RU2475238C1 - Method of treating lumbar radicular pain syndrome - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention refers to medicine, namely neurology, and is applicable for treating lumbar radicular pain syndrome. That is ensured by single catheterisation of an epidural space, and a microinfusion pump is used for the continuous introduction of 0.2% Ropivacaine for 5-10 days at 2.0-8.0 ml/h until pain syndrome is relieved.

EFFECT: method enables an immediate therapeutic and analgesic effect with low toxicity and reduced risk of treatment-induced complications, as well as reduced length of staying in hospital with safety, inspectability and controllability.

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Description

The invention relates to medicine, in particular to neurology, and can be used for the treatment of vertebrogenic pain syndrome caused by degenerative diseases of the spine.

Radicular syndrome - radiculopathy with severe pain syndrome - occurs more often than other neuralgic syndromes, occurs due to compression of the roots of the spinal cord. The reasons for its development are degenerative diseases of the lumbosacral spine: osteochondrosis, osteoporosis, herniated discs, spondylarthrosis, compression fracture of vertebral bodies, spinal cord tumors (neuromas), as well as infectious vertebral lesions (tuberculosis, osteomyelitis), etc. The most common are lumbar -sacral radiculopathies associated with the defeat of the fifth lumbar (L5) and first sacral (S1) spinal roots. The clinical differences in these radiculopathies relate to areas of localization of pain and sensitive disorders, as well as the presence of the Achilles reflex, which disappears with S1 radiculopathy.

Despite the abundance of treatment methods (surgical surgical, conservative medication, electrical stimulation), there is still no universal, effective and safe way to treat radicular syndrome. Known invasive treatment, consisting in the epidural administration of drugs. Catheterization of the epidural space is used, or epidural blocks are performed using epidural needles.

A known method of treating patients with osteochondrosis of the lumbar spine by epidural novocaine blockade, which is the introduction of novocaine, hormonal drugs (F. G. Portnov. Electropuncture reflexology. Riga, "ZINATNE", 1982, p.113). However, the known method is ineffective, as it is temporary in nature, there are certain contraindications and limitations.

A known method of treating degenerative-dystrophic diseases of the lumbar spine, in which catheterization of the epidural space is carried out through the lower sacral opening under x-ray control (patent RU 2222356). The disadvantage is that this method can only be carried out in a hospital, the patient is connected to the equipment for a long time. To implement this method, an X-ray unit with an electron-optical converter is required, while catheterization is carried out repeatedly, which is a significant radiation and pain load for the patient and increases the risk of traumatic and septic complications. In addition, with the sacred method of drug administration, analgesia is limited only to the sacral nerves and does not extend to the lower lumbar level (limited to S1-L5).

A known method of treating patients with traumatic and degenerative lesions of the spine and spinal cord, including combined anesthesia: epidural and cutaneous electrical stimulation at the level of damage to the spinal cord and / or affected roots (patent RU 2258496). The disadvantages of this method are the unpredictability of the results of electrical stimulation in a prognostic plan, only a partial restoration of neural connections and conductivity in the affected areas of the spinal cord, the preservation of the pain syndrome for a long time, in addition, electrotherapy has a number of contraindications, and with this method of treatment the patient's mobility is limited.

A known method of treating pain and compression syndromes of lumbar osteochondrosis, including medication and electrical stimulation, in which the supply of drugs to the spine and exposure to it by electric current is carried out by introducing two electrodes with a microirrigator into the epidural space (patent RU No. 2201266). The disadvantages are increased injuries of the operation, the danger of infection and unpredictability in the prognostic plan.

A known method of treating radicular pain syndrome, including the introduction of drugs into the epidural space (patent RU 2250116). However, the medicine with this method is administered repeatedly, for the injection of drugs each time requires repeated manipulation of the catheterization, which also increases the injury rate of the operation and the risk of infection of the patient.

A known method of treating vertebrogenic pain syndrome of lumbosacral localization by epidural administration of a drug (patent RU No. 1780751). However, injections require repeated repeated catheterization manipulations, which increases the risks of injury, infection and the formation of a hematoma. In addition, the introduction of a solution of sodium bicarbonate into the epidural space only relieves pain, but does not have a therapeutic effect.

Closest to the claimed is a method of complex treatment of patients with acute and chronic pain syndromes, including temporary catheterization and epidural administration of non-steroidal anti-inflammatory drugs of the oxycam group (RU No. 2234314). Moreover, for the treatment of radicular pain in discogenic radiculopathies, 20 mg of tenoxicam or 8 mg of lornoxicam dissolved in 10-20 ml of physiological saline are epidurally administered daily for 5 days. Epidural administration is carried out by temporary catheterization of the epidural space with a sterile disposable epidural catheter, after which the indicated preparations are administered every day through an established catheter. The course of treatment is 5 days. However, fractional infusion of non-steroidal drugs, the ineffectiveness of the introduction of these drugs in the acute period of the disease do not fully stop the pain in the acute period.

The objective of the invention is to increase the therapeutic efficacy of treatment while stopping pain radicular syndrome and reducing treatment time.

The problem is achieved in that in the method of treating radicular pain at the lumbar level, including temporary catheterization and the introduction of the drug into the epidural space, according to the invention, ropivacaine 0.2% is used as the drug, which is introduced by the microinfusion pump through the installed catheter at the lumbar level continuously for 5-10 days until the relief of pain. The drug is administered at a rate of 2.0-8.0 ml / h.

The introduction of drugs into the epidural space at the lumbar (lumbar) level in the treatment of radicular pain at the lumbar level is most optimal due to the anatomical features of the epidural space (the largest width of the epidural space).

The introduction into the epidural space, into the focus of pathological impulse associated with degenerative diseases of the lumbosacral spine, of a solution of local anesthetic with a low concentration of ropivacaine 0.2%, leads to sympathetic neurovegetative blockade, pronounced analgesia, improved microcirculation, removal of edema, anti-inflammatory effect and improvement reparative processes.

Continuous, prolonged, prolonged for 5-10 days epidural analgesia with catheterization of the epidural space using a microinfusion disposable sterile pump for continuous administration of a 0.2% ropivacaine solution at a certain speed allows you to control the severity of the pain syndrome. The drug from the group of local anesthetics of the amide group - ropivacaine has a pronounced analgesic effect, due to prolonged prolonged administration of small doses it has an anti-inflammatory therapeutic effect. By blocking the transmission of nerve impulses, the drug acts on the roots of the spinal cord, pain, irritation, inflammation and edema decrease.

The rate of administration of ropivacaine 0.2% into the epidural space is 2.0-8.0 ml / h and is regulated by the doctor depending on the severity of the pain syndrome and hemodynamics of the patient. The use of a microinfusion pump provides patient mobility and more comfortable treatment conditions.

Catheterization of the epidural space at the lumbar level is performed as follows.

The patient is placed on the left side with legs bent in the hip and knee joints (in the baby’s position) and median access to the projection 1-2 segments above the pathological zone under local anesthesia 4.0-6.0 ml of 1% lidocaine solution is punctured and catheterized epidural space with an epidural set, for example, the company "Bi-Braun" or "Portex" (sets No. 16, 18).

The standard catheterization technique is used, the epidural space is identified using the “dip method” and “hanging drop” method. After identifying the epidural space, a test dose is carried out: 3 ml of a 2% lidocaine solution. A catheter is inserted into 1-2 segments cranially. After applying an aseptic dressing and fixing the catheter, 4.0-5.0 ml of a 0.2% ropivacaine solution is administered once. Then, an individual microinfusion disposable sterile pump, for example, Vogt Medical Fertrib GmbH, filled with a 0.2% solution of local anesthetic ropivacaine in a volume of 100-200 ml, is placed on the epidural catheter. As necessary, an additional injection of the drug into the pump is carried out in the special port provided for this. The rate of infusion of a local anesthetic is from 2.0-8.0 ml / h, while the rate of infusion is regulated by the doctor depending on the intensity of the pain. The treatment continues prolonged for 5-10 days and after the relief of the pain syndrome, which ensures adequate motor activity, restoration of the motor and sensitive function of the patient.

127 patients with radicular pain syndrome and neurological disorders caused by degenerative diseases of the lumbosacral spine were treated. Patients were divided into two groups. The first (experimental) group included 63 patients, the radicular pain syndrome in which was stopped by continuous epidural infusion of a local anesthetic of 0.2% ropivacaine, the second (control) group consisted of 64 patients who used the traditional drug treatment method and paravertebral blockade . The groups did not differ statistically by age or gender (p> 0.05). The average age of patients in both groups is 52.5 ± 12.3 and 54.2 ± 8.8 years (35-64), respectively. The number of men and women in the groups was approximately the same: 32 (50.8%) men and 31 (49.2%) women in the 1st group and 34 (53.1%) men and 30 (46.9%) women - in the 2nd. All patients had vertebrogenic radicular syndrome. To diagnose the pathology of the spine in all patients, computed and magnetic resonance imaging, clinical examination were performed. In both groups, hernias of the discs of the lumbar spine, radiculopathy, lumbar ischalgia were diagnosed, and 10% (6 and 7, respectively) of patients had a question about surgical correction of neurological pathology. The duration of pain before admission to the clinic ranged from 4 to 16 weeks. The intensity of pain in the hospital was evaluated daily on a visual analogue scale (VAS): 0 points - no pain, 1-2 points - weak, 3-4 points - moderate, 5-6 points - strong, 7-8 points - very strong, 9 -10 points - unbearable.

As a result of treatment, pain was completely stopped in all patients of both groups, operability (partial or complete remission) was restored in 89 (70%) patients, while all patients refused surgical treatment, or the operation was postponed (if the patients were no longer observed) .

However, in different groups the therapeutic effect was achieved at different times and had different dynamics. In the 1st group, acute radicular pain syndrome stopped on average in 24 ± 6 days (18-33). In the 2nd group, this indicator turned out to be on average more than 2 times (p <0.05) - 47 ± 8 days (from 25 to 75). Moreover, in the 1st group, on average, already on the 2nd day, a significant decrease in pain syndrome, restoration of motor functions and sensitivity were observed. In the 2nd group, this happened only by the 12th day of treatment.

When assessing the severity of radicular pain according to the YOUR scale, the intensity of pain as a result of treatment decreased from 8.4 ± 0.4 points at the beginning of treatment to 2.3 ± 0.3 points at discharge (p <0.01). The dynamics of this decline in the groups was completely different. The dynamics of the assessment (in points) of the condition of patients according to the YOUR scale, depending on the duration of treatment, is presented in Fig. 1. As can be seen from the graph, with a daily assessment of the condition of patients on the VAS scale in the 1st (experimental) group, a statistically more pronounced decrease in pain was observed than in the 2nd (control) group.

Clinical examples.

Example 1. Patient M., 50 years old, was admitted to the hospital with complaints of acute pain in the lumbar region, a sharp restriction of forward movement, difficulty walking, acute pain in the right leg, numbness of the big toe. From the anamnesis it is known that acute lower back pain appeared 2 days before admission to the clinic after lifting. The next morning, pain began to be given to the right leg, and a feeling of numbness of the thumb appeared.

At admission: the patient’s position is forced, with the slightest movement sharp pain in the lumbar region and right leg. Tendon reflexes from the knees D = S, right Achilles-, plantar reflexes absent. According to MRI, hernia L5-S1 is 6 mm in size. Assessment of pain on the scale of YOURS - 10 points.

The diagnosis was made: lumbar ischalgia on the right, compression of the root L5-S1, severe pain, with muscle tonic tension. Dorsopathy of the lumbar spine L5-S1.

In the emergency room, the patient was injected with baralgin, which had no effect.

The patient underwent an epidural block at the lumbar level. After catheterization of the epidural space, a microinfusion pump with 0.2% ropivacaine solution was installed. The drug was administered continuously at a rate of 6.0-8.0 ml / h for 6 days, followed by a decrease in the rate of infusion (after relief of acute pain) to 2.0 ml / h. The attack of acute pain was stopped within 2 hours, at rest the pain was practically not bothered. The pain intensified with movement. After 6 days, the acute pain syndrome in the patient began to be removed. The assessment of pain at rest on the YOUR scale was 2 points.

Subsequently, the patient underwent drug therapy, and after 20 days the patient was discharged home in satisfactory condition.

Example 2. Patient S., 48 years old, was hospitalized in a clinic with a referral from a clinic with acute pain. Complaints of acute pain in the lumbar region, restriction of movement in any direction, while walking the pain intensifies. From the anamnesis it is known that a patient a year ago was operated on for a herniated disc L4-S5. Six months later, the patient again had back pain, an MRI scan was done again, an 8 mm L4-S5 hernia was detected. The patient is offered a neurosurgical operation. The patient categorically refused the operation.

Upon admission, objectively: the patient’s position is forced, the pain intensifies when walking, right-sided scoliosis, the assessment of pain according to YOUR score is 10 points.

Diagnosis at admission: lumbar ischalgia on the left, L5-S1 root compression, severe pain, right-sided scoliosis, dorsopathy of the lumbar spine L5-S1.

The patient was made catheterization of the epidural space with the installation of a disposable microinfusion pump, with the introduction of a 0.2% solution of ropivacaine. Once administered bolus 5.0 ml of ropivacaine, then set the infusion rate of 6.0 ml / h. Acute pain stopped. After 7 days, the acute pain syndrome regressed, the assessment of pain according to YOUR - 2-3 points.

After the drug treatment and physiotherapy, the patient in satisfactory condition was discharged home after 19 days.

Example 3. Patient K., 35 years old, was admitted to the hospital with complaints of acute pain in the lumbar region, with irradiation in both legs. When moving, the pain intensifies sharply, forcing the patient to stop, difficulty in urinating as an incontinence. Considers herself ill for the past 2 weeks, when acute pain intensified. Diagnosis at admission: lumbar ischalgia on both sides, severe pain syndrome with muscle-tonic disturbance, dorsopathy of the lumbar spine.

On palpation, acute pain in the lumbar region, muscle tension in the lumbar region. A sharp restriction of the movement of the body to the side, flattened lumbar lordosis. Antalgic gait. On MRI, protrusion of L1-L2 discs of 2 mm in size is detected. L2-L3 disc protrusion of 3 mm, L4-S5 disc herniation - 4 mm. Assessment of pain by YOUR - 9 points.

The patient was made catheterization of the epidural space with the installation of a disposable microinfusion pump, with the introduction of a 0.2% ropivacaine solution at a rate of 4.0-6.0 ml / h. The drug was administered continuously for 8 days. Acute pain was stopped, the pain persisted during movement, a change in body position. After 5 days, the pain decreased, the assessment of pain on the YOUR scale was 1-2 points.

After the drug treatment and physiotherapy, the patient in satisfactory condition was discharged home after 17 days.

Thus, the use of prolonged epidural anesthesia for radicular pain provides a significantly faster therapeutic and analgesic effect, a shorter hospital stay than in the treatment of patients with traditional methods. The proposed method of treatment is safer, more controlled and manageable due to a single puncture and the introduction of a local anesthetic into the epidural space through a catheter with continuous infusion for a long time using a disposable infusion regulated pump, which reduces the risk of iatrogenic complications. The local anesthetic ropivacaine 0.2% is characterized by low toxicity, is the best drug for epidural analgesia in radicular pain syndrome. The one-time, painlessness of catheterization of the epidural space during relief of the radicular pain and prolonged analgesia provide comfort for the patient during his stay in the hospital.

Claims (2)

1. A method for the treatment of radicular pain at the lumbar level, including temporary catheterization and the introduction of the drug into the epidural space, characterized in that ropivacaine 0.2% is used as the drug, which is introduced by the microinfusion pump through the installed catheter at the lumbar level continuously within 5-10 days before the relief of pain. 2. The method according to claim 1, characterized in that the drug is administered at a rate of 2.0-8.0 ml / h.

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