Vertebrogenic lumboischialgia. Damage to nerve roots and plexuses Diagnosis m 54.4 transcript
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Vertebrogenic lumboischialgia is a syndrome that develops with problems in and denotes two main manifestations of the syndrome - pain in the lumbar region, radiating to the legs.
Information for doctors: according to ICD 10, vertebrogenic lumboischialgia (left, right or both sides) is encrypted with code M 54.4. According to the ICD 11 system, the diagnosis code is ME94.20. The diagnosis should include information about the stage of the process and the severity of the syndromes.
Symptoms of the disease
The diagnosis of vertebrogenic lumboischialgia is established when there is X-ray confirmation pathological process in the lumbar region, as well as detailed clinical picture of the disease, including the following symptoms:
- Pain in the lumbar region, radiating to one or both legs.
- Lower back muscle tension.
- Leg cramps.
- Numbness and crawling sensation in the legs.
- Weakness in the legs with severe pain.
- Limitations of trunk rotation in the lumbar region.
- The need to get up from a lying position with support on your hands ().
Diagnosis of the disease should include a complete neurological examination. A neurological examination confirming the presence of lumboischialgia (positive symptoms of tension, decreased reflexes from the involved leg, etc.) may also reveal radiculopathy, the presence of which will be an indication for consultation with a neurosurgeon.
Treatment of lumboischiaglia
Treatment should be approached comprehensively, using all possible means of therapy, including non-drug physical therapy, physical therapy, massage, and orthopedic devices.
Drug treatment includes the prescription of drugs acting on all links of a vicious circle: a problem in the spine causes inflammation, which in turn leads to pain and reflex muscle spasm, muscle spasm brings the vertebrae closer to each other and increases compression of the involved spinal roots, which increases inflammation - the circle closes.
Anti-inflammatory drugs must be used in adequate dosage in the acute period, unless there are strict contraindications (intolerance, severe peptic ulcer disease). If it is impossible to prescribe anti-inflammatory therapy, they resort to centrally acting painkillers (catadolon, finlepsin, Lyrica, etc.). Drugs that reduce muscle spasms, as well as prevent leg cramps, which improves the patient’s quality of life, are called muscle relaxants; neurologists most often use mydocalm and sirdalud, less often - baclosan and other drugs. Also, do not forget about the need for neuroprotective drug therapy. It necessarily includes B vitamins (in the absence of allergies), thioctic acid (Berlition), microcirculation correctors (Trental), etc.
Among the physiotherapeutic procedures, one should resort to diadynamic currents, electrophoresis with local analgesics, and magnetic therapy. A contraindication to the appointment of procedures is the presence of gynecological, oncological and decompensated somatic pathologies.
In the acute period, in the presence of pronounced syndromes, exercise therapy exercises are prescribed to stretch the muscles. Light pressure is used on the spine; if pain occurs, the exercise is suspended. During the recovery stage and for the purpose of prevention, exercises are prescribed to strengthen the muscular corset of the lumbar region, which can reduce the load on the spine, improve microcirculation and tissue nutrition.
- Massage for vertebrogenic lumboischialgia should include not only an impact on the lumbar region, but also on the legs. The massage should not lead to significant pain, but some discomfort may occur, especially in the first sessions. The basis of the massage effect for vertebrogenic pathology is kneading, which allows you to relieve muscle spasm, strengthen flabby muscles, and improve the nutrition of spinal tissues.
Among orthopedic products, it should be noted the need to wear a semi-rigid or rigid corset on the lumbosacral spine. The corset is worn no more than 4-5 hours a day. Also, a person who has developed a pathology at least once in his life should not forget about wearing a corset during upcoming heavy physical activity. Also, for vertebrogenic lumboischialgia, you can use various massagers, Lyapko and Kuznetsov applicators, orthopedic sleep products, etc.
IMPORTANT! The persistence of pain localized in the area of the hip and knee joints after complete treatment of vertebrogenic lumbar sciatica is a reason to conduct an X-ray examination of the joints and seek advice from a rheumatologist.
The clinical picture of the disease is expressed by sharp pain in the lower back, which occurs during any physical activity, intense or not. Sometimes it is enough for a person to cough or sneeze for a lumbago to occur in the back, after which it is impossible to straighten up.
With lumbago, the pain syndrome is localized in a small area of the lower back; if the pain radiates to other parts of the body, below the belt, the disease is said to be accompanied by sciatica.
The attack can last several minutes or hours. Usually men are affected by the problem, but symptoms of sciatica often appear in women as well.
What causes lumbago
The main reason is deformation, displacement of intervertebral discs or vertebrae, which causes pain and spasm due to stimulation of nerve endings.
Discs and vertebrae are damaged and displaced during intense physical activity, injury, and heavy lifting.
Such displacement can also be caused by ordinary osteochondrosis or intervertebral hernias, hypothermia, diseases of bones and joints.
In rare cases, the cause of the disease is congenital disorders of the musculoskeletal system. Even less commonly, the problem occurs due to various tumors in the spine or rheumatism.
The cause of lumbago with sciatica can be increased body weight due to metabolic disorders or during pregnancy, which results in increased pressure on the spinal column.
Symptoms
The main symptoms of lumbago include:
- Severe pain that looks like a prostration in the lower back. Often the pain is pulsating, tearing, piercing in nature and is observed in the back muscles. If pain symptoms appear in the thigh or buttock, then sciatica is observed, which is associated with pressure on the sciatic nerve. The pain is most severe within half an hour, then subsides, but may recur at night. Usually the attack goes away completely within a few days.
- Muscle spasm of the lower back appears reflexively against the background of pain, often it looks like tension in the muscles of the thigh or buttock. Upon palpation, you can find that the muscles are dense.
- Reduced mobility of the joints of the spine also causes symptoms of the disease; pain prevents a person from moving, so he is forced to freeze in one position, leaning forward a little. Any attempts to move lead to acute pain. A person cannot move either independently or with outside help.
Due to severe pain, a person is forced to spend a long time in two positions that help him survive the symptoms of the disease:
- lying on your back with your knees bent;
- lying on your stomach with a pillow.
If the disease is accompanied by sciatica, the nature of the pain changes, it becomes aching and sharp, shooting deep into the bones, muscles and ligaments.
It can not only radiate to the lower parts of the body, but cause numbness, tingling, and burning in some areas. Sciatica usually affects the lower back and radiates to one leg.
Lumbago requires treatment, otherwise symptoms of the disease will occur every time you experience hypothermia, heavy lifting, or awkward movements.
Drug treatment
Medications for treatment can only be prescribed by a doctor; in some cases tablets are prescribed, in others injections.
Therapy does not eliminate the main causes of lumbago with sciatica (displacement, deformation of the vertebrae or intervertebral discs), drug treatment relieves the inflammatory process, eliminates pain and spasm that are caused by compression of the nerve roots.
Treatment is usually carried out with:
- aspirin;
- ibuprofen;
- diclofenac;
- dimexide.
Additionally, the doctor may prescribe tranquilizers and drugs with a sedative effect. Injections, which act much faster than tablets, are prescribed for acute, unbearable pain.
Physiotherapy
As physical therapy, the doctor prescribes exercises that relieve the main symptoms of lumbago. In different periods of the disease, exercises differ in intensity:
- In the acute period of the disease, which is characterized by 1–2 days after the onset of the attack, it is necessary to perform only light movements (rotations) with the feet and hands, lying on your back, on a flat surface. You can also raise your arms up and bend your legs alternately at the knees, or move them to the sides in a horizontal position. The exercises are performed slowly.
- Starting from the 3rd day for the next 4, it is recommended to perform exercises that lead to tension in the muscles of the buttocks and abdominal muscles. It is also necessary to lift the lumbar region and move the bent knees to the sides. The exercises are also performed while lying on your back.
- In the subacute period, which occurs after a few weeks, the symptoms of the disease are relieved by a set of exercises that increases blood circulation in the lumbar region. At the same time, spasming muscles should be stretched. In this case, you can perform exercises using your legs, arms and shoulders while lying on your back, raising and lowering them.
Physiotherapy
An integrated approach to the treatment of lumbago includes physiotherapeutic procedures, which the doctor recommends starting after the acute burning pain subsides. Treatment is usually carried out with:
- magnetic therapy;
- diadynamic therapy;
- amplipulse therapy;
- ultraviolet irradiation;
- electrophoresis;
- relaxing baths.
The doctor may also prescribe manual therapy, acupuncture, reflexology, and acupressure.
What you can do at home
Treatment of lumbago at home comes down to preventive measures that help relieve pain and prevent the occurrence of new attacks.
- for periods of acute pain, maintain a forced position, lying on your back with bent legs or on your stomach with a pillow. This position helps relax the large muscles of the lower back and reduce pain. Once the attack begins, it is best for the patient not to move for several hours;
- use painkillers prescribed by your doctor;
- use ointments and gels to relieve pain and inflammation;
- wear a woolen elastic belt that fits tightly around the lower back. This compression of the lower back muscles helps reduce swelling and acts on the skin receptors with spreading heat;
- stick to a diet, reducing the consumption of foods that retain fluid in the body;
- engage in physical therapy, which perfectly helps with lumbago with sciatica.
Under such an unpronounceable name as vertebrogenic lumboischialgia, there is a very common problem - pain in the lumbosacral spine. The pain radiates to the buttocks and back of the legs. In rare cases, it even reaches the fingers.
The common ICD-10 code is M54.4. Additional numbers can be used by doctors to clarify the patient's condition.
Pain in the back, called dorsalgia in international practice, manifests itself in various ailments of the musculoskeletal system. Many people are beginning to notice similar signs, especially males over 40 years of age. Often, a doctor cannot correctly diagnose a combination of diseases such as lumbago and sciatica, and this leads to incorrect treatment.
Sciatica is a disease that affects the sciatic nerve or nerve endings located close to the sacral spine. A sick person experiences significant pain in the hip area, extending to the ankle.
Gradually, lumbago is added to progressive sciatica. This disease is characterized by lumbago - acute attacks with pain that begin with even minor irritation of the nerve endings. This condition requires accurate diagnosis, since it can be caused by completely different pathological processes. They should be identified and treated.
Vertebrogenic lumboischialgia is a syndrome manifested by severe pain. It can affect either one of the parties or both parties at the same time. Pain varies in nature and intensity. It can be caused by some visible factors, and sometimes it can be spontaneous, appearing for no apparent reason.
Often the pain flares up only on the right or left, that is, on one side. Gradually spreads into the buttock and leg. A person has great difficulty straightening his limb. He tries to take care of it, tries not to step on the foot completely. As a result, he begins to limp. Even while standing, the patient does not find the opportunity to put his leg in such a position that it does not experience any load.
Causes and symptoms of the disease
Vertebrogenic lumboischialgia usually begins for the following reasons:
- osteochondrosis in the progression stage, hernias, osteophytes;
- intervertebral arthrosis;
- osteoporosis, vertebral scoliosis;
- congenital problems with the vertebrae;
- tumors in the lumbar region;
- tumors of internal organs;
- problems with blood circulation in the lumbar region;
- muscle lesions;
- lumbar injuries, including after incorrectly performed injections;
- rheumatoid tissue diseases;
- infections leading to damage to nerve trunks.
Causes such as age, obesity, multiple pregnancies, constant stress, incorrect posture, heavy physical labor, and frequent hypothermia also contribute to the onset of the disease.
In addition to pain, the following symptoms may occur with the disease:
- fever - not in all patients;
- itching of the skin in the area of the affected nerve;
- paleness of the skin and its coldness;
- in particularly severe cases, a person is unable to control urination and bowel movements.
An attack of lumboischialgia on the right or left (or on both sides) can last from a minute to a much longer time - more than a day. The attack may recur on the same day, or may not make itself felt for several months.
What treatment methods are used to combat the disease?
The doctor diagnoses the patient with lumboischialgia according to the international classification based on the following studies:
- X-ray of the spine;
- MRI and CT of the spinal column, if necessary, blood vessels and joints;
- Ultrasound of the peritoneum;
- blood tests for possible infectious and autoimmune diseases.
Vertebrogenic lumboischialgia is treated comprehensively. This includes the use of medications, physiotherapeutic procedures, physical therapy, and the use of orthopedic devices. During the acute period, the doctor tries to ease the pain. The patient needs bed rest. He takes nonsteroidal anti-inflammatory drugs, various analgesics, and muscle relaxants. Physiotherapeutic procedures are carried out, and sometimes reflexology is used. Once the acute phase passes, the task of restoring the back muscles appears. During this period, therapeutic exercises and massage begin. The patient is recommended to be treated by a chiropractor.
For patients with the chronic form, an individual treatment regimen is selected. Dangerous diseases such as tumors and infections must be excluded. In this case, physical activity increases, non-drug methods are used: exercise therapy, weight loss, massage.
Lumboischialgia can also be treated surgically, but very rarely. About 90% of all patients return to health with the help of conservative treatment. Surgery is used, for example, if pain cannot be relieved by therapeutic methods.
RCHR (Republican Center for Health Development of the Ministry of Health of the Republic of Kazakhstan)
Version: Clinical protocols of the Ministry of Health of the Republic of Kazakhstan - 2017
Pain in the thoracic spine (M54.6), Pain in the lower back (M54.5), Other dorsalgia (M54.8), Sciatica (M54.3), Lumbago with sciatica (M54.4), Lesions of the thoracic roots, not classified in other sections (G54.3), Lesions of the intervertebral discs of the lumbar and other parts with radiculopathy (M51.1), Lesions of the brachial plexus (G54.0), Lesions of the lumbosacral plexus (G54.1), Lesions of the lumbosacral roots, not classified elsewhere (G54.4), Cervical root lesions not elsewhere classified (G54.2), Radiculopathy (M54.1), Cervicalgia (M54.2)
Neurology
general information
Short description
Joint Care Quality Commission approved
Ministry of Health of the Republic of Kazakhstan
dated November 10, 2017
Protocol No. 32
Damage to nerve roots and plexuses can have both vertebrogenic(osteochondrosis, ankylosing spondylitis, spondylolisthesis, ankylosing spondylitis, lumbarization or sacralization in the lumbosacral region, vertebral fracture, deformities (scoliosis, kyphosis)), and non-vertebrogenic etiology(neoplastic processes (tumors, both primary and metastases), damage to the spine by an infectious process (tuberculosis, osteomyelitis, brucellosis) and others.
According to ICD-10 vertebrogenic diseases are designated as dorsopathies (M40-M54) - a group of diseases of the musculoskeletal system and connective tissue, in the clinic of which the leading one is pain and/or functional syndrome in the area of the trunk and extremities of non-visceral etiology [ 7,11
].
According to ICD-10, dorsopathies are divided into the following groups:
· dorsopathies caused by spinal deformation, degeneration of intervertebral discs without their protrusion, spondylolisthesis;
· spondylopathies;
· dorsalgia.
Damage to the nerve roots and plexuses is characterized by the development of so-called dorsalgia (ICD-10 codes M54.1-
M54.8
). In addition, damage to nerve roots and plexuses according to ICD-10 also includes direct damage to roots and plexuses, classified in headings ( G 54.0-
G54.4)
(lesions of the brachial, lumbosacral plexus, lesions of the cervical, thoracic, lumbosacral roots, not classified elsewhere).
Dorsalgia is a disease associated with back pain.
INTRODUCTORY PART
ICD-10 code(s):
ICD-10 | |
Code | Name |
G54.0 | brachial plexus lesions |
G54.1 | lesions of the lumbosacral plexus |
G54.2 | lesions of the cervical roots, not classified elsewhere |
G54.3 | lesions of the thoracic roots, not elsewhere classified |
G54.4 | lesions of the lumbosacral roots, not classified elsewhere |
M51.1 | lesions of the intervertebral discs of the lumbar and other parts with radiculopathy |
M54.1 | Radiculopathy |
M54.2 | Cervicalgia |
M54.3 | Sciatica |
M54.4 | lumbago with sciatica |
M54.5 | lower back pain |
M54.6 | pain in the thoracic spine |
M54.8 | other dorsalgia |
Date of protocol development/revision: 2013 (revised 2017)
Abbreviations used in the protocol:
TANK | - | blood chemistry |
GP | - | general doctor |
CT | - | CT scan |
Exercise therapy | - | Healing Fitness |
ICD | - | international classification of diseases |
MRI | - | magnetic resonance imaging |
NSAIDs | - | nonsteroidal anti-inflammatory drugs |
UAC | - | general blood analysis |
OAM | - | general urine analysis |
RCT | - | randomized controlled trial |
ESR | - | erythrocyte sedimentation rate |
SRB | - | C-reactive protein |
UHF | - | Ultra high frequency |
UD | - | level of evidence |
EMG | - | Electromyography |
Protocol users: general practitioner, therapists, neurologists, neurosurgeons, rehabilitation specialists.
Level of evidence scale:
A | A high-quality meta-analysis, systematic review, randomized controlled trial (RCT), or large RCT with a very low probability of bias (++) whose results can be generalized to an appropriate population. |
IN | High-quality (++) systematic review of cohort or case-control studies, or High-quality (++) cohort or case-control studies with very low risk of bias, or RCTs with low (+) risk of bias, the results of which can be generalized to an appropriate population . |
WITH |
Cohort or case-control study or controlled trial without randomization with low risk of bias (+). The results of which can be generalized to the relevant population or RCTs with very low or low risk of bias (++ or +), the results of which cannot be directly generalized to the relevant population. |
D | Case series or uncontrolled study or expert opinion. |
GGP | Best clinical practice. |
Classification
By localization:
· cervicalgia;
· thoracalgia;
· lumbodynia;
· mixed localization (cervicothoracalgia).
According to the duration of the pain syndrome :
acute - less than 6 weeks,
· subacute - 6-12 weeks,
· chronic - more than 12 weeks.
According to etiological factors(Bogduk N., 2002):
· trauma (muscle overextension, rupture of fascia, intervertebral discs, joints, sprained ligaments, joints, bone fractures);
· infectious lesion (abscess, osteomyelitis, arthritis, discitis);
· inflammatory lesion (myositis, enthesopathy, arthritis);
· tumor (primary tumors and sites);
· biomechanical disorders (formation of trigger zones, tunnel syndromes, joint dysfunction).
Diagnostics
DIAGNOSTIC METHODS, APPROACHES AND PROCEDURES
Diagnostic criteria
Complaints and anamnesis
Complaints:
· for pain in the area of innervation of the affected roots and plexuses;
· for disruption of motor, sensory, reflex and autonomic-trophic functions in the area of innervation of the affected roots and plexuses.
Anamnesis:
· long-term physical static load on the spine (sitting, standing);
physical inactivity;
· sudden lifting of weights;
hyperextension of the spine.
Physical examination
· in andzualinspection:
- assessment of the statics of the spine - antalgic posture, scoliosis, smoothness of physiological lordosis and kyphosis, defence of the paravertebral muscles of the affected part of the spine;
- assessment of dynamics - limitation of movements of the arms, head, various parts of the spine.
· PalpaciI: pain on palpation of paravertebral points, spinous processes of the spine, Walle's points.
· PerkussiI hammer of the spinous processes of various parts of the spine - positive Razdolsky's symptom - the "spinous process" symptom.
· positive tonut samples:
- Lassegue's symptom: pain appears when bending the straightened leg at the hip joint, measured in degrees. The presence of Lasegue's symptom indicates the compressive nature of the disease, but does not specify its level.
- Wasserman's symptom: the appearance of pain when lifting a straight leg back while lying on the stomach indicates damage to the L3 root
- Matskevich’s symptom: the appearance of pain when bending the leg at the knee joint while lying on the stomach indicates damage to the L1-4 roots
- Bekhterev's symptom (Lasègue's cross symptom): the appearance of pain in the supine position when bending the straightened healthy leg at the hip joint and disappearing when it bends at the knee.
- Neri's symptom: the appearance of pain in the lower back and leg when bending the head while lying on the back indicates damage to the L3-S1 roots.
- cough impulse symptom: pain when coughing in the lumbar region at the level of the spinal lesion.
· OpriceAmotorfunctions for the study of reflexes: decrease (loss) the following tendon reflexes.
- flexion-ulnar reflex: a decrease/absence of the reflex may indicate damage to the CV - CVI roots.
- ulnar extension reflex: a decrease/absence of the reflex may indicate damage to the CVII - CVIII roots.
- carpo-radial reflex: a decrease/absence of the reflex may indicate damage to the CV - CVIII roots.
- scapulohumeral reflex: a decrease/absence of the reflex may indicate damage to the CV - CVI roots.
- upper abdominal reflex: a decrease/absence of the reflex may indicate damage to the DVII - DVIII roots.
- average abdominal reflex: a decrease/absence of the reflex may indicate damage to the DIX - DX roots.
- lower abdominal reflex: a decrease/absence of the reflex may indicate damage to the DXI - DXII roots.
- cremasteric reflex: a decrease/absence of the reflex may indicate damage to the LI - LII roots.
- knee reflex: decreased/absent reflex may indicate damage to both the L3 and L4 roots.
- Achilles reflex: a decrease/absence of the reflex may indicate damage to the SI - SII roots.
- Plantar reflex: decreased/absent reflex may indicate damage to the L5-S1 roots.
- Anal reflex: decreased/absent reflex may indicate damage to the SIV - SV roots.
Scheme for express diagnostics of root lesions
:
· PL3 root lesion:
- positive Wasserman symptom;
- weakness in the leg extensors;
- impaired sensitivity along the anterior surface of the thigh;
· L4 root lesion:
- violation of flexion and internal rotation of the leg, supination of the foot;
- impaired sensitivity on the lateral surface of the lower third of the thigh, knee and anteromedial surface of the leg and foot;
- change in knee reflex.
· L5 root lesion:
- impaired heel walking and dorsal extension of the big toe;
- impaired sensitivity on the anterolateral surface of the leg, dorsum of the foot and fingers I, II, III;
· S1 root lesion:
- impaired walking on toes, plantar flexion of the foot and toes, pronation of the foot;
- impaired sensitivity on the outer surface of the lower third of the leg in the area of the lateral malleolus, the outer surface of the foot, IV and V fingers;
- change in the Achilles reflex.
· OpriceAsensitive functionAnd(sensitivity study using cutaneous dermatomes) - the presence of sensory disorders in the area of innervation of the corresponding roots and plexuses.
· laboratoryresearch: No.
Instrumental studies:
Electromyography: clarification of the level of damage to roots and plexuses. Detection of secondary neuronal muscle damage allows one to determine the level of segmental damage with sufficient accuracy.
Topical diagnosis of lesions of the cervical roots of the spine is based on testing the following muscles:
· C4-C5 - supraspinatus and infraspinatus, teres minor;
· C5-C6 - deltoid, supraspinatus, biceps humerus;
· C6-C7 - pronator teres, triceps muscle, flexor carpi radialis;
· C7-C8 - extensor carpi communis, triceps and palmaris longus muscles, flexor carpi ulnaris, abductor pollicis longus;
· C8-T1 - flexor carpi ulnaris, long flexor muscles of the fingers, intrinsic muscles of the hand.
Topical diagnosis of lesions of the lumbosacral roots is based on the study of the following muscles:
L1 - iliopsoas;
· L2-L3 - iliopsoas, graceful, quadriceps, short and long adductor muscles of the thigh;
· L4 - iliopsoas, tibialis anterior, quadriceps, major, minor and short adductor muscles of the thigh;
· L5-S1 - biceps femoris, extensor toes longus, tibialis posterior, gastrocnemius, soleus, gluteal muscles;
· S1-S2 - intrinsic muscles of the foot, flexor digitorum longus, gastrocnemius, biceps femoris.
Magnetic resonance imaging:
MRI signs:
- protrusion of the fibrous ring beyond the posterior surfaces of the vertebral bodies, combined with degenerative changes in the disc tissue;
- protrusion (prolapse) of the disc - protrusion of the nucleus pulposus due to thinning of the fibrous ring (without its rupture) beyond the posterior edge of the vertebral bodies;
- disc prolapse (or disc herniation), the release of the contents of the nucleus pulposus beyond the annulus fibrosus due to its rupture; disc herniation with its sequestration (the fallen part of the disc in the form of a free fragment is located in the epidural space).
Consultation with specialists:
· consultation with a traumatologist and/or neurosurgeon - if there is a history of trauma;
· consultation with a rehabilitation specialist - in order to develop an algorithm for a group/individual exercise therapy program;
· consultation with a physiotherapist - in order to resolve the issue of physiotherapy;
· consultation with a psychiatrist - in the presence of depression (more than 18 points on the Beck scale).
Diagnostic algorithm:(scheme)
Differential diagnosis
Differential diagnosisand rationale for additional research
Table 1.
Diagnosis | Rationale for differential diagnosis | Surveys | Diagnosis exclusion criteria |
Landry manifestation |
· the onset of paralysis in the muscles of the legs; · steady progression of paralysis with spread to the overlying muscles of the trunk, chest, pharynx, tongue, face, neck, arms; · symmetrical expression of paralysis; · hypotonia of muscles; areflexia; · objective sensory disturbances are minimal. |
LP, EMG |
LP: an increase in protein content, sometimes significant (>10 g/l), begins a week after the manifestation of the disease, for a maximum of 4-6 weeks, Electromyography - a significant decrease in the amplitude of the muscle response when stimulating the distal parts of the peripheral nerve. Nerve impulse transmission is slow |
manifestation of multiple sclerosis | Impairment of sensory and motor functions | LHC, MRI/CT | Increase in serum immunoglobulin G, presence of specific scattered plaques on MRI/CT |
lacunar cortical stroke | Impaired sensory and/or motor functions | MRI/CT | Presence of a cerebral stroke focus on MRI |
referred pain in diseases of internal organs | Severe pain | UAC, OAM, BAK | Presence of changes in analyzes from internal organs |
osteocondritis of the spine | Severe pain, syndromes: reflex and radicular (motor and sensory). | CT/MRI, radiography | Reduced height of intervertebral discs, osteophytes, sclerosis of endplates, displacement of adjacent vertebral bodies, “spacer” symptom, absence of protrusions and disc herniations |
extramedullary tumor of the spinal cord | Progressive development of transverse spinal cord lesion syndrome. Three stages: radicular stage, half-damage stage of the spinal cord. The pain is first unilateral, then bilateral, intensifying at night. Spread of conduction hyposthesia from bottom to top. There are signs of blockade of the subarachnoid space, cachexia. Low-grade fever. Steadily progressive course, lack of effect from conservative treatment. | Possible increased ESR, anemia. Changes in blood tests are nonspecific. | Expansion of the intervertebral foramen, atrophy of the roots of the arches and an increase in the distance between them (Elsberg-Dyck symptom). |
ankylosing spondylitis | Pain in the spine is constant, mainly at night, the condition of the back muscles: tension and atrophy, constant restriction of movements in the spine. Pain in the area of the sacroiliac joints. The onset of the disease is between the ages of 15 and 30 years. The course is slowly progressive. The effectiveness of pyrazolone drugs. | Positive CRP test. Increasing ESR to 60 mm/hour. | Signs of bilateral sacroiliitis. Narrowing of intervertebral joint spaces and ankylosis. |
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Treatment
Drugs (active ingredients) used in treatment
Treatment (outpatient clinic)
OUTPATIENT TREATMENT TACTICS:
Non-drug treatment:
· mode III;
· Exercise therapy;
· maintaining physical activity;
· diet No. 15.
· kinesio taping;
Indications:
· pain syndrome;
· muscle spasm;
· motor dysfunction.
Contraindications:
· individual intolerance;
· violation of the integrity of the skin, sagging skin;
NB! In case of pain syndrome, it is carried out according to the mechanism of estero-, proprioceptive stimulation.
Drug treatment:
For acute pain ( table 2 ):
· non-narcotic analgesics - have a pronounced analgesic effect.
· opioid narcotic analgesic has a pronounced analgesic effect.
For chronic pain( table 4 ):
· NSAIDs - eliminate the effect of inflammatory factors during the development of pathobiochemical processes;
· muscle relaxants - reduce muscle tone in the myofascial segment;
· non-narcotic analgesics - have a pronounced analgesic effect;
· opioid narcotic analgesic has a pronounced analgesic effect;
· cholinesterase inhibitors - in the presence of motor and sensory disorders, improves neuromuscular transmission.
Treatment regimens:
· NSAIDs - 2.0 IM No. 7 e/day;
Flupirtine maleate 500 mg orally 2 times a day.
Additional drugs: in the presence of nociceptive pain - opioid narcotic analgesics (in transdermal and intramuscular form), in the presence of neuropathic pain - antiepileptic drugs, in the presence of motor and sensory disorders - cholinesterase inhibitors.
List of essential medications for acute pain(having a 100% probability of application):
Table 2.
Drug group | Mode of application | Level of evidence | |
Lornoxicam | A | ||
Non-steroidal anti-inflammatory drug | Diclofenac | A | |
Non-steroidal anti-inflammatory drug | Ketorolac | A | |
Non-narcotic analgesics | Flupirtine | IN | |
Tramadol | Orally, intravenously 50-100 mg | IN | |
Fentanyl | IN |
Scroll additional medicines for acute pain ( less than 100% probability of application):
Table 3.
Drug group | International nonproprietary name of the drug | Mode of application | Level of evidence |
Cholinesterase inhibitors |
Galantamine |
WITH | |
Muscle relaxant | Cyclobenzaprine | IN | |
carbamazepine | A | ||
Antiepileptic drug | Pregabalin | A |
List of essential medications for chronic pain(having a 100% probability of application):
Table 4.
Drug group | International nonproprietary name of the drug | Mode of application | Level of evidence |
Muscle relaxant | Cyclobenzaprine | Orally, daily dose 5-10 mg in 3-4 divided doses | IN |
Non-steroidal anti-inflammatory drug | Lornoxicam | Orally, intramuscularly, intravenously 8 - 16 mg 2 - 3 times a day | A |
Non-steroidal anti-inflammatory drug | Diclofenac | 75 mg (3 ml) IM/day No. 3 with transition to oral/rectal administration | A |
Non-steroidal anti-inflammatory drug | Ketorolac | 2.0 ml IM No. 5. (for patients from 16 to 64 years old with a body weight exceeding 50 kg, no more than 60 mg intramuscularly; patients with a body weight less than 50 kg or with chronic renal failure are administered no more than 30 mg per 1 injection) | A |
Non-narcotic analgesics | Flupirtine | Orally: 100 mg 3-4 times a day, for severe pain 200 mg 3 times a day | IN |
Opioid narcotic analgesic | Tramadol | Orally, intravenously 50-100 mg | IN |
Opioid narcotic analgesic | Fentanyl | Transdermal therapeutic system: initial dose 12 mcg/hour every 72 hours or 25 mcg/hour every 72 hours; | IN |
Scroll additional medications for chronic pain(less than 100% chance of application):
Table 5
Drug group | International nonproprietary name of the drug | Mode of application | Level of evidence |
Antiepileptic drug | Carbamazepine | 200-400 mg/day (1-2 tablets), then the dose is gradually increased by no more than 200 mg per day until the pain stops (on average, up to 600-800 mg), then reduced to the minimum effective dose. | A |
Antiepileptic drug | Pregabalin | Orally, regardless of food intake, in a daily dose of 150 to 600 mg in 2 or 3 divided doses. | A |
Opioid narcotic analgesic | Tramadol | Orally, intravenously 50-100 mg | IN |
Opioid analgesic | Fentanyl | IN | |
Glucocorticoid | Hydrocortisone | Locally | WITH |
Glucocorticoid | Dexamethasone | V/v, v/m: | WITH |
Glucocorticoid | Prednisolone | Orally 20-30 mg per day | WITH |
Local anesthetic | Lidocaine | B |
Surgical intervention: No.
Further management:
Dispensary activities indicating the frequency of visits to specialists:
· examination by a GP/therapist, neurologist 2 times a year;
· carrying out parenteral therapy up to 2 times a year.
NB! If necessary, non-drug treatment: massage, acupuncture, exercise therapy, kinesiotaping, consultation with a rehabilitation therapist with recommendations for individual/group exercise therapy, orthopedic shoes, splints for foot drop, and specially adapted household items and instruments used by the patient.
Indicators of treatment effectiveness:
· absence of pain syndrome;
· increase in motor, sensory, reflex and autonomic-trophic functions in the area of innervation of the affected nerves.
Treatment (inpatient)
TREATMENT TACTICS AT THE INPATIENT LEVEL:
· leveling of pain syndrome;
· restoration of sensitivity and motor disorders;
· use of peripheral vasodilators, neuroprotective drugs, NSAIDs, non-narcotic analgesics, muscle relaxants, anticholinesterase drugs.
Patient observation card, patient routing: No.
Non-drug treatment:
Mode III
· diet No. 15,
· physiotherapy (thermal procedures, electrophoresis, paraffin treatment, acupuncture, magnetic, laser, UHF therapy, massage), exercise therapy (individual and group), kinesio taping
Drug treatment
Scroll essential medicines(having a 100% probability of application):
Drug group | International nonproprietary name of the drug | Mode of application | Level of evidence |
Non-steroidal anti-inflammatory drug | Lornoxicam |
Inside, intramuscularly, intravenously 8 - 16 mg 2 - 3 times a day. |
A |
Non-steroidal anti-inflammatory drug | Diclofenac | 75 mg (3 ml) IM/day No. 3 with transition to oral/rectal administration; | A |
Non-steroidal anti-inflammatory drug | Ketorolac | 2.0 ml IM No. 5. (for patients from 16 to 64 years old with a body weight exceeding 50 kg, no more than 60 mg intramuscularly; patients with a body weight less than 50 kg or with chronic renal failure are administered no more than 30 mg per 1 injection) | A |
Non-narcotic analgesics | Flupirtine |
Adults: 1 capsule 3-4 times a day with equal intervals between doses. For severe pain - 2 capsules 3 times a day. The maximum daily dose is 600 mg (6 capsules). Doses are selected depending on the intensity of pain and the patient’s individual sensitivity to the drug. Patients over 65 years of age: at the beginning of treatment, 1 capsule in the morning and evening. The dose may be increased to 300 mg depending on the intensity of pain and tolerability of the drug. In patients with severe signs of renal failure or hypoalbuminemia, the daily dose should not exceed 300 mg (3 capsules). In patients with reduced liver function, the daily dose should not exceed 200 mg (2 capsules). |
IN |
Additional drugs: in the presence of nociceptive pain - opioid narcotic analgesics (in transdermal and intramuscular form), in the presence of neuropathic pain - antiepileptic drugs, in the presence of motor and sensory disorders - cholinesterase inhibitors.
List of additional medicines(less than 100% chance of application):
Drug group | International nonproprietary name of the drug | Mode of application | Level of evidence |
Opioid narcotic analgesic | Tramadol | Orally, intravenously 50-100 mg | IN |
Opioid narcotic analgesic | Fentanyl | Transdermal therapeutic system: initial dose 12 mcg/hour every 72 hours or 25 mcg/hour every 72 hours). | IN |
Cholinesterase inhibitors |
Galantamine |
The drug is prescribed at 2.5 mg per day, gradually increasing after 3-4 days by 2.5 mg, divided into 2-3 equal doses. The maximum single dose is 10 mg subcutaneously, and the maximum daily dose is 20 mg. |
WITH |
Antiepileptic drug | Carbamazepine | 200-400 mg/day (1-2 tablets), then the dose is gradually increased by no more than 200 mg per day until the pain stops (on average, up to 600-800 mg), then reduced to the minimum effective dose. | A |
Antiepileptic drug | Pregabalin | Orally, regardless of food intake, in a daily dose of 150 to 600 mg in 2 or 3 divided doses. | A |
Glucocorticoid | Hydrocortisone | Locally | WITH |
Glucocorticoid | Dexamethasone | V/v, v/m: from 4 to 20 mg 3-4 times/day, maximum daily dose 80 mg up to 3-4 days | WITH |
Glucocorticoid | Prednisolone | Orally 20-30 mg per day | WITH |
Local anesthetic | Lidocaine | 5-10 ml of 1% solution is injected intramuscularly to anesthetize the brachial and sacral plexus | B |
Drug blockades according to the spectrum of action:
· analgesic;
· muscle relaxants;
· angiospasmolytic;
· trophostimulating;
· absorbable;
· destructive.
Indications:
· severe pain syndrome.
Contraindications:
· individual intolerance to drugs used in the medicinal mixture;
· presence of acute infectious diseases, renal, cardiovascular and liver failure or diseases of the central nervous system;
· low blood pressure;
· epilepsy;
· pregnancy in any trimester;
· presence of damage to the skin and local infectious processes until complete recovery.
Surgical intervention: No.
Further management:
· observation by a local therapist. Subsequent hospitalization as planned in the absence of effectiveness of outpatient treatment.
Indicators of treatment effectiveness and safety of diagnostic and treatment methods described in the protocol:
· reduction of pain syndrome (assessment on VAS scales, G. Tampa kinesiophobia scale, McGill pain questionnaire, Oswestry questionnaire);
· increase in motor, sensory, reflex and autonomic-trophic functions in the area of innervation of the affected nerves (assessment without a scale - based on neurological status);
· restoration of ability to work (assessed by the Barthel index).
Hospitalization
INDICATIONS FOR HOSPITALIZATION, INDICATING THE TYPE OF HOSPITALIZATION
Indications for planned hospitalization:
· ineffectiveness of outpatient treatment.
Indications for emergency hospitalization:
· severe pain syndrome with signs of radiculopathy.
Information
Sources and literature
- Minutes of meetings of the Joint Commission on the Quality of Medical Services of the Ministry of Health of the Republic of Kazakhstan, 2017
- 1. Barulin A.E., Kurushina O.V., Kalinchenko B.M. Application of the kinesiotaping technique in neurological patients // RMZh. 2016. No. 13. pp. 834-837. 2. Belskaya G.N., Sergienko D.A. Treatment of dorsopathy from the standpoint of effectiveness and safety // Breast Cancer. 2014. No. 16. P.1178. 3. Danilov A.B., N.S. Nikolaeva, Efficacy of a new form of flupirtine (Katadolon forte) in the treatment of acute back pain //Manage pain. – 2013. – No. 1. – P. 44-48. 4. Kiselev D.A. Kinesio taping in the medical practice of neurology and orthopedics. St. Petersburg, 2015. –159 p. 5. Clinical protocol “Damage to nerve roots and plexuses” dated December 12, 2013 6. Kryzhanovsky, V.L. Back pain: diagnosis, treatment and rehabilitation. – Mn.: DD, 2004. – 28 p. 7. Levin O.S., Shtulman D.R. Neurology. Handbook of a practicing physician. M.: MEDpress-inform, 2012. - 1024s. 8. Neurology. National leadership. Brief edition/ed. Guseva E.I. M.: GEOTAR – Media, 2014. – 688 p. 9. Podchufarova E.V., Yakhno N.N. Backache. - : GEOTAR-Media, 2014. – 368 p. 10. Putilina M.V. Features of diagnosis and treatment of dorsopathies in neurological practice // Consilium medicum. – 2006.– No. 8 (8). – pp. 44–48. 11. Skoromets A.A., Skoromets T.A. Topical diagnosis of diseases of the nervous system. St. Petersburg “Polytechnics”, 2009 12. Subbotin F. A. Propaedeutics of functional therapeutic kinesiological taping. Monograph. Moscow, Ortodinamika Publishing House, 2015, -196 p. 13. Usmanova U.U., Tabert R.A. Features of the use of kinesio tape in pregnant women with dorsopathies // Materials of the 12th international scientific and practical conference “Education and Science of the XXI Century - 2016”. Volume 6. P.35 14. Erdes S.F. Nonspecific pain in the lower back. Clinical recommendations for local therapists and general practitioners. – M.: Kit Service, 2008. – 70 p. 15. Alan David Kaye Case Studies In Pain Management. – 2015. – 545 rub. 16. Bhatia A., Bril V., Brull R.T. et al. Study protocol for a pilot, randomized, double-blinded, placebo controlled trial of perineural local anaesthetics and steroids for chronic post-traumatic neuropathic pain in the ankle and foot: The PREPLANS study.// BMJ Open/ - 2016, 6(6) . 17. Bishop A., Holden M.A., Ogollah R.O., Foster N.E. EASE Back Study Team. Current management of pregnancy-related low back pain: A national cross-sectional survey of UK physiotherapists. //Physiotherapy.2016; 102(1):78–85. 18. Eccleston C., Cooper T.E., Fisher E., Anderson B., Wilkinson N.M.R. Non-steroidal anti-inflammatory drugs (NSAIDs) for chronic non-cancer pain in children and adolescents. Cochrane Database of Systematic Reviews 2017, Issue 8 Art. No.: CD012537. DOI: 10. 1002 / 14651858. CD 012537. Pub 2. 19. Elchami Z., Asali O., Issa M.B. and Akiki J. The efficacy of the combined therapy of pregabalin and cyclobenzaprine in the treatment of neuropathic pain associated with chronic radiculopathy. // European Journal of Pain Supplements, 2011, 5(1), 275. 20. Grant Cooper Non-operative Treatment Of The Lumbar Spine. – 2015. – 163 rub. 21. Herrmann W.A., Geertsen M.S. Efficacy and safety of lornoxicam compared with placebo and diclofenac in acute sciatica/lumbo-sciatica: an analysis from a randomized, double-blind, multicentre, parallel group study. //Int J Clin Pract 2009; 63 (11): 1613–21. 22. Interventional Pain Control in Cancer Pain Management/Joan Hester, Nigel Sykes, Sue Pea RUR 283 23. Kachanathu S.J., Alenazi A.M., Seif H.E., et al. Comparison between kinesio taping and a traditional physical therapy program in treatment of nonspecific low back pain. //J. Phys Ther Sci. 2014; 26(8):1185–88. 24. Koleva Y. and Yoshinov R. Paravertebral and radicular pain: Drug and/or physical analgesia. //Annals of physical and rehabilitation medicine, 2011, 54, e42. 25. Lawrence R. Robinson M.D. Trauma Rehabilitation. – 2005. – 300 rub. 26. McNicol E.D., Midbari A., Eisenberg E. Opioids for neuropathic pain. Cochrane Database of Systematic Reviews 2013, Issue 8. Art. No.: CD006146. DOI: 10.1002/14651858.CD006146.pub2. 27. Michael A. Überall, Gerhard H.H. Mueller-Schwefe, and Bernd Terhaag. Efficacy and safety of flupirtine modified release for the management of moderate to severe chronic low back pain: results of SUPREME, a prospective randomized, double-blind, placebo- and active-controlled parallel-group phase IV study October 2012, Vol. 28, No. 10, Pages 1617-1634 (doi:10.1185/03007995.2012.726216). 28. Moore R.A., Chi CC, Wiffen P.J., Derry S., Rice ASC. Oral nonsteroidal anti-inflammatory drugs for neuropathic pain. Cochrane Database of Systematic Reviews 2015, Issue 10. Art. No.: CD010902. DOI: 10.1002/14651858.CD010902.pub2. 29. Mueller-Schwefe G. Flupirtine in acute and chronic pain associated with muscle tension. Results of a postmarket surveillance study].//Fortschr Med Orig. 2003;121(1):11-8. German. 30. Neuropathic pain – pharmacological management. The pharmacological management of neuropathic pain in adults in non-specialist settings. NICE clinical guideline 173. Issued: November 2013. Updated: February 2017. http://guidance.nice.org.uk/CG173 31. Pena Costa, S. Silva Parreira. Kinesiotaping in Clinical practice (Systematic review). - 2014. – 210p. 32. Rossignol M., Arsenault B., Dione C. et al. Clinic in low back pain in interdisciplinary practice guidelines. – Direction de santé publique. Montreal: Agence de la santé et des services sociaux de Montreal. – 2007. - P.47. 33. Schechtmann G., Lind G., Winter J., Meyerson BA and Linderoth B. Intrathecal clonidine and baclofen enhance the pain-relieving effect of spinal cord stimulation: a comparative placebo-controlled, randomized trial. //Neurosurgery, 2010, 67(1), 173.
Information
ORGANIZATIONAL ASPECTS OF THE PROTOCOL
List of protocol developers with qualification information:
1) Tokzhan Tokhtarovna Kispaeva - Doctor of Medical Sciences, neuropathologist of the highest category of the RSE at the National Center for Occupational Health and Occupational Diseases;
2) Aigul Serikovna Kudaibergenova - Candidate of Medical Sciences, neuropathologist of the highest category, Deputy Director of the Republican Coordination Center for Stroke Problems of JSC National Center for Neurosurgery;
3) Smagulova Gaziza Azhmagievna - Candidate of Medical Sciences, Associate Professor, Head of the Department of Propaedeutics of Internal Diseases and Clinical Pharmacology of the West Kazakhstan State Medical University named after Marat Ospanov.
Disclosure of no conflict of interest: No.
Reviewer:
Baimukhanov Rinad Maratovich - Associate Professor of the Department of Neurosurgery and Neurology of the FNPR RSE at the Karaganda State Medical University, a doctor of the highest category.
Specifying the conditions for reviewing the protocol: review of the protocol 5 years after its publication and from the date of its entry into force or if new methods with a level of evidence are available.
Attached files
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As a rule, this pathology is the first and most common sign of cervical osteochondrosis.
What is cervicalgia syndrome?
This pathology is included in the category of the most common diseases of modern people.
According to statistics, more than 70% of people experience neck pain. The term “cervicalgia” refers to pain that is localized in the neck and radiates to the shoulder, back of the head and arms. According to ICD-10, the disease has code M54.2 “Cervicalgia: description, symptoms and treatment.”
The presence of this pathology can be suspected when a person experiences difficulties with head movements - they are limited, often cause pain or are accompanied by muscle spasms.
If you have been prescribed the medicine Allopurinol, the instructions for use are required to be studied, since the medicine has many side effects. What can cause spastic torticollis in adults and children and methods of treating the disease.
Classification of pathology
Currently, it is customary to distinguish two main types of cervicalgia:
- Vertebrogenic. It is associated with disorders in the cervical spine and is a consequence of spondylosis, intervertebral hernia, rheumatoid arthritis and other inflammatory processes.
- Vertebral. This form of the disease develops as a result of muscle or ligament sprains, myositis, and occipital neuralgia. Sometimes this pathology has a psychogenic origin. It can be a consequence of epidural abscess, meningitis, subarachnoid hemorrhage.
Vertebrogenic cervicalgia
Neck pain or vertebrogenic cervicalgia
Vertebrogenic cervicalgia is neck pain accompanied by limited muscle mobility and, often, autonomic dysfunction. The disease is caused by
In turn, the vertebrogenic form is divided into several types:
- Spondylogenic – is a consequence of irritation of the nerve roots. The result is pain that is difficult to eliminate. Typically, this type of cervicalgia occurs in case of damage to bone structures as a result of osteoma, radiculopathy, osteomyelitis.
- Discogenic - develops in the case of degenerative processes occurring in the cartilage tissue of the spine. This form of pathology most often becomes a consequence of osteochondrosis, intervertebral hernia, etc. It is accompanied by persistent pain and sometimes requires surgical intervention.
However, pain in the neck area is not always the result of a serious spinal disease.
Typically, cervicalgia occurs as a result of high stress on the spine and muscles. That is why the disease, depending on the characteristics of its course, can be:
- acute - it is characterized by severe pain when turning the neck, moving, tilting the head;
- chronic - may be accompanied by various pain sensations that radiate to the back of the head and upper limbs.
Causes of the syndrome
Discomfort in the neck area appears due to irritation of the nerve fibers that are located in this area.
A hernial protrusion gradually forms, which irritates first the longitudinal ligament, and then the roots of the spinal nerves.
However, osteochondrosis is not the only disease that leads to the appearance of the disease. The development of pain in the neck area can be caused by the following pathologies:
- tumor formations;
- autoimmune pathologies - in particular, ankylosing spondylitis;
- infectious diseases – retropharyngeal abscess, epiglottitis;
- spondylosis – degenerative arthritis and osteophytosis;
- stenosis – narrowing of the spinal canal;
- disc herniation - protrusion or protrusion of the disc;
- mental disorders.
The cause of pain can be hidden in any of the structures in the neck area, including blood vessels, nerves, digestive organs, respiratory tract, and muscles.
In addition, cervicalgia can be a consequence of the following factors:
- pinched nerve;
- stressful situations;
- prolonged stay in an uncomfortable position;
- uncomfortable head position during sleep;
- minor traumatic injuries;
- hypothermia.
Symptoms and signs
Pain in the neck area can be shooting, throbbing, or tingling. Even slight movement, physical stress or a normal cough can lead to exacerbations. The following symptoms are usually characteristic:
- dizziness;
- numbness in the back of the head or upper extremities;
- noise in ears;
- pain in the back of the head.
Cervicalgia with muscular-tonic syndrome also occurs. This condition is characterized by soreness and tension in the neck muscles, as well as limited mobility.
Diagnostic methods
To diagnose cervicalgia, the following examinations are usually performed:
- Radiography. Although this test can only look at bone tissue, it can help identify the causes of neck pain. The image will show damaged joints, broken bones, and age-related changes.
- Magnetic resonance imaging. This study allows you to assess the condition of soft tissues - nerves, muscles, ligaments, intervertebral discs. MRI can detect tumors, infectious lesions, and hernias.
- Electromyelography and nerve conduction velocity analysis. These studies are carried out in cases of suspected dysfunction of the spinal cord. Typically indications are weakness and numbness of the hands.
How to treat the manifestation of the syndrome?
To eliminate the manifestations of the disease, the approach to treating the disease must be comprehensive.
Typically, therapy includes medications, therapeutic exercises, and physiotherapy. Sometimes there is a need for surgical intervention.
The main goals of treatment are as follows:
- increased mobility of the cervical spine;
- elimination of pain;
- releasing a jammed spine;
- preventing the progression of cervical osteochondrosis;
- muscle strengthening.
For pain relief, non-steroidal anti-inflammatory drugs are usually used - paracetamol, ibuprofen, nimesulide.
This therapy should not last very long as it can lead to problems with the digestive organs. In especially severe cases, the use of muscle relaxants is indicated - Baclofen, Tolperisone, Cyclobenzaprine.
If there is severe muscle tension, local anesthetics - novocaine or procaine - can be prescribed.
In some cases, a cervical collar should be used - it should be worn for 1-3 weeks. To reduce pain, traction treatment may be prescribed, which involves stretching the spine.
Therapeutic gymnastics is of no small importance for the successful treatment of cervicalgia. Also, many patients are prescribed physiotherapeutic procedures - massage, compresses, mud baths.
Surgery
In some cases, there is a need for surgical treatment of the pathology. Indications for the operation are the following:
- acute and subacute lesions of the cervical spinal cord, which are accompanied by sensory disturbances, pelvic pathologies, and central paresis;
- an increase in paresis in the area of innervation of the spinal root in the presence of a danger of its necrosis.
The main methods of surgical treatment in this case include the following:
Preventive measures
To prevent the onset of the disease, you should be very careful about the condition of your spine. To keep it healthy, you must follow these rules:
- When working sedentarily, it is necessary to take breaks. It is very important to properly equip your workplace.
- Do not jerk heavy objects.
- The bed should be quite hard, in addition, it is advisable to choose an orthopedic pillow.
- It is very important to eat properly and balanced. If you have excess weight, you need to get rid of it.
- To strengthen your muscle corset, you should play sports. It is especially important to train the muscles of the back and neck.
Cervicalgia is a fairly serious pathology, which is accompanied by severe pain in the neck area and significantly worsens a person’s quality of life.
To prevent its development, you need to exercise, eat a balanced diet, and properly organize your work and rest schedule. If signs of the disease still appear, you should immediately consult a doctor.
Thanks to adequate and timely treatment, you can quickly get rid of the disease.
Dorsopathies (classification and diagnosis)
Anatoly Ivanovich Fedin
The term “dorsopathies” refers to pain syndromes in the trunk and extremities of non-visceral etiology and associated with degenerative diseases of the spine. Thus, the term “dorsopathies” in accordance with ICD-10 should replace the term “spinal osteochondrosis”, which is still used in our country.
M40 Kyphosis and lordosis (spinal osteochondrosis excluded)
M41.1 Juvenile idiopathic scoliosis
M41.4 Neuromuscular scoliosis (due to cerebral palsy, poliomyelitis and other diseases of the nervous system)
M42 Osteochondrosis of the spine M42.0 Youthful osteochondrosis of the spine (Scheuermann's disease)
M42.1 Osteochondrosis of the spine in adults
M43 Other deforming dorsopathies
M43.4 Habitual atlantoaxial subluxations.
As you can see, this section of the classification contains various deformities associated with pathological alignment and curvature of the spine, disc degeneration without protrusion or hernia, spondylolisthesis (displacement of one of the vertebrae relative to the other in its anterior or posterior version) or subluxations in the joints between the first and second cervical vertebrae. In Fig. Figure 1 shows the structure of the intervertebral disc, consisting of the nucleus pulposus and the fibrous ring. In Fig. Figure 2 shows a severe degree of osteochondrosis of the cervical intervertebral discs with their degenerative lesions.
Rice. 1. The structure of the intervertebral disc (according to H. Luschka, 1858).
Rice. 2. Severe degeneration of cervical intervertebral discs (according to H. Luschka, 1858).
Rice. 3. MRI for osteochondrosis of intervertebral discs (arrows indicate degeneratively changed discs).
Rice. 4. Idiopathic scoliosis of the spine.
Rice. 5. Spinal motion segment at the thoracic level.
Rice. 6. Cervical dorsopathy.
With degeneration, spondylosis with compression syndrome of the anterior spinal or vertebral artery (M47.0), with myelopathy (M47.1), with radiculopathy (M47.2), without myelopathy and radiculopathy (M47.8) are distinguished. The diagnosis is established using radiation diagnostics. In Fig. Figure 6 shows the most characteristic changes on a spondylogram with spondylosis.
Rice. 7. X-ray computed tomography (CT) for lumbar dorsopathy, arthrosis of the left facet (facet) joint of the L5–S1 spine.
Rice. 9.Stenosis of the intervertebral foramen with compression of the L5 root
M50 Degeneration of intervertebral discs of the cervical spine (with pain)
M51.4 Schmorl's nodes [hernia]
When formulating diagnoses, one should avoid terms that frighten patients such as “disc herniation” (it can be replaced with the term “disc displacement”, “disc damage” (synonymous with “disc degeneration”). This is especially important in patients with a hypochondriacal personality and anxiety-depressive conditions In these cases, a carelessly spoken word by a doctor can be the cause of long-term iatrogenicity.
Rice. 10.Topography of the spinal canal and protrusion of the intervertebral disc.
Rice. 11.Options for displacement of intervertebral discs.
Rice. 12.Morphology and radiation diagnostic methods for displaced intervertebral disc.
The section “other dorsopathies” in heading M53 includes sympathalgic syndromes associated with irritation of the afferent sympathetic nerve during posterolateral displacement of the cervical disc or spondylosis. In Fig. Figure 14 shows the peripheral cervical nervous system (plexus of the somatic nervous system, cervical ganglia of the sympathetic nervous system and its postganglionic fibers located in the soft tissues of the neck and along the carotid and vertebral arteries. In Fig. 14a
Rice. 13.MRI for Schmorl's hernia.
Rice. 14.Cervical sympathetic nerves.
Cervicocranial syndrome (M53.0) corresponds to the widely used term “posterior cervical sympathetic syndrome” in our country, the main clinical manifestations of which are repercussive (widespread) sympathalgia with cervicocranialgia, orbital pain and cardialgia. With spasm of the vertebral artery there may be signs of vertebrobasilar ischemia. With anterior cervical sympathetic syndrome, patients experience a violation of the sympathetic innervation of the eyeball with Horner's syndrome, often partial.
M54.1 Radiculopathy (brachial, lumbar, lumbosacral, thoracic, unspecified)
M54.4 Lumbodynia with sciatica
M54.8 Other dorsalgia
Rice. 15. Innervation of soft tissues of the spine.
Rice. 16. Fascia and muscles of the lumbar region.
4 comments
“Dorsopathy” is not a PAIN SYNDROME itself (as follows from the definition given at the beginning of the article), but a GROUP OF DISEASES of the musculoskeletal system and connective tissue, the leading symptom complex of which is pain in the trunk and extremities of non-visceral etiology.
neurologist, Kyiv
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Structure of vertebroneurological diagnosis
Vertebrogenic (spondylogenic) dorsalgia associated with the pathology of the lumbar spine (degenerative, traumatic, inflammatory, neoplastic and other nature);
Nonvertebrogenic dorsalgia caused by sprained ligaments and muscles, myofascial syndrome, fibromyalgia, somatic diseases, psychogenic factors, etc.
Cervicalgia – neck pain;
Cervicobrachialgia – pain in the neck spreading to the arm;
Thoracalgia – pain in the thoracic back and chest;
Lumbodynia – pain in the lower back or lumbosacral region;
Lumboischialgia – lower back pain spreading to the leg;
Sacralgia – pain in the sacral region;
Coccydynia - pain in the tailbone.
Local vertebral syndrome, often accompanied by local pain syndrome (cervicalgia, thoracalgia, lumbodynia), tension and soreness of adjacent muscles. pain, deformity, limited mobility or instability of one or more adjacent segments of the spine;
Remote vertebral syndrome; the spine is a single kinmatic chain, and dysfunction of one segment can, through a change in the motor stereotype, lead to deformation, pathological fixation, instability or other change in the state of the upper or lower sections;
Reflex (irritative) syndromes: referred pain (for example, cervicobrachialgia, cervicocranialgia, lumboischialgia, etc.), muscular-tonic syndromes, neurodystrophic manifestations, repercussion autonomic (vasomotor, sudomotor) disorders with a wide range of secondary manifestations (enthesiopathy, periarthropathy, myofascial syndrome, tunnel syndromes, etc.);
Compression (compression-ischemic) radicular syndromes: mono-, bi-, multi-radicular, including cauda equina compression syndrome (due to herniated intervertebral discs, stenosis of the spinal canal or intervertebral foramen or other factors);
Syndromes of compression (ischemia) of the spinal cord (due to herniated discs, stenosis of the spinal canal or intervertebral foramen or other factors).
Course of the disease: acute, subacute, chronic (remitting, progressive, stationary, regressive);
Phase: exacerbation (acute), regression, remission (complete, partial);
Frequency of exacerbations: frequent (4-5 times a year), moderate frequency (2-3 times a year), rare (no more than 1 time a year);
Severity of pain syndrome: mild (not interfering with the patient’s daily activities), moderately expressed (limiting the patient’s daily activities), severe (severely complicating the patient’s daily activities), severe (making the patient’s daily activities impossible);
State of mobility of the spine (mild, moderate, severe limitation of mobility);
Localization and severity of motor, sensory, pelvic and other neurological disorders.
examples of formulations and diagnoses
ICD-10: M54 - Dorsalgia
Chain in classification:
5 M54 Dorsalgia
Diagnosis with code M54 includes 9 clarifying diagnoses (ICD-10 subheadings):
Excludes: cervicalgia due to intervertebral disc damage (M50.-).
Excluded: sciatic nerve damage (G57.0) sciatica: . caused by damage to the intervertebral disc (M51.1). with lumbago (M54.4).
Back pain. Formulation of diagnosis
This article may be of interest to neurologists, general practitioners, residents, and perhaps even students studying neurology. I hope the above-mentioned persons are present on the site and will read the article, or even better, express their thoughts on this issue.
Anyone, even those far from medicine, knows that we now have an “epidemic” of osteochondrosis. This diagnosis is given to almost everyone who goes to the doctor with the problem of pain in the spine. Accordingly, as a vertebroneurologist, I am interested not only in the issue of practice, but also in the formal approach in terms of clearly formulating the diagnosis and determining the appropriate ICD code.
In my research, I used the imperishable book of Stock and Lewin on the formulation of clinical diagnosis, ICD-10 itself and a not-everyone-known, but nevertheless existing source called “Use of the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision (ICD-10). 10) in the practice of domestic medicine" from 2002.
It all started when, finishing my internship, I intuitively doubted the approach to the formulation of the diagnosis and its encryption used where I specialized. Probably, this scheme was used in the hospital to simplify work, but nevertheless it is scary to imagine what morbidity statistics this scheme ultimately provided (and still provides today). The approach was as follows: a person has a sore neck, therefore ICD code M50.1, a pain in the lower back - M51.1, a pain in the thoracic spine or several parts - M42.1. The formulation of the diagnosis is accordingly also simple and unpretentious: osteochondrosis (.) of the spine with vertebral|muscular-tonic|radicular|polyradicular| syndrome or something like that with minor variations depending on the situation.
If we turn to the very recommendations of 2002, which I wrote about above, then it says: “The recording of the final diagnosis in the statistical card of a person leaving the hospital should not begin with a group concept like Dorsopathy, since it is not subject to coding, since it covers constitutes a whole block of three-digit headings M40 - M54 [. ] The diagnosis must clearly indicate the specific nosological form to be coded.” The following is an example:
Main disease: Dorsopathy. Osteochondrosis of the lumbar spine L5-S1 with exacerbation of chronic lumbosacral radiculitis. With such an incorrect formulation of the diagnosis in the statistical card of a person leaving the hospital, filled out for a patient who was undergoing inpatient treatment in the neurological department, code M42.1 may be included in the statistical development, which is not correct, since the patient received treatment for an exacerbation of chronic lumbosacral radiculitis. The correct formulation of the diagnosis:
Lumbosacral radiculitis against the background of osteochondrosis. Code - M54.1.
The same approach is used when formulating a detailed clinical diagnosis in Stock and Lewin, namely, it is proposed to indicate, first of all, the leading clinical syndromes:
- Local pain syndrome (cervicalgia, thoracalgia, lumbodynia, etc.).
- Reflex syndromes (referred pain: cervicobrachialgia, lumbar ischialgia, etc.; muscular-tonic syndromes; neurodystrophic manifestations in the form of enthesopathies, pariarthropathy, etc.).
- Compression radicular syndrome (radiculopathy, radiculoischemia).
- Syndromes of compression (ischemia) of the spinal cord (myelopathy).
Moreover, the same syndrome can occur in a number of pathological conditions. And in clinical practice, it is not always possible to say unambiguously whether a neurological syndrome is caused by a disc herniation, spondyloarthrosis, or sprain. In this case, coding should be carried out specifically according to the neurological syndrome (see headings M53 - other dorsopathies, M54 - dorsalgia). It must be remembered that even if an additional examination was carried out, which revealed some kind of pathology, it will not always be the cause of the disease, but it can easily cause iatrogenicity in particularly impressionable patients. It is because of this that the results of additional examination methods should be considered in the context of the overall clinical picture and performed strictly according to indications.
If additional examinations were carried out and, together with the clinical picture, they clearly indicate the cause of the neurological symptoms, then these reasons must necessarily be reflected in the diagnosis and it is no longer the leading syndrome that is coded, but the cause that caused it.
In addition, the diagnosis must contain a number of additional important information:
- Course of the disease (acute, subacute, chronic (remitting, progressive, stationary, regressive)).
- Phase of the disease (exacerbation, regression, remission (complete, partial)).
- Frequency of exacerbations (rare - no more than 1 time per year, average frequency - 2-3 times per year, frequent - 4 or more times per year).
- The severity of the pain syndrome (mildly expressed - does not complicate the patient’s daily activities, moderately expressed - limits the patient’s daily activities, severe - severely complicates daily activities, pronounced - makes daily activities impossible).
- You should also additionally indicate the state of mobility of the spine, the localization and severity of sensory, motor and pelvic disorders.
To summarize, we can give a number of examples of the formulation of a detailed clinical diagnosis:
- If the cause of the neurological syndrome has not been established, then the formulation may look like: cervicalgia with mild pain and moderate muscular-tonic syndromes, chronic relapsing course with exacerbations of moderate frequency, exacerbation phase (M54.2).
- If the cause of the neurological syndrome is clearly established:
A. Radiculoischemia L5 (paralyzing sciatica syndrome) on the left, due to lateral disc herniation LIV-LV, regression stage, moderate paresis and hypoesthesia of the left foot (M51.1).
b. Lumbodynia due to LIV-LV disc herniation with severe pain, chronic course with rare exacerbations, exacerbation phase (M51.2)
V. Lumbodynia due to osteochondrosis of the lumbar spine (LIII-LV) with mild pain syndrome, chronic remitting course with exacerbations of moderate frequency, incomplete remission phase (M51.3).
M54 diagnosis
under the leadership of Bogomolova N.A.
In 1999, in our country, the International Classification of Diseases and Causes Associated with them, the Xth Revision (ICD10), was legislatively recommended. The formulation of diagnoses in medical histories and outpatient cards with their subsequent statistical processing makes it possible to study the incidence and prevalence of diseases, as well as compare these indicators with those of other countries. For our country, this seems especially important, since there is no statistically reliable information on neurological morbidity. At the same time, these indicators are the main ones for studying the need for neurological care, developing standards for the staff of outpatient and inpatient doctors, the number of neurological beds and various types of outpatient care.
Professor, head Department of Neurology and Neurosurgery FUV RSMU
The section “other dorsopathies” in heading M53 includes sympathalgic syndromes associated with irritation of the afferent sympathetic nerve due to posterolateral displacement of the cervical disc or spondylosis. In Fig. Figure 14 shows the peripheral cervical nervous system (plexus of the somatic nervous system, cervical ganglia of the sympathetic nervous system and its postganglionic fibers located in the soft tissues of the neck and along the carotid and vertebral arteries. In Fig. 14a
ICD code: M54.5
Lower back pain
Lower back pain
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