Radicular syndrome according to ICD 10. Radicular syndrome: types of disease and their symptoms. Symptoms and diagnostic methods
Osteochondrosis of the spine is an insidious disease and, perhaps, one of the most common. Very often, people do not suspect that they are sick, and attribute pain in the lumbar region, in the thoracic region or in the neck to a variety of causes. However, osteochondrosis can be so different, with such big amount manifestations that it is worth treating it with due attention, it is especially often observed in women. An experienced doctor can accurately determine the cause of the disease, using the ICD code and signs of osteochondrosis. The disease is divided into 3 degrees, each of which has its own characteristics.
- Osteochondrosis of the 1st degree is characterized by pain in the muscles, this is caused by damage to the capsule of the intervertebral disc, and the load on the spine is redistributed. This leads to constant irritation of the above area and, as a result, to periodic pain.
- Osteochondrosis of the 2nd degree is characterized by the presence of constant pain, that is, the disease becomes chronic, and the pain intensifies with exercise. The intervertebral disc wears out, ceases to fully perform its functions and as a result; peripheral parts are affected nervous system.
- Stage 3 is the most difficult, as a hernia may form. This occurs due to disruption and displacement of the collagenous capsule, the pulp penetrates through the gaps and very severe pain occurs. The disc may fall out, then the patient becomes practically inactive, unable to straighten up.
Radicular syndrome
This common disease is characterized by several symptoms that occur due to compression of roots or nerves, they are called spinal. It provokes this compression, and the reason may also be due to the presence of:
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- hernias;
- tumors;
- spinal injury, vertebral fracture;
- infectious disease of the spine;
- spondyloarthrosis;
- compression by lateral osteophytes.
It takes a long time before such a syndrome can develop and a hernia forms. It is this that, growing, compresses, causes inflammation and the development of radiculopathy, the so-called osteochondrosis with radicular syndrome. X-rays of the spine in two projections help identify the disease. The most complete picture appears after an MRI, however, when diagnosing it is important to take into account the symptoms, since they play a significant role important role.
The main complaint with which patients come to a medical institution, assuming that they have osteochondrosis with radicular syndrome, is pain and numbness, these are the signs of osteochondrosis. The concentration of pain occurs in places where the root is compressed and in the organs that are innervated by the affected spinal nerve. The following relationship is defined:
- the root in the fifth vertebra is damaged - pain in the lumbar region, called lumbodynia;
- root at the level of the fourth vertebra - pain is felt starting from the buttock and passes along the thigh, ending in the lower leg;
- the eighth cervical root affects the shoulder area;
- the sixth extends from the neck and shoulder blades to the hand.
With radicular syndrome, there may be the following signs of osteochondrosis:
- decreased sensitivity of the skin;
- sharp or aching pain in the lumbar region, it is important not to confuse it with kidney or other pain.
In the ICD, osteochondrosis corresponds to a specific code. M51.1, for example, degeneration of intervertebral discs of the lumbar and other parts with radiculopathy. Thus, each disease has its own code, which helps doctors navigate the terms, reduces time, and eliminates sometimes inappropriate explanations to a suspicious patient. ICD is a convenient system that has been tested and shows excellent results.
Here are some codes for spinal diseases that correspond to the ICD:
- M41.1 – adolescent idiopathic scoliosis;
- M41 – scoliosis;
- M42 - code for spinal osteochondrosis;
The code carries certain information that only a specialist can understand. ICD codes for the vertebral region, or for diseases associated with the spine, are located in the dorsopathy section in the range from M-40 to M-54. Not all diseases are associated with osteochondrosis; the signs of osteochondrosis must be correctly interpreted.
Osteochondrosis with radicular syndrome, treatment
First of all, bed rest is necessary, and strict. The bed must have a hard surface. Painkillers and anti-inflammatory drugs are prescribed. You can use local irritants, that is, ointments and pepper plaster.
Since osteochondrosis with radicular syndrome often turns into chronic form, then it is important to adhere to a certain scheme; the course should not be long-term. When taking these medications, there are side effects, therefore, emphasis should be placed on more gentle methods, such as:
- physiotherapy;
- massage;
- electrophoresis;
- physiotherapy;
- diet.
In more severe cases, a decision is made about surgical intervention. Prevention has proven itself well; the main element is therapeutic exercises aimed at strengthening the back muscles.
There is such a thing as international classification diseases, ICD. Each disease corresponds to a specific code, which is easy to navigate; the ICD code significantly simplifies the doctor’s work. In the international classification ICD-10, osteochondrosis has its own code. Next, each type of disease that is related to this disease is assigned a different code, following the ICD.
No need to treat joints with pills!
Have you ever experienced unpleasant discomfort in your joints or annoying back pain? Judging by the fact that you are reading this article, you or your loved ones have encountered this problem. And you know firsthand what it is.
Radicular syndrome does not occur immediately; as a rule, it is caused by a long-term degenerative process in the intervertebral discs, which ends in the formation of a hernia. In turn, the hernia, growing and displacing, can damage the spinal root and ganglion, which leads to its compression and the development of an inflammatory reaction, ultimately developing radiculopathy and radicular syndrome.
Standard instrumental method Diagnosis of radicular syndrome includes radiography of the spine in anterior and lateral projections. Today, the most sensitive and informative method for diagnosing spinal pathology is magnetic resonance imaging. However, when making a diagnosis of radicular syndrome, clinical symptoms play an important role.
The first and most characteristic sign of radicular syndrome is pain along the affected nerve. Thus, the process in the cervical spine causes pain in the neck and arm, in the thoracic spine - in the back, sometimes there are sensations of characteristic pain in the heart or in the stomach (such pain disappears only after treatment of the radicular syndrome), in the lumbar spine - in the lower back, buttocks and lower extremities and so on. When moving or lifting something heavy, the pain intensifies. Sometimes the pain occurs in the form of lumbago, radiating to different parts of the body in accordance with the location of the corresponding nerve; in the lumbar region such a lumbago is called lumbago. The pain may be constant, but it still intensifies with any careless movement (for example, lumbodynia - pain in the lumbar region). Attacks of pain can be provoked by physical or emotional stress, hypothermia. Sometimes pain occurs at night or during sleep, accompanied by redness and swelling of the skin, and increased sweating.
Another sign of radicular syndrome is a violation of sensitivity in the zone of innervation of this nerve: with a slight tingling with a needle in this zone, a sharp decline sensitivity compared to a similar area on the opposite side.
The third sign of radicular syndrome is a violation of movements that appear as a result of changes in the muscles that occur against the background of damage to the nerves that innervate them. The muscles dry out (atrophy), become weak, sometimes this is visible even to the eye, especially when comparing two limbs.
The pain is localized in the area of compression of the root and in those organs that are innervated by the damaged spinal nerve. For example, when the root is affected at the level of the 5th lumbar vertebra (L5), pain is detected in the lumbar region (lumbodynia), when walking - in the upper outer quadrant of the buttock, radiating along the outer surface of the thigh and lower leg to the II-IV toes (lumboischalgia). When the L4 root is damaged, pain spreads from the buttock through the anterior surface of the thigh and the anterior-inner surface of the lower leg to the inside of the foot.
Since the spinal root includes motor processes of the neuron and sensory nerve fibers, with radicular syndrome there may be a disturbance (reduction) in the sensitivity of the tissue. For example, with L5 radicular syndrome, skin sensitivity (hypoesthesia) in the area of the outer surface of the thigh and lower leg decreases.
IN modern conditions intensification of industry, complication of production and educational processes require more physical and psycho-emotional stress from a person than before.
Stress factors affecting the body cause its responses, manifested in rational and irrational forms of adaptation.
The consequence of this is the development of a number of pathological processes, including spinal ailments.
Radicular syndrome is a symptomatic manifestation of changes affecting the bone and cartilage tissue of the spine, and is one of the most famous chronic recurrent human diseases.
What it is?
Radicular syndrome- a fairly common phenomenon of neuralgic etiology in vertebrological practice. The nerves running in the canals, their anatomical containers, are protected from external influences.
Due to deterioration of blood supply and tissue nutrition, pathological changes and deformations of the tunnel walls occur, which leads to compression (compression) of the nerve roots.
Less commonly, the syndrome is the result of swelling of the nerve itself against the background of general intoxication of the body, for example, during long-term drug therapy for a disease. As a result, a symptomatic pain complex develops with localization in the part of the spine where the source of the pathology is located. There may also be irradiation of painful impulses into internal organs - the heart, gastrointestinal tract.
Clinical picture
Onset of the disease characterized by sudden sharp pain of a shooting nature. The symptomatic picture is complemented by changes in the sensitivity of the skin: numbness, a feeling of “goosebumps”. Depending on the location of the focus of degenerative or inflammatory changes, clinical signs manifest themselves differently.
The syndrome can also develop due to:
- constant loads on the spinal column;
- injuries;
- the presence of tumors of the spine and spinal cord;
- vertebral fractures caused by osteoporosis;
- infectious lesions of the spine (for example, with HIV, tuberculosis or osteomyelitis);
- endocrine disorders;
- sedentary lifestyle;
- some types of birth defects that affect the structure of the spine;
- changes in hormonal status.
The risk factors for humans are:
- types of production activities associated with heavy lifting and vibration processes;
- working in conditions that do not meet the ergonomic requirements for the workplace;
- violation of the biomechanics of the spine due to anatomical defects (scoliosis, anisomelia, flat feet);
- overweight;
- monotonous, unbalanced, vitamin-poor diet;
- frequent hypothermia.
Consequences
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Next fact
Long-term symptoms of the pathology lead to the formation of a chronic, difficult-to-control pain syndrome. If compression of the nerve is not eliminated in a timely manner, it causes further development of the degenerative process in the tissues of the root, leading to permanent impairment of its functions. The result of this is irreversible paresis, dysfunction of the pelvic organs, and disability of the patient.
Treatment
The treatment method for radicular syndrome is determined primarily by considering the possible causes of the pathology and establishing the main one.
Drugs
Medications are prescribed for:
| Group of drugs | Purpose | Name |
| Analgesics | pain relief |
|
| NSAIDs | reducing inflammation |
|
| Muscle relaxants | eliminate muscle spasms | Mydocalm |
| Prescribe B vitamins | improving metabolic processes in nerve tissues | Neuromultivitis |
| Chondroprotectors | correction of the process of cartilage destruction in intervertebral joints | -- |
External agents have a distracting and anti-inflammatory effect- irritating ointments, gels (Capsicam, Finalgon).
If there is no therapeutic effect of these medications, blockades are prescribed.
Surgery
If conservative therapy does not produce results, surgical intervention is possible.
The main indications for this are:
- intense pain that is not relieved by taking NSAIDs and analgesics;
- impaired motor function of the limb with complete loss of active movements;
- complicated intervertebral hernia;
- irreversible osteo-ligamentous changes leading to compression of the nerve root;
- complete loss of sensation (anesthesia) of the limbs.
The operations are performed under anesthesia. Access to the source of pathology is created and those fragments of the vertebra that cause compression of the nerve root are removed. Currently, for radicular syndrome against the background of a vertebral hernia, it is increasingly used nucleoplasty, How minimally invasive intervention for reduction or excision of a prolapsed disc.
Exercises, exercise therapy, massage, physiotherapy
Effective therapeutic measures to slow down the development of the inflammatory process and neutralize its consequences, restore motor function of the limbs, strengthen the muscle corset, are:
- physiotherapy;
- massage;
- exercise therapy complexes;
- reflexology;
- swimming.
They are prescribed after relief of acute pain. An important aspect of the effectiveness of therapy is the consistency and regularity of such sessions.
Treatment at home
Folk remedies that are used for radicular syndrome mainly exhibit a local effect and are aimed at maintaining the general tone of the body. Rubbing, compresses, applications with decoctions, tinctures medicinal plants and fruits(chamomile, calendula, sea buckthorn, chestnuts) help reduce the manifestations of pain and inflammation, have a muscle relaxant effect, but do not eliminate the main cause of the disease - compression of nerve endings due to deformation of the vertebrae.
Video: "How to deal with radicular syndrome?"
Prevention
The best measures prevention of radicular syndrome are:
- constant physical activity with proper distribution of the load on the spine;
- regular sports exercises that contribute to the formation of a muscle corset;
- rational nutrition and weight control;
- optimization of work and rest schedules;
- timely treatment infectious diseases;
- sleeping on a hard surface using special orthopedic bedding.
Recovery prognosis
The prospect of recovery depends on the degree of root compression, as well as from the timeliness of therapeutic measures. In general, with proper diagnosis and adequate treatment, the prognosis is favorable. The patient should understand that not completely cured radicular syndrome can take a chronic form, and with periodic exacerbations, resumption of treatment may be required at any time. This cyclical process can continue for many years.
Conclusion
Radicular syndrome is one of the diseases that, due to the characteristics of the clinical picture, are sometimes disguised as other ailments. In order for the course and outcome of the disease to be favorable, some recommendations should be followed.
- Symptoms characteristic of radicular syndrome may also appear in other pathological processes, including tumors. Therefore, the very first step in case of pain in the spine should be a medical examination for the purpose of diagnosis and treatment.
- Ignoring the manifestations of the disease, as well as self-medicating, is dangerous. The consequences of this can be severe irreversible complications, including disability.
- The healing process will speed up strict compliance with medical instructions: adherence to strict bed rest, if prescribed, lifestyle correction.
- You should take medications only as prescribed.
- The intended use of medicinal plants to alleviate the course of the disease should be discussed with a doctor: depending on the individual characteristics of the patient, side effects of such procedures are possible.
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 | - | medicinal Physical Culture |
| 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 in knee joint 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 body, chest, pharynx, tongue, face, neck, hands; · 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 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;
· preservation 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 | Inside, daily dose 5-10 mg in 3-4 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 with a dangling foot, on 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 arterial 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. Nikolaev, Efficiency new form 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. SPb. “Polytechnics”, 2009 12. Subbotin F. A. Propaedeutics of functional therapeutic kinesiological taping. Monograph. Moscow, Orthodinamika 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. 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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:
Baymukhanov 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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The information posted on this site should not be used to unauthorizedly change doctor's orders.
The patient's complaints and neurological symptoms depend on the level of spinal cord damage and the rate of development of ischemia. Most often, such patients are sent to the neurosurgical department to remove the intervertebral hernia, after which the patients are treated by a neurologist or physiotherapist.
Treatment of such patients is labor-intensive; the effectiveness of the therapy depends on the duration of the process. The earlier treatment is started, the more extensive the recovery process. It was noted that the best dynamics were observed when the disease was less than 1 year old.
IR spectrum lasers are used on the segment and on the radiculomedullary arteries, at the level of the L5-S1 roots. The neurovascular bundle of the affected limb, the area of the neck of the fibula, and the tibialis anterior muscle are also subject to laser treatment. Laser therapy should be combined with drug treatment.
It should be remembered that spinal osteochondrosis is a rare cause of back pain (10%). Most often, the cause of such pain is functional blockades, inflammatory-dystrophic changes in the musculoskeletal system: damage to the intervertebral joints - spondyloarthrosis, ligaments (anterior and posterior longitudinal, yellow, interspinous, intertransverse, sacrospinous, sacrotuberous and iliopsoas), fascia, back muscles and limbs (myofascial syndrome). Rare causes of back pain and therefore poorly diagnosed are fibromyalgia, spinal osteoporosis, instability of individual vertebrae, lateral recessive stenosis, and rigid filum terminale syndrome.
Myofascial syndrome manifests itself as non-generalized, non-specific muscle pain and is non-segmental in nature. This pain is caused by dysfunction of myofascial tissues and the appearance in the muscle of foci of increased irritability (trigger points, when pressed, pain occurs in a distant part of the body) or foci of myogenesis. It is believed that this pain occurs when the facet joints are damaged, as well as when the muscles are overstrained and overstretched due to an uncomfortable posture during work, when the leg is shortened, an oblique pelvis, flat feet, or stress.
Mythoascial pain syndromes should be treated comprehensively, first magnetic laser therapy with an infrared laser is carried out at the points of maximum pain for 1-3 minutes, then after 5-10 minutes.
For the treatment of myofascial lumboischialgic syndromes, it is recommended to use IR lasers. The exposure time to the painful trigger zone is 1-2-4 minutes, the total exposure time is up to 15 minutes, changing the frequency values is practiced during the procedure.
On the first day, a frequency of 80 Hz is selected,
on the second day 150 Hz,
on the third day - 300 Hz,
on the fourth day - 600 Hz,
on the fifth day -1500 Hz,
on the sixth day - 3000 Hz,
on the seventh day - 1500 Hz,
on the eighth day - 600 Hz,
on the ninth day - 300 Hz,
on the tenth day - 150 Hz,
on the eleventh day - 80 Hz.
The procedure involves no more than 10-15 impact zones. The trigger zone and the area around the zone are irradiated with slow circular movements, pressing the emitter tightly against the surface of the body. The projection of the area of the spinal motion segments at the L3-S1 level is necessarily irradiated, 2 minutes for each zone.
Preference is given to the BIM block emitter with maximum radiation power.
