Discogenic radiculopathy according to mcb 10. Lumbosacral sciatica

Clinically, RCC is characterized by acute or subacute developing paroxysmal (shooting or penetrating) or constant intense pain, which at least occasionally radiates to the distal zone of the dermatome (for example, when taking Lasegue). Leg pain is usually accompanied by lower back pain, but in young people it may only be in the leg. Pain can develop suddenly - after a sharp unprepared movement, lifting heavy or falling. In the anamnesis, such patients often have indications of repeated episodes of lumbodynia and lumboischialgia. At first, the pain may be dull, aching, but gradually increases, less often immediately reaches its maximum intensity. If the radiculopathy is caused by a herniated disc, the pain is usually aggravated by movement, straining, heavy lifting, sitting in a deep chair, staying in one position for a long time, coughing and sneezing, pressure on the jugular veins and weakens at rest, especially if the patient lies on healthy side, bending the affected leg at the knee and hip joints.
On examination, the back is often fixed in a slightly flexed position. Often revealed scoliosis, aggravated by tilting forward, but disappearing in the supine position. It is most often caused by contraction of the square muscle of the lower back. With a lateral hernia, scoliosis is directed to the healthy side, with a paramedian hernia, to the sick side. Anterior inclination is sharply limited and is carried out only at the expense of the hip joint. Sharply limited and tilt to the affected side. There is a pronounced tension of the paravertebral muscles, which decreases in the supine position.
Characterized by a violation of sensitivity (pain, temperature, vibration and) in the corresponding dermatome (in the form of paresthesia, hyper- or hypalgesia, allodynia, hyperpathia), a decrease or loss of tendon reflexes that close through the corresponding segment of the spinal cord, hypotension and weakness of the muscles innervated by this root . Since in the lumbar spine in about 90% of cases, disc herniation is localized at the levels L4-L5 and L5-S1, in clinical practice most often detected radiculopathy L5 (about 60% of cases) or S1 (about 30% of cases). In older people, herniated discs often develop at a higher level, in connection with this, they often have L4 and L3 radiculopathy.
The relationship between the affected root and the localization of the hernia is complex and depends not only on the level of disc herniation, but also on the direction of the protrusion. Lumbar disc herniations are most often paramedian and exert pressure on the root that exits through the intervertebral foramen one level below. For example, with a herniated disc L4-L5, the root of L5 will most often suffer. However, if the herniation of the same disc is directed more laterally (toward the radicular canal), it will cause compression of the L4 root, if more medially, it can lead to compression of the S1 root (figure). Simultaneous involvement of 2 roots on one side with a hernia of 1 disc - a rare event, more often it is noted with a herniated disc L4–L5 (in this case, the roots of L5 and S1 suffer).
Typically, the presence of symptoms of tension and especially the symptom of Lasegue, however this symptom not specific for radiculopathy. It is suitable for assessing the severity and dynamics of vertebrogenic pain syndrome. The symptom of Lasegue is checked by slowly (!) raising the straight leg of the patient up, waiting for the reproduction of radicular irradiation of pain. When the roots of L5 and S1 are involved, pain appears or sharply increases when the leg is raised to 30–40 °, and with subsequent flexion of the leg at the knee and hip joints, it disappears (otherwise it may be due to the pathology of the hip joint or has a psychogenic character).
When performing the Lasegue technique, pain in the lower back and leg can also occur with tension in the paravertebral muscles or the posterior muscles of the thigh and lower leg. To confirm the radicular nature of the Lasegue symptom, the leg is raised to the limit above which pain occurs, and then the foot is forcedly flexed at the ankle joint, which causes radicular irradiation of pain in radiculopathy. Sometimes, with a medial disc herniation, there is a cross-symptom of Lasegue, when pain in the lower back and leg is provoked by raising a healthy leg. With the involvement of the L4 root, an “anterior” symptom of tension is possible - Wasserman's symptom: it is checked in a patient lying on his stomach, raising the straight leg up and unbending the thigh in hip joint or by bending the leg knee joint.
When the root is compressed in the root canal (due to lateral hernia, hypertrophy of the articular facet, or the formation of osteophytes), pain often develops more slowly, gradually acquiring radicular irradiation (buttock-thigh-shin-foot), often remains at rest, but increases with walking and staying in upright position, but unlike a herniated disc, it is relieved by sitting. It is not aggravated by coughing and sneezing. Tension symptoms are usually less pronounced. Forward bends are less limited than with median or paramedian disc herniation, and pain often provoked by extension and rotation. Paresthesias are often observed, less often there is a decrease in sensitivity or muscle weakness.
Muscle weakness in discogenic radiculopathies is usually mild. But sometimes, against the background of a sharp increase in radicular pain, pronounced paresis of the foot (paralyzing sciatica) can acutely occur. The development of this syndrome is associated with ischemia of the roots of L5 or S1, caused by compression of the vessels supplying it (radiculo-ischemia). In most cases, paresis safely regresses within a few weeks.
Acute bilateral radicular syndrome (cauda equina syndrome) occurs rarely, usually due to a massive median (central) hernia 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, and fecal incontinence. This clinical situation requires an urgent consultation with a neurosurgeon.

Radiculopathy, or damage to the nerve roots, is manifested by the appearance of segmental radicular symptoms (pain or paresthesia with distribution over the dermatome and weakness of the muscles innervated by this root). Diagnosis may require neuroimaging, EMG, or physical examination. Treatment of radiculopathy depends on the cause, but includes symptomatic therapy with NSAIDs and other analgesics).

ICD-10 code

M54.1 Radiculopathy

Causes of radiculopathy

Chronic pressure on the root inside spinal canal or near it causes damage to the nerve root (radiculopathy). The most common cause of radiculopathy is a herniated disc. Bone changes in rheumatoid arthritis or osteoarthritis, especially in the cervical and lumbar regions, can also put pressure on the nerve roots. Less commonly, a carcinomatous process leads to multiple mosaic radicular dysfunction.

Spinal cord lesions (eg, epidural abscesses and tumors, spinal meningiomas, neurofibromas) may present with radicular symptoms rather than normal spinal cord dysfunction. Diabetic radiculopathy is possible. Nerve root damage occurs with fungal (eg, histoplasmosis) and spirochetal (eg, Lyme disease, syphilis) infections. Usually herpetic infection causes painful radiculopathy with dermatomal loss of sensation and a characteristic rash, but motor radiculopathy with muscle weakness of the myotome and loss of reflexes is also possible.

Symptoms of radiculopathy

Nerve root lesions cause characteristic radicular pain syndromes and segmental neurological deficits depending on the level.

Characteristic symptoms of radiculopathy at different levels of the spinal cord

The muscles innervated by the affected root become weak and atrophy; fasciculations are possible in them. The defeat of sensitive nerve roots causes a violation of the sensitivity of the dermatomes. Corresponding segmental deep tendon reflexes may be weakened or absent.

Pain is aggravated by movements that cause pressure on the root through the subarachnoid space (eg, spinal movement, coughing, sneezing, Valsalva maneuver). Cauda equina involvement involving multiple lumbar and sacral roots causes radicular symptoms in both legs and may lead to sexual and sphincter dysfunction.

Signs of spinal cord compression may be the level of sensitivity impairment (a sharp change in sensitivity below the level of compression), flaccid pair or tetraparesis, changes in reflexes below the level of compression, hyporeflexia in the initial stages, then hyperreflexia and sphincter dysfunction.

Catad_tema Pain syndromes - articles

Chronic lumbosacral radiculopathy: modern understanding and features of pharmacotherapy

Professor V.V. Kosarev, Professor S.A. Babanov
GBOU VPO "Samara State medical University» Ministry of Health of the Russian Federation

Until now, the most difficult for practicing physicians of all specialties is the formulation of diagnoses in patients with pain syndromes associated with spinal lesions. Thus, in educational and scientific literature on nervous diseases late nineteenth - early twentieth century. pain in the lumbar region and lower extremity was explained inflammatory disease sciatic nerve. In the first half of the twentieth century. the term "sciatica" appeared, with which inflammation of the spinal roots was associated. In the 1960s Ya.Yu. Popelyansky, based on the works of the German morphologists H. Luschka and K. Schmorl, introduced the term "spinal osteochondrosis" into Russian literature. In the monograph by H. Luschka, degeneration was called osteochondrosis intervertebral disc, while Ya.Yu. Popelyansky gave this term a broad interpretation and extended it to the entire class of degenerative lesions of the spine.

In 1981, the proposed by I.P. Antonov classification of diseases of the peripheral nervous system, which included osteochondrosis of the spine. It contains two provisions that are fundamentally contradictory international classification:
1) diseases of the peripheral nervous system and diseases of the musculoskeletal system, which include degenerative diseases of the spine, are independent and different classes of diseases;
2) the term "osteochondrosis" is applicable only to disc degeneration, and it is wrong to call it the whole spectrum of degenerative diseases of the spine.

In the ICD-10, degenerative diseases of the spine are included in the class "diseases of the musculoskeletal system and connective tissue (M00-M99)", while "arthropathies (M00-M25)", "systemic lesions of the connective tissue (M30-M36)", "dorsopathies (M40-M54)", "soft tissue diseases (M60-M79)", "osteopathy and chondropathy (M80-M94)", "other disorders of the muscular system and connective tissue (M95-M99)".

The term "dorsopathies" refers to pain syndromes in the trunk and limbs of non-visceral etiology and associated with degenerative diseases of the spine. Thus, the term "dorsopathies" in accordance with the ICD-10 should replace the term "osteochondrosis of the spine" still used in our country. In the clinic of occupational diseases already long time the term "chronic lumbosacral radiculopathy" is used (orders No. 555 of the Ministry of Health of the USSR, No. 90 of the Ministry of Health and the Ministry of Health of the Russian Federation, No. 417n of the Ministry of Health of the Russian Federation).

Patients with professional chronic lumbosacral radiculopathy are equally men and women, workers in industry, agriculture (primarily machine operators and drivers of heavy equipment), medical workers with more than 15–20 years of experience.

Chronic occupational lumbosacral radiculopathy
according to the list of occupational diseases approved by order No. 417n of the Ministry of Health and social development RF dated April 27, 2012 “On Approval of the List of Occupational Diseases”) can develop when performing work in which there are systematic long-term (at least 10 years) static muscle tension, the same type of movement performed at a fast pace; forced position of the trunk or limbs; significant physical stress associated with a forced position of the body or frequent deep torso bending during work, prolonged sitting or standing with an unchanged working position, uncomfortable fixed working position, monotony of work performed, uniformity of work operations (serial work), static and dynamic loads on the body (frequent bending over, staying in a forced working position - kneeling, squatting, lying down, leaning forward, in suspension); uneven rhythm of work; wrong work practices.

Examples of such work are rolling, blacksmithing, riveting, chipping, construction (painting, plastering, roofing), the work of drivers of heavy Vehicle, work in the mining industry, loading and unloading, professional sports, ballet.

When linking a disease with a profession, indicators of workload (ergometric indicators) and work stress (physiological indicators) are taken into account. Thus, a significant role in the occurrence of occupational chronic lumbosacral radiculopathy is given to chronic overstretching of the posterior sections of the intervertebral segment and the posterior longitudinal ligament during physical stress in the position of maximum flexion. When lifting a load of 40 kg, the posterior segments of the capsular-ligamentous apparatus are under the influence of a force of 360-400 kg.

Concomitant factors provoking the development of professional chronic lumbosacral radiculopathy are microtraumatization of the limbs, torso, unfavorable industrial microclimatic conditions, chemical substances used in technological operations, industrial vibration of workplaces exceeding the maximum permissible levels, especially on transport equipment.

Also, the syndrome of lumbosacral radiculopathy is included in the classification of vibration disease, approved by the USSR Ministry of Health on September 1, 1982 (No. 10-11/60), and characterizes the presence of pronounced forms of vibration disease from exposure to general vibration. The impact of general vibration leads to a direct microtraumatic effect on the spine due to significant axial loads on intervertebral discs, local overloads in the spinal motion segment and to disc degeneration. There is a deformation of the tissues of the spinal motion segment, irritation of its receptors, damage to certain structures, depending on which structures are involved in the process in each case.

Occupational diseases of the back are characterized by their gradual development, the presence of improvement during long breaks in work, exacerbation of manifestations after breaks (the phenomenon of detraining), the absence of injuries, infectious and endocrine diseases in history, when assessing the severity and intensity of labor, the leading factor in the severity of the labor process - class of working conditions not less than 3.2, the presence of concomitant unfavorable factors.

Sometimes production factors aggravate functional inferiority, insufficiency of the neuromuscular and osteoarticular apparatus of a congenital or acquired nature, creating prerequisites for the development and aggravation of the pathological process in chronic lumbosacral radiculopathy (Table 1). So, concomitant general medical risk factors for occupational dorsopathies are age from 30 to 45 years, female gender, obesity (body mass index above 30), weak and underdeveloped skeletal muscles, indication of back pain in the past, developmental and skeletal disorders (congenital anomalies and dysplasia), pregnancy and childbirth.

Table 1.
Occupational lesions of the lumbar spine associated with functional overstrain (excerpt from Order No. 417n of the Ministry of Health and Social Development of the Russian Federation dated April 27, 2012 “On Approval of the List of Occupational Diseases”)

Clinical picture with lumbosacral radiculopathy
consists of vertebral symptoms (changes in the statics and dynamics of the lumbar spine) and radicular disorders (motor, sensory, vegetative-trophic disorders). The main complaint is pain - local in the lumbar region and deep tissues in the area of ​​the hip, knee and ankle joints; sharp, “shooting through” from the lower back to the gluteal region and along the leg to the fingers (along the affected nerve root).

Clinically, lumbosacral radiculopathy is characterized by acute or subacute developing paroxysmal (shooting or penetrating) or constant intense pain, which at least occasionally radiates to the distal zone of the dermatome (for example, when taking Lasegue). Leg pain is usually accompanied by lower back pain, but in younger patients it may be in the leg only. Pain can develop suddenly - after a sharp unprepared movement, lifting heavy or falling. In the anamnesis, such patients often have indications of repeated episodes of lumbodynia and lumboischialgia. At first, the pain may be dull, aching, but gradually increases, less often immediately reaches its maximum intensity.

There is a pronounced tension of the paravertebral muscles, which decreases in the supine position. Disturbance of sensitivity (pain, temperature, vibration, etc.) in the corresponding dermatome (in the form of paresthesia, hyper- or hypalgesia, allodynia, hyperpathia), a decrease or loss of tendon reflexes that close through the corresponding segment of the spinal cord, hypotension and weakness of the muscles innervated are characteristic. this spine. The presence of tension symptoms and, above all, the Lasegue symptom is typical, but this symptom is not specific for radiculopathy. It is suitable for assessing the severity and dynamics of vertebrogenic pain syndrome. The symptom of Lasegue is checked by slowly (!) raising the straight leg of the patient up, waiting for the reproduction of radicular irradiation of pain. When the roots of L 5 and S 1 are involved, pain appears or sharply increases when the leg is raised to 30–40 °, and with subsequent flexion of the leg at the knee and hip joints, it disappears (otherwise, the pain may be due to the pathology of the hip joint or has a psychogenic character) .

When performing the Lasegue technique, pain in the lower back and leg can also occur with tension in the paravertebral muscles or the posterior muscles of the thigh and lower leg. To confirm the radicular nature of the Lasegue symptom, the leg is raised to the limit above which pain occurs, and then the foot is forcedly flexed at the ankle joint, which causes radicular irradiation of pain in radiculopathy.

With the involvement of the L 4 root, an "anterior" symptom of tension is possible - Wasserman's symptom: it is checked in a patient lying on his stomach, raising the straight leg up and unbending the hip in the hip joint or bending the leg in the knee joint.

When the root is compressed in the root canal, the pain often develops more slowly, gradually acquiring radicular irradiation (buttock - thigh - lower leg - foot), often remains at rest, increasing when walking and staying in an upright position, but, unlike disc herniation, it is relieved with seat.

The pain is not aggravated by coughing and sneezing. Tension symptoms are usually less pronounced. Forward bending is less limited than with median or paramedian disc herniation, and pain is more often provoked by extension and rotation. Paresthesias are often observed, less often - a decrease in sensitivity or muscle weakness.

Muscle weakness in discogenic radiculopathies is usually mild. But sometimes, against the background of a sharp increase in radicular pain, pronounced paresis of the foot (paralyzing sciatica) can acutely occur. The development of this syndrome is associated with ischemia of the roots of L 5 or S 1 caused by compression of the vessels feeding them (radiculo-ischemia). In most cases, paresis safely regresses within a few weeks.

Diagnostics.
Diagnostic search for lumbosacral radiculopathy is carried out in the presence of additional clinical manifestations, incl. fever (characteristic of oncological pathology, connective tissue diseases, disc infections, tuberculosis); weight loss ( malignant tumors); inability to find a comfortable position (metastases, urolithiasis disease); intense local pain (erosive process).

Malignant neoplasms are characterized by an atypical course clinical syndromes. Most often, malignant tumors of the breast, prostate, kidney, lung metastasize to the spine, less often - of the pancreas, liver, gallbladder. Neurological disorders are caused by tumors, do not have specific signs.

When referring such patients to a doctor, it must be remembered that the pain associated with neoplasms has a number of characteristic features:

• begins before the age of 15 or after 60;
• does not have a mechanical character (does not decrease at rest, in the supine position, at night);
• intensifies over time;
• accompanied by fever, weight loss, changes in blood and urine parameters;
• in the anamnesis of patients there is an indication of neoplasms.

Tuberculous abscess (swelling) is characterized by the accumulation of pus in the muscular and subaponeurotic spaces. In the lumbar region, it can be located in the psoas major muscle, penetrate into the iliac region and the muscular femoral lacuna. In this case, the roots of the lumbosacral plexus may be affected. Accurate diagnosis of this process is possible only with the help of CT.

Epidural abscess is characterized by radicular syndrome with gradual compression of the spinal cord against the background of severe septic manifestations. When the process is chronic, the pain becomes moderate, localized, as a rule, in the thoracic region, the symptoms of spinal cord compression slowly increase.

In addition, pain phenomena in the lumbar spine are possible with the development of psoitis - inflammation of the iliopsoas muscle. Psoitis is characterized by pain in the lumbar and iliac region, aggravated by walking and radiating to the thigh. Characterized by flexion contracture of the thigh muscles. Psoitis is distinguished from femoral nerve damage by hectic fever, profuse sweating, and changes in blood counts indicative of inflammation.

Also, the occurrence of pain phenomena may be associated with various vascular processes (atypical variants of myocardial infarction, aneurysm of the thoracic (abdominal) aorta), retroperitoneal and epidural hematoma, bone infarcts in hemoglobinopathies.

The pain is radiating in nature in diseases of the pelvic organs (torsion of the cyst leg, prostatitis, cystitis, periodic pain in endometriosis, etc.) and abdominal cavity(pancreatitis, posterior wall ulcer duodenum, kidney disease, etc.). For the correct diagnosis of patients with spinal dorsopathy, it is recommended to consult with doctors of related specialties (therapist, gynecologist, urologist, infectious disease specialist) (Table 2).

Table 2.
Differential Diagnosis for low back pain syndrome

Pain on palpation and percussion of the spinous processes of the spine may indicate the presence of a fracture or infection of the vertebra. Identified inability to step from heel to toe or perform squats is characteristic of the "cauda equina" syndrome and other neurological disorders. Soreness on palpation of the sciatic notch with irradiation to the leg indicates irritation of the sciatic nerve.

Physical examination may reveal excessive lumbar curvature, hunching suggesting congenital anomalies or fractures, scoliosis, pelvic skeletal anomalies, and asymmetry of the paravertebral and gluteal muscles. The observed pain in the area of ​​the lumbosacral joint may be due to damage to the lumbosacral disc and rheumatoid arthritis. With damage to the L 5 root, there are difficulties when walking on the heels, with damage to the S 1 root - on the toes. Determination of the range of motion in the spine is of limited diagnostic value, but is useful for evaluating the effectiveness of treatment.

The study of knee and ankle (Achilles) reflexes in patients with pain in the lower back often helps topical diagnosis. The Achilles reflex weakens (drops out) with a herniated disc L 5 -S 1. With a herniated disc L 4 -L 5, tendon reflexes on the legs do not fall out. Weakening of the patellar reflex is possible with L 4 root radiculopathy in elderly patients with spinal stenosis. Weakness on extension thumb and foot indicates involvement of the L 5 root. Damage to the root of S 1 is characterized by paresis of the gastrocnemius muscle (the patient cannot walk on his toes). Radiculopathy S 1 causes hypesthesia along the back of the lower leg and the outer edge of the foot. Compression of the root L 5 causes hypesthesia of the dorsum of the foot, thumb and I interdigital space.

In addition, the progression of the pathological process in chronic lumbosacral radiculopathy can lead to the formation of radiculo-ischemia, radiculomyelopathy. It is also possible to develop myofascial syndrome, since any damage to the musculoskeletal system causes local muscle spasm (in particular, activation of the alpha motor neurons of the spinal cord leads to an increase in spasm - “spasm increases spasm”). A pathological muscular corset is created. It should be mentioned that there are reflex muscular-tonic syndromes of vertebrogenic origin with pain syndrome (which can be occupational) and vertebrogenic pain syndrome itself.

Myofascial syndrome is manifested by muscle spasm, painful muscle seals, trigger points, areas of referred pain. The main reasons for its development are antiphysiological postures, full tension, psychogenic factors (anxiety, depression, emotional stress), developmental anomalies, diseases of the visceral organs, the musculoskeletal system, hypothermia, overextension and muscle compression.

Laboratory tests.

If a tumor or infection is suspected, general analysis blood and ESR. Other blood tests are recommended only if any underlying disease is suspected, such as ankylosing spondylitis or myeloma (HLA-B27 test and serum protein electrophoresis, respectively). Calcium levels, phosphate levels, and alkaline phosphatase activity are measured to detect osteoporotic bone lesions.

The data of electroneuromyography are rarely of practical importance in vertebrogenic radiculopathy, but are sometimes important in the differential diagnosis with damage to the peripheral nerve or plexus. The rate of conduction of excitation along the motor fibers in patients with radiculopathy usually remains normal even if weakness is detected in the affected myotome, because only part of the fibers within the nerve is damaged. If more than 50% of the motor axons are affected, then there is a decrease in the amplitude of the M-response in the muscles innervated by the affected root. For vertebrogenic radiculopathy, the absence of F-waves is especially characteristic with a normal amplitude of the M-response from the corresponding muscle. The speed of conduction along sensory fibers in radiculopathy also remains normal, since root damage (as opposed to nerve or plexus damage) usually occurs proximal to the spinal ganglion.

The exception is radiculopathy L 5 (in about half of the cases spinal ganglion The 5th lumbar root is located in the spinal canal and can be affected by a herniated disc, which causes anterograde degeneration of the axons of the spinal cells). In this case, there may be no S-response when stimulating the superficial peroneal nerve. Needle electromyography can reveal signs of denervation and reinnervation in muscles innervated by a single root. The study of paravertebral muscles helps to exclude plexopathy and neuropathy.

In case of pain in the lumbar spine, an X-ray of the corresponding spine section is performed in frontal and lateral projections, to detect metastases in the spine - radioisotope osteoscintigraphy, and if spinal cord compression is suspected - myelography. In middle-aged and elderly people with recurrent back pain, along with oncopathology, it is necessary to exclude osteoporosis, especially in females in the postmenopausal period (osteodensitometry). If the picture is unclear, X-ray examination can be supplemented with MRI and CT.

Treatment.

The complex of therapeutic measures includes drug therapy, physiotherapy, exercise therapy, manual therapy, orthopedic measures (wearing bandages and corsets), psychotherapy, spa treatment. maybe topical application moderate dry heat or (with acute mechanical pain) cold (heater with ice on the lower back up to 15-20 minutes 4-6 rubles / day).

During the period acute pain, Besides non-pharmacological means, drug therapy is required, and above all, the appointment non-steroidal anti-inflammatory drugs(NSAIDs), which have been widely used in clinical practice for over 100 years (the German chemist F. Hoffman reported the successful synthesis of a stable form of acetylsalicylic acid suitable for medicinal purposes in 1897). In the early 1970s English pharmacologist J. Vane showed that pharmachologic effect acetylsalicylic acid is due to the suppression of the activity of cyclooxygenase (COX) - a key enzyme in the synthesis of prostaglandins (Nobel Prize in Physiology or Medicine in 1982 "for discoveries concerning prostaglandins and biologically active substances close to them").

As it turned out later, COX has varieties, one of which is more responsible for the synthesis of prostaglandins - inflammatory mediators, and the other for the synthesis of protective PGs in the gastric mucosa. In 1992, COX isoforms (COX-1 and COX-2) were isolated.

The working classification of NSAIDs divides them into 4 groups (moreover, the division into “primary” and “specific” COX-2 inhibitors is rather arbitrary):

• selective COX-1 inhibitors (low doses of acetylsalicylic acid);
• non-selective COX inhibitors (most of the "standard" NSAIDs);
• predominantly selective COX-2 inhibitors (meloxicam, nimesulide);
• specific (highly selective) COX-2 inhibitors (coxibs).

Nise is a 4-nitro-2-phenoxymethane-sulfonanilide and has a neutral acidity. According to the recommendations of the EMEA (European Medicines Agency), the EU body that controls the use of medicines in Europe, the use of nimesulide in European countries is regulated for a course of up to 15 days at a dose not exceeding 200 mg / day.

Clinical efficacy of Nise determined by a number of interesting pharmacological features. In particular, its molecule, unlike the molecules of many other NSAIDs, has "alkaline" properties that make it difficult to penetrate into the mucous membrane of the upper gastrointestinal tract and thereby significantly reduce the risk of contact damage. However, this property allows nimesulide to easily penetrate and accumulate in the foci of inflammation at a higher concentration than in blood plasma. The drug has anti-inflammatory, analgesic and antipyretic effects. Nimesulide reversibly inhibits the formation of prostaglandin E 2 both in the focus of inflammation and in the ascending pathways of the nociceptive system, including the pathways for conducting pain impulses in spinal cord; reduces the concentration of short-lived prostaglandin H 2, from which prostaglandin E 2 is formed under the action of prostaglandin isomerase. A decrease in the concentration of prostaglandin E 2 leads to a decrease in the degree of activation of prostanoid EP-type receptors, which is expressed in analgesic and anti-inflammatory effects. To a small extent, it acts on COX-1, practically does not prevent the formation of prostaglandin E 2 from arachidonic acid under physiological conditions, thereby reducing the number of side effects of the drug. Nimesulide inhibits platelet aggregation by inhibiting the synthesis of endoperoxides and thromboxane A 2, inhibits the synthesis of platelet aggregation factor; inhibits the release of histamine, and also reduces the degree of bronchospasm caused by exposure to histamine and acetaldehyde.

Nimesulide also inhibits the release of tumor necrosis factor-α, which causes the formation of cytokines. It has been shown that nimesulide is able to suppress the synthesis of interleukin-6 and urokinase, thereby preventing the destruction of cartilage tissue. Inhibits the synthesis of metalloproteases (elastase, collagenase), preventing the destruction of proteoglycans and collagen in cartilage tissue. It has antioxidant properties, inhibits the formation of toxic oxygen decay products by reducing the activity of myeloperoxidase. Interacts with glucocorticoid receptors, activating them by phosphorylation, which also enhances the anti-inflammatory effect of the drug.

An important advantage of nimesulide is its high bioavailability. So, after oral administration, after 30 minutes. 25-80% of the maximum concentration of the drug in the blood is noted, and at this time the analgesic effect begins to develop. At the same time, 1-3 hours after administration, the peak concentration of the drug and, accordingly, the maximum analgesic effect are noted. Plasma protein binding is 95%, with erythrocytes - 2%, with lipoproteins - 1%, with acidic α 1 -glycoproteins - 1%. Nimesulide is actively metabolized in the liver by tissue monooxygenases. The main metabolite is 4-hydroxynimesulide (25%).

On average, serious liver damage develops no more than 1 out of 10 thousand patients taking nimesulide, and the total frequency of such complications is 0.0001%. A comparative study of adverse effects when taking NSAIDs in almost 400 thousand patients showed that it was the appointment of nimesulide that was accompanied by a rarer development of hepatopathy: compared with diclofenac - 1.1 times, ibuprofen - almost 1.3 times. Conducted under the auspices of the Pan-European Authority for Drug Supervision in 2004, a safety analysis of nimesulide led to the conclusion that the hepatotoxicity of the drug is not higher than that of other NSAIDs.

ON THE. Shostak showed that in Moscow, 34.6% of hospitalizations with a diagnosis of "acute gastrointestinal bleeding" are directly related to the use of NSAIDs. It is believed that it is possible to significantly reduce the risk of complications from the gastrointestinal tract (development of ulcers, gastrointestinal bleeding, perforation) using selective NSAIDs. In Russia, this class of NSAIDs includes celecoxib, meloxicam and nimesulide, which, according to existing national guidelines on the rational use of NSAIDs, should be used in patients with a high risk of developing gastrointestinal complications (persons with a history of ulcers, the elderly (65 years and older), and those receiving low doses of acetylsalicylic acid as concomitant therapy, anticoagulants, glucocorticosteroids).

Proved total reduction in the frequency of side effects (primarily due to dyspepsia) in patients treated with nimesulide, compared with patients treated with traditional NSAIDs. In addition, there are data based on population-based studies ("case-control") conducted in Italy and Spain, indicating a fairly low relative risk of gastrointestinal bleeding when using nimesulide.

A characteristic feature of nimesulide is also a low risk of developing gastropathy compared to traditional NSAIDs. So, in a retrospective analysis of the frequency of erosive and ulcerative complications of the gastrointestinal tract when taking diclofenac and COX-2 selective NSAIDs in patients rheumatic diseases who received inpatient treatment at the Institute of Rheumatology of the Russian Academy of Medical Sciences (Moscow) from January 2002 to November 2004, a rarer occurrence of multiple erosions and ulcers was demonstrated when taking COX-2 selective NSAIDs, especially in the presence of an ulcerative history. Most rarely, lesions of the gastrointestinal tract developed precisely when taking nimesulide. A.E. Karateev et al. at the Institute of Rheumatology, an assessment was made of the incidence of side effects with prolonged use of nimesulide. The purpose of the study: a retrospective analysis of the incidence of side effects from the gastrointestinal tract, cardiovascular system and liver in patients with rheumatic diseases (RD) who took nimesulide 200–400 mg/day for a long time (for 12 months). In addition to nimesulide, patients received methotrexate and leflunomide. 322 patients with various RDs were examined ( rheumatoid arthritis, osteoarthritis, seronegative spondyloarthritis), admitted for inpatient treatment at the NIIR RAMS clinic in 2007–2008. Revealed side effects that occurred in patients during the observation period: gastric ulcer - 13.3%, destabilization or development of arterial hypertension - 11.5%, myocardial infarction - 0.09%, clinical signs of ALT increase - 2.2%. Long-term use of nimesulide was not associated with a significant increase in the frequency of dangerous hepatotoxic reactions. Thus, the favorable tolerance of the effective analgesic and anti-inflammatory drug nimesulide determines the possibility of its use for a long time (at least 12 months).

An analysis of 10,608 cases of reports of side effects of NSAIDs based on the results of a population study showed that adverse reactions from the gastrointestinal tract when taking nimesulide developed in 10.4% of cases, while complications from the gastrointestinal tract when taking piroxicam almost 2 times more often, and diclofen-ka and ketoprofen - more than 2 times more often. In 2004, F. Bradbury published data on the incidence of adverse effects from the gastrointestinal tract when taking nimesulide and diclofenac. It turned out that taking nimesulide caused these complications in 8% of patients, while taking diclofenac - in 12.1% of cases of prescribing the drug.

Great importance also has the effect of NSAIDs on the risk of developing cardiovascular complications and indicators blood pressure. Appointment of nimesulide and diclofenac to patients with osteoarthritis and rheumatoid arthritis for 20 days showed no significant increase in blood pressure in patients treated with nimesulide, and a significant increase in mean values ​​of systolic and diastolic blood pressure when taking diclofenac. Taking nimesulide did not require correction of therapy, while 4 out of 20 patients taking diclofenac were forced to stop taking the drug due to a persistent rise in blood pressure.

In addition, in the review by P.R. Kamchatnova et al. regarding the possibility of using nimesulide, it has been shown that the drug has low level cardiotoxicity compared with other selective COX-2 inhibitors, in particular coxibs, which makes it possible to use it in patients with cardiovascular risk factors. The data of a survey of 100 patients regarding the tolerability of nimesulide in comparison with naproxen, which were performed surgical intervention about coronary disease heart under cardiopulmonary bypass. It was shown that in patients receiving nimesulide at a dose of 100 mg 2 times a day, there were no side effects during the study.

The possibility of using ni-mesulide in the case of a previous development of allergic reactions when taking other NSAIDs has also been established. According to G.E. Senna et al., who prescribed nimesulide to 381 patients with previous allergic reaction to the use of NSAIDs, in 98.4% of cases this was not accompanied by any manifestations of allergies. It has been proven that nimesulide, unlike indomethacin, does not have a damaging effect on cartilage and, in addition, even at low concentrations, it is able to inhibit collagenase in synovial fluid. At the same time, the analgesic effect of nimesulide is not inferior to the effect of diclofenac and naproxen, surpassing that of rofecoxib.

In addition to chronic lumbosacral radiculopathy of professional origin, indications for the use of nimesulide are also rheumatoid arthritis, articular syndrome, ankylosing spondylitis, osteochondrosis with radicular syndrome, osteoarthritis, arthritis of various etiologies, arthralgia, myalgia of rheumatic and non-rheumatic origin, inflammation of the ligaments, tendons, bursitis, post-traumatic inflammation of soft tissues and the musculoskeletal system, pain syndrome of various origins.

Undoubtedly nimesulide, characterized by high safety and efficacy, various mechanisms of anti-inflammatory and analgesic action, should be considered among the most promising drugs for use in therapeutic, neurological, rheumatological, occupational pathology practice.

For pain phenomena in the lumbar spine in the presence of muscle spasms, muscle relaxants are used that stop muscle spasms, reduce contractures, and reduce multisynaptic reflex activity, overcoming spinal automatism. With pain in the lower back, it is possible to use glucocorticoid therapy, which has an anti-inflammatory effect by inhibiting the synthesis of inflammatory mediators.

After pain reduction and in the absence of night pains, galvanization and drug electrophoresis, pulsed galvanization, phonophoresis, diadynamic therapy, amplipulse therapy, magnetotherapy, laser therapy, laser magnetic therapy, mud applications (ozokerite, paraffin, naftalan, etc.), point, segmental, cupping massage, reflexology, acupuncture, electropuncture, electroacupuncture. Perhaps the appointment of radon, medicinal, mineral and pearl baths, hydrotherapy. Physical therapy methods can be used when, with the help of special exercises, certain muscle groups are strengthened and the range of motion is increased. Spa treatment is also shown, including at balneological resorts.

Prevention.

It consists of identifying hypermobile persons, scoliosis and other congenital deformities of the spine in adolescence and eliminating the factors of deformity progression, as well as optimizing the ergonomic indicators of the workplace.

The main contraindications for employment associated with overstrain of the musculoskeletal system, lumbar spine, provoking the development and progression of pain phenomena, are diseases of the musculoskeletal system with impaired function, chronic diseases peripheral nervous system, obliterating endarteritis, Raynaud's syndrome and disease, peripheral vascular angiospasm.

In primary prevention, the leading role belongs to the examination of professional suitability (preliminary and periodic medical examinations) - compliance with medical regulations for admission to work in accordance with the order of the Ministry of Health and Social Development of Russia No. during which preliminary and periodic medical examinations (examinations) are carried out, and the procedure for conducting preliminary and periodic medical examinations(examinations) of workers engaged in hard work and work with harmful and (or) dangerous working conditions.

With reflex and radicular syndromes during an exacerbation, the patient is recognized as temporarily disabled. At frequent relapses, persistent pain syndrome and insufficient effectiveness of treatment, severe vestibular disorders, asthenic syndrome, movement disorders, radiculo-ischemia, as well as in case of impossibility of rational employment without reducing the qualifications and wages of a patient with chronic lumbosacral radiculopathy of professional origin, they are sent to medical and social expertise to determine the degree of disability.

Literature

1. Kosarev V.V., Babanov S.A. Occupational diseases. M.: GEOTAR-Media, 2010. 368 p.
2. Mukhin N.A., Kosarev V.V., Babanov S.A., Fomin V.V. Occupational diseases. M.: GEO-TAR-Media, 2013. 496 p.
3. Nedzved G.K. Risk factors and the likelihood of neurological manifestations of lumbar osteochondrosis (principles primary prevention) / Guidelines. Minsk, 1998. 18 p.
4. Teschuk V.Y., Yarosh O.O. Causal and inherited development of the disease and the development of pain syndromes in the spinal gait // Likarska on the right. 1999. No. 6. S. 82–87.
5. Karlov V.A. Neurology. Guide for doctors. M.: MIA, 1999. 620 p.
6. Nasonov E.L. Non-steroidal anti-inflammatory drugs (prospects for use in medicine). M., 2000.
7. Nasonov E.L., Lazebnik L.B., Belenkov Yu.N. and collaborators The use of non-steroidal anti-inflammatory drugs. Clinical guidelines. M.: Almaz, 2006. 88 p.
8. Kosarev V.V., Babanov S.A. Clinical pharmacology and rational pharmacotherapy. Moscow: Infra-M. Vuzovsky textbook, 2012. 232 p.
9. Chichasova N.V., Imametdinova G.R., Nasonov E.L. The possibility of using selective COX-2 inhibitors in patients with diseases of the joints and arterial hypertension // Scientific and Practical Rheumatology. 2004. No. 2. S. 27–40.
10. Helin–Salmivaara A., Virtanen A., Vesalainen R. et al. NSAID use and the risk of hospitalization for first myocardial infarction in the general population: a nationwide case–control study from Finland // Eur Heart J. 2006. Vol. 27 (14). R. 1657–1663.
11. Senna G.E., Passalacqua G., Dama A. et al. Nimesulide and meloxicam are a safe alternative drugs for patients intolerant to nonsteroidal anti-inflammatory drugs // Eur. Ann. Allergy Clinic. Immunol. 2003 Vol. 35 (10). R. 393–396.
12. Degner F., Lanes S. et al. Therapeutic roles of selective COX-2 inhibitors. Ed. Vane J.R., Batting R.M. 2001. Part 23, pp. 498–523.
13. Boelsterli U. Nimesulide and hepatic adverse affects: roles of reactive metabolites and host factors // Int. J.Clin. Pract. 2002 Vol. 128 (supl.). R. 30–36.
14. Karateev A.E., Barskova V.G. Safety of nimesulide: emotions or a weighted assessment // Consilium medicum. 2007. No. 2. S. 60–64.
15. Traversa G., Bianchi C., Da Cas R. et al. Cohort study of hepatotoxity associated with nimesulide and other non-steroidal anti-inflammatory drugs // BMJ. 2003 Vol. 327. R. 18–22.
16. European Medicines Evaluation Agency, Committee for Proprietary Medicinal Products. Nimesu-lide containing medicinal products. CPMP/1724/04. http://www.emea.eu.int.
17. Shostak N.A., Ryabkova A.A., Saveliev V.S., Malyarova L.N. Gastrointestinal bleeding as a complication of gastropathy associated with the use of non-steroidal anti-inflammatory drugs // Therapeutic archive. 2003. No. 5. S. 70–74.
18. Pilotto A., Franceschi M., Leandro G. et al. The risk of upper gastrointestinal bleeding in elderly users of aspirin and other non-steroidal anti-inflammatory drugs: the role of gastroprotective drugs // Aging Clin Exp Res. 2003 Vol. 15(6). R. 494–499.
19. Menniti–Ippolito F., Maggini M., Raschetti R. et al. Ketorolac use in outpatients and gastrointestinal hospitalization: a comparision with other non-steroidal anti-inflammatory drugs in Italy // Eur. J.Clin. Pharmacol. 1998 Vol. 54. R. 393–397.
20. Karateev A.E. Gastroduodenal safety of selective inhibitors of cyclooxygenase-2: practical test // Therapeutic archive. 2005. No. 5. S. 69–72.
21. Karateev A.E., Alekseeva L.I., Bratygina E.A. Evaluation of the incidence of side effects during long-term use of nimesulide in real clinical practice // RMJ. 2009. No. 21. S. 1466–1472.
22. Conforti A., Leone R., Moretti U., Mozzo F., Velo G. Adverse drug reactions related to the use of NSAIDs with a focus on nimesulide: results of spontaneous reporting from a Northen Italian area // Drug Saf. 2001 Vol. 24. R. 1081-1090.
23. Bradbury F. How important is the role of the physician in the correct use of a drug? An observational cohort study in gereral practice // Int. J.Clin. Pract. 2004. Supl. 144. R. 27–32.
24. Chichasova N.V., Imametdinova G.R., Nasonov E.L. The possibility of using selective COX-2 inhibitors in patients with diseases of the joints and arterial hypertension // Scientific and Practical Rheumatology. 2004. No. 2. S. 27–40.
25. Kamchatnov P.R., Radysh B.V., Kutenev A.V. Possibility of using nimesulide (Nise) in patients with nonspecific pain in the lower back // BC. 2009. No. 20. S.1341–1356.
26. Senna G.E., Passalacqua G., Dama A. et al. Nimesulide and meloxicam are a safe alternative drugs for patients intolerant to nonsteroidal anti-inflammatory drugs // Eur. Ann. Allergy Clinic. Immunol. 2003 Vol. 35 (10). R. 393–396.
27. Tavares I.A., Bishai P.M., Bennet A. Activity of nimesulide on constitutive and inducible cyclooxygenases. Arzneim-Forsch // Drug Res. 1995 Vol. 45. R. 1093-1096.
28. Panara M.R., Padovano R., Sciulli M. et al. Effects of nimesulide on constitutive and inducible prostanoid biosynthesis in human beings // Clin. Pharmacol. Ther. 1998 Vol. 63. R. 672-681.

Excludes: cervicalgia due to intervertebral disc disease (M50.-)

Excluded:

• lesion of the sciatic nerve (G57.0)
• sciatica:
  • due to intervertebral disc disease (M51.1)
  • with lumbago (M54.4)

Excludes: due to intervertebral disc disease (M51.1)

Tension in the lower back

Excludes: lumbago:

• due to displacement of the intervertebral disc (M51.2)
• with sciatica (M54.4)

Excludes: due to damage to the intervertebral disc (M51.-)

In Russia, the International Classification of Diseases of the 10th revision (ICD-10) is accepted as a unified normative document to account for morbidity, the reasons for the population's appeals to medical institutions all departments, causes of death.

ICD-10 was introduced into healthcare practice throughout the Russian Federation in 1999 by order of the Russian Ministry of Health dated May 27, 1997. №170

The publication of a new revision (ICD-11) is planned by WHO in 2017 2018.

With amendments and additions by WHO.

Processing and translation of changes © mkb-10.com

Causes, symptoms and treatment of radiculopathy

Radiculopathy is a syndrome that occurs when the spinal nerve root is compressed as it exits the spine. It can present with pain, impaired movement in the limbs, and lack of sensation in the skin.

The terms "radiculopathy" and "sciatica" are often used interchangeably. These diagnoses, according to the international classification of diseases (ICD 10), have the same code - M54.1.

Causes

The most common cause of this disease is a herniated disc. The intervertebral disc is the cartilage that lies between the vertebrae. It performs a shock absorbing function. Inside its connective tissue sheath is a jelly-like substance. Unusually heavy or frequent repetitive stress on the spine, such as heavy lifting, exercise various types sports, this jelly can break through the disc and squeeze the nearby nerve.

In addition to disc herniation, vertebral osteophytes can be causes of nerve compression, i.e. bone outgrowths that form in the intervertebral space for reasons that are not entirely clear. The nerve can also be compressed in vertebral fractures. Such fractures can spontaneously occur in osteoporosis.

According to its mechanism, nerve damage in the above cases is a compression-ischemic neuropathy. This means that compression (compression) of the nerve trunk leads to ischemic changes in it, i.e. to oxygen starvation due to circulatory disorders. All other manifestations (pain, dysfunction) are the result of compression-ischemic injuries.

Radiculopathy is common. According to American studies, 3 to 5% of US residents suffer from lumbosacral radiculopathy. The cervical spine is somewhat less commonly affected. In the thoracic region, disc herniation is rarely formed due to the stabilizing effect of the rib cage of the chest.

If the treatment of compression radiculopathy is not started in a timely manner, the disease progresses to chronic stage. In the future, there is a high probability of disability.

Symptoms

The main symptom of compression of the nerves in the lumbosacral spine is pain. The pain can spread to the buttocks and lower - to the leg. Pain can be aggravated by walking, coughing, localized to the right, left or both sides of the spine. It is also sometimes possible to experience a feeling of numbness and weakness in the legs.

Symptoms of compression of the roots in the cervical region are pain in the neck and arm, as well as weakness during movement upper limb and a feeling of numbness in the fingers.

Diagnostics

Diagnosis of this disease consists of several stages. First, the doctor analyzes the patient's complaints:

• clarifies the main complaint (pain, weakness, numbness);
• assesses the localization of pain (height of the site of the disease, location to the right, to the left of the spinal column);
• asks about the circumstances under which the pain appeared, and the attempts made to treat it;
• finds out the patient's occupation and lifestyle features, since this aspect can be key in the occurrence of complaints.

The next step in the process of establishing a diagnosis is an objective examination. The doctor examines the patient, studying signs of asymmetric muscle tension on the right or left, then conducts a neurological examination. With the help of palpation, he finds out the points of maximum pain: on the right, on the left, on both sides. Using a neurological hammer, it checks the reflexes and sensitivity of the skin of the extremities.

After a direct examination of the patient, the time comes for X-ray methods. Plain x-rays of the spine are often used to diagnose compression-ischemic radiculopathy. However, its diagnostic value is limited. With the help of radiography, you can see signs of gross destruction of bones of a traumatic or tumor nature. But in most cases, you will not see a disc herniation on a plain radiograph.

The best way to detect a herniated disc is magnetic resonance imaging (MRI). MRI has excellent sensitivity and is the method of choice in diagnosing the causes of compression-ischemic nerve damage.

However, not everything is unambiguous in the issue of MRI diagnostics. This research sometimes finds intervertebral hernia in patients who experience absolutely no pain. And this means that a herniated disc does not necessarily cause compression-ischemic neuropathy in all cases.

Computed tomography (CT) is also used to diagnose compression radiculopathy, but is less sensitive than MRI. As with magnetic resonance imaging, false positive results are possible.

Differential Diagnosis

What diseases should be distinguished from radiculopathy?

Compression damage to the nerves of the lumbosacral region (ICD code 10 - M54.1) has similar symptoms with trochanteric bursitis (ICD code 10 - M70.60).

radiculopathy cervical region the spine must be differentiated with the following diseases:

• tendinitis of the rotator cuff of the shoulder (ICD code 10 - M75.1);
• arthrosis of the facet joints (ICD code 10 - M53.82);
• damage to the brachial plexus (ICD code 10 - G54.0);
• stretching of the neck muscles (ICD code 10 - S16).

Treatment of the disease

The tactics of treatment of compression radiculopathy varies depending on the phase of the disease. Due to the fact that the risk of developing disability is quite high, with this disease it is extremely undesirable to engage in self-treatment with folk remedies.

Non-steroidal anti-inflammatory drugs (NSAIDs) are the mainstay of therapy for the disease in the acute period. NSAIDs are prescribed to relieve pain and reduce inflammation. In the acute phase, muscle relaxants can also be prescribed to relieve spasm of the skeletal muscles. In some cases, to appease especially severe pain, a special class of drugs called anticonvulsants is needed.

Sometimes an anti-inflammatory treatment such as epidural steroid injection is used. It consists in the fact that with the help of a special needle a strong anti-inflammatory drug is injected directly under the membranes of the spinal cord.

Quite rarely, there are situations when surgical intervention is required in the acute phase. This can happen if there is a motor deficit, i.e. a person cannot move an arm or leg, while motor function continues to deteriorate.

An important aspect of treatment in any period of the disease is to maintain correct posture, the use of rational technique of lifting weights. The load to be lifted must be symmetrically distributed to the right and left of the midline of the body.

In the recovery phase, massage and various physiotherapy methods are usually used.

After stopping the course of treatment, a person should be attentive to his health and perform strengthening exercises of therapeutic exercises for a long time.

In conclusion, it must be said that radiculopathy is dangerous disease. Although it is not usually life-threatening, the disease carries high risks of chronicity and disability. With timely seeking medical help and refusing self-treatment, the prognosis is usually favorable.

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radiculopathy

Definition and background[edit]

Radiculopathy is a complex of symptoms resulting from damage to the spinal root.

The frequency of radiculopathy depends on age. It is rarely diagnosed in people under 20 years of age. Its relative risk increases by 1.4 every 10 years until age 64.

Regular walking increases the risk of its development by almost 2 times. Jogging has a twofold effect: those who did not suffer from back pain at the time they started running had a lower risk of developing radiculopathy than in the healthy population, and those who started running after an episode of back pain had a higher risk. It is higher in machine operators, carpenters, drivers, farmers, when working in an uncomfortable position, especially when bending and turning the torso or when raising the arms above the shoulder girdle.

Etiology and pathogenesis[edit]

In the vast majority of cases, root damage and spinal nerves due to vertebral causes - the presence of a herniated disc, degenerative changes in the intervertebral joints, a narrow spinal canal.

The main function of the intervertebral discs is to distribute the load associated with body weight and muscle activity along the spinal column. The intervertebral discs at the same time provide lateral tilt, forward and rotation. The height of the disc is about 7-10 mm, the diameter is about 40 mm. The disc consists of a thick outer fibrous ring surrounding the gelatinous contents - the nucleus pulposus, bounded above and below by cartilaginous end plates.

With degenerative changes in the disc, the nucleus pulposus is damaged not under the influence of mechanical stress, but rather by biochemical changes occurring in it. Since the substance of the nucleus pulposus can perform the function of an antigen, the violation of the barrier between it and microvasculature the vertebral body with mechanical damage to the cartilaginous end plate triggers a cascade of autoimmune reactions. With age, the nucleus pulposus becomes more fibrotic and less gel-like. In general, the disc changes its morphology and becomes less structured. The plates of the fibrous ring lose their strict orientation, bifurcate and intertwine. Collagen and elastin fibers also lose their strict order. Fissures and fissures begin to form in the disc, usually in the region of the nucleus pulposus. At the same time, nerve endings and blood vessels are usually found in the disc. There is an increase in the proliferation of cells that form clusters, especially in the region of the nucleus pulposus. Some of the cells die, which is morphologically confirmed by the detection of signs of necrosis and apoptosis in them. It is believed that more than 50% of adult disc cells are necrotic. However, it is extremely difficult to distinguish the signs of “normal aging” of the disc from its pathological changes.

One of the main reasons for the formation of degenerative changes in the disc is the malnutrition of its cells.

Damage to the fibrous ring is considered the most important in the pathogenesis of the pathology of the intervertebral disc.

In the pathogenesis of the development of radiculopathy, the significance of cytokines is not yet clear. In the intervertebral discs of patients operated on for radiculopathy, there was an increase in the level of IL-1α, IL-β, IL-6, IL-8, prostaglandin E2 and TNF-α

Clinical manifestations[edit]

The defeat of the roots from the level of T II to L I is mainly manifested by girdle pain in the trunk. The pain associated with a herniated disc in the chest is usually triggered by coughing, sneezing, and straining. Often it is characterized by aching, burning or tightening character.

Radiculopathy: Diagnosis[edit]

Imaging data (CT, MRI) of the spine must be analyzed in conjunction with the clinical manifestations of radiculopathy.

Needle EMG (electromyography)- a fairly sensitive method for the diagnosis of radiculopathy. To correctly interpret the data, it is necessary to identify pathological changes neural character in two or more muscles innervated by the same root, but different peripheral nerves. The detection of damage to all muscles within one myotome is not necessary, but the muscles of the adjacent segments should be intact.

Differential diagnosis[edit]

Radiculopathy: Treatment[edit]

In each of the cases of compression radiculopathy, it should be decided which treatment tactics to prefer: surgical or conservative methods of exposure. The goal of surgical treatment is the rapid elimination of compression of the spinal nerve root or its irritation with the substance of the disk that has undergone extrusion. Absolute indications for surgical treatment lumbosacral radiculopathy should be considered compression of the roots of the cauda equina with paresis of the feet, anesthesia of the anogenital region, dysfunction of the pelvic organs, an increase in paresis in the corresponding innervation of the affected root myotome.

Relative indications for surgical intervention in both cervical and lumbosacral radiculopathy are severe radicular (neuropathic) pain syndrome that is not amenable to adequate conservative treatment for 6 weeks, as well as an increase in neurological disorders. Patients in this group need neuroimaging (CT, MRI), and if clinically significant changes are detected, the issue of surgical treatment should be decided.

In the acute period, in most cases, preference is given to unloading the cervical and lumbosacral spine. This is achieved by short-term appointment of bed rest. It should be noted that in patients with acute radiculopathy of the lumbosacral roots, bed rest and maintaining daily activities equally affect the outcome of the disease with a high degree of evidence.

Conservative treatment includes the appointment vasoactive drugs-pentoxifylline 100 mg intravenously (5 ml of a 2% solution) or 400 mg / day orally, aminophylline 240 mg intravenously (10 ml of a 2.4% solution), detralex 2 times a day to reduce edema and improve microcirculation. With intense pain that is not relieved by other means, a short-term appointment is possible narcotic analgesics(tramadol 100 mg/day). From the position evidence-based medicine with radiculopathy of the lumbosacral roots, the appointment of NSAIDs is ineffective. Given the role of the neuropathic mechanism in the formation of pain syndrome, one can assume the potential effect of the use of anticonvulsants, but data on their effectiveness remain scarce. The use of topiramate at a dose of about 200 mg / day with chronic course lumbosacral radiculopathy has shown its effectiveness in reducing pain intensity, but side effects limit the wide use of this drug in the treatment of radicular pain. An open, non-comparative study suggests the potential efficacy of lamotrigine in the treatment of pain associated with compression radiculopathy. For the treatment of neuropathic pain in patients with compression radiculopathy, gabapentin (average effective dose - 1.8 g / day) and pregabalin (average dose mg / day) can be prescribed.

When the patient's well-being improves, physiotherapy is added to the treatment, aimed at reducing reflex muscle spasm (vacuum massage, phonophoresis with local anesthetics, massage). Depending on the patient's condition, already on the 3-5th day from the start of treatment, gentle manual therapy methods (mobilization techniques, muscle relaxation) can be connected, which leads to a decrease in antalgic scoliosis and an increase in the range of motion in the spine. Manual therapy is effective compared with placebo and traction therapy in patients with compressive radiculopathy of the lumbosacral roots. However, these manipulations can also lead to a deterioration in the condition of patients with cervical and lumbosacral radiculopathy, especially in cases where there are relative indications for surgical treatment.

The vast majority of patients with cervical or lumbosacral radiculopathy recover within 3 months. Some patients improve for longer (3-6 months), and finally, if the exacerbation lasts more than 6 months (approximately 14% of patients), the severity of the clinical manifestations of the disease is likely to remain at the same level over the next 2 years, without worsening or improving .

Currently, more and more attention is paid to the so-called minimally invasive interventions for herniated discs. Despite the long history of the use of these methods of exposure, there is still no scientifically based evidence of their effectiveness. The numerous non-comparative studies that have been conducted are characterized by small sample sizes, different technical characteristics of the equipment used for the intervention, criteria for enrolling patients in the study, outcome measures and follow-up periods.

ICD code: M54.1

radiculopathy

radiculopathy

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Complex of diagnostic and therapeutic measures for M54.1 Radiculopathy

Consultations of specialists for the diagnosis of children with other spondylosis with radiculopathy, damage to the intervertebral disc of the lumbar and other parts of the spine with radiculopathy, radiculopathy

Laboratory research methods for M54.1 Radiculopathy for diagnosing children with other spondylosis with radiculopathy, damage to the intervertebral disc of the lumbar and other parts of the spine with radiculopathy, radiculopathy

Instrumental research methods for M54.1 Radiculopathy for diagnosing children with other spondylosis with radiculopathy, damage to the intervertebral disc of the lumbar and other parts of the spine with radiculopathy, radiculopathy

Medical studies intended to monitor the effectiveness of treatment for children with other spondylosis with radiculopathy, damage to the intervertebral disc of the lumbar and other parts of the spine with radiculopathy, radiculopathy

Specialist consultations M54.1 Radiculopathy to monitor the effectiveness of treatment in children with other spondylosis with radiculopathy, damage to the intervertebral disc of the lumbar and other parts of the spine with radiculopathy, radiculopathy

Laboratory research methods for monitoring the effectiveness of treatment for children with other spondylosis with radiculopathy, damage to the intervertebral disc of the lumbar and other parts of the spine with radiculopathy, radiculopathy

Instrumental research methods M54.1 Radiculopathy to monitor the effectiveness of treatment in children with other spondylosis with radiculopathy, damage to the intervertebral disc of the lumbar and other parts of the spine with radiculopathy, radiculopathy

Therapeutic measures provided for children with other spondylosis with radiculopathy, damage to the intervertebral disc of the lumbar and other parts of the spine with radiculopathy, radiculopathy

Non-drug methods of treatment used in children with other spondylosis with radiculopathy, damage to the intervertebral disc of the lumbar and other parts of the spine with radiculopathy, radiculopathy

Drugs prescribed for children with other spondylosis with radiculopathy, damage to the intervertebral disc of the lumbar and other parts of the spine with radiculopathy, radiculopathy

• tab. 2 mg, 4 mg: 30 pcs.

• tab. 500 mg + 8 mg: 20 pcs.

• tab. 10 or 20 pcs.

• tab.: 6, 10, 12, 20 or 24 pcs.

• tab.: 10 pcs.

• tab.: 10 or 20 pcs.

• tab. 10 or 20 pcs.

• tab.: 10 or 20 pcs.

• tab. 500 mg + 50 mg + 38.75 mg: 10 or 20 pcs.

• tab.: 5 or 10 pcs.

• tab. 500 mg + 50 mg + 38.75 mg: 20 pcs.

• tab. cover captivity. shell, 325 mg + 400 mg: 10 pcs.;

• tab., cover shell 50 mg + 500 mg: 10 or 100 pcs.

• rr d / w / m introduced. 30 mg/1 ml: amp. 10 pieces.;

• tab. cover captivity. obol., 10 mg: 20 pieces;

• rr d / w / m introduced. 30 mg/1 ml: amp. 5 or 10 pcs.

• rr d / in / in and / m introduced. 30 mg/1 ml: amp. 5 or 10 pcs.

• tab. 10 mg: 10 or 20 pcs.

• caps. with mod. release: 30 pcs.

• tab. cover captivity. shell, 400 mg + 200 mg: 2, 4, 6, 10, 12, 20 or 24 pcs.

• tab. 300 mg + 100 mg + 50 mg: 6 or 10 pcs.

• tab., cover shell, 50 mg + 500 mg: 20 or 100 pcs.

• ointment for external note: tube 30 g

• tab. effervescent (orange) 400 mg + 300 mg: 10 pcs.

• gel for external note: tube 30 g

• gel for external approx. 50 mg+30 mg/1 g: tubes 15 g, 30 g, 50 g or 100 g

• capsule set: 75 mg caps. with prolongation release and 15 mg caps. enteric, 5 pcs. each type in a blister; 2, 4 or 6 blisters

• ointment for external approx. 3mg+10g+1g/100g: tubes 20g or 50g

• tab. 500 mg + 50 mg: 10 pcs.

• tab. effervescent 500 mg: 16 pcs.

• ointment for external approx. 5%: tube 20 g

• gel for external approx. 5%, 10%: tube 40 g

ointment for external approx. 10%: 40 g tube, 10, 15, 20, 25, 30 or 40 g jar

ointment for external approx. 10 mg/1 g: tube 30 g or 40 g

• rectal suppositories. 50 mg, 100 mg: 6 pieces;

• ointment for external approx. 10%: tube 40 g or can 50 g

• rectal suppositories. 50 mg, 100 mg: 10 pcs.

• tab., cover shell, 25 mg: 20 or 30 pcs.

• tab. prolongation action 75 mg: 25 or 50 pcs.

• caps. 60 mg: 20, 50 or 100 pcs.

• powder for preparation. suspension d / oral administration, 100 mg: Pak. 3 g 20 pcs.

• transdermal patch 15 mg/day, 30 mg/day: 2, 5, 7 or 10 pieces;

tab., cover intestinal solution. shell, 25 mg, 50 mg: 20 or 30 pieces;

rr d / w / m introduced. 25 mg/1 ml: amp. 5 pieces.;

rectal suppositories. 25 mg, 50 mg, 100 mg: 5 and 10 pcs.

Almost every person, at least once, is faced with such unpleasant feeling like back pain. More than half of all able-bodied people experience these pains regularly and last more than a day. There are many causes of back pain, one of them is called radiculopathy (an obsolete name) or radicular syndrome. This disease is also called sciatica.

Radiculopathy - what is it?

Radicular syndrome or radiculopathy, ICD code 10 - neurological disease caused with degenerative processes in the spine. Symptoms of radiculitis are caused by damage, inflammation, damage to the roots of the spinal nerves. The problem can arise both in one spine, and in several. The first manifestations of radicular syndrome are usually expressed as debilitating pain along the entire length of the spine and even on the body and organs, weak muscle tone, tingling and / or numbness.

Causes of radicular syndrome

• The main cause of radiculopathy is osteochondrosis. But the following factors can make an impetus for the disease:
• poor working conditions and hard physical labor;
• hypothermia of the body;
• heredity;
• flat feet;
• different leg lengths;
• excess weight
• improperly selected shoes;
• lack of proper nutrition.

The following back diseases can also provoke sciatica:

• osteochondrosis;
• intervertebral hernia;
• deforming spondylarthrosis;
• compression fracture of the spine;
• spondylolisthesis;
• spondylosis with marginal osteophytes;
• spinal injury;
• spinal tumors (osteosarcoma, hemangioma, neurinoma, etc.)
• tuberculous spondylitis
• infectious processes in the body
• congenital vertebral anomalies.

Discogenic radiculopathy appears, always, as a result of intervertebral hernias.

The radicular syndrome does not develop immediately, but as a complication after a chain of factors or diseases of the body. Also, there is a possibility of the transition of the disease into a chronic form. In this form, the inflammatory process in the roots will be continuous and will end in loss of sensitivity and loss of functionality, atrophy of muscle mass.

Varieties of radiculopathy

Depending on the location of the affected nerve, several types of sciatica are distinguished:

• Radicular syndrome of the cervical spine - occurs as a consequence of hernia, protrusion or degeneration of the disc, osteoarthritis, foraminal stenosis and other pathologies. Appears unexpectedly.
• radicular syndrome thoracic spine - manifests itself in the chest area. The causes of thoracic radiculitis are degenerative transformations, protrusions and herniated discs, osteoartitis, osteophyte, stenosis. It can be a consequence of infectious diseases, hypothermia, osteochondrosis, trauma or sudden movements.
• Radicular syndrome of the lumbosacral spine is the most common case of the disease. May be chronic. They provoke radiculopathy of this part of the spine, in most cases, destructive processes in the ligaments and joint lesions. May be the result of osteochondrosis, hernia and other diseases.
• Radicular syndrome of the lumbar spine - there are three types of lumbar sciatica: lumbago, luboishelgia and sciatica. The cause of lumbar radiculopathy is improper treatment, arthritis, degenerative changes vertebrae, stenosis, compression fracture, disc herniation and protrusion, spondylolisthesis.
• Mixed radicular syndrome.

There is also a division of the disease depending on the lesion:

• Discogenic radiculopathy is a consequence of the deformation of the cartilage tissue that has grown on the intervertebral discs, which infringes on the root. In the process, the roots become inflamed, causing severe pain and swelling.
• Vertebrogenic radiculopathy is necessarily a secondary disease. It manifests itself in parallel with stenoses that affect the foraminal openings where the nerve roots pass. Under the influence of destructive changes, the path along which the roots move becomes narrower and they are compressed, which leads to impaired blood circulation and swelling.
• Mixed radiculopathy.

This classification of the disease makes it possible to accurately distribute the main features of radiculopathy in each individual patient.

Symptoms - what should I look out for?

The clinical picture of sciatica combines various combinations of symptoms of irritation of the spinal roots and loss of its functionality. The severity of the disease depends on the degree of compression of the roots and on individual characteristics root structures.

There are several nuances of symptoms in sciatica that you should pay attention to:

1. Increasing pain syndrome

• - When moving - walking, changing the position of the body, bending and turning, lifting the leg.
• - From vibration - coughing, laughter, travel in transport.
• - When trying to put pressure on the affected area.

Radiculopathy of the lumbosacral spine, manifested by such features:

• - The combination of pain with the phenomena of paresthesia (tingling, burning, numbness, etc.).
• — Relationship of pain symptom with movements.
• - The presence of areas of muscle seals and scoliosis deformities in the lumbar or lumbosacral region.

What you need to pay attention to to determine the type of sciatica:

1. Pain sensations do not occur in one place, but can “wander” throughout the body. Depending on the location of the pain, it is possible to determine the localization of sciatica:

Radiculopathy of the cervical spine is expressed by the following symptoms:

• - areas of the neck, forehead and temple;
• - shoulder blades and shoulders;
• - hands.

Symptoms of thoracic radiculopathy:

• - pain in the sternum, under the left shoulder blade;
• - back pain.

Symptoms of radiculopathy of the lumbar and lumbosacral regions:

• - lumbar region and sacrum;
• - buttocks and groin;
• - thighs, lower legs.

1. Loss of sensation is a common symptom in radicular syndrome, indicating that the degenerative process in the nerve continues for a long time, and the process of death has begun.
2. Muscle dystrophy is another characteristic symptom of sciatica. And this is a sign that the nerve is already at the final stage of death and the muscles cannot cope with their task, which leads to a violation of the harmony of movement.

If you have these symptoms singly or in a group, you should definitely consult a doctor. This will help to identify the disease in its infancy and prevent complications.

Diagnosis of radiculopathy

In order for the treatment of sciatica to be effective, it is necessary not only to make an accurate diagnosis, but also to determine the source of the problem. Only after examining the patient by a doctor, after analyzing the results of the necessary laboratory tests, and getting acquainted with the results of radiography (a popular and affordable method) or MRI (a very accurate international method - it shows the most informative and detailed result).

It must be remembered that only a qualified doctor can make a diagnosis, confirm it or refute it. And only after that you can begin treatment of radicular syndrome.

Treatment of radicular syndrome

Treatment of sciatica requires serious, competent and properly selected treatment. To eliminate the disease, it is not enough to relieve the symptoms and eliminate the pain, it is also necessary to cure the source of the radicular syndrome.

Treatment is selected individually and depending on the severity of the patient's condition and the results of the research, its complexity and methods may vary:

• — conservative treatment medications - painkillers, non-steroidal drugs, anti-spasm drugs, vitamins of group D, etc.
• — additional treatment– Exercise therapy, reflexology, massage and self-massage, physiotherapy, laser therapy, etc.
• - surgical intervention - is used only in severe cases, when treatment by other methods does not give the desired result or the patient's condition requires drastic measures.

In no case should you self-medicate, all treatment, including methods traditional medicine must be appointed and agreed with a specialist.