease in the content of proteoglycans in cartilage, disruption of the architectonics of the matrix, and the appearance of microcracks and tears in the cartilage. These processes can intensify when microvasculature vessels grow into the cartilage. The inflammatory process involves the synovial membrane and subchondral bone. At this stage, pain may occur. Since cartilage is not innervated, pain is a sign of involvement of periarticular tissues in the pathological process. In addition, sources of pain in OA can also be synovitis, trabecular microfractures, pressure on the exposed subchondral bone, formation of osteophytes, increased intraosseous pressure due to venous stagnation, spasm of nearby muscles, and degenerative changes in ligaments [4].

One of the most significant and disabling forms of OA is gonarthrosis. Its main symptom is mechanical pain that occurs when walking and especially when going up or down stairs. The pain is localized in the front or inner parts of the joint and can radiate to the lower leg. The main place is given to the assessment of pain syndrome in OA, the clinical palette of which is determined by its various pathogenetic variants:

mechanical type of pain - associated with physical activity, relief at rest;
continuous night pain (first half of the night) - caused by venous stasis in the subchondral bone, increased intraosseous pressure;
“starting” pain for 15–20 minutes after periods of rest is a consequence of friction of articular surfaces, cartilage fragments in the joint cavity;
constant pain due to reactive synovitis, combined with morning stiffness and swelling of the joint area.

M. Lequene’s criteria are used as diagnostic criteria for knee OA, which best reflect the clinical understanding of this disease:

limitation and/or pain during passive flexion of the knee joint (normal flexion is at least 135°, extension is 0°);
narrowing of the gap of the femorotibial or femoral-patellar joints;
osteophytes and/or subchondral sclerosis, subchondral cysts.

The diagnosis is established in the presence of all three signs and the exclusion of diseases such as ischemic bone necrosis, Paget's bone disease, chondrocalcinosis (pyrophosphate arthropathy), hemochromatosis, ochronosis, hemophilia, arthritis, joint infections (including tuberculosis), Charcot's joint (neuroarthropathy) ), pigmented villonodular synovitis, chondromatosis [4].

At the present stage, factors for the progression of OA have been described:

age;
pain intensity > 60 mm on visual analogue scale (VAS);
reactive synovitis;
bone marrow edema according to magnetic resonance imaging (MRI);
local and systemic osteoporosis;
low vitamin D levels;
metabolic syndrome;
Muscle weakness/sarcopenia is an important risk factor for the development and progression of knee OA, as well as poor outcome and functional impairment.

In 85% of patients with OA, according to morphological data, inflammatory changes are detected in the area of the “synovioenthesial complex,” which indicates a close connection between the synovium and periarticular structures [5]. When describing periarticular pathology, the following terms are usually used:

Bursitis is an inflammation of the synovial bursae, mainly in the joint area (subacromial, olecranon, trochanteric, prepatellar, bursa anserine).

Tendonitis is inflammation of the tendon (tendinitis) and its sheath (tenosynovitis) (biceps, supraspinatus, calcaneal (Achilles) tendon, infrapatellar).

Enthesopathy/enthesitis - inflammation in the places of attachment of tendons, fascia, ligaments to bones, most often in places of apophyses, tuberosities, condyles, processes (lateral and medial epicondylitis).

The main causes of periarticular pathology (tendonitis and enthesitis):

overload (change in physical activity stereotype);
trauma (single or repeated microtrauma);
local injection of glucocorticosteroids into the thickness of the tendon;
congenital anomalies of joint structures leading to disruption of biomechanics;
imbalance of the muscles surrounding the joint;
physical inactivity (immobilization);
disruption of the blood supply to certain areas of the tendons;
age-related involution of the musculoskeletal system.

Characteristic clinical features of periarticular lesions are pain during certain movements and its local nature (the patient indicates the point of maximum pain), a decrease in the volume of active while maintaining the range of passive movements, asymmetry of the joint, the connection of swelling with a specific bursa, tendon sheath.

Anserine tendinitis/bursitis (pes anserinus - the place of attachment to the tibia of the sartorius (m. sartorius), thin (m. gracilis) and semitendinosus (m. semitendinosus) tendons. Anatomically located 3-4 cm below the projection of the knee joint gap along the medial its surface). Risk factors for the development of tendinitis are sports activities (running), osteoarthritis, meniscal tears, obesity, long walking, sudden increase in loads on the legs, flat feet, diabetes.

Anserine tendonitis is characterized by pain when climbing stairs (with gonarthrosis - increased pain when descending), lying on your side, when placing one knee on the other. The patient points to a painful point corresponding to the location of the anserine bursa; upon palpation, severe pain and swelling (less often) is noted in the “interested” area.

Tendinitis/bursitis of the greater trochanter (trochanteritis) - develops more often in women aged 40–60 years suffering from OA of the hip joint. Trochanteritis is characterized by deep, burning pain along the lateral surface of the joint and thigh, which increases when walking on a level surface and climbing stairs, squatting, which is combined with lameness in some patients. The constant nature of the pain indicates trochanteric bursitis. A decrease in pain intensity is noted at rest, intensifying at night, lying on the painful side. Upon examination, there are no restrictions on passive and active movements in the hip joint, local pain is noted in the area of the greater trochanter upon palpation, and pain occurs with resistance to active abduction of the hip.

Nonspecific LBP is a universal model of musculoskeletal disorders in patients of all age groups, including damage to the muscles, ligaments, and articular apparatus of the spine. In the occurrence of acute BS, an important role is played by local damage to the ligamentous apparatus of the spinal column, primarily the short ligaments (yellow, intertransverse and interspinous), which stabilize the spine at the segmental level against the background of non-physiological movements and excessive load. The development of muscle dysfunction, enthesopathies, tendinopathy of the involved muscles, combined with OA of the facet joints, spondylosis, underlies the development of chronic PS, while the maintenance of pain in some patients is due to the development of phenomena of peripheral and central sensitization (Fig.) [5].

Myofascial dysfunction (myofascial syndrome, MFS), associated with physical or postural stress, is characterized by the formation of dense painful bands and areas of increased sensitivity (trigger points, TT) within the affected muscle with a pattern of referred pain or sensory disturbances (paresthesias) upon palpation, and also limiting range of motion.

MFS of the quadratus lumborum muscle is accompanied by pain in the lumbar region of a deep nature with irradiation to the sacroiliac joint and gluteal region, with a deep location of the TT - to the thigh, the region of the iliac crest and the groin region. The formation of TT in the quadratus lumborum muscle occurs during forced movements, accompanied by bending and turning the torso, lifting a load, as well as during postural tension associated with gardening work. Pain in the lumbar region occurs and intensifies when walking, bending the body, turning in bed, getting up from a chair, coughing, sneezing. The pain is most intense in a horizontal position. To identify TT, deep palpation is necessary with the patient lying on the healthy side. When bending the torso in the direction opposite to the localization of the spasmed muscle, the pain syndrome intensifies [6].

MFS of the piriformis muscle is characterized by aching, pulling, cerebral pain in the gluteal region, in the sacroiliac joint, hip joint and along the back surface of the sore leg. Painful phenomena intensify after prolonged sitting, at the beginning of walking, in a standing position, half-squatting, or when trying to adduct the hip. Pain relief occurs in a lying position, sitting with legs apart, and during a short walk. The range of motion in the lumbar spine is not changed, straight leg raising is often limited. TPs in the piriformis muscle are most often activated during movements associated with forced rotation on one leg, falls, and prolonged abduction of the legs at the hip and flexion at the knee joints during obstetric and urological manipulations.

Pain with spondyloarthrosis is localized in the paravertebral region, is unilateral or bilateral, and can radiate down the leg to the level of the knee. Pain syndrome occurs after episodes of prolonged immobility, increases with extension, decreases with flexion and movement, neurological disorders are not typical. Overextension of the spine or a combination of extension and rotation provokes pain (positive Kemp test) [7].

A screening assessment of the condition of the musculoskeletal system (GALS - Gait - gait, Arm - arm, Leg - leg, Spine - spine) is recommended to be carried out, taking into account the following anamnestic information [8]:

Do you have pain and stiffness in your muscles, joints, and spine?
Can you fully dress yourself?
Are you able to go up and down stairs without difficulty?

In the diagnosis of diseases of the articular apparatus, it is important to assess the signs of direct damage to the joint and periarticular pathology. In the first case, the pain is constant, present at rest, intensifies with movement, is accompanied by a decrease in the volume of both active and passive movements; an objective examination reveals effusion in the joint (reactive synovitis in OA), thickening of the synovial membrane, and intra-articular crunch.

Therapeutic tactics for OA, periarticular pathology, and nonspecific LBP are reduced to relieving pain as quickly as possible using nonsteroidal anti-inflammatory drugs (NSAIDs), the effectiveness of which is assessed 7–14 days from the start of taking the full therapeutic dose; oral administration is preferable. For short-term treatment of very intense acute pain and/or when oral administration is not possible, the use of injectable NSAIDs for a duration of no more than three days is recommended. For mild or moderate pain and a high risk of complications when taking NSAIDs systemically, local forms of NSAIDs (ointments, gels, sprays) are used [5].

The algorithm for managing patients with OA includes following recommendations for weight loss, a balanced diet, and physical therapy. In the presence of reactive synovitis, a protective regimen is indicated until the inflammation is relieved. To curb the progression of OA, a course of basic therapy (symptom-modifying drugs with delayed action) is indicated. Balneotherapy, ultrasound therapy, magnetic therapy, and electrophoresis with glucocorticosteroids (GCS) are used as physiotherapeutic treatment.

In the presence of periarticular lesions, it is recommended to limit active movements involving the involved structures for 2–3 weeks. Periarticular administration of corticosteroids is carried out if NSAIDs are ineffective, physiotherapeutic procedures (phonophoresis, electrophoresis, cryotherapy, magnetic currents, balneotherapy), and physical therapy. Local injections of GCS are carried out in the presence of local inflammation in the area of a clearly defined anatomical structure and the absence of effect when using NSAIDs for at least 7-14 days. The interval between injections of GCS should be 2–3 weeks; no more than three injections in one area within 12 months are recommended [5].

For nonspecific LBP, bed rest should be limited to 72 hours. Drug therapy in the acute period can be multicomponent (NSAIDs, muscle relaxants for a short course of up to 10 days, analgesics). In the presence of MFS, preference is given to the prescription of muscle relaxants and the use of manual muscle relaxant techniques. Weekly assessment is recommended for acute LBP or exacerbation of chronic LBP. Correction of management tactics (including consultation with a neurologist) if it is ineffective is carried out after 4–6 weeks (for a chronic course - monthly examination) [9].

Priority in the treatment of OA is given to drugs with delayed symptomatic action (SYSADOA - Symptomatic Slow-Acting Drugs for Osteoarthritis). The latter are characterized by their natural origin, the presence of reliable data on clinical effectiveness and a low frequency of undesirable effects. In the treatment of OA, chondroitin sulfate, glucosamine, unsaponifiable compounds of soy and avocado, diacerein, and hyaluronic acid are used.

In clinical practice, for several decades, a multicomponent drug of delayed symptomatic action has been widely used, demonstrating high clinical efficacy and safety - Alflutop - a standardized injection solution based on a bioactive concentrate from small marine fish. The drug contains sulfated glycosaminoglycans, similar to the matrix of hyaline cartilage: chondroitin-4-sulfate, chondroitin-6-sulfate, dermatan sulfate, keratan sulfate, glucuronic acid, free amino acids, macro- and microelements (sodium, potassium, calcium, magnesium, iron, copper , zinc) (table).

According to new experimental data obtained in vitro, Alflutop demonstrates a pathogenetic mechanism of action in OA.

The mechanism of action of the drug Alflutop:

Inhibition of cartilage degradation - inhibition of the expression of proteases, hyaluronidase.
Strengthening catabolic processes - increasing the synthesis of aggrecan and hyaluronic acid.
Anti-inflammatory effect - inhibition of extracellular release of interleukins (IL-1β, IL-6, IL-8), vascular endothelial growth factor (VEGF), expression of cyclooxygenase-2, regulation of the expression of pro-inflammatory cytokine genes.
Antioxidant effect - inhibition of the production of superoxide radicals, activation of enzymes involved in oxidative reactions.
Effect on phosphorus-calcium metabolism - slows down bone resorption and reduces the loss of calcium ions.

In addition, experimental studies on a standardized cell line of normal human bone chondrocytes (CHON-001) have proven the chondroreparative effect of Alflutop. Proliferative status (indicative of dynamic cellular regeneration) and extracellular release of transforming growth factor beta (TGF-β), a key protein in extracellular matrix homeostasis, were studied. In the study, Alflutop demonstrated TGF-β activation and an improvement in cell proliferative index by more than 50% compared to control cells; the drug stimulates the synthesis of deoxyribonucleic acid and mitosis of chondrocytes, this effect is dose-dependent [10].

The drug Alflutop has a wide range of clinical evidence base. With the participation of employees of the Department of Faculty Therapy named after. acad. A. I. Nesterov Russian National Research Medical University named after. N.I. Pirogov conducted a two-year, multicenter, blind, randomized, placebo-controlled clinical trial to study the symptom- and structure-modifying effects of the drug Alflutop in gonarthrosis [11]. The study included 90 patients with knee OA of stages 2 and 3 according to the Kellgren–Lawrence classification. Patients were randomized into two groups of 45 people each: the first received intramuscular injections of Alflutop 1 ml in courses of 20 days at intervals of six months for two years (four courses in total), the second received injections of placebo (isotonic sodium chloride solution) according to a similar scheme . Ibuprofen was prescribed as concomitant therapy at a dose of 600–1200 mg/day. The differences in the absolute value of the reduction in pain intensity according to the Western Ontario and McMaster Universities Osteoarthritis Severity Index (Western Ontario McMaster Universities OA Index - WOMAC) between the groups were significant. A significant decrease in stiffness in the Alflutop group was observed by the third visit (p < 0.001). A statistically significant improvement in quality of life was noted by the sixth visit only in the Alflutop group (p = 0.0045). Patients in the main group reduced their intake of NSAIDs in 79% of cases and discontinued them in 21% of cases. A significant slowdown in joint space narrowing was observed in patients receiving Alflutop, in contrast to patients receiving placebo (p = 0.0003). After three months of treatment with Alflutop, there was a trend toward a decrease in the level of the cartilage degradation marker C-terminal cross telopeptides of type II collagen (CTX-II). In the placebo group, CTX-II levels did not change. Based on the results obtained, the authors of the study concluded that Alflutop has a structure-modifying effect in OA of the knee joints.

The effectiveness of periarticular administration of Alflutop in patients with gonarthrosis with signs of damage to the tendon-ligamentous apparatus, as well as enthesopathies of the supraspinatus and/or subscapularis muscles has been demonstrated in several studies [12, 13]. A course of administration of the drug to pain points corresponding to the entheses of the affected muscles led to a decrease in pain in the shoulder joint, an increase in range of motion, and a decrease in the dose of NSAIDs taken. In a double-blind, placebo-controlled study by O. S. Levin et al. the drug was prescribed for chronic vertebrogenic lumboischialgia associated with spondyloarthrosis. The study compared the effectiveness of intramuscular and paravertebral routes of administration of Alflutop. The authors conclude that there is a statistically significant decrease in the intensity of pain with paravertebral administration compared to placebo [14].

The drug is prescribed according to the following regimens:

For OA of large joints - 2 ml intra-articularly once every three days (six injections), followed by intramuscular injection of 1 ml daily for 20 days.
For spondyloarthrosis - paravertebral 0.25 ml at four points (1 ml in total) at the level of two adjacent vertebral segments twice a week (five injections), followed by intramuscular injection of 1 ml daily for 20 days.
For generalized osteoarthritis - deep intramuscular injection, 1 ml per day (20 injections in total).

Thus, the available data on the high clinical efficacy and safety of the drug Alflutop, which has a clear symptom- and structural-modifying effect, allows us to recommend its use as basic therapy in patients with musculoskeletal disorders such as gonarthrosis, spondyloarthrosis, tendonitis, enthesitis, including in patients with comorbidity, if long-term therapy for OA is necessary and limiting the intake of NSAIDs.

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N. A. Shostak, Doctor of Medical Sciences, Professor N. G. Pravdyuk1, Candidate of Medical Sciences

Federal State Budgetary Educational Institution of Russian National Research University named after. N. I. Pirogova Ministry of Health of the Russian Federation, Moscow

1 Contact information

* It is advisable to repeat the course of treatment after six months.

Musculoskeletal disorders in internist practice - diagnosis, approaches to treatment / N. A. Shostak, N. G. Pravdyuk

For citation: Attending physician No. 12/2017; Issue page numbers: 68-73

Tags: pain syndrome, joints, spine, myofascial syndrome

Diagnostic tests

In case of injury, the important task for the doctor is to relieve the swelling; in other cases, if such a pathology is suspected, patients are sent for tests and to undergo hardware techniques. The following studies are considered appropriate:

CT or MRI. with their help, the condition of the vertebral bodies, nearby systems and internal organs, and soft tissues is studied. If there is swelling, they will show you best.
X-ray. The image shows any injuries and other processes that lead to the appearance of ascending edema.
Blood test for tumor markers and rheumatoid factors. Such a study is necessary when determining the cause of the disease.
Study of liquor pathways. Prescribed for suspected complications in the functioning of the spinal cord located in the central spinal canal.

Additionally, a biopsy is used to exclude a malignant process. But this technique is quite painful, so it is prescribed as a last resort, when it is necessary to determine the nature of the formation that caused the swelling.

MRI allows you to quickly identify the onset of the edema process and take the necessary measures

How to eliminate swelling?

There is no universal remedy to relieve swelling, so therapy for each patient is selected individually. If the development of pathology is suspected, the doctor recommends that the patient follow the following rules:

Strict adherence to bed rest, complete exclusion of stress or physical activity.
Placing the lower extremities on a support to elevate them above the level of the heart and thereby reduce swelling.
Applying a cold heating pad several times a day to the site of inflammation.
Taking medications according to the chosen regimen to relieve pain.
Wearing a corset or bandage to prevent mobility of the vertebrae in the damaged area.

In order to prevent unpleasant consequences, it is necessary to completely eliminate pressure in the affected area and not provoke a deterioration in the general condition. And it is also important to eat right, enrich your diet with protein, vitamins B and D, and give up bad habits.

Drug treatment

The mainstay of treatment for spinal cord edema is taking medications. They are selected individually, depending on the cause, degree of damage and symptoms in the patient. Typically the complex consists of the following medications:

Analgesics (“Metamizole sodium”) Painkillers are necessary to relieve an acute attack and alleviate the patient’s general condition. If they are ineffective, Tramadol is prescribed.
Non-steroidal anti-inflammatory drugs (Diclofenac, Ketorol, Nimesulide). In addition to suppressing the inflammatory process, they additionally help relieve pain.
Glucocorticoids (Dimexide, Hydrocortisone). They reduce inflammation and exudation.
To stimulate blood movement (Actovegin, Trental). The active substance improves the circulation of biological fluid and thereby reduces swelling.
B vitamins (“Combilipen”). They promote tissue nutrition and enhance immunity.

If the cause of the disease is an infection, general antibiotics are prescribed, most often Clarithromycin or Amoxicillin; in the case of tuberculosis, specific therapy is required. In cases of severe inflammation, potassium iodide is also used.

Surgical correction

Taking into account etiological factors, sometimes the only treatment option is surgery. Usually you cannot do without it in case of injuries, osteomyelitis, spinal pathologies, intervertebral hernia and other diseases. Only by eliminating the cause in this way can the rapid accumulation of fluid in the bone structures of the vertebrae be stopped.

Possible complications

Swelling of the spinal cord is quite favorable if you consult a specialist in a timely manner. With complex treatment, the patient completely restores all impaired functions and mobility of the spine; any physical activity is allowed after rehabilitation. If treatment is started late, there is a risk of paralysis, partial or complete, or death.

The most common consequence of the pathology is loss of limb mobility and dysfunction of the pelvic organs. The prognosis largely depends on the location of the lesion, the degree of progression of the disease before seeking medical help, and the age of the patient. The higher the swelling is located, the higher the likelihood of complete paralysis.

The patient's legs should be higher than the level of the head, to reduce swelling, bed rest is strictly observed

Preventive actions

You can avoid such a serious illness only if you eliminate back injuries, give up extreme sports, or change your profession to a safer one. And it is also important to consult a doctor in a timely manner in case of accidental falls on a slippery surface, infection or after accidents on the road, even if it seems that the overall condition has not been disturbed.

The following recommendations should be considered specific prevention of pathology:

Enrich the diet with foods that improve hematopoietic function (veal, beef liver, pomegranates, apples).
Limit salt intake to 1 teaspoon per day.
Supports the optimal balance of nutrients and minerals to prevent edema.
Visit a massage therapist regularly to maintain normal back condition.

Taking care of your health and spine is extremely important not only to exclude serious pathologies, but also to maintain the functionality of all systems and normal life. Bone marrow edema is much easier to prevent than to treat it later and deal with the consequences.

Bone marrow edema can cause a variety of unpleasant consequences if it is not treated in time and competent medical care is not received. Therefore, if symptoms appear even insignificant at first glance, it is necessary to consult a doctor, follow the recommendations given and not violate bed rest.

Localization and symptoms

As already mentioned, bone marrow edema can manifest itself in almost any area of large parts of the skeletal system - the pelvic bones, hip and knee joints, and the spinal column. It has both general and specific symptoms, depending on the affected area.

Spine

The higher the area of edema is located, the more serious its consequences

Swelling of the bone marrow of the spine leads to compression of the spinal trunk. This, in turn, is characterized by various, sometimes opposing symptoms - from acute pain at the slightest movement to complete loss of sensitivity leading to paralysis. The higher the affected area is located, the more serious the consequences of swelling. In some cases, dysfunction of the pelvic and intestinal organs occurs, which can lead to both the inability to independently empty the bladder and rectum, and to uncontrolled involuntary urination and defecation.

Hip and knee

As a result of bone marrow edema in the epiphyses of the tibia, i.e. in the area of the hip and knee joints, a person experiences general traumatic symptoms: pain, bruising, a feeling of bursting in the bone. The leg at the site of injury swells, its functionality is impaired - it can no longer serve as a full-fledged support when walking. The range of motion in the joints is limited: the limb is difficult to bend/extend, adduct or abduct.

Pelvic bones

With bone marrow edema in the pelvic bones, severe pain occurs when walking and sitting, radiating to one or both lower extremities, and hyperemia (redness) in the hip joint. Swelling and hyperthermia (local increase in temperature) are clearly visible.

Long-lasting pain, swelling, and extensive hematomas are characteristic signs of bone marrow edema following injury to any other part of the skeleton that contains a sufficiently large volume of this hematopoietic substance.

Also common to all cases of bone marrow edema are changes in laboratory blood test data. It is characterized by lower hemoglobin levels compared to normal levels - from 120 to 150 g/l, as well as signs of anemia (anemia). This is explained by a decline in the functional qualities of the hematopoietic organ, which, being sick, no longer has time to supply the body with the required number of new blood cells to replace the dead.