Chronic pain. Treatment of neurogenic pain syndromes

Pain is inherently a vital biologically expedient phenomenon, in normal conditions playing a key role physiological mechanism protection. It mobilizes all the functional systems necessary for the survival of the organism, allowing to overcome the harmful effects that provoked pain, or to avoid them. About 90% of all diseases are associated with pain.
The classification of the temporal aspect of pain distinguishes between transient, acute and chronic pain.
Transient pain provoked by the activation of nociceptive transducers of receptors in the skin or other tissues of the body in the absence of significant tissue damage. The function of such pain is determined by the rate of its occurrence after stimulation and the rate of elimination, which indicates that there is no danger of a damaging effect on the body. In clinical practice, for example, transient pain is observed during intramuscular or intravenous injection. It is assumed that transient pain exists to protect a person from the threat of physical damage by environmental factors in the form of a kind of learning or pain experience.
acute pain- a necessary biological adaptive signal about a possible (in the case of pain experience), incipient or already occurred damage. Development acute pain As a rule, it is associated with well-defined painful irritations of superficial or deep tissues and internal organs or a violation of the function of smooth muscles of internal organs without tissue damage. The duration of acute pain is limited by the time of repair of damaged tissues or the duration of smooth muscle dysfunction. Neurological reasons acute pain can be traumatic, infectious, dysmetabolic, inflammatory and other damage to the peripheral and central nervous system(CNS), meninges, short neural or muscular syndromes.
Acute pain is divided into superficial, deep, visceral and reflected. These types of acute pain differ in subjective sensations, localization, pathogenesis and causes.
chronic pain in neurological practice, the condition is much more relevant. The International Association for the Study of Pain defines chronic pain as "...pain that continues beyond the normal healing period." In practice, this can take several weeks or more than six months. Chronic pain can also include recurring pain conditions (neuralgia, headaches, various genesis and etc.). The point, however, is not so much in temporal differences, but in qualitatively different neurophysiological, psychological and clinical features. The main point is that acute pain is always a symptom, while chronic pain can become essentially a disease in itself. It is clear that the therapeutic tactics in the elimination of acute and chronic pain has significant features. Chronic pain in its pathophysiological basis may have a pathological process in the somatic sphere and / or primary or secondary dysfunction of the peripheral or central nervous system, it can also be caused by psychological factors. From a medical point of view, it is acute and chronic pain that becomes the reason for going to the doctor because of its destabilizing and maladaptive role.
According to various researchers, from 7 to 64% of the population periodically experience pain, and from 7.6 to 45% suffer from recurrent or chronic pain. According to WHO, pain syndromes are one of the leading causes (up to 40%) of visits to a doctor in the primary care system. medical care. In the structure of chronic neurogenic pain syndromes pain of musculoskeletal origin (radiculopathy, lumboischialgia, cervicobrachialgia, etc.) and headaches predominate. In the structure of neurological admission, patients with chronic pain syndromes account for up to 52.5%. According to some reports, up to 75% of patients suffering from chronic pain syndromes prefer not to see a doctor.

Pain formation mechanism

Therapy of pain syndromes involves identifying and eliminating the source or cause of pain, determining the degree of involvement various departments nervous system in the formation of pain and the removal or suppression of the pain itself.
The first central link that perceives multimodal afferent information is the neuronal system of the dorsal horn of the spinal cord. It is a cytoarchitectonically very complex structure, which in functional terms can be considered as a kind of primary integrative center of sensory information.
After a very complex processing of pain afferentation in the segmental apparatus of the spinal cord, where it is affected by excitatory and inhibitory influences emanating from the peripheral and central parts of the nervous system, nociceptive impulses are transmitted through interneurons to the cells of the anterior and lateral horns, causing reflex motor and autonomic reactions. Another part of the impulses excites neurons whose axons form ascending pathways.
Nociceptive afferentation is directed to the brain along the spinothalamic, spinoreticular, and spinomesencephalic pathways. Afferent information comes to the somatosensory cortex from the ipsilateral parts of the thalamus. Cortico-fugal fibers go from the post-central parts of the parietal cortex to the same nuclei of the thalamus opticus and are partly part of the cortico-bulbar and cortico-spinal descending tracts. At the level of the somatosensory cortex, spatiotemporal analysis of pain information is carried out. Corticofugal fibers from the frontal cortex are directed both to the same thalamic structures and to the neurons of the reticular formation of the trunk, formations of the limbic system (cingulate gyrus, hippocampus, fornix, septum, entorhinal cortex) and the hypothalamus. Thus, along with the provision of cognitive and behavioral components of the integrative response to pain, the frontal cortex is involved in the formation of a motivational-affective assessment of pain sensation. The temporal cortex plays important role in the formation of sensory memory, which allows the brain to evaluate the actual pain sensation, comparing it with the previous ones. Thus, the state of the suprasegmental structures of the CNS - the cortex, the limbic system, the stem-diencephalic formations that form the motivational-affective and cognitive components of pain behavior, also actively influences the conduction of pain afferentation.
Descending inhibitory cerebrospinal control over the conduction of pain impulses is a function of the antinociceptive system, carried out by the structures of the cerebral cortex, the diencephalic level, the periventricular and periaqueductal gray matter, rich in enkephalin and opiate neurons, some nuclei of the reticular formation of the brain stem (the main of which is the large raphe nucleus), in whose main neurotransmitter is serotonin. The axons of the neurons of this nucleus go down the dorsolateral funiculus of the spinal cord, ending in surface layers back horn. Some of them, like most of the axons from the reticular formation, are noradrenergic. The participation of serotonin and norepinephrine in the functioning of the antinociceptive system explains the pain relief caused by tricyclic antidepressants, the main property of which is the suppression of reuptake in serotonergic and norepinephrine synapses and, thereby, an increase in the descending inhibitory effect on the neurons of the dorsal horn of the spinal cord.
Critical importance in the functioning of the antinociceptive system have opiates. Opiate receptors are located at C-fiber terminals in the dorsal horn of the spinal cord, in descending inhibitory pathways from the brain to the spinal cord, and in areas of the brain that transmit pain signals. There are three main types of opiate receptors: m- (mu), k- (kappa) and d- (delta) receptors. These main types of opiate receptors are also subdivided, and each subtype is affected by different endo- and exogenous opiates.
The distribution of opiate peptides and opiate receptors is observed at different levels of the CNS. Dense placement of receptors is found in the dorsal horns of the spinal cord, midbrain, and thalamus. high density opiate receptors was also found in the middle part of the thalamus and in the limbic structures forebrain; these structures may play an additional important role in the analgesic response to injected drugs and in the addiction mechanism. The highest concentration of spinal opiate receptors is observed in the superficial layers of the posterior horns of the spinal cord. Endogenous opiate peptides (enkephalin, endorphin, dynorphin) interact with opioid receptors whenever painful stimuli occur as a result of overcoming the pain threshold. b-Endorphin has an equal affinity for m- and d-receptors, while dynorphins A and B have a high affinity for k-receptors. Enkephalins have a high affinity for d-receptors and a relatively small affinity for k-receptors.
C-type fibers can contact inhibitory enkephalinergic interneurons that inhibit the conduction of pain impulses in the posterior horns and the nucleus of the spinal cord. trigeminal nerve. Inhibition of the release of excitatory transmitters is also provided by other pain inhibitors - these are GABA and glycine found in the intercalary neurons of the spinal cord. These endogenous substances modulate CNS activity and inhibit pain signal transmission. The pain response is also inhibited by serotonin and norepinephrine as part of the descending pathway from the brain to the spinal cord that controls the pain mechanism.
Thus, under normal conditions, there is a harmonious relationship between the intensity of the stimulus and the response to it at all levels of the organization of the pain system.
However, long-term repeated damaging effects often lead to a change in the functional state (increased reactivity) of the pain system, which gives rise to its pathophysiological changes. From this point of view, there are nociceptive, neuropathic and psychogenic pain.
nociceptive pain occurs with any tissue damage that causes excitation of peripheral pain receptors and specific somatic or visceral afferent fibers. Nociceptive pain is usually transient or acute, the painful stimulus is obvious, the pain is usually clearly localized and well described by patients. The exception is visceral pain and referred pain. Nociceptive pain is characterized by rapid regression after the appointment of a short course of painkillers, including narcotic analgesics.
neuropathic pain due to damage or changes in the state of the somatosensory (peripheral and / or central departments) system. Neuropathic pain can develop and persist in the absence of an obvious primary pain stimulus, manifests itself in the form of a series of characteristic features, often poorly localized and accompanied by various disorders of surface sensitivity: hyperalgesia (intense pain with mild nociceptive irritation of the primary injury zone, or neighboring and even distant zones); allodynia (the occurrence of pain when exposed to non-painful stimuli of various modalities); hyperpathy (pronounced reaction to repeated pain effects with the preservation of the sensation of severe pain after the cessation of pain stimulation); pain anesthesia (feeling of pain in areas devoid of pain sensitivity). Neuropathic pain is less susceptible to morphine and other opiates at conventional analgesic doses, indicating a difference in its mechanisms from nociceptive pain.
Neuropathic pain can be spontaneous or induced. Spontaneous pain is defined by a burning sensation, usually on skin surface, which reflects the activation of peripheral C-nociceptors. Such pain can also be acute when it is caused by stimulation of low-myelinated A-delta nociceptive skin afferents. Shooting pains, similar to an electrical discharge, radiating to a segment of a limb or face, usually the result of ectopic generation of impulses along the paths of low-myelinated C-fibers of muscle afferents that respond to damaging mechanical and chemical stimuli. The activity of this type of afferent fibers is perceived as "cramp-like pain".
Psychogenic pain occur in the absence of any organic lesion that would explain the severity of pain and associated functional disorders. The question of the existence of pain of exclusively psychogenic origin is debatable, however, certain features of the patient's personality can influence the formation of pain. Psychogenic pain is one of the many disorders characteristic of somatoform disorders. Any chronic illness or malaise, accompanied by pain, affects the emotions and behavior of the individual. Pain often leads to anxiety and tension, which themselves increase its perception. Psychophysiological (psychosomatic) mechanisms, acting through the corticofugal systems, change the state of internal organs, striated and smooth muscles, stimulate the release of algogenic substances and the activation of nociceptors. The resulting pain, in turn, exacerbates emotional disturbances, thus closing vicious circle.
Among other forms mental disorders most closely associated with chronic pain is depression. Possible various options temporary relationships of these disorders - they can occur simultaneously or one ahead of the manifestations of the other. In these cases, depression is more often not endogenous, but psychogenic. The relationship between pain and depression is quite complex. In patients with clinically significant depression, the pain threshold decreases, and pain is a common complaint in patients with primary depression, which can occur in a "masked" form. Patients with pain associated with a chronic somatic disease often also develop depression. The rarest form of pain in mental illness is its hallucinatory form, which occurs in patients with endogenous psychoses. Psychological mechanisms Pain also includes cognitive mechanisms that link pain with conditional social benefits, receiving emotional support, attention, and love.

Principles of pain management

The general principles of pain treatment provide for a clinical assessment of the state of the neurophysiological and psychological components of the nociceptive and antinociceptive systems and the impact on all levels of organization of this system.
1. Elimination of the source of pain and restoration of damaged tissues.
2. Impact on the peripheral components of pain - somatic (elimination of inflammation, edema, etc.) and neurochemical (stimulation of pain receptors). In this case, drugs that affect the synthesis of prostaglandins have the most pronounced effect: non-narcotic analgesics (paracetamol), non-steroidal anti-inflammatory drugs (potassium and sodium diclofenac, ibuprofen, etc.) and provide a decrease in the concentration of substance P in the terminals of fibers that conduct pain impulses (drugs capsicum for external use - capsaicin, capsin, etc.).
3. Inhibition of the conduction of pain impulses along the peripheral nerves and in ultrasound (the introduction of local anesthetics, alcohol and phenol denervation, transection of peripheral nerves, ganglionectomy).
4. Impact on the processes occurring in the posterior horns. In addition to applications of capsicum preparations that reduce the concentration of CP in the posterior horns, a number of other methods of therapy are used:
a) the introduction of opiates systemically or locally (epidurally or subdurally), which provides increased enkephalinergic inhibition of pain impulses;
b) electrical stimulation and other methods of physical stimulation (physiotherapy, acupuncture, transcutaneous electrical nerve stimulation, massage, etc.) that cause inhibition of nociceptive neurons of the posterior horn by activating enkephalinergic neurons;
c) the use of drugs that affect GABA-ergic structures (baclofen, tizanidine, gabapentin);
d) application anticonvulsants(carbamazepine, diphenin, lamotrigine, valproates and benzodiazepines), which inhibit the conduction of nerve impulses along sensory nerves and have an agonistic effect on GABAergic receptors of neurons of the posterior horns and cells of the nucleus of the spinal tract of the trigeminal nerve. These drugs are especially effective in neuralgia;
e) the use of agonist drugs a 2 -adrenergic receptors - clonidine, etc.;
f) the use of serotonin reuptake blockers that increase the concentration of this neurotransmitter in the nuclei of the reticular formation of the brain stem, from which descend the descending inhibitory pathways that act on the interneurons of the posterior horn (fluoxetine, amitriptyline).
5. Impact on the psychological (and at the same time on the neurochemical) components of pain with the use of psychotropic pharmacological drugs (antidepressants, tranquilizers, antipsychotics); use of psychotherapeutic methods.
6. Elimination of sympathetic activation in the corresponding chronic pain syndromes (sympatholytic agents, sympathectomy).
Treatment of acute pain involves the use of four main classes of drugs: opiates, non-steroidal anti-inflammatory drugs (NSAIDs), simple and combined analgesics.
Opiate analgesics are used to relieve acute pain syndrome: buprenorphine, butorphanol, meperidine, nalbuphine, etc. Of this group of drugs, the most widely used tramadol, which, according to WHO recommendations, belongs to the second stage of pain therapy, occupying an intermediate position between therapy with non-steroidal anti-inflammatory drugs and narcotic analgesics. The unique dual mechanism of action of tramadol is realized through binding to m-opioid receptors and simultaneous inhibition of serotonin and norepinephrine reuptake, which contributes to additional activation of the antinociceptive system and an increase in the threshold of pain sensitivity. The synergy of both mechanisms determines the high analgesic efficacy of tramadol in the treatment of various pain syndromes in neurology. Clinically important is the fact that there is no synergy side effects, which explains the greater safety of the drug compared to classical opioid analgesics. For example, unlike morphine, tramadol does not lead to respiratory and circulatory disorders, gastrointestinal motility and urinary tract, and long-term use at recommended doses (maximum daily dose of 400 mg) does not lead to the development of drug dependence. It is used in injectable form (for adults intravenously or intramuscularly in a single dose of 50-100 mg), for oral administration(single dose 50 mg) and in the form of rectal suppositories (100 mg). AT acute period pain syndrome, its combined use with NSAIDs is most effective, which allows not only to achieve the inclusion of various analgesic mechanisms and enhance the effectiveness of analgesic therapy, but also to reduce the number of side effects from the gastrointestinal tract associated with the use of NSAIDs.
In the treatment of chronic pain syndromes, first-line drugs are tricyclic antidepressants, among which most widespread received the non-selective reuptake inhibitor amitriptyline. The next series of drugs are anticonvulsants GABA-agonists: valproic acid derivatives, gabapentin, lamotrigine, topiramate, vigabatrin. The use of anxiolytics, phenathiazine derivatives (chlorpromazine, fluanxol, etc.), potentiates the action of opiates, benzodiazepines - promotes muscle relaxation.
These drugs and methods can be used separately, depending on the specific clinical situation, or, more often with neurogenic pain, combined. A separate aspect of the problem of pain is the tactics of managing patients. The experience currently available has proven the need for examination and treatment of patients with acute and especially chronic pain in specialized centers inpatient or outpatient type. Due to the wide variety of types and mechanisms of pain, even with a similar underlying disease, there is a real need for participation in their diagnosis and treatment of various specialists - neurologists, anesthesiologists, psychologists, clinical electrophysiologists, physiotherapists, etc. Only a comprehensive interdisciplinary approach to the study of theoretical and clinical problems of pain can solve the urgent problem of our time - delivering people from the suffering associated with pain.

V.V. Alekseev

MMA them. I.M. Sechenov

Article from the Directory of the polyclinic doctor
Publisher MediaMedica

Chronic pain syndrome (CPS)- it is independent neurological disease, characterized prolonged pain. As a rule, HBS occurs due to illness or injury.

It is necessary to distinguish between pain caused directly by the disease, and chronic pain syndrome, which is a complex disorder of the work of a number of organs and systems. "Normal", physiological pain is protective. It subsides simultaneously with the pathological process that caused the pain, while the symptoms of CPS appear regardless of the underlying disease. That is why modern neurology considers chronic pain syndrome as a separate problem, the successful solution of which is possible only with the participation of specialists in the treatment of CHD, using A complex approach to illness.

Reasons for development

Most often, chronic pain syndrome develops as a complication of diseases of the musculoskeletal system. The most common causes of HBS - joint diseases (osteoarthritis, rheumatoid arthritis) and fibromyalgia. Patients with spinal tuberculosis and various tumors often suffer from chronic pain.

It is believed that for the development of chronic pain syndrome, the presence of one diagnosis is not enough - it is also necessary special type organization of the nervous system. As a rule, CPS develops in people prone to depression, hypochondria, and severe stress overeating.

It is important to understand that in such patients chronic pain syndrome is a manifestation of depression, its “mask”, and not vice versa, although the patients themselves and their relatives usually consider depressed mood and apathy to be the result of painful sensations.

However, chronic pain syndrome should not be considered a problem of an exclusively psychological nature. Psychogenic pain, which was discussed above, really plays a huge role in the development of CHD, but inflammatory, neurogenic (due to impaired functioning of the nerves responsible for the transmission of pain impulses) and vascular mechanisms of chronic pain formation are no less important. Even such seemingly far from medicine problems as the social isolation of patients can worsen the course of CPS. A vicious circle is formed: the patient cannot meet with friends, because pain in the knee or back does not allow him to leave the house, and the lack of informal communication leads to an even greater increase pain.

A separate problem is chronic pain syndrome in cancer patients. As a rule, it develops in the late stages of oncological diseases, however, the timing of the onset of pain and their intensity depend not only on the location of the neoplasm and the extent of the tumor process, but also on the patient's individual sensitivity to pain, the characteristics of his psyche and constitution.

Diagnosis of chronic pain syndrome

The starting point in the diagnosis of CHD is a conversation between the doctor and the patient and a thorough history taking. It is important that the conversation does not come down to a formal enumeration of past and existing illnesses: events such as the death of loved ones, the loss of a job, or even moving to another city deserve mention no less than arthrosis or a sprain suffered a year ago.

To assess the intensity of pain, the patient may be offered verbal rating scale (SHVO) or visual analogue scale (YOUR). Using these scales allows the doctor to understand how serious problem pain for a particular patient, and choose the most appropriate treatment option.

An important stage in the diagnosis of chronic pain syndrome is the determination of the mechanism that plays a key role in the formation of CPS. Whether it turns out to be psychogenic, neurogenic, or something else depends treatment strategy.

Pain in cancer patients

In cancer patients, pain syndrome can be associated not only with the disease itself, but also with the process of its treatment. So, surgical interventions often lead to the development of phantom pains and adhesions, chemotherapy damages the nervous system and provokes the development of pain in the joints. In addition, by itself serious condition and the need for bed rest are risk factors for the development of CHD: bedridden patients often develop bedsores. Determining the cause of increased pain in a severe cancer patient is the first step towards alleviating his condition and improving the quality of life.

Treatment of chronic pain syndrome

CHD is a complex disease, which is based on several mechanisms at once.

The effectiveness of traditional painkillers (primarily non-steroidal anti-inflammatory drugs, NSAIDs) in the treatment of chronic pain is low: they only slightly reduce the intensity of pain or do not help at all. The fact is that NSAIDs can affect only some of the mechanisms of development of chronic pain syndrome, for example, inflammation.

In order to influence the processes taking place directly in the central nervous system, patients are prescribed drugs of other groups, primarily antidepressants .

Medical therapy is just one of the areas complex treatment HBS. Used extensively in the management of chronic pain physio- and psychotherapy , autotraining techniques and relaxation. The fight against the underlying disease, such as osteoarthritis, plays an important, but not decisive role in the treatment of CHD.

The strategy for treating chronic pain syndrome in cancer patients is somewhat different. In addition to medical and psychotherapeutic methods of dealing with pain, they are also shown palliative care : a set of measures aimed at improving the quality of life and minimizing the damage that the tumor process causes to the body. For example, cleaning the blood of tumor toxins or surgical removal of a part of the tumor mass can improve well-being and, as a result, stabilize emotional condition, which will naturally lead to a decrease in the severity of pain.

In addition, for cancer patients developed special schemes medical anesthesia that allow you to effectively stop the pain syndrome and improve, as far as possible, the quality of life.

Patients with acute and chronic pain often turn to neurologists at the Yusupov Hospital. Doctors of the neurology clinic use modern research methods to determine the cause of pain. For the treatment of patients using the latest effective drugs that have a minimum range of side effects.

Candidates and doctors of medical sciences, who are leading specialists in the field of neurology, work at the Yusupov Hospital. They individually approach the treatment of patients with chronic pain. Complex therapy includes not only painkillers. It aims to eliminate the cause of the pain. In addition to medical support, doctors at the Yusupov Hospital widely use non-drug methods treatment (physiotherapy, exercise therapy, manual therapy, acupuncture).

Causes of Chronic Pain

Patients often complain of back pain. Dorsopathies are a group of diseases of the connective and musculoskeletal system, the leading symptom complex of which is pain in the limbs and torso. The defining symptom in dorsalgia is the appearance of severe pain associated with irritation of the nerve endings that are located in the soft tissues of the spine.

Sources of pain impulses for back pain are:

fascia, ligaments, muscles;
facet joints;
spinal nodes, nerves;
vertebrae, intervertebral disc, dura mater.

The cause of primary back pain is degenerative changes in the structures of the spine. Secondary pain occurs when there are other pathological conditions. When examining a patient with chronic pain syndrome, the neurologists of the Yusupov hospital conduct differential diagnosis musculoskeletal pain from pain syndromes associated with oncological or somatic pathology.

Syndromes of chronic back pain

Depending on which structures of the spinal column are involved in the pathological process, clinical picture diseases are dominated by either compression or reflex syndromes. If the altered structures of the spine deform or compress the roots, spinal cord or vessels, develop compression syndromes. Reflex vertebrogenic syndromes occur as a result of irritation various structures spine.

According to the location, vertebrogenic syndromes of the cervical, lumbosacral and thoracic levels are distinguished. In the neck, blood vessels, the spinal cord or nerve roots are subjected to compression. When squeezing the root of the third spinal nerve patients complain of pain in the corresponding half of the neck. Compression of the fourth nerve root causes the following symptoms:

pain in the shoulder girdle and collarbone;
atrophy of the belt, trapezius and longest muscles of the head and neck;
heartache.

Compression of the root of the fifth cervical nerve is accompanied by pain in the neck, shoulder girdle, lateral surface of the shoulder, weakness and atrophy of the deltoid muscle. With compression of the sixth nerve, patients complain of pain in the neck, shoulder girdle, shoulder blade, radiating along the radial edge of the hand to the thumb. Their neurologists determine the weakness and hypotrophy of the biceps of the shoulder, a decrease in the reflex from the tendon of this muscle. Compression of the seventh cervical nerve root is manifested by pain in the neck and scapula, which spreads along outer surface forearms to the II and III fingers of the hand, weakness and atrophy of the triceps muscle of the shoulder, a decrease in the reflex from its tendon. When the root of the 8th nerve is compressed, pain from the neck spreads along the inner edge of the forearm to the fifth finger of the hand, and the carporadial reflex decreases.

Cervical reflex syndromes are clinically manifested by lumbago or chronic pain in the neck with irradiation to the back of the head and shoulder girdle. On palpation, neurologists determine pain in the area of the facet joints on the diseased side.

chronic pain syndrome in thoracic region spine often occurs in inflammatory and inflammatory-degenerative diseases (spondylitis, ankylosing spondylarthrosis). Neurologists define the following lumbar compression syndromes:

compression of the root of the second lumbar nerve is manifested by pain and loss of sensitivity along the anterior and inner surfaces of the thigh, a decrease in knee reflexes;
compression of the fourth lumbar nerve is manifested by pain in the anterior inner surface hips, a decrease in strength, followed by atrophy of the quadriceps femoris muscle and loss of the knee jerk;
when the root of the fifth lumbar nerve is compressed, patients are worried about lower back pain radiating along the outer surface of the thigh, the anterolateral surface of the lower leg, the inner surface of the foot and thumb. Patients have a decrease in the strength of the dorsal flexors of the thumb, hypotension and hypotrophy of the tibial muscle.

Lumbar pain reflex syndromes

Chronic pain syndrome in the lumbar spine is manifested by dull, aching pain in the lower back. During palpation, neurologists determine the soreness of the spinous processes, interspinous ligaments and facet joints. Movement in the lumbar spine is limited.

With lumbar osteochondrosis, the piriformis muscle is tense and the nerve is compressed. Patients are worried sharp pain in the subgluteal region with irradiation along the posterior surface of the lower limb. Achilles reflex is reduced Adduction of the hip causes pain. The pain syndrome is accompanied by regional vasomotor disorders.

Diagnosis and differential diagnosis of chronic pain syndrome

The Yusupov hospital uses the following modern methods for diagnosing dorsopathies:

X-ray examination;
spondylography;
computed and magnetic resonance imaging.

After analyzing the results of the studies, neurologists conduct a differential diagnosis of compression and reflex vertebrogenic syndromes. Compression vertebrogenic syndromes are characterized by the following features:

the pain is localized in the spine, pours into the limb to the toes or hands;
the pain is aggravated by sneezing, coughing, straining, movements in the spine;
a violation of sensitivity, a decrease in tendon reflexes, and muscle hypotrophy are determined. With reflex vertebrogenic syndromes the pain is local, dull, deep, without irradiation. It increases with the load on the spasmodic muscle, its stretching or deep palpation. There are no withdrawal symptoms.

Treatment of chronic pain syndrome in neurology

The basis of chronic pain are changes in the central and peripheral nervous system, which "tear off" the pain from the root cause of the disease, making it an independent disease. Rapid, effective relief of acute pain helps prevent chronic pain. For this purpose, neurologists at the Yusupov hospital use non-steroidal anti-inflammatory drugs. They are effective at the initial stage of treatment. For the prevention of chronic pain syndrome, the load on the affected spine is limited by fixing it with special orthopedic aids (reclinator, corset, Shantz splint).

In the case of neuropathic pain syndrome, combined therapy is used. It includes non-steroidal anti-inflammatory drugs and a complex of B vitamins, which have a pathogenetic effect in case of damage to peripheral nerves. If within one week the pain syndrome is not stopped, the neurologists of the Yusupov hospital review the treatment tactics. Non-steroidal anti-inflammatory drugs may be ineffective due to poor blood supply to the site of inflammation. In this case medicinal product injected directly into the epicenter of pain and inflammation by blockade with local anesthetics under ultrasound or fluoroscopic guidance.

In the presence of persistent spasm of the paravertebral muscles, a repeating circle of "pain-spasm-pain" is formed. In this case, non-steroidal anti-inflammatory drugs as monotherapy are not effective. They are not able to "calm down" the disinhibited parts of the nervous system. For the relief of chronic pain syndrome as a result of muscle spasm using muscle relaxants. These drugs inhibit the excitation of motor neurons in response to painful stimuli. There is a normalization of increased muscle tone. If combined treatment nonsteroidal drugs in combination with muscle relaxants is not effective enough, the neurologists of the Yusupov hospital prescribe a short course of weak narcotic analgesics (tramadol).

In the absence of contraindications, treatment is supplemented with non-drug therapy: manual therapy, thermal physiotherapy, vacuum and manual massage. The most effective conservative method of treating chronic pain syndrome in neurology is local injection of corticosteroids into the focus of the degenerative-dystrophic process or inflammation. Glucocorticoids are administered foraminally, epidurally, paraarticularly into the facet joints, into myofascial trigger points. Blockades in the Yusupov hospital are performed under the control of an ultrasound scanner or an X-ray unit with an electron-optical converter.

In chronic pain syndrome in patients with lumbosacral radiculopathy, psychotropic drugs from the category of antidepressants and anticonvulsants are used. Gabapentin is one of the latest generation of anticonvulsants. The drug not only reduces the severity of pain, but also improves the quality of life of patients.

In order to stimulate patients and restore their desire to fight the disease, psychologists at the Yusupov Hospital use behavioral and cognitive-behavioral psychotherapy. Rehabilitators use treatments to reduce the fear associated with pain. It is based on the method of exposure - the gradual presentation of a stimulus in a safe environment.

To normalize the condition of patients with chronic pain syndrome, neurologists at the Yusupov Hospital use an integrated approach that combines the methods of pharmacotherapy, psychotherapy, reflexology and exercise therapy. Make an appointment with a neurologist by phone.

Bibliography

ICD-10 (International Classification of Diseases)
Yusupov hospital
Abuzarova G.R. Neuropathic pain syndrome in oncology: epidemiology, classification, features neuropathic pain at malignant neoplasms// Russian journal of oncology. - 2010. - No. 5. - S. 50-55.
Alekseev V.V. Basic principles of treatment of pain syndromes // Russian Medical Journal. - 2003. - T. 11. - No. 5. - S. 250-253.
Pain syndromes in neurological practice / Ed. A.M. Wayne. - 2001. - 368 p.

Prices for the treatment of chronic pain syndrome in neurology

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*The information on the site is for informational purposes only. All materials and prices posted on the site are not a public offer, determined by the provisions of Art. 437 of the Civil Code of the Russian Federation. For exact information, please contact the clinic staff or visit our clinic.

Pain- an unpleasant physical or emotional sensation associated with possible or actual tissue damage or described as damage. Back pain is one of the leading reasons for seeking medical attention worldwide. Almost every adult experiences back or neck pain. Back pain begins with irritation of one or more special sensitive nerve endings, nociceptors, in the skin or internal organs. In the spine, the signals from nociceptors can change under the influence of other nerve endings. This may lead to an increase or, more often, a decrease in the intensity of pain impulses. The signal then goes to some parts of the brain, where they are recognized as pain. Back pain plays a major role in protecting the body and therefore should not be ignored.

Causes of neck and back pain

osteochondrosis — degenerative change cartilage tissue intervertebral disc, accompanied by severe pain and limited mobility of the spine, painful muscle tension increases with exercise;
radiculitis- pinching of the roots of the spinal nerve, manifested by acute pain, "shooting" down the leg, a decrease in skin sensitivity in the foot area;
myositis of the muscles of the back and neck- Pain of a constant nature, repeatedly aggravated during movement;
hernia intervertebral disc - a phenomenon in which there is a rupture of the disc membrane and the release of fibrous contents into the spinal canal, which leads to pinched nerves and other dangerous pathological effects;

note that constant pain in the back is one of the symptoms of various kidney diseases! Do not waste time, consult a doctor.

At the consultation, a neurologist will help you choose the most optimal treatment for you.

Back and neck pain can be divided into three types:

acute pain
chronic pain
Neuropathic Pain It is very important to determine the type of pain you are suffering from. suitable for every type of pain different methods treatment.

Acute pain in the back is usually caused by inflammation resulting from irritation or injury, but very often the cause of acute pain is difficult to determine. This type of pain can be localized to the spinal joints, discs, vertebrae, or soft tissues. First of all, acute pain attacks the lumbar region. It could be:

lumbago or backache
idiopathic/unexplained low back pain
lumbosacral sprain or sprain
sciatica/lumbosacral sciatica (sciatica)
Acute back pain is usually constant and varies in severity. This is usually a very sharp or dull pain. It may be more severe in one area, such as the center or both sides of the lower back. The pain can also spread to the buttocks, thighs, knees, and even feet.
Acute back pain, complicated by movement of the spine and coughing, is characteristic of a herniated disc.

If back pain has been bothering you for several months more or less the same and with approximately the same level of severity, it can be considered chronic . This pain in the spine can be described as a deep, aching, dull pain, with a burning sensation in the back or lower legs. Chronic pain is often accompanied by numbness, tingling, burning, or tingling in the legs and buttocks. Chronic back pain lasts a long time and does not go away after traditional treatments. The cause of chronic pain may be an injury that you treated a long time ago. Or it may be caused by some permanent condition, such as a pinched nerve or arthritis.

neuropathic pain in the back was investigated relatively recently. With such pain, the signs of the primary injury go away and the pain experienced by the person is not related to the observed injury. It's just that some nerve endings continue to send signals to the brain, although tissue damage no longer occurs. Neuropathic back pain, also called neuralgia or neuropathy, is very different from the pain that was originally caused by an injury. Although the nature of this pain is not yet fully understood, it is believed that damage to sensory or motor nerves in the peripheral nervous system could possibly cause neuropathy. Neuropathic pain can be categorized as chronic but is accompanied by different sensations than chronic musculoskeletal pain. Neuropathic back pain is often described as: severe, sharp, cutting/boring/jerking/shooting, stabbing, stabbing, burning or cold, may be accompanied by numbness, tingling, and weakness. It can move along the conduction path of the nervous system along the spine to the extremities. It is important to identify neuropathological pain in order to apply appropriate treatment techniques. Treatment for neuropathic back pain includes:- drugs - injections to block the nerve - other treatments used for chronic pain - and finally, osteopathic techniques of treatment, which involve exploring the pathology of the pathology, identifying the cause and eliminating it.

How serious is your problem?

When you suffer from back pain, the first step is to assess the severity and identify the cause. This is important to decide whether you can handle the problem yourself, or if you should seek professional help.

It is worth bearing in mind that back pain may not be related to the spine. Sometimes back pain can appear due to problems with internal organs. It could be liver disease gynecological problems. In such cases, in addition to back pain, other symptoms may also bother you. If you are unwell and have back pain, be sure to consult your doctor.

If this is your first time experiencing such back pain, or if it is caused by a sudden flare-up of a previous illness, then it should be considered acute pain.

See a spinal specialist right away if you are experiencing severe pain and if:

this is pain from a fall or injury, and you feel pain or numbness in your limbs and have difficulty moving them.
You partially or completely do not control the process of urination.
You have a fever, general unwellness, severe headache, and other symptoms, such as a change in bowel habits.
You are in your 60s and have already been deprived due to illness or taking steroids for several years.
You have pain in your chest or in your left arm. If none of the above is observed for you, try the quick measures described below. Consult with a specialist as soon as you return to normal mobility.

Urgent measures for back pain

An attack of acute pain can be very severe and can render you incapacitated. It can occur immediately after a sprain caused by a fall or heavy lifting. Sometimes, you don't feel the effects of an injury until you wake up the next morning and realize that you can't get out of bed because of the pain and stiffness. Either way, there are a number of steps you can take to help manage your pain and speed up your recovery. In general, the rest period after an attack of acute back pain is no more than 24-48 hours (1-2 days). Even at this time, if the pain allows small movements in the back, you can gently pull your knee towards you while lying on your side. If the pain has subsided enough that you can afford to move more, you can start doing some light exercise.

The sooner you return to normal life activities, the less the risk of pain becoming chronic.

Rest position

In an episode of acute pain, it is necessary to remove pressure from the spine, especially if you suspect a disk injury. Ideally, you should lie down as this removes the gravitational pressure on the disc and allows the muscles to relax more quickly and easily. It is better to lie down on the bed, because. there is insufficient support on the floor and it is more difficult to get up from it. Sometimes, it's most comfortable to sit in a chair, so choose what works for you. Do not stay in a position that increases pain. Try to periodically change position, avoiding sudden painful movements. When you are able, get up and walk for a few minutes every hour.

Your choice of position

It is very important that you yourself choose the position in which you are most comfortable. Different positions suit different people, so choose which one is best for you. If you will be lying down, place a pillow under your head and neck. Bend your knees and, if necessary, place one or more pillows under your knees for support. You can also place your ankles on the seat of a chair so that your legs are bent at the correct angle. Thus, your lumbar arch straightens towards the bed or floor, gently stretching the back muscles. If your back continues to hurt, you can place a small rolled towel underneath. lumbar. If it’s uncomfortable to lie on your back, roll onto your side, pulling your knees in towards you so that your spine arches. Sometimes it is convenient to lie on your chest with a pillow under your stomach so that your back is slightly rounded.

Painkillers

Pain serves as a signal to us that something is wrong with our body, but we should not put up with prolonged pain, which can often be alleviated with the help of appropriate drugs.

Several over-the-counter drugs are effective in managing pain. Non-steroidal anti-inflammatory drugs will work better than paracetamol, because. They are both anti-inflammatory and pain relievers. If you have had asthma or stomach ulcers, talk to your doctor before taking these medicines. If you feel any discomfort in the stomach, discontinue use. Always read the package insert and do not exceed the recommended dose. Medicines containing codeine can cause constipation.

If over-the-counter medicines don't work for you, talk to your doctor. He can write you more strong drugs and perhaps a small course of muscle relaxants if you have a severe back spasm.

Relaxation

Back strain pain can result from muscle spasm caused by the injury. Once you're comfortable, try to focus on relaxing the muscles that hurt. Breathe in through your nose and count slowly to 4, then hold your breath for a count of 3 and exhale through your mouth for a count of 6. As you exhale, try to relax your body, starting at the head and jaw, and continuing down to the limbs and toes. Continue doing this exercise for several minutes.

In the treatment of vertebrogenic pathology, both drug and non-drug methods are used ( massage, manual therapy, reflexology, hirudotherapy, physiotherapy). The goal of treatment is to relieve pain, normalize muscle tone, restore normal mobility spine.

From medical methods treatment in our clinic is a priority therapeutic - drug blockade.

This method was once widespread, but with the development of the pharmaceutical market, it was forgotten. However, as practice shows, the widespread use of various pharmaceuticals is fraught with the development of complications, has a number of side effects and contraindications.

Therapeutic - drug blockade have a number of advantages: the minimum number of drugs with maximum effect, since the drug is injected directly into the painful focus. This is also the reason for the instant effect: the pain goes away for a long time after a few minutes! The terms of treatment and financial costs with the use of therapeutic - drug blockades are reduced several times .

In Moscow only in our clinic You can undergo treatment with effective therapeutic - drug blockades!

Osteopathy

The task of osteopathy is to identify and gently correct these disorders with the activation of internal reserves for self-healing in a natural way. Everything happens in the most natural way, without rough intervention from the doctor.

There are three main areas in osteopathy:

for the treatment of the articular-ligamentous apparatus.
for the treatment of internal organs.
for the treatment of the brain and surrounding structures

Osteopathy as a whole is an independent medical system, which is based on the principles of practical anatomy, physiology, and pathology. Osteopathic treatment carried out according to the principles laid down by Dr. Still.

The body is one whole. Illness always affects all systems and structures.
The body has healing energy for a cure.
Structure and function closely related to each other .

Osteopathy treats the body as a whole, taking into account its physical, emotional and spiritual characteristics.

Osteopathy has a wide range of indications, among which the main ones are:

Diseases of the musculoskeletal system.
Consequences of accidents, injuries and operations.
Allergic and chronic diseases.
Chronic and acute pain.
neurological diseases.
Degenerative diseases of the internal organs.
Loss of energy and depression.

chronic pain is a term used to describe pain sensations that last longer, according to various authors, than 1, 3 or 6 months, or longer than the time required to cure a particular type of pain. Chronic pain is one of the obligatory symptoms of a number of chronic and degenerative diseases. The International Association for the Study of Pain (IASP) recommends chronic pain that lasts more than 3 months.

chronic pain- this is a significant problem for the patient, violating his physical and psychological health. Her treatment is expensive. Pain brings not only significant material, but also moral damage to the patient, his family members and society as a whole. This chapter discusses different types chronic pain.

Types of chronic pain Neuropathic pain

Symptomatology. Neuropathic pain can be represented by several types of sensations even in one patient. It is usually described as burning, cutting, throbbing, aching, stabbing. It can be paroxysmal in the form of separate acute short-term attacks. Pain symptoms may be accompanied by numbness, muscle weakness and atrophy, fasciculations and convulsions. Some types of neuropathic pain are associated with restless leg syndrome.

Causes of Chronic Pain

Polyneuropathies.
- Metabolic polyneuropathy, for example, with diabetes, with uremia.
- Polyneuropathy in malnutrition, for example, with vitamin deficiency, alcoholic polyneuropathy.
- Toxic polyneuropathy, for example, in case of poisoning with heavy metals, organic fertilizers, drugs.
- Vascular/inflammatory polyneuropathies, e.g. rheumatoid arthritis, systemic lupus erythematosus, Guillain-Barré syndrome and chronic inflammatory demyelinating polyradiculoneuropathy.
- Infectious polyneuropathies, for example, with AIDS.
- Polyneuropathy in malignant neoplasms.
- Hereditary polyneuropathies, such as hereditary sensorimotor neuropathy and Fabry disease.
- Ischemic polyneuropathy, for example, with peripheral vascular disease. (9) Idiopathic forms.

Mononeuropathies/multiple mononeuropathies

Metabolic, for example, diabetic amyotrophy.
- Vascular/inflammatory, eg, collagen vascular disease, periarteritis nodosa, sarcoidosis.
- Infectious, for example, with herpes zoster, infectious mononucleosis, leprosy.
- In malignant neoplasms - primary or metastatic tumors.
- Traumatic/surgical.
- Idiopathic.

Musculoskeletal pain

1. Symptomatology. Patients describe deep or superficial aching, throbbing, burning, or pressing pain, which can be diffuse or local. This type of pain is often associated with muscle spasms and limited range of motion.
2. Etiology
- Arthritis.
- Fibromyalgia or myofascial pain.
- Myopathies.
- Injury/after surgery.
- Metabolic lesions of bones and muscles.

Psychological/psychosocial pain.

chronic pain often accompanied by depression, anxiety and insomnia. The level of physical and/or social activity of the patient is significantly reduced. Treatment aims to break the vicious circle of pain-psychological dysfunction-increasing symptoms.

In some patients, psychological or psychosocial disturbances are primary. cause of chronic pain. In such situations, consultation and treatment with a psychotherapist or psychiatrist is required. Before referring the patient to these specialists, the therapist must explain in detail to the patient that psychological and emotional stress can be the cause of all his ailments. Then the patient realizes the need for the help of appropriate specialists, and the treatment will be effective.