RU2765684C2 - Method for treating vertebrogenic lumbar ischialgia in degenerative-dystrophic spinal diseases - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to the field of medicine and pharmaceuticals, namely, to a method for treating vertebrogenic lumbar ishialgia in degenerative-dystrophic spinal diseases. The method includes an epidural sacral block followed by a modified combined block. In order to perform a sacral epidural block, a medicinal mixture of lidocaine 2%, saline solution NaCl 0.9%, diprospan and xefocam is prepared, followed by performing local anesthesia and puncturing the sacral canal with a needle with a mandrel, wherein the needle is inserted perpendicular to the membrane covering the entrance to the channel, the needle is then lowered by 20 to 25° downward and inserted horizontally into the sacral canal until contact with the bone wall of the canal, then the mandrel is removed, and after a negative aspiration, the medicinal mixture is injected. To perform a modified combined block, a medicinal mixture is prepared from a solution of naropin, diprospan, and xefocam, injected in doses and in stages by a syringe, wherein the needle is first inserted perpendicular to the surface of skin and advanced perpendicularly deep until contact with the transverse process of the corresponding vertebra, and 2 ml of the mixture is injected, blocking the Lusсhka nerve, then the needle is pulled back by 2 to 3 mm, moved downwards medially and deep from the transverse process, and at the contact of the needle with the sought nerve, wherein a "stabbing" sensation occurs in the leg, 4 ml of the mixture is injected, performing a transforaminal and periganglionic block, followed by pulling the needle back by 2 to 3 mm, moving along the path of the found nerve root downwards by 1 cm and injecting 2 ml of the mixture, performing a periradicular block, then the needle is pulled back by 2 to 3 mm, moved outward by 1 cm, inserted deep until contact with the facet joint, and 1 ml of the mixture is injected, performing a periarticular block, followed by pulling the needle back by 2 to 3 mm, moving inward and downward, inserting 1 cm deep until contact with the intervertebral foramen and injecting 1 ml of the mixture, performing an additional periganglionic block.

EFFECT: invention increases the effectiveness of treatment of vertebrogenic lumbar ishialgia in degenerative-dystrophic spinal diseases while simultaneously eliminating all possible pain syndromes in a patient, providing fast and long-term relief of exacerbation of lumbar ishialgia, reducing the duration of treatment.

1 cl, 1 ex

Description

The invention relates to medicine, in particular to neurology, and can be used for the treatment of acute or chronic drug-resistant vertebrogenic lumboischialgia in degenerative-dystrophic diseases of the lumbar spine.

Back pain, namely the lumbar spine, radiating to the lower extremity, is the most common complaint in neurological or neurosurgical patients.

If at the same time, back pain is mainly amenable to relief by taking non-steroidal anti-inflammatory drugs or other analgesics, then back pain with irradiation to the lower limb in some cases is resistant to drug resistance and significantly limits the patient's mobility and worsens his quality of life. The cause of such pain is most often discogenic stenosis of the intervertebral foramina and roots of the spinal nerves. At the same time, in most clinical cases, the compression is insignificant and does not require surgical treatment aimed at eliminating the hernia of the intervertebral disc, and in some cases, surgery is indicated. Whatever it was, at the appointment with a specialist, there is a need to quickly and effectively relieve pain, especially if the patient has a sleep disorder due to a pronounced pain radicular syndrome.

One of the effective methods for the rapid relief of pain is the local injection (blockade) of a drug that has anti-edematous and anti-inflammatory effects into the focus of aseptic inflammation and sustained muscle spasm.

This technique of anesthesia has been used for more than a century, during which it has proved its high efficiency. Drug blockade allows you to get rid of pain in a very short time and significantly improve the quality of life and well-being.

When carrying out therapeutic blockades, a large arsenal of medications is used, which, on the one hand, is determined by the pharmacodynamics and mechanism of their action, and, on the other hand, by the etiopathogenetic features of the development of back pain.

The drugs used are divided into two groups: basic and additional. Due to the rapid onset of analgesic action, local anesthetics have found the greatest use as the main means. Unfortunately, the duration of action of local anesthetics is several tens of minutes. In addition, they do not have anti-inflammatory and anti-edematous activity, so a long-term therapeutic effect when using them is impossible in most cases.

Additional drugs used to treat back pain in therapeutic blockades include hormonal agents (glucocorticoids). Their use is based on anti-inflammatory, desensitizing and anti-edematous action both locally in tissues and systemically in the body.

Alternative additional drugs are NSAIDs.

In most clinical cases, a patient with pain in the back and leg is a combination of syndromes at the reception: lumbar, myofascial, muscular-tonic, facet and radicular. And during the initial examination, it is quite difficult to establish which of the syndromes manifests itself more or less in this clinical case. To isolate the leading syndrome, a combination of treatment is often prescribed: medications, physiotherapy, blockades. And at the re-admission after 7-10 days, the patient is examined and the result of the treatment is evaluated and, if necessary, its correction is carried out. For a patient with back and leg pain, this delays treatment and recovery in time.

From the literature data and our own clinical observations, we found that the effectiveness of monoblockades (paravertebral, epidural, transforaminal) may be insufficient and in the presence of a root compression substrate, it would be more anatomically, physiologically and methodologically correct to deliver drugs simultaneously from the inside and outside of the spinal cord. nerve for more complete relief of pain (epidural administration - relieves back pain by blocking the dural membrane, transforaminal - pain in the leg - by blocking the spinal nerve root and spinal ganglion).

Known Method for the treatment of vertebrogenic pain radicular syndrome, including the introduction of a mixture of drugs into the acupuncture points. The mixture contains 0.05% cyanocobalamin solution, 1% lidocaine solution and diprospan suspension. The ratio of drugs in the mixture is 1:1:1, and the introduction of the mixture is carried out in the acupuncture points VB 25 (2), V 24 (2), V 52(2), T4 to a depth of 0.4-2.0 cm ( patent RU 2392920, filed 06/01/2009, op. 06/27/2010).

The disadvantage of this method is its low efficiency in stopping drug-resistant lumboischialgia.

The closest analogue adopted for the prototype is a method for the treatment of radicular pain syndrome, in which the level of the required foraminal opening is determined and at the lumbar, sacral and thoracic levels the needle is inserted from the posterolateral access paravertebral, and at the cervical level from the anterolateral access prevertebral. In this case, a 16-20 Tuohy needle is used. At the thoracic, lumbar, sacral levels, the needle is inserted, retreating 7-12 cm from the midline of the spine towards the intervertebral foramen at an angle of 50-80° to the table surface with the patient in the prone position. After the needle rests against the facet joint, it slides off in the lateral direction. At the cervical level, the needle is inserted towards the intervertebral foramen with the patient in the supine position and slide off the transverse process in the ventral direction. When a short-term increase in pain is achieved, drugs are administered. The method is carried out under the control of CT (patent RU 2250116, filed 04.06.2003, op. 27.12.2004).

The disadvantage of this method is primarily its low efficiency in the relief of drug-resistant vertebrogenic lumboischialgia. Also, the disadvantage of the method is its complexity. The use of expensive equipment increases the costs and time of the procedure.

The problem of the claimed invention is the development of an effective method for the treatment of vertebrogenic lumboischialgia in degenerative-dystrophic diseases of the spine

The technical result of the claimed invention is to increase the effectiveness of the treatment of vertebrogenic lumboischialgia in degenerative-dystrophic diseases of the spine, the simultaneous elimination of all possible pain syndromes in the patient, the rapid and prolonged relief of the exacerbation of lumboischialgia, the reduction in the duration of treatment and days of disability.

To achieve the claimed technical result in a method for the treatment of vertebrogenic lumboischialgia in degenerative-dystrophic diseases of the spine, an epidural sacral blockade is first performed, then a modified combined blockade is performed, while in order to perform the epidural sacral blockade, a medicinal mixture is preliminarily prepared from 4 ml of lidocaine 2%, 20 ml of physiological solution NaCl 0.9%, 1 ml of diprospan, 1 ml of xefocam, then local anesthesia and puncture of the sacral canal with a needle with a mandrel are performed, while the needle is inserted perpendicular to the membrane that closes the entrance to the canal, then the needle is lowered 20-25 ° down and inserted horizontally into the sacral canal until it stops against the bone wall of the canal, then the mandrin is removed and after a negative aspiration test, the drug mixture is administered, then a modified combined blockade is performed, for which a drug mixture is prepared from a solution of naropin 7.5 mg-10 ml, 1 ml of diprospan, 1 ml xefoc ma, which is injected through a syringe in doses and in stages, while the needle is first inserted perpendicular to the skin surface and advanced perpendicularly deep into the transverse process of the corresponding vertebra and 2 ml of the mixture is injected, blocking the Luschka nerve, then the needle is pulled back by 2-3 mm, displaced downwards medially and inward from the transverse process, and when the needle comes into contact with the desired nerve, at which a “lumbago” appears in the leg, 4 ml of the mixture is injected, performing a transforaminal and periganglionic blockade, after which the needle is pulled back 2-3 mm, shifted along the course of the found nerve root down by 1 cm and 2 ml of the mixture is injected, performing a periradicular blockade, then the needle is pulled back by 2-3 mm, shifted outward by 1 cm, injected deep into the facet joint until it stops and 1 ml of the mixture is injected, performing a periarticular blockade, after which the needle is pulled back by 2-3 mm, shifted inwards and down, injected 1 cm deep into the intervertebral foramen until it stops and 1 ml of the mixture is injected, carrying out additional nitrous periganglionic blockade.

The method is carried out as follows.

A method for treating vertebrogenic lumboischialgia in degenerative-dystrophic diseases of the spine includes performing an epidural sacral blockade and a modified combined blockade. The sequence of blockades depends on the severity of pain, vertebrogenic, and radicular symptoms. The patient with both blockades lies in one position - on the stomach. In an exemplary embodiment, an epidural sacral block is first performed. To do this, prepare a medicinal mixture of 4 ml of 2% lidocaine, 20 ml of saline NaCl 0.9%, 1 ml of diprospan, 1 ml of xefocam. Palpate the sacral fissure between the horns of the sacrum. Spend local anesthesia and puncture of the sacral canal with a needle with mandrin. In this case, the needle is first inserted almost perpendicular to the membrane that closes the entrance to the canal. Then, after puncturing the skin and membrane, the needle is lowered 20-25° down and inserted almost horizontally into the sacral canal until it stops against the bone wall of the canal. Then the mandrin is removed and a test suction is carried out with a syringe put on the needle. In the absence of CSF in the needle, the drug mixture is administered. A positive criterion for the introduction of the drug mixture into the sacral canal is the patient's sensation in the form of a "balloon inflation" in the lumbar spine and a short-term increase in pain in the "sick" leg as a result of hydraulic contact of the drug mixture with the inflamed root. The second stage is a modified combined blockade, for which a drug mixture is prepared from a solution of naropin 7.5 mg-10 ml, 1 ml of diprospan, 1 ml of xefocam. The median region of the lumbar spine and the lateral located area of the skin (right or left, depending on the irradiation of pain) with an area of 10×5 cm is treated with an antiseptic solution. The iliac crests are felt for, and the Jacobi intercrest line is marked with a brilliant green solution (it runs at the level of the lower edge of the spinous process L4 or the intervertebral space L4-L5). The spinous processes of the lumbar vertebrae are counted to the intended level of block and marked brilliant green. The puncture point is located 2.5-3 cm lateral to the spinous process at the level of its cranial margin. This point is projected onto the exit point of the lumbar nerve from under the transverse process of the corresponding vertebra. At the site of the intended injection of the needle on the skin, local anesthesia is performed with a solution of lidocaine 2% 1 ml. After that, the needle is inserted perpendicular to the skin surface and advanced perpendicularly deep into the transverse process of the corresponding vertebra and 2 ml of the mixture is injected, blocking the Luschka nerve passing there. Next, the needle is pulled back by 2-3 mm, shifted downward medially and inward from the transverse process. When the needle comes into contact with the desired nerve, the patient has a feeling of “lumbago” in the leg (make sure that the pain during the “lumbago” is the same as that worries the patient - a diagnostic sign of the needle hitting the desired root), 4 ml of the mixture is injected, performing transforaminal and periganglionic blockade . After that, the needle is again pulled back 2-3 mm, displaced along the root found down by 1 cm, and 2 ml of the mixture is injected, performing a periradicular blockade. Then the needle is pulled back by 2-3 mm, displaced outward by 1 cm, injected deep into the facet joint until it stops (the facet joint is blocked) and 1 ml of the mixture is injected, performing a periarticular blockade. After that, the needle is pulled back by 2-3 mm, displaced inwards and down, injected 1 cm deep into the intervertebral foramen until it stops, and 1 ml of the mixture is injected, performing an additional periganglionic blockade. Due to the simultaneous elimination of all possible pain syndromes, the patient leaves the doctor's office not with a possible reduction in pain, but without pain at all.

The claimed invention makes it possible to increase the effectiveness of the treatment of vertebrogenic lumboischialgia in degenerative-dystrophic diseases of the lumbar spine, simultaneously eliminate all possible pain syndromes in the patient, quickly, effectively and for a long time stop the exacerbation of lumboischialgia.

Clinical example.

Patient K, 38 years old, came to the primary outpatient appointment with a neurosurgeon with complaints of intense pain in the lower back and on the lateral surface of the right leg, aggravated by verticalization and walking.

From the anamnesis it was found out that he fell ill acutely, in the form of the simultaneous appearance of pain in the lumbar spine and right leg, and this exacerbation lasted 2 months. He applied initially and again to the appointment of a therapist, a neurologist, was treated on an outpatient basis, with the appointment of groups of drugs - NSAIDs, muscle relaxants, analgesics, physiotherapy. For 2 months, a total of 3 blockades were performed for therapeutic purposes - 2 - paravertebral on the right, 1 - blockade of the interspinous ligament and trigger points in the right leg.

During the treatment, no satisfactory positive dynamics was achieved: the pain syndrome remained almost the same.

On examination: the patient's condition is satisfactory, the skin and mucous membranes are of physiological color; constitutionally - normosthenic. In the lungs - vesicular breathing is carried out in all departments. Heart - tones are clear, clean, rhythmic, no murmurs are heard. ECG: horizontal position of the electrical axis, PS 74 in 1 min. BP=120/80 Hg The abdomen is soft, painless on palpation in all areas. Local status: movements in the lumbar spine are limited due to pain, extension in the back is especially difficult and painful, local tenderness of the spinous processes at the level of L4-S1 vertebrae, paravertebral - on the right at the level of the L4-5 gap - muscle tension - spasm.

Neurological status: Consciousness is clear. There are no meningeal signs. From the cranial nerves without changes. Tendon and periosteal reflexes from the upper extremities are preserved, alive, symmetrical, D=S. There were no motor or sensory disturbances in the upper extremities. Tendon and periosteal reflexes from the lower extremities are reduced: knee D=S, the Achilles reflex is reduced on the left, depressed on the right. There are no movement disorders. Radicular hypesthesia in the L5 segment on the right. Sharply (+) tension symptoms - Lasegue, Wasserman - on the right. X-ray of the lumbosacral spine: signs. Degenerative-dystrophic changes in intervertebral discs and facet joints at the level of L3-L4-L5-S1; no vertebral displacement. At MPT of the lumbar spine: degenerative-dystrophic changes at the level of the intervertebral discs L4-S1, right-sided protrusion of the intervertebral disc L4-5, 5 mm in size, with discoradicular conflict 1-2 tbsp.

The assessment of pain vertebrogenic and radicular syndromes according to the visual analogue scale of pain (VAS) was 8-9 points.

When evaluating the patient's complaints, several components could be distinguished in the structure of the pain syndrome: painful lumbalgic, painful radicular, muscular-tonic and facet.

The patient was diagnosed with a clinical diagnosis of degenerative-dystrophic disease of the spine, protrusion of the L4-5 intervertebral disc on the right, chronic lumboischialgia on the right, secondary muscular-tonic, facet syndromes.

Given the small size of the protrusion of the L4-5 intervertebral disc on the right, the absence of neurological disorders in the form of foot paresis, it was decided to refrain from surgical treatment.

The patient was asked to perform a combined blockade at the level of the lumbar spine. After much persuasion, due to the low effectiveness of previous paravertebral and trigger blockades, consent was obtained for another blockade. A blockade was performed according to the claimed method.

The first stage for a more comfortable position on the couch was an epidural sacral blockade - the patient noted a significant improvement and settled down more relaxed on the couch. The second stage performed a modified combined blockade.

After the blockade was completed, the patient stood upright, noted the complete (VAS 0) absence of pain in the leg and back. At a remote consultation after 3 days - the level of pain in the back and leg according to VAS 0, after 7 days - VAS 1, does not particularly affect the quality of life. Against the background of corrected drug treatment, 14 days after the blockade, the patient was discharged for work.

Claims (1)

A method for the treatment of vertebrogenic lumboischialgia in degenerative-dystrophic diseases of the spine, characterized in that first an epidural sacral blockade is performed, then a modified combined blockade is performed, while in order to perform the epidural sacral blockade, a drug mixture is preliminarily prepared from 4 ml of lidocaine 2%, 20 ml of physiological NaCl solution 0.9%, 1 ml of diprospan, 1 ml of xefocam, then local anesthesia is performed and the sacral canal is punctured with a needle with a mandrel, while the needle is inserted perpendicular to the membrane that closes the entrance to the canal, then the needle is lowered 20-25 ° down and horizontally inserted into the sacral canal until it stops against the bone wall of the canal, then the mandrin is removed and after a negative aspiration test, the drug mixture is administered, then a modified combined blockade is performed, for which a drug mixture is prepared from a solution of naropin 7.5 mg-10 ml, 1 ml of diprospan, 1 ml xefocam, which by means of sh The rice is injected in doses and in stages, while the needle is first inserted perpendicular to the skin surface and advanced perpendicularly deep into the transverse process of the corresponding vertebra and 2 ml of the mixture is injected, blocking the Luschka nerve, then the needle is pulled back by 2-3 mm, shifted down medially and deep into from the transverse process, and when the needle comes into contact with the desired nerve, in which there is a feeling of "lumbago" in the leg, 4 ml of the mixture is injected, performing transforaminal and periganglionic blockade, after which the needle is pulled back 2-3 mm, displaced along the found nerve root downwards by 1 cm and 2 ml of the mixture is injected, performing periradicular blockade, then the needle is pulled back by 2-3 mm, shifted outward by 1 cm, injected deep into the facet joint until it stops and 1 ml of the mixture is injected, performing periarticular blockade, after which the needle pulled back by 2-3 mm, displaced inwards and down, injected 1 cm deep into the intervertebral foramen until it stops and 1 ml of the mixture is injected, carrying out additional English blockade.