Back muscle defence—localization, types and consequences. Viscerovertebral syndrome. Case analysis from clinical practice Neck Muscle Defense
![Back muscle defence—localization, types and consequences. Viscerovertebral syndrome. Case analysis from clinical practice Neck Muscle Defense](https://i0.wp.com/vashaspina.ru/wp-content/uploads/2013/01/boli-spine.jpg)
Defensiveness of the back muscles is an important diagnostic sign that is detected in the tension of the back muscles. This is not an independent disease, but a symptom indicating a variety of pathologies, which is why it is so important for a neurologist to identify the location of such points and determine the severity and degree of tension. In some cases, this process is localized only on one side, but sometimes it is also bilateral.
In most cases, this condition is a protective reaction of the body and appears reflexively, in response to an inflammatory process, pain syndrome, which can be of both vertebrogenic and discogenic nature.
Neck area
Neurologists note that most often muscle defence develops in the cervical spine. Most often this indicates a herniated disc, headache, or simply muscle tissue tension.
In more rare cases, this symptom also indicates other nervous disorders, for example, diagnosed or Strumpel's disease.
Thoracic and lumbar regions
Muscular defence of the back of the thoracic and lumbar region primarily indicates the presence of vertebrogenic pathology. If a symptom is observed only on one side, and its visual assessment is minimal, then we can talk about the spinal column.
In some cases, spasms can reach such a degree that movement is limited. When diagnosing, this symptom must be determined first.
During therapy, the strength of this symptom is also regarded as a criterion for the effectiveness and adequacy of the therapy. Therapy is most often based on taking muscle relaxants, for example, it can be baclosan, mydocalm, sirdalud and many others. But only the attending physician should prescribe these medications and they can only be used in a hospital setting.
Massage, physiotherapy and exercise therapy are also often used in treatment. In most cases, such prescriptions are enough to reduce the load on the spinal column. The exercise therapy complex is selected strictly individually. And here great importance is attached to exercises that are aimed at stretching the muscles of the spine. Gymnastics are carried out only during the period of remission. The first sessions should be carried out only under the supervision of a specialist, but in the future therapy can be continued at home.
However, muscle weakness is just a symptom, one of the manifestations of a particular disease, so therapy should be aimed not only at getting rid of muscle tension, but also at curing the patient of the underlying disease. And since patients often carry out independent treatment, this leads to a deterioration in their general condition and to the fact that the underlying disease becomes so advanced that only surgery can help in its treatment.
Kinds
There are two types of muscle tension: tonic and clonic. With prolonged stress, as well as with fatigue, tonic spasm develops. Most often, this condition occurs in office workers and schoolchildren. The main symptoms are observed in the cervical spine, and the cause of this condition is prolonged exposure to an incorrect or uncomfortable position while working at a desk.
Aching pain spreads to the entire back, but during an exacerbation the patient is able to accurately indicate the location of the pain syndrome. The muscles are hard, spasmodic, and pressing on them only intensifies the pain.
Clonic muscle spasms are rapid contractions of muscle fibers that occur over a short period of time and may or may not be rhythmic.
Consequences
The main consequences of back muscle defence, if left untreated, can be considered:
- Negative effect on the spine, up to its curvature.
- Constant headaches.
- Dryness and laxity of the skin at the site of constant spasm.
This is also often the cause of severe pain, which affects not only well-being, but also performance. With severe pain, a person may lose the ability to move independently for several days.
Defensiveness of the back muscles is an important diagnostic sign that is detected in the tension of the back muscles. This is not an independent disease, but a symptom indicating a variety of pathologies, which is why it is so important for a neurologist to identify the location of such points and determine the severity and degree of tension. In some cases, this process is localized only on one side, but sometimes it is also bilateral.
In most cases, this condition is a protective reaction of the body and appears reflexively, in response to an inflammatory process, pain syndrome, which can be of both vertebrogenic and discogenic nature.
Neck area
Neurologists note that most often muscle defence develops in the cervical spine. Most often this indicates cervical osteochondrosis, a herniated disc, headache, or simply muscle tissue tension.
In more rare cases, this symptom also indicates other nervous disorders, for example, diagnosed multiple sclerosis or Strumpel's disease.
Thoracic and lumbar regions
Muscular defence of the back of the thoracic and lumbar region primarily indicates the presence of vertebrogenic pathology. If the symptom is observed only on one side, and its visual assessment is minimal, then we can talk about scoliotic deformity of the spinal column.
In some cases, spasms can reach such a degree that movement is limited. When diagnosing, this symptom must be determined first.
During therapy, the strength of this symptom is also regarded as a criterion for the effectiveness and adequacy of the therapy. Therapy is most often based on taking muscle relaxants, for example, it can be baclosan, mydocalm, sirdalud and many others. But only the attending physician should prescribe these medications and they can only be used in a hospital setting.
Massage, physiotherapy and exercise therapy are also often used in treatment. In most cases, such prescriptions are enough to reduce the load on the spinal column. The exercise therapy complex is selected strictly individually. And here great importance is attached to exercises that are aimed at stretching the muscles of the spine. Gymnastics are carried out only during the period of remission. The first sessions should be carried out only under the supervision of a specialist, but in the future therapy can be continued at home.
However, muscle weakness is just a symptom, one of the manifestations of a particular disease, so therapy should be aimed not only at getting rid of muscle tension, but also at curing the patient of the underlying disease. And since patients often carry out independent treatment, this leads to a deterioration in their general condition and to the fact that the underlying disease becomes so advanced that only surgery can help in its treatment.
Kinds
There are two types of muscle tension: tonic and clonic. With prolonged stress, as well as with fatigue, tonic spasm develops. Most often, this condition occurs in office workers and schoolchildren. The main symptoms are observed in the cervical spine, and the cause of this condition is prolonged exposure to an incorrect or uncomfortable position while working at a desk.
Aching pain spreads to the entire back, but during an exacerbation the patient is able to accurately indicate the location of the pain syndrome. The muscles are hard, spasmodic, and pressing on them only intensifies the pain.
Clonic muscle spasms are rapid contractions of muscle fibers that occur over a short period of time and may or may not be rhythmic.
Consequences
The main consequences of back muscle defence, if left untreated, can be considered:
- Negative effect on the spine, up to its curvature.
- Constant headaches.
- Dryness and laxity of the skin at the site of constant spasm.
This is also often the cause of severe pain, which affects not only well-being, but also performance. With severe pain, a person may lose the ability to move independently for several days.
Peritonitis is the cause of protective muscle tension in almost 90% of cases.
However, there are non-emergency surgical conditions and diseases that can simulate peritonitis and peritoneal symptoms.
Causes
In simple terms, defence is the tension of the abdominal wall muscles (rectus and oblique), independent of the desires of the patient himself, at the hands of the doctor performing the examination.
Peritonitis is the main cause of defence.
Since the main cause of muscular protective tension is peritonitis, it is necessary to dwell in detail on the diseases leading to the development of this dangerous condition. All these diseases are quite serious and require emergency surgical intervention.
As a rule, peritonitis develops as a result of:
- inflammatory acute diseases of the abdominal organs;
- open and closed injuries, ruptures of hollow organs with spillage of their contents into the cavity;
- circulatory disorders in the intestinal vessels;
- operations on internal organs for chronic diseases;
- for no apparent reason or when infected with blood or lymph;
- any other irritation of the peritoneum by chemical, mechanical and infectious agents;
- inflammatory diseases of the retroperitoneal organs.
Depending on the area of the peritoneum involved in peritonitis, local, widespread and total peritonitis are distinguished. Accordingly, in the first case, the tension of the abdominal muscles will be local, in the projection of the location of the organ affected by the disease. In other cases, the tension may involve most of the abdominals or the entire anterior abdominal wall.
Irritation from the peritoneum is transmitted along the nerve processes to the spinal cord, and from there back to the muscle fibers, which leads to their contraction. The localization of tension will approximately indicate the organ, and the intensity will indicate the degree of damage.
The most striking and indicative symptom of abdominal muscle tension will be when a stomach ulcer or duodenal ulcer is perforated. Then, after the outpouring of gastric juice and food debris into the abdominal cavity, a “chemical burn” of the peritoneum with the acidic contents of the stomach develops and the patient goes into shock. In this case, visually the abdomen is tense, motionless, and upon superficial palpation (palpation) it has a “board-shaped” appearance. Muscle tension will cover the entire surface of the abdomen, less often only the upper section and the right half. In elderly people, due to weakening muscle tone, defence may not be clearly expressed. The clinical picture of a perforated ulcer is quite typical, so the surgeon will immediately prescribe an esophagogastroduodenoscopy, after which the patient will be in the operating room within half an hour.
Other diseases accompanied by abdominal muscle tension
Peritoneal symptoms often accompany diseases of the pancreaticobiliary system.
- So, in case of acute purulent cholecystitis, the doctor will detect a defence in the right hypochondrium, in the area where the gallbladder is located.
- With pancreatitis, the symptom of protective muscle tension will appear in the upper abdomen. The clinician will be assisted by ultrasound examination data or computed tomography of the abdominal organs. On them, a functionalist doctor will detect signs of inflammation in the wall of the gallbladder, stones, swelling or necrosis of the pancreas, and fluid.
- With purulent or destructive appendicitis, defence is typical in the right iliac region with the classic location of the appendix.
It should be noted that in patients of childhood, the elderly or pregnant women, due to physiological characteristics (underdevelopment of the muscular corset, weakness, overextension), defence will be either weakly expressed or absent.
With perforations (perforations) of the intestine against the background of UC, dysentery, Crohn's disease, typhoid fever, diverticulitis, iatrogenic ruptures (after colonoscopic examination or removal of polyps), disintegration of tumors with the formation of a hole in the intestine, as well as with gangrene of the gallbladder or appendix, rupture aortic aneurysm, the clinical picture and muscle tension will be similar to those of a perforated ulcer. Here, an infectious cause of complicated colitis will be indicated by fever, vomiting, nausea, frequent loose stools, often mixed with pus or blood. For an intestinal tumor in advanced stages - weight loss in a short period of time, lack of appetite, anemia (decreased hemoglobin level), high ESR numbers in a blood test, intestinal problems for 6-12 months. The iatrogenic nature of intestinal rupture (during medical procedures) will be suggested by the thought of recently performed endoscopic procedures. A patient with the above conditions clearly requires surgical intervention.
It should be noted that damage to the liver, spleen, kidney, bladder with bleeding into the abdominal cavity, inflammation of the pelvic organs and retroperitoneal space are more difficult to diagnose, since they are not so pronounced when examining and palpating the abdomen. Here, clarifying points will include indications of a recent injury, gynecological and urological examinations, ultrasound of the kidneys, uterus and appendages, urinary tests and samples, and x-ray examinations.
For splenic ruptures, the most typical symptom is the “Vanka-stand up” symptom, when, due to pain, the patient immediately gets up from the couch when trying to lie down. For women with symptoms of abdominal muscle tension, it is imperative to exclude the diagnosis of ectopic pregnancy.
Treatment
All considered organ injuries with bleeding require emergency surgical stopping. Inflammatory diseases without abscess formation - massive antibacterial therapy. Formed purulent foci are also subject to surgical treatment.
Defense may not be determined in cases of intestinal obstruction, strangulated hernia, thrombosis of intestinal vessels with death (necrosis) of a section of the intestine, in old people and women who have given birth many times, against the background of diabetes mellitus, with a gunshot wound to the abdominal muscles or spinal cord injury, after radiation treatment, toxic exposure, in collapse or shock. This is due to initially pronounced bloating or significant loss of muscle tone.
Also, muscle tension can occur outside of illness in people who abuse alcohol, in a stressful situation, after intense training with abdominal stress, or when carrying heavy loads.
Protective tension in the muscles of the anterior abdominal wall is a pathological condition that can only be determined by a doctor upon shallow palpation of the abdomen and is accompanied by a number of pain sensations. As a rule, it indicates diseases requiring surgical treatment. The patient cannot determine and interpret it independently. Therefore, it is logical to contact a professional in case of any questionable abdominal symptoms. After ruling out serious illnesses, antispasmodics can be used.
Ivanova Irina Nikolaevna
Muscle tension
Muscle defence – this is the scientific name for muscle tension in one or another part of the body; it is a fairly common phenomenon. In a normal state, the work of muscle tissue appears as a smooth and elastic surface with equal relaxation or tension. However, there are situations when, for one reason or another, individual muscle fibers or even muscle groups are constantly in a tense, tense state, regardless of the person’s will. This phenomenon is usually called a spasm. It causes discomfort and interferes with a person’s normal life.
What are the dangers of muscle spasms?
A muscle that is under constant tension experiences a deficiency of nutrients, because the nerves and blood vessels are constantly pinched. At the same time, due to the special structure of the human body, namely its circulatory system, not only those muscles that do not receive nutrition can suffer. For example, when the neck muscles are tense, the vagus nerve, which is responsible for the energy-information exchange of the pancreas, is often pinched. Due to this, the pancreas does not produce a sufficient amount of enzymes, and a person faces digestive tract disorders even if he is in full health.
How does muscle defence manifest itself?
Typically, patients with muscle deficiencies report the following problems:
1.Pain in the affected area – aching, pressing, itching;
Also, when examined by a doctor, pain is often noted in the area of the muscles that extend the back and support the scapula. The pain intensifies with palpation of the affected area and brings significant discomfort.
Why do muscle spasms occur?
In most cases, muscle tension occurs due to the following reasons:
1. Osteochondrosis of the spine and its complications (protusion, hernia);
The mechanism of occurrence of muscle spasm has not yet been fully studied, however, several factors are noted that influence the occurrence of muscle spasm:
1.Electrolytic metabolism - scientists have identified a clear connection between the state of hydration of the body and the occurrence of muscle spasms. That is why it is recommended to drink alkaline drinks during intense sports. However, there is no need to overdo it either - excess water also leads to an imbalance of minerals;
Treatment of muscle tension
The treatment algorithm includes not only pain relief, but also an effective course in relation to the cause of the spasm. After all, most often muscle spasm should be considered not as a local manifestation of pain, but as the body’s reaction to constant compression of the nerve roots.
After effective treatment, special attention should be paid to the prevention of such conditions. To do this, you should thoroughly stretch and warm up your muscles before the upcoming physical activity, and also try to do regular gymnastics to keep your muscles flexible.
Abdominal muscle defence
Muscle defence is of great diagnostic importance. However, it can occur not only with peritonitis, but also with other conditions (meningitis, pneumonia, renal colic, diabetic coma, schizophrenia, etc.). You need to be especially careful when muscle defence is detected in the singular, without the other two signs (positive Shchetkin-Blumberg symptom, soreness).
In such cases, the technique of superficial palpation of the abdomen requires some adjustment. It is necessary to position the patient correctly (lying on his back, arms at his sides, slight flexion in the hip and knee joints), be able to distract him and, most importantly, catch the reaction of his face during palpation. Palpation should begin with the least painful area and move towards the greatest pain.
To differentiate muscular defence of peritoneal origin from false muscular defence of non-peritoneal origin (pneumonia, renal colic, etc.), we resort to the following option of deep palpation: after we put our hand on the patient’s stomach and he gets used to it, he is asked to “breathe” with his stomach. The examiner at this time, with each act of breathing, immerses his hand more and more, without much violence, into the “stomach” of the patient.
With muscular defence of peritoneal origin, it is never possible to reach deep with the examining hand, to the posterior wall of the abdomen, but with muscular defence of non-peritoneal origin, as a rule, this is possible. In addition, the proposed version of palpation can be completed by withdrawing the hand, with skillful distraction of the patient, and once again check the truth of the Shchetkin-Blumberg symptom.
Percussion reveals pain throughout the entire abdominal wall, but most pronounced in the projection of the source of peritonitis and where there is dullness of percussion sound, i.e. effusion in the abdominal cavity. In the case of perforated peritonitis or damage to hollow organs, it is possible to detect, but not always, the disappearance or shortening of hepatic dullness. During auscultation, bowel sounds may still be heard.
During digital rectal examination, pain and overhang of the anterior wall of the rectum are noted.
Toxic and terminal phases of acute general peritonitis
In these late, advanced phases of acute generalized peritonitis, the exudate becomes purulent or putrefactive, and the intestinal loops and stomach are distended and filled with a large amount of decomposing contents and gases. In these phases, the nature of the pain syndrome changes. The intensity of the pain decreases somewhat, but it becomes more constant and more painful.
There are complaints associated with impaired passage through the gastrointestinal tract (intestinal paresis): frequent and constant vomiting of intestinal contents, and then “fecal”, hiccups and regurgitation with the release of large amounts of intestinal contents, often with a fecal odor, bloating and non-excretion gases Thirst associated with dehydration becomes a constant complaint of patients.
Protective tension of the abdominal wall - Surgical diseases of the abdominal cavity under the guise of foodborne toxic infection
PROTECTIVE TENSION OF THE ABDOMINAL WALL.
In the process of recognizing an acute surgical disease of the abdominal cavity and differentiating it from acute foodborne toxic infection, the doctor uses many signs. Their value varies. Some are of relative importance, because they can occur with a certain frequency in both the first and second diseases, others claim a leading role. True, the latter also require certain reservations, but their enormous value in recognizing them is generally recognized. We are talking primarily about the protective tension of the abdominal wall, the presence or absence of which often determines the decision on surgical intervention, and therefore on saving the patient’s life. Vomiting, frequent relaxation, retention of stool and gas, difficult or painful urination, rapid pulse, high or low temperature, blood changes - everything is important for the diagnosis, but all of the above gives way to the indicated symptom.
When a duodenal or gastric ulcer perforates, many of the signs we mentioned above may or may not be present. But protective tension in the muscles of the abdominal wall must be required. A board-shaped abdomen will be the first and main sign of perforation. However, as soon as a piece of food plugs the perforation hole from the inside, or some nearby organ, such as the omentum, covers this hole from the outside, the picture is transformed. The acidic juice of the stomach no longer flows into the free abdominal cavity, the pathogenetic meaning of the protective tension of the abdominal wall disappears.
Analyzing a huge number of case histories, we, however, did not get the impression that out of the sum of heterogeneous symptoms used by the doctor, he always singles out the indicated symptom in first place. In a large audience of outpatient physicians, when asked what symptom they consider to be the main one when perforation of an intra-abdominal organ is suspected, the correct answer was not always followed.
It would seem that determining the muscle tension of the abdominal wall is so simple that this issue should not be given so much attention. Unfortunately, it is not! You need to be able to palpate the abdomen. We are not talking about the virtuosity that such luminaries of Russian medicine as V.P. Obraztsov and N.D. Strazhesko achieved. We mean an ordinary practical doctor. Sometimes you are surprised to see how a doctor, burdened with years of practical work and considerable degrees and titles, palpates the abdomen with the tips of his bent fingers, resorting to a technique that can cause deceptive contractions where they really should not be.
To accurately determine the presence and degree of contraction of the abdominal muscles, you need to place both hands flat on your stomach with the entire palmar surface. You should never start an investigation with cold hands and from a place that may seem suspect in the process.
Some great authorities in domestic and foreign medicine attached such importance to this sign and the ability to detect it that they made it dependent on the gift and talent of the observer. Poor mastery of research methodology can negate the value of this characteristic (N. D. Strazhesko). “As painful as it is to see an inexperienced, rough, and ineffective hand,” wrote Mondor, “so pleasant and instructive is the sight of two gentle, dexterous, and skillful palpating hands that successfully collect the necessary data.” “I had,” Mondor further says, “to observe palpation techniques that were amazing in their completeness and subtlety.” Calling for help for differential diagnosis of this leading symptom, the doctor should not imagine that the muscular protection of the abdominal wall is always defined as a plank-shaped abdomen. On the contrary, by “the lightest, most delicate, gradual examination of the abdominal wall (almost stroking) it should cause various gradations of tension, resistance, and rigidity” (B. S. Rozanov).
Having accepted the exceptional diagnostic value of the noted feature as an immutable truth, we still must make a number of reservations. It is in vain to look for tension in the anterior abdominal wall if the patient has retroperitoneal or pelvic appendicitis. There is muscle contraction, but it must be looked for in the proper place and be able to detect it. It is in vain to look for this sign in a patient who is in such a serious condition that his reflexes are lost: this could be a patient with extremely advanced peritonitis, or a severe typhoid patient with a perforated intestinal ulcer; We can encounter this in a decrepit old man, in a seriously mentally ill person, sometimes even in a neuropath.
It is quite natural that both qualitatively and quantitatively the contraction of the muscles of the abdominal wall will differ from the nature of the stimulus that caused this parietomotor reflex. Whether it is an acute chemical irritant in case of a perforated stomach ulcer, or an infectious irritant in case of perforated appendicitis, or spilled blood in case of a disturbed tubal pregnancy, bile or urine - the reaction from the abdominal wall will be different.
In practice, we often limit ourselves to recognizing the fact of muscle tension or muscle defense (defense musculaire), without attempting to detail this most important symptom. Meanwhile, the doctor can often, without going into details, just based on the degree of tension in the patient’s abdominal wall, immediately decide whether he is dealing with acute food intoxication or an acute surgical disease of the abdominal cavity.
The infectious disease specialist on duty at the emergency department does not need to clarify what kind of surgical disease we are talking about. He faces only one question: whether the patient has a picture of an acute surgical disease or not. The immediate impression is of great importance. The impression of “first sight” (A.F. Bilibin, 1967) can often instantly shed light on seemingly ordinary phenomena. Diarrhea and vomiting - these standard symptoms, in the presence of which the doctor resorts to the diagnosis of acute foodborne toxic infection, often lose all their persuasiveness as soon as he looks at the patient’s face, notes his behavior and the degree of tension in the abdominal wall.
On 20/V 1969, we were called by the infectious disease specialist on duty to see a 30-year-old man admitted with a diagnosis of acute food intoxication. The young doctor confidently rejected the referral diagnosis, despite the patient’s repeated vomiting and three bowel movements, on the grounds that the patient’s abdomen was very tense. He was right. At the same time, he replaced one mistake with another, settling on the diagnosis of a perforated stomach ulcer. He did not insist on this diagnosis either, as soon as his attention was drawn to the patient’s behavior: the latter was extremely restless, jumped up, ran around the ward, lay face down, and assumed various bizarre positions. When examining the abdomen, the tension of the abdominal wall was uneven: the right half from top to bottom, to the medial line, was much more sharply tense than the left, and also painless on palpation.
The listed symptoms were quite enough to suspect renal colic, which was later confirmed by urine analysis and chromocystoscopy. Both vomiting and so-called diarrhea lost all their significance as symptoms as soon as attention was paid to the patient’s behavior and the peculiarity of the tension in the abdominal wall.
There is nothing reprehensible if the doctor’s turn of thought is caused by some “trifle”. A small detail can reveal the whole picture and “not only enter into equal communication” with “large” symptoms, but even exceed the significance of the latter (A.F. Bilibin).
We must not forget that the symptom of contraction of the muscles of the abdominal wall can be misinterpreted: we mean a contraction caused by pathological processes of a traumatic or inflammatory nature in the chest and in the retroperitoneal space. Basal pneumonia can give noticeable local muscle tension in the right or left upper quadrant of the abdomen, but on palpation the area of tension will be painless or slightly painful, while muscle tension in the same area in acute cholecystitis will be combined with severe pain on palpation.
Hemorrhage caused by a spinal injury can also cause a reflex, sometimes significant tension in the muscles of the abdominal wall.
From all that has been said, it is obvious that during acute food poisoning, muscle tension does not occur. In cases where an infection from the intestine penetrates to some extent per diapedesin into the abdominal cavity, a motor reflex begins to appear, but it will differ from the strength of the reflex that occurs when the abdominal organ is perforated. In those rare cases when toxic enterocolitis simulates the picture of an “acute abdomen,” the intestinal wall is deeply infiltrated to the subserous layer, riddled with hemorrhages and areas of necrosis. The visceral serous layer covering the intestine reacts accordingly. In these cases, pain and tension in the rectus abdominis muscles and foodborne illnesses appear. If such patients undergo surgery by mistake, the outcome is often very poor. Of the 11 patients observed by G. P. Kovtunovich (1946), 10 were operated on for acute intestinal obstruction; of these, 8 patients died. All 4 patients with a disease of the same nature, described by N. G. Sosnyakov (1957), died after surgery.
Let us give several examples from the case histories we analyzed, in which the diagnosis of acute foodborne toxic infection could be rejected at the first glance at the patient, which, unfortunately, was not done.
A sick young woman, in full health, suddenly felt severe pain in her stomach, from which she almost lost consciousness. She vomited twice and became weak 3 times at short intervals. The stools were mushy in nature. In the emergency department, she fainted several times. Coming to her senses, she complained of excruciating pain in the right hypochondrium and right shoulder joint. The abdomen was somewhat distended, sensitive to palpation, and a mild Blumberg sign was noted. However, the abdominal wall was not tense and the abdomen was easily palpable. It is not difficult to guess that the patient most likely has a disturbed ectopic pregnancy with large hemorrhage in the abdominal cavity. In any case, there was no talk of acute foodborne toxic infection. Many hours passed before the erroneous diagnosis made upon admission was rejected.
A middle-aged patient was admitted 4 hours after the onset of severe abdominal pain, mainly near the navel. He is in serious condition. Constant severe pain does not let him go for a minute, vomiting occurs with every sip of water. He is extremely excited and rushes about. The chair is delayed. Despite this serious condition, the abdominal wall is not tense, it is only slightly rigid, and the abdomen is significantly swollen above the navel. There is no correspondence between the severity of complaints and scanty objective symptoms of the abdomen. You can think about acute pancreatitis, and finally, about some other acute disease of the abdominal organs, but not about food poisoning. In any case, the infectious disease doctor on duty had enough data indicating that he should have consulted with a surgeon before sending the patient to the infectious diseases department.
A healthy young girl was lying in bed reading a book. Turning on her right side to turn off the light, she suddenly experienced severe pain in her lower abdomen, after which she vomited twice and had three loose stools for a short time. The abdominal wall remained soft throughout. During the operation, which was undertaken with great delay, there was torsion of the appendages. Was there at least one symptom of food poisoning here!
A 13-year-old girl developed sharp, severe pain in the epigastric region. There was vomiting several times. Brought to the hospital 3 days later, she complained of diarrhea, which began shortly before admission to the hospital. The abdomen is soft, only above the pubis is tense and sharply painful. Terminal pain when urinating. A digital rectal examination was not performed. During the operation, which was undertaken with a significant delay, pelvic gangrenous appendicitis was discovered.
A 36-year-old man, who drank heavily and ate a lot of all kinds of food, fell ill six hours later. I vomited many times and felt weak several times. However, a day later, when it seemed that the patient’s condition had improved significantly, an unbearable pain suddenly set in in the abdomen, his face became covered with drops of sweat, the patient began to moan loudly and froze in the position in which he was, afraid of the slightest movement. My stomach became hard as a board. The patient turned out to have a perforated duodenal ulcer due to the food intoxication that he fell ill with the day before.
There are more than enough examples like these in the analyzed case histories. The task of the infectious disease doctor on duty in such cases is to question the diagnosis of the referral and, without wasting time, consult with other specialists.
Back muscle defense - localization, types and consequences
Defensiveness of the back muscles is an important diagnostic sign that is detected in the tension of the back muscles. This is not an independent disease, but a symptom indicating a variety of pathologies, which is why it is so important for a neurologist to identify the location of such points and determine the severity and degree of tension. In some cases, this process is localized only on one side, but sometimes it is also bilateral.
In most cases, this condition is a protective reaction of the body and appears reflexively, in response to an inflammatory process, pain syndrome, which can be of both vertebrogenic and discogenic nature.
Neck area
Neurologists note that most often muscle defence develops in the cervical spine. Most often this indicates cervical osteochondrosis, a herniated disc, headache, or simply muscle tissue tension.
In more rare cases, this symptom also indicates other nervous disorders, for example, diagnosed multiple sclerosis or Strumpel's disease.
Thoracic and lumbar regions
Muscular defence of the back of the thoracic and lumbar region primarily indicates the presence of vertebrogenic pathology. If the symptom is observed only on one side, and its visual assessment is minimal, then we can talk about scoliotic deformity of the spinal column.
In some cases, spasms can reach such a degree that movement is limited. When diagnosing, this symptom must be determined first.
During therapy, the strength of this symptom is also regarded as a criterion for the effectiveness and adequacy of the therapy. Therapy is most often based on taking muscle relaxants, for example, it can be baclosan, mydocalm, sirdalud and many others. But only the attending physician should prescribe these medications and they can only be used in a hospital setting.
Massage, physiotherapy and exercise therapy are also often used in treatment. In most cases, such prescriptions are enough to reduce the load on the spinal column. The exercise therapy complex is selected strictly individually. And here great importance is attached to exercises that are aimed at stretching the muscles of the spine. Gymnastics are carried out only during the period of remission. The first sessions should be carried out only under the supervision of a specialist, but in the future therapy can be continued at home.
However, muscle weakness is just a symptom, one of the manifestations of a particular disease, so therapy should be aimed not only at getting rid of muscle tension, but also at curing the patient of the underlying disease. And since patients often carry out independent treatment, this leads to a deterioration in their general condition and to the fact that the underlying disease becomes so advanced that only surgery can help in its treatment.
There are two types of muscle tension: tonic and clonic. With prolonged stress, as well as with fatigue, tonic spasm develops. Most often, this condition occurs in office workers and schoolchildren. The main symptoms are observed in the cervical spine, and the cause of this condition is prolonged exposure to an incorrect or uncomfortable position while working at a desk.
Aching pain spreads to the entire back, but during an exacerbation the patient is able to accurately indicate the location of the pain syndrome. The muscles are hard, spasmodic, and pressing on them only intensifies the pain.
Clonic muscle spasms are rapid contractions of muscle fibers that occur in a short period of time and may or may not be rhythmic.
Consequences
The main consequences of back muscle defence, if left untreated, can be considered:
- Negative effect on the spine, up to its curvature.
- Constant headaches.
- Dryness and laxity of the skin at the site of constant spasm.
This is also often the cause of severe pain, which affects not only well-being, but also performance. With severe pain, a person may lose the ability to move independently for several days.
By the way, you may also be interested in the following FREE materials:
Abdominal muscle defence
Tension of the muscles of the anterior abdominal wall is a symptom most often found in cases of damage to the hollow organs and muscles of the anterior abdominal wall.
When examining a child immediately after an abdominal injury, N. G. Damier (1960) noted increased tension in the muscles of the abdominal wall precisely at the site of the bruise. During laparotomy, the author found a damaged section of the intestine, which, in his opinion, due to paralysis of peristalsis, remains in the place where it was damaged. A distinct tension in the muscles of the anterior abdominal wall was noted by E. S. Kerimova (1963) in 128 adult patients out of 155, of which 105 were diffuse in nature, and local in only 23 patients. Emphasizing the importance and demonstrativeness of this symptom, the author considers it insufficiently complete, since tension often appears only a few hours after the injury (in 53 patients, muscle tension was recorded only 6 hours after the injury).
As our observations show, in children with closed injuries of hollow organs, after several hours from the moment of injury, local tension in the muscles of the abdominal wall disappears and in most patients, diffuse tension is already noted.
Diffuse tension of the abdominal wall was noted in 47 children with various injuries to hollow organs, and 45 of them were admitted to the hospital 1.5 hours or later after the injury. Local tension was noted in 23 patients (11 children from this number were admitted within an hour after the injury and 12 patients later). The discussion about the mechanism of local stress continues to this day.
According to B. S. Rozanov et al. (1960), tension in the abdominal wall is a consequence of rapidly developing peritonitis. However, A. A. Bocharov (1967) believes that this symptom is the result of a protective reaction of the body, ensuring sufficient immobility of the intestines. This assumption, apparently, is most likely in the interpretation of the mechanism of tension of the anterior abdominal wall, since it is difficult to imagine that after an injury the phenomena of peritonitis will have time to develop in such a short time. In 3 children, we did not detect tension in the anterior abdominal wall, which may be due to shock, which developed as a result of concomitant severe combined injuries. Although some surgeons (Leifer L. Ya., 1934; Gaisinsky B. E., Vasilenko D. A., 1956) explain the lack of tension in the muscles of the anterior wall as a result of their paresis, which arose due to overstretching of their fibers at the time of injury, or paresis intestines and increasing flatulence.
At the same time, there are other views on the mechanism of muscle tension in the anterior abdominal wall. Tension of the muscles of the anterior abdominal wall can be caused by a reflex act due to irritation of the intercostal and lumbosacral nerves, i.e., with chest bruises, retroperitoneal hematomas, etc. Therefore, the surgeon’s focus is only on such a seemingly very reliable symptom as Tension of the anterior abdominal wall, considered by many surgeons to be a direct indication for surgical intervention, can sometimes lead to serious tactical errors.
Flatulence in children with damage to a hollow organ
Most authors divide flatulence into early and late. Early flatulence, developing immediately after injury, according to A. P. Krymov (1912), I. N. Askalonov, G. I. Lukashin (1935), N. I. Minin (1939), B. E. Gaisinsky ( 1941), is explained by trauma to the neuro-reflex apparatus* and does not indicate damage to the hollow organs. At the same time, late flatulence, which occurs several hours after the injury, leads the surgeon to think about peritonitis developing in the patient.
Some surgeons (Kerimova E. S., 1963; Mikeladze K. D., Kuzanov E. I., 1965) noted abdominal bloating in adult patients in the first hours after injury. Thus, E. S. Kerimova observed early flatulence in 44 out of 155 patients, and in 21 flatulence occurred within the first 6 hours after damage to various parts of the intestine.
Of the 70 children operated on in the hospital with intestinal injuries, 45 also had symptoms of flatulence, and in the first hours after the injury (up to 6 hours) this symptom was detected in 32 Children and in 13 after 12 hours. Our data show that in children with Damage to hollow organs results in both early and late flatulence.
Muscle tension (muscle defence)
Detection of back muscle tension (muscle defence) is an important diagnostic task. This sign can indicate many different pathological conditions. During a neurological examination of the patient, it is important to indicate the location of the defect and its severity. It is often important to have a one-way process. In general, this symptom develops reflexively in response to the existing inflammatory process, pain syndrome of vertebrogenic or discogenic nature and is a pathological defense reaction of the body.
Neck and collar area
Very often in neurological practice there is tension in the muscles of the neck and collar area. Painful muscle spasm in these areas may indicate that the patient has cervical osteochondrosis, herniated intervertebral discs, headaches, or tension. Sometimes, in the context of other manifestations, this symptom may speak in favor of degenerative diseases of the nervous system, in particular multiple sclerosis, Strumpel's disease.
Thoracic and lumbar region
Muscle tension in the thoracic and lumbar spine indicates, first of all, vertebrogenic pathology. With a unilateral location, as well as minimal visual assessment of the position of the spinal axis, it can be assumed that the patient has scoliotic deformity. Sometimes muscle defence reaches such a degree that limitation of movements in the spine becomes pronounced, which also needs to be noted during the examination.
It is the defence of the muscles of the neck and back that is one of the most important criteria for assessing the effectiveness and adequacy of treatment. As a rule, the prescription of muscle relaxants (baklosan, mydocalm, sirdalud and others), massage procedures (in the absence of contraindications) and physiotherapy are sufficient to solve this problem.
Physical therapy also plays an important component in the treatment of muscle tension. In the exercise therapy complex, the main role in this case is played by stretching exercises for the spinal muscles; during the period of remission, strengthening exercises are also necessary. More detailed measures for the treatment of spinal diseases, which most often lead to this problem, can be found in the relevant articles (vertebrogenic cervicalgia, vertebrogenic lumbodynia, etc.).
If you have a painful muscle spasm, it is important to remember that this is just one of the manifestations of the disease. And therapeutic measures, accordingly, should be aimed at treating the pathology as a whole. While patients themselves often try to cope with this symptom on their own, which ultimately leads to a deterioration in their general condition.
Abdominal muscle defence
MUSCLE PROTECTION SYMPTOM (syn. defense muscles) - a symptom of muscle tension in the abdominal wall. Most often observed and most pronounced in acute inflammatory processes in the abdominal cavity (peritonitis, acute appendicitis, acute cholecystitis, perforated gastric or duodenal ulcer), with penetrating wounds of the abdomen, closed damage to hollow and parenchymal organs. This symptom is less pronounced with bleeding into the abdominal cavity, weakly expressed or absent in acute intestinal obstruction, peritonitis in the pelvis (gynecol, diseases), retroperitoneal processes (retrocecal appendicitis, retroperitoneal hematoma or abscess), damage to the abdominal wall. M. z. With. less pronounced in elderly people, in women who have given birth many times, in patients in a state of shock, collapse, toxemia, exhaustion, as well as in patients after the administration of narcotic drugs or in a state of alcohol intoxication. M. z. With. can also be observed in certain diseases with localization patol, process outside the abdominal cavity (pneumonia, subdiaphragmatic abscess, myocardial infarction, kidney stones, chest trauma).
The emergence of M. z. With. explained by the fact that the irritation that appears in the affected organ and in the adjacent parietal peritoneum is transmitted to the corresponding segment of the spinal cord and from the motor cells of its anterior horns to the muscles innervated by this segment, which come into a state of motor contraction or tension. Thus, muscle tension is the result of a visceromotor reflex (see Visceral reflexes), which causes a kind of immobilization of the abdominal wall and protection of the pathologically altered organ. This can be seen most demonstrably in patients with a perforated ulcer of the stomach or duodenum, when even upon examination a scaphoid-like retracted anterior abdominal wall is visible, and the upper part of the abdomen does not participate in the act of breathing. The plank-like tension of the rectus abdominis muscles leads to immobility of the abdominal wall, paresis of the diaphragm in a state of forced exhalation, which creates conditions of immobilization for a diseased stomach. With diffuse peritonitis, tension of all abdominal muscles is observed. After approximately 12 hours. with local or general peritonitis, muscle tension disappears and the phenomena of bloating begin to predominate.
The value of M. z. With. is that its localization generally corresponds to the location of the diseased organ, and the intensity of the muscle reaction often gives an idea of the severity of the inflammatory process.
In the process of identifying M. z. p., which is carried out, as a rule, in cases of acute processes in the abdominal cavity, all techniques of superficial palpation should be strictly observed (see). With gentle, careful palpation, starting from healthy areas of the abdomen, it is possible to detect even slightly pronounced compaction of the abdominal wall, which makes it possible to diagnose the process in the early stages. With a local process, muscle tension can be limited, with a diffuse process - diffuse.
M. z. With. is only one of the symptoms of acute processes in the abdominal cavity, therefore, even if it is present, a diagnosis of the disease can only be made taking into account medical history, subjective and objective signs, radiological, laboratory and other studies.
Acute stomach
Acute abdomen, what kind of disease is this?
Acute abdomen is a clinical syndrome that develops with injuries and acute diseases of the abdominal organs and retroperitoneal space and requires emergency surgical care. The following main symptoms are typical for an acute abdomen: abdominal pain of varying nature and intensity, muscle tension in the abdominal wall, and intestinal motility disorders.
These diseases, although they may be accompanied by a number of signs of an acute abdomen, are subject mainly to conservative treatment.
The main reasons for the development of acute abdomen:
1. Acute nonspecific inflammatory diseases of the digestive system. The most common acute inflammatory processes are observed in the appendix, gall bladder, and pancreas.
2. Perforations of a hollow organ, most often occurring as a result of various diseases or injuries of the abdominal organs and leading to the development of peritonitis.
3. Internal bleeding into the abdominal cavity and retroperitoneal space, occurring spontaneously (for example, rupture of the fallopian tube during tubal pregnancy or dissecting aneurysm of the abdominal aorta) or due to trauma (traumatic ruptures of the liver, spleen, mesenteric vessels, etc.).
4. Intestinal obstruction resulting from intestinal volvulus, nodulation, intestinal strangulation in an internal or external hernia, obstruction, intussusception, compression of the intestine by adhesions.
Acute disorders of mesenteric circulation (arterial and venous), leading to intestinal infarction.
6. Acute inflammatory processes and circulatory disorders of the internal genital organs (acute adnexitis, torsion of the tumor stalk or ovarian cyst, necrosis of the uterine myomatous node or ovarian tumor, etc.).
Symptoms of acute abdomen:
The leading symptom is pain, localized or spreading throughout the abdomen, usually aggravated by movement. In case of extensive and severe lesions that cause the occurrence of an acute abdomen, for example, traumatic ruptures of the abdominal organs, widespread hemorrhagic pancreatic necrosis, the pain syndrome is pronounced and may be accompanied by the development of shock. In young children, especially with malnutrition, in elderly patients, in exhausted patients, with a decrease in the body's reactivity and severe intoxication, pain is insignificant.
Sometimes persistent, painful hiccups are observed, which is usually associated with irritation of the phrenic nerve. The so-called phrenicus symptom (sharp pain when pressing between the legs of the sternocleidomastoid muscle) usually occurs due to irritation of the nerve endings of the phrenic nerve by exudate, spilled contents of the gastrointestinal tract or blood. The so-called vanka-stand-up symptom has the same origin - a sharp increase in abdominal pain when trying to take a horizontal position, and therefore remains in a sitting or semi-sitting position.
Diagnosis of acute abdomen:
In diagnosis, a significant role is played by the study of complaints, characteristics of the anamnesis and the course of the disease. Indications of past attacks of abdominal pain, information about previous diseases and operations, and the results of previously performed diagnostic and therapeutic measures may be of great importance. Important data can be obtained by examining the patient and monitoring him. Thus, diffuse peritonitis and massive bleeding into the abdominal cavity are characterized by the patient’s immobile position in a certain position (often on the side with the legs brought to the stomach), since the slightest movement causes sharp pain.
Treatment of acute abdomen:
A patient with suspected “acute abdomen” should be immediately hospitalized in a specialized institution. Transportation of patients in serious condition must be fast, safe, and gentle. It is necessary to provide for the possibility of carrying out therapeutic measures aimed at stabilizing hemodynamic disorders at the prehospital stage.
Forecast:
The prognosis depends on the nature and severity of the underlying disease, as well as on the period elapsed from the onset of the disease to the patient’s admission to the hospital, his age and concomitant diseases. The prognosis is unfavorable for advanced common forms of peritonitis, intestinal obstruction with extensive necrosis, thrombosis of mesenteric vessels, especially in the elderly and senile. The sooner a patient is hospitalized with acute abdominal syndrome, the sooner an accurate diagnosis is made and adequate (including surgical) treatment is carried out, the lower the mortality rate and the better the immediate and long-term results.
Acute abdomen: what is it, symptoms, treatment, causes, signs
Acute abdomen refers to surgical diseases of the abdominal organs that threaten or lead to the development of peritonitis, as well as intraperitoneal bleeding.
The concept of “acute abdomen” is collective, but it has great practical significance. This concept has a certain generality, but the doctor should not limit himself to a formal appeal to this concept, but try to get closer to the presumable particular diagnosis and set rational indications for surgery.
The term "acute abdomen" evokes a mental image of a patient suffering from sudden, sharp abdominal pain, which may be accompanied by vomiting. The patient is surrounded by doctors, anxiously deciding whether to take him to the operating room. However, acute abdominal pain can manifest itself in many different diseases and conditions, and further management of the patient depends on the diagnosis.
It should be borne in mind that it is not the severity and strength of symptoms that determine the diagnosis of acute abdomen. For example, in acute appendicitis, especially in the case of a retrocecal location of the appendix, the symptoms may be mild, but acute appendicitis is classified as an acute abdomen. On the contrary, with renal colic with reflex tension of the abdominal wall, a very severe clinical picture is observed, but renal colic does not belong to the acute abdomen, since it does not threaten the development of peritonitis.
Acute abdominal syndrome usually includes the following diseases: acute appendicitis, phlegmonous cholecystitis, pancreatitis, peritonitis; perforation of the gallbladder, perforated ulcer of the stomach and duodenum, dissecting aneurysm of the abdominal aorta, thrombosis and embolism of mesenteric vessels, bleeding into the abdominal cavity and some other rare syndromes. It should be remembered that the symptom complex of an acute abdomen, its peculiar “mask,” can be observed with diaphragmatic pleurisy, lower lobe pneumonia and the gastralgic form of myocardial infarction.
Differential diagnosis of acute abdomen
Depending on the clinical picture, the list of diseases that can cause an acute abdomen can be lengthy or short. For example, a 12-year-old boy with diffuse abdominal pain, which after some time intensified and concentrated in the right iliac region, most likely has acute appendicitis; although Crohn's disease or mesadenitis are also possible. On the other hand, severe mid-abdominal pain in a 65-year-old man with ascites may indicate, among other things, primary (spontaneous bacterial) peritonitis, intestinal ischemia, perforation of a gastric or duodenal ulcer, and rupture of an abdominal aortic aneurysm - to name just a few of the possible causes. .
Symptoms of "acute abdomen"
The clinical picture of acute abdomen is varied and depends on the nature of the developing disease. The main symptom is abdominal pain. It is a wrong idea that with an acute abdomen the pain is always sharp and severe. For example, with acute appendicitis, the pain is often less intense; its intensity increases in the case of a sharp reaction from the peritoneum.
The abdominal press is most often tense; palpation reveals increased sensitivity of the skin. To take into account the reaction of irritation of the parietal peritoneum, one should use the Blumberg-Shchetkin symptom, which is very well known in clinical practice: the pain that the patient experiences when gently pressing the hand on the abdomen over the area of inflammation intensifies if the hand is quickly withdrawn.
The abdomen in the initial period may be non-bloated, even retracted, and not tense (for example, with strangulation ileus). As irritation of the peritoneum develops, it becomes tense and swollen. The tension is especially pronounced with perforation of a gastric or duodenal ulcer; as intestinal paresis develops due to peritonitis, the abdomen becomes swollen and less tense. In the case of peritonitis, percussion in the sloping parts of the abdomen reveals dullness (effusion); Auscultation indicates absence of peristalsis.
It is necessary to remember about examination through the rectum and vagina, which makes it possible to palpate the infiltrate, hematoma, invaginated area of the intestine, and also establish local pain.
Body temperature is often (but not always) elevated. The presence and degree of temperature increase depend on the nature of the disease and the addition of peritonitis. The facial expression is usually pained, the face is haggard, with sunken eyes and sharpened features. Breathing is not free; the patient usually spares the stomach; deep breaths increase pain. The pulse may initially be rare, but with the development of intoxication and peritonitis it becomes more frequent.
Although acute abdominal syndrome is generally recognized and its most characteristic features are well known, it is recommended in all cases, based on a carefully collected history, objective signs and dynamics of the disease, to strive to establish a nosological (local, anatomical) diagnosis. Then a lot becomes clearer in understanding the characteristics of the symptoms of acute abdomen in each case, and it also seems possible to make a more specific solution to the issues of surgical treatment of the patient.
Anamnesis
Nature of pain. Pain is an invariable symptom of an acute abdomen. It can be of three types, which can be observed separately or in combination.
- Visceral pain is caused by stretching of the abdominal organs or their inflammation. This pain is diffuse and difficult to localize. It is aching, burning or cramping in nature.
- Somatic pain occurs when the abdominal wall, parietal peritoneum, root of the mesentery or diaphragm are affected. It is more intense and more clearly localized than visceral pain.
- Referred pain is felt in an area distant from the affected organ, but this area is in the same zone of innervation of the spinal roots. Referred pain is usually sharp and clearly localized, which is similar to somatic pain.
The pain may begin suddenly or develop gradually over several minutes or even hours. Sudden severe pain occurs, for example, with perforation of a gastric or duodenal ulcer, rupture of a hollow organ, spontaneous pneumothorax, dissecting aortic aneurysm.
Vomit. An acute abdomen is often accompanied by vomiting of varying severity. As a rule, in diseases requiring surgical treatment, pain occurs before vomiting, but if vomiting precedes pain, then the disease is treated conservatively. In some cases, for example with intestinal obstruction, repeated vomiting is observed. With prolonged obstruction, vomiting may acquire the smell of feces due to the spread of colon microflora above the site of obstruction. Hematemesis indicates that the source of bleeding is above the ligament of Treitz.
Other data. A history of gastrointestinal disease is an indication that the patient's condition may be caused by this disease. If the patient has previously undergone surgery on the abdominal organs, the cause of abdominal pain may be an adhesive process. Alcohol abuse may result in pancreatitis or cholelithiasis.
Physical examination
Basic physiological indicators. A high temperature indicates sepsis, which may be due to inflammation or infection in the abdominal cavity. In acute abdomen, tachycardia is usually observed. Blood pressure may also be elevated, but hypotension may occur in shock caused by viscus perforation or septic syndrome.
- Position of the patient. A patient with peritonitis most often lies motionless, with his knees bent. In acute pancreatitis, the patient cannot lie on his back and tries to assume the “fetal position.” With acute cramping pain, the patient rushes about and cannot find peace.
- The abdomen may be enlarged with ascites or intestinal obstruction. In thin patients with complete obstruction through the abdominal wall, increased intestinal motility may be noticeable. Cyanosis of the lateral surface of the abdomen (Gray Turner's sign) or around the navel (Cullen's sign) may indicate pancresmecrosis or a terminated ectopic pregnancy.
Auscultation. With complete or partial intestinal obstruction, peristalsis is enhanced, and intestinal sounds are ringing and increase and decrease in waves. With intestinal paresis caused by peritonitis, electrolyte disturbances, severe inflammatory process (toxic megacolon, pancreatitis), prolonged intestinal obstruction, peristalsis is sluggish or absent. During auscultation, vascular and friction sounds can also be heard. A vascular murmur may indicate an aortic aneurysm, while a friction murmur may indicate a splenic rupture or a ruptured liver tumor.
Percussion. With bloating caused by intestinal obstruction or toxic megacolon, a tympanic sound is detected. Percussion helps to determine the boundaries of the liver and identify enlargement of other organs.
- With an acute abdomen, palpation is usually painful. Peritonitis, both diffuse and local, is characterized by muscle tension in the anterior abdominal wall. Local tenderness on palpation sometimes makes it possible to make a diagnosis. To determine the Shchetkin-Blumberg symptom, gently press on the abdomen with one or two fingers, and then sharply remove the hand. Severe pain at this moment indicates inflammation of the peritoneum. For many patients, this is a very painful procedure, so it should not be repeated unnecessarily during subsequent examinations. It should be remembered that in elderly or seriously ill patients, the signs of peritonitis may be mild.
- Careful palpation can also reveal enlarged organs or space-occupying lesions. A pulsating mass in the mid-abdomen may be an abdominal aortic aneurysm. In Crohn's disease, a painful mass formation is often detected in the right iliac abdomen.
Digital rectal examination and pelvic examination can provide valuable information. It is possible to identify tumors, infiltrates, abscesses, and urinary tract infections.
Examination and treatment
Laboratory research.
When making a diagnosis and during treatment, blood and urine tests are performed.
General blood analysis. An acute abdomen is characterized by leukocytosis, especially in the presence of inflammation or infection. With septic syndrome, viremia and during treatment with immunosuppressants, leukopenia is possible. Low hematocrit and hemoglobin levels indicate chronic anemia or recent internal bleeding or rupture of a blood-filled internal organ. Thrombocytopenia may increase gastrointestinal bleeding; it is also observed in sepsis. Malignant neoplasms can be accompanied by both thrombocytosis and thrombocytopenia.
Serum electrolyte levels (sodium, potassium, chloride, bicarbonate) as well as calcium and magnesium levels should be measured regularly because fluid and electrolyte disturbances may develop in patients with an acute abdomen.
If the patient's condition is serious, constant monitoring of blood glucose control is also indicated.
Serum amylase activity may increase in acute pancreatitis, intestinal obstruction and intestinal ischemia, as well as in diseases that do not give a picture of an acute abdomen, for example, diseases of the salivary glands, renal failure, macroamylasemia.
An increase in the level of bilirubin, the activity of AST, ALT and alkaline phosphatase is observed in diseases of the liver or biliary tract. Increased ALP activity may be an early sign of extrahepatic or intrahepatic bile duct obstruction.
General urine analysis. Possible leukocyturia in acute pyelonephritis or hematuria in urolithiasis.
ECG. Performed on all patients to assess their condition and to identify possible changes characteristic of myocardial infarction.
Radiation diagnostics.
A chest x-ray is required. It allows you to identify pneumonia, pulmonary embolism, accumulation of free gas under the diaphragm, expansion of the mediastinal shadow (a sign of dissecting aneurysm). Plain radiography of the abdomen in a standing and lying position can detect fluid levels in the colon and small intestine, free gas in the abdominal cavity, and calcifications. An abscess or other mass formation can displace intestinal loops. Pronounced dilatation of the intestine is observed with intestinal obstruction and toxic megacolon.
Ultrasound, CT, cholescintigraphy with iminodiacetic acid derivatives and excretory urography can provide valuable additional information.
Diagnostic laparocentesis
In some cases, examination of ascitic fluid or fluid previously injected into the abdominal cavity can help make the diagnosis. Leukocytosis indicates the presence of infection; Culture of ascitic fluid in these cases often gives positive results. An admixture of blood may indicate bleeding from the abdominal organs, organ infarction, or pancreatic necrosis. Amylase activity is increased in intestinal infarction and pancreatitis.
The safest site for inserting a needle during laparocentesis is in the midline of the abdomen 2 cm below the navel. There are few vessels passing through this area of the abdominal wall, but there is a danger of touching a distended bladder. The midline approach cannot be used if there is a postoperative scar in the midline of the abdomen. In this case, laparocentesis is safer and more reliable, performed using a peritoneal dialysis catheter, which is inserted through an incision on the side of the midline of the abdomen.
Treatment
It includes general treatment for all patients and specific treatment, the choice of which depends on the diagnosis.
General treatment. In acute abdomen, intravenous fluids, complete fasting (“nothing by mouth”), and, in most cases, aspiration of gastric contents through a nasogastric tube are indicated to decompress the stomach and prevent air from entering the intestines. Sometimes a long probe is additionally inserted to decompress the intestine. It is important to carefully monitor the amount of fluid administered and urine output. As discussed above, continuous monitoring of serum electrolyte and BAB levels is necessary.
Specific treatment depends on what causes the acute abdomen. One of the most important decisions a doctor must make is whether a patient needs surgery. If a hollow organ ruptures, immediate surgical intervention is required. Surgery is also necessary for intestinal ischemia caused by a heart attack or mechanical compression of the intestine, which has already led or threatens to lead to necrosis. Some inflammatory diseases also require surgical intervention, including acute appendicitis, pancreatic necrosis, gangrenous cholecystitis, toxic megacolon, if conservative treatment within 24-48 hours has not been successful. Finally, diseases such as acute cholecystitis or acute diverticulitis can be treated conservatively, but elective surgery is possible in the future.
Acute appendicitis
The most common form of acute abdomen (60-70% of cases). Clarification of the anatomical form (catarrhal, purulent) is of no practical importance, since one form can transform into another, and the diagnosis of catarrhal appendicitis demobilizes the practitioner. A diagnosis of “acute appendicitis” is quite sufficient, which is an indication for urgent surgery.
Clinical picture. The pain at first is diffuse in nature, often appearing in the first hours in the epigastric region (which can be the cause of diagnostic errors). After a few hours, when the inflammatory process spreads to the parietal peritoneum, the pain is localized in the right lower quadrant of the abdomen or in the right iliac region. The pain is often very persistent, sometimes paroxysmal; accompanied by nausea, sometimes vomiting.
To confirm the diagnosis, it is important to identify objective symptoms of abdominal pain: the appearance of pain with deep pressure at the Mac Burney point - in the middle of the line connecting the navel with the right upper iliac spine; Sitkovsky's symptom - increased pain when the cecum is displaced towards the navel when the patient is positioned on the left side.
The blood picture (leukocytosis, neutrophilia with a shift to the left, accelerated ROE) has an important diagnostic value. Sometimes leukocytosis is absent, but a characteristic shift in the leukocyte formula (occasionally to metamyelocytes) is evident. The presence of toxigenic granularity of leukocytes indicates an inflammatory process, and its high degree ++++) indicates suppuration and peritonitis.
Serious importance should be given to temperature and pulse. The temperature is usually in the range of 38-39, often low-grade; pulse is frequent. The symptom of discrepancy between temperature and pulse (frequent pulse at low or even normal temperature) is important in the diagnosis of acute appendicitis. The weakening or even cessation of pain while the remaining symptoms of appendicitis tend to increase does not indicate the elimination of the process, but rather the threat of perforation of the suppurating appendix. With the retrocecal location of the process, palpation pain and muscle protection are localized - laterally and posteriorly.
In children, acute appendicitis can occur in an atypical manner and often develops very rapidly, leading to suppuration and perforation within a few hours.
It is necessary to differentiate from the onset of acute colitis, exacerbation of chronic typhlitis, chronic gastritis, from acute cholecystitis, renal colic, thrombosis of the mesenteric arteries, and some gynecological diseases (right-sided ectopic pregnancy, adnexitis, torsion of the pedicle of the right ovarian cyst).
Treatment. The tactics of the attending physician in acute appendicitis are very important. Delaying the operation under various pretexts (“appendicular colic”, “catarrhal form”, “favorable course”) can cost the patient his life. If infiltration develops with a delayed diagnosis, after consultation with a surgeon, a wait-and-see approach is followed. Vigorous antibiotic therapy is prescribed. However, if the infiltrate leads to the development of phlegmon (high temperature, leukocytosis), it is necessary to operate immediately.
Acute intestinal obstruction (ileus)
Intestinal obstruction due to mechanical obstruction or functional reasons (dynamic obstruction). Mechanical causes: tumors in the intestinal lumen or compression of the intestine by a tumor of other organs, foreign bodies, helminths, fecal stones, perivisceritis, intussusception, volvulus, strangulation of intestinal loops in the hernial sac and some others. Dynamic obstruction is reflexive in nature and is associated with damage to the abdominal organs (intestinal paresis with peritonitis, pancreatitis, renal colic, etc.) or even more distant ones (with severe myocardial infarction, some lesions of the nervous system, severe infectious diseases, etc.). P.).
Clinical picture. With dynamic obstruction, peristaltic sounds are not heard, gases do not escape; nausea, vomiting mixed with bile. If the cause of paretic obstruction is myocardial infarction, there is usually a typical clinical picture of the underlying disease, a characteristic electrocardiogram, increased activity of aminotransferases and lactate dehydrogenase; with pancreatitis - high levels of diastase in the urine and amylase in the blood, left-sided skin pain zone of Kacha. Often paralytic ileus occurs during peritonitis, which leads to a diagnostic error: the doctor does not see the abdominal wall tension characteristic of peritonitis and diagnoses only paretic ileus.
Mechanical obstruction is characterized by severe paroxysmal abdominal pain, intermittent swelling (ridge) in the area of intussusception, muscle protection, bloating, and vomiting. The most dangerous form of mechanical obstruction is strangulation ileus, since its development is accompanied by damage to the mesentery (necrosis due to circulatory disorders and a sharp decrease in nutrition of the intestinal wall). With obstruction localized in the small intestines (high obstruction), cramping pain is noted in the upper half of the abdomen and in the navel, bloating, rumbling and transfusion in the intestines during painful contractions. Sometimes feces are released from the lower intestines (especially after an enema), which should not lead the doctor’s mind away from the diagnosis of obstruction. In advanced cases - profuse vomiting of bile, fecal vomiting. X-ray (do not give enemas before X-ray examination!) Kloiber's cups are determined. With obstruction localized in the large intestines (low obstruction), cramping pain below the navel, nausea, a feeling of fullness, Val's symptom (limited protrusion of the abdominal wall in the area of a visible peristaltic intestinal loop), sometimes increased peristaltic noise. In some cases, the stomach is generally soft. For the diagnosis, an increase in intoxication, failure to pass gas, pain, dry tongue, and erythremia due to blood thickening (the latter is associated with increased exudation into the intestinal lumen) are important. Next comes profuse “never-ending” vomiting. Frequent pulse and leukocytosis are observed only in the second stage, when irritation of the peritoneum develops.
Treatment. In case of dynamic obstruction - prozerin, carbocholine under the skin, 10 ml of 10% sodium chloride solution into a vein again. Evacuation of gastric contents through a thin tube, followed by careful gastric lavage. For mechanical obstruction, early surgery. In the first stages, you can try subcutaneous administration of 1 ml of 1% atropine solution (morphine is contraindicated!), siphon enema, turning the patient from side to side, on the stomach, on the back, perinephric novocaine blockade. In case of obstruction due to helminth infestation, deworming is required, but in case of large balls of helminths, surgery is necessary. Fecal stones can often be removed with a finger or using a siphon enema.
Acute peritonitis
Develops due to purulent appendicitis, phlegmon of the appendiceal infiltrate, perforation of a stomach and duodenal ulcer, phlegmon of the gallbladder and its perforation with a stone, acute pancreatitis, breakthrough of intestinal ulcers in typhoid fever, tuberculosis, lymphogranulomatosis, strangulated intestinal obstruction, etc., as well as by hematogenous route from extraperitoneal foci (with pneumonia, gonorrhea). In weakened patients with ascites, the latter often becomes infected; in such cases, ascites-peritonitis develops.
Clinical picture. In the first hours, sharp abdominal tension and local pain are noted (corresponding to the localization of the organ that is the source for the development of peritonitis). Subsequently, the pain becomes diffuse, the abdomen is tense (muscular protection), respiratory immobility of the abdominal wall, delay in the passage of gases and feces; gradual development of the picture of paralytic obstruction. The most characteristic features are high body temperature, phenomena of increasing severe intoxication, persistent vomiting, rapid pulse, dry tongue, severe thirst, drop in blood pressure (Hippocrates’ face, sometimes the correct diagnosis can be made by facial expression); in the blood there is hyperleukocytosis with sharp neutrophilia, left shift and toxic granularity of neutrophils (++++). We must always remember that treatment with antibiotics changes the clinical picture: a decrease in body temperature, a prolonged course, and periods of apparent improvement are observed.
Treatment. Immediate surgery. Before being sent to a surgical hospital, the patient is administered cardiac and vascular drugs (camphor, cordiamine, strophanthin, etc.). Drugs, enemas and laxatives are contraindicated.
Thrombosis and embolism of the mesenteric artery
Occurs in older and older people due to atherosclerosis; may be a complication of rheumatic carditis, heart defects, acute and prolonged septic endocarditis. As a result of thrombosis (embolism), necrosis occurs in the area of the intestine fed by the branch of the affected vessel; the process can spread to the peritoneum.
Clinical picture. Acute onset with the appearance of sharp abdominal pain, collapse, vomiting; often bloody stools (exclude dysentery); picture of obstruction: retention of stool and gases, flatulence, muscle, protection, increased body temperature. Neutrophilic leukocytosis.
Treatment. Urgent hospitalization in a surgical hospital. Anticoagulants; for rheumatic etiology - antirheumatic therapy. In case of symptoms of peritoneal irritation and peritonitis or obstruction, urgent surgery is required.
Neurological complications in spinal osteochondrosis
The first stage of neurological complications in spinal osteochondrosis
Clinical manifestations at the first stage of neurological complications of osteochondrosis are caused by protrusion of the IVD back towards the spinal canal and irritation of the posterior longitudinal ligament, rich in pain receptors.
The main manifestation of this stage is local pain syndrome. The features of this syndrome depend on the location of the damaged SMS, which is reflected in the name of the variants of the clinical syndrome. If it manifests itself at the lumbar level, it is designated as lumbago, lumbodynia, if at the cervical level - cervicago, cervicalgia, if at the thoracic level - thoracalgia. Thoracalgia due to osteochondrosis is rare, since the thoracic spine is inactive.
Along with local pain at the level of the affected SMS, due to a reflex muscle reaction, in the first stage there is a pronounced tension ("defense") of the paravertebral muscles, which leads to increased pain and flattening, smoothing of the cervical or lumbar physiological lordosis (depending on the location of the pathological process ), as well as limited mobility of the spine. In the acute period, defense of the paravertebral muscles can be considered as a defensive reaction.
When examining a patient, pain in the spinous processes and paravertebral points may be detected at the level of manifestations of discopathy and IVD protrusion. Depending on the characteristics of the level of damage to the PDS, the clinical picture in the first stage of neurological manifestations has some specific signs:
- Cervicago - cervical lumbago. It is characterized by acute pain in the neck, provoked by head movements, tension of the neck muscles due to irritation of the receptors of the ligamentous apparatus of the cervical spine. Cervicago lasts, with immobilization of the cervical spine and adequate treatment, usually 7-10 days.
- Cervicalgia - severe pain and paresthesia in the cervical spine due to irritation of the receptors of the meningeal branches of the spinal nerves. On examination, there is pronounced tension in the neck muscles, fixation of the head, pain in the spinous processes of the cervical vertebrae and paravertebral points, which can persist for 2-3 weeks.
- Lumbago or lumbodynia. Conventionally, they differ from each other in the degree of severity and duration of pathological manifestations. Characterized by flattening of the lumbar lordosis (board symptom) and a pronounced limitation of movements in the lumbar spine due to pain in the acute period.
In the first stage of neurological manifestations in osteochondrosis, there are no signs of radicular syndrome and, as a rule, tension symptoms are negative.
Over time, adaptation occurs to irritation of the pain receptors of the posterior longitudinal ligament. The extinction of the pain syndrome in cervicalgia and lumbodynia is facilitated by the immobilization of the affected SMS. Pain, which usually occurs acutely or subacutely, with compliance with the orthopedic regimen and adequate treatment, gradually decreases. In this case, the exacerbation of the pathological process is transformed into a stage of remission, which can last indefinitely.
Exacerbations of cervicalgia or lumbodynia may recur. Each exacerbation indicates an additional displacement of the IVD (its protrusion or prolapse), leading to increased pressure on the posterior longitudinal ligament, which over time leads to its thinning and decreased strength. During the next episode, which provokes additional prolapse of the IVD towards the spinal canal, perforation of the posterior longitudinal ligament occurs, which leads to the development of the second stage of neurological complications in osteochondrosis.
The second stage of neurological complications in osteochondrosis or the stage of discogenic radiculitis
The posterior longitudinal ligament undergoes perforation more often in the area of the thinned edge (“where it is thin, it breaks”), and not in its central, most durable part. Thus, posterolateral IVD herniation occurs more often than posteromedial (median) herniation.
As a result of perforation of the posterior longitudinal ligament, prolapsed IVD tissue penetrates into the epidural space, often in the dorsolateral direction, that is, close to the intervertebral foramen and the spinal roots and radicular arteries passing through it. In such cases, the disc can directly irritate the spinal roots and spinal nerve, causing radicular syndrome at the level of the affected spinal segment.
However, among the causes of pathological effects on the spinal roots, not only mechanical factors are important, but also biochemical and immunological ones. They are caused by the reaction of the tissues of the epidural space to the penetration of a fragment of IVD cartilaginous tissue into them that forms a hernia. The cartilage tissue found in the epidural space performs the functions of an antigen in such cases. As a result, a focus of aseptic autoimmune inflammation appears in the epidural space. In such cases, the nerve roots are also involved in the inflammatory process. This allows us to explain the often occurring prolongation of pain in the second stage of neurological complications in osteochondrosis. This stage can be called radicular stage or stage of discogenic radiculitis .
The term "radiculitis" was used a long time ago, when most diseases of the peripheral nervous system were recognized as a consequence of infectious damage to the nerve roots. Later, when this version was rejected, it caused heated debate for some time, but with the recognition of the development of epidural aseptic inflammation in discogenic pathology, the term “sciatica” was rehabilitated and again gained recognition, although the interpretation of its essence has undergone fundamental changes.
In each case of discogenic radiculitis, certain radicular symptoms are characteristic:
- Neri's symptom: passive forward tilt of the head in a patient lying on his back causes a pain reaction at the level of the affected SMS. However, in the case of lumboischialgia or ischioradiculitis, involuntary flexion of the affected leg at the hip and knee joint also occurs simultaneously.
- Dejerine's symptom: the appearance or intensification of pain at the level of the pathological focus when coughing, sneezing or straining. If in the first stage of neurological complications of lumbar osteochondrosis the pain is mainly median and local, then in the second stage it is more often lateralized and radiates along the corresponding spinal roots and peripheral nerves.
Thus, the second (radicular) stage of neurological complications in spinal osteochondrosis is characterized by pain at the level of the affected SDS and radicular symptoms, usually homolateral to the side of the protrusion of the disc herniation .
Irritation of the posterior spinal roots and spinal nerve causes radicular pain, which radiates to the area of the corresponding dermatome, myotome, sclerotome and is accompanied by reflex tension of the corresponding muscles. The radicular symptoms that arise in this case are characterized by specificity due to the localization of the affected SDS: cervicoradicalgia, thoracoradicalgia or lumboradicalgia.
Cervical sciatica
A manifestation of cervicoradicalgia, or cervical radiculitis, with osteochondrosis of the cervical spine can be, often occurring, secondary neuralgia of the occipital nerves. It is characterized by constant, sometimes sharp pain in the occipital region, caused by irritation of the occipital nerves, formed from fibers passing through the cervical spinal nerves C II - C III. In this case, patients usually fix their head, slightly tilting it back and to the side.
With neuralgia of the greater occipital nerve, the pain point is located on the border of the middle and internal third line connecting the mastoid process and the occipital protuberance; with neuralgia of the lesser occipital nerve, the pain point is usually detected behind the sternocleidomastoid muscle at the level of its upper third (Kerer's point).
Cervical radiculitis with osteochondrosis is a consequence of compression of the spinal roots or spinal nerves, as well as the result of the development of local aseptic autoimmune epiduritis at the same level. The presence of cervical radiculitis can be confirmed by: irradiation of pain in the zone of irritation of the spinal roots, the appearance of symptoms of loss of functions against the background of cervical radicalgia (hypoesthesia with elements of hyperpathy in the occipital region, features of the hypoesthesia zone, decreased muscle strength, and with prolonged, chronic pain syndrome - and their hypotrophy).
With vertebrogenic cervical or cervicothoracic radiculitis, Sperling's symptom may be positive: tilting the head towards the affected roots leads to increased pain due to an increase in radicular compression in the area of the intervertebral foramina.
Often, with cervical osteochondrosis, complicated by manifestations of cervicalgia and cervical radiculitis, which is in remission, nocturnal dysesthesia of the hands occurs (Wartenberg brachialgia, Putman-Schultz nocturnal brachialgia) - pain, dysesthesia, paresthesia that arise in the area of the SDL-Sush dermatomes during sleep and disappear with active movements of the hands. Nocturnal hand dysesthesia most often occurs in women during menopause. Regarded as a consequence of brachial plexus strain or secondary hemodynamic disorders. The course of this clinical syndrome can take on a chronic relapsing nature and last for years.
Sometimes, with cervical osteochondrosis with symptoms of radicalgia or cervical radiculitis, along with a reflex muscular-tonic reaction, vegetative-trophic disorders occur, which, in particular, can manifest themselves in the form of glenohumeral periarthritis (frozen shoulder syndrome or Dupleix syndrome). Chronic glenohumeral periarthritis in combination with edema and other vegetative-trophic changes in the area of the hand and wrist joint is known as the “shoulder-hand” syndrome (Steinbrocker syndrome). It is often regarded as a neurodystrophic and vegetative-vascular syndrome in cervical osteochondrosis.
Lumbosacral radiculitis
In clinical practice, lesions of the spinal roots and spinal nerves are more common in lumbar osteochondrosis, since protrusion of the intervertebral disc predominantly occurs at the lumbar level.
The second stage of neurological manifestations in osteochondrosis of the lumbar spine is characterized by lumboradicalgia or lumbosacral radiculitis, especially often manifested in the form of lumboischialgia or ischioradiculitis.
In this case, lateralized lumbar pain is observed, usually combined with pain radiating along the sciatic nerve, that is, lumbar ischialgia syndrome, or ischioradiculitis, occurs. This is due to the fact that of the SMS at the lumbar level, the most vulnerable are the lower ones, which bear a particularly large load, and therefore the roots and spinal nerves L4-S1 are most often involved in the pathological process.
If with lumbodynia there is usually a straightening of the lordosis at the level of pain, then with lumboischialgia scoliosis is also characteristic, often with a convexity towards the irritated roots. In both cases, patients strive for immobilization of the lumbar spine. With lumbodynia, patients spare mainly the lower back, with lumbar sciatica - also the sore leg. In cases of lumboischialgia, patients also prefer to keep the sore leg semi-bent at the hip and knee joints.
When examining a patient with lumbosacral radiculitis, areas of the body that are painful when pressed can be identified - Hara’s pain points. The anterior point of the Hara is located slightly below the navel on the midline of the abdomen (pressure is transmitted to the anterior surface of the L5 vertebra and the adjacent intervertebral discs), the posterior point of the Hara is above the transverse processes of the L4-L5 vertebrae, the iliosacral is above the joint of the same name, the iliac - above the posterior superior spine of the iliac crest. In addition, Haar's pain points are present in the Achilles tendon area (pain when squeezing it) and on the heel (painful tapping on the heel with a neurological hammer).
Vale's pain points identified during lumbosacral radiculitis should also be taken into account. They are located in the middle of the gluteal fold, between the ischial tuberosity and the greater trochanter (the place where the sciatic nerve exits the small pelvis), at the superoposterior iliac spine, in the middle of the back of the thigh, in the popliteal fossa, behind the head of the fibula, in the middle of the gastrocnemius muscle, behind the external condyle, at the infero-posterior edge of the outer ankle, on the dorsum of the foot in the area of the first metatarsal bone.
Domestic neurologists Ya. M. Raimist and V. M. Bekhterev described the following pain points for lumbosacral radiculitis: Raimist’s pain points - detected by lateral pressure on the spinous processes of the lumbar vertebrae; medioplantar ankylosing spondylitis pain point - in the middle of the plantar surface of the foot.
As a rule, with lumboischialgia, one of the main symptoms of tension is positive - the Lasegue symptom. To identify this symptom, the patient is placed on his back with his legs straightened, then one and then the other leg, straightened at the knee joint, is bent at the hip joint. In this case, on the side of lumboischialgia, pain occurs or sharply intensifies along the sciatic nerve and in the lumbar region. In such cases, it is usually taken into account at what angle relative to the horizontal plane it is possible to raise this leg. If after this the same leg is bent at the knee joint, the pain decreases or disappears. At the same time, hip flexion becomes possible to a much greater extent.
The symptom of sitting is also very demonstrative in ischioradiculitis: the patient lying on his back cannot sit up on the bed, while keeping his legs straight at the knee joints, as pain arises or intensifies along the sciatic nerve, and reflex flexion of the lower leg occurs on the side of ischioradiculitis.
In cases of lumbosacral radiculitis, when trying to sit up in bed from a supine position, the patient rests his hands on the bed, behind the body (tripod symptom, or Amoss symptom).
V. M. Bekhterev (1857-1927) established that with lumbar sciatica, a patient sitting in bed can often stretch out the sore leg, but only after bending the leg on the healthy side at the knee joint (Bekhterev’s symptom with lumbar sciatica). It is also known that if a patient with lumboischialgia sits in bed, then passive pressing of the knee on the side of the pathological process is accompanied by an involuntary abduction of the body back (symptom of abduction of the body).
With ischioradiculitis, in the case of dysfunction of the L5 motor nerve root or the motor portion of the spinal nerve, the standing patient cannot, leaning on the heel, straighten the foot, cannot walk, leaning only on the heels, since the foot hangs down on the affected side (Alajuanin-Turel symptom) .
With lumbosacral radiculitis and ischioradiculitis, pathological influences on the nerve roots and spinal nerves can cause not only their irritation, but also a disruption in the conduction of nerve impulses along their constituent nerve fibers. This is manifested by a decrease in the strength of the muscles innervated by the affected spinal nerve, suppression of tendon (myotatic) reflexes due to a violation of their reflex arc. Thus, when the upper lumbar spinal roots (L2-L4) and the femoral nerve are involved in the process, a decrease in the knee reflex occurs, and with ischioradiculitis, the Achilles reflex occurs. Moreover, along with movement disorders, paresthesia, hypalgesia, sometimes with elements of hyperpathia, anesthesia, and sometimes disturbances in the trophism of denervated tissues are possible in the corresponding dermatomes.
With discogenic lumboischialgia, the pelvis of a standing patient is in a horizontal position, despite the presence of scoliosis. When there is a curvature of the spine of another etiology, the pelvis is tilted and is at one angle or another relative to the horizontal plane (Vanzetti's symptom). In addition, with lumboischialgia, bending the torso of a standing patient towards the affected side does not lead to a decrease in the tone of the lumbar muscles on this side, as is normally observed, however, it is usually accompanied by increased pain in the lumbar region and along the sciatic nerve (Rothenpieler's symptom) .
Normally, in a standing position with support on one leg, relaxation of the ipsilateral and tension of the contralateral multifidus muscle is noted. With lumboischialgia, relying only on the affected leg is not accompanied by relaxation of the ipsilateral multifidus muscle on the affected side, and both the contralateral and ipsilateral multifidus muscles are tense - a symptom of ipsilateral tension in the multifidus muscle of Ya. Yu. Popelyansky.
When examining a patient with lumboischialgia in a standing position, on the affected side, a lowered position, smoothness, or disappearance of the gluteal fold (Bonnet sign) is noted, caused by hypotonia of the gluteal muscles. Due to hypotonia and hypotrophy of the gluteal muscles on the affected side, the intergluteal gap, especially its lower part, is warped and shifted to the healthy side (Ozechowski’s gluteal symptom).
In case of damage to the spinal roots or the spinal nerve S1, the sciatic and tibial nerves, the patient cannot walk on tiptoe, since on the affected side the foot drops onto the heel. In this case, hypotension and hypotrophy of the calf muscle are possible (Barre's symptom in ischioradiculitis). In such cases, some laxity of the Achilles tendon is noted on the affected side, which, as a rule, is somewhat widened and flattened, and the posterior malleolar groove is smoothed (Oppenheim's symptom). In this case, a loss or decrease in the Achilles reflex from the heel tendon is detected - Babinsky's symptom in ischioradiculitis. Described by a French neurologist ^|. VaYnzK!, 1857-1932.
If a patient with damage to the S 1 roots and the corresponding spinal nerve kneels on a chair and his feet hang down, then on the healthy side the foot “falls” and forms approximately a right angle with the anterior surface of the leg, and on the affected side the foot is in a plantar position. flexion and a similar angle turns out to be obtuse (Wechsler's symptom). In patients with a similar pathology, hypoesthesia or anesthesia in the 5m zone of the dermatome on the side of the pathological process can be noted - Sabo's symptom (Srabo).
To differentiate lumbodynia and lumbar ischialgia in osteochondrosis of the lumbar spine, you can use L. S. Minor’s test. When performing this test for lumbodynia, the patient tries to get up from the floor, first kneeling, and then slowly rises, resting his hands on his hips and sparing the lower back. With lumboischialgia, the patient, when getting up, first of all rests his hands and healthy leg on the floor, while the affected leg is set aside and maintains a half-bent position all the time. Thus, the patient first sits down, resting his hands on the floor behind his back, then leans on the healthy leg bent at the knee joint and gradually assumes a vertical position with the help of the same hand. The other hand makes balancing movements at this time. When a patient with lumboischialgia has already stood up, the sore leg still does not perform a supporting function. It does not touch the floor with the entire sole, but mainly only with its anteromedial part. If a patient with lumboischialgia is asked to rise on his toes, then his heel on the affected side turns out to be higher than on the healthy side (Minor's symptom, or Kalitovsky's high heel symptom).
If the pathological process manifests itself mainly in the II-IV lumbar SMS, which happens infrequently, the pain radiates along the femoral nerve. In this case, there may be a decrease in the strength of the muscles - hip flexors and leg extensors, loss of the knee reflex, decreased sensitivity in the corresponding dermatomes, and the symptoms of Wasserman and Matskevich tension are usually positive.
Wasserman's symptom is checked as follows: the patient lies on his stomach; The examiner strives to maximally straighten the patient’s leg on the affected side in the hip joint, while at the same time pressing his pelvis to the bed. With a positive Wasserman sign, pain occurs on the anterior surface of the thigh along the femoral nerve.
Matskevich's symptom is also caused in a patient lying on his stomach by sharp passive flexion of his lower leg. Pain in this case, as in Wasserman syndrome, occurs in the area of innervation of the femoral nerve. With positive symptoms of Wasserman and Matskevich tension, the pelvis usually spontaneously rises (a symptom of the Russian neurologist V.V. Seletsky).
Of particular practical interest when examining patients with lumbosacral radiculitis is the symptom of stretching and push back. When checking this symptom, a patient with lumbosacral radiculitis hangs for a while, holding the crossbar of a horizontal bar or gymnastic wall with his hands, and then lowers himself to the floor. If the disease is caused by discogenic pathology, then while hanging from your arms, pain in the lumbar region may weaken, and when lowered to the floor, it may intensify. In such cases, the domestic neuropathologist A.I. Zlatoverov, who described this symptom, considered the treatment of the patient using the traction method to be promising.
Exacerbations of the second stage of neurological manifestations in osteochondrosis, alternating with remissions of varying duration. can be repeated many times. After 60 years, ossification of the ligamentous apparatus leads to a gradual limitation of the range of motion in the spine. Exacerbations of discogenic radiculitis are becoming less and less common. Lumbar pain that occurs in older people is more often associated with other causes, and in differential diagnosis, first of all, one should keep in mind the possibility of developing hormonal spondylopathy and metastases of malignant tumors in the spine.
However, with radiculitis caused by osteochondrosis of the spine, it is possible to develop disturbances in the blood supply to the nerve roots, spinal nerves and spinal cord, as well as the development of cerebral vascular pathology. In such cases, we can talk about the development of the third and fourth stages of neurological disorders in osteochondrosis.
The third, vascular-radicular, stage of neurological disorders in spinal osteochondrosis.
Vascular-radicular conflict
Ischemia of the corresponding roots or spinal nerve in patients with spinal osteochondrosis, complicated by the formation of an IVD hernia and the occurrence of occlusion of the corresponding radicular artery, leads to the development of movement disorders and to impaired sensitivity in a certain myotome and dermatome.
The development of paresis or paralysis of muscles and sensory disorders is usually preceded by an awkward or sudden movement, followed by short-term acute pain in the lumbosacral region and along the peripheral, often sciatic, nerve (“hyperalgic crisis of sciatica”), and muscle weakness immediately occurs. , innervated by the ischemic spinal nerve. At the same time, sensory disorders occur in the corresponding dermatome. Typically, in such cases, occlusion of the radicular artery occurs, which passes into the spinal canal along with the L5 spinal nerve. In this case, the acute development of the syndrome of “paralytic sciatica” is characteristic.
The syndrome of “paralytic sciatica” is manifested by paresis or paralysis on the affected side of the extensors of the foot and fingers. With it, a “stepping” (“stamping” or “cock” gait) occurs, which is characteristic of dysfunction of the peroneal nerve. While walking, the patient raises his leg high, throws it forward and at the same time slams the front of the foot (toe) on the floor. “Paralytic sciatica”, which occurs as a result of circulatory disorders in the S1 radicular artery, is observed less frequently in spinal osteochondrosis with symptoms of discopathy. Acute ischemia in the spinal roots and spinal nerves at other levels is extremely rarely diagnosed.
The fourth stage of neurological manifestations in spinal osteochondrosis
Osteochondrosis of the spine can cause disruption of blood flow in the largest radicular arteries involved in the blood supply to the spinal cord, and in this regard, called radicular-spinal or radiculomedullary arteries. The number of such arteries is very limited and disruption of hemodynamics in them leads to a disruption of the blood supply not only to the spinal nerves, but also to the spinal cord. Disturbances in the blood supply to the spinal cord and cauda equina caused by a herniated intervertebral disc can be recognized as the fourth stage of neurological manifestations in osteochondrosis .
If the functions of the radicular-spinal arteries at the cervical level are disrupted, the patient may develop a clinical picture of cervical dyscirculatory myelopathy, which in its clinical picture resembles the manifestations of the cervical-superior-thoracic form of amyotrophic lateral sclerosis.
In 80% of people, the blood supply to the lower thoracic and lumbosacral levels of the spinal cord is provided by only one large radicular spinal artery - the artery of Adamkiewicz, which penetrates the spinal canal along with one of the lower thoracic spinal nerves. In 20% of people, in addition, there is an additional radicular-spinal artery - the Deproge-Hutteron artery, which often enters the spinal canal along with the fifth lumbar spinal nerve. The blood supply to the caudal spinal cord and cauda equina depends on it. The functional insufficiency of these arteries can cause the development of chronic cerebrovascular insufficiency of the spinal cord, manifested in the form of intermittent claudication syndrome. This is characterized by weakness and numbness of the legs that occurs during walking, which may disappear after a short rest.
The most severe manifestation of the fourth stage of neurological disorders in spinal osteochondrosis, complicated by the formation of an IVD hernia, must be recognized as acute disorders of the spinal circulation such as spinal ischemic stroke.
Possible, sometimes dangerous, manifestations of complicated cervical osteochondrosis include hemodynamic disorders of varying severity in the vertebrobasilar region.
Page 2 | total pages: 4 |
Name " Defanotherapy" comes from the French word defence - tension, and therapy - treatment, that is, the treatment of tension.
In the 19th century, specialists in the treatment of the spine were called chiropractors, in the 20th century - chiropractors. 21st century - the era of DEFANOTHERAPY!
The main element of defanotherapy is the traction-impulse effect on the spine. Eliminating not only pain, but also the cause of its occurrence is the principle of this method.
Pathological muscle tension - defence - is signaled much earlier than pain. The defanotherapist identifies this deviation and “removes it,” relieving the patient of future pain, as well as often long-term and not always harmless drug treatment.
Particular attention should be paid to the spine upon reaching 40 years of age. From this point on, a person’s height, due to everyday and traumatic wear and tear of the spine, decreases by an average of one centimeter every ten years. Without drugs, hormones and operations, it is the defanotherapist who can slow down this process, and with it the general aging of the body associated with a sharp decrease in a person’s vital activity, more successfully than other specialists today.
It is especially clearly revealed advantage of defanotherapy before the practice of long-term artificial stabilization of the patient’s body, dating back to the Middle Ages, as a means of treating advanced scoliosis. Defanotherapist is not limited to putting deformed fragments of the spine “in place.” He creates (with the help of the patient!) a natural symmetrical musculoskeletal corset on the damaged area, forcing the reserve potential of his body to serve the patient.
It is through finding and assessing foci of pathological tension (defense) of the paravertebral muscles that the defanotherapist makes a diagnosis and gives a prognosis for the prospects of healing. For example, first degree scoliosis is removed in 2-3 sessions, second degree - in 5-6 sessions over 3-6 months, third - in 6-8 sessions over a period of 9 to 14 months.
Defanotherapy scheme does not boil down to what an outside observer records. Looking does not mean seeing. This method of treatment consists not only in manual manipulation, but also in the interaction of the consciousnesses and energy of the defanotherapist and the patient.
Curable diseases
- Scoliosis, kyphosis of the first, second and partially third degree;
- Lumbodynia, thoracalgia, cervicalgia (pain in the lower back, thoracic spine, neck) arising for the following reasons: pathological (painful) myofixation (subluxation) of a certain vertebra due to injury or degenerative (osteochondrotic) changes in the intervertebral disc, radiculitis, intervertebral disc herniation, coccygenia (pain in the tailbone);
- Headache of osteochondrosis origin, including tension headaches in children and adults and headaches in women that appeared after the birth of a child;
- Shoulder periarthrosis, arthrosis of the hip-femoral joint up to the second degree, arthrosis of the knee joint up to the second degree, flat feet in children.
The essence of the technique
Defanotherapy technique consists of three sections:
- Impact on the osseous-ligamentous apparatus of the spine using an original method in order to normalize the spinal motion segment.
- Impact on a muscle or muscle groups using massage or other reflexology methods.
- Formation of the patient’s muscular corset through the use of special (autopsychophysical) exercises.
- The therapeutic effect is achieved by a defanotherapist in two or three sessions. High effectiveness of treatment with painlessness is achieved due to the fact that the manipulation is performed in two planes, and the manipulation of a chiropractor in one.
- Effective treatment of scoliosis and kyphosis is possible only using defanotherapy;
- It is known that manual therapy sessions are accompanied by pain in many cases, but manipulation using the defanotherapy method is painless.
- Only in the defanotherapy technique, simultaneously with the restoration of movement in the spine, the patient’s own muscular corset is formed.
- Works on the biokinetics of statics and motility of the human body show that the spine and limbs are a single biokinetic chain, if one link is disrupted, the remaining links will necessarily undergo changes, therefore defanotherapy uses an integrated approach.
Defanotherapy- an original, highly effective and humane system of correction and restoration of health through painless non-surgical effects on the patient’s spine, muscles and psyche in order to activate (with his direct participation) the internal forces and resources of the body.