Clinic, diagnosis and treatment of vertebrogenic pain syndromes

L.G. Turbina, Doctor of Medical Sciences, Professor, MONIKI, Moscow

Pain in the back and limbs, not associated with inflammatory damage to the peripheral nerves, in our country is traditionally classified as vertebrogenic, implying spinal osteochondrosis as the etiological factor. However, studies of the last decade have shown that osteochondrosis is only one of the causes of such pain, but not the main one.

The causes of back pain can be divided into vertebrogenic and non-vertebrogenic.

Vertebrogenic causes of pain in the back and limbs:

• Disc herniation
• Spondylosis
• Osteophytes
• Sacralization or lumbalization
• Arthrosis of the intervertebral (facet) joints
• Ankylosing spondylitis
• Spinal stenosis
• Spinal segment instability with spondylolisthesis
• Vertebral fractures
• Osteoporosis
• Vertebral tumors
• Ankylosing spondylitis
• Functional disorders of the spine

Nonvertebrogenic causes of back pain:

• Myofascial pain syndrome
• Psychogenic pain
• Referred pain in diseases of internal organs
• Intra- and extramedullary tumors
• Metastatic lesions
• Syringomyelia
• Retroperitoneal tumors

Let us consider in detail the etiology, pathogenesis, clinical picture, diagnosis and treatment of the most common vertebrogenic and non-vertebrogenic pain.

Vertebrogenic pain

The causes of vertebrogenic back pain are often degenerative-dystrophic processes: osteochondrosis and spondyloarthrosis. With osteochondrosis, the intervertebral disc is primarily affected, resulting in reactive changes in the bodies of adjacent vertebrae, tissues of the facet joints and ligaments.

The process is primarily localized in the nucleus pulposus of the intervertebral disc, which becomes less elastic due to loss of moisture. Under the influence of mechanical stress, the nucleus pulposus can sequester and protrude towards the annulus fibrosus of the disc.

Over time, cracks form in the annulus fibrosus. A disc with an altered nucleus and fibrous ring can prolapse into the lumen of the spinal canal (disc prolapse), and masses of the nucleus pulposus penetrate through the cracks of the fibrous ring, forming disc herniations. The described processes in one spinal segment lead to reactive changes in adjacent vertebrae and intervertebral joints, resulting in disruption of the kinematics of the entire spinal column. In addition, the process may involve the ligamentum flavum, which becomes denser over time and puts pressure on the root or membranes of the spinal cord. Over the years, the process can stabilize due to disc fibrosis, but it never reverses.

Congenital bone anomalies, excessive physical activity and other reasons that contribute to the wear of cartilage tissue lead to the development of spinal osteochondrosis and aggravation of its course.

Depending on which structures of the spinal column are involved in the process in each specific case, either compression or reflex syndromes predominate in the clinical picture (see table).

Compression syndromes develop if altered structures of the spine deform or compress the roots, blood vessels or spinal cord. Reflex vertebrogenic syndromes arise as a result of irritation of various structures of the spine, which has powerful sensory innervation. It is believed that only the bone tissue of the vertebral bodies and the epidural vessels do not contain nociceptive receptors. Afferent impulses from the irritated elements of the spinal column through the dorsal root and spinal structures close on the motor neurons of the anterior horn, causing muscle-tonic reactions at the appropriate level. However, it should be remembered that the division of vertebrogenic syndromes into compression and reflex is very arbitrary, since reflex syndromes can occur in their pure form or accompany compression manifestations.

Based on localization, vertebrogenic syndromes are distinguished at the cervical, thoracic and lumbosacral levels.

Vertebrogenic pathology in children: everything you need to know about

Vertebrogenic diseases of the nervous system occur not only among adults, but also in children. According to official statistics, the number of children who need highly qualified care from a vertebroneurologist is 2.6-8%.

Treatment and diagnosis of early manifestations of vertebrogenic diseases of the nervous system in childhood have their own characteristics. Dina Khamitovna Khaibullina , Associate Professor of the Department of Neurology and Manual Therapy of the KSMA Ministry of Health and Social Development of Russia, Honored Doctor of the Republic of Tatarstan, told us about this .

— What vertebrogenic diseases of the nervous system occur in children? How relevant is this problem?

— Vertebrogenic pathology in adults has been studied quite well. A number of authors note that patients in whom vertebrogenic diseases of the nervous system (VND) clinically manifested in adulthood had spinal pathology already in childhood. During a total in-depth examination carried out by employees of the VL RCH, the number of children in need of specialized vertebroneurological care was 72 - 87%. This is explained by the fact that most of the pathology occurs in the form of subclinical forms that can only be identified by a vertebroneurologist or chiropractor.

At first glance, the clinical manifestations of SUD in children differ little from those in adults: complaints of pain in various parts of the spine, headaches, limited range of motion, the presence of spinal curvature, etc. But there is a significant difference - children have growth zones. And this point must be taken into account both when diagnosing and choosing treatment methods.

In terms of age, vertebrogenic pathology is distributed as follows: in preschool age (3-7 years), subclinical forms predominate and changes in the pelvic region and upper cervical spine are more often detected; In primary and secondary school age, clinically pronounced forms of SUD are more often diagnosed. At the age of 8-13 years, diseases of the cervical spine predominate, and at older school age (over 13 years), pathologies of the thoracic and lumbosacral spine are more common. If we talk about the mechanism of damage to the spinal motion segment (SMS), then in children the dysfixation variant of vertebral syndrome predominates.

— What is the etiology of early manifestations of SUD in childhood?

— I would consider this issue a little more broadly and talk about the etiology of back pain in childhood. The main causes of back pain in children: static-dynamic overloads, disorders of the statics of the spine, trauma, degenerative-dystrophic diseases, juvenile spondyloarthrosis, osteochondropathy, infectious diseases of the discs or vertebral bodies, osteoporosis, tumor diseases, hematological diseases. We must not forget about the so-called projection back pain, which is caused by diseases of the internal organs and psychogenic back pain.

If we talk directly about the reasons for the occurrence of VSNS in childhood, then we can distinguish four main reasons: static-dynamic overloads, disorders of the statics of the spine, trauma, degenerative-dystrophic diseases. Any of these four reasons leads to the occurrence of so-called functional blockades in the spinal motion segments of the spine.

In general, the formation of VZNS in childhood seems to us as follows. Children, to a greater extent than adults, are susceptible to so-called minor injuries without violating the anatomical integrity of the osseous-ligamentous apparatus, which is associated with the peculiarities of the development of stato-coordinating functions. This is especially true for children who have minimal cerebral impairment as a result of various reasons. In addition, the structural features of the intervertebral disc, joints, spinal ligaments and the condition of the muscle corset play a significant role in the formation of the clinical manifestations of SUD. Since the children's spine is intact, since dystrophic processes have not yet developed in it, it has sufficient plasticity to compensate for the function of the “switched off” SMS by increasing the load on neighboring segments. Under certain conditions, for example, inadequate static load, prolonged stay in one position, the blockade cannot resolve on its own and persists for a long time. Accordingly, hypermobility of the overlying and underlying SMS persists for the same time, in which functional blockades develop compensatoryly over time. Thus, a vicious circle arises. Local overload in the segment negatively affects the trophism of the disc itself, as well as the growth zones, contributing to the early development of degenerative processes and vertebral deformities.

The most important biokinematic zone in childhood is the sacroiliac joint (SIJ) and the pelvis as a whole. Functional changes in the SIJ and pelvis occur in all age groups. The frequent localization of functional blockades in the SIJ region in childhood is explained by two aspects. Firstly, this joint is a flat joint and movement in it is minimal. Secondly, the most common injury in children is a fall on the buttocks or a jump on outstretched legs, since the sacrum is the basis for the spinal column, then any deviation from the horizontal (functional blockade of the SIJ, anomaly in the development of articular facets, oblique position and pelvic hypoplasia and others condition) will affect the condition of the spine as a whole. As a result of pathological changes in the sacrum, blocking of the SIJ and, to a lesser extent, the SMS, a restructuring of the entire motor stereotype occurs, as the child subconsciously strives to maintain a stable body position. In this case, according to the laws of biomechanics, the spine twists in a spiral with areas of “refraction” in key areas, in which, as a rule, these are transition areas, and secondary blocking gradually develops. This process is inevitably, due to the anatomical unity of the musculoskeletal system, accompanied by the involvement of the muscles of the affected region. At first, muscle participation is limited to a muscular-tonic reaction; later, over time, areas of LMG and more severe neurodystrophic changes appear in tonically contracted muscles (as a result of changes in trophism). All of the above changes are maximally manifested in conditions of primary inferiority of the central nervous system (hypotonia or hypertension of muscles, LMG, shortening or flaccidity of muscles, asynergic distribution of tone during movements, hyperkinesis, awkwardness, hypoplasticity, pyramidal symptoms, difficulty maintaining balance, etc.).

The triggering point is, in our opinion, the non-optimality of the motor mode. This position is supported by the fact that the clinically expressed form of SUD practically does not occur in the group from 3 to 6 years, that is, during the period when there are no prolonged static loads on the spine and surrounding tissues, and there are no inadequate physical activities. Analysis of the motor mode in older groups (7-13 and 13.5-15 years) shows an increasing static load. The cervical region primarily suffers from excessive static load. A significant contribution to the formation of pathology is made by the incorrect selection of furniture, for example, a table with a horizontal tabletop, when the head is in anteflexion for a long time, resulting in overstrain of the atlanto-occipital ligaments or blocking at this level.

In addition, we must not forget about the premorbid background. In particular, about connective tissue dysplasia, diffuse muscle hypotonia syndrome, minimal cerebral dysfunction, etc., which, on the one hand, contribute to the development of SUD, and on the other hand, aggravate the course of this pathology.

— What modern methods exist for diagnosing and treating early manifestations of SUD in childhood?

— The clinic was and remains in first place. Of the diagnostic methods, I would put in first place the correct, I want to emphasize, correctly carried out visual examination of the child and competent palpation of the structures of the spine and joints. Among special techniques, various manual diagnostic techniques are used.

Of the paraclinical methods, the most used can be identified: radiography of the spine in 2 projections, if necessary, radiography of the pelvis; blood and urine tests; Magnetic resonance imaging; CT scan; electromyography (for symptoms of unspecified radiculopathy); densitometry; radioisotope osteoscintigraphy.

Speaking about paraclinical techniques, I want to note that they are only an addition to the clinic and I urge my colleagues not to forget about this.

Treatment of children and adolescents with vertebrogenic pathology is one of the urgent tasks of practical healthcare. The first stage of work consists of actively identifying patients through medical examinations in preschool and school institutions by a medical specialist who has both pediatric and vertebroneurological training. It is advisable to conduct such medical examinations annually in children from 5 to 18 years of age. Patients identified as a result of these examinations are registered at the dispensary by a vertebroneurologist, who draws up an individual examination and treatment plan. Depending on the severity of the pathology and the effectiveness of treatment, they are divided into dispensary groups. Belonging to a specific dispensary group determines the frequency of observations by a vertebroneurologist and the courses of treatment performed.

— What difficulties do neurologists face when diagnosing and treating vertebrogenic diseases of the nervous system?

— Children with early manifestations of SUD practically do not receive specialized vertebroneurological care. This, in my opinion, is due to the lack of qualified specialists in this field. In this case, the doctor must be well versed in many specialties: pediatrics, child neurology, manual therapy, physical therapy, orthopedics and traumatology, rheumatology, radiology. In addition, neurologists and pediatricians are not sufficiently informed about the clinical manifestations of SUD in children. Today, pediatrics is trying to solve the problem of vertebrogenic diseases in children with the help of massage rooms and exercise therapy, which, despite its importance, is only a small part in the arsenal of available means and cannot lead to the desired result. As a result, children come to the adult network with already formed spinal diseases. However, most of these diseases could be avoided if early diagnosis, treatment and preventive correction of the identified pathology are carried out.

— In your opinion, what method of treating SUD in childhood is promising? Why?

— The most promising is timely initiation of complex treatment, including correction of biokinematic disorders of the spine and motor stereotype, massage, physical therapy, reflexology, physiotherapy, as well as treatment or correction of premorbid changes. It is mandatory to properly select furniture for such patients, taking into account the child’s growth.

Ideally, children with SUD should be treated by a highly qualified vertebroneurologist or chiropractor with basic pediatric education. Let me remind you of the old truth that a child is not a small adult, which is why basic pediatric education is necessary. Probably, it is impossible to give preference to only one treatment method. Although, in terms of effectiveness in the treatment of SUD, manual therapy, of course, comes first. Like any other treatment method, manual therapy has its own indications and contraindications that must be taken into account. In skillful hands, this is an excellent treatment method. I would like to emphasize that properly performed manual therapy is practically painless. Therefore, when parents of patients come and say that during a manual therapy session the child screamed in pain, this causes some bewilderment and doubt about the doctor’s qualifications.

Gulnara Abdukaeva

Compression syndromes of the cervical localization

At the cervical level, not only roots and vessels, but also the spinal cord can be subjected to compression. Compression of blood vessels and/or the spinal cord is manifested by a clinical syndrome of complete or, more often, partial transverse lesion of the spinal cord with mixed paresis of the arms and lower spastic paraparesis.

Root compression can be clinically divided into:

• root C3 – pain in the corresponding half of the neck;
• root C4 – pain in the area of ​​the shoulder girdle, collarbone. Atrophy of the trapezius, splenius and longissimus muscles of the head and neck. Possible cardialgia;
• root C5 – pain in the neck, shoulder girdle, lateral surface of the shoulder, weakness and atrophy of the deltoid muscle;
• root C6 – pain in the neck, scapula, shoulder girdle, radiating along the radial edge of the arm to the thumb, weakness and hypotrophy of the biceps brachii muscle, decreased reflex from the tendon of this muscle;
• root C7 - pain in the neck and scapula, spreading along the outer surface of the forearm to the II and III fingers, weakness and atrophy of the triceps brachii muscle, decreased reflex from its tendon;
• root C8 – pain from the neck spreads along the inner edge of the forearm to the fifth finger of the hand, decreased carporadial reflex.

Symptoms of cervical radiculopathy

Vertebrogenic cervical radiculopathy most often begins without any specific provoking reasons. Patients complain of neck pain, headaches, pain in the shoulder and arm. The pain can be either acute or subacute, and occurs most often in the morning, but periodic pain may also occur during the day. A characteristic symptom is also a feeling of stiffness in the neck muscles.

When examining patients suffering from cervical radiculopathy , limited mobility of the cervical spine and tension in the cervical muscles are revealed - paravertebral (running along the spine), the upper parts of the trapezius muscle (a flat, wide superficial muscle located in the back of the neck and in the upper back). Pain with cervical radiculopathy increases with tension in these muscles, coughing, sneezing, and can radiate to the arm, shoulder and interscapular region. The area of ​​pain irradiation depends on the location of the lesion. There may be sensations of numbness and tingling in the area of ​​innervation of the compressed nerve roots. weakness and motor impairment in the affected limb. In general, a feeling of numbness is detected in 50-80% of cases, muscle weakness - in approximately 1/3 of cases, changes in reflexes - in 70%.

Sometimes patients with cervical radiculopathy experience compression of the cervical spinal cord, which can lead to myelopathy.

Cervical reflex syndromes

Clinically manifested by lumbago or chronic pain in the neck area with irradiation to the back of the head and shoulder girdle. On palpation, pain is detected in the area of ​​the facet joints on the affected side. Sensitivity disorders, as a rule, do not occur.

It should be noted that the cause of pain in the neck, shoulder girdle, and scapula can be a combination of several factors, for example, reflex pain syndrome due to spinal osteochondrosis in combination with microtrauma of the tissues of the joints, tendons and other structures of the musculoskeletal system. Thus, with glenohumeral periarthrosis, many researchers note in such patients damage to the C5-C6 discs, as well as injury to the shoulder joint, or myocardial infarction, or other diseases that play the role of triggers.

Clinically, with glenohumeral periarthrosis, pain in the periarticular tissues of the shoulder joint and limitation of movements in it are noted. Only pendulum-like movements of the shoulder in the sagittal plane are possible (frozen shoulder syndrome). The adductor muscles of the shoulder and periarticular tissues are painful on palpation, especially in the area of ​​the coracoid process and the subacromial zone. Sensory disorders are not determined, tendon reflexes are preserved, sometimes somewhat animated.

Reflex cervical syndromes include the anterior scalene muscle syndrome. The anterior scalene muscle connects the transverse processes of the middle and lower cervical vertebrae with the first rib. When this muscle is involved in the process, pain occurs along the anterior outer surface of the neck, radiating along the ulnar edge of the forearm and hand. When palpating the anterior scalene muscle (at the level of the middle of the sternocleidomastoid muscle, somewhat laterally), its tension is determined, and in the presence of muscle trigger points, pain distribution zones are reproduced in it - shoulder, chest, scapula, hand.

Vertebrogenic neurological complications in the thoracic spine with osteochondrosis are rare, since the bone frame of the chest limits displacement and compression. Pain in the thoracic region more often occurs in inflammatory (including specific) and inflammatory-degenerative diseases (ankylosing spondylitis, spondylitis, etc.).

In medical practice, the first place in terms of treatment is taken by lesions of the lumbar and lumbosacral spine.

Vertebrogenic thoracalgia - symptoms and treatment

The determining factor in examining a patient is to determine the source of pathological pain impulses, which is important when carrying out differential diagnosis and prescribing pathogenetic treatment for VT.

Differential diagnosis , as a rule, is carried out with diseases of the lungs, heart and gastrointestinal tract.[6]

The study of functional disorders of the musculoskeletal system in thoracalgia should be carried out using neurological, neuroorthopedic and manual techniques, since the use of only clinical examination greatly facilitates diagnosis, reducing the range of possible diagnoses due to the diversity of symptom complexes of the disease.[9]

Neuroorthopedic examination is a complex of techniques:

• curvimetric diagnostics;
• angular surveys;
• myotonometric examinations;
• tensoalgimetric examinations.

To interpret the data of a comprehensive neuro-orthopedic examination, it is necessary to convert them into comparable units, which is achieved by comparing each studied parameter with the corresponding norm, and their integral indicator reflects the severity of the disease and can be used as a criterion for assessing the effectiveness of treatment.

During manual testing:

• the nature, severity and localization of functional changes in the musculoskeletal system are established;
• pathologically tense or relaxed muscles, active and latent trigger points are identified;
• the degree of limitation of movements and their pain in three mutually perpendicular planes - sagittal, frontal and horizontal - is assessed;
• the symmetry of bilateral structures is assessed.

Then the identified biomechanical disorders need to be clarified. To do this, palpation, study of active and passive movements, isometric muscle tension, diagnosis of relaxed and shortened muscle groups, as well as joint play are carried out.

X-ray examination plays a leading role in the diagnosis of VT and allows:

• establish the level and degree of dystrophic damage to the spine;
• carry out differential diagnosis with other diseases of the spine;
• identify anomalies and individual characteristics of the musculoskeletal system.

Functional spondylography , carried out at maximum flexion and extension, allows us to identify the stability of the SMS, the degree of displacement of the vertebrae in relation to each other, and the condition of the ligamentous apparatus.

The most informative neuroimaging methods for diagnosing VT are computed tomography and magnetic resonance imaging (CT and MRI):

• CT scan determines the severity and nature of damage to the spinal column and spinal cord, allows you to identify the presence of a tumor or injury, determine the presence of protrusion and prolapse of discs, their size and the diameter of the spinal canal.
• MRI provides a more contrasting image of soft tissue formations, allows you to determine the presence and degree of spinal canal stenosis and sequestration (rejection of the necrotic area), changes in the ligamentum flavum, the condition of the intervertebral joints and discs, as well as the spinal cord. The advantage of the method is the absence of radiation exposure.

The use of CT and MRI allows adequate planning of treatment tactics and determination of indications for neurosurgical treatment.[7]

The functional state of the segmental reflex apparatus and peripheral nerves is determined using electroneuromyography . Stimulation electroneuromyography contributes to a qualitative assessment of the speed of nerve impulses along the motor and sensory fibers of peripheral nerves, which is very important in topical diagnostics for compression-neural syndromes.

When differentially diagnosing VT with somatic diseases and assessing the adaptive capabilities of the patient’s body, the following are used:

• bicycle ergometry (study of the cardiovascular system under increasing load);
• phonocardiography (diagnosis of heart sounds and murmurs);
• Holter monitoring (recording of cardiac signals);
• ECG (study of the electrical activity of the heart);
• spirography (measurement of breathing volume and speed);
• fibrogastroscopy (examination of the gastrointestinal tract);
• sonography (ultrasound);
• X-ray of the chest organs.

Lumbar compression syndromes

Upper lumbar compression syndromes are a relatively rare location.

Compression of the LII root (LI-LII disc) is manifested by pain and loss of sensitivity along the inner and anterior surfaces of the thigh, and decreased knee reflexes.

Compression of the LIV root (LII-LIV disc) is manifested by pain along the anterior inner surface of the thigh, decreased strength and subsequent atrophy of the quadriceps femoris muscle, loss of the knee reflex.

Compression of the LV root (LIV-LV disc) is a common location. It manifests itself as pain in the lower back with irradiation along the outer surface of the thigh, the anterior surface of the leg, the inner surface of the foot and big toe. Hypotonia and wasting of the tibialis muscle and decreased strength of the dorsal flexors of the thumb are noted.

Compression of the SI root (LV-SI disc) is the most common location. It manifests itself as pain in the buttock, radiating along the outer edge of the thigh, lower leg and foot. The strength of the triceps surae muscle decreases, sensitivity in the areas of pain irradiation is impaired, and the Achilles reflex fades.

Lumbar reflex syndromes

Lumbago - acute pain in the lower back (lumbago). Develops after physical activity. Manifests itself with sharp pain in the lumbar region. The antalgic posture and tension of the lumbar muscles are objectively determined. Neurological symptoms of loss of function of the roots or nerves of the lumbosacral region, as a rule, are not detected.

Lumbodynia is chronic lower back pain. It manifests itself as dull aching pain in the lower back. Palpation determines the pain of the spinous processes and interspinous ligaments and facet joints (at a distance of 2-2.5 cm from the midline) in the lumbar region. Movement in the lumbar region is limited. Sensory disorders are not defined.

What is chronic vertebrogenic lumbodynia?

Lumbodynia due to spinal osteochondrosis in most cases is aching in nature. It bothers me more in the morning, but decreases somewhat or goes away during work. Especially if this work involves movement. When lying down, the pain subsides. This is due to a decrease in the load on the lumbar intervertebral discs. While in bed, patients try to choose the most comfortable position. They usually lie with their legs bent on their healthy or sore side.

If lumbar pain (lumbago) involves the entire lower back. Then chronic pain can be localized only on one side. For example, right-sided lumbodynia or left-sided lumbodynia. It most often worries in the lower lumbar region. The pain may radiate to one or both buttocks.

What is lumboischialgia

Lower back pain can be combined with “pulling” pain in the leg. In other words, if lumbodynia and sciatica are combined, then this is lumbar sciatica. This is described in detail on the corresponding page.

Lumbodynia with muscular-tonic syndrome.

In some cases, the pain intensifies not only during movement. It can worsen when talking, sneezing, straining, or bending the head forward. Moderate curvature of the spine is often detected. This is due to a stronger reflex tension of the lower back muscles on one side. In such cases, the diagnoses may sound slightly different, but the essence is the same. For example, “vertebrogenic lumbodynia with muscular-tonic syndrome.” Or - “lumbodynia with muscular-tonic syndrome, antalgic scoliosis.”

Pressing on the spinous processes of the lumbar vertebrae and points near the vertebrae at this level is usually painful. Patients have difficulty bending forward. But at the same time, bending the body to the sides may be less limited.

Vertebrogenic lumbodynia syndrome, as the main manifestation of the chronic course of lumbar osteochondrosis, is more often observed in men. The duration can be from several weeks or months to 5-7 years or more.

Piriformis syndrome

The piriformis muscle begins at the anterior edge of the upper sacrum and attaches to the inner surface of the greater trochanter of the femur. Its main function is hip abduction. The sciatic nerve passes between the piriformis muscle and the sacrospinous ligament. Therefore, when the piriformis muscle is tense, compression of the nerve is possible, which occurs in some cases with lumbar osteochondrosis.

The clinical picture of piriformis muscle syndrome is characterized by sharp pain in the subgluteal region radiating along the posterior surface of the lower limb. Adduction of the hip causes pain (Bonnet test), the Achilles reflex is reduced. The pain syndrome is accompanied by regional autonomic and vasomotor disorders, the severity of which depends on the position of the body - pain and autonomic disorders decrease in the supine position and intensify when walking.

Coccydynia – pain in the sacral area. A polyetiological clinical syndrome that may be caused by discopathy of the first coccygeal disc, causing reflex tension of the pelvic floor muscles, or ligament pathology. No sensory disorders are detected. A rectal examination reveals areas of tenderness in the muscles involved (usually the levator ani muscle).

Vertebrogenic cervicocranialgia

Cranialgia refers to headaches localized in the lower part of the back of the head (“cranio” in Latin means “skull”), often accompanied by compression of the nerve roots. “Cervico” is a prefix referring to the neck, “vertebro” is everything connected with the spine. That is, vertebrogenic cervicocraniaglia is a headache caused by pain or other unpleasant sensations in the cervical area, caused by diseases or pathologies of the spine.

Specific headaches in the skull are caused by disturbances in the passage of nerve impulses along the fibers or insufficient blood supply to certain areas of the brain, which can cause increased intracranial pressure and severe pain. Treatment of headaches of this etiology requires a special approach; conventional analgesic drugs, as a rule, do not bring patients the expected relief.

Cranialgia can cover only the occipital part of the head or spread to the temples, parietal region or frontal region, in some cases it manifests itself unilaterally. The nature of the pain is also different: it can be bursting and pressing, chronic or sharp, paroxysmal with spasms and burning. Quite often accompanied by dizziness, nausea, loss of coordination, limited neck mobility, impaired hearing and vision, muscle weakness or numbness of the upper extremities. It intensifies with physical exertion, sudden movements, hypothermia, and prolonged stay in forced positions.

Reasons for the development of the disease

Most often, vertebrogenic cervicocranialgia is preceded by the development of osteochondrosis (a disease of the spine in which the intervertebral discs wear out). A sedentary, inactive lifestyle of modern life, bad habits and unfavorable ecology gradually have a detrimental effect on cartilage tissue. The walls of the discs begin to crack and wear out, and the gelatinous substance inside begins to lose moisture. The spine becomes less and less mobile, flexible and is no longer able to withstand the previous loads.

For a long time, the symptoms of cervical osteochondrosis may practically not bother patients and attract attention with severe pain already in advanced stages, when a protrusion or herniation of the intervertebral disc has formed.

Similar manifestations (gradual wear and aging of the anatomical structures of the disc, degeneration of the outer fibers, pathological changes in the longitudinal ligaments, proliferation of osteophytes) are also observed in spinal spondylosis, the treatment of which is carried out mainly in older people. In addition, the development of cranialgia can be caused by traumatic injuries to the spine or nearby soft tissues.

Flattening of the vertebral discs, the growth of osteophytes (bone growths), the formation of vertebral hernias provokes compression of the nerve roots emerging from the spinal cord (radicular syndrome), blood vessels located in the neck (vertebral artery syndrome or hypertensive syndrome - difficulty in the outflow of venous blood from the brain) , and this in turn brings patients to the headache clinic.

Manifestations of cervicocranialgia

The manifestations of the symptoms of the disease depend entirely on the affected areas. So, for example, with compression of the cervical, occipital or facial nerve endings, the nature of the pain is acute, shooting, usually one-sided. Dizziness and nausea are usually not observed; there may be difficulties with speech and swallowing. Cranialgia intensifies even with minor physical exertion and subsides slightly at rest.

Insufficient blood supply to the vessels of the brain (vertebrobasilar insufficiency) with vertebral artery syndrome has cerebral paroxysmal symptoms. Painful sensations cover the back of the head, crown, temporal lobes, eyes, and are pulsating and burning in nature. Accompanied by dizziness, a feeling of rotation of the surrounding world or the person himself, nausea, vomiting, hearing and vision disorders (tinnitus, darkening in the eyes or flickering “butterflies”, pulsating in the temples). The patient is irritated by bright lights and noise.

Similar bilateral manifestations also occur with hypertensive syndrome, only the nature of the pain is bursting and pressing with an increase in intracranial pressure and/or blood pressure. In all cases, anxiety, insomnia, lacrimation, burning in the parietal region, redness of the skin of the face and eyes are noted.

Thus, for the correct diagnosis of the causes of vertebrogenic cervicocranialgia and adequate treatment, the patient must carefully differentiate the symptoms that arise and the nature of their changes and report them to the attending physician at the headache center when collecting an anamnesis.

Treatment of cranialgia

To establish a final diagnosis, the attending physician will prescribe an x-ray to the patient; if more detailed data is needed, a computed tomography or MRI scan of the spine or brain tomography may be prescribed. The condition of the blood vessels, the direction, intensity and speed of passage of blood fluid through them will be shown by Doppler ultrasound. It will be necessary to undergo general clinical and laboratory tests and have a cardiogram done.

headache treatment will be comprehensive, aimed at eliminating spinal pathologies and relieving pain. When nerve roots are compressed, anti-inflammatory drugs and agents that improve the conductivity of nerve fibers, neuroprotectors, and B vitamins are prescribed. Factors associated with blood vessels will be eliminated by vasodilators that improve blood circulation and the outflow of venous blood.

In the initial acute period, muscle relaxants and/or local anesthetic blockades (lidocaine or novocaine) can be prescribed to relieve pain in the neck and soft tissue spasms. A good healing effect during all periods of treatment is provided by manual therapy sessions (massage, reflexology and relaxation therapy, acupuncture, etc.), physiotherapy (swimming, exercise therapy, electrophoresis, shock wave therapy, etc.).

Self-treatment of vertebrogenic cervicocraniology with painkillers, anti-inflammatory and antispasmodic drugs, as a rule, does not bring patients the expected relief, since only pain is relieved, but not the causes of its occurrence.
Competent treatment can only be prescribed by a highly qualified doctor if the results of all the necessary studies are available. Author: K.M.N., Academician of the Russian Academy of Medical Sciences M.A. Bobyr

Differential diagnosis of compressive and reflex vertebrogenic syndromes

Treatment of vertebrogenic pain syndromes

In the acute period of the disease, when the pain syndrome is severe, the main task of the doctor is to relieve pain. To successfully complete this task you must:

1. Create peace for the spine. To do this, place a shield under the mattress or place the patient on a special orthopedic mattress. For 5-7 days, the motor mode is limited, and the patient is allowed to stand only in an immobilizing belt or corset and only when physiologically necessary. The rest of the time, bed rest is indicated. The expansion of the motor regime is carried out carefully; the recommended movements should not cause pain.
2. Drug treatment should be structured taking into account all links in the pathogenesis of pain. The source of pain in compression syndromes is pathologically altered structures of the spinal column, which either irritate tissue nociceptors or compress the spinal roots. In reflex syndromes, the source of pain can be both the spine itself and reflexively spasmed muscles that form tunnel syndromes. In addition, with chronic (lasting more than 3 months) or recurrent pain, depressive, anxiety, hypochondriacal and other affective disorders develop. The presence of such disorders must be actively identified and treated, since they have an extremely negative impact on the course of the disease.
3. Non-drug treatment. Physiotherapy, manual therapy, kinesitherapy, etc. are widely used in the treatment of vertebrogenic pain syndromes.
4. Surgery. Used when conservative treatment is ineffective for 4 months or there are signs of spinal cord compression with dysfunction of the pelvic organs, sensory conduction disorders or damage to the central motor neuron (in the presence of pyramidal signs).

Rubric “Conversation with a specialist” Vertebrogenic radiculopathy” (this is osteochondrosis)

Lumbosacral radiculopathy (RCR) is one of the most severe types of vertebrogenic pain syndromes, which is characterized by particularly intense and persistent pain, usually accompanied by a sharp limitation of mobility. Although radiculopathy accounts for about 5% of cases of back pain, it is the most common cause of permanent disability. While in 90% of patients with acute back pain (when all variants are included) it goes away on its own within 6 weeks, in at least 30% of people with radiculopathy the pain persists longer.

Epidemiology RCC occurs in approximately 35% of individuals worldwide. The incidence of men and women is approximately equal, but its peak in men occurs at the age of 4050 years, in women – 5060 years. The risk of developing vertebrogenic radiculopathy is increased in individuals who engage in heavy physical labor, smoking, and a family history. Regular physical activity may reduce the risk of radiculopathy, but the risk may be increased for those who begin physical activity after an episode of discogenic back pain.

Causes The most common cause of RCC is a herniated disc. At a young age, due to higher intradiscal pressure, the nucleus pulposus more easily penetrates between the damaged fibers of the fibrous ring, which causes the more frequent development of discogenic radiculopathy. Herniated intervertebral discs that can compress the root are conventionally divided into three types: lateral (displaced towards the intervertebral foramen), paramedian (mediolateral) and median.

In elderly people, radiculopathy is most often caused by compression of the root in the area of ​​the lateral recess or intervertebral foramen due to the formation of osteophytes, hypertrophy of the articular facets, ligaments or other reasons. Rarer causes - tumors, infections, dysmetabolic spondylopathies - together explain no more than 1% of cases of radiculopathy.

Pathogenesis of pain syndrome in radiculopathy Although mechanical compression of the root and/or spinal ganglion plays a decisive role in the initiation of pain during disc herniation, persistent maintenance of intense pain syndrome may be associated not so much with mechanical factors, but with secondary toxic, dysimmune and dysmetabolic processes that are triggered insertion of the disc into the epidural space and exposure to material released from the nucleus pulposus.

The pain syndrome with vertebrogenic radiculopathy is of a mixed nature. The nociceptive mechanism is associated with irritation of nociceptors in the outer layers of the damaged disc and surrounding tissues, including the dura mater, as well as in spasmodic muscles. The neuropathic component of the pain syndrome is associated with damage and irritation of the nerve fibers of the root due to its compression, inflammation, edema, ischemia, demyelination and axonal degeneration.

Clinical picture Clinically, RCC is characterized by acutely or subacutely developing paroxysmal (shooting or piercing) or constant intense pain, which at least occasionally radiates to the distal zone of the dermatome (for example, when taking Lasegue). Pain in the leg is usually accompanied by pain in the lower back, but in young people it can only be in the leg. Pain can develop suddenly - after a sudden unprepared movement, lifting something heavy or falling. Such patients often have a history of repeated episodes of lumbodynia and lumbar sciatica. At first, the pain may be dull and aching, but it gradually increases, rarely immediately reaching maximum intensity. If radiculopathy is caused by a herniated disc, the pain usually intensifies with movement, straining, lifting heavy objects, sitting in a deep chair, staying in one position for a long time, coughing and sneezing, pressing on the jugular veins and weakens with rest, especially if the patient lies on the healthy side, bending the affected leg at the knee and hip joints.

Acute bilateral radicular syndrome (cauda equina syndrome) occurs rarely, usually due to a massive median (central herniation of the lower lumbar disc. The syndrome is manifested by rapidly increasing bilateral asymmetric pain in the legs, numbness and hypoesthesia of the perineum, lower flaccid paraparesis, urinary retention, fecal incontinence. This clinical situation requires urgent consultation with a neurosurgeon.

Diagnosis The diagnosis of radiculopathy is primarily established on the basis of characteristic clinical signs. The presence of a disc herniation, radicular canal stenosis at the appropriate level, or another cause of root compression can be determined using computed tomography (CT) or magnetic resonance imaging (MRI). However, when interpreting imaging data, it is important to consider that in approximately 2/3 of people who have never experienced back pain, these research methods reveal certain changes in the lumbosacral spine, often at several levels. In half of these patients, uniform symmetrical protrusion of the disc is detected, in a quarter - focal or asymmetric protrusion; spinal stenosis and facet joint arthropathy are also often detected. Only disc extrusion, which is understood as the extreme degree of its protrusion, when the length of the protrusion exceeds the width of its base, clearly correlates with radiculopathy.

According to indications, radiography of the lungs, ultrasound examination of the abdominal and pelvic organs, retroperitoneal space, excretory urography, and sigmoidoscopy are performed. For women, examination by a gynecologist is also required. The examination complex may also include a clinical blood test and a general urine test, determination of sugar, electrolytes, urea nitrogen, creatinine, calcium, phosphorus, uric acid, and serum protein electrophoresis. In men, a prostate-specific antigen test is performed.

Course Over time, in most cases, the size of the disc herniation and signs of root compression spontaneously decrease, regardless of the method of conservative treatment used and age. The vast majority of patients with RCC recover within 3 months. However, in some patients, recovery occurs over a longer period (36 months). If an exacerbation lasts more than 6 months (about 15% of patients), clinical manifestations can be predicted to persist for at least the next 2 years. The prognosis is worse with compression of the root in the radicular canal. Prognostically favorable factors are the absence of pronounced symptoms of tension, spinal stenosis on CT or MRI, the patient’s active participation in rehabilitation programs, the absence of pronounced psycho-emotional disorders and a rental attitude.

General principles of treatment In most people with discogenic radiculopathy, conservative therapy can achieve a significant reduction and regression of pain. The basis of conservative treatment of radiculopathy, as well as other types of back pain, are non-steroidal anti-inflammatory drugs, which should be used from the first hours of the development of the disease, preferably their parenteral administration. For intense pain, tramadol can be used at a dose of up to 300 mg/day. An obligatory component of treatment should be a short (7-14 days) course of muscle relaxants (for example, tizanidine or tolpazone).

In recent years, along with traditional discectomy, more gentle surgical techniques have been used: microdiscectomy, laser decompression (vaporization) of the intervertebral disc, high-frequency disc ablation, etc. For example, laser vaporization is potentially effective for radiculopathy associated with intervertebral disc herniation while maintaining integrity fibrous ring, its protrusion by no more than a third of the sagittal size of the spinal canal (about 6 mm) and in the absence of movement disorders or symptoms of compression of the cauda equina roots in the patient. The minimally invasive nature of the intervention expands the range of indications for it. However, the principle remains the same: surgery should be preceded by optimal conservative therapy for at least 6 weeks.

The use of a complex of high doses of B vitamins in the treatment of RCC. The results obtained indicate that a complex of high doses of B vitamins (as part of the drug Milgamma) can potentiate the analgesic effect of non-steroidal anti-inflammatory drugs and contribute to a more rapid regression of the pain syndrome in vertebrogenic radiculopathy, effectively affecting the neuropathic component pain. At the same time, adding a 14-day course of oral administration of Milgamma compositum tablets to a 10-day course of intramuscular administration of the drug Milgamma can contribute to a more complete manifestation of the therapeutic potential of the drug not only in the short term, but also in the medium term. Thus, the inclusion of a complex of high doses of B vitamins in the form of the drug milgamma can increase the effectiveness of conservative therapy for radiculopathy.

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Source: https://neuronews.com.ua/ru/issue-article-410/Diagnostika-i-lechenie-vertebrogennoy-poyasnichno-krestcovoy-radikulopatii#gsc.tab=0

Drug treatment

1. Analgesics, anti-inflammatory non-steroidal drugs, anesthetics. To relieve pain, the use of analgesics metamizole sodium (Analgin), paracetamol, tramadol (Tramal) and non-steroidal anti-inflammatory drugs (NSAIDs) enterally and parenterally is indicated. The use of NSAIDs is pathogenetically justified, since drugs in this group have an analgesic effect, and also, due to their effect on cyclooxygenase (COX-1 and COX-2), inhibit the synthesis of prostaglandins, which prevents the sensitization of peripheral nociceptors and the development of neurogenic inflammation.
   Of the drugs in this group, the following have proven themselves well: diclofenac, which is available in the form of tablets of 50 and 100 mg, rectal suppositories and solutions for parenteral administration. The drug ketorolac (Dolac) has a powerful analgesic effect, which is recommended to be administered for severe pain syndromes 30 mg intramuscularly for 3-5 days, and then switch to tablet forms, prescribing 10 mg 3 times a day after meals for no more than 5 days.

   In addition to those listed above, you can use other drugs in this group: meloxicam (Movalis), lornoxicam (Xefocam), ketoprofen (Ketonal), etc. But it should be remembered that most NSAIDs are contraindicated for gastric and duodenal ulcers, with a tendency to bleeding . If the patient is diagnosed with the above diseases, even in remission, the listed NSAIDs are contraindicated. In such cases, the drugs of choice are selective COX-2 inhibitors, which do not have such a significant effect on the gastrointestinal tract. These drugs include celecoxib (Celebrex), a selective COX-2 inhibitor. It should be prescribed at a dose of 200 mg 3 times a day after meals for 7-10 days.

   To reduce pain, paravertebral blockades can be performed with an anesthetic (procaine, lidocaine, etc.) in combination with corticosteroids (50 mg hydrocortisone, 4 mg dexamethasone, etc.). Blockades using anesthetics and corticosteroids are recommended to be carried out once every 3 days. In most cases, 3-4 blockades are sufficient for a course of treatment (elimination of acute pain).

2. Vascular agents. Considering the mandatory participation of the vasomotor component in the pathogenesis of vertebrogenic syndromes, especially those of a compression nature, it is necessary to introduce vasoactive drugs into the treatment complex. The choice of drug depends on the presence of concomitant vascular disease and the severity of vasomotor disorders. In mild cases, oral administration of vasodilators (nicotinic acid preparations or their analogues) is sufficient. If the patient is diagnosed with severe compression radiculopathy, parenteral administration of drugs that normalize both the arterial inflow and venous outflow of pentoxifylline (trental) is necessary.
3. Psychotropic drugs. Patients with chronic pain need correction of affective disorders. To carry out adequate correction of psychoaffective disorders, their diagnosis is necessary (consultation with a psychotherapist or psychodiagnostic testing). In case of predominance of anxiety-depressive and depressive disorders, the prescription of antidepressants is indicated. Preference is given to drugs that have, along with an antidepressant, anxiolytic effect: amitriptyline - from 25 to 75 mg/day. for 2-3 months, tianeptine (Coaxil), mianserin (Lerivon), etc. If the patient has predominant hypochondriacal disorders, tricyclic antidepressants should be combined with antipsychotics that do not cause extrapyramidal disorders, tifidazine (Sonapax) - 25-50 mg/day. , sulpiride (eglonil) - 25-50 mg/day.

Non-drug treatment of vertebrogenic pain syndromes

Physiotherapy plays an important role in the treatment of pain syndromes. In the acute period of the disease, preference is given to the use of physical factors that reduce pain, improve regional hemodynamics, especially the outflow of blood from the area of ​​compression, and relieve muscle spasm. At the first stage, diadynamic currents, microwave fields, magnetic therapy, ultraviolet irradiation, and acupuncture are used. As the pain subsides, physiotherapy is prescribed to improve tissue trophism and increase the range of movements (laser therapy, massage, light therapy, kinesitherapy). During the recovery period, it is recommended to actively involve the patient in the treatment process: expand the motor mode, strengthen the muscle corset, etc.

It should be remembered that complete comprehensive treatment of patients with vertebrogenic lesions of the nervous system allows one to achieve complete and long-term remission. During the period of absence of pain, it is necessary to recommend an active lifestyle, physical exercise (without significant vertical and “twisting” loads on the spine), and recreational swimming.

Literature

1. Belova A. N., Shepetova O. N. Guidelines for the rehabilitation of patients with movement disorders. M., 1998. 221 p.
2. Kukushkin M. L. Pathophysiological mechanisms of pain syndromes//Pain. 2003. No. 1. P. 5-13.
3. Podchufarova E. V., Yakhno N. N., Alekseev V. V. et al. Chronic pain syndromes of lumbosacral localization: the significance of structural musculoskeletal disorders and psychological factors // Pain. 2003. No. 1. P. 34-38.
4. Shmyrev V.I. Treatment and rehabilitation program for patients with dorsalgia. Guidelines. M., 1999. 28 p.
5. Yakhno N. N., Shtulman D. R. Diseases of the nervous system. T. 1. 2001

Treatment of cervical radiculopathy

Surgery for cervical radiculopathy is indicated only for symptoms of spinal cord compression (spondylogenic cervical myelopathy) and severe pain.

In the vast majority of patients with vertebrogenic cervical radiculopathy, conservative therapy shows good results. The main task at the first stage of treatment is pain relief. Nonsteroidal anti-inflammatory drugs (NSAIDs) are used, which have both analgesic and anti-inflammatory effects. NSAIDs should be used from the first hours of the development of the disease. The choice of drug is determined by the ratio of its effectiveness and safety. To reduce the severity of the pain syndrome and improve the patient's condition, some drugs from the group of anticonvulsants and antidepressants can be used (if the pain syndrome lasts more than 6-7 weeks). To relieve acute pain, combined vitamin preparations of group B (B1, B6, B12) are also used, which have a positive effect on processes in the nervous system (metabolism, metabolism of mediators, transmission of excitation) and on the regeneration of damaged nerves.

In the acute period, immobilization of the neck with a soft or semi-rigid collar is indicated (primarily at night), the duration of which should be limited to several days

Subsequently, physiotherapy, reflexology, massage, and therapeutic exercises are carried out. In case of chronic pain syndrome, a comprehensive psychophysiological approach is required, taking into account the importance of both peripheral and psychological factors in the origin of pain.