Drug treatment of spinal osteochondrosis

Neurological complications of spinal osteochondrosis is an important medico-social and economic problem. A large number of patients of working age are forced to spend a lot of time and money each year on stopping and preventing the complications of this disease. In this regard, the urgency of the problem of choosing a rational treatment of 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, musculo-tonic component, improvement of microcirculation and tissue trophism.

If an acute pain syndrome occurs within a few days, the patient should maintain bed rest in order to reduce the volume and intensity of movements in the affected area. The patient should take a comfortable, relaxed position on the back. Often, patients choose their own posture with a slightly raised back and slightly bent knees. The main requirement is that the patient lay on a hard surface in a comfortable position. Cold or mild dry heat can relieve pain, while deep or strong warming intensifies it more often. With the gradual expansion of the regime, patients are recommended to temporarily limit physical activity and avoid prolonged stay in an unphysiological posture, sharp movements in the spine (extension, rotation, tilting), and weight lifting. If there are signs of instability of the vertebral motor segment and a tendency to recur pain, it is advisable to wear a corset for several days. However, it should be remembered that prolonged wearing of a corset can lead to a weakening of the muscles. After complete relief of pain and elimination of discomfort, it is necessary to begin special exercises of physical therapy with teaching the patient correct movements without increasing the load on the spine, strengthening the muscles of the back and neck. As a rule, the course (7-10 procedures) of a qualified massage, swimming in warm water, has a positive effect.

An important component of treatment is the appointment of analgesic drugs that need to be taken in a course (by the hour), without waiting for the increase in pain. Analgin, paracetamol, sedalgin are most commonly used . In the first days of acute pain syndrome use mixtures containing, along with analgesics, dehydrating (decongestants), anti-inflammatory, muscle relaxants, sedatives. Analgin (1-2 ml of 50% solution) and analgesics of other groups - baralgin (5-10 ml), novocaine (from 20 to 100 ml of 0.5% solution) are often combined with the prescription of hydrocortisone (20-40 mg), lasix ( 20-40 mg), aminophylline (10 ml of a 2.4% solution), tranquilizers (Relanium 1-2 ml), vitamin B ₁₂ (up to 2000 μg per administration). Drip administration of these mixtures (in various compatible combinations) can be carried out 2 times a day. Application novocaine possible in various dilutions and its derivatives trimekain (0.5-0.25%), sovkain (0.5-10%); lidocaine (0.5; 1; 2%)

Approximate composition of mixtures:

• Solution of dipyrone 50% - 1.0 No-shpa - 2 g Lasix - 40 mg Solution of novocaine 0.25% - 100.0 Phys. Solution - 150.0 - in / in drip
• Baralgin - 5.0 Relanium - 2.0 Dexazone - 4 mg Novocain - 0.25% - 50.0 Glucose - 5% - 200.0 - in / in the drip
• Analgin 50% - 2.0 V ₁₂ - 1000 µg No-shpa - 2% - 2.0 Reopirin - 5.0 - V / m

The dehydrating (anti-edematous) treatment complex is indicated mainly in patients with severe radicular syndrome. Most often in this situation, use quick-acting saluretics or dexazone. There is no consensus about the effectiveness of these drugs.

Non -steroidal anti-inflammatory drugs (NSAIDs) are drugs of combined action (including a pronounced analgesic effect ). Most often, the following drugs are used from this group: diclofenac (voltaren; diclovit); ortofen; ibuprofen; indomethacin; piroxicam; ketoprofen (arthrosilene, ketonal); Ketorolac (Dolak); lornoxicam (xefokam). Their action is based on non-selective inhibition of cyclooxygenase, which results in blocking the reactions of the arachidonic cascade and disrupting the synthesis of prostaglandins. This leads to a reduction in damage to the cell membranes, which hinders the progression of the inflammatory process. The drugs of this group have a pronounced anti-inflammatory, antirheumatic, analgesic, antipyretic, antiplatelet effect. A variety of forms of diclofenac release provides ease of use. Voltaren tablets are 25 and 50 mg each, 100 mg long-acting tablets, injection solutions in 3 ml ampoules (25 mg / 1 ml), rectal suppositories 50, 100 mg and 25 mg each for children. Usually, volt-arenas are prescribed orally for 25-50 mg 2-3 times per day (but not more than 150 mg / day). When therapeutic effect is achieved, 50 mg per day is used. Suppositories prescribed 50 mg 2 times a day, cream for external use "voltaren emulgel" - 1% 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 per os, there is a direct damaging effect of diclofenac on the cells of the gastric mucosa with mitochondrial damage and dissociation of oxidative phosphorylation. Therefore, in the presence of signs of lesions of the stomach and duodenum 12, preference is given to candle forms of diclofenac, such as, for example, diclovit suppositories (50 mg each ). It is shown that the duration of the suppository diklovit longer than the duration of the tablet form. This reduces the number of doses of the drug per day, which is of great importance, especially for elderly patients. Diklovit suppositories are usually used 2 times a day (monotherapy) or in combination therapy: during the day the patient receives injections or tablets, and at night - suppositories, which creates the best therapeutic effect due to more uniform and long-term maintenance of the drug concentration in the blood. For external use, 1% Diklovit-gel is produced .

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

Also used are selective inhibitors of cyclooxygenase type 2 (COX 2): Naise (nimesulide); celecoxib (celebrex); Meloxicam (Movalis). It is recommended to use adequate doses of NSAIDs in a short course (no more than 5-7 days). In some cases (if the patient is contraindicated for oral use of these drugs in the case of hemorrhagic syndrome, gastrointestinal ulcer), intramuscular injections of NSAIDs are shown. Also, these drugs can 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 when parenteral or rectal use of NSAIDs, dyspeptic symptoms occur less frequently than when taking the tablet form, however, according to most researchers, the risk of developing ulcers and erosions is slightly reduced. If you need a short course of NSAIDs for people with a high risk of erosive and ulcerative lesions of the stomach and duodenum (elderly, with a history of peptic ulcer, cardiovascular diseases, taking corticosteroids and anticoagulants), it is advisable to combine blockers H ₂ -histamine receptors (ranitidine 150-300 mg / day., Famotidine 40 mg / day.), Proton pump inhibitors (omeprazole 20 mg / day., Lansoprazole 30 mg / day., Etc.) or a synthetic analogue of the prostaglandi. New Misoprostol (100-200 mg 3-4 rd). The appearance of dyspepsia or erosive and ulcerative complications requires the urgent cancellation of NSAIDs and the choice to treat a combination of other drugs with analgesic, anti-inflammatory and microcirculation-improving effects.

Selective type 2 COX inhibitors, for example, movalis, celecoxib, are less likely to cause side effects from the gastrointestinal tract than traditional NSAIDs. Celecoxib has proven to be effective in osteoarthritis and ankylosing spondylitis. At the same time, with vertebral pain syndromes, its effectiveness has not been reliably established. According to some researchers, the drug can serve as a means of choice in case of poor tolerance to traditional NSAIDs, a history of gastric ulcer and 12 duodenal ulcer, and, if necessary, long-term use of NSAIDs.

The optimal combination of high efficacy and safety is characterized by the use of movalis, which is increasingly being used in the treatment of both osteoarthritis and arthritis, and pain syndromes of vertebrogenic and muscular genesis. Recently, when the injection form of meloxicam appears, the use of the so-called “stepwise” therapy with Movalis is recommended: in the acute period, for 3-6 days, depending on the severity of the pain syndrome, injections are given daily in 15 mg dosage (1 ampoule ) per day, then switch to the tablet form of the drug, also 15 mg once a day. If the severity of pain syndrome does not decrease within 3-4 days, treatment can be enhanced by prescribing agents that have an inhibitory effect on the cortex and limbic structures of the brain, for example, chloral hydrate (no more than 2 g in enema) or opioid synthetic analgesics, for example tramadol (tramal ). This drug has a pronounced analgesic effect, stimulating opiate receptors, reduces the reverse synaptic seizure of norepinephrine and serotonin. The dosage is individual, depending on the intensity and nature of the pain. On average, use 50-100 mg / day., With very intense pain - no more than 400 mg / day. Tablets or capsules (50 mg each) are swallowed without chewing, with a small amount of water. The solution for injection is released in 1 ml ampoules (50 mg) or 2 ml (100 mg). Convenient release form in suppositories (100 mg). It must be remembered that during the period of treatment it is necessary to refrain from driving, (as the reaction rate changes), and with prolonged use of large doses, the development of drug dependence is possible. Only with intolerable pains resort to narcotic drugs (opium in candles, leoran, fenadon, promedol).

Along with systemic administration of analgesics, with pain and muscular-tonic syndrome, local applications based on Dimexidum (aqueous solution 10-30-50%) have a good effect. Dimexide is diluted with 0.5-2% solution of novocaine at the rate of 1 to 2. Given the ability of Dimexid to "carry out" the active drug substance deep into the tissues, it is advisable to include hydrocortisone in the application solution [dimexide 5 ml + novocaine 0.5% 10 ml + hydrocortisone (for intravenous injections) 2.5 ml (75 mg)] for 5 days once a day, and then voltarena [dimexide 5 ml + novocaine 0.5% 10 ml + voltaren 3 ml] for 5 days 1 once a day. For applications, 5-layer gauze is impregnated with an appropriate solution and applied to the projection of pain points (for a local thermal dressing) for 30-40 minutes 1 time a day. The general course of local applications is 10 procedures: 5 - with hydrocortisone and 5 - with a volt arena.

In practice, quite often used procaine paravertebral blockade. Paravertebral blockade is a collective concept. It only indicates that the blockade is in close proximity to the spine. Paravertebral blockade can be intracutaneous, subcutaneous, muscular, perineural, and so-called "radicular". Sometimes the ganglia of the border sympathetic trunk are paravertebrally blocked. It is necessary to consider the preferential localization of the pathological process with discogenic lumbosacral radiculopathy. 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 trauma of the lumbosacral disc, as well as the fact that the intervertebral foramen at this level is particularly narrow (1-3 mm versus 5 mm for the overlying vertebrae) and the cord completely covers the foramen. Paravertebral root blockade is indicated for radiculopathy. Apply a 0.5-1% solution of novocaine or mix it with an emulsion of hydrocortisone, less often - other drugs. A mixture of hydrocortisone with a solution of novocaine 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 blockade and the physical condition of the patient). You must have a clean solution of novocaine of the desired concentration. Novocaine is used for preparatory anesthesia, and its mixture with hydrocortisone is used for administration directly into the area of the spermatic cord. The technique of paravertebral blockade is described in special manuals. Injections are repeated after 2-3 days, only 3-5 injections per course. Along with novocaine, it is possible to use various derivatives of it: trimecain (0.5-0.25%), sovkain (0.5-10%); lidocaine (0.5; 1; 2%).

Local irritating and distracting agents (external use of ointments containing NSAIDs (for example, diclofit-gel, voltaren-emulgel, etc. Mentioned above), lidocaine cream, betanikomilon, finalgon, microflex, es-sex, efkamone, tiger cream can reduce the severity of pain. , snake and bee venom, anuzole, bantin, local use of pepper patch) and local reflex therapy and physiotherapy effects.

Impact on the musculo-tonic (musculo-tonic) component of pain includes post-isometric relaxation, massage and therapeutic exercises, including exercises to strengthen the muscular system or stretching the spastic muscles. A positive effect is made by blockade of trigger and painful points with several ml of a solution of a local anesthetic and / or a corticosteroid. Irrigation of the painful zone with chloroethyl and subsequent stretching of the muscles is also used. With prolonged myofascial pain caused by secondary musculo-tonic reactions, muscle relaxants are prescribed, for example, sirdalud (tizanidine). Sirdalud is a centrally acting muscle relaxant. Stimulating presynaptic a ₂ -adrenoreceptors, it inhibits the release of excitatory amino acids from the intermediate neurons of the spinal cord, which leads to inhibition of polysynaptic transmission of excitation in the spinal cord, which regulates the tone of skeletal muscle. Sirdalud is effective against acute painful muscle spasms and chronic spasms of spinal and cerebral origin. Available in tablets of 2 and 4 mg. To relieve painful muscle spasm, sirdalud is prescribed by mouth for 2-4 mg 3 times a day, in severe cases, an additional 2-4 mg at night. With caution, the drug is prescribed to patients with renal and hepatic insufficiency. During treatment, one should refrain from work requiring quick psychomotor reactions. Of the other drugs in this group, baclofen 30–75 mg / day, diazepam 10–40 mg / day, and tetrazepam (miolastan) 50–150 mg / day are used. Or a combination of muscle relaxants with analgesics (myalgin). The duration of this treatment is about 2 weeks.

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

Improvement of microcirculation and metabolism, symptomatic treatment of spinal osteochondrosis

The complex of drug therapy includes drugs that improve microcirculation. Among them, it is advisable the appointment of pentoxifylline (trental) 400 mg 2-3 times a day by mouth or 100-300 mg IV drip per 200 ml of isotonic sodium chloride solution, 10% solution of courantyl (dipyridamole) 75 mg IV.

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

In order to improve the trophism of the tissues of the spinal cord, the musculo-ligamentous apparatus, a 20% solution of aktovegin, 2-5 ml intramuscularly 14 days, is used; Tanakan 40 mg 3 times a day.

Restorative effect of vitamin preparations. These substances belong to the group of nonspecific immunoprotectors and can be additional agents of pathogenetic and symptomatic therapy. Many of them have antioxidant properties that reduce various pathological manifestations in the development of inflammatory and pain reactions. This group of drugs is especially necessary in the recovery period after the relief of the acute period of radiculopathy. So, preparations of vitamins A, E, _B2, P, C contribute to the strengthening of the capillary vascular wall, especially with their low resistance. Preparations of vitamins B6, B12, PP normalize the conduction of nerve impulses along peripheral nerve fibers and through the neuromuscular synapse, help reduce feelings of pain, reduce swelling. High-dose ascorbic acid causes stimulation of endogenous glucocorticosteroidogenesis with subsequent manifestation of the analgesic and anti-inflammatory activity characteristic of glucocorticosteroids.

Outside the exacerbation of pain syndrome, it is widely possible to use so-called chondroprotectors, which are cartilage extracts (rumalon 1-2 ml / m / d, arteparon 1 ml / m 2 times a week), chondroitin preparations to improve the metabolism of articular cartilages. -sulfat {arthron 1-2 ml / m; struktum 750 mg 2 times a day for 3 weeks., then 500 mg 2 times a day, chondroxide, ointment 2-3 times a day), alflutop 1 ml / m, glucosamine (don) 1.5 g orally. These drugs have a stimulating effect on the regeneration of cartilage tissue, reduce concomitant inflammation and alleviate pain in the affected joints and spine. In particular, chondroxide, the active principle of which is chondroitin sulfate, refers to replacement-reducing agents that are 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, contributes to a deeper penetration of chondroitin sulfate in the tissue. Hondroksid recommended for external use by applying 2-3 times a day on the skin over the lesion and rubbing for 2-3 minutes until completely absorbed. The use of chondroxide in osteochondrosis by phonophoresis is more effective. The duration of therapy with chondroprotectors is individual.

Other biogenic stimulants are quite often used: aloe liquid extract for injection; solcoseryl; vitreous body; Phibs; glutamic acid.

An important problem in osteochondrosis of the cervical spine is the treatment of dizziness, which occurs quite often, especially in those of the older age group. Vertebral dizziness worries patients not so much during exacerbations (here the above mentioned pain syndromes come to the fore), as during relative remissions, affecting the general level of vital activity, emotional background and working capacity. Trauma osteophytes of the vertebral artery, accompanied by the development of changes in its intima and the possibility of the formation of vascular spasm, creates prerequisites for the deterioration of blood circulation in the vertebrobasilar basin. In older patients, given the presence of atherosclerotic changes in the vessels, this leads to the emergence and progression of vertebrobasilar insufficiency, manifested primarily by cochleovestibular disorders (systemic or non-systemic vertigo, paracuses, mild-like syndrome). In the treatment of vertigo, drugs of different groups can be used in one way or another, reducing the excitability of the central and peripheral parts of the vestibular analyzer. Among them is a synthetic analogue of histamine betaserk (betahistine). This drug acts on 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 main artery, normalizes the endolymph pressure in the maze and cochlea. The drug is effective in oral administration of 8 mg 3 times a day; treatment course is 1-3 months. However, it is necessary to remember about its careful use by patients with a history of peptic ulcer, pheochromocytoma, bronchial asthma. It is also possible to recommend to the use of vasoactive drugs [cinnarizine (stugeron) Vinpocetine (Cavinton)], improving microcirculation [pentoxifylline (Trental)] combined vascular metabolic means (tanakan, pikamilon, vazobral), antihistamines (Tavegilum, Suprastinum), biostimulants.

With pronounced radicular syndrome, treatment time is significantly increased (up to 6-8 weeks compared to 2-3 weeks with uncomplicated lumbodynia). Treatment should be carried out in a hospital. 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, which cannot be stopped by conventional methods, they resort to using drugs with a more pronounced analgesic effect, for example, such synthetic analgesics as the already mentioned tramadol (tramal), fortral, etc. The method of choice is the use of epidural blockades carried out through the sacrococcygeal opening, by translumbal way or through the first sacral opening. Preferably for blockades the use of drugs with local action and forming a depot at the injection site. In severe cases, in the absence of contraindications, a short course (3-5 days) of treatment with corticosteroids (prednisone at a dose of 80-100 mg per day orally for 3-5 days, followed by an accelerated dose reduction) is carried out. Apply therapy aimed at improving microcirculation and tissue trophism.

For radicular syndromes caused by verified herniation of the intervertebral disk, intradiscal administration of chymopapain is possible for enzymatic disk lysis.

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). An analysis of the totality of psychological, somatic and other factors contributing to chronic pain is also needed.

The emphasis in the treatment of chronic pain syndrome is transferred to non-drug methods of exposure (massage, physical therapy, swimming, reflex therapy, physiotherapy) and the gradual expansion of the motor mode. It is advisable to use drug administration by phonophoresis. Thus, the inclusion of phonophoresis of chondroxide ointment in the program of rehabilitation activities of patients with stage I-II spinal osteochondrosis contributes to a more rapid relief of pain, the disappearance of the symptoms of tension, the restoration of the patient's physical activity. It has been clinically proven that the use of phonophoresis chondroxide ointment in patients with osteochondrosis of the spine is safe and does not cause side effects. The course of treatment includes 12-15 procedures. The ultrasound intensity of 0.2-0.4 W / cm ² in a pulsed mode by a labile method for 8-10 minutes.

When forming the psychological attitudes of the patient on pain syndrome or the appearance of depressive symptoms, consultation of a clinical psychologist and a psychiatrist is necessary. The effectiveness of remedial measures often increases while taking “mild” antidepressants or tranquilizers.

In cases resistant to drug therapy, consultation with a neurosurgeon is necessary to decide on the surgical treatment of osteochondrosis. Surgical treatment of spinal osteochondrosis is absolutely shown in intervertebral disk sequestration with the formation of a “foreign body” inside the epidural space. Urgent consultation of a neurosurgeon with a decision on an operation is also necessary in cases of acute compression of the roots (including the horse's tail), accompanied by an increase in paresis of the limbs and pelvic disorders. Another indication for surgical treatment is severe pain-causing pain, which is not amenable to conservative treatment for several months.

Thus, the treatment of spinal osteochondrosis should be complex, including drug and non-drug therapy, and long. To maintain the patient’s motivation for recovery, patient attitude to treatment, they need to understand the essence of pathological processes and neurological complications in osteochondrosis of the spine. Otherwise, treatment will be reduced only to relief of more frequent exacerbations. Only the active participation of the patient in the treatment process creates the basis for sustained regression of the neurological manifestations of spinal osteochondrosis and the preservation of a full-fledged life.

[5], [6], [7]