Sciatica - one of the most common complaints that patients are placing in general practice. Often they are caused by spinal osteochondrosis - degenerative cartilage lesions of the intervertebral disc and reactive changes of the adjacent vertebral bodies. The defeat of the intervertebral disc develops because of his repeated trauma (heavy lifting, excessive static and dynamic load, fall, etc.) and age-related degenerative changes. Nucleus pulposus, the central portion of the disc, dried and partially loses its shock absorbing function. Fibrous ring, located on the periphery of the disk becomes thinner, it cracks, which shifted the nucleus pulposus, forming a bulge (prolapse), and rupture the fibrous ring - a hernia.Currently, drugs are developed that provide structural and modifying effects on cartilage (the old name - chondroprotectors). A typical representative of a drug chondro designated course of 4 months (the effect persists 2 months after withdrawal). In the affected spinal segment, there is the relative instability of the spine, develop osteophytes of the vertebral bodies (spondylosis), damage to ligaments and intervertebral joints (spondylarthrosis). Herniation of intervertebral discs are most frequently observed in the lower lumbar discs, at least - in the lower cervical and upper lumbar, extremely rare - in infants. Herniated disc in the vertebral body (Schmorl's hernia) are not clinically significant, disc herniation in the posterior and posterolateral direction can cause compression of the spinal nerve root (radiculopathy), spinal cord (myelopathy at cervical level), or their vessels.
In addition to compression syndromes may reflex (muscle-tonic), which are caused by impulses from receptors in response to changes in the discs, ligaments and joints of the spine - a painful muscle spasm. The reflex muscle tension initially has a protective nature, since it leads to immobilization of the affected segment, but in the future, this factor becomes the cause of pain. Unlike compression syndromes of spinal osteochondrosis, which are relatively rare, painful muscle spasms occur during the life of almost every second person.
A classic example of the painful muscle spasms is lumbago (lumbar backache), which is characterized by sharp, shooting pain in the back, emerging usually during exercise (lifting weights, etc.) or an awkward movement. The patient is often frozen in an awkward position, trying to motion leads to increased pain. On examination detected the voltage of the back muscles, usually scoliosis, flattening the lumbar lordosis and kyphosis.
Lumbodynia - sciatica - and sciatica - pain in the back and the back of the legs - often develop after physical exertion, awkward movement, or hypothermia, at least - without any reason. Pains are aching in nature, aggravated by movements in the spine, specific postures, walking. For sciatica is characterized by pain in the buttocks, legs in posteroexternal departments, not reaching your fingers. On examination reveals pain, muscle tension and back rear leg muscle groups, limiting the mobility of the spine, scoliosis often, the symptoms of tension (Lasegue, Wasserman and others).
At cervical level there may be reflex muscular-tonic syndromes: cervicalgia tservikobrahialgiya and that often develop after physical exertion or awkward movement neck. Cervicalgia - pain in the neck, which often extends to the back of the head (tservikokranialgiya). Tservikobrahialgiya - pain in the neck region, which covers the hand. Characterized by increased pain with movement in the neck or on the contrary, prolonged static position (in the movie, after sleeping on a thick cushion of high, etc.). On examination detected the voltage of the neck, often a limitation of movement in the cervical spine, tenderness to palpation of the spinous processes and intervertebral joints on the side of pain.
When compression of the nerve root (radiculopathy) than painful muscle spasm and limited mobility in the spine and the extremities revealed sensory, reflex, and (or) movement disorders in the affected zone root. At the lumbar level often affects the fifth lumbar (L5) and first sacral (S1) roots, at least - the fourth lumbar spine and very rare - the upper lumbar roots. Radiculopathy of the lower cervical roots are much rarer.
Painful muscle spasm occurs and another fairly common cause of sciatica and legs - myofascial pain caused by the formation of the so-called trigger zones in the muscle and (or) the associated fascia. Myofascial pain and muscle tension are manifested by the presence of trigger points, the identification of which is carried out by the study of manual muscle. The active trigger point - a constant source of pain, worse when her tenderness in the muscle; Latent trigger points cause pain only when it is palpation. For each muscle there is a self-myofascial syndrome with a characteristic localization of pain during stimulation of the trigger zone that spreads beyond the projection of the muscles on the skin surface. Focal neurologic deficits are absent, except in cases where tight muscles compressing the nerve trunk.
It is important to remember that sciatica can be the only symptom in spinal cord tumors, syringomyelia and other diseases of the spinal cord. Pain occur during destruction of the vertebrae and nerve root lesions due to infectious processes (tuberculosis spondylitis, spinal epidural abscess), tumors (primary and metastatic spinal tumors, multiple myeloma), dysmetabolic disorders (osteoporosis, hyperparathyroidism, Paget's disease). sciatica can be caused by spinal fractures, it congenital or acquired deformities (scoliosis, etc.), spinal canal stenosis, spondylolisthesis, ankylosing spondylitis.
It is possible with various somatic diseases (heart, stomach, pancreas, kidney, pelvic, and others) on the reflection mechanism of pain.
Examination of the patient with sciatica requires thoroughness. Can not be any sciatica to write off "osteochondrosis" - a condition which X-ray examination revealed the majority of middle-aged and elderly. For neurologic manifestations of osteochondrosis and myofascial pain is characterized by painful muscle spasm and limited mobility of the spine.
The diagnosis of reflex and compression complications of degenerative disc disease based on clinical data and requires the exclusion of other possible causes of sciatica . X-rays of the spine are used primarily to prevent birth defects and deformities, inflammatory disease (spondylitis), primary and metastatic tumors. X-ray CT or MRI can detect a rupture disk to determine its size and location, as well as to detect spinal stenosis, spinal cord tumor.
The diagnosis of myofascial pain is based on clinical data (detection of painful muscle tension, one or more muscles), and requires the exclusion of other possible causes of pain, the differential diagnosis of reflex syndromes (muscular-tonic syndromes) due to osteochondrosis often causes difficulty, perhaps a combination of these diseases.
Treatment of reflex syndromes and radiculopathy due to degenerative disc disease in the acute period based on achieving of peace - the patient should avoid abrupt slopes and painful postures. Prescribed bed rest for a few days before the sharp pain subsided, hard bed (board under the mattress), muscle relaxants, centrally acting technique, if necessary - as an additional analgesics, nonsteroidal anti-inflammatory drugs. To facilitate the movement during this period should be put on the cervical or lumbar corset (fixing belt). You can use physical therapy procedures analgesics, rubbing pain ointments, compresses with 30-50-percent solution of novocaine and Dimexidum, procaine and hydrocortisone blockades. With the weakening of pain recommend a gradual increase in physical activity and exercise to strengthen muscles.
In the chronic course of reflex syndromes and radiculopathy can be effective manual therapy, reflexology, physiotherapy, spa treatment. Surgical treatment (removal of the herniated disc) is necessary in those rare cases where there is compression of the spinal cord or cauda equina roots. Surgical treatment is also shown in discogenic radiculopathy, accompanied by severe paresis, and with prolonged (more than three or four months) and no effect of conservative treatment and have a large disc herniation. For the prevention of exacerbations of osteoarthritis recommend avoiding trigger factors (lifting heavy loads, carrying a heavy bag in one hand, hypothermia, etc.) regularly engage in physiotherapy.
When myofascial pain is necessary that the muscle was at rest for a few days. As the treatment can be prescribed exercises to stretch muscles (postisometric relaxation), physiotherapy, reflexology or topical administration of anesthetics in the trigger zone compresses Dimexidum and anesthetics.
As already mentioned, and in acute pain and chronic pain syndromes is very important treatment of painful muscle spasm. Tonic muscle tension may not only itself be a cause of pain, but can cause distortion and limit the mobility of the spine, but also causes compression of the nerves passing close and blood vessels. For its treatment in addition to NSAIDs, analgesics (eg, in the form of a transdermal NIMULID gel for local therapy or in the form of lingual tablets in acute pain syndrome), physical therapy and physiotherapy as first-line drugs used muscle relaxants - drugs that can break the "vicious circle "of pain .
For the treatment of painful muscle spasms muscle relaxants are used inside or parenterally. By lowering the reflex muscle tension, muscle relaxants, reduce pain, improve motor function and facilitates exercise therapy. Treatment of muscle relaxants begin with the usual therapeutic dose and continue as long as the pain, usually a course of treatment is several weeks. In the course of a number of studies failed to prove that when the painful muscle spasms addition to standard therapy (nonsteroidal anti-inflammatory drugs, analgesics, physiotherapy, physical therapy) muscle leads to more rapid regression of pain, muscle tension and improve spinal mobility.
As a muscle relaxant used Midokalm, baclofen and sirdalud. Muscle relaxants are usually not combined with each other. To remove the painful muscle spasms can also be used diazepam (seduksen, Relanium) in matched to individual dose.
Baclofen has muscle relaxant effects mainly at the spinal level. The drug is similar in structure to the ?-aminobutyric acid (GABA), binds to presynaptic GABA receptors, leading to a decrease in allocation ekstsitsatornyh amino acids (glutamate, aspratata) and suppression of the mono-and polysynaptic activity in the spinal level, which causes decreased muscle tone; baclofen also has a moderate central analgesic effect. It is well absorbed from the gastrointestinal tract and maximum concentration in blood is achieved in 2-3 hours after ingestion. The initial dose is 15 mg per day (three meals), then increase the dose by 5 mg every day until the desired effect, the drug is taken with food. The usual dose for treatment of painful muscle spasm of 20-30 mg. The maximum dose of baclofen for adults is 60-75 mg per day. Side effects often occur drowsiness, dizziness. Sometimes there is nausea, constipation, diarrhea, hypotension, caution is required in the treatment of elderly patients.
Sirdalud (tizanidine) - agonist a-2 adrenergic receptors. The drug reduces the muscle tone due to the suppression of polysynaptic reflexes at the spinal cord, which can be caused by inhibition of the release of excitatory amino acids and activation of glycine reduces the excitability of spinal interneurons; sirdalud also has a mild central analgesic effect. When administered at the maximum concentration sirdaluda levels achieved after an hour, food intake does not affect its pharmacokinetics. The initial dose is 6 mg per day in three divided doses, the average therapeutic dose - 12-24 mg per day, maximum dose - 36 mg per day. As a side effect observed drowsiness, dizziness, a slight decrease in blood pressure need to be careful while taking the drug in elderly patients.
Midokalm (tolperizon) for a long time widely used in the treatment of reflex and compression complications degenerative changes of the spine (osteochondrosis, spondylosis, spondylarthrosis) and myofascial pain . Midokalm has predominantly central muscle relaxant effect. Reduced muscle tone while taking the drug binds to the inhibitory effect on the caudal portion of the reticular Pharmacy and the suppression of spinal reflex activity. The drug has a mild central analgesic effect and a slight vasodilator effect. Receiving midokalma begin with 150 mg per day three times a day, gradually increasing the dose to effect, in adults, usually up to 300-450 mg per day. For a quick effect, the drug is injected intramuscularly and 1 ml (100 mg) twice daily or intravenous injection of 1 ml once a day.
Efficacy and safety of midokalma with painful muscle spasms proved in a double-blind, placebo-controlled study . In the eight research centers, 110 patients aged 20 to 75 years were randomly given Midokalm 300 mg daily or placebo in combination with physical therapy and rehabilitation for 21 days. As an objective criterion for considering the effectiveness of treatment of pressure pain threshold measured with a special device (Pressure Tolerance Meter) at 16 symmetrical points of the trunk and extremities. In addition, patients rated their subjective state of pain intensity, a sense of tension in the muscles and mobility of the spine, the doctor also assessed muscle tension and flexibility of the spine. Before treatment and after it conducted a detailed clinical and laboratory examination, including ECG, blood pressure, blood chemistry and 16 indicators.
According to studies, the use of midokalma significantly reduce painful muscle spasm, as measured objectively instrumental method. The difference between the treatment groups and placebo, which is already noted on the fourth day, gradually increased and became statistically significant at the 10 th and 21 th days of treatment, which were chosen as endpoints for the comparison of evidence.Analysis of the subjective assessment of treatment outcomes, given doctors and patients after it (21 days), showed that patients treated with Midokalm, significantly more treatment results were evaluated as very good, whereas in the placebo effect is significantly more often absent. According to the subjective assessment of treatment outcome, this patient after graduation (21 days), no significant differences regarding tolerability midokalma and placebo were found. The vast majority of patients had good tolerance midokalma. Results of ECG, biochemical and hematological parameters in patients treated with both Midokalm and placebo, also did not differ.
It is important to note that more than half (62%) patients in the study received other therapies prior to study, and most of them (68%) with no noted improvement. This demonstrates the effectiveness in treating painful midokalma muscle spasm that is resistant to other therapies.
Introduction middleman parenteral to quickly relieve pain and reduce muscle tension.