RU2618460C2 - Method for lumbar spine department radicular pain syndrome treatment (versions) - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: for treatment of radicular pain in the lumbar spine under outpatient conditions by neuroorthopedic examination of the patient, lumbar spine magnetic resonance imaging and pain syndrome (PS) intensity assessment by means of a visually analogue scale (VAS) and patient's functional activity determination according to Table 1, diagnosis is established, and treatment is carried out taking into account the patient's physical status according to the ASA classification. A mixture of local anesthetics in doses for spinal anesthesia is injected epidurally diluted to the required volume for the type of access used and the level of intervertebral disc changes and corticosteroids with high glucocorticoid activity. Epidural administration is performed by caudal access in a position on the abdomen. Then the patient is turned on the affected side for 15-20 minutes and returned to the initial position for 10-15 minutes. During the second visit (2-3 days later), PS intensity is evaluated and, depending on the result obtained, further treatment, including pharmacopuncture, is carried out until the PS disappears completely. At PS intensity during the initial visit of 8 points or more, epidural injection of a mixture of local anesthetics and corticosteroids with high glucocorticoid activity is carried out by central median access in the position from the side intervertebral disc changes, wherein the epidural space is punctured one intervertebral space above the set level intervertebral disc changes, followed by patient posture retaining for 15-20 min and turning to the stomach for 20-25 min, then during the repeated visit (2-3 days), pain intensity is evaluated, as described above, and further treatment is performed depending on the result including pharmacopuncture, until the pain syndrome disappears completely.

EFFECT: method allows to reduce treatment time with its effectiveness, reliability, safety and economy.

48 cl, 2 tbl, 8 ex

Description

The invention relates to medicine, in particular to anesthesiology, and can be used on an outpatient basis in the treatment of pain syndromes of the lumbar spine caused by various reasons.

Currently, the treatment of acute and chronic pain syndromes in patients with pathology of the musculoskeletal system is a very difficult problem that specialists around the world are trying to solve. Most often in clinical practice, one has to deal with acute radicular pain syndromes caused by protrusions or hernias of the intervertebral discs.

One of the widespread methods of treating the aforementioned problem is surgical intervention performed in a hospital, while it is known that in 15-60% of patients persistent pain persists, and in 5-33% of cases repeated surgical intervention is required (White A., 1992, Katz J., 1996).

At the same time, the views on the pathophysiological mechanisms of the formation of radicular pain syndrome, only as on the mechanical compression of the spinal nerve (“nerve root”), are currently being revised. First of all, radicular pain syndrome is considered as an acute inflammatory process, in the pathogenesis of which it is necessary to emphasize the leading role of inflammation. Studies of nerve roots in laminectomy in the vast majority of cases reveal their inflammation and swelling (Murphy R.W., 1977, B. Rydevic et al., 1984). The disappearance of negative pressure in the epidural space is considered as a manifestation of an exudative inflammatory process with a corresponding increase in capillary permeability and is considered significant in the genesis of pain (Kepes E.R., Duncalf D., 1985).

It is logical that, based on the foregoing, in addition to surgical treatment, other methods of treatment began to be actively used and, accordingly, the proportion of conservative invasive techniques in the treatment of patients with back pain increased.

A known method of treating degenerative-dystrophic diseases of the lumbar spine, including administering drugs through the sacral opening, in which epidural space is catheterized through the lower sacral opening, the distal end of the catheter is brought to the pathological section of the spine, and its proximal part is performed under skin and bring above the puncture site to the level of the upper edge of the ilium, hem to the skin, connect the bacterial filter and carry out local long-term supply of drugs to the pathological site (RU 2222356, IPC A61M 25/00, 01/27/2004). The disadvantage of this method is the mandatory use of x-ray equipment and a bacterial filter during the procedure, which requires qualified personnel and increases the cost of treatment.

There is also known a method of treating diseases of the nervous system, including the introduction of drugs into the celiac plexus, in which, under x-ray control, in a sitting patient, local anesthesia is performed with 2 ml of a 2% lidocaine solution, while 200 mm a 16 G needle in a certain way, then an aspiration test is performed for the presence of blood or cerebrospinal fluid and, if the result is negative, a blockade of 3-4 ml of a 2% solution of lidocaine is performed, if after 7-10 minutes the patient has a decrease in if no sensory or motor blockade, administered through the needle mounted catheter for prolonged epidural administration of drugs (RU 2324429, IPC A61B 17/00, 20.05.2008). However, this method of treatment is not pathogenetic for radicular pain syndrome and does not remove its cause, because, despite the effective relief of pain, it does not have accurate delivery of drugs to the lesion area and is not feasible on an outpatient basis due to possible infection of the epidural catheter.

There is a method of treating discogenic radiculopathy in the postoperative period, in which complex homeopathic preparations Goal T and Discus compositum are injected epidurally in 2.2 ml, the course of treatment is 10 procedures (RU 2368387, IPC A61K 36/18 09/27/2009). This method of treatment is not applicable for the treatment of radicular pain, since it is used only as an additional therapeutic complex of clinical homeopathy to reduce the intensity of the pain after discectomies in order to improve the quality of rehabilitation treatment, that is, when the cause of radicular pain has already been surgically eliminated.

A known method of treating dorsalgia, including the epidural administration of a non-steroidal anti-inflammatory drug of the oxycam group in dosages authorized for parenteral administration, in which, along with the administration of tenoxicam, they influence biologically active points of a patient with low-intensity electromagnetic radiation of an extremely high frequency noise spectrum (RU 2010101757, IPC A61N 5/02 July 27, 2011). The disadvantage is that the use of tenoxicam for introduction into the epidural space is not safe, since it is a solution with an acidic environment with a pH> 5, which can cause a chemical burn of nerve trunks. Due to the pH values, Tenoxicam is not combined with the use of local anesthetics, therefore, epidural injection of the drug does not lead to a rapid decrease in the intensity of pain after the procedure. There is also no official permission to introduce these drugs into the epidural space, including foreign requirements. In addition, the use of Tenoxicam can be complicated by the well-known side effects of non-steroidal anti-inflammatory drugs and is contraindicated in many diseases of the gastrointestinal tract and hepatobiliary zone, including the “aspirin” triad (http://asal-ltd.ru/portfolio/teksamen- bystryj-i-silnyj-npvs).

In addition, there is a method of treating radicular pain of the lumbar level, including temporary catheterization and the introduction of the drug into the epidural space, where 0.2% ropivacaine 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 before the relief of pain (RU 2475238, IPC A61K 31/167, 02.20.2013). As mentioned above, the use of a catheter on an outpatient basis is impossible due to the lack of personnel with the necessary qualifications and the possible infection of the catheter, which requires mandatory hospitalization of the patient. In addition, the cost of treatment is high due to the high cost of the drug and an elastometric microinvasion pump with a speed controller.

The closest analogue of the proposed method of treatment is a method of treating radicular pain of the lumbar spine, the intensity of which is 8-10 points on a visually analogue scale (YOUR), described in the abstract of the dissertation of A.V. Gnezdilova (Gnezdilov A.V. Diagnosis and treatment of phantom and vertebral pain syndromes. - M., 1999, p. 9, 28-32). The method includes establishing a diagnosis by an initial examination of a patient, neurological, radiological and electroneurophysiological studies, magnetic resonance imaging or computed tomography of the lumbar spine, assessing the intensity of the pain syndrome in points according to YOUR. Treatment is carried out in the acute period by epidural blockade with the introduction of steroidal and non-steroidal anti-inflammatory drugs and acupuncture in the intervals between blockades. However, this method is applicable only to a severe form of pain (not less than 8 points according to YOUR), while the treatment is carried out under stationary conditions, since the constantly used (1-4 times) central midline type of access for epidural drug administration requires special equipment and low conditions operating, and the applied amount of local anesthetic (lidocaine - 100 mg) implies the possible development of the motor block, which requires many hours of monitoring the patient. In addition, in the interval between epidural blockages, acupuncture is used, which is a lengthy procedure (the session takes 30-40 minutes, where the needles are twisted every 15 minutes). From the above it follows that this method is not suitable for use on an outpatient basis.

The objective of the present invention is to provide an effective, reliable and safe method for the treatment of radicular pain of the lumbar spine of varying severity (6-10 points according to YOUR) in patients of different somatic status (I-III class ASA) and the presence of various concomitant pathologies on an outpatient basis and day hospital conditions.

The problem is solved in a method for the treatment of radicular pain of the lumbar spine of moderate severity on an outpatient basis, including the diagnosis by neuro-orthopedic examination of the patient, magnetic resonance imaging of the lumbar spine and assessment of the intensity of the pain by YOUR and treatment involving the use of at least one of the methods of reflexology and traditional pharmacotherapy, in which according to the invention at the initial visit to the strict period, the pain intensity indicator obtained by YOUR is additionally clarified by determining the functional activity of the patient, the treatment is carried out taking into account its somatic status according to the ASA classification (Classification of the American Association of Anesthetists of the patient's physical condition), and a bolus epidural mixture of local anesthetics is administered, in doses for spinal anesthesia diluted to the required volume for the type of access used and the level of change in the intervertebral disc , and corticosteroids with high glucocorticoid activity by caudal access in the abdominal position, followed by turning the patient on the side of the lesion for 15-20 minutes and returning to the original position for 10-15 minutes, then at the next visit, which is prescribed after 2-3 days , evaluate the intensity of the pain syndrome, as described above, and depending on the result obtained, further treatment is carried out, including pharmacopuncture, until the pain syndrome disappears completely.

The refinement of the pain intensity indicator by comparing the patient’s clinical complaints and subjective sensations (assessed by YOUR) and the patient’s functional activity determined by the doctor as a result of examination on an independent expert evaluation scale developed by the authors in the research process allows us to establish the true degree of pain syndrome intensity. This, combined with an accurate determination of the level and side of the change in the intervertebral disc according to magnetic resonance imaging and the somatic status of the patient, makes it possible to choose for epidural administration the optimal mixture in terms of efficacy and safety, consisting of local anesthetics with different latent periods and duration of action, different forms of corticosteroids and solvent. The simultaneous epidural administration of the indicated mixture by caudal access, carried out in a position on the stomach, due to the rapid administration of the entire volume of preparations, excludes filtration into the surrounding tissues, which makes it possible to increase the effect of the mixture at low anesthetic concentrations, since the pressure of the solution in this case spreads the loose fiber of the caudal canal pumping the injected volume upward to the caudal plexus and the site of the change in the intervertebral disc, washing more structures and nerve fibers, providing more fast and complete therapeutic and analgesic effect. Turning the patient on the side of the lesion after the introduction of the mixture allows you to create the maximum concentration of drug components at the site of change in the intervertebral disc, and exposure in this position for 15-20 minutes allows you to fix the injected mixture. Then, so that the volume of the mixture is distributed over the ponytail capsule, the patient is again placed on the stomach and this position of the patient is maintained for another 10-15 minutes. As a result of treatment, which is a combination of new and traditional methods of treatment, such as pharmacotherapy and reflexology, the necessary clinical result is obtained as quickly as possible with respect to the initial condition of the patient with a reasonably minimized pharmacological load and the absence of complications.

If changes in the intervertebral disc are between L1-L2, L2-L3, L3-L4, then immediately after the patient returns to the original position, the above mixture is additionally administered by supra-and inter-spinal access above the level of change in the intervertebral disc in the required volume by 2-3 segments epidural space of the lumbar spine.

If during the second visit the pain intensity indicator during movement is more than 3 points, the epidural administration of this mixture is repeated, while the dose of these corticosteroids is reduced by half compared with the dose for the first epidural administration.

If changes in the intervertebral disc are between L4-L5, L5-S1 and upon a second visit the pain intensity indicator during movement is 3 points, conductor peripheral nerve blockade is performed by transacral access with a mixture of local anesthetics, these corticosteroids and vitamins, while the dose of these corticosteroids reduced by three times compared with the dose for the first epidural administration, the procedure is repeated after 2-3 days until the pain completely disappears at rest.

If the changes in the intervertebral disc are between L1-L2, L2-L3, L3-L4 and the pain intensity during movement during a second visit is 3 points, conductor peripheral nerve blockade is performed by paravertebral access with a mixture of local anesthetics, these corticosteroids and vitamins, this dose of these corticosteroids is reduced by three times compared with the dose for the first epidural administration, the procedure is repeated after 2-3 days until the pain syndrome completely disappears at rest.

If during the second visit the pain intensity indicator is 2 or 1 points, pharmacopuncture is carried out with a mixture of local anesthetic and homeopathic medicine using acupuncture points of general effect, the procedure is repeated 5-7 times until the pain syndrome disappears completely.

Studies have shown that a refinement of the pain intensity indicator at each visit in combination with selected medicinal mixtures allows the dose of epidural corticosteroids to be reduced as much as possible and faster to switch to more gentle procedures, which is especially important when conducting treatment on an outpatient basis.

As local anesthetics, a combination of local anesthetics with a delayed onset and a prolonged period of action, such as a 0.5% solution of bupivacaine or a 0.2% solution of ropivacaine, and local anesthetics with a fast onset and a short period of action, such as a 2% solution of lidocaine, are used.

Clinical trials made it possible for the first time in medical practice to use the indicated local anesthetics in the epidural space in the equivalent of spinal doses, which minimizes the possibility of developing the motor block after the procedure and at the same time provides a sufficient analgesic effect necessary for the relief of pain. At the same time, local anesthetics have a powerful systemic anti-inflammatory effect (even at minimal plasma concentrations), therefore, at repeated visits, their dose does not change, since this allows to reduce the number of corticosteroids and minimize the risk of possible side effects with the necessary clinical result.

Due to the influence of local anesthetics with different periods of the latent period and the subsequent “connection” of various dosage forms of corticosteroids, the desired beginning of the action of reducing the intensity of the pain syndrome occurs, which is optimized by changing the patient’s posture.

To perform pharmacopuncture, a 0.5% solution of novocaine is used as a local anesthetic, to which a homeopathic preparation traumeel C is added in a ratio of 1: 1.

In patients of class I and II of ASA and patients with diabetes mellitus, local anesthetics are used in medium doses for spinal anesthesia, which is 40-60 mg of lidocaine or 10-15 mg of bupivacaine, and in medium or minimum doses for extended infusions by epidural administration, which is 6-10 mg of ropivacaine.

In class III ASA patients and patients with diabetes mellitus, local anesthetics are used in combination of the minimum doses for spinal anesthesia, which is 30-50 mg of lidocaine and 8-10 mg of bupivacaine, or in the minimum or medium doses for extended infusions by epidural administration, which is 4-8 mg of ropivacaine.

A mixture of “depot” and water-soluble corticosteroids is used as corticosteroids for epidural administration, while betamethasone is used as a “depot” of corticosteroids, which is an official mixture of betamethasone salts containing 5 mg / ml betamethasone dipropionate suspension and 2 mg / ml betamethasone sodium phosphate and as a water-soluble corticosteroid - 4 mg / ml dexamethasone.

Depot "corticosteroid Betamethasone (Diprospan) has a high glucocorticoid and insignificant mineralocorticoid activity, has a powerful anti-inflammatory, anti-allergic and immunosuppressive effect. Betamethasone sodium phosphate is readily soluble and, after administration, is rapidly hydrolyzed, absorbed almost immediately from the injection site, which ensures a rapid onset of therapeutic effect. It is almost completely eliminated within one day after administration. Betamethasone dipropionate is slowly absorbed from the depot, metabolized gradually, which determines the long-term effect of the drug, and is excreted for more than 10 days.

The use of a mixture of these forms of corticosteroids due to the lack of systemic action and, at the same time, the possibility of creating the necessary therapeutic concentration for a sufficient time necessary for the treatment of radicular pain syndrome, allows the procedure to be dispensed with without the use of epidural catheters or pumps, and at the same time ensures the safety of the patient , which is especially important when performing the procedure on an outpatient basis.

Use of corticosteroids that do not contain

excipients: polyethylene glycol, preservatives of benzyl alcohol and methyl paraben, avoids allergic reactions, which at the same time leads to the absence of neurotoxicity.

In addition, the proposed ratio of the components of this mixture act in different directions on the systemic hemodynamics, so the procedure performed is not accompanied by a change in blood pressure and the possible development of orthostatic reactions in the patient.

At the initial visit to ASA class I, II, and III patients, the minimum doses of betamethasone for systemic therapy, which is 3.5-7 mg of betamethasone, and the average or minimum doses of dexamethasone, which is 2-4, are used as a dose of corticosteroids for the first epidural administration mg dexamethasone.

If during the initial visit the specified indicator of the intensity of pain in a patient of class I or II of ASA is 6 points, then by caudal access a mixture containing 5.25 mg of betamethasone and 10-12.5 mg of bupivacaine or 6-8 mg of ropivacaine in dilution is epidurally administered NaCl 0.9% to 20-25 ml.

If during the initial visit the specified indicator of the intensity of pain in a patient of class II ASA with diabetes is 6 points, then by caudal access a mixture containing 2.3 mg of betamethasone, 2-3 mg of dexamethasone and 10-12.5 mg of bupivacaine or 6-8 mg of ropivacaine in a dilution of 0.9% NaCl to 20-25 ml.

Due to the fact that the increased glucocorticoid activity of dexamethasone and betamethasone can lead to a more pronounced increase in blood glucose, the ratio of “depot” and aqueous forms of corticosteroids is changed in the direction of the increase of the latter due to their short half-life (180 min).

If during the initial visit the specified indicator of the intensity of the pain syndrome in a patient of class III ASA is 6 points, then by caudal access a mixture containing 3.5 mg of betamethasone, 8-10 mg of bupivacaine and 20 mg of lidocaine or 4-8 mg of ropivacaine in breeding is epidurally administered NaCl 0.9% to 20-25 ml.

If during the initial visit the specified indicator of the intensity of the pain syndrome in a patient of class III ASA with diabetes is 6 points, then by caudal access a mixture containing 1.75 mg of betamethasone, 2-3 mg of dexamethasone and 8-10 mg of bupivacaine, 20 mg is epidurally injected lidocaine or 4-8 mg of ropivacaine in a dilution of 0.9% NaCl to 20-25 ml.

If during the initial visit the specified indicator of the intensity of pain in a patient of class I ASA is 7 points, then by caudal access a mixture containing 5.25 -7 mg of betamethasone and 12.5-15 mg of bupivacaine or 8-10 mg of ropivacaine in breeding is epidurally administered NaCl 0.9% to 20-25 ml.

If during the initial visit the specified indicator of the intensity of pain in a patient of class II ASA with diabetes is 7 points, then by caudal access a mixture containing 3.5 mg of betamethasone, 2-3 mg of dexamethasone and 12.5-15 mg of bupivacaine or 8-10 mg of ropivacaine in a dilution of 0.9% NaCl to 20-25 ml.

If changes in the intervertebral disc are between L1-L2, L2-L3, L3-L4, 1-2 mg of dexamethasone and 20-40 mg of lidocaine in a dilution of 0.9% to 6-8 ml are additionally administered via interspinous access.

If during the initial visit, the specified indicator of the intensity of the pain syndrome in a patient of class III ASA is 7 points, then by caudal access a mixture containing 3.5-5.25 mg of betamethasone and 8-10 mg of bupivacaine, 20-30 mg of lidocaine or 6 -10 mg of ropivacaine in a NaCl dilution of 0.9% to 20-25 ml.

If during the initial visit the specified indicator of the intensity of the pain syndrome in a patient of class III ASA with diabetes is 7 points, then by caudal access, a mixture containing 2.3-3.5 mg of betamethasone, 2-3 mg of dexamethasone and 8-10 mg is epidurally injected bupivacaine, 20-30 mg of lidocaine or 6-10 mg of ropivacaine in a dilution of NaCl 0.9% to 20-25 ml.

If changes in the intervertebral disc are between L1-L2, L2-L3, L3-L4, 1-2 mg of dexamethasone and 20-30 mg of lidocaine in a dilution of 0.9% to 6-8 ml are additionally administered via interspinous access.

If the epidural administration of the mixture by caudal access is repeated at the second visit, the dose of corticosteroids is reduced by half compared with the dose for the first epidural administration.

If, on a second visit, conduction blockade of the peripheral nerves is performed by transacral or paravertebral access, then the dose of corticosteroids is reduced by a factor of three compared to the dose for the first epidural administration, while only water-soluble forms of corticosteroids are used in doses equivalent to the doses for the first epidural administration, which corresponds to 2-4 mg of dexamethasone, and as vitamins - 100-250 mg of cyancobalamin.

To perform pharmacopuncture, a 0.5% novocaine solution is used as a local anesthetic, to which the homeopathic preparation traumeel C is added in a ratio of 1: 1 in a volume of 1.5-2 ml per procedure, using classical acupuncture points recommended for the treatment of vertebrogenic pain syndrome, the procedure is repeated 5-7 times until the pain syndrome disappears completely.

All of these doses of drugs are optimal for these cases and are obtained as a result of clinical studies. They allow you to minimize pharmacological load on the patient and quickly get a therapeutic effect.

Epidural administration by caudal access of the specified mixture of local anesthetics and corticosteroids is carried out simultaneously using a 21G needle for 5-10 seconds.

Due to the small distance to the entrance to the caudal canal (from 0.5-2 cm) and the small diameter and size of the needle, tissue infiltration with an anesthetic solution is not required, since the procedure is not painful. The 21G needle length from the pavilion is 3.5 cm, which eliminates the risk of damage to the sacral nerve branches by a shear needle and at the same time allows the solution to be injected directly into the caudal canal beyond the sacrococcygeal ligament, which completely eliminates the risk of the mixture getting into the subarachnoid space above, excluding the possible development of the spinal block. The vascular bundle lining the ventral wall of the sacral canal ends at the level of the fourth sacral vertebra, therefore, the needle section reaches it, which also excludes the mixture from getting into the lumen of the vessel with subsequent manifestation of cardiac or neurotoxicity of the mixture. In addition, the low cost of the invasive procedure performed using the specified needle is obvious.

The second variant of the method for treating radicular pain of the lumbar spine is intended for the treatment of patients with severe pain in an outpatient setting and in an outpatient setting and includes the diagnosis by a neuro-orthopedic examination of the patient, magnetic resonance imaging of the lumbar spine and assessment of the intensity of the pain syndrome using a visually analogue scale and treatment comprising at least one epidural administration of corticosteroids, isp the use of at least one of the methods of reflexology and traditional pharmacotherapy, according to the invention, during an initial visit in an acute period, the pain intensity indicator obtained on a visually analogue scale is further clarified by determining the functional activity of the patient, treatment is carried out taking into account its somatic status according to classification ASA, however, if at the initial visit the pain intensity indicator is equal to or greater than 8 points, then an epidural bolus is performed the introduction of a mixture of local anesthetics, in doses for spinal anesthesia, diluted to the required volume for the type of access used and the level of change in the intervertebral disc, and corticosteroids with high glucocorticoid activity by central mid-access at the side position of the side of the change in the intervertebral disc, with the puncture of the epidural space one intervertebral gap above the established level of change in the intervertebral disc, followed by maintaining the patient’s posture for 15-20 minutes and turning on the stomach for 20-25 minutes, then at a second visit, which is prescribed after 2-3 days, assess the intensity of the pain syndrome, as described above, and depending on the result, further treatment is carried out, including pharmacopuncture, until the pain syndrome disappears completely .

If the intensity index of the pain syndrome at the initial visit is more than 8 points, then at the second visit the epidural administration of this mixture is repeated by central median access, while the dose of these corticosteroids is reduced by half compared with the dose for the first epidural administration.

If the pain intensity indicator at the next visit during movement decreases by half, but more than 4 points, then epidural administration of this mixture is performed by caudal access, while the dose of these corticosteroids is reduced by half compared to the dose for the first epidural administration, then after 2-3 days, an indicator of the intensity of the pain syndrome is evaluated and, if it is more than 4 points, then the epidural administration of this mixture is repeated by caudal access.

If the pain intensity indicator at the next visit decreases to 4 points during movement, then conduction blockade of the peripheral nerves is performed by transacral access or by paravertebral access with a mixture of local anesthetics, these corticosteroids and vitamins, while the dose of these corticosteroids is reduced by three times compared to dose for the first epidural administration, the procedure is repeated after 2-3 days until the pain disappears at rest.

If at the next visit the pain intensity indicator during movement is 2 or 1 points, then pharmacopuncture is carried out with a mixture of local anesthetic and homeopathic medicine using acupuncture points of general effect, the procedure is repeated 7-10 times until the pain syndrome disappears completely.

To perform pharmacopuncture, a 0.5% novocaine solution is used as a local anesthetic, to which the homeopathic preparation traumel C is added in a ratio of 1: 1.

When the above mixture is epidurally administered via central median access, local anesthetics with a fast onset and short duration of action, such as a 10% or 2% lidocaine solution, in medium or maximum doses for spinal anesthesia, respectively, are used as local anesthetics.

The positive effect of these drugs is due to both a decrease in the permeability of microvessels and a suppression of the activity of ectopic foci characteristic of lidocaine even in subtherapeutic concentrations (Devor M., 1991), in combination with a decrease in nerve fiber conductivity achieved by both lidocaine and a corticosteroid (Johansson A . Et al., 1990).

When epidural administration of the above mixture by caudal access, local anesthetics with a delayed onset and a prolonged period of action, such as a 0.5% solution of bupivacaine or 0.2% solution of ropivacaine, are predominantly used as local anesthetics.

In patients with ASA class I and II and patients with diabetes mellitus, local anesthetics are used in maximum and medium doses for spinal anesthesia, which is 60-80 mg of lidocaine or 15-20 mg of bupivacaine, and in medium or maximum doses for extended infusions by epidural administration , which is 8-12 mg of ropivacaine.

In patients of class III ASA and patients with diabetes mellitus, local anesthetics with a fast onset of action are used in medium doses, which is 60 mg of lidocaine or in a combination of the minimum doses for spinal anesthesia, which is 30-50 mg of lidocaine and 10-12.5 mg of bupivacaine , or in average doses for extended infusions by epidural administration, which is 6-10 mg of ropivacaine.

The use of a mixture of bupivacaine and lidocaine as local anesthetics makes it possible to reduce the time of onset of anesthesia and increase the duration of action, that is, to improve the quality of analgesia, and at the same time mitigate the negative consequences of their separate use, such as frequent postural reactions when using only lidocaine.

A mixture of “depot” and water-soluble corticosteroids is used as corticosteroids for epidural administration, while betamethasone is used as a “depot” of corticosteroids, which is an official mixture of betamethasone salts containing 5 mg / ml betamethasone dipropionate suspension and 2 mg / ml betamethasone sodium phosphate and as a water-soluble corticosteroid - dexamethasone 4 mg / ml.

At the initial visit to ASA class I and II patients, average doses of betamethasone for systemic therapy, which is 7 mg of betamethasone, are used as a dose of corticosteroids for the first epidural administration.

If at the first visit the specified indicator of the intensity of the pain syndrome in a patient of class II ASA is 8 points, then by means of central median access a mixture containing 7 mg of betamethasone and 60-80 mg of lidocaine or 12.5-15 mg of bupivacaine or 20-40 mg is epidurally administered lidocaine and 10 mg of bupivacaine in a dilution of 0.9% NaCl to 6-8 ml.

If during the initial visit the specified indicator of the intensity of the pain syndrome in a patient of class II ASA with diabetes is 8 points, then by means of central median access a mixture containing 3.5 mg of betamethasone, 2-4 mg of dexamethasone and 60-80 mg of lidocaine or 12 , 5-15 mg of bupivacaine or 20-40 mg of lidocaine and 10 mg of bupivacaine in a dilution of 0.9% NaCl to 6-8 ml.

If during the initial visit, the specified indicator of the intensity of the pain syndrome in a patient of class III ASA is 8 points, then by means of central median access, a mixture containing 3.5-5.25 mg of betamethasone, 50-70 mg of lidocaine or 10-12.5 bupivacaine is epidurally administered or 20-40 mg of lidocaine and 8-10 mg of bupivacaine in a dilution of 0.9% NaCl to 6-8 ml.

If during the initial visit the specified indicator of the intensity of the pain syndrome in a patient of class III ASA with diabetes is 8 points, then by means of central median access a mixture containing 3.5 mg of betamethasone, 2-4 mg of dexamethasone, 50-70 mg of lidocaine or 10 -12.5 bupivacaine or 20-40 mg of lidocaine and 8-10 mg of bupivacaine in a dilution of 0.9% NaCl to 6-8 ml.

If during the initial visit the specified indicator of the intensity of the pain syndrome in a patient of class I ASA is 9-10 points, then by means of central median access a mixture containing 7 mg of betamethasone and 70-80 mg of lidocaine or 15-17.5 mg of bupivacaine or 30 -40 mg of lidocaine and 10-12.5 mg of bupivacaine in a dilution of 0.9% NaCl to 6-8 ml.

If during the initial visit the specified indicator of the intensity of the pain syndrome in a patient of class II ASA with diabetes is 9-10 points, then by means of the central median access a mixture containing 3.5 mg of betamethasone, 3-4 mg of dexamethasone and 60-80 mg of lidocaine is epidurally administered or 15-17.5 bupivacaine or 30-40 mg of lidocaine and 10-12.5 mg of bupivacaine in a dilution of 0.9% NaCl to 6-8 ml.

If at the first visit the specified indicator of the intensity of the pain syndrome in a patient of class III ASA is 9-10 points, then by means of central median access a mixture containing 3.5-5.25 mg of betamethasone and 50-70 mg of lidocaine or 10-15 mg is epidurally administered bupivacaine or 20-40 mg of lidocaine and 8-10 mg of bupivacaine in a dilution of NaCl 0.9% to 6-8 ml.

If during the initial visit the specified indicator of the intensity of the pain syndrome in a patient of class III ASA with diabetes is 9-10 points, then by means of central median access a mixture containing 3.5 mg of betamethasone, 3-4 mg of dexamethasone and 50-70 mg of lidocaine is epidurally injected or 10-15 mg of bupivacaine or 20-40 mg of lidocaine and 8-10 mg of bupivacaine in a dilution of 0.9% NaCl to 6-8 ml.

If upon repeated visits to patients of I-III class ASA and patients with diabetes mellitus, epidural administration of this mixture is carried out by caudal access, the dose of corticosteroids is reduced by half compared with the dose for the first epidural administration.

If during the second visit the epidural administration of the mixture by central mid-access is carried out, the dose of corticosteroids is reduced by half compared with the dose for the first epidural administration.

If at the next visit the epidural administration of this mixture is carried out by caudal access, then the dose of corticosteroids is halved compared to the dose for the first epidural administration in a dilution of the mixture with a NaCl solution of 0.9% to 20-25 ml, the procedure is repeated after 2-3 days until the pain intensity indicator decreases to 4 points during movement.

If changes in the intervertebral disc are between L4-L5, L5-S1 and at the next visit the pain intensity indicator during movement is 3 points, conductor peripheral nerve blockade is performed by transacral access with a mixture of local anesthetics, these corticosteroids and vitamins, while the dose of corticosteroids is reduced three times compared with the dose for the first epidural administration, the procedure is repeated 2-3 days before the disappearance of the pain at rest.

If changes in the intervertebral disc are between L1-L2, L2-L3, L3-L4 and at the next visit the pain intensity indicator during movement is 3 points, conductor peripheral nerve blockade is performed by paravertebral access with a mixture of local anesthetics, indicated corticosteroids and vitamins, this dose of these corticosteroids is reduced by three times compared with the dose for the first epidural administration, the procedure is repeated 2-3 days before the pain disappears at rest.

If at the next visit the pain intensity indicator is 2 or 1 points, then pharmacopuncture is carried out with a mixture of 0.5% solution of novocaine and homeopathic preparation traumeel C in a ratio of 1: 1 in the amount of 1.5-2 ml per procedure, using points of classical acupuncture, recommended in the treatment of vertebrogenic pain syndrome, the procedure is repeated 7-10 times until the pain syndrome disappears completely.

The invention is illustrated by examples of the implementation of the proposed methods of treatment using illustrative material, which presents the following information:

Table 1 is a scale of independent expert evaluation, according to which the doctor, upon examination of the patient, determines an updated indicator of the intensity of the pain syndrome in YOUR scores.

Table 2 - A summary table of the dosages of the drugs used.

Abbreviations adopted in the description of examples of the method:

KBS - radicular pain syndrome;

FA - functional activity;

MRI - magnetic resonance imaging;

ShNEO - scale of independent expert assessment (Table 1);

B - points according to YOUR or ShNEO;

BS - pain;

Diabetes mellitus; diabetes mellitus;

1 p., 2 p., 3 p., ... - serial number of the patient’s visit to the doctor;

NSAIDs are non-steroidal anti-inflammatory drugs.

In ₁₂ - cyancobalamin 500 μg / ml, 0.9% NaCl - physiological saline (solvent);

IRT - acupuncture;

HELL - blood pressure;

Heart rate - heart rate;

Caudal blockade - bolus epidural administration of a mixture of local anesthetics and corticosteroids by caudal epidural access.

Epidural blockade by the central median access - a bolus epidural administration of the indicated mixture of local anesthetics and corticosteroids through the central median access.

Transacral blockade - conduction blockade of peripheral nerves by transacral access with a mixture of these local anesthetics, corticosteroids and vitamins. It is used for repeated calls.

Paravertebral blockade - conduction blockade of peripheral nerves by paravertebral access with a mixture of these local anesthetics, corticosteroids and vitamins. It is used for repeated calls.

OTBS - Department of Therapy of Pain Syndromes Acad. B.V. Petrovsky. "

A method of treating LSC of the lumbar spine is as follows.

At the first visit, the doctor simultaneously conducts a neuroorthopedic examination, assesses the patient’s FA, clarifies the history of the disease and life, and correlates the data with the results of MRI. He makes a diagnosis, finds out the presence of concomitant diseases and determines the patient's somatic status according to the ASA classification, asks the patient to independently evaluate the intensity of BS according to YOUR. Then the doctor determines the patient’s FA in accordance with table 1 (SESE), which is developed on the basis of clinical studies and allows you to determine the true indicator of BS intensity in contrast to the patient’s subjective assessment of his condition by YOUR (the difference in assessment is usually 1-2 B, which allows reduce the dose of drugs administered). Depending on the result, determine the type of procedure, medications, calculate their amount and the necessary dosages, determine the method and place of administration (table 2), taking into account the minimization of the pharmacological load.

As a rule, with an intensity of the pain syndrome of 6 B, epidural administration by caudal access is performed once, at 7 B - twice, with an interval of 2-3 days, while the procedure must be performed in two stages.

At the first stage, the patient is placed on the stomach with a roller under the pubic joint. A mixture for introduction into the epidural space is prepared ex tempore, it must be shaken before introduction, which reduces the number of large particles in the solution. To exclude damage to the dura mater and the development of the spinal block and injury to the vascular bundle, an aspiration test is performed before the mixture is introduced. After determining the anatomical landmarks, processing the puncture site and the surrounding area, according to the standard rules for performing caudal epidural blocks, in the recess between the sacral horns at an angle of 45 ° to the skin surface and parallel to the axis of the spine with a 21G needle (21G⋅1 _1/2 , 0.8⋅40 mm ), connected to a 20 ml disposable syringe, pierce the skin, subcutaneous tissue and sacrococcygeal ligament until a positive “loss of resistance” test is obtained, which confirms the correctness of the manipulations . The method for verifying the epidural caudal space or the sensation of “loss of resistance” is based on the fact that when the solution is introduced into various layers of tissues through which the needle passes when they are punctured, different resistance to the fluid flow occurs. If the needle section is in the interspinous ligaments, the resistance to fluid flow is average, in the sacrococcygeal ligament it is maximum, and when it enters the caudal epidural space, it is minimal, that is, there is a “loss of resistance”. Due to the small distance to the entrance to the caudal canal (from 0.5-2 cm) and the small diameter and size of the needle, tissue infiltration with an anesthetic solution is not required, since the procedure is not painful.

The introduction of the mixture with a 21G needle of sufficient length from a disposable syringe with a volume of 20 ml, which is smaller in comparison with the caudal needle, eliminates the risk of damage to the needle section of the sacred nerves located above. This makes it possible to inject the solution directly into the caudal canal beyond the sacrococcygeal ligament, which completely eliminates the risk of the mixture getting into the subarachnoid space above and the possible development of the spinal block. The vascular bundle lines the ventral wall of the sacral canal and ends at the level of the fourth sacral vertebra, therefore, as a rule, the section of the needle does not reach it, which also eliminates the mixture getting into the lumen of the vessel with the manifestation of cardiac or neurotoxicity of the injected solution.

After the introduction of the needle, the total volume of preparations (solvent, anesthetic and corticosteroid) should be administered simultaneously, for 5-10 seconds, with a sufficient volume of solvent up to 20-25 ml. Due to the rapid administration of the entire volume of preparations, filtration into the surrounding tissues is excluded, which makes it possible to increase the effect of the mixture at low concentrations of anesthetic, since the solution pressure in this case pushes the loose fiber of the caudal canal, forcing the injected volume upward to the caudal plexus and the site of change of the intervertebral disc, washing a greater number of structures and nerve fibers, providing a faster and more complete therapeutic and analgesic effect. Subsequent changes in the patient's posture allows you to achieve the maximum concentration of the solution used.

At the second stage, the patient is turned on the side of the lesion, and if the changes in the intervertebral disc are between L1-L2, L2-L3, L3-L4, the pillow is left, which helps to distribute the mixture to the desired place if the changes are at the level of L5-S1 clean the pillow. To fix the mixture, it is necessary to maintain this position for 15-20 minutes. Then, so that the volume of the solution is distributed over the capsule of the horse’s tail, the patient is again placed on the stomach and this position is maintained for another 10-15 minutes. If changes in the intervertebral disc are between L1-L2, L2-L3, L3-L4, then immediately after the patient returns to the original position, they additionally administer a water-soluble steroid and a fast-acting local anesthetic (lidocaine) by supra-or inter-spinal access.

Upon a second visit, the doctor again asks the patient to evaluate the intensity of the pain syndrome according to YOUR and clarifies its value as described above according to ShNEO (table 1).

If changes in the intervertebral disc are between L4-L5, L5-S1 and during a second visit the pain intensity indicator during movement is 3 B, conductor peripheral nerve blockade is performed by transacral access with a mixture of local anesthetics, these corticosteroids and vitamins, while the dose of these corticosteroids reduced by three times compared with the dose for the first epidural administration. To perform a conduction blockade by transacral access, a conventional technique and a 20 ml disposable syringe with a 21G needle (21G⋅1 _1/2 , 0.8⋅40 mm) are used.

If changes in the intervertebral disc are between L1-L2, L2-L3, L3-L4 and the pain intensity during movement during a second visit is 3 B, conduction blockade of the peripheral nerves is performed by paravertebral access with a mixture of local anesthetics, these corticosteroids and vitamins, this dose of these corticosteroids is reduced by three times compared with the dose for the first epidural administration. To perform conduction blockade by paravertebral access, a disposable syringe of 10 or 20 ml with a needle of 16-18G (18G⋅1 _1/2 , 1.3 mm45 mm) is used.

When conducting pharmacopuncture, the formulations recommended by A. Gnezdilov are used. in the treatment of vertebrogenic pain syndrome (see the dissertation Gnezdilov A.V. Diagnostics and treatment of phantom and vertebral pain syndromes. - M., 1999, p. 138-141). The drugs are injected into biologically active points using the two-stage method of positioning a 24G cannula for intradermal or subcutaneous administration of drugs. Features of the technique are to create a “Lemon Peel” at the first stage by intradermal administration of drugs in order to prevent sensitization of peripheral nociceptors. At the second stage, the needle is turned 90 ° and transferred to the intramuscular route of administration in order to influence the muscular-tonic component of BS.

When implementing the method of treating CHD according to the present invention, in order to obtain the desired effect of therapy, the basic safety principle of performing epidural blockade on an outpatient basis is based on the combination of the use of minimal spinal doses of various local anesthetics (the result is the absence of a motor block on an outpatient basis) in appropriate dilutions and, at the same time, low concentrations, where as a result, during the procedure, the desired onset of action of the latter occurs, accompanying this reduction in the intensity of BS due to exposure to local anesthetics with different periods of the latent period and the subsequent "connection" of various dosage forms of corticosteroids, which is optimized by changing the patient’s posture.

The effect of corticosteroids with this pathology is direct and expressed with local application, and not systemic. Local therapeutic concentration is maintained for two weeks after injection of the suspension form of the drug (Burn J.M., Langdon L., 1974). Obviously, the elimination of pain immediately after injection is due to the direct action of a local anesthetic and is associated with the development of sensory epidural blockade, which suppresses afferentation with the corresponding relaxation of muscles and ligaments of the lumbar spine, which breaks the vicious circle “pain - muscle spasm-pain”.

At the same time, in the absence of degenerative neuronal changes (fibrosis, adhesions) in the early periods of root compression (6-8 weeks), when BS is associated with perineural edema due to stasis and increased permeability of the epineural vessels, diffusion of drugs to nerve fibers and stopping of edema due to normalization are easily achievable microcirculatory processes. Confirmation of this is the result of studies conducted by the authors, where a stable positive effect after a single injection was achieved in 62% of patients. However, the severity of BS requires a certain local therapeutic concentration, which is achieved by repeating the procedures on an outpatient basis.

The difference between the second treatment option and the first is that the intensity of the BS during the initial visit is 8-10 B. As a rule, with the intensity of the BS 8 B, epidural administration by central access at the lumbar level is performed once, at 9-10 B - twice, s an interval of 2-3 days, followed by a twofold use of caudal blockade with an interval of 2-3 days.

Clinical examples of a method for treating CHD according to a first embodiment of the invention.

Example No. 1.

Patient G., 56 years old. II-III ASA. Height is 178 cm. Body weight is 76 kg.

Complaints during the initial examination for BS in the lower back in the lower back and gluteal region and in the right leg.

Medical history: Sick for a week, receiving tablet therapy without significant effect. Earlier - notes the periodic appearance of minor pain in the lumbar back during the last 2-3 years, which took place after taking the NSAID course and horizontal position. A BS with radiating to the right leg appeared for the first time. According to MRI: Degenerative-dystrophic changes in the lumbar spine. L3-L4 intervertebral disc herniation with signs of neural compression and a tendency to sequestration. Protrusion of the intervertebral discs L5-S1 and L4-L5. Violation of the statics of the spine.

1 p. On examination: Lame on the right foot. Complains of sharp pulling pains in the lumbar region, spreading along the lateral (strip) surface of the right thigh and lower leg with irradiation in 1 finger of the right foot. Emotionally somewhat anxious. Receives standard NSAID therapy; slight improvement. Climbed onto the couch independently. Pain on palpation of trigger points of the lumbar and gluteal region on the right is determined. St Lasega + from 45 ° on the right. Radiation of pain along the right posterior thigh is noted. Tendon reflexes from the lower extremities - live: knee D≤S slightly. Achilles reflex D≤S slightly. Sensitivity is not changed. Pelvic functions - no change.

Assessment of BS intensity according to YOUR (patient's assessment) 7-8 B, according to ShNEO (doctor's assessment) - 6 B.

Diagnosis: Dorsopathy with a primary lesion of the lumbosacral spine amid degenerative-dystrophic (L3-L4 intervertebral disc herniation) and myofascial disorders. KBS on the right.

Concomitant: Bronchiectasis of the upper lobe of the left lung, bullous emphysema. Condition after lower lobectomy on the left. (At the time of appeal - compensated).

Treatment and procedures: 1 p. Conducted caudal blockade. Composition: ropivacaine 8 mg, betamethasone 5.25 mg, NaCl 0.9% to 20 ml. Peripheral blockade was performed by supra- and interspinous access at the L3-L4 level (taking into account the MTP data). Composition: dexamethasone 2 mg, lidocaine 30 mg, NaCl 0.9% to 6 ml. Complications: no. HELL 142/82 mm Hg, heart rate - 76 / min.

2 p. YOUR 6-7 B, according to ShNEO 4-5 B (moderate pain). According to the patient, a decrease in BS by 40-50%. Trigger points in the lumbar spine are not painful. There was pain on the outer surface of the leg. St Lasega + with 45 ° on the right and negative on the left. Conducted caudal blockade. Composition: ropivacaine mg, betamethasone 3.5 mg, NaCl 0.9% to 22 ml.

3 p. YOUR 5-6-7 B, according to ShNEO 3-4 B (moderate pain). A transacral block on the right was performed. Composition: lidocaine 40 mg, dexamethasone 2 mg, B ₁₂ 250 mcg, NaCl 0.9% to 20 ml.

4 p. YOUR 2-3 B, according to ShNEO 1-2 B. Drawing on the back of the lower leg to the right. A pharmacopuncture session was conducted at the points of classical acupuncture. Composition: novocaine 0.5% 1 ml, traumeel C 1 ml.

5 p. YOUR 2-3 B, according to ShNEO 1-2 B. A pharmacopuncture session was conducted.

6 p. YOUR 0-1 B, according to ShNEO 0-1 B. A pharmacopuncture session was conducted.

7 p. YOUR 0-1 B, according to ShNEO 0-1 B. A pharmacopuncture session was conducted.

8 p. YOUR 0-1 B, according to ShNEO 0 B. A pharmacopuncture session was conducted.

Therapy: Fixing belt, per os: Lornoxicam (xefocam) 8 mg in the morning and evening after eating - 10 days, then traumeel C according to the scheme under the tongue - up to 3-4 weeks. Tizanidine (Sirdalud) - 14 days.

The treatment is completed in the complete absence of BS. Additionally, traumel C is prescribed in tablets for 1.5-2 months per os and rubbing the traumeel C ointment into pain zones (lower back, thigh, lower leg).

The duration of treatment is 16 calendar days.

Follow-up: From the moment of treatment, there was repeated treatment after 5 months due to the appearance of pulling sensations in the lumbar region, the external lateral surface of the lower leg.

A preventive course of pharmacopuncture No. 5 on the points of classical acupuncture was carried out. Composition: novocaine 0.5% 1 ml, traumeel C 1 ml.

Example No. 2.

Patient K., 62 years old. III ASA. Height is 158 cm. Body weight is 51 kg.

Complaints during the initial examination for BS in the lumbar region and the gluteal region are periodic with rare backache in the left leg to the middle of the lower leg. Restriction of active movements in the lumbar spine.

Anamnesis of the disease: Notes the periodic appearance of minor pain in the lumbar spine for about 12 years, which passed after the course of taking NSAIDs courses per os. Over the past 2 years, there has been an increase in BS, which required a course of NSAID injections with a satisfactory effect. According to MRI: Severe degenerative-dystrophic changes in the lumbosacral spine (Signs of osteochondrosis and spondylaprotrosis). Disc herniation L4-L5, L5-S1. Disc protrusion L1-L2 L3-L4. Static violation. Compared with the previous MRI (8 years earlier) - moderate negative dynamics.

1 p. On examination: Is in a forced position. Complains of pain in the lumbar region, spreading along the back surface of the left thigh and lower leg, sometimes with radiation in 1-4 toes of the left foot. She lays down on the couch herself with difficulty. Pain on palpation of trigger points in the lumbar region, the area of the supraspinous ligament and the paravertebral region on the left is determined. St Lasega + with 90 ° on the right and + 40 ° on the left. SM tension is weakly positive. Irradiation of pain along the left posterior thigh is noted. Tendon reflexes from the upper extremities - live: knee D = S. Achilles reflex D = S. Sensitivity and pelvic function - N.

Assessment of BS intensity according to YOUR 7-8 B, according to ShNEO 6 B.

Diagnosis: Dorsopathy with a primary lesion of the lumbosacral spine amid degenerative-dystrophic (L4-L5, L5-S1 intervertebral disc hernias) and myofascial disorders. KBS on the left.

Concomitant: Rheumatoid arthritis, seropositive, non-erosive (radiological art. 2), FC1, ATsPs (+). GB III. (3 component therapy).

Treatment and procedures: 1 p. Conducted caudal blockade. Composition: ropivacaine 6 mg, betamethasone 3.5 mg, NaCl 0.9% to 22 ml. Complications: no. HELL 140/90 mm Hg

2 p. YOUR 5-6 B, according to ShNEO 3-4 B (moderate pain). According to the patient, a decrease in BS by 50-60%. Inspection: trigger points in the lumbar spine are not painful. There was pain in the ankle and on the outside of the thigh. St Lasega + with 45 ° on the left and negative on the right. Conducted transacral blockade. Composition: lidocaine 60 mg, dexamethasone 2 mg, 12125 mcg, NaCl 0.9% to 20 ml. Complications: no.

3 p. YOUR 4-5 B, according to ShNEO 3 B. Transacral blockade was performed. Composition: lidocaine 60 mg, dexamethasone 1 mg, B ₁₂ 125 mg, NaCl 0.9% to 20 ml.

4 p. YOUR 2-3 B, according to ShNEO 1-2 B. A pharmacopuncture session was conducted at the points of classical acupuncture. Composition: novocaine 0.5% 1 ml, traumeel with 1 ml. Complications: no.

5 p. YOUR 2-3 B, according to ShNEO 1-2 B. A pharmacopuncture session was conducted.

6 p. YOUR 2-3 B, according to ShNEO 0-1 B. A pharmacopuncture session was conducted

7 p. YOUR 2-3 B, according to ShNEO 0-1 B. A pharmacopuncture session was conducted

8 p. YOUR 2-3 B, according to ShNEO 0-1 B. A pharmacopuncture session was conducted.

9 p. YOUR 1-2 B, slight sensations of tension in the lower leg in the morning according to ShNEO 0-1 B. A pharmacopuncture session was conducted.

10 p. YOUR 1-B, according to ShNEO 0 B. A pharmacopuncture session was conducted.

Recommended ointment (Traumeel C).

Therapy per os: Lornoxicam (xefocam) 8 mg in the morning and evening after eating - 10 days, then traumeel C according to the scheme under the tongue - up to 3 weeks. Tizanidine (Sirdalud) -14 days.

The treatment is completed in the complete absence of BS in the lumbar region and the absence of irradiation in pain in the left limb. Additionally, traumel C is prescribed in tablets for 1.5-2 months per os and rubbing the traumeel C ointment into pain zones (lower back, thigh, lower leg).

The duration of treatment is 26 calendar days.

Follow-up: Follow-up treatment after 6 months. There were no problems in connection with the exacerbation of the disease.

Example No. 3.

Patient (s) X., 64 years old, III ASA. Height is 158 cm. Body weight is 85 kg.

Complaints during the initial examination of pulling, periodically shooting pains in the lumbar region, the lower part of the buttocks with irradiation in the left or right thigh for 1.5 months, in the last 3 weeks noted a gradual increase in BS with a clear localization on the back of the right thigh and lower leg with periodic backache in the right leg. Turned to the regional neurologist, prescribed tablet therapy of NSAIDs + muscle relaxants + co-analgesics - ineffective.

Anamnesis of the disease: Suffers from BS in the lumbar spine over the past 3 years. Exacerbation 2-3 times a year associated with a violation in everyday life (lifting weights, working in the country, a long stay in an uncomfortable position). Treatment of NSAIDs with courses, vitamin therapy, massage, restriction of the motor regime and wearing an orthopedic corset belt with a positive effect.

According to MRI: Degenerative-dystrophic changes in the lumbar spine. Hernia of the intervertebral disc Th12-L1. Disc protrusion L3-L4. Herniated disc L4-L5.

1 p. On examination: Moves, resting on the hand of his son. Climbed onto the couch independently, with certain efforts. Pain on palpation of trigger points of the lumbar and gluteal region on the right is determined. St Lasega + with 30 ° on the right and + 60 ° on the left. Irradiation of pain along the right posterior thigh. Tendon reflexes from the lower extremities - live: knee D≤S slightly. Achilles reflex D≤S slightly. Sensitivity is not changed. Pelvic functions - no change.

Assessment of BS intensity according to YOUR 7-8 B, according to ShNEO - 7 B.

Diagnosis: Dorsopathy with a primary lesion of the lumbosacral spine amid degenerative-dystrophic (L3-L4 disc protrusion. L4-L5 disc herniation) and myofascial disorders. KBS on the right.

Concomitant: Stage II hypertension, risk 3. Paroxysmal atrial fibrillation, NK II FC. Hyperlipidemia. Hyperlipidemia (metabolic syndrome). Mild myopia, hypertensive retinal angiosclerosis. Obesity II.

Treatment and procedures: 1 p. Conducted caudal blockade. Composition: ropivacaine 6 mg, betamethasone 3.5 mg, dilution up to 20 ml. Complications: no. Holds a pose for the procedure without any difficulties, is in the required position for 35 minutes. He gets up on his own. (HELL 147/97 mmHg, heart rate - 78 / min.)

2 p. YOUR 6 B, according to ShNEO 3-4 B. Decrease in BS by 50-60%. Trigger points in the lumbar spine are not painful. Assessment of the BS intensity: Lasega is negative on the left and weakly “+” on the right. An epidural blockade was performed with caudal access. Composition: ropivacaine 6 mg, betamethasone 1.75 mg, NaCl 0.9% to 20 ml.

3 p. YOUR 5-6 B, according to the ShNEO 3 B. The pain in the ankle is weak, it remains in the gluteal region and in the area of attachment sites with the 4th head of the thigh muscle. Conducted transacral blockade on the right. Composition: lidocaine 40 mg, dexamethasone 2 mg, B 12 250 mcg, NaCl 0.9% to 20 ml. Complications: no.

4 p. YOUR 5-6 B, according to ShNEO 3 B. Transacral blockade on the right was carried out. Composition: lidocaine 40 mg, dexamethasone 2 mg, B 12 100 mcg, NaCl 0.9%, about 20 ml.

5 p. YOUR 2-3 B, according to ShNEO 1-2 B. A pharmacopuncture session was conducted at points of classical acupuncture. Composition: novocaine 0.5% 1 ml, traumeel C 1 ml. Complications: no.

6 p. YOUR 2-3 B, according to ShNEO 1-2 B. A pharmacopuncture session was conducted. Composition: novocaine 0.5% 1 ml, traumeel C 1 ml.

A break for a week at the request of the patient (I went to the cottage).

7 p. YOUR 4-5 B, according to ShNEO 3 B, so the transacral blockade is repeated.

8 p. YOUR 2-3 B, according to ShNEO 1-2 B. A pharmacopuncture session was conducted.

9 p. YOUR 2-3 B, according to ShNEO 1-2 B. A pharmacopuncture session was conducted.

10 p. YOUR 2-3 B, according to ShNEO 1-2 B. A pharmacopuncture session was conducted.

Therapy: Fixing belt, per os Etoricoxib (Arcoxia) 90 mg in the morning after meals - 7 days, then Etoricoxib (Arcoxia) 60 mg - up to 3 weeks. Tizanidine (Sirdalud) - 14 days.

The treatment is completed in the complete absence of BS.

The duration of treatment is 30 calendar days.

Additionally, traumel C is prescribed in tablets for 1.5-2 months per os and rubbing the traumeel C ointment into pain zones (lower back, thigh, lower leg).

Example No. 4.

Patient K., 56 years old, III ASA. Height 165 cm. Body weight 71 kg.

Complaints during the initial examination for BS and severity in the lumbar region and gluteal region with periodic backache in the right leg that appeared a week ago. A sharp restriction on the volume of active movements due to pain and tension in the lumbar.

Anamnesis of the disease: Three years earlier, she contacted the OTBS regarding drawing pains in the lumbar spine. Diagnosis: Dorsopathy of the lumbosacral spine on the background of degenerative-dystrophic and myofascial disorders. Muscular-tonic pain syndrome.

Concomitant pathology: Type 2 diabetes mellitus. A 3-week course of treatment for RTI was performed with full effect. Then, a year later, a preventive course of pharmacopuncture was carried out in connection with the main diagnosis. There were no exacerbations requiring outpatient treatment during this period. According to MRI: Degenerative-dystrophic changes in the lumbar spine with arthrosis. L3-S1 disc protrusions with signs of neural compression on the right and left. L5-S1 herniated disc with signs of neural compression on the right.

1 p. On examination: Is in a forced position. Complains of pulling pains in the lumbar region, spreading along the lateral (strip) surface of the right thigh and lower leg. She lays on the couch herself. Determined: pain on palpation of the trigger points of the lumbar and gluteal region on the right. Tension of the paravertebral muscles of the lumbar region on the right. St Lasega with 45 ° on the right and + 90 ° on the left. Irradiation of pain along the right posterior - lateral surface of the thigh and lower leg is noted. Tendon reflexes from the lower extremities are living: knee D = S slightly. Achilles reflex D = S. Sensitivity - slight numbness in the lower leg. Pelvic functions are normal.

Assessment of BS intensity according to YOUR 7-8 B, according to ShNEO 7 B.

Diagnosis: Dorsopathy with a primary lesion of the lumbosacral spine amid degenerative-dystrophic and myofascial disorders. Herniated discs L5-S1. KBS on the right.

Concomitant: Type II diabetes mellitus. GB II (Therapy: Concor, Prestarium).

Treatment and procedures: 1 p. Conducted caudal blockade. Composition: ropivacaine 8 mg, betamethasone 3.5 mg, dexamethasone 4 mg, NaCl 0.9% to 22 ml. Complications: no. HELL 145/90 mm Hg, heart rate - 82 / min.

2 p. YOUR 5-6 B, according to ShNEO 4-5 B (moderate pain). According to the patient, a decrease in BS by 50-60%. Inspection: Trigger points in the lumbar spine are not painful. There was pain in the ankle and on the outer surface of the thigh, St. Lasega + 60 ° on the right and negative on the left. Conducted caudal blockade. Composition: ropivacaine 6 mg, betamethasone 1.75 mg, dexamethasone 2 mg, NaCl 0.9% to 22 ml. Complications: no.

3 p. YOUR 5 3 B, according to ShNEO 3-4 B. Transacral blockade on the right was carried out. Composition: ropivacaine 6 mg, dexamethasone 2 mg, B ₁₂ 250 mcg, NaCl 0.9% to 22 ml.

4 p. YOUR 5 3 B, according to ShNEO 3-4 B. At rest, the pain began to disappear completely, numbness in the lower leg passed. A transacral block on the right was performed. Composition: ropivacaine 6 mg, dexamethasone 1 mg, B ₁₂ 250 mcg, NaCl 0.9% to 22 ml.

5 p. YOUR 2-3 B, according to ShNEO 1-2 B, up to 3 B when driving. A pharmacopuncture session + blockade of trigger points of the lumbar spine was performed. Composition: novocaine 0.5% 2 ml, traumeel C 2 ml.

6 p. YOUR 2-3 B, according to ShNEO 1-2 B. A pharmacopuncture session + blockade of trigger points of the lumbar spine was performed. Composition: novocaine 0.5% 2 ml, traumeel C - 2 ml.

7 p. YOUR 2-3 B, according to ShNEO 1-2 B. A pharmacopuncture session was conducted.

8 p. YOUR 2-3 B, according to ShNEO 0-1 B, the pulling unpleasant sensations of the shin on the right are preserved. A pharmacopuncture session was conducted.

9 p. YOUR 1-B, according to ShNEO 0-B. There were sensations of tension in the lower leg. A pharmacopuncture session was conducted. Composition: novocaine 0.5% 1 ml, traumeel C 1 ml.

10 p. YOUR 0 B, according to ShNEO 0 B. A pharmacopuncture session was conducted. Recommendations are given.

Therapy: Fixing belt, per os Etoricoxib (Arcoxia) 90 mg in the morning and evening after meals - 5 days, then Arcoxia 60 mg in the morning traumeel C according to the scheme under the tongue - up to 3 weeks., Tizanidine (sirdalud) - 14 days .

The treatment is completed in the complete absence of BS. Additionally, traumel C is prescribed in tablets for 1.5-2 months per os and rubbing the traumeel C ointment into pain zones (lower back, thigh, lower leg).

Blood sugar was tested 2 times a day (morning and evening). Additional correction of blood sugar was not required.

The duration of treatment is 20 calendar days.

Follow-up: Follow-up treatment after 6 months. There were no problems in connection with the exacerbation of the disease.

Clinical examples of a method for treating CHD according to a second embodiment of the invention.

Example No. 5.

Patient (s) M., 53 years old. I ASA. Height is 170 cm. Body weight is 67 kg.

Complaints during the initial examination for BS in the lumbar region and the gluteal region are periodic with sharp backache in the right leg. Four days ago I put on my boots, at this time I felt a sharp pain in my lower back and could not straighten up. Diclofenac was made intramuscularly, then the patient was escorted by relatives to a private clinic. However, the assistance provided (paravertebral block) did not have a significant effect. According to MRI: Right medial - paramedial hernia of the intervertebral disc L4-L5, L5-S1. Manifestations of intervertebral osteochondrosis, deforming spondylosis and spondylarthrosis of the lumbar spine.

Anamnesis of the disease: the presence of back pain is absent.

Concomitant pathology: None.

1 p. On examination: Delivered to the OTS by relatives in a day, moves with great difficulty, with the help of relatives (daughter). It is in a bent position, supported by an attendant. Complains of sharp pulling pains in the lumbar region, spreading along the lateral (strip) surface of the right thigh and lower leg with irradiation in 1-4 toes of the right foot. Appealed at the place of residence to the therapist and neurologist, has a sick leave. Day 3 receives standard therapy, does not notice a significant improvement in the day after paravertebral blockade. Climbed onto the couch with the help of her daughter. Pain on palpation of trigger points of the lumbar and gluteal region on the right is determined. St Lasega + with 30 ° on the right and negative on the left. A sharp irradiation of pain on the right posterior thigh is noted. Tendon reflexes from the lower extremities - live: knee D≤S slightly. Achilles reflex D≤S slightly. Sensitivity - slight "numbness, like goosebumps." Pelvic functions - no change.

Assessment of BS intensity according to YOUR 9-10 B, according to ShNEO 8 B.

Diagnosis: Dorsopathy with a primary lesion of the lumbosacral spine amid degenerative-dystrophic and myofascial disorders. Pronounced KBS on the right.

Companion: no.

Treatment and procedures: 1 p. An epidural block was made by central median access at the L3-L4 level. Composition: lidocaine - 70 mg, betamethasone 7 mg, dilution up to 8 ml. Complications: no. HELL 135/82 mm Hg, heart rate - 78 / min.

2 p. YOUR 5-6 B, according to ShNEO 4-5 B (moderate pain). According to the patient, a decrease in BS by 50-60%. Inspection: trigger points in the lumbar spine are less painful. There was pain in the ankle and on the outside of the thigh. St Lasega + with 45 ° on the right and negative - on the left.

Conducted caudal blockade. Composition: lidocaine 80 mg, betamethasone 3.5 mg, NaCl 0.9% to 22 ml. Complications: no.

3 p. YOUR 5-6 B according to ShNEO 4-5 B. Caudal blockade was carried out. Composition: lidocaine 80 mg, betamethasone 1.75 mg, dexamethasone 2 mg, NaCl 0.9% to 22 ml. Complications: no.

4 p. YOUR 5-6 B according to ShNEO 3 B. Transacral blockade on the right was carried out. Composition: lidocaine 80 mg, dexamethasone 2 mg, B and 250 μg, NaCl 0.9% to 22 ml.

5 p. YOUR 2-3 B according to ShNEO 1-2 B. A pharmacopuncture session + blockade of trigger points of the lumbar spine was performed. Composition: novocaine 0.5% 2 ml, traumeel C 2 ml.

6 p. YOUR 2-3 B, according to ShNEO 1-2 B. A pharmacopuncture session was conducted. Composition: novocaine 0.5% 1 ml, traumeel C 1 ml.

7 p. YOUR 2-3 B, according to ShNEO 1-2 B. A pharmacopuncture session was conducted. Composition: novocaine 0.5% 1 ml, traumeel C 1 ml.

8 p. YOUR 2-3 B, according to ShNEO 0-1 B, pulling the unpleasant sensations of the lower leg on the right. A pharmacopuncture session was conducted.

9 p. YOUR 1-B sensation of tension in the lower leg, according to ShNEO 0-B. A pharmacopuncture session was conducted.

10 p. YOUR 0 B, according to ShNEO 0 B. A pharmacopuncture session was conducted.

Therapy: Fixing belt, per os Lornoxicam (xefocam) 8 mg in the morning and evening after eating - 10 days, then traumeel C according to the scheme under the tongue - up to 3 weeks. Tizanidine (Sirdalud) - 14 days. The treatment is completed in the complete absence of BS.

The duration of treatment is 16 calendar days.

Additionally, traumel C is prescribed in tablets for 1.5-2 months per os and rubbing the traumeel C ointment into pain zones (lower back, thigh, lower leg). Recommendations on the regimen and a set of therapeutic exercises are given.

Example No. 6

Patient S., 25 years old, I-II ASA. Height is 176 cm. Body weight is 93 kg.

Complaints during the initial examination of acute pain in the lumbar region and gluteal region with periodic sharp lumbago in the right leg during a session of manual therapy. A sharp exacerbation after the 3rd session at the reception of a neurologist.

Anamnesis of the disease: Notes the periodic appearance of minor pain in the lumbar back during the last year, which took place after taking a horizontal position and contacting a chiropractor and massage therapist. Pain of such pronounced intensity arose for the first time. Turned to a neurologist, has a sick leave. A day later, with a second appointment with a neurologist, I felt a sharp pain in the lower back and could not straighten. Diclofenac was made intramuscularly and the patient was sent home, accompanied by relatives. The next day there was no improvement; the ambulance was delivered to the OTSB accompanied by her mother. Receives NSAID therapy, no improvement noted. According to MRI: Posterior subligamentous intervertebral hernia (9 mm) of the L4-L5 intervertebral disc with a right-handed component. Rear protrusion of the intervertebral disc L3-L4. Initial degenerative-dystrophic changes.

1 p. During examination: Is in a bent position, held by an accompanying person, cannot step on his right leg. (The patient was practically brought in by the companions on her hands) Complains of sharp pulling pains in the lumbar region, spreading along the lateral (strip) and back surface of the right thigh and lower leg with irradiation in 1-4 toes of the right foot. When moving with the help of relatives: right-sided antalgic scoliosis, crying “in voice” from pain. Climbing onto the couch with great difficulty with the help of medical staff and an accompanying person. Pain on palpation of the trigger points of the lumbar and gluteal region on the right and the irradiation of pain along the right posterior thigh are determined. St Lasega + with 25 ° on the right and + 60 ° on the left. Tendon reflexes - live: knee EX slightly. Achilles reflex D≤S slightly. Sensitivity: sensation of "creeping goosebumps" on the right lower leg. Pelvic functions - no change.

Assessment of BS intensity according to YOUR 9-10 B, according to ShNEO 8-9 B.

Diagnosis: Dorsopathy with a predominant lesion of the lumbosacral spine against a background of degenerative-dystrophic (posterior subligamentous intervertebral hernia (9 mm) of the intervertebral disc L4-L5 on the right) and myofascial disorders. Pronounced KBS on the right.

Concomitant: Obesity II. (Earlier periodically noted an increase in blood sugar. Corrects the diet.) Vegetovascular dystonia. Headaches of tension.

Treatment and procedures: 1 p. An epidural block was performed with central median access at the L3-L4 level. Composition: lidocaine 80 mg, betamethasone 7 mg, dilution up to 8 ml.

2 p. YOUR 5-6 B, according to ShNEO 4-5 B. According to the patient, a decrease in BS by 60-50%. Remained moderate pain and numbness in the ankle and on the outer surface of the thigh, "crawling creeps" on the lower leg. On examination: trigger points are determined in the lumbar spine and the area of the trochanter of the femur slightly painful with SM Lasega + from 45 ° to the right and negative to the left. Conducted caudal blockade. Composition: lidocaine - 80 mg, betamethasone 3.5 mg, dilution up to 22 ml.

2 p. YOUR 4-5 B, ShNEO - 3-4 B. The pain is mild, it shortened to the gluteal fold during exercise, moderate pain, moderate numbness in the ankle and on the outer surface of the thigh. Conducted caudal blockade. Composition: lidocaine 80 mg, betamethasone 3.5 mg, NaCl 0.9% to 22 ml.

3 p. YOUR 3-4 B, according to ShNEO 3-4 B. The pain is mild, with moderate pain, numbness in the ankle and on the outer surface of the thigh. Transacral blockade and blockade of trigger points of the lower leg were performed. Composition: lidocaine - 80 mg, dexamethasone 2 mg, B ₁₂ 250 mcg, NaCl 0.9% to 20 ml.

4 p. YOUR 2-3 B, according to ShNEO - 3 B. The pain is weak or periodically disappears, with exercise moderate pain on the outer surface of the thigh, numbness in the ankle is reduced. It works part-time. A transacral blockade was performed on the right, composition: lidocaine 80 mg, dexamethasone 2 mg, B12 250 mg, NaCl 0.9% to 20 ml.

5 p. YOUR 2-3 B, according to ShNEO 1-2 B. Complains of remaining numbness in the ankle. A pharmacopuncture session + blockade of trigger points of the lumbar spine with a solution of traumel C was carried out. Composition: novocaine 0.5% 2 ml, traumel C 2 ml.

6 p. YOUR 2-3 B, according to ShNEO - 1-2 B. A pharmacopuncture session was conducted according to the standard formulation of points of the lumbar spine and lower leg.

7 p. A pharmacopuncture session was conducted. Break for holidays (14 days).

8 p. YOUR 2-3 B, according to ShNEO 0-1, pulling discomfort in the lower leg on the right. A pharmacopuncture session was conducted. It works full time without restrictions.

9 p. YOUR 1-2 B, according to ShNEO 0-1 B, pulling the unpleasant sensations of the lower leg on the right. A pharmacopuncture session was conducted.

10 p. YOUR 1-2 B, according to ShNEO 0 B, periodically pulling the unpleasant sensations of the lower leg on the right. A pharmacopuncture session was conducted.

11 p. YOUR 0 B, according to ShNEO 0 B, no complaints. A pharmacopuncture session was conducted.

Therapy: Fixing belt, per os Xefocam (lornoxicam) 8 mg in the morning and evening after eating - 10 days, pregabalin (lyrics) - 3 days 75 mg, then 150 mg - 2 months. further traumeel C according to the scheme under the tongue - up to 6 weeks. Tizanidine (Sirdalud) - 14 days. On trigger points: Nanoplast for 12 days.

The treatment is completed in the complete absence of BS. The duration of treatment is 22 calendar days. (Holidays break 10 days).

Additionally, it is prescribed: traumeel C tablets for 1.5-2 months per os and rubbing the ointment traumeel C into the pain zones (lower back, thigh, lower leg).

Follow-up: Since the treatment of repeated calls in connection with the exacerbation of the disease was not. A pharmacopuncture session was prophylactically performed. Monitoring is carried out every six months.

Example No. 7.

Patient S., 53 years old. III ASA. Height is 168 cm. Body weight is 68 kg.

Complaints during the initial examination for BS in the lumbar region and the gluteal region are periodic with sharp backache in the right leg. A day ago, while brushing my teeth I felt a sharp pain in my lower back, I bent and could not straighten. Diclofenac was made intramuscularly. Appealed at the place of residence to the therapist and neurologist, has a sick leave. He receives standard therapy, does not notice a significant improvement. A day later, was delivered to the OTSB by a group of relatives.

Anamnesis of the disease: Notes the periodic appearance of pain in the lumbar spine over the past 5 years, which have passed after one or two single doses of NSAIDs, or suppositories with diclofenac, taking a horizontal position. She was operated on the pelvis (two years ago), without complications. A BS of such pronounced intensity arose for the first time. According to MRI: L5-S1 right-sided foraminal hernia of the intervertebral disc with neural compression. Posterior protrusion of the intervertebral discs L1-L2 and L4-L5. Manifestations of intervertebral osteochondrosis, deforming spondylosis and spondylarthrosis of the lumbar spine (most pronounced in the L5-S1 segment). Left-sided scoliosis. Retrolisthesis and right-sided lateralisthesis of the vertebral body L1.

1 p. On examination: Is in a bent position, held by an accompanying person (daughter). Complains of sharp pulling pains in the lumbar region, spreading along the lateral (strip) surface of the right thigh and lower leg with irradiation in 1-4 toes of the right foot. Can not move, arrived with the help of relatives. Emotionally labile, crying from pain. It is laid on the couch with the help of medical staff and relatives. Pain on palpation of trigger points of the lumbar and gluteal region on the right is determined. St Lasega + with 25 ° on the right and + 60 ° on the left. Radiation of pain along the right posterior thigh is noted. Weakness in the limbs and a decrease in muscle strength - can not be determined on the right. Tendon reflexes from the lower extremities - live: knee D≤S slightly. Achilles reflex D≤S significantly. Sensitivity according to the patient’s sensations “leg in a case”. When using the “pin prick” test, the sensitivity is not changed. Pelvic functions - no change.

Assessment of BS intensity according to YOUR 9-10 B, according to ShNEO 8-9 B.

Diagnosis: Dorsopathy with a primary lesion of the lumbosacral region against the background of degenerative-dystrophic and myofascial disorders. Pronounced KBS on the right.

Concomitant: Uterine fibroids. Condition after surgery. GB II (concor, prestarium). Headaches of tension. Anxious Depressive Disorder.

Treatment and procedures: 1 p. An epidural block was made by central median access at the L3-L4 level. Composition: lidocaine 70 mg, betamethasone 5.25 mg, NaCl 0.9% to 8 ml. Holds a pose with difficulty. Complications: no. HELL 145/82 mm Hg

2 p. YOUR 5-6 B, according to ShNEO 4-5 B. According to the patient, a decrease in BS by 50-60% (moderate pain). Inspection: Can move independently with the help of attendants. Trigger points in the lumbar spine remain painful. There was pain in the ankle and on the outside of the thigh, the “leg thawed”. St Lasega + with 45 ° on the right and + with 75 ° on the left. Conducted caudal blockade. Composition: lidocaine 80 mg, betamethasone 3.5 mg, NaCl 0.9% to 22 ml. Complications: no.

3 p. YOUR 5-6 B, according to ShNEO 3 B. Transacral blockade on the right was carried out. Composition: lidocaine 80 mg, dexamethasone 4 mg, B ₁₂ 250 mcg, NaCl 0.9% to 22 ml.

4 p. YOUR 5-6 B, according to ShNEO 3 B. Transacral blockade of sp. Composition: lidocaine 80 mg, dexamethasone 2 mg, B ₁₂ 250 mcg, NaCl 0.9% to 22 ml.

5 p. YOUR 2-3 B. according to ShNEO 1-2 B. A pharmacopuncture session was conducted at the points of classical acupuncture + blockade of trigger points of the lumbar spine. Composition: novocaine 0.5% 2 ml, traumeel C 2 ml.

6 p. YOUR 2-3 B, according to ShNEO 1-2 B. A pharmacopuncture session + blockade of trigger points of the lumbar spine was performed. Composition: novocaine 0.5% 2 ml, traumeel C 2 ml.

7 p. YOUR 2-3 B, according to ShNEO 1-2 B. A pharmacopuncture session + manual therapy session of the cervicothoracic spine was performed (on the recommendation of a neurologist, he complains of headaches). Complications: no.

8 p. YOUR 2-3 B, according to ShNEO 0-1 B. Drawing unpleasant tibia sensations on the right. A pharmacopuncture session + a session of manual therapy of the cervicothoracic spine was performed.

9 p. YOUR 1 B (sensation of tension in the lower leg), according to ShNEO 0 B. A pharmacopuncture session + manual therapy session of the cervicothoracic spine was performed.

10 p. YOUR 0 B, according to ShNEO 0 B. A pharmacopuncture session was conducted. Therapy: Fixing belt, per os Ksefokam (lornoxicam) 8 mg in the morning and evening after eating - 10 days, then traumeel C according to the scheme under the tongue - up to 3 weeks. Tizanidine (Sirdalud) - 14 days. The treatment is completed in the complete absence of BS.

The duration of treatment is 18 calendar days.

Additionally, traumel C is prescribed in tablets for 1.5-2 months per os and rubbing the traumeel C ointment into pain zones (lower back, thigh, lower leg). Continue therapy for concomitant pathology.

Follow-up: Since the treatment of repeated calls in connection with the exacerbation of the disease was not. After 6 months a preventive course of pharmacopuncture was carried out.

Example No. 8

Patient K., 49 years old. III ASA. Height is 172 cm. Body weight is 89 kg.

Complaints during the initial examination of the expressed BS in the lumbar region and the gluteal region are periodic with sharp backache in the left leg. A sharp aggravation after a flight in an airplane from Murmansk. During the flight, I felt a sharp pain in my lower back and could not straighten up. Voltaren was made intramuscularly and the patient was brought by relatives (brother) to the OTSB department. Hospitalized on the 3rd day in a day hospital for the period of initial treatment.

Anamnesis of the disease: The patient works at the mine as a sinker. She notes a constant feeling of “heaviness” and aching lower back pain and the periodic appearance of significant pain with backache in the lumbar spine over the past 4 years, which partially passed after the IM course of NSAIDs (diclofenac, movalis), taking a horizontal position and going to the therapist Neurologist at the place of residence. The last year of pain in the lumbar region became permanent, tablet therapy with NSAIDs is completely without effect. Two months ago, after an unsuccessful movement, there was a sharp backache, an ambulance call, a pain attack and subsequent outpatient therapy were removed - without a significant effect. Further, he was hospitalized for three weeks. Diagnosis: Lumbar osteochondrosis. Left-sided lumbar ischalgia, exacerbation. Expressed BS. Pronounced statodynamic disturbances. Concomitant pathology: Chronic cholecystopancreatitis, fatty hepatosis. Obesity II-III. Type II diabetes mellitus, compensated. Anxious Depressive Disorder. He received treatment: iv drip aminophylline, novocaine, diphenhydramine, sibazon, Lasix No. 5. Movalis, neuromidine, midocal, famotidine, phenazepam. Massage, Electrophoresis with caripazim. Exercise therapy. The result is virtually no effect. According to MRI: Degenerative-dystrophic changes in the lumbar spine according to the type of osteochondrosis. Disc protrusions L2-L3, L3-L4 L4-L5 intervertebral disc herniation with left-side component. Dorsal disc herniation L5-S1. Narrowing of the spinal canal at the level of L4-S1.

1 p. During examination: Is with an accompanying person in a bent position, can’t stand practically, can’t step on his left leg. Complains of sharp pulling pains in the lumbar region, spreading along the lateral (strip) surface of the left thigh and lower leg with irradiation in 1-2 fingers of the left foot. He moves only with the help of relatives, relying on his companion, he cannot raise his leg. Climbing onto the couch with great difficulty with the help of medical staff and an accompanying person. Pain on palpation of trigger points of the lumbar and gluteal region on the right is determined. It’s impossible to see Lasega + on the left, and + 50 ° on the left. Radiation of pain along the left posterior and lateral surface of the thigh is noted. He does not notice weakness in the left leg, bends the left leg in a horizontal position in the knee joint, and does not reduce muscle strength in the right leg. Tendon reflexes from the lower extremities - live: knee S≤D slightly. Achilles reflex S≤D significantly. The sensitivity is not changed, periodically notes the sensation of "crawling" on the back and strip surface of the left lower leg. Pelvic functions - no change.

Assessment of BS intensity according to YOUR 9-10 B, according to ShNEO 9 B.

Diagnosis: Dorsopathy with a primary lesion of the lumbosacral region against the background of degenerative-dystrophic and myofascial disorders. L4-L5 intervertebral disc herniation with left-side component, dorsal disc herniation L5-S1. Pronounced KBS on the left.

Concomitant: Hypertension II. Chronic cholecystopancreatitis, fatty hepatosis. Hyperlipidemia. Obesity II-III. Type II diabetes mellitus, compensated. Anxious Depressive Disorder.

Treatment and procedures: 1 p. On the left side on the couch was laid with the help of medical staff, holds the pose with difficulty. An epidural blockade was performed with central median access at the L3-L4 level. Composition: lidocaine 80 mg, betamethasone 3.5 mg, dexamethasone 4 mg, NaCl 0.9% to 8 ml. She holds the posture after the procedure with difficulty. Complications: no. HELL 146/87 mm Hg, heart rate 64 / min. An hour later, he was transferred to a day hospital for conducting infusion therapy (for the main disease: glucose-novocaine mixture, NSAIDs; and concomitant diseases).

2 p. YOUR 5-6 B, according to ShNEO 5-6 B. According to the patient, a decrease in BS by 40-50%. On examination: pain in the lumbar region persists, there are trigger points in the lumbar spine. Remained moderate pain on the back of the thigh and numbness in the ankle and on the outer thigh of the left leg. An epidural blockade was performed with central median access at the L3-L4 level. Complications: no. Composition: lidocaine 80 mg, betamethasone 3.5 mg, dexamethasone 2 mg, NaCl 0.9% to 8 ml. An hour later he was transferred to a day hospital for carrying out infusion therapy (glucose-novocaine mixture, NSAIDs, and concomitant diseases).

3 p. YOUR 5-6 B, according to ShNEO 4-5 B. Caudal blockade was carried out. Composition: lidocaine - 80 mg, betamethasone 1.75 mg, dexamethasone 2 mg, NaCl 0.9% to 22 ml. Complications: no.

4 p. YOUR 4-5 B, according to ShNEO 3-4 B. The pain became less, shortened to the gluteal fold; under load, moderate pain remains in the piriformis muscle, there is numbness in the ankle and on the outer surface of the thigh. Conducted caudal blockade. Composition: lidocaine - 80 mg, dexamethasone 2 mg, NaCl 0.9% to 22 ml. Complications: no.

5 p. YOUR 3-4 B, according to ShNEO 3-4 B. The pain is mild, with exercise moderate pain, numbness and pain in the ankle and on the outer surface of the thigh. A transacral blockade on the left and a blockage of trigger points of the lower leg were performed. Composition: lidocaine 80 mg, dexamethasone 2 mg, vitamin B ₁₂ 250 mg, NaCl 0.9% to 20 ml. Complications: no.

6 p. YOUR 2-3 B, according to ShNEO 3 B. The pain is weak or periodically disappears, with moderate pain, numbness in the ankle is reduced and there is no on the outer surface of the thigh. Blocked trigger points in the lumbar region and lower leg on the left; lidocaine at a dose of 80 mg, dexamethasone 2 mg, B12100 mg, NaCl 0.9% to 20 ml. Complications: no.

7 p. YOUR 2-3 B, according to ShNEO 1-2 B. Complains of remaining numbness in the ankle. A pharmacopuncture session + blockade of trigger points of the lumbar spine with a solution of traumel C was carried out. Composition: novocaine 0.5% 2 ml, traumel C 2 ml.

8 p. YOUR 1-2 B, according to ShNEO 0 B. A pharmacopuncture session was conducted according to the standard formulation of points of the lumbar spine and lower leg. Composition: novocaine 0.5% 2 ml, traumeel C 2 ml. Complications: no.

The course of treatment in connection with the end of the vacation in the complete absence of BS was completed.

Therapy: Fixing belt, per os Xefocam (lornoxicam) 8 mg iv in the morning and IM 8 mg in the evening after eating - 5 days, then per os 5 days for 8 mg in the morning and evening after eating. Further: Etoricoxib (Arcoxia) 90 mg 3 days, then 60 mg - 10 days. Pregabalin (Lyric) - 3 days 75 mg, then 150 mg - 2 months, then traumeel C according to the scheme under the tongue - up to 6 weeks. Tizanidine (Sirdalud) - 14 days. On the trigger points ointment Dolobene-indovazin ointment - 2 times a day for 10 days. Additionally, traumel C is prescribed in tablets for 1.5-2 months per os and rubbing the ointment with traumeel C or Dolobene + Indovazin into the pain zones.

The duration of treatment is 32 days. 3 days of a day hospital + carrying out infusion therapy.

Follow-up: Since the treatment of repeated calls in connection with the exacerbation of the disease was not. A year later, a pharmacopuncture course was conducted with a preventive purpose.

By the treatment methods of the present invention, 100 patients with moderate and severe coronary heart disease and neurological impairment against degenerative-dystrophic diseases of the lumbar spine were treated in OTBS. As a result of treatment for the period of invasive procedures, acute BS was stopped extremely quickly (within the first visit), which is confirmed by the given clinical examples. Further, as a result of the treatment, 96 patients fully received complete remission. In 4 patients, partially mild BS remained and after consultation with a neurosurgeon, later on, they were operated on for sequestered herniated discs in the neurosurgery department of the Neurosurgery Department of the Federal State Pedagogical Research Center named after Acad. B.V. Petrovsky.

The duration of BS before treatment left from 1 week to 4 months. The average treatment time is 3 weeks. The average number of visits is 10 (from 8 to 13) with a frequency of 2-3 times a week.

Assessment of the intensity of BS according to YOUR (patient assessment) and assessment by a doctor (NECS, Table 1) was carried out at each visit to determine the type of epidural access, the multiplicity of procedures, and the choice of a mixture of drugs (Table 2), which avoided complications that may occur when applying regional techniques outpatient anesthesia.

In addition, 60 people in the study group evaluated the possibility of using regional blockades on an outpatient basis in the treatment of acute KBS of lumbar localization, taking into account possible complications and patient tolerance of the procedures.

As a result, it was found that regional epidural blockages are quite easily tolerated by patients, their use allows you to quickly reduce the nociceptive component, however, due to the severity of BS, you must have an anesthesiologist who knows the fast technique of performing the procedures.

The above examples confirm that the method of treating LSC of the lumbar spine of varying severity according to the present invention is effective, reliable and safe. In addition, it reduces the treatment time, does not require the use of expensive equipment, and therefore is cost-effective.

Claims (48)

1. A method of treating radicular pain of the lumbar spine on an outpatient basis, including establishing a diagnosis by a neuroorthopedic examination of a patient, magnetic resonance imaging of the lumbar spine and assessing the intensity of the pain by visually analogue scale and treatment involving the use of at least one of the methods of reflexology and traditional pharmacotherapy, characterized in that during the initial visit in the acute period, the indicator is intense the pain syndrome findings obtained on a visually analogue scale are further clarified by determining the functional activity of the patient according to table 1, the treatment is carried out taking into account its somatic status according to the ASA classification, and a bolus epidural administration of a mixture of local anesthetics in doses for spinal anesthesia is diluted to the required volume for the type of access used and the level of change in the intervertebral disc, and corticosteroids with high glucocorticoid activity by caudal access position on the abdomen, followed by turning the patient on the side of the affected side for 15-20 minutes and returning to the original position for 10-15 minutes, then at the second visit, which is prescribed after 2-3 days, assess the intensity of the pain syndrome, as described above, and depending on the result, further treatment is carried out, including pharmacopuncture, until the pain syndrome disappears completely. 2. The method according to p. 1, characterized in that if the changes in the intervertebral disc are between L1-L2, L2-L3, L3-L4, then immediately after the patient returns to the original position, the above mixture is additionally administered by supra- and interspinous access above the level of changes in the intervertebral disc in the required volume for 2-3 segments of the epidural space of the lumbar spine. 3. The method according to p. 1, characterized in that if during the second visit the intensity indicator of pain during movement is more than 3 points, the epidural administration of the mixture is repeated, while the dose of these corticosteroids is reduced by half compared with the dose for the first epidural introduction. 4. The method according to p. 1, characterized in that if the changes in the intervertebral disc are between L4-L5, L5-S1 and upon a second visit the pain intensity indicator during movement is 3 points, conductor peripheral nerve blockade is performed by transacral access a mixture of local anesthetics, these corticosteroids and vitamins, while the dose of these corticosteroids is reduced by three times compared with the dose for the first epidural administration, the procedure is repeated 2-3 days until the pain disappears at rest. 5. The method according to p. 2, characterized in that if the changes in the intervertebral disc are between L1-L2, L2-L3, L3-L4 and the pain intensity during movement during a second visit is 3 points, a conductor peripheral nerve block is performed by paravertebral access with a mixture of local anesthetics, the indicated corticosteroids and vitamins, while the dose of these corticosteroids is reduced by three times compared with the dose for the first epidural administration, the procedure is repeated 2-3 days until pain Droma alone. 6. The method according to p. 1 or 2, characterized in that if, on a second visit, the pain intensity indicator is 2 or 1 points, pharmacopuncture is performed with a mixture of local anesthetic and homeopathic medicine using acupuncture points of general effect, the procedure is repeated 5-7 times until the pain disappears completely. 7. The method according to any one of paragraphs. 1-3, characterized in that as local anesthetics use a combination of local anesthetics with a delayed onset and a prolonged period of action, such as a 0.5% solution of bupivacaine or 0.2% solution of ropivacaine, and local anesthetics with a quick onset and short period of action such as 2% lidocaine solution. 8. The method according to p. 1 or 6, characterized in that to perform pharmacopuncture as a local anesthetic, use a 0.5% solution of novocaine, to which is added a homeopathic preparation traumeel C in a ratio of 1: 1. 9. The method according to any one of paragraphs. 1-3, characterized in that as a corticosteroid during epidural administration, a mixture of "depot" and water-soluble corticosteroids is used, while as a "depot" of corticosteroids, betamethasone is used, which is an official mixture of betamethasone salts containing 5 mg / ml betamethasone adipropionate - suspensions and 2 mg / ml betamethasone sodium phosphate, and as a water-soluble corticosteroid - 4 mg / ml dexamethasone. 10. The method according to p. 1, characterized in that at the first visit to patients of class I, II and III of class ASA, the dose of corticosteroids for the first epidural administration uses the minimum dose of betamethasone for systemic therapy, which is 3.5-7 mg of betamethasone, and medium or minimum doses of dexamethasone, which is 2-4 mg of dexamethasone. 11. The method according to p. 1, characterized in that if during the initial visit the specified indicator of the intensity of the pain syndrome in a patient of class I or II of class ASA is 6 points, then by caudal access, a mixture containing 5.25 mg of betamethasone and 10-12 5 mg of bupivacaine or 6-8 mg of ropivacaine in a dilution of 0.9% NaCl to 20-25 ml. 12. The method according to p. 1, characterized in that if during the initial visit the specified indicator of the intensity of the pain syndrome in a patient of class II ASA with diabetes is 6 points, then by caudal access, a mixture containing 2.3 mg of betamethasone, 2- 3 mg of dexamethasone and 10-12.5 mg of bupivacaine or 6-8 mg of ropivacaine in a dilution of 0.9% NaCl to 20-25 ml. 13. The method according to p. 1, characterized in that if during the initial visit the specified indicator of the intensity of the pain syndrome in a patient of class III ASA is 6 points, then by caudal access a mixture containing 3.5 mg of betamethasone, 8-10 mg of bupivacaine is epidurally administered and 20 mg of lidocaine or 4-8 mg of ropivacaine in a dilution of 0.9% NaCl to 20-25 ml. 14. The method according to p. 1, characterized in that if during the initial visit the specified indicator of the intensity of the pain syndrome in a patient of class III ASA with diabetes is 6 points, then by caudal access, a mixture containing 1.75 mg of betamethasone, 2- 3 mg of dexamethasone and 8-10 mg of bupivacaine, 20 mg of lidocaine or 4-8 mg of ropivacaine in a dilution of 0.9% NaCl to 20-25 ml. 15. The method according to p. 1, characterized in that if during the initial visit the specified indicator of the intensity of the pain syndrome in a patient of class I ASA is 7 points, then by caudal access a mixture containing 5.25-7 mg of betamethasone and 12.5 -15 mg of bupivacaine or 8-10 mg of ropivacaine in a dilution of 0.9% NaCl to 20-25 ml. 16. The method according to p. 1, characterized in that if during the initial visit the specified indicator of the intensity of the pain syndrome in a patient of class II ASA with diabetes is 7 points, then by caudal access a mixture containing 3.5 mg of betamethasone is epidurally administered, 2- 3 mg of dexamethasone and 12.5-15 mg of bupivacaine or 8-10 mg of ropivacaine in a dilution of 0.9% NaCl to 20-25 ml. 17. The method according to any one of paragraphs. 11, 12, 15, 16, characterized in that if the changes in the intervertebral disc are between L1-L2, L2-L3, L3-L4, 1-2 mg of dexamethasone and 20-40 mg of lidocaine in NaCl dilution are additionally administered via interspinous access 0.9% to 6-8 ml. 18. The method according to p. 1, characterized in that if during the initial visit the specified indicator of the intensity of the pain syndrome in a patient of class III ASA is 7 points, then by caudal access, a mixture containing 3.5-5.25 mg of betamethasone and 8 -10 mg of bupivacaine, 20-30 mg of lidocaine or 6-10 mg of ropivacaine in a dilution of 0.9% NaCl to 20-25 ml. 19. The method according to p. 1, characterized in that if during the initial visit the specified indicator of the intensity of the pain syndrome in a patient of class III ASA with diabetes is 7 points, then by caudal access a mixture containing 2.3-3.5 mg is epidurally injected betamethasone, 2-3 mg of dexamethasone and 8-10 mg of bupivacaine, 20-30 mg of lidocaine or 6-10 mg of ropivacaine in a dilution of 0.9% NaCl to 20-25 ml. 20. The method according to any one of paragraphs. 13, 14, 18, 19, characterized in that if the changes in the intervertebral disc are between L1-L2, L2-L3, L3-L4, 1-2 mg of dexamethasone and 20-30 mg of lidocaine in NaCl dilution are additionally administered via interspinous access 0.9% to 6-8 ml.  21. The method according to any one of paragraphs. 3, 11-16, 18, 19, characterized in that if epidural administration of the mixture by caudal access is repeated at the second visit, the dose of corticosteroids is reduced by half compared with the dose for the first epidural administration. 22. The method according to p. 4 or 5, characterized in that if, on a second visit, conduction blockade of the peripheral nerves is performed by transacral or paravertebral access, the dose of corticosteroids is reduced compared to the dose for the first epidural administration, using only water-soluble forms of corticosteroids, which corresponds to 2-4 mg of dexamethasone, and as vitamins - 100-250 mg of cyancobalamin. 23. The method according to p. 1, characterized in that to perform pharmacopuncture as a local anesthetic, use a 0.5% solution of novocaine, to which is added a homeopathic preparation traumeel C in a ratio of 1: 1 in a volume of 1.5-2 ml per procedure, using the points of classical acupuncture recommended in the treatment of vertebrogenic pain syndrome, the procedure is repeated 5-7 times until the pain syndrome disappears completely. 24. The method according to p. 1, characterized in that the epidural administration by caudal access of the specified mixture of local anesthetics and corticosteroids is carried out simultaneously using a 21G needle for 5-10 seconds. 25. A method of treating radicular pain of the lumbar spine on an outpatient basis, including establishing a diagnosis by a neuroorthopedic examination of the patient, magnetic resonance imaging of the lumbar spine and assessing the intensity of the pain through a visually analogue scale and treatment involving at least one epidural corticosteroid, the use of at least one of the methods of reflexology and traditional pharmacotherapy, characterized in that about the initial visit in the acute period, the pain intensity indicator obtained on a visually analogue scale is further clarified by determining the functional activity of the patient according to table 1, the treatment is carried out taking into account his somatic status according to the ASA classification, while if the pain intensity indicator is the first visit equal to or greater than 8 points, then carry out a bolus epidural injection of a mixture of local anesthetics, in doses for spinal anesthesia, diluted to the required volume for the type of access used and the level of change in the intervertebral disc, and corticosteroids with high glucocorticoid activity by central mid-access at the side position of the side of the change in the intervertebral disc, while the epidural space is punctured one intervertebral space above the established level of change in the intervertebral disc, with subsequent preservation patient poses for 15-20 minutes and a turn on the stomach for 20-25 minutes, then at the second visit, which is prescribed after 2-3 days, evaluate Intensity of pain, as described above, and depending on the result is carried further treatment including pharmacopuncture, until complete disappearance of pain syndrome. 26. The method according to p. 25, characterized in that if the intensity indicator of the pain syndrome at the initial visit is more than 8 points, then at the second visit the epidural administration of the mixture is repeated by central median access, while the dose of these corticosteroids is reduced by half compared to dose for the first epidural administration. 27. The method according to p. 26, characterized in that if the intensity indicator of the pain syndrome during the next visit during movement is reduced by half, but more than 4 points, then epidural administration of the mixture by caudal access is performed, while the dose of these corticosteroids is reduced in twice as compared with the dose for the first epidural administration, then after 2-3 days the pain intensity indicator is evaluated, and if it is more than 4 points, then the epidural administration of the indicated mixture is repeated by udalnogo access. 28. The method according to p. 27, characterized in that if the intensity indicator of the pain syndrome at the next visit is reduced to 4 points during movement, then the conductor blockade of the peripheral nerves is performed by transacral access or by paravertebral access with a mixture of local anesthetics, these corticosteroids and vitamins, at the same time, the dose of these corticosteroids is reduced by a factor of three compared with the dose for the first epidural administration, the procedure is repeated 2-3 days before the pain disappears at rest. 29. The method according to p. 28, characterized in that if at the next visit the pain intensity indicator during movement is 2 or 1 points, then pharmacopuncture is performed with a mixture of local anesthetic and homeopathic medicine using acupuncture points of general effect, the procedure is repeated 7-10 times until the pain disappears completely. 30. The method according to p. 29, characterized in that to perform pharmacopuncture as a local anesthetic, a 0.5% solution of novocaine is used, to which the homeopathic preparation traumel C is added in a ratio of 1: 1. 31. The method according to p. 25, characterized in that when epidural administration of the above mixture by central mid-access, local anesthetics with a fast onset and short duration of action, such as a 10 or 2% solution of lidocaine, in medium or maximum doses for spinal anesthesia respectively. 32. The method according to p. 27, characterized in that when epidural administration of the above mixture by caudal access, local anesthetics with a delayed onset and a prolonged period of action, such as a 0.5% solution of bupivacaine or 0.2% solution, are predominantly used as local anesthetics. ropivacaine. 33. The method according to any one of paragraphs. 25-27, characterized in that as a corticosteroid during epidural administration, a mixture of "depot" and water-soluble corticosteroids is used, while as a "depot" of corticosteroids, betamethasone is used, which is an official mixture of betamethasone salts containing 5 mg / ml betamethasone adipropionate - suspensions and 2 mg / ml betamethasone sodium phosphate, and as a water-soluble corticosteroid - 4 mg / ml dexamethasone. 34. The method according to p. 25, characterized in that at the first visit to patients of class I and II of the ASA, as a dose of corticosteroids for the first epidural administration, average doses of betamethasone are used for systemic therapy, which is 7 mg of betamethasone. 35. The method according to p. 25, characterized in that if during the initial visit the specified indicator of the intensity of the pain syndrome in a patient of class II ASA is 8 points, then by means of a central median access, a mixture containing 7 mg of betamethasone and 60-80 mg of lidocaine or 12.5-15 mg of bupivacaine or 20-40 mg of lidocaine and 10 mg of bupivacaine in a dilution of 0.9% NaCl to 6-8 ml. 36. The method according to p. 25, characterized in that if, during the initial visit, the specified indicator of the intensity of the pain syndrome in a patient of class II ASA with diabetes is 8 points, then a mixture containing 3.5 mg of betamethasone is epidurally administered through central median access -4 mg of dexamethasone and 60-80 mg of lidocaine, or 12.5-15 mg of bupivacaine, or 20-40 mg of lidocaine and 10 mg of bupivacaine in a dilution of 0.9% NaCl to 6-8 ml. 37. The method according to p. 25, characterized in that if during the initial visit the specified indicator of the intensity of the pain syndrome in a patient of class III ASA is 8 points, then by means of the central median access a mixture containing 3.5-5.25 mg of betamethasone is epidurally administered 50-70 mg of lidocaine, or 10-12.5 bupivacaine, or 20-40 mg of lidocaine and 8-10 mg of bupivacaine in a dilution of 0.9% NaCl to 6-8 ml. 38. The method according to p. 25, characterized in that if during the initial visit the specified indicator of the intensity of the pain syndrome in a patient of class III ASA with diabetes mellitus is 8 points, then a mixture containing 2.3-3.5 is epidurally administered through central median access mg of betamethasone, 2-4 mg of dexamethasone, 50-70 mg of lidocaine, or 10-12.5 bupivacaine, or 20-40 mg of lidocaine and 8-10 mg of bupivacaine in a dilution of 0.9% NaCl to 6-8 ml. 39. The method according to p. 25, characterized in that if during the initial visit the specified indicator of the intensity of the pain syndrome in a patient of class I ASA is 9-10 points, then by means of a central median access, a mixture containing 7 mg of betamethasone and 70-80 mg lidocaine, or 15-17.5 mg of bupivacaine, or 30-40 mg of lidocaine and 10-12.5 mg of bupivacaine in a dilution of 0.9% NaCl to 6-8 ml. 40. The method according to p. 25, characterized in that if during the initial visit the specified indicator of the intensity of the pain syndrome in a patient of class II ASA with diabetes mellitus is 9-10 points, then a mixture containing 3.5 mg of betamethasone is epidurally administered through central median access 3-4 mg of dexamethasone and 60-80 mg of lidocaine, or 15-17.5 bupivacaine, or 30-40 mg of lidocaine and 10-12.5 mg of bupivacaine in a dilution of 0.9% NaCl to 6-8 ml. 41. The method according to p. 25, characterized in that if during the initial visit the specified indicator of the intensity of the pain syndrome in a patient of class III ASA is 9-10 points, then by means of a central median access, a mixture containing 3.5-5.25 mg betamethasone and 50-70 mg of lidocaine, or 10-15 mg of bupivacaine, or 20-40 mg of lidocaine and 8-10 mg of bupivacaine in a dilution of 0.9% NaCl to 6-8 ml. 42. The method according to p. 25, characterized in that if during the initial visit the specified indicator of the intensity of the pain syndrome in a patient of class III ASA with diabetes mellitus is 9-10 points, then a mixture containing 3.5 mg of betamethasone is epidurally administered through central median access 3-4 mg of dexamethasone and 50-70 mg of lidocaine, or 10-15 mg of bupivacaine, or 20-40 mg of lidocaine and 8-10 mg of bupivacaine in a dilution of 0.9% NaCl to 6-8 ml. 43. The method according to any one of paragraphs. 35-38, characterized in that when re-visiting patients with I-III class ASA and patients with diabetes mellitus carry out epidural administration of this mixture by caudal access, the dose of corticosteroids is reduced by half compared with the dose for the first epidural administration. 44. The method according to any one of paragraphs. 39-42, characterized in that when epidural administration of the aforementioned mixture by central mid-access is carried out at the second visit, the dose of corticosteroids is reduced by half compared with the dose for the first epidural administration. 45. The method according to any one of paragraphs. 27, 39-42, characterized in that if at the next visit epidural administration of the above mixture is carried out by caudal access, the dose of corticosteroids is reduced by half compared with the dose for the first epidural administration in a dilution of the mixture with 0.9% NaCl solution to 20- 25 ml, the procedure is repeated after 2-3 days until the intensity of the pain syndrome decreases to 4 points during movement. 46. The method according to p. 25, characterized in that if changes in the intervertebral disc are between L4-L5, L5-S1 and at the next visit the pain intensity indicator during movement is 3 points, a peripheral nerve conduction blockade is performed by transacral access with a mixture local anesthetics, indicated corticosteroids and vitamins, while the dose of corticosteroids is reduced by three times compared with the dose for the first epidural administration, the procedure is repeated 2-3 days before the pain disappears at rest. 47. The method according to any one of paragraphs. 35-42, characterized in that if the changes in the intervertebral disc are between L1-L2, L2-L3, L3-L4 and at the next visit the pain intensity indicator during movement is 3 points, conductor peripheral nerve blockade is performed by paravertebral access with a mixture local anesthetics, these corticosteroids and vitamins, while the dose of these corticosteroids is reduced by three times compared with the dose for the first epidural administration, the procedure is repeated 2-3 days before the pain disappears oops. 48. The method according to p. 25, characterized in that if at the next visit the pain intensity indicator is 2 or 1 points, then pharmacopuncture is carried out with a mixture of 0.5% solution of novocaine and homeopathic preparation traumeel C in a ratio of 1: 1 in a volume of 1, 5-2 ml per procedure, using classical acupuncture points recommended in the treatment of vertebrogenic pain syndrome, the procedure is repeated 7-10 times until the pain syndrome completely disappears.