Medication treatment of osteochondrosis of the spine

Neurological complications of spinal osteochondrosis are an important medical, social and economic problem. A large number of patients of working age are forced to spend a lot of time and money every year to relieve and prevent complications of this disease. In this regard, the relevance of the problem of choosing a rational treatment for osteochondrosis is understandable. As is known, this treatment is complex and includes both the prescription of drugs (pharmacotherapy) and the use of non-drug therapy methods, as well as surgical treatment. Let us dwell in more detail on the possibilities of pharmacotherapy. Its main areas are the impact on pain syndrome, muscle-tonic component, improvement of microcirculation and tissue trophism.

If acute pain occurs, the patient should remain in bed for several days to reduce the volume and severity of movements in the affected area. The patient should be in a comfortable, relaxed position on the back. Patients often choose a position with a slightly raised back and slightly bent knees on their own. The main requirement is that the patient lies on a hard surface in a comfortable position. Cold or light dry heat can relieve pain, while deep or strong heating often intensifies it. With a gradual expansion of the regime, patients are recommended to temporarily limit physical activity and avoid prolonged stay in a non-physiological position, sudden movements in the spine (extension, rotation, bending), and lifting weights. If there are signs of instability of the spinal motor segment and a tendency for pain to recur, it is advisable to wear a corset for several days. However, it should be remembered that long-term wearing of a corset can lead to muscle weakening. After the pain has been completely relieved and discomfort has been eliminated, it is necessary to begin special exercise therapy sessions with teaching the patient the correct movements without increasing the load on the spine, strengthening the muscles of the back and neck. As a rule, a course (7-10 procedures) of professionally performed massage and swimming in warm water have a positive effect.

An important component of treatment is the prescription of analgesics, which must be taken in a course (by the hour), without waiting for the pain to intensify. Most often, analgin, paracetamol, sedalgin are used. In the first days of acute pain syndrome, mixtures are used that contain, along with analgesics, dehydrating (anti-edematous), anti-inflammatory, muscle relaxants, sedatives. Analgin (1-2 ml of a 50% solution) and analgesics of other groups - baralgin (5-10 ml), novocaine (from 20 to 100 ml of a 0.5% solution) are often combined with the prescription of hydrocortisone (20-40 mg), lasix (20-40 mg), euphyllin (10 ml of a 2.4% solution), tranquilizers (relanium 1-2 ml), vitamin B ₁₂ (up to 2000 mcg per administration). Drip administration of these mixtures (in various compatible combinations) can be carried out 2 times a day. The use of novocaine is possible in various dilutions and its derivatives: trimecaine (0.5-0.25%), sovkaine (0.5-10%); lidocaine (0.5; 1; 2%)

Approximate compositions of mixtures:

• Analgin solution 50% - 1.0 No-shpa - 2 g Lasix - 40 mg Novocaine solution 0.25% - 100.0 Saline solution - 150.0 - intravenous drip
• Baralgin - 5.0 Relanium - 2.0 Dexazone - 4 mg Novocaine - 0.25% - 50.0 Glucose - 5% - 200.0 - intravenous drip
• Analgin 50% - 2.0 V ₁₂ - 1000 mcg No-shpa - 2% - 2.0 Reopyrin - 5.0 - i/m

Dehydrating (anti-edematous) treatment complex is indicated mainly for severe radicular syndrome. Fast-acting saluretics or dexazone are most often used in this situation. There is no consensus on the effectiveness of these drugs.

Non-steroidal anti-inflammatory drugs (NSAIDs) are drugs with combined action (including those with a pronounced analgesic effect). The following drugs are most often used from this group: diclofenac (voltaren; diclovit); orthofen; ibuprofen; indomethacin; piroxicam; ketoprofen (arthrozilen, ketonal); ketorolac (dolac); lornoxicam (xefocam). Their action is based on non-selective inhibition of cyclooxygenase, as a result of which the reactions of the arachidonic cascade are blocked and the synthesis of prostaglandins is disrupted. This leads to a decrease in damage to cell membranes, which slows down the progression of the inflammatory process. Drugs of this group have a pronounced anti-inflammatory, antirheumatic, analgesic, antipyretic, antiplatelet effect. The variety of forms of diclofenac makes it easy to use. Voltaren tablets are available in 25 and 50 mg, prolonged-release tablets of 100 mg, injection solutions in 3 ml ampoules (25 mg/1 ml), rectal suppositories of 50, 100 mg and 25 mg for children. Voltaren is usually prescribed orally at 25-50 mg 2-3 times a day (but not more than 150 mg/day). When a therapeutic effect is achieved, 50 mg is used per day. Suppositories are prescribed at 50 mg 2 times a day, cream for external use "Voltaren emulgel" - 1% is rubbed into the skin over the lesion (2-4 g) 2 times a day (used to enhance the effect with other dosage forms).

When taken orally, diclofenac has a direct damaging effect on the cells of the gastric mucosa, damaging mitochondria and dissociating oxidative phosphorylation. Therefore, if there are signs of damage to the stomach and duodenum, preference is given to suppository forms of diclofenac, such as, for example, diclovit suppositories (available in 50 mg). It has been shown that the duration of action of diclovit suppositories is longer than that of tablet forms. This allows for a reduction in the number of doses of the drug per day, which is of considerable importance, especially for elderly patients. Diclovit suppositories are usually used twice a day (monotherapy) or in combination therapy: during the day, the patient receives injections or tablets, and at night - suppositories, which creates a better therapeutic effect due to a more uniform and long-term maintenance of the drug concentration in the blood. For external use, 1% diclovit gel is available.

The course of treatment with NSAIDs is determined by the doctor depending on the severity of the disease, but usually does not exceed 7-14 days.

Selective inhibitors of cyclooxygenase type 2 (COX 2) are also used: nise (nimesulide); celecoxib (celebrex); meloxicam (movalis). It is recommended to use adequate doses of NSAIDs for a short course (no more than 5-7 days). In some cases (if the patient is contraindicated in oral use of these drugs in case of hemorrhagic syndrome, gastrointestinal ulcer), intramuscular injections of NSAIDs are indicated. These drugs can also be used in the form of ointments (for example, fastum gel) or in the form of rectal suppositories (for example, ketoprofen). It should be emphasized once again that with parenteral or rectal use of NSAIDs, dyspeptic phenomena occur less often than when taking tablet forms, however, according to most researchers, the risk of ulcers and erosions is reduced insignificantly. If it is necessary to administer a short course of NSAIDs to individuals with a high risk of erosive and ulcerative lesions of the stomach and duodenum (the elderly, with a history of peptic ulcer disease, suffering from cardiovascular diseases, taking corticosteroids and anticoagulants), it is advisable to combine NSAIDs with H2-histamine receptor blockers ₍ ranitidine 150-300 mg/day, famotidine 40 mg/day), proton pump inhibitors (omeprazole 20 mg/day, lansoprazole 30 mg/day, etc.) or the synthetic prostaglandin analogue misoprostol (100-200 mg 3-4 times a day) to protect the gastrointestinal tract. The appearance of dyspepsia or erosive and ulcerative complications requires immediate discontinuation of NSAIDs and selection of a combination of other drugs with analgesic, anti-inflammatory and microcirculation-improving effects for treatment.

Selective COX-2 inhibitors, such as movalis and celecoxib, are less likely to cause gastrointestinal side effects than traditional NSAIDs. Celecoxib has proven its effectiveness in osteoarthritis and ankylosing spondylitis. At the same time, its effectiveness in vertebrogenic pain syndromes has not been reliably established. According to a number of researchers, the drug can be a drug of choice in cases of poor tolerance to traditional NSAIDs, a history of gastric ulcer and duodenal ulcer, and the need for long-term use of NSAIDs.

The optimal combination of high efficiency and safety characterizes the use of movalis, which is increasingly used in the treatment of both osteoarthrosis and arthritis, and pain syndromes of vertebrogenic and muscular genesis. Recently, with the appearance of the injection form of meloxicam, the use of the so-called "step" therapy with movalis is recommended: in the acute period, daily for 3-6 days, depending on the severity of the pain syndrome, injections are prescribed - intramuscularly at 15 mg (1 ampoule) per day, then they switch to the tablet form of the drug also at 15 mg 1 time per day. If the severity of the pain syndrome does not decrease within 3-4 days, the treatment can be enhanced by prescribing agents that have an inhibitory effect on the cortex and limbic structures of the brain, such as chloral hydrate (no more than 2 g in an enema) or opioid synthetic analgesics, such as tramadol (tramal). This drug has a pronounced analgesic effect, stimulating opiate receptors, reduces the reverse synaptic uptake of norepinephrine and serotonin. The dosage is individual, depending on the intensity and nature of pain. On average, 50-100 mg / day is used, with very intense pain - no more than 400 mg / day. Tablets or capsules (50 mg) are taken orally without chewing, washed down with a small amount of water. The injection solution is released in ampoules of 1 ml (50 mg) or 2 ml (100 mg). A convenient form of release in suppositories (100 mg). It is necessary to remember that during the treatment period you should refrain from driving a car (since the reaction rate changes), and with prolonged use of large doses, drug addiction may develop. Only in case of unbearable pain do they resort to narcotic drugs (opium in suppositories, leoran, phenadone, promedol).

Along with the systemic administration of analgesics, local applications based on dimexide (aqueous solution 10-30-50%) have a good effect in case of pain and muscular-tonic syndrome. Dimexide is diluted with 0.5-2% novocaine solution at a ratio of 1 to 2. Considering the ability of dimexide to “conduct” the active medicinal substance deep into tissues, it is advisable to include hydrocortisone [dimexide 5 ml + novocaine 0.5% 10 ml + hydrocortisone (for intra-articular injections) 2.5 ml (75 mg)] in the application solution for 5 days once a day, and then voltaren [dimexide 5 ml + novocaine 0.5% 10 ml + voltaren 3 ml] for 5 days once a day. For applications, 5-layer gauze is soaked in the appropriate solution and applied to the projection of pain points (under a local thermal bandage) for 30-40 minutes once a day. The general course of local applications is 10 procedures: 5 with hydrocortisone and 5 with voltarene.

In practice, novocaine paravertebral blockades are used quite often. Paravertebral blockade is a collective term. It only indicates that the blockade is performed in close proximity to the spine. Paravertebral blockade can be intradermal, subcutaneous, muscular, perineural and the so-called "radicular". Sometimes the ganglia of the border sympathetic trunk are blocked paravertebrally. It is necessary to take into account the predominant localization of the pathological process in discogenic lumbosacral radiculopathies. One of the important general provisions is that osteochondrosis of the spine is especially often accompanied by irritation or a more pronounced stage of compression of the L1 and S1 roots. This circumstance is associated with increased traumatization of the lumbosacral disc, as well as with the fact that the intervertebral opening at this level is especially narrow (1-3 mm versus 5 mm for the overlying vertebrae) and the cord completely closes the opening here. Paravertebral radicular block is indicated for radiculopathy. A 0.5-1% solution of novocaine or a mixture of it with hydrocortisone emulsion is used, less often - other drugs. A mixture of hydrocortisone with novocaine solution is prepared immediately before use. Usually 50-75 mg of hydrocortisone and up to 100 ml of novocaine are used (depending on the number of points used for the block and the physical condition of the patient). It is also necessary to have a pure solution of novocaine of the required concentration. Novocaine is used for preparatory anesthesia, and its mixture with hydrocortisone is for injection directly into the area of the cords. The technique of paravertebral block is described in special manuals. Injections are repeated after 2-3 days, a total of 3-5 injections per course. Along with novocaine, its various derivatives can be used: trimecaine (0.5-0.25%), sovkaine (0.5-10%); lidocaine (0.5; 1; 2%).

Local irritants and distractors (external use of ointments containing NSAIDs (for example, the above-mentioned diclovit gel, voltaren emulgel, etc.), lidocaine cream, betanicomilon, finalgon, nikoflex, espol, efkamon, tiger ointment, snake and bee venom, anusol, bantin, local use of pepper plaster) and local reflexotherapy and physiotherapy can help reduce the severity of pain.

The effect on the muscular-tonic (muscular-tonic) component of pain includes post-isometric relaxation, massage and therapeutic exercises, including exercises to strengthen the muscular corset or stretch the spasmodic muscles. A positive effect is provided by blockades of trigger and painful points with several ml of a local anesthetic solution and/or corticosteroid. Irrigation of the painful area with ethyl chloride followed by muscle stretching is also used. In case of prolonged myofascial pain caused by secondary muscular-tonic reactions, muscle relaxants are prescribed, for example, sirdalud (tizanidine). Sirdalud is a centrally acting muscle relaxant. By stimulating presynaptic a ₂ -adrenoreceptors, it suppresses the release of excitatory amino acids from intermediate neurons of the spinal cord, which leads to the inhibition of polysynaptic transmission of excitation in the spinal cord, which regulates the tone of skeletal muscles. Sirdalud is effective against acute painful muscle spasms and chronic spasms of spinal and cerebral origin. It is available in tablets of 2 and 4 mg. To relieve painful muscle spasms, sirdalud is prescribed orally at 2-4 mg 3 times a day, in severe cases - an additional 2-4 mg at night. The drug is prescribed with caution to patients with renal and hepatic insufficiency. During treatment, one should refrain from work that requires rapid psychomotor reactions. Other drugs in this group include baclofen 30-75 mg / day, diazepam 10-40 mg / day, tetrazepam (myolastan) 50-150 mg / day or combinations of muscle relaxants with analgesics (myalgin). The duration of such treatment is about 2 weeks.

[ 1 ], [ 2 ], [ 3 ], [ 4 ]

Improvement of microcirculation and metabolism, symptomatic treatment of osteochondrosis of the spine

The complex of drug therapy includes drugs that improve microcirculation. Among them, it is advisable to prescribe pentoxifylline (Trental) 400 mg 2-3 times a day orally or 100-300 mg intravenously by drip in 200 ml of isotonic sodium chloride solution, 10% curantil solution (dipyridamole) 75 mg intravenously by drip.

To improve peripheral circulation, vasodilators are used: complamine or theonikol (150-300 mg 3 times a day), nicotinic acid from 1 to 6 ml intramuscularly, as well as drugs that stimulate venous outflow - escusan, troxevasin, glivenol.

In order to improve the trophism of the spinal cord tissue and the muscular-ligamentous apparatus, a 20% solution of actovegin is used, 2-5 ml intramuscularly for 14 days; tanakan 40 mg 3 times a day.

Vitamin preparations have a general strengthening effect. These substances belong to the group of non-specific immunoprotectors and can be additional means of pathogenetic and symptomatic therapy. Many of them have antioxidant properties that reduce various pathological manifestations during the development of inflammatory and pain reactions. This group of drugs is especially necessary during the recovery period after the relief of the acute period of radiculopathy. Thus, preparations of vitamins A, E, B ₂, P, C help to strengthen the vascular wall of capillaries, especially with their reduced resistance. Preparations of vitamins B6, B12, PP normalize the conduction of nerve impulses along peripheral nerve fibers and through the neuromuscular synapse, help to reduce the feeling of pain, reduce swelling. Ascorbic acid in high doses causes stimulation of endogenous glucocorticosteroidogenesis with subsequent manifestation of analgesic and anti-inflammatory activity inherent in glucocorticosteroids.

Outside of exacerbation of pain syndrome, so-called chondroprotectors can be widely used to improve the metabolism of articular cartilage. As a rule, they are cartilage extracts (rumalon 1-2 ml intramuscularly once a day, arteparon 1 ml intramuscularly twice a week), chondroitin sulfate preparations (artron 1-2 ml intramuscularly; structum 750 mg twice a day for 3 weeks, then 500 mg twice a day, chondroxide, ointment 2-3 times a day), alflutop 1 ml intramuscularly, glucosamine (dona) 1.5 g orally. These preparations have a stimulating effect on the regeneration of cartilage tissue, reduce concomitant inflammation and relieve pain in the affected joints and spine. In particular, chondroxide, the active ingredient of which is chondroitin sulfate, is a substitutive and restorative agent identical to mucopolysaccharides and glycosamines. Due to this, it has a stimulating effect on the regeneration of articular cartilage. The second component of the ointment - dimethyl sulfoxide - has a pronounced analgesic and anti-inflammatory effect, promotes deeper penetration of chondroitin sulfate into tissues. Chondroxide is recommended for external use by applying 2-3 times a day to the skin over the lesion and rubbing for 2-3 minutes until completely absorbed. More effective use of chondroxide for osteochondrosis by ultraphonophoresis. The duration of therapy with chondroprotectors is individual.

Other biogenic stimulants are also used quite often: liquid aloe extract for injections; solcoseryl; vitreous body; FiBS; glutamic acid.

An important problem in cervical osteochondrosis is the treatment of dizziness, which occurs quite often, especially in older people. Vertebrogenic dizziness bothers patients not so much during periods of exacerbation (here the above-mentioned pain syndromes come to the fore), but during periods of relative remission, affecting the general level of vital activity, emotional background and ability to work. Traumatization of the vertebral artery by osteophytes, accompanied by the development of changes in its intima and the possibility of vascular spasm, creates the prerequisites for deterioration of blood circulation in the vertebrobasilar basin. In older patients, given the presence of atherosclerotic changes in the vessels, this leads to the occurrence and progression of vertebrobasilar insufficiency, manifested primarily by cochleovestibular disorders (systemic or non-systemic dizziness, paracusia, Meniere-like syndrome). In the treatment of dizziness, it is possible to use drugs of different groups, which in one way or another reduce the excitability of the central and peripheral parts of the vestibular analyzer. Among them is the synthetic analogue of histamine betaserk (betahistine). This drug acts on the histamine H2 and H3 receptors of the inner ear and vestibular nuclei of the central nervous system, improves microcirculation and permeability of the capillaries of the inner ear, increases blood flow in the basilar artery, normalizes the pressure of the endolymph in the labyrinth and cochlea. The drug is effective when taken orally at 8 mg 3 times a day; the course of treatment is 1-3 months. However, it is necessary to remember about its careful use in patients with a history of peptic ulcer, pheochromocytoma, bronchial asthma. It is also possible to recommend the use of vasoactive agents [cinnarizine (stugeron), vinpocetine (cavinton)], agents that improve microcirculation [pentoxifylline (trental)], combined vascular-metabolic agents (tanakan, picamilon, vasobral), antihistamines (tavegil, suprastin), and biostimulants.

In case of severe radicular syndrome, the treatment period increases significantly (up to 6-8 weeks compared to 2-3 weeks for uncomplicated lumbago). It is advisable to conduct treatment in a hospital setting. The principles of treatment remain the same - bed rest for at least 10-14 days, the use of analgesics, in particular NSAIDs. In case of severe pain syndrome that cannot be relieved by conventional methods, drugs with a more pronounced analgesic effect are used, for example, synthetic analgesics such as the already mentioned tramadol (tramal), fortral, etc. The method of choice is the use of epidural blockades, performed through the sacrococcygeal foramen, translumbar method or through the first sacral foramen. For blockades, it is preferable to use drugs that have a local effect and form a depot at the injection site. In severe cases, in the absence of contraindications, a short course (3-5 days) of treatment with corticosteroids is administered (prednisolone at a dose of 80-100 mg per day orally for 3-5 days, followed by an accelerated reduction in the dose). Therapy aimed at improving microcirculation and tissue trophism is used.

In radicular syndromes caused by verified intervertebral disc herniations, intradiscal administration of chymopapain is possible for the purpose of enzymatic lysis of the disc.

In cases of chronic pain syndrome (pain lasts more than 3 months), a thorough examination of the patient is required to establish the possible cause of pain (compression by a tumor, abscess, severe osteoporosis). It is also necessary to analyze the totality of psychological, somatic and other factors that contribute to the chronicity of pain.

The emphasis in the treatment of chronic pain syndrome is shifted to non-drug methods of influence (massage, exercise therapy, swimming, reflexology, physiotherapy) and a gradual expansion of the motor regime. It is advisable to use the introduction of drugs by phonophoresis. Thus, the inclusion of phonophoresis of chondroxide ointment in the program of rehabilitation measures for patients with stage I-II spinal osteochondrosis contributes to a more rapid relief of pain, the disappearance of tension symptoms, and the restoration of motor activity of patients. It has been clinically proven that the use of phonophoresis of chondroxide ointment in patients with spinal osteochondrosis is safe and does not cause side effects. The course of treatment includes 12-15 procedures. Ultrasound intensity 0.2-0.4 W / cm ² in pulsed mode using a labile technique for 8-10 minutes.

When forming psychological attitudes of the patient on pain syndrome or appearance of depressive symptoms, consultation of a clinical psychologist and psychiatrist is necessary. The effectiveness of treatment measures often increases against the background of taking "soft" antidepressants or tranquilizers.

In cases resistant to drug therapy, a neurosurgeon consultation is necessary to decide on surgical treatment of spinal osteochondrosis. Surgical treatment of spinal osteochondrosis is absolutely indicated in case of intervertebral disc sequestration with the formation of a "foreign body" inside the epidural space. An urgent neurosurgeon consultation with a decision on surgery is also necessary in cases of acute compression of the roots (including the equine tail), accompanied by increasing paresis of the limbs and pelvic disorders. Another indication for surgical treatment is severe disabling pain syndrome that does not respond to conservative treatment for several months.

Thus, treatment of spinal osteochondrosis should be comprehensive, including drug and non-drug therapy, and long-term. To maintain the patient's motivation for recovery, patient attitude to treatment, it is necessary for him to understand the essence of pathological processes and neurological complications in spinal osteochondrosis. Otherwise, treatment will be reduced only to stopping increasingly frequent exacerbations. Only active participation of the patient in the treatment process creates the basis for sustainable regression of neurological manifestations of spinal osteochondrosis and maintaining a full life.

[ 5 ], [ 6 ], [ 7 ]